st christopher's hospice · st christopher's hospice quality report 51-59 lawrie park...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Outstanding –

Are services safe? Good –––

Are services effective? Outstanding –

Are services caring? Good –––

Are services responsive? Outstanding –

Are services well-led? Outstanding –

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

StSt ChristChristopher'opher'ss HospicHospiceeQuality Report

51-59 Lawrie Park RoadSydenhamLondon SE26 6DZTel:0208 7684 500Website:www.stchristophers.org.uk

Date of inspection visit: 11th to 12th December 2019Date of publication: 11/03/2020

1 St Christopher's Hospice Quality Report 11/03/2020

Overall summary

St Christopher’s Hospice is operated by St ChristophersHospice. It has 38 beds and provides hospice care foradults including inpatient care, outpatient clinics andcommunity services. We inspected all of these areas.

We inspected this hospice using our comprehensiveinspection methodology and carried out theunannounced inspection on 11th and 12th December2019.

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

The main service provided by this hospice is palliativecare and care of the dying.

Services we rate

Our rating of this hospice stayed the same. We rated it asOutstanding overall, because:

• Staff and volunteers proactively kept patients safefrom avoidable harm and abuse. Staff regularlycompleted thorough risk assessments to tailor care.

• Patient care was accurately recorded, and theserecords were available to staff when requiredincluding to consultants off site when on call.

• Staff and volunteers had appropriate training to carefor patients. Training needs were regularly assessed,and staff told us they were able to access learning toimprove the level of care they were able to offer.

• Services were designed to meet patients changing,and often complex, needs.

• Staff cared for patients with compassion and treatedthem with dignity and respect. Staff saw each patientas an individual and involved them in decisionsabout their care goals.

• The hospice had a range of bereavement support toallow relatives and carers to access the support theyneeded.

• The hospice actively reached out to groups that werehard to reach, to enable them to use their services.

• There were clear processes for recording andresponding to complaint and concerns, these hadbeen strengthened in the past year.

• Leaders had the skills and abilities to run the hospiceand were passionate about the care they delivered.They were aware of the potential risks facing theservice and planned to minimise these risks.

• Staff were engaged with the service and told us therewas an open, honest and caring culture.

• The hospice actively involved patients and staff indecisions about changes to services.

• The hospice had a clear vision of what it wanted toachieve and a strategy to make this happen.

However, we also found the following issues that theservice provider needs to improve:

• The infection control policy, after death, was not fullybeing adhered to, therefore potentially putting staffat risk.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Hospiceservices foradults

Outstanding –

St Christopher’s Hospice provides care for patients inBromley, Southwark, Lewisham and Lambeth andCroydon. It has a main inpatient and outpatient basein Sydenham, with some staff working from theBromley site. The service also has a large communitybranch to provide specialist care in the community.We rated the hospice as outstanding overall as it wasgood for safe, and caring and outstanding foreffective, responsive and well led.

Summary of findings


Contents

PageSummary of this inspectionBackground to St Christopher's Hospice 6

Our inspection team 6

Information about St Christopher's Hospice 6

The five questions we ask about services and what we found 8

Detailed findings from this inspectionOverview of ratings 10

Outstanding practice 39

Areas for improvement 39

Action we have told the provider to take 40

Summary of findings


St Christopher's Hospice

Services we looked at:Hospice services for adults.

StChristopher'sHospice

Outstanding –


Background to St Christopher's Hospice

St Christopher’s Hospice is operated by St ChristophersHospice. The hospice opened in 1967 and is based inSydenham. The hospice primarily serves thecommunities of South London and covers the areas ofSouthwark, Lewisham, Lambeth, Croydon and Bromley.

The hospice cares for people in their own homes, ran anoutpatient service and an inpatient unit, based inSydenham. It also ran a frailty service and a palliativeheart failure service in conjunction with Bromley ClinicalCommissioning Group. The hospice also providedservices designed to support families and carersincluding bereavement support, welfare advice andsupport groups for children or young adults.

The hospice has had a registered manager in post sinceNovember 2018. A registered manager is a person whohas registered with the Care Quality Commission tomanage the service. They have legal responsibility formeeting the requirements set out in the Health andSocial Care Act 2008.

The hospice was last inspected in 2015, by our adultsocial care team, and was rated outstanding overall. Weinspected the hospice on 11 and 12 December 2019, ourinspection was unannounced.

Our inspection team

The team that inspected the hospice comprised a CQClead inspector, one other CQC inspector, one CQC

assistant inspector and two specialist advisors withexpertise in end of life care. The inspection team wasoverseen by Carolyn Jenkinson, Head of HospitalInspection.

Information about St Christopher's Hospice

The hospice has three wards and is registered to providethe following regulated activities:

• Treatment of disease, disorder or injury

• Diagnostic and screening procedures

• Transport services, triage and medical adviceprovided remotely

• Personal care

During the inspection, we visited Rugby ward, Alex wardand City ward, the outpatient service, visited the staffworking from Bromley and attended two home visits withthe community team. We spoke with 30 staff includingregistered nurses, health care assistants, allied healthcare professionals, medical staff, orderlies, stewards,administration staff and senior managers. We spoke with12 patients and relatives and volunteers. During our

inspection, we reviewed five sets of electronic patientrecords. We also reviewed information the hospice sentus prior to inspection and data requested after theinspection.

Activity

In the reporting period September 2018 to August 2019the hospice cared for 4,480 patients.

The accountable officer for controlled drugs (CDs) was aconsultant nurse, who was a non-medical prescriber.

Track record on safety

• No never events

• One serious injury

• No incidences of hospital acquiredMeticillin-resistant Staphylococcus aureus (MRSA),

Summaryofthisinspection

Summary of this inspection


• No incidences of hospital acquiredMeticillin-sensitive staphylococcus aureus (MSSA)

• No incidences of hospital acquired Clostridiumdifficile (c.diff)

• No incidences of hospital acquired E-Coli

• 28 complaints, of which nine were upheld. Thehospice also received 477 compliments.

Services provided at the hospice under service levelagreement:

• Speech and language therapy support.

• Pharmacy




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Our rating of safe stayed the same. We rated it as Good because:

• Staff we spoke with understood how to protect patients fromabuse. There were systems in place for managing safeguardingreferrals and these were managed by the safeguarding lead, inline with current best practice.

• Risk assessments were completed and updated at appropriateintervals.

• There were enough staff, who were suitably qualified andexperienced to ensure patients received appropriate care andtreatment.

• The service managed patient safety incidents well. Staffrecognised and reported incidents and near misses.

However, we also found the following issues that the serviceprovider needs to improve:

• The hospice needed to ensure all staff were adhering to thecare after death policy with regards to infection preventioncontrol to ensure staff members were kept safe.

Good –––

Are services effective?Our rating of effective stayed the same. We rated it as Outstandingbecause:

• The hospice provided care and treatment based on nationalguidance and evidence-based practice.

• Staff monitored patients regularly and delivered pain relief in atimely way, when required.

• Patient outcomes were monitored and interrogated at qualityand governance meetings to ensure the hospice was providingappropriate care and treatment.

• The hospice made sure staff were competent for their roles,providing both internal and external training to facilitate this.

Outstanding –

Are services caring?Our rating of caring stayed the same. We rated it as Good because:

• Staff always communicated with patients about their care andtreatment in a way they could understand. Staff involvedpatients and those close to them in decisions about their careand treatment.

Good –––




• Staff understood the importance of providing emotionalsupport to patients and those close to them and were willing togo ‘the extra mile’ in order to meet their needs.

• Staff truly cared for patients with compassion. Feedback fromall patients and those close to them confirmed that staff treatedthem well and with kindness.

Are services responsive?Our rating of responsive improved. We rated it as Outstandingbecause:

• The hospice planned services to meet the needs of thecommunities it served. It was proactive in reaching out to hardto reach groups and tailored care to their needs.

• The hospice was inclusive and took account of patient’sindividual needs and preferences. Staff made adjustments tohelp patients access services and coordinated care with otherservices and providers.

• People could access the hospice when they needed it andreceived the right care promptly, the hospice risk assessedreferrals to allow emergency admissions to be prioritised.

• The hospice ensured patients knew how to make complaints orraise concerns about the care they received.

Outstanding –

Are services well-led?Our rating of well-led stayed the same. We rated it as Outstandingbecause:

• Leaders had the skills and abilities to run the hospice. Theyunderstood and managed the priorities and issues the hospicefaced.

• The hospice had a vision for what it wanted to achieve and astrategy to turn it into action. The vision and strategy werefocussed on the sustainability of services.

• Staff felt respected, supported and valued. They were focussedon the needs of patients receiving care. The hospice had anopen culture where patients, their families and staff could raiseconcerns without fear.

• Leaders and teams identified and escalated relevant risks andissues and identified actions to reduce their impact.

• Leaders and staff actively and openly engaged with patients,staff and the wider community to plan and manage services.They also collaborated with partner organisations to helpimprove services.

Outstanding –




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Hospice services foradults Good Good

Overall Good Good

Detailed findings from this inspection


Safe Good –––

Effective Outstanding –

Caring Good –––

Responsive Outstanding –

Well-led Outstanding –

Are hospice services for adults safe?

Good –––

Our rating of safe stayed the same. We rated it as good.

Mandatory training

• The hospice provided mandatory training in keyskills to all staff and made sure everyonecompleted it.

• Staff received and kept up-to-date with theirmandatory training. Staff we spoke with were up todate with all their mandatory training. They told usthere were processes in place to remind them whenthey were due to undertake training, and this was inthe form of an email. The email was sent a few monthsbefore training was due to lapse which gave staff timeto book onto the necessary course. Staff told us theywere given time to undertake training once in post andall new staff were enrolled on the corporate inductionwhich covered most mandatory training topics as wellas an introduction to the hospice.

• We were told by the volunteer leads that, wherenecessary, volunteers also attended mandatorytraining and updates. For example, volunteerssupporting the inpatient unit undertook safeguardingtraining and some would undertake communicationtraining, if applicable.

• The mandatory training was comprehensive and metthe needs of patients and staff. Staff told us they feltthe mandatory training was appropriate and enabled

them to do their jobs safely. Mandatory training topicsfor clinical staff included safeguarding, MentalCapacity Act, Deprivation of Liberty Safeguards,manual handling and infection control.

• Managers monitored mandatory training and alertedstaff when they needed to update their training. Wewere told there was a database of staff mandatorytraining numbers and this was used to email staffwhen they were due to undertake training. Althoughmanagers would have oversight of their staff’s trainingit was the staff members responsibility to get thetraining arranged. This was a topic of conversation atannual appraisals.

• The hospice’s induction programme wascomprehensive and prior to staff being employed bythe hospice IT access and email accounts were set up.This enabled staff to access e-learning from thebeginning of their employment.

Safeguarding

• Staff understood how to protect patients fromabuse and the hospice worked well with otheragencies to do so. Staff had training on how torecognise and report abuse, they knew how toapply it and could provide examples of when theyhad applied it.

• Staff received training specific for their role on how torecognise and report abuse. Staff told us they receivedand were up to date with their safeguarding trainingand that they found it informative. We were told that92% of staff requiring adult safeguarding level onetraining were up to date and 89% of staff requiringlevel two training were up to date. Staff told us that

Hospiceservicesforadults

Hospice services for adults

Outstanding –


alongside the training, if they were concerned aboutanything they could refer to the safeguarding policy onthe intranet and felt they could always approach thesafeguarding lead for support.

• Staff knew how to identify adults and children at riskof, or suffering, significant harm and worked with otheragencies to protect them. Staff could give examples ofsetting up best interest meetings to discuss patientsand their relatives needs with other agencies. Bestinterest meetings were aimed at making decisions forpeople who lack the capacity to do so any more andoften involve other agencies to ensure care is cohesivebetween agencies.

• Staff knew how to make a safeguarding referral andwho to inform if they had concerns. Staff could explainthe safeguarding referral process and give examples ofwhen they had needed to make referrals. We were tolda large proportion of safeguarding referrals wereconcerning care of dependents following abereavement. The hospice made these referrals beforethe patient died to ensure their wishes could beincluded in the ongoing care plans for dependents.

• Clinical staff told us safeguarding referrals couldsometimes be complex, particularly when the patientlived in one local authority, but ongoing care needswere identified to be needed in another localauthority. The safeguarding lead confirmed that thiswas the type of case they would support and guidestaff through.

• Although the hospice was for the care of adults, staffand volunteers undertook child safeguarding trainingto enable them to notice if a child was at risk and to beable to act upon this information in an appropriatemanner. We were told that 100% of staff needed itwere up to date with their safeguarding children levelthree training.

Cleanliness, infection control and hygiene

• Staff used equipment and control measures toprotect patients, themselves and others frominfection. They kept equipment and the premisesvisibly clean. Staff used infection controlmeasures when visiting patients on wards.

• Ward areas were clean and had suitable furnishingswhich well-maintained. We observed cleaning rotaswere completed and signed by staff and theenvironment was visibly clean with no dust settled onsurfaces.

• There was a rolling replacement and repairprogramme for recliner chairs on the ward to ensurethey remained intact and able to be effectivelycleaned when required.

• The hospice also conducted monthly mattress auditsto assess the appropriateness of the mattresses in useand to highlight if any required disposal ordecontamination. This was in addition to clinical staffvisually checking at linen changes. The hospice had anoutsourced contract with a cleaning company todecontaminate any mattresses that required thoroughdecontamination.

• Clinical staff told us they were supported to keep theenvironment clean by a team of orderlies. There weretwo orderlies per ward and two assigned to theground floor communal areas each day. In theevening, when there were fewer visitors to the hospice,there was one orderly assigned to each ward and theground floor. This enabled thorough cleaning of theenvironment and flexibility if deep cleans wererequired if infection control risks were highlighted.

• Staff followed infection prevention and control (IPC)principles including the use of personal protectiveequipment (PPE). We observed all clinical stafffollowed bare below the elbow principles andappropriately cleaned their hands before and afterpatient contact. We also observed appropriate use ofPPE when required.

• The adherence to IPC principles was proven to beeffective as the hospice had no incidents of colostrumdifficile (C Diff), MRSA or vomiting or diarrhoeaoutbreaks in the year leading up to the inspection.

• One steward told us they were not routinely informedof potentially infection risks when they transferreddeceased patients to the mortuary. We raised this withhospice managers while on inspection and were toldthat processes would be reviewed. Since inspectionwe have been sent the hospice’s ‘care after deathpolicy’ and the paperwork to be completedmentioned in the policy. This documentation clearly



Outstanding –


outlines the procedures to follow if a patient’s bodycould pose an infection risk. The hospice has clarifiedthey will reiterate and, where necessary, retrain staff inthis policy to ensure safe procedures are followed.

• Staff cleaned equipment after patient contact andlabelled equipment to show when it was last cleaned.We saw thorough use of “I am clean” labels on thewards and throughout the wider hospiceenvironment. The “I am clean” labels were all datedand signed to enable staff to identify when theequipment had last been cleaned and if it requiredanother clean before use.

• The hospice generally performed well for cleanliness.The hospice produced an annual infection preventionreport, in addition to the more frequent hand hygieneaudits. The annual infection prevention reportcollated all the smaller audits and looked for themesand areas that required improvements over thecoming year. The infection control audit, carried outby a matron of a nearby trust, found the hospice to be100% complaint with standards set by the departmentof health and was scored using the infection controlnurse’s association audit for monitoring infectioncontrol standards.

• The hospice was peer reviewed for compliance withIPC guidelines by an infection prevention and controlmatron from a nearby trust in March 2019 and all areasincluding the mortuary was found to be fullycompliant.

• All clinical areas had hand washing facilities and therewas access to hand sanitiser throughout the hospice.In all clinical areas we checked there were disposablesanitising wipes available to ensure surfaces could becleaned.

• The hospice completed regular water testing forlegionella and bacteriological infections andprioritised high-risk areas to have more regularinspections. There was a policy in place to action anypositive results that may occur, this policy includednotifying external agencies.

Environment and equipment

• The design, maintenance and use of facilities,premises and equipment kept people safe. Staffwere trained to use them. Staff managed clinicalwaste well.

• The design of the environment followed nationalguidance. The environment followed nationalguidance, with flooring that was easily cleaned,handwashing sinks in clinical areas and single roomsall had private bathroom facilities. All corridors werewide enough to fit a bed and wheel chair down andfollowed fire safety recommendations. We noted allfire doors were closed, where not on automaticclosure mechanisms.

• In the wider hospice environment we found all patienttoilets had pull cords, which reached to the ground incase a patient fell.

• We found one consultation room in the outpatientenvironment that did not have a call bell in, this wasknown to the hospice and the risk was mitigated as wewere told patients would not be left alone in the room.

• The hospice was set over four floors and there wereaccessible lifts, which were regularly serviced. Inaddition to the patient lifts there was a staff lift whichwas situated near the mortuary. This lift could beoverridden to bypass other staff calls to allow patientsto be transferred from the wards to the mortuary in adignified manner. The lift override process wasincluded in the hospice ‘care after death’ policy.

• The mortuary followed national guidance and wasvisibly clean. There was lifting equipment whichenabled stewards to safely move deceased patientsinto fridges or into viewing rooms. There was space for18 patients, with capacity to take bariatric patients.

• The hospice design had taken into patient’s individualneeds into account. For example, the garden hadpathways that were paved and wide enough forpatient beds to be taken outside. This was to allowbed bound patients to experience the gardens if theywished. They also had complementary therapy roomsset up for massages and a hair dressing salon on sitefor patients to use.

• The hospice had suitable facilities to meet the needsof patients’ families. Each ward had dedicated spacefor families to sit separate to patients should they



Outstanding –


need space. These spaces had computers and gamesto play if families were on site for an extended periodand could also function as an area to have privatediscussions

• The hospice had enough suitable equipment to helpthem to safely care for patients.

• Staff told us they had not experienced not being ableto access equipment they needed. The hospice kept alog of all equipment and medical devices and had acontract with an external company to loan equipmentwhen repairs were required. We were told that whenmedical devices faulted the hospice reported thesefaults to the Medicines and Healthcare productsRegulatory Agency (MHRA).

• Staff disposed of clinical waste safely. We observed allclinical waste to be disposed of safely and inappropriate bins. These were routinely changed byorderlies and taken to the bin store for collection. Inthe community setting nurses took sharps bins outwith them to allow for safe disposal of equipment ifneeded.

• The head of facilities confirmed the hospice had acomputerised maintenance system to log all jobswhich required action and to plan routine servicingand maintenance. The head of facilities confirmed thehospice had backup generators that were regularlytested and serviced by an external contractor. Theyalso confirmed the hospice carried out regular fire riskassessments with an external agency to ensureunbiased assessments were completed. While oninspection we saw additional signage being added tofire doors following one of these assessments.Following the inspection we were sent a copy of one ofthe surveys and the associated action plan.

Assessing and responding to patient risk

• Staff completed and updated risk assessments foreach patient and removed or minimised risks.Risk assessments considered patients who weredeteriorating and in the last days or hours of theirlife.

• Staff completed risk assessments for each patient onadmission and updated them when necessary andused recognised tools. These risk assessmentsincluded falls risk, skin and wound assessments and

moving and handling needs, nutrition, swallow andpain assessments. Some of these were completed byspecialist allied health professionals for example theswallow assessment was completed by a speech andlanguage therapist. All risk assessments were kept aspart of the patient’s electronic record and wereupdated as required.

• All patients, including outpatients and communitypatients, were assessed for their suitability to receivecardiopulmonary resuscitation (CPR). We observed athorough discussion with a new patient to the hospiceabout their decision to receive CPR or not. Weobserved that patients who were assessed to be toounwell to receive CPR had ‘do not attempt CPR’ formsin their care records. This was mirrored in theco-ordinate my care system so other healthcareproviders were able to access the form.

• Staff knew about and dealt with any specific riskissues. At ward rounds, staff demonstrated clearknowledge of patients’ care needs and any specificrisks facing them. If a patient was refusing an elementof care which was likely to increase a risk to them,such as turning to reduce the risk of pressure sores,this was discussed along with the steps the staff hadtaken to encourage the patient to allow care andwhether the patient had the capacity to make thesedecisions.

• Staff also discussed how to minimise any risks facingpatients, such as physiotherapy and occupationaltherapy input to help mobilise patients safely anddietician and speech and language support to enablesafe feeding on a suitable diet. These additional needswere logged and added to the patient record.

• At the community multidisciplinary meeting we heardrisks being discussed before staff went out to people’shomes or to care homes. This meant plans to mitigatethese risks were discussed prior to staff going out andthe staff member was aware of any concerns beforeentering the patient’s home.

• Staff shared key information to keep patients safewhen handing over their care to others. When patientswere discharged from the inpatient unit we sawthorough discharge plans which were shared, with the



Outstanding –


patient’s permission, with other care agencies such asa care home or the patient’s GP or district nurse. Thisallowed connected care and for gaps in care providedto be kept to a minimum.

• Within the hospice there was communication betweenthe inpatient unit and community teams when apatient was discharged home. This meant thecommunity team were aware they would need to addthe patient back onto their case load for review.

• Shift changes and handovers included all necessarykey information to keep patients safe. We observed ashift handover and noted all of the patient’s medical,social and psychological conditions were handed overensuring a holistic approach to care. Staff did not onlydiscuss the patients’ physical health but also theirsocial and psychological needs as well. There was alsodiscussion about family support at these handovers,considering all elements that would be important to apatient.

Clinical staffing

• The hospice had enough staff with the rightqualifications, skills, training and experience tokeep patients safe from avoidable harm and toprovide the right care and treatment. Managersregularly reviewed and adjusted staffing levelsand skill mix, and gave bank, agency and locumstaff a full induction.

• The hospice had enough nursing staff and supportstaff to keep patients safe. We were told the modelwas to have 60:40 split on each shift in the inpatientsetting between registered nurses and health careassistants. The planned number of nurses on eachshift was 3 in the day and 2 on each ward overnight. Inaddition to this there was a supernumerary nurse andhealth care assistant based at the inpatient unitovernight. The extra members of staff on the nightshift were allocated to undertake any emergencycommunity visits that were identified by the nightco-ordinator, this meant wards were not left shortstaffed overnight if a community visit was needed.Nursing staff told us they felt staffing levels wereappropriate, and they had time to delivercompassionate care.

• Community staff told us their staffing levels allowedfor manageable caseloads, and this was set toimprove when the recently recruited members of staffjoined the team. Caseloads were not set by thenumber of patients a staff member was seeing but byhow complex their needs were and how frequentlythey needed contact with the hospice. The hospicehad an assessment system for monitoring patient’sneeds and grading them to decide the frequency ofvisits.

• Managers accurately calculated and reviewed thenumber and grade of nurses, nursing assistants andhealthcare assistants needed for each shift. We weretold the current nurse staffing levels on the inpatientunit were calculated approximately three years agowhen the hospice did observational studies to workout where nurses and healthcare assistants spent theirtime and then they compared these with otherhospices. This was fed into a workforce planning tooland was monitored by the senior nursing team. Wewere told the team are looking to repeat the cycle ofobservational studies and benchmarking again nextyear (2020) to prove to themselves they are stillworking safely.

• The ward manager could adjust staffing levels dailyaccording to the needs of patients. The overall nursingteam was flexible and could be moved between wardsdepending on the needs of patients and thecomplexity of cases. We were told if one ward hadseveral complex patients and another ward had moresimple cases the senior nursing staff would be movedfor increased oversight of the complex cases and morejunior members of the team would be assigned to thesimpler cases. This meant there was flexibility in thesystem to enable staff to care for patients.

• The hospice had low turnover and vacancy rates. Thecommunity team was due to be fully staffed inmid-December, with new members of staff joining theteam. The inpatient unit was nearly fully staffed at thetime of inspection, with three nurse posts outstanding.

• The hospice had low sickness rates. The nursing andallied health professional sickness rate was low at4.1%, with health care assistants slightly higher at 5%.

• The hospice had low usage of bank or agency staff andpreferentially used bank staff as they knew the hospice



Outstanding –


already. We were told some of the nurses on thehospice’s bank were retired nurses who had workedfor them previously. Agency usage was done sparinglywhen needed clinically.

• The number of allied health professionals wascalculated to enable specialist support when neededon the wards. We were told by members of the alliedhealth professional team that their workload wasmanageable, and they were able to have input intopatient case management to enable them to be caredfor safely.

• The hospice had developed a document to identifydifferent categories of volunteers and within that toidentify appropriate checks, for example DBS, andtraining requirements. Volunteers were invited, andrequired, to attend applicable parts of the staffcorporate induction to ensure that, where necessary,they received the same training as staff.

Medical staffing

• The hospice had enough medical staff with theright qualifications, skills, training andexperience to keep patients safe from avoidableharm and to provide the right care andtreatment. Managers regularly reviewed andadjusted staffing levels and skill mix and gavelocum staff a full induction.

• The hospice had low turnover and vacancy rates formedical staff. The hospice employed five consultantsand consultant turnover was low and there were novacancies. There was a higher rate of turnover formore junior members of the medical team, this wasexplained as junior doctors rotated more frequently inorder to gain experience in more areas of clinicalpractice.

• Sickness rates for medical staff were low. Sicknessrates in the reporting period of June to August 2019were very low at 0.2%.

• The hospice had a good skill mix of medical staff oneach shift and reviewed this regularly. There wasmedical cover seven days a week and the inpatientunit had a specialist registrar assigned to each ward.Consultants were not assigned to specific wards in the

inpatient setting but were available to cover andsupport more complex cases, these were discussedand decided at the morning ward rounds, or if apatient’s condition changed in the day.

• The hospice had a review of consultant roles plannedto take place in 2020 to ensure they were being used inan effective way.

• Patients were not always under the care of a specificconsultant, however consultants were involved in thedaily ward rounds and so had oversight of all patientson the inpatient unit and were contacted if a patient’sneeds increased in complexity and more senor inputwas needed. This was formally done through theelectronic record, there was a section for “consultantinput required” where the needs could be explained.

• The hospice had access to locum staff when required.These locum doctors were known to the hospice andwere often trainee GPs from the local area who hadlinks with the hospice. This flexibility meant thehospice was able to maintain a safe level of medicalcover.

• The hospice always had a consultant on call duringevenings and weekends. We were told there wasalways a consultant on call to provide support for staffshould they need it. These consultants had remoteaccess to the electronic patient records so couldaccess all the pertinent information about thepatient’s condition. The on-call consultant would alsomake community visits overnight if there wereparticularly complex patients and the nurses neededsupport, we were told this was not often needed asthe nursing staff and junior doctors were equipped tomanage most situations but that they knew it was anoption. Staff we spoke to confirmed this and said theywould contact the consultant if they felt it wasnecessary.

Records

• Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date, storedsecurely and easily available to all staff providingcare.

• Patient notes were comprehensive, and all staff couldaccess them easily. All patient records, apart from drugcharts for inpatients, were electronic. This meant staff



Outstanding –


could access patients notes from anywhere on site,and certain staff such as consultants had secureaccess at home to enable them to give advice while oncall.

• Patients had the option to complete a ‘One PageProfile’ to inform staff about what was important tothem and how to best support them. This wascompleted by the patient or relative and was copiedinto the patient’s electronic record. It enabled staff topersonalise their approach to each patient.

• When patients transferred to a new team, there wereno delays in staff accessing their records. As all recordswere electronic and they were instantly available toteams within the hospice. When patients weredischarged from the inpatient unit information wasput in records to alert the community team of thedischarge, so they were aware they would need tostart up support for the patient again.

• In addition to the full patient record being electronicthe hospice, with patient consent, created a‘co-ordinate my care’ record that was available forother healthcare providers. This was a reduced versionof the full patient record and held details of thepatient’s physical condition and symptoms and anyadvanced care plans, do not attemptcardiopulmonary resuscitation forms or patientpreferences. ‘Co-ordinate my care’ records wereavailable to primary medical care providers such asGPs and district nurses and the aim was to reduce theamount of times a patient had to repeat their careneeds.

• Medicine chart records were stored securely. Thesewere kept in the nurse’s station on each ward, this wasalways manned by staff and was therefore secure.

Medicines

• The hospice used systems and processes to safelyprescribe, administer, record and storemedicines.

• Staff followed systems and processes when safelyprescribing, administering, recording and storingmedicines.

• The pharmacy management had been taken over inAugust 2019 by an acute NHS hospital trust. As part ofthis process the pharmacy managers were in theprocess of reviewing and strengthening themedication and prescribing policies and procedures.

• The pharmacy technician attended multidisciplinarymeetings to allow them to pick up on potential issuesbefore prescriptions were submitted for filling out.This meant patients with complex needs, who were onmany medicines, were routinely discussed with thepharmacist to enable safe prescribing.

• There was a hospice wide prescribers meeting whichwas attended by medical and non-medical prescribersto allow for open conversation about concerns or anychanges to practice. We were told that previouslythere were two meetings, one for medical staff andone for non-medical prescribers. This was deemed tobe a less effective use of time and as such themeetings were merged to allow a full discussion to beheld.

• Staff reviewed patients' medicines regularly andprovided specific advice to patients and carers abouttheir medicines.

• Patients and relatives we spoke with told us theyunderstood how to safely take the medication theywere prescribed and knew why they were taking it.

• We observed nurses in the community reviewing andaltering a patient’s medication as their needs hadchanged. The reasons for this change were thenexplained to the patient and their relatives and theywere told how and when to take the medication forthe greatest effect.

• We saw evidence, in care records of inpatients, ofmedicines being started, reviewed and stopped if theywere not effective.

• Staff stored and managed medicines and prescribingdocuments in line with the provider’s policy. Medicineswere locked in the pharmacy store on site. Andtemperature sensitive medicines were stored in afridge and the temperature was regularly monitoredand recorded. Within the pharmacy store there was aseparate, secured controlled drugs cupboard.Controlled drugs are drugs that have the potential toalter behaviour or be abused and therefore extra



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security is needed. St Christopher’s hospice had anallocated controlled drugs accountable officer, one oftheir consultant nurses, who was ultimatelyresponsible the safe storage and prescribing of thesedrugs.

• The pharmacy store was randomly spot checked forout of date medicines and we found that they werestored appropriately. There were medicines availablefor use in an emergency and these were regularlychecked.

• The hospice used syringe drivers to delivermedication, when required, and nurses receivedtraining on their induction to train them to use thehospice’s syringe drivers. Syringe drivers were markedas sterile when cleaned and were regularly reviewedthroughout shift. Medication doses were discussed ateach ward round.

• The hospice had systems to ensure staff knew aboutsafety alerts and incidents, so patients received theirmedicines safely. There were mechanisms in place toensure safety alerts about medicines were effectivelyacted upon. The pharmacy technician at the hospiceexplained processes to quarantine and send themedicines back to the acute hospital that managedthe pharmacy store. The technician explained that thiswas a proactive process and even if the hospice didnot stock the medicines they had to confirm they hadnone on site. This removed the risk that somebodymight wrongly assume they did not stock amedication and miss a safety alert.

• Decision making processes were in place to ensurepeople’s behaviour was not controlled by excessiveand inappropriate use of medicines. We observed amultidisciplinary meeting for community staff where itwas discussed if prescriptions for pain relief wereappropriate as a slight increase in the amount of painrelief being prescribed had been noticed. As part ofthis meeting the team also discussed each patient’scurrent pain medication and reviewed whether it wasstill appropriate or, if the patient needs had changedand therefore the medication was changed.

Incidents

• The hospice managed patient safety incidentswell. Staff recognised incidents and near missesand reported them appropriately. Managers

investigated incidents and shared lessons learnedwith the whole team and the wider service. Whenthings went wrong, staff apologised and gavepatients honest information and suitablesupport. Managers ensured that actions frompatient safety alerts were implemented andmonitored.

• Staff knew what incidents and near misses to reportand how to report them. Staff were clear about theirduties when it came to reporting incidents and wereable to report them using the intranet system. Thenew reporting system had been brought in as staff feltthe old system was not user friendly. The new systemwas available for all staff to report on and wasaccessible from the intranet home page.

• Staff reported serious incidents clearly and in line withhospice policy. Staff reported one serious incident, achoking incident, in the reporting period of September2018 to August 2019. This had been reported in linewith hospice policy and was reported to CQC prior tothe inspection. The incident had been thoroughlyinvestigated and changes were made to policies andprocedures because of learning from the incident.While on inspection staff we spoke with were told usabout the changes to protocols and that they wereable to contact the dysphagia team should they haveany concerns regarding a patients ability to swallowsafely.

• The hospice had no never events on any wards or inthe community care setting.

• Staff understood the duty of candour. They were openand transparent and gave patients and families a fullexplanation if and when things went wrong. Staff wereable to explain their responsibilities to be open andhonest with patients and relatives under duty ofcandour. In addition to this they told us where to findthe hospice “being open; a duty of candour” policy.

• Managers debriefed and supported staff after anyserious incident. The documentation we wereprovided with following the serious incidentdemonstrated that staff involved had been debriefedand offered ongoing support following the incident.Staff we spoke with while on site knew about theincident and were aware of the changes to policiesthat had been made.



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• Managers investigated incidents thoroughly. Managersand staff carefully discussed and unpicked incidentsconsidering factors that had played into them andways to mitigate this in the future. For seriousincidents timelines leading up to and following theincident were created to highlight step by step whathad been done and how, if possible, this could beimproved.

• Staff received feedback from investigation ofincidents. Staff were able to detail changes to policiesand procedures that had been made because ofincident reporting and investigation. Staff were offeredthe chance to debrief with ward managers if they hadto deal with a difficult situation on the ward.

• Staff met to discuss the feedback and look atimprovements to patient care. Ward managers andassistant ward managers met to discuss anychallenging situations they had come across on theirwards and to discuss how they could be managedbetter in the future. This was then shared with clinicalstaff working on the wards.

Are hospice services for adults effective?(for example, treatment is effective)

Outstanding –

Our rating of effective stayed the same. We rated it asOutstanding.

Evidence-based care and treatment

• The hospice provided care and treatment basedon national guidance and best practice. Managerschecked to make sure staff followed guidance.Staff protected the rights of patients subject tothe Mental Health Act 1983.

• Staff followed up-to-date policies to plan and deliverhigh quality care according to best practice andnational guidance.

• The medical director worked with a number ofgovernment and national working parties to supportdevelopment of national guidelines published by the

Royal College of Physicians and the Association forPalliative Medicine. They also supported governmentenquiries and worked as an expert advisor for legalcases.

• We saw anticipatory medicines for pain management,breathlessness, nausea, distress and agitation wereprescribed. These were given in line with the NationalInstitute of Health and Care Excellence (NICE)guidelines for care of the dying adult in the last days oflife and palliative care for adults. The hospice auditedthe use of these anticipatory medicines to ensurepatients were benefitting from them.

• The hospice used a carers’ support needs assessmenttool to ensure carers needs were also considered andattended to. Following a bereavement, the hospiceran multiple bereavement support groups whichtargeted different demographics to ensure relativesand carers were supported through the bereavementprocess.

• The hospice used recognised measures to quantifiablyidentify whether patient goals and outcomes werebeing met and potentially improving. The hospiceused Integrated Palliative Outcome Score (IPOS) whichwas a tool to identify patient priorities of care andchanges in patient symptoms. The IPOS tool wasdesigned to create a standardised set of outcomemeasures for use in palliative care and was focussedon promoting a holistic and patient-centred approach.

• The hospice used the Karnofsky Performance StatusScale to standardise its measure of patient’s status.The Karnofsky scale is a standardised tool used tomeasure the ability of a patient to perform day to daytasks. All staff were knowledgeable about the differentpoints on the scale and we saw posters in the nurses’station on each ward as a reminder of what they were.

• Staff protected the rights of patients subject to theMental Health Act and followed the Code of Practice.All staff we spoke with had a good understanding ofthe Mental Health Act and could explain how they tookto ensure patient’s rights were protected.

• At handover meetings, staff routinely referred to thepsychological and emotional needs of patients, theirrelatives and carers. We observed patients, relativesand carers holistic needs being thoroughly discussedat ward rounds. Staff discussed potential social worker



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involvement and began planning for postbereavement care. Emphasis was also placed on thespiritual wellbeing of patients and the hospicearranged for religious leaders to attend the hospice if itwas a patient’s wish to have this happen.

Nutrition and hydration

• Staff gave patients enough food and drink tomeet their needs and improve their health. Theyused special feeding and hydration techniqueswhen necessary. The hospice made adjustmentsfor patients’ religious, cultural and other needs.

• Food and drink were available for patients throughoutthe day in the in-patient unit, although there were setmeal times for full meals. Patient’s relatives werepermitted to bring in food from home and there werefacilities on each ward for them to heat this up, ifneeded.

• Specialist support from staff such as dieticians andspeech and language therapists was available forpatients who needed it. The inpatient hospice haddieticians and there was a speech and languagetherapist who was contracted to come into thehospice from a local hospital. On days the speech andlanguage therapist were not available on site toperform swallow assessments staff had a flow chart tofollow to ensure patients were being fed and hydratedsafely if they were at risk of choking. This chart wasavailable in every ward kitchen and advised ward staffon ways to keep patients safe, staff were aware ofwhere it was.

• As patient relatives were welcome to bring food anddrink from home into the inpatient unit staff explainedhow they communicated the advice of the speech andlanguage therapist and dieticians to the family toensure patients were not put at unnecessary risk ofchoking.

• The hospice had a nutrition and dysphagia championgroup which was formed of a dietician, link nurses anda speech and language therapist. Dysphagia meansdifficulty with swallowing. This group meets regularlyand regularly review the policies and proceduressurrounding nutrition and swallow assessments toensure they were appropriate and kept patients safe.

• Staff were able to routinely refer patients to dieticiansor speech and language therapists for specialist inputinto a patient’s care. Staff were aware of how to accessthese services and we saw referrals being discussed atward rounds.

• The hospice had developed a leaflet whichsummarised the answers to frequently askedquestions about ‘eating and drinking when ill’ tosupport patients and relatives.

Pain relief

• Staff assessed and monitored patients regularlyto see if they were in pain and gave pain relief in atimely way. They supported those unable tocommunicate using suitable assessment toolsand gave additional pain relief to ease pain.

• Staff assessed patients’ pain and gave pain relief inline with individual needs and best practice. Therewas an individualised approach to pain relief at thehospice that was patient driven. Some patientspreferred to live with some pain to allow them to feelless drowsy and enable communication with familyand loved ones. The hospice worked with thesepatients to balance pain relief with side effects.

• In conjunction with an NHS trust St Christopher’soffered indwelling epidural nerve blocks to controlpain in patients with complex needs and whose painwas otherwise uncontrolled. Indwelling epidural nerveblocks are a way of controlling pain by blockingnerves, however it is complex to manage and notoften seen outside of specialist hospital settings. Thehospice ensured senior nurses were trained tomanage the epidural sties. We were told although theteam from the hospital routinely attended on aWednesday, they were flexible and came to supporton other days if there was a patient who was sufferingwith uncontrolled pain and the hospice had no otheroptions for managing it.

• Staff prescribed, administered and recorded pain reliefaccurately. We reviewed drug charts and found themto be completed in full and demonstrated thatpatients received the correct medication at the righttime, unless the patient had refused it.

• The hospice told us patients were asked to keep paindiaries which were then discussed with clinicians



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enable them to best optimise pain controlprescriptions. Pain assessment tools were available onthe patient’s electronic record and included thePAINAD scale, which was a tool to support pain relief inpatients with dementia.

Patient outcomes

• Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved good outcomes forpatients.

• Outcomes for patients were positive, consistent andmet expectations, such as national standards.

• The hospice participated in Hospice UK benchmarkingfor falls, pressure ulcers and medication incidents. Wenoticed St Christopher’s had a high number ofpressure ulcers identified compared to hospices of asimilar size and were work was on-going intoidentifying why this was. The hospice was looking at anumber of factors including whether they had aparticularly frail and therefore immobile population,whether patients attended with pressure ulcers andwhether their staff were very good at noting andreporting pressure ulcers therefore the increase innumbers was reflective of good practice. Thesediscussions were not only happening at a local levelbut also with other hospices in the area to ensureconclusions were valid. The hospice was assured theywere caring for patients well and had a tissue viabilitygroup who advised on skin care.

• The hospice used the integrated palliative careoutcome score (IPOS) to assess their effectiveness forindividual patients. These scores were also looked aton a hospice wide level to ensure patients benefittedfrom inpatient care. These were scrutinised at thequarterly quality and governance meetings and wereused as indicators to ensure the changes to the modelof care was not negatively impacting on the quality ofcare and the outcomes for patients. The aim in thefuture was to use the IPOS “splattergrams” at dailyward rounds and at MDT’s to inform patient care andnext steps. The “splattergrams” were a graphicalrepresentation of the data collected from IPOSassessments.

• The hospice had also implemented the OutcomeAssessment and Complexity Collaborative (OACC)

initiative which was aimed at implementing outcomemeasures in routine palliative care. The coding toenable OACC to be successfully used was in theelectronic records therefore clinicians were confidentthe output was accurate.

• Following inspection the hospice told us they alsoparticipated in training other hospices across the UKon how to collect and report on data relating to painand symptom control management.

• The hospice had designated staff who wereresponsible for ensuring hospice policies andprocedures followed the national guidance. Allpolicies and procedures we saw were within theirreview dates.

• Managers and staff carried out a comprehensiveprogramme of repeated audits to check improvementover time. The hospice had an audit register whichincluded all the regular audits that were carried out,how frequently they needed repeating, which memberof staff was responsible for them and any outcomesidentified at the last audit. For example, theequipment store audit was owned by the medicaldevices administrator and had no outstandingactions.

• In addition to the audit register staff were empoweredto identify and propose new audits and the hospicehad audit proposal forms that were assessed by thequality team before being agreed.

• Each year there was a push to get more members ofstaff involved in the audit processes. The quality teamprovided training to a multi-professional team,including administration staff, allied healthprofessionals, doctors and nurses and asked themabout any concerns about care and to think aboutways to improve this. The 2018-2019 cohort identifiedthe change in the case management model as aconcern and transfers in care between health agenciesas a potential downfall. This was followed through andstaff looked at all elements of the discharge process toidentify necessary changes, such as how the teamscommunicated with external agencies. The changesmade are being re-audited to ensure they wereeffective.

• Managers then used information from the audits toimprove care and treatment. Audits led to changes in



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practice which were then re-audited for success.Managers shared and made sure staff understoodinformation from the audits. We were told there were anumber of mechanisms by which staff were informedof changes. These included team meetings, emailsand huddles at the end of shifts.

Competent staff

• The hospice made sure staff were competent fortheir roles. Managers appraised staff’s workperformance and held supervision meetings withthem to provide support and development.

• Staff were experienced, qualified and had the rightskills and knowledge to meet the needs of patients. Allregistered nursing staff were enrolled into afoundation course for palliative end of life care tosupplement their knowledge, this was funded by thehospice and staff were given study leave to completeit.

• Health care assistants were given significant trainingon induction which resulted in them gaining a carecertificate. They were also given the opportunity toenrol on professionally recognised palliative carecertificate courses at level two and three.

• Medical staff could be part of a weekly journal club topromote ongoing learning and discussion and wereable to enrol on external courses if their developmentplan identified an area of interest that could bedeveloped. The assistant medical director was thelead for medical education and co-ordinated thislearning.

• Staff were given training that was relevant for their roleand they had competency checks to complete. Forexample, nurses on the ward were trained andassessed for their competence in how to use thesyringe drivers that were used by the hospice and inindwelling epidural care.

• Managers gave all new staff a full induction tailored totheir role before they started work. There was aninduction for new staff and this was monitored by theirline managers. Line managers were supported by thehuman resources team. The induction period was 12months and staff had formal reviews at months one,three, six and were signed off at month 12, there wasthe possibility for an extra meeting to be added at

month nine if staff needed extra support.Managerswere given a checklist of all areas staff needed to havemet to be signed off. This checklist meant allinductions were run equally and all staff were trainedin the same things to the same level.

• Managers supported staff to develop through yearly,constructive appraisals of their work. Most staff hadreceived an appraisal in the reporting period, 80% ofdoctors had, 75% of nurses or allied healthprofessionals had and 82% of health care assistantshad.

• Staff told us they found their appraisals useful as theyhad ongoing informal conversations throughout theyear with managers about their progress. Theconversations were also an opportunity to identifynew learning although they were not recorded. Thisprovided us assurances that staff were able tocontinually raise concerns and did not have to waituntil a formal review to do so.

• Staff had the opportunity to discuss training needswith their line manager and were supported todevelop their skills and knowledge. Staff we spokewith told us they had ongoing discussions with theirline managers about their training needs and did notfeel they had to wait for formal appraisals to requestfurther training. One health care assistant we spokewith told us they worked closely with their linemanager and therefore discussions around trainingand development were frequent and they felt wellsupported. We were also told by other members ofstaff that they were proactively contacted abouttraining opportunities and that they felt the hospicevalued its staff and supported development.

• Managers made sure staff received any specialisttraining for their role. We were told about specifictraining given to the senior nurses who took on therole of night co-ordinator for the single point ofcontact line to support decision making for patientswith palliative heart failure needs. This was deliveredby the palliative heart failure team lead.

• Managers identified poor staff performance promptlyand supported staff to improve. The hospice had aperformance management framework that was usedby managers to support staff who were struggled tomeet their goals. This performance management was



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supported by the human resources team and wasguided by the organisational values and increased thenumber of formal conversations that were requiredbetween staff.

• Managers recruited, trained and supported volunteersto support patients in the hospice. There was a teamwho managed the recruitment, training and supportof volunteers in the hospice. The team supported alarge number of volunteers, approximately 1,350, andkept databases to ensure they held the correct trainingfor each role.

• The volunteer team told us the process for recruitingvolunteers was varied. Some people approached theteam to offer their help, some were relatives of formerpatients and some were recruited at a ‘taster day’where people were invited to come and discuss howtheir skills might help support the hospice. Once apotential volunteer had been identified they wereinvited for an interview to ensure they wereappropriate and understood the role they wereapplying for and following this, pending checks, wereoffered a volunteer role.

Multidisciplinary working

• Doctors, nurses and other healthcareprofessionals worked together as a team tobenefit patients. They supported each other toprovide good care.

• Staff held regular and effective multidisciplinarymeetings to discuss patients and improve their care.We observed three multidisciplinary meetings, one foroutpatients, one for community care and one todiscuss a patient’s potential admission. These wereboth well attended by relevant doctors, clinical nursespecialists, allied health professionals, social workersand other professionals involved in the patients care.We observed that staff not only discussed the patient’sillness but also their personal goals and their holisticsocial and mental wellbeing. Patient cases werepresented by the professional who had the closestrelationship with the patient and options for ongoingcare were discussed and agreed before being put tothe patient and their relatives. We heard instances ofsafeguarding concerns being discussed along withreferrals to the local authority for further investigationwere made.

• The multidisciplinary team meeting was open, andeach professional group was given their time to haveinput before decisions were made.

• In the community multidisciplinary meeting we sawstaff taking the opportunity to check in with eachother and offer support to care for more complexpatients. At the end of the meeting a list of patientswho had died in the past week was discussed toensure their preferences were met, and learningidentified if their preferences were not met.

• Staff worked across health care disciplines and withother agencies when required to care for patients.

• We saw evidence of staff working with other careagencies to support patient care. This includedinformation sharing with GP’s and district nurses,conversations with local ambulance services todiscuss patient preferences and advance care plans,local care home staff and local hospitals. All thesediscussions were had with patient’s consent to sharetheir information. The hospice also had workingrelationships with all the local authorities its patientslived in and provided evidence of safeguardingreferrals and deprivation of liberty safeguardapplications submitted to ensure patient’s care wassafe.

• The hospice worked with a hospital pain managementteam to enable patients to have indwelling epiduralsto help control pain that was otherwiseuncontrollable. Epidurals are a way of delivering painrelief directly into the nervous system and works toeffectively block nerves. This relationshipdemonstrated the close link the two organisationshad, normally patients would have to be on specialistwards in hospitals to receive this level of pain relief. Wewere told doctors from the hospital routinely came onWednesday afternoons, but were open to coming atother times in the week if a patient was admitted withuncontrolled pain that required this intervention. Thehospice had trained senior nurses to support thedoctors in the insertion of the catheters thereforelessening the burden on hospital staff having to attendthe hospice.

Seven-day services

• Key services were available seven days a week tosupport timely patient care.



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• Consultants attended daily ward rounds on all wards.Consultants were involved in the ward rounds duringthe week and, although not on site, were available oncall on weekends if more support was needed. At theward round patients who required more consultantinput were identified and then were reviewed byconsultants if the care pathway required it. If required,the on-call consultant would also go out to complexcommunity patients at short notice. We were told thiswas not often required as the nursing staff were ableto manage most situations but was an option toescalate to.

• Staff and patients could call for support from doctorsand other disciplines, 24 hours a day, seven days aweek.

• The hospice offered a ‘single point of contact’telephone service for patients, relative and other careagencies to call if they were concerned about apatient’s condition or care needs. We were told thiswas used not only by patients and their relatives butalso care homes and ambulance services who neededto clarify identified care needs. The service was staffed24 hours a day seven days a week and there wascapacity planned into staffing numbers to allowcommunity visits to be made at short notice, evenovernight.

Health promotion

• Staff gave patients practical support to help themlive well until they died.

• The hospice had relevant information promotinghealthy lifestyles and support on wards/units. Thehospice followed a rehabilitative palliative care ethos,meaning they aimed to keep patients living the mostnormal life as possible for as long as possible,

• We observed that patients were encouraged, whereappropriate, to keep physically active. The hospiceoffered daily circuits classes that patients could bookinto to promote their mobility. One patient told usthey felt stronger and more motivated to look afterthemselves once they started participating in thecircuits classes as they were setting goals.

• The hospice also promoted and provided services tosupport the mental health of patients and their

relatives. Patients could be referred to cognitivebehavioural therapists, who worked for the hospice, towork through various problems such as heightenedanxiety.

• There were rooms in the hospice that were dedicatedto complementary therapies, for example a massageroom was available. There was also a space in thepavilion in the garden for art and music therapysessions which allowed patients to expressthemselves in a creative manner if they could not findthe words.

Consent and Mental Capacity Act

• Staff supported patients to make informeddecisions about their care and treatment. Theyfollowed national guidance to gain patients’consent. They knew how to support patients wholacked capacity to make their own decisions orwere experiencing mental ill health. They usedagreed personalised measures that limit patients'liberty.

• Staff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Health Act, MentalCapacity Act 2005. Staff were clear as to their rolesunder the Mental Capacity Act 2006 and were able toexplain how they would protect a patient’s rightsunder it.

• Staff gained consent from patients for their care andtreatment in line with legislation and guidance. Weobserved staff gaining consent for procedures andrecording this in their records. Staff explainedprocedures to patients and their relatives and madesure they had the information they needed to make aninformed decision about a treatment. Staff includedfamilies in discussions about courses of treatment butultimately the decision to proceed with treatment wasmade by the patient.

• Staff understood how and when to assess whether apatient had the capacity to make decisions about theircare. Staff were clear about the processes to assess apatient’s capacity and explained how they would varytheir approach if a patient had fluctuating capacity.Fluctuating capacity means that a patient may havethe capacity to make decisions at certain times and



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not others. Staff explained with this group of patientsthey would time conversations when they knew thepatient would have the capacity to make decisions forthemselves and would work on developing advancedcare plans with patients, so they could make choicesfor the future of their treatment.

• The hospice worked with patients as much as possibleto develop advanced care plans to ensure their wisheswere documented for future care needs. An advancedcare plan is a plan patients make that sets out theirdecisions for future treatment, should they lack thecapacity to do so. Advanced care plans are used whenpatients no longer have the capacity to makedecisions for themselves and enable health careprofessionals to honour patients’ wishes. The hospicesupported patients and their relatives to createadvanced care plans as early as possible in their care,these were then logged in both the hospice patientrecords and in the patient’s ‘co-ordinate my care’record.

• We saw that mental capacity assessments wererecorded in patient’s electronic records. Theassessment we looked at was completed in full andupdated as required. Each decision that was made forthe patient who was deemed not to have capacity waslogged in the record.

• When patients could not give consent, staff madedecisions in their best interest, considering patients’wishes, culture and traditions. If patients did not haveadvanced care plans in place or relatives with powerof attorney over health care, staff set upmultidisciplinary best interest meetings to makedecisions. The hospice had arranged three wellattended conferences about best interest meetings toteach other care providers how to manage them. Wewere not able to observe any best interest meetingswhile on site, however we saw notes taken duringmeetings and found them to be well attended andopen discussions were recorded.

• Staff made sure patients consented to treatmentbased on all the information available.

• Staff received and kept up to date with training in theMental Capacity Act and Deprivation of LibertySafeguards. The hospice was in the process ofredeveloping its training package teaching staff about

the Mental Capacity Act and Deprivation of LibertySafeguards. Staff were still able to access the currenttraining information, but the hospice felt it needed anupdate. Staff we spoke with were able to explain whenthey would consider asking for a Deprivation of LibertySafeguards assessment and the processes that wereneeded to ensure this happened in a timely manner.

• Managers monitored the use of Deprivation of LibertySafeguards and made sure staff knew how tocomplete them. The safeguarding lead monitoredDeprivation of Liberty safeguarding applications andwas part of the team involved in signing off emergencyapplications to allow safeguards to be put in place forup to seven days while waiting for the local authorityto approve longer term use.

• Staff could describe and knew how to access policyand get accurate advice on Mental Capacity Act andDeprivation of Liberty Safeguards. Staff were able tolocate both the Mental Capacity Act and Deprivation ofLiberty Safeguards policy on the intranet. We saw thatthese policies were comprehensive, followedguidance and were in date.

• Managers monitored how well the hospice followedthe Mental Capacity Act and made changes to practicewhen necessary. The hospice had a safeguarding,Mental Capacity Act and Deprivation of Libertycommittee where the number of referrals were notedand case studies were scrutinised and discussed andchanges to policy following changes to guidancecould be agreed. This was where the changes to thetraining programmed had been instigated. The leadwas able to identify the common themes andproblems faced by staff and was tailoring training tocover these.

• Staff implemented Deprivation of Liberty Safeguards inline with approved documentation. The hospice hadintake from multiple different local authorities and staffwere able to explain how they would submitdocumentation to all of them.

Are hospice services for adults caring?

Good –––

Our rating of caring stayed the same. We rated it as good.



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Compassionate care

• Staff truly cared for patients with compassion.Feedback from all patients and those close tothem confirmed that staff treated them well andwith kindness.

• Staff within the service took the time to understandpatients as individuals and created care that waspersonalised to their needs. Individual needs andpreferences were always reflected in the way care wasprovided. For example, we observed a patient with acognitive impairment had a list of preferred things toeat and activities they enjoyed. Staff told us thisinformation was collected on admission for allpatients with cognitive impairments such as dementiafrom family and carers to ease the transition into thehospice environment. We observed staff alwaysprioritising patient goals in the care delivered.

• Patient’s feedback confirmed that staff treated themwell and with kindness. Staff highly valued therelationships between patient, relative and staff. Theleadership team encouraged and supported thebuilding of these relationships. We observed patientsbeing offered to attend the hospice’s brass band in theanniversary centre and staff sitting and interactingwith patients while this was going on. In thecommunity setting, staff set the length of time theyspent with patients, this enabled them to extend visitswhen needs became more complex or the patientneeded longer to make decisions about their care andtreatment. Staff told us there was no pressure frommanagers to spend a certain amount of time witheach patient and this gave them the flexibility to carefor patients in a compassionate way as they had timeto get to the heart of what patients wanted.

• Staff were consistently observed displaying kindnessand compassion towards patients and their relativeswhich helped to reduce their anxiety. We observedthat patients, family members, friends and fellow staffwere always treated with dignity and respect.Consideration of patient’s privacy and dignity wasfirmly embedded in the way staff approached dailytasks. For example, we observed staff ensuring patientdignity was protected during personal care by closingdoors and curtains of bedrooms and bays.

• There were good patient feedback channels and staffacted on any concerns patients highlightedthroughout their stay. The results from this feedbackwere consistently highly positive over both 2018 and2019. In the ‘Voices’ survey patients and relatives wereasked ‘Overall, how satisfied were you with the careyou received from St Christopher’s?’. The hospicescored 9.36 out of 10 in 2018 and 9.38 out of 10 in2019. Patients repeatedly told us they valued therelationships they built with staff and the ‘limitlesslengths’ they felt staff would be willing to go whenproviding care and support.

• Staff told us the hospice conducted weddings in thegardens or anniversary centre, allowing patients tocelebrate special occasions with loved ones and thatthey did all they could to ensure these were specialoccasions. The hospice had a chaplaincy team toconduct ceremonies but, if patients wanted, theycontacted other religious leaders to conductceremonies. The hospice conducted bothheterosexual and same sex wedding and civilceremonies.

• Staff were passionate about creating positivememories for patients and families during their timeas an inpatient. For example, during our inspection weobserved a local school brass band visited the hospiceto provide music for patients. Families were supportedto eat together by staff, depending on the patient’scondition they could eat at a table in the anniversarycentre away from the ward.

• Dignity of deceased patients was maintained throughthe hospice’s processes of last offices and transferringthe deceased person to the mortuary to awaitcollection by local funeral services. Last offices is theprocess to prepare the deceased for a funeral homeand involves washing the person.

• Patients could reach call bells and staff respondedquickly when called. We observed all call bells to bewithin the reach of patients and to be attended toquickly. No patients we spoke with said they had beenleft waiting for help when a call bell had been used.

• Staff told us about a patient who travelled to the UKand became acutely unwell. They were cared for in thehospice and a member of staff was preparing to fly



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home with the patient, as an escort, as their preferredplace of death was home. Staff worked collaborativelyto facilitate the repatriation by approaching theembassy and airlines.

Emotional support

• Staff understood the importance of providingemotional support to patients and those close tothem and were willing to go ‘the extra mile’ inorder to meet their needs.

• We observed that staff were attentive to andprioritised the holistic needs of patients at thehospice. The hospice had a chaplaincy team, socialworkers, cognitive behavioural therapists and acomplementary therapy team who worked withclinical staff to ensure patient’s and relative’s holisticneeds were catered for. Members from these teamsattended ward rounds and multidisciplinary meetingsand were regularly consulted to ensure staff had a fullunderstanding of all the needs of the families caredfor.

• The emotional and social needs of patients were asimportant as their physical needs with a wellbeingteam made up of four health care assistants (HCA)dedicated to this purpose. Patients had a monthlyreview with a member of the wellbeing team toevaluate the support they were currently receiving andany additional support they might benefit from.

• The day therapy service included the option to takepart in wellbeing crafts, music therapy and art therapy.This included conducting life story work with patientswhich allowed them to create memory boxes,photobooks, video diaries and audio recordings oftheir lives. For example, one patient told us they hadbeen assisted by the music therapist to create asoundtrack of songs for their family to remember themby.

• Bereavement sessions were offered on a one to onebasis or as a group depending on the preferences ofrelatives. A specialised bereavement service called‘Candle’ was run for bereaved children. The groupprovided one to one and group counselling to offerpractical support to bereaved children and meet theiremotional needs. The service also offered training oradvice to support to local schools to support them inunderstanding the needs of bereaved children.

• The bereavement team ran events to support andremember loved ones such as a quarterlyremembrance event for relatives who had lost lovedones. The bereavement team also set up and ranbereavement help points in seven locationsthroughout South East London that provided the localcommunity an opportunity to access bereavementsupport without visiting the hospice.

• Staff communicated sensitively and thoroughly withpatients and their relatives. Patients told us they wereable to ask any questions and were given answersthey understood and emotional support when upset.Patients and relatives commended staff provision ofthoughtful and empathetic support. Staff offeredassurance and reassurance to relieve anxiety andenable patients to settle into the hospice and benefitfrom the support provided.

• Staff emphasised the holistic needs of individuals.People’s personal, cultural, social and religious needswere always considered with innovative ways to meetthem being found. Patient needs were reviewedregularly and dynamically to relieve as many worriesas possible and ensure needs continued to be meteffectively. Staff had undergone training with thecomplementary therapy team in the ‘Namaste Care’programme to help to provide holistic care to patientswith advanced dementia.

• The hospice provided ‘Compassionate Neighbours’support across the five boroughs the hospice served.Patient referrals could be made through any memberof staff or relatives and friends through a form on thepublic website. ‘Compassionate Neighbours’ is asocial movement where local trained volunteers visitpatients in their home to alleviate social isolation. Thehospice also ran a ‘Coach4Care’ programme whichpaired a carer who was bereaved with a carer caringfor somebody at the end of their life. This allowedcarers to use their experience in a meaningful way andto be able to give real examples of how they helpedtheir loved ones. New carers were able to speak withsomebody to had real experience of what they weregoing through and who could truly empathise withthem.

• The hospice also ensured they supported theemotional wellbeing of their staff. They ran ‘Schwartzrounds’. Schwartz rounds are used in healthcare to



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provide staff, and in this case volunteers, anopportunity to discuss any emotional or social issuesthat may arise from caring for people at the end oftheir life. They also encouraged huddles to allow staffto discuss complex or upsetting cases daily,particularly in the community team who were oftenworking alone.

Understanding and involvement of patients andthose close to them

• Staff always communicated with patients abouttheir care and treatment in a way they couldunderstand. Staff involved patients and thoseclose to them in decisions about their care andtreatment.

• The hospice had a clear patient-centred culture. Staffwere impassioned to provide kind care that promoteddignity and independence wherever possible. This wassupported by the hospice’s rehabilitative palliativecare ethos aimed at keeping patient’s living as well aspossible for as long as possible, as defined by thepatient.

• Staff routinely included patients and relatives inplanning and decision making about their care andtreatment. Patients took an active role in their careand defined personal goals they wanted to achieve.We observed that patient goals were always discussedat ward rounds and at multidisciplinary meetingsdemonstrating they were used as the foundations forbuilding care plans for patients.

• Patients carers, advocates and representativesincluding family and friends, were identified,welcomed, and treated as key partners in the deliveryof their care. Staff took their concerns on board whendiscussing patient care, but ultimately deliveringpatient wishes was their priority.

• We saw evidence in patient care records that staffroutinely involved patients and those close to them inthe decisions about the patients’ care and treatmentand in developing their care plans. Patients andrelatives told us that staff answered questions abouttheir care openly and with clear information. Weobserved community nursing staff involving andengaging patients and their relatives in discussionsabout care planning.

• Staff supported patients in making advanceddecisions about their care. Patients were giveninformation about their options and support inmaking choices about topics such as the preferredplace of care. We observed staff talking to patients andtheir families about death and the dying process. Theywere clear yet compassionate and caring towardspatients or relatives who became upset and enabledthose involved to ask as many questions as theywanted to.

• The hospice provided a ‘Coach4Care’ programme thatenabled current family carers to receive one to onecoaching from trained ex-family carers. We were toldthis was beneficial for the current carers as theyreceived advice from people who had experiencedtheir reality. The coaches also reported they foundbeing able to use their experience fulfilling and gavemeaning to their experience.

• Staff were able to access advanced communicationcourses to ensure they communicated effectively andcompassionately with patients and relatives.

Are hospice services for adultsresponsive to people’s needs?(for example, to feedback?)

Outstanding –

Our rating of responsive improved. We rated it asoutstanding.

Service delivery to meet the needs of local people

• The hospice planned and provided care in a waythat met the needs of local people and thecommunities served. It also worked with othersin the wider system and local organisations toplan care.

• Managers planned and organised services so they metthe changing needs of the local population. Thehospice kept a database tracking the ethnicity andother protected characteristics of patients they caredfor and made safeguarding referrals for. This wasinterrogated by the trustees to ensure the hospice wascaring for people that was representative of thedemographic it served.



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• Managers explained how they tailored services tospecific populations depending on the demographicsof those areas. For example, they knew that one oftheir local clinical commissioning groups (CCG) hadthe highest average age population of any LondonCCG. CCGs cover a certain population and assignfunding to the health care services which serve thosepopulations. This knowledge led to the hospice, withsupport from the CCG, setting up a frailty service as thehospice had noted an increase in non-specific referralsfor frail, elderly patients. The frailty service assessedand co-ordinated care for frail patients in a proactiveway as opposed to reacting to problems as theyoccurred. This involved the hospice making ‘parallelplans’ with patients and relatives. Parallel plans areplans which run in parallel and diverge as outcomeschange. By making parallel plans the hospice aimed toplan for as many eventualities as possible, with thepatient’s involvement in their care. The frailty serviceco-ordinated the care of patients with other careproviders and gave patients a single point of contactshould their condition change or develop. 70% ofpatients cared for under the frailty service weresupported to die at home, this is in contrast to 16.7%of comparable patients across the South East EnglandRegion.

• Another service that had been developed to meet thespecific needs of a patient group was the heart failureservice. This service was developed, in collaborationwith a local acute hospital, to support patients withheart failure access services smoothly and thereforeimprove outcomes. The pilot was deemed successfulby the clinical commissioning group (CCG), with a 36%reduction in admissions, a 51% reduction in hospitalbed days and reduction in the proportion of patientsattending A and E for cardiac reasons. As a result theCCG are now funding a heart failure nurse to supportthis project to be continued in the long term.

• Another area where the hospice was responding to thespecific needs of its population was in Croydon, whichhad a large homeless population. The hospice wasworking with hostels in the local area to train staff toidentify the signs that a homeless person might needend of life care and then to refer them to the hospice.This was aimed at reaching a traditionally difficult toreach group to ensure they receive care at the end oftheir lives.

• Managers had also identified certain care homes in thearea that needed support in caring for dying patients.They had produced a data base of care homes in theircatchment area and detailed how frequently they hadto manage end of life care and how effectivelyadvance care plans and/or end of life care had beenmanaged historically. This meant they were able totarget resources and provide more community visits tocare homes which required more support. Thisinformation was available to the telephone andvisiting service who took the calls from the care homesand formed part of their decision-making processwhen allocating resources.

• Managers explained to us about the hospice’s evolvingmodel of care, which was developed to enable themto support as many people as possible. Traditionallythe hospice model of care was to care for people atthe end of their life and to facilitate a comfortabledeath. St Christopher’s was moving to a morecommunity-based care model and prioritisingin-patient referrals to help patients gain control ofsymptoms. Once symptoms were controlled patientswere discharged either home, to a loved one or to acare home if needed and care was handed back to thecommunity team. Alongside this new model of carethe hospice supported members of the community tocare for people more effectively and usedprogrammes such as ‘coach4care’ and ‘compassionateneighbours’. This was part of the hospice’s long-termplan to ensure everybody received high quality end oflife care but, with the recognition that the average ageof the population was increasing as were people’s careneeds. By increasing community involvement in caremore patients could be cared for then just those ableto access the inpatient unit.

• Another part of the new care model was ‘rehabilitativepalliative care’. This model of care understands thatpalliative patients can live a long time and want tomaintain a high quality of life. The model worked withpatients to set goals that were important to them andthen develop plans that helped them achieve theirgoals.

• Staff knew about and understood the standards formixed sex accommodation and knew when to report apotential breach. Most of the in-patientaccommodation was single rooms to allow patients



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and relatives privacy. On the wards which did havebays these were kept single sex, and this was adheredto all the time. We asked staff what would happen ifthere was a bed on a female bay and a male patientneeded admitting and were told they would look atstepping down a female patient from a side room,with their consent, to free a space. If this were notpossible the bed would remain unfilled and thepatient would be admitted when a suitable bed couldbe found. We were told this had not happened in thepast 12 months and the hospice had enough flexibilitywith beds, with patients being discharged or passingaway that they had always managed to adhere tosingle sex bays.

• Facilities and premises were appropriate for theservices being delivered. Facilities and premises weredesigned with patient’s needs in mind. Wardsprovided enough space for patients to independentlymobilise if they wanted to and had seating forrelatives, with space for them to sleep if they felt theyneeded to.

• Managers told us previously they had noted lowerengagement from the LGBT population they servedand sought to ensure they felt included in the hospiceservices. They noted, in particular, the community hadnot made use of the wedding and civil partnershipsservices they offered. In order to address this, theyamended their leaflets to ensure same sex coupleimages were included on the front cover. We were toldthis had greatly increased the engagement from theLGBT community throughout the hospice.

• Wards also all had side rooms for relatives to use ifthey needed privacy, or to facilitate private discussionswith families. The anniversary centre had a range ofseating for patients to be able to sit in a chair that wascomfortable for them.

Meeting people’s individual needs

• The hospice was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patientsaccess services. They coordinated care with otherservices and providers.

• Wards were designed to meet the needs of patientsliving with dementia. The ward environment was calm

and quiet and as patients were predominantly insingle rooms they were able to bring in items fromhome to help reduce anxiety. There was good naturallight in all bed areas and social spaces, the flooringwas matte and not overly patterned, there were placesfor patients to sit and rest along corridors and instairwells and the signage was clear and in contrastingcolours with an easy to read font.

• Staff understood and applied the policy on meetingthe information and communication needs of patientswith a disability or sensory loss. The staff were trainedto care for patients with dementia and there were‘dementia champions’ throughout the hospice whowere able to support with any more complex careneeds. Staff not only supported patients withdementia but also their relatives. While on inspectionwe were told they were creating a memory box for onepatient’s spouse to help preserve physical memoriesand for another patient’s spouse, with sight loss, theywere creating a music CD and memory box which hadbraille writing on, so they were able to identify it.

• Managers made sure staff, and patients, relatives andcarers could get help from interpreters or signers whenneeded. The hospice had access to interpreters, whenrequired, and they were routinely used for clinicaldiscussions or mental capacity assessments to ensurethe information was translated accurately. Interpreterswere available on the phone or in person.

• Patients were given a choice of food and drink to meettheir cultural and religious preferences. The hospiceoffered a wide range of food for patients and allowedrelatives to bring favourite food from home, ifpreferred. Food was prepared carefully and in line withspecific religious requirements. Patients werepermitted to drink alcohol with dinner if they wantedto.

• The hospice actively sought to achieve goals set bypatients and these were routinely discussed alongwith the medical, social and psychological needs.Examples of goals we heard discussed includedgetting out into the gardens every day or reducingbreathlessness to enable the patient to move aroundmore comfortably.

• The hospice had no restrictions on visiting hours,however staff asked relatives to let the nurses know if



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they wanted to stay overnight so beds could be set upif required. They allowed pets to visit, as this was oftenimportant to patients and helped to keep them calm.The hospice had a resident cat, Colin, who patientswere welcome to pet if their own pets could not bebought in.

• The hospice actively sought out patient’s views ontheir services when they were making changes. Forexample, they were planning to refurbish the wardsand, in preparation to make plans, had asked forpatients and relatives views on what could be done tomake their experiences easier.

• The hospice also had a gym on site. We were told thegym was primarily used by outpatients to promote amore active lifestyle in a safe environment but wasalso used for inpatients undergoing physiotherapy.The gym had equipment that could be modified forpatient requirements. For example, an upper bodyweight machine that could be used standing or sittingin a wheelchair if a patient’s lower body strength wascompromised. Similarly, there were recumbent bikeswhich allowed patients to use either upper body orlower body to drive them.

• The patient rooms and all bays had reclining chairs forrelatives to sleep in and enough space for a spare bedto be set up for a family member to stay overnight.

• The hospice had a multi faith space called the ‘Pilgrimroom’ for anybody to use to sit and reflect or pray ifthey wanted. In the Pilgrim room there were religioustexts and books of a more spiritual nature. There wasspace to safely light a candle for a loved one and arosary or prayer mat if patients or relatives needed.The space also held a book for relatives to writemessages for loved ones, all the old books were alsoavailable in the room. We were told many relativeschose to come back each year and write a newmessage and reflect on previous messages they hadleft; therefore, the hospice left the old books forreference.

Access and flow

• People could access the hospice when theyneeded it and received the right care promptlyand the hospice had provisions in place to risk

assess referrals to allow emergency admissions toservices to be prioritised. Any wait lists werereviewed by managers or senior care staff toallow urgent referrals to be prioritised.

• Managers monitored waiting times and made surepatients could access services when needed. Thehospice had a ‘single point of contact’ where allreferrals and patient queries went through. Thisservice was monitored by the managers and was open24 hours a day seven days a week. The service tookcalls and then risk assessed for how quickly a referralto either the inpatient unit, community team oroutpatient service was needed. This original riskassessment was supposed to be completed within 24hours of taking the phone call. The most recent auditcompleted in November 2019 and reviewed 142 casesdiscussed over a seven-day period showed the servicewas meeting this target 88% of the time. 14 of the 17referrals which missed the 24-hour time frame wereresponded to within 26 hours, however the computersystem did not display time stamps to the contactteam, this was due to change with an upgrade to thesystem plan for January 2020. The remaining threereferrals were responded to late due to a lack ofstaffing over the weekend and there was an extraadministrative position created to cover this, theywere due to start in January 2020. A re-audit wasplanned for February 2020.

• Community teams explained their processes forreviewing and prioritising caseloads depending on theneeds of the patients. For example, a patient withrelatively simple needs and who was relatively wellwould be seen once every few weeks by a healthcareassistant and a patient with more complex and acuteneeds would be seen more frequently by a clinicalnurse specialist. Patient needs were assessed regularlyand the category they fell into was fluid. Theassessments and categories were written intoprotocols meaning staff were confident they deliveredappropriate care.

• The hospice told us the average number of days apatient waited for admission to the inpatient unit wastwo, the minimum number of days was zero and themaximum nine. It was explained that the longestwaits, of nine days, were where patients had beenreferred from local hospitals and were not fit for



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transfer, therefore the patient had to wait until theywere well enough to be transferred. The wait list forinpatient admissions was reviewed twice a day by aconsultant nurse or a doctor which the single point ofcontact team.

• The hospice told us the wait times for access tocommunity teams was between zero and 11 days,including weekends. If patients were assessed ashaving urgent care needs they were seen on the sameday as referral. The waiting times for an outpatientappointment were between one and nine days, withan average of five days.

• St Christopher’s had also begun discharging patientsfrom community caseloads when symptoms weremanageable for patients and relatives. However, thedischarge allowed self-referral back into the systemshould things change by calling the ‘single point ofcontact’ number. This enabled community staff tomaintain a manageable caseload but also gavepatients and relatives the reassurance they couldaccess help and support as and when they needed itin the future. This was part of the hospice’s new caremodel and enabled them to care for a higher numberof patients as they were not routinely seeing patientswhose conditions were stable and did not requireintervention.

• The outpatient clinics were open long hours to enablepatients or relatives to book appointments at timesthat were suitable for them. Bereavement supportgroups ran over evenings and weekends so relatives orloved ones could access these outside of work hours.

• Managers and staff worked to make sure that theystarted discharge planning as early as possible.Potential discharge plans were discussed withpatients and relatives early to ensure their needs andpreferences were considered. When patients wereadmitted to the hospice, to aid control of symptoms,we observed they were told that this was the case andthey would be discharged back to the community or acare home once symptoms had been controlled.

• Staff planned patients’ discharge carefully. We sawevidence of complex discharge planning and staffwere clear about their duties to ensure thoroughdischarge plans were in place before patients wenthome. The hospice had robust links with the local

authorities it served, and staff knew the social caresystem and how to guide patients and relatives to getthe support they required. When patients or relativeswere unable to access the support, the hospice didthis on their behalf.

• When patients had stipulated a preferred place ofdeath as home in their advanced care plans thehospice was able to fast track discharge to achieve thisgoal.

• The complementary therapy team offered a range oftherapies supporting patients and their relativesincluding massage and acupuncture. The teamincluded a community-based member who couldtravel to patients’ homes in circumstances where thepatient was unable to travel to the hospice.

Learning from complaints and concerns

• It was easy for people to give feedback and raiseconcerns about care received. The hospicetreated concerns and complaints seriously,investigated them and shared lessons learnedwith all staff. The hospice included patients in theinvestigation of their complaint.

• Patients, relatives and carers knew how to complain orraise concerns and the hospice clearly displayedinformation about how to raise a concern in patientareas. Patients and relatives we spoke with wereaware of how to raise concerns or complaints if theyhad any. There was clear signage throughout thehospice environment detailing how to complain andpatients were given a “Welcome to the inpatient unitat St Christopher’s” leaflet when they were admitted tothe ward which detailed the complaints process.

• Hospice volunteers were also trained to speak withpatients on the wards to ask for real time feedbackand to collate this in the form of a survey. This meantproblems could be addressed in real time andstopped issues escalating, rather than patients havinga poor experience and complaining after discharge.

• Staff understood the policy on complaints and knewhow to handle them. Staff were clear in their role forhow to manage complaints. We saw a clearcomplaints policy with defined dates for responses tobe sent to patients or relatives by. This policy hadrecently been updated to ensure it was thorough.



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When a formal complaint was received the hospiceacknowledged this by letter and offered thecomplainant a meeting to discuss the complaint. Thisallowed the hospice to understand the complaintthoroughly and ensure it was investigatingappropriately. All complaints would then beinvestigated and discussed by a multidisciplinaryteam at a learning panel. There the complaint waslooked at for any potentiallearning. This learning wasthen disseminated to staff and sent to the originalcomplainant, so they were aware of the changes theyhad enabled for future patients. We were told by thehospice they were proud of their complaintsinvestigations and had a previous complainantworking as a volunteer as they were so impressed bythe hospice’s reaction to their complaint.

• Managers investigated complaints and identifiedthemes. We were told one of the themes that wasidentified was that small concerns that were notidentified while a patient was on the ward led to largercomplaints being fed back on the bereavementquestionnaire. This led to the hospice trainingvolunteers to gather feedback from patients andrelatives while they were on the ward, so anyproblems could be actioned in real time. The hospiceexplained the rationale for using volunteers which wasthat patients felt more comfortable to speak freelywith somebody who was not delivering their care.

• Managers shared feedback from complaints with staffand learning was used to improve the hospice andstaff could give examples of how they used patientfeedback to improve daily practice. Therecommendations from the learning panels was usedto inform changes to policies and procedures and staffwere able to speak about changes that had happenedas a response to complaints.

• Managers looked at the content of compliments aswell to understand what the hospice was doing welland to see if this could be built on in any other areas.

• During the reporting period, of September 2018 toAugust 2019, the hospice received 28 complaints ofwhich nine were upheld and 27 were responded towithin the target date. In the same reporting periodthe hospice received 477 compliments.

Are hospice services for adults well-led?

Outstanding –

Our rating of well-led stayed the same. We rated it asoutstanding.

Leadership

• Leaders had the skills and abilities to run thehospice. They understood and managed thepriorities and issues the hospice faced. They werevisible and approachable in the hospice forpatients and staff. They supported staff todevelop their skills and take on more senior roles.

• The management at the hospice were committed totheir roles and were passionate about delivering greatcare and pushing forwards to ensure the hospiceremained a sustainable organisation. They werevisible to staff and staff told us they knew who theywere and found them to be approachable. Thehospice had two chief executives who workedcollaboratively, underneath them there was theexecutive team who managed the wider leadershipteam. The leadership was clear and had definedstructures and channels of communication. Theexecutive team had defined roles such as medicaldirector and director of quality and innovation andthese roles were defined and had clear responsibilityand accountability.

• Staff told us they found managers approachable andfelt supported by them. There were initiatives at thehospice, such as the audit teaching programme thatwere designed to integrate hospice leaders with thestaff and to enable open and honest conversationsabout the challenges that faced staff daily.

• We noted that as we were walking around the hospicewith managers that they knew all the staff and staffknew who they were. There appeared to be no barriersto communication and staff approached managers toask questions while we were there. This was alsodemonstrated in the 2019 staff survey with a 20%improvement in staff confidence from the 2018 survey.

• The registered manager was dedicated to the hospiceand felt the board and trustees were equally



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passionate about delivering the best care they wereable to. They were equally committed to theeducation programme St Christopher’s offered. Thisprogramme was a mixture of delivering speeches atconferences, classroom learning for clinical staff andcommunity members and electronic learningdelivered to staff from other organisations. Alleducation programmes were aimed at achieving thenew care model of enabling effective care for dyingpatients in the community as much as possible andpreserving in-patient care for those with acutesymptom burden.

• The director of people and organisationaldevelopment explained to us that the hospice hadsent 28 managers on management developmentprogrammes. This enabled managers in the hospice tofeel more confident in their roles and supported staffto progress to more senior roles.

Vision and strategy

• The hospice had a vision for what it wanted toachieve and a strategy to turn it into action,developed with all relevant stakeholders. Thevision and strategy were focused onsustainability of services, increasing the reach ofthe hospice and improving the quality of theservice.

• The hospice had a clear vision which was “a world inwhich all dying people and those close to them haveaccess to the care and support they need, when andwhere ever they need it”. They hospice hoped tofacilitate this vision by promoting and providing“skilled and compassionate palliative care of thehighest quality”.

• The hospice also had well defined values, which wereembedded in protocols and therefore in day to dayworking at the hospice. These values were to be“empowering and compassionate”, “expert”, “of and forthe community”, “stronger through partnerships, “oneteam working together” and to be “pioneering andbold”. We saw these were translated into practice andstaff were able to tell us them. These values were alsoembedded in the appraisal system.

• The hospice had organisational objectives andbehaviours and ensured they were aligned to thecorporate values. This was looked at by the leadershipteam and a document had been produced to assesshow well they were achieving their values in each area.

• The hospice had a five-year plan that wascomplimented by yearly objectives set by the seniorleadership team and approved by trustees and theboard members.

• Part of the hospice’s overall strategy was to change itsmodel of care to increase the sustainability of itsimpact on patients, this was an ongoing process. Thehospice was acutely aware of the demographic trendof an ageing population with a higher disease burdenand recognised that their previous model of care oflooking after people on the inpatient unit until theypassed away was not sustainable. This had led to ashift in the care model and the hospice was caring forthose with high symptom burden in the inpatient unitwhile also caring for patients in the community for aslong as possible under the rehabilitative palliative careformat. This enabled patients to live normal lives, outof care environments, for as long as possible and aswell as possible.

Culture

• Staff felt respected, supported and valued. Theywere focused on the needs of patients receivingcare. The hospice promoted equality anddiversity in daily work and providedopportunities for career development. Thehospice had an open culture where patients, theirfamilies and staff could raise concerns withoutfear.

• Teams worked collaboratively with each other with theshared focus of providing high quality care forpatients. We saw evidence of community teams andthe inpatient unit communicating seamlessly toensure patients were not lost in the system andtherefore miss out on any care they required. This levelof teamwork extended beyond the immediate hospicestaff and into the hospitals and other care agenciesthey had links with. The hospice had forgedmeaningful working relationships with many otheragencies such as local hospitals, hostels and CCGs andthis allowed integrated care to be delivered.



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• Community staff told us that although they physicallyworked outside the hub of the organisation they felt apart of it and were able to voice their opinions and feltvalued.

• The hospice valued staff safety and promoted safeworking practices. There was an in date lone workingpolicy and staff from the community had personalsafety devices should they require assistance when ina patient’s home. We noted that at themultidisciplinary meeting staff safety was discussedand risks were mitigated with the decision to send twomembers of staff to some patients where support maybe needed.

• All staff we spoke with told us they felt the goal ofachieving good patient care was at the crux ofeverything the hospice was doing. They told us theywere not pressured to discharge patients from servicesand community staff were able to set their own dayplans to enable them to spend as long as wasnecessary with patients. This meant visits were notrushed and staff felt they were able to provide the carethey needed to. This flexibility enabled andempowered staff to deliver patient centric and holisticcare.

• The hospice had an in-date whistle blowing policy andstaff told us they were aware of it. In addition to thisthe hospice had a trained freedom to speak upguardian staff could approach. However, staff wespoke with said they would not feel the need to use itas they felt able to raise issues openly, without fear offuture repercussions.

• Staff we spoke with told us they were proud to tellpeople they work for the hospice and that they feltable to deliver truly personalised care for theirpatients. We were told by staff they were hesitantwhen the new model of care was being bought inbecause they were afraid they would deliver lesspatient centric care. However, once the model was inplace and the audit data was published they were ableto see this was not the case. We were told by onemember of staff who was contracted to the hospicethat they felt the care they observed was “effortlesslynatural” and “truly holistic”.

Governance

• Leaders operated effective governance processes,throughout the hospice and with partnerorganisations. Staff at all levels were clear abouttheir roles and accountabilities and had regularopportunities to meet, discuss and learn from theperformance of the hospice.

• There was an effective governance structure. Allmeetings within the governance framework were wellattended, and this had been actively worked on in theprevious year. Staff at all levels were clear about whattheir roles and responsibilities were. There were clearlines of accountability throughout the hospicestructure and all staff were clear about who they wereaccountable to and who to escalate problems to.

• The hospice enabled and promoted open discussionsat all levels about care delivered and potentialimprovements to the care being offered.

• The hospice had peer group meetings such as theconsultant forum, the ward managers meeting and theprescriber’s meetings to enable open discussionsabout any good practice to be highlighted or concernsto be shared. These meetings were recorded, andminutes were shared with members for sign off. Allmeeting minutes we saw were clear and had definedoutcomes and actions which were owned by membersof staff to complete.

• The hospice held quality and governance meetingsfour times a year and these were chaired by thedirector of quality and innovation. This role of ‘thegovernance and innovation’ lead was new and wascreated as the two were intrinsically linked. It wasappreciated by the hospice that all innovation neededgovernance processes to maintain safety, but thatgovernance should not suppress innovative ideas, bycreating a new role the two could remain in balance.

• The hospice had a clear governance process tocontinually improve services. Staff of all levels wereclear in their roles and responsibilities in relation togovernance and we found governance arrangementsto be suitably vigorous.

• The hospice held board meetings which were attendedby the executive team and trustees. Directors submittedreports containing performance, quality or incidents for



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each other and the trustees to interrogate. We were toldby the members of the executive team that the trusteeswould challenge the content of the reports wherenecessary.

Managing risks, issues and performance

• Leaders and teams used systems to manageperformance effectively. They identified andescalated relevant risks and issues and identifiedactions to reduce their impact. They had plans tocope with unexpected event.

• The hospice had continuity plans in place to covervarious issues and had mitigated risks such as powerloss by having routinely serviced backup generators. Inearly 2019 we received notification that some of thefire precautions at the hospice were not safe. Sincethen we have been provided a thorough action planand updates to how this is being managed and areassured the hospice had managed this risk well.

• The hospice held a risk register and all members of thesenior leadership team were able to describe the mainrisks. The register contained mitigating actions, aresponsible member of staff in charge of the actionand the review date. We found the items on the riskregister, such as ongoing charitable funding, to beappropriate.

• There were clear lines of accountability andresponsibility in the hospice. The hospice hadnominated leads for areas such as infection control,safeguarding and finance. These leads reported ontheir areas at meetings and answered to the chiefexecutives and trustees for the quality of theinformation they presented.

• The hospice reviewed the content of complaintscompliments and concerns to drive improvementsand to uncover risks they may otherwise have notbeen aware of. The full complaints review process isdiscussed in responsive.

• The hospice had developed a risk appetite statement.This statement was aimed at guiding staff andvolunteers about the hospice’s definition ofappropriate risk taking.

Managing information

• The hospice collected reliable data and analysedit. Staff could find the data they needed, in easilyaccessible formats, to understand performance,make decisions and improvements. Theinformation systems were integrated and secure.Data or notifications were consistently submittedto external organisations as required.

• We found the information systems to be secure andappropriate for use. The hospice had identifiedimprovements that would be driven by updates to thepatient record system in due in January 2020. Thesystems enabled data to be extracted and analysedaccurately as all entries were automatically timed anddate stamped. Most staff we spoke with, apart fromnew staff who were still undergoing training, wereconfident to use the systems.

• The hospice had mechanisms in place to managesafety notifications from outside agencies to ensurepatients and staff were kept safe. The hospice alsosubmitted statutory notifications to us, as appropriate,and was compliant with requests for furtherinformation when required. We were also told aboutthe mechanisms of reporting to other agencies, suchas the yellow card reporting to the Medicines andHealthcare products Regulatory Agency.

• Information governance training was part of themandatory training for all new staff. Staff members wespoke with were aware of their responsibilities tocomply with good information governance andmanagement. We observed that computers werelocked when staff were not using them.

• IT systems were all password protected and users hadto log into each system individually once a computerhad been accessed. This enabled accurate records tobe maintained as staff had to proactively log intosystems to update notes.

Engagement

• Leaders and staff actively and openly engagedwith patients, staff, the public and localorganisations to plan and manage services. Theycollaborated with partner organisations to helpimprove services for patients.

• The hospice asked its staff to complete an annual staffsurvey and acted upon the results of these. We were



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told the 2018 survey had raised some concerns withmanagers and improvements had been made. The2019 staff survey demonstrated improved satisfactionof staff.

• The hospice had multiple mechanisms for patientsand relatives to provide feedback on services. All thisfeedback was scrutinised, and themes and trendswere identified to improve the future service thehospice provided.

• Along with these ongoing programmes the hospicealso sought targeted feedback when projects werelaunched. For example, when the hospice wasplanning to refurbish the ward environment it askedstaff and patients what could be done to improvethings. As the end users of the services the hospicerecognised they could provide insight into details thatmay otherwise be missed. This feedback was used tofine tune designs and ensure the environment was asappropriate for as many patients as possible.

• The hospice worked collaboratively with the localauthorities and Clinical Commissioning Groups (CCGs)to deliver services which were needed in the areasthey covered. An example of this is the frailty servicethat was set up in conjunction with the CCG. Thehospice and CCG work collaboratively to provide thisservice to the population and the service was drivenby demographic needs as these patients would nothave previously met hospice referral criteria.

• The hospice also worked with services that were nottraditionally deemed health care providers. Theseservices included hostels and enabled the hospice toprovide care to the homeless population it served.From this engagement the hospice had spoken withmembers of the homeless population and had abetter understanding of their needs. Because of thisthey had made a funding application for a newprogramme called “ripples” aimed at ensuringeverybody could leave a legacy, as this was oftenhighlighted as a concern by homeless patients.

• The hospice ran a staff forum, that was chaired by amember of staff. They also ran a forum for volunteersto give them a formal way of speaking with theorganisation and voicing their opinions.

Learning, continuous improvement and innovation

• All staff were committed to continually learningand improving services. They had a goodunderstanding of quality improvement methodsand the skills to use them. Leaders encouragedinnovation and participation in research.

• The hospice was committed to learning from whenthings had gone wrong and when things had gone welland regularly audited itself to benchmark progress.

• The hospice had a ‘people and workforce developmentstrategy’ which offered training and developmentopportunities including a new ‘Never too Busy to Learn’programme which focussed on using everydayexamples to learn as part of their role. Many seniormembers of staff we spoke with had worked at thehospice for years and had been upskilled to take onmore responsibility and new roles. The hospiceunderstood the benefit of cultivating talent andproviding new opportunities to staff to retain them.

• The hospice had introduced Schwartz rounds for staff toattend. Schwartz rounds are used in healthcare toprovide staff, and in this case volunteers, an opportunityto discuss any emotional or social issues that may arisefrom caring for people at the end of their life.

• The hospice was in the end processes of building a neweducational hub. This was a building separate to thehospice which was to become the hub from which alltraining was delivered. They utilised technology indelivering training and understood not all care serviceswere able to release staff from duties for whole days toattend training. Therefore, they offered dial in sessionswhich were held on a digital platform, this increased thenumber of people they would reach with training. Thehospice was targeting training and educationprogrammes at care homes and local communities. Thiswas part of the long-term strategy to keep as much carein the community as high quality as possible.

• The hospice was actively engaged in research anddelivered speeches and posters at conferencesworldwide. At the time of inspection, they werecontributing data to a new research project which wasaimed at providing more accurate methods for hospicesto benchmark effectiveness against each other. The aimbeing to compare their services with other servicesnationally to allow them to identify areas forimprovement in the future.



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• The director of quality and innovation was activelyinvolved in a ‘community of imagination project’. Thiswas a collaborative project that promoted out of the boxproblem solving to enable creative solutions toproblems in end of life care.



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Outstanding practice

• The hospice had specialist services set up inpartnership with a local NHS trust to enable patientsto have indwelling epidurals to deliver constant painrelief when traditional pain relief was not working.This was not normally offered outside of specialisthospital units.

• The hospice had a dedicated frailty service targetingthe older community. This had been set up incollaboration with the local CCG and providedpatients with non-specific symptoms expert care andsupport at the end of their life.

• The hospice had taken steps to reach traditionallyharder to reach communities such as the homeless

population and were speaking with them tounderstand what was important to them and was inthe process of tailoring a new programme to meetthese needs.

• The hospice was developing a new model of care toallow it to provide high-quality care to as manypeople as possible in a sustainable manner. Theywere planning and anticipating an increaseddemand for hospice care, because of this they wereadjusting their model of care to allow for greaterflexibility in the future.

• The bereavement team ran bereavement help pointsin seven locations throughout South East Londonthat provided the local community an opportunity toaccess bereavement support without visiting thehospice.

Areas for improvement

Action the provider SHOULD take to improve

• The provider should ensure that all staff are awareand compliant with the ‘care after death’ policy, withreference to the infection control procedures to keepother staff members and undertakers safe.

• The provider should continue to work tofully understand the causes for the higher thanaverage prevalence of pressure ulcers.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

This section is primarily information for the provider

Requirement noticesRequirementnotices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

This section is primarily information for the provider

Enforcement actionsEnforcementactions


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