Sue Ryder palliative Care Hub- South Oxfordshire

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People received care based on comprehensive assessments of their individual needs and preferences. We looked at 5 people’s records and saw they received holistic assessments before care commenced. Assessments considered people's physical, emotional, social, cultural and spiritual needs and were used to develop personalised care plans. Records showed dependency scores were used to support care planning, determine levels of support and allocate resources appropriately.

People's communication and information needs were assessed and recorded. The service had systems in place to identify communication needs at the first point of contact. Staff recorded people's needs within care records, ensuring they were visible to relevant staff and appropriately shared when care was transferred between services

The service had an accessible information standards and interpretation policy to support staff in meeting people's communication needs. The policy required staff to provide accessible information and communication support, review needs when they changed and escalate concerns where identified needs had not been met.

The service provided a dedicated accessibility hub containing document templates, guidance on producing accessible information and resources to support disability awareness and reasonable adjustments.

Communication needs formed part of the assessment process and were considered alongside people's health, wellbeing and care needs. This helped staff ensure information was provided in a way people could understand and supported them to participate in decisions about their care and treatment.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The service provided effective care and treatment based on current guidance from The National Institute of Clinical Excellence (NICE). Staff completed training to recognise when people were entering the last days of life and worked with specialist nurses, including Parkinson's, heart failure and diabetes teams, to support people with complex needs.Pharmacy support was available to help staff deliver safe and effective care. Expert pharmacy advice and support was available centrally from the wider Sue Ryder team through the Medicine Optimisation Pharmacist, as the local pharmacy service only provided support to the inpatient community hospital.

People benefited from care and treatment informed by a range of healthcare professionals. The service used a multidisciplinary approach, bringing together nurses, healthcare assistants, social workers, occupational therapists, physiotherapists, dietitians, speech and language therapists, counsellors and medical staff to support assessment, care planning and treatment.

The service had systems in place to monitor care quality and identify areas for improvement. We saw evidence of audits where the outcomes identified learning opportunities. For example, an audit found that non-pharmacological pain relief was not always discussed with people. The root cause analysis found that staff were focusing mainly on providing pain relief advice. Staff were reminded to also discuss non-pharmacological options for managing pain and to document discussions. The service had an annual audit programme which set out the audits required and when they should be completed. This included pressure ulcer reporting, nutrition and hydration assessment, moving and handling and hand hygiene. We also saw unannounced visits from the national quality and governance team, which provided further oversight.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff, teams and partner organisations worked together to provide coordinated care and support for patients and those important to them. The service worked as a multidisciplinary team, with input from clinical nurse specialists, doctors, physiotherapists, occupational therapists, social workers, wellbeing staff, counsellors and bereavement services. The service also worked with local care homes and provided training through its learning academy.

We attended 2 multidisciplinary team meetings and saw people’s needs were discussed holistically. For example, staff reviewed people's physical health, emotional wellbeing, social circumstances, safeguarding concerns and support from other professionals. Barriers to care, including communication needs, language and understanding, were discussed to help ensure people received appropriate support. Staff also considered the needs of family members, including whether bereavement support was required. Where needed, people were referred to the service’s online bereavement support service and online bereavement counselling.

Meetings followed a structured approach. Care plans and actions were discussed openly and agreed by the team. Actions were clearly documented and confirmed to ensure staff understood their responsibilities. Staff told us consultant cover was always available for multidisciplinary meetings and decision-making.

We saw a culture of collaborative working and shared learning. For example, staff felt able to ask questions and share information openly. Learning from deaths was discussed to identify whether any improvements could be made to future care and support.

Systems were in place to support communication and continuity of care. For example, the service had introduced an artificial intelligence note-taking system to reduce administration time and allow staff to spend more time with people using the service. Also, standard templates were being used following the changes to the service to support a consistent approach to assessments, reviews and multidisciplinary discussions.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

People and those important to them were supported to maintain their physical, emotional and spiritual wellbeing. Staff told us care was provided holistically and recognised the impact a life-limiting illness could have on people and their families. Records showed assessments considered people's emotional, social, cultural and spiritual needs alongside their physical health needs.

The service provided spiritual care and support for people with and without a religious belief. Staff recognised that people may seek spiritual support during difficult periods of illness, loss or uncertainty and ensured this was available when required.

People and their families had access to a range of services to support their wellbeing. For example, the service provided 24-hour advice and support, bereavement counselling services and bereavement support. Staff told us family members could access support before and after a person’s death. Records showed people could access an online bereavement community where they could share experiences, seek support from others who had experienced bereavement and access information tailored to their needs.

The service recognised the importance of supporting staff wellbeing. Staff had access to a range of wellbeing initiatives, including an employee assistance programme providing free, 24-hour counselling. Resilience-based clinical supervision, reflective debriefs, mental health first aiders, wellbeing services and staff support networks were also available. For example, reflective debriefs were offered following challenging situations to give staff an opportunity to reflect on their experiences and identify whether they needed any further support.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

People using the service were regularly discussed at multidisciplinary team meetings, where staff reviewed changes in people’s conditions, identified risks and agreed actions to support positive outcomes. For example, staff discussed physical health, symptom management, psychological wellbeing, safeguarding concerns and family support needs.

The service had a clinical development programme to monitor and improve outcomes. For example, structured mortality review meetings were being introduced, providing opportunities for learning, reflection and service improvement. Learning from these reviews was used to identify themes, share good practice and support improvements in patient care.Technology was used to support monitoring, communication and care delivery. For example, staff used electronic records, digital referral systems and an artificial intelligence note-taking system to support documentation and reduce administrative burden, enabling more time to be spent with people using the service.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

People were supported to make informed decisions about their care and treatment. We observed staff seeking consent before providing care. For example, before carrying out an abdominal assessment and before discussing a person’s care with a family member. We also observed staff involving people and those important to them in discussions about treatment options, symptom management and future care wishes.

Staff took practical steps to help people make their own decisions. For example, staff discussed advance care planning, treatment escalation plans and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms with people and their families to support understanding and informed decision-making. ReSPECT forms were reviewed regularly with people and those important to them. People were also invited to participate in multidisciplinary team discussions about their care where appropriate, and their wishes were considered when planning treatment and support.

Staff assessed and recorded capacity when people may have had impaired decision-making ability. Staff followed the principles of the Mental Capacity Act 2005 and received mandatory training on consent. Staff told us they completed mental capacity assessments when required and recorded the outcomes within care records.