Teesside Hospice Care Foundation

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Teesside Hospice had a proactive, systematic approach to managing safety. Leaders embedded, maintained and sought to continuously improve a culture of openness and collaboration, and safety was everyone’s top priority. Staff recognised and reported incidents and near misses.

Operational systems supported safe, coordinated care. There was a collaborative approach to working with partners to identify and manage shared risks. Safeguarding risks were proactively identified, managed, actioned and reduced.

The hospice teams ensured environmental safety and infection control were consistently monitored for safety. Effective systems and processes were used to safely prescribe, administer, record and store medicines.

The service was well staffed with a range of skilled professionals and high training compliance. There was a proactive approach to workforce planning.

At our last inspection we rated this key question requires improvement. At this inspection, the rating has changed to good.

This service scored 81 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had adopted the Patient Safety Incident Response Framework (PSIRF). This framework is a requirement for all NHS services and sets out a standardised response to incident management with a no blame culture. All organisations holding NHS contracts must develop a Patient Safety Incident Response Plan (PSIRP).

In recognition of the limitations of smaller hospice organisations in applying requirements from a strategy designed for larger NHS organisations Teesside Hospice had worked in collaboration with other local hospices as part of the North East and North Cumbria (NENC) Hospice Network. This enabled pooling knowledge, resources and sharing learning from incidents across the region. There was a joint PSIRP in place that was reviewed annually by the network of clinical leads for the NENC Hospice Network.

The service had recently adopted a process where reviews of all deaths were carried out. We saw this enabled the team to learn where improvements could be made but also recognise when people had a ‘good death’ and use this evidence to recognise, celebrate and reinforce good practice and team morale. There was a formalised Patient Safety, Mortality and Learning group.

Where actions were identified following incident reviews we saw there were clear action plans, target dates and named leads. The team were proactive in setting up task and finish groups to improve processes.

There had been no serious incidents or adverse events in the last 12 months.

Staff were familiar with the incident reporting system and aware of what to report and how to report an incident. Staff received appropriate training in incident reporting. Trained facilitators supported systematic investigation and reflection. Themes from incidents were monitored and reviewed.

Staff understood responsibilities under the Duty of Candour, which is a legal and ethical obligation for healthcare providers to be open and transparent with patients when things go wrong in their care. There was a policy in place that set out a process to follow if and when things went wrong. There were no recent examples where the team had needed to apply Duty of Candour.

Staff received feedback from investigation of incidents. This included internal incidents and external incidents through shared learning with other organisations. Staff told us a learning culture was embedded through daily handovers and monthly team meetings. There was also a bulletin sent to all staff that would include learning and recent incidents when there had been any. Examples had included pressure ulcers and discharge processes.

Pressure ulcers were routinely reported as incidents. We reviewed audits demonstrating pressure ulcers were consistently reported 100% of the time.

Staff were actively encouraged to participate in incident reviews and to discuss feedback.

Staff told us changes were made following learning and reflection from reported incidents. For example, a task and finish group had been set up to review the discharge process following on from staff identifying that there had been some omissions in discharge planning.

Staff had the opportunity to take part in debrief and receive support after a serious incident. Five staff had completed Resilience Based Clinical Supervision (RBCS) training and were able to support reflective debriefs. RBCS is a model of supervision for anyone who is affected by emotional demands in their work or personal life. One member of the team also attended the Hospice UK network for RBCS.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about patients was received to determine if needs could safely be met. The Community and Wellbeing team oversaw all referrals into Teesside Hospice for inpatient, community and wellbeing support. This team held real time knowledge of bed availability within the hospice and took this into account alongside individual wishes when managing expectations regarding the most appropriate place to provide care. There were direct referral routes for the Lymphoedema Clinic and Bereavement Support services.

The Community and Wellbeing team did regular in-reach visits through the week to the local hospital to support transitions to the hospice services. This included transitions to any Teesside Hospice service and was not limited to transfers to the in-patient unit (IPU). Where appropriate to meet individual needs joint visits with district nurses, specialist palliative care team or other acute hospital teams were carried out.

The hospice completed robust discharge checks. A task and finish group had been set up to review discharge processes from the hospice to home, hospital or other care facilities. We saw processes were carried out smoothly and all staff were clear on their responsibilities. Onward referrals were completed in a timely way for community palliative care teams and district nurse.

There was a formal information sharing agreement in place with the local acute trust allowing the hospice team to access relevant electronic patient records when needed.

Specialist palliative care ambulance provision was requested from the local NHS ambulance service provider through a recognised ordering protocol.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. For example, a close working relationship with the local NHS ambulance service meant a patient flag could be applied to a person’s records. This meant the ambulance call handler was notified to access additional information about the person. This ensured sensitivity when working with people.

Detailed handovers were held at the change of each shift. Multi-disciplinary team (MDT) meetings took place during the week to support effective systems and pathways.

The evidence showed an exceptional standard. The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

The service had comprehensive systems in place to keep people safe. Policies were actively updated and changed to reflect changes in legislation for example, to ensure more subjective assessment for Deprivation of Liberty Safeguards (DoLs).

The team were actively engaged in understanding themes and trends within the local area to ensure continual detection of concerns that may be less obvious. Local data was reviewed against national data to support knowledge of local trends through established joined up working with the local authority social services teams.

There was an adult and a children’s safeguarding lead. The safeguard leads actively participated in learning events with the local authority for shared learning, for example, where there had been complex circumstances surrounding death and safeguarding needs of others involved. The team regularly reviewed safeguarding incidents as opportunities for learning and sharing best practice with others. For example, support was offered to one care home regarding managing end of life care following a safeguarding incident.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff shared examples of when they had raised safeguarding concerns. Staff were skilled in understanding the complex nature of people’s circumstances and worked with individuals to determine what being safe meant to them.

Staff found innovative ways to work with individuals in complex social situations to ensure they could receive the best end of life care whilst safety of others within the hospice was not impacted upon. For example, where people used substances or had loved ones who did so.

Staff were trained to appropriate levels for children and adult safeguarding. The service aligned the training requirements with the Royal College of Nursing intercollegiate standards. Three people were trained to level 4 for adult and children’s safeguarding and were designated safeguarding leads. All other staff training for safeguarding children and adults was above the providers compliance target. Staff had achieved the target rate for compliance on autism and learning disability training level 1. The service was rolling out level 2 training.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

There was a safeguarding policy for adults and a safeguarding policy for children. The policies outlined all local contact details for local authorities where people accessed the service from. There were clear responsibilities and training requirements for each staff role set out.

Staff followed safe procedures for children visiting the service. The safeguarding children policy set out procedures for children visiting whether this was as part of a school choir to the wellbeing centre or to visit loved ones on the IPU. Monthly children’s safeguarding supervision sessions were facilitated for staff.

The service promoted a ‘think family’ approach and identified information regarding families with children or young carers should be recorded on patient records and shared with the MDT.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At the point of referral for hospice services an Outreach Nurse Practitioner (ONP) undertook assessments and worked with patients to determine the most appropriate intervention and best place of care depending upon needs, wishes and risks.

Staff communicated with patients so they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. For example, by using picture cards. Staff worked with patients and their loved ones in a holistic way to manage risks in the most enabling way possible.

The hospice MDT implemented treatment escalation plans with inpatients and their loved ones based on individual conversations and wishes. A comprehensive range of clinical risk assessments were carried out within 24 hours of admission to the in-patient unit.

The service had a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) Policy. This included guidelines for communicating patients future care to multi-professionals.

The wellbeing service used a red, amber, green (RAG) rating for patients accessing the wellbeing services. Red patients were reviewed on a weekly basis with frequency reducing depending upon RAG rating. Visual displays available to staff evidenced clear RAG rating of individuals. Ratings were determined using a standardised scoring system based on assessment of individual need.

Staff enabled patients to make advance decisions. An Individual Plan of Care (IPOC) was completed and set out a person wishes, needs and preferences for the last phase of life.

There was an operational procedure setting out a clear process for people who may choose to self-discharge against medical advice.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Patients and their loved ones provided consistently positive feedback about the hospice environment. Descriptions included a ‘home from home’ environment, ‘like a hotel’ and like ‘being in a spa’.

All inpatients had individual rooms. Some rooms were en-suite. There was an accessible bathroom for use on the IPU. This was a jacuzzi type accessible bath. There were additional level access shower spaces. Lighting could be altered within bathrooms and jacuzzi experiences offered.

Some bedrooms had hoisting facilities and patients were assigned to rooms according to moving and handling needs.

Inpatients had access to lounge areas that were fully furnished and tastefully decorated. Each bedroom had direct access to the garden area and its own outdoor seating area with a path leading around to a pond. Garden spaces were equipped with seating and umbrellas.

All rooms had air conditioning and could be cooled allowing patients to ‘Rest in Peace’ after their death. Loved ones did not have to feel pressured to vacate the room. A cooling system was available for use if the deceased patient was resting at the hospice overnight.

There were some kitchen facilities accessible for preparing food and hot drinks. There was a spacious wellbeing area where people attended for group sessions. There was also a separate counselling building with spacious rooms that could be used by patients and their loved ones. Spaces were also equipped for use by children.

The main reception area to the hospice was welcoming and spacious. There was a reflection space accessed directly from the main reception that could be closed off as a private space if required. This area did not have natural daylight but picture windows had been installed to allow for a natural lighting feel.

All patient areas were level access. Appropriate security systems were in place, including accessible pull cords in toilets, self-opening and closing doors. Swipe access was used out of hours for ensuring security of the environment.

Medical devices and equipment were clean, intact and ready for use. An asset register was kept up to date and identified the responsible team for each piece of equipment, for example, when a patient came in with a syringe drive in place this equipment would be identified as belonging to an external team.

There was a store cupboard between each patient bedroom with necessary equipment for providing care. Each store cupboard was set up in the same way making it easy to locate required equipment quickly.

Resuscitation equipment was appropriately stored on the IPU. There was an automated external defibrillator in the main reception area and first aid kits available for each area across the hospice site. Regular checks were carried out to ensure safety of equipment.

Staff were appropriately trained in the use of equipment such as syringe drivers. Where required we saw competencies were in place.

Fire extinguishers were placed appropriately and had up to date servicing. There was weekly fire alarm testing. To avoid disruption for patients, tabletop major incident training was carried out with staff including simulation of fire evacuation procedures. We reviewed the content of these sessions and saw comprehensive content with sessions being repeated frequently to reach a target of 100% attendance. Feedback from these sessions was proactively implemented into policy reviews, for example, the implementation of ready to go emergency bags at key locations. At the time of inspection, the hospice had also been working with a fire specialist and the local fire brigade to carry out a full review of fire safety across the site.

Patient emergency evacuation plans (PEEPS) were in place for each individual patient. PEEPS were reviewed daily based on individual needs, for example, mobility and oxygen use.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing was reviewed daily following each morning handover using a recognised tool to determine staffing requirements based on patient acuity and dependency. This was further reviewed later in the day to ensure responsiveness to changing needs throughout the shift. Professional judgement was also incorporated into the staffing daily reviews. Events such as MDT meetings or mandatory training were taken account of when planning the daily staffing requirements. A small team of regular bank staff were offered shifts as required. There was a clear escalation process for staff to follow when staffing levels on the IPU fell below the minimum number. If staffing could not sufficiently meet the needs of patients safely then admissions would be limited.

Staff were able to work into other teams, for example inpatient staff could support the wellbeing team if there were staff shortages.

Turnover and sickness rates were monitored by team leads and actions taken if themes began to emerge. For example, a recent short-term increase to staff sickness had been reviewed and a clear understanding of reasons identified.

Staff groups had individual competencies according to role. Leaders also supported each staff group to attend bespoke away days. For example, there were two away days each year for registered nurses (RN’s) and two away days for health care assistants (HCA’s).

All staff, including bank staff, received a comprehensive induction when starting. We reviewed the induction programme and found this appropriate for individual roles with clear timescales for completion. The induction orientated staff to all areas within the hospice service regardless of where the job role was based. The induction for IPU staff included, for example, time within the Wellbeing and Outreach team and with the Income Generation team.

The hospice had medical cover 24 hours, seven days a week. The medical team was led by a dedicated palliative medicine consultant and made up of experienced physicians with an extensive range of previous experience. The dedicated hospice medical staff were on shift throughout the week. There was an out of hours Specialist Palliative Care consultant arrangement for cover including the local hospital, community palliative care and end of life care services.

The hospice was a General Practitioner (GP) training site. One-year placements were offered for GP trainees.Teesside Hospice was also an approved placement provider for Internal Medicine Training (IMT) registrar trainees, offering supervised clinical experience within the hospice setting.

Allied health professionals worked within the hospice on service level agreements from the local NHS trust. There was designated physiotherapy, occupational therapy, dietetics and pharmacy input. A social worker was directly employed by the Teesside Hospice.

The hospice also employed a comprehensive range of counsellors and complementary therapists on a paid contractual and voluntary basis.

Volunteers had equal access to online training. If extra support was required to access training for people who were less experienced in managing online training or who had additional needs the volunteer lead found ways to adapt the training approach to support completion.

Staff were supported to develop by taking up shadowing opportunities with other teams and other disciplines within the hospice provision. Staff could also access the local NHS trust for training opportunities.

All staff had access to mandatory training online. Mandatory training rates were above the target for compliance for all regular staff. However, in some areas the rates for compliance for volunteers and bank staff were below the recognised compliance target of 85%. This included volunteer roles for the Wellbeing and Outreach team (69.74%) and bank staff on the IPU (83.87%). Due to the relatively small size of these staff groups this related to only three members of staff across both groups who were all still within induction periods. Autism training had also been added for all volunteer staff groups in the weeks previous to the inspection which had temporarily altered training figures whilst staff worked through the training.

The mandatory training was appropriate for the patient group using the service. Staff told us they had time to complete training.

In addition to mandatory training, additional specialist training could be provided in response to need. For example, additional training had been sought for Non-Invasive Ventilation (NIV) and management of PICC (Peripherally Inserted Central Catheter) lines.

The evidence showed an exceptional standard. The service thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly.

The service maintained a high standard of infection prevention and control practices. The NHS cleaning standards had been adopted and were consistently adhered to. All areas of the hospice were clean, had appropriate furnishings and were well maintained.

Housekeeping staff were present and available to respond to any additional cleaning requirements. Cleaning schedules were clearly displayed in all areas and demonstrated regular cleaning was completed. Cleaning audits were completed daily, weekly and monthly.

Infection prevention and control (IPC) learning was shared across the local NHS hospital and the Teesside Hospice. External audits were carried out. The last audit reviewed IPC practices against nine standards. The overall score for the audit was 97%. Each standard was rated low risk. Where action plans had been indicated these were developed and implemented immediately following the audit.

Deep cleaning including removal of radiators for dusting took place monthly and when rooms were vacated.

Staff adhered to infection control principles, including handwashing. There were hand hygiene posters displayed in all hand wash basin areas and hand gels appropriately located within the service. There was a dedicated hand wash only sink in the sluice.

Bespoke infection prevention and control training days were provided by the local NHS hospital within the hospice.

The service carried out their own laundry. There was a laundry management policy outlining safe management and segregation of laundry where it might be soiled or from an infected patient. The policy followed appropriate national guidelines.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service had a strict governance process in place to ensure patient safety in relation to medicines management. Routine audits and monitoring were carried out. Medication omissions, refusals and errors were all reported and investigated. The medicine management policy set out clear responsibilities of staff groups and key individuals.

Accurate medication histories were taken at admission. Changes to medications were clearly communicated to patients and across all relevant care settings. MDT discussions included medication consideration. Prescribing practices followed national and local guidance. We saw controlled drugs were prescribed and documented correctly.

We saw a patient centred approach to managing medications. Patients and families were involved in medication decisions where possible and appropriate. Information was provided in accessible formats. For example, verbal explanations tailored to the individual or written information. Self-administering of medicines was supported through a competency-based risk assessment of individual patients by a doctor.

Medicines were stored securely with swipe access available only to staff authorised to handle medications. Controlled drugs (CD’s) were stored according to guidelines. Temperature checks were recorded and monitored.

Staff administering medicines were trained and competent. Patients had the option to receive support to self-administer medications if they chose to. We saw single nurse administration of CD’s had become a well-established practice within the hospice. This had been implemented to support faster access to pain relieving medications for patients. This in turn, enhanced their end-of-life experience and meant loved ones did not hold memories of the person they cared for experiencing prolonged pain and discomfort whilst waiting for two members of staff to become available to administer CD’s. Staff had taken part in a robust and well supported training package with theoretical and practical competency assessments. Staff who lacked confidence and preferred to continue with double nurse checking were supported and did not feel compromised to practice beyond their skillset.

Medical gases were used for comfort and symptom relief. The service had piped oxygen in all rooms. This allowed for a more peaceful environment without noise and obstruction from standalone equipment. Medical gases were safely and securely stored according to guidelines.

Syringe drivers were used for administering pain medications directly into the body for comfort. Clear documentation was maintained including the indication for the use of the syringe driver and compatibility of medicines. Regular checks were carried out once the syringe driver was sited. Symptom control was assessed and recorded regularly. Anticipatory medicines were prescribed in discussion with the patient and loved one’s involvement. Clear escalation plans were in place and there was out of hours on call support for medication management through local joined up pharmacy arrangements.

Disposal of medications was done in line with legislation.

A service level agreement was in place with the local hospital pharmacy department for supply of named patient medication, provision of weekly pharmacist input for oversight of prescribing and clinical audit. There was also access to emergency on call pharmacy services.