Ellenor Gravesend

At our last inspection to the service on 11 and 12 May 2016 Ellenor Gravesend provided specialist palliative care, advice and clinical support for adults with life limiting illness and their families. Since this inspection, the service has been registered as one service with Ellenor’s children services and now provides palliative care for babies, children and adults. They deliver personal, emotional and holistic care through a multi-disciplinary team of nurses, doctors, counsellors, physiotherapists, therapists, spiritual leaders and a range of volunteers. On site the 15 bedded ‘Inpatient Ward’ admits people from 14 years to adulthood and the ‘Hospice day service’ provides support for up to twenty adults. Community teams provide services for babies, children and adults. There are two adult teams: 'The Hospice at home’ for people in their own homes and the ‘Care Home Support team' for people in care and nursing homes. Children's services include a respite service for parents/carers; cancer care for children so they can receive chemotherapy in their own homes and a range of clubs and activities. The service was providing support for around 1420 people and their families at the time of the inspection.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 11 May 2016, we asked the provider to take action to make improvements in the management of medicines and record keeping with regards to the care and treatment. This was with regards to adults in the Inpatient Ward. Guidance was not in place for the use of some medicines and creams and waste medicines were not disposed of in a timely manner. Accurate records were not always kept with respect to each person's individual care. The breaches were of Regulation 12, Safe care and treatment and Regulation 17, Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider sent us an action plan in August 2016 which stated that they would comply with all Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by the end of September 2016.

At this inspection on 25, 26 and 27 July 2017 improvements had been made to the management of medicines in the Inpatient ward and people’s records with regards to their care and treatment.

There were safe systems in place for the administration, recording, handling, storage and disposal of medicines. Staff were trained in how to give medicines safely, a pharmacy technician ensured medicines were available when people needed them, and a community pharmacist provided a clinical review of people’s prescribed medicines.

Since the last inspection to the adult service on 11 and 12 May 2016 and the children’s service on 19 and 20 July 2016 the service had maintained standards of care and continuously strived towards developing creative and innovate ways of supporting children, adults and their family members.

In the children’s service there had been a major cultural shift led by the head of children’s nursing. Staff reported that the head of children’s nursing had been very brave in the changes and developments within the team, and this had resulted in them having a shared understanding of the aims of the service. This benefitted children and their carers as they were able to take assessed risks and positively engage the whole family, by directing their resources where they were most needed. This had included designing and implementing a tool for children transitioning to adulthood which proactively encouraged partnerships with other teams in the community and across the organisation. Young people could access the Inpatient Ward to receive respite care in a way that met their individual needs and wishes as teenagers such as themed sleep-overs. When young people transitioning had not meet the eligibility criteria for the adult service, the multi-disciplinary team had held a brain storming session and came up with lots of ideas about how existing adult day services and groups could be adapted to meet their needs. This is a national issue and ensured the service continued to offer support and remain in contact with the young person until they time when they would meet the criteria.

The adult service had built on and further developed its services and management and staff reported that they had started to reap the benefits of these initiatives. They had continued to work towards closer relationships with people from local communities that were underrepresented in the service such as Black, Asian and Ethnic groups to discuss how to engage them in palliative care services. This work had been effective as during the inspection a nurse was called to the home of a person from one of these groups and stayed with them until their death, to ensure they died at home as per their wishes and those of their family. The head of well-being was new to their position at the last inspection, but was now established in post. They had further developed the range of health, social and therapeutic activities available as a direct response to the needs of children and adults. Groups included music for well-being, cooking, poetry, meditation and breathlessness, gardening, spiritual reflection, an after school club and a tea and movie night. The service had taken the basis of a Schwartz round and developed it in an innovative and creative way to focus on the experiences of people who used services, rather than those of staff. The Schwartz round which took place during the inspection was called, “From the horse’s mouth- what it is really like to be referred to Ellenor”.

Commissioners said the service had been effective in reducing the numbers of children and adults admitted into hospital. A children’s commissioner told us, “Ellenor have prevented the children in their care from being admitted into hospital through the innovative interventions they have put in place in the child’s home”. A Commissioner for adult services said, “The service has made such a difference to people in care homes, supporting them to keep them in the community and out of hospital. Patient care is their priority and they work with us to ensure this”.

In the adult service initiatives had been undertaken to make contact with people with palliative care needs so interventions and support could commence for the person as soon as possible, rather than in their last few days. The ‘Care Home Support team' had contacted all nursing homes in the local area to identify each adult with a life-limiting condition. It had grown from supporting 140 people in January 2017 to 770 people at the time of the inspection. The service had met with all GPs in the local area and through this process had identified over 300 people whom they could offer support to help them to remain in their own homes, in preference to spending their last days in hospital.

Bereavement services were tailored to children and adults’ individual needs, provided over a significant period of time after death and were continually developed to meet local need. These included therapeutic sessions led by a play therapist for small groups of siblings and children of adult’s who had died at the service and ‘drop in’ sessions for their carers.

Relatives spoke overwhelmingly of the positive support their child or adult family member received from the service. Adults, children and their family members valued their relationships with the staff team and felt that they often went ‘the extra mile’ for them, when providing care and support. They were full of praise for the staff in terms of their kindness, compassion and individual responses to their family member’s needs. The service viewed supporting the person or child and their family members was seen as a key to people’s well-being.

People and relatives said they or their family member felt safe and well looked after when receiving care from the service. Ensuring people were safeguarded was at the centre of the service. All staff had received training in safeguarding adults and children and understood the importance of protecting people, visitors and themselves.

The service provided outstanding end of life care where children and adults were enabled to experience a comfortable, dignified and pain-free death in the place of their choice when possible. Staff embodied the values of the service which included providing compassionate and professional care and supporting the 'whole family' before, during and after a death.

Staff were motivated and keen to convey to inspectors their pride in working at the service. Staff were listened to, empowered with training and fully supported in their roles. The provider was mindful of the emotional challenges staff experienced and had developed strategies and opportunities for reflection and resilience. This included Schwartz rounds and a journal club to enable staff to have the support they required to continue to provide caring and compassionate care.

Adults and children were supported by a multi-disciplinary team who put them and their family members at the centre. Joint working with other professionals was central to how care was delivered and in identifying people who would benefit from their services. Adults and children’s nutritional and hydration needs were assessed and guidance was in place about how to meet them. Food provided by the service was appet

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were safe systems in place for the ordering of medicines, but there were some shortfalls in the administration and disposal of medicines.

Most records were held on a computer system and available to all health professionals involved in the person’s care to ensure continuity of care. However, some records, such as aspects of people’s health care on the in-patient unit, were inconsistent and contradictory so although people received the care they required, this was not reflected in their records.

People said that they felt well looked after and safe when receiving care from the service. Staff received training in safeguarding adults and children and understood the importance of protecting people, visitors and themselves.

People said that there were enough staff available to promptly attend to their needs. They were were cared for by a staff team who felt well-supported so they had the skills and knowledge to meet people’s needs.

Assessments of risk were individual to people’s specific needs and identified how risks could be minimised. Accidents and incidents were responded to and monitored to see if there were any patterns or trends that required improvements to be made to ensure people’s safety.

Checks were carried out on all staff at the service, to ensure that they were fit and suitable for their role. New staff received a comprehensive induction and training to ensure staff had the skills and knowledge to support people with long-term illnesses or who needed end of life care. The service encouraged staff to further their learning and had an educational centre which delivered accredited training in palliative care.

People were supported by a multi-disciplinary team and referrals were made to other professionals to seek their advice and input when it was required. Their health, medical and nutritional and hydration needs were assessed and closely monitored.

The service recognised that some young people saw themselves as adults and had established a transitional pathway which enabled them to receive age-appropriate respite care on the in-patient ward. Young people received support from nurses whom were known to them and undertook activities that they enjoyed during their stay, making it a positive and valuable experience.

Staff understood their roles and responsibilities in relation to the Mental Capacity Act 2005 (MCA). This provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The service had made an application under DoLS to ensure that people were not unlawfully deprived of their liberty.

The service provided outstanding end of life care and people were enabled to experience a comfortable, dignified and pain-free death in the place of their choice when possible. It had received a large number of compliments concerning the kind, compassionate and outstanding caring manner of the staff team.

Peoples’ psychosocial, spiritual and therapeutic needs were catered for and supporting the person and their family members was seen as a key to people’s well-being. This included bereavement counselling, therapies and support from the chaplain based at the service.

People and family members were involved in planning their care and treatment. People’s individual wishes with regards to their care were recorded and staff went the ‘extra mile’ to ensure they were realised.

People benefitted from the service building links with other hospices, the ambulance service and with the local community. They were able to make their views known and knew how to make a complaint or raise a concern. When complaints had been received, these had been investigated and used as lessons learned to improve the service.

The service was led by a strong management team, who led by example. There was an open culture, staff and people were listened to and valued. The service had a clear direction of the areas in which it intended to develop further to meet the needs of the local community. Education and research was seen as key to making improvements in the lives of people with palliative care needs.

We found two breaches of the Health and Social Care Act 2008 (Regulated activities 2014). You can see what action we told the provider to take at the back of the full version of the report.

Both the people we spoke with said that they were very happy with the care that they received. One person we spoke with described the service as 'Excellent.' A second person we spoke with said, 'It is wonderful. I feel as if I have come to heaven.'

On the day of our inspection all areas of the in-patient unit and the day care unit were seen to be clean, bright and airy. We saw that the service had an infection control policy which included detailed instructions on hand hygiene. We spoke with two nurses. Both told us that they followed the service's infection control policy and wore protective clothing, aprons and gloves, when these were required.

We saw that the recruitment files contained a 'new employee checklist' that ensured that all necessary checks were taken before the person took up their new post. Documentary evidence of identity had been recorded for each member of staff.

We saw that the records for people who used the service were multi-disciplinary and were completed by the teams within the service that had contact with the person, be that the in-patient unit, day unit or home visiting service.