Ellenor Gravesend

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. There was a culture of learning and people were cared for in an environment that was appropriately clean and well maintained. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Staff knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses in line with hospice policy. They were involved in discussions about learning from incidents during team meetings and received relevant feedback. Staff and leaders had a good understanding of duty of candour and gave examples of when they would use this.

Leaders had implemented the NHS Patient Safety Incident Framework to develop effective systems and processes to respond, learn and improve from patient safety incidents. Incidents were comprehensively investigated and there was clear analysis of incident data and trends with comparison with previous reporting periods. Top priorities had been identified as medicines, falls, pressure ulcers and information governance data and confidentiality. We reviewed 6 months’ incident data between April and September 2024 as saw that all incidents resulted in no harm or low harm.

Incidents were reviewed at quarterly quality and patient experience group meetings and at regular care leadership team meetings. There was a culture of sharing learning from incidents externally, for example, with other local hospices. There were also arrangements for joint investigations and learning from incidents with other local NHS services.

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

People and those close to them we spoke with told us they understood what was happening with their care. They told us they were involved in planning care, including discharge planning and plans for where people wanted to be cared for at the end of life.

Patient assessment processes included the use of recognised tools to identify changes in a patient’s condition and potential deterioration. The use of the Integrated Palliative Care Outcome Scale (IPOS) guided staff in identifying changes to patient illness and ability to function. Assessments were undertaken every 3 days in the inpatient ward and at every contact in the community. The scale was used to inform multidisciplinary and handover discussions about care. There were clear support structures in place in the event of changes to a patient’s health, including 24 hour medical cover for people on the inpatient unit. A weekly virtual ward round was held with the out of hours medical provider prior to the weekend. These processes supported the timely transfer of people between different services as necessary.

There were clear processes and pathways for patient transfers, and collaborative arrangements with other local services to ensure safety and continuity of care. Leaders and staff worked closely with healthcare partners to ensure people were cared for in the most appropriate environment and in line with their wishes. There were clear communication arrangements with both community and NHS acute services.

The electronic patient record used within the hospice was integrated with GP records. There were appropriate data sharing arrangements in place. The hospice was in the processes of extending this arrangement with community services. This enabled information to be shared in real time which supported the continuity of care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff received training specific to their role on how to recognise and report abuse in both adults and children. Doctors were trained to safeguarding level 3. Training for nursing and other clinical staff was provided at level 2, however, leaders had reviewed this with external safeguarding teams and implemented adaptions to the length of training to make it level 3. Volunteers received safeguarding training relevant to their roles.

The operational lead for the inpatient ward was the safeguarding lead for the hospice. They attended external safeguarding meetings and were part of a Kent wide safeguarding group. There were clear structures for sharing concerns quickly and appropriately, including outside of normal working hours.

Staff could give examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff demonstrated a good understanding of safeguarding processes and gave examples of when these had been implemented.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff understood what constituted a safeguarding concern and how to escalate concerns internally and externally. External contact numbers were included in the safeguarding protocols for both adults and children.

Staff followed safe procedures for children visiting the ward. They ensured all children were supervised by a parent or guardian.

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.

Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident. Staff knew about and dealt with any specific risk issues. For example, relating to sepsis, falls and pressure ulcers. They used nationally recognised risk assessment tools to identify risks associated with malnutrition, the use of bed rails and manual handling considerations. They took steps to mitigate and manage risks.

The service had access to specialist mental health support. Staff completed, or arranged, psychosocial assessments and risk assessments for people thought to be at risk of self-harm or suicide. They had internal psychological support services and could refer people for more specialist mental health support.

People and those close to them were involved in the identification of risks and ways to minimise the impact of these. Central to this was people’s wishes so that they could continue to do what was important to them, where possible, while receiving care.

Staff shared key information to keep people safe when handing over their care to others. Handovers included a holistic approach to assess physical, emotional and social needs and staff ensured these aspects of the assessment process bore equal weight in identifying risks to patient wellbeing.

Shift changes and handovers included all necessary key information to keep people safe. Staff had enough time to share information during shift changeovers.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

People could reach call bells and staff responded quickly when called. People told us that staff responded promptly to any requests for help.

The design of the environment followed national guidance. People were cared for in individual rooms and shared bays. Health and safety risk assessments with mitigating actions were carried out in line with Health and Safety Executive (HSE) guidance. These included fire safety, water safety, security and other environmental risk management practices.

Staff carried out daily safety checks of specialist equipment. They ensured that emergency equipment and essential equipment such as syringe pumps (for continuous administration of palliative and end of life care medicines) were routinely monitored, maintained and accessible.

The service had enough suitable equipment to help them to safely care for people. Staff told us that equipment was readily available and there were no concerns with access. The hospice maintained an equipment register and complied with relevant equipment safety and calibration checks. This included Lifting Operations and Lifting Equipment Regulations (LOLER) for moving and handling equipment. There were arrangements for medical device servicing and decontamination and staff received relevant training.

Risk management of information technology included arrangements as part of business continuity and disaster recovery plans. Systems were appropriately backed up and patient records were available with essential information contained, in the event of issues with the electronic patient record.

Staff disposed of clinical waste safely. We observed appropriate segregation of clinical and non-clinical waste. Sharps containers were clean, labelled and not overfilled.

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

Managers regularly reviewed staffing levels and skill mix. On the inpatient ward there were 2 trained nurses and 2 healthcare assistants during the day and 2 trained and 1 healthcare assistant at night. We reviewed staffing rotas and saw that actual staffing reflected the planned establishment.

The inpatient service used bank and agency staff to cover unfilled shifts. This was generally due to the one-to-one care needs of individual people or due to staff absences. The service used regular bank and agency staff, all of whom were assessed as competent in areas such as medicines administration and the use of syringe pumps.

Within the hospice at home team there were 2 clinical nurse specialists on shift each day, working within 2 locality teams linked to geographical areas and GPs. In addition, there were staff nurses, a nurse associate and healthcare assistants providing care in the community. The care home support team was ked by a CNS and undertakes daily visits to local care homes to support them with the care of residents at the end of life. A flexible bank staff system was used within the community service, agency staff were not used. A healthcare assistant night sitting service was provided on 2 nights a week to provide families with respite when caring for someone at the end of life at home.

The absence rate for care services was between 3.8% and 5.4% over the course of 2024/2025 year to date. This was in part due to long term absences. At the time of our assessment there was 1 part time registered nurse vacancy within the inpatient ward and 2 staff nurse vacancies within the hospice at home service. Staff turnover was between 6% and 7%.

Medical staffing was provided by 2 palliative care consultants and 3 speciality doctors working Monday to Friday. There was an on call system overnight and at weekends. Additional consultant on call support was provided from a national provider at weekends, including the provision of a Friday virtual ward round.

Staff had access to a range of training and development opportunities. This included induction, role specific competency training and more specialist training based on the needs of the role. This included access to the European Certificate in Palliative Care and palliative care updates, in-house speakers and skills updates.

Staff received and kept up to date with their mandatory training. The mandatory training was comprehensive and met the needs of people and staff. Training covered a number of modules including health and safety, basic life support and infection prevention and control. The hospice’s target of 95% training completion had been met or exceeded in all training modules for all staff and volunteers. Essential training was developed and delivered in response to learning from incidents, for example, in pressure ulcer prevention and wound care.

Staff completed training on recognising and responding to people with mental health needs, learning disabilities, autism, and dementia.

Managers monitored mandatory training and alerted staff when they needed to update their training.

Staff received an annual appraisal and had individual development plans. Recent improvements to the performance management of appraisal rates had seen an increase from 64% to 95% achievement overall for the organisation. Staff we spoke with told us they had received an appraisal in the last year.

Staff had access to clinical supervision, this could be individual or group depending on individual roles. The service had recently reviewed the clinical supervision offering due to low uptake and were adapting the offer to better meet the needs of staff.

New volunteers completed recruitment checks based on the role they applied for. All volunteers undertook mandatory training and role specific training and induction. This included face to face training sessions.

People were positive about the support they received from staff, telling us they felt safe in the care they received.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The inpatient ward manager was the infection prevention and control (IPC) lead. They participated in a local Integrated Care Board (ICB) joint IPC group and liaised with relevant agencies to ensure that IPC practice was in line with national guidance.

Ward areas were clean and had suitable furnishings which were clean and well-maintained. We observed that all areas were tidy and free from clutter and visibly clean. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly.

Infection control audits were conducted annually on the inpatient ward. These were supported by the local NHS infection prevention and control team. We saw that action from the audits was completed. For example, furniture that was not up to infection control standards was replaced.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Staff used infection control measures when transporting people after death. There was a cold body store and this was monitored to ensure safety, including daily records of temperatures.

The service had systems for prescribing, administering and handling medicines. We found a few areas where processes were not being followed correctly but the provider responded immediately ensuring they were actioned; staff were informed and polices were revised.

People were prescribed and administered their medicines by staff, and this was recorded on a treatment chart. People’s allergies were recorded and when required medicines were clearly prescribed with maximum doses and indications. There were discretionary medicines available for staff to respond to minor ailments.

There was a policy to allow people to self-administer their own medicines and we saw that one person was administering their own inhaler and pain relief when attending appointments away from the service. The relevant risk assessments had not been completed and there was no policy to cover the supply of medicines to people temporarily leaving the service. The provider responded immediately by instigating a secondary dispensing policy allowing doctors to perform this task until nurses had completed competencies. Appropriate dispensing containers were obtained and a reminder to staff to complete risk assessments along with links to the amended policy were immediately circulated to staff.

There was a patient information leaflet regarding the off-label use of medicines (when the use is not covered by the manufacturer) available, following our inspection this was revised to make it more informative and easier to read for patients.

A pharmacy service was provided by a local community pharmacy. The pharmacist visited twice a week and attended the weekly multi-disciplinary team (MDT) meeting. There was no out of hours pharmacy provision. The pharmacy was responsible for ensuring the medicines stocked at the hospice were fit for use.

Medicines ordered were supplied within 24 hours and anything unable to be supplied was obtained from another local chemist including anything required out of hours.

Staff told us they received annual medicines training including calculations and syringe pump competencies.

Medicines were stored in locked cupboards within the treatment room, however we found 4 items which had expired. The service responded by raising with the pharmacy and starting a secondary checking process.

Prescription stationery (FP10s) was securely stored which only authorised staff could access and it was audited appropriately.

Emergency medicines and equipment to treat anaphylaxis were in a broken box with no tamper evident seal and expiry of Aug 2020 on the outside of the box. The medicines inside were in date but one piece of equipment had expired. Records did not indicate these were being checked regularly. This was immediately addressed by the service; a new box and tamper proof seals were ordered; a new checking procedure was started, and policies updated.

People receiving their medicines by injection through the skin via a syringe pumps had all the necessary checks in place and the equipment was serviced regularly.

There was a process for medicine recalls and safety alerts within the service, but we found that one alert ensuring people were given the correct information when steroids were prescribed had not been actioned and people did not receive the necessary alert cards when they were discharged from the service. The service immediately undertook a review of historical alerts and ensured all actions had been completed.

Two of the five people examined had not had VTE risk assessment completed, and one assessment had not been updated and did not match the current prescription. The provider immediately audited a sample of people and identified the reasons for incomplete assessments and addressed the issues appropriately. Additional checks were put in place to ensure these are completed accurately in the future.

Controlled Drugs were being monitored by the service regularly, but policy was not always being followed, such as crossing out in the CD register and not undertaking a weekly check of all CD stock. Immediate actions were taken to ensure that staff followed best practice when checking Controlled Drugs.

Medical staff undertook the process of medicines reconciliation when people were admitted to the service, but this was not always recorded on the treatment charts but was recorded on a proforma on the electronic system. Medicine reconciliation is the process where staff check that people have the correct medicines when they move between services or are admitted from home.

When people’s care was transferred for example to the acute hospital, medicines information was transferred with them to allow the receiving service to continue providing medicines safely.

The medicine management group met monthly with the ICB where incidents were shared. Examples of learning from incidents included the introduction of a red tabard system to cut down on distractions for staff when completing medicines administration rounds.

A medicine audit had been completed in April 2024 by the contracted pharmacy, but the issues found on inspection had not been identified or highlighted to the provider.