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Inspection Summary

Overall summary & rating


Updated 20 April 2017

This inspection took place on 14 December 2016 and was unannounced. Following the inspection we received feedback from family members of the people who used the service, volunteers and other services working in partnership with St Luke`s Hospice.

St Luke`s Hospice is registered to provide specialist palliative care, advice and clinical support for adults with life limiting illness and their families. The service delivers physical, emotional, spiritual and holistic care through teams of nurses, doctors, counsellors and other professionals including therapists. The service provides care for people through an In-Patient Unit, Day Service and Out- Patient Care. St Luke`s Hospice contracted with a registered nursing care provider to run a ‘hospice at home service’. The hospice at home service and a fast response team called ‘One Response’ were based and had their offices in St Luke`s Hospice and offered a service for people with palliative care needs living in the community.

The 'One Response' service was an innovative fast response service which offered support, assessment and advice to people with life limiting condition living in their own homes over 24 hour seven days a week. The support could be accessed via telephone where the call was triaged and staff could arrange specialist visits to people within two hours. This service was run in conjunction with Macmillan nurses, Marie Curie nurses and end of life specialists. At the time of our inspection the service was supporting approximately 300 people either with direct care or by telephone support.

At the time of the inspection there were three people using the inpatient service and around 500 people using day services. The day services offered a range of services to people recently diagnosed with life limiting conditions, their carers and families. The service provided specialist advice, courses, complementary therapy sessions and outpatient clinics. It aimed to empower people to be in control of their condition and achieve what was important to them.

St Luke`s Hospice had a registered manager 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.

Staff had permanent support and guidance from a social care professional employed by the hospice and were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to report any concerns they had. Risks to people`s well-being were assessed by staff daily and there were measures in place to mitigate risks and keep people safe. Risk assessments were reflective of people`s changing abilities and needs and measures to ensure people were as safe as possible were implemented accordingly.

People received care based on best practice from experienced staff with the knowledge, skills and competencies to support their complex health needs. People and families received care from staff and volunteers who developed positive, caring and compassionate relationships with them. The service promoted a culture that was caring and person centred. Staff worked together as a multidisciplinary team to provide the care people wanted and needed.

People told us they were fully involved in setting their priorities for care. Care plans in regard to all aspects of people`s medical, emotional and spiritual needs were personalised and written in partnership with people. Staff delivered support to people respecting their wishes and preferences.

People who used the various services offered at the day hospice told us the help and support they received was invaluable for them and their family. They valued the support they received from the different activities, courses and clinics which helped them to live with and manage their symptoms to maximise their health and helped them prepare for the future. They also appreciated the opportunity to meet with people in similar conditions and the social aspect of the services provided.

People told us that staff understood their individual care needs and were compassionate and understanding. Staff told us they undertook training which enabled them to provide good quality care to people in the inpatient unit, in the community and in the day hospice.

Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced. Staff reported any concerns so these could be reviewed and discussed to identify if lessons could be learnt to reduce the likelihood of recurrence.

Recruitment procedures were robust and ensured that staff working at the service were qualified and skilled to meet people`s complex needs. Staff told us they worked and trained towards their personal development plans and were happy with the support from their managers. There were sufficient numbers of staff to ensure people received support when they needed it.

People’s medicines were administered by trained and qualified staff who had their competency to give medicines safely assessed regularly by their manager. Any changes in people`s medication were discussed by the medical team, nurses and pharmacist to manage and support people’s symptoms and pain management. Medicines were regularly reviewed and audited to ensure they met people’s needs.

The registered manager and staff were clear about their responsibilities around the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and were dedicated in their approach to supporting people to make informed decisions about their care.

The registered manager was committed to improve and broaden the services the hospice offered. They established seamless working relationships with other organisations to be able to reach out to as many people with complex needs as possible. They were constantly involved in research and development of new services together with partner organisations and promoted coordinated personalised care for people in the community. The services provided by the hospice had the support of volunteers who were closely involved in every aspect and department the hospice operated.

The service actively encouraged and provided a range of opportunities for people who used the service and their relatives to provide feedback and comment upon the service in order to continue to drive improvement.

There was a comprehensive auditing programme for all the services the hospice provided carried out by the quality and education service team. Action plans were comprehensive in detailing actions taken, time frames and the person responsible for the actions.

Inspection areas



Updated 20 April 2017

The service was safe.

Staff had been trained to recognise and respond to any actual or potential abuse. The provider had developed systems for reporting and monitoring allegations of abuse.

Potential risks to people were assessed and discussed with people and measures were put in place to reduce risks.

Accidents and incidents were analysed and learning was shared amongst staff in meetings to prevent recurrence.

There were sufficient numbers of staff with the appropriate skills and knowledge to meet people`s needs at all times.

People received their medicines from staff who were trained and qualified in safe administration of medicines and the use of specialist equipment to ensure people received their medicines in time and safely.



Updated 20 April 2017

The service was very effective.

People received effective care, based on best practice from staff with the knowledge and specialist skills to manage their pain and physical symptoms.

Staff received excellent training and support to gain practical skills as well as develop their knowledge and abilities further and met people`s needs holistically.

People’s human and legal rights were respected because staff understood their responsibilities in relation to the Mental Capacity Act (MCA) (2005) and Deprivation of Liberty Safeguards (DoLS). Staff were qualified and followed best interest processes where people lacked capacity.

People were supported to eat and drink and maintain a balanced diet. The chef and the catering team worked very closely with the nurses and doctors from the hospice to improve the quality of life for people and meet their nutritional needs.

People's health needs were carefully monitored by nursing staff and if people`s health required, appropriate referrals were made to other professionals.



Updated 20 April 2017

The service was very caring.

People’s and their relative`s feedback about the caring approach of the service and staff was overwhelmingly positive.

People told us staff showed kindness and showed empathy when they faced challenging situations.

Staff made exceptional efforts to ensure people could achieve their preferred place of death.

The service was very flexible and responded quickly to people’s changing needs or wishes. Staff communicated effectively with people and treated them with compassion and respect.

People were consulted about and fully involved in their care and treatment. The service provided effective end of life care and people were enabled to experience a comfortable, dignified and pain-free death.



Updated 20 April 2017

The service was very responsive.

People and their families were fully involved in assessing and reviewing their needs and planning how their care should be provided. This included their wishes and priorities regarding their end of life care and preferred place of death.

The service provided person-centred care based on best practice and focussed on continuous improvement.

Staff and the management from the hospice developed new services in response to the needs of the people using the hospice and people living in the community.

The service encouraged people with life limiting conditions and their family’s involvement in the hospice by offering a range of services and complementary therapies in the day service centre.

People’s families were offered bereavement support and counselling for as long as they needed it.

The service had a positive approach to using complaints and concerns to improve the quality of the service.



Updated 20 April 2017

The service was very well-led.

The service promoted a positive and open culture. It provided a range of opportunities for people who used the service, their relatives and people from the wider community to comment on and influence the quality of service provided.

The Board of Trustees, the Chief Executive and the Registered Manager met regularly to discuss the services offered to people and their families and ways to improve and diversify these.

The service worked in partnership with other organisations to ensure they followed best practice and provided a high quality service. They developed new services to meet the needs of the people in and outside their catchment area.

There were robust auditing systems in place to ensure the quality of the service was monitored and actions were in place to constantly drive improvement.

There was a constant effort to improve and people`s voice was actively listened to by staff and the management in the hospice.