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Sue Ryder - Leckhampton Court Good

All reports

Inspection report

Date of Inspection: 13 December 2011
Date of Publication: 23 December 2011
Inspection Report published 23 December 2011 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

Overall, we found Sue Ryder Leckhampton Court Hospice was compliant with this essential standard.

People who come to Leckhampton Court for care and support do so in a service that makes effective decisions about the care and treatment it delivers. This is done by regular audit, assessment, and monitoring of the quality of the service. The service takes action from learning about adverse events, complaints, incidents and accidents, and compliments from visitors, and views of members of staff.

User experience

We did not talk with people who use the service specifically about this outcome area.

Other evidence

The service had a number of different processes for assessing and monitoring the quality of care delivered. There were regular meetings of members of staff including multi-disciplinary meetings with staff from all areas of the hospice, doctors meetings, senior management (heads of department) meetings and quality reviews.

The hospice quality improvement steering group met bi-monthly but this had recently moved to monthly quality meetings. The hospice quality improvement steering group fed into the national quality action group. The quality meeting looked at many areas of the hospice service including complaints, compliments, the quality improvement plan, quality visits from the corporate team, the staff skill mix, incidents and accidents and the risk register. The group also looked at audits recently undertaken, research projects, continuity of care arrangements, policy updates, educations and training, and feedback from service users.

The service operated a risk management tool called Datix. This system was used for recording incidents and accidents, including health and safety incidents and any incidents that involved service users. The hospice used the system to analyse trends of incidents and developed action plans to address any emerging trends and report on lessons learned.

In the service user experience survey for 2010/11, the Leckhampton Court hospice scored 100% for service users rating the service as 'good' or 'excellent'.