Hospice of the Good Shepherd

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 2 quality statement from this key question. We have combined the scores for this area with scores based on the rating from the last inspection, which was good. Our rating for this key question is requires improvement. The service did not always instil team working, staff felt communication was ineffective between different teams. However, staff supported each other to provide good care. The service monitored patient outcomes but did not always use the findings to make improvements.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

The medical and nursing staff were involved in the morning handover and daily admission dependency meeting. Nursing staff attended morning and evening safety huddles which discussed personalised care planning, patient safety, risk, observations, medicines management, infection prevention control, the monitoring of patient outcomes and red flag staffing risks. Leaders planned to introduce joint safety huddles. During the assessment period the daily staffing resource sheets were amended to include medical staffing risks. There was no SLA in place to provide a medical consultant, leaders were exploring options with the ICB and with local partners to resolve the gaps in medical cover. The hospice had been without a formal agreement with a Responsible Officer for a number of months but had entered into a memorandum of understanding from July 2024 with a third party to provide an external Responsible Officer service. The staff survey showed 30% of staff felt communication between different teams were effective. 36% off staff felt they were not well informed about what was happening within the charity. Staff described working with general practitioners, pharmacists and district nurses to ensure timely care was received. Staff told us they worked well with external teams such as tissue viability, physiotherapy, pharmacy and speech and language therapy. Hospice leaders told us they had local MDT meeting that they held twice a week. The service also held Living Well MDT sessions and integrated MDT which consisted of hospitals and relevant committees. Leaders were engaged with local hospice partnerships, the ICB and stakeholders to work collectively to drive improvements. The hospice worked with the Cheshire and Merseyside hospice network and end of life care network. During the temporary inpatient unit closure, service leaders provided staff with MDT learning sessions, such as fire evacuation simulations, oncological emergencies, safeguarding scenarios and discussions.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Audits were undertaken to monitor and improve outcomes for patients. We reviewed completed audits for syringe driver set up and use, infection prevention and control, hand washing, pressure ulcers, falls, medicines, and clinical records. External audits were completed for medicines, and controlled drugs. Leaders held daily huddles to discuss learning from audits. The service participated in local and national clinical audits and bench-marked itself against other services in the area and nationally. They were involved in Hospice UK programme for bench-marking pressure ulcers, falls, and medicines errors. We reviewed their Management of Controlled Drugs audit March 2023, the service met 100% compliance in 5 of the 7 areas and identified 2 areas for improvement. The service had an action plan in place to improve compliance, part of this action plan included re-auditing in 1 year, using the same audit tool. The service's last 12 months preferred place of death (PPD) audit from August 2023 to September 2024 was 65% of wishes being met, 20% not getting their PPD and 15% of patient with PPD wishes unknown. The provider followed National Institute for Health and Care Excellence (NICE) guidelines and nationally recognised evidenced based care and treatment to assess patients’ needs and deliver care and treatment. The hospice engaged in a local hospice collaborative project which had a vision to strategically drive regional improvements. Leaders engaged with the Integrated Care Board around the Patient Safety Incident Response Framework (PSIRF) implementation.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.