Hospice of the Good Shepherd

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• 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 assessed a total of 3 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question is requires improvement. We found the service did not always work effectively with partners to establish and maintain safe systems of care. The service had systems in place to manage risk but did not always take timely action to mitigate its impact. There was a system that ensured staff learned from any incidents that occurred within the service. The service did not always have enough skilled and experienced medical staff to care for people who used the service. Suitable cover for medical staff shortages was not always arranged leaving gaps in rota's and the inability to admit patients. However, the service had enough nursing and support staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right nursing care and treatment.

This service scored 59 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

On the day of our first visit, 22 August 2024, we were told that admissions to the inpatient unit had been paused due to not enough medical staff being available to cover the rota and care for patients. A daily single point of referral meeting took place with external care providers to discuss all new referrals suitable for admission to the service with a weekly integrated MDT. We saw issues with medical cover had been noted since May 2024 due to planned leave and vacancies. The service had not fully addressed risks presented when senior medical staff were on planned or unplanned leave. The service relied on staff good will. A service level agreement was in place with an external virtual palliative care consultant advice service who undertook 2 virtual patient ward rounds a week and provided remote virtual specialist advice 24 hours a day, 7 days a week. In the absence of appropriate medical staff specialist palliative care advice could not be followed, medicines prescribed, and clinical examinations undertaken. Clinical records were recorded on an electronic patient record system. Records were stored securely on site. We reviewed 4 patient records during our inspection. We noted one patient record did not include the notes of the virtual ward round. Care records demonstrated holistic assessments took place in collaboration with patients and person-centred care and support plans were in place. Risk assessments were completed for falls, manual handling, pain scores and pressure ulcers. Patient safety incidents were managed well. Staff could report positive care experiences. The service had a system to ensure staff stayed and up to date with policies and procedures and best practice guidance.

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

Up to the time of our first visit, leaders had not worked effectively with system partners to mitigate the risk and gaps in medical cover in the upcoming weeks. An action plan was in place to undertake an external independent review into medical staffing. During our second site visit leaders appeared engaged, involving the board, medical staff and system partners to try and resolve their issues with medical cover. The board were awaiting the results of the independent review. A number of meetings took place where patient risk and updates could be shared such as; handover, safety huddles, and ward rounds. Staff had access to reflective sessions facilitated by a counsellor. Safety bulletins were produced to inform and update staff of any risks and associated policies. We looked at a sample of patient records and risk assessments which demonstrated a patient centred care approach. Individual risk assessments were completed for each patient on admission to the ward and community services and were reviewed regularly, including after any change in circumstances. These included pressure area risk assessments, falls, nutrition, moving and handling and infection prevention and control. Risk assessments were reviewed regularly to make sure they remained up to date and reflected the patient's needs. Staff were knowledgeable about people’s needs and how to support them, taking into account their individual preferences and what was important to them. Staff we spoke with knew how to escalate concerns and how to access the safeguarding policy and guidance.

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

At the time of the inspection there was one registered nurse vacancy and Consultant in palliative medicine. There was only one senior doctor available to act as Responsible Clinician (RC) and therefore reciprocal arrangements to provide cover during their absence was not in place. There was a rota for senior management site cover and clinical on call rota out of hours in place. However, during the RC’s absence these measures were not enough to support the indemnity cover of one doctor to ensure admissions continued. Leaders had drafted a plan to cover the medical rotas, however this was yet to be implemented. The medical appraisal policy was not updated when the SLA with a local trust ceased and there were many references to requirements and training etc. stipulated by the local trust. The service used an acuity tool to establish safe nursing levels. The nursing rota was well staffed for the number of patients receiving care and treatment at the time of the inspection.

We spoke with all medical staff as part of the assessment process and were advised that the medical staff appropriately escalated concerns to senior management around the shortage of on-site consultant support, permanent Responsible Clinician cover and progression opportunities through clinical supervision, prior to escalating externally.

Nursing rotas demonstrated safe staffing levels and skill mix. Admissions were pre-planned so staffing could be adjusted appropriately. Nursing staff received full inductions, regular appraisals and felt supported by their manager. Volunteers received a full induction. The service checked staff suitability for work, requesting references, reviewing staff qualifications and checking Disclosure and Barring Service records. However, the service could not easily provide evidence to show all medics had appropriate indemnity. The recruitment policy made no reference to checking indemnity insurance. There were ongoing concerns in relation to one doctors’ indemnity insurance and ability to work without supervision of the RC. There were no mitigations in place to provide this supervision during the period of assessment and the RC’s imminent annual leave. Staff had regular mandatory training; leaders monitored training compliance. Staff received training in safeguarding, dementia, and mental health training. Nurse’s training levels were 95%. 2 of the 5 medics were not up to date with their mandatory training. Non-clinical staff mandatory training was 86% July 2024.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.