St Margaret's Somerset Hospice - Taunton

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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 rated safe as Outstanding. We assessed two quality statements that reviewed the safety of systems, pathways and transitions and the safety and effectiveness of staff. Patients told us they felt safe under the care of the service and that continuity of care was maintained when they needed to move between internal and external services. Patients said they accessed the hospice services when needed. The views of patients, relatives and staff were listened to and considered during care discussions. Patients told us nursing staff were genuinely empathetic, kind, helpful and caring. Risk assessments considered patients who were deteriorating and/or in the last days or hours of their life. Care was focused on ensuring patients remained comfortable. Staff were knowledgeable and treated patients with respect and dignity. There was a strong sense of mission running through the organisation. Patient records were systematically reviewed and had clearly documented discussions with patients and families about symptom control, medicines management, preferred place of care and death, and prognosis where appropriate. The hospice had a well-defined incident reporting system and encouraged staff to report any safety concerns promptly. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and provided patients honest information and suitable support. Staff told us morale was high and they felt listened to and valued for what they contributed to the lives of patients in end-of-life care. Staff said they had the utmost respect for the leadership team who fostered a learning culture without blame. The approach to identifying and managing risks was proactive and effective. The effectiveness was systematically monitored and managed. There was a spiritual care team which was available 365 days a year. Staff received support to deliver safe care. This included supervision, appraisal and support.

This service scored 81 (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.

Patients told us the service worked with them and their families, carers and guardians. They were involved in the development of their care plans, including pain management plans, advanced care plans and their social needs. They said the service arranged all associated tests and appointments such as radiology, imaging, nerve blocks and doctor’s appointments. They said they felt supported and trusted the quality of information they received. They said call bells were answered quickly and their pain was kept under control.

Nursing staff completed and updated risk assessments for patients and removed or minimised risks. Staff shared key information to keep patients safe when handing over their care to others. Documentation and risks associated with the last days of life were noted and acted on. Staff said that where the progression of a patient’s illness was clear towards the end of their life, the level of interventions were reduced to a minimum. For example, staff balanced the need to reposition a patient at risk of pressure ulcers while acknowledging this could be uncomfortable for them. There was a project to ensure end-of-life care maximised the time patients had, doing what was important to them in the place they wanted to be, aimed to improve patient experience and hospital flow for end-of-life patients. The project involved the patients, their families, the local NHS Trust’s discharge teams and various other external organisations. Safeguarding policies and procedures ensured staff were knowledgeable about identifying and reporting risks. Staff told us they felt comfortable reporting patient safety incidents. Staff told us that learning was shared through follow up meetings. Staff told us they were consistently offered debrief meetings after traumatic events. They told us they were open and transparent and gave patients and families a full explanation when things went wrong. Although we did not see examples of where duty of candour had been applied, staff demonstrated an understanding of their responsibilities by describing the process and what they would do, in line with the service’s policies and legislation. The Community Nursing Team provided a Rapid Home to die option which is a 72-hour wrap around service to enable people to die at home if wanted. Safety and continuity of care happened through a collaborative, joined-up approach to safety, involving patients, staff and other partners in their care.

There was positive feedback from partners. There was a full complement of Trustees with a good skill metrics including: clinical, business, finance, digital, fundraising and retail in a variety of longevity. Trustee board meetings were held quarterly with a clinical element at the start of each meeting, for example, a patient story, to ensure the board were grounded and connected to the purpose of the organisation. They told us there were four “power of the hour” meetings to discuss bigger topics, for example, the impact of assisted dying. There were 2 strategic away days to discuss updating the strategic 5-year strategy. Trustees told us there was always lots of challenge at meetings with a high-quality professional debate and an effective flow of information to the board. We reviewed the results of the annual staff survey and saw they fed into decision making in relation to recruitment and staff rates and had helped to focus on retention and training locally for both medical and nursing staff. Leaders told us “We want to build staff’s ownership, we want to …build and give staff a clear voice with consistency to improve staff’s engagement.”

Care and support were planned and organised in ways that ensured continuity. Policies and processes about safety were aligned with other key partners who were involved in people’s care journeys, enabling shared learning and driving improvement. The service used tools to measure patients' physical symptoms, psychological, emotional, spiritual, and support needs; and other tools to enable accurate clinical assessments. In addition, the service had developed a complexity tool which allowed better case load management in the community. Staff were supported by senior staff when patients deteriorated. There was a clear out of hours escalation protocol. The hospice had transferred to a different Electronic Health Record system in January 2024. The service was on phase 2 to launch electronic prescribing on the inpatient unit. We reviewed 6 patient records and respective medication charts. All inpatient and community care records assessments we checked were completed accurately and clearly. All necessary care plans and Integrated Palliative Care Outcomes Scale (IPOS) were completed where appropriate. The medication charts and syringe driver checklists reviewed were completed appropriately and legibly. Records showed that prescribed medications were in line with national and local guidelines, such as: “End of life care for adults: Service delivery [NG142]” and “Care of dying adults in the last days of life [NG31]”, “End of life symptom control Guidelines for Somerset” and the prescribing formulary. The computer terminals staff used to manage patient’s records were kept safe and secure. The service managed patient safety incidents well. Staff reported serious incidents clearly and in line with the provider’s policy. There were systems to make sure incidents were investigated appropriately. Staff were open, transparent and honest about reporting incidents. They were clear about how they would report them.

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

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

People felt nursing staff were genuinely empathetic, kind, caring and helpful. Patients we spoke with told us there were enough staff to ensure the care they needed was provided, even during nights and weekends.

Patients experienced a high standard of care, delivered by a team of qualified and experienced staff. The hospice ensured there were always enough staff on duty with a suitable skill mix to meet the needs of patients. The inpatient ward had 8 patients with 3 registered nurses and 4 healthcare assistants during the day and 2 registered nurses at night and 3 healthcare assistants. The community nursing team was divided into geographical areas, each area had consultant cover. There were no vacancies within the team. There were community nurses available 7 days a week. The day hospice was open 3 days/week between 10am – 2pm. There was a lead nurse supported by a healthcare assistant and volunteers. There was maximum 10 patients per session. This allowed staff to meaningfully care for people and offer advice and support. Volunteers were an essential part of care and provided a welcoming, caring environment. Volunteers felt valued and part of the team. They received an induction and a training programme. There was a dedicated education team which included 2 clinical leads, 1 manager, 1 administration support and 1 community nurse. Staff said the training was good and there were additional sessions available should they need them. There were induction programmes for each clinical role; staff said it was thorough. We heard an example of a member of housekeeping staff internally trained to a healthcare assistant, a healthcare assistant trained to nurse associate and a registered nurse training to advanced care practitioner. The team had good working relationships with the Integrated Care Board, charities, the local NHS Trust and the head of education at NHS England. There were mutual agreements to share training opportunities, pilot projects and funding for higher studies. Staff had clinical supervision on a regular basis. Staff in the day hospice had requested, and received, professional development in areas where patients sought further information.

Recruitment processes were reviewed by checking 5 staff records. We found they were generally complete, except the reasons for gaps in employment were not documented in all 5 records we reviewed. Two out of the 5 records had not received 2 references . After informing the provider of our findings, actions were taken that made the recruitment process more robust by including information about employment gaps and personal references in the new recruitment form and documenting this information thoroughly at the job offer stage. Staff received training appropriate and relevant to their role. Mandatory training included safeguarding adults and children, moving and handling, Mental Capacity Act, medicines management, learning disability, equality and diversity, dementia awareness, cardiopulmonary resuscitation and infection prevention. Continual professional development training was delivered each year. The education team had been inventive in ways of accessing training and had organised training in specific topics. For example, they had brought in guest speakers to talk about Somerset Coroner’s service and trialled the use of virtual reality (VR) headsets to simulate what it was like to be a patient receiving end of life care. We received evidence of staff’s supervision dates being recorded and updated in line with the supervision policy. Staff had received their annual appraisal. Staff at all levels had opportunities to learn, and poor performance was managed appropriately. Developmental pathways were in the process of being developed and rolled out across services. These included clinical skills, self-awareness, leaders in area and outcome and results.

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.