duchess of kent hospice · quality report dellwood community hospital 22 liebenrood road reading...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Outstanding –

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Outstanding –

Are services responsive? Good –––

Are services well-led? Outstanding –

DuchessDuchess ofof KentKent HospicHospiceeQuality Report

Dellwood Community Hospital22 Liebenrood RoadReadingBerkshireRG30 2DXTel: 01189550474Website: www.suerydercare.org

Date of inspection visit: 7 - 8 November 2019Date of publication: 13/01/2020

1 Duchess of Kent Hospice Quality Report 13/01/2020

Letter from the Chief Inspector of Hospitals

Duchess of Kent Hospice is operated by Sue Ryder a national charitable organisation which specialises in providingpalliative and neurological care to people living with life-limiting conditions.

The hospice has 15 inpatient beds. Facilities include an inpatient unit, day therapy unit, lymphoedema service,community specialist palliative care to patients at home service, and a bereavement service. Duchess of Kent hospiceoperated from a location in Reading and had satellite centres in Wokingham and Newbury.

The hospice provides end of life and palliative care for adults.

We inspected this service using our comprehensive inspection methodology. We carried out a short-notice announcedinspection on 7th and 8th November 2019. We gave staff two days’ notice that we were coming to ensure that everyonewe needed to talk to was available. We inspected services at Reading and Wokingham.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are theysafe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and compliedwith the Mental Capacity Act 2005.

Services we rate

Our rating of this service improved. We rated it as Outstanding overall.

We found outstanding practice in relation to:

• Staff treated patients and their families with compassion and kindness, respected their dignity and privacy, andwent above and beyond expectations to meet their individual needs and wishes. Staff were devoted to doing allthey could to support the emotional needs of patients, families and carers to minimise their distress. Staff helpedpatients live every day to the fullest.

• Services were delivered in a way to ensure flexibility, choice and continuity of care and were tailored to meetpatients’ individual needs and wishes. The service planned and provided care in a way that fully met the needs oflocal people and the communities served. It also worked proactively with others in the wider system and localorganisations to plan care and improve services.

• It was easy for people to give feedback. Concerns and complaints were taken seriously and investigated, andimprovements were made in response to feedback where possible. Patients could access services when theyneeded them.

• Leaders ran services well using best practice information systems and supported staff to develop their skills. Staffunderstood the vision and values, and how to apply them in their work. Staff were motivated to provide the bestcare they could for their patients. There was a common focus on improving the quality and sustainability of careand people’s experiences. Staff were proud to work at the service and felt respected, supported and valued.Leaders operated effective governance processes and staff at all levels were clear about their roles andaccountabilities. The service engaged well with patients, staff and the local community.

We found good practice in relation to:

Summary of findings


• Despite some staff vacancies, the service had enough staff to care for patients and keep them safe. Staff hadtraining in key skills and understood how to protect patients from abuse. The service controlled infection risk well.Staff assessed risks to patients and acted on them. The service managed safety incidents well and learned lessonsfrom them. Staff collected safety information and used it to improve services.

• The service provided care and treatment based on national guidance and best practice. Staff gave patients enoughto eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of theservice and made sure staff were competent. Staff worked well together for the benefit of patients, supported themto make decisions about their care and had access to good information. Key services were available seven days aweek.

• The service planned care to meet the needs of local people, took account of patients’ individual needs and wishes,and made it easy for people to give feedback. Concerns and complaints were taken seriously and investigated, andimprovements were made in response to feedback where possible. Patients could access services when theyneeded them.

We found areas of practice that require improvement:

• Clinical and pharmaceutical waste was not always stored securely.

• ReSPECT forms were not audited to check for completeness.

Following this inspection, we told the provider that it should make some improvements, even though a regulation hadnot been breached, to help the service improve. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Hospiceservices foradults

Outstanding – We rated this service as outstanding for caring andwell-led and good for safe, effective and responsive.

Summary of findings


Contents

PageSummary of this inspectionBackground to Duchess of Kent Hospice 7

Our inspection team 7

How we carried out this inspection 7

Information about Duchess of Kent Hospice 7

The five questions we ask about services and what we found 9

Detailed findings from this inspectionOverview of ratings 14

Outstanding practice 43

Areas for improvement 43

Summary of findings


Duchess of Kent Hospice

Services we looked atHospice services for adults

DuchessofKentHospice

Outstanding –


Background to Duchess of Kent Hospice

Duchess of Kent is operated by Sue Ryder a nationalcharitable organisation which offers palliative care andtreatment for adults living with life-limiting conditions.The hospice opened in 1992 as a NHS organisation,however was taken over by the Sue Ryder organisation in2011. The service covers a catchment area in WestBerkshire, including Reading, Wokingham and Newbury.The main hospice is located in Reading where theinpatient facility is located, day services are run from hereand two satellite centres in Wokingham and Newbury.

The hospice has had several registered managers in postsince 2011. At the time of the inspection, the currentregistered manager had been in post and registered withthe CQC since January 2019.

The registered manager is the hospice’s accountableofficer for controlled drugs.

Our inspection team

The team that inspected the service comprised a CQClead inspectorand a specialist advisor with expertise inend of life and palliative care. The inspection team wasoverseen by Cath Campbell, Head of Hospital Inspection.

How we carried out this inspection

We inspected this service using our comprehensiveinspection methodology. We carried out a short-noticeannounced inspection on 7th and 8th November 2019.

We gave staff two days’ notice that we were coming toensure that everyone we needed to talk with wasavailable. We inspected services at Reading andWokingham.

Information about Duchess of Kent Hospice

The Duchess of Kent Hospice is a local service run by theSue Ryder charity.

The hospice service provides specialist palliative care,advice and clinical support for adults with

life limiting illness and their families. They deliverphysical, emotional and holistic care through teams ofnurses, doctors, counsellors, chaplains and otherprofessionals including therapists. The service cares forpeople in three types of settings: at the hospice in 15beds 'In-Patient Unit', or in their 'Hospice day service' thatwelcomes up to 10 people per day, and in people's ownhomes through their community service. The serviceprovides specialist advice and input, symptom controland liaison with healthcare professionals. Services are

free to people. The Duchess of Kent hospice is partfunded by an NHS contract agreement but is dependenton donations and fund-raising by dedicated staff andvolunteers in the community.

The services provided include counselling andbereavement support, family support, clinicalpsychology, chaplaincy, an out-patient clinic,occupational therapy, physiotherapy, dietetics,befriending, complementary therapies and diversionaltherapies and a lymphoedema service (for people whoexperience swellings and inflammation, usually to theirlimbs, after cancer treatments).

The hospice accepts both male and female adultpatients.

Summaryofthisinspection

Summary of this inspection


The hospice is registered to provide the followingregulated activities:

• Diagnostic and screening procedures

• Transport services, triage and medical adviceprovided remotely

• Treatment of disease, disorder or injury

During the inspection, we inspected the inpatient unit atReading and the day therapy unit, lymphoedema service,and community services at Reading and Wokingham. Wespoke with 38 staff including registered nurses, nursingassistants, medical staff, therapists, the chaplain,volunteers, social worker, team leaders and seniormanagers. We spoke with 8 patients and 3 relatives. Weobserved the environment and care provided to patientsin the hospice setting and one home visit. We reviewedfour patient records. We also reviewed information thatwe held about the hospice and information requestedfrom the hospice, including performance data, policiesand meeting minutes.

There were no special reviews or investigations of thehospice ongoing by the CQC at any time or during the 12months before this inspection. The hospice has beeninspected three times, and the most recent inspectiontook place in December 2015, which found that thehospice was meeting all standards of quality and safety itwas inspected against. We rated the hospice good forsafe, effective, caring, responsive and well-led. Thehospice was rated good overall.

Activity (July 2018 to June 2019)

• In the reporting period July 2018 to June 2019, 1,843patients were treated for palliative care. Of these,1,351 (73%) were aged between 18 and 65 years, and492 (27%) were aged over 65 years.

Track record on safety:

• Zero Never events

• Zero serious incidents

• Zero incidences of healthcare associated MRSA

• Zero incidences of healthcare associated Clostridiumdifficile (C. diff)

• Zero complaints

Services provided at the hospice under service levelagreement:

• Clinical and or non-clinical waste removal

• Laundry

• Maintenance of medical equipment

• Pathology, histology and microbiology

• Pharmacy

• Medical gases




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Our rating of safe stayed the same. We rated it as Good because:

• The service provided mandatory training in key skills to all staffand made sure everyone completed it.

• Staff understood how to protect patients from abuse and theservice worked well with other agencies to do so. Staff hadtraining on how to recognise and report abuse and they knewhow to apply it.

• The service controlled infection risk well. Staff used equipmentand control measures to protect patients, themselves andothers from infection. They kept equipment and the premisesvisibly clean.

• The design, maintenance and use of facilities, premises andequipment kept people safe. Staff were trained to use them.

• Staff completed and updated risk assessments for each patientand removed or minimised risks. Risk assessments consideredpatients who were deteriorating and in the last days or hours oftheir life.

• Despite some nurse staffing vacancies, the service had enoughnursing and support staff with the right qualifications, skills,training and experience to keep patients safe from avoidableharm and to provide the right care and treatment. Managersregularly reviewed and adjusted staffing levels and skill mix,and gave bank and agency staff a full induction.

• The service had enough medical staff with the rightqualifications, skills, training and experience to keep patientssafe from avoidable harm and to provide the right care andtreatment. Managers regularly reviewed and adjusted staffinglevels and skill mix.

• Staff kept detailed records of patients’ care and treatment.Records were clear, up-to-date, stored securely and easilyavailable to all staff providing care.

• The service used systems and processes to safely prescribe,administer, record and store medicines.

• The service managed patient safety incidents well. Staffrecognised incidents and near misses and reported themappropriately. Managers investigated incidents and sharedlessons learned with the whole team and the wider service.When things went wrong, staff apologised and gave patientshonest information and suitable support. Managers ensuredthat actions from patient safety alerts were implemented andmonitored.

Good –––




• The service used monitoring results well to improve safety. Staffcollected safety information and shared it with staff.

However,

• Clinical and pharmaceutical waste was not always storedsecurely.

Are services effective?Our rating of effective stayed the same. We rated it as Goodbecause:

• The service provided care and treatment based on nationalguidance and best practice. Managers checked to make surestaff followed guidance.

• Staff gave patients enough food and drink to meet their needs.They used special feeding and hydration techniques whennecessary. The service made adjustments for patients’religious, cultural and other needs.

• Staff assessed and monitored patients regularly to see if theywere in pain, and gave pain relief in a timely way. Theysupported those unable to communicate using suitableassessment tools and gave additional pain relief to ease pain.

• Staff monitored the effectiveness of care and treatment. Theyused the findings to make improvements and achieved goodoutcomes for patients.

• The service made sure staff were competent for their roles.Managers appraised staff’s work performance and heldsupervision meetings with them to provide support anddevelopment.

• Doctors, nurses and other healthcare professionals workedtogether as a team to benefit patients. They supported eachother to provide good care.

• Key services were available seven days a week to supporttimely patient care.

• Staff gave patients practical support to help them live well untilthey died.

• Staff understood how and when to assess whether a patienthad the capacity to make decisions about their care. Theyfollowed the hospice’s policy and procedures when a patientcould not give consent.

However,• ReSPECT forms where not audited to check for completeness.

Good –––

Are services caring?Our rating of caring improved. We rated it as Outstanding because:

Outstanding –




• Staff treated patients and their families with compassion andkindness, respected their privacy and dignity, and went aboveand beyond expectations to meet their individual needs andwishes. Patients and their families were truly respected andvalued as individuals by an exceptional service.

• Staff were devoted to doing all they could to support theemotional support to patients, families and carers to minimisetheir distress. People’s emotional and social needs were seenas being as important as their physical needs.

• Staff supported and involved patients, families and carers tounderstand their condition and ensure they were activepartners in their care and treatment. Staff helped patients liveevery day to the fullest.

Are services responsive?Our rating of responsive stayed the same. We rated it as Goodbecause:

• The service planned and provided care in a way that met theneeds of local people and the communities served. It alsoworked with others in the wider system and local organisationsto plan care.

• The service was inclusive and took account of patients’individual needs and preferences. Staff made reasonableadjustments to help patients access services. They coordinatedcare with other services and providers.

• Patients could access the specialist palliative care service whenthey needed it. Waiting times from referral to achievement ofpreferred place of care and death were in line with goodpractice.

• It was easy for people to give feedback and raise concernsabout care received. The service treated concerns andcomplaints seriously, investigated them and shared lessonslearned with all staff. The service included patients in theinvestigation of their complaint.

Good –––

Are services well-led?Our rating of well-led improved. We rated it as Outstandingbecause:

• Leaders at all levels had the integrity, skills and abilities to runthe service. They understood and managed the priorities andissues the service faced and had successful leadershipstrategies in place to ensure sustainability in the desired

Outstanding –




culture. They were highly visible and approachable in theservice for patients and staff. They supported staff to developtheir skills, including management and leadership skills andtake on more senior roles.

• The service had a clear vision for what it wanted to achieve anda detailed strategy to turn it into action, developed with allrelevant stakeholders. The vision and strategy were focused onsustainability of services and aligned to local and nationalplans within the wider health economy. Leaders and staffunderstood and knew how to apply them and monitorprogress.

• Staff felt respected, supported and valued with an emphasis onstrong collaboration and team-working. Staff were very proudto work for the hospice and could articulate why. There was acommon focus on providing the best possible care to patientsand continually improving the quality of care and people’sexperiences. The service promoted equality and diversity indaily work and provided opportunities for career development.The service had an open culture where patients, their familiesand staff could raise concerns without fear and were confidentto do so. The service used these as an opportunity to learn andimprove the service.

• Leaders operated highly effective, proactive governanceprocesses, throughout the service and with partnerorganisations. Staff at all levels were clear about their roles andaccountabilities and had regular opportunities to meet, discussand learn from the performance of the service.

• Leaders and teams used systems to manage performanceeffectively. They proactively identified and escalated relevantrisks and issues and identified actions to reduce their impact.They had clear and tested plans to cope with unexpectedevents, which were understood by staff at all levels. Staffcontributed to decision-making to help avoid financialpressures compromising the quality of care.

• The service collected reliable, detailed data and analysed it todrive forward improvements. Staff could find the data theyneeded, in easily accessible formats, to understandperformance, make decisions and improvements. Theinformation systems were integrated and secure. Data ornotifications were consistently submitted to externalorganisations as required.

• Leaders and staff actively and openly engaged with patients,staff, equality groups, the public and local organisations to planand manage services. They proactively collaborated withpartner organisations to help improve services for patients.




• All staff were committed to continually learning and improvingservices. Staff actively shared learning throughout teams. Theyhad a good understanding of quality improvement methodsand the skills to use them. Leaders encouraged innovation andparticipation in research.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Hospice services foradults Good Good Good

Overall Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Outstanding –

Responsive Good –––

Well-led Outstanding –

Are hospice services for adults safe?

Good –––

Our rating of safe stayed the same. We rated it as good.

Mandatory training

The service provided mandatory training in keyskills to all staff and made sure everyone completedit.

The Sue Ryder central mandatory training policy definedthe mandatory training requirements of staff includingbank workers. This included a mandatory training matrixwhich identified the mandatory training requireddependent on job role.

The mandatory training requirements met the needs ofpatients and staff. Courses covered key areas such as firesafety, health and safety, basic life support and infectionprevention and control. Staff understood theirresponsibility to complete mandatory training and told usthe training was relevant to their roles.

The Duchess of Kent hospice set a target of 90% forcompletion of mandatory training. Training moduleswere a mix of e-learning and face-to face practicalsessions. There was an on-site practice education teamwho could provide much of the face-to face training. Thismeant courses could be arranged when needed and at atime suitable for staff. Staff we spoke with told us therewere no barriers to accessing mandatory training.

Staff could monitor their own training needs via thehospice’s electronic system. The system would send anemail alert to the individual when training was due. Thisgave staff ownership for their training.

In addition, the practice education team and linemanagers monitored mandatory training compliance andwould also alert staff when they needed to update.Managers received regular reports about mandatorytraining compliance. This meant they had oversight ofstaff compliance and could address any areas ofnon-compliance when needed.

Most staff were up-to-date with their mandatory training.As of October 2019, compliance with mandatory trainingfor staff working across the whole hospice was 90%.

Safeguarding

Staff understood how to protect patients from abuseand the service worked well with other agencies todo so. Staff had training on how to recognise andreport abuse and they knew how to apply it.

The Sue Ryder central policy for safeguarding adultsprovided staff with guidance on the prevention of abuseof service users in all Sue Ryder care environments inEngland (which included Hospices and services in thecommunity) and those individuals who have contact withSue Ryder either as supporters or members of the public.There were clear systems, processes and practices inplace for reporting safeguarding concerns which reflectedlegislation and local requirements. Safeguarding policiesand pathways were in-date and were accessible to staff.

The Duchess of Kent hospice had a designated lead forsafeguarding adults and another lead for safeguardingchildren. Although the hospice did not provide services

Hospiceservicesforadults

Hospice services for adults

Outstanding –


for patients under the age of 18, they recognised theirresponsibilities to identify and report safeguardingconcerns in children that might be visiting service users atthe hospice. The safeguarding leads were available toprovide support, supervision, training and updates forstaff.

We saw safeguarding information displayed in locationswe visited during the inspection indicating the actionsneeded to be taken by staff if there was a safeguardingconcern.

All staff we spoke with were aware of the signs of abuseand demonstrated an understanding about safeguardingadults and child and young people processes. They knewwho the safeguarding leads were at the hospice and howto escalate if they had concerns. We were given exampleswhen staff had needed to raise concerns and the actionsthat they had taken.

Staff liaised with other professionals and agencies, suchas GPs, the police and the local authority safeguardingleads, when needed. The safeguarding lead attendedregular meetings with their counterparts from other SueRyder hospice sites and local authority safeguardingmeetings. Topics discussed included nationalsafeguarding guidance and learning from serious casereviews.

Staff received safeguarding training appropriate for theirrole and according to Sue Ryder central policies.Safeguarding level 3 training was completed by thesafeguarding lead for adults and the head of clinicalservices. Safeguarding level 2 was completed by the leadfor children and young people and all other staff workingwith patients. The hospice set a target of 90% forcompletion of safeguarding training. As of October 2019,97% of staff had completed safeguarding training.

Cleanliness, infection control and hygiene

The service controlled infection risk well. Staff usedequipment and control measures to protectpatients, themselves and others from infection.They kept equipment and the premises visibly clean.

Sue Ryder had central infection control policies to helpcontrol infection risk, these included the Infectionprevention and control policy, uniform and appearancepolicy, waste management policy and procedure and

safer sharps policy. These and other related policiescovered the actions required by staff to minimise the riskof infection and cross infection in Sue Ryder hospices,homecare services, outpatient and satellite services.

The inpatient unit, clinic areas and other areas wherepatients visited were visibly clean and tidy and hadsuitable furnishings which were clean andwell-maintained. The hospice had housekeeping staffwho were responsible for cleaning patient and publicareas, in accordance with daily and weekly checklists. Wereviewed these records during the inspection and foundthem to be up-to-date and complete. Cleaningequipment was stored securely in locked cupboards. Thismeant unauthorised persons could not access hazardouscleaning materials.

Staff cleaned equipment after patient contact andlabelled equipment to show when this had last beendone. We saw all equipment not in use had a dated, ‘I amclean’ label to indicate to staff when it was last cleanedand was ready for use. We inspected equipmentincluding mattresses and commodes and found them tobe clean.

Staff were observed following good infection controlpractices to help stop the spread of infection such as‘bare below the elbow’ and cleaning their hands beforeand after contact with patients. Staff also had access tohand washing facilities and personal protectiveequipment, such as gloves and aprons in a variety ofsizes. In addition, hand sanitiser gel dispensers wereavailable throughout the hospice, such as reception,corridors, bedrooms and clinical areas. Community staffcarried a supply of infection, prevention and control (IPC)equipment for use when they visited patients at home,such as hand sanitising gel, gloves and cleaning wipes.

Effective measures were in place to ensure the health andsafety of everyone who came into contact with adeceased person’s body after death. Staff we spoke withwere knowledgeable about these IPC measures andcould describe how they washed and prepared the bodyafter death.

Staff were required to complete IPC training during theirinduction and then annually at the level appropriate totheir role as part of their mandatory training. As ofOctober 2019, 93% of staff had completed IPC training.



Outstanding –


There was a service level agreement with the localcommunity trust infection control team, whom thehospice worked closely with when required. Thisincluded an annual audit of the hospice withrecommendations and suggestions to help improve theoverall IPC standards.

The hospice had a designated lead for IPC who wasavailable to provide support, advice, training and updatesfor staff and monitored compliance with IPC policies.They also held three-monthly meetings with the IPC linknurses who were responsible for overseeing IPC practicesin their area. The IPC lead reported to the hospice’s seniormanagement team (SMT) via the monthly QualityImprovement Group meeting. This meant there was goodoversight of IPC practices throughout the hospice and itsservices.

There were effective systems to ensure standards ofhygiene and cleanliness were regularly monitored, andresults were used to improve IPC practices if needed. Anaudit programme was used to increase and maintainstandards and help prevent the spread of infection.Audits included, monthly hand hygiene audits and wastemanagement audits and three-monthly inpatient unitinfection control audits.

Post inspection we reviewed audit reports and anyresulting action plans. From January to October 2019,hand hygiene audits results were >93% except fromAugust 2019. Following August’s results an action planhad been put in place which included emailing staffabout their practices, addition training and informationposted on the IPC noticeboard. Audits results from thefollowing months, September and October 2019 showedincreased results of 90% and 96% respectively. FromMarch to September 2019 the three-monthly inpatientunit IPC audits, which looked at all areas of the unit,including patient bedrooms, medical equipment, laundryand housekeeping facilities, showed results over thehospice compliance rate of 85% for all three months.91%, 89% and 85% respectively. From the action plan wecould see the IPC lead was working with the Head ofsupport services to work with staff on areas where IPCstandards had started to drop.

During the inspection we saw the correct management ofcontainers for sharps and the use of coloured bags tocorrectly segregate hazardous and non-hazardous waste.However, on each day of the inspection, the outside

yellow bin used for storing infected waste beforecollection, although[MS1] closed had not been pusheddown to make sure it was locked. This meant clinicalwaste was not stored according to the Sue Ryder centralpolicy.

From November 2018 to October 2019, the hospicereported zero incidences of healthcare acquired infection

Environment and equipment

The design, maintenance and use of facilities,premises and equipment kept people safe. Staffwere trained to use them.

On entering the hospice, there was a reception deskwhere day patients and visitors were required to sign in/out. Access to and from the inpatient unit, clinical areasand the day hospice was secured with an intercom/keypad to prevent access by unauthorised persons.

We observed during the inspection that meeting rooms,cleaning and storage cupboards and utility rooms werekept locked and secured at all times. This meant thataccess to areas unsuitable for patients and visitors wascontrolled.

There were 15 bedrooms on the inpatient unit. All roomswere ensuite with 11 bedrooms having shower facilitiesand four having smaller bathrooms with a sink and toiletonly. There was a main bathroom that could be used forbathing and showering, if required. All bedrooms had atemporary bed for relatives to stay.

All bedrooms looked out on and had access to thegarden. This meant patients could be moved out into thegarden whilst still in bed, if patients wished to spend timeoutside but were unable to leave their beds.

The hospice was light and airy with areas which could beused as communal spaces for inpatients and families orthe day hospice patients. There was also the sanctuary, asmall room which was used by patients, families and staffas a place for reflection.

Clinic rooms which were used for outpatient serviceswere bright and well maintained.

The hospice maintained a central medical equipmentregister. This had details of all medical equipment used inthe hospice and when it required servicing and electricaltesting. During the inspection, all equipment looked at



Outstanding –


was stored neatly and had the required up to datechecks. Staff told us they had enough equipment neededto provide safe and effective care and treatment topatients both at the hospice and in the community.

We checked a sample of consumable items for expirationdates and all were in-date. Store rooms were tidy, wellorganised and items stored correctly according topolicies and procedures. This meant consumables wereeasily located for staff.

Staff carried out daily checks of emergency equipment. Adefibrillator (used to treat a life-threatening abnormalheart beat) and emergency equipment trolley weresituated on the inpatient ward. Records showed allchecks were up-to-date and completed. This showedthere was a consistent and regular approach to safetychecks.

Assessing and responding to patient risk

Staff completed and updated risk assessments foreach patient and removed or minimised risks. Riskassessments considered patients who weredeteriorating and in the last days or hours of theirlife.

Staff in all the hospice services completed riskassessments for each patient on admission and thesewere reviewed when a patient’s condition changed. Riskassessments were in patient’s notes. We reviewed foursets of notes on the inpatient unit and sawcomprehensive risk assessments were carried out. Theseincluded risk assessments for moving and handling, falls,nutrition and hydration and pressure damage.Recognised tools were used, such as the Waterlow (usedto identify patients at risk of pressure ulcers) and theMalnutrition Universal Screening Tool, commonlyreferred to as ‘MUST’. When a risk was identified, we sawactions were taken to minimise any potential harm to thepatient, such as from falls or pressure damage. In boththe inpatient unit, and out in the community, appropriateequipment was identified and ordered, such as bed railsand pressure relieving mattresses. Clinical staff we spokewith told us there was no problem obtaining equipmentfrom the suppliers, with most equipment available on thesame day.

Hospice patients were assessed daily by a member of themedical team. Patients who had deteriorated or their

symptoms had increased overnight were identified at themorning inpatient unit handover and priority was givenfor these patients to be reviewed by the doctor. Patientswere also assessed by the nursing staff every two hourson the care round and four-hourly during the medicationround, any change was reported to the doctor for review.

Shift changes and handovers included all necessary keyinformation to keep patients safe when handing over careto others. During the inspection we observed all aspectsof patient care were discussed and planned, includingthose with ‘Do not attempt cardiopulmonaryresuscitation’ (DNACPR) orders in place, current patientrisks and observations.

Patient records we reviewed and observations we madeduring the inspection demonstrated that riskassessments, action planning and reviews weredeveloped in collaboration with the patient and theirfamily and supported patient choice.

An initial multidisciplinary assessment was carried outwhen patients were identified to be within the last daysor hours of life. This included consideration of advancecare planning, symptom management, nutrition andhydration, as well as spiritual and psychological needs.We saw end of life care plans were individualised anddeveloped in accordance with patient wishes, followingdiscussion with them and those close to them. Patientswith end of life care plans were reviewed a minimum oftwo-hourly. Staff took into account symptom and comfortmeasurements, including pain, elimination, mouth care,secretions, agitation and pressure care.

Staff completed intentional care rounding assessments.Intentional care rounding is a structured process wherestaff are required to perform regular checks of patients atset intervals. Checks carried out by staff includedassessment of patient comfort, mobility, falls risk, skincondition and position. We saw there were completed inthe four sets of patient records we reviewed.

The hospice had named leads for falls prevention andpressure damage prevention who were responsible forchampioning best practice and provided support,training and advice to staff as needed. During theinspection we spoke with the tissue viability lead whowas knowledgeable and passionate about providing thebest care and treatment for patient’s to minimum theirdiscomfort and the training of the hospice staff.



Outstanding –


The central team for Sue Ryder instigated workforcesteering groups in areas of key responsibility such as falls,and pressures ulcers which staff at the Duchess of Kentwere part of. These working groups identified commonthemes across Sue Ryder and developed ways to worktogether to reduce risk and inform best practice as aunified working team approach.

Vulnerable patients or patients with complex needswould often be identified prior to admission. In thesecases, senior inpatient nurses or the specialist doctorwould visit the patient to make sure the hospice was wellequipped to meet their needs. During the inspection wewere given examples of such cases and the specialistdoctor had planned a visit to a patient at home that day.This patient was due for admission to the inpatient wardand the team wanted to make sure their needs wereassessed so effective care could be delivered.

Nurse staffing

Despite some nurse staffing vacancies, the servicehad enough nursing and support staff with the rightqualifications, skills, training and experience tokeep patients safe from avoidable harm and toprovide the right care and treatment. Managersregularly reviewed and adjusted staffing levels andskill mix, and gave bank and agency staff a fullinduction.

Before permanent and bank staff could work at thehospice, pre-employments checks were carried out andrelevant information required to demonstrate theirsuitability for the role. This included up-to-datedisclosure and barring service (DBS) checks, references,full employment history, evidence of qualifications andprofessional registration, where applicable. As part oftheir continuing employment, DBS checks were repeatedevery three years and evidence of nurse’s registrationchecked at their annual appraisal. Agency nursing staffprovided evidence of their registration, level ofsafeguarding and life support training to theiremployment agency and where provided with a thoroughinduction before starting work at the hospice. Havingrobust employment checks meant the hospice couldmake safer recruitment decisions and prevent unsuitablepeople from working with vulnerable patients.

The nursing establishment for the inpatient unit hadbeen reviewed two years ago over a six-month period tounderstand the nursing and nursing assistant needs. Thecurrent establishment was:

Ward Manager: 1.0 WTE band 8

Team Leader: 3.2 WTE band 7

Senior Staff Nurse: 3.9 WTE band 6

Staff Nurse: 8.4 WTE band 5

Senior Nursing Assistant 3.0 WTE band 3

Nursing Assistant 12.0 WTE band 2

In general, the inpatient unit had three registered nursesduring day shifts with four nursing assistants and tworegistered nurses during night shifts with one nursingassistant plus a nursing assistant working a twilight shift.However, we were told there was a flexible approach tonurse staffing as it could be dependent on the complexityof patients admitted to the unit. In addition, the wardmanager would work Monday to Friday 9am to 5pm in asupernumerary role.

At the time of the inspection the clinical team had avacancy rate of 5.5 WTE registered nurses and 2.0 WTEnursing assistants. The clinical team were using overtime,bank and agency staff to fill gaps. In addition, the wardmanager and other nursing staff who were not patientfacing were working clinical shifts to fill the gaps.

When we spoke to the nursing team they told us theywere feeling the impact of having reduced nursing andnursing assistant staff numbers. For example, lack of timefor non-patient tasks such as attending meetings,training, personal development and general oversightand support of staff on the inpatient unit. Staff we spokewith said presently there was no impact on the patientcare given but were worried that present staff levels couldstart to affect standard of care given or the number ofpatients they could admit to the unit. We observed theinpatient unit had enough staff of an appropriate skillmix, to keep patients safe and provide effective care andtreatment, on the days of our inspection.

The senior management team were aware of the nursingstaffing issues, were actively recruiting and looking forways to support staff. They were also looking at patientoutcome and audit data to make sure there was no



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impact on the care and treatment patients and theirfamilies received. Nursing vacancy rates was on theDuchess of Kent risk register and was discussed at themonthly quality improvement meetings.

The inpatient unit operated an on-call system forproviding out of hours support for nursing staff. Thisnurse could be called upon for advice or support orwould come to the unit if an addition registered nursewas required.

The community clinical nurse specialist (CNS) hadcaseloads of appropriately 30 patients per 1 WTE CNS. Wewere told there was some flexibility in this numberdepending the level of support required by the patient.Caseloads were monitored at the quality improvementmeeting. The CNSs we spoke with during the inspectionfelt their caseload was appropriate.

At the time of the inspection the establishment was:

In Reading 5.0 WTE CNSs

In Newbury 3.35 WTE CNSs

In Wokingham 2.8 WTE CNSs

The day services supported a caseload of patients andthere was an agreed maximum number of patients ineach of the sites on any given day:

In Reading the day hospice ran three days a week coveredby three registered nurses and one nursing assistant.They were supported by a diversional therapist,physiotherapist, occupational therapist and volunteers.

In Wokingham the day hospice ran three days a weekcovered by three registered nurses and one nursingassistant. They were supported by a diversional therapist,physiotherapist, occupational therapist and volunteers.

In Newbury the day hospice ran two days a week coveredby three registered nurses and one nursing assistant.They were supported by a diversional therapist,physiotherapist, occupational therapist and volunteers.

Caseload and capacity were monitored on a monthlybasis and discussed at the monthly quality improvementmeetings. The clinical team we spoke with during theinspection felt their caseload was appropriate.

Medical staffing

The service had enough medical staff with the rightqualifications, skills, training and experience tokeep patients safe from avoidable harm and toprovide the right care and treatment. Managersregularly reviewed and adjusted staffing levels andskill mix.

The hospice had their own medical team which was ledby a consultant in palliative medicine. As of July 2019, thehospice employed one doctor full-time and eight on apart-time basis. There was always a consultant orspeciality doctor on the inpatient unit Monday to Friday9am to 5pm. They were supported by GP trainee and/orfoundation doctors. There was a member of the medicalteam present on the inpatient unit Saturday and Sunday9am to 5pm.

Out of hours and overnight there was no doctor presenton the unit but they were available on-call and wouldattend the unit if required. There was also a seconddoctor on call, either a consultant or specialist doctor,who could be contacted to provide advice and support,as needed. Nursing staff we spoke with on the inpatientunit told us medical staff were easy to get hold ofout-of-hours and would always come into the unit whenneeded.

There were daily handover and ward rounds on theinpatient unit and a multidisciplinary team meeting oncea week to discuss patients care and treatment.

Every Thursday there was a Sue Ryders live streamdoctors’ presentation, where all doctors working for SueRyder had the opportunity to attend an hour trainingsession on areas relating to palliative care.

The medical team were actively encouraged to attend thehospice journal club and the mortality and morbiditymeetings to increase their knowledge and share learning.

The day hospice’s at Reading, Wokingham and Newburyhad their own palliative care doctors who were involvedin the patients care and treatment. There was a dailyhandover between the doctor and the hospice team,nurses and therapists before the start of each dayhospice. This meant the team were up-to-date with theirpatients and could work in a safe and effective way.

Records



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Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date, storedsecurely and easily available to all staff providingcare.

The hospice had been using an electronic patient recordsystem since June 2019, with templates designedspecifically for the hospice. These included a range of riskassessments as well as individualised care plans. Somepaper records were also used, such as intentionalrounding forms and assessment of symptoms andcomfort measurements for patients with end of life careplans. We reviewed four sets of patient notes and foundthem to be completed in full and were up to date. Theycontained details of patients emotional, social andspiritual needs, alongside their physical health needs.Patients mental health, dementia, learning disability andbehavioural needs were evident, where appropriate.Patient records also reflected their protectedcharacteristics, where relevant.

The Duchess of Kent hospice were using theRecommended Summary Plan for Emergency Treatmentand Care (ReSPECT) process and advance care planningto document patient’s wishes in emergency situationsand for end of life care. Using the ReSPECT process meantpatients were involved in decisions about their care andthey were empowered to make choices, know whatquestions to ask their doctor and feel able to makeinformed decisions. We reviewed four ReSPECT forms; allwere filled out comprehensively and showed discussionswith the patient and families. They were completed bythe registrar and countersigned by a consultant.

Team leaders audited patient records against bestpractice and identified areas for improvement whereneeded. We reviewed the documentation audit fromMarch 2019 to September 2019. Prior to the hospicechanging over to the electronic patient record overallcompliance was consistently above the hospice’s targetof 90%. Since changing over to the new systemcompliance rate had dropped to 77% in June 2019 and79% in September 2019. Team leaders were aware of thedrop-in compliance and were working with their teams toimprove completion and knowledge on the computersystem. We reviewed the action plans team leaders hadput in place to improve the standard of record keeping.

The electronic patient record system was the same asthat used by local GPs and the district nurses. This meant

staff could share details of hospice care with otherprofessionals and agencies and had had immediateaccess to up-to-date patient information. The system wasnot used by the local NHS trust but the hospital palliativecare team did have access to the system. This meantpatient details could be shared and helped withconsistency of care. Hospice staff who cared for patientsin the community had access to the same electronicsystem via laptops. This meant they could up-datepatient records at each visit.

During the inspection records were stored securely. Staffused key cards to access the electronic patient recordsystem. These were password protected. Therefore, therisk of unauthorised persons accessing patient recordswas minimal. Paper records were stored securely in thenurse’s office. Consent to storing and sharing patientinformation was obtained.

Medicines

The service used systems and processes to safelyprescribe, administer, record and store medicines.

Staff followed Sue Ryder policies and procedures whenprescribing, administering, recording and storingmedicines. As of June 2018, the hospice commissionedpharmaceutical products and clinical pharmacy servicesfrom an external provider through a service levelagreement. Under the agreement the hospice had accessto a pharmacist on call seven days a week 9am to 10pmand a pharmacist would visit the hospice weekly tomonitor stock, storage, review patient prescriptionrecords and facilitate staff training. They produced aweekly report which highlighted any prescribing errorsand attended the monthly hospice medicinesmanagement meeting where issues were discussed, andaction plans put in place.

During the inspection we found medicines were storedappropriately in locked cupboards. We checked aselection of medications in the inpatient unit and foundall were in date and kept in line with manufacturersadvice. Fridges temperatures were recorded daily, andstaff sought advice from the pharmacist whentemperatures were found to be outside recommendedranges

Controlled drugs (CDs), medicines that are controlledunder the Misuse of Drugs legislation (and subsequentamendments), were stored in separate locked cupboards.



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We checked the CD register and found entries werecompleted in line with best practice. Controlled drugsbrought in by patients were stored securely and therewere adequate controls in place to prevent misuse. Thehospice had a controlled drugs accountable office asrequired by legislation.

Controlled drugs were frequently used to managepatient’s pain. The hospice permitted single nurseadministered controlled drugs (SNAD) to ensure patientsreceived them promptly when needed.

Blank prescription pads (FP10 prescriptions) were storedsecurely and monitoring systems were in place to ensureall prescriptions were accounted for. The hospicecompleted a basic audit of FP10 prescriptions.

We reviewed two patient prescription records and foundthey were signed, dated, timed and legible. Patientallergies were documented, and medicines were given asprescribed. We saw patient medicines were regularlyreviewed, including the use of ‘as needed’ medicines.

Patients being cared for at home administered their ownmedicines. Anticipatory medicines and controlled drugsfor pain relief were managed by the district nurse service.The community clinical nurse specialists worked closelywith district nurses and GPs to make sure patients hadthe appropriate medicine management to manage theirpain and/or symptoms. Each of the community teams(Reading, Wokingham and Newbury) had twonon-medical prescribers, a health professional who is nota doctor. This meant patients in the community could beprescribed medication to help relieve their symptomswithout needing to see their GP. The Duchess of Kentnon-medical prescribers received regular supervision andpeer review of prescribing habits.

Medicines were disposed of safely and records ofdestruction were maintained. Unwanted or expired[MS2]medicines were kept separate from other medicines andwere disposed of correctly. However, the temporarystorage of pharmaceutical waste before collection wasnot always secure as it was kept in an area where otheritems were stored and collected from. This meantpharmaceutical waste could have been accessed andremoved for misappropriate usage.

There was a medicines management group and adesignated medicines lead. This team met monthly toreview policies and procedures, address medicine related

alerts and looked at medicine incidents. If trends wereidentified, for example an increase in prescription errors,then the medicine management group would investigateand make sure action was taken to minimise recurrence.The information from this meeting fed into the Duchessof Kent quality improvement meeting. We reviewedminutes from the medicine’s management group and thequality improvement meetings and saw the hospice hadgood oversight in their medicine management.

Incidents

The service managed patient safety incidents well.Staff recognised incidents and near misses andreported them appropriately. Managers investigatedincidents and shared lessons learned with the wholeteam and the wider service. When things wentwrong, staff apologised and gave patients honestinformation and suitable support. Managers ensuredthat actions from patient safety alerts wereimplemented and monitored.

The Duchess of Kent hospice took incidents very seriouslyas they were passionate in ensuring patients and theirfamilies have the best experience possible when usingthe hospice services which were often at a period ofemotional distress.

The hospice followed the Sue Ryder Central accident,incident and near miss reporting policy. The policyincluded definitions of incidents and their level of harmand how incidents should be reported, investigated andactions taken. Also included was an incident reportingflowchart to follow to make sure all steps were completedwithin the correct timeframe. There were also Sue RyderCentral policies on serious incident management andcritical incident for staff to follow.

The hospice used an electronic reporting system forreporting incidents. All grades of staff could access theincident reporting system and those who workedremotely could access the system through their laptops.Staff said they knew what constituted as an incident,were encouraged to report incidents in a no-blameculture and felt confident in doing so.

From November 2018 to October 2019 there had been225 incidents reported. 49.8% of incidents were rated asno harm, 49.8% rated at low harm (minimal harm –



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patient required extra observation or minor treatment)and 0.4% rated as moderate harm (moderate harm: shortterm harm - patient required further treatment, orprocedure).

From November 2018 to October 2019, the hospicereported one serious incident, which was beinginvestigated at the time of the inspection and zero neverevents. Never events are serious patient safety incidentsthat should not happen if healthcare providers follownational guidance on how to prevent them. Each neverevent type has the potential to cause serious patientharm or death but neither need to have happened for anincident to be a never event.

All incidents were reviewed and investigated followingSue Ryder procedures and policies. Incidents werediscussed at the monthly quality improvement meeting,common themes identified and action plans put in placeto minimise recurrence. We reviewed the minutes fromthree of the quality improvement meeting and sawincidents, their root cause analysis and resulting actionswere a set item on the agenda.

Themes of incidents from the Duchess of Kent hospiceand other Sue Ryder hospices were discussed at thequarterly Sue Ryder Central performance and qualitymeeting. This meant the central quality team and chiefexecutive for Sue Ryder had oversight of all incidentsreported.

Staff we spoke with confirmed they received feedbackfrom reported incidents, both those relating to theirimmediate area of work and those that had beenreported elsewhere in the hospice. This promoted sharedlearning from incidents throughout the hospice. Staff saidlearning from incidents would be communicated to themmainly at handovers, team meetings, emails and noticeboards. Staff confirmed managers supported them whenthey were involved in incidents. Staff could give usexamples of when procedures had changed or additionaltraining had occurred due to an incident. All staff wespoke with during the inspection were committed toproviding an excellent service to their patients. Staff toldus they saw learning from incidents as a vital tool to helpthem achieve this.

Sue Ryder Central had cross hospice work streams. Thismeant staff from other Sue Ryder centres could gettogether to discuss certain topics, for example, there were

falls, pressure ulcers, safeguarding and medicinesmanagement work streams. Information on incidentsrelating to the work stream was talked about in thesemeetings. This was a good way to share experiences andlearning from incidents. The Duchess of Kent tissueviability lead told us she found these meetings extremelyuseful and valued the input from other Sue Ryder clinicalteams.

The hospice held mortality and morbidity meetings todiscuss patient deaths or adverse incidents affectingpatients. These meeting gave an opportunity for theclinical team to review deaths as part of their professionallearning and reflective practice in a safe space. By talkingthrough patient case studies was seen as a way toimprove quality of care given to patients and theirfamilies at the hospice.

Sue Ryder Central had a duty of candour procedurewhich contained a set process that would be followed inthe event of an incident occurring that would trigger aftera notifiable safety incident. The hospice was committedto being open, honest and transparent in all instancesand their practice was to inform patients and/or theirrelatives whenever an error had occurred and not just incases that were considered reportable.

The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (or otherrelevant persons) of certain notifiable safety incidentsand provide reasonable support to that person, underRegulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. A notifiable safetyincident includes any incident that could result in, orappears to have resulted in, the death of the person usingthe service or severe, moderate or prolongedpsychological harm. Clinical staff were aware of the dutyof candour and all staff we spoke with were aware of theimportance of being open and honest with patients andfamilies when something went wrong and the need tooffer an appropriate remedy or support to put mattersright. From November 2018 to October 2019, the hospicehad one incident which required the duty of candour tobe instigated. All Sue Ryder procedures and policies werefollowed.



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Patient safety alerts were a set agenda at the qualityimprovement meetings. Team leaders for servicesensured actions from patient safety alerts were actedupon where needed and information shared with staff.

Safety Thermometer (or equivalent)

The service used monitoring results well to improvesafety. Staff collected safety information and sharedit with staff.

Staff monitored safety performance to indicate how safethe service was in providing harm free care. Theprevalence of patient harm because of falls, pressuredamage and healthcare associated infections wasmonitored and reported monthly.

From September 2018 to August 2019, the servicereported 29 hospice acquired pressure damage , 57 fallsand zero healthcare associated infections (MRSA and C.Diff).

Prevalence of patient falls had started increasing duringthe three months from May - July 2019 (May 2019 – 10falls, June 2019 – 7 falls, July 2019 – 11 falls). This trendwas identified in the quality improvement meetings. Theclinical team had investigated why this had happenedand had put actions in place. For example, there hadbeen additional staff training and new guidance on theuse of bed rails. Actions the hospice had taken sawpatient falls reduced to two for August 2019.

Are hospice services for adults effective?(for example, treatment is effective)

Good –––

Our rating of effective stayed the same. We rated it asgood.

Evidence-based care and treatment

The service provided care and treatment based onnational guidance and best practice. Managerschecked to make sure staff followed guidance.

Patients’ needs were assessed and care and treatmentwas delivered in line with legislation, standards andnational best practice clinical guidance. Policies andprocedures seen were up-to-date and referenced

national guidelines and legislation. These included theNational Institute for Health and Care Excellence (NICE)guidelines. For example, care of patients in the last daysand hours of life was in line with the recommendationspublished in June 2014 by the Leadership Alliance for theCare of Dying People (LACDP 2014) and NICE guidance‘care of dying adults in the last few days of life’ qualitystandard [QS144] March 2017.

The NICE guidelines and other legislation were reviewedby Sue Ryder central, cascaded to the individual hospicesand shared with staff. At a local level the practiceeducator, head of clinical services and senior members ofstaff would be responsible for reviewing informationsources and updates in guidelines. It was theirresponsibility to ensure these changes were incorporatedinto the working practices of the hospice and its staff. Thiswould be discussed at the monthly quality improvementmeeting.

Nutrition and hydration

Staff gave patients enough food and drink to meettheir needs. They used special feeding and hydrationtechniques when necessary. The service madeadjustments for patients’ religious, cultural andother needs.

Staff completed assessments in nutrition and hydration.Staff used the Malnutrition Universal Scoring Tool (MUST)on admission to assess patients at risk of malnutritionand dehydration. This was reviewed weekly or when therewas any change in the patients’ condition and recordedin the patient records.

Individual patient care plans were established from theassessment and in consultation with the patient. Ifrequired, the patient would be referred to the on-sitedietician for advice on their dietary needs. Patients whoneeded assistance to eat and drink were identifiedthrough the initial and ongoing assessments. Thedietitian was also trained to help with any social oremotional difficulties patients might be experiencingrelating to food during these times.

The catering department prepared freshly made mealson-site. Hot and cold food options were available for eachmeal and patients could specify meal size. The servicecatered for all types of needs including vegetarian, soft,dairy and gluten free and any religious or cultural



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requirements. Meals could be fortified with full fat milk orcream if required. The chef spoke with each patient on aregular basis and provided individualised menus whenneeded.

Food and drinks were available outside of mealtimes. Theinpatient unit had a tea bar where patients and thoseclose to them could help themselves to hot and colddrinks. Families and carers could also bring in their ownfood or order takeaways to be delivered to the hospice, ifthey wished. There were also vending machine inreception where snacks could be purchased.

The inpatient unit completed two hourly care roundingduring the day, where food and drinks were offered anddocumented on the chart that it had been offered.Nutritional intake was also monitored and recorded onthe care rounding chart. We observed water jugs ininpatient’s rooms and were told ice was available, ifwanted by the patients.

Staff provided support and advice to families of patientsnearing the end of life with limited or no oral intake, thisincluded giving mouth care to patients to maintain theircomfort. For patients that could not maintain their ownhydration subcutaneous or intravenous fluids could beoffered depending on the patient’s requirements.

The catering service at the hospice had been brought inhouse to provide a high-quality service for their patients.The hospice had been working on improvements to thecatering services and had reinstated catering meetings.This was chaired by the head of support services and hadinput from the hospice dietician and representatives fromthe inpatient unit and day hospice. Feedback was alsogathered from the service user group who had an interestand could give insight into the catering needs of patientsespecially around menu choice.

Pain relief

Staff assessed and monitored patients regularly tosee if they were in pain, and gave pain relief in atimely way. They supported those unable tocommunicate using suitable assessment tools andgave additional pain relief to ease pain.

Clinical staff discussed pain and pain relief with patientsduring admission. This was documented in the patient’scare record. Patient pain levels were then regularlyreviewed using recognised tools and staff gave pain relief

in line with individual needs and best practice. Otherrecognised tools were used to help identify distress cuesin patients who because of cognitive impairment orphysical illness, had limited communication. Staff alsoregularly assessed patient’s ability to tolerate oralmedicines with alternative administration routesprescribed if necessary, such as intravenous infusion orpain relief patches.

Patient’s pain levels were regularly reviewed anddiscussed at the daily handovers, during drug rounds. Inaddition, pain and pain management would be discussedduring ward rounds and at the weekly multidisciplinaryteam meeting.

Patient records we reviewed showed care plans includedan appropriate pain assessment and management plan.Anticipatory medicines with individualised indications foruse, dosage and route of administration were prescribedfor patients identified as being in the last days of life.These included medicines for pain, agitation, respiratorytract secretions, nausea/vomiting and dyspnoea (difficultor laboured breathing). Prescribing medicines inanticipation can prevent a lapse in symptom control,which could cause distress for the person who is dyingand those close to them.

The hospice permitted single nurse administeredcontrolled drugs to ensure patients received pain reliefpromptly when needed.

We observed a patient’s initial assessment whenattending the day hospice when the patient’s pain andpain management was discussed. We were told by theclinical staff that it was important to manage and getpatient’s pain under control as this helped improvepatient’s quality of life.

The palliative community clinical nurse specialistsmonitored patients’ comfort levels during their visits andwould escalate to the district nurse service or their GP forreview when needed. Nursing staff were trained on theuse of syringe drivers which were used to administer acontinuous subcutaneous infusion of drugs which helpedto control pain.

Patient outcomes



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Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved good outcomes forpatients.

There was a clear approach to monitoring, auditing andbenchmarking the quality of the services and outcomesfor patients receiving care and treatment.

Information on clinical quality outcomes for example,healthcare associated infections and acquired pressuredamage, were monitored and tracked over time. Thesewere reviewed and discussed at the monthly integratedquality and performance meetings. There was evidenceof action taken in response to any areas of concern.

The Duchess of Kent hospice took part in the Sue RyderCentral audit programme. This was a rolling programmeof audits and included audits of documentation,management of falls, medication management andsafeguarding. Outcomes were collated and used tobenchmark against the other Sue Ryder hospices. Therewas also an internal audit programme, which includingaudits on hand hygiene and waste management.

Results from the central and local audits were monitoredand discussed at the hospice’s integrated quality andperformance meetings. If actions were required thiswould be fed back to the departments, actions taken andthe area re-audited. Assessing, evaluating and improvingcare via an audit programme meant the hospice wascommitted to providing and maintaining a high quality ofclinical care for their patients.

The hospice used patient and relatives feedback tools tomeasure patient outcomes. This included inpatient unitsurvey results, patients in the community andanonymous real-time feed-back. Information was soughton a range of quality indicators and the findings wereused to make improvements to services were needed.

Staff used the Integrated Palliative care Outcome Scale(IPOS) to capture patients most important concerns, bothin relation to physical symptoms, but also extending toinformation needs, practical concerns, anxiety or lowmood, family and friends’ anxieties and overall feeling ofbeing at peace.

The Duchess of Kent hospice were introducing theOutcome Assessment and Complexity Collaborative(OACC) tool to measure patient outcome. The OACC is a

suite of measures used to assess the care that mattersmost to people and their families at the end of life, suchas control of their pain, breathlessness and fatigue, theopportunity to discuss worries, or to achieve one morepersonal goal before they die. By collecting this data themultidisciplinary team caring for patients would be ableto plan care, treatment and support to best meet theneeds of each individual patient. At the time of ourinspection, staff were waiting to be trained on the OACCbefore its implication.

Competent staff

The service made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held supervision meetings with them to providesupport and development.

When starting work at the hospice, there was a two-weekmandatory induction programme for new members ofstaff, including the bank staff. This induction includedtraining on safeguarding, health and safety, infection,prevention and control, moving and handling and basislife support. Nurses and nursing assistants worked in asupernumerary capacity alongside an experienced staffmember until they were competent to work alone. Staffwe spoke with spoke highly of the induction programmeand said it was relevant, useful and met their needs in thenew workplace.

Mandatory training was not offered to nursing agencystaff as this was the responsibility of the agency toprovide. However, the hospice ran checks to make sureagency staff had completed the correct mandatorytraining before they started work. Before being allowed towork with patients, agency staff were orientated to thehospice environment and, before being allocatedpatients to care for, needed to have completed medicinestraining.

Clinical staff had to complete competency training onspecific areas to ensure they had the appropriate skillsand knowledge to manage patients safely and effectively.Sue Ryder Central were currently working on acompetency framework for staff which would detail thecompetences required for each grade of staff, for examplesenior staff nurse, staff nurse and nursing assistants.Completed competencies would be recorded on a centralcomputer rather than in individual’s workbooks.



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Clinical supervision was provided to staff. This wasprovided on a one-to-one or group basis. Clinicalsupervision was a safe and confidential environment forstaff to reflect on, discuss their work and their personaland professional responses to their work. The focus wason supporting staff in their personal and professionaldevelopment and in reflecting on their practice. Ad hocsupervision sessions were arranged to support stafffollowing any significant events or incidents.

The Duchess of Kent had an education team, with apractice educator and a clinical educator. The teamplayed an active role by providing support, educationalinput, development activities and internal training daysfor staff working in the hospice. Staff we spoke with talkedhighly of the team and the educational support theyprovided to the them. The clinical educator workedclinically one day a week on the inpatient unit to providesupernumerary support to the team.

Staff could attend external training courses if they addedvalue for the individual attending and benefit to thehospice. Staff we spoke with said managers weresupportive if they asked to go on training courses andcould give us examples of courses they had been on. Staffalso told us it was expected of them to disseminate theirlearnings to their colleagues when they returned fromtraining courses, which they were happy to do so.

Trainee doctors had a clinical supervisor who theyworked with regularly during their placement. Medicalstaff we spoke with told us they felt supported fromsenior medical staff and could approach them for adviceat any time.

Volunteers were used throughout the hospice and weretrained and supported for the roles they undertook.There was a volunteer’s coordinator who made surevolunteers had the required DBS checks and mandatorytraining before they started volunteering at the hospice.Volunteers were also invited to attend training courseoffered to the permanent and bank staff. Volunteers wespoke with said if they were available and training wasrelevant they attended as it increased they knowledgewhich helped when caring for the patients. Volunteerswho worked in more specialist areas, such as thebefriending service and the bereavement team, hadaddition training, including counselling, safeguarding andlone-working, to make sure they were competent for theroles they undertook.

Managers supported staff to develop through regulardevelopment meetings and yearly, constructiveappraisals of their work. As of July 2019, 98% of staff hadcompleted an annual appraisal (Source: ProviderInformation Request). At the beginning of each appraisalyear, managers met with staff to agree their performanceand development objectives for the coming year. Thesewere linked to the service’s strategic objectives andpriorities and the Sue Ryder behavioural standards. Staffhad regular one-to-one meetings with their manager tomonitor their performance. They had the opportunity todiscuss training needs and were supported to developtheir skills and knowledge. Staff told us they found theappraisal process useful and they were encouraged toidentify any learning needs they had, and any trainingthey wanted to undertake.

Multidisciplinary working

Doctors, nurses and other healthcare professionalsworked together as a team to benefit patients. Theysupported each other to provide good care.

We observed excellent multidisciplinary team (MDT)working throughout the hospice. MDT working was a fullyembedded practice which helped delivered a joined-upapproach to delivering care and treatment to the patient.This facilitated better communication betweenhealthcare professionals, patients and relatives andpositively impacted on the care and treatment patientsreceived.

Staff held regular and effective MDT meetings to plan anddeliver holistic patient care. We observed the weekly MDThandover on the inpatient unit. This was attended by themedical team, nursing team, physiotherapist,occupational therapist, admission/discharge coordinator,and the patient and family support team leader. We alsoobserved the day hospice morning meeting which wasattended my day hospice doctor, nursing staff, thediversional therapist and the befriending coordinator. Atboth meetings, each patient was discussed in detail, withcare and treatment planned in accordance with theirphysical, psychological, emotional, spiritual and socialneeds, as well as their wishes. The well-being of patient’sfamily was also discussed and plans put in place to makesure they were also supported.

The community clinical nurse specialist (CNS) teams hadgood working relationships with the GPs, surgery’s and



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district nursing teams they worked with. CNS attendedGold Standard Framework (GSF) meetings with local GPswhere they discussed each patient on the end of liferegister and how they could best support them. The GSFis a framework which promotes best-practice in end of lifecare. It is used by many GPs, hospices and hospitals toenable earlier recognition of patients with life-limitingconditions, helping them to plan ahead to live as well aspossible.

The hospice had good links with the local NHS trusts andlocal authorities, information and support was shared tooffer joined up services, care and treatment for patients.

We observed positive interactions between staff andvolunteers. Staff and volunteers we spoke with told usthey worked together to provide the best care andsupport they could for patients and their families orcarers. The volunteer coordinator had developed a roledescription so staff and volunteers understood the role ofthe volunteer. This meant there were clear guidelines asto what a volunteer could and could not do. Thissafeguarded both the patients and volunteer. Clinicalstaff on the day hospice always made sure there was ahandover with the volunteers before patients arrived.This meant volunteers could give the appropriate supportto patients.

Seven-day services

Key services were available seven days a week tosupport timely patient care.

The inpatient unit was operational 24 hours a day, sevendays a week to provide timely patient care when needed.The hospice had an open visiting policy. Family, friendsand carers were welcome to visit their loved one any timeof the day or night.

A consultant or specialty doctor was present on theinpatient unit Monday to Friday 9am to 5pm, with a wardround daily. On Saturday and Sunday the on-call doctorwas present between 9am and 5pm and conducted thedaily ward round. Out of hours there was a doctor on call,supported by a second on call consultant for advice andsupport.

The community clinical nurse specialists working in thecommunity operated an out of hours service and wereavailable to provide support and advice over the phone24 hours a day, seven days a week.

The chaplaincy services were multi-faith and provided 24hours a day, seven days a week service.

Health promotion

Staff gave patients practical support to help themlive well until they died.

Staff assessed each patient’s health and well-being whenthey were admitted. The specialist teams at the hospiceworked together to give personal co-ordinated care topatients. Services offered by the hospice supportedpatients physical, psychological, spiritual and socialneeds.

The day hospice teams provided a six to twelve-weekprogramme aimed at empowering patients to live well bysupporting them to manage their condition, maintainindependence and make new friendships. Theprogramme was provided by a multidisciplinary team,including clinical staff, palliative social worker,complementary and diversional therapists,physiotherapist and occupational therapists.

The team told us they offered palliative care to patientswith a life-limiting illness, that treatments could still beoffered but were aimed at improving quality of life ratherthan a cure. This could include both physical andpsychological solutions.

Therapy programmes were tailored to individual needsand goals. A variety of methods were used to helppatients, such as mindfulness and relaxation techniques,exercise sessions and complementary therapies, such asmassage. We were told by staff they had recently had agong therapy session for patients. This was a form ofsound therapy where a gong was played softly for thepurposes of relaxation.

All the patients we spoke with during the inspection, toldus how attending the day hospice had had a huge impacton their health and well-being and had improved theirquality of life.

The inpatient unit offered a service where patients couldbe referred to for symptom management such as pain orbreathlessness or respite care.

Consent and Mental Capacity Act and Deprivation ofLiberty Safeguard



Outstanding –


Staff understood how and when to assess whether apatient had the capacity to make decisions abouttheir care. They followed the hospice’s policy andprocedures when a patient could not give consent.

The service had up-to-date policies and proceduresregarding consent and the Mental Capacity Act 2005.These included the Mental Capacity Act documentation,deprivation of liberty procedure, consent procedure andlack of capacity procedure.

Staff we spoke with understood the importance ofconsent when delivering care and treatment to patients.We observed staff seeking consent from patients prior toexamination, observations and delivery of care. In mostcases this was implied consent and not documented.However, when an intervention was required, formalwritten consent was sought.

Staff demonstrated a good knowledge andunderstanding of the Mental Capacity Act 2005 (MCA) andDeprivation of Liberty Safeguards (DoLS), and theprocedures and documentation used by Sue RyderCentral to assess a patient’s capacity. Staff were awarewhen patients lacked the mental capacity to make adecision, best interest decisions were made inaccordance with legislation and took into accountpatients’ wishes, culture and traditions. Information wasdocumented in the patient’s records.

Eligible staff completed training on the MCA and DoLs. Asof October 2019, 95% of staff had completed MCA andDoLS training, which exceeded the hospice target of 90%.

The Duchess of Kent hospice were using the ReSPECT(recommended summary plan for emergency treatmentand care) process and advance care planning todocument patient’s wishes in emergency situations andfor end of life care. By using the ReSPECT process meantpatients were involved in decisions about their care andthey were empowered to make choices, know whatquestions to ask their doctor and feel able to makeinformed decisions.

We reviewed four ReSPECT forms and all were filled outcomprehensively, showing discussions with the patientand families. They were completed by the registrar andcountersigned by a consultant. Staff were knowledgeableabout the ReSPECT process, the completing ofdocumentation and the importance it played in carryingout patient’s wishes. However, currently the hospice did

not audit ReSPECT forms for compliance withcompletion[MS1]. This meant there was no process inplace to make sure standards were maintained and theforms continued to be completed correctly and in full.

Most staff we spoke with had received training to makethem aware of the needs of people with mental healthconditions and dementia. Sue Ryder had recognised itneeded to be more effective at equipping staff with toolsto manage mental health. This need was being addressedand in October 2019, an e-learning module on mentalhealth was launched. The hospice practice educator hada special interest in people leaving with dementia,learning disabilities and autism and was currently puttingon training sessions for hospice staff and volunteers. Theyhad forged links with external networks in the ThamesValley region and hoped to bring learning back to thehospice. Staff we spoke with told us they had limitedknowledge in dementia, learning disabilities and autismbut if a patient with these conditions was admitted to theunit they would take advice from others, risk assessmentthe patient and make sure they had a personalisedcare-plan that was appropriate for their care andtreatment.

Are hospice services for adults caring?

Outstanding –

Our rating of caring improved. We rated it asoutstanding.

Compassionate care

Staff treated patients and their families withcompassion and kindness, respected their privacyand dignity, and went above and beyondexpectations to meet their individual needs andwishes. Patients and their families were trulyrespected and valued as individuals by anexceptional service.

Staff were passionate and committed to providingcompassionate care for patients and those close to them.Staff were aware of the importance of providingcompassionate care and the impact their actions had onthe patient and their families at this time of their lives.Staff fostered and promoted an atmosphere of calm andtranquillity throughout the services at all three sites.



Outstanding –


Staff took time to interact with patients and those closeto them in a respectful and considerate way. We observedstaff interact and how they treated patients and theirfamilies in a friendly, warm, caring and compassionatemanner. Patient-centred care was embedded in all staffworking at the hospice and the other services weinspected. We could see staff had built strong and trustedrelationships with patients and those close to them. Weobserved staff displayed an understanding andnon-judgmental attitude when caring for, or talkingabout, vulnerable patients.

Staff told us how much of a privilege it was and how ithumbled them to work with patients at the most difficulttime of their lives. By listening to their patients and thoseimportant to them, staff got to know their patients andwere aware of the things that mattered to them. Weobserved this whenever staff spoke about their patients,for example, during handovers, MDT meetings and inclinics. We were told how staff and volunteers spent timegetting to know patients and what was important tothem, their interests and what lifted their spirits. Forexample, staff and volunteers would find books onsubjects that interested their patients. They would look atthe photos together and talk about the subject. Duringthe inspection we observed patients receiving highlypersonalised care with patient’s wishes being creativityfulfilled by staff. We said examples of this in the dayhospice where patients were helped and encouraged tocreate very tailored lasting memories for loved ones.

We were given many examples where staff had goneabove and beyond for their patients. For example,arranging a drive in a sports car, arranging for pets to bebrought in to say a final farewell, arranging for certainmenu requests, arranging special family get togethersand making sure a patient could be at a loved one’swedding via a skype link. The hospice had facilitatedweddings and blessings for patients and those close tothem, often at very short notice and moved Christmasforward. We were given examples when staff continued tothink about their patients outside of the working hours.The patient’s needs were continuously thought of andstaff had innovative ways to meet them. For example,staff would see things and ideas when not at work andbring them back to the hospice to support or enhance apatients well-being under their care.

Staff understood and respected the personal, cultural,social, religious needs and protected characteristics ofpatients and how they may relate to care needs. Patientrecords we reviewed and observations we madedemonstrated the totality of people’s needs wererecognised and respected, including spiritual, religiousand cultural needs. We were given examples when thechaplain had been with patients at the end of life, at anytime of the day or night, when family members wereunable to be there. This had given comfort to both thepatient and relatives to know that they were not alone.

Patients and relatives we spoke with told us their privacyand dignity were always respected and protected. Wesaw ‘Please do not enter’ signs used on the inpatient unitwhen patients and those close to them did not want tobe disturbed. We observed these were respected by staff.Feedback from relatives who’s loved ones had beenpatients on the inpatient unit between July andSeptember 2019 showed that 18 out of the 22 relativesfelt their loved one had been completely treated withrespect, with three feeling their loved one had beenmostly treated with respect and one relative answeringdid not know.

All patients and relatives we spoke with at the hospiceand at other services we inspected told us they wereextremely happy with the care and treatment they hadbeen provided with. We looked at thank you cards andfeedback received via patient and relative surveys. Wordsfrequently used to describe the service provided were;‘compassion’, ‘kindness’, ‘dedication’, ‘supportive’.Patients and relatives described staff as ‘angels’ and theservice they provided as ‘a lifeline’ and ‘helped to getthings into perspective’. Patients told us ‘they wereamongst friends’.

Emotional support

Staff were devoted to doing all they could to supportthe emotional support to patients, families andcarers to minimise their distress. People’s emotionaland social needs were seen as being as important astheir physical needs.

All staff demonstrated a deep understanding of theemotional impact living with a life-limiting condition hadon patients and their relatives and consistently tookaccount of this when providing care and treatment.



Outstanding –


During the inspection we were told emotional supportcame in different forms depending what was required bythe patient and those close to them. The services at theDuchess of Kent hospice worked together as amultidisciplinary team to support the emotional needs ofthe patient and their families.

We spent time with the clinical teams, in the inpatientunit, day hospice, community services and thelymphoedema service and were told about and observedhow patients and their loved ones were given emotionalsupport to limit their distress. Staff listened to patient’sstories and addressed their concerns.

The patient and family support team offered emotionalsupport to the individual and families who may bestruggling with how to cope with the challenges ofserious illness and the changes it brought. Support wasoffered on a one-to-one basis, with family or in groups.They undertook anticipatory grief work and looked forcoping strategies, which included working with patientsand their wider families. The hospice social workerworked closely with the patient and family support team.Their role was multifaceted and included advising onbenefits and advocacy services and supported patientsand their families with accessing these as required.Through their experience and training they were skilled atrecognising families in distress and facilitating difficultconversations. Patients and their families spoke highly ofthe support offered and how it had elevated stresses atan extremely difficult time in their lives.

The Duchess of Kent hospice offered a befriendingservice. Trained volunteers would be matched withpatients in the community who were in need of support.Their role included companionship to the patient, runsmall errands, accompany patients to appointments andbe with the patient so relatives/carer could have a fewhours respite. This service had been shown, throughpatient user feedback, to provide a real difference to theemotional well-being of the patient, with 100% ofpatients saying they were happy with the service, it madea positive difference to them and they would recommendthe service to others.

The hospice had a chaplain who offered emotional,spiritual, religious or pastoral support to patients,

relatives and staff of all, any or no faith. Staff and patient’srelatives gave excellent feedback for the support offeredby the in-house chaplain and the comfort it had giventhem and the patient when needed.

The hospice had a Bereavement Care Team, whichincluded 10 trained bereavement volunteers, offeredtrained counsellors and therapists to talk with patientsabout their situation, offer advice, practical help andunderstanding. The team offered support to bereavedrelatives and friends before and after the death of theirloved ones. This included one-to-one counselling,informal drop in sessions and bereavement groups. Wesaw positive feedback from service users for the supportthat was provided which included the comments ‘verythoughtful, respectful, insightful, comforting’ and ‘Ithought it would be a waste of time but am now thankfulI used this service’.

Patients were supported to make memory boxes for theirloved ones. The box could contain special things to helpand give comfort to those left behind. We were told manystories by the diversional therapist of memory boxesmade in the day hospice, each special and individual tothe patient making the box. We were told how it gavecomfort to know that they could continue bonds withloved ones after they had died.

Understanding and involvement of patients andthose close to them

Staff supported and involved patients, families andcarers to understand their condition and ensure theywere active partners in their care and treatment.Staff helped patients live every day to the fullest.

Staff were fully committed to working in partnership withpatients and their relatives, involving them in decisionmaking processes about care and treatment.

We observed staff explaining to patients and theirrelatives the care and treatment that was being provided.Medical ward rounds were conducted not just in front ofpatients and relatives but involving them, making allinformation and decisions transparent and inclusive.Handovers we observed referenced conversations withpatients and relatives and their views were very muchtaken into account when discussing and planning careand treatment.



Outstanding –


Staff discussed advance care planning, includingpreferred plan of death, with patients and thisinformation was included in the ReSPECT forms. Bycompleting advance care plans patients were making aplan for future health and personal care if they shouldlose their decision-making capacity. It captured theirvalues and wishes and enabled them to continue toinfluence treatment decisions even when they could nolonger actively participle. The advance care plans wereviewed during the inspection were filled incomprehensively and documented discussions with thepatient and their family.

Relatives of patient’s we spoke with felt they and theirloved ones had received the information they needed tounderstand about and make informed decisions abouttheir care. Information was explained gently and withsensitivity, questions were never ignored or remainedunanswered. We were told they were kept fully informed,staff had time to answer questions and would answer in away they could understand.

Families were invited to use the communal areas, quietroom and gardens. Which gave patients and their familiesareas away from patient’s bedrooms to be together.Family pets were welcome to visit the hospice and thehospice regular had a visit from a registered pet astherapy (PAT) dog. A PAT dog has been shown to broughtjoy, comfort and companionship to many patients whoappreciated being able to touch and stroke a friendlyanimal.

Are hospice services for adultsresponsive to people’s needs?(for example, to feedback?)

Good –––

Our rating of responsive stayed the same. We rated it asgood.

Service delivery to meet the needs of local people

The service planned and provided care in a way thatmet the needs of local people and the communitiesserved. It also worked with others in the widersystem and local organisations to plan care.

The services provided by the Duchess of Kent hospicereflected the needs of the population and promotedflexibility, choice and continuity of care. The specialistpalliative care services provided aimed to ensure localpeople were cared for in their preferred place of care anddeath. This was not limited in terms of diversity, ethnicity,culture or aimed at any particular community group. Itwas available to all people requiring specialist palliativecare, symptom management or end of life care. Thehospice provided inpatient services, day services and ‘athome’ palliative and end of life care services to supportthe local community with individualised person-centredpalliative care.

The day therapy services offered in Reading, Newbury orWokingham aimed to help with specialist palliative careneeds so patients could continue living at home safetyand in comfort. Patients under the care of the dayservices had access to treatments which otherwise theywould have had to attend the local hospital. For example,lymphoedema clinics, physiotherapy and occupationaltherapy, blood transfusions and variable infusions.Complementary therapies were also offered such asmassage and art therapy.

The community nurse specialists worked collaborativelywith others in the wider system to design and planpalliative and end of care services for patients in the localcommunity. This included local GP surgeries, care homesand district nurses from the local trusts.

The inpatient hospice located in Reading had facilitiesavailable for family and friends. There was a free on-sitecar park. The inpatient unit had an open visiting policy.Family, friends and carers were welcome to visit theirloved one any time of the day or night. This meant therewere no limitations on visiting loved ones. All bedroomswere large and had facilities for visitors to stay overnight ifthey and the patient wished. All patients and visitorscould use the hospice’s free Wi-Fi. This meant they couldeasily keep in touch with people. There was a kitchenarea for relatives to use for drinks or prepare food. Visitorscould order food from the on-site kitchen, there was avending machine in reception and a public house andlocal shops a short distance away from the hospice.These details and transport links were in a folder in eachof the inpatient bedrooms. The hospice had thought ofthe practicalities for visiting family and friends, whichreduced the burden on them at a difficult time.



Outstanding –


Sue Ryder had an on-line community service. This wasavailable to anyone. It provided information and adviceabout a range of topics, such as going on holiday, makinga will and what to expect when someone is dying. It alsoprovided an opportunity for people to chat on-line withpeople in similar circumstances, so they could share andhelp each other with valuable emotional support.

Meeting people’s individual needs

The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patientsaccess services. They coordinated care with otherservices and providers.

Staff told us they treated every patient as an individual.Staff strove to provide care that was not limited in termsof diversity, ethnicity, culture or aimed at any particularcommunity group. They demonstrated a holistic,patient-centred approach to care planning and deliveryof care. Patients’ spiritual, religious, psychological,emotional and social needs were taken into account.Care plans we reviewed demonstrated that’s people’individual needs were taken into consideration, thisincluded personal, cultural, social and religious needs.

Staff spoke sensitively and confidently about the differingneeds of patients with learning disabilities, mental healthconcerns and dementia. Clinical staff told us they wouldliaise with and involve relatives, specialist practitioners inthe community and from the local trust who were alreadyinvolved in the patient’s care. By working in partnershipwould aid continuity of care and enabled the hospice touse and increase their knowledge and skill base.

Sue Ryder had introduced ‘What Matters to Me’ trainingfor staff. This training workshop had been developed withthe British Institute of Human Rights. It was designed tohelp practitioners use human rights as a practicalframework for ethical decision-making and for ensuringcompassion and dignity in end of life care. As of October2019, 81% of eligible staff had completed this training.

Staff told us they had rarely needed to use interpreters,but they could access translation services for patients forwhom English was not their first language or would find asign language interpreter, when needed.

Patients on the inpatient unit were encouraged to bringpersonal belongings to make them feel more at home, forexample bedding, pillows and photographs.

Inpatients could reach call bells and staff respondedquickly when called. We observed call bells beinganswered promptly during the inspection.

The hospice used volunteers. Some of the volunteerswere drivers who picked people up and took patientshome from the day hospice, which made the day hospiceaccessible to them, others tended the hospice garden,which provided patients with a safe, wheelchair friendlytranquil outdoor space. The garden included raised bedswhich could be accessed and tended by patients inwheelchairs. A garden shelter had recently been addedmeaning the garden could still be enjoyed by patientsand their families in inclement weather.

The family support service provided support to childrenwithin a patient’s family. They could do this directly or byreferral to other agencies, for example Daisy’s Dream, acharity which supported children and their family whohad been affected by life threatening illness orbereavement of someone close to them.

The hospice had a chaplain who offered emotional,spiritual, religious or pastoral support to patients,relatives and staff of all, any or no faiths. There was asanctuary where patients, families and staff could use asa place for reflection. In the room was a tree statue litwith fairy lights where messages had been tied to itsbranches. This gave people a place to pay tribute to aloved one at a difficult time. The chaplain hadestablishing links with different faiths to help supportpatients and at the time of our inspection, wascompleting flowcharts for different faiths for staff to use.The flowcharts would be a reference for all staff to knowhow a patient’s faith could influence their decisionsbefore, during and after death.

Access and flow

Patients could access the specialist palliative careservice when they needed it. Waiting times fromreferral to achievement of preferred place of careand death were in line with good practice.

The hospice had effective processes to manageadmission to the services. Referrals came into the servicemainly from GPs, district nurses, the local hospital



Outstanding –


specialist palliative team and the hospice’s owncommunity and day hospice services. Each specialistteam, for example the inpatient unit, day hospice andlymphoedema were responsible for managing andreviewing their referrals.

Referrals to the inpatient unit were through a single pointof access and were assessed at the daily referral meetingeach morning, where patients were triaged and admittedaccording to the capacity and occupancy on the inpatientunit and the needs of the patient. Any referrals requesting‘same day admission’ or ‘urgent’ were reviewed by theinpatient unit ward manager and the lead doctor for theshift as soon as they arrived. A decision again was madeon patient need and capacity. We attended the dailyreferral meeting during the inspection, and observed theprocess for managing admissions, which included anurgent referral. Staff discussed the patient’s need,capacity in the unit and safe staffing. Once the decisionhad been decided to admit, the information was taken tothe daily handover to organise and prepare for thepatient’s arrival.

In August 2019, data supplied by the hospice showed theinpatient bed occupancy was 80%. This was above thehospice target of 75%. Data collected September 2018 toAugust 2019 showed the inpatient bed occupancyoperated around the 80% for most months. The hospiceoperated a waiting list. We were told during theinspection there were patients on the waiting list to beadmitted to the unit for symptom management andrespite. These patients had been assessed and wereknown to be in a place of safety and receiving care fromthe local hospital or the local community teams. Inaddition, these patients and their families would besupported by the Duchess of Kent hospice communityclinical nurse specialists.

Most admissions occurred during the day, but the servicewould admit out of hours and at weekends, whennecessary, to meet patients care needs and preferences.During the inspection we observed the clinical teamdiscussing arrangements for a weekend admission.

The service has seen referrals for the inpatient unitincreasing with some referrals not always appropriateand this was impacting on the number of referralsreceived. The Duchess of Kent team were currently

undertaking a piece of work to look at referrals andadmission criteria to streamline the procedure and makesure care and treatment was available to the appropriatepatients.

The hospice followed the Sue Ryder Central transfer anddischarge policy. Inpatients were reviewed regularly, andthe hospice would discharge patients if they could, sothey could return home. The hospice had a dedicateddischarge coordinator to facilitate fast track dischargesfor patients to their preferred place of death.

The hospice did not have a mortuary. Cold blankets wereused to cover the deceased patient until the funeraldirector of the family’s choice collected the body. TheDuchess of Kent had an arrangement with a local funeraldirector to collect the body within 24 hours including on abank holiday, if required. Once the body was transferredto the funeral director’s care, relatives of the deceasedcould arrange for transfer to a funeral director of theirchoice, if required.

Nurses and medical staff could verify death, with themedical team completing the certificate. Families wereinvited to attend collection of the certificate and todiscuss other arrangements. If death was expectedfamilies were supported by the team at the Duchess ofKent hospice. Families would be given information andtold what would happen. Leaflets with the sameinformation would also been given to the family. It wasrecognised it was a difficult and confusing time familiesand providing information in different ways helped thefamilies understand what was happening. We sawfeedback from families thanking staff for the support andhelp shown to them after their relatives had passed.

Day hospices operated from Reading, three days a week;Newbury, two days a week; and Wokingham, three days aweek. With 10 spaces each day. The percentage uptakefor the day hospice service was appropriately 60% fromSeptember 2018 to August 2019. Patients were not alwaysable to attend due to feeling unwell or other healthissues. Patients usually attended the day hospice for a sixor 12-week programme. Patients attending the dayhospice, stayed under the care of their GP’s, with the dayhospice team contacting the GP, if required, regardingchanges in medication or care and treatmentrecommended.



Outstanding –


There was coordinated care between the hospice servicesand good links with the local hospital palliative careteam, GPs and the local district nurses. This meanteveryone involved in the patients care where informed ofthe person’s changing health and social care needs. Thisbenefited patient’s by providing coordinated care,treatment and well-being at a distressing time.

At the Duchess of Kent Quality Improvement Groupmonthly meeting data was reviewed for all servicesoffered. Data included, occupancy rate, length of stay,non-acceptance of referrals in the inpatient unit andpatient uptake at the day hospice. By reviewing this datathe hospice could look at demand, capacity and makeplans for the services.

Learning from complaints and concerns

It was easy for people to give feedback and raiseconcerns about care received. The service treatedconcerns and complaints seriously, investigatedthem and shared lessons learned with all staff. Theservice included patients in the investigation of theircomplaint.

The Duchess of Kent hospice took concerns andcomplaints very seriously as they were passionate inensuring patients and their families have the bestexperience possible when using the hospice serviceswhich were often at a period of emotional distress.

The hospice followed the Sue Ryder Central complaintspolicy. The policy included a complaints flowchart tofollow to make sure all steps were completed within thecorrect timeframe. The complaints policy stated thatcomplaints would be acknowledged within three workingdays, and routine complaints investigated and respondedto within 20 working days. Where the complaintinvestigation took longer than 20 working days, a holdingletter was sent to the patient, explaining why theresponse was delayed.

The hospice director had overall responsibility for themanagement of complaints. Complaints were logged onthe electronic reporting system. Complainants wereoffered a face-to-face meeting or a telephone call withthe hospice director and appropriate staff such as thehead of clinical services. At the end of the process aformal letter would be sent to the complainant which had

to include how the complaint had been investigated,conclusions drawn, what action was to be taken followingthe complaint and next steps the complainant could takeif they were not happy with the outcome.

All staff we spoke with were aware of the complaint’sprocedure. Staff told us they always tried to resolve anyissues or complaints at the time they were raised. If thiswas not possible, patients could be referred to the nursein charge or a team leader in the first instance. Emphasiswas placed on listening to the patient or relative toidentify their needs and to address their concerns in amanner that improved outcomes for them, whereverpossible. If concerns could not be resolved informally,patients and/or those close to them were supported tomake a formal complaint.

The hospice clearly displayed information about how toraise a complaint. We saw ‘How to raise a concern ormake a complaint’ leaflets throughout the hospice. TheSue Ryder website had a section detailing how to make acomplaint. Complaints could be made in person, bytelephone, and in writing by letter or email. In addition,patients could raise concerns using the hospice’sfeedback opportunities such as, real time feedback,‘we’re listening, please let us know how we can improve’cards and patient and relatives’ surveys.

Complaints were discussed at the monthly qualityimprovement meeting, common themes identified, andaction plans put in place to minimise recurrence. Wereviewed the minutes from three of the qualityimprovement meeting and saw complaints and resultingactions were a set item on the agenda.

Staff said learning from complaints and concerns wouldbe communicated to them mainly at handovers, teammeetings, emails and notice boards. The hospice used‘you said, we did’ boards to show how they had madeimprovements in response to patient and relative’sfeedback.

All staff we spoke with during the inspection werecommitted to providing an excellent service to theirpatients. Staff told us they saw learning from complaintsand concerns as a vital tool to help them achieve this.

From July 2018 to June 2019 there had been onecomplaint received and five informal concerns raised. All



Outstanding –


complaints and concerns were responded to according tothe Sue Ryder policy and reviewed at the qualityimprovement group meeting to identify any themes ortrends and if any changes in practice are required.

In the same reporting period the hospice had received107 formal compliments. However, we saw many moreexpressions of gratitude during the inspection. Since April2019 compliments were logged on the hospice’sreporting system. This meant the hospice couldbreakdown compliments by service, examine what wasmaking the biggest impact on people using the serviceand feedback people’s thanks to the staff. Complimentswere discussed at the monthly quality improvementmeeting and common themes identified. These includedthe whole family feeling cared for not just the patient,care was focussed and individual and how caring the staffwere and how patients and their families were treatedwith dignity and compassion.

Are hospice services for adults well-led?

Outstanding –

Our rating of well-led improved. We rated it asoutstanding.

Leadership

Leaders at all levels had the skills and abilities to runthe service. They understood and managed thepriorities and issues the service faced and hadsuccessful leadership strategies in place to ensuresustainability in the desired culture. They werehighly visible and approachable in the service forpatients and staff. They supported staff to developtheir skills, including management and leadershipskills and take on more senior roles.

The hospice had a clear management structure in placewith defined lines of responsibility and accountability.The senior leadership team were a stable team, with awealth of experience and expertise developed fromworking in the palliative care sector and different areas ofthe health service. The hospice was led by a hospicedirector, who had overall responsibility for the hospice.They were supported by the medical lead; the head ofclinical services who was responsible for the clinicalteams at Reading, Wokingham and Newbury, the family

support team and befriending service; the head ofsupport services was responsible for the administrationstaff, catering and the domestic teams and the head ofhospice fundraising. The hospice, had in the last month,recruited a deputy hospice director to help support thehospice director, as the hospice director also managedanother Sue Ryder hospice in the local area. The seniorleadership team was accountable to the Sue Ryderexecutive leadership team, who in turn were responsibleto the council of trustees.

Local leadership was strong. Each level of leadershipworked in accordance with the hospice vision andcreated a positive culture. Each service, for example theinpatient unit, day hospices and lymphoedema had ateam leader who was responsible for the day to dayrunning of their service. These team leaders weresupported to lead and develop their service by theexecutive team. The inpatient unit had a medical leadwho was responsible for the medical team working in theservice. There was a volunteer coordinator responsiblefor the volunteers at Reading, Wokingham and Newbury.

The senior management team and team leadersunderstood the issues, challenges and priorities in theirservice, and beyond, and proactively sought to addressthem. A culture of continuous improvement and servicedevelopment was a common thread throughout all areasof the hospice. They worked collaboratively with partnerorganisations, stakeholders and other agencies to deliverhigh-quality, patient and family-centred palliative andend of life care services.

Staff we spoke with were positive about their leaders.They told us they were very visible, approachable andthey felt well supported. We observed this during theinspection. Staff working at the centre at Wokingham saidthey had close working relationships with the seniormanagement team and team leaders at the Duchess ofKent hospice and the team leaders at Newbury. Althoughnot on the same site they did not feel isolated or that theywere working in a silo.

The service provided good development opportunitiesfor staff by supporting them to develop leadership andmanagement skills though both formal and informallearning. Staff were encouraged to learn and build on



Outstanding –


their prior knowledge. The hospice had promoted fromwithin as well as recruiting from outside. This meantthere was a good balance of experience and new ideas inthe leadership roles at the hospice.

Vision and strategy

The service had a clear vision for what it wanted toachieve and a detailed strategy to turn it into action,developed with all relevant stakeholders. The visionand strategy were focused on sustainability ofservices and aligned to local and national planswithin the wider health economy. Leaders and staffunderstood and knew how to apply them andmonitor progress.

The Duchess of Kent hospice’s vision, mission and valueswere those of Sue Ryder, and were focused on providinghigh-quality palliative care for patients and those close tothem living with life-limiting conditions. The Sue Rydervision was, “We see a future where our palliative andneurological care reaches more communities; where wecan help more people begin to cope with bereavement;and where everyone can access the quality of care theydeserve.” The mission was, “Sue Ryder supports peoplethrough the most difficult times of their lives. Whetherthat’s a terminal illness, the loss of a loved one or aneurological condition – we’re there when it matters. Ourdoctors, nurses and carers give people the compassionand expert care they need to help them live the best lifethey possibly can.”

There was an established set of values, which were:

• Make the future together – sharing our knowledge witheach other and collaborating with our volunteers,supporters and people who use our services to deliverpositive outcomes.

• Do the right thing – working with honesty andintegrity, having courage and resilience to face thechallenges in delivering our goals.

• Push the boundaries – constantly looking at ways toimprove what we do and how we do it, with creativityand innovation.

The values were underpinned by Sue Ryder‘behaviours’ which staff were expected todemonstrate at all times. These included emotionalawareness, honesty and integrity, resilience, delivering

outcomes and working together. We observed thatstaff worked in a way that demonstrated they upheldthe values in practice and kept exceptional patientcare as the basis for all they did. The appraisal processincorporated the Sue Ryder values and behaviours,whereby staff had to evidence how they demonstratedthem at work. We saw the Sue Ryder vision, missionand values were publicly displayed throughout thehospice. Most staff we spoke with could articulate theSue Ryder vision and mission.

Sue Ryder had developed a five-year strategy for 2018to 2023. This had been developed in collaborationwith staff, service users and external partners, and wasaligned to national recommendations for palliativeand end of life care. The strategy recognised thechallenges presented by a growing and ageingpopulation, with more people being diagnosed withcomplex conditions, and outlined how theorganisation planned to deliver services which metthe needs of more people and enabled them to accesspersonalised, life-enhancing care. There were twostrategic aims: provide care and support for morepeople; influence new models of care across the UK. Inpartnership with relevant stakeholders, the hospicehad developed services in line with the strategy.

The Duchess of Kent hospice had a local businessdevelopment plan 2019/2020 which outlined four keysareas it was focusing on; ‘ensure we demonstrate anddeliver excellent quality driven care within all ourclinical services and departments’; ‘to develop ourpeople to ensure everyone undertakes their roles withprofessionalism and skill, working as proudambassadors for Sue Ryder’; ‘to grow income, makingsure Sue Ryder Duchess of Kent is sustainable nowand for the future’; and ‘to review and develop allaspects of our core business practices andstakeholder management’. There were actionsassociated with each of the four key areas, who wasleading the actions, the timescale for delivery andreview of progress. Progress against delivering thestrategy and plans were monitored and reviewed. Thesenior manager team spoke to us in detail and withknowledge about their strategy, their progress, thechallenges they faced, and how they were working tosustain and develop the Duchess of Kent hospiceservices for the local community for the future.



Outstanding –


Culture

Staff felt respected, supported and valued withan emphasis on strong collaboration andteam-working. Staff were very proud to work forthe hospice and could articulate why. There was acommon focus on providing the best possible careto patients and continually improving the qualityof care and people’s experiences. The servicepromoted equality and diversity in daily workand provided opportunities for careerdevelopment. The service had an open culturewhere patients, their families and staff couldraise concerns without fear and were confident todo so. The service used these as an opportunity tolearn and improve the service.

Staff felt respected, supported and valued by patientsand their families, their peers and their managers.Staff told us there was good team work and very goodworking relationships throughout the hospice. Staffwere proud to work for the hospice, they wereenthusiastic and passionate about the care andservices they provided for patients. They enjoyedcoming to work, with many staff having worked at thehospice for many years. Staff told us they werecommitted to providing the best possible care forpatients and those close to them. They felt it was aprivilege to care for people at the most difficult time oftheir lives.

Throughout the inspection we saw pleasant,respectful and non-judgmental interactions betweenstaff, patients and their relatives. There was aninclusive culture with the service centred on the needsof the patients and those close to them.

There was a culture of honesty, openness andtransparency. Staff were encouraged to reportincidents and raise concerns or issues, so they couldbe learnt from and the service offered to patientsimproved. The senior management team promoted an‘open door’ culture and it was evident staff feltconfident to voice any concerns or issues they had.None of the staff we spoke with raised any concernsabout bullying or inappropriate behaviours from

colleagues. Arrangements were in place to ensure staffcould raise concerns safely and without fear ofreprisal, including a Sue Ryder Central whistleblowingpolicy.

Success was celebrated by staff, we were told howpositive feedback received was shared with staff bythe senior management team. Sue Ryder held anannual ‘Incredible Colleagues Awards’ event whichrecognised staff and volunteers who had gone theextra mile. The hospice in 2019 had two winners, withthe hospice director winning the leadership award forgreat people management category and a member ofthe lymphoedema team winning the unsung heroaward category.

There was a supportive network for staff. The hospicehad two Schwartz round facilitators. Schwartz Roundswere evidence-based forums for staff to come togetherto talk about the emotional and social challenges ofcaring for patients. Schwartz rounds were available toall staff, including volunteers and domestic staff.Debrief sessions were organised for staff after difficultor upsetting patients. Staff told us clinical supervisionwas available to them and staff could access thechaplaincy service for support. Every member of staffwe spoke with during the inspection said they feltsupported and they well-being was looked after.

Staff spoke positively about development and trainingopportunities. Staff felt able to discuss personaldevelopment with their line managers and one-to-onemeetings and the annual appraisals were seen asconstructive and a time to identify and agreeobjectives as well as training needs.

Governance

Leaders operated highly effective, proactivegovernance processes, throughout the serviceand with partner organisations. Staff at all levelswere clear about their roles and accountabilitiesand had regular opportunities to meet, discussand learn from the performance of the service.

The Duchess of Kent hospice had a governanceframework in place through which the hospital wereaccountable for continuously improving their clinical,corporate, staff, and financial performance.



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Patient outcomes, the audit program and hospitalmeetings fed into the governance framework. Eachmonth a hospice integrated quality and performancereport would be produced which was discussed at themonthly quality improvement meetings. Thesemeetings followed a set agenda which was aligned tothe Care Quality Commission (CQC) domains of safe,effective, caring, responsive and well-led. We reviewedthree sets of meeting minutes which showedgovernance matters, such as, incidents, audit findings,complaints, activity trends and quality improvementwere discussed. Actions arising were monitored,completed and updated at each meeting.

The governance and risk structure for Sue Rydershowed information discussed at qualityimprovement group meetings fed into relevant SueRyder Central groups, such as the researchgovernance group and medical devices group. Thesegroups fed into the Sue Ryder Central healthgovernance committee, which fed into the Sue RyderCentral health and social care sub-committee, whichfed into the council of trustees (board) meetings. Thismeant there was oversight of the service at hospice toboard level.

Relevant information from the quality improvementmeetings was reviewed by team leaders to understandhow their services were performing. It was up to theteam leaders to disseminate this to their teams and toact on any issues arising. We were told by staff workingin the inpatient unit that information would be sharedwith in various ways including, handovers, meetingsand via emails. They were committed to improving thequality of services for people who used the service.

Arrangements were in place to manage and monitorcontracts and service level agreements with partnersand third-party providers. Contracts were reviewed onan annual basis, which included a review of qualityindicators and feedback, where appropriate.

Managing risks, issues and performance

Leaders and teams used systems to manageperformance effectively. They proactivelyidentified and escalated relevant risks and issuesand identified actions to reduce their impact.They had clear and tested plans to cope with

unexpected events, which were understood bystaff at all levels. Staff contributed todecision-making to help avoid financial pressurescompromising the quality of care.

There was a Sue Ryder Central risk management inhealth and social care procedure and risk policy whichexplained the aim of risk management, explainedwhat risk was and how to identify, record, review andmitigate risk.

There was a Sue Ryder health and social care riskregister which was a high-level risk register thatidentified key risks to the operation of the Sue Rydercharity within the context of health and social careservices.

The Duchess of Kent had its own local risk register. Theregister included a description of each risk, thepotential impact of the risk and the risk owner,alongside mitigating actions and controls in place tominimise the risk. Each risk was scored according tothe likelihood of the risk occurring and its potentialimpact.

At the time of our inspection, six risks were detailed onthe risk register; We saw the risk register had beenrecently reviewed and action had been taken tominimise each risk. Risks were reviewed regularly atthe monthly governance meeting. There wasalignment between the recorded risks and what staffidentified as risks within the service, such as staffing.

From speaking with staff and reviewingdocumentation we were assured the service were ableto recognise, rate and monitor risk. This meant theservice could identify issues that could cause harm topatients or staff and threaten the achievement of theirservices.

There was a systematic corporate programme ofclinical and internal audit to monitor quality,operational and financial processes in Sue Ryderhospices. During our inspection we could see fromspeaking with staff and reviewing documentation thatthe services was carrying out these audits andidentifying and taking action where required.

The service had an up-to-date business continuityplan which was accessible to staff and detailed whataction should be taken and by who, in the event of a



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critical incident involving loss of building, informationtechnology or staff. Emergency contact numbers formanagers and services, such as electricity, gas andwater providers, was included. We were told by thehead of support services that the hospice ran desk topscenarios a few times a year to test out their criticalincident plan to practice what was required in a realemergency and to see if the plan needed improving.

Staff confirmed they received feedback on risks, issuesand performance in a variety of ways, such as teammeetings, noticeboards, newsletters and email.

Managing information

The service collected reliable, detailed data andanalysed it to drive forward improvements. Staffcould find the data they needed, in easilyaccessible formats, to understand performance,make decisions and improvements. Theinformation systems were integrated and secure.Data or notifications were consistently submittedto external organisations as required.

The hospice had clear service performance measures,which were recorded and reported and monitored bythe hospice, Sue Ryder Central organisation and thelocal commissioners. Information was recorded in themonthly integrated quality and performance report.We saw these reports were detailed and included dataon a range of performance and quality indicators, suchas incidents, staffing, service user feedback,complaints and activity. Areas of good and poorperformance were highlighted and used to challengeand drive forward improvements, where indicated.Statistical process control (SPC) charts were used totrack performance over a period of time, whererelevant, and to highlight unexpected variations inperformance which warranted investigation. Thismeant staff could identify at a glance, performancetrends and areas that required investigation andimprovement.

There were systems in place to ensure that data andnotifications were submitted to external bodies asrequired, such as local commissioners and the CareQuality Commission (CQC).

The hospice employed a data analyst and togetherwith the senior manager team reviewed all datacollected to make sure it was accurate, valid, reliable,timely and relevant.

Information technology (IT) systems were usedeffectively to monitor and improve the quality of care.For example, there was a computer system whereincidents, near misses and complaints were recorded.

Staff had access to a range of policies, procedures andguidance which was available on the service’selectronic system. Staff also told us IT systems wereused to access the e-learning modules required formandatory training.

Staff had access to up-to-date and comprehensiveinformation regarding patients’ care and treatment.The hospice had updated to using an electronicpatient record system which was the same as thatused by local GPs and district nurses. There werearrangements to ensure confidentiality of patientinformation held electronically and staff were aware ofhow to use and store confidential information.Computers and laptops were encrypted, andpassword protected to prevent unauthorised personsfrom accessing confidential patient information.

Sue Ryder Central had policies and processes in placegoverning Information Governance, Security andPersonal Data Protection. All data controllerregistrations for the processing of personal data weremaintained in accordance with the requirements ofthe UK Information Commissioners Office andinformation security and governance policies werecompliant with ISO/IEC27002 the Code of Practice forInformation Security Management.

Engagement

Leaders and staff actively and openly engagedwith patients, staff, equality groups, the publicand local organisations to plan and manageservices. They proactively collaborated withpartner organisations to help improve servicesfor patients.

The hospice actively encouraged patients to givefeedback through patient satisfaction questionnaires,real-time feedback, suggestion cards and via thehospital’s complaint process to help improve services.



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Feedback was reviewed by staff and used to informimprovements and learning, where possible. SinceApril 2019, feedback from all the various mediums waslogged on the hospice’s IT system and analysed. Thisinformation was then shared at the monthly qualityimprovement group meeting where trends andthemes in feedback could be discussed, improvementof services implemented, and success celebrated.

Volunteers on the inpatient unit collected anonymousreal-time feedback from patients and their relatives.By asking for feedback in this way, staff hoped issueswould be raised soon after they arose and meant theycould be acted upon quickly.

Patients who were discharged for a hospice servicewere sent a survey to fill out on the care they hadreceived. The hospice undertook a survey of bereavedrelatives. This was sent out six months after thepatient had died. Relatives were asked to rate andcomment on their experience of their loved one’s careand treatment. From July to September 2019, thefeedback showed respondents rated the servicehighly.

Other services who carried a caseload of patients for asignificant time, such as the lymphoedema andcommunity clinical nurse specialists sent out sixmonthly surveys to their patient groups to gatherfeedback to gain an insight on the care and servicebeing provided.

The hospice had a service user group which had beenrunning for seven years. The group met every sixweeks and helped the hospice see things from apatient or relatives’ point of view. They had helpedreview leaflets and information given to patients andrelatives, monitors service user feedback and makesuggestions, for example suggesting the gardenneeded a shelter so it could be enjoyed by patientseven in bad weather. A member of the service usergroup attended the monthly quality improvementgroup meeting, so the voice of the patients and theirrelatives could be heard at a senior level.

There were high levels of engagement with patients,families and carers, partner organisations and thepublic. For example, the hospice held manyfundraising events across the local community to raisepublic awareness and support for the hospice.

Families and carers were invited to attend the hospicefor an annual day of remembrance where peoplecould come together to reflect and remember theirloved ones. Four times a year the family support andbereavement services ran a family and friends meetup, where people could come and talk, sharememories and find support in each other’s company.

The views of staff were sought and acted on. Staff wereinvited to participate in the annual Sue Ryder staffsurvey. In the 2019 survey, the hospice scored 6.8 (outof 10) for an overall indicator of staff engagement. Thiswas lower (worse) than the national Sue Ryderaverage of 7.5, and indicated staff were reasonablywell engaged but this could be improved. 47% of staffcompleted the survey which was lower than the SueRyder average of 66.4%. There was no reference in thequality improvement group meeting minutes wereviewed, regarding discussion of these results andtherefore it was unclear how the senior managementteam planned to address staff engagement. Staffscored highest on the survey question ‘I would behappy for a member of my family or a close friend tobe cared for in one of the Sue Ryder care centres’.

Learning, continuous improvement andinnovation

All staff were committed to continually learningand improving services. Staff actively sharedlearning throughout teams. They had a goodunderstanding of quality improvement methodsand the skills to use them. Leaders encouragedinnovation and participation in research.

The Duchess of Kent hospice was committed toimprove the quality of services offered to patients andtheir relatives. The hospice had a quality improvementplan which was a live document which broughttogether feedback from service users, incidentreporting, concerns, complaints, audit findings. It wasreviewed at the monthly quality improvement groupand actions put in plan to address any issuesoccurring.

Team leaders of the services were actively encouragedto think of ways to improve their service. During theinspection we had told of many ways improvementhad been made,



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• The lymphoedema team were piloting an ‘educationsession’ for new patients who had been referred to theservice. This was a group session where patientswould come together to learn about lymphoedema,how to manage it and be with others who were insimilar situations and help reduce the feeling ofdealing with the condition in isolation. Also, byrunning group sessions new patients could be seenquicker after referral.

• The lymphoedema team had also written a new leaflet‘managing oedema (swelling)’. This leaflet was nowbeing used by all the Sue Ryder units nationally.

• The practice educator had been running sessions forstaff to raise awareness of the needs of people livingwith dementia, learning disability and autism in theend of life care setting.

• The practice educator had obtained funding to trainfour members of staff to deliver sage and thyme. Thiswas a foundation level workshop that teaches clinicaland non-clinical staff evidence-based communicationskills to provide person-centred support to someonewith emotional concerns.

• The hospice social worker had introduced monthlycarers drop-in sessions, which offered practical andemotional support to carers.

• The befriending volunteer co-ordinator had madeimprovements in lone working for their team of

volunteers and staff. A call in/out system had beenintroduced in September 2018 and had recently beenupdated to include guidance and clear instructionswhat to do if the befriender should find themselves inan urgent situation, such as if the patient had fallen.Volunteers and staff welcomed this guidance and gavethem more confidence in their role.

The hospice ran a ‘journal club’ which was open to allstaff. At this meeting staff were encouraged to presenttopics of interest to them relating to end of life care, orshare information gained from attending conferencesand training courses. We were told they had recentlybeen a presentation on the issue of hard to reachgroups such as the homeless to raise awarenesswithin the hospice.

Sue Ryder as a group championed the use of‘hangouts’ for staff to have meetings with other SueRyder staff in similar roles at other hospices.‘Hangouts’ were video communications via computerlinks. Senior staff, team leaders and staff in specialistroles, such as the tissue viability and infectionprevention and control lead found these meetings anexcellent way to improve their services through sharedlearning and group discussion talking through issuesand incidents that had happened in their service. Stafftold us they found the meetings supportive and agood way to make contacts in other Sue Ryderorganisations.



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Outstanding practice

There was a strong commitment from all staff to providetruly person-centred, compassionate care and supportpeople’s holistic needs. Staff were highly motivated andinspired to offer innovative ways to support patients withtheir end of life care which included outreaching into thecommunity.

The Duchess of Kent leadership team understood andproactively mitigated risks within their own services, so itwas safe, responsive and meets the needs of individualpatients.

Areas for improvement

Action the provider SHOULD take to improve

• The provider should make sure clinical andpharmaceutical waste was stored securely.

• The provider should consider auditing ReSPECTforms.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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