St Luke's Hospice

Updated 12 January 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was carried out to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection was carried out on 17 and 18 October 2016 and was unannounced. The inspection team consisted of two adult social care inspectors, a specialist advisor in palliative care and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Prior to our inspection, we spoke with stakeholders, including local NHS Clinical Commissioning Groups. This information was reviewed and used to assist with our inspection and the findings are included throughout the report. Stakeholders we spoke with told us they had no concerns about St Luke’s Hospice and provided very positive feedback about the service.

Before our inspection, we reviewed the information we held about the hospice. This included correspondence we had received about the service and notifications submitted by the service.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection we spent time observing the care and support being offered to people and families on the inpatient centre, and therapies and rehabilitation centres. We spoke with seven people and ten family members or visitors who used the services of the hospice.

We also, with prior agreement from the family, accompanied the community team to visit two people who were receiving care and support in their own home. During these visits we spoke with two people and two family members.

Over the two days of inspection we spoke with 35 hospice staff and volunteers. Staff we spoke with included the registered manager/director of care, heads of inpatient and community care, head of wellbeing, medical director, social workers, allied health professionals, nursing and medical staff. We also spoke with the chief executive officer, risk management coordinator, head of human resources, learning and development coordinator, bereavement services coordinator, maintenance and portering service manager, administration staff, maintenance, catering and housekeeping staff and people who worked as volunteers at the hospice.

We spent time looking at records, which included six people’s care records, six staff records and other records relating to the management of the hospice such as training records and quality assurance audits and reports.

Updated 12 January 2017

This inspection took place on 17 and 18 October 2016 and was unannounced. This meant staff at St Luke’s did not know we were coming. Our last inspection at St Luke’s took place in August 2014. The hospice was found to be meeting the requirements of the regulations we inspected at that time and overall we rated the service Good.

St Luke’s Hospice provides a range of specialist palliative care services for adults within a dedicated building offering 20 inpatient beds along with outpatient services. The hospice also has a community team who provide care and support for people and families in the home environment.

At the hospice there is a therapies and rehabilitation centre providing day care support, physiotherapy, occupational therapy (including art therapy), wellbeing services (including complementary therapies), psychology, spiritual care, social work and bereavement services.

St Luke’s had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager also has the role of deputy chief executive and director of patient care.

Day-to-day operation of the hospice is delegated by the Board of Trustees to the Chief Executive Officer (CEO). The CEO discharges responsibilities through the Hospice Executive Team.

At the time of our inspection there were 18 people being cared for on the Inpatient Centre, 10 people were being supported in the therapies and rehabilitation centre and approximately 250 people were being cared for in the community around the city of Sheffield.

People, relatives and healthcare professionals consistently praised the exceptional standards of care, treatment and support provided by hospice staff.

People received exceptional care which was founded on best practice ensuring people were involved and central in the planning and review of their care.

We observed staff supporting people who used the service with consideration, dignity and utmost respect.

People received excellent care and treatment which enabled them to have a dignified and pain free death. Families and those that mattered to the person were supported to spend quality time with them. Relatives were also able to access bereavement support following their family member’s death.

People gave exceptional feedback about the meals and innovation provided by the hospice surrounding their nutritional needs.

St Luke’s Hospice was continually striving for excellence through consultation, research, and reflective practice. The hospice was extremely forward thinking and had a number of new developments underway based on best or evidence based practice to improve care or develop new initiatives.

We saw a number of quality assurance systems and audits to monitor performance and to drive continuous improvement.

The hospice had undertaken innovative work to support people and communicate with different groups of people within the city of Sheffield.

We found suitable arrangements were in place to help safeguard people from abuse. Staff knew what to do if an allegation of abuse was made to them or if they suspected that abuse had occurred.

We found people were cared for by sufficient numbers of suitably skilled, competent and experienced staff who were safely recruited.

We were informed there were over 800 volunteers providing support to the hospice. Volunteers had a wide range of skills and experience. Some worked in the charity shops, others helped with fundraising, running events, collecting donations, driving, bereavement support and many other roles. All the St Luke’s staff, people and relatives we spoke with said volunteers formed a vital part of the St Luke's team.

The service had appropriate arrangements in place to manage medicines so people were protected from the risks associated with medicines. Staff had received training and support to manage people’s medicines.

Systems were in place to maintain the safety of the hospice. The environment was well designed, welcoming, well maintained, clean and suited people’s needs.

The hospice provided a wide range of learning opportunities to staff employed in the service and other professionals.

People said that they took part in, and enjoyed, a wide range of activities and therapies which were extremely beneficial to their care and support.

The service was actively involved in building local community links, took part in project work and close working wither other hospices and organisations at regional and national level. This was to promote excellent standards for palliative and end of life care.