Southern Health NHS Foundation Trust RW1

End of lif lifee car aree Quality Report

Headquarters Tatchbury Mount Calmore Southampton Hampshire SO40 2RZ Tel: 023 8087 4036 Website: wwwsouthernhealth.nhs.uk

Date of inspection visit: 7 -10 October 2014 Date of publication: 25 February 2015

This report describes our judgement of the quality of care provided within this core service by End of life care. Where relevant we provide detail of each location or area of service visited. Our judgement is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by End of life care and these are brought together to inform our overall judgement of Southern Health NHS Foundation Trust

1 End of life care Quality Report 25 February 2015

Summary of findings Ratings Overall rating for End of life care

Requires Improvement

–––

Are End of life care safe?

Requires Improvement

–––

Are End of life care effective?

Requires Improvement

–––

Are End of life care caring?

Good

–––

Are End of life care responsive?

Good

–––

Are End of life care well-led?

Good

–––

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Summary of findings Contents Summary of this inspection

Page

Overall summary

4

Background to the service

5

Our inspection team

5

Why we carried out this inspection

5

How we carried out this inspection

6

What people who use the provider say

6

Good practice

6

Areas for improvement

6

Detailed findings from this inspection Findings by our five questions Action we have told the provider to take

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7 18

Summary of findings Overall summary • The trust had a strategy for End of Life Care (EOLC) that it was in the process of revising because of changes to the national guidance. • We observed staff treating patients with dignity and respect both in the community hospital wards and in patients’ own homes. • We spoke with seven patients and/or their family. All patients gave us positive feedback about the care they received. • All incidents, accidents, near misses, complaints and allegations of abuse were logged on the trust-wide reporting system. We found some staff were not always aware what to report. • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms were filled with varying level of completeness. • There were not sufficient staff available to carry out their work to a good standard. The district nurses providing end of life care to people in their homes were “stretched.” • Community staff told us there were frequent delays in obtaining mattresses and beds for their patients. Whilst the service for mattresses and beds were provided by a third party provider, the quality of the service was not monitored and no action had been taken to address delays.

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• We found instances where there was no record of mental capacity assessments being undertaken to assess patients’ capacity to make decisions about their end of life care. • There was information available for families and carers. However, the information was not standardised across the trust. • The trust had recently taken actions to ensure the needs of the local people were being met. They had submitted a business case to the clinical commissioning groups (CCG) on the different models of end of life care to be provided across the county. This discussion was ongoing and a decision is going to be made by February 2015. We spoke with four patients and three relatives. We also spoke with 24 staff, including: the specialist palliative care team of nurses; ward nurses; doctors; consultants; senior managers; allied health professionals; a chaplain; bereavement and mortuary staff. We also attended staff focus groups and collated evidence on End of Life Care from CQC inspection teams inspecting a range of relevant services across all geographical areas of the trust. We observed care and treatment and looked at care records. We received comments from our listening event and we also reviewed the trust’s performance data.

Summary of findings Background to the service Southern Health NHS Foundation Trust received Foundation Trust status in April 2009 under the name Hampshire Partnership NHS Foundation Trust and in April 2011, it merged with Hampshire Community Health Care. The trust provides end of life care to patients in their own homes and on the inpatient wards at the trust’s seven community hospitals. End of life care is a core service provided by Southern Health community teams and community hospitals within Hampshire, with over 95% of the end of life care delivered in this way. Specialist Palliative Care Services

are commissioned from the trust solely in the Southeast Hampshire geography. The SHFT Specialist Palliative Care team comprises of 13 WTE staff. The specialist service provides a well-defined clinical service including advice and guidance to community teams and GPs in the area. The specialist palliative care team were available from 9am to 5pm, Monday to Friday. Outside of these hours a consultant based at the local hospice provided a telephone on-call service.

Our inspection team Our inspection team was led by: Chair: Shaun Clee, Chief Executive, 2gether NHS Foundation Trust Team Leader: Karen Wilson, Head of Inspection for Mental Health, Learning Disabilities and Substance Misuse, Care Quality Commission The team included CQC inspection managers, inspectors, Mental Health Act reviewers, pharmacy inspectors, CQCs national professional advisor for learning disabilities, analysts and inspection planners. There were also over 100 specialist advisors, which included consultant psychiatrists, psychologists, senior nurses, student nurses, social workers GPs, district nurses, health visitors, school nurses and an occupational therapist. In addition, the team included Experts by Experience who had personal experience of using or caring for someone using the types of services that we

Why we carried out this inspection We inspected the Trust as part of our comprehensive inspection programme.

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inspected. Five Experts by Experience were involved in the inspection of mental health and learning disability services and two were involved in inspecting community health services. Team Leader (Community Services Inspection): Anne Davis, Care Quality Commission The team that inspected this service included a CQC inspector and specialist palliative care nurses. The team visited the specialist palliative care service, a sample of community hospital wards and community teams across the trust geography, and visited patients receiving end of life care at home. Evidence was collected from a range of focus groups with staff across inpatient and community settings. The team also worked closely with, and collated evidence on end of life care from, other CQC inspection teams visiting community hospitals and community teams across the trust.

Summary of findings How we carried out this inspection To get to the heart of people who use services’ experience of care, we always ask the following five questions of every service and provider: • • • • •

Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led?

Before visiting Southern Health NHS Foundation Trust, we reviewed a range of information we hold about the trust and asked other organisations to share what they knew. We also received comments from people who had attended a listening event prior to the inspection and via

comment cards left at services. We carried out announced visits on 7th to 10th October 2014 to sample end of life services across all geographical areas of the trust: During the visit we held focus groups with a range of staff who worked within the service, such as nurses, doctors, therapists. We observed how people were being cared for and talked with carers and/or family members and reviewed care or treatment records of people who use services. We accompanied staff on home visits and met with people who use services and carers, who shared their views and experiences of the core service.

What people who use the provider say Patients and relatives told us that the care and support provided to them by the palliative care team and the staff on the wards and in the community was good. One person receiving palliative care in a community hospital said “I know what heaven is like now.”

A few patients were dissatisfied with the time it took to get hospital equipment at home.

Good practice • The “virtual ward rounds” where health care professionals come together to discuss the ongoing of patients and the support to be given to them and their family highlighted how seamless care could be provided.

The expediency of transfer of patients from one community hospital to another or to the community, so as to meet their emotional and psychological needs.

Areas for improvement Action the provider MUST or SHOULD take to improve Action the provider MUST take to improve

• The trust must improve the numbers of suitably qualified, skilled and experienced staff to provide end of life care. • The trust must improve the overall recording of information and decision making on Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms.

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Action the provider SHOULD take to improve • The trust should fully develop and implement an evidence based end of life pathway. • The trust should improve the processes for reporting and learning from incidents, accidents, near misses, complaints and safeguarding concerns. • The trust should improve the timeliness of the provision of equipment to patients receiving end of life care at home.

Southern Health NHS Foundation Trust

End of lif lifee car aree

Detailed findings from this inspection

The five questions we ask about core services and what we found Requires Improvement –––

Ar Aree End of lif lifee car aree saf safe? e? By safe, we mean that people are protected from abuse Summary

The specialist palliative care team were aware of the process for reporting any identified risks to patients, staff or visitors. All incidents, accidents, near misses, Never Events, complaints and allegations of abuse were logged on the trust-wide reporting system. However, some staff were not always aware what to report. We found there was slow progress regarding applying the learning from incidents across the organisation and little progress on publicly reporting on these incidents. We looked at Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms throughout the trust. We saw that there were variations in the completeness of the forms across the organisation. Community staff told us there were frequent delays in obtaining mattresses and beds for their patients. Whilst the service for mattresses and beds were provided by a third party provider, the quality of the service to patients was not monitored and no action taken to address delays. Staff were able to explain what constituted a safeguarding concern and the steps required to report such concerns.

Detailed findings

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Incident reporting, learning and improvement • There had not been any Never Events (serious largely preventable patient safety incidents that should not occur if proper preventative measures are taken) in the specialist palliative care service in the past 12 months. • The specialist palliative care team were aware of the process for reporting any identified risks to patients, staff or visitors. All incidents, accidents, near misses, complaints and allegations of abuse were logged on the trust-wide reporting system. However, some community staff we spoke were not always aware what to report. For example, some staff told us that they would record when patient equipment was not delivered to an end of life patient on time, others were not aware they could record this as an incident. • The specialist palliative care team held regular team meetings and discussed learning from incidents. • The trust had promoted Duty of Candour amongst staff. We spoke with staff who told us there was support for staff when they made a mistake in the delivery of care.

There was also a culture change taking place where there was improvement in the reporting of patient safety incident. However, there was little progress on publicly reporting on these incidents.

Safeguarding • Staff spoken with all confirmed they had all completed adult safeguarding training in the previous year; they had a sound understanding of safeguarding processes and policies. The specialist palliative care team told us that safeguarding training was mandatory. Mandatory training records confirmed a high percentage of staff had completed safeguarding training. • Staff were able to explain what constituted a safeguarding concern and the steps required to report such concerns. • Staff also knew about their whistleblowing policy and how to report concerns if they had them. • Patients told us they felt safe being cared for in the community hospitals and when they were visited by community nurses. Relatives we spoke with told us they knew how to raise concerns and felt these would be taken up seriously.

Medicines management • There were clear guidelines for medical staff to follow when prescribing anticipatory medicines for patients. We looked at six records and found that anticipatory end of life care medication was appropriately prescribed. Nursing staff were clear as to how to administer the medication when required.

Safety of equipment • Community staff told us there were frequent delays in obtaining mattresses and beds for end of life patients. Whilst the service for mattresses and beds were provided by a third party provider, the quality of the service to patients, for example, the length of the delays in the arrival of equipment, was not monitored. Community staff told us of some examples when equipment arrived after the patient died. They told us of some examples when equipment arrived after the patient had died. Senior staff were not aware of these delays and action had not been taken to address. • Clinical staff we spoke with told us that patients care was affected because of the lack of equipment such as a hospital bed and mattresses. Whilst the service for mattresses and beds were provided by a third party 8 End of life care Quality Report 25 February 2015

provider, the quality of the service to patients, for example, the length of the delays in the arrival of equipment, was not monitored. Clinical staff told us that as that chasing for equipment took a lot of their time and this meant that valuable time to provide care was taken up for this task. • Whilst accompanying a community district nurse on a home visit we saw that appropriate equipment was available in the patient’s home • Each ward area we visited had sufficient moving and handling equipment to enable end of life patients to be cared for safely. • Equipment was maintained and checked to ensure it continued to be safe to use.

Records and management • In all of the ward areas we saw that records were stored securely in order to ensure they could not be accessed by people who did not have the authority to access them. An electronic system of recording of information was available in most cases. However, in some areas, paper records were still in use. • The records for patients visited at home were kept by the patient bedside. • We looked at ten medical notes and found they were completed sensitively and detailed discussions that had taken place with patients and their relatives. • We saw that all decisions relating to resuscitation were recorded on a standard ‘lilac form.’ The Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form was at the front of the notes, allowing easy access in an emergency. We looked 20 Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms across five community inpatient wards, of those four were completed correctly. We saw that there were variations in the completeness of the forms across the organisation.

Cleanliness, infection control and hygiene • We saw that the wards and mortuary viewing area we visited were clean and bright. We visited the mortuary at Petersfield Hospital, Lymington Hospital, and Gosport War Memorial Hospital. Records of temperature checks of mortuary fridges were inspected and were within required limits. There were arrangements in place with local funeral directors to collect the deceased within two hours of death. This arrangement was in place at other community hospitals that did not have mortuaries

• General and clinical waste bins were covered. There was appropriate signage used. When we entered wards we observed that hand gel was available at the entrances for visitors and staff to use. • Ward and departmental staff wore clean uniforms with arms ‘bare below the elbow’ and that personal protective equipment (PPE) was available for use by staff in all clinical areas. • The wards we inspected had separate hand washing basins; hand wash and sanitiser were available. • We observed most staff sanitised their hands between patient contacts and wore aprons and gloves when delivering personal care to patients. However in two places we visited, Petersfield Hospital and Gosport War Memorial the inspectors had to remind staff entering the ward to use the hand hygiene gel.

Mandatory training • Some staff told us that although e-learning was available, they found that some courses could also benefit from some classroom instruction. Information gained from the trust’s training department demonstrated that classroom based training sessions were available for all mandatory training in addition to the e-learning courses.

Assessing and responding to patient risk • The trust was working towards updating its existing “End of Life Strategy.” The revised strategy was going to be available for wider consultation in December 2014. Through this strategy, the trust has identified and intends to respond to patient risks directly related to end of life care. The trust has already undertaken a “gap analysis” and through this it had identified the areas for the work it has to do. • During our inspection, we found there were a number of patients on the wards we visited who were in the later

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stages of a terminal illness. For these patients, there was no documentation of any decision making or discussion about whether a DNACPR order would be appropriate. This meant in the case of a cardiac arrest, attempts would be made to resuscitate the patient which may not have been appropriate.

Staffing levels and caseload • There were not sufficient staff available to carry out their work to a good standard. For example, staffing levels for palliative care team has been flagged on the in the South East Hampshire divisional risk register. There were plans in place to address this so that patient experience can continue to improve and not get worse because of lack of specialist assistance. The trust was examining various models of care with the local clinical commissioning groups and there was evidence of progress in how this could be realistically and practically resolved. • The district nurses providing end of life care to people in their homes were “stretched.” They were not enough of them and the demand for their services was high. Staff had also highlighted that they did not have enough time to complete their visits and write up their notes. Sometimes, the notes were written days after the visit. All this was contributing to the stress for staff. This has resulted in some nurses leaving their roles. This meant there were fewer nurses and each had a higher number on their case load.

Managing anticipated risks • Staff told us that they worked very closely with their own teams and the neighbouring teams to address anticipated risks such as heavy snowfall and flooding. They gave examples of flooding recently and how local arrangements worked to overcome this. We were told people were provided with the care they needed.

Requires Improvement –––

Are End of life care effective? By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Summary

The trust phased out the Liverpool Care Pathway and has started to pilot Achieving Priorities of Care in the Community but not yet fully embedded. There were audits undertaken on DNACPR forms. We were shown an action plan following this. However, our spot check on DNACPR forms highlighted that the trust had some way to go before these were being appropriately filled out. Nutritional and hydration assessment tools and care plans were in place for patients receiving end of life care, where a need had been identified. The trust had recently appointed end of life link nurses who were based on the wards in the community hospitals in line with a trust-wide initiative. The appointment of these nurses was very new. We saw that multidisciplinary team working was undertaken in the trust. We found instances where there was no record of mental capacity assessments being undertaken to assess patients’ capacity to make decisions about their end of life care.

Detailed findings Evidence based care and treatment • The use of the Liverpool Care Pathway has been phased out and replaced with Achieving Priorities of Care in the Community. This document has been trialled in two community hospitals and in community teams in some geographical areas. The pilot will be evaluated and based on that it will be rolled out across the trust. • The current strategy is being revised to take into account national guidance, such as recognition that the patient was dying, advance care planning decisions, symptom management, involvement of the patient and their family and consideration of the patient’s spiritual and emotional wellbeing. • During our inspection we did not see the pilot version of the end of life care plan in use in the community. However, we spoke with staff who told us that their initial feedback was that the documentation was too long and will have to be adapted to the community setting. • There were audits undertaken on DNACPR forms. We were shown an action plan following this. However, our 10

End of life care Quality Report 25 February 2015

spot check on DNACPR forms highlighted that the trust had some way to go before these were being appropriately filled out. We looked 20 Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms throughout the trust. We found six forms had not been completed in line with the national guidance published by the General Medical Council. Four forms identified the reasons that CPR is unlikely to be successful because of “old age.”

Pain relief • We saw trust-wide guidelines on pain management in palliative care that had been written by the consultant in palliative care. There were also referral pathways coordinated with the oncology team. • A specialist palliative care nurse identified a number of community hospitals wards where staff delivered high quality end of life care and were able to provide appropriate pain relief to patients. • We spoke with seven patients and/or their family. All patients gave us positive feedback about the care they received. We saw nursing staff giving good pain management support and advice to two patients. • Staff, in both hospitals and community teams told us that part of the end of life care was pain control and if they could not achieve this for the patient then this is one reason they would refer to the palliative care team. However, during our inspection we saw a patient who could have benefited from being referred to the palliative care team but no arrangements had been put in place for this to happen. We requested the community matron to look into the care being provided to that patient.

Nutrition and hydration • Nutritional and hydration assessment tools and care plans were in place for patients receiving end of life care, where a need had been identified. • We observed community nurses undertaking ongoing reviews of patients to ensure they received appropriate nutrition and hydration. During one community visit, we saw how palliative care nurses provided advice on hydration and nutrition.

Requires Improvement –––

Are End of life care effective? • Community hospitals had guidance on the use of artificial hydration for patients at the end of their life.

Outcomes of care and treatment • Patients identified as requiring end of life care were sometimes started on an end of life care plan. The palliative care team had produced guidance for ward staff. Staff were aware of this guidance however not being used consistently

Competent staff • The palliative care clinical nurse specialist told us that additional training was available for staff. They told us that due to the demand for their service and the vacancies at present, their role had changed to provide more training programmes to staff. • The wards had very recently appointed “End of Life Champions" and they were going to be trained to ensure “End of Life” care was well embedded on the ward. However, we found that this was a very recent initiative and had not been embedded as yet. • Hospital staff told us that the palliative care team was readily available to support patients on the wards and support staff in terms of advice and delivery of care.

Appraisal and supervision • All staff we spoke with told us they had received appraisal in the last financial year. They also told that there was a great emphasis that this be completed in a timely manner. • Supervision was provided to staff. We found line managers were acting as clinical supervisor.

Multi-disciplinary working and coordination of care pathways • We saw that multidisciplinary team working was undertaken in the trust. • Hospital staff told us that the palliative care team was readily available to support patients on the wards and support staff in terms of advice and delivery of care. • The end of life team had access to spiritual support from the chaplaincy service. This included support for people of all religions and beliefs 24 hours a day, seven days a week. • The trust used virtual ward rounds where a group of healthcare professionals come together to discuss patients and the palliative care given to them. These 11

End of life care Quality Report 25 February 2015

virtual ward rounds allowed healthcare professionals to discuss care given to patients with a number of other healthcare professionals involved in the care of that particular patient. • Staff we spoke with were highly complementary of these virtual ward rounds and felt that they improved the quality of patient care. • We found there was generally good coordination across the trust and with GPs and other providers. However, we found there were instances of poor coordination.

Referral, transfer, discharge and transition • The transfer and discharge of patients from one hospital to another was undertaken efficiently. We saw an example of how a patient who was at the end of their life, their wishes were accommodated by the ward manager.

Availability of information • There was information that guided staff how to share records across the teams. We found staff were well versed on information sharing records of patients across the community and hospital setting. • The Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form was at the front of the notes, allowing easy access in an emergency. • We found that for some terminally ill patients in community hospitals patients, there was no documentation of any decision making or discussion about whether a DNACPR order would be appropriate. • Community team staff told us that there was discussion at virtual ward meetings to challenge when the documentation had not yet been completed appropriately, explore the reasons, and then complete the documentation to evidence patient or relative involvement in their care decisions.

Consent, Mental Capacity Act, and Deprivation of Liberty Standards • Staff had received training on Mental Capacity Act as part of safeguarding training. Those we spoke with told us they had also received training on the Deprivation of Liberty Safeguards (DOLS), some staff were unsure about the implications for their practice. • We examined documents to evidence discussions that staff had regarding decisions about Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR). In community teams we found some records of a genuine

Requires Improvement –––

Are End of life care effective? discussion about the decision with the person or relatives if appropriate. We saw an example of a best interests meetings being held for one patient in the community, to establish if they had capacity to make decisions re DNACPR. • But we found instances, particularly in community hospital wards, where there was no record of appropriate discussion or mental capacity assessments being undertaken to assess patients’ capacity to make decisions about their end of life care. • Within a sample of 20 DNACPR forms across five community hospital, four DNACPR forms had been completed correctly and showed that they had been

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completed at the request of the patient. This meant that the patient or their family’s wishes had been taken into account. Four forms showed no evidence that a discussion had taken place with the patient or any of their relatives before the form had been signed by medical staff. Three forms stated that the patient lacked capacity to make decisions around DNACPR but we found no evidence of a mental capacity assessment. This meant that decisions about care at end of life had been made without a record showing that consideration had been made for their ability to be involved, or that decisions had been taken in line with the legal requirements of the Mental Capacity Act 2005 (MCA).

Good –––

Are End of life care caring? By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Summary

We observed staff treating patients with dignity and respect both in the community hospital wards and in patients’ own homes. There was information available for families and carers. However, the information was not standardised across the trust. We found staff supported and promoted patients to undertake greater self-care. We found patients were provided with support on how to control their own symptoms. They were encouraged to seek more analgesia if their pain was not in control.

Detailed findings Dignity, respect and compassionate care • We observed staff treating patients with dignity and respect both in the community hospital wards and in patients’ own homes. We observed nurses knock on the doors outside the room before entering • Throughout our inspection we witnessed patients being treated with compassion, dignity and respect. We spoke with many patients during our inspection about their experience of care. A majority of patients told us that they were looked after well or exceptionally well. • We observed staff interactions with families that were compassionate and appropriate at all times. • Staff ensured that privacy was maintained by staff when they assisted patients with their needs. • Patients and a family member we spoke with told us they were happy with the level of care they or their family members received. • We spoke with chaplains in various community hospitals who told us they were able to assist the nursing staff to ensure that care and treatment was available to patients taking into account their faith and beliefs.

Patient understanding and involvement • There was information available for families and carers. However, the information was not standardised across the trust. Relatives in Lymington would get very detailed information following the death of a loved one. In Gosport, the information was not as detailed as in the

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Lymington hospital’s leaflet. The leaflet was printed by a local funeral director. The information available from Petersfield Hospital was patchy. This variation leads to a differing experience by patients and relatives across the different areas of the trust geography. • The palliative care nurses ensured that patient choice was always fulfilled.

Emotional support • Staff showed considerable compassion towards relatives who wished to see their loved one following their death. We were told how the room would be prepared before relatives were invited to see the deceased. Relatives were given the choice to participate in requests regarding religious and cultural practices to ensure that the patient received their last wishes at the time and after their death. One relative told us that “this is what heaven would be like.” We found patients were cared for in an environment of their choice. This was done in response to the wishes of the patients. • One relative told us that the explanations given by the palliative care nurse to her and her husband were very supportive and enabled them both to make the decision on DNACPR. Prior to that, no one had explained to them in such detail the process of DNACPR. • Staff in the Winchester team told us that when supporting a patient at end of life the team undertook a lot of support visits but let the patient and family lead the process and how many visits they felt they required.

Promotion of self-care • We found staff supported and promoted patients to undertake greater self-care. During one of our visits to a patient’s home, we observed a nurse showing a patient what actions to take when they found themselves unable to breathe. The nurse explained how such situations were more psychological and the staff advised the patient on how to relax and undertake deep breathing exercises.

Good –––

Are End of life care responsive to people’s needs? By responsive, we mean that services are organised so that they meet people’s needs. Summary

The trust had recently taken actions to ensure the needs of the local people were being met. They had submitted a business case to the clinical commissioning groups (CCG) on the different models of care to be provided across the county. Staff were well versed on legal duty equality and human rights. For example, patients and staff both knew how to access interpreters. During our inspection, we met three patients who were receiving end of life in their own homes in the community. We found plans on how the needs of the individuals were going to be met.

Detailed findings Planning and delivering services which meet people’s needs • The trust had recently taken actions to ensure the needs of the local people were being met. They had submitted a business case to the clinical commissioning groups (CCG) on the different models of care to be provided across the county. The cabinet group of the CCG were going to meet in November 2014 to make a decision on their preferred model and the investment that was going to be made by them. The trust senior management team responsible for end of life told us that their focus had been more strategic than operational as they need to have the infrastructure in place to support the delivery of high quality care. • The trust had contracted to another provider to provide beds and other equipment within seven days of the order being received. We were told there was no provision for prioritising people needing equipment for end of life care within the contract.

Equality and diversity • Staff were well versed on legal duty equality and human rights. For example, patients and staff both knew how to access interpreters. • In some areas covered by the trust, we found leaflets in other languages besides English. However, this was not consistent across the trust. Most leaflets were only available in English. • Staff were aware how they would meet the needs of black and ethnic minorities including Eastern European 14

End of life care Quality Report 25 February 2015

communities. They shared with us how arrangements for getting death certificates for Muslim burial to ensure Muslim burials took place as soon as possible were put in place.

Meeting the needs of people in vulnerable circumstances • During our inspection, we met three patients who were receiving end of life in their own homes in the community. We found plans on how the needs of the individual were going to be met. • We observed care given to people living with dementia and found there were detailed plans for staff on how to meet their needs.

Access to the right care at the right time • The needs of patients were being met when community services worked together seamlessly. There were many examples of such coordination. We saw evidence of multidisciplinary meetings where information was shared across services through virtual ward rounds. • When patients moved from acute hospital to the community hospital, it was with their wishes. Arrangements were made to ensure patients and relatives were supported in this movement. However, we also found instances when patients were not accessing the right care at the community hospitals because staff had not made the link to palliative care. • Staff were aware of anticipatory prescribing for patients dying at home. We undertook visits at home with nursing staff and found arrangements were in place for four medications that might be required for end of life symptom control. • Some patients requested to be cared for at home. In such instances, we saw some coordination amongst the various services. There were arrangements to facilitate timely transfers between the community and community hospital for patients requiring end of life care. For example a patient was admitted to Romsey Hospital for 24 hours to assess and treat medical issues and then was discharged back home according to the patient’s wishes. However, in some instances the delay of response from other services such as equipment, a patient’s quality of care was affected.

Good –––

Are End of life care responsive to people’s needs? Complaints handling (for this service) and learning from feedback • During our inspection, we did not see evidence of complaints specifically relating to end of life care. However, we found that the trust received positive feedback regarding the care it provided. The trust welcomed feedback and comments from patients.

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Good –––

Are End of life care well-led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. Summary

The trust had a strategy for end of life care (EOLC) that it was in the process of revising because of changes to the national guidance. To enable the implementation of the strategy, the trust had undertaken a ‘gap analysis’ on what was actually happening in the trust in the delivery of end of life care and what should actually happen. The trust recognised that its audits and the quality monitoring of end of life care was at the early stages of development. Until recently, the current strategic focus was to establish the right infrastructure. It was now building on this structure in partnership with the clinical commissioning groups.

Detailed findings Service vision and strategy • The trust had a strategy for EOLC that it was in the process of revising because of changes to the national guidance. To enable the implementation of the strategy, the trust had undertaken a ‘gap analysis’ on what was actually happening in the trust in the delivery of end of life care and what should actually happen. The strategy was going to go out for consultation in December 2014.

Governance, risk management and quality measurement • The trust recognises that its audits and the quality monitoring of end of life care was at the early stages of development. The strategic focus it has given to establishing the right infrastructure was taking place. However, it has already identified that it had no measurements in place to monitor the effectiveness of its strategy. Hence it established a work stream to help them identify how they know they are doing a good job. • Specialist palliative care staff are well integrated with the senior team leading on palliative care. There are regular quality meetings on the new end of life strategy and the team leading it had representation from across the organisation including chaplains, ward staff and educational leads. • The trust risk register was used to highlight any issues of immediate risk. The workload of the specialist palliative care nurses and the difficulties they were facing in 16

End of life care Quality Report 25 February 2015

meeting demand resulted in this being placed on the risk register. The senior leadership team’s response for submitting a business care to the CCG was a direct result of this.

Leadership of this service • Staff spoke positively about their immediate and team leaders. They felt supported and involved in the delivery of the service. However, we heard varied opinions about the trust-level leadership. Some staff knew that the board had visited their areas of work whilst other staff had no received board members on their wards. • We found that there was good leadership at the divisional director level. For example, the lead for putting the business case to the CCG was taken up by the divisional director. We inspected minutes of the trust board and found end of life care was regularly discussed at the board level. The recent response to submit a business case to the CCG was as a direct result of the leadership team recognising and putting the necessary importance of ensuring support to end of life care. End of life care was not an afterthought.

Culture within this service • The specialist palliative team linked across SE Hampshire, Fareham and Gosport and West Meon, and was not commissioned across the whole of the geography supported by the trust. They linked with education in the provision of educational programmes to staff across the trust. They provided the necessary leadership to embed the service across the organisation.

Public and staff engagement • There was little evidence of public and staff engagement specific to end of life care. For example, patients and relatives had not been consulted on the current draft strategy for end of life care. The trust had an End of Life Care steering group. There were no patient or relatives representation on this group. • There were a few examples of engagement with bereaved relatives. Integrated community teams regularly undertook Bereavement follow-ups and had

Good –––

Are End of life care well-led? participated in the ‘National Voices’ Bereaved Survey. The community teams and community hospitals also regularly carried out patient and carer surveys which included those who were in receipt of palliative care.

Innovation, improvement and sustainability • The palliative care team gave examples of practice that the team felt had worked well. They had increased their focus on education so as to ensure their services were

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End of life care Quality Report 25 February 2015

used in specialist circumstances. They had also created a referral pathway in partnership with the oncology team at the acute hospital. This they felt would provide optimal care for patients. • The new replacement for the Liverpool Care Pathway, Achieving Priorities of Care in the Community was a direct result of several health professionals coming together to design a process for providing care to patients at the end of their life.

Compliance actions Action we have told the provider to take The table below shows the regulations that were not being met. The provider must send CQC a report that says what action they are going to take to meet these regulations.

Regulated activity Treatment of disease, disorder or injury

Regulation Regulation 20 HSCA 2008 (Regulated Activities) Regulations 2010 Records (1)The registered person must ensure that service users are protected against the risks of unsafe and inappropriate care and treatment arising from a lack of proper information about them by means of the maintenance of (a)an accurate record in respect of each service user which shall include appropriate information and documents in relation to the care and treatment provided to each service user How the regulation was not being met: Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form were not always completed correctly. Information about the basis for decisions for DNACPR, involvement of the patient and family and mental capacity assessments were not always documented.

Regulated activity Treatment of disease, disorder or injury

Regulation Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 Staffing In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitable qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity. How the regulation was not being met: People who use services and others were not protected against the risks associated with insufficient numbers of staff in the specialist palliative care team and some community teams providing end of life care.

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End of life care Quality Report 25 February 2015