Demelza, Hospice Care for Children - SE London

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 1 quality statement in the well-led key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. The assessment of these areas showed good practice since the last inspection, and our rating for well led remains good. Staff included health, social, and spiritual requirements in ongoing assessments, which allowed for recognising and planning changes in their conditions and preferences. Families believed various therapies, such as play, art, and music, benefitted their children. The therapies facilitated communication, and children enjoyed the sessions, so they helped their sense of wellbeing. The programme encouraged family-centred care, and staff designed plans with this goal. Demelza SEL worked in partnership with neonatal intensive care units to support families whose unborn babies had life-limiting conditions. People were aware of the complaint's procedure and felt confident about using it. The trustees visited the service, and the staff informed them about the service's performance so they could ensure progress towards the agreed goals. Management arrangements were open, and managers sought views from staff when planning. The hospice conducted various quality audits to ensure the ongoing quality of care provided.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff had clear responsibilities and roles. Staff said leaders were visible and approachable, and staff felt involved and valued. Senior staff informed us there were weekly clinical services meetings involving all lead nurses and the director. In addition, the service held clinical governance committee meetings, medicines management assurance committee meetings and safeguarding assurance committee meetings. Senior staff were aware of their main risks and mitigations to manage them. They identified staffing as one of their main risks and explained how they managed it. The service used bank staff to fill gaps in rotas. They also had a recruitment drive in place. Staff informed us that they have a workforce development strategy to grow their nurses. They had successfully trained two nursing associates; two others were training.

There were clear systems of accountability and good governance. A board of trustees oversaw the senior management team and the organisation's overall governance. The senior management team members attended the board meetings and discussed developments within the service. The governance arrangements ensured that the trustees were involved with the overall management of the service. For example, nominated trustees had leadership responsibilities for various committees, including fundraising and marketing, clinical governance and safeguarding assurance. The service had a clear vision, mission, objectives and values, all embedded in the Demelza Strategic Document 2022-27. The document highlights the vision "to see a world where children and young people with serious or life-limiting conditions, and their families, have access to personalised, expert care – enabling them to live their best lives". The service had a risk register, and risks were reviewed and discussed regularly, including at the executive board level. The director and lead nurses attended the weekly clinical services meetings. The service also held clinical governance committee meetings where senior staff discussed several topics, including risks on the risk register, safeguarding assurance, KPIs, Incidents, policies and audits, among other issues. Service level agreements were in place with partner organisations (e.g. GP practice) to provide safe and effective care. The service had processes in place for safe and effective care. These included an audit program, policies and procedures for patients who deteriorate and require transfer to hospital, symptom management and assessment and incident management, amongst others.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.