Ellenor Gravesend

Updated 8 November 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 checked 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. At our last inspection in 2016 we found the children's service met legal requirements, but the adults' service required improvements.

This inspection took place on 25, 26 and 27 July 2017 and was announced. The inspection team consisted of two inspectors, a specialist adult nurse, a specialist children palliative care nurse, two medicines inspectors and an expert by experience. An expert by experience is a person who has personal experience of using similar services or caring for family members

Prior to the inspection we looked at previous inspection reports and notifications about important events that had taken place at the service. Before the inspection, we asked the provider to complete 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. This helped us plan and inform our inspection.

We spoke with twelve adults who used the service, seven relatives and 39 staff. We spoke with the management team including the heads of department for patient care, community services, education and research, wellbeing, human resources, quality, ward sister and children nursing. We also spoke with staff that included the pharmacist, family support worker, play therapist, seventeen nurses, four health care assistants, two housekeeping staff, cook, two volunteers, chaplain and an administrator.

Home visits were undertaken with consent to two adults who received support from the community team; and one child with their parents. We spent time on the Inpatient Ward talking to people, relatives and staff and observed medicines being administered to people. In the adult day hospice we joined some people for lunch and in undertaking an activity. We attended the children multi-disciplinary meeting, a multi-disciplinary meeting at a local GP surgery and a Schwartz round. This is where staff come together to talk about the emotional and social challenges of caring for people. We also received feedback from two children’s commissioners of the service, a commissioner and quality lead for the adult services, a paramedic and nursing home manager.

During the inspection we viewed three children’s and six adults care plans and notes to check how their care was planned and delivered. We also looked at eight staff recruitment records; the staff training programme; staff rotas; meeting minutes; six people’s medicine records; health and safety records; risk assessments and audits; compliments and complaints logs and quality assurance questionnaires.

Updated 8 November 2017

The inspection took place on 25, 26 and 27 July and was announced. 48 hours’ notice of the inspection was given because the children community service was office based and we needed to be sure that the manager and staff were available and to arrange visits to families in the community.

At our last inspection to the service on 11 and 12 May 2016 Ellenor Gravesend provided specialist palliative care, advice and clinical support for adults with life limiting illness and their families. Since this inspection, the service has been registered as one service with Ellenor’s children services and now provides palliative care for babies, children and adults. They deliver personal, emotional and holistic care through a multi-disciplinary team of nurses, doctors, counsellors, physiotherapists, therapists, spiritual leaders and a range of volunteers. On site the 15 bedded ‘Inpatient Ward’ admits people from 14 years to adulthood and the ‘Hospice day service’ provides support for up to twenty adults. Community teams provide services for babies, children and adults. There are two adult teams: 'The Hospice at home’ for people in their own homes and the ‘Care Home Support team' for people in care and nursing homes. Children's services include a respite service for parents/carers; cancer care for children so they can receive chemotherapy in their own homes and a range of clubs and activities. The service was providing support for around 1420 people and their families at the time of the inspection.

A registered manager was in post. 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.

At the last inspection on 11 May 2016, we asked the provider to take action to make improvements in the management of medicines and record keeping with regards to the care and treatment. This was with regards to adults in the Inpatient Ward. Guidance was not in place for the use of some medicines and creams and waste medicines were not disposed of in a timely manner. Accurate records were not always kept with respect to each person's individual care. The breaches were of Regulation 12, Safe care and treatment and Regulation 17, Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider sent us an action plan in August 2016 which stated that they would comply with all Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by the end of September 2016.

At this inspection on 25, 26 and 27 July 2017 improvements had been made to the management of medicines in the Inpatient ward and people’s records with regards to their care and treatment.

There were safe systems in place for the administration, recording, handling, storage and disposal of medicines. Staff were trained in how to give medicines safely, a pharmacy technician ensured medicines were available when people needed them, and a community pharmacist provided a clinical review of people’s prescribed medicines.

Since the last inspection to the adult service on 11 and 12 May 2016 and the children’s service on 19 and 20 July 2016 the service had maintained standards of care and continuously strived towards developing creative and innovate ways of supporting children, adults and their family members.

In the children’s service there had been a major cultural shift led by the head of children’s nursing. Staff reported that the head of children’s nursing had been very brave in the changes and developments within the team, and this had resulted in them having a shared understanding of the aims of the service. This benefitted children and their carers as they were able to take assessed risks and positively engage the whole family, by directing their resources where they were most needed. This had included designing and implementing a tool for children transitioning to adulthood which proactively encouraged partnerships with other teams in the community and across the organisation. Young people could access the Inpatient Ward to receive respite care in a way that met their individual needs and wishes as teenagers such as themed sleep-overs. When young people transitioning had not meet the eligibility criteria for the adult service, the multi-disciplinary team had held a brain storming session and came up with lots of ideas about how existing adult day services and groups could be adapted to meet their needs. This is a national issue and ensured the service continued to offer support and remain in contact with the young person until they time when they would meet the criteria.

The adult service had built on and further developed its services and management and staff reported that they had started to reap the benefits of these initiatives. They had continued to work towards closer relationships with people from local communities that were underrepresented in the service such as Black, Asian and Ethnic groups to discuss how to engage them in palliative care services. This work had been effective as during the inspection a nurse was called to the home of a person from one of these groups and stayed with them until their death, to ensure they died at home as per their wishes and those of their family. The head of well-being was new to their position at the last inspection, but was now established in post. They had further developed the range of health, social and therapeutic activities available as a direct response to the needs of children and adults. Groups included music for well-being, cooking, poetry, meditation and breathlessness, gardening, spiritual reflection, an after school club and a tea and movie night. The service had taken the basis of a Schwartz round and developed it in an innovative and creative way to focus on the experiences of people who used services, rather than those of staff. The Schwartz round which took place during the inspection was called, “From the horse’s mouth- what it is really like to be referred to Ellenor”.

Commissioners said the service had been effective in reducing the numbers of children and adults admitted into hospital. A children’s commissioner told us, “Ellenor have prevented the children in their care from being admitted into hospital through the innovative interventions they have put in place in the child’s home”. A Commissioner for adult services said, “The service has made such a difference to people in care homes, supporting them to keep them in the community and out of hospital. Patient care is their priority and they work with us to ensure this”.

In the adult service initiatives had been undertaken to make contact with people with palliative care needs so interventions and support could commence for the person as soon as possible, rather than in their last few days. The ‘Care Home Support team' had contacted all nursing homes in the local area to identify each adult with a life-limiting condition. It had grown from supporting 140 people in January 2017 to 770 people at the time of the inspection. The service had met with all GPs in the local area and through this process had identified over 300 people whom they could offer support to help them to remain in their own homes, in preference to spending their last days in hospital.

Bereavement services were tailored to children and adults’ individual needs, provided over a significant period of time after death and were continually developed to meet local need. These included therapeutic sessions led by a play therapist for small groups of siblings and children of adult’s who had died at the service and ‘drop in’ sessions for their carers.

Relatives spoke overwhelmingly of the positive support their child or adult family member received from the service. Adults, children and their family members valued their relationships with the staff team and felt that they often went ‘the extra mile’ for them, when providing care and support. They were full of praise for the staff in terms of their kindness, compassion and individual responses to their family member’s needs. The service viewed supporting the person or child and their family members was seen as a key to people’s well-being.

People and relatives said they or their family member felt safe and well looked after when receiving care from the service. Ensuring people were safeguarded was at the centre of the service. All staff had received training in safeguarding adults and children and understood the importance of protecting people, visitors and themselves.

The service provided outstanding end of life care where children and adults were enabled to experience a comfortable, dignified and pain-free death in the place of their choice when possible. Staff embodied the values of the service which included providing compassionate and professional care and supporting the 'whole family' before, during and after a death.

Staff were motivated and keen to convey to inspectors their pride in working at the service. Staff were listened to, empowered with training and fully supported in their roles. The provider was mindful of the emotional challenges staff experienced and had developed strategies and opportunities for reflection and resilience. This included Schwartz rounds and a journal club to enable staff to have the support they required to continue to provide caring and compassionate care.

Adults and children were supported by a multi-disciplinary team who put them and their family members at the centre. Joint working with other professionals was central to how care was delivered and in identifying people who would benefit from their services. Adults and children’s nutritional and hydration needs were assessed and guidance was in place about how to meet them. Food provided by the service was appet