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

The inspection took place on 11 and 12 May and was unannounced. Ellenor Gravesend is a hospice that offers specialist palliative care, advice and clinical support for adults with life limiting illness and their families. They deliver personal, emotional and holistic care through a multi-disciplinary team of nurses, doctors, counsellors, physiotherapists, spiritual leaders and a range of volunteers. The service cares for people in three types of settings: at the hospice in a 15 bedded ‘In-Patient Unit’; in the ‘Hospice day service’ which provides support for up to twenty people; and in people’s homes. The service was providing services for 503 people in the hospice and the community 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.

There were safe systems in place for the ordering of medicines, but there were some shortfalls in the administration and disposal of medicines.

Most records were held on a computer system and available to all health professionals involved in the person’s care to ensure continuity of care. However, some records, such as aspects of people’s health care on the in-patient unit, were inconsistent and contradictory so although people received the care they required, this was not reflected in their records.

People said that they felt well looked after and safe when receiving care from the service. Staff received training in safeguarding adults and children and understood the importance of protecting people, visitors and themselves.

People said that there were enough staff available to promptly attend to their needs. They were were cared for by a staff team who felt well-supported so they had the skills and knowledge to meet people’s needs.

Assessments of risk were individual to people’s specific needs and identified how risks could be minimised. Accidents and incidents were responded to and monitored to see if there were any patterns or trends that required improvements to be made to ensure people’s safety.

Checks were carried out on all staff at the service, to ensure that they were fit and suitable for their role. New staff received a comprehensive induction and training to ensure staff had the skills and knowledge to support people with long-term illnesses or who needed end of life care. The service encouraged staff to further their learning and had an educational centre which delivered accredited training in palliative care.

People were supported by a multi-disciplinary team and referrals were made to other professionals to seek their advice and input when it was required. Their health, medical and nutritional and hydration needs were assessed and closely monitored.

The service recognised that some young people saw themselves as adults and had established a transitional pathway which enabled them to receive age-appropriate respite care on the in-patient ward. Young people received support from nurses whom were known to them and undertook activities that they enjoyed during their stay, making it a positive and valuable experience.

Staff understood their roles and responsibilities in relation to the Mental Capacity Act 2005 (MCA). This provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The service had made an application under DoLS to ensure that people were not unlawfully deprived of their liberty.

The service provided outstanding end of life care and people were enabled to experience a comfortable, dignifie

We spoke with two people who used the service. They told us that staff members always asked if it was alright before they carried out any care and treatment. One person told us, “They always ask, they say, “can we have an arm” when they want to do a blood test. I never fell that it is an invasion of my space or body.”

Both the people we spoke with said that they were very happy with the care that they received. One person we spoke with described the service as “Excellent.” A second person we spoke with said, “It is wonderful. I feel as if I have come to heaven.”

On the day of our inspection all areas of the in-patient unit and the day care unit were seen to be clean, bright and airy. We saw that the service had an infection control policy which included detailed instructions on hand hygiene. We spoke with two nurses. Both told us that they followed the service’s infection control policy and wore protective clothing, aprons and gloves, when these were required.

We saw that the recruitment files contained a ‘new employee checklist’ that ensured that all necessary checks were taken before the person took up their new post. Documentary evidence of identity had been recorded for each member of staff.

We saw that the records for people who used the service were multi-disciplinary and were completed by the teams within the service that had contact with the person, be that the in-patient unit, day unit or home visiting service.

People said that they had been provided with information about the service and that their treatment options were discussed with them. They said that there were different complimentary therapies that they could access if they wanted to. People said that they were happy with the support they received and that staff looked after them well. They said they liked the food, that there was a choice of menu and that they chose where to eat. People said they knew who to speak to should they have any concerns, but said they had no complaints.