St. Luke’s Hospice (Harrow ; Brent) Ltd
St Luke’s Hospice Kenton Grange
Hospice Harrow & Brent
Inspection summary
CQC carried out an inspection of this care service on 13 September 2016, 15
September 2016 and 16 September 2016. This is a summary of what we found.
Overall rating for this serviceGood
Is the service safe?Good
Is the service effective?Good
Is the service caring?Good
Is the service responsive?Good
Is the service well-led?Good
This inspection took place on the 13, 15 and 16 September 2016 and was unannounced.
St Luke’s Hospice Kenton Grange Hospice Harrow ; Brent is a registered charity providing
specialist palliative and clinical support for people over the age of 18 years with life limiting
illnesses irrespective of diagnosis. The services provided included a 12 bed in-patient unit, a day
service, outpatients’ service and care in people’s own homes provided by community teams. The
hospice also provides support for families, friends and carers of people using its services.
At the time of our inspection there were approximately 760 people using or known to the service.
Two of the beds in the inpatient unit were closed to ensure people’s safety whilst there were a
number of nurse vacant posts. The number of inpatients varied each day of the inspection.
The service had a registered manager who was the Director of Nursing and Patient Services of the
hospice. A registered manager is a person who has registered with the Care Quality Commission
CQC 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
and associated Regulations about how the service is run. The registered manager was supported
in the managing and running of the services by the Chief Executive Officer (CEO), Board of
CQC is the independent regulator of all health
and social care in England. We are given
powers by the government to register, monitor
and inspect all health and care services.

Trustees, Medical Director and other management staff.
People were very positive about the care and support they received from highly motivated staff.
They told us staff were very kind, listened to them and respected their wishes and preferences
regarding their care and support needs. People received a service which was person centred in
meeting each person’s individual needs. People were supported to be fully involved and to take the
lead in all decisions about the care and support they received. They told us they felt listened to and
were respected by staff.
People received care and support from a multi-disciplinary team MDT and volunteers. The staff
we spoke with from all the services were very enthusiastic about their jobs and had a good
understanding of their role and responsibilities. They showed they cared very much about the
people they supported and were committed to deliver a high standard of service to people. Staff
treated people with sensitivity and respect and had positive and caring relationships with people
using the hospice services, people’s families and others important to them. People’s emotional,
spiritual and other individual needs were met by staff who were competent, compassionate and
People received the care, treatment and emotional support they needed as staff and volunteers
had the training they needed to develop their skills and provide them with the knowledge and
competence to meet people’s individual care needs.
The hospice was committed to promoting high quality end of life care for people by providing
education and training for a wide range of health and social care professionals working in the
community, hospitals and nursing homes. People with life limiting illnesses and those at the end of
their life benefitted by receiving the care and support they needed from skilled and caring staff and
were more likely to avoid hospital admission.
The hospice was responsive to people’s feedback and very proactive in working in partnership with
an exceptional number of other professionals and organisations to develop best practice and
provide people with a range of services that met their individual needs including advice and
emotional support.
People received the medicines they needed on time and in a safe manner. People’s pain was
monitored closely and managed well.
The hospice provided a 24 hour advice line for people in Harrow that used its services, their
families and friends and for health and social care professionals. This service provided a range of
advice including management of pain, symptom control for people receiving end of life care or
support with managing a life limiting illness in their own home, hospital or nursing home. A rapid
response team provided support, care and treatment for people within 24 hours. This and the
telephone advice line contributed to people being supported to remain in their preferred place and
avoid hospital admission.
People told us they felt safe when receiving care and support from the hospice services. Staff
knew how to report concerns internally and to outside agencies and were confident concerns
would be addressed appropriately.
There were systems and processes in place to protect people from the risk of harm. Staff knew
how to recognise signs of abuse and report any concerns. Risks to people’s well-being were
assessed by staff and measures were in place to mitigate risks and keep people safe within the
hospice and in their own home. There was a system in place to record, assess and monitor

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accidents and incidents. Incidents were analysed to minimise avoidable risks and the risk of re-
The provider’s staff recruitment process made sure that staff and volunteers were suitable to work
with people who needed care and support. The registered manager and staff were clear about
their responsibilities around the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty
Safeguards (DoLS) and supported people to make informed decisions about their care. Staff knew
when a person did not have the capacity to make a decision about their care and treatment that it
would need to be made in a person’s best interest. Staff knew when safeguards needed to be in
place to protect people who were unable to make decisions about their care.
People knew how to complain and were confident that they would be listened to and any concerns
they raised would be addressed appropriately. People were asked for their feedback about the
service they received and staff were committed to learning from people’s experiences and making
improvements to the services when this was required.
People told us they enjoyed the meals, were offered choices and had their individual food
preferences catered for. The importance of good nutrition was understood by staff and promoted.
Risks of malnutrition were assessed and measures to support people to have the nutrition they
needed were in place and regularly reviewed.
A range of activities were available for people using the day service or inpatient unit. These
included complementary therapies which people spoke very positively about.
Staff and people using the service told us that the service had an open, inclusive and positive
culture. Senior staff showed clear lines of responsibility and leadership. They with their staff teams
demonstrated a strong commitment to providing people with a safe, high quality and caring service
and worked hard to promote, improve, extend and develop the service to reach as many people as
possible within Brent and Harrow.
Systems were in place to maintain the safety of the hospice. This included addressing
maintenance issues, fire prevention and carrying out health and safety checks of equipment and
the building. A high standard of cleanliness was maintained in the hospice. Systems and
processes were in place to monitor standards of hygiene and control of infection and to make
improvements when needed.
A range of comprehensive and effective systems were in place to monitor and improve the quality
of the services provided.
You can ask your care service for the full report, or find it on our website
at www.cqc.org.uk or by telephoning 03000 616161


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