Core Service: End Of Life Care - Care Quality Commission

securely). Are the systems, processes andpractices that are essential to keeppeople safe identified, put in place andcommunicated to staff? Is implementation of safety systems,processes and practices monitored andimproved when required?Key line of enquiry: S4How are risks to people who use services assessed, and their safety monitored and maintained?Report sub-heading: Assessing and responding to patient riskGeneric prompts Are comprehensive risk assessmentscarried out for people who use servicesand risk management plans developedin line with national guidance? Are risksmanaged positively? How do staff identify and respondappropriately to changing risks topeople who use services, includingdeteriorating health and wellbeing,medical emergencies or behaviour thatchallenges?Professional StandardAdditional prompts How does the provider ensure that ifpeople have increased needs this isidentified? I.e. mouth care, need forchange to medication (especially if onsyringe driver or if they need one)? How often are people who are dyingreviewed and what is taken intoaccount? If there is no palliative care ward, whatReport sub-heading: Nurse staffing How are staffing levels and skill mixplanned and reviewed so that people20160905 acute core service inspection framework for EOLC V3

receive safe care and treatment at alltimes, in line with relevant tools andguidance, where available? How do actual staffing levels compareto the planned levels? Do arrangements for using bank,agency and locum staff keep peoplesafe at all times? How do arrangements for handoversand shift changes ensure people aresafe?specialist nurse provision is there? Is there a nominated lead or champion/link worker for end of life care on eachward?NB – if wards are very busy and thereforepeople identified as EOL are not seenregularly by either medical or nursing staff,this should be commented on in EffectiveReport sub-heading: Medical staffing How are staffing levels and skill mixplanned and reviewed so that peoplereceive safe care and treatment at alltimes, in line with relevant tools andguidance, where available? How do actual staffing levels compareto the planned levels? Do arrangements for using bank,agency and locum staff keep peoplesafe at all times? How do arrangements for handoversand shift changes ensure people aresafe?20160905 acute core service inspection framework for EOLC V3NB – if wards are very busy and thereforepeople identified as EOL are not seenregularly by either medical or nursing staff,this should be commented on in Effective

Key line of enquiry: S5How well are potential risks to the service anticipated and planned for in advance?Generic promptsProfessional StandardAdditional promptsReport sub-heading: Major incident awareness and training How are potential risks taken intoaccount when planning services, forexample, seasonal fluctuations indemand, the impact of adverseweather, or disruption to staffing? What arrangements are in place torespond to emergencies and majorincidents? How often are thesepractised and reviewed? How is the impact on safety assessedand monitored when carrying outchanges to the service or the staff?20160905 acute core service inspection framework for EOLC V3Does the mortuary service have a policyabout how to response in the event of amajor disaster?

EffectiveBy effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is basedon the best available evidence.Requires further investigation:Key line of enquiry:Data to be considered when making judgements:E1Are people’s needs assessed and care and treatment delivered in line with legislation, standards and evidence-based guidance?Generic promptsAdditional promptsProfessional StandardReport sub-heading: Evidence-based care and treatmentHow are relevant and current evidence-basedguidance, standards, best practice andlegislation identified and used to develop howservices, care and treatment are delivered?(This includes from NICE and other expert andprofessional bodies). Do people have their needs assessed andtheir care planned and delivered in line withevidence-based, guidance, standards andbest practice? How is this monitored toensure compliance?Is discrimination, including on grounds ofage, disability, , gender, genderreassignment, pregnancy and maternitystatus, race, religion or belief and sexualorientation avoided when making care andtreatment decisions?NICE QS13 Statement:Defines clinical best practice within Endof Life care for adults. Is EOLC managed in accordancewith NICE guidelines? Does EOLC achieve the Prioritiesfor Care of the Dying Person setout by the Leadership Alliance forthe Care of Dying People? What action has the service takenin response to the 2013 review ofthe Liverpool Care Pathway? What actions are they taking inrelation to the implementation ofthe ‘Ambitions for Palliative andEnd of Life Care: A nationalframework for local actionNICE NG31 Care of dying adults in lastdays of lifeThe guideline covers the clinical care ofadults (those over 18) who are dyingduring the last 2-3 days of life.National Framework for end of life care:http://endoflifecareambitions.org.uk/20160905 acute core service inspection framework for EOLC V3

How is technology and equipment used toenhance the delivery of effective care andtreatment?Are the rights of people subject to the MentalHealth Act (MHA) protected and do staffhave regard to the MHA Code of Practice?NICE QS66 Statement 2:Adults receiving intravenous (IV) fluidtherapy in hospital are cared for byhealthcare professionals competent inassessing patients’ fluid and electrolyteneeds, prescribing and administering IVfluids, and monitoring patient experienceNICE QS3 Statement 5:Patients assessed to be at risk of VTEare offered VTE prophylaxis inaccordance with NICE guidance2015/2020? Has an action plan been created inresponse to the service’sperformance in the National Careof the Dying audit? Have they audited any of the above– if so – what are the results? What percentage of people arereferred to specialist palliativecare? What percentage of people areseen by the Palliative care teamwithin 24 hours?Is this audited?How are the team made aware ofnewly admitted people with EOLCneeds? Are they automaticallyflagged?Report sub-heading: Nutrition and hydration How are people’s nutrition and hydrationneeds assessed and met?20160905 acute core service inspection framework for EOLC V3 Are they aware of GMC guidancefor doctors in supporting nutritionand hydration in EOLC? Are nutrition and hydration needsincluded in people’s individual careplans?

Report sub-heading: Pain relief How is the pain of an individual personassessed and managed?The Royal College of Anaesthetists corestandards for pain management:Core Standards for pain managementSpecifically:Core Standards for Pain ManagementServices in the UK (Faculty of PainMedicine, 2015) As these are newstandards, the Faculty of Pain Medicinehave identified the following standards asparticularly relevant and an indicator asgood practice in this core service:6.5 Standard 1 - Patients with cancerrelated pain must receive a painassessment when seen by a healthcareprofessional, which at a minimumestablishes aetiology, intensity and theimpact of any pain that they report.6.5 Standard 2 - Access to analgesiamust be available within 24 hoursfollowing a pain assessment whichdirects the need for analgesia. This mustinclude access to a prescriber as well asaccess to a dispensed prescription.6.5 Standard 3 - Patients and carersmust receive adequate information on theuse of analgesics, especially strongopioids (in accordance with NICEguidance on Opioids in Palliative Care).20160905 acute core service inspection framework for EOLC V3 How has the service implementedthe Faculty of pain medicines’ corestandards for pain management(2015)?

This must cover how to take analgesia,the likely effectiveness of this, how tomonitor side effects, plans for furtherfollow-up, and how to get help especially out of hours.NICE CG140 Palliative Care for adults:strong Opioids for pain relief Opioids for pain relief in palliative careAre anticipatory medicationsprescribed in people identified asrequiring EOLC? Is this prescribedappropriately? Have they audited this?Key line of enquiry: E2How are people’s care and treatment outcomes monitored and how do they compare with other services?Generic promptsProfessional StandardAdditional promptsReport sub heading: Patient outcomes Is information about the outcomes ofpeople’s care and treatment routinelycollected and monitored? Does this information show that the intendedoutcomes for people are being achieved? How do outcomes for people in this servicecompare to other similar services and howhave they changed over time?20160905 acute core service inspection framework for EOLC V3 Does the service use the End of LifeCare Quality Assessment Tool(ELCQuA) or similar tool? Does the service contribute dataabout end of life care to the NationalMinimum Data Set? What are the results from theNational Care of the Dying Audit?

Is there participation in relevant local and national audits, benchmarking, accreditation,peer review, research and trials? How is information about people’s outcomesused and what action is taken as a result tomake improvements? Are staff involved in activities to monitor andimprove people’s outcomes?Gold Standards FrameworkAccreditation for Acute Hospitals(GSF)20160905 acute core service inspection framework for EOLC V3 Is the service working towards anindependent accreditation standard,for example, have any of the wardsachieved routes to success forhospitals or GSF?

Key line of enquiry:E3Do staff have the skills, knowledge and experience to deliver effective care and treatment?Generic promptsProfessional StandardAdditional promptsReport sub heading: Competent staff Do staff have the right qualifications, skills,knowledge and experience to do their jobwhen they start their employment, take onnew responsibilities and on a continualbasis? What EOLC training have staff hadin identifying people in the last 12months of their life in the last year? What EOLC/ up-skilling is providedto ward staff, to ensure that peoplesreceive appropriate care 24/7. (i.e.specific training programme such asGSF Acute Hospitals Programme,Amber care bundle etc) How are the learning needs of staffidentified? Do staff have appropriate training to meettheir learning needs? Are staff encouraged and givenopportunities to develop? What are the arrangements for supportingand managing staff? (This includes one-toone meetings, appraisals, coaching andmentoring, clinical supervision andrevalidation.)Are staff trained in Advance CarePlanning? Are there regulardiscussions about care plans? Is there specialist palliative careservice staff providing support andtraining to generalist staff? If staff are found to be too busy tosee people in a timely manner? How is poor or variable staff performanceidentified and managed? How are staffsupported to improve?20160905 acute core service inspection framework for EOLC V3

Key line of enquiry:E4How well do staff, teams and services work together to deliver effective care and treatment?Generic promptsProfessional StandardAdditional promptsReport sub-heading: Multidisciplinary working Are all necessary staff, including those indifferent teams and services, involved inassessing, planning and delivering people’scare and treatment? How is care delivered in a coordinated waywhen different teams or services are Does the service use an ElectronicPalliative Care CoordinationSystem? If not, how is EOLCcoordinated across areas, and withexternal providers and services? Does the service have a PalliativeCare Multidisciplinary Teammeeting? Is there effective communicationbetween the EOLC team and otherservices within the hospital; forexample the medical servicescaring for older people? Is there a personalised end of lifecare plan in use which helps staffidentify and care for people at theend of their life? Is there a clear process for thetransfer of care from hospital tocommunity services including careplans and medication?involved? Do staff work together to assess and planongoing care and treatment in a timely waywhen people are due to move betweenteams or services, including referral,discharge and transition?When people are discharged from a serviceis this done at an appropriate time of day,are all relevant teams and services informedand is this only done when any ongoing careis in place?20160905 acute core service inspection framework for EOLC V3

Does the service avoid dischargingolder people late at night if theyhave complex needs and livealone? How does the service ensure thatthe objectives of The Academy ofRoyal Colleges Guidance for TakingResponsibility: AccountableClinicians and Informed Patientshas been implemented? Are all team members aware of whohas overall responsibility for eachindividual’s care? How is key information about olderpeople with complex needscommunicated to members of thecommunity health team ondischarge? For example, sharing ofassessments, including tissueviability (pressure risk) andnutritional assessment and risk? Is there, at minimum a 9-5pm 7/7week, with telephone support out ofhours service provided?Report sub-heading: Seven-day services20160905 acute core service inspection framework for EOLC V3

Key line of enquiry:E5Do staff have all the information they need to deliver effective care and treatment to people who use services?Generic promptsProfessional StandardAdditional promptsReport sub-heading: Access to information Is all the information needed to delivereffective care and treatment available torelevant staff in a timely and accessibleway? (This includes care and riskassessments, care plans, case notes andtest results.)When people move between teams andservices, including at referral, discharge,transfer and transition, is all the informationneeded for their ongoing care sharedappropriately, in a timely way and in line withrelevant protocols?How well do the systems that manageinformation about people who use servicessupport staff to deliver effective care andtreatment? (This includes coordinationbetween different electronic and paperbased systems and appropriate access forstaff to records).NICE QS15 Statement 12:Patients experience coordinated carewith clear and accurate informationexchange between relevant health andsocial care professionalsDischarge summaries should include: Reasons for admission Investigations done and results Changes to medication Destination on discharge Plan for follow up Plan for rehabilitation if appropriate DNACPR status if appropriate Important information that will aidcommunity management e.g.pressure risk, weightAre GP’s informed that a personhas been identified as requiringEOLC? If so, how is this done?Are medication changes, inparticular those of older people withcomplex needs communicatedpromptly to the GP, and care homestaff or domiciliary care staff ifappropriate?How is discharge communicated toGPs? How soon after dischargedoes this occur?Are care summaries sent to thepatient’s GP on discharge to ensurecontinuity of care within thecommunity?How does the service ensure thatdetails of the surgery, and anyimplant used, are sent to the patientand the patient’s GP?Do GPs have direct access? Canthey speak to a medicalconsultant/SpR for advice on the20160905 acute core service inspection framework for EOLC V3

phone?Key line of enquiry:E6Is people’s consent to care and treatment always sought in line with legislation and guidance?Generic promptsProfessional StandardAdditional promptsReport sub-heading: Consent, Mental Capacity Act and DOLs Do staff understand the relevant consentand decision making requirements oflegislation and guidance, including theMental Capacity Act 2005 and the ChildrenActs 1989 and 2004?How are people supported to makedecisions?Consent: patients and doctors makingdecisions together (GMC)Department of Health Reference guide toconsent for examination or treatment Are DNA CPR decisions madeappropriately and in line withnational guidance? Is this audited? Specifically looking at DNA CPRforms, have they been signed by anappropriately senior clinician? When was the last audit of theirDNA CPR forms and what was theresults?Do they audit what time forms aresigned? i.e. what proportion aresigned out of hours? (implicationthat decisions made by more juniormembers of staff)Consent - The basics (MedicalProtection) How and when is a person’s mental capacityto consent to care or treatment assessedBMA 2015 consent toolkitand, where appropriate, recorded? When people lack the mental capacity tomake a decision, do staff make ‘bestinterests’ decisions in accordance withlegislation? How is the process for seeking consentmonitored and improved to ensure it meetsresponsibilities within legislation and followsrelevant national guidance? Do staff understand the difference betweenlawful and unlawful restraint practices,including how to seek authorisation for adeprivation of liberty?Resuscitation Council DNACPR decisionmaking guidance20160905 acute core service inspection framework for EOLC V3

Is the use of restraint of people who lackmental capacity clearly monitored for itsnecessity and proportionality in line withlegislation and is action taken to minimise itsuse?20160905 acute core service inspection framework for EOLC V3

CaringBy caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.Requires further investigation:Data to be considered when making judgements: Complaints Only include Family and Friends Test results if specificPalliative CareKey line of enquiry: C1Are people treated with kindness, dignity, respect and compassion while they receive care and treatment?Generic promptsProfessional StandardAdditional promptsNICE QS15 Statement 1:Patients are treated with dignity, kindness,compassion, courtesy, respect,understanding and honesty What do porters say about how wardstaff handle bodies before they aretransferred to the mortuary? What do mortuary staff say abou

Core service: End of life care End of life care encompasses all care given to patients who are approaching the end of their life and following death, and may be delivered on any ward or within any service of a trust. It includes aspects of basic nursing care, specialist palliative care, bereavement support and mortuary services.