Sue Ryder palliative Care Hub- South Oxfordshire

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to good. This meant people’s needs were met through good organisation and delivery.

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 scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

People received person-centred care that reflected their needs, preferences, wishes and what was important to them. Staff took time to understand people's physical, emotional, social, cultural and spiritual needs and used this information to plan and deliver care. People and those important to them were involved in decisions about treatment, symptom management and future care wishes. For example, staff discussed advance care planning, treatment escalation plans and ReSPECT forms to support informed decision-making.

Care was tailored to each person's individual circumstances and staff adapted support to reflect what was important to people. For example, staff helped one patient find a gardener because maintaining their garden brought them enjoyment and improved their wellbeing. We also saw evidence staff respected people's beliefs and values. For example, staff ensured a patient's religious items were handled respectfully and returned to their preferred place following personal care.

People were supported to receive care in their preferred place whenever possible. The service offered hospice at home, inpatient beds if required, a consultant-led virtual ward, counselling, wellbeing and bereavement services. The virtual ward supported people with complex symptoms or deteriorating health to receive specialist multidisciplinary care at home, helping them avoid unnecessary hospital admission and remain where they wished to be cared for.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

People received coordinated care from teams and services that worked together to support continuity of care. Referrals were received through a single point of access service and prioritised according to clinical need. Staff told us they worked closely with hospital palliative care teams, GPs, district nurses and specialist nurses to ensure people received timely care and support.

Multidisciplinary teams worked together to plan and review care. For example, patients were discussed during regular multidisciplinary team meetings where staff considered physical health, emotional wellbeing, safeguarding concerns and family support needs. Agreed actions were documented and shared to support continuity of care.

Services were designed to support people across different stages of their illness. People could access hospice at home, a consultant-led virtual ward, counselling, wellbeing services and bereavement support. Staff worked closely with hospital teams to secure fast-track funding and equipment to support timely discharge and care in people's preferred place.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

People received timely, accessible and relevant information to help them understand their care, treatment and support options. Staff discussed advance care planning, with people and those important to them, helping people understand their choices and make informed decisions about their care and future treatment.

People and families received information about additional support available to them. For example, staff signposted people and relatives to counselling, wellbeing and bereavement services, including online bereavement support.

Information was provided in ways that met people's communication needs. The service used accessible document templates, communication guidance and resources to support reasonable adjustments. Staff told us interpreter and communication support could be arranged when required to help people understand information and participate in decisions about their care.

People's information was managed securely and confidentially, and information governance incidents were reviewed and acted upon. For example, where data issues were identified, actions were taken to reduce risk and learning was shared with staff through training, reminders and changes to processes.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

People were encouraged to share their views, raise concerns and help improve services. The service had a complaints policy and participation strategy which promoted a person-centred approach and welcomed feedback from people, families and carers. Information was available to help people understand their right to raise concerns, how to make a complaint and the support available to them. People were provided with updates on the progress of complaints, outcomes were shared and feedback was used to support learning and improvement. Staff told us the leaders encouraged an open culture where people could raise concerns without fear that it would affect their care or treatment.

The service had received 3 complaints between 2025 and 2026. Themes included pain and symptom control, communication and responsiveness. 2 complaints were partially upheld and one complaint was withdrawn. We saw no evidence of complaints being escalated to the Ombudsman.

The service used a feedback system to collect and analyse real-time feedback from patients and staff. This helped the service identify opportunities for learning and improvement. Furthermore, we saw numerous compliments from family members thanking and praising staff for the care, compassion and attention they had provided to their loved ones.

Complainants received an apology and were kept informed of progress and outcomes. Information provided by the service stated that concerns would be handled fairly and respectfully, and that raising a complaint would not affect a person's care or treatment. Staff told us feedback and complaints were used to support learning and improve services. For example, a complaint about pain and symptom management was partially upheld and improved communication about information and choice was implemented.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

People were able to access care and support based on their needs and preferences. Referrals were received through a single point of access service and prioritised according to clinical need using a recognised triage process. People could access a range of services, including physiotherapy, occupational therapy, hospice at home, a consultant-led virtual ward, wellbeing services, therapies, counselling, bereavement support, 24-hour phone access to speak with a nurse and specialist health services. Occupational therapists worked closely with hospital teams to support timely discharge from the unit, including arranging fast-track funding and equipment.

The service worked to reduce barriers and inequalities in access. Assessments considered language needs, cultural and spiritual preferences, family circumstances and other factors that could affect how people received care. Staff told us interpreter and communication support could be arranged when required. A wellbeing coordinator worked with people from communities who may be less likely to access healthcare, providing information about available support and helping them engage with services. For example, staff supported a family from a travelling community who had not previously received palliative care at home, ensuring care was delivered in a way that respected their values, beliefs and preferences.

The service identified and responded to challenges affecting access. Staff told us delays could occur when specialist equipment or support from external services was required. People and staff also told us that changes to district nursing arrangements had sometimes resulted in delays to care visits and responses to referrals. Leaders had identified these concerns and implemented action plans to improve communication, access and continuity of care.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The service ensured people had equitable experiences and outcomes regardless of their background, identity or personal circumstances. Staff considered how policies, practices and individual circumstances could affect people’s access to care and outcomes, and adapted support where needed. For example, staff used respectful communication and person-centred approaches when planning care, taking account of people’s individual circumstances and needs.

We observed multidisciplinary team discussions considered potential barriers such as language, communication needs, understanding and family circumstances. Staff used this information to adapt care and support people and their families to participate fully in decisions about treatment. This helped reduce the risk of people experiencing poorer outcomes because of barriers to accessing or understanding their care.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

People were supported to plan for future changes in their health and make decisions about their care and treatment. Staff held advance care planning discussions with people and those important to them. For example, staff discussed preferred place of care, future treatment options, treatment escalation plans and ReSPECT forms. Staff told us they supported people to understand their choices and make informed decisions about their future care.

Care plans reflected people's wishes, needs and preferences and were reviewed when circumstances changed. People and staff told us they regularly discussed future care needs to ensure plans remained relevant and achievable.

People with complex needs received coordinated planning for their future care. Multidisciplinary teams worked together to plan and review care. For example, one person preferred place of death was at home. When a rapid review found they were actively dying and needed additional symptom management, a best interest decision was made to admit them to a hospital following discussions with those involved in their care.