Sue Ryder palliative Care Hub- South Oxfordshire

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had policies in place for reporting incidents, near misses and patient safety incidents, including a Patient Safety Incident Response Framework (PSIRF) policy. These provided guidance on reporting concerns and outlined the service's approach to responding to patient safety incidents, with a focus on learning and improving safety. In the previous 12 months, the service reported one serious incident and 36 incidents.

Incidents, risks and learning were regularly reviewed through established governance processes. Clinical leaders and the senior management team (SMT) met monthly to review incidents from the previous month, identify themes and learning, and produce a Learning for Safety Memo for staff. Incidents were also reviewed through the monthly Quality Improvement meeting. The SMT held a formal risk register meeting every four weeks, with additional meetings arranged where risks were escalating or new risks were identified, including input from subject matter experts.

Staff told us there was a positive reporting culture and that they felt confident raising incidents and concerns. Managers encouraged staff to report issues and told us this had resulted in increased reporting. Incidents were investigated, with themes and trends identified to support learning and improvement. Learning was shared through safety memos, staff noticeboards and monthly team meetings. For example, we saw that falls incidents were routinely reviewed to identify themes and opportunities for improvement.

Evidence showed changes were made following incidents. For example, learning from pressure ulcers was shared with staff and specific care plans were developed for people at risk of pressure ulcers. Staff told us they received support and debriefs following serious incidents and were kept updated throughout investigations. Staff we spoke with understood their responsibilities under the duty of candour, which is the importance of being open and honest when incidents occurred.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had systems and processes to support safe transitions of care. Referrals were received through a single point of access service and prioritised according to clinical need using a recognised triage tool. Staff told us referrals from acute palliative care teams were detailed and provided the information needed to assess people’s' needs. Where additional information was required, staff contacted the person, referrers, or other healthcare professionals to support safe care planning. If a referral was not accepted, the service informed the person’s general practitioner (GP) and explained the decision to the person.

The service worked closely with GPs, district nurses, specialist nurses, hospital teams and out of hours providers to coordinate care. Staff told us discharge planning could be completed quickly to support people to receive care in their preferred place. For example, staff worked with hospital palliative care teams to arrange fast-track funding and equipment. Before care started, staff completed home and environmental risk assessments which considered people's physical, cultural, spiritual and communication needs, as well as any environmental risks.

The service had a clinical observations and treatment escalation plan in place. This provided staff with a framework to monitor people using an early warning score system, recognise deterioration and ensure appropriate treatment escalation plans were in place.

Service users and staff told us communication challenges had occurred following recent organisational change, which resulted in delays to care visits and responses to referrals. Senior leaders were aware of these concerns and had identified opportunities to improve communication and information sharing with people using the service and healthcare partners. For example, new standard operating procedures had been introduced to improve referral documentation and staff were being trained to use a structured communication tool during urgent reviews.

The service used two electronic record systems which did not share information. Leaders had identified the associated risks, recorded them on the risk register, and developed action plans and mitigations to address them. Work was underway to implement a single electronic record system to improve information sharing, communication and continuity of care.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had systems and processes in place to protect people from abuse and avoidable harm. Safeguarding leads were identified across a range of clinical teams, with Level 4 safeguarding leads meeting monthly to review safeguarding incidents and current cases. Additional ad hoc meetings could be arranged where leads required further support. Staff had access to weekly safeguarding drop-in sessions, and told us concerns could be reported through the incident reporting system, with safeguarding referrals able to be made by any member of staff. A national social worker supported local teams and formed part of the multidisciplinary team, providing support with safeguarding and risk management.

Safeguarding reporting had increased since January 2026. Managers told us this reflected improved awareness and reporting rather than an increase in safeguarding concerns. Staff received safeguarding training appropriate to their role. The minimum requirement for clinical staff was safeguarding level 3, with senior leaders trained to higher levels. Training compliance exceeded the service target of 90%, with 96.3% of staff completing safeguarding training appropriate for their role

Staff told us they knew how to recognise and report safeguarding concerns, and we saw examples of completed safeguarding referrals made by staff. Records showed the service worked effectively with external agencies to support the safeguarding process and provide appropriate support where required.

The service had standard operating procedures for mental capacity assessments, best interest decision-making and deprivation of liberty safeguards (DoLS). Staff told us mental capacity training had improved the quality of documentation. Records showed best interest decisions were made when people lacked capacity. For example, when one person’s condition deteriorated, a best interest decision was made to admit them to an inpatient unit to ensure their care needs were met. Electronic records included alerts to identify people subject to DoLS or safeguarding arrangements, to support safe care and decision-making.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were involved in making decisions about their care and treatment, including discussions about risks and future wishes. Staff told us they started these conversations as early as possible and explored what was important to people and their families, including their preferences for care and treatment.

Staff used a structured assessment process to identify risks and involve people in planning their care. Staff told us they supported people, and those important to them, to understand advance care planning documents and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms so they could make informed decisions about their care.

Staff told us they regularly discussed advance care planning with people and ensured people understood that a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision did not limit other treatment or care options available to them.

Staff told us they had access to training and specialist support to help identify and manage risks associated with deteriorating health and complex symptoms. Nurses could seek advice from medical staff where there were concerns about a potentially reversible condition, and doctors were available 24 hours a day to to review people when required to support safe decision-making. Healthcare assistants took part in daily huddles with senior nurses following care visits. These meetings enabled staff to share information, discuss concerns about people’s' health or wellbeing, and ensure appropriate action was taken and escalated where necessary.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had a lone working policy and systems in place to support staff safety while providing care in the community. Risks were assessed before visits using a risk assessment tool, and staff undertaking lone working were provided with personal safety devices linked to a 24-hour monitoring centre. Staff understood the lone working arrangements, knew how to access support, and were aware of emergency escalation procedures, including the use of a safe word.

Records showed incidents relating to lone working were reported through the incident reporting system and reviewed by managers. For example, staff were required to record whether a personal safety device had been used during an incident. This helped ensure risks were monitored and staff had access to support while providing care in people’s homes.

The service maintained a safe environment for people and staff through regular equipment checks, fire and environmental risk assessments. Records showed equipment used in people’s care was logged, serviced and underwent electrical safety testing in line with manufacturer guidance. Staff completed health and safety risk assessments in patients' homes to identify potential hazards and implement measures to reduce risk.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were planned and monitored to ensure people received safe care and support. The service was staffed to meet patient demand and considered people’s dependency, planned leave, sickness absence and training requirements when reviewing staffing levels. Managers told us the aim was for each whole time equivalent clinical nurse specialist (CNS) to support a specified caseload of people. Leaders reviewed caseloads across localities after some CNS staff experienced significantly higher workloads, with the aim of reducing pressure on nurses.

At the time of the assessment the service was managing a period of workforce change, which had resulted in a recent turnover of staff. Records showed that vacancies in the hospice at home staff and administration teams were filled promptly. A 1.2 full time equivalent (FTE) hospice at home vacancy was filled following a restructure, with the new staff member starting in January. One hospice at home vacancy was filled immediately, and a 0.4 FTE administration vacancy was filled four weeks after it became vacant. CNS vacancies were recorded from March to July, ranging from 0.4 FTE to 1.4 FTE. In July, recruitment was ongoing for 1.78 FTE CNS posts.

The service was mainly staffed by permanent staff, which supported continuity of care. Occupational Therapy and Physiotherapy were fully staffed by permanent staff.The CNS and registered nurse teams also had a high proportion of permanent staff and did not use agency staff for CNS or Hospice at Home roles. Temporary staffing was used most within the medical team, where 39% of the team comprised one long-term locum who had been in post since the start of 2025. They provided continuity of care and were treated as a permanent member of the senior medical team, attending the daily doctors’ handover and weekly consultant meetings. Overall, the service had limited reliance on bank and agency staff.

Staff received training, supervision and support to carry out their roles safely. The service had clear processes to ensure staff completed relevant training, clinical competencies and competency assessments before undertaking clinical skills independently. Staff received regular supervision, formal appraisals every 4 months and had access to buddying arrangements where required. They also had regular meetings and informal check-ins with their managers to discuss their learning, development and support needs.

Records showed staff had access to a range of relevant training, including palliative and end of life care, pressure area care, diabetes, bowel care, verification of expected death, delirium, safeguarding and the Mental Capacity Act. Staff were also offered additional learning in areas such as spiritual care at the end of life, compassion fatigue and grief. Further professional development opportunities included diplomas in palliative and end of life care, bereavement care and degrees in healthcare education.

New staff were supported to develop the skills needed for their roles. For example, senior healthcare assistants completed a structured induction programme which covered community working, clinical processes, multidisciplinary working and end of life care. Nurses had access to a professional development programme to support their transition into practice. Healthcare assistants told us they valued the opportunities available for training and development.

The service promoted an open culture and acted on workforce concerns. Staff told us recent service changes, including changes to working hours and clinical responsibilities, had affected morale and resulted in some staff leaving. Leaders listened to staff feedback and were reviewing service delivery models to improve capacity and make the best use of specialist staff time. For example, a proposal to change the management of overnight advice calls was being piloted and monitored. We also saw speaking-up information displayed for staff and opportunities for staff to share concerns or suggestions for improvement.

Volunteers were recruited safely through DBS (Disclosure and Barring Service) checks and supported in their roles. Records showed volunteers completed an accessible recruitment process, were matched to suitable roles and received relevant training before commencing their duties.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Infection prevention and control (IPC) processes helped protect people, staff and visitors from the risk of infection. Records showed the service had effective systems in place to prevent and control infection. For example, the most recent IPC audit achieved a score of 100%, including hand hygiene compliance within community services.The service had an IPC policy which set out the responsibilities of staff and the procedures to be followed to support safe care. Staff received training and support to maintain safe IPC practices. IPC training was mandatory for staff and formed part of the service's core training requirements. Training rates were 100%. This included volunteers where appropriate to their role and level of contact with people.

Some staff completed additional competency assessments for IPC during procedures. Clinical staff, for example, had to demonstrate the required skills before being signed off to practise independently. This helped ensure staff had the knowledge and skills to follow IPC procedures and provide safe care in people’s’ homes.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service had appropriate arrangements in place to support the safe prescribing and monitoring of medicines within the scope of the service. The service did not store, supply or administer medicines, but doctors and non medical prescribers could prescribe medicines for patients. The prescriptions could be obtained through their GP and community pharmacy, with responsibility for obtaining and administering medicines remaining with people, carers and community healthcare providers.

Staff monitored medicines in partnership with GPs and the wider multidisciplinary team and provided people and carers with information about prescribed medicines when needed. Staff communicated with GPs about prescribing recommendations, medication changes and ongoing medicines management to support continuity of care.