Willow Burn Also known as Maiden Law Hospital, Maiden Law Hospital,DH7 0QS

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

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.

Willow Burn had a proactive, systematic approach to managing safety. Leaders embedded, maintained and sought to continuously improve a culture of openness and collaboration, and safety was everyone’s top priority. Staff recognised and reported incidents and near misses and reported them appropriately.

There was a comprehensive safeguarding system. Staff had clear roles and responsibilities. This meant safeguarding risks were proactively identified, managed, actioned, and reduced.

Willow Burn consistently applied person centred care with a positive culture which supported patient choice. This created trust between patients and staff and protected the safety and wellbeing of all people using services.

There was a collaborative approach to working with partners to comprehensively identify and manage shared risks and joint processes for monitoring their effectiveness. This led to enhanced standards of treatment and care at each step of patients’ care journeys.

The design, maintenance and use of facilities, premises and equipment kept patients safe.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The continuing development of the staff skills, competence and knowledge were recognised as being integral to ensuring high quality care.

Staff controlled infection risk well. They used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

The service used systems and processes to safely prescribe, administer, record and store medicines.

This service scored 84 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Willow Burn had a proactive, systematic approach to managing safety. Leaders embedded, maintained, and sought to continuously improve a culture of openness and collaboration. Staff told us, and we observed through actions, safety was everyone’s top priority.

Staff recognised incidents and near misses and reported them appropriately. There were no serious incidents in the 12-month period from August 2024 to July 2025.

Managers investigated incidents and shared lessons learned with the whole team. Patient safety incidents were also shared with other local hospice staff so learning could be shared as widely as possible. When things went wrong, staff apologised and gave patients honest information and suitable support.

Managers ensured that staff had access to regular weekly team meetings. They held bi-monthly clinical staff meetings and actions were identified for named staff following these meetings. A monthly action log was created. Progress was monitored through the clinical quality management review meetings which looked at and identified any opportunities to learn. Managers investigated any reduced performance or trends and shared lessons learned with the whole team. Key areas for improvement included the review of referral and admission information received compared with what was provided on admission. This included 1 patient’s details where different medicines were provided, compared to discharge information. This was followed up by staff who obtained a correct prescription from the patient’s GP, although this caused a delay in the patient receiving their medicine. Two separate cases involved referrers omitting patient information regarding infections. Staff followed up with referrers to ensure full information was provided in future.

The service was part of the North East North Cumbria Hospices Collaboration and leaders from independent hospices across the whole region met and shared data, trends, and action plans to address them.

Staff undertook clinical incident trend analyses to proactively address themes and trends. This included patient falls following incidents where 2 patients had each suffered more than 1 fall with a total of 5 falls between October and December 2025. Although no harm had occurred, the service had carried out a falls review that highlighted risk assessment process improvements were required. The review showed patients previously mobile and independent had struggled with their deteriorating ability and avoided calling staff for help when mobilising. Staff had completed falls risk assessments on admission and both patients had been assessed as low risk of falls. However, the review found these were not always reviewed quickly enough. The team met together and identified opportunities for completing new risk assessments as patients deteriorated and agreed actions to continue to monitor and increase observation and care rounding, where staff monitored patients to address key needs, at night. These actions had been implemented, and falls had reduced in the following months.

Patients and staff, including volunteers, were actively encouraged to raise concerns about safety and ideas to improve, and the value of learning was continually demonstrated and reinforced by leaders. Progress was monitored through regular clinical staff and multidisciplinary team (MDT) meetings which looked at and identified any opportunities to learn.

Staff received feedback from investigation of incidents, both internal and external to the service. The service displayed a no blame culture and staff corroborated this. Following any incident, the team met for a debrief where support was offered and staff talked through what had happened. Incidents from each shift were documented and discussed at each handover. All clinical staff attended a 30-minute handover period at the beginning of every shift to ensure all staff were informed about every patient’s needs and status before starting work.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service’s referral and admission policy and processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Only clinicians directly involved in a patient’s care could refer via a referral form followed by a conversation with the senior nurse on duty. The admission criteria were clearly defined and exclusions were stated.

Staff supported patients to be involved in their own care. This enabled patients to maintain as much control as possible throughout their care and treatment. Staff worked with patients when moving between services, such as from an acute hospital or community care to the hospice, and ensured they and their loved ones had all relevant information. Risk assessments were person-centred and were focused upon patients’ wishes. Patients told us that they had felt involved in their own care and the care of their loved ones and were informed of transitions to different services.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. There was a collaborative approach to working with partners to comprehensively identify and manage risks. The service collaborated across the healthcare network to provide timely access to medication, equipment and support to the patient and their loved ones.

The service worked in collaboration with the local trust to provide a 24-hour, 7 day a week palliative care consultant on-call list. Leaders explained how the community palliative care team, led by an experienced palliative care consultant, led on all hospital referrals to the hospice. There were excellent links between the local NHS trust and local GPs as well as Macmillan nurses. Staff were open and honest when receiving referrals, and if they felt the hospice could not provide suitable, safe care they liaised with the North East and North Cumbria Hospice collaborative to find the best service for the referral. They worked across County Durham and the North East of England palliative and end of life network to review and audit their care against national standards. This had led to enhanced standards of treatment and care at each step of the person’s care journey.

Staff told us they could access the information they needed. Patient records were on paper with key information being available electronically via an electronic patient records system to all health professionals who provided care, to ensure patient’s wishes were shared. Staff provided holistic care through comprehensive support for patients, addressing the needs of the whole person; physical, emotional, social, cultural, and spiritual needs, rather than just treating a condition or symptoms.

Staff could also access other professional services when needed such as speech and language therapists, and mental health professionals including psychologists The hospice employed trained counsellors. The service worked closely with other services to support patient pathways and transitions.

The service worked closely with system colleagues including GPs to support safe systems of care for patient both within the unit and in the community. Managers held meetings with NHS acute healthcare providers to ensure safe and effective transfers of care. The service asked for and received regular feedback from these providers to ask what was working well and what could be improved.

Continuity of care was a clear priority for the service; this was reflected across all services provided. The hospice team offered individualised care and support to patients and their loved ones. Patient records showed how the hospice worked collaboratively with others such as general practitioners and district nurses to ensure patients received appropriate and timely care. We also saw how allied health services such as occupational therapy, physiotherapy and social workers were key to safe and effective patient care. Staff told us how community physiotherapists were involved in multidisciplinary planning and discharge meetings to ensure patients and their loved ones would be able to manage for example with the help of a hoist at home or at an alternative service such as a care home.

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.

There was a comprehensive safeguarding system, with clear roles and responsibilities, through which safeguarding risks were proactively identified, managed, actioned and reduced. Staff followed an approach to safeguarding that included the empowerment of patients who used services and proactive work to promote their safety, well-being and rights.

Staff and volunteers were trained to the appropriate safeguarding levels and knew how to raise safeguarding concerns and alerts when appropriate. Records showed clinical staff and staff who had face to face contact with patients and their loved ones completed level 3 safeguarding adults and children training. Staff followed safe procedures for children visiting the service.

The lead nurse was trained to level 4 and acted as safeguarding advocate to provide day to day support and advice to hospice staff.

Staff knew how to identify adults and children at risk of, or suffering, significant harm, and worked with other agencies to protect them. Staff were knowledgeable about safeguarding and gave us examples of actions taken when potential safeguarding concerns were identified. Information was displayed strategically on noticeboards throughout the hospice highlighting types of abuse and actions to safeguard vulnerable people.

Staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

There was a commitment to taking immediate action to keep patients safe from abuse and neglect. This included working with partners in a collaborative way and working alongside other agencies to keep people safe.

The hospice had a safeguarding adults and safeguarding children policy which was available for all staff. The policy included information and actions required in case of all types of abuse including domestic violence, female genital mutilation and radicalisation. The safeguarding policy was in date and reviewed 3-yearly or earlier if legislation or local authority advice changed.

Safeguarding systems, processes and practices gave assurance staff upheld patients’ human rights, and staff protected them from discrimination. Staff supported patients to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 (MCA) and the Equality Act 2010.

The hospice ensured staff recorded all required information, including potential or actual safeguarding concerns. The records were available to clinical staff and other key staff. Any safeguarding concerns were discussed during daily handovers and multidisciplinary meetings

Staff received safeguarding supervision from the lead nurse who was the safeguarding lead for Willow Burn. The safeguarding lead worked closely with the safeguarding lead nurse at the ICB. Staff discussed safeguarding in their supervision meetings and offered support to any staff member, patient as appropriate. Staff shared information, actions undertaken and considered if they needed to take further action.

Staff had a clear understanding of the Deprivation of Liberty Safeguards (DoLS), which staff only used when in the best interest of the person. This legal framework protects vulnerable people who lack the mental capacity to consent to care that restricts their freedom. Staff received training in the Mental Capacity Act 2005 (MCA), were confident in its use, and sought innovative ways to ensure they respected patients’ human and legal rights.

The service had comprehensive systems to monitor and proactively improve how the MCA was applied and decisions communicated with all relevant people and organisations involved in the person’s care. This included DoLS when applicable.

There was a culture that actively sought and valued opportunities to promote and enhance human rights in the service.

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.

There was an open culture that encouraged creative thinking in relation to patients’ individual safety. Staff enabled patients to take positive risks to maximise their own control over their care and treatment. They were also actively involved in managing their own risks along with their relatives, friends and other carers. Patients and their loved ones said they had regular and open conversations about risks around their health. We saw evidence of this in patients’ care plans.

Staff ensured that patients could access advocacy, and provided information to all patients and families on advocacy and available local services.

Staff showed empathy and had an enabling attitude that encouraged patients to challenge themselves, while recognising and respecting their lifestyle choices. The service used imaginative or innovative ways to manage risk, while supporting patients to stay safe. Staff helped patients to make decisions that may have elements of risk, including advance decisions, by sharing information about risk to help inform choice and control. Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Willow Burn staff consistently applied person centred care with a positive culture which supported patient choice around treatment. This created trust between patients and staff and protected the safety and wellbeing of all patients using services.

Staff upheld patients’ rights, provided and followed the principle of least restriction and promotion of quality of life, including patients receiving end of life care.  The service proactively sought out new and creative solutions and best practice to ensure that patients lived with as few restrictions as possible and provided evidence to support this and worked with partners to resolve this. A patient wanted to use the spa bath so staff assessed what support they would need then agreed they could make the call bell accessible and leave the bathroom so the patient could enjoy their bath alone.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Facilities, premises, and equipment were designed and used to meet the needs of the range of patients who used the service.

Staff completed health and safety risk assessments. They identified mitigating actions where risks were identified. Staff carried out actions in line with Health and Safety Executive (HSE) guidance. Assessments included fire safety, water safety, security and other environmental risk management practices.

The hospice had enough suitable equipment to help staff safely care for patients. Staff told us that equipment was readily available and there were no concerns with access.

Staff carried out daily safety checks of specialist equipment. They ensured that emergency equipment and essential equipment such as syringe pumps (for continuous administration of palliative and end of life care medicines) were routinely monitored, maintained and accessible.

Patients had the equipment they needed to keep them safe, manage their pain and maintain their independence. Patients could reach call bells. Patients told us staff responded promptly to any requests for help. All patient areas were accessible and located on the ground floor. Staff had access to fitted hoists in each bedroom to ensure patients that needed it could be lifted safely. All patients had access to pressure relieving mattresses. Staff were trained to use all equipment including specialist equipment to administer pain relief.

There was a thorough system to ensure safety, upkeep, and repairs for buildings and equipment. Managers ensured the facilities, premises, equipment and technology were maintained. Managers supported staff to use the equipment to consistently deliver safe and effective care. There was an estate manager who oversaw the maintenance of the building and gardens. The estate manager was responsible for the management of faulty equipment and oversaw service contracts and the assets register (an assets register is a list of all equipment used by a service). There were arrangements for medical device servicing and decontamination and staff received relevant training.

Leaders and staff considered how environments could keep patients safe from psychological harm as well as physical harm, for example access to the premises and facilities to promote their mental wellbeing.

Staff disposed of clinical waste safely. We observed appropriate segregation of clinical and non-clinical waste. Sharps waste containers were clean, labelled and not overfilled. They were stored in the medical room until they were collected, in line with the clinical waste policy.

The service made sure there were enough qualified, skilled and experienced staff to deliver effective, safe care and treatment to meet patients’ needs.Senior managers checked the staff rota to ensure suitable cover was in place.

Patients and their loved ones were positive about staff, whom they described as kind and knowledgeable. They told us there were enough staff who came to them quickly when they rang for assistance, including during the night.

Managers had calculated the number and grade of nurses and healthcare assistants required and staff rotas showed the number of nurses and healthcare assistants matched this number on all shifts. The manager could adjust staffing levels daily to take account of case mix.

There were 9 registered nurses (RNs) and 10 health care assistants (HCAs) with a further 8 bank RNs and 7 bank HCAs who could be called upon to support shifts. The lead RN and 4 HCAs worked full time, and all other clinical staff worked part time.

Managers followed safe recruitment practices to make sure that all staff, including bank staff and volunteers, were suitably experienced, competent and able to carry out their role. including Disclosure and Barring Service (DBS) checks.

We checked 5 staff personnel files (including volunteers), and all contained all information and checks required to promote safe recruitment. Recruitment, disciplinary and capability processes were fair and were reviewed to ensure there was no disadvantage based on any specific protected characteristics under the Equality Act 2010.

The hospice did not use agency staff. The service maintained its own nurse bank to provide cover for annual leave and sick leave and to maintain safe staffing levels. All bank nursing staff received an induction and were familiar with the area.

At the time of the assessment, 1 RN post had recently been filled and there were no vacancies. Staff reported very low turnover with only 1 retirement in the last year. There were no recruitment issues or delays and a very low sickness rate. There were clear pathways for development opportunities and the service shared learning and training opportunities with another local hospice.

There was sufficient medical cover with a doctor on site 4 days a week. Medical cover was made up of GPs with a special interest in palliative care and there was also provision for a specialist palliative care consultant to spend at least 1 session per week at Willow Burn. Out of hours there was an NHS palliative care consultant on-call rota. We met with the consultant who was very committed to providing the best possible care and support. Prior to this, medical support had relied only on GPs with a special interest in palliative care. Staff reported they could always access a doctor for help or advice regarding their inpatients. There was a collaborative working group comprised of Willow Burn, another local independent hospice, the local NHS trust, and the integrated care board (ICB), established in March 2024. The group’s aim was to establish and provide a sustainable and integrated medical staffing model for inpatient adult specialist palliative and end of life care throughout the area.

All staff including bank staff and volunteers had completed a structured induction and were up to date with appraisals, clinical supervision, and appropriate mandatory training, all in line with policy. The training was appropriate for the patient group using the service and included statutory learning disability and autism training. Nurses and healthcare assistants completed a formal competency framework and worked as supernumerary staff until this was complete. A new RN showed us the competency pack and each task that was required to be signed off. They shadowed and learnt from an experienced RN and regularly reported their progress to the lead nurse. This was all in preparation before being ready to lead the team on a shift.

The percentage of staff that received regular supervision and appraisals in the last 12 months was 100%. Managers ensured that staff received the necessary specialist training for their roles.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. For example, training in non-invasive ventilation and enteral (tube) feeding. All staff were encouraged to identify their own developmental needs for clinical link lead roles and self-development. There had been some challenges in accessing the practical elements of training courses and a review of these was underway with an aim to strengthen workforce knowledge, expertise, and consistency. The hospice staff training needs analysis and development opportunities were to be organised and shared between Willow Burn and another local hospice with support of the ICB.

There was a clear policy for dealing with poor staff performance promptly and effectively.

The hospice also accessed support from community physiotherapists, occupational therapists, a chaplain, and social workers. They employed a family support worker, complementary therapists, and administration staff to support patient care.

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.

There was a comprehensive system for assessing and managing infection control risks, incorporating policies, procedures, roles and responsibilities, training and monitoring. Managers oversaw infection prevention and control (IPC) audits which were done routinely. Managers took immediate action if IPC procedures fell below expected standards.

All staff had received IPC training in the last 12 months. Staff undertook regular hand hygiene audits. The February 2025 audit results confirmed all staff met required hand hygiene standards. Staff had sufficient personal protective equipment (PPE), such as gloves and aprons to carry out procedures and personal care activities. Staff were observed to be ‘arms bare below the elbow’ in accordance with National Institute for Health and Care Excellence (NICE) guidance. Handwashing sinks and hand sanitiser dispensers were accessible and were available throughout the hospice. Posters showing effective handwashing techniques were displayed at handwashing sinks. We observed staff washing their hands before and after contact with patients.

There were clear arrangements to assess and control infection risk. The lead nurse was the infection control lead for the hospice and had oversight of IPC.

Records showed, and we observed, good housekeeping practices in all areas. We saw Control of Substances Hazardous to Health 2002 (COSHH) regulations were met. Cleaning products were stored appropriately and waste was safely managed and disposed of. The ICB had carried out an infection control assurance visit in October 2024, following which no actions were required.

There were schedules and checking systems in place to ensure all areas were cleaned as indicated in the identified cleaning schedule. There were facilities to support good infection prevention control in the toilets, corridors and clinical rooms. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Housekeepers signed checklists to show all areas had been cleaned and line managers carried out spot checks for cleanliness and infection control. There was a very clear housekeeping, cleaning and laundry standard operating procedure (SOP) and all staff were aware of and followed it. All areas in public and private spaces were visibly clean and tidy, had required furnishings and were well-maintained. Staff maintained equipment well and kept it clean. Staff used dated labels to show that equipment had been cleaned and was ready for use.

Staff had carried out risk assessments of the environment and every patient had an infection control risk assessment carried out prior to admission. If the environment was not suitable for any particular patient needs, then the hospice would not accept them for admission. Staff followed a comprehensive process for ensuring cleanliness and deep cleaning.

Although patient rooms were carpeted, all carpets were suitable for effective, deep cleaning and bleaching. The service had produced a clear SOP for cleaning carpets and staff followed this for daily cleaning, any spillages, and terminal cleans. Housekeepers were taught the agreed carpet cleaning techniques on induction and had clear instructions on how to do this. We observed the carpets were visibly clean, with no marks or stains. Patients and their loved ones appreciated the aesthetic value and comfort the carpets provided. Staff took great care to ensure carpets were cleaned correctly. Since the opening of the inpatient unit there had been no incidences of any areas not cleaned properly and no IPC concerns or evidence of infection from carpets.

The service made sure that medicines and treatments were safe and met people’s needs, capacitiesand preferences. They involved people in planning, including when changes happen.

Staff followed good practice in medicines management and did it in line with national guidance. There was a clear medicines management policy, and processes in place to ensure adherence and safe practice for all. There were appropriate policies, systems and processes in place to ensure safe and appropriate antibiotic prescribing.

There were safe and secure storage arrangements for medicines including intravenous fluids. Medicines were stored securely. Access to medicines storage was limited with access only to authorised clinical staff. Nursing staff checked medicine storage with audit and oversight by the lead nurse and external pharmacy support and guidance.

We reviewed 3 medicine prescription records and found medicines were prescribed, supplied and administered in line with the relevant legislation, current national guidance, and in line with the Mental Capacity Act 2005. Staff maintained accurate and clear records of medicines given to patients and recorded when medicines were not given and the reason for this. Staff recorded patients’ allergies on their treatment charts.

Staff ensured accurate, up-to-date information about patients’ medicines was available. When patients moved between health and care settings staff shared or requested information about patients’ medicines, in line with current national guidance. The team discussed a patient’s needs in advance of their admission and liaised with community teams and the palliative care service to ensure everything was in place to ensure a patient’s comfort and safe care. The service requested during handover that on admission, and where possible, patients would bring a week’s supply of their medicines from home. This was to ensure there were no missed doses or difficulties in requesting medicines especially at weekends. The hospice had very good relationships with local GPs and the NHS hospitals who supported these requests or would prescribe in preparation for a planned admission.

Handover discussions also included patients’ capacity to make decisions about their medicines, and this was recorded. Willow Burn’s medicines management policy included use of covert administration of medicines where necessary in line with mental capacity assessments. Guidance was clear and in line with Mental Capacity Act 2005 requirements. However, we found no examples of covert medicines administered, and staff explained they would always try to obtain patients’ consent before prescribing or administering any medicine.

There were appropriate and safe arrangements for the management, use and oversight of controlled drugs. Controlled drugs are medicines which require additional arrangements for their storage and administration under the Misuse of Drugs 1971 legislation (and subsequent amendments). The lead nurse was the controlled drugs accountable officer for the service to ensure safe management of controlled medicines.

All controlled drugs were securely stored. Staff reported all controlled drugs received and administered in a central record in addition to patients’ medicine records. Nurses, the pharmacist and the accountable officer followed appropriate systems to regularly check controlled medicines. Staff followed a process for the safe and appropriate disposal of controlled drugs and other medicines when they were no longer required. The controlled drug accountable officer carried out controlled drug audits and presented medicines management information in quarterly reports to the quality and compliance committee. These reports outlined any themes of incidents and any other concerns that had occurred, identified lessons learned and shared, and actions required to reduce incidents.