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

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management, and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. We looked to find evidence there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last inspection in 2016 we found the service was not always well led, and there had been a breach of Regulation 17 of the Health and Social Care Act 2014: Good governance. At this assessment there was no breach of regulation and we rated well-led as good.

The service vision and strategy reflected the needs of patients who used the service, wider communities, and challenges the service faced. Staff, including trustees, patients and partners were well-informed, involved, supported, and worked together to progress and achieve the vision, values, and strategic objectives.

Staff and leaders led by example and demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and patients who used the service. The culture was focused on learning and improvement and there was mutual trust and respect between leadership and staff.

All staff and patients felt psychologically safe and empowered to speak up and raise concerns to help learn and improve. Staff were highly motivated and consistently felt well-supported by leaders.

The service promoted equality, diversity, and inclusivity. Equality and diversity and human rights approaches were embedded in everything Willow Burn did; policies, procedures, and actions, and were understood and displayed by all staff.

Governance and management systems enabled leaders to identify information about risks, performance and outcomes. There was a clear and comprehensive risk register. Staff were aware of risks and mitigations to ensure safe care and practice at all times. Policies were written in a way that supported staff and provided information on how to manage difficulties or any situations that might arise outside of usual practice.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care.

An inclusive, positive learning and improvement culture was well-established and was driving improvements in outcomes for patients who used services and wider communities. Learning was shared with and sought from partners.

This service scored 86 (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 clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

The hospice had a clear shared vision, strategy and culture. The provider’s senior leadership team worked very closely with frontline staff and had successfully communicated the provider’s vision and values to all.

The hospice strategy was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of patients and their communities. In a challenging commissioning economy leaders had identified a strategy which promoted excellence in the provision of compassionate and bespoke end of life and palliative care which maximised efficiency and minimised duplication with other services. Staff and managers actively promoted equality and diversity, they took action to identify and address any areas of inequality.

The service strategy was aligned to local plans in the wider health and social care economy and palliative care pathways. Leaders planned to meet the needs of the local population, improve care and patient wellbeing, tackle health inequalities and obtain best value for money. Managers and staff worked closely with local hospitals, commissioners, local hospices, regional teams, and other healthcare partners to support patients.

Staff were committed to delivering high quality care in every way they could. They could explain how and why they were working to achieve this.

The evidence showed an exceptional standard. The service had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

There was a very stable and experienced leadership team. Leaders and staff at all levels understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively, each with many years’ experience in their field. They always did so with integrity, openness and honesty. The lead nurse and chief executive officer (CEO) both had offices within the inpatient unit and, whilst carrying out their leadership responsibilities, they were also involved in liaison with all staff as well as patients, families and visitors. They made themselves available to support staff as needed. Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and focused on learning and improvement.

Staff said they felt supported respected and valued. Results of the staff survey showed 100% of staff who completed the survey were proud to work for the service and staff at all levels told us how proud they felt about the high-quality care they provided. Staff said everyone was passionate about delivering the best care.

There was strong collaboration, team-working and support and a common focus on improving the quality and sustainability of care and patients’ experiences. The culture of the service centred on the needs and experience of the patients and their loved ones who used the service.

Leadership development opportunities were available, including opportunities for staff. Succession planning was effective and staff were encouraged to take on additional training and responsibilities should they wish to, and with consistent support.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Staff regularly asked patients and their loved ones if anything could be improved to make their experiences better. Staff regularly went out of their way to help patients get what they needed, such as shopping before or after a shift, or organising for items from home to be accommodated in a patient’s room.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. The service collected opinions formally and informally and published the results of surveys in the quarterly newsletter. Staff listened to feedback, shared comments, questions, and requests with the team or the wider service, and took action to achieve them.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback.

Openness and honesty were encouraged at all levels within the organisation, leaders and staff understood the importance of being able to raise concerns without fear of retribution. There was a culture of speaking up. Leaders supported staff to raise and concerns. Leaders and managers supported patients who did raise concerns without fear of detriment. When patients did raise concerns, leaders investigated sensitively and confidentially and took appropriate action on any findings. When something went wrong, people received a sincere and timely apology, and leaders and managers told them about any actions being taken to prevent the same happening again.

To support staff to speak up, Willow Burn had a freedom to speak up guardian who worked to ensure the organisation was an open, transparent and inclusive workplace. Processes were in place which guaranteed confidentiality for anyone wishing to contact the freedom to speak up guardian. All staff we spoke with were confident they would be listened to. Staff gave us examples of how leaders listened to their suggestions about changes to the service. Staff said they were able to make suggestions to improve the work of their team. Staff were aware of the Freedom to Speak up Guardians and the whistle- blowing (speaking up) policy.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff were able to work flexibly and working agreements were formalised to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their role. Staff suffering grief or bereavement were treated with the same care and respect given by the team to any patient or family member.

The provider undertook equality monitoring of staff within the service as part of the recruitment processes. The service promoted equality, diversity and inclusivity. All faiths were welcomed and celebrated. There was a recognition that staff and volunteers’ cultural backgrounds and values differed, and all were respected to provide a diverse and inclusive workforce. Managers provided support for individual staff to identify their needs and required adjustments were implemented.

The lead nurse was the equality, diversity, and culture link practitioner who championed all aspects of equality for patients and staff within the service. The lead nurse researched and produced policies to ensure all aspects of equality were encouraged and developed by the whole team. The service provided training in equality and diversity to all staff members and volunteers as part of the mandatory training syllabus. Human resources policies and processes ensured the appointment and employment of staff was inclusive and fair. These included directions to ensure all staff were treated equally regardless of age, gender, ethnicity, sexuality and religious beliefs.

Willow Burn hospice charity was awarded Leader status (level 3) in disability confidence in recognition of their work around equality and diversity training, open recruitment and wellbeing support for staff.

Staff told us they were supported personally and professionally. They raised no concerns about equality and diversity being supported and they described a culture where discrimination would be challenged.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was an up-to-date business continuity plan that covered plans for emergencies, for example, adverse weather or an information technology (IT) breakdown. Responsibilities were defined during and after any emergency. These included a reporting strategy and post-emergency actions and debrief.

Although cost improvements and working within a strict budget were an essential part of the business strategy, staff and leaders ensured they did not compromise patient care.

Staff had access to all equipment, records, and information technology needed to do their work. Information was in an accessible format, and was timely, accurate and identified areas for improvement. Information governance systems included confidentiality of patient records, and all staff were aware of and worked within General Data Protection Regulation (GDPR) principles.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. There were clear and effective structures, processes and systems of accountability to support the delivery of the service. The service had a meeting structure in place which gave senior leaders and managers regular opportunities to discuss operational issues and performance. Essential information, such as learning from incidents and complaints, was shared and discussed. When a complaint was received about a possible data breach the leadership team changed the sign-in system from a book to an electronic process, thereby not revealing names or addresses of anyone using the premises.

The governance system monitored the quality of care provided, patient feedback, staff performance and changes to best practice guidance. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn about the performance of the service. Leaders undertook a range of reviews and audits to monitor performance. They discussed the results of audits at governance meetings including reporting to the quality and compliance sub-committee, which they also shared with the board and appropriate staff for learning. The trustees asked questions regarding governance and performance to gain a clear understanding of any problems or lessons learnt. Managers provided staff with a fob with prompt cards which showed key information such as mental capacity act and safeguarding guidance, fire safety and key priorities for care of the dying. This information was also available in staff files and on posters to ensure staff had all the tools and guidance to provide the best quality and safe care. Staff undertook or participated in local clinical audits. The data required for audit was easily available and the audits were sufficient to provide assurance and staff acted on the results when needed.

Leaders used effective governance processes to monitor risks and outcomes, and to drive improvement. Leaders took a proportionate approach to managing risk that allowed them to assess new and innovative ideas. The risk registers for the hospice set out key risks as well as actions, mitigations, and environments, workforce and financial strategies. Key reports kept leaders informed of challenges faced with short, medium, and long-term plans identified. There were 2 risk registers: 1 for organisational risk and the other for clinical risks. Risks were scored and rated according to likelihood and impact. The top 2 clinical risks were about insufficient clinical staff due to planned or unplanned absence of doctors or nurses. The top organisational risk was regarding funding and contractual requirements. However, there were clear reasons and implications set out, with mitigating actions discussed and effectively prepared to meet the requirements within their control. Staff at ward level could escalate any concerns when required.

Leaders shared updates and learning with staff through a range of communications. Policies and procedures reflected this, and leaders benchmarked the hospice’s performance against other regional and national services to measure outcomes of care and treatment. Performance compared favourably with other similar services.

Managers and staff consistently submitted data and notifications to external organisations as required.

The strategic priorities included providing the highest quality care, improving community engagement, and maintaining good governance, whilst ensuring sustainability of hospice care against increasing costs, minimal commissioner funding and being reliant on charitable donations and fundraising. Leaders continually reviewed services and those provided by others. The strategy aimed to support high quality end of life care and to secure its long-term future. Staff understood the arrangements for working with colleagues and other teams, both within the hospice and throughout the hospice and palliative care networks, to meet the needs of the patients.

Willow Burn had a sustainability plan with ‘green’ initiatives which provided additional support to its sustainability. The hospice had already achieved most of its green initiatives including fitting solar panels to building roofs and providing an e-charging point in the car park. They had plans for the following 6 months to switch to a green energy supplier and introduce some live plants within the building where it would be safe to do so. Volunteers staffed a tea hatch within a local hospital and there were plans to continue to provide this service. Staff reported it had already raised the profile of the hospice within the local community and there were more ideas to improve on this.

Willow Burn had delivered an Advanced Care Planning workshop to support local people to discuss and record their healthcare and end of life wishes. There had been a low uptake for the first workshop, but feedback had been very positive. In addition, the community palliative care team had produced a video outlining the benefits of advanced care plans.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Directorate leaders regularly engaged with external stakeholders such as commissioners, Healthwatch, and local organisations.

Leaders made themselves available to patients and their families and were receptive to any feedback. Patient feedback was valued as a means to understand individual needs and to enable changes to be made. Patients and their loved ones had met senior leaders and spoke very highly of them in feedback they gave. Staff regularly met with the hospice’s senior leadership team and commissioners to give feedback.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders.The hospice worked in partnership with others to build seamless experiences for patients based on good practice and their informed preferences. The hospice had a focused approach to delivering the best possible care that supported patients’ care needs, pathways, and choices.

Stakeholder feedback positively identified the commitment Willow Burn had to ensure access to provide high quality and timely end of life and palliative care. Stakeholders told us there was usually a very effective transfer of patients depending on individual needs. Some emergency care was provided for management of symptoms, supporting patients as well as their families and loved ones.

Leaders, managers and staff strove for excellence through collaboration and shared practice. Leaders and managers provided an excellent role model for others.

Leaders invested in developing diverse networks at a local and national level. Partnerships supported leaders to identify innovative ways of working and priorities to support these. Willow Burn staff and leaders maintained openness and transparency with commissioners and local teams around changes to ensure its ongoing sustainability. They used these networks to identify new or innovative ideas that led to better outcomes for patients.

Staff made effective and creative changes in response to better meet the needs of local patients. Staff and leaders engaged with patients, communities and partners to share learning with each other that resulted in continuous improvements to the service. For example, the hospice worked closely with another local hospice that provided more complex care and Willow Burn staff shared training opportunities to learn and develop their own team.

Willow Burn proactively provided information for carers in a variety of formats. Information within the hospice publicised events and resources. The hospice had recently facilitated a workshop for people from the local community about advance care planning.

The service planned and provided innovative approaches to care, providing integrated person-centred pathways of care that involved other service providers including local GPs and NHS hospitals. Managers planned and organised services, so they met the changing needs of the local population. The organisation provided holistic care, and its services reflected the needs of the population it served. They had achieved this through community engagement; patient experience feedback and individualised care planning. Induction and mandatory training taught staff how to engage patients in conversations about disability and equality including protected characteristics and to consult closely with other key professional teams, for example, . social services and community health care, to ensure patients accessed the right help and support at the right time. Willow Burn staff attended the annual Hospice UK conference sharing areas of innovation and work they had carried out.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The hospice service worked to continually improve care, treatment and safety for patients and their loved ones. Nursing staff completed a comprehensive competency programme before leading a shift. The lead nurse had introduced special interest lead roles for staff, for example an infection prevention and control (IPC) lead and encouraged clear audit processes and opportunities for learning. Staff made notifications to external bodies as needed.

Staff had opportunities to participate in research. Staff used quality improvement methods and knew how to apply them. The hospice participated in accreditation schemes relevant to the service and learned from them. Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. Staff participated in national audits relevant to the service and learned from them.

The service held an Advance Care Planning workshop for the local community to help inform and involve local people, raise awareness of the hospice and its facilities and to provide details of partner organisations and the Willow Burn ethos.

Quality improvement methods included an audit cycle with regular reviews, actions, and learning undertaken. Staff maintained a best practice database, collating feedback from patients, relatives, community, staff, and volunteers. This provided information to teams on projects and actions that had exceeded expectations and therefore a source of learning to be carried forward.

Willow Burn had achieved the Macmillan Quality Environment Mark award, and the assessor had commented that Willow Burn had “the best inpatient bedrooms that I have seen” and praised the use of the café by the local community to promote awareness and engagement.

Innovations were taking place in the service. There was an established, significant and sustained culture of continuous and creative learning, innovation and improvement based on evidence and local need. This delivered improved outcomes, equity of access, experience and quality of life for patients. Staff adopted roles as Clinical Service Link Practitioners whereby those with a specific interest in any area would research and develop ideas and opportunities to share good practice and provide education to others.

Staff learnt from incidents. Clinical staff attended regular clinical meetings where they had in depth discussions about what went well and what could have been done differently. They held multidisciplinary meetings to discuss and learn from incidents. Information from these meetings was cascaded to all staff.

Willow Burn, its leaders and staff had a clear focus on quality of life for patients. This included work to identify patients’ wishes, support for younger adults and children of patients, bereavement, and use of acute services in the last stages of life. We saw examples where collaborations with NHS, other local providers, and hospice networks worked to improve patient outcomes.

Leaders and staff proactively fostered a wide range of external networks, including participating in research in partnership with a local university and embedding evidenced based care. They used these to identify and share improvements and innovations. As part of this collaboration staff identified a research strategy to uphold the hospice’s strategic priorities: good governance, community engagement, and talk about death. These relationships had improved palliative and end of life care not only within the service but also locally and regionally through hospice network and palliative care networks. Research was ongoing into assisted dying as proposed in theTerminally Ill Adults (End of Life) Bill,and its ethos and implications for staff and the community. The hospice had hosted meetings with local professionals and shared information with the trustees.

The hospice worked with local schools offering grief and bereavement counselling. There were various fundraising events including initiatives to raise awareness of hospice care in the community. A hospice mascot; Will O’Burn, had been designed by an illustrator and family member of a previous patient. It was developed to make the hospice and the concept of the hospice more child friendly. The mascot had been taken to meet children who had accessed the Children’s Counselling service and to school events. Staff said it was “helping us to engage more with schools and younger audiences, as we know from communications from schools that there isn’t a lot of support out there, or knowledge for bereaved children and their friends.

Staff worked with Hospice UK and a local charity to provide once a week care sessions for people with a life limiting illness to enable carers to take time for themselves. These 2-hour sessions were provided so that carers could take planned time for shopping, their own care needs, or appointments. The hospice provided a range of services during these sessions including a social group with activities, free complementary therapies and use of the Willows café. Staff could also offer carers their own free complementary therapies.