Hospice of the Good Shepherd

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Our overall rating of effective at Hospice of the Good Shepherd has improved from good to outstanding.

Care records showed that patients received timely assessments and personalised, holistic care plans, with active involvement from patients and families. Documentation was clear and accurate, including risk assessments, consent, and treatment decisions, with appropriate best‑interest processes when patients lacked capacity. Multidisciplinary team input and communication supported coordinated patient care.

The hospice demonstrated strong leadership, skilled staff, and effective multidisciplinary working. Ongoing training, audit systems, and integrated working with community services supported high‑quality care. The Living Well Centre enhanced this by offering broad clinical, emotional, and social support for patients and carers, contributing to a comprehensive, compassionate service.

This service scored 88 (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’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff shared key information to keep patients safe when handing over their care to others. Shift changes and handovers included all necessary key information to keep patients safe.

Staff took account of patient’s communication needs, particularly those with disabilities and with a sensory loss. We observed staff using appropriate skills to engage with patients and to assess their needs. They also took account of cultural and social needs when planning care and treatment.

We reviewed 6 patient care records during the assessment. We found that staff had completed comprehensive health assessments for patients during or shortly after admission. Staff had developed care plans that met the needs identified during the assessments. The care plans were personalised and holistic, and staff updated them when necessary.

The hospice completed an audit of 4 randomly selected patient records from the inpatient unit. The audit found consistent evidence of person‑centred, individualised care planning, with patients and/or families actively involved in decision‑making. Risk assessments (including IPC, falls, malnutrition, and pressure area care scores) were completed and reviewed appropriately. Patients’ psychological, spiritual, and emotional needs were documented. Treatment escalation plans, do not attempt resuscitation (DNAR) status, and preferred place of care (PPC) and death (PPD) were clearly recorded during patient admissions.

Multidisciplinary team (MDT) discussions were documented in most records. The single exception related to a patient with a very short admission who died before MDT review. Care and communication records were present in some cases and were completed to a good standard where used.

Carers’ needs were consistently assessed, considered, and appropriate referrals made. Medication charts were complete, legible, and accurate, with no omissions identified. One record demonstrated particularly high-quality nursing documentation, which was shared as positive feedback with senior staff.

A neuropathic pain history clinical re-audit was undertaken in May 2025. The re‑audit reviewed 16 patient admissions (Jan to Mar 2025) where pain was a presenting symptom. The hospice established an audit process to monitor pain assessment documentation. The findings showed 100% of patients had some elements of pain history recorded, with an average SOCRATES pain assessment score of 4.9 out of 8, showing improvement from 4.6 in 2024. Documentation of pain site was recorded in 100% of cases, while character and associated factors were each recorded in 56% of patients. SOCRATES is a mnemonic acronym used by clinicians and health professionals to evaluate the nature of pain that a patient is experiencing.

The proportion of patients with all three key elements documented (site, character, associated factors) improved to 37.5%, compared with 29% in 2024. However, the agreed standard of 100% was not met, and documentation of pain had declined to 56% compared with 2024 (89%). Findings were reviewed through governance processes, fed back to the medical team, and actions agreed to reinforce SOCRATES based documentation, including negative findings, and a further re‑audit to ensure improvements.

We scored the service as 4. The evidence showed an exceptional standard. The service always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

Staff followed up-to-date policies to plan and deliver high quality. All policies we looked at contained a creation and review date, and clear references to current national guidelines. There were systems to communicate changes in guidance through meetings and management newsletters. Staff said they received information both in person and electronically.

Polices and processes took account of changes to professional guidelines and National Institute for Health and Care and Excellence (NICE) guidelines. We looked at end of life pathways and saw they followed gold standard guidance.

The service showed a strong commitment to education and future workforce development. Medical students from local universities regularly undertook clinical placements at the hospice. Feedback from students was consistently positive, and the service explored opportunities to expand its teaching offer, further supporting workforce development and organisational sustainability.

The Living Well Centre service supported patients with increasingly complex needs, which the service had recognised required enhanced medical input. Medical support was provided through regular multidisciplinary team (MDT) meetings, facilitating coordinated care planning and timely escalation of complex cases.

During the 2025 / 26 financial year, the End of Life Partnership (EOLP) received a grant from the hospice to support education, training, and staff support in palliative and end of life care. An average of 3.75 hours per week was provided to the hospice to deliver supervision to 7 staff groups on a 7 week cycle and to maintain the education matrix. In house education sessions were also delivered in response to identified service needs and workforce priorities.

The hospice leadership programme commenced in January 2026, with 2 staff members enrolled. In addition, 3 staff completed the key elements 7 week care assistant course in September 2025.

The inpatient unit manager received formal supervision every 6 weeks. A bespoke training day supported the Living Well Centre away day, and staff also accessed the EOLP core education programme, which was funded through the grant.

The multidisciplinary team comprised the full range of professionals required to meet patient needs, including doctors, nurses, social workers, pharmacists, chaplaincy staff, counsellors, therapists, and allied health professionals.

Care was planned and delivered in partnership with individuals and focused on what mattered most to them, including preferred place of death. We saw that all patients know to the hospice in February and March 2026, achieved their preferred place of death.

Outcome assessment and complexity collaborative (OACC) measures were used to assess need, monitor complexity, and evaluate outcomes. These measures were reviewed during weekly MDT meetings and daily admission and dependency meetings, supporting safe decision making, effective care planning, and alignment with national best practice and recognised clinical standards.

A structured annual clinical audit programme was in place and provided assurance that standards were consistently met. Audits covered all key areas of practice, including admissions, transfers, discharges, clinical care and symptom management, decision making, end of life care, equality, diversity, and inclusion, medical equipment, infection prevention and control, medicines management, nutrition and hydration, patient safety and risk management, housekeeping and facilities, governance and reporting, and data protection.

Departmental team meetings captured day to day learning, risks, and quality concerns. Relevant information was escalated through established assurance forums, including the patient safety assurance forum, health and safety assurance forum, and service user participation group. These forums reviewed concerns and learning and escalated issues to the appropriate committees where required.

Bespoke task and finish groups were established in response to emerging priorities, including falls, infection prevention and control, Motor Neurone Disease, and staff wellbeing. This demonstrated a responsive, proactive, and flexible approach to governance and continuous improvement.

On admission, a member of the catering team met with each patient and those close to them to discuss individual preferences, including likes, dislikes, dietary requirements, and allergies. Patients were visited daily throughout their stay to review menu choices and make amendments as needed. The service accommodated a range of dietary requirements, including gluten free, vegetarian and vegan, Halal, and diabetic diets.

Catering staff were trained in the International Dysphagia Diet Standardisation Initiative (IDDSI) and provided appropriate soft textured diets for patients with swallowing difficulties, in line with IDDSI standards. The hospice also provided freshly cooked meals using herbs grown in the hospice garden and root vegetables from the hospice allotment.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Staff had access to shared information through service level agreements with community nursing teams, specialist palliative care, district nursing, GPs, physiotherapy and speech and language therapy. The regional shared care record provided a secure multi agency record with real time access, supported by an integrated electronic clinical system. Doctors also accessed the local acute hospital system to view histology results promptly, supporting timely decisions.

Continuity of care was maintained during transitions between services. All relevant staff and services participated in assessments, referrals, and discharge planning. A single point of access managed referrals to the inpatient unit and linked with a local specialist palliative care referral and triage service. With patient consent, referrals to community services supported ongoing care after discharge.

This role of a consultant in palliative medicine was developed collaboratively with community and acute hospital partners and was supported by the ICB transformation team. The consultant provided clinical leadership across both community and hospice services, improving continuity, assessment, and care planning. Outcomes included improved bed throughput, stronger relationships with patients and families, better understanding of social circumstances, and more effective discharge planning. Weekly reviews were increased, including reviews of DNAR decisions, treatment escalation plans, and Venous Thromboembolism (VTE) prophylaxis.

Integrated multidisciplinary team working ensured coordinated care when people were supported by multiple services. Daily single point of referral meetings involved community, acute and hospice representatives to review referrals and direct patients to the most appropriate service. Weekly integrated palliative care MDT meetings strengthened collaboration across the system. Since the joint consultant appointment, medical leadership and MDT working improved, enabling greater responsiveness to emergency admissions.

Within the hospice, continuity of care was supported through robust internal communication. Daily safety huddles, medical handovers, situation reports, debriefs, clinical handovers, inpatient MDT meetings and consultant led ward rounds ensured staff shared awareness of patient needs, risks, and care plans.

We observed the weekly MDT and observed staff share information about patients. Medical and nursing teams ensured that the patient had consented to their information being shared with the wider team.

We observed structured shift handovers at 07:30 and 20:00, led by the outgoing nurse in charge and attended by incoming staff. These handovers supported continuity of care and ensured clear communication of patient needs, risks, and clinical priorities.

Safety huddles took place at 08:15 and 20:45 within the clinical area. These were led by the nurse in charge and attended by all staff on duty. During these meetings, key safety roles such as first aider, fire warden and call bell responder were allocated and recorded. Staffing information was also shared with reception to support effective coordination of visitors.

We attended the medical team handover at 09:00, where the nurse in charge was present. This ensured that risks identified during safety huddles were effectively communicated across the multidisciplinary team.

Records confirmed that a daily situation report meeting was held at 09:15 and chaired by the nurse in charge. Attendees included representatives from the medical team, clinical administration, facilities, senior clinical leadership, social work, and the living well centre. This meeting provided oversight of service delivery, supported risk management, and enabled coordinated decision making.

We saw that a daily admission and dependency meeting took place at 14:00, led by the late shift nurse in charge with medical staff in attendance. This meeting focused on reviewing admissions and patient dependency levels to inform care planning and resource allocation.

A staff regroup was held at 15:00 with all staff on duty. This provided updates following the admission and dependency meeting and supported reflection and debrief from the early shift.

Records reviewed showed that the nurse in charge completed daily operational checklists to ensure all clinical and organisational responsibilities were fulfilled. Documented examples were available, reviewed and demonstrated consistent compliance.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The Living Well Centre within the hospice was an activity hub that provided day services and outpatient clinics. The centre supported patients, family members, friends, and carers. Staff and volunteers helped to improve quality of life by providing the information people needed to make informed choices. Teams focused on improving symptom management, addressing individual concerns, and enhancing coping strategies.

The Living Well Centre offered a wide range of support and activities, including medical support, nursing care, rehabilitation, wellbeing support, coffee and chat sessions, complementary therapies, and support for carers.

The centre also delivered short courses designed to support symptom management, reduce anxiety, improve sleep, enhance strength, and balance, and help prevent slips and trips.

Patients attending the Living Well Centre were able to access up to 6 weekly complementary therapy sessions, including reiki, aromatherapy massage, and reflexology, which helped promote relaxation and ease worry and tension.

Social Work support was available to individuals’ accessing services at the Living Well Centre. This support included discussions about care options and challenges at home, such as financial concerns, carer fatigue, or stress, which sometimes required the initiation or improvement of care packages.

The hospice provided counselling and support to patients and families known to the hospice, as well as to individuals supported by specialist palliative care teams across the region who faced the challenges of a life‑limiting illness. Bereavement support was also offered to families and those close to the patient, including children and young people aged 4 to 18 years.

Music therapy was provided on Thursdays at the hospice, both as part of the Living Well Service and within the inpatient unit.

The Living Well spiritual care team was available to everyone at the hospice regardless of faith or belief, including patients, relatives, visitors, and staff.

The Living Well Centre provided comprehensive support to individuals within the community through a range of structured services. Monthly programmes included a Motor Neurone Disease (MND) group, alongside breathing and movement support sessions. The service supported individuals in developing appropriate support networks and offered ongoing assistance to carers and live‑in carers through dedicated groups and consistent communication for both patients and carers.

Patients primarily accessed the Living Well Centre service for symptom management, alongside support to address fear and anxiety. Volunteer involvement was integral to the service, offering companionship where desired and enabling patients to access outings and social engagement. Core areas of patient need included nutritional support and eating well, pain management, and overall symptom control.

The hospice worked collaboratively with a range of community partners. Physiotherapy services were delivered in conjunction with the Living Well Centre to support patient mobility and staff development. The Living Well Centre also maintained a variety of community partnerships, including engagement with funeral directors to gain insight into their processes, which proved informative and valuable.

The service facilitated carer support groups and provided access to complementary therapies and social work support, enabling discussion, emotional support, and guidance. Weekend visits were promoted, with structured afternoon rest periods encouraged to reduce fatigue. Clear and effective communication with families was maintained, and families were contacted promptly if a patient needed to return.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff monitored the effectiveness of care and treatment through audit and benchmarking to compare with other similar services. The service used the findings to make improvements and achieved good outcomes related to getting patients to their treatment on time. Completed audits were reviewed by the clinical governance subcommittee, with medicine related audits discussed separately at the medicines management meeting. These groups reviewed the results, agreed learning points, and escalated any risks where needed. Audit leads were responsible for completing audits on time, while the quality team tracked progress, followed up delays, logged actions in the electronic quality system, and monitored their completion.

Learning and good practice from audits were shared with staff through relevant meetings and included in the quarterly quality report. Any significant safety, strategic, or regulatory issues were reported to the board.

Actions were followed through, improvements were checked through re‑audits, and strong clinical governance ensured safe, effective, and compassionate care in line with national standards.

Improvements had been made as a result of audits, for example, the management of nausea in patients and pressure area care. An audit of admissions between 1 September and 30 November 2025 to assess compliance with guidelines for the management of nausea and vomiting was undertaken. The hospice identified 25 patients, 11 met inclusion criteria. All reversible causes of nausea and vomiting were appropriately identified and treated, and where symptoms persisted beyond 24 hours, 90% of patients were prescribed parenteral antiemetics, with 1 exception reflected in documentation which stated patient choice. Symptoms were controlled within 72 hours in 73% of cases, demonstrating sustained improvement compared to the 2021/2022 baseline. In all appropriate cases, patients were prescribed both regular and PRN antiemetics.

A retrospective audit of clinical documentation of acquired pressure ulcers recorded between July 2025 and September 2025 had been completed. Findings showed that all patients had a skin assessment within 6 hours of admission and received pressure ulcer prevention information. Risk and MUST (Malnutrition Universal Screening Tool) assessments were completed for all patients, with personalised nutritional plans in place. Vulnerable skin areas were identified in 3 patients, moisture associated skin damage in 1, and medical devices were present in 4.

All patients had personalised care plans for nutrition, mobility, and pressure ulcer prevention, with daily reviews completed. Mattress provision was appropriate in 3 cases; 2 patients declined air mattress use and remained on foam. In addition, 4 patients declined elements of pressure area care despite risks being explained. Mattress checks were completed each shift in 4 cases.

The service had systems to monitor and improve outcomes. Managers reviewed and ensured the service met all their key performance indicators (KPIs) and targets. Wherever possible managers sought their commissioner’s performance data to monitor and improve patient outcomes.

The provider considered health inequalities and took steps to ensure outcomes across people with protected characteristics were in line with the wider community.

The hospice clinical audit schedule 2025/2026 showed a total of 47 audits across a broad range of areas, including admissions, transfers and discharges; clinical care and symptom management; decision making; end of life care; equality, diversity and inclusion; equipment; governance and reporting; housekeeping and facilities; infection prevention and control; invasive procedures; medicines management; nutrition and hydration; patient safety and risk management. Of the 47 audits, 32 had been completed, 13 were in progress, and 2 were not yet due for completion.

The hospice falls audit showed that out of 98 inpatient admissions between January and December 2025, there was a strong overall compliance with the completion of falls and manual handling risk assessments. It was documented that 89 patients receiving a full assessment and a further five starting on a communication and care record (CCR).

The latest audit of inpatient care plans covering the period November 2025 to January 2026, assessed documentation and compliance across key domains of patient care. The audit showed that patients were receiving safe, person‑centred care, with most gaps relating to documentation rather than the care delivered. Core assessments such as pressure ulcer, falls, pain, nutrition, and mobility were completed for most patients, and narrative notes confirmed that key interventions like repositioning, physiotherapy involvement, feeding support, and pain management took place even when not fully recorded. Care plans overall demonstrated a holistic, dignified, and multidisciplinary approach.

The documentation issues identified (for example, missing IDDSI (International DysphagiaDietStandardisationInitiative) scores, mobility aids, or links between nutrition and pressure care) were administrative and were being addressed through staff reminders, training, and further audit cycles. No evidence of unsafe practice or unmet clinical need was identified.

A further care planning review was completed as a snapshot in February 2026. In total 45 IPU care plans were reviewed in depth, 80% were personalised, and 20% were partially personalised. All inpatients had their mandatory assessments completed and personalised with compliance at 100%.

Overall, the audits demonstrated consistently safe, effective, and person‑centred care, supported by improved documentation and a robust clinical governance process, with recommendations to broaden future audits in line with updated regional palliative care guidance.

We scored the service as 4. The evidence showed an exceptional standard. The service always carefully explained to people what their rights around consent were, making sure they fully understood them and always fully respected these when delivering person-centred care and treatment.

When patients had impaired mental capacity, staff assessed and appropriately recorded capacity to consent. The hospice had a supporting people who lack capacity policy and procedure in place, which outlined the process for completing mental capacity assessments and detailed the use of Deprivation of Liberty Safeguards (DoLS). The policy and procedure were up to date and appropriate in content. Where patients lacked capacity, decision‑making was clearly recorded as having been discussed and agreed with family members. Documentation across medical and nursing records was clear, accurate, and timely.

When patients lacked capacity, staff made decisions in their best interests, and recognised the importance of the individual’s wishes, feelings, culture, and life history. Decisions were made on a decision specific basis, particularly in relation to significant decisions.

Where patients had been assessed as lacking capacity to consent to their care or treatment and had not made a valid and applicable Advance Decision to Refuse Treatment (ADRT), the hospice ensured decisions were made in accordance with the Mental Capacity Act 2005 and were recorded clearly in the individual’s best interests.

Consideration was given to patients known wishes, feelings, beliefs, and values, as well as their comfort, dignity, and emotional wellbeing. Care and treatment were provided only when they were considered necessary, proportionate and in the individual’s best interests.

We saw that for decisions related to medical treatment, the healthcare professional responsible for delivering the treatment acted as the decision maker. Where a valid and registered Lasting Power of Attorney (LPA) for health and welfare was in place, or where a court appointed deputy had authority, the hospice collaborated with them and respected their legal role within the scope of their appointment.

The hospice followed a clear and structured best interest decision making process. This included, where appropriate, involving family members, carers and other individuals who knew the individual well, to support an informed understanding of what the patient would have wanted. Decisions and the rationale for them were clearly documented, reviewed as circumstances changed, and communicated sensitively.

Staff demonstrated a good understanding of consent, capacity and best interest principles and applied them consistently. We observed that practice and process was embedded within the service. Where possible, staff took all practical steps to enable patients to make their own decisions.

Mental capacity assessment forms and Deprivation of Liberty Safeguards assessments were completed using the hospice electronic patient record system.

We reviewed the use of restraint policy and found it was up to date and appropriate in content. The policy provided a clear framework for staff working at the hospice to follow a consistent and safe approach to patient restriction and restraint. This included restrictive interventions, physical restraint, mechanical restraint, chemical restraint, technological surveillance, psychological restraint, seclusion, and segregation.

We observed that between April 2025 and March 2026, 9 Deprivation of Liberty Safeguards (DoLS) applications were made and submitted to the local authority, all as standard authorisations. Of these, 7 also required urgent authorisations due to the immediate risk of individuals already being deprived of their liberty. All patients were assessed and prioritised based on clinical vulnerability and carer engagement.

We observed that all applications were completed appropriately and submitted in a timely manner, with ongoing review to ensure compliance and the use of least restrictive practice. No concerns were identified regarding the inappropriate use of DoLS, and all decisions were made in the best interests of the individuals involved.