Hospice of the Good Shepherd

On this page

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

Our overall rating of responsive at Hospice of the Good Shepherd has improved from requires improvement to good.

There was strong person-centred care, with patients and families involved in decisions, clear documentation of consent, risk assessments, and care preferences. Records were accurate, and care plans consistently reflected individual needs, including emotional and spiritual support.

The hospice delivered well-coordinated care, supported by effective referral systems and multidisciplinary working. The joint consultant role improved continuity between community and inpatient services, enabling timely admissions, better discharge planning, and a positive patient experience.

Feedback processes were robust, with high satisfaction and minimal complaints. The hospice also focused on equity and service improvement through outreach, inclusive care practices, and ongoing analysis to address gaps in access and meet diverse patient needs.

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Staff knew how to ensure patients had equal access to their service. When staff received patient admission information, they asked about any reasonable adjustments such as disability or sensory loss as part of their additional needs. Staff had all the necessary information and knew what to expect because information was shared with them. The service had a reasonable adjustments policy to which staff adhered. This referenced legal frameworks such as the Equality Act 2010 and NHS England's Accessible Information Standard.

The service had systems to support patients with complex healthcare needs, sensory loss, mental health, learning disabilities and dementia. Staff were able to access support through the wider multidisciplinary team.

Staff were aware that some patients aged between 16 and 18 years of age were children and adapted the service to take account of this. Staff demonstrated an awareness that patients aged between 16 and 18 years were classified as children and adapted their practice to ensure care was appropriate to this age group. For example, additional tailored conversations were held with young people to support their understanding of information sharing, confidentiality, privacy, and dignity, ensuring they were appropriately informed and involved in decisions about their care.

Young adults were supported in a way that recognised both their developing independence and their potential vulnerabilities. Staff took time to explain processes in an age-appropriate manner, encouraged questions, and ensured that consent and capacity were considered in line with relevant guidance. Where appropriate, families or carers were involved, while still maintaining the young person’s rights to confidentiality. This helped to ensure that young patients felt safe, respected, and empowered, and that their individual needs were recognised and met within the service.

In addition to the 6 records reviewed during our assessment, we reviewed the audit undertaken by the hospice of 4 randomly selected patient records. Findings showed that all records demonstrated a person-centred approach when care planning was initiated. Care plans were implemented with the agreement of the patient and/or their relatives. Each record included completed risk assessments, such as infection prevention and control, falls, malnutrition, and waterlow assessments. Spiritual and psychological needs were discussed and documented with patients and/or their families. Medical staff clearly documented treatment escalation plans.

Three out of the 4 patient records had patient consent to treatment documented. In cases where the patient was unable to provide consent, all treatment and care plans were clearly documented as having been discussed and agreed with family members. Documentation by both medical and nursing teams was clear, accurate, and timely. All records had DoNotAttemptResuscitation (DNAR) status, preferred place of care (PPC) and death (PPD) documented within the initial doctor’s assessment. Multidisciplinary team (MDT) discussions were clearly documented in 3 out of 4 records. The record without an MDT discussion was appropriate due to clinical status.

Two out of 4 patient records included a care and communication record. Both were completed to a good standard, with no omissions identified. All records showed that carers’ needs were discussed and considered, and appropriate referrals were completed where needed. Medication charts reviewed in relation to these patient records were all correct, legible, and had no omissions noted.

Overall, this audit identified that individualised care was being practised on the inpatient unit by the medical and nursing teams, involving patients, families, and the wider hospice services.

Staff empowered patients to make their own decisions about their care and treatment. One patient commented on the hospice service user experience report and stated, “I felt heard for the first time.” other Living Well Centre patients reported that staff “truly listen.”

We scored the service as 4. The evidence showed an exceptional standard. The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

When patients moved between services, all necessary staff, teams, and services participated in assessing their needs to maintain continuity of care. The hospice ensured that transitions, referrals, and discharges were planned fully and considered each person’s individual needs, circumstances, ongoing care arrangements, and anticipated outcomes.

A single point of access (SPA) for all referrals into the inpatient unit was supported by the integrated local specialist palliative care single point of referral. Shared referral and triage services were in operation between the specialist palliative care teams, the local hospital, and the Hospice of the Good Shepherd. This process ensured an embedded smooth and safe transfer of care by consulting closely with wider health and social care teams. With the patients consent, the hospice made appropriate referrals to community services, ensuring continuity of support following discharge.

A significant development for improving the quality of care through working together included the appointment of a joint consultant in palliative medicine in June 2025. Following this appointment, the hospice worked collaboratively with system partners, and support from the ICB transformation team, to develop an integrated model and medical job plan.

The consultant in palliative medicine was the responsible clinician across both the community specialist palliative care team (4 PAs) and the hospice (4 PAs). This enabled seamless assessment, care planning, and continuity across settings. Since this appointment, the hospice had improved bed throughput.

There were stronger relationships developed with patients and families, as visiting individuals at home had provided a clearer understanding of their social circumstances. This supported more effective and timely discharge planning. Patients and families were also better informed about what to expect should admission to the hospice be required, due familiarity with their responsible clinician.

Patients could access the hospice when they needed it and received the right care promptly and the hospice had provisions in place to risk assess referrals to allow emergency admissions to services to be prioritised.

Feedback was continually positive about the service and about the way staff treated people and supported choice.

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

The service complied with NHS England’s accessible information standard. Staff could use communication aids for non-verbal, speech impaired or neuro-diverse patients. Staff had access to pictograms with phrases and smiley faces, which helped staff to ask those with accessibility needs how they felt, including pain scores.

Staff were observed openly communicating with patients and their carer’s, providing information in a clear way, which could be understood. Questions asked by patients were responded to openly and honestly. Staff used accessible ways to communicate with people when their protected equality or other characteristics made this necessary, For example, they used interpretation and translation services and made reasonable adjustments. Staff ensured carers and families were regularly updated about the patient’s progress. A relative said “discussions are thorough and considered. Communication between different parts of the team and handover are very effective.”

Information was available on the services website and there was a member of staff with responsibility for keeping all information updated. Staff ensured that patients could obtain information on treatments, local services, patients’ rights, and how to complain. The information provided was in the form of leaflets and further information was available on the hospice website. However, although website accessibility tools enabled text formatting for easier reading, there was no option for alternative languages. We did not see information leaflets available in languages other than English.

Information governance systems included confidentiality of patient records. The hospice had an information governance and records management policy in place which was appropriate in content and up to date. In addition, the access to records policy and procedure provided staff with guidance on subject access requests received for patient data.

The hospice was registered with the Information Commissioners Office, which meant regular updates on legislation and the opportunities for learning through webinars and online resources were maintained.

The hospice kept staff up to date with information, advice and learning through regular information governance bulletins as well as ad hoc documents such as a data protection day bulletin.

Staff made notifications to external bodies as needed, such as safety incidents or record risks and outcomes via the Learning from Patient Safety Events Service.

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

Patients were involved in decisions about their needs related to hospice service provision. Leaders told us patients knew how to give feedback about their experiences of care and support, including how to raise any concerns or issues and could do so in a range of accessible ways. The service and staff made it easy for people to share feedback and ideas or raise complaints about their care, treatment and support.

Patients were aware of how to raise concerns or make a complaint. The hospice had provided patients and relatives with feedback leaflets outlining how to make a complaint, raise a concern, or share a compliment. The leaflet had included various options for providing feedback to the hospice, as well as to health regulators and the ombudsman. Information on accessing independent advocacy support to assist with raising concerns had also been provided. The hospice policy followed the NHS complaints standards and the model complaints managing procedure to ensure staff listened and responded to feedback from the public, volunteers, staff, patients, and families.

No formal complaints were raised with the hospice since the last inspection in August 2024, and no complaints were referred to the Ombudsman during this period.

There had been one informal complaint. The hospice undertook a complaint investigation, as the concern was not resolved at the initial resolution stage, in line with hospice policy. The individual who raised the concern chose not to escalate it to a formal complaint.

When concerns or complaints were raised, patients received appropriate feedback. We saw a letter sent to a relative with the findings of an informal complaint investigation.

Staff ensured that patients who raised concerns or complaints were protected from discrimination and harassment. Staff understood how to manage complaints appropriately.

Staff received feedback on the outcomes of complaint investigations and acted on the findings. We reviewed areas of learning identified from informal complaint resolutions and provided feedback to staff. This included emphasising the importance of clear introductions and compassionate communication, as well as revisiting advanced communication training to support staff in managing complex emotional responses and conducting bereavement conversations.

We scored the service as 4. The evidence showed an exceptional standard. The service was exceptional at ensuring people could access the care, support, and treatment they needed when they needed it.

People were able to access the service when needed and received appropriate, timely care. The hospice undertook a scoping review to better understand current palliative and end-of-life care needs across the region, identify inequalities, and set priorities to improve equity and access. Findings highlighted increasing demand due to an ageing population, significant deprivation in key neighbourhoods, and ongoing gaps in early identification, advance care planning, and community-based support.

In response, the hospice hosted the West Cheshire palliative medicine out-of-hours advice line, providing clinical support to healthcare professionals during evenings and weekends. This ensured rapid access to specialist palliative care advice for patients with life-limiting conditions, supporting community-based care and helping to reduce avoidable hospital admissions.

The hospice also supported a homelessness project by providing outreach counsellors for people experiencing homelessness across West. This formed part of its commitment to improving access for groups who often experience poorer outcomes in palliative and end-of-life care.

The service supported up to 20 people experiencing homelessness, as well as individuals with a history of homelessness, to process loss related to their experiences. Delivery was flexible, with sessions held at various locations across the borough. The service provided a safe, confidential, and trusting therapeutic environment, using a strengths-based, trauma-informed approach. This supported individuals to build a positive identity, increase self-confidence, and develop coping strategies to manage triggers, regulate emotions, improve self-awareness, and plan for crisis situations, including those linked to addiction.

The hospice provided a range of day services and programmes through its Living Well Centre to support patients’ physical, mental, and spiritual wellbeing. Services were delivered by a multidisciplinary team including nurses, bereavement counsellors (for adults and children), spiritual care workers, a palliative care social worker, complementary therapists, physiotherapists, occupational therapists, and a carers support worker.

Services included nurse assessments, signposting (for example to Macmillan resources, GPs, social workers, advance care planning, and the inpatient unit), a bathing service, carer support (including group sessions and telephone support), condition-specific groups such as MND, fatigue and breathlessness management, and complementary therapies.

There was adequate medical cover available 24 hours a day, with a doctor able to attend the ward promptly in an emergency, supported by a two-tier rota system.

Integrated single point of referral meetings were held daily (Monday to Friday) to review referrals and ensure patients were directed to the most appropriate service. A weekly hospice multidisciplinary team (MDT) meeting and a West Cheshire specialist palliative care integrated MDT meeting supported collaborative working and consistent care. These meetings, alongside tools such as the occupancy tracker, dependency tool, and SITREP, informed decisions about admissions to the inpatient unit (IPU).

Data showed that patients were admitted promptly, with a mean waiting time of two days. All patients who were referred and wished to be admitted were accommodated. Of the 12 patients who died in the IPU in February and March 2026, all had chosen the hospice as their preferred place of death.

Staff planned discharges effectively, demonstrating strong collaboration with all professionals involved in patient care. Discharges were only delayed for clinical reasons.

The hospice was fully accessible, with reasonable adjustments made to meet individual patient needs.

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

The service monitored patient access and outcomes to identify potential health inequalities. This information was used to inform service planning a delivery. There were systems and processes for gathering feedback, which enabled collection of information about equity of patient's experiences and outcomes. We saw information which showed analysis of service data to identify which patient groups were accessing provisions and to determine where inequalities might exist. Initial findings from the Living Well Centre indicated that the majority of users were women, particularly those diagnosed with breast or ovarian cancer. Inpatient data further demonstrated a patient population predominantly aged between 64 and 74 years, with women outnumbering men by approximately 2 to 1.

People who did not speak English as their first language could access the service. Staff had access to interpretation services by telephone. There was a range of pictorial information to assist staff in engaging with people who had additional needs.

The Director of Clinical Services had observed that the local population was largely White; however, notable areas of significant deprivation were present within the catchment area. In response, the hospice had begun to establish links with community partnership initiatives and primary care networks within these areas to enhance awareness of, and access to, hospice services.

Additional initiatives included the provision of counselling support for individuals experiencing homelessness, the strengthening of bereavement services, and the continuation of carer support despite the withdrawal of external funding.

We observed through the hospice service user experience report for quarter 3 of 2025/26 that staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views.

Staff were trained in equality, diversity, inclusion, and human rights with compliance rates of 94%.

The hospice ensured that their policies and procedures did not place vulnerable people or people with protected characteristics at a disadvantage.

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

Patients were supported to make informed choices about their continuing needs which relied on hospice care. Their family or carer was involved if they wished.

Patients who had care plans and information about their wishes for resuscitation were encouraged to bring these documents with them when they attended the hospice. Similarly, where individuals had medicines they needed to take whilst away from home, they carried these with themselves. Care for people who were nearing the end of their life was managed and communicated in a sensitive and dignified way.

Staff supported patients to make decisions about their care, treatment, and their future. We were provided with information as part of the assessment process which showed patients being involved in decision making and consent to medical intervention such as blood transfusions, and individualised care planning. We also saw examples of good practice when it was determined that patients were not in a position to make their own decisions.

Staff ensured all relevant healthcare professionals and other relevant bodies participated in planning the care and treatment of people with complex needs.