Hospice of the Good Shepherd

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

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

The hospice demonstrated a strong safety culture, encouraging openness and consistent reporting of incidents. Structured processes ensured incidents were investigated, learning was identified, and improvements were embedded. Staff understood duty of candour, communicated transparently with patients and families, and received feedback and support following incidents.

Operational systems supported safe, coordinated care. Daily briefings, clear processes, and strong safeguarding arrangements ensured patient safety. Hospice staff ensured environmental safety, infection prevention control, and equipment management were consistently well monitored.

The service was well staffed, with high training compliance, low sickness rates, and proactive workforce planning. Medicines were safely managed with strong audit processes and no patient harm from incidents. Continuous improvement was evident through antimicrobial stewardship, reflective learning, and a commitment to high-quality, patient care.

This service scored 81 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The hospice had a clear, proactive and positive safety culture that promoted openness, honesty, and continuous learning. Staff were encouraged to raise concerns, which were listened to and responded to appropriately. Patient safety incidents were consistently reported, investigated, and reviewed, with learning identified and embedded into practice to support ongoing improvement.

The hospice operated a patient safety incident response plan that was aligned with the national NHS England Patient Safety Incident Response Framework (PSIRF). This supported a structured and proportionate approach to incident response, including the use of Swarm huddles (immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk) and After Action Reviews. This change was prompted in part by an incident involving a misplaced medication, where a nurse felt personally blamed and became very distressed. The new approach led to a much more supportive culture.

Trained facilitators applied the SEIPS tool (Systems Engineering Initiative for Patient Safety) to support systematic investigation and reflection, which enabled practice to be reviewed against both internal policies and external standards and best practice.

The hospice undertook thematic analysis of incidents to identify trends and areas for improvement. Learning and improvement actions were clearly documented, monitored, and implemented. There was effective Board oversight of patient safety themes, and incidents were directly linked to the organisational risk register, ensuring risks were appropriately escalated, managed and reviewed.

The hospice had a reporting, response and learning from incidents policy and procedure. The document outlined the Hospice of the Good Shepherd’s policy requirements for reporting and responding to all clinical and non-clinical incidents which had occurred on hospice premises or were related to hospice service delivery. The policy was up to date and appeared appropriate in content.

Staff understood professional and statutory responsibilities under duty of candour. Staff received feedback from investigation of incidents, both internal and external to the service. Staff also met to discuss feedback, were debriefed and received support after a serious incident.

We observed that a structured daily operational framework was in place to support effective communication, patient safety, and coordinated multidisciplinary working across all shifts.

Records showed that twice daily debriefs were undertaken at 07:15 and 19:45, led by the nurse in charge and attended by all staff on duty. These meetings facilitated the sharing of key operational updates, which were reviewed and amended as required throughout the day.

There were no serious incidents or adverse events reported at the service in the last 12 months. The service demonstrated a strong learning culture from the recent service turn around, with effective reflection on events that informed shared learning and led to updates in processes, methodologies, and policies.

Stakeholder feedback received described peers at Hospice of the Good Shepherd were diligent in their practice to ensure the care delivered was safe and well managed. The team were quick to share their learning with other organisations and were enthusiastic about learning from others to continuously improve practice and effectiveness. Policies and processes were frequently reviewed to ensure they were operating as efficiently as possible.

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

The hospice referral and admission processes ensured essential information was obtained to assess whether patients’ needs could be safely met. We saw that acute hospital teams completed a transfer checklist prior to admission. This supported the safe transfer of care by ensuring accurate and sufficient information was shared.

An inpatient unit (IPU) admission process map had been developed as part of a wider project reviewing both the hospice admissions process and the electronic patient record system. This document clearly outlined the steps undertaken by medical and nursing teams when admitting a patient. It provided an overview of the current process and identified opportunities to improve the experience for patients and staff. The process also supported safe patient transitions to and from the hospice, ensuring key information was shared with partner services, including community nursing teams. Staff involved appropriate health and social care professionals to maintain continuity of care both within the hospice and following discharge.

The hospice referral and admission processes ensured essential information was obtained to assess whether patients’ needs could be safely met. We saw that acute hospital teams completed a transfer checklist prior to admission. This supported the safe transfer of care by ensuring accurate and sufficient information was shared.

The IPU admission and discharge checklist was completed by nursing staff prior to and during admission. All relevant patient information was recorded to support care delivery in line with patient’s individual needs. The checklist also supported safe transitions from the hospice, ensuring key information was shared with partner services, including community nursing teams. Staff involved appropriate health and social care professionals to maintain continuity of care both within the hospice and following discharge.

There were systems in place to monitor bed occupancy, patient dependency level referrals to the unit, and reasons for declined or delayed admissions. This supported effective oversight and service planning.

After death care was appropriate. The Hospice of the Good Shepherd had a cooling room, which was used for the temporary care of a person following death. It was a respectful area allowing families the opportunity to spend time saying their final goodbyes. The use of the cooling room ensured that dignity was maintained at all times and that appropriate hygiene standards were upheld. Future plans were to change this arrangement to enable people to remain in their room with the use of cooling blankets.

We scored the service as 4. The evidence showed an exceptional standard. The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

The hospice had both a safeguarding vulnerable adults’ policy and a safeguarding children and young people policy in place. These were up to date, comprehensive, and appropriate in content. A designated safeguarding lead (DSL) was responsible for overseeing safeguarding practices and ensuring compliance with these policies, supported by two deputy designated safeguarding leads.

A dedicated safeguarding forum, attended by the multidisciplinary team (MDT), provided structured oversight and assurance that safeguarding practices aligned with best practice guidance and regulatory requirements. The DSL, supported by deputy leads, including the hospice social worker, contributed to weekly MDT meetings. These meetings supported effective clinical decision-making and facilitated peer safeguarding supervision.

In addition, the DSL and deputies provided accessible advice and support to clinical and medical staff as required, ensuring consistent safeguarding cover throughout the working week. Medical staff also participated in bi-monthly peer review through the doctors’ business meeting, supporting reflective practice and clinical governance.

Staff demonstrated a clear understanding of how to identify adults and children at risk of, or experiencing, significant harm, including the importance of working in partnership with external agencies. Safeguarding practices were embedded and staff followed appropriate procedures for children visiting the service. We reviewed evidence of concerns being escalated appropriately where additional family support was required for school-aged children.

The hospice maintained a comprehensive safeguarding log of all concerns reported to local authorities, the Care Quality Commission (CQC), and partner agencies, including NHS mental health services, general practitioners, community nursing teams, schools, and local youth groups. The log, which recorded 28 safeguarding referrals between 2025 and 2026, was reviewed. Referrals, actions, and outcomes were found to be appropriate.

Staff were appropriately trained in safeguarding, understood how to raise a safeguarding alert, and did so when required. Compliance rates were high: 100% for level 3 safeguarding (adults and children), 96% for level 2, and 97% for level 1. Compliance with mandatory training on learning disability and autism was 95%, and preventing radicalisation training compliance was 100%.

Staff provided examples of how they protected patients from harassment and discrimination, including those with protected characteristics under the Equality Act. For example, people experiencing homelessness with addiction and end of life care needs were invited to the hospice for medication review and support with personal care, such as bathing.

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

Staff followed the inpatient unit referral and admission policy (which outlined the processes in place to ensure that patient referrals and admissions were managed safely, effectively and in a timely manner, in accordance with best practice and regulatory requirements.

The service worked with patients to understand and manage risks. patients' needs were met in ways which were safe and supportive and enabled them to do the things that mattered to them. This included for example, supporting patients to make advance decisions about their care and treatment in line with relevant legislation and best practice guidance.

Staff were knowledgeable and had access to tools to support identifying medical emergencies that may affect the patient, such as sepsis. The sepsis policy provided staff with guidance staff with guidance on the early recognition, monitoring, and management of sepsis, supporting timely intervention and reducing the risk of patient deterioration. The policy was up to date and appropriate in content.

Staff communicated with patients in a clear, inclusive, and accessible manner to ensure they understood their care and treatment. This included the use of appropriate communication methods and tools to support patients with identified communication needs.

Systems and processes were in place to enable patients to provide feedback on the services they received. This included surveys and engagement opportunities. Feedback was used to inform service development and improvement.

Staff ensured that patients had access to independent advocacy services, where required, in order to support informed decision-making and uphold patients’ rights.

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

Appropriate systems and processes were in place to maintain effective oversight of risks relating to the premises and equipment. Actions identified were monitored by the estates manager, with governance oversight provided by the health and safety committee on behalf of the Board.

Water hygiene and the annual risk assessment were undertaken by an external company in accordance with HTM 04-01 safe water in healthcare premises guidelines and recorded on an electronic portal. The estates manager also monitored this. Compliance was sustained at 100% over the previous seven months, which provided assurance that water safety was effectively managed.

The fire safety policy and fire and emergency evacuation procedures were current and appropriate. Fire evacuation drills were completed regularly with the last one undertaken on 3 March 2026. Risks within the care environment were identified and controlled through robust fire safety systems, including mandatory training, clear procedures, and effective evacuation and containment processes, ensuring the safety of patients, visitors, and staff.

Systems and processes were in place for the oversight of medical devices. The director of quality and improvement held overall accountability for medical device management, (supported by the medical device safety officer), including reporting to the Medicines Healthcare products Regulatory Agency (MHRA).

A clinical equipment register demonstrated 100% compliance with all 171 items, which were up to date with service requirements. Monthly reporting to the clinical governance committee provided Board assurance.

During the ongoing refurbishment of the inpatient unit, comprehensive risk assessments were completed to ensure safe delivery of works with minimal disruption. Control measures were detailed in a patient, visitors and staff impact risk assessment and construction phase plan, which included enhanced infection prevention, noise and dust mitigation, contractor controls, updated fire procedures, daily environmental checks, and strengthened communication through SITREPs and staff briefings. SITREP stands for situation report, a structured update used in medical and emergency settings to communicate conditions, actions taken, and required support.

The environment had been adapted for those with accessible needs. A dementia friendly environment audit was undertaken in four areas of the hospice using the Alzheimer’s Society checklist across seven environmental domains. The audit found that 71% of criteria were fully met and 29% were partially met, with no criteria unmet. The findings showed demonstrated good practice in several domains, particularly in the use of warm lighting, recognisable seating, and visual landmarks to aid navigation. The Living Well Centre scored highest overall, reflecting thoughtful design and accessibility. Actions were in place to provide more consistent signage, improved colour contrast in toilet areas, visual markings on glass doors, and the removal of potentially confusing flooring.

We scored the service as 4. The evidence showed an exceptional standard. The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Workforce planning arrangements were clear and responsive to patient need. Nursing rotas were consistently maintained in a clear and accessible format, with all amendments recorded and traceable. This ensured transparency in staffing changes and enabled effective monitoring of staff deployment and replacements.

The hospice had implemented a recruitment policy, disclosure, and barring service (DBS) policy, fit and proper persons requirements (FPPR) and standards policy and procedure, as well as a trustee conflict of interest procedure and declaration. All policies and procedures were current, comprehensive, and appropriate in content.

The service demonstrated a well-structured approach to staff induction on employment. All staff members, including the senior management team (SMT), completed a formal induction plan which was documented. In addition, the SMT undertook fit and proper person refresher briefings every two years. Evidence of completed induction processes were kept across all staffing groups, including for agency staff. A comprehensive review of safer staffing was undertaken in accordance with Hospice UK: Safe and Effective Staffing for Palliative Care Inpatient Services – An Improvement Resource (September 2025). The required nursing establishment was calculated at 22.75 whole-time equivalents (WTE), compared with an available workforce of 26.4 WTE. Mandatory training compliance was high at 94.59%. The attrition rate for staff was recorded at 18.6% across clinical and non-clinical staff, while the sickness absence rate remained low at 0.7%.

Medical staffing was organised across defined tiers, including consultant, Tier 3 Senior specialtyassociatespecialist (SAS), and Tier 2 SAS doctors, supplemented by bank staff as required. Out of hours cover arrangements were clearly defined, with first on-call provision operating on a 1 in 5 rota, and second on-call support provided by contracted external medical support. A daily staffing resource sheet, aligned to patient acuity, supported safe and appropriate allocation of clinical resources.

The inpatient unit operated within safe staffing parameters. At the time of review, the unit was running 8 beds, with flexibility to expand to 10. Medical cover comprised 2.8 WTE (whole time equivalent) specialtyassociatespecialist doctors and 0.4 WTE Consultant input was assessed as appropriate to meet patient needs. A potential risk relating to reduced medical cover on Fridays had been identified and discussed at a previous doctors’ business meeting. Mitigating actions were implemented, including proactive management of annual leave requests to facilitate rota swaps or bank cover, demonstrating awareness of risk and responsive service management.

Clinical leadership and oversight were evident through regular consultant involvement in patient care. This included weekly consultant board rounds and ward rounds, ensuring senior clinical input into decision-making and care planning. Doctors were able to work within core hours, with plans in place to monitor workload should bed capacity increase. The introduction of a revised supporting professional activities (SPA) rota was reviewed positively and was functioning effectively.

There was evidence of proactive workforce management and succession planning. The service managed a forthcoming staffing change following the resignation of a substantive doctor, with recruitment processes initiated in a timely manner to fill the vacant post. This demonstrated forward planning to maintain safe staffing levels.

Service delivery models reflected current capacity and system integration. At the time of the assessment, outpatient services were not delivered directly by the hospice, with patients continuing to be seen by hospital consultants at the local hospital.

On-call arrangements were well embedded and effective. First on-call cover was consistently provided by substantive SAS doctors, with escalation to contracted external medical support, as required. Low escalation rates over a two-month period indicated that the rota was functioning effectively. The service was actively engaged in system-wide discussions to strengthen out of hours consultant advice provision, demonstrating collaborative working and continuous service improvement.

Staff were experienced, appropriately qualified, and demonstrated the skills and knowledge required to meet the needs of the patient group. A review of training and competency records confirmed that staff had completed a wide range of role specific clinical competencies to support safe and effective care. These included patient observations, support with activities of daily living (ADL), and the provision of oral hygiene in line with individual care plans.

Records confirmed that staff were competent in fluid balance monitoring and bowel management, including stoma care, and in the application of aseptic technique for wound care and specimen collection. Staff had also completed training in sensory systems and falls prevention, catheter care, and after death care.

There was clear evidence of competency based training in advanced clinical interventions, including the use of syringe pumps, administration of subcutaneous fluids, intravenous antibiotics, blood transfusions, oxygen therapy, insulin management, and enteral feeding. Records also demonstrated advanced clinical skills such as peripherally inserted central catheter (PICC) care, venepuncture, cannulation, digital rectal examination, and verification of expected death.

At the time of the on site assessment, staff appraisal compliance was 95%. Medical appraisal and revalidation processes were robust, with all substantive doctors up to date and appropriately supported through an external provider. Indemnity arrangements were in place and aligned with individual scopes of practice.

The service demonstrated a strong commitment to education, training, and professional development. Medical staff regularly engaged in internal and external teaching opportunities, including regional training programmes and academic seminars. Mandatory training compliance was high among medical staff at 97%.

The nursing training records showed consistently high performance across a wide range of essential topics, with all results meeting or exceeding the target of over 90%. Most results were in the mid to high 90% range, with several achieving full compliance. Areas such as diabetes awareness, infection prevention and control (tier 2), moving and handling (clinical), patient safety (access to practice 2), and preventing radicalisation reached 100% compliance, showing a competent level of understanding. Strong results were also seen in areas of conflict resolution (98%), risk management (98%), sepsis (97%), and sexual harassment in the workplace (99%). Face to face clinical mandatory study day attendance 2025/26 programme including advanced life support (ALS) compliance was 92%.

Overall, the service demonstrated multiple features of outstanding practice. Staffing levels exceeded minimum requirements, with supernumerary staff enhancing flexibility, patient experience, and opportunities for mentorship. A strong and positive workforce culture was reflected in exceptionally low sickness rates and consistently high engagement with training, and appraisal across all staff groups. The hospice had established itself as a centre for learning, delivering regular teaching sessions and introducing student doctors into the hospice setting, which contributed to wider workforce development.

Clinical support was robust with a two-tier on-call rota ensuring safe and effective escalation. The service was also highly responsive to community needs, providing staff resource to extend its reach to include a living well centre service and advice line, supporting earlier intervention and improved access to specialist palliative care.

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

The hospice ensured there was an effective approach to assessing and managing the risk of infection, which was in line with current national guidance. There were clear roles and responsibilities around infection prevention and control outlined in the standard (universal) infection control precautions policy. We reviewed the policy and found it to be up to date and appropriate in content.

Systems and processes were in place in the event of suspected outbreak of infection to support the early recognition of outbreaks of food poisoning or communicable diseases. The procedure set out measures to prevent further spread, reduce the risk of recurrence where possible, and ensure effective communication with external agencies with a legitimate interest in the outbreak.

In addition, the hospice had implemented a healthcare associated infections procedure in line with department of health guidance. This included arrangements to make immunisation available to staff and outlined the actions required to ensure staff received appropriate treatment without delay, following exposure to healthcare-associated infections or inoculation incidents. We reviewed both procedures and found them to be appropriate, comprehensive, and up to date.

All ward areas were clean, had the required furnishings and were well-maintained. We observed staff adhere to infection control principles, including handwashing. The infection prevention and control (IPC) audit report showed that out of 10 modules, six achieved 100% compliance. The remaining four modules also demonstrated levels of compliance over 90%. Hand hygiene achieved 96.2%, healthcare linen achieved 92.3%, safe disposal of waste achieved 94.1%, and occupational safety relating to prevention of exposure, including sharps injuries, achieved 96.6%. Re-audits were planned for those areas that did not meet audit compliance.

Cleaning records were up to date, and we observed ward areas had been cleaned thoroughly and routinely. Housekeeping audits covering the six month period prior to the assessment were comprehensive and identified areas of concern, such as floor clutter or drip hazards, which were promptly addressed and rectified.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

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

The hospice had implemented a safe management of medicine policy which was up to date and appropriate in content.

Systems and processes were in place to ensure the safe and secure storage of medicines. The service demonstrated effective arrangements for the management, storage, and security of medicines. Medicines cupboards, fridges, and storage areas were locked when not in use, and access to medicines were restricted to authorised staff. Keys to medicines cupboards were held securely by registered professionals, and reconciliation processes were in place to reduce the risk of unauthorised access.

Medicines were stored appropriately in their original containers, with no unsecured medicines identified within the clinical area. There was clear segregation of medicines where required, including internal and external preparations, and appropriate controls were in place for high risk medicines. Intravenous potassium was not stocked in the same area, which reduced the associated risk of any error.

Checks confirmed that no expired medicines were identified during random stock sampling. Processes were in place to ensure that expired stock would be removed and disposed of safely.

Ambient room temperatures and medicines fridge temperatures were monitored and recorded, with evidence that temperatures were maintained within recommended ranges. Records demonstrated consistent monitoring where required, and clear action processes were in place. Medicine fridge temperatures were recorded morning and evening. Between January and March 2026, 100% of recordings were within the recommended storage range of 2 to 8 degrees centigrade.

IV fluids, insulin, and other medicines requiring enhanced safety controls were managed in line with policy. Insulin syringes and safety needles were available and stored separately to minimise the risk of medication errors. Emergency medicines were sealed and in date, providing assurance that they were safe and available for use if required.

Medicines at the bedside were stored securely in lockers accessed via key fob systems. Medicines kept at the bedside were appropriate for that setting, and medicines requiring fridge storage or controlled drug arrangements were not stored in bedside lockers. This reduced the risk of accidental or inappropriate access.

Competencies for controlled drug secondary signatures were in place. These competencies were observed or witnessed on three occasions by the advanced nurse practitioner before signing off. This included one tablet dose, one oral liquid dose, and one medication administered by subcutaneous injection. Competency sign off for dermatological preparations required a minimum three stage proficiency assessment, consisting of a self-assessment, two observed assessments, and a final sign off.

The hospice inpatient unit demonstrated good practice in antimicrobial stewardship, with clear evidence of improvement since the previous audit. Overall antibiotic prescribing had reduced significantly, indicating more selective and appropriate use, particularly within a palliative care setting where treatment decisions were balanced against patient comfort and potential benefit.

The use of intravenous antibiotics had decreased, with most patients managed using oral therapy alone. Where IV (Intravenous) antibiotics were prescribed, clinicians documented clear clinical justification. This reduction did not result in any unplanned hospital transfers or adverse outcomes, providing assurance that patient safety was maintained.

Antibiotic selection was appropriate and aligned with the hospital antimicrobial formulary. Prescribing decisions were frequently informed by microbiology culture results or specialist advice, enabling more targeted treatment. A small number of deviations from formulary guidance were identified but were isolated and addressed as learning points rather than systemic issues.

The service demonstrated improved use of microbiological investigations, with a high proportion of samples returning positive results. However, blood cultures were not consistently taken in cases of suspected sepsis despite policy. This issue had been recognised and was incorporated into a defined action plan.

End of life care was well managed. Antibiotics were discontinued appropriately when patients entered the dying phase, and no patients received antibiotics in the final 48 hours of life, in line with best practice guidance. Discontinuing burdensome treatments prioritised comfort, minimised adverse drug effects and avoided invasive interventions.

The hospice demonstrated safe management of medicines through a comprehensive clinical audit programme. In addition to routine medication audits, controlled drug stock was checked weekly, with counts alternating between day and night staff. This approach ensured effective oversight and reduced the risk of the same individuals carrying out consecutive checks. Externally completed controlled drug audits showed 100% compliance for the last three consecutive quarters reviewed.

A risk assessment was in place to manage periods when the automated medicines management system was unavailable, such as during power or system failures. During these periods, controlled drug stock was checked daily to maintain safety and ensure compliance.

Between October 2025 and January 2026, 17 medication incidents were reported. These included seven controlled drug incidents, 10 non-controlled drug incidents, and 4 medication related equipment incidents. Of the 17 incidents reported since October 2025, 7 related to administration errors, 6 to prescribing errors, and 4 to supply issues. This included four incidents involving medication equipment such as the automated medication management machine and syringe driver. Lessons were learning and appropriate changes made where necessary. All incidents resulted in no patient harm.

An overall increase in medication incident reporting was observed. Incident rates in October and November 2025 exceeded the standard deviation from the twelve month mean and were therefore monitored through the Patient Safety Incident Response Framework (PSIRF). No incidents met the threshold for a Patient Safety Incident Investigation. During this period, 6 After Action Reviews relating to controlled drug incidents were completed, with learning themes captured.