Hospice of the Good Shepherd

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

Our overall rating of well-led at Hospice of the Good Shepherd has improved from requires improvement to outstanding.

The hospice had a clear, shared vision based on equality, inclusion, and community needs, with strategic aims focused on delivering safe, effective care. Data, patient feedback, and partnership working were used to improve access and outcomes, while a strong culture and wellbeing focus supported sustainability.

Leadership was visible and supportive, with staff understanding and contributing to the organisation’s goals. There was a strong emphasis on psychological safety, open communication, and using feedback to drive improvement. Staff felt engaged and confident to raise concerns, and ongoing initiatives strengthened culture and leadership development.

Governance and risk management were robust, with clear oversight and use of data, audits, and KPIs to ensure quality and safety. Continuous learning and improvement were embedded, with strong collaboration across partners and active involvement of patients and families to deliver responsive, person-centred care.

This service scored 89 (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 4. The evidence showed an exceptional standard. The service had a very 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.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. Staff spoken with had awareness of how their work contributed to achieving the aims and objectives set out within the strategy. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and the community in order to meet these. Staff were focused on the needs of patients receiving care and delivering a high quality of service.

The organisation’s objectives were closely aligned with its strategic aims, supporting the delivery of safe, effective, and well-led services. Equitable access was improved through use of population health data to identify unmet need, particularly among underrepresented groups, while partnership working strengthened continuity of care. Patient reported outcomes informed ongoing improvement.

Following our last inspection, leaders created a business recovery plan. Each of the tasks in the recovery plan was aligned with the strategic aims. The plan was reviewed regularly, discussed at SMT meetings and Board. As part of the hospice focus on recovery and stability in service delivery, medical workforce resilience, and staff health and wellbeing, the self‑assessment task and finish group had evolved into the CQC Action Group. This was an open, collaborative forum where all staff could contribute to improvement in a psychologically safe space.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff could explain how they were working to deliver high quality care.

Leaders promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear. We heard how feedback from service users, staff, and the community informed change, alongside improved staff engagement.

Staff felt respected, supported and valued. Staff reported the leadership culture to be inclusive and spoke about feeling valued and respected. Relationships between staff were positive, with strong teamwork and collaboration. Collectively and with senior medical oversight the multi-professional teams come together to triage and allocate each new referral to the appropriate service, ensuring the right patient has access to the right team at the right time. The multidisciplinary team (MDT) met weekly as 3 distinct teams, ensured coordinated, patient centred care through shared decision making.

Staff felt motivated about the future and planned changes for the service, for example introducing new ways of working to improve efficiency, enhancing person-centred care approaches and increased staff training opportunities.

Team and individual staff achievements were recognised through a range of inclusive, community-focused activities that celebrated staff contributions and encouraged connection. These included seasonal and celebratory events, wellbeing and social initiatives, and peer-to-peer recognition. Recognition was embedded within both social and wellbeing activities, fostering a positive culture where achievements and contributions were valued and celebrated collectively. Staff told us they were thanked for their work.

We scored the service as 4. 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.

Leaders demonstrated the skills, knowledge, and experience required to perform their roles and exhibited a strong understanding of the services they managed, as well as the future developments they were planning. They clearly articulated how teams were working to deliver high-quality care and had established robust meeting and reporting structures within the service to support effective governance.

Staff reported that managers were visibly present on a daily basis, and those we spoke with expressed no hesitation in approaching senior managers with concerns. Regular supervision was provided, and debriefing sessions were routinely embedded in practice following challenging events. Leadership development opportunities were also available, including those accessible to staff at various levels.

Staff had ongoing opportunities to raise concerns or make suggestions through end of shift wellbeing debriefs (IPU staff), one‑to‑ones, appraisals, team meetings, and all‑staff meetings with leaders and Trustees. Information was also cascaded to staff during team meetings, safety huddles and handovers.

Survey feedback from both staff and patients was reviewed and acted upon. For example, IPU staff reported that the introduction of end of shift wellbeing debriefs has had a significant positive impact on their emotional wellbeing.

We noted that 96 hospice staff participated in the survey, representing an overall response rate of 74%. The service had implemented an improvement plan aimed at increasing employee participation and engagement, as well as addressing aspects of the working environment and staff health and wellbeing. At the time of our assessment, staff reported noticeable improvements in organisational culture and in communication with the leadership team.

Leadership development was supported through recruitment processes, structured leadership programmes, practice forums, and participation in quality improvement initiatives.

The former Clinical Leads Group had been renamed the Clinical Practice Forums to better reflect leadership within professional practice rather than hierarchical positions. Additionally, a Service Leads Meeting had been introduced to bring together operational and non-clinical leaders, enabling broader contribution to organisational development.

Leaders described their style as visible, compassionate, and focused on empowering staff while maintaining accountability. Emphasis was placed on the importance of acknowledging the impact of previous organisational challenges on staff and supporting teams in rebuilding confidence and trust.

Stakeholder feedback told us “The clinical and medical leadership at Hospice of the Good Shepherd are knowledgeable about the work they do and have worked hard to establish a positive culture within the organisation in recent years. Their integrity, openness and honesty in dealing with issues as they arise is inspiring”.

Additionally, other stakeholders told us that “leaders within the hospice are regarded as highly visible, approachable and value driven. Supervision feedback highlights leadership that promotes openness, psychological safety and reflective practice. Leaders demonstrate strong insight into the challenges of palliative and end of life care and actively support staff wellbeing, development and inclusion. They role model compassion, integrity and professionalism, fostering a culture where staff feel respected, heard and confident in delivering high-quality care. This leadership approach underpins the organisation’s ability to sustain excellence and continuous improvement”.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard.

Staff told us when they had raised valid concerns or felt they would be able to, were or would be supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially. The local senior leadership were aware when whistleblowers had raised serious concerns and took steps to investigate and address the matters raised.

A risk register and management reports contained analysis of concerns over time and associated action plans.

The hospice had a freedom to speak up/whistleblowing policy and procedure in place which was up to date and appropriate in content.

There was a freedom to speak up guardian in post at the time of the assessment. The guardian was available Monday to Friday and based at the hospice site.

When a concern was raised, it was acknowledged within two working days. An initial review was then conducted to understand what the concern was about and how urgent it was. If needed, a fair and unbiased investigation was completed by someone who was not involved. Feedback was then shared, explaining the outcome, any actions taken, and any lessons learned, while keeping everything confidential. Finally, a follow-up check was conducted to make sure the person felt supported and safe after raising the concern.

We saw posters promoting the freedom to speak up process with contact and support details.

We scored the service as 3. The evidence showed a good standard. 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.

Leaders acted to address any negative experiences reported by staff with protected characteristics. They took steps to remove bias and promote equality of opportunity and experience throughout employment.

Staff told us they had access to opportunities such as project work, new roles, and external study through an open and transparent application process.

The service worked to prevent and address bullying and harassment at all levels, with a clear focus on supporting staff with protected characteristics and those from marginalised groups. Staff felt people were treated fairly and said they would feel confident raising concerns about inappropriate behaviour or attitudes.

Staff with disabilities were supported through reasonable adjustments to enable them to perform their roles effectively.

The hospice typically conducted a staff survey every two years. However, in response to the scale and significance of the 2024 feedback, leaders undertook an additional full survey in 2025 to monitor progress more closely. Following this, a structured organisational action plan was developed.

Actions to improve communication, visibility, and cross-team understanding included the introduction of open staff meetings and forums on key strategic topics, alongside regular all-staff updates to ensure timely communication.

Regular team leader meetings aligned with the senior management team (SMT) were introduced to strengthen two-way communication and ensure frontline feedback was escalated effectively. A leadership development day (“Leap 76”) was also implemented to improve communication and professional relationships. Further initiatives, including a staff suggestion scheme and a “Meet the Teams” programme, were planned for 2026.

Leadership visibility and engagement were increased through SMT and chief executive walkabouts and staff engagement events. Trustees also attended all-staff meetings and other engagement activities, and staff were encouraged to participate in CQC and wellbeing action groups.

Recognition and engagement initiatives were strengthened, including the introduction of a monthly Director of Clinical Services recognition award and continued opportunities for staff to engage with trustees. Plans were in place to relaunch broader staff recognition awards in 2026.

A range of wellbeing initiatives was implemented, including a staff wellbeing task and finish group, wellbeing events, and a wellbeing day offered to all staff. Weekly chaplaincy drop-in sessions were available, and a revised appraisal template placed greater emphasis on wellbeing and organisational culture. Wellbeing champions were also introduced in August 2025.

Although not a primary theme of the staff survey, environmental initiatives were progressed to reflect organisational values and support staff pride. These included relaunching “Team Green,” improving recycling practices, developing a sustainability infographic, and drafting an environmental strategy for 2026.

These actions demonstrated a proactive response to the 2024 survey findings. They supported measurable improvements, identified areas requiring further focus, and indicated a positive cultural shift. Data showed that 89% of staff felt comfortable being themselves at work.

The hospice recruitment policy promoted equality, prevented discrimination and harassment, and supported positive relationships between people with protected characteristics. It also aligned with a human rights-based approach and the FREDA principles of fairness, respect, equality, dignity, and autonomy.

We scored the service as 4. The evidence showed an exceptional standard. 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service operated effective governance processes through a range of committees and on-site activities. Performance information was routinely collected, monitored, and reviewed at local and committee level, with escalation to the Board. Where improvements were identified, targeted action plans were developed and implemented.

Staff at all levels were clear about their roles and accountabilities. Job descriptions outlined expectations and responsibilities, and staff with specific responsibilities for audit and quality monitoring understood their duties.

Staff could access the data they needed in clear and user-friendly formats to support decision-making and service improvement. Information systems were secure and integrated, and required data and notifications were consistently submitted to external organisations.

Leaders ensured accurate and relevant information was shared effectively with staff through established communication channels.

Risks were clearly identified, recorded, and managed through a formal risk register. This supported oversight, mitigation, and timely resolution. Staff contributed to decision-making processes to improve both sustainability and quality of care.

Audit activity was used effectively to maintain and improve service quality. Where improvements were required, leaders implemented and monitored action plans to ensure positive and sustained change.

The service had comprehensive business continuity and major incident plans in place to manage unexpected events and ensure continuity of care.

No data breaches had been reported, and systems were secure. Patient-identifiable information was handled appropriately. Policies and procedures were up to date, regularly reviewed, and easily accessible, with appropriate leadership oversight.

Board oversight was supported through quarterly assurance, assessment, and action reports from a range of committees, including care (quality, safety and experience); health and safety; finance and fundraising; information governance; and people and development.

The clinical governance subcommittee provided oversight of clinical quality and safety. This was supported by monthly medicines management meetings and the patient safety assurance forum. Patient safety risks, incidents, and concerns were routinely reviewed, escalated, and tracked through to resolution.

Clinical audit activity was undertaken bi-monthly, with findings reviewed through governance forums and key learning themes escalated to the care committee. Actions arising from audits and incident reviews were clearly documented, monitored, and translated into service improvements.

Medicines management arrangements were well embedded and effectively governed. Learning and areas of non-compliance were openly discussed with managers, with no evidence of unmanaged risks.

Medical staff were actively engaged in clinical governance, with clear responsibilities and regular attendance at governance and business meetings. Clinical incidents and significant events were routinely reviewed, and staff demonstrated a good understanding of the patient safety incident response framework, including the use of swarm methodology.

The risk register provided a central, real-time view of operational, clinical, financial, and strategic risks. It supported informed decision-making, organisational learning, and strong governance from frontline to Board level.

Systems were in place to monitor current and future performance, as well as risks to quality. Information relating to risk, performance, and outcomes was used effectively and shared securely with relevant partners where appropriate.

A corporate KPI dashboard was updated monthly and reviewed by the senior management team, before being considered at quarterly committee and Board meetings. A comprehensive set of key performance indicators provided assurance across care, estates, health and safety, information governance, workforce, finance, and fundraising.

The risk register was actively maintained and regularly updated to reflect current risks. Departments contributed to identifying and managing risks within their areas, with each risk assigned a named owner responsible for controls and mitigation.

Risks were reviewed at multiple levels. Teams managed risks locally, escalating where required. The senior management team scrutinised risks and trends, while sub-committees reviewed risks within their remit. The Board maintained oversight of the overall risk profile and high-level strategic risks.

All deaths were reported to the medical examiner, with referrals made to the coroner where appropriate. No concerns were identified at the time of inspection.

Day-to-day management was supported through regular departmental meetings, operational leadership forums, and task and finish groups focused on specific risks and improvement priorities.

Clinical leadership and professional practice were supported through structured specialist groups overseeing key areas such as safeguarding, infection prevention and control, medicines optimisation, nutrition, falls prevention, and Motor Neurone Disease.

Policies, procedures, and supporting documents were centrally managed through an electronic system. Staff had access to up-to-date guidance, with automated reminders to support review cycles, training compliance, and audit activity.

Dedicated groups promoted staff wellbeing and equality, diversity, and inclusion, while volunteers were supported through an established governance structure. Organisation-wide communication was maintained through quarterly all-staff meetings involving both staff and trustees.

Service user involvement was supported through a participation group, which met quarterly and contributed to service development and improvement, such as the Wednesday Group. This was a group that helped people to socialise and maintain links with the hospice. The group had been operating for many years, and group numbers varied from week to week. They organised events at the hospice or a day out once a week. Importantly, the group was run by a small number of dedicated hospice volunteers, and they always provided a lively atmosphere and support, along with a strong sense of friendship in a safe and supportive environment.

External engagement included effective management of contracts and service level agreements, as well as active participation in local, regional, and national networks.

We scored the service as 4. The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

The hospice worked closely with a range of system partners to support effective partnership and multi‑agency working. This included collaboration with local NHS trusts, community nursing services, GP practices, specialist palliative care teams, social care providers, and voluntary and charitable organisations. The hospice actively participated in regional palliative and end‑of‑life care networks and Integrated Care System (ICS) forums, which enabled shared learning, coordinated service planning, and access to specialist expertise.

Multi‑agency working was evident through joint care planning, shared discharge and admission processes, contribution to multidisciplinary team (MDT) meetings, and collaborative management of patients with complex needs. The hospice also worked in partnership with commissioners and system leaders to support service development, early awareness of policy and pathway changes, and benchmarking against comparable providers.

The senior management team engaged with external stakeholders. Stakeholder feedback highlighted that the hospice played a central role in supporting collaborative working between consultants, hospice teams, general practitioners, community nurses, care home staff, and hospital teams. It also provided timely remote specialist advice, helping to reduce delays in care and improve responsiveness. This enabled shared clinical decision-making coordinated care planning across services, and effective sharing of clinical assessments and management plans to support continuity of care.

Additional feedback from other stakeholders indicated that partnership arrangements strengthened integrated working across services, enhanced continuity and safety of care for patients and families, and ensured that hospice services remained evidence-based, compliant, and responsive to the needs of the local population.

Communication from the leadership team was consistently described by stakeholders as open, transparent, and professional. During a sudden gap in the hospice medical workforce, leaders responded proactively by exploring available options. They identified the out-of-hours medical support model as a well-established and effective approach to maintaining safe and reliable clinical services.

Leaders also engaged constructively during the Medical Leadership Day held in December 2025, demonstrating a willingness to collaborate and share learning.

Stakeholders highlighted a clear and visible commitment to partnership working and integrated care across organisations. Regular shared governance and review meetings evidenced strong, collaborative leadership, with a sustained focus on delivering safe, effective, and high-quality care. Two supporting reports were submitted alongside stakeholder feedback, providing further assurance of ongoing partnership working, oversight, and continuous improvement.

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

We scored the service as 3. The evidence showed a good standard. 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.

Staff were committed to continually learning and improving services. An improvement methodology was in place. Staff and leaders had a strong understanding of how to initiate and implement improvement. This included using consistent approaches to measure outcomes and evaluate impact.

Co‑production with people who use services was embedded. Staff and leaders ensured that patients, families, and carers participated in shaping, testing, and evaluating improvement and innovation initiatives.

The hospice had embedded a learning culture with processes to ensure learning happened when things went wrong and from examples of excellence. Leaders promoted reflective practice, collective problem-solving, and psychological safety.

Staff were supported to prioritise time to develop their skills in improvement and innovation. A clear organisational strategy guided how these capabilities were strengthened, and staff were continually encouraged to contribute.

Leaders actively welcomed ideas for improvement and innovation. They invested time to listen, engage, and build trust adopting an environment where staff felt confident to raise suggestions.

Strong external partnerships were embedded as the organisation maintained effective external relationships that supported improvement and innovation. Staff and leaders contributed to external networks and research, and embedded evidence-based practice across the hospice.

During 2024/2025, a key focus of the hospice recovery was stabilising service delivery. This included strengthening the medical workforce and prioritising staff health and wellbeing to rebuild stability across clinical service delivery.

The quality and improvement strategy, supported by robust governance, drove service development and actions. A positive culture, wellbeing initiatives, financial control, and an embedded environmental strategy supported sustainability and long-term resilience.

In 2025/2026, the director of clinical services championed a vision of inclusive improvement creating a psychologically safe environment where all staff could contribute openly and transparently. Through the CQC action task and finish group, every team member had the opportunity to share insights, raise challenges, and contribute to solutions. This led to a fully co-produced self‑assessment of the CQC framework.

The senior management team listened to staff and drew on the full range of intelligence from the board assurance framework, including staff surveys, pulse surveys, patient, and service‑user feedback, and corporate KPI dashboard to aide improvement.

Inclusive access to care patient experience ensured equitable, inclusive, and responsive access to hospice care by embedding personalised support, holistic wellbeing, coordinated services, and community engagement - aligned with NHS long term plan and end-of-life care priorities.

Culture of safety, workforce development and staff wellbeing supported a psychologically safe, supportive, and agile working environment where staff felt empowered to speak up, grow professionally, and maintain wellbeing.

Governance, clinical systems, and digital transformation strengthened governance, digital systems and data quality to enable safe, effective care aligned with national standards.

The hospice link nurses were strengthening clinical practice, enhancing communication, and ensuring best evidence was consistently embedded at the frontline. By championing high standards and supporting their colleagues, they were creating a culture where expertise was shared, learning was continuous and patient care continued to grow in quality and compassion.