St Michael's Hospice (North Hampshire)

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

The service had a proactive, transparent, and multidisciplinary approach to safety. This was managed using assessment tools, and real-time data monitoring which allowed the team to identify risks and implement solutions. The service excelled in safe transitions and collaborative care, using electronic records and daily meetings to promote continuity across hospital and community settings. However, there were shortfalls in environmental safety, including fire escape obstructions and unsecured hazardous substances. Despite this, the service was supported by a reliable workforce that enabled specialist care to be delivered consistently and safely.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The hospice created an environment for learning and safety by making teamwork a part of everyday life. To ensure consistent monitoring, managers told us they held meetings twice a day and met monthly to review complex cases. For example, when data revealed an increase in pressure damage and falls during April and May 2025, leaders appointed ‘champions’ for both areas to lead targeted training and create regular information bulletins. This helped to create a proactive learning culture and improved clinical outcomes for patients using the service.

The hospice adopted a ‘no blame’ approach when reviewing incidents, and leaders implemented an accident and incident policy which focused on identifying shortfalls in their systems and processes. This was evidenced by a review of 45 low harm incidents. For example, when a controlled drug was mistakenly discarded, managers logged the event and used it as a learning opportunity for the whole team. This open culture also encouraged staff to report near misses which helped to reduce the risk of future incidents. Staff told us they knew how to report incidents and near misses to ensure continuous safety. Managers supported this by providing constructive feedback, which staff used to adapt their ways of working and improve future care.

The service was in the process of preparing staff for the transition to the Patient Safety Incident Response Framework (PSIRF). This approach focused on systemic learning and improvement, rather than assigning blame. Leaders introduced an online incident reporting form and provided guidance through clinical study days and one to one support. Leaders undertook investigator training and the wider team took part in ‘systems thinking’ awareness sessions. This helped to ensure the workforce was well-equipped to identify and report risks, resulting in a culture of safety and organisational learning.

The hospice had a culture of learning supported by quality improvement (QI) projects that helped reduce risks. For example, to stop people from being interrupted while giving out medicines, staff wore red tabards and took regular drug calculation tests. Staff put sensors on beds to help prevent falls and used red markers on patient records to highlight who was at risk of falling. This meant leaders used learning from incidents to start QI projects which positively impacted on patient safety. These efforts worked well, as the hospice had no never events in the last year and reduced medicine errors. A never event is a preventable safety incident that should not happen if a healthcare provider follows national safety guidance.

The hospice demonstrated a commitment to learning by updating clinical protocols following an undetected case of urinary retention. In response, the team introduced new guidance requiring catheters for all patients with spinal cord compression to ensure safer, more proactive management. Similarly, the staff simplified their communication to overcome delays in emergency care. They identified that using the phrase “urgent symptom control” prompted a faster 4-hour response from paramedics. These practical changes removed barriers, allowing staff to provide people with faster and more effective care and treatment.

The service had highly effective safe systems, pathways and transitions that prioritised patient safety and continuity of care during every phase of the patient journey. For example, staff used a computer system which allowed clinicians to view medical notes from hospitals and district nurses. Every morning, a multidisciplinary meeting was held which included outside specialist teams to talk about available beds and how to get patients home safely. These systems helped staff manage difficult moves, such as bringing a very sick patient from the hospital to the hospice in less than 24 hours.

The team worked creatively to help patients reach personal goals while staying safe. For example, they helped one patient travel overseas by contacting airlines and providing 2 months of medicine, which is more than they usually give. This meant patients were supported to do things that mattered to them, without losing the high-quality medical care they needed. In another case, a hospice consultant identified a surgical intervention that had not previously been considered. This resulted in the patient being transferred for life-extending treatment and recovery.

To make sure people stayed safe after leaving the hospice, the team used assessment scales to track how they were doing and adjust their care as needed. For example, staff applied the Australian-Modified Karnofsky Scale (AKPS) and Phase of Illness metrics to track and adjust care pathways. This meant patients received the right level of care at the time they needed it, and care stayed consistent.

Occupational therapists visited patients’ homes to assess equipment needs, such as hoists or mobility aids. The team used digital tracking to monitor medical pumps used in the community to make sure they worked correctly. Staff described their response in supporting a patient and their family, where their home became unsafe due to a relative experiencing mental health crisis. The hospice stepped in to move the patient to a safe hospital. These systems helped to ensure clinicians identified medical needs and functional declines early, resulting in safe transitions of care where patients received the correct equipment and specialist support regardless of their care setting.

The service maintained a good safeguarding culture, supported by a workforce that demonstrated a clear understanding of risk and escalation pathways. Permanent clinical staff achieved 100% compliance in level 3 adult and level 2 children’s safeguarding, as well as 96.97% for level 3 children’s safeguarding. Regular bank staff compliance rates showed 84.6% for level 3 adult safeguarding and 90% for level 3 children’s safeguarding. This meant all staff had the knowledge and skills to identify people who were at risk of harm and acted accordingly to keep them safe.

Oversight of these standards were managed through a Safeguarding Committee, who were responsible for driving action plans to improve the accuracy of training records. The committee acknowledged that in-person training delivered at away days was not always easily captured by the existing digital training platform, and they took responsibility for ensuring future data would clearly demonstrate the competency of both permanent and bank staff.

The hospice maintained a safe and effective safeguarding culture. For example, staff understood what safeguarding meant and could give examples of how to identify this risk. This was supported by an escalation pathway, where staff reported concerns to a designated safeguarding lead who held responsibility for local authority referrals. Additionally, clinical risks such as pressure sores were managed using body maps and wound care plans. This meant vulnerable patients were protected through timely intervention and professional accountability. By integrating safeguarding into daily clinical practice, the service created a secure environment where risks were identified and addressed before they could escalate.

The hospice had a safeguarding policy for adults and children that aligned with national guidance. The policy mandated ‘everyday vigilance’ from all staff and volunteers, regardless of their role or seniority. It described recruitment protocols, including regular Disclosure and Barring Service checks, and required all staff to complete safeguarding training tailored to their specific responsibilities. These measures ensured the hospice created a protective culture where staff identified risks early, shared information appropriately, and empowered patients to live free from harm, abuse and neglect.

Staff monitored deteriorating patients by using standardised assessment tools tailored to individual needs. Staff employed the National Early Warning Score (NEWS2) and the Integrated Palliative Outcome Scale (IPOS) to track clinical changes, alongside a sepsis standard operating procedure. During morning handovers, the multidisciplinary team (MDT) used these metrics to identify the phase of illness, distinguishing between stable, unstable, and deteriorating states. We observed this in practice during a discussion regarding a patient with abdominal discomfort and declining kidney function. The team discussed the prioritisation of comfort and pain relief over continuous monitoring and active treatment. This meant the patient received appropriate care in a way that considered their deteriorating state and comfort needs. Beyond clinical observations, staff conducted risk assessments for Activities of Daily Living (ADLs), creating specific care plans to manage falls, pressure ulcers, and the need for physical assistance.

We observed nurses using the NEWS2 scale to monitor early signs of sepsis or physical decline, and managers audited staff compliance with this tool which achieved 94% from April to June 2025. Staff told us this level of assessment remained an important aspect of care as it gave them the ability to monitor signs of deterioration and support patients with symptom control. For example, we saw a patient who was struggling to breathe, and the nurses immediately conducted physical observations (using the NEWS2 scale), and reviewed their medicine chart to see what could be given to help them feel more comfortable. This vigilant approach meant clinical changes were caught early, providing a safe environment where medical interventions were both timely and accurate.

Furthermore, the service balanced clinical safety with patient autonomy, particularly regarding falls. Records from the Clinical Governance Committee demonstrated that the team engaged in peer reviews to assess the balance between the risk of falling and the benefit of maintaining a patient’s independence. This nuanced approach respected the choices of patients who understood the risks but wished to remain independent to achieve personal goals.

Care planning also focused on clear communication and documented limits on medical intervention. For patients stuck in cycles of hospital readmissions, the team used the ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process. While a ReSPECT form was not a legally binding document, it was a highly recognised plan designed to guide healthcare professionals by clearly expressing a patient’s choices, wishes, and preferences for a time when they might be unable to communicate. By ensuring these ‘ceilings of treatment’ were documented, the service protected the patient’s voice in future care decisions. This proactive oversight empowered the team to manage complex cases and reduced distress by ensuring the right specialists were involved at the right time, while always respecting the patient’s right to decline hospital transfers in favour of a clear safety plan.

This oversight helped to ensure that current and future risks were managed through clear, documented limits on care. For the patient with declining kidney function, the team held a discussion about potential infections (sepsis) and recorded how much medical intervention was agreed upon. Although offered a transfer to an acute hospital, the patient declined and staff respected this choice while keeping a clear safety plan in place. This helped to reduce distress for patients nearing the end of life by involving the right specialists at the right time.
 

The service did not consistently meet fire safety standards, creating potential hazards for patients and staff. During the inspection, we observed instances where escape routes were compromised. For example, in the Inpatient Unit (IPU) equipment such as a stand-aid and a wheelchair were stored directly outside a patient’s cubicle. This obstruction prevented the entry doors from opening fully, which would have delayed an evacuation. Similarly, the main corridor (a primary escape route) was narrowed by equipment stored on both sides, including 3 commodes and 2 stools. We also identified a chair which was placed directly in front of a fire exit. This increased the risk to patients in the event of an emergency because staff would have to clear equipment to ensure a safe exit. These concerns were immediately brought to the attention of senior leaders during our visit. While the facility was fitted with fire doors that underwent weekly testing, an external audit in September 2025 identified technical failures in the laundry and IPU staff room doors. Although leaders have since resolved these issues, our onsite observations meant further senior oversight was needed to strengthen fire safety in the service.

The hospice did not always manage or control substances hazardous to health (COSHH), resulting in unauthorised access to potentially harmful chemicals. Under the COSHH Regulations 2002, healthcare providers are legally mandated to prevent or control exposure to hazardous substances to ensure the safety of patients, staff, and visitors. During our inspection, we found hazardous items, including air fresheners, flying insect killer, and air deodoriser, stored openly in the sluice area. Furthermore, air fresheners were left unsecured in toilets throughout the IPU. This meant members of the public and vulnerable patients could easily access chemicals capable of causing harm. We raised these concerns immediately with the provider, who took prompt action to secure the items and rectify the issue.

The IPU was a well-equipped clinical environment consisting of 10 patient rooms, each containing amenities such as en-suite bathrooms, air mattresses, and televisions. Beyond clinical care, the facility incorporated several dedicated spaces designed for holistic support, including a sanctuary, and a family room with kitchen facilities. Communal ‘cubby hole’ areas and a community hub provided comfortable social spaces, styled with flowers and comfortable sofas to create a less institutional atmosphere.

The service used safety and clinical protocols, evidenced by the appropriate segregation of waste and the display of fire safety instructions. The building was fitted with fire doors throughout, which were integrated into a weekly testing schedule every Thursday. The unit included specialist features like a jacuzzi bath and a Chapel of Rest. To support families during bereavement, room temperatures could be individually controlled to allow patients to remain in their rooms after death. Staff confirmed this practice provided families with more time to say goodbye in a private, familiar environment.

The service had a multidisciplinary workforce that included Consultants, Registrars, Foundation Doctors, Nurse Consultants, Nurse Prescribers, Registered Nurses (RNs), Healthcare Assistants (HCAs), Complementary Therapists, and several volunteers and housekeepers. While the physiotherapist post was vacant for 8 months following a departure in December 2024, the service effectively mitigated this gap by using collaborative links with external physiotherapists from local hospices and the nearby acute hospital until a full-time physiotherapist was appointed in December 2025. This meant patient mobility assessments continued alongside the work of the occupational therapy team. The service also recently expanded its Hospice at Home provision to a 24/7 model, supported by a structured team of registered nurses and healthcare assistants to ensure patients and relatives could always access clinical care.

Staffing levels were managed through an objective dependency tool that converted patient needs into required clinical hours, ensuring ward managers could justify staffing based on evidence. Staff told us planned numbers met actual staffing numbers most of the time, and they had the ability to provide the care needed. This internal stability was reflected in a low turnover rate of 4.88% and a total avoidance of clinical agency staff over the past year. Instead, the service used a dedicated bank staff pool, which accounted for 17% of the workforce. These bank employees were fully integrated into the organisation, completing the same clinical competencies and study days as permanent staff to ensure a consistent skill set across the entire team. During a period of recruitment between April and June 2025 (where clinical vacancies stood at 7.9 full-time equivalents), bank staff were deployed to maintain safe ratios and supported the transition to the 24/7 service model. Additionally, the medical team onboarded 3 new doctors during the summer to support the turnover associated with the rotation of medical training programmes.

The service had a proactive approach to workforce development by hosting an Education Committee in July 2025, focusing on training pathways and enhancing clinical competency. This included the implementation of a Service Level Agreement with a local NHS Trust to deliver training in cannulation and intravenous therapy. The hospice also conducted clinical away days which integrated some elements of mandatory training, such as manual handling, resuscitation, and learning on Patient Safety Incident Response Framework (PSIRF) case studies. This meant staff could remain up to date and consistent with their skills and knowledge, enabling them to provide safe care and treatment.

While internal monitoring initially flagged 2 mandatory training modules as being below 75% compliance, updated data provided further context. The 71.43% compliance in Food Hygiene was skewed by a new starter who had only been in post for 3 days. Excluding this entry, staff compliance in this area was 83.3%. Autism training achieved 100% compliance in Tier 1 Learning Disability and Autism Awareness. The service was proactively addressing Tier 2 Oliver McGowan training through a rolling programme, reaching 75% compliance by February 2026, with additional sessions planned for the autumn.

Continuing Professional Development (CPD) enabled staff to gain specialist skills in palliative care. This was evidenced by ‘Core Skills Passports’ for Registered Nurses, which aligned with Nursing and Midwifery Council standards and involved a 2-year pathway for the completion of clinical and leadership competencies. For example, the hospice funded additional external training such as non-medical prescribing, a Masters in Palliative Medicine, and Motor Neurone Disease care. This investment fostered a culture of clinical expertise but also ensured staff had the specialist knowledge needed to manage complex symptom control, and support patients with diverse needs.

The service demonstrated excellent infection prevention and control (IPC) practices through high standards of clinical hygiene and with the monitoring of invasive devices. We observed all areas within the hospice to be visibly clean, with housekeeping staff diligently sanitizing high, low, and difficult to reach surfaces. We saw the consistent use of ‘I am clean’ stickers on all medical equipment, which provided staff with immediate assurance devices were ready for patient use. Staff followed best practices for hand hygiene, which we observed in both the inpatient unit and during home care visits, and we saw guidance displayed above all sinks on the ‘7 Steps to Clean Hands’. There were no incidents relating to healthcare associated infections.

The service made infection control a part of every medical decision. For example, they used a simple scoring system to check for signs of irritation around cannulated sites. This helped staff avoid using skin that was already swollen or sore. They also regularly checked ‘Butterfly’ needles (small, subcutaneous needles used for pain relief pumps) for any redness, leaking, or swelling. This helped keep vulnerable patients safe and made sure that skin health and equipment safety were a top priority.

The hospice had a robust system for monitoring IPC practices. For example, they conducted a Hospital UK IPC Audit in May 2025, which returned 100% compliance scores in the categories of patient placement, respiratory hygiene, use of Personal Protective Equipment (PPE), and equipment cleanliness. These results demonstrated the leadership team had established a culture of safety where staff understood the 10 elements of Standard Infection Control Precautions, including the ‘5 Moments for Hand Hygiene’, and the correct selection of PPE. This meant the hospice provided a safe environment that protected patients, staff, and visitors from the risk of healthcare-associated infections.

The service’s internal auditing processes functioned as a proactive tool for identifying and rectifying clinical shortfalls. This was evidenced in hand hygiene audits from June to August 2025 which showed 18 out of 19 staff members adhered to the ‘bare below the elbow’ protocol. Identified gaps included staff wearing stoned rings or watches in clinical areas and this was immediately addressed. By carrying out these audits, managers could make sure staff were following safety policies and maintain a clear picture of how the department was running. Leaders also incorporated IPC practices in a clinical skills study day in May 2024, where an ultraviolet lightbox was used to visually demonstrate poor hand-washing techniques, and scheduled a review of audit actions for November 2025. This cycle of targeted education ensured that minor lapses in hygiene or environmental maintenance did not escalate into systemic failures.

The hospice had a framework for oversight of medicines management that involved a Service Level Agreement with a local hospital pharmacy. A pharmacist or technician visited every weekday, providing a direct link between the hospice clinical team and specialist pharmacist expertise. During these visits, pharmacy staff reviewed drug charts and participated in multidisciplinary team (MDT) meetings which helped to ensure medicine arrangements remained clinically appropriate. This oversight was further strengthened by the Medicine Management Group (MMG), which met quarterly to review clinical effectiveness, prescribing protocols, and best practice guidance. The MMG also provided high-level supervision of all medication errors and near miss incidents, analysing themes and reporting findings to the quarterly Clinical Governance Committee.

Staff told us they requested medicines before stock depletion and had access to a 24/7 out-of-hour pharmacy service for urgent requirements. As a result, the hospice always had access to a supply of essential medications, preventing delays in symptom management for patients in critical phases of care.

The service set up proactive medical protocols that allowed staff to react immediately to worsening symptoms or emergencies. We looked at medicine prescription charts and found doctors prescribed multiple PRN (as required) anticipatory medicines. By having these prescriptions signed and medicines available in advance, nurses could react immediately to symptoms like pain, breathlessness, or agitation. This helped to ensure patients did not have to wait long for relief during sudden changes in their condition.

Controlled Drugs (CDs) were stored in wall mounted locked cupboards within a restricted access treatment room. Nurses followed the ‘2-person rule’ for all CD counts and administrations. We observed this practice on 3 separate occasions and nurses we spoke with clearly understood their legal obligation to follow these rules. This meant high-risk medicines were tracked with total transparency from delivery to patient administration.

Internal audits served as a primary tool for measuring medication practices. The August 2025 pharmacy audit recorded 100% compliance across key indicators, including the security of locked cupboards, the management of out-of-date medicines, and regular CD checks. When a July 2025 audit identified that patient names were not always recorded accurately in the CD book, the issue was escalated to the Clinical Director (who also serves as the Controlled-Drug Accountable Officer). This was then integrated into daily safety briefings and inductions to improve standards. This action helped to improve medicine safety standards and ensured managers had oversight of issues early on.

The clinical team monitored storage temperatures of medicines, although we observed areas where records required strengthening. A review of August 2025 records showed that fridge and room temperature checks were missed on 3 dates. Despite the gaps in recording, temperatures were managed safely during the periods they were checked, and no impact came to patients as a result.