KEMP Hospice

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

We reviewed all 8 quality statements for safe, learning culture, safe systems, pathways and transitions, safeguarding, involving people to manage risk, safe and effective staffing, safe environments, infection prevention and control, and medicines optimisation. We found:

Safety was a priority for everyone, and leaders embedded a culture of openness and collaboration.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Staff worked with patients to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enabled them to do the things that matter to them.

Staff detected and controlled potential risks in the care environment.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

Patients were protected as much as possible from the risk of infection because premises and equipment were kept appropriately clean and hygienic.

The service used systems and processes to safely administer, record and store medicines.

However,

The facilities and premises were not designed to fully meet the needs of the range of patients who used the service.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Safety was a priority for everyone and was supported by those with clear roles and responsibilities for safety. Leaders embedded a culture of safety and learning that is based on being proactive, open, transparent and professionally curious. Staff recognised and reported incidents and near misses and reported them appropriately.

The incident management policy had been reviewed in November 2025. It set out clear responsibilities for staff and managers, outlined investigation processes, timescales for investigating, and methods for disseminating learning. Staff knew how to access the policy and where to go for advice and support. Staff demonstrated a good understanding of what incidents to report, how to report them, and how to escalate patient safety concerns.

Reporting of incidents was improving. Staff reported incidents on a new electronic incident reporting system which had been implemented in April 2025. This led to improvements in staff reporting incidents, with 13 out of 15 incidents from November 2024 to October 2025 being reported after its implementation. No serious incidents or never events had been reported over this time.

Staff described reporting incidents such as medicines management issues, near misses, and falls in line with the incident management policy.

Managers investigated incidents using a proportionate approach, including root cause analysis. Investigations included patients and families and were appropriate, ensuring people received clear explanations, apologies, and support when things went wrong. This was in line with duty of candour requirements. Action plans were developed to address findings and prevent recurrence.

Lessons learned were shared with the whole team and the wider service which included staff who worked in other parts of the organisation. Learning was shared with staff through daily handovers and clinical team meetings, as well as at caseload review and multi-disciplinary meetings.

Changes had been made as a result of learning. We observed protected daily handovers were used to review patient safety risks such as falls and time critical medicines administration for patients attending the hospice.

Staff described a culture of continuous learning, and they were provided with opportunities to develop their knowledge and skills. For example, attendance at national conferences, and formal and informal in-house learning sessions. Following a falls incident, staff were provided with a refresher on manual handling.

Continuous learning was driven by the needs of the patient. For example, the service sought teaching sessions from other providers or services where they had a patient with specific needs such as patients receiving medicines through a syringe driver.

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.

There was a robust referral and service acceptance process. The service had a clear acceptance criterion for patients being referred for symptom management, and advanced care planning support. Most of these referrals came from health professionals in the community or local hospitals. There were online referral forms, but telephone referrals could be made for people requiring more urgent support.

There were daily handovers where new referrals and admissions were discussed. Waiting lists and caseloads were reviewed in weekly multi-disciplinary meetings where each new referral was discussed and booked in for an assessment with the nursing team. These appointments were generally offered within 5 days of referral.

Risk assessments were person-centred and were focused upon patients’ wishes. All new referrals were offered a home assessment by a registered nurse. The nurse completed a holistic assessment of their health, social care, and emotional needs. Nurses made referrals for support where the patient had unmet needs or where there were specific risks. For example, where the patient was at risk of falling or struggled with their mobility, they referred to the Kemp therapy team to undertake an assessment and provide equipment to keep patients safe at home as well as when attending the hospice.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care. Staff were responsive to patients changing needs. For example, where a patient could not attend the hospice due to a deterioration in their health, the nursing team arranged to visit the patient at home to check their well-being. Staff could also access other professional services when needed such as speech and language therapists, dietitians and mental health professionals including psychologists. The service worked closely with other services to support patient pathways and transitions.

'There was joint ownership of safety, by the relevant care partners, across the patients' care journey. KEMP staff worked closely with other local palliative care services and GPs to ensure the patients' needs were being met.

Staff supported patients to be involved in their own care. This enabled patients to maintain as much control as possible throughout their care and treatment. Patients told us staff encouraged them to be as independent as possible whilst at the hospice and supported them with ordering of equipment to maintain independence at home.

Staff worked with patients when moving between services. Staff recorded the patient’s stage of illness and discussed this with patients and in daily handovers to continuously review the patients’ changing needs and risks. Patients told us that they had felt involved in their own care and were informed of transitions to different services. For example, patients were supported to transition to in-patient hospice care or to a care home where their needs had changed and additional support was required.

Staff could access patients shared healthcare records which improved continuity of care for patients. Patient records were electronic with key information being available to all health professionals who provided care to ensure patient’s wishes were shared. Staff told us they could access the information they needed.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had effective safeguarding systems, policies, and practices to protect adults and children from abuse. Safeguarding policies had been reviewed in November 2025. They were aligned with current legislation and best practice and were accessible to staff. Clear governance, escalation pathways, and training supported a strong safeguarding culture. Local and internal safeguarding processes were displayed within the service and staff knew where to go for advice and support.

Staff demonstrated a thorough understanding of adult safeguarding, and they understood their roles and responsibilities. All clinical and patient-facing staff achieved 100% compliance with level 3 safeguarding training; the safeguarding team included a level 4-trained member, and 2 trustees with safeguarding oversight were trained to level 3. Staff provided examples of how they identified safeguarding risks for their patients, took appropriate action, and worked with external agencies to safeguard patients. Furthermore, staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

From November 2024 to October 2025 KEMP Hospice had 71 internal safeguarding incidents reported by staff of which 5 were referred to the local authority safeguarding teams. Most of these included people experiencing suicidal ideations and risk of self-harm. The care services team raised concerns around neglect and cognitive decline in patients.

Safeguarding systems, processes and practices gave assurance staff upheld patients’ human rights, and staff protected them from discrimination. Staff supported patients to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 (MCA) and the Equality Act 2010. For example, staff assessed patients capacity to safely administer their own medicine whilst using the day hospice and when having discussions about their future and advanced care planning. Staff had a clear understanding of the Deprivation of Liberty Safeguards, and they worked with other organisations to support patients where there were concerns with a patient’s capacity. Staff received training in the MCA and were confident in its use.

The hospice used electronic records which included an assessment to ensure staff recorded all required information, including potential or actual safeguarding concerns. The electronic records were available to clinical staff and other key staff including GPs and therapy staff.

Safeguarding concerns were discussed during daily handovers and multidisciplinary meetings. We observed the team at Kemp Hospice work collaboratively to support patients to manage any safeguarding risks or concerns. Staff shared information and considered if they needed to take further action.

Staff worked with patients to understand and manage risks by thinking holistically so that the care met their needs in a way that was safe and supportive and enabled them to do the things that mattered to them.

Individual risks were assessed, and patients were appropriately involved in this. The provider had systems and processes to ensure risks were assessed and mitigated effectively. Staff described using electronic nationally recognised assessment tools to identify and manage clinical risks. For example, risk assessments included reviewing safeguarding concerns, skin integrity, mobility, nutrition, medicines and falls risks. Mobility risk assessments also included personal emergency evacuation plans. Records we viewed showed a consistent multi-disciplinary approach to risk management and care planning. Patients and their relatives described regular and open conversations about risks around their health. We saw evidence of this in patient care plans.

Risk assessments and care plans were regularly reviewed. All 6 records we reviewed demonstrated patients had risk assessments completed which had been regularly reviewed. Managers audited compliance with reviews which demonstrated from June to October 2025, on average 86.4% of patients had an up-to-date assessment and re-assessment. Where records were not up to date, the rationale was documented, this showed themes such as holidays and patient non-attendance.

Staff were always appropriately informed about or understood risks relating to their patients. Daily handover meetings took place before patients arrived. The multi-disciplinary team reviewed each patient, considered risks and documented actions to follow up specific risks. We observed a clinical staff handover which demonstrated a very good level of oversight of individual patient risks. The multi-disciplinary team contributed to discussions, and they agreed actions to reduce risks. For example, where a patient was at risk of falling, the occupational therapy team made contact to assess them and put preventative measures in place. Furthermore, staff agreed a plan for blood sugar monitoring for diabetic patients and liaising with other services where input was required around risks such as difficulties swallowing or incontinence.

There was a balanced and proportionate approach to risk in individual care and treatment that supported patients and respected the choices they made about their care. Patients told us staff supported them to be as independent as possible whilst using the facilities. Patients and staff jointly agreed what level of support was needed. For example, agreeing a patient might need additional support mobilising to ensure they were safe and independent. Patients were referred into groups such as the breathlessness group and exercise group to support them in managing symptoms and risks.

Staff knew how to recognise and respond to patients who may deteriorate whilst at the hospice. Records showed 100% of nursing staff had completed adult resuscitation training.

The facilities and premises were not designed to fully meet the needs of the range of patients who used the service. However, staff detected and controlled potential risks in the care environment.

The facilities and premises were not designed to fully meet the needs of the range of patients who used the service. For example, there was limited storage space to store equipment which meant it was sometimes stored in corridors or rooms. There was limited space for storing linen and consumable items such as dressings and rooms for activities were restricted with space. However, the triage room used to carry out regulated activities including health and risk assessments had suitable equipment, maintained privacy and dignity and was in line with expected standards. The leadership team had a good awareness of the restrictions of the building, recognised its limitations and had mitigations in place to reduce any risks. For example, they restricted the number of patients attending per day to 10 to ensure there were enough chairs and facilities to meet their needs. Furthermore, all patients had personal emergency evacuation plans in place which were regularly reviewed. Leaders were in the process of scoping a new premises.

The sluice did not meet expected standards. It did not have a separate clean and dirty utility or a macerator to safely dispose of bodily fluids and there was no dedicated hand-washing sink. However, there was a risk assessment in place with effective mitigations to reduce the risks. At the time of our site assessment, the sluice was not used as a dirty utility. Occasional urine bottles used by patients were emptied in patient toilets and disposed of in clinical waste bins within toilets. Hand sanitising gel was located in the sluice and hand wash basins in toilets. Charitable funds had been raised to refurbish the sluice planned for January 2026.

Staff completed health and safety risk assessments. They identified mitigating actions where risks were identified. Staff carried out actions in line with Health and Safety Executive (HSE) guidance. Assessments included fire safety and other environmental risk management practices.

A fire risk assessment had been undertaken in May 2025. An action plan was in place, and most actions had been completed. There were nominated fire wardens and instructions displayed explaining what to do in the event of an emergency or fire. The service had a fire safety check matrix in place to ensure checks of equipment and fire safety were fully implemented. We saw these were completed in line with the matrix. Fire exits were visible and free from obstruction.

The hospice had enough suitable equipment to help staff safely care for patients and staff knew how to report any concerns with specialist equipment. Staff had access to equipment to enable them to check patients’ observations including blood pressure, pulse, temperature and blood glucose levels. Equipment to support the safe transfer of patients with mobility issues were readily available such as hoists. Mobility aids were available to use in the hospice, and they had a stock to give to patients to use at home. An equipment maintenance programme was in place. Staff told us that equipment was generally readily available and there were no concerns with access. Staff told us managers consulted with staff before purchasing new equipment to ensure it was suitable for people who used the service. For example, the service needed to replace a faulty standing hoist. Staff had been involved in discussions with suppliers to ensure the equipment was adequate.

Single-use, sterile instruments and consumable items were stored appropriately, and we saw these were within their expiry dates.

Staff carried out daily safety checks of specialist equipment. They ensured that emergency equipment and essential equipment such as blood glucose monitoring equipment was in good condition and calibrated. Daily checks of the defibrillator were carried out.

There were emergency call bells in place within patient areas to summon help in the event of an emergency. Staff knew where these were and understood how to use them to seek urgent support. The emergency bells were checked daily.

Processes were in place to ensure electrical equipment had undergone safety checks. Equipment we checked had labels to demonstrate when it had last undergone a safety check and these were in date.

Staff disposed of clinical waste safely. We observed appropriate segregation of clinical and non-clinical waste. Sharps containers were clean, labelled and not overfilled.

There were sufficient and safe recruitment practices to make sure that all staff, including seconded staff from NHS trusts and volunteers, were suitably experienced, competent and able to carry out their role.

We checked 3 staff files, and all contained information and checks required to promote safe recruitment. Recruitment, disciplinary and capability processes were fair and were reviewed to ensure there was no disadvantage based on any specific protected characteristics under the Equality Act.

Twelve out of 15 staff had an in-date Disclosure and Barring Service checks (DBS) completed. We saw evidence that staff whose DBS was not in date, had an application in progress and had been submitted prior to the DBS expiring. Managers told us there were delays with DBS checks being returned. For example, a staff member had submitted an application on 29 September 2025 which had not yet been fully processed at the time of our onsite assessment. These staff members had risk assessments completed which provided assurance that staff were safe and suitable to continue working whilst waiting for the DBS to be completed. New staff recruited in the 12 months prior to our site visit had a DBS check completed prior to commencing employment.

The service had invested in an electronic staff management system which was planned to be implemented following our site assessment. Managers described this as enabling them to improve the recruitment process and have better oversight of ongoing staff management.

There were appropriate staffing levels and skill mix. Where staffing levels could not be met, leaders supported front line staff to develop short term adaptations to make sure people continued to receive consistently safe, good quality care that met their needs. The service had recently undertaken a minimum staffing review. A standard operating procedure had been developed which outlined the staffing levels and escalation processes when minimum levels could not be met.

The service operated Monday to Friday from 8.30am to 4.30pm. A minimum of 2 Registered Nurses (RN) were required, 1 needed to be a senior RN such as a clinical nurse specialist or the care service manager. One nursing assistant was required daily as well as the service manager or hospice leadership team. The service supported up to 10 patients daily in the hospice, apart from Thursdays which were mostly home visits or new assessments. This meant there were a minimum of 2 RNs to support a maximum of 10 patients.

The service had a vacancy for a healthcare assistant. The hospice used their own bank staff to provide cover. The bank staff were familiar with the service and were included in staff meetings and expected to complete mandatory training.

During our site assessment there were 3 RNs on site as well as a healthcare assistant and the wider care service team, including an occupational therapist. There were 2 managers on site and available. Staff considered the staffing levels to be safe, and patients fed back ‘there are plenty of staff’ to support them. All patients we spoke to described staff as responsive and able to meet their individual needs. Staff told us staffing levels rarely dropped below the minimum standards and where they did managers were always available to take on a more clinical role.

The hospice also had an occupational therapist, an exercise and well-being practitioner, complementary therapists, a creative artist and administration staff to support patient care.

At the beginning of each day, staff held a handover meeting where they discussed patient acuity and staffing levels. Managers and staff had oversight of all patients attending and their individual needs, to ensure the staff on duty had the skills required to manage each patient.

Staff received training appropriate and relevant to their role. Managers could easily check staff were up to date with required training. Staff at all levels had opportunities to learn and develop their practice. There was a comprehensive mandatory and statutory training programme in place. The service had achieved 98% compliance with mandatory training across all modules. The mandatory training modules reflected requirements under the Skills for Health Core Skills Training Framework (CSTF). All staff had completed statutory learning disability and autism level 1 training and 92% level 2. All relevant clinical staff had completed level 2 resuscitation training. Registered nurses had all completed specific training modules relevant to their role including verification of death and syringe driver training.

Staff received support to deliver safe care. However, the service did not have a process implemented for ongoing clinical supervision at the time of our site assessment. The staff had multiple opportunities to meet as a team to discuss patients and staff told us the management team were open and approachable. Furthermore, the service had sought a clinical supervisor who was starting to offer regular supervision from January 2026.

All staff working in the care services had undergone an appraisal in the 12 months prior to our site visit. Staff told us their development was prioritised by the service. Managers sought bespoke training to meet patients’ needs. For example, where a patient needed support with a Percutaneous Endoscopic Gastronomy (PEG) feed, training was sought externally to enable registered nurses to safely administer this. Staff also told us they regularly attended palliative care conferences and external training funded by the hospice. Specialist staff were encouraged to attend multi-disciplinary meetings with other specialists to support their development and extend their peer network.

Patients were protected as much as possible from the risk of infection because premises and equipment were kept appropriately clean and hygienic. The hospice was generally clean and had suitable furnishings which were easily cleanable and well-maintained.

Storage areas were clean and tidy. Equipment such as patient chairs, mobility aids and clinical equipment was visible clean and generally in good condition. Staff used labels to confirm when clinical equipment had last been cleaned and these were up to date. The service was undertaking a programme of replacing furniture to ensure it met infection control standards. At the time of our site assessment, most furniture such as patient armchairs had been replaced and were wipeable clean.

Stock was stored neatly so it could be checked and did not hamper cleaning.

The 2025 annual patient survey showed 91% of respondents considered the cleanliness and hygiene of the hospice to be good or excellent. Patients we spoke to in general considered the hospice to be clean and tidy. For example, 1 patient told us ‘It’s clean here, the staff use disinfectant to wipe everything down’.

All staff had completed infection, prevention and control training. Hand hygiene observation and cleanliness checks were undertaken twice yearly. Audits undertaken in April and November 2025 demonstrated all staff met required hand hygiene standards.

Personal Protective Equipment (PPE) was readily available to staff within the hospice and for staff to take out on home visits. There was easy access to PPE in clinical areas including the triage room and sluice, so staff had easy access to protective equipment required prior to entering the room. We observed staff using PPE and were bare below the elbow.

Handwashing sinks and hand sanitising gel was readily available. Information about effective handwashing was displayed at handwashing sinks. We observed staff washing their hands and using hand sanitiser between contact with patients. Staff carried hand sanitising gel, and we observed staff regularly using this. However, we observed a build-up of dirt on radiators in patient toilets. This was escalated to managers and immediate action was taken. Cleaning schedules and checking systems were in place to ensure all areas were cleaned.

There were systems and processes in place for assessing and managing the risk of infection. An Infection Prevention and Control (IPC) policy and hand hygiene policy was in place and had been recently reviewed. The policy was reflective of most up to date best practice and legislation. Staff knew how to access the policy, and all staff had received IPC training. There was an IPC lead nurse who had driven improvements in IPC practice.

IPC audits were undertaken routinely. There was a nurse who led on IPC and had implemented a programme of audits. Quarterly audits were undertaken which looked at cleanliness, the state of facilities and access to PPE and handwashing facilities. Audits undertaken showed the service IPC compliance standards overall had been met with 90% compliance in July 2025 and 92% in October 2025. Furthermore, managers undertook weekly audits and spot checks of the environment. Immediate action was taken if infection prevention and control procedures fell below expected standards.

KEMP Hospice did not prescribe medicines to patients or store medicines on site other than homely medicines such as paracetamol. Staff administered patients' own medicines who attended the day hospice where they needed assistance or lacked capacity to safely self-administer.

The approach to medicines reflected current legislation, relevant best practice and professional guidance. We reviewed the medicines management policy and oxygen policy, of which both had been recently reviewed. The policies were in line with the most up to date legislation and best practice. A programme of audits was in place to ensure compliance with the medicines management policies. This included stock takes of homely medicines stored on site, compliance with medicines administration charts and safe storage requirements.

There were clear roles and responsibilities that supported the safe optimisation of medicines. The service had a Controlled Drug (CD) accountable officer. Registered Nurses (RN) responsible for the administration of patients own medicines had all completed medicines management training. All staff understood their role in the management of medicines.

Patients were appropriately involved in decisions about their medicines. They were involved with assessments and reviews about the level of support they needed to manage their medicines safely and to make sure their preferences were included. All patients underwent an initial assessment by a RN which included a review of medicines and agreeing how patients would take medicines whilst attending the day hospice. Medicine discussions included management of their symptoms which included the effectiveness of pain relief and other side effects. Staff referred patients to holistic support such as complimentary therapy and breathlessness groups to support them with pain management. This was clearly documented in the assessment and care plans we reviewed. Furthermore, patients individual medicine needs were discussed at daily handover meetings for patients attending that day.

Medicines were appropriately recorded and administered in line with the relevant legislation, current national guidance or best available evidence, and in line with the Mental Capacity Act 2005. Registered nurses were responsible for recording and administering patients own medicines and home remedies such as paracetamol whilst patients attended the day hospice. Staff recorded patients' allergies on the electronic patient system. All RNs had completed medicines transcribing training. Transcribing training enabled qualified staff to transfer medicines patients were prescribed onto a Medicines Administration Record (MAR) chart and into a controlled drug book. We reviewed 3 MARs and found they were accurately transcribed, allergies were recorded, and administration of medicines were clearly and accurately documented for each patient.

Staff discussed patients' medicines during the daily handover and multi-disciplinary team meetings to ensure staff knew which patients had medicines on site and who needed assistance with administration. Discussions also included patients' capacity to make decisions about their medicines and was recorded.

Medicines were safely and securely stored. The service only stored homely medicines such as paracetamol. These were stored in a locked cupboard in a secure triage room only accessible by authorised clinical staff. We found the systems for medicines storage were well managed. Medicines were stored and managed neatly, safely and securely with access only to authorised staff.

The service had 5 oxygen cylinders and a concentrator which were labelled and safely and securely stored. An oxygen concentrator is a medical device that provides supplemental oxygen to patients who have difficulty breathing.

A medicines fridge was in place in the triage room to store patient medicines requiring refrigeration. The fridge was secure and daily temperature checks were undertaken.

All controlled drugs were securely stored. Controlled drugs brought into the day hospice by patients were handed over to RN staff and safely stored in a locked CD cabinet in a room which was authorised access only by keypad. CDs were recorded in a central CD book. This was located in the triage room on a shelf. At the time of our inspection the CD book was not in a locked drawer. However, managers provided assurance this had been moved to a locked drawer in line with the service policy following our request. All medicines were signed in and out and we saw were updated when administered.

Accurate, up-to-date information about people's medicines was available, particularly when they move between health and care settings, in line with current national guidance. The service had access to patient healthcare records. This meant they had access to the most up to date information regarding medicines. RNs were proactive in liaising with other services to ensure patients were reviewed where their pain management needs had changed. The KEMP Hospice clinical nurse specialist attended weekly palliative care MDT meetings where individual patients were discussed.

Staff completed an incident report if medicines were not given as prescribed. From April to October 2025, 3 medicines incidents were reported by staff. Incidents were reported monthly at clinical care meetings and team meetings. Managers shared learning from medicine errors with clinical staff. Changes were also made to improve practice. For example, the service introduced protected daily handovers to review all patients attending that day and included a discussion about medicine requirements. Staff involved were also expected to complete medicines competencies.