KEMP Hospice

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

We rated well-led as good. We assessed all 7 quality statements for well led: shared direction and culture, capable, compassionate and inclusive leaders, freedom to speak up, workforce equality, diversity and inclusion, governance, management and sustainability, partnerships, communities, and learning, improvement and innovation.

There was a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and wider communities to meet these.

Leaders had the skills and abilities to run the service. They were visible and approachable in the service for patients and staff.

The culture supported staff to speak up and report any issues or concerns to their managers. Staff and leaders acted with openness, honesty, and transparency.

Staff received training in inequality, diversity and inclusion. There were policies and processes to ensure the service was inclusive and fair.

There were effective structures, processes, and systems of accountability to support the delivery of good quality, sustainable services.

The service worked with partnership organisations and the local community to improve the care they provided.

Leaders supported focus on continuous learning, innovation and improvement across the organisation and the local system. Staff and leaders had an understanding of how to make improvement happen.

At our last inspection we rated this key question good. At this inspection, the rating remained as good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and wider communities to meet these. A 5-year strategy was in place from 2024 to 2029, developed through a structured planning process in collaboration with patients, staff, and external partners. The focus was on sustainability and people. Access to care and inclusion was a main priority as well as improving the building and facilities of the day hospice.

Staff and leaders described a positive, compassionate and listening culture that promoted trust and mutual respect. The culture was focused on learning and improvement, and staff consistently told us they felt respected, supported and valued. They were proud to work at the hospice and committed to meeting the needs of patients and families. Staff felt confident that feedback was acted upon and that managers took steps to address concerns. Workforce equality was actively promoted, and any causes of inequality were identified and addressed. A staff member told us ‘it is the best place I have ever worked because of the difference it makes to patients and families’.

Communication was recognised as an area for improvement in the last staff survey. Leaders responded by introducing a monthly newsletter to share updates, policies and celebrate achievements. Staff reported that communication from leaders and managers was now consistent and effective.

The service strategy was aligned to local plans in the wider health and social care economy and planned to meet the needs of the local population, improve care and patient wellbeing, tackle health inequalities and obtain best value for money. Managers and staff worked closely with local hospitals and hospices, commissioners and other healthcare partners to support patients.

Staff and leaders ensure any risks to delivering the strategy, including relevant local factors, are understood and have an action plan to address them. They monitor and review progress against delivery of the strategy and relevant local plans.

Leaders at all levels were inclusive, visible and approachable. They understood the context in which care was delivered and embodied the organisation’s vision and values. Leaders demonstrated integrity, openness and honesty, and had the skills, knowledge and credibility to lead effectively. They were alert to cultural issues that could affect care and acted promptly to address them.

Staff described a positive, compassionate and listening culture where they felt respected, supported and valued. Leaders promoted trust and mutual respect and focused on learning and improvement. Communication had improved since the last staff survey which showed only 23% of staff considered management kept them informed of changes. Furthermore only 31% considered important organisational updates were communicated in a timely way. Leaders implemented initiatives to improve this such as listening events and the introduction of a monthly newsletter to share updates and celebrate achievements. All staff we spoke to considered communication had greatly improved.

Leaders had completed external leadership and management courses funded by the hospice. Leaders were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. They were able to clearly articulate the priorities and how they intended to implement and address any barriers. They were alert to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff.

Managers and leaders had close working relationships. Trustees were hands on who took on lead roles, chairing sub-committees. This meant they had good oversight of hospice activity and could support service developments and innovation. There were succession plans in place and development opportunities for staff. For example, the service had recently created a development clinical nurse specialist role which was a progression opportunity for a registered nurse who was recruited into the post. Nursing staff had lead roles and were given opportunity to undertake training and development linked to that role.

Staff told us they felt supported, respected and valued by management. There was collaborative team-working with a common focus on improving the quality and sustainability of care for patients. The culture of the service centred on the needs and experience of the patients who used services. Staff were passionate about delivering high quality care and treatment for patients requiring it as well as their loved ones.

There was a culture of speaking up where staff actively raised concerns and those who did were supported, without fear of detriment. A whistleblowing policy was in place and a speaking up policy had been recently implemented. At the time of our site visit the service was actively seeking to recruit speak up champions and guardians. We observed this had been advertised within the day hospice. There was a clear emphasis on listening to staff and acting on what was heard. Managers encouraged staff to raise concerns and promoted the value of doing so. All staff were confident their voices were heard.

When concerns were raised, leaders investigated sensitively and confidentially, and lessons were shared and acted on. A complaints policy was in place and had been reviewed. The service had not received any complaints in the 6 months prior to our site visit. However, there were clear policies and procedures in place which outlined how concerns should be handled. There was oversight of concerns at all levels through subcommittees and to the board of trustees. All staff knew how to respond to a complaint. Feedback from complaints was shared with staff sensitively and any learning was shared with the wider team through team meetings, daily handovers and quality and safety sub-committee.

The service promoted equality, diversity and inclusivity. All faiths were welcomed and celebrated. There was a recognition that people’s cultural backgrounds and values differ from one person to the next and that different cultures and values needed to be respected.

KEMP Hospice was recognised locally as an 'inclusive Worcestershire leader'. This was awarded in recognition the service demonstrated inclusivity through the induction process for staff.

Training in equality and diversity was provided to all staff members and volunteers as part of their mandatory training. There were policies and processes in place to ensure the appointment and employment of staff was inclusive and fair. These included directions to ensure all staff were treated equally regardless of age, gender, ethnicity, sexuality and religious beliefs.

Staff told us they were supported personally and professionally. Staff described an open and supportive culture. They considered poor culture would be challenged. Managers ensured adjustments were in place to support staff to return to work who had been off for extended periods.

All staff had a monthly one to one meeting with their manager where they discussed staff well-being and needs. If staff had any additional needs, these were discussed during one-to-one meetings and actions put in place to support staff. Managers supported flexible working arrangements to enable work life balance and support equality and diversity needs.

There were clear and effective governance arrangements in place, with defined structures, processes and systems of accountability to support the delivery of safe, high-quality and sustainable care. Leaders demonstrated a strong understanding of their roles and responsibilities, and staff at all levels were clear about their accountabilities.

The governance framework ensured oversight of performance, safety and risk. Leaders monitored patient feedback, staff performance and compliance with best practice guidance through a programme of audits and reviews. These processes were embedded within the service and generally resulted in positive outcomes. Compliance checks were effective in identifying issues and ensuring timely resolution. However, whilst audits assessed whether care plans and assessments were completed, they did not consistently evaluate the quality of these interventions. Leaders recognised this and were implementing improved systems to measure outcomes and quality more effectively.

The service had a monthly activity dashboard where they monitored referrals received, assessments undertaken and activities patients were involved in. This gave managers an oversight of service activity.

There was a clear meeting structure that enabled senior leaders and managers to review operational issues, performance and audit findings. Governance meetings provided opportunities for shared learning and outcomes were reported to the board. Trustees had oversight of quality, safety and risk through established committees, including quality and safety, health and safety, and safeguarding committees.

Risk management processes were robust. Risks were identified and escalated through team and hospice meetings, then reviewed by board subcommittees and recorded on the hospice risk register. The register included risk descriptions, impact, ratings, mitigation actions and monitoring frequency. Leaders were able to articulate their most significant risks, such as building suitability, financial sustainability and workforce recruitment and retention. Plans were in place to address these risks, and progress was regularly reviewed.

Managers could account for the actions, and performance of staff. The implementation of the new digital patient and human resource record enabled managers to monitor staff compliance in terms of workload, training, and appraisals. Managers held regular one to one meetings with staff where they reviewed performance and well-being of staff.

Arrangements were in place to ensure the availability, integrity and confidentiality of data and records. Legal requirements for data submissions and notifications were understood and complied with. However, information was not always used effectively to monitor and improve equity of access to care. Leaders acknowledged this and were confident that new digital systems would strengthen data use for quality improvement.

Legal requirements about data submissions and notifications were understood. Staff and managers understood how to submit notifications to regulators, commissioners and the local authority.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders. For example, they worked with other services who also provided specialist palliative care to ensure patients received a seamless service. The service was involved in driving improvements locally alongside other services and commissioners to improve hospice care. For example, they participated in a pilot locally to trial the use of electronic Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms.

The service shared information and learning with partners and collaborated for improvement. Feedback we received from external stakeholders was positive. They told us the service encouraged joined up working through regular multi-disciplinary meetings which were held at the hospice. KEMP Hospice provided other services with rooms to deliver specialist clinics which enabled services to be responsive and accessible.

The community specialist palliative care team were based at KEMP Hospice which enabled staff to maintain strong partnership working. They worked well with other local services to build a skilled workforce through collaborating on training opportunities. For example, in providing bereavement training to staff locally.

Leaders, managers and staff strove for excellence through collaboration and shared practice. The service worked closely with universities to support student nurse and occupational therapy placements. Furthermore, the service offered medical student placements. Feedback from placements was very positive and the service was praised for the quality of support and mentoring provided by the service.

Staff and leaders ensured that people using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives.

Leaders supported focus on continuous learning, innovation and improvement across the organisation and the local system. Staff and leaders had an understanding of how to make improvement happen. The service had recently invested in technology to digitise patient records and organisational governance processes such as Human Resource (HR) systems. This enabled leaders to more effectively record patient outcomes to demonstrate improvements overtime.

Processes were in place to embed learning when things went wrong and also to implement good practice. Staff described a positive learning culture where they learnt from incidents that had occurred. Clinical staff attended regular meetings where they discussed what went wrong and how they can improve. Staff described being supported to reflect and learn where they made mistakes. Information from specific incidents were cascaded to all staff for learning purposes.

Leaders encouraged reflection and collective problem-solving. For example, staff were encouraged to share ideas to implement projects and also required clinical staff to complete reflections where incidents had occurred. We observed managers encouraged the whole team to contribute ideas to service developments.

Staff were supported to prioritise time to develop their skills around improvement and innovation. There was a clear strategy for how to develop these capabilities. Staff were consistently encouraged to contribute to improvement and innovation initiatives. Clinical staff had lead roles, and they were given time to learn and develop these roles. New staff were supported by more experienced staff who were given time to induct. Managers ensured the Clinical Nurse Specialist (CNS) was given time to engage with other CNS from other services locally to build their skills, knowledge and competence.

Staff attended local and national events for professionals working in palliative and end-of-life care including research activities and conferences.

Staff and leaders engaged with external work, including research, and embedded evidence-based best-practice in the organisation. For example, the service was in the process of evidencing the effectiveness of its breathlessness group and developing outcome measures to demonstrate this. The service had presented initial findings at a conference.

The service has strong external relationships that supported improvement and innovation. For example, the service took part in a local pilot to implement digital ReSPECT forms.