Kirkwood 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. The rating has remained good.

The service delivered care that made people feel safe, supported, involved, and listened to. Safety events were thoroughly investigated and reported, with lessons learned to embed good practices. The environment and equipment were clean, tidy, and well-maintained. The service collaborated with people to maintain safe care systems, ensuring continuity when moving between services. The service had a mandatory training assurance framework that covered a range of modules that included learning disability and autism. Person-centred risk assessments were proportionate and regularly reviewed, prioritising individual needs and safety. Partner feedback was consistently positive about safety and continuity of care. The service provided care that followed best practice and national guidance and had processes in place to identify and manage risks.

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 service demonstrated a strong commitment to promoting a safe learning culture, with clear processes to support staff and continuous improvement. Staff consistently recognised and reported incidents and near misses appropriately, supported by a culture that encouraged raising concerns and safety events. Incidents and accidents were logged through an established electronic reporting system, which facilitated oversight, action tracking, and daily monitoring through built-in checks. This included daily clinical reviews and twice-weekly incident meetings identifying trends or issues. We saw evidence of leaders conducted thorough investigations, sharing lessons learned through transparent processes, such as team discussions and email updates. Staff told us, “We’re kept informed; reporting incidents is encouraged for our learning, management are very supportive.” Clinical governance minutes showed regular incident reviews and shared learning outcomes.

The service reported zero never events, severe harm incidents or serious incident investigations in the past two years. Staff demonstrated a clear understanding of the duty of candour, providing explanations to people when incidents occurred. In the last 12 months, two minimal harm cases triggered duty of candour processes, recorded within incident forms where formal duty of candour was not required. Most reported incidents related to patient falls, medication administration or documentation, and pressure ulcers (low or no harm), with evidence of appropriate investigation, action, and shared learning with improved outcomes for those using the service. Incident summaries were accessible via dashboards, and learning points were displayed on information boards in staff areas. Data provided showed there had been a 40% reduction rate in incidents from last year from 70 reported incidents (non-patient safety) to 43. Managers provided debriefing and support to staff following serious incidents. Kirkwood Hospice was actively working to update its Incident Policy to align with the Patient Safety Incident Response Framework (PSIRF) by 2026, demonstrating a commitment to continuous improvement in patient safety.

Staff demonstrated a clear understanding of the complaints policy and procedures for managing concerns. They exhibited strong awareness of incident reporting protocols. Learning from these incidents was shared across teams to improve practice.

To enhance safe care delivery, a Legacy Nurse with extensive clinical experience was appointed to mentor staff, strengthen clinical competencies and promote a culture of continuous learning and safe, high-quality care. Staff told us this had increased their confidence in dealing with complex cases and strengthened their clinical skills ensuring lasting benefits for those using the service. Staff also told us that with the support of the Legacy Nurse, they had increased their awareness of environmental risk. This included the importance of maintaining a clean and tidy bedspace to reduce the risk of falls and other incidents.

The service demonstrated robust and effective systems to ensure safe care pathways and transitions throughout care provisions. A clear and accessible referral process provided a single point of contact for people using the service, relatives, carers, and healthcare professionals to access advice and clinical assistance. From 2023, the service, supported by a centralised team of clinical staff, had facilitated a 79% increase in self-referrals, reflecting its effectiveness and accessibility. Feedback from healthcare professionals highlighted the streamlined referral process, integrated with peoples' existing electronic records, which enabled quicker and more responsive referrals. The service operated 24 hours a day 7 days a week, with people reporting high levels of satisfaction due to ease of accessibility.

Care was person-centred, coordinated around the individual needs to reduce unnecessary stress and promote unified, responsive, and holistic care delivery. Effective MDT working was evident, involving the Integrated Care Board (ICB), social care, community nursing teams, and the local hospital. Continuity of care was prioritised, particularly during transitions between services.

The service managed admission requests from Kirklees community, local hospitals, and out-of-area services. Community staff adhered to the Community Specialist Palliative Care Team Operational Policy, providing safe and effective care in the community.

The palliative care support hub provided advice and support to both professionals and members of the public. This hub streamlined access to care, often diverting people from acute services. All admissions were discussed with the MDT on the day of admission, with assessments tailored to people’s needs, involving relatives and other healthcare professionals as required.

Staff demonstrated strong collaboration with the medical team and people using the service, enabling early identification of deterioration. Staff told us, “We work really closely with the doctors and get to know our families well, so we can pick up signs of deterioration very quickly,” and added, “We look at evidence of deterioration from admission through to discharge.”

A review of six clinical records confirmed that assessments were accurate, with clear evidence of MDT working and up-to-date information on needs and preferences. Transfers of care were well-documented, with comprehensive discharge summaries that included anticipatory medicines and social care plans. Clinicians worked closely with the on-site social work team to support effective discharge planning.

The service had a comprehensive safeguarding policy which provided clear guidance for staff on identifying and reporting safeguarding concerns. Safeguarding training compliance rates were 98%, exceeding the provider target of 95%. Staff demonstrated a clear understanding of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act 2010. We heard examples of safeguarding incidences demonstrating staff were committed to taking immediate action and keeping people safe from abuse and neglect.

The safeguarding lead was well-known to staff, with contact information prominently displayed throughout the service. Following an independent safeguarding review, data confirmed Kirkwood Hospice was fully compliant with the overarching standard: “The organisation is fully committed to partnership working to safeguard children, families, and adults at risk.” Of the standards assessed, zero standards were rated Red, indicating no critical concerns. Kirkwood Hospice had appointed a Trustee with a dedicated safeguarding role and a designated PREVENT lead to further strengthen their safeguarding framework.

Additionally, the service presented a newly developed Safeguarding Strategy and Framework at the Safeguarding Adults Health Alliance meeting for Calderdale, Kirklees, and Wakefield, supporting a commitment to enhancing safeguarding practices.

The service effectively involved people in managing risks, evidence showed risk assessments were person-centred, proportionate, and regularly reviewed. Risks to peoples’ health and well-being, including mobility, skin care, and nutritional needs, were thoroughly assessed and managed in both the IPU and community settings. People reported feeling safe and listened to, with their concerns addressed promptly and managed effectively.

A review of care plans confirmed comprehensive risk assessments, including bedrails assessments, falls assessment templates, repositioning charts, and the PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) for skin integrity. These assessments were consistently completed and up to date, reflecting a systematic approach to risk management.

The ‘Pressure Ulcer Prevention Management Policy’ provided clear safeguarding and risk management guidance. Where abuse or neglect was identified as a potential factor, multi-agency safeguarding referrals could be made via the local authority (LA) and discussed at the Patient Safety Panel within clinical services. Staff we able to provide examples of when they would refer.

A risk management system recorded people’s risks which were discussed during daily handovers, patient safety meetings, and MDT reviews. Staff told us they had access to senior doctors and consultants when needed, supported by clear terms of reference and guidelines. Staff demonstrated a strong understanding of peoples’ needs and provided positive support for known risks, such as deteriorating health, medical emergencies, or changes in behaviour with a combination of clinical observation, structured assessment tools and holistic evaluation. This ensured timely interventions and personalised care planning.

We saw evidence to show the number of falls at the service was below the average for comparable hospices, as reported by Hospice UK data. Internally, senior management introduced innovative training methods, such as a Falls Quiz Night, which led to immediate improvements in clinical practice.

The therapy team and Admiral Nurse adopted focused occupational approaches to understand triggers for falls by analysing incident data. The falls team demonstrated professional curiosity and vigilance, promoting best practice across the hospice sector.

The service has introduced a Patient Safety Partner (PSP) role, integrating PSPs into the safety and quality governance framework. Work includes helping families raise potential concerns, developing information leaflets, participating SLT meetings.

The service demonstrated a proactive approach to ensuring there was a safe, well-maintained, and accessible environment designed to meet the needs of those using the service and their families. They demonstrated strong systems for ensuring safety, cleanliness, and equipment maintenance, with clear adherence to national guidance.

The main reception, staffed seven days a week, offered level access via automatic doors. Closed-circuit television (CCTV) monitored the entrance, and reception staff maintained a clear line of sight. A sign-in and sign-out register generated a label with the visitor’s photograph. Out of hours, the main doors were locked, and access was granted via a buzzer system alerting ward staff. A first aid kit was available at reception, with a trained first aider on site. An emergency grab bag was accessible on IPU.

The IPU was clean, tidy, and well-maintained, with all rooms offering single occupancy, ensuite bathrooms, hoist systems, air mattresses, and chairs. Rooms opened to private decking areas and an award-winning communal garden, accessible to all. The environment included three lounges, some with multifunctional use, convertible into residential rooms for larger families. Visitors could stay overnight and with no restrictions on visitor numbers. The service demonstrated a welcoming approach to the presence of animals, with appropriate risk assessments completed to ensure the safety and wellbeing of people using the service. During the inspection two dogs were observed in the IPU.

Personal Protective Equipment (PPE) and hand gels were readily available at the entrance and within the IPU. The environment was bright, spacious, and maintained to a high standard of cleanliness. Staff conducted daily cleaning checks and kept complete, dated, and signed cleaning records, which were reviewed during the inspection.

The service had sufficient, suitable equipment to safely care for people, including call bells in bedrooms. Monthly audits and daily checks showed environment and equipment remained safe and fit for purpose. Equipment maintenance was managed through an electronic central logging system and compliance stickers, indicating service dates and upcoming checks. The asset and inventory database included a service next due field and triggered monthly reports. All reviewed equipment was appropriately serviced.

Health, safety, and welfare risk assessments were conducted on every room, with action plans developed for identified concerns. Fire safety measures were robust, with signposted and serviced fire extinguishers, clear fire exits and corridors, and a fire evacuation plan. Fire evacuation drills were conducted, and fire wardens were clearly identified. The Kirkwood Fire Response Policy was up to date. The service participated in an exercise evaluating emergency response to extreme weather events causing structural damage, assessing decision-making, people management, and resource mobilisation.

The design of the IPU and communal areas aligned with national guidance, ensuring safety and accessibility for all. Staff, volunteers, and people using the service were encouraged to contribute their views and make suggestions regarding the layout and design of all areas. The service’s proactive approach alongside comprehensive systems, ensured equipment maintenance, safety checks, and emergency preparedness were supported to maintain a safe care environment and demonstrated a strong commitment to providing a safe, clean, and accessible setting.

Staffing allocation considered skill mix, staffing ratios, and complexity when assigning the named nurse and auxiliary for each shift. An appropriate acuity tool was used, providing a numerical guideline based on risk factors. Staff also completed a daily situation report (SITREP). Managers adjusted staffing based on peoples’ needs, utilising a flexible workforce by drawing on resources from other areas, including the SLT. Kirkwood Hospice has resident medical staff available from 0830 to 1700 Monday to Friday. Outside these hours, medical staff were available on a medical first on-call rota. Data showed no gaps in shift cover. Business continuity plans had been developed for individual services to address potential staff shortages, which managers could reference as needed.

At the time of the inspection there were no job vacancies within the service. A comprehensive recruitment process ensured competent staff were employed through background checks, professional registration verification where applicable, and confirmation that staff met role-specific competency requirements. Clear job descriptions outlined expectations and responsibilities. A working group of auxiliary staff was established to ensure new auxiliary job descriptions accurately reflected the role. Auxiliary staff reported feeling valued, respected, and listened to, with one telling us, "The senior staff appreciate and respect what we do, there is no hierarchy here, we all work together for our patients."

Staff received regular supervision and annual appraisals, with the option to request discussions with managers outside the formal review process if concerns arose. Nursing supervision was developed in line with a resilience-based model led by the matron. Opportunities for learning were available to all staff, and poor performance was managed appropriately. Compliance with annual Personal Development Reviews (PDRs) was monitored and reported to the SLT. Training was well-managed through an online learning management system, with a training matrix tailored to each staff role. Development plans included mandatory training, individual needs, and professional interests, supporting meaningful growth. A clear induction process for new staff included both corporate and clinical skills training.

Post-inspection data confirmed 99.1% essential training compliance across all staff. One staff member described the learning culture as highly positive, noting, “Senior management are visible and supportive; this is the most supportive unit I’ve worked in.”

During the inspection, a close working relationship between managers and staff was evident. Managers told us this enabled them to promptly identify and address poor performance while supporting staff improvement. Managers of community services maintained daily oversight of care provided by community staff.

There was a large group of volunteers who supported both clinical and non-clinical areas, as well as income generation. Volunteers underwent the same recruitment checks as substantive staff, including appropriate induction and mandatory training. Clear policies and procedures, managed by the volunteer manager and human resources (HR), governed volunteer recruitment. Volunteers were matched to roles based on their interests, aspirations, and skills. Volunteers told us they felt valued as part of the team and noted personal health and well-being benefits from their contributions.

The service maintained a consistently high standard in managing infection risks. Monthly infection control audits were conducted using a dedicated audit tool, results were reviewed, and action plans complied accordingly. Following an unannounced external audit by Kirklees and Wakefield Council, Kirkwood Hospice achieved a 99% score, earning a Certificate of Recognition for 2024/2025.

Patient areas, communal spaces, and public areas were clean and furnished with well-maintained items. Housekeeping staff were observed actively maintaining environmental cleanliness throughout the inspection, ensuring equipment and premises remained visibly clean. Face masks and hand gel were available at ward entrances and encouraged for those who chose to use them.

Consistent hand hygiene practices were observed among staff during the inspection. Staff adhered to the 'bare below the elbows' policy during care and treatment delivery. Disposable aprons and gloves were accessible and used by staff to minimise the risk of cross-infection.

Clinical waste audits were conducted as part of comprehensive audit reviews, and findings shared with staff. Evidence of food safety and hygiene audits was also reviewed, including compliance with personal hygiene practices among kitchen staff.

Staff cleaned equipment after patient contact and labelled it to indicate the last cleaning date, with evidence supporting this practice observed during the inspection.

Community teams, including volunteers at The Kirkwood shops, retail spaces supporting the hospice through fundraising and community engagement, assessed IPC risks in peoples’ homes when delivering items. We heard examples where staff had engaged sensitively with families and local agencies to manage these risks, ensuring safe practice while respecting peoples’ preferences.

Kirkwood Hospice conducted medication audits twice yearly, led by the accountable officer or senior lead alongside a relevant staff member. These audits were updated in 2025 to enhance ease of assessing and demonstrating compliance with medication policies and procedures. External pharmacist inspections were also undertaken, supplemented by self-assessments against a recognised tool, which achieved 100% compliance this year.

People received clear information about their medicines. Staff ensured understanding by providing explanations when needed, we observed evidence of this during the inspection.

Standardised drug charts were used, incorporating risks, consent, infusions, immediate-dose emergency medication prescribing, and aligning with good practice. A service-level agreement with the local hospital ensured a reliable and timely supply of medicines with no reported issues. A pharmacy technician was onsite, and auxiliary staff received additional training to perform medication checking and stocking tasks, overseen by the unit manager. Auxiliary staff valued this training and told us it supported their learning, development, confidence, and career progression opportunities.

Medicines were stored securely in a locked central medicines room with access restricted to appropriate staff. Kirkwood Hospice had a designated Controlled Drug Accountable Officer (CDAO), correctly registered, with evidence of quarterly reporting to the Controlled Drug Local Intelligence Network (CDLIN). An adequate supply of syringe drivers was available for people requiring them, supported by comprehensive policies, records, and checks.

A full medicines policy, specific to the service, was in place, covering medicines-related elements, including prescribed drugs, supplements, gases, and those provided by alternative practitioners or obtained from other sources. A medicines management group met monthly.

Staff followed established systems and processes to prescribe and administer medicines safely. Post-inspection data confirmed all staff completed mandatory medicines management training relevant to their roles. People reported no issues with medicine-related support.

The primary reported medication incidents involved individual staff errors, such as missed or late administration, unsigned medication charts, or documentation errors. Management maintained effective oversight of these incidents, mitigating risks through investigations, shared learning, and staff feedback. The introduction of CCTV in the medication room supported staff in reviewing and reflecting on medication errors. This approach has been positively received and enabled the team to consider environmental factors such as distractions, to identify learning points. Daily checks on controlled drugs and routine medicine stocks ensured accurate reconciliation. All medicines and prescribing documents were stored and managed safely, with observed adherence to controlled drug management and recording procedures. Fridge temperatures were monitored and recorded daily.