Kirkwood 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question good. At this inspection, the rating has remained good, with evidence demonstrating leaders and the culture they established improved high-quality person-centred care.

Leaders contributed positively to experiences and high-quality care for those using the service through clear vision and values. They possessed the skills, knowledge, and credibility to implement this vision while managing risks effectively.

Leaders were highly visible, creating a supportive culture where staff felt respected and valued. An open, inclusive environment encouraged feedback and honesty, with regular team meetings and debriefs, facilitating shared learning from incidents to drive continuous improvement. A comprehensive quality assurance framework ensured policy compliance, with regular audits identifying areas for development to maintain high care standards. Leadership prioritised sustainability through robust continuity plans and initiatives.

This service scored 86 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Kirkwood Hospice exhibited strong leadership, a clear strategic vision, and an inclusive culture prioritising care, staff engagement and transparent communication. Staff told us they felt heard and actively shaped the service’s direction.

A robust management structure outlined clear responsibility and accountability. There was an established SLT and an experienced board of trustees. Senior managers effectively oversaw patient safety, governance, and performance through daily involvement and quality monitoring. Leaders were described approachable, with out-of-hours support available. Governance structures managed risks and ensured clinical effectiveness.

The service’s vision, outlined in ‘The Kirkwood Movement’ strategy (2025), aimed for “a world where no one faces a life-limiting illness alone.” Developed with input from staff, people using the service, stakeholders, and health guidance, it was reviewed annually and embedded in induction packs, shared publicly, and with local organisations. The 2025-2030 goals focused on expanding influence, delivering support, and building resilience, informed by national statistics, local needs, health inequities, feedback, and staff via forums, surveys, and focus groups.

Employees described a supportive, cohesive team environment and expressed pride in their work, calling Kirkwood Hospice an amazing workplace.

Staff shaped the vision and strategy through engagement initiatives such as meetings, surveys, and focus groups. One senior leader highlighted, “Being supported by your local community is very special.” Collaboration with local organisations ensured the vision was actionable.

The service demonstrated compassionate, inclusive, and effective leadership across all levels, with leaders possessing the experience, capacity, and capability to deliver excellent and sustainable care. A robust management structure was maintained with clear lines of responsibility and accountability. The Chief Executive Officer (CEO) reported to a board of Trustees and was supported by a Director of Clinical Services, Medical Director, Director of Finance, and Director of Fundraising and Marketing. Senior managers possessed the skills and expertise to manage services effectively, with strong oversight of patient safety, governance, and performance through daily involvement and quality monitoring. A system of leadership development and succession planning ensured a diverse and skilled leadership team, reflecting the workforce’s diversity and addressing the service’s challenges and priorities.

All leaders we spoke to were highly experienced and able to clearly articulate the service’s priorities and challenges. Senior leaders and team managers actively participated in day-to-day care when needed, demonstrating direct engagement with the challenges faced by staff. The CEO and SLT intentionally joined MDT during work hours to enhance visibility and accessibility, adding to an open and approachable culture.

Staff were supported to progress within the organisation, with examples including a volunteer advancing to a clinical lead role and auxiliary staff being supported to pursue nurse training. One staff member shared that, after exploring options for social work training, the SLT enabled them to remain in post while completing the training, demonstrating equitable support for career progression across health and social care roles.

Staff recruitment adhered to fit and proper person requirements, as evidenced by our review of staff files.

Leaders held regular team meetings and one-to-one sessions to maintain open communication. A monthly staff forum, led by the CEO, provided updates, shared key messages, and invited questions, with a follow-up CEO brief distributed to those unable to attend. Senior leaders encouraged “check and challenge” discussions, promoting a culture of constructive feedback. Staff described communication systems and teamwork as effective, saying, “Everyone works well together, it’s one of the few places where you can ask any question to anyone.”

Leaders demonstrated an understanding of local and broader challenges in palliative care, proactively adapting to meet changing needs and ensuring the sustainability of high-quality care. For example, they introduced flexible staffing models and community outreach initiatives in response to increased demand for home-based end of life care, ensuring people continued to receive the personalised support aligned to their preferences.

Kirkwood Hospice maintained an open culture that encouraged staff to raise concerns without fear of reprisal, supported by clear policies and accessible leadership.

The service had an appointed Freedom to Speak Up Guardian, known to staff, who was available to support those wishing to raise concerns. Staff were aware of the guardian’s role and felt confident in raising issues. The Freedom to Speak Up policy, accessible to all staff, clearly outlined the process for speaking up and what to expect, ensuring transparency and support.

Staff reported that formal Freedom to Speak Up processes were rarely used, as managers were approachable and accessible, enabling concerns to be addressed informally.

An open feedback culture was promoted through a comprehensive staff survey, which identified themes, addressed concerns, and implemented actions to drive improvement. Completion rates for the survey exceeded 90%. Following concerns raised, leaders conducted a policy review, resulting in clearer processes for staff and volunteers to follow, further strengthening the framework.

No concerns were raised to the Care Quality Commission in the last 12 months.

The service promoted an inclusive and fair culture, valuing diversity and ensuring staff felt heard, supported, and respected across all roles. The service’s commitment to equality and inclusion was evident in its policies, support mechanisms, efforts to promote staff wellbeing and celebrate achievements.

Kirkwood Hospice maintained dignity at work procedures and had an equal opportunities protocol to uphold principles of equality and prevent unlawful discrimination in recruitment, selection, promotion, transfer, training, pay, benefits, discipline, redundancy, and dismissal. Reasonable adjustments were made to accommodate and support staff, ensuring accessibility in their roles.

The service scored above the national average for peer support among colleagues, reflecting strong team cohesion.

The service recognised the varied emotional impacts of its work and demonstrated a positive culture around mental wellbeing. The SLT collaborated with a local mental health charity to review workplace mental wellbeing and implement appropriate support measures. Staff trained as mental health first aiders, along with offerings such as complementary therapies, sleep hygiene workshops, and open access to a reflection room, further supported wellbeing. Volunteers reported receiving the same level of support.

Kirkwood Hospice celebrated staff and volunteer successes. An example was Team Serenity’s nomination and win of the Fundraiser Award at the BBC Leeds Make a Difference Awards in September 2024, highlighting the recognition of contributions at all levels.

Kirkwood Hospice integrated the Kirklees Care Charter, based on the Ambitions for Palliative and End of Life Care: A national framework for local action 2021-2026, into its operations. Through its ‘Our Culture, Our Care’ approach, the service adopted ‘we statements’ to set clear standards of care and principles for the workforce, embedding these values across teams to ensure consistent, inclusive, and high-quality care delivery.

Kirkwood Hospice demonstrated effective governance, strong management, and a commitment to sustainability, underpinned by collaboration, continuous improvement, and proactive planning.

A clear organisational structure featured a board of trustees providing strategic direction through monthly meetings, reviewing executive reports, regularly reviewed risk registers, and finances. The registered manager used feedback, alongside best practice to drive improvements benefiting both staff and those using the service. Leaders empowered staff to propose and implement enhancements, promoting collaborative efforts to meet needs effectively.

Regular clinical lead meetings ensured data sharing with the executive board and trustees, maintaining robust oversight of performance and safety. A clinical governance subcommittee reviewed audit reports, performance data, case studies, and incidents including medicine errors, falls, and safeguarding issues, while monitoring national guidance and satisfaction surveys to drive improvement. Policy approval involved a quality control group and board sign-off, with accessible online and hard-copy versions for staff. Evidence of these meetings was provided to the inspection team.

A comprehensive risk policy and register addressed staffing shortages, financial stability, and emerging risks, reviewed regularly for proactive planning. An effective incident reporting system tracked local and national incidents, identifying trends and setting quality improvement priorities. The management team promptly reported accidents and incidents to authorities, including the CQC, ensuring transparency.

Audits, including monthly fitness-to-practice checks, quarterly employee file reviews, and quality improvement projects, enhanced communication, and reduced hospital admissions. Staff received annual information governance training and stayed updated with current guidance. Leaders encouraged continuous learning through conferences, workshops, and local partnerships to share best practices.

Sustainability was prioritised through five-year plans aligned with The Kirkwood’s vision. Comprehensive business continuity plans, and clear protocols prepared the service for emergencies, with regular reviews. Quality improvement measures enhanced information flow between the ward and board, supporting effective decision-making.

Kirkwood Hospice showed a strong commitment to engaging with people and the wider community through diverse and inclusive methods. These efforts ensured continuous service improvement, raised awareness of palliative care, increased collaboration within local and regional healthcare systems.

The service proactively engaged through informal interactions, patient surveys, feedback forms, and community events. Feedback was systematically reviewed to identify themes and trends, driving service improvements where needed. The overwhelmingly positive feedback reviewed highlighted the effectiveness of these engagement efforts. Regular public engagement events, attended by community members and local representatives, further promoted the services available and strengthened community ties.

Kirkwood Hospice developed the innovative Support Life Champions programme, designed to raise awareness and improve access to palliative care across Kirklees. The programme included a bespoke learning session to educate participants about the services, supported illnesses, referral processes, and funding. A comprehensive ‘toolkit’ with supporting materials, frequently asked questions, and video blogs was created to enhance Champions’ knowledge and confidence. Initially tested with employees from a local business, the session received positive feedback, with 100% of attendees reporting confidence in applying their knowledge in and out of the workplace. To date, 13 ‘Introduction to The Kirkwood’ sessions have been held, onboarding 196 Support Life Champions from 17 local businesses and health and social care partners. The programme has successfully increased community awareness, with Champions sharing information, dispelling misconceptions, and tackling barriers to accessing care.

Kirkwood Hospice actively participated in and led system-wide initiatives to enhance palliative and end-of-life care. As part of the West Yorkshire Clinical Network and ICB Strategic Hospice Forum, they contributed to delivering sustainable care across the region. They also collaborated with other organisations to engage ethnic minority communities, aligning with its strategic plan to “become more diverse in every aspect of who we are and what we do.”

Through initiatives like the Support Life Champions programme, active participation in regional healthcare networks, and inclusive engagement strategies, the hospice enhanced awareness, reduced barriers to care, and ensured continuous improvement in service delivery and culture.

The service was widely recognised as an expert in palliative care, delivering excellent care and support to people. The service’s commitment to improving people’s experiences of palliative care extended beyond its own services, as it provided additional training to care home staff, district nurses, local council, and students.

Interfaith initiatives promoted inclusivity, including hosting Muslim women from a local library community group to learn about services for life-limiting illnesses. This was part of the Community Champions project, enhancing engagement in the community.

As part of their ongoing plan, Kirkwood Hospice has focused on increasing visibility and accessibility in 3 geographical areas through targeted initiatives. By establishing focus groups and promoting integrated and collaborative working, ensuring its services were responsive to local needs and accessible to diverse communities forming stronger connections and enhancing the delivery of person-centred care.

Kirkwood Hospice demonstrated considerable contribution to end of life care in West Yorkshire by strengthening the capabilities of external organisations and healthcare providers. With increased accessibility through Kirkwood Shops and collaborations with local organisations, the service ensured high-quality, inclusive, and sustainable care that met the diverse needs of its communities.

Kirkwood Hospice showed a strong commitment to learning, improvement, and innovation through sustainable care models, effective governance, and collaborative partnerships. Continuous learning and data-driven decision-making drove enhancements in peoples’ care and palliative care practices.

A detailed falls review improved risk assessment practices, with findings shared at Hospice UK conferences and through engaging staff activities like a falls quiz night. The ‘Talking About Dying’ project, led by Kirkwood Hospice and funded by the West Yorkshire Integrated Care Board (ICB), empowered people with learning disabilities to shape their end-of-life care, promoting inclusivity.

Quality Improvement (QI) projects enhanced care and efficiency. The ‘Mattress Passport’ project, involving the Practice Development Lead, Auxiliary Nurses, and the Asset Facilities Team, collaborated with the local NHS hospital to establish best practices. Mattress Champions delivered training, and the Mattress Passport centralised documentation, including photographs, serial numbers, and cleaning records, improved audits, and safety. QI outcomes and audits were shared via posters, ensuring organisation-wide learning.

The clinical educator collaborated with universities to ensure evidence-based training and resources, creating opportunities for deeper learning. Governance structures supported improvements, with delegated management roles empowering staff to propose solutions. We saw evidence of nurses’ enhancing their clinical knowledge through upskilling, and a transformation programme established an onsite hub team to streamline referrals and visits, improving operational efficiency.

The OT and counselling teams undertook work to understand patterns of falls to ensure people could be best supported in managing risk and implemented strategies to support this, with initiatives shared at the Hospice UK Conference in 2024. These strategies have influenced national trends, prompting other hospices to adopt similar data collection and investigation practices. We were told of other organisations approaching Kirkwood Hospice for advice on auditing and analysing to improve care and outcomes.

We saw evidence of leaders engaging in conferences, workshops, and local partnerships to drive continuous improvement, ensuring high-quality, innovative care.