Douglas Macmillan 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

At our last assessment we rated this key question as Good. At this assessment the rating has changed to Outstanding.

This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 91 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed an exceptional standard. The service had a strong, proactive, and positive culture of safety, based on openness and complete honesty. The service actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Douglas Macmillan Hospice had a proactive, systematic approach to managing safety. Leaders embedded, maintained and sought to continuously improve a culture of openness and collaboration, and safety was everyone’s top priority. Staff recognised and reported incidents and near misses and reported them appropriately.

Managers investigated incidents and shared lessons learned with the whole team. Patient safety incidents were also shared with partnership agencies working in end-of-life care so learning could be shared as widely as possible.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. When things went wrong, staff apologised and gave patients honest information and suitable support.

We saw that when safety incidents occurred, they were reported and investigated appropriately. Staff told us they were made aware of actions taken to reduce further incidents through staff handover meetings, safety alerts, and changes to people’s care records.

All staff, including patients and volunteers were actively encouraged and rewarded for raising concerns about safety and to share ideas to improve services, the value of learning was continually demonstrated and reinforced by leaders.

When we spoke with staff and leaders, they told us that they carefully reviewed themes and trends of all incidents. Clinical incident trend analyses were undertaken to proactively address the themes and trends. This included pressure ulcers, safeguarding concerns and falls. The review highlighted most pressure ulcers were acquired before admission although the service proactively ensured pressure relieving mattresses were available on all inpatient beds and regular review of patients’ skin to avoid further deterioration. We saw reviews identified both good practice and areas where improvement was needed. Actions were identified for named staff to investigate and to share any relevant information with staff. Action logs were reviewed regularly; we saw that incidents were discussed in their quality meetings with progress monitored through the clinical quality management review meetings. The service reported 152 incidents in the reporting period of April 2025 to November 2025 and 2 moderate harms of which related to medication and falls, in between May and September 2025.

Staff told us they were aware of what to do if an incident happened and were able to give an example of an incident that had happened.

The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always managed and monitored. They made sure there was always a continuity of care, including when people moved between different services.

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. Staff worked with patients when moving between services, such as from an acute hospital to community care to the hospice; and ensured they and those close to them had all relevant information. Risk assessments were person-centred and were focused upon patients’ wishes. Patients told us that they had felt involved in their own care and the care of those close to them and were informed of transitions to different services.

The service worked closely with other services to support patient pathways and transitions. Staff were able to access dietician, speech, and language team, their inhouse well-being team, including mental health and psychologist support. We saw evidence of this during our inspection and observed staff speaking with other services to discuss support for patients.

Douglas Macmillan Hospice in 2024, took over the local dementia services, covering the local areas within Staffordshire and Stoke on Trent, and was the first point of contact to many providing support for those living with dementia.

Patient records were electronic and included areas to record such as care plans, risk assessments, Deprivation of Liberty Safeguards (DoLS) status, information around admission, ethnicity, hobbies, and interests. We also saw they contained information on communication support. GP, allergies, and medications.

The service worked closely with system colleagues including general practitioners to support safe systems of care for patients both within the unit and in the community. Managers held meetings with local NHS healthcare providers to ensure safe and effective transfers of care. The service asked for feedback from these providers to ask what was working well and what could be improved. Following this feedback, changes were made at the service to improve patient transitions from one service to another.

The service collaborated across the healthcare network to provide timely access to medication, equipment, access to community services and support to the patient and those close to them. Leaders told us they worked closely with Staffordshire and Stoke on Trent Integrated Care Board (ICB). Douglas Macmillan Hospice collaborated and contributed to the local palliative and end of life network to review and audit their care against the ambitions for end-of-life care national framework. This had led to enhanced standards of treatment and care at each step of the person’s care journey. This was a comprehensive approach to identify and manage shared risks, a joint processes for monitoring their effectiveness.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. We saw examples of the referral process and saw what information was provided. Continuity of care was a clear priority for the service; this was reflected across all services provided. During the assessment, we saw how the hospice worked collaboratively with others such as general practitioners and district nurses to ensure patients received appropriate and timely care. We also saw how allied health services such as occupational therapy, physiotherapy, and social workers a key priority of patients was care. The service worked in collaboration with health and care trusts to provide a 24-hour 7 day a week palliative care consultant on call list.

Staff were respectful when moving patients who had deceased. We observed staff come into a room to say they were closing the ward, closing doors and shutters whilst a deceased person was taken out of the unit.

The evidence showed an exceptional standard. The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. They always shared concerns quickly and appropriately.

There was a comprehensive safeguarding system, with clear roles and responsibilities, through which safeguarding risks were proactively identified, managed actioned. The hospice had a safeguarding adults and safeguarding children policy which was available for all staff. The policy included all types of abuse including domestic violence, female genital mutilation, and radicalisation. The safeguarding policy was reviewed yearly to ensure they remained up to date with current legislation.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate; 98% of clinical staff and staff who had face to face contact with patients and those close to them had completed level 3 safeguarding adults and children training. We saw the safeguarding leads had completed Level 4 training.

The hospice had 4 designated safeguarding leads who all worked in senior roles and were trained to level 4. We spoke to a safeguarding lead at the hospice who was able to share lots of safeguarding examples and how they had linked in with other external agencies. They also spoke to us about the action log and safeguarding committee meetings that took place. They had also been involved in local safeguarding panels.

Staff were aware of safeguarding and spoke about the hospice safeguarding officers, how they were easily accessible and how they had a good multi-disciplinary team meeting where they could discuss safeguarding if needed. They were also able to give an example of when they had needed to raise a safeguarding in relation to financial abuse and the outcome. The hospice electronic recording system had a safeguarding tab for the recording of any safeguarding concerns.

Staff received safeguarding supervision, either from safeguarding officers or the safeguarding leads. The safeguarding leads received clinical supervision from an outside agency.

Staff had a clear understanding of the Deprivation of Liberty Safeguards, which staff only used when in the best interest of the person. Staff received training in the Mental Capacity Act (MCA) and were confident in its use and sought innovative ways to ensure they respected patients’ human and legal rights.

There was a commitment to taking immediate action to keep patients safe from abuse and neglect. This included working with partners in a collaborative way. Staff were knowledgeable about safeguarding and gave us examples of actions taken when potential safeguarding concerns were identified. Information was displayed strategically on noticeboards throughout the hospice highlighting types of abuse and actions to safeguard vulnerable people.

The evidence showed an exceptional standard. The service always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive, and enabled people to do the things that mattered to them.

Douglas Macmillan Hospice consistently applied person centred care with a positive culture which supported patient choice around treatment. This created trust between patients, staff and those close to them, and protected the safety and wellbeing of all patients using services.

The service had a transparent and open culture which encouraged creative thinking in relation to patients’ individual safety. Patients were enabled to take positive risks to maximise their control over their care and treatment, we saw examples of this during our assessment. The service also actively encouraged patient, friends/family, and carers to get involved in managing their own risks. Patients and those close to them said they had regular and open conversations about risks around their health. We observed and saw evidence of this in patients’ care plans.

The service proactively sought out new and creative solutions and best practice to ensure that patients lived with as few restrictions as possible and provided evidence to support this and worked with partners to resolve this.

Staff showed empathy and had an enabling attitude that encouraged patients to challenge themselves, while recognising and respecting their lifestyle choices.

Staff told us that “Care is personalised, recognising each person's unique values, needs, and wishes. We provide holistic, personalised care planning tailored to each individual.”

The service ensured they provide and completed a comprehensive assessment of activities of daily living forms the foundation of their care planning. This included personalised care plans that address key patient concerns such as pain and nausea, ensuring they aligned with the overall care approach. Leaders told us that a use of an assessment tool was fundamental to ascertain risk and measures to support patients.

Person-centred care plans were developed for all patients, including the Future Care Plan (FCP) and the Last Days of Life Care Plan. Care planning was based on the patient’s values, preferences, and priorities, including their choices about who they wanted involved in their care.

Staff actively encouraged patients and their families to participate in care decisions, respecting advance wishes as well as cultural and spiritual needs.

The service was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

The inpatient unit had 28 beds with all rooms named after the potteries. Most rooms were ensuite and had access to the garden area. There were some double and triple rooms available. Inpatient units were split into 3 areas which were named blue, green or red.

There were various rooms available that patients and their families could utilise including a quiet room, kitchen, conservatory, therapy rooms, garden areas and a relative's room with tea and coffee making facilities a microwave and a fridge. There were also a vast selection of books, games, and entertainment available. Bedrooms, bathrooms and toilets had equipment so support patients with disabilities such as commodes, grab rails, and raised seats. There were specific toilets available for those with a disability.

There was a gym for patient use with a variety of machines. We spoke to one patient who gave positive feedback on how this had positively impacted on their wellbeing.

We spoke with one patient who showed us that they had been provided with new equipment to support their independence. There were also recliner chairs, bariatric equipment, specialist hospital beds, and mattresses in place.

The hospice had its own cold room. The cold room was accessible externally with a secure door lock. Arrangements were in place for ensuring the privacy and dignity of the deceased.

At the time of the inspection the hospice was in the process of installing closed circuit television in the cold room and ensuring staff were aware of this. The on-site estates team received reports on mortuary fridge temperatures and processes were in place if temperatures were ever deranged. However, this was not clearly documented in any hospice policy or communicated to staff to ensure all staff were aware of what to do in the situation the cold storage temperatures were not in range when the estates team were not in the building. We raised this with the leadership team at the time who recognised that this needed to be better communicated and included within a specific policy.

We looked at various pieces of equipment and noted that they had been serviced. The hospice had its own facilities team on site. Staff told us how the facilities department were very visible and that it was an effortless process to make a report to them and that they responded as quickly as possible.

Patients had call bells within their reach and told us that staff came as quickly as they could.

There was a thorough system to ensure safety, upkeep, and repairs for buildings and equipment. Managers ensured the facilities, premises, equipment, and technology were maintained. Managers supported staff use the equipment to consistently deliver safe and effective care. There was an estates department that oversaw the maintenance of the building and gardens. The estates department was responsible for the management of faulty equipment and oversaw service contracts. There were arrangements for medical device servicing and decontamination, and staff received relevant training.

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

Leaders and staff considered how environments can keep patients safe from psychological harm as well as physical harm, for example access to the premises and facilities to promote their mental wellbeing.

The evidence showed an exceptional standard. The service made sure there were always enough qualified, skilled, and experienced staff, who received thorough support, supervision, and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

The service had enough medical care staff to cover the service. We saw the service was running with 1.6 whole time equivalent (WTE) consultants in palliative care, 1.4 WTE Specialty palliative care doctor, 1.6 WTE advance nurse practitioner and 4.0 WTE trainee doctors. A rolling rota was in place for covering out of hours and weekend cover, all staff knew who was always on shift. Staff told us staffing levels was not an issue.

The service follows the Hospice UK Safe and Effective Staffing 2025 guidance; Douglas Macmillan Hospice had planned a quality improvement project to ensure their staffing assessments were based on the most robust evidence. This included consideration of key factors such as staffing formulas (ratios), skill mix, shift patterns, local operational factors, and patient acuity. Seniors told us that incidents occurring on the inpatient wards, incorporate a flag question to identify whether staffing may have contributed to the event, enabling the service to detect patterns and themes for improvement. Leaders told us, that to support 28 beds, the service required 58.45 full time equivalent (FTE), the service currently had 61.6. In the community the service was running with Head of Community Dementia Services 1.0 FTE. Community Manager 0.8, Team leaders /Palliative Care Nurse Specialist (PCNS) 2.8, PCNS/Paramedics 22.8, Senior Health Care Support Worker (SHCSW) 3.8, total of 31.2 FTE. Leaders told us this would go up and down depending on caseloads and demands.

To provide cover for the 24/7 adviceline and the 8am to Midnight rapid response service the hospice require 6.72 FTE. Currently running with PCNS 3.1 FTE, Paramedics 5.4FTE with 1 staff member on maternity leave -1.0 FTE.

The Hospice at Home team supported patients in the last two weeks of life 24/7. The service aspired to have enough resource to offer 2 early shift, 2 late shift and 2 nights shift, and the hospice offered these based on priority. The hospice at home service was delivered by SHCSW and day to day organisation was managed by a coordinator. To offer these prescribed shifts the service requires 10.75 FTE. Hospice at home coordinators 1.25 FTE, Paramedics 13.24 FTE. Total of 14.5.

Staff told us if they were short staffed, they had a pool of bank staff they could call upon. They also had a WhatsApp group where they could put messages on to cover shifts if needed. If they were short staffed, we were told how this would be escalated to the manager and on occasions this would be escalated to the community teams to see if they could provide support. Staff did not raise any concerns with us about staffing levels.

Staff had received and were up to date with all appropriate mandatory training. The training was appropriate for the patient group using the service, all training compliance were above 85% for all subjects.

The hospice had 2 practice development leads whose roles included overseeing student placements and allocating duty, liaising with universities and devising clinical skills and study days. The leads had put together staff induction packs that included useful information such as photos of the leadership team, maps, and information on Freedom to Speak up Guardians. They also had the hospice values, information on safeguarding and staff rewards.

The practice development lead told us how they were working towards an electronic competency system. One of the practice development leads told us how they completed resilience based clinical supervision. We also heard of a simulation arm for staff to practice with.

We looked at some examples of competencies completed by healthcare staff such as capillary blood glucose and vital signs monitoring. The practice development leads were cascade trainers for blood transfusions and had trained the hospice nurses. They had worked with a local hospital to do this.

The practice development leads had also arranged various clinical skills days for trained staff and for healthcare workers including topics such as palliative care emergencies, aseptic non touch techniques and stoma care. A prostate cancer day was being arranged for early 2026. They had also arranged any external speakers.

Doctors were involved in essentials in palliative care teaching sessions at the hospice. The practice development leads spoke of how these days were well attended by staff. We also heard how an actor had come into the hospice so staff could do role play in areas such as having difficult conversations.

New starters completed a 4-week induction period where they worked in a supernumerary role. We reviewed a sample of staff inductions and noted they included lots of relevant areas such as reviewing wound care documentation, completing mandatory training, syringe driver competencies and nursing duties.

There was a separate induction checklist for inpatient unit staff. This needed to be signed off by the manager or team leader and included areas such as phone calls, the mortuary, oxygen storage and infection prevention control.

The hospice had its own physiotherapist on site who also visited the community to complete access visits with the community occupational therapists. They also worked with patients in the onsite gymnasium. The physio told us how they held groups in the gym of up to 6 people.

Staff had yearly and half yearly appraisals, we saw 93% of appraisals were carried out on the in-patient unit and 80% community teams.

Staff told us how they felt they had a lot of development opportunities. They gave examples of how they had been put through the nurse associate role. One nurse told us how they had started as a volunteer and had progressed through to a nursing role. Staff described a culture of continuous learning, and they were provided with a lot of different opportunities to develop their knowledge and skills. For example, attendance at national conferences, formal and informal learning sessions, and through participation in research.

All staff had access to and completed statutory learning disability and autism training. Managers had introduced this before it was a legal requirement for all healthcare providers. Staff also had access to an accredited training module to support their understanding and competency when working with patients with learning disability and/ or autistic patients.

Leaders ensured that all staff participated in the ongoing palliative care training, covering many topics essential to their role, such as symptom management, communication skills, and end-of-life care protocols. The hospice also provided a rolling training sessions on the essentials of palliative care and developed individualised training and development plans with staff during their annual appraisals. Examples of supported education include non-medical prescribing qualification, Principles of physical assessment, Subscription to the National Association of Hospice at Home, Aspiring Leaders course, European Certificate in Palliative Care (ECEPC), Sensitive conversations, Responding to patient safety incidents, NVQ in Health and Social Care.

The evidence showed good standard. The service thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly.

The hospice had a team of 9 housekeepers who worked various hours. All areas we visited on the inpatient unit appeared clean and tidy and free of clutter. We saw staff completed cleaning records to show areas such as bathrooms had been cleaned. There were schedules and checking systems in place to ensure all areas were cleaned as indicated in the identified cleaning schedule. There were facilities to support good infection prevention control in the toilets, corridors and clinic rooms.

We noted that I am clean stickers were also used. Clinical waste bins were not overflowing, and all staff were following infection control measures such as being arms bare below the elbow. We saw personal protective equipment (PPE) was available and used by staff. Hand basins and gel were available on the inpatient units.

Quality indicators such as hand hygiene compliance were displayed on a notice board. We noted that hand hygiene compliance for November 2025 was 98.86%.

Staff had sufficient PPE equipment, such as gloves and aprons to carry out procedures and personal care activities. Handwashing sinks and hand sanitizer dispensers were accessible and were available throughout the hospice. Information about effective handwashing was displayed at handwashing sinks. We observed staff washing their hands and using hand sanitiser between contact with patients.

The storage areas were clean and tidy. Stock was stored neatly to ensure it could be checked and cleaned efficiently. There were clear arrangements to assess and control infection risk. A senior manager was the infection control lead for the hospice and had oversight of infection prevention and control.

Patients were protected as much as possible from the risk of infection because the hospice and equipment were kept clean and hygienic. The hospice was visibly clean and had suitable furnishings which were easily cleanable and well-maintained. The service reported 1 case of C.Diff, in 2025, all appropriate actions were taken.

All rooms were deep cleaned on regular basis, all scheduled and documented.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

We looked at 2 resus trolley and found it had a checklist which was to be completed on the 1 day of each month. Most of the contents were found to be in date except for 1 item which had recently expired. There was a defibrillator available which was up to date with its service.

We looked at various oxygen cylinders in the building and found these to be in date and fixed to the wall.

Medicines were stocked in a secured locked room and stored in a locked cupboard with access only via an electronic keypad, codes were changed often and only certain people had access. Syringe drivers were regularly checked, and we saw ample stock available.

Patients were involved with assessments and reviews about the level of support they needed to manage their own medicines safely. We observed community staff on patient homes visit and saw they worked collaboratively with other services to ensure patients’ pain and other symptoms such as nausea, tiredness and breathlessness were managed well and that patient knew who to contact if they required additional support around medicines management. Accurate, up-to-date information about patients’ medicines was available. When patients moved between health and care settings staff shared or requested information about patients’ medicines, in line with current national guidance. We observed this during our inspection.

Medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence. Staff maintained accurate and clear records of medicines given to patients and recorded when medicines were not given and the reason for this. Staff recorded patients’ allergies on their treatment charts.

There were appropriate policies, systems and processes in place to ensure safe and appropriate around prescribing medicines such as antibiotics along with self-medication policy for those patients able and wanting to manage own medicines. There were appropriate and safe arrangements for the management, use and oversight of controlled drugs. Controlled drugs are medicines which require additional arrangements for their storage and administration under the Misuse of Drugs legislation (and subsequent amendments). There was a controlled drugs accountable officer for the service to ensure safe management of controlled medicines. December 2025, latest control drugs inspection report showed that 92% of staff had completed the documentation correctly.

Medicines were supplied by a local pharmacy. Staff and the pharmacist ordered and checked the medicines received. There was a process for medicines charts to be reviewed and checked by the pharmacist who visited the hospice on regular basis. Nurses, the pharmacist and the accountable officer followed appropriate systems to regularly check controlled medicines.

Staff followed a process for the safe and appropriate disposal of controlled drugs and other medicines when they were no longer required. The controlled drug accountable officer presented an annual report to the clinical governance committee. The report outlined themes of incidents and any other concerns that had occurred in the previous 12 months, and action required to reduce incidents, including any additional learning required to be shared.

Staff completed an incident report if medicines were not given as prescribed. Medicines errors were reported at the monthly clinical forum. We attended the medicines optimisation meeting during our inspection and observed many topics on the agenda were discussed such as medicine errors, learning from medicine incidents, additional training requirements and any alerts or changes around medicine guidance or policy. The Hospice manager attended these meetings and had full oversight of the process. The service was currently re-writing their standard operation procedure and updating their policy.

When a member of staff was involved with a medication error, duty of candour was conducted which meant the patient and/or next of kin was informed of the error and an apology made.