Douglas Macmillan 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

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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This meant service leadership was exceptional and distinctive. Leaders and the service culture they created drove and improved high-quality, person-centred care.

This service scored 96 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

There was a positive and inclusive culture at the service. Staff were made aware of the service’s values and philosophy through their induction and training. One staff member said, “Our values and strategy are our bread and butter, they ensure we work with these values close to heart, with patients at the core of what we do each day”. All staff we spoke with knew their values word by word and all staff were extremely passionate about Douglas Macmillan Hospice.

There was a clear management structure at the service. Staff we spoke with were aware of the roles of the management team and told us that the managers were approachable and had a regular presence within the service. All the managers we spoke with demonstrated they had an excellent understanding of the care provided, that showed they had a regular contact with the staff and the people who used the service. Senior staff acted as a role model to ensure the staff knew what excellence care looked like and promoted their values in all aspects of work with staff and within the community groups.

We saw leaders celebrated staff success; notice boards displayed employees of the month nominees as well as which staff member had achieved this title.

Staff and people who used the service were empowered to share any concerns about the care at the service. All the staff we spoke with were aware of their role in reporting any concerns and they told us they would report concerns in accordance with the service’s whistleblowing policy.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. 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, commissioners and other healthcare partners to support patients.

Volunteers, local organisations, and community support networks were integrated into Douglas Macmillan Hospice care approach, providing companionship, practical help, fundraising support, and emotional encouragement for patients and families during difficult times. Leaders told us that community generosity was essential in sustaining care, with the hospice relying on local donations and volunteer involvement to deliver services free of charge.

The evidence showed an exceptional standard. The service had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Staff felt leaders were visible and approachable across the organisation, they felt well supported by them and told us they knew their door was always open. They also spoke of good staff morale; told us they felt well informed and received regular newsletters and emails with updates. One staff member gave an example of how during a difficult period they were provided with reassurance by leaders.

Leaders arranged welcome events for new starters where they could learn all about the hospice and meet all the staff. Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care; They were visible in the service and approachable for patients and staff.

Staff said they felt supported respected and valued. Staff said they were proud to work for the service and the high-quality care they provided. Several staff said it was a privilege to work for the service and provide support to patients and those close to them. There was strong collaboration, team-working and support and a common focus on improving the quality and sustainability of care and patients’ experiences. 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 those close to them.

Staff attended multidisciplinary meetings with GP’s and district nurses to discuss the end-of-life care needs of people in the local area. These meetings were based upon the Gold Standards Framework (GSF) a national organisation that aims to enable a ‘gold standard’ of care for all people nearing the end of life. Staff told us these meetings were an opportunity to discuss people’s health needs but also to educate and promote their services to other health professionals.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard

The hospice had Freedom to Speak Up Guardians in place (FTSU). We spoke to the pastoral lead who was also a FTSU Guardian, they told us there was no specific themes and trends at the time of the inspection. FTSU guardians recorded any concerns on the hospice system, and these were reported back to the National Guardians office. However, not all staff we spoke with were clear who the Guardians were.

Openness and honesty were encouraged at all levels within the organisation, leaders and staff understood the importance of being able to raise concerns without fear of retribution. There was a culture of speaking up. Leaders supported staff to raise concerns.

When patients raised concerns, leaders investigated sensitively and confidentially and took appropriate action on any findings, we were given numerous examples during our inspection. When something went wrong, people received a sincere and timely apology, and leaders and managers told them about any actions being taken to prevent the same happening again. Staff told us leaders would meet with patients and relatives to provide feedback from concerns/complaints.

The evidence showed an exceptional standard. The service strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them.

The service promoted equality, diversity and inclusivity. All faiths were welcomed and celebrated. There was a recognition that staff’s cultural backgrounds and values differed and were respected to provide a diverse and inclusive workforce.

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 were able to apply to work flexibly. Flexible working agreements with Douglas Macmillan Hospice took account for personal circumstances such as caring responsibilities and health issues. Some staff we spoke with told us when they required flexibility due to personal changes, Douglas Macmillan Hospice supported them to manage home and work life whilst they were going through some personal challenges. Managers were able to provide reasonable adjustments for staff members to help them carry out their role.

The service had successfully completed training for those senior leaders who wanted a different role within the hospice. Some staff told us they had been successful in the training and opportunity to become a professional nurse advocate, providing a service for staff around restorative clinical supervision, this role commences in February 2026.

The evidence showed an exceptional standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Leaders shared updates and learning with staff through a range of communications. Policies and procedures reflected this, and leaders benchmarked the hospice’s performance against other services to measure outcomes of care and treatment.

We saw that systems were in place to monitor the quality of the care. The governance system monitored the quality of care provided, patient feedback, staff performance and changes to best practice guidance. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. Leaders undertook a range of reviews and audits to monitor performance. Leaders and managers discussed the results of audits at governance meetings, which they also shared with the board and appropriate staff for learning.

Leaders took a proportionate approach to managing risk that allowed them to assess new and innovative ideas. The service used effective governance processes to monitor risks and outcomes, and to drive improvement. The risk register for the hospice set out key risks as well as actions, mitigations, and environments, workforce and financial strategies. Key reports kept leaders informed of challenges faced with short, medium and long-term plans identified. All risks were rated as Red, Amber, Green (RAG) with individual staff members allocated to each action associated with risk.

The hospice Clinical Governance Committee was a sub-committee of the board, which met quarterly. The committee received quality reports, which enabled the group to review the quality of care provided by all the clinical services at Douglass Macmillan. The rolling agenda were underpinned by their 7 pillars such as patient experience, clinical effectiveness, patient safety, governance and leadership, information management, education/training and performance and monitoring of clinical governance. This ensured that all aspects of the clinical governance were reviewed, assurances were discussed with continual improvement.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Information was in an accessible format, and was timely, accurate and identified areas for improvement. The strategy included providing a quality service whilst ensuring sustainability of hospice against increasing costs, minimal NHS funding and being reliance on charitable donations and fundraising. As part of the strategy, leaders had reviewed services the hospice provided, and services provided by other services. The new strategy aimed to support high quality end of life care whilst avoiding duplication.

The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

Douglas Macmillan Hospice and staff were committed to provide high quality care that was based on best practice. The service offered regular training opportunities to the staff and external health and social care professionals and worked closely with local universities. This collaborative working ensured the provider could strive for excellence by using the skills of other trained professionals. The focus of the training was to improve care at the service, but also to improve end of life care that was provided by other local services.

The hospice accommodated student work experience placements. There was a practice development team in place to support these. The hospice had won a local university practice placement of the year award in 2025. We were told the hospice had approximately 12 student nurses in 2025.

Staff worked in partnership with other agencies to participate in project work and research with the aim of improving the quality of care. The service continually reviewed the needs of the local population and implemented changes in care provision to meet the population’s changing needs.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders. The hospice worked in partnership with others to build seamless experiences for patients based on good practice and their informed preferences. The hospice had a focus on delivering care in a way that supported patients’ care pathways.

Managers planned and organised services, so they met the changing needs of the local population. The organisation provided holistic care, and its services reflected the needs of the population it served. They had achieved this through community engagement; patient experience feedback and individualised care planning. Induction and mandatory training taught staff how to engage patients in conversations about characteristics and to consult closely with other key professional teams e.g. social services and community health care to ensure patients accessed the right help and support at the right time.

The service maintained an open channel of communication with community partners, ensuring their services remain inclusive, culturally sensitive, and responsive to local needs. This included a strategic collaboration with local health services, support groups, and charities to connect people with additional resources and support.

Douglas Macmillan Hospice was a core participant of an “All age clinical and Professional Group” within the ICB. Senior leaders told us that ICB have identified key themes form national ambitions framework as their main objectives for the hospice to focus on.

Douglas Macmillan Hospice was involved in many streaming groups such as but not limited to, electronic system pilot site, launch date was aimed for January and February 2026, that supported a coordinated, person-centred end-of-life care by providing a single, shared digital record that captured key clinical information, patient preferences, and anticipatory care plans. Compassionate communities steering group, dementia steering group, this was a local authority steering group with providers of dementia services within North Staffordshire and Stoke on Trent. The hospice has been integral in developing the local authority dementia strategy for Stoke on Trent which has embedded a key recommendation for all GPs to refer directly to the Douglas Macmillan Hospice for patients diagnosed with dementia and their carer’s.

The service participated in the palliative crisis avoidance, response and management work, working with other local hospices, this was a hospice-led service delivering consultant-led, multidisciplinary care in people's homes across Staffordshire Stoke-on-Trent, enabling patients to remain where they wish whilst reducing hospital admissions. The latest figures provided by the service showed there was 1,100 patients on community caseload, 46 unnecessary admissions were avoided monthly, 85% achieved preferred place of death with 1,104 hospital bed-days saved annually.

The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The practice development team had devised a healthcare abbreviations booklet as a guide to abbreviations used within palliative healthcare for new starters/students. It also contained some other relevant information such as medications used for different conditions and pictures of different stool types.

Leaders told us how they encouraged the upskilling of staff by seeing who was interested in being involved in completing audits, this had also included healthcare assistants.

Role specific competency-based assessments and observations were completed to ensure staff provided care and support effectively. We saw that when quality issues were identified, immediate action was taken to address them by meeting with the staff member to set learning goals. This showed the provider provided staff with opportunities to reflect on their practice to facilitate improvement and strive for excellence.

The service continued to engage with local and national forums, such as “Find Me Help”, and “Dying Matters” and many others.