Hospice in the Weald

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

This meant, 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.

At our last assessment, we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We assessed all quality statements in this key question.

We found a breach of regulations in relation to good governance, not all policies were routinely reviewed or kept up to date. There were insufficient systems to ensure staff were informed of changes and supported to implement updated guidance.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. People with protected characteristics felt supported. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas. However, the service did not have all elements of its governance framework operating consistently.

This service scored 71 (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 a good standard. The service had 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 their communities.

The service’s vision was ‘to provide care, advice and support for everyone in the community living with terminal or life limiting illness, together with their loved ones.’ The service had a well defined leadership team with clear responsibility and accountability.

The service had identified 4 strategic aims. To provide earlier access to hospice care, continue its commitment to high-quality person-centred care, maintain financial sustainability and cost-effectiveness and empower and support staff and volunteers.

The service held a workforce partnership forum every 2 months. This brought staff and leaders together to improve engagement. It gave leaders the chance to share updates, listen to feedback, and work with staff on ideas for improvement.

The service carried out workforce surveys to understand staff views and the potential impact of the planned refurbishment works. This led to a set of actions to support staff through the changes, including reviewing shift times, transport arrangements and opportunities for flexible working. Staff told us they had been kept fully informed of the proposed plans and that their views have been listened to.

Leaders shared plans with staff through ‘Friday Feelings’ emails. Staff told us that they were kept fully informed and consulted by leaders about planned changes within the organisation. Staff told us they were “proud to work for the service”, and that they had “one chance to get care right”.

Leaders told us an annual staff survey was planned for September 2025, which would support benchmarking with other hospices to help identify areas for improvement and share good practice. However, at the time of our assessment, this had not yet been completed, and survey results were therefore not available.

The evidence showed a good standard. The service had inclusive leaders 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 did so with integrity, openness and honesty.

Leaders understood their teams and the challenges faced by staff and services. Leaders and team managers involved themselves in day-to-day patient care, directly engaging with the challenges staff experienced.

The service supported staff to progress through the organisation. Leaders supported staff who had worked at healthcare assistant level to train as nursing associates.

The service ensured staff recruitment processes met fit and proper person requirements, as evidenced by our review of staff files.

Leaders responded to staff feedback from a just culture survey, by increasing senior leadership visibility. Leaders aimed to spend more time at a clinical level through a back-to-the-floor initiative. Staff described leaders as approachable and told us they were confident, if raising concerns, that they would be heard.

Leaders recognised the need to not only to focus on improvement but were also working to find ways to celebrate achievements and success across the teams.

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 service supported staff to share their opinions through a work partnership forum, which enabled open dialogue with managers. Staff discussed issues included changes to the physical environment, staff and volunteer wellbeing, and organisational change.

We saw Freedom to Speak Up information for staff visible at the hospice. The Freedom to Speak up Guardian was external to and independent from the service and presented at staff meetings to raise awareness of the service.

Staff told us they felt confident raising issues directly with leaders but were also aware of the Freedom to Speak Up service and would know how to access it.

The evidence showed a good standard. The service valued diversity in their workforce. Leaders worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service had a clear commitment to equality and diversity, supported by a formal policy. Leaders actively valued diversity within the workforce and worked to ensure fair and equitable treatment for all staff. As part of ongoing refurbishment works, leaders developed temporary relocation plans for the hospice, where staff were directly affected. Leaders recognised the proposed alternative site was located at a considerable distance and would significantly increasing travel times for some staff. Leaders carefully considered the impact, exploring ways to lessen potential challenges.

The hospice’s admission process ensured a fair and holistic assessment of each person. Staff promoted equality by using structured tools to identify and respond to people’s physical and psychological needs. These tools helped staff balance individual requirements with available capacity, so that people with the most urgent needs were prioritised.

The service had a strategy for 2025/26 aimed at promoting equity, diversity and inclusion. The strategic aim was to ensure that everyone felt respected, valued and able to thrive. Leaders recognised this was a short-term plan. Their longer-term plan would be introduced in 2027 and would be formulated in collaboration with the local community, patients and their next of kin, staff and volunteers.

The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. However, staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Some elements of the governance framework were not operating consistently and were still being strengthened. Not all policies and standard operating procedures (SOPs) were up to date. There was a lack of effective systems to ensure that changes to policies were communicated to staff and embedded into practice. Leaders recognised at senior leadership meetings that a number of policies and procedures were out of date. A project was underway to review these, and planning had begun to address the gaps. This meant that staff were not always working to appropriately reviewed procedures, which could affect the consistency and safety of care.

However, most of the policies we reviewed as part of our assessment were within their review date. Leaders had shared new or updated policies with staff through local governance meetings, and this was evidenced in minutes.

The service recorded risks on the corporate risk register and reviewed them regularly. The service had recently introduced a new system for recording risks, which improved oversight for staff and leaders.

The board had recently introduced a board assurance framework, which was in the process of embedding. The framework aimed to improve patient safety and identification of risks. Leaders clearly identified risks and mitigations, which were reviewed and scheduled for presentation to the board twice a year. Minutes showed that risks were discussed at local governance meetings.

The service was introducing a new Patient Safety Event Response Framework (PSERF) policy to strengthen learning from incidents and improve monitoring of actions taken. Leaders recognised that while learning occurred locally, the oversight of action completion needed to be more robust. Staff training on the new policy was underway at the time of our assessment.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff shared information and learning with partners and collaborate for improvement.

Leaders worked in partnership with relevant services and communities to provide the best possible care and services for patients and their families. They worked with the local acute NHS hospital to improve pathways for patients transitioning into palliative care.

Staff worked with local care homes to support palliative care for residents, helping to ensure people received appropriate care in familiar settings.

The hospice had an end of life matters group which reviewed input from people using the service and those with lived experience to share feedback, thoughts and ideas. This helped people act as partners in shaping the service.

The service had built a strong partnership with a local transport provider to support people using hospice services with transport needs.

The hospice hosted Kent Medway Palliative Care Hub. This online hub brought together contributions from the 5 adult hospices across Kent and Medway and supported more consistent care by giving professionals easier access to high-quality information.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contributed to safe and effective practice.

The service led a scheme to improve links and pathways with the local acute NHS hospital, which supported timelier referral and treatment for people with palliative care needs who would benefit from hospice support.

The service was working to launch a Patient Safety Event Response Framework (PSERF) approach to incident investigation, with a clear emphasis on learning from incidents. Staff told us that learning from incidents was shared with them at regular face-to-face staff meetings, and through email updates, and that they received feedback when they reported incidents.

The service contributed to a national palliative care and end of life care study. Leaders shared updates on the trial with teams and worked to benchmark performance with similar organisations through a national hospice charity.

Leaders carried out a ‘Just Culture’ survey in 2024 and shared the results with staff at engagement sessions. The resulting actions included increasing senior leadership visibility and improving communication about future plans and hospice developments.