Pilgrims Hospice Ashford

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

We reviewed 8 quality statements for Safe: learning culture, safe systems, pathways and transitions, safeguarding, involving people to manage risk, safe and effective staffing, safe environments, infection prevention and control, and medicines optimisation. At our last inspection we rated this key question good. At this inspection, the rating has remained good. This meant people were safe and protected from avoidable harm.

The hospice worked with people and partners to establish and maintain safe systems of care and ensured continuity of care when people moved between different services. Risk assessments about care were person centred, proportionate and regularly reviewed.

There was a comprehensive safeguarding system, with clear roles and responsibilities, through which safeguarding risks were proactively identified, managed, actioned and reduced.

There was a collaborative approach to working with partners to identify and manage shared risks and joint processes for monitoring their effectiveness.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff controlled infection risk well. They used equipment and control measures to protect patients, themselves, and others from infection.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

The service used systems and processes to safely prescribe, administer, record and store medicines.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders investigated incidents and shared lessons learned with the whole team and the wider service. There were clear, open and transparent processes for reporting and learning from incidents. One staff member told us ‘We get an email or it’s discussed at team meetings, we’re kept informed for our own learning’.

The hospice followed NHS England’s Patient Safety Incident Response Framework (PSIRF). The PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.

Incidents were discussed at MDT and clinical incident review meetings. We reviewed the MDT and clinical review meeting minutes which showed evidence of incidents being reviewed and learning from incidents being shared.

Staff told us that the hospice was committed to operating in a manner that was safe, effective, and accountable. The service 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, in accordance with the hospice’s governance and reporting structure policy. We found that there was a good learning culture and staff we spoke with told us that they felt they could raise concerns

Patient safety incidents were also shared with partnership agencies working in end-of-life care so learning could be shared as widely as possible. When things went wrong, staff apologised and gave patients honest information and suitable support.

Clinical incident trend analyses were undertaken by the Clinical Governance and Quality Committee at quarterly meetings, to identify themes and trends, which included pressure ulcers, safeguarding concerns and medication errors. 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 regularly reviewed people’s skin to avoid further skin deterioration.

The hospice viewed every incident as an opportunity for learning and actively encouraged open and honest reporting. When adverse events occurred, they could pose risks to both patients and staff and may have a wider impact across the organisation.

The hospice’s priority, when incidents were reported, was to understand what happened and take steps to reduce or eliminate future risks. They were equally committed to ensuring that those affected were fully supported throughout the process. They recognised that most incidents arose from system or process failures, rather than individual error or omission.

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.

The hospice had an incident reporting system that informed key members of staff immediately when an incident had been raised and allocated a lead investigator within 24hrs and sent reminders. Reports were run to ensure incident investigations were completed and learning shared. These were reported through the Nursing and Care Leadership group, escalated to Nursing and Care Strategic group and reported to Quality and Governance Committee and the ICB Quality Team.

We looked at the incident reporting list for January 2025 and saw that all incidents reported, had been thoroughly investigated with learning outcomes that were shared with all staff. For example, we looked at a clinical incident in the IPU regarding the lack of documentation, relating to recording of seizure symptoms. We saw that this had been discussed at the ward huddle and would be discussed again at the February 2025 ward meeting.

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

Pilgrims Hospice Ashford worked closely with partners across the healthcare sector, including the local NHS hospital. In order to provide support to the maximum number of patients, the hospice opened additional beds to facilitate admissions for end of life (EOL) patients and continued to facilitate short term admissions for patients in their last months of life, who were waiting for a discharge package, which in turn reduced pressure on local acute services.

The hospice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. This included the Integrated Care Board (ICB), social care, community nursing teams and the local NHS hospital.

Referrals came from healthcare professionals within the community or hospital settings, and these were received centrally before being triaged by a clinician and then allocated it to the relevant service. This included a medicines review and assessment of suitability of patients own medicines.

All admissions were discussed jointly by registered nursing staff and a doctor or Advanced Clinical Practitioner on the day of the admission and clerked with the senior doctor covering the ward. Patients were reviewed face to face 7 days a week. If clinically indicated, the Consultant or Specialty doctor would review patients face to face on the ward out of hours including weekends and bank holidays.

The length of admission assessment was tailored to individuals and the hospice involved relatives and other healthcare professionals in their care when needed.

The service used the Integrated Palliative care Outcome Scale (IPOS) as a measure of symptoms and concerns

Staff told us they could access the information they needed. Patient’s records were electronic with key information being available to all health professionals who provided care to ensure patient’s wishes were shared. There were systems to access patients GP records.

We reviewed 5 patients records and found the assessments to be accurate, joined up with doctors and nurses and up to date with information on people’s needs and preferences. Transfer of care was clearly recorded in notes, with comprehensive discharge summaries including anticipatory medicines and social care plans. Anticipatory medications are medications prescribed in advance, so the person has access to them as soon as they need them.

We observed a handover which was attended by members of the MDT team. Staff discussed patient’s emotional needs, referral to the living well services, physiotherapy input and discharge planning.

Clinicians worked with the social worker who were based at the hospice with discharge planning.

Staff could also access other professional services when needed such as speech and language therapists, mental health professionals, tissue viability specialists as well as psychologists. The service worked closely with other services to support patient pathways and transitions.

For example, continuity of care was a clear priority for the service; this was reflected across all services provided. The living well team offered individualised care and support to patients and their loved ones. During the assessment we saw how the hospice worked collaboratively with others such as general practitioners and district nurses to ensure people received appropriate and timely care. We also saw how allied health services such as occupational therapy, physiotherapy and social workers were a key priority of patients’ care. The service had access to a palliative care consultant 24-hours 7 days a week.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service 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 and reduced.

The hospice had a safeguarding group who held quarterly meetings. There was a Designated Safeguarding Lead (DSL) who was supported by a Lead Social Worker/Deputy DSL and 6 other named professional members of staff.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff we spoke with were aware of who the safeguarding lead was.

Staff received safeguarding adult and children level 1 to 3 training depending on their role and had access to Adult and Children safeguarding policies and procedures were in line with national guidance. Both of these policies were in date and due for review in 2025. In addition to the policies, the hospice had Safeguarding leaflets available for patients and families. We looked at the mandatory training compliance matrix and saw that safeguarding training was at 100%.

Staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. For example, the hospice provided counselling using independent interpreters for patients and carers for whom English was not their first language, or for those who were hearing impaired, when the need had arisen to ensure equity in accessing psychological support through the hospice.

The hospice had developed an inclusive approach to hospice chaplaincy services promoting and supporting the spiritual needs of patients and families from all faiths and of no faith. The hospice had developed strong links with local community faith leaders who could be called upon to support specific religious needs of patients and families, that could not be met by their own chaplaincy team.

The hospice provided education to staff across the organisation by raising awareness of different belief systems and rituals around death and dying from all world religions through All Come Together (ACT) sessions delivered to celebrate Inter-faith week in January 2025.

There was a commitment to taking immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way.

Safeguarding systems, processes and practices gave assurance staff upheld people’s human rights, and staff protected them from discrimination. Staff supported people to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 (MCA) and the Equality Act 2010.

The hospice used electronic records which included a template to ensure staff recorded all required information, including potential or actual safeguarding concerns. The electronic records were available to clinical staff and other key staff.

Data provided to us during the assessment showed that the hospice had not had any grade 3 or 4 pressure ulcers that required reporting to the local authority (LA) or CQC in the last 3 months. We looked at the Clinical Quality and Governance Safeguarding Report 2024/25 and saw that these were safeguarding concerns raised to the hospice internally and did not require escalation to LA.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a transparent and open culture which encouraged creative thinking in relation to people’s individual safety. People were enabled to take positive risks to maximise their control over their care and support. They were also actively involved in managing their own risks along with their relatives, friends and other carers. People and their loved ones said they had regular and open conversations about risks around their health. We saw evidence of this in peoples care plans.

Staff showed empathy themselves, while recognising and respecting their lifestyle choices. Patients and their families were involved in managing risks, risk assessments were person-centred, proportionate and reviewed regularly. Patients felt safe, listened to, and supported on the ward, and in the community. Their concerns were dealt with, individual risks were well managed.

Risks to each person's health and well-being had been considered and assessed in the inpatient unit (IPU) and at home. These included risks relating to people's mobility, skin care and nutritional needs. We reviewed patient records and found evidence of bedrails assessment, falls assessment template, repositioning and PURPOSE-T (Pressure Ulcer risk primary or secondary evaluation tool) skin for skin integrity.

Staff demonstrated a good understanding of people’s needs and how to positively support them with their known risks. A member of staff told us ‘We have high and low beds for people at risk of falls. Rooms also have sensor alarms, bed rails and mattresses on the floor for patients who had delirium and at risk of falling out of bed.’ Staff told us they provided one to one care overnight for confused patients and sat with them until their family arrived.

Pilgrims Hospice consistently applied person centred care with a positive culture which supported patient choice. For example, we saw a staff member sitting with a patient to minimise the risk of falling or one to one support overnight whilst family arrived

People's risk management plans were reviewed daily by the Multi- Disciplinary Team (MDT), with all significant risks and decisions discussed at the formal weekly MDT meeting. Staff were kept informed of people's risk management plans in the IPU at each shift handover meeting. These included signs of deteriorating health, medical emergencies or behaviours that may challenge. The hospice had terms of reference to reflect this and assessment guidelines which indicated when to raise any risk aspects.

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

The premises were secure, and visitors signed in on entry to ensure that only people who were authorised to be within the hospice were allowed into the building. The reception area was manned by volunteers. Out of hours the doors were locked and the nursing staff had to allow visitors entry, there was a video doorbell which allowed staff to have a two-way conversation with the potential visitor. The hospice had on call security if required.

Facilities, premises and equipment were designed and used to meet the needs of a range of all people who used the service. The design of the environment followed national guidance. People had their own bedroom space and access to various communal areas. This included quiet areas where people could spend time with their family members, a faith room and areas for children and younger visitors

People had the equipment they needed to keep them safe, manage their pain and maintain their independence. People could reach call bells. People told us that staff responded promptly to any requests for help. All outpatient areas were on the ground floor with accessible access throughout.

All bedrooms were on the first floor and had direct access to their own patio area with additional accessible access to a large communal garden with several seating areas.

The inpatient bedroom doors were wide enabling access for people with mobility challenges who may require assistance whilst also promoting their independence. There was appropriate equipment with training available to administer pain relief.

The hospice had enough suitable equipment to help staff safely care for people. Staff told us that equipment was readily available and there were no concerns with access. The hospice maintained an equipment register and complied with relevant equipment safety and calibration checks. This included Lifting Operations and Lifting Equipment Regulations (LOLER) for moving and handling equipment. There were arrangements for medical device servicing and decontamination and staff received relevant training. The maintenance log confirmed equipment including hoists had been serviced and maintained. 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 and the assets register.

Equipment used to deliver care and treatment was suitable for the intended purpose. Staff understood and were trained how to use equipment safely. This included being aware of and appropriately applying the relevant good practice standards, guidance or manufacturers guidelines. Staff carried out daily safety checks of specialist equipment. They ensured that emergency equipment and essential equipment such as syringe pumps (for continuous administration of palliative and end of life care medicines) were routinely monitored, maintained and accessible.

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

Health and safety risk assessments with mitigating actions were carried out in line with Health and Safety Executive (HSE) guidance. These included fire safety, water safety, security and other environmental risk management practices.

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

We viewed 2 staffing recruitment files for people who had been recruited in the last 12 months. We saw that procedures were in place to ensure that staff were suitable to work with vulnerable people. The procedures included taking proof of identity, two written references, interviews with two senior staff, Disclosure and Barring System checks, and viewing records for previous qualifications, and nurses ‘PIN’ number checks. New staff were taken through a comprehensive staff induction programme which included basic training subjects. They worked alongside other staff until they had been assessed as being able to work on their own.

The service made sure there were enough qualified, skilled and experienced people to deliver effective, safe care and treatment to meet people's needs. Senior managers checked the staff rota to ensure suitable cover was in place. Managers told us they could flex the rotas depending on patient needs.

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 received support, supervision and development opportunities. They worked together well to provide safe care that met people’s individual needs.

Staff completed mandatory training via e-learning, and these included mental health awareness training and safeguarding. Managers were able to monitor compliance for their teams and individuals. Staff told us they were up to date with their mandatory training and managers reminded staff to complete these. Data provided to us following the inspection showed a 92% completion.

Learning Disability and Autism training prior to the statutory requirement for accredited training had been delivered in house.

The continuing development of staff skills, competence and knowledge were recognised as being integral to ensuring high quality care. Staff at all levels had opportunities to gain experience, develop transferable skills, and share best practice. Managers were innovative and supported staff to undertake training in advanced techniques to provide complex care such as management of breathing tubes and syringe drivers and included simulation-based learning.

The hospice offered courses and training for local health and social care professionals to facilitate education around end-of-life care. For example, Principles and Practices in Palliative and End of Life Care, for Registered Practitioners. This course provided registered nurses and allied health professionals with the foundations of end-of-life and palliative care, to support their patients and families, in any setting during their final months, weeks and days.

Staff received an annual appraisal as well as clinical supervision in line with the hospice’s policy. In addition to the usual staff appraisal processes, line managers offered staff the opportunity to meet on a one-to-one basis to discuss their future learning requirements in line with their new role and personal specification during the transition period of moving into a new role or leaving an existing one

The hospice also employed physiotherapists, occupational therapists, a chaplain, social workers, complementary therapists, and administration staff to support patient care. A Clinical Psychologist and Psychological Care Facilitator were available to support clinical teams and provided mental health support for patients and their loved ones.

There was a Clinical Nurse Specialist available to provide end of life and palliative care advice and support 7 days a week, Monday to Friday 8am to 10pm and weekends 8.30 am to 4.30 pm.

A doctor was available within the hospice between 8.30am to 7pm Monday to Friday and for 6 hours on Saturday and Sunday. On call medical cover was available outside of these times. There was at least one consultant available Monday to Fridaywithin standard hours and out of hours consultant cover provided by a shared rota. We looked at the on-call rota for January to May 2025 and saw that the hospice had not had any gaps in their on-call medical cover during this time.

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

There was a comprehensive system for assessing and managing infection control risks, incorporating policies, procedures, roles and responsibilities, training and monitoring. The service-controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.

We saw that staff adhered to the 'bare below the elbows' policy when providing care and treatment. Disposable aprons and gloves were readily available. Staff used them when delivering care and treatment to patients to reduce the risk of cross infection.

People were protected as much as possible from the risk of infection. The hospice was visibly clean and had suitable furnishings which were easily cleanable and well-maintained. Pilgrims Hospice Ashford employed their own housekeeping staff who were available daily. Housekeepers spoke proudly of their work and their role within the team to keep the premises clean.

Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. 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.

Infection prevention and control (IPC) audits were done routinely. We looked at the Pilgrims Hospice Ashford - Monthly Cleaning Audit for April 2025 undertaken by the domestic supervisor. We saw that it had scored 99% and that there were corrective actions, for example, minor dust in cleaning cupboard of the laundry room and mop not stored correctly in the lower floor kitchen.

We looked at the Annual Report and Strategic Plan for Infection Prevention and Control, March 2025. We saw that this included a summary of last year’s Infection Prevention and Control (IPC) and that last year, the IPC team had been on each site in maintaining and improving standards of IPC for patients, staff and visitors. This had included repeated features such as World Health Organisation (WHO) hand hygiene day, updating display boards, performing audits and recording Key Performance Indicators (KPIs - a measurable value that demonstrates how effectively a company is achieving key business objectives).

The IPC team continued with their professional development and had taken part in the Infection Prevention Solutions training day. With the reintroduction of quarterly meetings the IPCT had been able to support each other and share ideas. The IPCT performed informal walk rounds of the in-patient units (IPUs) resulting in an action plan for the IPCT and the wider teams.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The service had systems for prescribing, administering and handling medicines. We found a few areas where processes were not being followed correctly but the provider responded immediately ensuring they were actioned; staff were informed and polices were revised.

There were 5 inpatients at the time of our visit. We conducted a review of areas that stored medicines, reviewed medication charts, care records, policies, procedures and audits.

People were prescribed and administered their medicines by staff, and this was recorded on the electronic system. People’s allergies were recorded and when required medicines were clearly prescribed with maximum doses clear time intervals and indications. There were homely remedies available for staff to respond to minor ailments.

The service had no risk assessment or oversight of whether people had been assessed for the risk of venous thromboembolism (VTE or blood clot). There was no mechanism to see if the risk assessment had been updated if a patient’s condition changed. Following our inspection the provider sent evidence to show that this was identified in previous audits and had now embedded a mandatory VTE box in the admission clerking template. In addition, the service submitted an action plan which showed how they intended address this issue.

There was a working group since late 2024 that was creating a template for in patient unit (IPU) admissions. This would contain the reference to the VTE status. A final draft of the policy was expected by 4 June 2025 for discussion at their next medical team meeting and expected to be implemented by end of July 2025.

There was a limited policy to support patients to self-administer their own regular medicines, except for a few select medicines, which included items such as inhalers, eye drops and insulin. The policy did not include any risk assessment to ensure patients were able to do this safely. Following our inspection, the service provided an updated policy which had been reviewed and expanded upon. It now included a risk assessment and patient consent form, as well as covering patient's own medicines. This was being signed off virtually by the hospice’s Medicines Management Group.

There was no general information provided to patients about the use of unlicensed or off-label medicines (where its use is not covered by the manufacturer) but if there was a more unusual medicine used then staff ensured that people were involved in discussions and consented to its use. Following our assessment the service provided us with a patient leaflet to show that information was available to help them to understand some important aspects of medicine licensing regulations and how these issues might affect them.

National guidance for Controlled Drugs (CD) was not being followed, however, this was put in place immediately following our inspection. As the supplying pharmacy was a different legal provider the ordering processes were not in line with the Misuse of Drugs Regulations 2001. The provider was not following the service level agreement with the trust where each CD requisition order must be signed by a doctor or non-medical prescriber. The service did not have the required exemption certificate in place to authorise the destruction of Controlled Drugs, however, this was put in place immediately following our inspection.

A pharmacy service was provided by the local NHS trust, and a pharmacist was onsite one day a week and contactable on the other days for advice. The pharmacist attended the multi-disciplinary team (MDT) morning handover meeting, and a top up service ensured that medicines were available and fit for use.

Medicines were stored safely and securely. Although, the service made us aware that they had recently taken action as their refrigerator readings were out of range. The maximum readings were recorded as being high since October 2024. They had destroyed the affected medicines and ordered a new refrigerator which was waiting to be operational.

There were procedures to ensure medicines were available out of hours and to ensure that medicines were supplied to people during weekend leave. Pain relief was provided when people attended hospital appointments.

Medical staff undertook the process of medicines reconciliation when people were admitted to the service. Following an incident in December 2024, this process was being reviewed because since the introduction of the electronic system there was no oversight of the timeliness or quality of the medicines reconciliation process. Medicine reconciliation is the process where staff check that patients have the correct medicines when they move between services or are admitted from home.

Emergency medicines were available and checked regularly and intravenous antibiotics were available if required, nursing staff had access to the relevant guidance to ensure safe administration through an online portal. Following our inspection, the service provided us with the policies which been printed for each hospice site so that a hard copy was now available to nursing staff rather than online portal.

People receiving their medicines by injection through the skin via a syringe driver had all the necessary checks completed.

Patients were provided with an accurate list of medicines on discharge from the service and the pharmacist liaised with other providers in the community such as care agencies to ensure that people were supported with their medicines after discharge.

Staff had actioned safety alerts and supplied additional information to patients such as the fire risk with emollients.

The medicine management group met every 2 months and reviewed any medicines incidents with medicines reconciliation. We reviewed minutes in December 2024 and April 2025 for timeliness and quality.

A culture of learning was evident, and staff told us about educational opportunities that were provided following learning from medicines incidents, with recent sessions being held on insulin and controlled drugs.

Audits had been completed recently including one on prescription stationery (May 2025) and a medicines audit (February 2025) in which the issues with medicines reconciliation and temperature monitoring had previously been highlighted as actions.

The provider did not routinely monitor or analyse missed or delayed doses of administration medicines as prescribed including those recorded as being out of stock. However, following our inspection the service told us they would be implementing audits to capture this and take action.