St Rocco's 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 good. At this assessment the rating has remained good.

The service demonstrated a strong safety culture, with staff actively reporting incidents and learning from them. Safeguarding and staffing were well-managed, training compliance was high, medicines were handled safely, and care transitions were smooth. However, there were some shortfalls in infection control audits, environmental risk assessments, and escalation processes, which constituted a breach of regulation. These issues were acknowledged and addressed promptly by leadership.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The incident management policy was up-to-date and relevant to the service. This identified and explained the levels of harm and outlined the process and expected timelines for outcomes. We reviewed the process for incidents and saw these had been investigated appropriately and promptly.

The hospice had a process for reviewing incidents at the senior leadership level, with reports being discussed with the board and action plans being managed if required. This was evidenced in meeting minutes from the board and subcommittee meetings.

All staff we spoke with could identify and explain the process for reporting incidents and were all confident in raising concerns with leaders and completing online incident reports. Staff could tell us of examples where debriefs have been held for some incidents.

Leaders distributed safety bulletins and medication newsletters to inform and update staff of any risks and associated policies.

Staff told us that they did not always receive written feedback from incidents, and the senior leadership team were working to implement this.

The service had a practice development nurse which staff told us was “proactive”.

We scored the service as 3. 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.

Patients and their loved ones told us they were involved in the planning of their care and kept informed about what would happen next and who to contact for support.

Staff completed and updated risk assessments for each patient and removed or minimised risks. On admission, a care plan was completed in conjunction with them and family members, this was individualised to their needs.

A daily single point of referral meeting took place with external care providers to discuss all new referrals suitable for admission to the service with a weekly integrated MDT. Referrals were discussed at meetings, which consisted of doctors, senior nurses, and senior management. There were clear processes and systems to help with deciding the eligibility of each patient to access the service.
The service had clear processes with policies and procedures that supported safe care when patients were transitioned between different services.

Clinical records were recorded on a mix of electronic patient record systems. Records were stored securely on site.

We scored the service as 3. 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.

Patients reported feeling safe, supported, and listened to, and were confident in raising concerns with staff.

Staff demonstrated strong safeguarding knowledge, including identifying abuse, reporting procedures, and accessing policies. Regular safeguarding meetings ensured incidents were reviewed and addressed.

All staff received role-specific safeguarding training, with a compliance rate of 96.33%, exceeding the service’s 95% target. Disclosure and Barring Service (DBS) checks were completed across all staff levels.

Clear processes were in place for raising concerns, supported by visual aids such as flowcharts and contact details. Staff could name safeguarding leads and gave examples of referrals made. The provider worked collaboratively with the local authority to monitor and review safeguarding outcomes.

We scored the service as 2. The evidence showed significant shortfalls. The service did not always work well with people to manage risks.

The service had a sepsis policy that was mostly in line with evidence-based guidance and had a policy for the use of National Early Warning Scores (NEWS2) observation tool which staff received training on induction for. However, the NEWS2 policy did not have clear guidance for escalation of the deteriorating patient. This was a breach of regulation as there was a risk that deteriorating patient’s symptoms would not have always been escalated to medical staff. Following our feedback the service amended the policy to include escalation guidance.

Staff had training in NEWS2 and sepsis, with training compliance for medical staff at 100% and 88% for nursing staff.

Staff held regular meetings including handovers, ward rounds, and multi-disciplinary reviews to share patient risks and updates.

Risk assessments were person-centred, proportionate, and regularly reviewed, with patients and loved ones actively involved in discussions.

Patients felt safe and supported, with concerns addressed effectively. Virtual ward patients were assessed regularly. We reviewed five patient records and saw that risk assessments were complete and up to date, covering areas such as pressure care, falls, nutrition, manual handling, and infection control.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment.

We observed items in clinical areas that could be hazardous to health such as batteries and potential ligatures. We raised these concerns during our assessment, and these were immediately rectified by leaders. At the time of the inspection the service did not have a risk assessment in relation to ligatures or a policy, however this was implemented following our feedback along with training for staff.

Staff ensured that equipment was maintained regularly and had processes in place to monitor and manage this.

The service had a fire risk assessment, and we saw that fire extinguishers were in date, fire exits were clear and regular testing of the alarm system was undertaken. We saw that there were personal emergency evacuation plans in place when required, and staff had access to equipment to assist in evacuation as needed.

We observed that chemicals listed under the Control of Substances Hazardous to Health (COSHH) were stored correctly.

We scored the service as 3. 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.

Staff told us that staffing levels across the hospice including the virtual ward, hub, and inpatient unit were sufficient to ensure safe care. Shift gaps were primarily covered by internal bank staff, particularly among care support roles.

Medical staff were available on site from Monday to Friday, with on-call out of hours ensuring staff had access to a palliative care consultant out of these hours.

A structured induction process helped staff feel prepared for their roles. They reported feeling supported by senior leaders and confident in approaching them when needed. Staff had time to complete mandatory training, with overall training compliance at 94%.

A patient acuity assessment process enabled responsive staffing adjustments. Senior leaders could reallocate staff to maintain safe ratios during shortfalls or absences. During the inspection, the inpatient unit experienced staff absences but remained safely staffed. The hospice had escalation protocols, including bed closures or pausing admissions, to ensure safe staffing levels.

Patient and loved one’s feedback showed that they had felt safe in the care of the hospice staff who were “compassionate” and “capable” at both looking after them and their loved one receiving treatment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection.

We found that cleaning records were not always up to date, and we observed some areas and equipment with dust on.

Managers did not always audit internal cleaning records to ensure compliance. However, the service received external audits for IPC and the audit for April 2025 showed an overall compliance of 99%.

We saw that staff adhered to infection control principles, including handwashing and correct use of Personal Protective Equipment (PPE).

Staff were aware and could explain IPC practices, such as managing a person with an infection and could identify where to access advice and policies.

The hospice had 100% on both mattress and hand hygiene audits, and the hospice received the highest level from the local council concerning food hygiene.

We scored the service as 3. 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 happened.

We saw that people were given their medicines in a kind and person-centred manner. Medicines were stored safely and securely in a locked treatment room, and only authorised staff had access to the treatment room.

The use of antibiotics across the service was regularly monitored, and the prescribing was in accordance with their policy and national guidance.

People were supported to self-administer their medicines, and risk assessments were completed to ensure this was done safely.

Medicine incidents were identified, reported and analysed. Learning from these incidents was shared across the service and the wider care system.

We saw evidence that medicines audits were in place, but they had not been undertaken for a short period of time due to a pharmacist vacancy. However, a pharmacist had been appointed, and medicines audits and governance work was due to resume.