The Prince of Wales 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

We checked that risks to people’s safety were identified, assessed and managed well, and that systems were in place to prevent mistakes and reduce the likelihood of harm. We also looked for evidence that when things went wrong, the service learnt from incidents and took action to improve safety. We considered how leaders promoted a culture where people’s safety was prioritised, concerns were listened to, and improvement in safe practice was part of everyday work.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service demonstrated a positive approach to learning and continuous improvement. Leaders and staff understood the importance of learning from daily practice, incidents, feedback and complaints to improve the quality and safety of care.

Staff told us they felt encouraged to reflect on their practice and to speak openly about what was working well and what could be improved. They said managers were approachable and supportive, and that learning was viewed as an opportunity to improve rather than to blame. This helped to create an open and honest learning culture. Managers debriefed and supported staff after any serious incident.

The service had systems in place to learn from incidents, accidents and near misses. Records showed these were reviewed, with clear actions identified to reduce the risk of reoccurrence. Where appropriate, learning points were shared with the wider staff team through team meetings, handovers and written communications to support shared learning. There had been 0 reported never events in the preceding year. Never Events are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed.

Incidents were analysed to identify trends or themes. There had been repeated themes of pressure damage, falls, and medication errors. We saw evidence the service acted on these.

The service had a current incident management policy, which reflected the provider and national guidance. When things went wrong, staff apologised and gave patients honest information and suitable support. We reviewed the Duty of Candour Policy and saw examples of where it had been used.

Staff received induction, training and ongoing development that supported safe and effective care. Supervision and appraisals were used to reflect on practice, identify learning needs and agree development goals.

Managers monitored quality and performance through audits and checks. Findings from audits were used to inform learning and service improvement. Action plans were developed where shortfalls were identified, and progress was reviewed to ensure improvements were sustained.

The service provided mandatory training in key skills to all staff. Managers monitored mandatory training and alerted staff when they needed to complete updates.

Staff received and kept up to date with their mandatory training. The data showed a completion rate of 98% at the time of inspection.

The hospice had effective systems to support safe admission, care transitions and discharge. Referral pathways were clear and understood by staff. Referrals were accepted from appropriate professionals, including hospitals, GPs and community services, and were reviewed by senior clinicians to support timely and appropriate decision making.

There were safe handover processes at each stage of the patient pathway, including admission from hospital and the community, ongoing care and discharge. Relevant clinical, psychosocial and social care information was shared to support continuity of care and risk management.

Staff worked closely with external professionals, including acute hospitals, GPs, community teams and social care, to ensure information was shared in a timely way. This supported coordinated care and safe transitions between services.

Staff supported people to make decisions about future care, including preferred place of care, and these preferences were recorded and reviewed. Advance care plans were documented and shared with the multidisciplinary team. Staff were aware of patients’ wishes and used these to guide care and decision making.

There were several structured meetings including a multi-disciplinary team (MDT) led discussion focussing on holistic care, daily consultant reviews, daily safety huddles, and a daily capacity safety huddle with another hospice in the area for discussion of community referrals and capacity.

We observed an MDT meeting where there was a range of professionals, including nursing, medical, physiotherapy, occupational therapy and well-being staff present. All patients on the unit were discussed, addressing their individual needs. Special attention was given to families; we saw great staff communication detailing individualised plans for each patient.

Arrangements for post‑death care were respectful and well organised. Patients’ dignity was maintained, and families were given time and support following bereavement.

The hospice had effective safeguarding systems in place to protect patients and others from abuse and neglect. There was a clear safeguarding policy that reflected current national guidance, and staff were aware of how to access and follow it in practice.

Staff understood how to raise safeguarding concerns and were confident in identifying and reporting abuse, neglect or exploitation. Safeguarding concerns were shared appropriately within the team and managed by a named safeguarding lead, with learning discussed and used to improve practice.

Clear arrangements were in place to liaise with local authority social work teams and other safeguarding partners. The hospice engaged with local safeguarding systems and shared relevant information when required.

Safer recruitment processes were followed. This included appropriate checks, such as Disclosure and Barring Service (DBS) checks, before staff and volunteers started work. Safeguarding was included in induction and reinforced through ongoing training.

Staff and volunteers received safeguarding training appropriate to their role and knew what action to take if they had concerns. The staff safeguarding training compliance rate was 100%. Trustees and senior leaders had oversight of safeguarding and received appropriate awareness training.

Mental Capacity Act principles were applied in practice. Staff supported patients to understand information and make decisions wherever possible. Where patients lacked capacity, best interest decisions were made with involvement from family or advocates and were documented.

Mental health support was available when needed. Assessments and care plans were shared with relevant staff to ensure coordinated and safe care.

The hospice supported patients to make informed decisions about their care and activities, including where there were potential risks. Staff worked with patients to understand their wishes and balanced risk appropriately, respecting individual choice where patients had capacity. This included supporting people to fulfil preferences at the end of life while taking reasonable steps to reduce harm.

Patients and their families were involved in discussions about care, treatment options and future decision making. Staff explained treatment plans, when to escalate concerns and when care would focus on palliation rather than active treatment. Families were kept informed and supported, including where views differed, and decisions were made in the patient’s best interests.

Individual risk assessments were completed and reflected people’s specific needs and conditions. These covered key risks such as falls, pressure damage, moving and handling, continence and communication. Risk assessments were regularly reviewed and used to inform personalised care planning. Risks and agreed mitigation measures were shared with patients and families.

There were arrangements to identify and manage patient deterioration. Staff were trained to recognise acute and reversible deterioration and understood escalation processes. Patients were observed to receive prompt assessment and review by the most appropriate person for their needs. There were identified ceilings of care, observations and monitoring were carried out in line with policy and individual care plans.

Medical advice and review were available out of hours, with on‑call arrangements. Senior clinicians were involved in reviewing care and treatment, supporting safe and timely decision making.

Staff received training to support people with additional needs, including those with mental health conditions, learning disabilities or autism. However, the hospice had only recently been able to access tier 2 of this training on disabilities and autism and the compliance rate was 18% for clinical staff (96% compliance for part 1). Tier 2 training had been booked for May and June 2026 for all clinical staff.

The hospice provided a safe, clean and well‑maintained environment. Patients benefited from a warm and welcoming environment. Patients had their own bedroom space and access to various communal areas. This included the garden room and an extensive garden area where patients could spend time with their family members, a quiet room and a space for children and younger visitors to play.

Facilities were appropriate for the service provided and took account of people’s diverse needs, including those with mobility difficulties or sensory sensitivities. Call bells were accessible, and staff responded promptly. There were private areas available for staff handovers, confidential discussions and record keeping.

The environment was clean and well organised, with appropriate storage and designated single‑sex facilities for staff. Noise was minimised where possible, and staff took steps to protect other patients from distress where people were dying, including sensitive use of space and privacy measures. There was discreet access for funeral directors.

Equipment and facilities were maintained to support safe care. Staff told us they could easily report faults and arrange repairs, servicing or replacement. Medical devices and electrical equipment were managed in line with relevant guidance, with routine servicing, checks and audits in place. There was sufficient equipment available to meet patient needs, including for pressure care and symptom management.

Fire safety arrangements were in place, with regular risk assessments. We saw records of fire evacuation events and drills, including action taken and further actions required.

Incidents related to the environment or equipment were reported and reviewed, and actions were taken to reduce future risk.

Staff had access to emergency medicines required for cardiopulmonary resuscitation, as well as an anaphylaxis kit. During our discussions, staff were able to clearly explain the actions they would take in an emergency if a patient became critically ill and was for resuscitation.

Clinical staff training compliance for Basic Life Support (BLS) was 100%. We reviewed the cardiopulmonary resuscitation policy, which was in date and provided clear guidance for staff.

The hospice had effective systems in place to ensure there were sufficient numbers of suitably skilled and experienced staff to meet people’s needs safely. Recruitment processes followed required standards, including appropriate checks such as identity, qualifications, right to work, health checks and Disclosure and Barring Service (DBS) checks. These processes applied to permanent staff, temporary staff, locums and volunteers.

Leaders used workforce planning tools and service activity data to inform staffing levels and skill mix across services. Staffing levels were reviewed regularly, and adjustments were made to respond to changes in patient acuity and demand.

The service had clear medical cover arrangements. There was access to specialist palliative medical advice, including out‑of‑hours, and senior clinical input was available for decision making and escalation.

Nursing staff levels and skill mix were planned to meet patients’ needs across shifts. Staff told us staffing levels were generally safe and that they could raise concerns if they felt patient safety was at risk. New nursing staff received a supernumerary period, and agency and bank staff were used appropriately and supported by local induction.

The hospice had access to a specialist MDT including a physiotherapist, occupational therapist, counsellor, social worker and regular pharmacist. Other disciplines, such as dieticians, speech and language therapists and tissue viability nurses were accessed through established referral arrangements.

The hospice had infection prevention and control systems in place to reduce the risk of infection and protect patients, staff and visitors. There was an up‑to‑date IPC (infection prevention and control) policy and plan aligned with national guidance, and staff understood their responsibilities.

The hospice had clear arrangements to identify and manage infection risks, including for people with known or suspected infectious conditions. There were systems to communicate new or emerging IPC risks promptly to staff.

Healthcare‑associated infections were monitored and reviewed. Admissions were assessed for infection risks, and rates were recorded and discussed through governance processes. Environmental measures, including water outlet flushing, were in place to reduce risks such as legionella.

Staff followed infection control practices in line with policy, including hand hygiene, use of personal protective equipment and bare‑below‑the‑elbows guidance. Compliance was monitored through audits and observations, and learning was shared with staff.

The hospice requested an external IPC audit was completed in October 2025 to ensure objectivity in IPC standards to aid learning and improvements. This reviewed 242 IPC criteria across 10 standards. The audit found that most standards were met, with 77% of applicable criteria compliant. Where gaps were identified, these related mainly to infection risk and statutory requirements. An action plan was in place, with actions, timescales and named leads.

We also reviewed the provider’s internal IPC audit completed in March 2026, which showed an overall compliance score of 82%. The lowest scoring area related to the management of urinary catheters, with compliance of 60%. We reviewed the associated action plan and saw that a clinical training day focusing on catheter care was scheduled for April 2026.

Medicines were stored safely, securely and were well organised. Controlled drugs were stored securely with restricted access, record keeping was accurate and there was a process in place to report any discrepancies. Temperature monitoring for areas where medicines were stored was completed daily and there was a process in place to review expiry dates of medicines.

There was a system to review the appropriateness of patients own medicines for use and to replenish medicines when needed. There were arrangements in place to obtain medicines out of hours and a process for obtaining medicines for patients being discharged.

There was a designated pharmacist who attended regularly and was involved in tasks such as medicines reconciliation (comparing the list of medicines people were taking prior to admission with what was currently prescribed), reviewing prescription charts, completing audits and involvement in nurse education and training sessions. Medicines reconciliation was conducted using various sources to ensure the information was correct and up to date.

Details of patient allergies were documented well in all patient records. Patient weights to ensure appropriate doses of medicines were prescribed were also well documented as a result of audit improvement work. Where medicines had been prescribed for short term use, such as antibiotics, or had specific dosing regimes, this was marked clearly on prescription charts.

Some patients required medicines to be administered via syringe drivers, and this was managed well and clearly documented. There was an information leaflet available for patients on the unlicensed use of medicines in palliative care.

There was a process in place to report medicines related errors and incidents and these were reviewed and analysed for trends. Learnings from patient safety incidents, including those relating to medicines, were shared with all staff during team meetings and displayed on a noticeboard. National patient safety alerts were monitored and actioned regularly.

Medicines Management training and competency assessments were up to date for all staff administering medicines and was incorporated into the induction programme for new starters.

Audits on medicines, including controlled drugs, were conducted regularly with actions plans created and implemented ensuring any learning were shared with relevant stakeholders. Standard Operating Procedures were in place and there was a process in place for these to be reviewed and updated.