Saint Catherine's - Scarborough

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that patients and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of patients and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that patients could access care in ways that met their personal circumstances and protected equality characteristics.

At our last assessment we rated this key question outstanding. At this assessment the rating was good. This meant patients’ needs were met through good organisation and delivery.

This service scored 82 (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 made sure patients were at the centre of their care and treatment choices and they decided, in partnership with patients, how to respond to any relevant changes in patients’ needs.

Staff showed us where they recorded the information regarding patients and carers within the care plans. Individual care plans were completed for every person accessing the service which showed how patients made informed choices about their care and plans for their future care. These were reviewed as needed. We saw patients’ plans when approaching the end of their life were appropriate and staff had asked patients what was important to them and recorded this in the records. The electronic patient records were updated regularly as patients’ conditions changed which enabled information to be shared with GPs and community services.

We also saw evidence of carers communication with the staff. Staff told us that when any carer required support such as counselling, a new care plan for that care was commenced to ensure confidentiality and an individual care plan for that person.

Carers said that they were kept informed and described when care had been tailored to patients on the unit, for example making pizza for their loved one. Carers said they could not fault the service received and the hospice had been very responsive to the family members needs when they changed.

The service understood the diverse health and care needs of patients and their local communities, so care was joined-up, flexible and supported choice and continuity.

The hospice had worked with other partnerships and communities to ensure its services and care provision met the needs of all patient groups, for example, the Masonic Aware and Armed Forces initiatives. More detail of these initiatives can be found in the partnerships and communities’ section of the report.

The hospice has rebuilt working relationships with the acute Trust and the community district nursing teams. The hospice held two sessions to network and rebuild working relationships. A facilitated meeting took place with the community nursing specialist team and the Humber community district nurses as an opportunity to build working relationships and improve collaboration. A second meeting and a tour of the site was held with the community nursing specialist team and the hospital palliative care team and acute oncology which included a question-and-answer session.

The hospice was part of the End-of-life Professional standard group which met with other hospice providers, the local NHS Trust and community services. Discussions included service updates, any preventable admissions, any incidents regarding discharge and transfer of care.

The hospice met at a working together group with local clinical leads from the community and NHS Trust. This meeting was used as an opportunity to network, provide support and to discuss any service issues or challenges.

Hospice clinical leads met at the regional clinical directors meeting. The agenda covered national updates, areas of good practice, external speakers, any challenges and support and advice for developing new services and peer support.

The hospice was dementia friendly and had key staff with additional Dementia Training. Staff could also access the admiral nurse based at the local NHS Trust.

Staff could access learning disability champions based within the hospice.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service complied with the Accessible Information Standard which promoted equal access to information and communication support for individuals with disabilities which ensured they could participate in health and social care services. At the front of every In-Patient Unit welcome pack was a section titled ‘Accessible Information Standard’ which informed patients, and their families should they have any communication support needs, to inform a member of staff.

Staff said information formats could be personalised to patients’ needs, for example, braille, audio format, large print formats and easy to read formats using simplified text and images. We saw some examples of leaflets provided in large font and images.

Patients could access either of the e2 portable and 2 fixed hearing aid loops located around the hospice.

Translation and interpretation services could be accessed.

The hospice was assured that information about people met data protection legislation requirements. The hospice audited its processes; an annual submission tothe NHS Data Security and Protection Toolkit benchmarked their performance against national information governance standards and confirmed compliance.

Information leaflets were available for patients and their families / carers to access, for example: Constipation in end-of-life care guidance advised to contact the GP or clinical nurse specialist if they had answered one yes from each of the four sections.

Telephone contact information was available which shared details for the district nurses, community specialist palliative care team and Palcall which was the out-of-hours contact line.

The hospice pods / buses go out to rural communities and share information and educational materials. People were signposted to relevant services run by an occupational therapist and a support worker.

Hospice leaders confirmed there had been 2 public and professional engagement days at the hospice where information was shared.

The volunteer coordinator attended schools, colleges and university meetings and engaged with the local community.
 

The service made it easy for patients to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved patients in decisions about their care and told them what had changed as a result.

The relatives and / or carers we spoke with confirmed their satisfaction with the service and staff within the service. Patients’ records confirmed their involvement when decisions were made about their care.

We saw patients/carers and family members could provide feedback either through compliments or complaints processes. Feedback forms were seen throughout the hospice which could be completed. We saw there were 177 compliments from January to May 2025.

Information around the hospice complaints process was accessible and displayed throughout the hospice. Staff were aware of how complaints would be managed. The service had received one complaint from January – May 2025.

A counselling service for adults and children was based at the hospice. The counselling service lead was new in post and said they felt supported by the senior management team who were currently reviewing the current service. An open-door approach was adopted by the senior management team to support the new counselling lead. The lead could also ‘drop-in’ with the hospice CEO on a Thursday and their non-working day. Additional support was provided through a senior accredited counsellor and supervisor who were based in Durham.

The team were about to increase as another new counsellor was about to start at the hospice. The children’s counselling service had ceased but they had since recruited a counsellor with children’s experience this service was to be recommenced. Veterans were also supported by the counselling service.

The service made sure that patients could access the care, support and treatment they needed when they needed it.

The service cared for people over 18 years of age with advanced progressive, life limiting illness and accepted referrals from medical, nursing and therapy staff. A total of 174 inpatients had used the service over the last 12 months. The service medical staffing out of hours arrangements were confirmed so that patients and their families could be assured they could access medical support 24/7.

A new referral policy was awaiting Board approval. The policy identified the criteria for referral to the hospice and how the referral process would work.

Referrals were through the use of a single referral form. This referral was reviewed by the relevant clinical team by the end of the next working day. Staff confirmed that referrals to the inpatient unit were discussed every morning and community referrals discussed daily. Staff said referral meeting discussions included the patients clinical need, their palliative care requirements and their preferred place of death. Referral to admission data for the last 12 months confirmed the majority of patients were admitted within one day of referral (67), followed by 36 patients having been admitted on the day of referral.

Staff said some counselling session waiting lists existed which were reviewed monthly. The waiting list was triaged which identified inpatients took priority followed by community patients when accessing counselling services. The hospice clinical governance steering group minutes for April which were attached to the hospice board report dated 12 May 2025 confirmed counselling waiting lists had improved. Waits were now on average 4 weeks from referral until the patients first counselling session.

The Mental Health First Aider (MHFA) provided initial, non-clinical support to individuals experiencing mental health challenges by applying the core principles of Identify, Respond, and Refer. This role was key to fostering a culture of mental health awareness, offering early intervention, and connecting individuals with appropriate professional or community resources.

Referrals were triaged and reviewed by a specialist nurse; referral waits were now 2 weeks. Lymphoedema services used the mobile pods in the community to reach rural areas. The second nurse was appointed to allow service expansion.

Patients could be seen by a Consultant in Specialist Palliative Medicine in the outpatient setting. Home visits could be arranged if appropriate after discussion with the consultant.

The hospice commissioned a dementia assessment to ensure they were dementia friendly. The ‘Dementia Assessment’ visit had determined how accessible the hospice was. Recommendations from this visit were implemented, for example, clinical areas had dementia clocks and in the newly refurbished inpatient unit an awareness of the colours to use to promote a calm environment.

Staff told us and we saw they had purchased two ‘cuddle beds’ for use by patients. This is a bed which has the same footprint of a standard ward bed, at the touch of a button, it can widen to a double bed. Staff said this then gave patients and their family members the option of cuddling together whilst at the hospice.

There was a specialist palliative care social work service. The team offered practical and emotional support with any non-medical issue which may affect the well being of a person or their families and/or carers.

Following the assessment the provider confirmed the hospice had 5 falls beds which had resulted in no falls from beds.

We saw that patients could access the hospice website to access videos and resources which included: fatigue, well being and breathlessness.

Staff and leaders actively listened to information about patients who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The hospice started a volunteer steering group in April 2025 to reach people and communities whose voices are seldom heard. Two volunteers attended the first meeting, and the next meeting was planned for the 2 June; the main item on the agenda was to plan volunteer week and to make the group more formal.On Wednesday mornings volunteers could drop in to speak about opportunities, development and to feedback about what was happening at the hospice.

The hospice worked with Colleges in Low Participation Neighborhood's and attended their volunteer and employment fairs. Students may not be able to attend work placements; the hospice linked with the Speakers for Schools work experience to develop a work experience (online) offer.

The hospice expanded access to its care in rural communities through mobile outreach units. The mobile units operated twice weekly and were staffed by qualified staff and supported by health care workers or support staff.

The hospice has joined the Scarborough Coastal Health and Care Research Collaborative (SCHAC) which commenced in April 2025 which looked at local targeting of inequalities to narrow the gap and was inclusive of community involvement.

Motor neurone disease and neurology clinics worked together to support patients with these conditions.

Recently deceased people were discussed at the multi-disciplinary meetings. The hospice has in place a service level agreement with two different funeral directors to transfer 2 hours after death.

Six clinical nurse specialists (CNS) provided a five-day Monday to Friday community service. Three local area hubs were each led by a band 7 CNS. Referrals to the hospice community team were initially triaged by the duty nurse. This ensured patients care, support and treatment were tailored closer to home by a local community team.

Staff told us how they tailored patients care and support whilst at the hospice, for example, one patient had requested and was supported to visit the beach one last time. Staff said if patients were unable to leave the hospice and they wanted a beach experience, a virtual beach experience would be created on site. Another patient had restricted use of their fingers so was given a big buzzer which ensured he could call for help when needed.

Patients were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) standard operating procedure advised staff in this area. The ReSPECT process created a personalised recommendation for a person’s clinical care in emergency situations where they are unable to make decisions or express their wishes. The process consists of conversations between a patient and healthcare professionals.

Staff completed ReSPECT training. Staff compliance training levels were 100% for Respect Authorship and Awareness; 95.2% for Respect Interpretation as 2 staff were booked onto complete this module by June 2025.

Following a patient’s death the service audited patient records to ensure that all decisions that had been made by the person were followed. Carers and family members were invited to these reviews.

The outcome of the audit of ReSPECT plans and associated Advance Care Planning (November 2024 – April 2025) audited 6 patients per month (3 from Inpatient and Community CNS services) had identified 4 actions which included the establishment of a regular monthly ReSPECT audit data collection. An area of improvement related to the patients preferred place of death, this audit had identified 53% had died in their preferred place of death; the hospice hoped to increase this to 75%.

Staff showed us where ReSPECT plans was recorded within the electronic record and where in the department printed copies of these were stored for easy access. All staff knew how to access both the electronic record and paper record.

The hospice used the electronic palliative care coordination system to electronically capture patients end of life care discussions and decisions, this in turn linked to regional EPaCCs. The four records reviewed had documented where the person wished to be for their last days of life. Patients, carers and visitors described a good service. Patients were asked their wishes about the end of life and where they wanted to be for the last days.

Bereavement support services were offered to the wider community and region. People could attend a monthly bereavement group and / or one to one counselling. Up to six counselling sessions were offered at the hospice site.

The statutory notifications of deaths received by CQC suggested good quality end of life care with compassion.