Saint Catherine's - Scarborough

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 looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that patients were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked patients’ liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question good. At this assessment the rating has been rated good. This meant people were safe and protected from avoidable harm.

However, we did find some areas in which the service could improve and these related to premises and equipment, and staffing.

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 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 Duty of Candour policy identified the actions required for this process. Staff knew about the policy and what Duty of Candour meant.

Three duty of candour incidents occurred in the last 12 months. Families for the three incidents received apologies from the hospice. Learning was identified for the three incidents. One incident was to be discussed further at the hospice mortality review meeting.

From May 2024 -May 2025 there were a total of 371 incidents, of which, 5 internal moderate harm incidents were recorded. The clinical incidents identified two patient falls and four of the five incidents had taken place on the inpatient unit. The overall learning from the review of incidents identified a more robust process for review of incidents was required. Staff training regarding the harm identification and accuracy of reporting harm levels was to be implemented. The level of harm is to be reviewed by the patient safety group monthly.

Learning took place following patient survey feedback collected from 91 patients and service users (1 January – 31 May 2025). Six actions were identified from the feedback and incorporated into an action plan with completion dates. Some of the learning included the development of the communication of patient feedback within the hospice teams. Options included the introduction of screen savers and changes to the way shared learning updates to staff were delivered.

We asked for evidence which confirmed staff had learnt from safety events. Staff meeting minutes were provided from the inpatient unit. Documentation shortfalls were identified on one set of staff meeting minutes (10 March 2025). Staff were asked to improve on these shortfalls.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when patients moved between different services.

The emergency transfer agreement was part of the hospice block contract and service specification with the local Integrated Care Board. We requested the service provide the transfer agreement with the local NHS Trust and latest transfer agreement meeting minutes with the Trust. This information was not provided. However, we saw the hospice had a business continuity plan in place which advised staff and managers of the processes to follow should patient transfers be required in an emergency. The business continuity management plan (v2) gave clear instruction in the event of a disruption to services, for example, critical IT failure, significant absence of staff.

Staff said the electronic palliative care communication system ensured effective communications took place between different partners such as GPs, ambulance services and district nursing.

The patient record system (SystmOne) has an initial assessment template used by all teams across community and inpatient services.

Weekend admissions information was logged onto a referral’s outcome diary so community teams who did not work weekends could see which patients were admitted. Full information was given in the daily referrals meeting. Monthly monitoring of this calendar took place; staff said compliance rarely fell below 95%.

Continuity of patient care and record sharing ensured patients’ needs were met, for example, the fast-track team provided support to people in Scarborough and Filey. Community nursing staff provided support to patients across the Scarborough, Whitby and Ryedale area. Community nursing staff provided support to patients throughout the community.

Additional safe systems of care which ensured safety was managed and monitored included: the incident reporting system, complaints and compliments, some audit and risk management systems. Incidents were reviewed at the established patient safety group which met monthly. We spoke with different staff groups who all confirmed they knew how to use the hospice incident reporting system and were aware of the patient safety group.

Staff said although introduced the Patient Safety Incident Response Framework (PSIRF) was not embedded.The hospice had identified six patient safety priorities for PSIRF which were identified within the patient safety incident response plan (reviewed March 2025). These included pressure damage, safeguarding, medications, falls, systems and processes and unplanned responses.

Patient risks were identified and reviewed weekly using evidenced based tools. These systems identified potential patient safety issues at an early stage so actions could be implemented to safeguard patients.

Safety huddles were introduced to identify ongoing risks and were well established; staff said members of the multi-disciplinary teams met at 09:30 each morning. We saw the electronic handover document dated 20 May 2025 which provided updates in all areas pertinent to the patient.

Staff said neurological consultant staff from other organisations had run outpatient sessions from the hospice to ensure patients were seen locally.

The last staff survey took place in August 2024 which resulted in 6 actions. The lowest response rate to an action was 26% where staff agreed that ‘communication between different teams/departments is effective’. This response was followed by a 64% response rate to ‘My views are listened to and valued’. Actions were identified for all six areas in response to staff feedback. The hospice provided an updated action plan on the 20 March 2025.

Feedback from volunteers was captured via drop-in sessions every Wednesday (08:00-12:00) at the hospice. Volunteers could also provide feedback by phone.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving patients’ 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 said that they felt very safe in the hospice, and they were treated well. Relatives said they had no concerns about their family members being at the hospice.

The hospice had six designated adult and child safeguarding leads; four staff had completed level 4 safeguarding adults or children’s training, whilst the safeguarding lead was level 3 trained. Each department had a designated safeguarding link person whose responsibility included feedback updates to their teams and that staff safeguarding training was achieved. Staff described their safeguarding process and confirmed confidence in using it. Staff knew who the safeguarding leads were in the hospice.

Safeguarding governance processes included monthly safeguarding meetings which fed into the clinical governance group and monthly patient safety group. Policies and procedures were in place to support the safeguarding process.

Safeguarding concerns were discussed at the weekly multi-disciplinary team meeting and at the community clinical nurse specialists’ meetings. Following the assessment, we were told that safeguarding supervision sessions had taken place as part of the multi-disciplinary team meeting. No safeguarding concerns were escalated to the hospice board in the last 12 months.Staff on the Inpatient Unit said they did not have access to safeguarding supervision sessions.

The hospice used an electronic referral system to report safeguarding concerns and had a process in place for referring to the local authority. The service discussed all their safeguarding referrals in house prior to referral to the local authority. The hospice supported the local authorities’ investigations when safeguarding concerns were identified. Safeguarding concerns were also recorded on the hospice incident reporting system. Feedback could be provided via the electronic recording system or in person dependent on how the reporter had asked for feedback to be given.

Staff recognised other forms of safeguarding, such as people suffering from domestic abuse and female genital mutilation (FGM). Staff training statistics confirmed FGM overall training compliance was 98.6% as of the 19 May 2025.

Staff could describe what Deprivation of Liberty Safeguards (DoLS) meant and said should there be an urgent DoLs request this would be managed through the local authority. Training statistics dated week commencing 19 May 2025 confirmed Mental Capacity Act and Deprivation of Liberty Standards training compliance ranged from 85.7% to 100%. Overall compliance for MCA/DoLS was 97.14%.

Training statistics dated week commencing 19 May 2025 confirmed staff were trained to the required level in Safeguarding adults and children; training compliance ranged from 95.6% to 100%. Equality, Diversity and Human Rights – Level1 training overall compliance was 98.8%.

Permanent staff overall compliance for PREVENT training was 98.82%; bank staff compliance in this training was 58.82% (Board Report 12 May 2025).

Level 1 safeguarding training was completed by 59% of volunteers.

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

When patients were transferred out in an emergency situation and as part of Business Continuity plan the hospice contacted the bed management team and senior site manager at the local NHS Hospital. The patient would be transferred to the Accident and Emergency department in liaison with the Ambulance Service.

The Resuscitation, Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) Policy (v3) provided clear advice to staff.

The Patient Clinical Emergency Procedure (v2) informed staff of the procedures to follow should a patient or person collapse. Training statistics confirmed 96.77% of staff had completed basic life support training.

The risk management policy advised on clinical and non-clinical risk processes.

Evidence based risk assessment tools were used and recorded into an electronic patient record. These tools supported the staff to ensure robust, detailed and individualised risk assessment plans were in place. Staff told us where the risk assessments were, showed us these in the electronic record system and demonstrated how easy risk assessments could be re-assessed. We reviewed 4 risk assessments and saw they had been completed and reviewed weekly.

Patients and carers were involved in managing all risks. Risks were assessed on admission using an individual approach for each person and reviewed weekly or more often if required.

The electronic record system confirmed that medical staff had completed the venous thromboembolism (VTE) risk assessments on those patients at risk of developing blood clots in the veins.

The service ligature risk assessment policy provided advise to staff. The Patient Environment Risk Assessment, Use of ligature points risk assessment was reviewed in December 2024. This risk assessment identified existing control measures, recommended control measures and risk ratings against each risk. We observed that the existing control measures were risk rated 10 which was identified as timed action required (10-16 risk levels). However, we observed that despite having a rating of 10 the risks had been colour coded as a lower risk 6-9 adequate. Following the inspection the provider confirmed an error was made in relation to the colour used. Progress against the action plan’s recommended control measures was not shared.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment supported the delivery of safe care.

Reception staff ensured all visitors to the hospice signed in electronically. We saw this in action and as visitors were provided with the necessary badges to allow access to the hospice areas. Access to the inpatient unit was via an electronic locked door.

The hospice was well maintained and decorated; rooms had en suite facilities. Another inpatients area had recently been renovated; staff said patients were due to be moved from the existing inpatients area to this area now it was finished. Additional bathing facilities for patients who wanted a bath or required assistance with the use a hoist was available. The hospice had recently upgraded this bathroom following patient feedback so that the bathroom provided a ‘spa like ambience’.

Staff made sure equipment, facilities and technology supported the delivery of safe care. Staff said they had all the equipment required to provide good care to the patients. We received the senior maintenance technician and staff nurse inductionpacks which confirmed which equipment the staff group would be trained in. Once competent staff signed and dated confirmation of having completed the training.

We requested for the all-staff groups the training log which confirmed completion of training for clinical and non-clinical equipment; we received confirmation of training in the use of bed rails only. As such, we were unable to determine whether all staff groups had completed the necessary equipment training.

Hospice preplanned maintenance schedules, equipment servicing and portable appliance testing records confirmed equipment was well maintained and serviced as per equipment guidance. Random equipment checks confirmed portable appliance testing and / or servicing had taken place. Resuscitation equipment was checked monthly and documented.

The Patient Clinical Emergency Procedure identified the resuscitation trolley, including medication, was to be checked weekly or after any use of the equipment. The resuscitation equipment and medicines log from March to May 2025 confirmed monthly checks had taken place. This meant staff had not followed policy with regards to resuscitation equipment and resuscitation medicines checks.

We requested the latest environmental, fire and health and safety risk assessments. The information was provided on excel spreadsheets. The dates the risk assessments took place were identified and mitigation was identified against each assessment. Individual action plans were not provided.

The medicines fridge temperatures were checked daily. However, we observed that on 2 occasions the fridge temperature had been over 8 degrees for 3-days in April and May 2025 and this had not been reported to the manager.

The service did not always make sure there were enough qualified, skilled and experienced staff. Staff did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met patients’ individual needs.

Prior to the inspection some concerns were raised anonymously. The concerns related to staff leaving the service and new staff being allowed to start work at the hospice before the disclosure and barring service (DBS) check outcome was received. We approached the hospice who provided evidence which confirmed new staff DBS checks were completed prior to them starting in post, this was therefore unsubstantiated. At inspection we reviewed 7 new staff recruitment records and noted all the checks were completed.

Medical Staff

The hospice risk register identified the shortfall of medical staff as a moderate risk; monitoring this shortfall was through bi-monthly reviews by the board and executive team. One consultant was currently employed at the hospice. The current shortfall in permanent senior medical presence at medical director and consultant levels was due to two recent vacancies at this level. Hospice staff said the medical director and consultant post had been advertised.

The hospice currently had sufficient medical cover; however, the existing consultant was due to leave by September 2025 which would leave the hospice with limited permanent medical cover at consultant level. Two part-time specialty doctors both worked 3-days a week provided support, clinical cover and training sessions at the hospice. Five on-call non-resident doctors (all GPs) also worked at the hospice.

Currently, there were 3 specialist doctors (1.2 wte). An increase to 4 specialist doctors (1.4wte) was planned. A foundation year doctor worked 5 days a week.

Registrar level cover was provided from two doctors who worked part time hours. One was in post, and one was joining imminently. Whilst there was limited consultant cover, they were supported from the locum agency who offered supervision and advice.This agency also provided expert clinical palliative care advice, twice weekly board rounds for the hospice community palliative care team, clinical supervision and caseload reviews.

The hospice had paused GP trainee training due to lack of consultant oversight but were continuing with core trainee year 1 (CT1) trainees. This was to be reviewed if the vacant consultant and medical director posts were not filled.

We reviewed 3 doctor's personnel files and noted the checks were completed. One doctor's DBS was due for renewal in 2024 and staff were alerted to this during the inspection. Following the assessment the hospice informed CQC that the doctor's DBS was issued in 2024.Two doctors’ records confirmed appraisals had taken place. One doctor's appraisal was in 2022, the other doctor’s appraisal was in 2023; no evidence of an appraisal was seen for the third doctor. Following the assessment the hospice informed CQC that appraisal of the GP was done by the GP's own practice and that evidence of appraisal completion was not required by the hospice. The hospice confirmed that GP's shared any ongoing relevant clinical issues.

Some medical staff worked at the hospice under practising privileges agreements. To work at the hospice doctors submitted an application, were interviewed and their request discussed at the hospice medical advisory committee.

Staff said the rota comprised of first and second on call consultants; electronic medical staff out of hours rotas could be accessed by staff. Staff said good working relationships existed between medical and nursing staff.

Inpatient Unit

Staff told us the inpatient unit was currently operating on 10 beds due to funding. To calculate staffing needs the service used the Mary Potter tool. Staff told us the tool did not capture patients’ dependency levels. Currently, new nursing and healthcare assistants (HCA) were being recruited into post.

The electronic staffing rotas reflected actual staffing levels against the planned staffing levels. In addition, the senior staff member who provided out of hours support was identified on the rotas.

Staff we spoke with generally said staffing levels were safe, although staff sickness, staff skill mix and patients’ dependency levels could impact staffing. Where additional help was needed staff would either volunteer to work additional shifts or would be approached directly to work the additional shift(s).

Staff said monthly staff meetings took place, although, on occasion these meetings were cancelled if staff were unable to attend. Staff said the last ward meeting took place the week prior to the inspection.

Community Team

The hospice community team was overseen by a band 8a clinical nurse specialist (CNS). Six CNS provided a five-day Monday to Friday service. The CNS team were based in the inpatient unit at the hospice. Defined caseload levels were identified per CNS and outcome measures were used to identify patient need, for example. whether patients were stable, deteriorating, unstable or dying.Three community team hubs were each led by a band 7 CNS. Staff meeting minutes confirmed the team met monthly.

Fast Track Team

This team comprised of healthcare assistant (HCA) level 3 trained staff. Staff said staffing consisted of 11 HCA plus two bank staff. These staff were commissioned to work in Filey and Scarborough only.

Volunteers

Volunteers at the hospice were managed by an identified staff member. A volunteer agreement identified a named supervisor for the individual; this was signed and dated by both parties. Volunteers received a training pack which confirmed the training topics within the handbook; to-date 59% of volunteers had completed the training in the handbook. Volunteers signed to confirm their understanding of the topics on receipt of this handbook.

Allied Health Professionals

Occupational therapy and Physiotherapy staff were employed at the hospice. Occupational therapists were employed from assistant level at band 4 to senior therapist levels at band 6. Staff said there had been an additional investment in staffing over the last 12 months and as such were happy with the current staffing levels and arrangements for their staff groups. Staff said they had received a good induction to the service and were well supported by leaders. From June 2025 there would be an increase in AHP staffing. Staff said AHP cover to the Inpatient ward had been provided 5 days a week.

Bank, Agency and Locum Staff

Leaders said bank, locum and agency staff were used to address staffing shortfalls. There had been an increase in bank and agency use in March 2025 due to higher levels of staff sickness. From 1 December 2024 until 30 April 87 bank staff were employed to work in the inpatient unit. The Fast Track health care assistants’ team (FTHC) required the most additional hours, and the majority of these hours were provided by in house staff. Medical cover was provided by doctors.

2024 – 2025 - Staff sickness

Staff sickness levels for all staff groups from January 2024 until April 2025 ranged from 2% (61 days) to 8% (203/204 days).

Training, Appraisals and Supervision

At the 2021 inspection SHOULD actions were identified in relation to an improvement in mandatory training compliance, L3 Safeguarding, Mental Capacity Act and Deprivation of liberty safeguards (MCA/DoLS) and to include medicines management training. We were told the training target was 95%.

The training statistics supplied confirmed that all staff groups overall mandatory training compliance was 95.2%. There were shortfalls in compliance for individual staff groups, however, we were not provided with the detail as to why these shortfalls had occurred.

Mandatory training statistics confirmed staff could access learning disabilities and autism training – current overall compliance for week commencing 19 May 2025 was 83.3%. Community services and medical staff compliance was 100%; compliance within other services ranged from 65% to 86.2%.

Training statistics dated 19 May 2025 were provided by the hospice for safeguarding, MCA/DoLS and medicines management training. Compliance ranged from 92.86% for medicines management to 97.14% for MCA/DoLS. One person of 14 identified staff had not completed the medicines management training. Staff told us they had or were about to complete the Oliver McGowan training.

Some staff said there were some restrictions on training provision, for example, there were no trainers available to provide some face-to-face training sessions and training dates were not identified. Some training could be accessed online; however, some staff had been asked to complete this in their own time. This meant dedicated training time was not provided for staff to complete the required training.

We saw examples of the training provided to all staff groups to develop their skills and competencies, for example, Lunch and Learn – Advanced Palliative Care Practice. All new staff attended an induction. Service specific training programmes were available for staff, for example, the Clinical Nurse Specialist Extension for Community Outcomes focused on widening access to specialist knowledge and best practices in palliative care.

Face to Face dementia Friend training took place at Saint Catherines on the 8 May 2025. This was a 2-hour session ran by the Alzheimer’s Society. Future training dates would be agreed. This was attended by 3 volunteers and 5 paid staff. Staff said dementia training will be added onto the mandatory training matrix following the roll out of the learning disability training.

Clinical supervision and safeguarding supervision sessions had not been offered to staff on the inpatient unit. Staff said community team staff had monthly clinical supervision.

Medical staff had annual reviews and quarterly clinical supervision sessions. Leaders told us that 2025 doctors’ appraisals would be completed before the clinical lead left the hospice. Education sessions included attendance at the quarterly regional learning group.

Staff said they should have annual appraisals; however, not all staff we spoke with had an appraisal in 2024/25. Leaders said that staff had to be trained in the appraisal process. The appraisal training was currently offered to staff at ward manager and senior staff nurse level. Staff said staff appraisals when due would now flag on the new human resource system. We asked for confirmation of the 2024/2025 appraisal statistics, but did not receive this information. The appraisal window was extended to the end of September 2025 to allow staff and managers time to engage fully with the new performance system.

All staff: 40% completed, with remaining appraisals scheduled ahead of the September deadline.

Nursing Staff: 25% completed, with remaining appraisals scheduled ahead of the September deadline.

AHP Staff: 20% completed, with adjustments made for recent team changes, the remaining appraisals scheduled ahead of the September deadline.

Medical Staff: 100% completed

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff said the service had a formal service level agreement with the local NHS Trust and could access a microbiologist and the trusts infection prevention and control team (IPC) for advice.

IPC discussions which included policy updates were discussed at the hospice IPC committee. Changes were circulated to staff through staff newsletters, at ward meetings and by the IPC lead nurses. IPC policies and procedures were in date.

The hospice had two infection control leads, both, had completed online Level 1 and level 2 infection, prevention and control training. We saw no evidence they had completed additional training to ensure progression from novice to expert practitioner level as identified by the NHS England guidance ‘the Education Framework for the Infection Prevention and Control Practitioner (IPC) Workforce (October 2023)’

IPC training at induction and IPC training at level 1 and level 2 were provided to staff as part of the statutory and mandatory training provision at the hospice. Training statistics for 2024/25 for clinical staff including medics, nursing and Allied Health Professionals staff groups was 100%. Volunteer staff received IPC guidance through their induction handbook. Confirmation of volunteer infection control training compliance was not provided.

Staff said all staff were ‘Face Fit’ tested. This is where staff who wear a tight (or close) fitting mask for work have to be ‘fit tested’ before wearing a close-fitting respirator mask for the first time.

The hospice environment and equipment were visually clean. Hand gel pumps were present throughout the hospice, although, there were limited hand pumps in corridor areas. Staff confirmed individual hand gel pumps were located in patient rooms. Staff said there had been a shortage of hand gel, however, a delivery was due. Handwashing guidance was displayed above some sinks.

We observed carpeting in one inpatients unit area; staff said this inpatient area was due to be upgraded in July 2025 which included removal of the carpet. The current inpatients unit was to be relocated to another area within the hospice which had recently been upgraded. We toured the new area and saw no carpeting present. The hospice have confirmed this carpet has now been removed from the inpatient area.

Staff confirmed cleaning practices followed the new cleaning standards. ‘I am clean’ tags on equipment confirmed cleaning had taken place.

Cleaning schedules, weekly and daily cleaning check lists confirmed cleaning took place. Monthly deep cleans took place and again when the patient no longer needed the room. We reviewed some room cleaning audit documents from January 2024 to April 2025 and observed none had a nurse signature present which indicated the standard of cleaning was satisfactory.

Cleaning audits were completed daily and weekly. Where audits fell below expected standards the service IPC Environmental Audit (2024) action plan ensured ongoing monitoring took place. A weekly leader’s audit looked at all aspects of the local environment within the inpatient unit. The daily cleaning audits provided for different areas throughout the hospice for the week commencing 29 April 2025 to the 5 May 2025 confirmed the majority of areas were cleaned daily.

Completion of the hospice UK audit had taken place at the end of 2024, for which no actions were identified. This audit information could be accessed through the hospice information technology system. Staff confirmed monthly IPC audits took place, the results were reported to the monthly IPC meeting.

Staff said 3-monthly handwashing audits took place; 100% compliance for was achieved for week commencing 19 May 2025.

The hospice had achieved a five-star food hygiene rating.

The hospice had recently purchased toys for use by visiting children, however, we were not shown the toys management policy. Later, during the inspection we were shown a toy cleaning schedule which had one date identified.

Legionella inspections dated 13 March 2025, and 13 May 2025 identified no actions.

Waste disposal was through a contracted service. Waste segregation guidance was displayed for staff guidance. We saw clinical waste locked in an external cage.

The Hospice Health and Safety Lead was responsible for ensuring compliance against Control of Substances Hazardous to Health Regulations (COSHH). Staff told us that all COSSH sheets were available for staff to access. We saw COSSH products in locked storage.

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.

Staff followed systems and processes when safely prescribing, administering, recording and storing medicines.

During the inspection we spoke with the consultant, pharmacist and pharmacy technician, nursing staff and three people about medicines.

We talked to the registered manager who was also the hospice's accountable officer about the arrangements for handling-controlled drugs (drugs liable to misuse). The accountable officer has a legal responsibility to ensure that controlled drugs were kept secure and safely managed. We found controlled drugs were handled safely. The stock balances of the four controlled drugs we checked were correct. The accountable officer participated in local meetings and submitted reports to the controlled drugs local intelligence network. Comprehensive policies had been reviewed recently by the new pharmacy team and were awaiting ratification by the board of directors. During, the inspection staff told us they had continued to use the current medicines management policy (v2).

A procedure was in place to allow people to self-administer their own medicines if they wished, though this was not promoted. Facilities were available within people’s rooms so they could keep their medicines safely with them.

Staff followed current national practice to check patients had the correct medicines, although there was no clear process for a second check to ensure that people’s normal medicines are continued appropriately.

We were told that the service did not have a clear process to assess patient’s own medicines when they were admitted ensuring they were suitable for use.

Medicines, including medical gases, were stored securely. however, one oxygen cylinder was noted as out of date, this was changed immediately.Emergency medicines were available should they be required.

The service had a pharmacy team who worked at the hospice consisting of a pharmacist 1 day per week and pharmacy technician 3 afternoons per week.Medicines were supplied by a combination of the local community pharmacy and direct from suppliers.

The pharmacist attended multi-disciplinary team meetings when they were in the service to ensure the safe use of medicines within the service.

There was a paper record system and prescribing were clear, safe and appropriate to be able to respond to symptoms that patients may experience during their stay. It was clear to staff which medicines were to be administered for which symptom and in which order. If medicines were not administered or administered late, reasons were clearly documented.

People told us that they were involved in decisions around their care. They were happy that medicines were administered on time and that requests for additional pain relief, prescribed when required, would be administered in a timely manner.

Staff reviewed patient’s medicines regularly and there was evidence of medicines being appropriately titrated to respond to patients’ increasing symptoms or to consider other medical conditions (for example renal or hepatic disease). Staff provided specific advice to patients and carers about their medicines. At discharge the patients were provided with a list of their medicines and how to take them.

Patients received medicines through syringe pumps (medicines delivered through the subcutaneous skin layer) which were monitored in line with expectations.

Prescription stationery for use by the community team was safely stored and controlled.

Medicines were prescribed off-label and occasionally unlicensed medicines were used within the hospice. This meant the use of these medicines were not covered by the manufacturer. This prescribing was guided by standard practice within palliative care and prescribers gave additional information to people if required.

Nurses received medicine training and had their competency to administer medicines assessed at least annually. These competency checks included a medicine round competency check, preparing, dispensing and administering controlled drugs and correctly using a syringe driver. A syringe driver enabled medicines to be given via a small portable battery-operated pump which provided a continuous dose of medicine.

Medicines management training compliance was 92.86% for week commencing 19 May 2025. Since the assessment we were informed that 13 of the 14 staff named on the medicines management training compliance record were all clinically faced nursing staff.

Audits of quality were completed for medicines. There was a system for recording the receipt of national drug safety alerts and any action taken. Staff were encouraged to report medicine errors, including those that did not affect patients, so lessons could be learnt and practices made safer. These were discussed at the medicine management group.