Saint Catherine's - Scarborough

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Key question commentary

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patients who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question good. At this assessment the rating remains good. However, we have identified some areas which require further development within governance and the freedom to speak up area.

This service scored 64 (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 vision, values and strategy whose aim was to improve the service for patients, their carers’ and /or family and local communities. Concerns were raised about the culture and lack of staff engagement.

Prior to the CQC inspection CQC had received feedback from some staff; anonymous staff feedback was also received post inspection. We have spoken with some staff post inspection and have also spoken with hospice board members due to the nature of the concerns shared with us. Some staff described the hospice culture as challenging and slightly unsettling when staff left and wondered why staff had left, some leavers were described as staff who had recently been employed by the hospice. Staff said monthly staff meetings were planned, however, on the inpatient unit these had not always occurred. Some staff said they had not been involved in decision making about the hospice changes and there had been limited communication to staff about the progress of any changes, one example given was a new service where GPs would care for respite patients.

Discussions with board members described the hospice as having an open and inclusive culture. Leaders were visible within the hospice; encouraged discussion with staff which included sharing information. We were told the Chief Executive Officer managed the hospice as they should and that the new human resource function had to be robust to ensure accountability. There was recognition that at times some staff may have been resistant to the changes being made, however, staff had been involved and informed through regular meetings and staff feedback.

Leaders said staff feedback was also collected and shared by management teams through the ‘You said, we did’ initiative. This alerted staff to any changes made as a result of their feedback.

The leadership team recognised staff contributions through the annual star awards, monthly awards and personalised staff emails from the executive team.

The service had a vision, mission and values in place. Staff had been involved in developing the hospice values: excellence, people centred, integrity and collaboration. Behaviours’ which linked into the values were agreed, for example, integrity – effective communication was one behaviour of the three identified. This information was displayed throughout the hospice.

The service strategy identified both short-term objectives (2024-2026) and three long-term goals. The long-term goals were:

1. Deliver outstanding, personalised patient care
2. Deepen community engagement and advocacy
3. Ensure organisational sustainability and smart growth.

Strategic initiatives were identified alongside an action plan, performance measurement indicators and a communication plan. Key risks and mitigation strategies were also identified as part of the strategy.

Leaders understood the context in which the service delivered care, treatment and support. Concerns were raised about some leadership behaviours within the hospice which did not embody the culture or values of their workforce and organisation.

The service’s leadership team had undergone some changes since the last CQC inspection. A new Chief Executive Officer, registered manager and senior managers were in post.

Prior to this inspection staff had identified some concerns pertaining to some members of the leadership team and said the hospice had a high turnover of staff who had left the hospice. We had seen and were assured by the information about staff turnover and the reasons for this prior to the inspection following a request for information.

We have spoken with some staff post inspection and have also spoken with hospice board members due to the nature of the concerns shared with us. We discussed leadership and culture with members of the Board following the inspection. Assurances from these interviews confirmed the Chief Executive Officer (CEO) and Board were held to account. Communications between the Board and teams improved following a change in governance communication structures which was instigated by the CEO. Leaders said they could challenge what goes on and questioned processes to ensure the right decisions are made. There was a recognition the CEO’s intervention and engagement with staff had resulted in positive changes within the acute care setting and had implemented new ways of working despite high challenges at times.

Discussions with the multi-disciplinary team (MDT) identified a mixture of positive and negative feedback about the leadership teams. We were told that the executive team were visible throughout the hospice and of the positive atmosphere experienced in the hub when one executive member was present. Members of the leadership team we spoke with said they had an ‘open door’ policy so staff could access them.

Staff shared some experiences they had with individual members of the senior leadership team; some were positive and supportive, others less so. Some positive comments included ‘they are one of the team’ and ‘they have impacted positively as now the clinical voice is heard’. Some staff said they did not feel confident in approaching one member of the leadership team and felt communication could be better.

Staff were given opportunities to meet with senior leaders through the CEO and Director drop-in sessions, the open-door policy and when senior leaders were present on clinical and / or non-clinical areas.

Succession planning was in place to enable staff progression. Staff told us this could be external coaching and expansion of their roles. Some of the senior leaders we spoke with said they had received / were receiving coaching as a form of development.

Freedom to speak up guardians were available to support staff; however, people did not always feel they could speak up and that their voice would be heard.

Some staff said they did not feel safe speaking up and if they had any concerns, they would discuss them with people outside of the hospice as they did not know the Freedom to Speak Up Guardians (Guardians) well and as such were afraid the discussions would not be kept confidential. Leaders confirmed that appointed guardians were trained within their role and fully aware of the importance of confidentiality. When some staff had raised concerns, they said their experiences with some senior people within the organisation had not been supportive.Staff could access the team through the use of drop boxes, during attendance at team meetings where the guardian was present and during departmental and shop floor visits.

Leaders said a nominated Trustee served as the designated board lead for freedom to speak up and acted as an independent, non-executive point of contact for staff and volunteers who felt unable to raise concerns internally. This Trustee ensured cases were handled fairly, promptly, and without conflict of interest. The trustee provided constructive challenge to the executive team.A quarterly meeting was held between the Trustee, the Guardians, and the executive human resource (HR) lead. Guardians had weekly access to an external HR consultant for resilience and professional guidance.

Staff knew who the Guardians were and how to report a freedom to speak up concern. Staff were kept informed through freedom to speak up at their initial service induction, the staff handbook, newsletters, posters displayed on boards, an article on the Hub. Staff could access the team through the use of drop boxes and during attendance at team meetings where the guardian was present.

Following the inspection, we asked for the latest freedom to speak up (F2SU) report as we were told that the F2SU team (Guardians) provided a report to the Hospice Board of numbers and trends. The F2SU team met weekly with a Board trustee and the human resource lead who was the executive lead for the freedom to speak up process. They explained how they ensured that staff details were not shared with any other staff members and how they ensured confidentiality between themselves.

We reviewed the F2SU information provided by the hospice post inspection which comprised of F2SU data and a separate summary report of this information. The data and report were for the time period August 2024 – May 2025. A review of these documents showed that the summary report case classification data was different to what was in the F2SU excel data sheet entries. This meant the report was not representative of the data within the F2SU excel data report.Following the assessment the provider confirmed that areview of these documents showed that the summary report case classification data was different to what was in the F2SU excel data sheet entries. The separate summary report was an ad-hoc document prepared post-inspection under time constraints. A clerical misclassification occurred in this summary, which the provider acknowledged.

Staff said the hospice Freedom to speak up policy (v2.1) was written by an executive leader from the hospice.

Two Guardians worked at the hospice. The Guardians initially did not have protected time to support staff or the hospice with concerns. One Guardian of the team of two had recently been given one hour by their manager.

The Guardians said they had felt supported by the leaders of the service and the national team to help them develop within the role. This included attendance at the national Guardian training which was refreshed annually. Additional support was provided through the national guardian office who provided mentor support if required.

The Guardians described the process they followed when they received a concern and the type of concerns they had received. They said managers had listened to them and they had felt supported by the person they reported into.

The Guardians attended online meetings with the national hospice and Northeast Regional Guardian Group. To-date, 19 F2SU cases had been raised to the guardians.

Leaders told us that they also had an open-door policy and regular drop-in sessions so that staff can come and talk to them. Leaders said they were currently reviewing the guardian roles and further discussions were planned to take place at the July 2025 hospice board meeting.

The service did not provide key staff with the knowledge around the Workforce Race Equality Standard to apply when working with staff. Staff may not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The leader for equality could not explain what the Workforce Race Equality Standard (WRES) was; this information was not available for the Hospice. They confirmed an equality and diversity policy was in place. We had received the service Equality, Diversity and Inclusion policies prior to the inspection as part of an information request. We were told no actions had taken place to reach out to the staff since this policy was written. Information received post inspection confirmed 3 actions were identified for 2025 – 2026. These actions included the production of an annual Race Equality Standard by January 2026 and to develop an inclusive practice and policy by October 2025. We also received 2 sets of Equality, diversity, and inclusion meeting minutes from meetings which had taken place in 2024/2025. Most staff we spoke to said that they were treated fairly and equitably, and that they had not seen any other member of staff treated badly.

Staff could access Equality training to help them understand about protected characteristics. The Equality lead said that they had not had any further equality training to support them in fulfilling this role. However, following the assessment we were told that equality training was part of the induction process.They confirmed they had completed some online training and the Oliver McGowan level 1 training.

Staff explained how they went out into the community to speak to harder to reach groups and were looking at ways to invite these groups into the hospice. Some people had since been supported to become volunteers at the hospice. In addition, staff reached out to communities which may be excluded by visiting different communities, cancer well being clinics, motor neuron clinics and had reached out to local religious groups. Engagement had also taken place with the PRIDE community which is a diverse and inclusive group of individuals, organisations and events that celebrate lesbian, gay, bisexual, transgender, and queer or questioning. (LGBTQ+).

Engagement had taken place with the Care Alliance which served local and regional communities with over 300 community members across a variety of disciplines and businesses.

Work to support people with autism and learning disabilities included the creation of pictorial information. One staff member had invited people with a learning disability or autism to the hospice, as yet, this visit had not taken place.

Leaders described some positive support given to nurses on the 12 May 2025 which was International Nurses Day. Leaders said staff were thanked with a personalised card and cake.

Governance systems were in place; however, we found some shortfalls in compliance within these systems. The service had identified clear responsibilities, roles and systems of accountability within its governance framework. We saw that new systems were being put in place, however, needed to be embedded and areas within governance required further development.

The information provided and discussions with staff confirmed governance systems were in place at the hospice; however, we observed that in some areas furtherdevelopment was needed. Twelve subgroups reported into the clinical governance steering group. Staff said this included the patient safety group. The clinical governance steering group reported to the Executive team and Board of Trustees.

Multi-disciplinary daily operational meetings captured risks, concerns and staffing issues. Staff said the current management team encouraged open communication pathways.

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.

Staff said although introduced the Patient Safety Incident Response Framework (PSIRF) was not embedded.

Leaders said the hospice had 2024/2025 audit schedules. We requested further information following the inspection and the hospice shared non-clinical and patient safety audit schedules for 2024 – 2025. Staff confirmed involvement in how the service was monitored through audit. Audit outcomes were shared at staff meetings and through email correspondence.

The hospice training target of 95% was not achieved in some training sessions by some staff groups. Training statistics confirmed not all staff groups had completed their mandatory training.

We requested the all-staff groups training log which confirmed completion of training for clinical and non-clinical equipment, this was not provided. As such, we were unable to determine whether all staff groups had completed the necessary equipment training.

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.

A newly appointed hospice training lead had additional support provided by a new staff member who had started work at the hospice 4-weeks previously. Leaders said a palliative care training plan was in development which was approved by the Board and senior leadership teams. A training matrix was in place; the training analysis and report was to be agreed and embedded into the hospice training plan. An education steering group was to be formed.

The newly appointed information governance lead was reviewing hospice policies and procedures in line with the multi-disciplinary team. We reviewed 15 clinical policies and procedures and found referencing was out-of-date or not present for five policies. These policies included the care after death policy, tissue viability, freedom to speak up and safeguarding adults and children’s policies.

During, the inspection staff told us they had continued to use the current medicines management policy (v2) which identified two different review dates May 2025 within the information reader box and 14 August 2025 on the front page of the document. We were told a new medicines management policy was due to be approved by the Board.

Responses from the August 2024 staff survey identified communication throughout the hospice required improvement. The lowest staff survey response rate 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. Interviews held with members of the board confirmed work was ongoing to improve communications throughout the hospice.

Staff told us a new human resources (HR) function was in development. Currently, the hospice had contracted out the HR function to provide a HR system and implement the new system. A designated recruitment coordinator led on recruitment processes and absence management. Currently, managers were being trained in absence management and how to support absent staff.

Workforce planning for the inpatient unit had commenced in light of planned increases in bed capacity. The plan used a validated staffing tool and insights from the Mary Potter Hospice workforce model. The staffing model was planned to be reviewed quarterly to evaluate the plan’s effectiveness.

The risk register was on the new information technology (IT) system which provided systems for data management and incident, risk and compliance management for the hospice. Staff had completed training in the use of the new IT system.

Staff confirmed some clinical risks included medicines, falls and inherited pressure sores. When asked ‘what kept them up at night’ staff said medical and nursing staffing. Financial risks were the highest risks on the risk register. One clinical risk on the risk register recognised the reduced number of permanent consultant staff. Board meeting minutes confirmed that the hospice risk register was a standing agenda item for discussion.

Information Security and data protection policies (v2) were in place. The service had identified a Caldicot Guardian and Data Protection lead persons. Leaders said staff completed information governance online training sessions.

Following the assessment the hospice confirmed new boilers, lighting, windows and waste management systems had been installed.

From May 2024 – May 2025 the service had 9 data protection breaches. Investigations were carried out in all cases, and no significant harm was identified. Lessons were identified and where necessary actions implemented to reduce the risk of recurrence.

Assurance systems supported and monitored service performance measures. Performance in specific areas for example, falls, were discussed at the falls groupthen shared with the patient safety group who would make any required recommendations.

The service business continuity plan had been reviewed, discussions with staff explained how the service would continue in different scenarios. Leaders had met with individual departments who identified their critical areas as part of the review. Business continuity practices have taken place for fire management and a collapsed patient. Generators and solar panels provided additional support should mainline power be disrupted.

Staff said service level agreements were in place with external providers to support their services, for example, pathology, microbiology, and patient transfer agreements.

The registered manager had overall responsibility for the submission of statutory notifications to the Care Quality Commission.

The environmental sustainability action plan was monitored by the hospice environmental sustainability group. Some of the actions identified we saw were in place; these included solar panels and electric vehicle chargers. The majority of the actions where in progress or ongoing and two were due for review in May 2025.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. Staff share information and learning with partners and collaborate for improvement.

The service was identified as the first UK Hospice to launch the ‘First Masonic Aware Initiative’ which meant it was veteran aware and had achieved the gold award.This initiative has strengthened the hospice role in the provision of essential assistance to Freemasons and their families during times of need. Families and Freemasons past and present are offered practical support and companionship during periods of illness or vulnerability.

The hospice partnered with Help force, a national charity that supports health and care organisations across the UK to maximise the impact of their volunteers, to offer the Volunteer to Career for the Armed Forces community programme. This i project was designed to create pathways for retired Veterans and their family members to transition into the healthcare sector, whether in clinical, non-clinical, or other support roles.

Palcall was the palliative care, out of hours nurse led telephone helpline for patients, their named contacts and healthcare professionals involved in the patients care. Advice and information were offered to patients outside of GP surgery hours. Patients could access the Palcall leaflet which described the service offered and what to expect. Patients were also directed to the complaints function and what to do should they have any concerns.

The service focused on learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. Staff actively contribute to safe, effective practice and research.

The hospice mortality lead’s role included sharing the learning from deaths. They described the use of the integrated palliative outcome scale (IPOS) a tool for the assessment of physical, social, psychological, and spiritual symptoms and concerns to improve palliative care outcomes and support personalised treatment plans. Through, this tool they determined if the patient’s symptoms well managed, what went well and did the patient have a good death. Staff recognised the need to arrange an IPOS training session for staff. Following the assessment the provider confirmed thatIPOS training was in place and established.

Weekly multi-disciplinary team (MDT) meetings reviewed patient deaths and decisions were made as to look at patients’ deaths in more depth as part of the mortality review process. The monthly MDT mortality review meeting involved all departments and external organisations representatives would also be present.

A monthly multi-disciplinary patient safety group met to discuss incidents. A decision was made to either close the incidents or agree when further investigation was required.

The hospice had worked with a research centre in Hull and a local medical school in respect of palliative and end of life care research. This aimed to improve the quality and availability of palliative and end of life care services.

Volunteers had work placements in services for looked after children and rehabilitation centres. This educated the community in the work of the hospice and also had helped break down people’s preconceptions about the hospice.

The hospice had worked with a technical college in Scarborough who now offer a level 3 ‘Introduction to nursing’ course. Students when they reach 18 years could progress to university to complete a nursing course.

The hospice had expanded its community outreach service. The hospice and integrated care board had looked at the need for unplanned care provision per postcode. The fast-track team service model was developed in liaison with district nursing staff. Hubs were located in buildings close to district nursing teams. All partners now met monthly. Qualitative data was being collected as part of this project.

Two mobile pods had been introduced for community-based service delivery which included lymphoedema and wellbeing support.

The hospice encouraged local communities and / or groups to visit the hospice which reduced community misconceptions about hospice care. During the assessment we saw a local group visit the hospice.

A respite service had been relaunched and marketed to local communities.

Saint Catherine's had a corneal donation procedure in place. On the last days of life, the patient’s wishes, and consent were obtained and documented should the patient wish to donate. Following death, family consultation occurred before the eye or corneal tissue was retrieved. In the decision-making section of the last days of life document, ‘This is Me’ the patient’s wishes regarding organ and tissue donation were recorded and a plan put in place to ensure the corneal donation was possible if conversations and consent were obtained ahead of the patient death.

Flavours café was established on site to help break down barriers between the Hospice and the community which raises awareness around the services.