Harlington 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 was a focus assessment to check improvements had been made in the areas highlighted at our last inspection in which the safe key question was rated requires improvement.

This key question has now been rated good. This meant people were safe and protected from avoidable harm. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with staff. The service had suitable premises and equipment and looked after both well. The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

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

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty.

The service had an incident reporting system that was accessible to staff. All staff we spoke with during the onsite assessment knew what constituted an incident, how to report it, and felt comfortable doing so. Managers investigated safety events and identified lessons learned which were shared with their team to enable good practice to be embedded.

The hospice had an up-to-date Patient Safety Incident Response Framework (PSIRF) policy which set out the approach to developing and maintaining effective systems and processes for responding to patient safety incidents and learning from incidents.

Managers analysed incident reports and took actions to manage, mitigate or remove risks. Incident reports reviewed showed incidents were appropriately investigated and lessons learnt. For example, staff reminders to complete risk assessments where there was a failure to follow the hospice’s incident reporting and management policy. Senior managers had oversight of themes from incidents and complaints. These were discussed at governance meetings with action plans agreed to address these issues. Minutes of the governance meetings reviewed demonstrated incidents and complaints were discussed and actions to be taken shared.

Clinical staff we spoke with had received feedback on incidents they had reported. Staff were able to provide examples of methods used to share learning from incidents such as emails, meetings, and safety bulletins.

Staff reported incidents as part of the monthly performance and assurance framework. This meant incidents were reviewed and discussed in order to identify themes and trends which could then inform service improvements. For example, the service had 9 incidents in April 2025 and 4 of these related to communication and patients’ appointments, an action plan was developed to address these issues. Incidents were also discussed at specialty meetings to inform any necessary learning.

Patients we spoke with during the assessment told us they knew how to raise a complaint or concern. Patients said they would feel comfortable raising an issue with the staff caring for them and knew how to make a formal complaint, should they need to do so. We did not see or review any formal complaint or complaint response as part of this assessment.

Staff understood the duty of candour regulation and the need to be open, honest, and transparent with people when things went wrong with their care. We saw evidence from incident reports that duty of candour was followed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment and facilities supported the delivery of safe care.

Patients who use the service told us the environment was safe, the design and condition of the rooms were good and met their needs. We reviewed documents that showed the service recorded and monitored when equipment had been serviced and repaired. The service had suitable facilities to meet the needs of patients. These included waiting rooms which were spacious and well equipped with patients’ information leaflets.

Staff conducted daily safety checks of specialist lymphoedema equipment. These checks included daily, weekly, monthly, and an annual audit to ensure equipment and guidance were up to date, the audit report showed 100% compliance with safety and cleanliness of equipment.

We saw that all equipment checks in the hospice were up to date. Staff maintained a reliable and documented programme of checks including electrical safety testing and servicing. All the equipment we inspected had maintenance stickers showing they had been serviced in the last year (2025). For example, the lymphoedema machines in the procedures room and patient couch were all checked and in date. The matron monitored environmental audit results, these included housekeeping, environment, and fire safety. Environmental audit responsibilities rotated between staff in each department, which helped them develop auditing skills and ensured results reflected the range of knowledge in the service.

Staff and patients we spoke with did not raise any concerns about the environment. The environment was visibly clean and we were told by the matron that a routine cleaning and maintenance programme was in place at the hospice. Staff were able to report any maintenance issues. We saw the site maintenance log which detailed maintenance carried out because of the issues reported by staff. Equipment that we saw in the service was fit for purpose. For example, wheelchairs and trolleys were in good condition and visibly clean and were all ready to be used by patients using the service.

Staff managed clinical waste well and appropriately disposed of it in line with the organisation’s policy. Disposal of waste was monitored by the clinical staff, and audits showed staff were compliant with the organisation’s waste disposal policies and procedures. The cleaning equipment and hazardous chemicals (liquids) were stored appropriately and locked away in a secured locked room, and this was found to be in line with control of substances hazardous to health (COSHH) standards. The storeroom was visibly clean and clutter free.

The evidence showed a good standard. The service made sure there were qualified, skilled and experienced staff, who received effective training and supervision. They worked together well to provide safe care that met people’s individual needs.

The service had two clinical nurse specialists who provided the lymphoedema treatment service at the hospice, training record showed they had the right qualifications, skills, training and experience to provide the right care and treatment. We were told the service had sufficient staff to provide services to all patients in a safe manner. At the time of our visit, the service had no vacancies and was fully staffed.

There was a process in place for staff to receive regular supervision. The matron told us all staff received an annual appraisal of their work and the opportunity to discuss any concerns or professional development opportunities; this was by staff we spoke with and the staff training log we reviewed. The matron told us managers monitored staff compliance with training and ensured staff were competent to undertake their roles. The review of staff supervision and appraisal records showed managers undertook supervision and appraisals with staff on a monthly basis to monitor performance and to encourage continued professional development.

Staff told us they attended training specific to their roles, including lymphoedema management and safeguarding people from abuse, this was noted in the staff training record. The director of clinical services has the oversight of all staff mandatory training at the hospice. Line managers ensure their staff are compliant with training. The review of mandatory training records showed all staff had received mandatory training courses in key skills including manual handling, health and safety, infection control, conflict resolution, equality, diversity and human rights, fire safety, information governance and data security, preventing radicalisation, resuscitation, safeguarding vulnerable adults and safeguarding children. This ensured staff were competent and confident in their roles.

Patients told us they had time to ask staff questions during their treatment. Patients said staff were knowledgeable and helpful.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns appropriately.

Clinical staff followed infection control processes to reduce the risk of infections. The environment was visibly clean, and patients reported good standards of cleanliness. People who use the service told us the premises and equipment were visibly clean and tidy, and they did not have any concerns relating to the cleanliness of the environment and equipment.

The service had a cleaning schedule and checklist in place for the cleaning of equipment in the treatment rooms. This meant there was an assurance that the equipment had been cleaned and there was no risk of dirty equipment being used when delivering care and treatment to patients. We reviewed the cleaning log which demonstrated compliance with the cleaning regime at the hospice.

The service had IPC lead and IPC policies which guided staff on processes and practices such as hand hygiene and cleaning of the environment. Staff we spoke with told us they were aware of these policies and knew how to access them. The service had an IPC lead who oversaw infection control processes and provided support for staff. Staff told us they had received training in IPC and hand hygiene; the training data showed 100% compliance with IPC and hand hygiene training.

The quarterly in-house audit showed the service performed consistently well in infection prevention and control (IPC) audits and had achieved 100% in the last year (2025). IPC audits showed that staff were working to the provider’s policies. The review of records showed environmental cleaning audits reflected consistently good standards in each area of the service.

There were enough hand washing basins and hand gels available at the hospice. We were told patients and visitors were encouraged to wash their hands. We observed staff following hand hygiene and 'bare below the elbow' guidance appropriately. Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care and this reduced the risk of cross contamination between patients.

The evidence showed a good standard. The service made sure that bandages used for treatments were safe and met people’s needs.

Staff followed up to date clinical practice guidance when undertaking lymphoedema dressings using bandages (medical products). The service did not use any medicines except bandages, and these were prescribed by GP’s and brought into the service by the patient on the day of their dressing change. In some instances, bandages prescribed by the GP were delivered to the hospice by the pharmacy for patients who could not receive and bring the bandages to the hospice themselves.

The provider made sure that bandaging, lymphoedema garments and treatments were safe and met patient’s needs and preferences. Staff involved patients in planning their care and treatment, including when there were changes in their condition.

At the last inspection we identified that patients’ own bandages were not returned to them on discharge at the end of the day and were stored onsite. This meant that the bandage could be used for a patient that it was not prescribed for. At this assessment, the service no longer kept patient’s bandages onsite; this was an improvement from the last inspection.

We noted that regular auditing of bandages had taken place, this included checking whether all bandages were accurately recorded in patient notes what was used and what was returned to patients, this ensured no bandages were kept on site at the end of the treatment. We noted that patient’s bandages when brought to the hospice were kept appropriately and securely in line with Medicines and Healthcare products Regulatory Agency (MHRA) legal requirements to prevent deterioration, contamination, and damage before usage on the day of treatment. We checked and observed that bandages for lymphoedema dressings were ordered appropriately through the GP by the clinical nurse specialist on behalf of patients.