St Richard's 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

We reviewed all 8 quality statements for safe, learning culture, safe systems, pathways and transitions, safeguarding, involving people to manage risk, safe and effective staffing, safe environments, infection prevention and control, and medicines optimisation.

St Richard's Hospice had a proactive, systematic approach to managing safety. Leaders embedded, maintained and sought to continuously improve a culture of openness and collaboration, and safety was everyone’s top priority. Staff recognised and reported incidents and near misses and reported them appropriately.

There was a comprehensive safeguarding system. Staff had clear roles and responsibilities. This meant safeguarding risks were proactively identified, managed actioned and reduced.

St Richard's Hospice consistently applied person centred care with a positive culture which supported patient choice. This created trust between patients and staff and protected the safety and wellbeing of all people using services.

There was a collaborative approach to working with partners to comprehensively identify and manage shared risks and joint processes for monitoring their effectiveness. This led to enhanced standards of treatment and care at each step of patients’ care journey.

The design, maintenance and use of facilities, premises and equipment kept patients safe.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The continuing development of the staff skills, competence and knowledge were recognised as being integral to ensuring high quality care.

Staff controlled infection risk well. They used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

The service used systems and processes to safely prescribe, administer, record and store medicines.

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

This service scored 87 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

St Richard's Hospice had a proactive, systematic approach to managing safety. Leaders embedded, maintained and sought to continuously improve a culture of openness and collaboration, and safety was everyone’s top priority. Staff recognised and reported incidents and near misses and reported them appropriately.

Managers investigated incidents and shared lessons learned with the whole team. Patient safety incidents were also shared with partnership agencies working in end-of-life care so learning could be shared as widely as possible. When things went wrong, staff apologised and gave patients honest information and suitable support.

Clinical incident trend analyses were undertaken to proactively address themes and trends. This included pressure ulcers, safeguarding concerns and medication errors. The review highlighted most pressure ulcers were acquired before admission although the service proactively ensured pressure relieving mattresses were available on all inpatient beds and regular review of patients’ skin to avoid further skin deterioration.

Patients and staff, including volunteers, were actively encouraged and rewarded for raising concerns about safety and ideas to improve, and the value of learning is continually demonstrated and reinforced by leaders.

Managers and staff held monthly mortality meetings to review of all patient deaths. The meetings included a full review of each patient and their management by each professional group and the care and treatment provided. We saw these reviews identified both good practice and areas where improvement was needed. Key areas for improvement included review of mental capacity and the challenges of mouth care records identified within both paper and electronic records. Actions were identified for named staff following these to share the information with staff. A monthly action log from mortality meetings was created. Progress was monitored through the clinical quality management review meetings which looked at and identified any opportunities to learn.

There was joint ownership of safety, by the relevant care partners, across patients’ care journey. Staff supported patients to be involved in their own care. This enabled patients to maintain as much control as possible throughout their care and treatment. Staff worked with patients when moving between services, such as from an acute hospital to community care to the hospice; and ensured they and their loved ones had all relevant information. Risk assessments were person-centred and were focused upon patients’ wishes. Patients told us that they had felt involved in their own care and the care of their loved ones and were informed of transitions to different services.

There was a collaborative approach to working with partners to comprehensively identify and manage shared risks and joint processes for monitoring their effectiveness. The service collaborated across the healthcare network to provide timely access to medication, equipment and support to the patient and their loved ones. Leaders explained how they worked across Herefordshire and Worcestershire and the local palliative and end of life network to review and audit their care against the ambitions for end of life care national framework.This had led to enhanced standards of treatment and care at each step of the person’s care journey.

Staff told us they could access the information they needed. Patient records were electronic with key information being available to all health professionals who provided care to ensure patient’s wishes were shared.

Staff could also access other professional services when needed such as speech and language therapists, mental health professionals including psychologists. The service worked closely with other services to support patient pathways and transitions.

The service worked closely with system colleagues including general practitioners to support safe systems of care for patient both within the unit and in the community. Managers held meetings with NHS acute healthcare providers to ensure safe and effective transfers of care. The service asked for feedback from these providers to ask what was working well and what could be improved. Following this feedback, changes were made at the service to improve patient transitions from one service to another.

Continuity of care was a clear priority for the service; this was reflected across all services provided. Living well team offered individualised care and support to patients and their loved ones. During the assessment we saw how the hospice worked collaboratively with others such as general practitioners and district nurses to ensure patients received appropriate and timely care. We also saw how allied health services such as occupational therapy, physiotherapy and social workers were key to safe and effective patient care. The service worked in collaboration with the health and care trusts to provide a 24 hour 7 day a week palliative care consultant on call list.

There was a comprehensive safeguarding system, with clear roles and responsibilities, through which safeguarding risks were proactively identified, managed actioned and reduced.

Staff and volunteers were trained to the appropriate safeguarding levels. Clinical staff and staff who had face to face contact with patients and their loved ones completed level 3 safeguarding adults and children training. The hospice had safeguarding advocates within every team (at least 1 in every team for all services) to provide day to day support and advice.

The hospice had 2 safeguarding leads (one for adults and one for children) who were trained to level 4 and provided safeguarding oversight and additional advice and support for hospice staff. Staff also received training awareness about hoarding and self-neglect; in addition to their mandatory training because they have a genuine interest in the area and feel passionate about it.

Staff followed an approach to safeguarding that included the empowerment of patients who used services and proactive work to promote their safety, well-being and rights. The hospice staff had received a nomination for a Safeguarding Award Worcestershire Safeguarding Board 2024, for their work to protect vulnerable people from abuse or neglect.In addition members of staff (the social work team) had received a national award for their contribution to safeguarding.

Staff knew how to identify adults and children at risk of, or suffering, significant harm, and worked with other agencies to protect them. From March 2024 to February 2025 St Richard’s Hospice had 147 internal safeguarding incidents reported by staff. The incidents were reported to the safeguarding lead for investigation. Most of these included people experiencing suicidal ideations, risk of self-harm, possible physical abuse, financial abuse or psychological abuse, possible domestic violence and neglect.

From the 147 internal incidents, 7 needed to be referred formally to the local authority safeguarding team for intervention. In these instances, St Richard’s Hospice worked alongside other agencies to keep people safe. Most internal safeguarding incidents were managed by contacting alternative services such as a GP or mental health services, or more support was put in place by St Richard’s Hospice in place from the family support team.

St Richard’s Hospice had supported a patient who had shared suicidal thoughts during a consultation and disclosed they were a victim of historic sexual abuse.The member of staff not only followed the safeguarding procedures but went out of their way to spend additional time with the patient exploring their feelings and concerns and ensuring they felt heard and understood. The staff member liaised with their line manager, professional body and sought advice on the legal aspects of the disclosure of sexual abuse. As a direct result of the concerns shared, the patient was referred to external mental health services (with consent). In communication with the external agency, St Richard’s Hospice agreed to continue to support this patient whilst they remained on the waiting list for mental health support. This ensured there was a safe handover to the external service when the time came. Feedback from the individual regarding St Richard’s Hospice support included “The intervention by the social worker was lifesaving. Nobody had ever talked to me about suicidal ideations in any great depth before having support from St Richard’s. In the past I only had risk assessments and workers would shut down any exploration of these thoughts. Once I could understand my thoughts it opened up more choice on how to manage it.”

The hospice had a safeguarding adults and safeguarding children policy which was available for all staff. The policy included all types of abuse including domestic violence, female genital mutilation and radicalisation. The safeguarding policy was reviewed yearly to ensure they remained up-to-date with current legislation.

Staff were knowledgeable about safeguarding and gave us examples of actions taken when potential safeguarding concerns were identified. Information was displayed strategically on noticeboards throughout the hospice highlighting types of abuse and actions to safeguard vulnerable people.

Staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

There was a commitment to taking immediate action to keep patients safe from abuse and neglect. This included working with partners in a collaborative way.

One recent example outside usual working hours a patient asked to leave the Inpatient unit to meet their friend outside. When there was a delay in their return, and staff could not contact them and there were concerns about their welfare. The on call clinical manager was called for advice and guidance and an internal incident form was completed. The Police were contacted, advice given to the hospice. The patient returned shortly afterwards but immediate escalation of potential safeguarding concerns were undertaken.

Safeguarding systems, processes and practices gave assurance staff upheld patients’ human rights, and staff protected them from discrimination. Staff supported patients to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 (MCA) and the Equality Act 2010.

The hospice used electronic records which included a template to ensure staff recorded all required information, including potential or actual safeguarding concerns. The electronic records were available to clinical staff and other key staff.

The whole hospice team was engaged in reviewing and improving safeguarding systems. Safeguarding concerns were discussed during daily handovers and multidisciplinary meetings. In addition advocates attended safeguarding advocate meetings, discussed safeguarding in their department’s team meeting and offered support to any staff member, patient or client as appropriate. Staff shared information, actions undertaken and considered if they needed to take further action.

Staff received safeguarding supervision, either from safeguarding advocates or the safeguarding leads. The safeguarding leads received clinical supervision from an outside agency.

Staff had a clear understanding of the Deprivation of Liberty Safeguards, which staff only used when in the best interest of the person. Staff received training in the MCA and were confident in its use and sought innovative ways to ensure they respected patients’ human and legal rights.

The service had comprehensive systems to monitor and proactively improve how the Mental Capacity Act (MCA) was applied and decisions communicated with all relevant people/organisations involved in the person’s care. This included the Deprivation of Liberty Safeguards when applicable. Staff communicated decisions with all relevant people/organisations involved in the person’s care. This included the Deprivation of Liberty Safeguards when applicable.

There was a culture that actively sought and valued opportunities to promote and enhance human rights in the service.

There was a transparent and open culture which encouraged creative thinking in relation to patients’ individual safety. Patients were enabled to take positive risks to maximise their control over their care and treatment. They were also actively involved in managing their own risks along with their relatives, friends and other carers. Patients and their loved ones said they had regular and open conversations about risks around their health. We saw evidence of this in patients’ care plans.

Staff showed empathy and had an enabling attitude that encouraged patients to challenge themselves, while recognising and respecting their lifestyle choices. The service used imaginative or innovative ways to manage risk, while supporting patients to stay safe. Staff helped patients to make decisions that may have elements of risk, by sharing information about risk in imaginative or innovative ways to help inform choice and control.

St Richard's Hospice consistently applied person centred care with a positive culture which supported patient choice around treatment. This created trust between patients and staff and protected the safety and wellbeing of all patients using services.

Staff upheld patients’ rights, provided and followed the principle of least restriction and promotion of quality of life including patients receiving end of life care.  The service proactively sought out new and creative solutions and best practice to ensure that patients lived with as few restrictions as possible and provided evidence to support this and worked with partners to resolve this.

Facilities, premises and equipment were designed and used to meet the needs of a range of patients who used the service. The design of the environment followed national guidance.

Staff completed health and safety risk assessments. They identified mitigating actions where risks were identified. Staff carried out actions in line with Health and Safety Executive (HSE) guidance. Assessments included fire safety, water safety, security and other environmental risk management practices.

Patients had the equipment they needed to keep them safe, manage their pain and maintain their independence. Patients could reach call bells. Patients told us staff responded promptly to any requests for help. All patient areas were on the ground floor with accessible access throughout. Staff had access to fitted hoists in each bedroom to ensure patients that needed it could be lifted safely. All patients had access to pressure relieving mattresses. Staff were trained to use all equipment including specialist equipment to administer pain relief.

There was a thorough system to ensure safety, upkeep, and repairs for buildings and equipment. Managers ensured the facilities, premises, equipment and technology were maintained. Managers supported staff use the equipment to consistently deliver safe and effective care. There was an estates department that oversaw the maintenance of the building and gardens. The estates department was responsible for the management of faulty equipment and oversaw service contracts and the assets register (an assets register is a list of all equipment used by a service). There were arrangements for medical device servicing and decontamination and staff received relevant training.

The hospice had enough suitable equipment to help staff safely care for patients. Staff told us that equipment was readily available and there were no concerns with access.

Staff carried out daily safety checks of specialist equipment. They ensured that emergency equipment and essential equipment such as syringe pumps (for continuous administration of palliative and end of life care medicines) were routinely monitored, maintained and accessible.

Leaders and staff considered how environments can keep patients safe from psychological harm as well as physical harm, for example access to the premises and facilities to promote their mental wellbeing.

Staff disposed of clinical waste safely. We observed appropriate segregation of clinical and non-clinical waste. Sharps containers were clean, labelled and not overfilled.

There were sufficient staff to provide patients with high quality and safe care and treatment. Patients and their loved ones were positive about staff, whom they described as kind and knowledgeable. They told us there were enough staff who came to them quickly when they always rang for assistance, including during the night.

The service made sure there were enough qualified, skilled and experienced staff to deliver effective, safe care and treatment to meet patients’ needs. Senior managers checked the staff rota to ensure suitable cover was in place. Managers told us they could flex the rotas depending on patient needs.

There was a clinical nurse specialist available to provide end of life and palliative care advice and support 7 days a week, Monday to Friday 8am to 6pm and weekends 8.30 am to 4.30 pm.

A doctor was available within the hospice between 8.30am to 5pm Monday to Friday and for 6 hours on Saturday and Sunday. On call medical cover was available outside of these times. There was at least one consultant available Monday to Friday with out of hours consultant cover provided by a shared rota with other services.

The hospice also employed physiotherapists, occupational therapists, a chaplain, social workers, complementary therapists, and administration staff to support patient care.A benefits advisor employed by another service but funded by St Richard's visited the hospice 3 days a week.
Two clinical psychologists and a psychological care facilitator were available to support clinical teams provide mental health support for patients and their loved ones.

Managers developed coordinated and adaptive anticipatory strategies to manage demand and capacity issues relating to staffing and have systems and processes that support this. As part of recent changes to hospice, managers had reviewed staff teams and staffing arrangements. There were 4 locality community teams and an additional rapid response team. Each community team included a clinical nurse specialist, nurse, registered nurses, health care assistants and therapists. The changes had included an overall reduction of staff in most teams. During the transition recruitment had been stopped, during this time the number of beds in the inpatient unit had reduced to ensure there were sufficient staff available. Staff vacancies remained, but managers had recommenced recruitment to appoint to these posts.

Staff received mandatory training which was booked by an electronic system. Managers could easily check staff were up to date with required training.

The continuing development of staff skills, competence and knowledge were recognised as being integral to ensuring high quality care. Staff at all levels had opportunities to gain experience, develop transferable skills, and share best practice. Managers were innovative and supported staff to undertake training in advanced techniques to provide complex care such as management of breathing tubes and syringe drivers and included simulation-based learning.

Staff described a culture of continuous learning, and they were provided with a lot of different opportunities to develop their knowledge and skills. For example, attendance at national conferences, formal and informal learning sessions, and through participation in research.

Staff had ongoing development opportunities with clear pathways set out. This included opportunities for staff at all levels; unregistered staff wishing to become trainee nurse associates and accredited learning such as non-medical prescribing and advanced health assessment for qualified nurses.

Staff received an annual appraisal as well as clinical supervision in line with the hospice’s policy. In addition to the usual staff appraisal processes, the Head of Learning offered staff the opportunity to meet on a one to one basis to discuss their future learning requirements in line with their new role and personal specification during the transition period.

All staff had access to statutory learning disability and autism training. Managers had introduced this before it was a legal requirement for all healthcare providers. Staff also had access to an accredited training module to support their understanding and competency when working with patients with learning disability and/ or autistic patients.

Managers had sourced training to enable wider staff groups to undertake psychological interventions for patients with mild mental health symptoms including worry management and behavioural activation for low mood.

Managers had access to safe recruitment practices to make sure that all staff, including bank staff and volunteers, were suitably experienced, competent and able to carry out their role. including Disclosure and Barring Service checks (DBS).

We checked 5 staff files (including volunteers), and all contained all information and checks required to promote safe recruitment. Recruitment, disciplinary and capability processes were fair and were reviewed to ensure there was no disadvantage based on any specific protected characteristics under the Equality Act.

All new staff including bank staff and volunteers received an induction. Clinical staff received an extended induction which included clinical tasks.

The hospice whenever possible used their own bank staff to provide cover for annual leave and sick leave. The hospice used minimal agency staff. (In the last 6 months, 1 agency nurse for half a shift and 1 agency healthcare assistant for 2 shifts) to maintain safe staffing levels. All bank and agency staff had a departmental induction with a short induction checklist completed at the start of the shift. Bank staff received regular statutory and mandatory learning which was monitored by the central learning team.

There was a comprehensive system for assessing and managing infection control risks, incorporating policies, procedures, roles and responsibilities, training and monitoring. Managers oversaw infection prevention and control (IPC) audits which were done routinely. Managers took immediate action if infection prevention and control procedures fell below expected standards.

The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. All staff had received infection prevention and control training in the last 12 months. A hand hygiene audit undertaken by the service in February 2025 confirmed all staff met required hand hygiene standards. Staff had sufficient PPE equipment, such as gloves and aprons to carry out procedures and personal care activities. Staff were observed to be ‘arms bare below the elbow.’ Handwashing sinks and hand sanitizer dispensers were accessible and were available throughout the hospice. Information about effective handwashing was displayed at handwashing sinks. We observed staff washing their hands and using hand sanitiser between contact with patients.Staff were encouraged to participate in infection prevention control awareness week. Infection Prevention and control link staff had presented information to each clinical department. The current years focus this years was on appropriate use of gloves, person protective equipment and environmental sustainability.

St Richard's Hospice employed their own housekeeping staff who were available daily. Housekeepers spoke proudly of their work and their role within the team to keep the premises clean and minimise the risk of infection. Housekeeping staff demonstrated a good understanding of national guidance relating to the correct cleaning equipment to be used in different areas of the hospice. They described how information was shared about any infections so they could follow hospice policies and procedures to minimise the risks of the infection spreading.

The storage areas were clean and tidy. Stock was stored neatly to ensure it could be so it could be checked and cleaned efficiently.

There were clear arrangements to assess and control infection risk. A senior manager was the infection control lead for the hospice and had oversight of infection prevention and control.

Patients were protected as much as possible from the risk of infection because the hospice and equipment were kept clean and hygienic. The hospice was visibly clean and had suitable furnishings which were easily cleanable and well-maintained.

Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. There were schedules and checking systems in place to ensure all areas were cleaned as indicated in the identified cleaning schedule. There were facilities to support good infection prevention control in the toilets, corridors and clinic rooms.

Patients participated in decisions about their medicines. Staff discussed patients medicines with them and their loved ones. Medicines discussions included management of their symptoms which included the effectiveness of pain relief and other side effects. Patients and their loved ones said staff ensured their pain and other symptoms were controlled.

Patients were involved with assessments and reviews about the level of support they needed to manage their medicines safely. Staff, including the complimentary therapists worked collaboratively to ensure patients’ pain and other symptoms such as nausea, tiredness and breathlessness were managed.

Medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence, and in line with the Mental Capacity Act 2005. Staff maintained accurate and clear records of medicines given to patients and recorded when medicines were not given and the reason for this. Staff recorded patients’ allergies on their treatment charts.

There were appropriate policies, systems and processes in place to ensure safe and appropriate antibiotic prescribing.

There were safe and secure storage arrangements for medicines including intravenous fluids. Medicines were stored securely. Access to medicines storage was limited with access only to authorised clinical staff and this was monitored by their digital access. The pharmacist and nursing staff checked medicine storage. During our on site assessment, we found 2 syringes of a medicine which had expired at the end of February 2025 alongside the newly received stock. This medicine was immediately removed by staff during our onsite assessment.
The service also confirmed further actions undertaken following our inspection which included weekly pharmacy checks which were more clearly recorded by the pharmacist and in the absence of the pharmacist, the inpatient unit manager would carry out these checks.

Medicines were supplied by a local pharmacy. Staff ordered and checked the medicines received. There was a process for medicines charts to be reviewed and checked by the pharmacist.

Staff completed an incident report if medicines were not given as prescribed. Medicines errors were reported on monthly at the clinical practice forum. Managers shared learning from medicine errors was with clinical staff.

When a member of staff was involved with a medication error, duty of candour was conducted which meant the patient and/or next of kin was informed of the error and an apology made. The Learning Team met with the member of staff to discuss reflection around the medicine error and where appropriate identified any learning needs not only for the individual involved but also for the organisation. The Hospice manager had full oversight of the process.

Staff discussed patients’ medicines during the multi-disciplinary team meeting to ensure medicines were appropriately prescribed for patients. Discussion also included patients’ capacity to make decisions about their medicines and this was recorded.

Accurate, up-to-date information about patients’ medicines was available. When patients moved between health and care settings staff shared or requested information about patients’ medicines, in line with current national guidance.

There were appropriate and safe arrangements for the management, use and oversight of controlled drugs. Controlled drugs are medicines which require additional arrangements for their storage and administration under the Misuse of Drugs legislation (and subsequent amendments). There was a controlled drugs accountable officer for the service to ensure safe management of controlled medicines.

All controlled drugs were securely stored. Staff reported all controlled drugs received and administered in a central record in addition to patients’ medicine records. Nurses, the pharmacist and the accountable officer followed appropriate systems to regularly check controlled medicines. Staff followed a process for the safe and appropriate disposal of controlled drugs and other medicines when they were no longer required. The controlled drug accountable officer presented an annual report to the clinical governance committee. The report outlined themes of incidents and any other concerns that had occurred in the previous 12 months and action required to reduce incidents, including learning to be shared.