Rainbows Hospice for Children and Young People

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

Rainbows Hospice consistently delivered safe, person-centred care through excellent systems, highly skilled staff, and a deeply embedded learning culture. Staff proactively used After Action Reviews to reflect and improve, and safeguarding was fully integrated with trained leads and scenario-based training. The environment was meticulously maintained, with strong fire safety, infection control, and digital systems supporting real-time risk management. Staffing levels were very flexible and responsive to individual needs, and training was creative and innovative with compliance remaining high. Safety was a shared responsibility, with continuous improvement driven by feedback, audits, and compassionate leadership.

This service scored 94 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with staff who showed a strong commitment to learning from incidents and using learning to improve practice and outcomes. They told us that learning was regularly shared during handovers, multidisciplinary team (MDT) meetings, clinical discussions, and staff supervision sessions. Focused learning groups also provided a safe and reflective space to explore incidents and share best practices. Staff consistently emphasised the importance of listening to the voices of children, young people, and their families, using their experiences to shape care and drive positive change. There was a culture of openness, reflection, and collective responsibility. Learning from incidents was seen as a vital tool for growth, development, and delivering best care.

We saw that complaints and concerns were taken seriously and used as valuable opportunities for learning and service improvement. One parent fed back about aspects of routine and care during their child’s short break. This was addressed promptly by the Lead Nurse, who worked in partnership with the family to agree changes and ensure their experience was improved for future stays. Learning from this feedback was shared with relevant staff to support consistent and person-centred care. We also saw that a young person had raised frustration about poor Wi-Fi connectivity, which affected their ability to stay in touch with their family. This concern was escalated, and a solution was being implemented through collaborating with the Director of Digital Transformation. These examples showed a proactive culture of listening, learning, and enhancing the quality of care and the overall experience for young people and families.

Learning from missed medication doses prompted a review which revealed that most incidents occurred during handover times. The root cause analysis showed timing issues during handovers and transcription errors during admissions. As a response, late shift start times were adjusted to prevent overlap with critical medication rounds, and admission processes were being streamlined.

Rainbows fully embedded After Action Review (AAR) as the standard method for reflecting on and learning from clinical incidents and events. AAR methodology, was endorsed by NHS England, and promoted a structured format to review incidents by exploring 4 core questions: what was expected to happen, what actually happened, what went well, and what could be learned for future improvement. This method had become a central part of the hospice’s learning culture and was routinely used to support reflective practice and drive quality improvement.

The Head of Quality, Governance and Compliance delivered a full day of AAR training and this contributed to wider system learning; delivered in partnership with other NHS organisations and hospices. The Head of Quality, Governance and Compliance also took part in a national AAR conference where they shared practical insights and lessons learned from the service.

The Clinical Education team used incident reports and clinical outcomes to plan training. Staff were provided with advanced communication training to help staff support people who could not communicate verbally. Healthcare assistants were supported to develop sign language skills and competencies to support people with learning disabilities, when they were distressed.

Staff said they worked in a philosophy of “nothing is a mistake, if we learn from it,” which promoted open and honest learning. Incident investigations focused on finding issues in work systems that contributed to errors and opportunities for change.

The hospice’s clinical dashboard for May 2025 showed there had been 9 clinical incidents reported. 7 reported no harm and 2 reported low harm incidents. All incidents were fully investigated and changes made as necessary and learning shared.

Systems were in place to ensure staff working in the community were safe and had access to rapid support. This included a digital tracking system, an on-call manager, and a communication system that enabled staff to get help, discreetly if needed. This enabled staff to work effectively together.

We saw that a detailed and thorough pre-admission process was in place and was consistently applied by the service. This process supported staff in assessing and understanding the individual clinical needs, risks and preferences of children and young people prior to admission. It enabled proper planning and coordination of care, including input from relevant clinical teams where needed. The process also included clear checks on the suitability and availability of any required equipment, alongside verification of service and maintenance dates. This helped ensure that only safe, appropriate, and fully maintained resources were used in care delivery.

The service ensured compliance with legal safeguards, with Deprivation of Liberty Safeguards (Dols) applications (for people over 18 years old). We saw records which showed the process was fully completed in line with national and guidance and sent promptly. Capacity assessments were conducted on each admission to support lawful and appropriate care planning. Staff were all provided with DoLS training and were knowledgeable about the Mental Capacity Act.

Families, children, and young people were at the centre of the care delivered. The service learned from incidents. One example included feedback from a family about the lack of information provided before an admission. This feedback was shared at a range of local meetings and staff recognised the importance of direct and early engagement with the child and family before admission to ensure the children and parents were at the centre of care planning.

Staff shared how audits served not only as compliance tools but also as opportunities for reflection, reminders of best practice, and prompts for quality conversations. The use of pathways and audit guide and enhanced care showed a mature and reflective approach to clinical governance across the service.

The service implemented a nationally recognised Paediatric Early Warning Score (PEWS) tool which had been adapted for the Hospice environment known as PEWS/Hto support the early identification of deterioration in children and young people. Staff received proper training, and we saw PEWS/H being discussed in MDT meetings.

The service continued to improve systems and care pathways. For example, they introduced communication passports to better support children and young people with communication needs and developed advanced clinical practices. These improvements showed evidence of the 4 pillars of advanced clinical practice: clinical care, leadership, education, and research. This means staff were providing expert care, leading service improvements, supporting learning and training, and using evidence to guide their practice

Staff kept people safe. The service had safeguarding policies in place, and the staff we spoke with were able to describe the safeguarding process. The safeguarding lead told us the service had no new safeguarding referrals at the time of our inspection. All staff and volunteers had completed the right level of safeguarding training (level 1 2 and 3), which was mandatory. The service had a safeguarding lead as well as safeguarding link nurses so there was always access to advice and support.

The safeguarding team developed a proactive approach to supporting families and young children. They understood the risk factors and developed community links to signpost and refer families to ensure they received targeted support before there was a crisis, particularly when children expressed a desire to remain at Rainbows but were encouraged to move home with continued support and specialist care.

Safeguarding issues were clearly shown within the care plans of children and young people. Each individual had a personalised care plan that assessed and balanced the risks associated with activities against their quality of life, personal wishes, and expectations of care.

Safeguarding was embedded in all aspects of care, support, and treatment and staff at all levels had a deep understanding of how to protect people at risk. Staff underwent safeguarding supervision every 2-3 weeks, tailored to their area of work. All staff have completed Level 3 Safeguarding training. The Safeguarding Lead met monthly with the Executive Nurse to provide assurance and oversight of safeguarding practices. Risks related to staffing, recruitment, and safe staffing levels were regularly reviewed and covered through a structured risk management process.

The Safeguarding Policies for both babies and adults were reviewed and updated in April 2025 and reflected the intercollegiate guidance. All staff were informed of the updates, and any changes were clearly communicated. Supervisions are in place and consistently completed to ensure ongoing awareness, compliance, and support on safeguarding practices.

The service redesigned the Level 3 Safeguarding Adults (SGC ) training in collaboration with external professionals. This updated, scenario-based training for Safeguarding Adults and Children, was piloted in January 2025 and is now fully implemented.This approach aimed to strengthen safeguarding knowledge and improve practical understanding, enhancing training for staff and leaders across the organisation.

Staff were able to describe what to do if they had any safeguarding concerns and felt supported by the organisation, the training they had and the support available to them.

The provider had systems and processes to ensure risks were assessed and mitigated effectively. Staff described using nationally recognised assessment tools to identify and manage clinical risks. Records we viewed also showed a consistent multi-disciplinary approach to care planning. Management systems involved multidisciplinary working and training. For example, the youth and transition team completed safety training to support people with a learning disability to use the hydrotherapy pool alongside clinical colleagues. This helped teams with different skills to work together to manage risk in specialist settings.

Staff recently completed interdisciplinary professional boundaries training involving all teams. Professional boundaries training equips individuals with the knowledge and skills to support appropriate and ethical relationships in professional settings, particularly in caregiving roles. Those we spoke with described this as a positive experience, which they said helped to empower them to keep safe boundaries and focus on the care of people. Such training was particularly important in an environment that often involved emotional and challenging situations.

Staff balanced a risk-averse approach to care delivery whilst ensuring people had choice and control over how they accessed services. For example, staff facilitated support groups in the building evening and weekends and they set up safety protocols for such periods, such as a temporary fire warden for the duration of the group.

The service actively contributed to collaborative working through attendance at multi-agency safeguarding (MASH) meetings, multidisciplinary team (MDT) discussions, and service planning forums. Staff took part in Child Death Overview Panel (CDOP) and Mortality Morbidity (MM) reviews to support shared learning and quality improvement.

Staff engaged in education and training activities, including the delivery of a scenario-based pilot for Level 3 safeguarding training. Team members also attended a study session on trauma-informed care and contributed to the development of an improved PEWS (Paediatric Early Warning Score) pathway.

Progress was also made on individual professional goals, including work toward a Master’s level project focused on improving the quality of MDT handovers. All activities reflected the 4 pillars of advanced practice clinical care, leadership, education, and research and contributed to strengthening staff knowledge, service delivery, and improved outcomes for children and young people.

Rainbows supported a consistently high standard of security, with thorough identity checks for all visitors and robust safety measures in place throughout areas chosen for young people. We saw safe and attentive supervision across the entire service, with visible staff and leaders. Access to secure areas was controlled through staff fob systems, ensuring safety at all times.

Staff had a good understanding of fire safety and how to support the safe evacuation of people with limited mobility, including those attached to medical equipment that could not be removed. Each area of the hospice had clear fire safety protocols, and staff understood how and when to begin an evacuation. Areas with highly specialised equipment or potential barriers to a swift evacuation, such as the music therapy room and hydro pool, had specific fire safety policies in place. Named fire marshals were on duty in each area at all times. We viewed up to date fire risk assessments and evacuation plans in place.

We saw that the hospice had a fire safety action in place and that all required actions had been completed (and the plan signed off on 19 June 2025).

During the assessment, we sampled a range of audits and reviewed key safety documentation, including pool risk assessments, the safe water risk assessment, and up-to-date PAT testing, water checks and oversight of environmental and health and safety checks by external contractors and onsite checks. These documents showed a consistent and proactive approach to supporting a safe environment.

The Head of estates and facilities was leading a digitisation programme to improve and streamline the estate’s management systems. They had trialled and implemented a new tablet-based digital platform that staff used to report defects and repair requests, enabling the estates team to prioritise and manage work in real time. The hydrotherapy pool was undergoing refurbishment to reduce the use of chemicals and provider a safer environment. This included the introduction of application-based monitoring that enabled the site safety team to check chlorine and pH levels remotely.

The service showed excellent oversight and maintenance of its facilities and equipment, ensuring a safe and well-managed environment for all who use it. All key systems, including electronic access control, air conditioning, CCTV, electrical installations, and extraction systems, were subject to regular, scheduled servicing and certification. Contracts were in place with qualified providers, and records of completed works were well documented and stored appropriately. Asbestos and COSHH registers were maintained and accessible, and electrical remedial work had been promptly completed following inspection. The hospice’s commitment to ongoing safety was also shown by proactive steps to commission services such as electric gate servicing and electric vehicle charger maintenance. Environmental health ratings and energy performance certification were up to date, showing robust and accountable facilities management. The service kept a clear, regularly updated action plan to support ongoing monitoring, ensure prompt follow-up of service schedules, and respond promptly to emerging needs, showing a strong commitment to continuous improvement. Leaders checked the environment and overall health and safety. Portable appliance testing was conducted and detailed results were provided to the hospice.

The head of estates had commissioned an external health and safety audit and a fire safety audit. These provided an independent view of risk and compliance.

The head of estates collaborated with colleagues to manage risks in the gardens and play areas. External specialists conducted safety checks on play equipment, tree surveys, and pesticide monitoring for plant beds.

The young persons’ lounge had a relaxed, social atmosphere, featuring gaming equipment, a height adjustable kitchen, and secure storage for restricted items, allowing young people to enjoy age-appropriate independence safely. The dining room included soundproofing that blended seamlessly with the design, creating a calm space that supported those with sensory sensitivities.

There were sufficient numbers of suitably trained staff working in the service. The service was compliant with legal requirements relating to the safe recruitment of staff. The Human Resources department kept comprehensive details of the references and work history of each member of staff and verified queries before making a contractual offer. All new staff had to complete a probationary period. Probation records were detailed and included a review of each person’s competencies and a reflective account from the new employee that helped identify if more support was needed.

The People Team collaborated with applicants to make sure they were prepared for the unique work environment. For example, they worked to normalise conversations about death and dying to help people acclimatise to the hospice setting. They checked whether each person had experience of being around sick or dying people as a tool to support staff who found it emotionally challenging adapting to the setting.

The service adapted the ratio of nurses to patients based on individual needs. When people took part in recreational activities, such as music therapy or youth groups, nurses went with them if they needed continuous medical supervision, such as support with a tracheostomy.

Demand for outreach services was intense, and staff planned their time to meet the needs of as many people as possible. The music therapy outreach service covered 5 counties across the East Midlands and included provision to visit schools and an acute trust. 2 members of staff was funded for this work and two people employed in music services, they planned a rolling programme of weekly visits to do it. Music therapists and physiotherapists were registered with the Health and Care Professions Council and undertook external clinical supervision.

Leaders completed a Safety and Risk Briefing to assess staffing levels, capacity, and clinical risks for children and young people over the following 24 hours. The team reviewed actions from the previous day, identified any deteriorating patients, and discussed current admissions, discharges, and safety concerns. Risks were documented, and actions were agreed to ensure safety and effective care was maintained learning from any actions.

The service had appointed an on-site IT technician to provide on-demand support to staff.

The service had vacancies for a chef and a cook. The director of people engaged with a university culinary school to explore options for future staffing and development as an innovative approach to meeting recruitment challenges.

The hospice’s clinical dashboard for May 2025 showed there were no current vacancies for nurses or HCA's and the hospice was at full establishment with 7 to 8 beds open at all times. Staff retention was 98% with 0 leavers. Sickness has decreased for HCA's to under 1% and nurses has increased to just under 6%. The Lead Nurse for Clinical Operations and People Team managed all sickness and absence. Training and competency compliance had remained static in most areas with compliance between 90 - 100%. Face to face mandatory training continued with new ways of Basic Life Support and manual handling training, allowing staff to self-assess competence and the correct levels of training was given to the different roles within clinical services. Dedicated time was given as part of the mandatory training day to ensure staff have adequate opportunity to conduct all mandatory e-learning and keep compliance levels high.

The service embedded systems to always include a minimum one-to-one staffing ratio. Staffing levels were externally reviewed every 2 years to ensure they were in line with patient complexity and acuity.

The service effectively assessed and managed the risk of infection. Risks were found, checked, and addressed promptly, with concerns shared with appropriate external agencies when necessary. The compliance across the service consistently achieved 100 percent for hand hygiene and overall 93 percent for infection control. The service developed actions as part of daily 10@10 meetings daily to improve.

We saw robust practices across the service, including sanitising hands and using personal protective equipment (PPE) when entering areas and moving across the service. All areas, including lounges, bathrooms, and the milk kitchen were immaculately clean. Risk assessments were completed, including an infection control risk assessment that considered both specific personal risks and broader infection prevention needs.

We reviewed a completed PPE and precaution audit form, which showed a structured approach to infection prevention and control. The audit clearly highlighted staff groups using coded identifiers such as medical and nursing teams and detailed their compliance with designated PPE requirements. It covered key areas including the correct use of gloves, handling of clean linen, and ensuring hands were cleaned before and after delivering care. Staff showed strong awareness of these practices, and there was clear evidence that infection control measures were consistently followed across all departments. We saw housekeeping maintaining cleanliness during our assessment with high standards.

They also showed an excellent understanding of infection prevention and control (IPC) procedures. One staff member told us, “Infection control is everyone’s responsibility. We know exactly what is expected of us”. We observed good practices throughout our assessment.

Regular audits and processes were in place and clearly conducted. Findings were shared centrally with staff through clinical governance meetings. We saw clear evidence of this in spot check documentation, confirming a proactive and embedded culture of safety.

Following audits, improvements in water safety and management meant the service was now compliant with national requirements relating to the management of the risk of water borne infections.

Audits for IPC showed effective compliance (with audits showing 98% compliance for June 2025, above the target of 95%).

Systems were in place to ensure the safe administration and storage of medicines. Staff reported feeling confident and supported in their responsibilities and confirmed they had received right medicines training. Parents and carers were actively involved in the administration of medicines where appropriate, and staff ensured they were confident in continuing this safely when children were discharged. For children and young adults over the age of 16, the service had clear processes in place to support self-administration, underpinned by individual risk assessments.

We saw good practice in the management of transdermal patches, with clear systems in place to ensure safe application and rotation.

Medicines reconciliation processes were robust. Staff had access to shared systems and ensured medicines were accurately reviewed and recorded prior to admission. Children’s care plans were detailed and included comprehensive symptom management protocols, enabling staff to provide consistent, safe and effective care. Advanced Clinical Practitioners (ACPs) provided prescribing and clinical support, working closely with children’s wider medical teams and adopting a multidisciplinary approach to care planning and coordination.

Staff showed a clear understanding of incident reporting procedures. Medicines-related incidents were discussed in regular medicines management meetings, and learning was shared through team briefs to support continuous improvement.

Audits for drug charts showed satisfactory compliance (with audits showing 87% compliance for June 2025, below the target of 95%).

The clinical dashboard for May 2025 showed there were 8 medicines related incidents in May 2025. All resulted in no harm. All incidents were fully investigated and changes made as necessary and learning shared to reduce the risk of similar incidents from reoccurring.