St Joseph's Hospice Association

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

At our last assessment we rated this key question requires improvement. At this assessment the rating remains requires improvement.

During our assessment we found that daily safety huddles were not held, and some risk assessment documentation was fragmented and difficult to follow. Environmental and equipment concerns were identified, including unlocked sluice areas, expired clinical supplies, faulty call bell indicators, and a contaminated oxygen cylinder. Infection Prevention and Control audits showed variable compliance, and gaps existed in supervision, appraisals, practical training, and some staff competencies, which required timely review to ensure consistent safe care.

However, St Joseph’s Hospice maintained mostly effective safety systems, including structured handovers, incident reporting, Duty of Candour processes, medicines management with secure controlled drug procedures, and high levels of role-specific training. The environment was clean, accessible, and well maintained, with routine maintenance, equipment servicing, and fire safety checks in place. Patients were supported through robust end-of-life care planning, risk assessments, and responsive symptom management.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

St Joseph’s Hospice did not hold daily safety huddles. However, they ensured that there was either the in-patient unit manager (IPUM) on shift each day or one of the ward sisters to provide consistency and support for the clinical staff.

Morning handovers took place between the nightshift and day-shift nurses, including healthcare assistants (HCAs), with a full update on all patients and overnight care provision. This process was repeated in the evening. The in-patient unit manager or ward sisters carried out daily walk-arounds of each unit following handover. They spoke with staff about patients and checked on staff wellbeing.

A Patient Safety Incident Response Plan had been created in March 2025 and was detailed and appropriate. The policy outlined reportable patient safety incident types, required responses, and improvement routes to provide guidance and direction for all staff. It incorporated both national and local requirements. The hospice was in the process of establishing a new patient safety team that met weekly for incident review meetings. These meetings aimed to promote learning from incidents and to determine whether they met PSII (Patient Safety Incident Investigation) requirements.

Patient falls were one of two most frequently reported patient safety incidents and were benchmarked through a national organisation who were known as a national champion for hospices and represent a community of more than 200 hospices across the UK. Review of patient falls incidents showed that most occurred when patients did not use the nurse call bell for assistance when mobilising. These were not deemed to be avoidable, although the service had taken action to encourage patients to mobilise with support from staff.

Reportable incidents included safeguarding concerns, death notifications, pressure ulcers, and serious medication incidents and complaints. All incidents were logged and tracked through the electronic reporting system, which enabled effective monitoring and traceability of each case.

Additional mechanisms in place included the maintenance of the business risk register.

Records of compliments, concerns, and feedback were held within the electronic system and weekly reviews of medication audits and related incidents were undertaken and analysed. No recurring themes or trends were identified in relation to falls, urinary tract infections (UTIs), or catheter-associated infections.

Staff were supported through one-to-one discussions to identify areas for improvement, reflect on lessons learned, and share good practice across teams. A teaching pack was developed from a rescue pack as part of the organisation’s commitment to continuous learning.

An Incident Policy was in place, supported by a formal governance process. All clinical policies were reviewed by the Clinical Governance Committee prior to Board approval. Staff were required to sign to confirm they had read and understood new or updated policies. We found that the Incident Investigation Process followed a structured investigation process to ensure safety, accountability, and learning.

A Duty of Candour policy was in place, reviewed in May 2025 and clearly outlined the roles and responsibilities of each staff group and was appropriate in its content. Records of all duty of candour (DoC) communications and actions were securely maintained within the electronic system. Learning outcomes and key information were disseminated both verbally and via email to ensure staff awareness and promote continuous improvement.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

St Joseph’s Hospice had an Admissions Policy in place, which was last reviewed in June 2024. There was a clear admissions criterion in place. Formal referrals were required from a healthcare professional in a hospital or hospice, a GP, district nurse, or palliative care specialist nurse to Continuing Healthcare (CHC), who in turn submitted the referral to St Joseph’s Hospice once funding had been approved. Eligibility for CHC funding was determined by the relevant Integrated Care Board (ICB), and funding had to be agreed before a patient could be referred.

Systems were in place to assess people referred to the service if they were experiencing a life limiting illness with a prognosis of up to 6 months. Staff also ensured that they had appropriate staff to care for the patient’s needs.

St Josephs Hospice admitted patients with lower needs and transferred those patients with more complex needs to another local hospice and vice verses, once patient needs changed. We were informed that the two hospices worked well together to ensure that the right patients received the right care in the right place.

Deteriorating patients were reviewed by the palliative GP and if required the Palliative care consultant. Caring for a dying patient was guided by the St Joseph’s Hospice Individualised Plan for Care at the End of Life (IPOC), which provided clear standards to support good end-of-life care. The IPOC would be implemented following multidisciplinary review and agreement a patient was nearing the end of life. Once started, the patient and their family were involved in the discussion wherever possible.

The IPOC helped staff anticipate and manage common symptoms at the end of life. Ongoing assessment supported the medical and nursing teams in providing effective and compassionate care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure staff had the right qualifications. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There was a Safeguarding Adult’s Policy in place which had been reviewed and updated in June 2024. It provided clear guidance on staff training requirements and outlined the safeguarding process, including thresholds for initiating safeguarding procedures and how to make referrals to the police and local authorities. The Safeguarding Children’s Policy had been reviewed in August 2024 and was equally detailed.

We reviewed the hospice’s annual safeguarding report and found it to be detailed, containing the appropriate information to monitor allegations, investigations, and actions undertaken within the hospice in relation to all safeguarding cases. Information reviewed showed that there were no emerging themes or trends.

All safeguarding training was role-specific and tailored to the responsibilities of each staff group. Hospice-based volunteers received safeguarding training as part of their initial induction, followed by a face-to-face session delivered by the Hospice Safeguarding Lead. The structure of this training provided participants with key information and the opportunity to ask questions and discuss learning. This training was repeated every two years and was considered mandatory.

The safeguarding policy was in date, and all staff had access to it via the electronic system. We saw that although only required to completed level 2 training, registered 71% of registered nurses had completed Level 3 Safeguarding Adults training and 96% had completed level 3 Safeguarding Childrens training. The Preventing Radicalisation course had been completed by 88% of staff. Trustees completed Level 1 safeguarding training for both adults and children, which was provided through an online training platform.

The clinical director was the service safeguarding lead and had completed Level 3 safeguarding adults and children training. However, Level 4 training was required for this lead role, in line with the Royal College of Nursing Adult Safeguarding: Roles and Competencies for Health Care Staff (2024), which referenced the Safeguarding Accountability and Assurance Framework. This omission was raised during the assessment, and the safeguarding lead enrolled on the appropriate Level 4 course the following day and was booked for 18 November 2025.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing behaviours which present with challenges.

Patients and their families were actively involved in the care planning process and in completing risk assessments. The service collaborated with individuals to understand and manage risks through a holistic approach, with dynamic risk assessments conducted in response to rapid changes in patients’ conditions.

Speech and Language Therapy (SaLT) assessments were carried out as required, with immediate adjustments made to accommodate swallowing needs. The chef was fully briefed and maintained detailed nutritional profiles to meet the requirements of patients with dysphagia. Additionally, behaviours that presented challenges were addressed proactively and appropriately, reflecting a responsive and person-centred approach to care.

The in-patient unit manager and ward sisters provided support on the units as required, whether by advising on symptom control, assisting with new admissions, or helping after a patient’s death. The hospice maintained a flexible culture in which all staff were prepared to move between units depending on workload, skill mix, or unplanned absences.

When required, the in-patient unit manager or Ward sister liaised with the hospice doctor, consultant, or the IMPaCT (Integrated Mersey Palliative Care Team) regarding patient care and symptom control. Internal support and advice were also provided by the clinical director when required.

A review of handover sheets showed that they were comprehensive and covered multiple areas, including medication, care needs, moving and handling assistance, intake and output, and DoLS (Deprivation of Liberty Safeguards) status. Detailed actions taken by staff on the previous shift were also recorded, such as patients’ bed rail requirements, communication and spiritual needs, activities of daily living, and other significant medical information relevant to the next shift.

A Standard Operating Procedure (SOP) was in place for the management of both electronic and paper records. Data protection trackers were reviewed and updated annually by each department. These trackers monitored the management and confidentiality of patient information, including individual patient records, complaints, accident reports, safeguarding logs, significant event logs, deprivation of liberty applications, and consent documentation.

On review of risk assessment documentation within the care records, we found them difficult to follow and track, due to the lack of flow. Information was held across separate files and was not always contemporaneous, which led to confusion.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environment was clean, inviting, and accessible, with some newly built areas and a new staff room. Pathways had been improved to encourage the local community, families, and relatives to spend time on site. The area had become much more accessible through a grant, and interpretation panels were installed.

There was an electronic maintenance reporting system in place; it functioned as a database with modules for scheduled maintenance, testing, and routine activities, which were flagged when due. It also contained contractor data, liability certificates, and method statements.

We reviewed the reported maintenance issue logs and found evidence that issues had been prioritised, with clear records of the date assigned, status, and date of completion. A Repairs and information technology (IT) Fault Reporting Log was also provided. Records were detailed, up to date, and demonstrated that all actions were tracked. Evidence showed that all repairs had been completed in a timely manner. Repairs were managed through service contracts, such as for boilers, and local contractors were used whenever possible due to better response times. Local utility services were preferred, and tree contractors and pest control were also engaged.

Fire alarm check logs were provided and showed that weekly checks had been consistently undertaken. Fire evacuation plans were available for each ward; all were detailed and up to date. A fire safety inspection had been carried out by the Fire and Rescue Service, which confirmed that the hospice maintained adequate fire safety standards.

All equipment had been routinely serviced. This included defibrillator, baths, hoists, bedpan washers, nebulisers, suction units, syringe drivers, air conditioning systems, fire detection equipment, hot water boilers, drainage pumps, and passenger lifts. Pest control management was also tracked, and Legionella testing had been undertaken on a six-monthly basis. Fire drills had been carried out in April and May 2025. We reviewed syringe driver service records, which showed that annual servicing of syringe drivers had been completed as required.

However, the sluice was not locked. An expired biohazard kit (expired in 2024) was identified on the unit. An in-date biohazard kit was available on the ward at the time of inspection; the expired kit had been moved for disposal but had not yet been disposed of. All biohazard kits were replaced in April 2025. The expired kit had been left on the unit in error; however, each unit had a new, in-date kit readily available for use.

Out-of-date needles and glucose monitoring strips were also identified and were requested to be removed. Call bells were observed to be functioning; however, the visual indicator lights used to alert staff when call bells were activated required repair in two rooms.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure staff received effective support, supervision and development..

The senior leadership team were confident in staff coverage and satisfied with the staffing model. Recruitment for registered nurses (RNs) and healthcare assistants (HCAs) had occasionally been challenging. The clinical establishment was reviewed with each vacancy, alongside other workforce requirements, to ensure an appropriate skill mix. At the time, the hospice operated on a 2:1 (2 patients to 1 nurse) dayshift and 5:1 (5 patients to 1 nurse) nightshift patient-to-staff ratio. Staffing data as of 1 September 2025 highlighted that there were zero registered nurse vacancies and 0.6 FTE HCA vacancies. Staff turnover (September 2024 – August 2025) for clinical staff was 1.8% and 0.7% for non-clinical staff.

The hospice was not regarded as a specialist end of life unit and therefore did not require specialist consultants; patients with increased complexity were referred accordingly. Plans were in place to train additional non-medical prescribers (NMPs).

Human resources (HR) monitored training compliance, supervision, appraisals, and emerging trends. Mandatory training was completed online and included Basic Life support, COVID-19 awareness, Safeguarding, General Data Protection Regulation (GDPR), and other core subjects. Face-to-face sessions covered Health and Safety, Dementia Awareness (for all staff, including shop and volunteer staff), in-house fire safety, and fire drills. Clinical appraisals were not fully up to date due to organisational changes. The supervisory structure was explained, and monthly meetings were held with the inpatient unit manager, and the clinical manager.

Specific training opportunities were also offered, such as “Breaking Bad News” and communication courses. Staff could seek support from the team when delivering bad news, including guidance on facilitating spiritual discussions.

A standardised induction plan was in place for all new starters. This included electronic modules, knowledge tests, and an induction checklist. Upon completion, certificates were generated and retained on file with HR.

Of 51 clinical staff required to complete Basic Life support (Level 2) training, 42 held up-to-date certification. Nine staff either had expired or incomplete training.

The ward sister conducted competency assessments, including End of Life (EOL) and Infection Prevention and Control (IPC) modules. Staff were encouraged to take on lead roles to develop their knowledge and enhance patient care. One nurse had completed a Postgraduate Certificate in Teacher Training and was awaiting enrolment on a non-medical prescriber course.

Efforts had been made to maintain regular staff meetings, though attendance was often low as staff did not wish to attend when off duty. The most recent meeting was attended by only one staff member. Various strategies were attempted to improve attendance, including adjusting meeting times and allowing shift swaps.

A sessional GP with a special interest in palliative care provided general medical services and specialist palliative input. The GP provided four sessions per week (16 hours total) on Mondays, Wednesdays, Thursdays, and Fridays, including Bank Holidays. Sessions were flexible but primarily took place in the mornings. The GP participated in weekly MDT meetings with the palliative medicine consultant on Wednesdays. Each session lasted approximately four hours and included ward rounds, patient reviews, prescribing, family communication, and completing medical certificates of cause of death in liaison with the medical examiner. The palliative medicine consultant was available Monday to Friday and at weekends for emergencies.

All staff received ongoing input from their line manager and regular feedback. Supervision varied by role and included one-to-one meetings, informal check-ins, observation, audits, wellbeing discussions, attendance monitoring, and professional supervision. Not all supervision activities were formally documented. Central records showed that 61% of clinical staff had received supervision within the last six months. All staff were expected to complete an annual appraisal, with 51% having done so within the previous 12 months at the time of review.

The mandatory clinical staff training programme was successfully completed across a wide range of subjects. High completion rates were achieved in key areas, including End of Life Care (98%), Principles of Health and Safety (98%), Medical Devices (98%), Medical Gases (96%), Pressure Ulcer Management (96%), and Safeguarding Children Level 3 (96%).

Training in Accident and Incident Reporting, Bullying and Harassment, Drug and Alcohol Awareness, Fluids and Nutrition, and Freedom to Speak Up also demonstrated strong engagement, with completion rates of 90% or higher.

Courses such as Adult Basic Life Support Level 2 (86%), COPD (85%), Consent (84%), and Equality and Diversity (84%) were well attended, showing good compliance. Moderate completion rates were recorded for Epilepsy Awareness (79%), Mental Capacity Act (78%), Anaphylaxis (75%), and Medicine Management (Practical – External) (75%).

Online manual handling training was 94%. However, moving and handling (practical 2025 – external) module had the lowest completion rate at 39%, indicating areas for improvement.

The clinical director undertook walk rounds across all units to identify any concerns or issues relating to patients, staff sickness, staff welfare, or the premises. The clinical director reviewed the off-duty rota and redeployed staff between units when alerted to staff sickness.

Induction checklists were completed for agency RNs. The hospice primarily used one agency, maintaining a core group of familiar RNs for consistency. Checklists were not completed for agency HCAs, as they always worked alongside the hospice’s own RNs during night shifts. Two agency staff were never rostered together.

When reviewing staff competencies, we were advised that one regular RN had a lapsed medication competency due to extended sickness absence; reassessment was planned upon their return. Three bank staff were due to complete medication competencies at their next shifts. New HCAs were progressing through their competency booklets, with a decision made to prioritise HCA completion before RN updates.

The Disclosure and Baring Service (DBS) Policy (Version 3) was reviewed in September 2024 and was found to be appropriate and current. The Recruitment Policy was last reviewed in December 2022, with the next review due in September 2025; it was considered appropriate and linked to other key HR policies.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

St Joseph’s Hospice had an Infection Prevention and Control (IPC) Policy, Version 3, which had last been reviewed in March 2023. The IPC policy appeared appropriate and detailed, containing guidance, for example, on the management of infection control, IPC standards, hand hygiene, PPE, management of blood and body fluid spills, and environmental decontamination. The IPC policy was intended to be used in conjunction with the Outbreaks of Communicable Disease Policy.

During the assessment, we observed a clean and well-organised environment. Walkways and corridors were uncluttered and spacious. Room layouts varied depending on equipment needs, and the presence of personal belongings contributed to a personalised atmosphere. The kitchen areas were clean, and we observed that they were cleaned after each meal.

Cleanliness audits were provided for the preceding six months; however, no audit had been undertaken for May 2025. The audits showed that all three wards (San José, St Francis House Lower, St Francis House Upper) had been compliant with hand hygiene and uniform standards throughout the six-month period. Cleanliness audits for all three wards were mostly compliant, apart from four occasions where compliance fell slightly below target by 1–7%.

The IPC audit dashboard showed that mattress audit compliance had been low over the six-month period, with the lowest compliance rate being 40% and the highest 70% against a target of 85%. On one occasion, St Francis House Lower achieved 80%. Action plans had been implemented each month for audits with poor outcomes; however, there was limited evidence of consistent month-on-month improvement over the six months.

Medical cleaning device audits showed variable compliance during the same period. Compliance targets had been met on three occasions on San José ward, on two occasions on St Francis House Lower ward, but not at all for St Francis House Upper ward, against a target of 85%. Action plans had been implemented each month for audits with poor outcomes, though evidence of month-on-month improvement remained limited.

Hand hygiene audits were 100% compliant at the time of the assessment.

We observed a lack of replacement earpieces for temperature-monitoring equipment, which was escalated at the time of the assessment and subsequently rectified. In addition, we observed that the blood collection kit had expired; this issue was also escalated and promptly resolved.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs.

The medicines procedure policy was in place and had last been reviewed in September 2023. The original policy had been created by an external pharmacy service. The policy was detailed and appropriate, covering procedures for receiving, storing, and administering medicines, including controlled drugs (CDs), at the hospice. It also included procedures for refusal of medicines, recording, PRN medications (as needed medications), managing drug recalls, medication reconciliation, oxygen, thickeners, and related matters.

A Standard Operating Procedure (SOP) was in place for checking medication administration recording charts (MAR charts) as part of the weekly medication audit. Each MAR chart in use at St Joseph’s Hospice was checked daily by the nurse administering the medication. All instances where patients received routine and PRN medication (as and when required) were documented at the time of administration.

To ensure effective practice, MAR charts were also checked weekly as part of the ongoing medication audit, usually conducted by the Medicines Management Assistant within the hospice.

A SOP for checking controlled medications was in place. All controlled medications were stored in a patient’s own labelled box within double-locked controlled medication cupboards, in accordance with the hospice medication policy. The in-patient unit manager was a Non-Medical Prescriber.

Medication incidents were one of two most frequently reported patient safety incidents for the Hospice and remained a key area of monitoring. Analysis of medication incidents showed 36 related to incorrect doses or omissions. A common theme occurred when medications were prescribed as multiple tablets or with varying strengths of the same drug. The hospice identified a total of six such incidents. To reduce these, the hospice introduced a balance check on the MAR (medicine administration record) chart to support improved oversight.

Controlled medications were checked into the cupboard either by two registered nurses or by one registered nurse and one medicine-trained HCA or student nurse. All medications in the cupboards were checked in and out by the same process.

At the end of each shift, both the outgoing and oncoming nurse performed a full controlled drug check to ensure that all medications were accounted for, in line with the standards expected by St Joseph’s Hospice. The CD check sheet had been reviewed and was found to be double signed; however, the comments section was not always legible.

During the weekly medicines audit, all supplies were counted to ensure stock levels matched usage, and all stock was checked for expiry dates. Blue stickers were applied to opened liquids, and prescriptions were requested according to the doctors’ diary.

MAR charts were reviewed for overall presentation and completeness. We observed that all transcripts were accurate, directions were clear and legible, and entries were countersigned. Signatures were verified for all administrations, entries were up to date, supporting documentation was present, and patient labels were checked on each page.

The controlled drugs register was examined for completeness. We observed that all entries were checked for date, time, patient name, dose given, two signatures, and updated balances. Calculations and balances were verified, and corrections were properly annotated, signed, and dated. Transfers to the destruction register were completed with page references, and two signatures.

Procedures iwere in place for occasions where protocols, checks, or countersignatures were missing, these were communicated to the RN on duty or recorded in the nurses’ handover diary. Completion was verified, and follow-up actions were taken.

The audit spreadsheet was updated and sent each Friday with a comprehensive list of findings and actions. Incidents were reported promptly through the electronic reporting system when applicable.

All findings were reported in the medicines management meeting. Any missed signatures were discussed with the responsible RN, and discussions were documented to ensure accountability and compliance.

However, we found that an oxygen cylinder located outside the building had been set up for patient use with piping attached. The equipment had become dirty and contaminated. This concern was escalated immediately on-site, and the items were removed.