St Joseph's Hospice Association

On this page

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

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

The culture was open and supportive, with high staff morale, visible leadership, and trustee oversight. Patient care was prioritised, with clinical matters central to meetings and effective monitoring of key performance indicators. Governance arrangements were robust, supported by well-attended clinical governance and quality improvement meetings, comprehensive minutes, and regularly reviewed policies and risk registers.

However, staff were unclear about the identity of the Freedom to Speak Up Guardian, the role was not visibly promoted. Although the EDI policy was up to date, there were no routine staff EDI surveys to support ongoing monitoring and assurance.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The hospice developed a five-year strategy dated 2021 - 2026. Ideas were discussed with trustees, focusing on consolidating the hospice’s achievements and maintaining the high standard of care. While outreach service developments had been considered, they were not implemented due to challenges faced by hospices in recent years. The strategy emphasised broadening income streams and promoting the hospice’s reputation with the ICB and the charitable public.

The organisational culture was described as open, supportive, and high in morale. Significant improvements had been made compared to previous years, making the hospice an attractive and well-maintained environment. trustees conducted inspections alongside clinical reviews to ensure standards were met.

Suggestions for further development included increasing public access, encouraging outdoor engagement, and exploring the introduction of a café on-site. Accessibility improvements for wheelchair users had been implemented, and fundraising initiatives such as the Saturday Bake Box contributed to community engagement.

The hospice undertook a formal strategic review every five years to ensure its mission remained aligned with evolving community needs. The most recent review took place in 2021 and included consideration of complex issues such as assisted dying and the adequacy of palliative care services, recognising that enhanced provision could influence community demand. This work remained ongoing. Strategic and operational objectives were reviewed annually, with managers presenting action plans for discussion and approval by the Trustees.

St Joseph’s Hospice aimed to reach all patients and their families in the community who required nurse-led end of life care, providing support and compassion through its service. The hospice’s work was guided by a set of core values, which formed the foundation for all interactions with patients, relatives, visitors, contractors, partner agencies, staff, and volunteers. These values also shaped the approach taken to achieving objectives and fulfilling the hospice’s mission, representing the principles upheld every day in all activities.

The values that guided the hospice included compassion, respect, dignity, hospitality, and trust. In addition, all trustees, staff, and volunteers were expected to uphold the Nolan Principles of Public Life, demonstrating selflessness, integrity, objectivity, accountability, openness, honesty, and leadership in every aspect of their work.

Throughout all activities, patient care remained the primary focus. Clinical matters were central to all meetings, with staff prioritising patient wellbeing above financial considerations. Key performance indicators, including falls, UTIs, unexpected hospital admissions, risk registers, complaints, pressure ulcers, and feedback from patients and families, were carefully monitored.

In recent years, greater emphasis had been placed on supporting families during the patient journey and following bereavement, ensuring consistent and compassionate care. Complaints were fully investigated and escalated to trustee and board level, with findings documented and addressed appropriately.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders ensured visibility to staff and patients by being present on the wards, engaging with nurses, and checking on staff wellbeing, particularly after patient deaths. Regular walkarounds and monthly engagement by management helped staff feel supported.

Staff development was actively encouraged through upskilling, attendance at conferences, and study days. Leadership opportunities were supported, and ongoing learning was promoted to ensure professional growth.

Trustees received assurance through regular meetings. Case studies and patient and family feedback were reviewed, emphasising the treatment of patients as individuals and recognising the important role of families in providing holistic care.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

There was an up to date and appropriate Freedom to Speak Up Policy in place and accessible to staff. It was last reviewed in December 2023, with the next review due in December 2026. There was also a Whistleblowing Policy in place which had been reviewed in line with current best practice and amended to reference Freedom to Speak up in November 2023.

Staff we spoke with were uncertain who the Freedom to Speak up Guardian was. Most staff stated that they would raise any concerns with their own line manager or with the senior team. All staff felt comfortable raising concerns with both immediate management and senior management.

We did not observe any advertisement or promotion of the Freedom to Speak up Guardian process of role throughout the ward areas or office bases.

At the time of our assessment no one had officially used the FTSU process.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The Equality, Diversity, and Inclusion (EDI) Policy (Version 3) was comprehensively reviewed in December 2024. This review considered the policy alongside a range of related organisational policies to ensure it remained aligned with current legal requirements, relevant guidance, and recognised best practice standards. It also reflected the hospice’s stated commitment to fostering an inclusive, respectful, and equitable environment for staff, patients, and visitors.

The review concluded that the policy itself remained fit for purpose and provided an appropriate framework for promoting equality, diversity, and inclusion within the organisation.

However, there was limited evidence to demonstrate how effectively the policy was embedded in practice. EDI surveys were not routinely undertaken with staff, which meant there were limited opportunities to systematically gather staff feedback, assess lived experiences, or monitor the impact of EDI initiatives across the hospice.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

St Joseph’s Hospice held clinical governance and quality improvement meetings on a quarterly basis, attended by trustees, and senior management. There was a full agenda covering compliance, safety, safeguarding, quality, service improvement, partnership working, and a review of the family support worker report. We reviewed three sets of minutes and found that meetings were well attended, with detailed and comprehensive records.

As part of the governance process, St Josephs Hospice regularly reviewed policies. We observed effective policy reviews, with appropriate changes and updates to policies, procedures and guidance.

The hospice maintained both strategic and operational risk registers, which included consideration funding and issues relating to contracts as its stop priority. Operational risks included areas such as staffing, with a preference to avoid reliance on agency staff. The risk registers were reviewed before being submitted to the trustees and were maintained as live documents.

The Trustee Recruitment Policy Procedure (Version 3) had been implemented June 2019 and reviewed June 2025. We found that the Hospice were not fully compliant with this policy, as required checklists had not been completed and the Fit and Proper Person Regulation had not been fully adhered to, representing a governance shortfall at the time of assessment. Actions were taken to commence compliance immediately.

As part of assurance processes, Trustees conducted twice-yearly inspections of the clinical operation. These include interviews with staff, patients and relatives. The inspections were formally documented, with findings, issues identified and the resulting actions all reported to the Clinical Governance Committee (CGC) and the Board of Trustees.

Senior nurses were visible on every shift each day and were always available to attend immediately in an emergency. They provided advice and guidance and offered both professional and personal support to staff. The clinical director and chief executive were also consistently available, visible, and approachable as needed. Senior managers operated an open-door policy, which encouraged accessibility and communication.

St Joseph’s Hospice maintained a records retention schedule to manage documentation effectively and appropriately.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The hospice participated in the Palliative Care Sustainability Network, maintaining strong links through webinars. Administrative work had increased significantly, including the replication of reports to the ICB.

The hospice engaged with a regional university to address substance misuse and a local Prison to provide end of lifecare support for older prisoners, with wardens attending in civilian clothes rather than uniforms. Initiatives encouraged marginalised and excluded individuals to access end of lifecare at the hospice.

The hospice engaged with the wider community by attending voluntary sector meetings and participating in initiatives such as beekeeping projects. They were proud of the volunteers, who came from a diverse range of backgrounds and life experiences, and of how the hospice looked after the staff.

The team also maintained contact with homeless charities regarding end of life care referrals. Efforts to collaborate with substance misuse initiatives did not progress as far as hoped.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The hospice maintained an open culture, and the senior management were proud of their achievements. They had overcome the challenges of the pandemic, which would not have been possible without the support of the whole staff team and the trustees. We were advised that the trustees were knowledgeable, challenging, and brought a constructive creative tension to decision-making.

Financial security had improved, and the hospice became a sustainable going concern, having previously not been in that situation. Numerous grants had been secured, supported by a healthy grant-searching system.

Two staff rooms were provided for staff, and a private consultation room for the doctor was created, despite challenges posed by the building’s footprint. A new nurses’ station, additional clinical storage, and an updated pharmacy were established. The three main bathrooms were modernised to remove the institutional feel and create a more therapeutic environment with improved lighting. Footpaths were created through the woodlands to support mobility.

The Hospice Bake Box had been developed into a snack facility, and three garden pods were installed in the garden for year-round use by patients and relatives. A wellness programme, including mindfulness, yoga, and breathing exercises, had been implemented and later extended to the wider community. The catering manager developed the hospice garden for vegetable growing. Hospice shops were organised to provide social opportunities for volunteers. Parking was improved with LED lighting to enhance winter safety for visitors.

The hospice participated in the Palliative Care Sustainability Network, maintaining strong links through webinars. Administrative work had increased significantly, including the replication of reports to the ICB.

The hospice engaged with a regional university to address substance misuse and a local Prison to provide end of lifecare support for older prisoners, with wardens attending in civilian clothes rather than uniforms. Initiatives encouraged marginalised and excluded individuals to access end of lifecare at the hospice.

The family support worker, assisted patients and families both before and after death, including support with benefits.

Open forum meetings were held, with questions and answers circulated to all staff, volunteers, and trustees. In January 2025, the first staff survey was conducted, achieving a good response rate. HCA pay was increased by 15% to maintain staff retention and align with the living wage.

Staff remained committed to learning and development, including in-house training in British sign language (BSL), mental capacity act (MCA), and moving and handling. All staff received annual appraisals, and continued professional development (CPD) support was provided, with encouragement to maintain royal college of nursing (RCN) membership.

Quarterly celebrations of life events were held, including readings, poetry, and music, with the names of deceased patients read aloud. HCAs organised a monthly bingo day, and pet therapy was provided. The kitchen received a five-star rating for environmental hygiene.

The hospice operated differently from others, providing end of lifecare that was less complex than some other facilities. The GP was retained but not required 24/7; two NMPs and a consultant attended one day per week, supported by an on-call GP service and the community palliative care team. The service was streamlined and ran efficiently, bringing in resources as needed. Patients requiring more complex care were transferred to other hospices.

The provider was most proud of the hospice’s reputation within the surrounding community and the positive feedback received from patients and families. They regularly received cards and letters of thanks, as well as donations and legacies, which were shared with staff as a form of feedback. Senior leaders told us that staff consistently went the extra mile in their work.

The hospice engaged with the wider community by attending voluntary sector meetings and participating in initiatives such as beekeeping projects. They were proud of the volunteers, who came from a diverse range of backgrounds and life experiences, and of how the hospice looked after the staff.

The organisational culture was flexible and family-friendly, allowing staff to work from home where possible. The hospice demonstrated transparency and a willingness to adapt to change.