Oakhaven 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

At our last assessment we rated this key question good. At this assessment the rating has remained the same. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service 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.

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.

Leaders investigated incidents and shared lessons learned with the whole team and the wider service. Staff told us there were clear open and transparent processes for reporting and learning from incidents and this was often shared via team meetings and emails.

The hospice held regular patient safety group meetings which was attended by representatives from all areas of the clinical services. During our inspection we observed the full meeting and saw evidence of multidisciplinary discussion around shared learning from reported patient safety incidents. This was in addition to reviewing meeting minutes from the patient safety group for the month of July 2025.

The hospice also held weekly multidisciplinary (MDT) meetings where patient safety incidents, such as pressure ulcers, and safeguarding concerns were discussed collaboratively at an individual patient level, to identify external reporting requirements, immediate learning/training needs or urgent actions. Discussions from these meetings were recorded directly into the electronic patient record and into the incident reporting system simultaneously.

Leaders told us all educational or learning points were discussed and recorded on the intranet under the education page so the wider team could access it.

The hospice had an incident reporting policy which described the processes for reporting, investigation and organisation wide learning. Staff told us they reported incidents through their electronic reporting system.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

The hospice reported no never events in the last 12 months and had never reported a never event.

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.

The hospice received referrals via the hospice referrals process. Referrals were reviewed at the daily referral meeting each morning, by a consultant/associate specialist and a community lead nurse. Once triaged, the patient was allocated to the appropriate caseload. The referrals meeting was also attended by the nurse in charge of the IPU to agree and prioritise admissions and bed availability for that day.

Staff told us that if required, the hospices’ community team were able to visit patients in their homes for review. A single point of access (SPA) phone line was manned from 08:30am until 4:30pm, seven days a week. Outside of these hours, patients could contact the hospice directly for advice.

The clinical team conducted holistic reviews of patients’ needs to monitor any change in the clinical situation, phase of illness or social support needs. There were clear medical handover protocols-based on General Medical Council (GMC) guidance for patients on the inpatient unit to ensure that there was continuous monitoring of the patients’ condition and appropriate changes to care plans were made according to the patients evolving needs.

The community team met every morning to discuss caseloads and prioritisation of planned visits and urgent response as well as team communication and opportunities for learning. The community nursing team had protected time slot each day which could be allocated at the morning meeting, enabling timely response to a change in clinical condition. In addition, working with 'Oakhaven Care' domiciliary care agency, there was provision to allocate 1 hour ‘crisis care’ daily in each of the north and south of the patch, to prevent unnecessary hospital admission.

All patients in the hospice received input from the therapy team which was made up of physiotherapists, occupational therapist and a therapy assistant.

The hospice provided an outreach service to the local community hospital twice weekly. This included clinical advice with review of patients as well as education to the teams by a consultant or associate specialist and a CNS.

There was a good system in place to support individuals with learning disabilities. Staff had completed training in Learning Disability and Autism and were experienced with the mental health act and safeguarding.

The evidence showed a good standard. 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.

Staff received safeguarding adult level 1 to 3 training and safeguarding children level 1 training. The adult safeguarding lead and medical director have also received training to level 4.The hospice had an in date safeguarding children and adult policy. The completion rate for safeguarding adults level 1 was 87%, 85% for level 2 and 80% for level 3.

Staff knew how to recognise, and report safeguarding issues and knew how to escalate safeguarding concerns if required. The hospice had a designated safeguarding lead who staff had access to for advice and support. The hospice also had a dedicated lead for Mental Capacity who staff had access to.

Data provided to us post inspection showed that the hospice had made 14 referrals to the local authority from May to July 2025. All safeguarding incidents were discussed at the MDT meeting. Any required referrals or contacts with social services were agreed at these meetings and documented in the electronic incident reporting system.

The hospice employed a patient and family support team lead who was a registered social worker and maintained contact with local authorities, direct individuals and through forums such as the Hampshire and Isle of Wight safeguarding forums and the multi-agency safeguarding hub (MASH).

Senior managers’ report a positive reporting culture and all staff we spoke to were aware of the main risks and challenges and were able to discuss how they would safeguard individuals and the reporting process.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were robust processes to ensure patients risks were assessed, monitored, and managed on a daily basis. The hospice used a risk management system to record risks and individual patient risks were discussed in patient safety meetings, and multi-disciplinary team reviews.

Risks to each person's health and well-being were considered and assessed in the IPU (inpatient unit) and in the community. These included risks relating to falls/bed rails, people's mobility, skin care and nutritional needs.

Pressure ulcers, falls and nutrition and hydration were regularly monitored through risk assessments. We reviewed patient records and found evidence of completed bedrail assessment, falls assessment template, repositioning and purpose T skin tool for skin integrity. The purpose of the purpose-T tool(Pressure Ulcer Risk Primary or Secondary Evaluation Tool) is to help healthcare professionals identify adults at risk of developing pressure ulcers(bedsores).

Symptoms and medication were reviewed throughout the day. Staff told us patients were reviewed regularly and risk assessments updated regularly to reflect change in needs.

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 service provided 10 ensuite rooms for people and were currently going through a refurbishment and had added 3 new rooms. The design of the environment followed national guidance. The service had enough suitable equipment to help them to safely care for patients. Call bells were in place in patients bedrooms to support their safety.

All rooms were single occupancy with ensuite bathroom and had doors that opened into a garden which patients had access to. All rooms had a hoist system for manual handling if needed and cushioned reclining chairs.

The hospice held a small stock of equipment aids (such as commodes and wheelchairs) for emergencies. We found these to be in in date and well maintained with I am clean stickers.

Staff told us they were able to report faulty equipment and this was actioned in a timely manner.

In addition to the inpatient unit the service ran a day hospice from 10:30am until 3pm and a wellbeing area for drop in sessions.

The hospice carried out environmental risk assessments which were updated annually. We reviewed 4 assessments and found these to be thorough with a risk evaluation and a reassessment date.

On the day of the inspection, we found some control of substances hazardous to health (COSHH) products were not securely stored in an unlocked cupboard. We also saw a storage room which was unlocked with access to sharps and needles. This was fed back to the hospice who stored the COSHH products securely and removed the sharps from the storage room with a new lock fitted within 24 hours.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff.

Inadequate staffing levels in clinical and support services particularly within the allied health professional services was one of the risk reported on the organisation risk register. The hospice had a list of controls in place to mitigate the risk which included use of the recently retired therapy lead who worked bank as an occupational therapist, alongside the substantive therapy assistant so patients requiring therapeutic support in the inpatient unit were prioritised and continued to be seen in a timely way. There were no significant incidents relating to the gap in service. Additionally the service reported they had successfully recruited 2 new allied health professionals post inspection.

The hospice also reported a gap in pharmacy provision since covid. Although there were mitigations, this did not replace skill set and role of a pharmacist. The service reported the lack of onsite pharmacist was due to lack of funding from the integrated care board (ICB) and had been appropriately escalated. As an interim measure whilst contractual discussions continued, the principal pharmacist from the local community hospital, provided one-hour onsite support pre attendance of the bi- monthly medicines management group. Clinical staff reported good relationships with the pharmacy at the local community hospital and could access telephone support for queries and guidance as required.

Staff told us there was a service level agreement in place that provided a remote pharmacy service from the local community hospital that supported dispensing of patients own and discharge medications.

Staffing was discussed at the referrals meeting, taking into consideration skill mix, dependency and occupancy and using professional judgement to support responsive admission to the IPU. Most staffing gaps were covered by substantive staff as overtime or from the hospice internal nursing bank staff. The hospice actively recruited to the nursing bank and had bank staff working regular shifts who were experienced hospice nurses.

Agency staff were used if there was no ability to cover shifts with bank or overtime and/or it is not possible to reduce occupancy and/or dependency. The hospice reported the total usage of bank and agency staff from January until June 2025 to be 17%, of which less than 2% was agency use.

Staff completed mandatory training via e-learning and face to face sessions, and these included mental capacity act and safeguarding. Additional data provided by the service showed overall compliance for mandatory training at 86.07% for regular staff and 67.75% for bank staff. The hospice had an action plan in place to improve compliance which included sending reminder emails to staff and leads to encourage activity and supporting staff to undertake training.

The hospice operated with a community nursing team, comprising of community registered nurses and clinical nurse specialists. There were also nursing teams within the inpatient unit and day hospice which comprised of registered nurses and health care assistants. The service employed their own doctors and consultants and provided medical cover with consultants and specialist doctors.

When we inspected the hospice had volunteers who provided support in different areas of the hospice. Volunteers completed appropriate mandatory training depending on the area they worked in and their role.

Staff told us they received regular supervision and appraisals. Data provided by the hospice reported a completion rate of 94% for annual appraisals.

New staff received a new starter induction checklist. All staff including volunteers had a renewed DBS (Disclosure and Barring Service) check every 3 years. Staff received checks of their competency to ensure they carried out their roles safely.

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

The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean and had access to the guidance and support from the infection control team if needed.

Staff adhered to the 'bare below the elbows' policy when providing care and treatment. Disposable aprons and gloves were readily available. Staff used protective personal equipment (PPE) when delivering care and treatment to patients to reduce the risk of cross infection.

There were adequate hand washing facilities within the service. We observed staff undertaking handwashing in line with guidance. Patients we spoke to on the day of the inspection told us that staff always had personal protective equipment (PPE) on and washed their hands.

The service completed monthly audits for hand hygiene and bare below elbow for the different areas within the hospice. Data provided by the hospice showed a compliance of 100% for the hand hygiene audit and 83% for the bare below elbow audit for the month of August 2025. Following this, the hospice had put together an action plan to improve compliance. This included reinforcing education and training and an enhanced observation for the next 4 months to achieve greater compliance.

There were appropriate arrangements for maintaining good standards of cleanliness and hygiene. Staff had a good understanding on infection prevention control (IPC) and we saw cleaning schedules on the day of the inspection which were completed and dated.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The hospice had 4 independent nurse prescribers within the team who prescribed medicines. We reviewed 4 prescription charts and found these to be completed in line with policy and national guidance. Syringe drivers were used for medicines administration appropriately and we saw that the checks were up to date.

Controlled Drugs (CD) were managed in line with the hospice policy and national guidance. Medicines were stored in a central medicines room, in a locked cupboards with keys held by nurses. We reviewed the fridge temperature checks for the month of July to August 2025 and found these to be completed and signed.

We observed CD destruction processes and evidence of effective governance arrangements for the oversight and safe management of CDs. Anticipatory medication was also prescribed to cover every eventuality. Anticipatory medicines, also known as "just-in-case" medications, are injectable drugs prescribed in advance for patients nearing the end of life, to ensure timely response to patient's needs.

Staff had access to a comprehensive management of general medicines policy, which included a number of underpinning procedures for medicines related elements.

The hospice reported gaps in pharmacy provision as one of the top risks on the risk register. This was reported as due to vacancies and funding issues from the integrated care system (ICS).