Oakhaven Hospice

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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question as good. At this assessment the rating has remained the same. This meant that leaders supported staff and there was a good system of governance and risk management.

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.

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.

There was a transparent and open culture where staff could escalate concerns and report incidents. Staff reported that the team was supportive and reported good team working.

Staff spoke passionately about the service they provided and were proud of the facilities they worked in and the care they could offer to patients. Staff described the culture as positive with good working relationships with different departments within the hospice.

The hospice had a looking to the future strategy for 2025-30 with three strategic priorities. These were to improve access, to enhance quality and to achieve financial sustainability. Organisational values which were made up of together, excellence, actively engaged and meaningful whilst personal values were compassion, accountability, respect and empathy.

The hospice had also developed a Oakhaven Hospice internal communications strategy which provided staff with a clear and consistent framework for internal communication across the organisation.

Engagement with staff was via meetings, emails and newsletters. The hospice held feedback forums and workshops for staff in order to improve communication and build a more supportive and inclusive culture. Leaders discussed the results of the staff survey and worked with staff for ideas/suggestions to help improve some of the challenges that were experienced, including communication, support and inclusion/cross team working.

The values of team and care formed part of the appraisal system with a section which both staff and manager completed, giving examples of where the individual had demonstrated the values. Staff and volunteer annual awards, which were peer nominated, were also specifically based on the values.

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.

All staff we spoke with reported that senior managers are visible, approachable and they feel confident they could approach them about anything. Staff received regular supervision and could request a debriefing post a difficult event.

Staff received manager training in five key operational areas to help staff manage people processes. This training also included sessions on unconscious bias. There was also a section on the intranet, specifically for managers which contained guidance and information.

We saw evidence of a mentoring programme being developed to build on core leadership and management competencies, as the hospice had identified a gap in experience and leadership skills. This included theory and reflective sessions on; leadership v management, communication and emotional intelligence, giving receiving feedback, performance, managing change conflict, strategic thinking and reflection as well as self assessments and journaling.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had access to a freedom to speak up guardian who was available should staff wanted to raise any concerns. Staff were aware of who this was and told us that they felt they could raise concerns without fear of reprisal. At the time of the inspection the hospice reported that they hadn’t received any concerns which were raised through this channel.

Staff could also access support through other routes, such as line managers, the people services team, as well as confidential surveys.

Staff had access to a speaking up policy which provided information on how to speak up and what to expect to happen after speaking up.

The hospice promoted an open culture around feedback from staff through staff discussion sessions and staff survey, where themes were identified, addressed, and actions were put in place.
There was a staff suggestion scheme in place, where ideas were taken to the senior leadership team for discussion and action. We were advised that new employees were invited to complete a survey based on their onboarding and first few months in post, to help learn and improve processes. Exit interviews were arranged by people services, who analysed and fedback comments to managers and the people governance group.

In addition there were specific confidential surveys available to staff, including for any experience or concern around sexual harassment.

The evidence showed a good standard. The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The hospice had an equality, diversity and inclusion policy which staff had access to. This policy was in date and due a review in 2028.

In addition to this staff could also access a section called ‘Every Person Matters’ on the hospice intranet. The section provided staff with links to resources, guidance and a sense
of belonging. Staff could also access information on menopause, neurodiversity and LGBTQ+. There were risk assessments in place for staff who could be vulnerable due to health conditions.

The hospice was a Disability Confident Committed Employer on thegGov.uk scheme and told us about plans to increase to Level 2 (Disability Confident Employer).

The hospice made reasonable adjustments to accommodate and support staff in their work where possible. Staff could be referred for occupational health support.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clearly defined structure to the organisation, with a board of trustees providing strategic vision and direction for the hospice. The board of trustees met quarterly, and topics of discussion included the key points from the executive report, risk register and management accounts.

Staff at all levels were clear about their roles and understood what they were accountable for, and to whom. There were clear responsibilities among staff which interconnected and ensured governance was fundamentally strong.

There were three main committees within the hospice. These were finance committee, clinical governance committee and people governance group. Clinical governance committee meetings were held quarterly to drive continuous improvement for the benefit of people who used the service and monitored significant events, critical incidents such as medicine incidents, falls, safeguarding reports and risk reports.

Risk reports from the medicine management team and the quality and risk group fed into the clinical governance committee meetings. We reviewed the medicine management risk report which was presented to the clinical governance committee for the month of June 2025. Topics of discussion included the current risks which were in place and how the team were addressing this.

The hospice ran a clinical governance week twice a year which provided opportunities for staff to keep themselves up to date with the latest evidence based guidance. The week of activities covered different elements of clinical governance. Sessions included external clinical speakers, education sessions on new guidance or practices, and posters outlining the learning from audits undertaken throughout the previous 6 months and how this may have changed practice. The hospice also held sessions to review learning from deaths and discharges, incorporating any feedback from the medical examiner service, and discussions on patient safety topics and relating these to policy and benchmarking from Hospice UK.

Additionally, the hospice also held weekly MDT meetings which served to provide a formal discussion forum where the care of patients, families and staff could be facilitated by considering service provision and collaboration across a number of professionals.

There were procedures to safely manage sensitive data which allowed them to maintain people’s privacy, dignity and confidentiality.

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 worked closely with local care providers, GPs, district nurses, specialist nurses and other health and social care professionals to coordinate and provide the best possible care.

In addition to this the hospice also worked in partnership with local charities to provide additional care and support to patients receiving chemotherapy at the local hospital.

As part of the service, the hospice provided freshly prepared, home-cooked meals which were delivered and distributed by the volunteers to patients and families. In addition, volunteers also provided refreshments during treatment sessions and offered companionship and support to both patients and their families.

The hospice had an arrangement in place with another hospice on digital transformation and improving collection and use of data. This was a formal process with a memorandum of understanding, honorary contracts and specific protected resource from the neighbouring hospice for Oakhaven. This partnership was due to expand with more cross working being agreed.

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 held learning sessions for staff through their clinical governance week and invited external speakers to cover new areas of learning. In addition to this, the hospice also kept a learning from death and discharges dashboard and reviewed this to identify themes and lessons to learn.

Through Hospice UK, the service benchmarked their standards against other hospices and accessed a range of support services. The service provided educational opportunities to staff which enabled them to share their expertise and experience with other healthcare professionals.

The service undertook several Quality Improvement (QI) projects and shared learning from this to help drive improvement and strive for excellence. We saw evidence of recent projects including a multidisciplinary neurological support day which was set up in day hospice to better support patients with life limiting neurological diseases and ongoing working groups reviewing the management of delirium and deteriorating patients in palliative care. Other examples we were told about included a project to review nursing caseloads in the community to improve safety and efficiency and how the single point of access service was moved to a clinical model to improve patient experience and outcome.

The hospice nurses also attended the quarterly meeting of the Wessex Research Active hospice development Group (WRAhdG) to network with the other hospices and palliative care research groups in our area. This provided an invaluable flow of current evidence and research data to feed back into the clinical teams, influencing and informing practice, as well as highlighting local and national opportunities to become involved in.