Halton Haven 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 good.

Good: This means we looked for evidence that people were protected from abuse and avoidable harm. People were safe and protected and safeguarded. Where people raised concerns about safety, or safety issues were identified, the primary response was to learn and improve.

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 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 through handovers, team meetings and emails.

Staff told us they were confident about raising concerns and how to report incidents and feedback was provided after incidents to share any learning identified. The service had an electronic system for reporting incidents and had identified three main themes which were pressure ulcers, falls and medicines. Actions had been identified to reduce these incidents, and these were monitored and reviewed by the leadership team.

The hospice also held monthly meetings where patient safety incidents, such as incidents, 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.

The service had a duty of candour policy. Staff were open and transparent and gave families and patients a full explanation when things went wrong. Staff could provide examples of when they followed duty of candour principles in their communication with patients and their families.

The service demonstrated a strong learning culture from the recent service turn around, with effective reflection on events that informed shared learning and led to updates in processes, methodologies, and policies.

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.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.

The service demonstrated interdisciplinary collaboration by establishing daily huddles between the community team and the two hospital-based specialist palliative care teams. This had significantly improved communication, care coordination, and timely decision-making for complex patients.

Leaders described and evidenced enhanced regional partnership working through active collaboration with neighbouring hospices, which enabled the service to manage capacity and assess suitability for admissions. This joint approach had been instrumental in supporting their planned refurbishment. As a result, the service had developed a cross-hospice working group focused on identifying new opportunities for shared practice, efficiency, and effectiveness, ultimately strengthening their collective influence in driving palliative and end-of-life care. This was corroborated through partner feedback received.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

We scored the service as 3. 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.

Patients told us they had no concerns to raise and were complimentary about how they were treated at the service.

Staff were trained in safeguarding to the appropriate level for their role with a 92% compliance rate in training. Staff knew how to make a safeguarding alert and did that when appropriate. The service had a dedicated safeguarding lead who also participated in quarterly partner safeguarding meetings and reviewed recent referral activity.

The service demonstrated robust governance processes with quality monitoring audits specifically for safeguarding. The safeguarding policy was up to date and currently under review with the addition of two statements which were waiting to be reviewed with their local authority partners to be included in an updated version.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff followed safe procedures for children visiting the service and were compliant with training requirements.

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 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 daily huddles, patient safety meetings, and multi-disciplinary team reviews.

Risks to each patient’s health and well-being were considered and assessed in the service. These included risks relating to falls/bed rails, people's mobility, skin care and nutritional needs.

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

Staff communicated with patients, so they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to give feedback on the service they received through discussions, surveys and reviews of their care and support.

Staff enabled patients to make advance decisions when appropriate and ensured that patients could access advocacy.

Leaders of the service demonstrated effective oversight of governance and risk management, ensuring clear accountability and visibility at board level.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was in the process of a refurbishment programme and were upgrading the main large communal lounge area to include a larger door opening to enable patients in bed to be taken outside into the garden if they wished. Corridors were being upgraded and the service had completed bathroom upgrades with sensory lights, and patients’ rooms had been renovated. We reviewed the service risk assessment for the work being undertaken and the service managed this safely and respectfully with their patients and with the support of community partners.

The hospice carried out environmental risk assessments, and a robust maintenance spreadsheet was held itemising all the equipment in the service and dates when it had been serviced. We found equipment in the service to be accessible, clean and well-maintained displaying ‘I am clean’ stickers for equipment ready to use.

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

Staff completed training in fire safety with a compliance average rate of 98% and health and safety with a compliance average rate of 96%.

The kitchen was clean and well maintained with a cleaning schedule for regular cleaning and deep cleaning undertaken and recorded electronically.

The service was also transitioning to an electronic safety and risk management system; the staff were praising the training received on the use of the system and the potential this system would have to further enhance monitoring and oversight.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing establishment and retention figures were at their highest in 2025 at 100% and at their lowest of 96%.

Average of staff sickness absence at their highest of 13% and lowest at 5% since April 2025.

Managers had calculated the number and grade of both nurses and healthcare support workers required and had a clear reporting and line management structure for oversight and support.

The service had introduced a shift coordinator model for each shift with an additional ward manager and deputy manager position for clearer accountability and leadership.

Doctors were working a 5-day week. There was adequate out of hours medical cover. The service was also working on a pilot program for a 7-day rota to reduce the use of on call out of hours to improve continuity.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the area.

Staff had received and were up to date with appropriate mandatory training with high compliance rates for mandatory and additional training subjects, the compliance rate was 94%. The training was appropriate for the patient group using the service.

Clinical competency assessments were undertaken to ensure staff carried out their roles safely with upcoming assessments scheduled.

All staff including volunteers had a DBS (Disclosure and Barring Service) and safe recruitment process was evidenced through reviewing staff files.

Staff told us they received regular supervision and appraisals. However, the service compliance data for staff supervision was not provided and an improvement plan was in place, the service was in the process of reviewing and strengthening their supervision and appraisal process to also include medical supervisions, this was also being undertaken in collaboration with staff.

Leaders and staff shared that a robust induction process was previously lacking in the service, through a review of the service processes, new staff received a new starter induction checklist and programme.

We scored the service as 3. 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.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly to also include deep cleaning regimes.

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.

Management of the service evidenced a schedule of Infection prevention and control (IPC) governance processes with regular audits being undertaken. The audits also evidenced where the compliance on any audit had a score of 92% an immediate action was triggered and prioritised for improvement.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

We reviewed medicines records for 2 patients and spoke with staff and leaders. Records demonstrated people were given their medicines safely and at the right time. Medicines were reviewed when people came to stay at the service and allergies were recorded.  Patients were supported to self-administer their medicines where they were able and wished to do so.  

Patients told us that their medication was regularly discussed with them, and they knew what medication they were prescribed.

Medicines were stored safely and there were processes to manage use, including controlled drugs.  Records of controlled drugs (CDs) were accurate and made in line with legislation and best practice. Syringe drivers were used for medicines administration appropriately and we saw that the checks for these were up to date.

We saw evidence that staff who gave medicines were trained and assessed as competent to ensure this was done safely. 

The service had an up-to-date medication policy which included several processes for medicines related elements and accessible to staff. Medicines audits were completed monthly to identify issues and drive improvement. This also included external pharmacy audits undertaken for additional oversight.

The service identified medicine incidents, which were reported and analysed. Learning from these incidents was shared across the service and there was a good safety culture that encouraged staff to report these.