Halton Haven 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

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

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

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.

Staff told us they knew and understood the provider’s vision and values and how they were applied in the work of their teams.

The leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff had the opportunity to contribute to discussions about the strategy for the service, especially where the service was changing. The service had undertaken a comprehensive review of its structure, including the appointment of new personnel, updates to policies and procedures, environmental considerations and refurbishment, as well as a review of service provision and staff wellbeing.

Staff shared with us their increased involvement and felt more included in shaping the direction of the service, as well as in the implementation of new systems and processes.

Staff spoke passionately about the service they provided and were proud of the departments 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. However, some staff members shared that communication could be improved between teams. The provider shared evidence that the leadership had reached out to staff to understand this further to make further improvements.

The values that guided the hospice included compassion, accountability, respect and empathy, this was published on the providers website. The service was currently reviewing their staff appraisal process to link in individual performance objectives, organisational objectives, values and outcomes.

The service was in year 2 of a 3-year strategy which was focused on digital transformation, electronic medication management and community engagement. The service was also working on developing their new 5-year strategy.

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 had the skills, knowledge and experience to perform their roles and demonstrated a good understanding of the services they managed, and the future developments they were planning for. They could explain clearly how the teams were working to provide high quality care with a robust meeting and reporting structure

Staff reported that managers were visible, approachable and they felt confident they could approach them about anything. Staff received regular supervision and could request a debriefing following difficult events.

Staff survey results from May 2025 showed a response rate of 40%. The service had implemented an improvement plan aimed at increasing employee participation and engagement, as well as addressing working environment considerations and staff health and wellbeing. At the time of our assessment, staff reported that they had experienced improvements in the organisational culture and in communication with the leadership team.

Leadership development opportunities were available, including opportunities for staff.

We scored the service as 3. 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 the 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 and the managers had an open-door policy.

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, this was last updated May 2024.

Staff could also access support through other routes such as a monthly drop in with management, line managers supervisions, the human resource team, as well as confidential surveys.

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.

The Friends and Family Test survey showed 100% positive responses. The service evidenced working closely with patient and carer representatives to develop more inclusive and diverse feedback mechanisms, ensuring they capture a broader range of views and continue to learn from lived experience.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback.

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 hospice had an up-to-date equality, diversity and inclusion policy which staff had access to. The service displayed their equality and diversity statement; annual report and data capture information published on their website.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group, these results were also captured in the service annual report.

Staff were trained in equality, diversity, inclusion and human rights with an average compliance of 95%.

Staff were able to apply to work flexibly, for example, flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Managers implemented reasonable adjustments to support staff in effectively carrying out their roles.

We scored the service as 3. The evidence showed a good standard. 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 bi-monthly, and topics of discussion included the key points from the executive report, risk register and management accounts. The trustees also shared that they visited the service regularly and spoke with patients and staff.

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 four main committees within the hospice. These were: finance committee, fundraising, clinical governance committee, risk and compliance committee. Leaders told us that they were introducing people and culture committee to commence in 2026. Clinical governance committee meetings were held bimonthly to drive continuous improvement, monitored significant events, critical incidents such as medicine incidents, falls, safeguarding reports and risk reports.

Weekly MDT meetings were held 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 was a clear framework of what must be discussed at a ward, team or department level in team meetings to ensure that essential information, such as learning from incidents and complaints, health and safety and IPC matters and areas for development was shared and discussed.

The hospice maintained both strategic and operational risk registers, which included consideration to funding and issues relating to contracts as its top priority. Operational risks included areas such as occupancy, health and safety and staffing, with a preference to avoid reliance on agency staff.

Leaders regularly reviewed policies. We observed effective policy reviews, with appropriate changes and updates to policies, procedures and guidance.

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

The service maintained a records retention schedule to manage documentation effectively and appropriately.

The service had plans for emergencies for example, environmental incidents, adverse weather or a flu outbreak with their business continuity plan.

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 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.

The service evidenced and enhanced regional partnership working through active collaboration with neighbouring hospices enabled the service to manage capacity and assess suitability for admissions.

The hospice had an active role in system wide collaboration, with representation at locality groups and collaborative engagements, helping to shape local priorities, strengthen pathways, and advocate for the needs of the community they serve.

Feedback from partners was positive and in praise of the recent leadership and management developments, complimenting the service overall for their engagement, open and transparent leadership and future endeavours.

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, outcomes 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 meetings, clinical innovation meetings and staff engagement initiatives. Outcomes and themes from these meetings and data analysis were reviewed to identify themes and lessons to learn.

Halton Haven hospice offered monthly bite-size education sessions to clinicians across the region, including hospice, community, hospital, and care home settings. These sessions covered topics such as palliative care emergencies, nutrition and hydration in end-of-life care, and person-centred approaches to advance care planning. This accessible format enabled wider knowledge sharing and promoted consistent standards of care across the system.

The service had accredited in-house facilitators who delivered nationally recognised training programmes, including ‘Mayfly Training’ and ‘Advanced Communication Skills’ training. This capability allowed development internally, which ensured teams and partners benefited from specialist education tailored to the needs of palliative care services.

Since 2024, the service had developed strong links with a local university, with members of the team invited to guest lecture on specialist palliative and end of life care topics. This collaboration not only enhanced the learning experience of future healthcare professionals but also strengthened their role in specialist education.

The service developed a ‘Hospice Journal Club’ which created a structured forum for clinical and non-clinical staff to engage with current research, share best practice, and opportunity to discuss emerging evidence in palliative and end of life care