Sue Ryder - Manorlands 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

Safe Rating: Requires Improvement

Safe- this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We found a breach of regulation in relation to safeguarding.

This service scored 62 (out of 100) for this area.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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.

Staff told us they reported incidents using the electronic incident reporting system. We reviewed 3 incidents and saw examples of learning actions. Staff told us they received feedback from incidents and that “incident reports are for learning”. The hospice had not had any incidents meeting their serious incident criteria since 2022.

Staff told us about changes to practice following learning from incidents.For example, following a review of falls incidents we heard about the implementation of a specific assessment tool allowing staff to clearly identify which patients were most at risk of falls, so early interventions could be put in place. We also heard that the welcome pack was to be updated to include more information around falls.

Incidents were shared through handovers and team meetings on a regular basis. We saw a display board detailing safety information about how the hospice responded to incidents such as falls and pressure ulcers. We observed daily safety huddles which reviewed patients and their risk factors and any changes.

We reviewed the Duty of Candour Policy and saw examples of where it had been used. Staff understood duty of candour. They were open and transparent and gave patients and their family or supporters a full explanation if things went wrong.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. They made sure there was continuity of care, including when people move between different services.

Hospice systems and pathways kept people safe. Established care planning processes demonstrated staffs’ structured approach to supporting patient choices and ensured their appropriate decision-making.

Safety and continuity of care were seen as a priority. There were several structured meetings including a multi-disciplinary team (MDT) led discussion focussing on holistic care, daily consultant reviews, daily safety huddles, and an MDT daily meeting for discussion of community referrals. There was also 7 day a week telephone support for patients and healthcare professionals in the community.

We observed a (MDT) safety huddle meeting where there was a range of professionals including nursing, medical, physiotherapy, occupational therapy, well-being and admin staff present. There was a common understanding of the goals to improve safety for staff and patients. Action items were reviewed, documented and assigned, for example equipment failure and wellbeing referrals. Staff discussed many topics including risk of falls, safe staffing, discharges, admissions and pressure ulcers. The huddles ended by sharing a positive practice example. We witnessed detailed discussion, all the staff were included, and the patients were kept at the centre of discussions.

A staff member told us the daily handover meetings were helpful as they kept them informed of any changes about their patients and said that ‘this is really useful when you have come back after a few days as things can change a lot’.

We saw staff handovers and reviewed the daily handover sheet where areas such as falls, personal emergency evacuation plan (PEEP), current issues, nutrition and social needs were documented.

The provider had a formal inpatient operational policy in place for the IPU. This outlined eligibility criteria for specialist palliative care for adults in the Bradford district.

The community team told us they were actively involved in the Gold Standard Framework Meeting. The purpose of these meetings was to improve the quality of care for people nearing the end of their lives. The meetings involved GPs, district nurses and other healthcare professionals. They were used to co-ordinate care, assess patient needs and plan appropriate interventions.

Staff at the service and external partners worked well, enhancing the experience of care for people using the service, whilst maintaining continuity. A local GP said “Manorlands Hospice is highly accessible for urgent advice or rapid admissions. Communication between our practice and the hospice team is excellent. Discharge workflows arrive in a timely and comprehensive format that ensures all necessary handover information is shared with us and other caring teams such as community nursing”.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people's lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Staff were not always adequately trained in safeguarding. During the onsite inspection we were told 17 staff required level 3 safeguarding adults training. We reviewed the safeguarding policy and found that significantly more staff should have been included as requiring safeguarding level 3 training as mandatory.

Leaders acted immediately to rectify the staff numbers identified who needed safeguarding level 3 training as mandatory. However, this left a significant shortfall in compliance rates as only 31% of staff were recorded as compliant with this training.

Health care assistants were not included on the list for requiring this training and there was some confusion, within the senior leadership team, as to whether they should be included or not.

We also found the named Safeguarding Lead did not have level 4 safeguarding training, as per Sue Ryder policy.

While both adult and children safeguarding policies were in place and version controlled, the adult policy did not reflect current national guidance—particularly NHS England’s guidance on protecting women and girls at risk of female genital mutilation (FGM). This omission could result in staff being unaware of their legal duty to report FGM, potentially missing vital safeguarding opportunities.

However, we heard examples of safeguarding incidences from staff, which demonstrated their commitment to taking immediate action and keeping people safe from abuse and neglect. Staff we spoke to were aware of their Safeguarding Lead and how to raise concerns.

We saw evidence of clinical supervision group meetings and regular safeguarding meetings to support safeguarding leads in each team, where any issues or worries could be discussed.

We were told any safeguarding incidents and learning involving a member of the medical team would be discussed by the medical team at the monthly Medical Team Business Meeting, from which minutes were recorded. We reviewed these minutes which showed there had been no recent incidents. All specialty doctors and resident doctors were assigned a Clinical Supervisor, who would discuss any incidents including safeguarding concerns as part of the supervisory process.

The staff compliance rate for Safeguarding adults’ level 1 and 2 and safeguarding children level 1 and 2 mandatory training were all 99%.

The provider kept a current Disclosure and Barring Service (DBS) tracker, we saw a staff member had an out of date DBS. However, there was evidence of an appropriate risk assessment for this.

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.

Risk assessments and care plans were co-produced in a prompt and accurate manner with clear sharing of decisions and actions through communication and documentation. These included moving and handling, falls risk and bed rail assessment.

People’s risks were discussed during daily handovers, patient safety meetings, and MDT reviews. Staff told us they had access to senior doctors and consultants when needed, supported by terms of reference and guidelines.

We were told about the clinical review meeting which was held weekly to discuss patients who team members may be struggling with or who were more complex. These meetings enhanced patient safety through early intervention, shared decision making and improved continuity of care.

Staff told us about advanced care planning and the importance of making decisions early on during admission. For example, about the type and frequency of monitoring that individual patients needed, as well as a range of interventions that may benefit patients as needs changed. This helped to ensure that the patients were treated appropriately in the event of an acute deterioration or changing needs.

Staff knew how to recognise and respond to unexpectedly deteriorating patients. They escalated promptly to the medical team and ensured the patient’s safety and comfort. They were aware of the patient’s individual plan of care about their wishes in such circumstances.

Patients had person-centred care plans in place, so they received the right level of care. Staff carried out frequent patient observations so changes to the patient’s medical condition could be promptly identified. We looked at 4 patient records and these showed patients were reviewed regularly and escalated appropriately for medical input when required.

A family member shared an example of person-centred risk management. They told us their family member expressed a clear wish to maintain their independence by walking to the toilet unaided, despite being at increased risk of falls. We were told staff responded by engaging the patient in a shared decision-making process. They conducted a risk assessment and discussed the potential hazards with the patient, a plan was agreed that balanced safety with dignity.

Records showed 100% of medical and nursing staff had completed adult resuscitation and anaphylaxis theory and falls strategy and risk management training.

There was a patient safety board in the nurses’ office which documented current risks, associated actions and documented outcomes.

There was a falls lead who worked with each patient individually to identify their own falls risks. This included taking time to understand the individuals views and wishes regarding assistive equipment and balancing risks whilst maximising independence.

We spoke to the falls lead and heard comprehensive falls risk assessments were carried out. Risk assessments informed care plans. Decision making and falls prevention leaflets were given out.

We saw an in date and version controlled falls risk management policy which provided practical guidance for staff in order to minimise the risk of harm and maintain patient safety. Whilst observing the safety huddle we saw the ‘falls risk today’ for each patient being discussed as well as the overall falls risk.

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 IPU was clean, tidy and well-maintained, with all rooms offering single occupancy and ensuite bathrooms The environment included facilities that supported family members and were inclusive for all ages and cultures. There was a family room, which could be converted into a residential room for families, where visitors could stay overnight, a family kitchen, a quiet spiritual space to support a range of faiths, as well as a dedicated building for living well services.

All inpatients were given an environment survey to complete 48 hours after admission and again after 7 days. This asked questions around cleanliness, staff handwashing and improvements that could be made to the environment.

We reviewed all equipment and found most equipment was checked appropriately.

Staff were able to describe safety checks, safe storage and servicing for the environment and equipment. This included areas such as fire alarms, clinical waste and legionella flushing of water outlets.

Food fridge temperatures were checked and recorded daily by the assistant chef. The records were checked weekly by the head chef.

The hospice had suitable equipment to help them safely care for patients and staff knew how to report any concerns with specialist equipment. Patient rooms had call bells and access to a hoist. There were hoist facilities within the day service area as well as gym equipment for patient use, to help build strength, support independence and improve their quality of life.

Single-use, sterile instruments and consumable items were stored appropriately, and we saw these were within their expiry dates. Staff handled, stored and disposed of clinical waste including sharps safely.

We saw records of fire evacuation events and drills, including action taken and further actions required.

We reviewed the Fire Risk Assessment by an external contractor in July 2025. This found a fire door, in the office area, was not meeting the required standard and was a serious breach of fire regulations. This finding was found to have been added to the risk register, with control measures listed and was discussed at the Quality Improvement Group. At the time of inspection, the job for replacement doors was out to tender, with a completion date due by 01/01/2026.

All rooms were cleaned daily and there was a system for completing cleaning checks. Patients had choice over when they had their rooms cleaned. An example of this was given by the housekeeping staff- “a patient does not always want to let us in, so we speak to clinical staff to check when they will be out of their room and we clean it then, for example whilst they are having a bath”.

Deep cleans were completed on patient discharge, which was a full clean of the room from top to bottom including blinds and removal of radiator covers. There were monthly deep cleans of communal areas.

Personal Protective Equipment (PPE) and hand gels were readily available at the entrance and within the IPU.

The service did not make sure there are enough qualified, skilled and experienced staff. Management did not always make sure staff received effective support, supervision and development.

Staff did not receive training appropriate to their role. On the day of the inspection, we heard that staff had not been able to access 6 mandatory training modules since March 2025. We found that:

• 60% of staff were compliant with Mental Capacity Act and Deprivation of Liberty Safeguards (MCA / DoLs) training
• 31% of staff were complaint with adult safeguarding level 3 training
• 40% of staff were compliant with intravenous (IV) passport training
• 63% of staff were compliant with blood transfusion training
• 61% of staff were compliant with insulin training
• 60% of staff were compliant with Practice Educator and Assessor Preparation (PEAP) training

A further module, blood transfusion training, was available through the local trust. However, staff were unable to access this because they could not access the online IV passport training that was required as a prerequisite.

There was no evidence immediately available regarding how the shortfall in training was being managed. Staff told us that the national education, learning and development team had requested the training be made unavailable. Staff and leaders were not aware of when the training would be made available again. We were not assured that there was always an appropriate skill mix to ensure people received consistently safe care that met their needs.

Following the inspection, we asked the service to provide rotas detailing how the service would be staffed to ensure appropriately trained staff were on each shift. Following the inspection, the service provided weekly updates on mandatory training compliance for the 6 modules that had been unavailable at the time of inspection. We saw the training compliance had increased.

Staff told us they had regular clinical supervision. However, data indicated that nursing clinical supervision was at irregular intervals with high levels of variability between staff. For example, some staff went for up to 6 months without clinical supervision, while others appeared to have had periods where they had monthly clinical supervision. The clinical supervision policy stated that a minimum of 4 clinical supervision sessions should be facilitated a year. We reviewed the clinical supervision timetable and saw some staff had not had supervision so far this year (April 2025 onwards). Therefore we were not assured staff were receiving clinical supervision according to the policy.

Leaders planned the rota in advance and had a process to monitor and review daily. There was a pool of bank staff should they be needed. All bank staff received a full induction before completing any shifts. Staff told us they had regular breaks and rest periods which allowed them to perform their roles to the best of their ability in a safe, caring, compassionate and effective way.

Staff told us that staffing levels were good across the inpatient unit and community outreach team. The ward manager accurately calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants needed for each shift following a recognised staffing acuity tool appropriate for hospice use.

The community team told us they felt able to raise concerns when they had more complex cases and needed additional support. Caseload reviews were conducted every 4 months.

The service checked appraisal compliance. The compliance with annual appraisals was 100% for both clinical staff and outreach support staff. Doctors working under practicing privileges had completed appraisals with their own organisations and were recorded on the hospice checklist.

The hospice had volunteers that supported the clinical and non-clinical areas. Volunteers underwent recruitment checks and had an induction and training.

The team was led by the medical director, who was the responsible clinician for the organisation and also worked clinically within the hospice. There were at least 2 members of the medical team on site between 9am and 5pm on weekdays and there was a duty doctor, 1st on call and 2nd on call at weekends and bank holidays. There was an on-call process for medical cover out of hours which included cover for the inpatient unit.

We were told that doctors employed by the NHS provided evidence of their Trust’s mandatory training, they also had Sue Ryder specific training. We were told that there was sometimes a delay in doctors being kept up to date with their training, but the hospice was working to get a process in place to ensure it was always in date.

We reviewed 10 staff files, 2 senior leaders files and 4 volunteer files. The service had safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role.

Staff told us that training was sometimes not completed, as space to sit at computers was not always available. In response the management team had set up specific workspaces away from the clinical areas for staff to sit and complete online training.

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.

All staff were observed to adhere to good hand hygiene practices. Premises and equipment were observed as clean and hygienic. All areas assessed during the visit were found to be clean, and staff were observed adhering to standard infection control precautions, including appropriate use of personal protective equipment (PPE), hand hygiene, and compliance with the “bare arms below the elbows” policy.

However, 3 chairs in the wellbeing service area were noted to have small areas of protective coating worn off.

Housekeeping staff were observed actively maintaining environmental cleanliness throughout the inspection, ensuring equipment and premises remained visibly clean.

Staff we spoke with were aware of hand hygiene audits and had no concerns regarding infection prevention and control (IPC). They knew who the IPC lead was to approach for support and guidance.

Infection prevention and control level 1 and level 2 training was above the providers target of 95% compliance.

The service consistently scored 100% in a range of IPC audits.

We saw of the hospice had passed an external healthcare associated infection assessment audit conducted by a local NHS Trust. The audit assessed compliance with national standards and best practices.

The service disposed of clinical waste safely and sharps bins were used correctly.

Personal protective equipment, such as masks, gloves and aprons were readily available across all the areas we inspected. We observed hand hygiene posters and hand sanitiser points.

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 happened.

Staff engaged with patients and their family or supporters to understand and review their medicines needs. Alongside discussions about managing symptoms or side effects, practicalities around any support needed to take medicines safely were also considered. A new leaflet explaining the use of ‘off label’ medicines (medicines that are not licensed for the condition they are being used for) had been developed for inclusion in the hospice welcome pack, to help people understand why these medicines were used.

Medicines optimisation was a quality priority for the hospice group. As part of this the hospice was planning to pilot a bespoke deprescribing tool focusing on stopping any inappropriate or ineffective medicines to improve quality of life. The hospice had recently established clinics enabling people who were well enough to attend for specialist consultations in 2 local GP practices, widening access for review in a familiar environment. Staff also supported specialist ‘ward rounds’ alongside the provision of information and education to support end-of-life care in care homes. On the inpatient unit, screening tools had been developed to support the identification and management of delirium.

A pharmacist provided clinical support to the inpatient unit, taking medicine histories and providing prescribing reviews. Prescription charts were generally clearly presented enabling staff to respond appropriately to patients’ symptoms. It was clear which medicines were to be administered for which symptom and in which order. Medicines, symptom management and therapies were discussed at handovers and multidisciplinary ‘huddles. Good support was provided to non-medical prescribers, including regular opportunities to complete case reviews with the consultant.

The hospice carried out a range of medicines related audits to provide assurance and help drive improvement. Appropriate arrangements were in place for reporting, investigating and sharing learning from incidents and national alerts. Medicines including controlled drugs were safely stored. However, a syringe driver was overdue for a service to ensure its continued safety and accuracy. This was included on the hospice service plan. Several medicines related training modules had recently been reviewed and were being relaunched following a period of unavailability. However, this meant that some staff had not completed all their required training modules. Staffing rotas were planned in such a way as to minimise this risk by ensuring at least one trained member of staff was available in each area.