Sue Ryder - Manorlands 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

Well Led Rating: Good

Well led- this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good.

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

The service was in breach of legal regulation in relation to good governance. We served Manorlands Hospice with a warning notice in relation to this breach.

This service scored 71 (out of 100) for this area.

This service scored 71 (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 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 an overarching national vision which set out board priorities and values for palliative and end of life care. The hospice had developed a more localised vision and strategy that aligned with national aims whist reflecting the needs of the community. For example, strong community engagement through the living well services, user group forums and the role of the community engagement coordinator in building trust with diverse local groups.

We reviewed feedback from the staff survey. This showed individual question responses were generally higher than Sue Ryder overall responses. Overall, there was a decrease in scores when compared to 2024 results.

We saw a copy of the 2025 Let’s Talk Plan, which provided actions for the lowest rated response statementsand asked, ‘what would make working at Sue Ryder even better’? However, there was no specific action plan, with target dates and actions listed, so we were not assured these responses were fully addressed.

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.

The chief executive and the executive leadership team (ELT) had oversight and managed the operational management of the charity, including approval processes for specific decisions, and delegated autonomy to senior managers and local teams to deliver routine day-to-day activities across the charity.

All Sue Ryder hospices, including Manorlands, were overseen by a national board of trustees, led by a chair. The role of this board was to provide strategic oversight and governance.

The local senior leadership team consisted of a service director, head of clinical service, head of operations, head of wellbeing and community support services and a medical director.

Staff were motivated, patient-focussed and spoke positively about working at the hospice. They told us there was a friendly and open culture and departmental and site managers were visible, approachable, and provided them with good support.

Staff were supported to progress within the organisation, with examples including a healthcare assistant completing assistant practitioner training and an upcoming internal advertisement for a senior nurse position.

Staff recruitment adhered to fit and proper person requirements, as evidenced by our review of staff files and discussion with the trustees.

Recruitment processes ensured new leads possessed the skills, experience, and values necessary for effective leadership.

The hospice had a fit and proper persons policy. It applied to all directors, trustees, and senior leaders responsible for overseeing the governance, strategy, and operational leadership of the hospice. The policy ensured they all adhered to agreed standards of integrity, professionalism, and compliance.

Senior local leaders were able to explain the key challenges faced by the service. They explained how they collaborated with partners and the actions taken to support the delivery of the service strategy and long terms goals.

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

Manorlands Hospice maintained an open culture that encouraged staff to raise concerns without fear of reprisal, supported by clear policies and accessible leadership. Staff reported feeling respected, supported, and valued.

The hospice had a freedom to speak up and whistleblowing policy with posters in public areas including in the staff dining room.

The Whistleblowing and Raising Concerns policy, accessible to all staff, clearly outlined the process for speaking up and what to expect, ensuring transparency and support. Staff had other channels to raise concerns other than their direct line or senior manager.

Staff reported formal freedom to speak up processes were rarely used, as managers were approachable and accessible, enabling concerns to be addressed informally. A staff member told us “you can raise concerns, if you’re not comfortable speaking to your manager or you want to be anonymous. I’d have no problem raising anything, although I haven’t needed to”. Another told us “all the management are approachable, I could speak to any of them if I needed to”.

No concerns were raised to the Care Quality Commission in the last 12 months.

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.

All staff had an inclusion passport, which was a personalised document that records agreed adjustments an employee needs to effectively perform their job. We heard examples of individualised support for staff with protected characteristics.

One member of staff with reasonable adjustments in place told us “it was no problem. It’s really very supportive here, the staff are all so good at checking in with everyone, asking how you’re doing”.

All new starters had to undertake mandatory diversity and inclusion training during their induction, the compliance rate was 98% at the time of inspection.

The service recognised the varied emotional impacts of its work and demonstrated a positive culture around mental wellbeing. Staff trained as mental health first aiders, along with offerings such as complementary therapies, and open access to a reflection room, further supported wellbeing. Volunteers reported receiving the same level of support.

Sue Ryder planned to build on their equality, diversity and inclusion strategy over the next year by, developing action plans for race equity and accessibility. Sue Ryder has equity, diversity and inclusion networks of which several staff at Manorlands were members.

The Sue Ryder recruitment policy ensured fairness and transparency in hiring processes. Documents had been reviewed to ensure that no one received less favourable treatment on their protected characteristics and ensured an inclusive and supportive interview for all.

The service made adjustments for staff to enable them to have quality time for themselves away from the workplace, striking a good work life balance in the process. Reasonable working adjustments were made for staff, where practicable and considered the needs of both the person and the demands of the organisation.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We were not assured that the trustees had oversight of governance issues, at both local and national levels. We reviewed national board papers and saw no evidence that the lack of national access to 6 mandatory training modules had been discussed. We also heard inconsistencies between the trustees and the local senior leadership team as to how this was being managed.

There were not always clear and effective governance, management and accountability arrangements. Leaders did not always manage risks to the quality of the service.

The service maintained a risk register; however, it did not provide sufficient assurance that risks were being effectively identified, monitored, and mitigated. Key operational risks were absent including the risk to patients and their family or supporters accessing services if staff mandatory training compliance fell below the compliance target. There was also no documented evidence of risk mitigations when staff were non-compliant with mandatory training.

Whilst the risk register had an action target date and date of last review, there was no date of when a risk was added to the register, making tracking, accountability and review more difficult.

We reviewed the Quality Improvement Group minutes and did not see evidence of discussion of risk or actions to resolve the lack of available training. This was added to the register during the inspection, once inspectors had raised the issue.

We were not assured that the provider had robust governance systems in place to manage risks and ensure service quality.

The service had an audit timetable for 2025-2026. This included a range of audits for each area and a process flowchart. Improvement actions from clinical audits were tracked through clinical improvement plans.

Staff including volunteers told us information on risks and governance was discussed during daily huddles, team meetings and shared via email or monthly board reports.

Managers were aware of their responsibility to report notifiable incidents. They told us there was a system in place to ensure safety alerts were actioned and cascaded to all staff.

We reviewed the Health Social Care Committee minutes dated 23 April 2025 and saw a matters arising and action tracker attached, with dates, updates and deadline dates completed.

We reviewed the Patient Safety Compliance Report for June 2025 which discussed safety alerts, audits, equipment, incidents and feedback.

We saw a document list for policies and procedures which was RAG rated, had review dates listed and a flagging sheet.

Governance meeting minutes were reviewed which showed staff from different areas of the service attended and participated in discussion about the service and how improvements could be made.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff told us about national Sue Ryder meetings where best practice and learning was shared between staff from the different hospices.

Community staff told us about the Gold Standard framework meeting with local GP practices. This was an MDT discussion each month that reviews patients nearing the end of life.

We heard positive feedback from a local GP practice about Manorlands Hospice and the collaborative and high-quality, joined-up care they give to patients.

The hospice employed a community engagement coordinator whose role was to ‘help provide more of the support that people need, in more accessible ways, to more communities’. This included working with relevant local faith organisations and local groups and individuals to support spiritual and specialist diverse needs of service users and family members or supporters.

The service proactively engaged through informal interactions, patient surveys, feedback forms, and community events. Feedback was reviewed to find themes and trends, driving service improvements where needed. The overwhelmingly positive feedback reviewed highlighted the effectiveness of these engagement efforts. Regular public engagement events, attended by community members and local representatives, further promoted the services available and strengthened community ties.

We saw a presentation from June 2025, which was about the hospice’s quality priorities and how each team had helped achieve these priorities. One of the presentations was from the community team and their collaborative working with a local dementia charity, and how this collaboration came about, as well as the joint work they did to support both those living with dementia and their carers.

The local community supported the hospice. We spoke to the relative of a former inpatient. They continued to attend the service often, now working as a volunteer. We also heard about an ice cream van that visits once a year for the patients and staff of the hospice, paid for by the family of a previous patient “as a small token of thanks for the care and compassion provided by the staff”.

We saw a community engagement board, which detailed events the hospice was involved in. There were 83 events attended or hosted by the hospice in the past year.

The hospice had plenty of clear information provision about their services, complaints and how to give feedback. This directly improved accessibility and patient engagement.

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 contributed to safe, effective practice and research.

We heard examples of learning to enhance people’s care and palliative care practices. For example, an Occupational Therapist had done work to understand patterns of falls to ensure people could be best supported in managing risk. We saw mention of this work in the “optimising medical assessment and documentation of post falls review” report.

Managers attended regular meetings with all staff where innovation, ideas, and learning were shared.

We heard about a ‘celebration morning’ where staff presented their achievements over the last year, and free pizza was provided to all at the end. We heard feedback from staff that they enjoyed this event and got a lot out of it, as it helped them understand what other individuals in different roles did and the benefit they brought to the service.