Sue Ryder - Wheatfields Hospice

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• 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

Leaders and staff did not have a shared vision and culture. Leaders were not visible, knowledgeable and supportive. Staff did not feel supported to give feedback and were not treated equally and were not free from bullying or harassment. People with protected characteristics did not always feel supported. Staff mostly understood their roles and responsibilities. Managers did not always work with the local community to deliver the best possible care and were not always receptive to new ideas. There was not a culture of continuous improvement and staff were not given time and resources to try new ideas.

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 whether leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This key question has been rated inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance of the service.

This service scored 31 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Leadership did not understand the challenges and the needs of people and their communities.

A significant number of staff across the organisation reported that they did not feel supported, safe, respected, or valued in their roles. Many described a genuine fear of speaking up, with some not feeling protected from bullying or harassment.

There was evidence of a developing closed culture, where staff concerns were not consistently acknowledged or addressed. The impact of this culture on staff wellbeing is well documented by NHS England and in academic healthcare leadership literature, which recognises such conditions as detrimental to

organisational effectiveness and the quality of care provided to patients and colleagues.

While many staff demonstrated commitment to patient care, not all felt psychologically safe or empowered to raise concerns. Inspectors spoke with staff who described their own experiences and those of colleagues, who remained anxious about speaking up. Accounts included bullying, harassment, intimidation, and disrespectful treatment by the leadership team.

Several staff reported having previously raised concerns but felt unsupported by internal processes or the wider organisation. Some described how concerns were passed between teams without resolution, leading to a loss of confidence in the process. Reports also included breaches of confidentiality, and cases where staff made the difficult decision to leave the organisation. Others stated they would not raise concerns again, having had a negative experience in attempting to do so.

The provider submitted evidence showing that multiple staff grievances had been raised between June 2024 and March 2025. This was further evidence of concerns about the organisational culture. Following our inspection, the provider stated that the grievance process was robust. However, they were unable to provide records of the outcomes of grievances raised in June 2024. This lack of documentation meant the provider could not demonstrate how these concerns had been addressed or resolved, which calls into question the effectiveness of the grievance process.

Data from the 2024 staff survey included information on bullying, harassment, and discrimination by staff. This data was clearly labelled as relating to Sue Ryder as an organisation, rather than specifically to Wheatfields. The survey reported that 12% of all Sue Ryder staff and 16% of healthcare staff across the organisation had experienced or witnessed such behaviours in the previous 12 months. These figures align with the Health and Social Care (HSC) sector average of 16%. The evidence provided did not include data showing whether Wheatfields staff were given the opportunity to state if they had personally experienced bullying, harassment, or discrimination.

Feedback from the staff survey also highlighted several areas of concern relating to leadership and organisational culture. Notably, some of the lowest scoring responses and areas of year-on-year decline included:

• Confidence in how the Executive Leadership Team (ELT) lead the charity (score: 4.6)
• Perception of fairness in pay
• Belief that the organisation demonstrates a commitment to staff wellbeing
• Willingness to recommend Sue Ryder as an employer

Whilst we were made aware that the provider had taken some actions at national level in 2024 regarding concerns they had identified, these had not been effective in Wheatfields Hospice when we assessed in 2025. Staff reported that the senior leadership team did not demonstrate a clear understanding of the specific staffing requirements for palliative care services. Concerns were raised about a lack of recognition of the distinct differences between specialist palliative care nursing and general nursing roles.

Leaders were perceived to lack the necessary oversight and did not demonstrate an understanding of the principles of safe staffing in a hospice setting, which was impacting the delivery of safe, person-centred care.

The provider had a corporate vision and strategy; however, staff were unable to clearly articulate the organisation’s direction or future plans. The strategic framework set out three key goals:

• Better grief support for everyone
• Helping people who are dying to live well
• Speaking up for people who are dying or grieving

However, staff reported that these objectives were not meaningfully embedded in local service delivery.

There were concerns that significant service reductions—including the closure of the day centre, nurse-managed beds, and the loss of the local palliative care social worker team—had been driven at a corporate level and implemented without local consultation or engagement.

During the inspection, the service director led a tour of the premises and informed the inspection team that the day unit was closed. Photographic evidence was obtained at the time to support this assessment. However, the provider later stated that the day unit was open after the inspection.

At the time of inspection, there was a palliative care social worker employed nationally to support the wellbeing team. However, staff reported that access to this role was limited due to its national remit.

Staff told us they had not been informed prior to the implementation of these changes, which had negatively impacted their confidence and morale.

The lack of visibility and local translation of the strategic vision contributed to a sense of disconnection and disengagement, limiting opportunities to deliver care aligned with the service’s stated values.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The hospice was overseen by a board of trustees led by a chair; however, trustees were not sufficiently involved in governance and did not provide adequate challenge or accountability to the local senior leadership team regarding concerns raised.

Board papers we saw for September 2024, demonstrated that the trustees were sighted on leadership, culture and Human Resource issues at the service and concluded that better trustee oversight was needed, however the papers did not indicate how this would be achieved.

During the December 2024 board meeting, trustees acknowledged that visits to the service could improve understanding and awareness of hospice-related issues. However, at the time of the assessment, this action had not been implemented.

Senior leaders did not consistently demonstrate the skills, knowledge, experience, or credibility required to lead effectively. Concerns were raised regarding a lack of integrity, openness, and honesty in leadership practices. Insufficient oversight in key areas resulted in risks to people’s safety, as systems to drive improvement were not effectively established or monitored.

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 one palliative care consultant. While most staff were aware of these individuals, staff raised concerns that leaders were not consistently visible or approachable.

Concerns were reported regarding poor leadership behaviours. Staff provided specific examples of unaddressed difficult behaviours, including bullying and intimidation. Some staff reported that past issues had never been appropriately reconciled or had gone without formal action.

Senior leaders did not adequately address cultural concerns that could negatively impact staff wellbeing and the quality of care provided to people.

At the time of assessment, there was no CQC registered manager in post and had not been for 10 months. After the assessment we received the application again, this is currently in progress.

During the onsite assessment, inspectors experienced challenging interactions with the regional director. The lead inspector was directly challenged on the questions used during the assessment and was asked to refrain from questioning staff around the culture.

We reviewed staff exit interview data, which highlighted several recurring themes and systemic issues across the hospice. Key reasons cited for leaving were dissatisfaction with employment conditions, poor communication from line managers and the wider organisation, poor working conditions, poor induction, lack of wellbeing support, inclusivity and values demonstrated by colleagues.

There were significant concerns regarding the robustness of recruitment processes and the governance systems in place to ensure compliance with the Fit and Proper Person Requirements (FPPR).

A review of staff files highlighted inconsistencies in the application of safe recruitment practices. While some documentation was present, there were notable gaps in key areas including Disclosure and Barring Service (DBS) checks, employment references, qualification evidence, and risk assessments. In several cases, staff had commenced employment prior to DBS clearance without documented risk assessments, and references were either incomplete or dated after employment had begun.

One staff member had a DBS with a criminal conviction; although a risk assessment was completed, it lacked a recorded review date. Several DBS checks were only recorded in spreadsheets without supporting documentation.

Reference checks were incomplete for multiple staff including senior leaders. While policy requires three references covering five years, many staff had only two references, and some were dated after employment commenced. In some cases, references did not align with the employment history provided in CV’s.

There was a lack of assurance that all staff had the appropriate qualifications and professional registrations verified and recorded. For clinical roles, including consultants and nurse specialists, qualification certificates were not consistently retained, and in one case, medical indemnity cover had expired.

These findings indicate that governance systems were not sufficiently embedded to ensure that recruitment processes were safe, consistent, and compliant with regulatory requirements. The provider was unable to demonstrate that all staff met the FPPR standards, particularly in relation to good character, qualifications, and fitness to carry out their roles.

People did not feel they could speak up and that their voice would be heard.

The provider did not have a formal Freedom to Speak Up policy or process in place. We were informed that this matter is currently under review at a corporate level, but at the time of inspection, no structured framework had been implemented.

Staff reported that the organisation does not foster an open and supportive learning culture. Many staff expressed concerns that they did not feel safe to speak up or that their voices would be heard.

Staff we spoke with told us they had witnessed colleagues raising concerns, only to face disciplinary action or suspension as a result. This has contributed to widespread hesitancy in reporting issues.

Evidence provided by the provider indicated that staff often felt the need to submit formal grievances rather than seek informal resolution. Between June 2024 and March 2025, there were 10 staff grievances or complaints recorded.

Staff told us that leaders did not take their concerns seriously or follow up appropriately. This contributed to a culture of disengagement and a lack of confidence in how staff feedback was managed.

Staff feedback data we reviewed indicated that there was a lack of wellbeing support and inclusivity for staff.

During the inspection, staff expressed concerns regarding the approach of senior management to staff wellbeing and confidentiality. Multiple team members reported a lack of supportive engagement from leaders when staff sought additional wellbeing support, particularly during periods of high workload and emotional distress.

Concerns were also raised regarding the management of confidential information. Staff described instances in which personal or sensitive information shared with senior leaders was disclosed to others without their consent. These breaches of confidentiality were reportedly raised with senior leadership, but staff stated that such concerns were dismissed or not taken seriously. This contributed to a perception of distrust and reduced confidence in the organisation’s leadership.

Staff told us that they did not feel psychologically safe and raised questions about the provider's ability to foster a culture based on openness, respect, and accountability. This failure to safeguard staff impacted staff willingness to speak up about patient safety concerns or personal wellbeing needs.

We were not assured that senior leadership consistently modelled the values and behaviours necessary to support a healthy, safe, and inclusive working environment.

The hospice supported cultural awareness through the regular sharing of a Faith Festivals calendar, helping staff to better understand and respect the beliefs and practices of colleagues, patients and families. In addition, colleagues were invited to participate in LGBTQ+ Pride events, including Leeds Pride, as part of Sue Ryder’s wider commitment to inclusion and visibility.

Staff had access to a comprehensive Employee Assistance Programme (EAP), which included confidential counselling, legal and financial advice, and support for family members. This was complemented by regional mental health services and suicide prevention training, ensuring equitable access to support for all staff.

The service also promoted staff voice and engagement through initiatives such as the Employee Engagement Forum and the Let’s Talk Action Plan Groups, which aimed to improve communication, wellbeing, and inclusivity across the organisation.

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

At the assessment undertaken in May 2025 we found that there were quality assurance and governance systems in place, but they were not always effective and did not drive continuous improvement. Following this assessment, we issued the provider with a warning notice to make improvements. We continue to receive information of concern about the areas we identified and issued the warning notice. At the time of writing the report the provider had not sent us an action plan about how they will address all areas of concern we have identified.

The Board Assurance Framework (BAF), last updated in March 2025, provided a view of strategic risks. However, several strategic risks (e.g., SR022 – Palliative Care Transformation, SR023 – National Profile, SR024 – Management Information, SR025 – Assisted Dying) have undetermined assurance ratings and gaps in assurance. We were not assured that the provider had overall control over emerging and complex risks.

However, following our assessment, the provider told us that from July 2025, the assurance ratings had been added to the document following review by email with the executive leadership team.

We reviewed the Health Social Care Committee minutes dated 13 November 2024 and 22 January 2025 and noted that none of the specific action items identified in the November 2024 meeting were explicitly referenced or confirmed as completed in the January 2025 minutes.

This lack of documented follow-up raises concerns regarding the effectiveness of action tracking and governance oversight. We were not assured that the provider is operating in line with its governance framework, particularly in relation to accountability, transparency, and the monitoring of agreed actions.

The provider had an up-to-date risk register. All active risks had been reviewed as of 24 February 2025, demonstrating a consistent and timely approach to risk management. There were no gaps in review dates, and each risk included clear ownership, control measures, and action plans. However, we did not see any evidence of, where risk had been identified, that the provider had a process and action plan to further reduce risks.

There were ongoing concerns regarding staff behaviours not consistently aligning with the Sue Ryder Code of Conduct. This included issues related to whistleblowing, bullying and harassment, and discriminatory behaviours. The risk was rated as high and remained open as of February 2025, as documented in the Workforce Culture Environment risk (WHE0011). While the risk register referenced values and behaviours training and leadership development initiatives, we saw no evidence that these had been actioned or that further steps had been taken to improve the culture.

Although the provider had focused significantly on frontline staff behaviours, there was no corresponding recognition of senior leadership conduct as a risk. We were made aware of multiple grievances submitted against senior leaders, including allegations of bullying, intimidation, and inappropriate conduct towards staff. Despite the seriousness of these concerns, there was no evidence that these issues had been formally acknowledged or addressed within the governance framework.

This lack of accountability at senior levels contributed to a perception of a blame culture and posed a risk of reputational damage. The absence of transparent action to address leadership concerns undermined efforts to build a positive and inclusive workplace culture.

The provider did not demonstrate effective governance arrangements to ensure the safe prescribing, administration, and monitoring of medicines. While a dedicated pharmacist team was in place and contributed to handover meetings, systems to oversee medicines safety and assurance were inconsistently applied and lacked accountability.

The absence of routine audits in this core area of palliative and end-of-life care represents a significant shortfall in governance. Without formal audit activity, the provider was unable to demonstrate assurance that care was being delivered in line with recognised best practice, that symptom control was consistently effective, or that people’s values and preferences were being met.

The provider did not demonstrate a consistent process for ensuring Mental Capacity Assessment (MCA) compliance across the service. Outstanding actions from previous audits had not been completed, and there was no documented follow-up in the Quality Improvement Plan. While the Mental Capacity Code of Practice was available and staff reported understanding their responsibilities, this was not always reflected in practice.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not focus on continuous learning, innovation and improvement across the organisation. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

We did not observe any creative or innovative approaches to the delivery of specialist palliative care within the hospice. There was limited evidence that people were actively involved in the design or planning of their own care. This meant that care delivery remained largely routine and task-focused, rather than being person-centred or aligned with individual preferences, values, or goals for end-of-life care. As a result, opportunities to promote autonomy, dignity, and quality of life were limited. The recent departure of both practice educator’s roles had created gaps in the delivery of staff training and quality improvement initiatives. We did not seeevidence that the provider had taken timely or proactive steps to mitigate these risks. Staff told us that training and induction sessions had been cancelled, and we were shown evidence that some staff competencies had lapsed, including in areas such as Percutaneous Endoscopic Gastrostomy (PEG) and resuscitation training. This posed a risk to the safe and effective delivery of care.