Dorothy House Hospice Care

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• 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 the same. This meant people were safe and protected from avoidable harm.

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.

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. Learning across the hospice was shared through governance forums, team meetings and reflective practice, and was translated into improvements in care, training and service delivery, ensuring risks were identified early and high‑quality, safe care was sustained. Staff told us there were clear open and transparent processes for reporting and learning from incidents and this was often shared via meetings and weekly wrap up emails.

The hospice had an open and compassionate learning culture where safety, honesty and continual improvement were everyone’s responsibility. Leaders encouraged staff, patients and families to raise concerns, incidents and near misses, supported by clear reporting, freedom to speak up and complaints processes.

All staff knew what incidents to report and how to report them. Staff we spoke with told us they used an electronic based reporting system to report incidents and received feedback from these. Staff described a medicine related incident that led to learning and improvements, resulting in medicines being stored in a secure bag and counted only on admission and at discharge.

The hospice had recently transitioned to the NHS England’s Patient Safety Incident Response Framework (PSIRF) to review incidents and discussed this via clinical governance meetings as an opportunity to put things right, learn and improve. Staff had access to the PSIRF policy which focused on effective learning and compassionate, meaningful engagement with those affected when incidents occurred. PSIRF is a mandatory NHS framework for responding to patient safety incidents, emphasizing learning and improvement over blame, replacing the previous Serious Incident Framework (SIF).

Additionally, the hospice also had an accident, incident and near-miss reporting policy which outlined key arrangements to support the active reporting and learning from all work-related accidents, incidents and near misses. However, at the time of our assessment, the policy was out of date, with a review date of 15 June 2025. Further evidence submitted by the hospice confirmed that the policy had since been reviewed, approved, and was now in date.

Staff were routinely supported with a debrief and support after clinical incidents. Staff at the hospice routinely undertook training on PSIRF and had carried out several after action reviews (AAR), two examples were provided, which included thorough learning and action plans that had been fully implemented and completed.

The hospice produced a quarterly incidents and accidents report for the inpatient unit and other services provided by the hospice. Our review of July to September 2025 reporting period showed a quarterly increase in patient safety incidents which included low level medication errors. The report also highlighted key themes and learning, one of which included maintaining accurate and timely documentation when a patient refused interventions for pressure area care.

The hospice had reported no never events from April 2025 to December 2026. A never event isa serious, preventable medical error that should never occur if proper safety procedures are followed. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

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.

There were clear referral pathways into the hospice. The hospice accepted referrals through their clinical coordination centre which was manned from 8am until 6pm from Monday to Friday and 9am until 5pm during the weekends. Outside of these hours, patients could contact a 24 hour advice line which was run by specialist nurses who had access to specialist medical advice. People could also be referred to the service by a health and social care professional or they could self-refer. Additionally friends and family of people with a life-limiting illness could also make referrals via a digital referral form.

All new referrals were reviewed during the daily team meeting, and cases were subsequently allocated to the appropriate nursing caseloads. Each team within the hospice also held weekly multi-disciplinary team (MDT) meetings which allowed the clinical team to conduct holistic reviews of patients’ needs and monitor any changes in the clinical situation, phase of illness or social support needs. We observed an MDT meeting and saw good evidence of patients and families being at the centre of all care and assertive clinical governance to ensure care was safe.

The community palliative care team (CPCT) leaders met to discuss caseloads and prioritisation of planned visits and urgent responses as well as team communication and opportunities for learning. The hospice was in the process of introducing a peer review process which would involve monthly peer reviews of every caseload. Additionally, the hospice also met regularly with the GP and community teams to review shared caseloads and new referrals.

Staff had access to the referral and admission policy, which provided a clear written framework outlining the referral criteria and the eligibility requirements for access to hospice services. The policy was in date with a review by date of September 2026.

All patients in the in-patient and day-patient unit were able to receive input from the specialist allied health professionals team which was made up of physiotherapists, occupational therapists, dietitian and speech language therapists (SaLT), plus exercise practitioner, and full family support team.

There was an effective systems to support individuals with additional needs such as learning disabilities, and leaders reported good connections with the local learning disability team and speech and language therapy services.

The hospice had strengthened its safety systems and pathways by introducing specialist roles, including a SaLT and a discharge coordinator working within the local hospital. A dedicated lead for transitions was in place to support safe pathways for children and young people moving from children’s to adult services, including joint quarterly transition clinics.

These arrangements supported effective coordination of care across services. Safety was proactively managed and assured through regular monitoring, audit, and learning, enabling early identification of risks and timely improvements to care pathways.

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.

Staff knew how to recognise, and report safeguarding issues and knew how to escalate safeguarding concerns if required. The hospice had a designated safeguarding lead who was on duty each day. Staff told us they had access to them for advice and support. Staff could also access support from the executive lead who was trained to level 5 in safeguarding for both adults and children.

Staff received safeguarding level 1 to 4 training for adults and level 1 to 3 for children. The hospice had an in date safeguarding children and adult policy. As of January 2026, the completion rate for safeguarding adults level 1 was 98%, 79% for level 2 and 66% for level 3. Leaders recognised that compliance with level 3 safeguarding training was low due to a vacancy in the operational safeguarding lead role. A plan was in place to address this, with training being delivered by an external provider and further sessions scheduled. The hospice was also recruiting to a psychosocial services lead role, who would take on the operational safeguarding lead responsibilities, and this post had now been filled.

Staff also received training in Prevent. Prevent training is a statutory safeguarding duty in the UK, aimed at stopping individuals from being drawn into terrorism or supporting extremist ideologies.

The hospice had a safeguarding assurance panel with external representation which provided structured oversight and assurance of safeguarding policies, procedures and practice which reported into clinical governance, care services committee and the board. The panel met quarterly and formed a key part of the organisation’s governance framework. They maintained responsibility for monitoring safeguarding risks, reviewing incidents and concerns, and ensuring that learning was identified and acted upon.

We reviewed the meeting minutes for May, August and November 2025 which included discussion of safeguarding training compliance, review of case studies and audit activity.

The hospice employed a family support social worker and two social workers who supported individuals, families, and communities through difficult challenges. They aimed to improve wellbeing, protect vulnerable people from harm, and promote human rights.

Additionally, the hospice also employed a homeless link worker who helped individuals secure, maintain, and manage stable housing. Staff described them as fantastic and gave an example of how they linked with disadvantaged groups and the difference they made by doing so.

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 effective processes to ensure patients’ risks were assessed, monitored, and managed on a daily basis. The hospice had invested in a comprehensive digital risk management system (RADAR) to records risks and individual patient risks were discussed daily during team meetings and SitRep meetings. A "SitRep" (Situation Report) meeting in a private healthcare setting is a structured, often daily briefing designed to provide decision-makers with a concise overview of the current operational status, capacity, and critical risks. We attended a SitRep meeting at which a multidisciplinary team and senior leaders reviewed operational status, capacity, risks (such as falls) and admissions for the in-patient unit for the day.

Staff had access to the acutely deteriorating (including sepsis) policy which provided staff with direction in decision-making processes involved in managing the acutely unwell patient under the care of the hospice. This included the identification, assessment and management of patients with suspected sepsis in the inpatient unit (IPU). Staff also completed a training tracker module for management of sepsis and use of national early warning score (NEWS2).

Effective risk assessment and action planning was carried out. Pressure ulcers, falls and nutrition and hydration were regularly monitored through risk assessments. We reviewed patient records and found evidence of completed falls risk assessment, nutrition and swallowing risk assessment and skin integrity risk assessment. Staff also completed VTE assessments and reported on these quarterly, in line with best practice.

Staff could access a pressure ulcer and prevention policy which included information on early identification of patients at risk of developing pressure ulcers and information on how to access support from external agencies. An enteral tube feeding policy was also in place which included the management of patients with eating and drinking with acknowledged risk.

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

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 hospice provided 10 ensuite rooms with views over the countryside. The design of the environment followed national guidance. The service had enough suitable equipment to help them to safely care for patients. Call bells were available in patients bedrooms to support their safety.

All rooms were single occupancy with ensuite bathroom which opened into the garden which patients had access to. Patients were able to control their room temperature according to their individual needs. All rooms also had their own fridges, cuddle beds to enable support or intimacy from loved ones and a hoist system for manual handling if needed and cushioned reclining chairs.

The hospice carried out environmental risk assessments which were updated annually. We reviewed a control of substances hazardous to health (COSHH) risk assessment and found this to be thorough with risks identified within the internal and external environment.

Staff received specific training in gas cylinder and oxygen awareness as well as fire Marshall and fire door maintenance. As of January 2026, the compliance for the gas and oxygen awareness training was 61%. The hospice stated this training only applied to 15 staff and was a new module which was launched at the end of November 2025 with an external trainer had been booked to deliver this.

The hospice had a lone worker policy, associated training and had invested in a digital app to ensure the safety of all staff and volunteers when working in people’s homes and environments not overseen by the hospice.

The hospice had also employed a night security worker to ensure the premises were safe at night for patients and staff working in the hospice.

The health and safety committee within the hospice was led by a dedicated health and safety officer who was employed by the hospice and routinely used external bodies to test their safety protocols.

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.

Both the inpatient unit (IPU) and the community team were well staffed and had a good skill mix with no vacancies within the care services team. Medical cover was at establishment with consultant and specialist doctors covering the IPU. Out of hours there was an on-call executive team member to escalate staffing concerns if needed.

The hospice used a workforce planning tool to support safe and effective staffing. This enabled leaders to regularly review staffing levels, benchmark against standards and comparable services, and adjust establishments to ensure care was delivered safely, sustainably, and within available resources.

Roles within the care services team included advanced nurse practitioners, specialist nurses, community staff nurse and medical director etc. Other staff roles included a physiotherapist, an occupational therapist, a specialist dietician and social workers.

Much of the education was done in house and there were competency frameworks which staff completed yearly. Some staff also taught on external university modules which brought in income for the hospice. The competency framework had been developed to provide a guide to both individual staff members and managers, to ensure they had the skills, knowledge, experience, attributes and behaviours to perform their job effectively and achieve their full potential to deliver high quality care.

Staff were required to keep up to date with all statutory and mandatory training and completed this through e-learning and face to face sessions. Some of the training modules included mental capacity act and safeguarding. Data provided by the hospice showed overall compliance for mandatory training at 92% as of January 2026.

Staff felt they had adequate training to provide safe care and commented that senior managers were supportive of them ensuring they were competent and safe in their practice.

Staff received regular supervision and appraisals and said the hospice was a “great place to work”. The team received regular personal development reviews (PDRs) internally at the hospice. In addition, the consultants and specialty doctor received an annual external appraisal, as per medical revalidation requirements. A key component of this was demonstrating CPD credits had been achieved to support the clinical role.

The hospice employed volunteers who completed mandatory training depending on the area they worked in and their role.

Staff had completed Oliver McGowan training and were experienced with the mental health act and safeguarding. The Oliver McGowan Mandatory Training on Learning Disability and Autism (Oliver's Training) aims to provide the social care and health workforce with the right skills and knowledge to provide safe, compassionate, and informed care to autistic people and people with a learning disability.

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 guidance and support from the infection control lead if needed. Additionally, staff completed infection prevention and control (IPC) as part of mandatory and statutory training and had access to the infection prevention and control (IPC) policy which provided guidance on the principles of IPC and a standardised approach to safe practice.

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. Patients we spoke to on the day of the inspection told us that staff always had personal protective equipment (PPE) on and washed their hands.

Staff had a good understanding of infection prevention control (IPC) and we saw cleaning schedules on the day of the inspection which were completed and dated.

The hospice completed quarterly audits in each clinical area using a national tool for healthcare cleanliness standards. The infection prevention and control (IPC) lead regularly attended system-wide meetings and worked closely with the IPC lead for the hospice commissioners as well as participating in south-west regional IPC forums to share best practice and learning.

IPC arrangements were overseen through comprehensive governance processes, with clear reporting pathways from clinical governance, clinical audit and quality improvement group, and the health and safety committee, through to the care services committee and ultimately the board.

We reviewed the audit for quarter 2 2025/26 for the inpatient unit which showed an overall score of 86.3%. Following this, the hospice had put together actions and recommendations to improve compliance. This included emailing staff about labelling commodes and clearing paperwork from vacated rooms.

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.

The hospice had strengthened its medicines governance by commissioning a senior pharmacist (15 hours per week) and an additional pharmacist (4 hours per week), both sourced from the local acute hospital. This arrangement supported the application of best practice standards and provided professional peer support.

Additional oversight was provided through line management by the chief pharmacist, who also held the role of ICB controlled drugs accountable officer.

We reviewed 6 prescription charts and found these to be completed in line with policy and national guidance. Syringe drivers were serviced yearly and in date and were used for medicines administration appropriately. We saw that the checks for these were up to date.

Symptoms and medicines were systematically reviewed throughout the day, in line with the hospices personalised care approach. Anticipatory medicine was prescribed to cover every eventuality at adequate doses which showed forward planning with the patient always at the forefront.

Controlled drugs (CD) were managed in line with the hospice policy, which was based on national guidance and legal frameworks. The hospice had two staff acting as controlled drugs accountable officers (CDAOs), both of whom were active members of the southwest local intelligence network (LIN) and had completed training through the NHS England recommended training provider.

Medicines were stored appropriately in locked cupboards and fridges if needed. Fridge temperatures were monitored and we found this to be documented and up to date.

Staff had access to a comprehensive management of general medicines policy, which included a number of underpinning procedures for medicines related elements.

The hospice took part in 6-monthly medicine management related audits which included medicine management administration audit and missed medication audit. This was overseen by the clinical audit and quality improvement group (CAQIG). The hospice also completed an annual CD audit with recommendations fed to the board via the clinical governance sub-committee. We reviewed this audit for September 2025 which showed there were no missed medications with all doses documented correctly.

All CD related incidents were reported and discussed 6 monthly by the CDAO at the LIN meetings. Our review of the clinical accidents and incidents showed 20 medicines related incidents had been reported from July to September 2025. All of these incidents were reported as no or low harm. A prescribing error accounted for one incident and the hospice reported no harm had come to the patient as a result of the this. The remaining, incidents were recorded as administration errors. Learning from these was identified and the hospice had a learning and action log for each incident.

The hospice demonstrated a proactive approach to medicines safety by commissioning an annual, comprehensive independent external audit of medicines management which reviewed all relevant policies and clinical practice across the hospice, with action plans developed and implemented where required.