Helen and Douglas House

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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 as good. At this assessment the rating has changed to outstanding. We found a service with a strong culture of learning, where incidents were consistently used as opportunities for reflection and improvement. Effective systems were in place to ensure safety and care was delivered within a clean, well-maintained environment that was compliant with safety standards. Staff were actively supported in their professional development and encouraged to expand their roles. Leaders promoted continuous learning and created opportunities for staff to enhance their skills, contributing to a confident, competent and forward-thinking workforce.

This service scored 91 (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 4. The evidence showed an exceptional 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.

The service demonstrated a proactive and positive safety culture rooted in openness, transparency and continuous learning. Staff at all levels told us they felt confident to raise concerns and report incidents and that these were taken seriously, investigated thoroughly and used to drive improvement. Leaders actively strengthened the incident‑reporting culture and created an environment where staff confidently report all concerns, including near misses.

Staff described communication as both “top-down and bottom-up,” explaining that while they were kept organisationally informed, their views were actively sought when problem-solving and shaping improvements.

The service adopted the Patient Safety Incident Response Framework (PSIRF) used within the NHS to support standardised responses to incidents and improving learning within the service.

We reviewed 10 incidents at the service and found there were numerous examples of learning being translated into real change. Managers broadened safety training beyond clinical teams to include volunteers and retail staff, recognising that a learning culture must include the whole organisation. This approach identified a gap in risk assessment processes after a volunteer experienced an allergic reaction to foam used during a local fundraising event. In response, the service introduced a pre-event risk assessment template that included allergy screening, strengthening oversight of non-clinical activities.

A managerial review of policies also demonstrated responsiveness to staff feedback. Staff had expressed discomfort with the language and purpose of a restraint policy. Leaders listened and replaced it with a behaviour support policy that was in line with directional change of breaking down barriers to behaviours that may challenge and help staff support children and young people in the hospice environment.

An incident involving incomplete diabetic glucose monitoring was investigated openly, without blame. As a result, managers increased training opportunities and strengthened competency assessment in glucose monitoring and diabetes management. This reflected a culture focused on learning and capability rather than fault-finding.

The medical team met quarterly to review incidents and trends specific to medical practice, ensuring shared learning and collective oversight of changes arising from investigations.

We scored the service as 4. The evidence showed an exceptional standard. The service demonstrated strong partnership working with children, families and healthcare providers to design and sustain safe, well-coordinated care pathways and transitions.

The service demonstrated a strong and proactive commitment to supporting children and young people transitioning from children to adult palliative care services.

The service demonstrated strong, proactive transition planning, with the medical lead and two youth transition workers supporting children and families from age 14 to ensure well-coordinated, needs‑led transitions into adult services. However, leaders ensured transition planning was highly person‑centred, with bespoke arrangements designed around each child’s individual needs, promoting continuity, emotional wellbeing, and positive outcomes.

Regular stakeholder events and quarterly review meetings strengthened joint working with GPs and partner organisations, supported by a standardised framework that informed national audit tool development. Managers also contributed to research projects to improve understanding of the transition process and young people’s experiences. The service collaborated with the local adult hospice to jointly support a young person with a tracheostomy, ensuring safe, continuous care.

The service used a forward-thinking, research-informed and highly collaborative approach to transition. Leaders demonstrated system-wide engagement, innovation and a strong commitment to ensuring young people experienced safe, personalised and well-coordinated transitions into adult care.

We observed two handovers from parents to staff for children staying overnight. During these handovers, staff systematically reviewed each child’s care plan to ensure all information remained current and accurate. This included confirmation of PEG feeding regimes, prescribed medicines, the child’s daily routine, current weight (to verify accurate medication dosing) and positioning and repositioning plans.

The service used a shared electronic records system with the local acute trust, ensuring timely, accurate information exchange and coordinated care. Regular joint meetings supported proactive caseload planning and smooth admissions. Maternity, neonatal and AE teams described strong collaborative links, supported by clear referral pathways for urgent and emergency cases.

Staff demonstrated effective communication with GPs to ensure joined up working across services. This collaborative approach ensured children and families experienced seamless care.

We scored the service as 4. The evidence showed an exceptional standard. The service worked with children, families and healthcare partners to improve children’s lives while protecting their right to live in safety.

Staff received regular, focused safeguarding training sessions that used real-life scenarios. One scenario involved a child who was well known to community services, but whose needs were not effectively communicated when they attended AE. The session explored the safeguarding implications of the case and highlighted the importance of ensuring that children bring their care passports with them to all medical appointments and interventions.

During multidisciplinary team meetings, we observed that safeguarding was consistently considered. Discussions extended beyond the identification of potential abuse and included a clear focus on the mental health and coping abilities of the child, parents and siblings. The service had completed a risk assessment of all ligature points following a concern about the mental health of one of the parents. In response, all alarms were now ligature free, ligature cutters were safely stored, and staff were trained in their usage, if light pull cords were used to self-harm.

Staff completed safeguarding adults’ and children’s training to the appropriate level, in line with national guidance. Staff completion rates were above the services target of 90%. All staff knew who the services designated safeguarding officer was, and they were appropriately trained. In addition, staff received focused safeguarding training on specific areas, including child death reviews, looked-after children, medical assessments, adverse childhood experiences (ACEs), trauma and safeguarding children with disabilities.

Staff also received training on female genital mutilation and child sexual exploitation. All staff we spoke with understood their role and responsibilities regarding identifying reporting and escalating concerns.

Staff attended regular education weeks, which were used to support ongoing safeguarding training. We reviewed documentation from the education week held in the month prior to the assessment, which demonstrated that safeguarding scenarios were routinely discussed.

The service’s safeguarding approach extended beyond children and families to include staff and volunteers. Safeguarding reminder cards, outlining disclosure and referral processes, were introduced to support all staff and the service provided safeguarding training to all staff, including volunteers.

The service safeguarding lead worked with the local Integrated Care Board (ICB) to develop a safeguarding audit and assurance tool, alongside a bronze, silver and gold escalation and reporting framework. Following implementation of the tool, managers introduced a 24-hour safeguarding on-call support system. The audit identified a need for further staff education to support consistent incident reporting of all concerns and to increase staff confidence in making safeguarding referrals using their own professional judgement, rather than seeking senior approval.

The service had clear processes in place for reporting and referring safeguarding concerns. These included defined timeframes for referrals (within 24 hours for non-urgent concerns and within one hour for urgent concerns), arrangements to support the person making the referral, clear allocation of lead roles and escalation pathways to the Local Authority Designated Officer (LADO), Multi-Agency Safeguarding Hub (MASH) and the police. The service had recently updated its statement of purpose to clarify how safeguarding notifications were referred to third-party agencies.

Staff received regular updates on safeguarding referrals during daily huddles, with summaries also shared via the service’s online communication channel.

The service worked in partnership with external agencies to support looked-after children and children subject to child protection plans. We observed detailed care planning and effective multidisciplinary working between the service, community health services, social workers and schools. Staff described how they had supported one looked-after child to move into foster care. At the time of our assessment, the service was also arranging for this child and several others to visit Clarence House to decorate a Christmas tree.

We scored the service as 4. The evidence showed an exceptional standard. The service worked collaboratively with children and families to identify, understand and manage risks. Staff aimed to deliver care that reflected children’s and families’ wishes while always maintaining safety.

Risk assessment extended to the wider family. Staff completed holistic assessments, including a recognised tool to assess the risk of postnatal depression where appropriate and a bereavement risk assessment tool. These measures supported early identification of emotional or psychological need and enabled staff to signpost families to appropriate internal or external support services.

Staff supported families to manage their own risks in accordance with their own preferences and wishes. The perinatal and medical teams supported a woman under perinatal care to give birth at home. Staff stated they had not received a request like that previously; however, they were keen to support the woman and her family in line with their wishes. Staff response to the case was “There are times in palliative care, where conventional protocols and risk assessments need to be viewed in a different context, offering a risk aware, not risk adverse approach.” The service worked with the family to create an anticipatory symptom management plan, to ensure that medicines would be available prior to birth. A multidisciplinary approach was used to ensure there was safe preparation and prescription of medication despite the baby not having a medical record number. After the birth, the case was presented at a national professional forum as an example of exceptional perinatal palliative care.

Managers had recently audited the daily safety huddle process to ensure that key clinical information was communicated effectively between teams. In addition, they had reviewed the deteriorating patient pathway and were in the process of formally approving the updated procedure to strengthen escalation processes and clinical oversight.

We scored the service as 3. The evidence showed a good standard. The service ensured facilities supported the delivery of safe care.

The environment was age‑appropriate, well‑designed, and safe for children of all ages. The service provided a range of separate and adaptable spaces that enabled children and their families to spend private time together when needed. Leaders had also ensured the environment met the differing needs of age groups, with designated areas for teenagers that offered privacy and separation from younger children. This supported dignity, emotional wellbeing, and positive engagement for all children using the service.

Leaders ensured environmental risks were well managed, including the safe selection, storage, cleaning, and maintenance of toys and equipment. This supported children’s developmental needs while maintaining a clean, safe, and therapeutic environment.

The service used secure entry systems and swipe‑card access to control who entered the building and bereavement suite.

Managers maintained equipment safely through regular servicing, calibration and replacement planning, and all bedrooms had ceiling hoists with personalised slings.

Staff followed clear fire‑safety procedures, took part in regular drills and ensured extinguishers met required standards.

Managers also tested water outlets for legionella and maintained contingency measures such as backup generators.

A review and risk assessment of the on-site emergency trolleys had also been completed. At the time of inspection, we checked the existing emergency trolleys and found that equipment was in date, signed as checked and matched the inventory list. The trolleys were stored securely to prevent unauthorised or accidental access.

We scored the service as 4. The evidence showed an exceptional standard. The service consistently ensured there were sufficient numbers of suitably qualified, skilled and experienced staff to keep children safe. Staff told us that teams worked seamlessly and collaboratively, enabling the delivery of consistently safe, high-quality care.

In the absence of a national paediatric safer staffing model, the service showed innovation and sector leadership by collaborating with other hospices to review staffing approaches and trial a model developed elsewhere. Staff also contributed to wider professional development initiatives, including supporting national hospice training programmes and reviewing alignment with professional standards.

Staffing levels across onsite and community nursing teams, medical staff, and therapy and support services were responsive to the acuity and complexity of children using the service. Workforce capacity was flexible and sufficient to safely accommodate emergency admissions without compromising care quality. Clinical leads had driven innovation through the development of an electronic rota system with an embedded skill-mix function, reducing the risk of inappropriate skill dilution when shifts were exchanged.

Leaders strengthened governance through an enhanced senior on‑call system, improving oversight and responsiveness. In addition to established weekend cover, a senior leadership on‑call rota operated every evening from 5pm to 8am, ensuring timely escalation and consistent decision making. Medical support was always available, with a minimum of two medical staff onsite during daytime hours Monday to Friday, and robust out‑of‑hours medical cover provided through the on‑call system. The community team staffing levels were thoughtfully aligned to the acuity and size of the community caseload, enabling the team to adapt promptly to changing needs. These arrangements ensured children and families received seamless, uninterrupted care, including during periods of increased clinical acuity or unplanned admissions

Although the service was operating below its funded establishment, leaders had taken effective action to mitigate risks. Sickness rates had reduced significantly, from 14% to 6%, which leaders attributed to improvements in organisational culture. Staff survey results reflected high morale, with staff describing how they “love coming into work.”

Staff received comprehensive, structured support, including regular supervision, one-to-one meetings, and access to external peer networks, with wellbeing fully embedded within appraisal processes. They also made a recognised contribution to wider sector development through involvement in national programmes and standards reviews.

Leaders demonstrated a strong commitment to career development, supporting staff to expand both their roles and the service offer, for example through increased physiotherapy provision and role diversification. Staff described a significantly improved culture with greater opportunities, although some noted that progress in achieving certain clinical competencies could be slower.

Mandatory training compliance met targets for permanent staff, and while it was lower for bank staff, leaders had clear, effective action plans in place to address this as a priority. Risks were well managed through collaborative team working, with carefully structured teams ensuring the appropriate mix of trained and competent staff. Recruitment, induction, and competency assessment processes were robust, and rotas were planned to maintain a safe and effective skill mix.

At the time of inspection, the service did not admit children with a tracheostomy. However, leaders were developing a structured training and competency framework to enable staff to safely care for children with more complex needs in the future, demonstrating a proactive approach to service development.

Following a staffing incident, managers implemented a policy on secondary employment, demonstrating proactive, supportive, and effective oversight of workforce risks.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading.

We observed that all areas of the service were clean and had suitable, well-maintained furnishings. All clinical areas met Department of Health standards. Staff followed infection control principles in line with best practice guidance.

Cleaning records were up to date and demonstrated that all areas were cleaned regularly. Managers reviewed infection control as part of governance processes, including pre-admission checks, audits, incident reporting and post-infection reviews. We reviewed hand hygiene audits, which were detailed and included observations of washing before and after patient contact, hand-washing technique, availability of hand-washing resources and correct disposal of waste. Where standards were not met, managers arranged refresher training and follow-up audits.

At the time of our assessment, 81% of permanent staff had completed up-to-date infection prevention and control (IPC) training. Although this was below the service’s target of 90%, leaders clearly demonstrated that this was due to recent changes in training frequency, with staff now undertaking more comprehensive and regularly scheduled IPC training. Managers had appropriate oversight of compliance and had implemented clear action plans to improve uptake, with achieving the 90% target identified as a priority.

We scored the service as 3. The evidence showed a good standard. The service ensured that medicines and treatments met children’s needs and preferences.

The service carried out thorough medicine audits covering prescribing, storage, documentation, and environmental standards. Each audit included a traffic-light action plan with clear ownership, and improvements were re-audited to confirm effectiveness.

The service had appropriate systems and processes in place to ensure the safe provision of medicines in the community. Medicines and medical equipment were checked and recorded to ensure items issued were traceable and monitored. This included equipment such as oxygen and syringe drivers.

Medicines were securely stored, fully traceable, and monitored daily, with staff demonstrating clear understanding of procedures, including managing temperature excursions. Security was strengthened through role-based card access, improved prescription pad controls, and the introduction of topical medicines records.

A risk assessment led to safer use of pre-filled adrenaline auto-injectors instead of manual preparation, reducing error risk and improving emergency response. Controlled drug requirements were fully met, and staff followed robust procedures when managing medicines on admission.

Managers had identified plans to replace the trolleys with two emergency grab bags and two oxygen cylinders, to improve accessibility and mobility in an emergency.

The service also showed learning from incidents, revising processes (e.g. feed storage) to reduce risks and improve safety.