The Rotherham 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

Managers encouraged staff to raise concerns when things went wrong. Staff provided continuity of safe care and treatment to patients and their families. Staff fulfilled and understood safeguarding requirements appropriate for their role and responsibilities. Staff managed and involved patients in discussions around risks, including clinical, to review and assess them. The hospice had staffing levels to meet the needs of their patients. The premises and equipment were appropriate for the service being delivered. All hospice areas were clean, monitored and audited for cleanliness. All prescribing staff were appropriately trained in managing and administering palliative medicines. These were stored and disposed of securely.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew where and how to record incidents or accidents. They knew how to escalate safety concerns. All staff and volunteers were trained and supported on how to report incidents. Staff told us training equipped them to report and learn from adverse events. During CQC’s assessment, 100% of regular staff were trained in incident reporting. Staff inductions included incident reporting system training.

Incidents forms and logs were completed in full. The hospice moved to a more appropriate incident reporting system over a year before our assessment. This resulted in improved service quality through an increased number of reported incidents. Staff also reported more near misses to help staff avoid future incidents. Incident leads worked to the patient safety incident response framework (PSIRF) from early 2025. They had implemented this before it became a contractual requirement by commissioners. At the time of our assessment, the hospice had no incidents which fit the PSIRF criteria.

Leaders could explain the system for learning from accidents, incidents and complaints. They could demonstrate how they learned from incidents.

Partners felt the hospice worked with them, and took appropriate action when things went wrong. The hospice had established patient-centred training days with their local foundation trust. The service also worked closely with a neighbouring hospice to share information and learning.

Policies and procedures for managing safety events were effective and in line with current best practice. The hospice had an incident reporting policy and procedure which staff followed.

Duty of candour was considered. The hospice had policies for duty of candour (DoC) and consent. The DoC policy specified how staff applied DoC. It clearly outlined governance structures for reporting DoC compliance. A clinical sub-committee monitored this. The policy was accompanied by a DoC improvement plan. The plan was actively monitored by the clinical governance forum. This demonstrated a structured framework for monitoring and auditing DoC.

Verbal and written apologies were given to all affected individuals. This was part of the hospice’s structured incident investigation process. CQC reviewed five complaint DoC letters offering patients an apology. The letters gave a full explanation of incidents which occurred.

Staff promptly reported, tracked and completed complaints on the incident management system. Leads sent all responses within 28 working days.

Post our assessment leads explained that in 2024, the hospice identified complaint leads did not always send patients a separate DoC letter but were completing a letter as part of the complaint’s response. This was picked up through the audit process and action taken to improve in this area.

Complaints or concerns about safety were effectively reviewed. Appropriate action was taken to aid learning and prevent re-occurrence. Hospice staff and volunteers helped people who wanted to complain. The service had a summary of complaints procedure which people could request. Leads acknowledged all complaints within five working days and gave complainants a timescale of when to expect a response. This was usually within 28 days.

Hospice deaths were reviewed by clinical staff for learning themes and trends. This process enabled clinical leads to learn from individual events, track learning themes and identify areas for improvements in patient care and experience. Outcomes were shared with relevant parties. This could include learning relating to external providers as well as the hospice.

The hospice offered patients a hospice at home (H@H) service. This team supported patients in their own home, which could be a care home with assessments and symptom management. The team comprised a Head and Deputy Head of Service, Clinical Nurse Specialists, Nurses, Healthcare Support Workers, Physiotherapists, and Occupational Therapists. The Patient and Family Experience Team also supported them. The H@H service had recently merged from two into one team. Two healthcare assistants visited up to three patients daily.

Hospice teams held multi-disciplinary team (MDT) clinical supervision, daily huddles and 9:00 inpatient unit (IPU) board rounds. Board rounds were held in the doctor’s office attended by medics, IPU coordinator, nominated community workers such as a coordinator or triage nurse, and at least one therapist and allied health professional (AHP). They discussed staffing, any significant risks, and dependency scores if appropriate. The agenda also covered appropriate referrals for admission that day, and handover from the IPU coordinator to the doctor.

Nursing and medical staff completed integrated assessments fully in all the seven care plans CQC reviewed. Plans included clear evidence of daily ward rounds including consultant or senior clinician review. Nurses had clearly documented any reviews with their name and grade. Medical staff added their weekly MDT notes onto a primary care system for improved joined up working with external providers.

Staff completed daily rounding records as part of patient’s care plans. These entailed nutrition and hydration intake and output, bedside alarms if patients fell, and pressure area care.

The service worked closely with other healthcare professionals to ensure seamless, personalised care. Staff could connect patients with additional services in the hospice, community or hospital.

Hospice leads were deeply committed to collaborative working through strong partnerships with healthcare professionals across multiple settings. Their team actively engaged with GPs, hospital palliative care teams, district nurses, and community services to coordinate care effectively. Beyond referrals, their multidisciplinary approach fostered ongoing dialogue between professionals to adapt care plans as patient needs evolved. This ensured patients received seamless, personalised continuity of care.

Leads also worked closely with social care providers, charities, and specialist support organisations. They helped connect patients and families with resources which enhanced their quality of life. The hospice was involved in regional and national palliative care networks. They shared learning and adopted best practices.

Hospice systems and pathways kept people safe. Established care planning processes demonstrated staff’s structured approach to supporting patient choices and ensured their appropriate decision-making. Patients had agreed care plans, such as last days of life care plans, or ReSPECT forms. These helped identify patients who did not want escalation for reversible conditions.

The hospice’s professional and self-referral pathways further enhanced accessibility and responsiveness. Patients and families could be referred to the service through their GP, consultant, district nurse or hospital palliative care team. The day hospice accepted self-referrals.

Clinical staff used and followed the Royal Marsden guidelines online for all clinical procedures such as catheter insertion or personal care for patients. These clinical procedures were evidence-based and well established. They ensured staff followed nationally recognised best practices, reinforcing safe and consistent care.

New medical staff were being trained on record keeping. The hospice used digital records with the exception of the inpatient unit which was paper based. Leads had plans underway for digital systems rollout in the inpatient unit. They were building staff’s confidence in how to use these new systems. An IT staff support function was introduced.

The hospice’s leadership and supervision were well-structured, offering both formal and informal support to staff and volunteers. Leads supported and developed competent leaders through a supervision framework. Managers provided non-clinical, professional and clinical supervision for all staff and volunteers who delivered their services. Their framework enabled access to general and specific supervision in different ways. Some of these were formalised and some were informal as part of everyday work. The framework was continuously reviewed to ensure it met the needs of the workforce. This promoted professional development and high standards of care.

The hospice assessed its current clinical and non-clinical supervision offer. Leads collated and incorporated everything within the refreshed framework. Their continuous improvement review included identifying staff’s further needs and requirements.

The hospice had an onsite IT team who provided essential support. This meant staff could work efficiently both on and off site.

On our last inspection in March 2019 not all volunteers and staff had the right safeguarding training at the right levels.

On this inspection CQC found significant improvement. All staff had achieved 97% overall safeguarding training compliance.

All hospice trustees and volunteers were trained to at least level 2 safeguarding adults and children. Trustees had achieved 100% compliance in both level 2 safeguarding adults and children training. This met the hospice’s 90% compliance ‘aim’ for post-probationary staff.

80% of volunteers had completed this module. The hospice had recruited 75 new volunteers in the financial year before our assessment. Leads were improving volunteers’ training compliance, including safeguarding towards their 90% aim.

Staff were aware of the vulnerable backgrounds and circumstances of the patients, families and communities they served. The hospice’s retail managers and assistant managers completed safeguarding adults’ level 3, safeguarding children level 2, de-escalation and first aid training.

The hospice had a safeguarding lead and operational lead both trained to level 4. Staff were encouraged to access them for advice and support. They also had both inpatient unit (IPU) and community staff champions for safeguarding. The safeguarding operational lead could outline recent learning examples from safeguarding cases and issues raised by hospice staff.

Staff were aware of, understood and responded to safeguarding issues appropriately. The safeguarding lead kept staff updated about latest case studies of potential abuse. This helped them share wider learning examples and encouraged open discussions.

The hospice had established clear, accessible, and well-embedded safeguarding procedures. These ensured staff were fully supported in identifying, escalating, and responding to concerns effectively.

The hospice had structured and embedded safeguarding measures. Staff had safeguarding ‘be in the know’ prompts and concern flowcharts to follow around the hospice. They had immediate access to safeguarding guidance in all key areas on noticeboards. Staff could access and read all related policies, processes and training resources on the hospice’s SharePoint and Hospice Buzz communication channels. Posters covered things to consider and staff to contact for further advice. This ensured their continuous access to up-to-date safeguarding information.

Staff would first discuss any concerns with their line manager, lead nurse, doctor or on-call staff member. They could also discuss concerns at the MDT meeting or with safeguarding leads or champions. Both were present across the hospice. They actively supported staff in recognising and addressing concerns.

Safeguarding champions had targeted safeguarding training, with a training needs analysis already completed. Oliver McGowan training was incorporated into staff’s mandatory learning.

If necessary, staff referred S42 forms for adults and children through their multi-agency safeguarding hub (MASH). Staff attended multi-agency risk assessment conference (MARAC) meetings for patients with families known to services.

The hospice had an exceptionally robust, proactive, and well-integrated safeguarding framework. The framework went beyond standard expectations.

Their safeguarding forum played a pivotal role in driving proactive and continuous improvement. The forum was also an active and structured mechanism for reviewing safeguarding effectiveness. This further strengthened the hospice’s safeguarding processes. The forum was an ongoing initiative no other local hospice had implemented at this level. This demonstrated a sector-leading commitment to safeguarding best practice.

We reviewed the hospice’s safeguarding forum improvement plan from March 2024, under review November 2024. This detailed targeted actions to continually enhance safeguarding measures across the organisation​. Key recent improvements driven by the forum included dedicated safeguarding noticeboards and safeguarding resource folders across all areas. The forum also helped introduce a formal role descriptor for safeguarding champions. This clarified their responsibilities and ensured consistent staff support across all areas. During our assessment leads were actively strengthening the hospice’s safeguarding governance.

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. All staff completed deteriorating patient training. They were aware of the patient’s individual plan of care regarding their wishes in such circumstances. Staff would discuss these with the patient or representative, gain consent to complete observations, and involve the patient in next steps and plans.

Medical staff used escalation planning documentation which supplemented all inpatient’s ReSPECT form. Medical ward round forms included any escalation plans for patients.

The hospice had a medical staffing model outlining opening and out of hours arrangements in place. This clarified how and when medical staff should escalate deteriorating patients. Palliative consultants were part of a regional on-call rota, who were non-resident for advice.

The hospice had a deteriorating patient and emergency admission to acute setting policy. This outlined the roles, responsibilities and duties of all staff. The hospice also had patient risk assessment and restraint policies.

Staff managed patient’s pressure areas using the SSKIN bundle. This comprised five steps to prevent pressure ulcers – surface, skin inspection, keep patients moving, incontinence or moisture, and nutrition or hydration. Nursing staff also used PURPOSE T, a framework for identifying and preventing pressure ulcers in adults.

Staff were reminded about medications which may increase patient’s risk of falls. Falls prevention information outlining people’s risk factors was also displayed in the learning corner. This helped staff better respond to and prevent the causes of fall-related harms and incidents. Staff could access a specialist falls service through their local community trust for some patients.

Medical leads were part of a regional rota of on-call palliative medicine consultants. This involved a daily triage of referrals with MDT input. Leads could admit patients over the weekend. If not, they would clearly document why patients were not admitted that day.

The hospice held monthly mortality and morbidity meetings for clinical professionals involved in patient’s care. Minutes from the 9 October 2024 meeting evidenced contributory factors, discussion and learning points were discussed and appropriate action taken to reduce future risk.

The hospice had a falls and pressure damage forum. Attendees met monthly to discuss issues and areas for improvement. They reviewed all falls resulting in harm, pressure ulcers categorised 3 or above, and poor discharges. CQC reviewed the latest forum minutes. The forum reported to the clinical quality committee. Leads explained they had no discharge forum, as they had very few unsafe discharges. The hospice had a discharge policy ratified in November 2024.

Patients, families, and visitors told CQC the hospice environment was very clean and welcoming. They had widely praised the significant refurbishments and improvements which received consistently positive feedback.

The hospice provided alternative, enhanced solutions to ensure accessibility for all. A lift was fully operational and accessible for patients. Staff actively supported patients and visitors in using the lift where needed. Alternative access routes were available for patients in bed or who found the lift claustrophobic.

Staff had enough suitable equipment to meet patients and service user’s needs and keep them safe. Equipment was in place to maintain environmental and equipment cleanliness.

Staff were trained to use specialist equipment.

On our last inspection in March 2019 not all areas used by patients had call bells so patients may not have been able to summon assistance if they fell or became unwell in these areas.

On this inspection CQC found all bedrooms had accessible call bells. Inpatients and visitors knew how to use these which kept them safe. Staff completed regular rounds and gave patient’s unable to use call bells one-to-one care if required. Inpatient unit (IPU) nursing staff at their station were alerted to individual inpatient room alarms. Triggered LED lights from all rooms linked to staff’s display screen. This helped them respond and address to any incidents, issues or risks promptly. Hospice leads planned to rebrand inpatient rooms in response to patient preference and feedback.

The hospice estate offered state-of-the-art heating, cooling, and air filtration systems. Facilities staff monitored remote temperature monitors installed in all key areas. This ensured both patients and staff could control their immediate environment.

During our assessment downstairs staff areas were particularly warm due to renewable energy machinery. Staff used air conditioning and fans during hot periods. These were present throughout the service and in people’s rooms to keep cool.

All inpatient rooms except one had a balcony or veranda. This allowed people and visitors outdoor access. The hospice had a disabled lift for people to move outside via the lower-ground floor. An alternative route was available through an outside decking area ramp.

All areas of the hospice building were clean, modern, comfortable and well decorated. All electronic equipment was portable appliance tested (PAT) and in date. Fire extinguishers were all full, checked and in date. Care plans were stored securely in a cupboard.

Significant refurbishments had transformed key areas. Extensive investment and improvements had been made to the hospice’s patient, visitor, and staff environment over the 18 months before our assessment. One major investment was a new outdoor veranda and entrance or exit through reception. This ensured all patients, including those in beds, had unrestricted garden access.

The hospice had a quiet room available to patients and visitors. This had soft furnishings and a bookcase of religious and spiritual literature for all ages. This meant staff could offer support in a quiet confidential space. There was also a family room where people could read, rest or have private conversations.

Sleeping accommodation and furnishings were available for family members. Staff would support family members who wished to stay with patients. The building had two multi-functional rooms which could be used as overnight bedrooms for visitors. These could be used when it was inappropriate for visitors to stay with the inpatient in their room.

The hospice ordered 16 new patient beds in February 2025. These could be joined together to make double beds, allowing staff to accommodate couples together if needed.

Managers had a system in place for checking and maintaining equipment.There was an Emergency Incident Response Plan for major incidents. This was reviewed in 2024 by both an internal and external agency.

Fire evacuation procedures for all hospice areas were clearly displayed. The hospice had six generic instructions staff knew to follow. Fire alarm call points were signposted with steps for staff outlined. Fire extinguishers’ maintenance records were up to date.

The hospice had enough staff for the services they offered which kept patients safe.

Medical staff were available for patients at all times. The hospice had one doctor onsite at weekends. They and hospice leads were aware of their prioritised duties. The on-call medical staffing rota was shared with all appropriate staff. This included the out of hours GP, district nurses and Rotherham Place.

The hospice offered all clinical staff training facilities to develop their practical skills and competencies. A clinical training room had a mannequin for clinical practice and simulation scenarios. This allowed staff to care for people with catheters, lines, hoists, pressure sores and amputations.

The hospice actively supported clinical development. For example, a nursing associate had been supported with funding to achieve full registered nurse qualification. A sister was undertaking training to become an Advanced Care Practitioner.

Staff had widescale opportunities for learning and continuous personal development (CPD). For example, healthcare assistants could achieve an award through a regional collaboration. This would enhance their palliative care skills and share best practice. During CQC’s assessment, the hospice was advertising a new clinical skills training role. This focussed solely on training for staff working on the inpatient unit.

The hospice had education champions in six key areas. These were safeguarding, learning difficulties and dementia, pressure ulcers, infection control, syringe drivers or falls and medicines management.

Staff and volunteers had champions to seek advice and guidance. The hospice had both inpatient unit (IPU) and community staff champions for infection prevention control (IPC), pressure ulcers, falls, medicines as well as dementia and learning disabilities. IPU champions also extended to patient experience and safety and quality.

The service’s approach to recruitment had changed. Managers now took on lesser-qualified staff and trained them up, rather than taking on already experienced staff. More staff new to the hospice sector were upskilling, willing to progress or working collaboratively across teams. The hospice had recruited 50 new staff since April 2024.

Teams had seen several recent staffing increases and new roles introduced. These teams included IT and the inpatient unit. Hospice and training leads explained there had been a cultural shift since newer staff members’ arrival. They had a positive impact on reporting incidents and near misses.

All staff, volunteers and trustees completed mandatory and statutory training (MaST) relevant to their role. During CQC’s assessment, regular staff’s overall MaST compliance was 95%. This met the hospice’s 90% compliance ‘aim’ for their post-probation workforce as stated in their training and development policy. Training reports were sent to all directors for their oversight and management.

However, during our assessment not all staff groups met the hospice’s 90% compliance ‘aim’. For example, housekeepers had achieved 78%, kitchen and catering staff 79% and the senior leadership team (SLT) 83%.

Post assessment leads explained they had several staff in identified groups still in their probationary and onboarding period. This reduced their overall average MaST compliance. All staff groups were over 90% compliant post-probation.

Managers had identified role specific training with full-time staff. All staff completed modules in communication, leadership, palliative care and teaching training. Junior staff roles completed this in-house, and senior positions more formally. Leads had invested significantly in staff’s training and development and were very proud of their progress and work achieved.

Staff could join person-centred care statutory and essential training (SET) days. These were open to multidisciplinary teams of inpatient unit and community medical, nursing, pharmacy and therapist. The hospice had various examples of additional bespoke training in place for specialist staff across the service. This helped staff focus on prioritising services and holistic treatments for their patients.

The hospice had a comprehensive training schedule in place. Managers monitored training completion rates closely. They did this through digital reports from their training system, as well as a physical whiteboard display. Training managers and leads held regular ‘tea and teach’ sessions at least monthly. All staff could attend sessions on different rotating internal and external topics. Recent topics included chaplaincy, duty of candour and funeral arrangements.

Staffing was safe and sufficiently skill mixed. CQC reviewed staffing rotas across all hospice services. Clinical leads reviewed daily dependency scores to help them agree numbers. All staff knew who they could escalate any staffing shortages or other issues to, as per the hospice’s escalation process.

Staff safety and support was a priority across all services. Teams often conducted night visits of community patients in pairs to avoid lone working and completed risk assessments. This was an identified risk on the community service’s risk register. Various controls were in place to mitigate higher risk visits.

The hospice had renewed its staff appraisal policy. Leads recognised their previous policy was not reflecting the service’s needs.

Leads monitored and reviewed all staff’s required competencies for their role. Line managers had completed up to date annual performance review appraisals for all medical and nursing staff. All clinical staff files contained current professional registrations.

Leads shared examples of non-clinical compliance for catering staff. Competencies in non-clinical areas were mainly addressed through recruitment and extra training the hospice actively provided if needed. All staff were trained to the appropriate levels.

Employment files reviewed contained all appropriate safeguards and background checks. We reviewed 12 trustee and 10 staff files. All were disclosure barring service (DBS) checked. The hospice obtained annual declaration of interest forms from all trustees as part of their statutory audit process. This meant we could ensure recruitment and human resources processes complied with our regulations.

All staff and volunteers were appropriately trained. Hospice training records were stored and updated on a SharePoint system.

All regular staff and volunteers were fully trained and competent during our onsite assessment. Leads provided evidence they retained DBS certificates for all staff and trustees.

Staff followed aseptic non-touch techniques for standard and surgical procedures. They also followed guidance when applying intravenous devices or adult venepuncture.

CQC observed staff using the appropriate personal protective equipment (PPE) and infection control measures. Cleaning staff used ‘I am clean’ labels in areas where equipment was cleaned. The hospice had an infection prevention control (IPC) policy CQC reviewed ratified in April 2024. Hand washing techniques were clearly displayed in staff bathrooms.

Audit leads undertook IPC audits including quarterly and annual infection control audits. Leads planned to complete all audits using a digital performance and quality improvement scoring system.

Their IPC lead produced an annual report for senior managerial review. The hospice also had a service-level agreement (SLA) with their local acute trust for IPC. This trust provided the hospice with quarterly IPC audits and teaching.

The IPC in-patient unit lead completed monthly audits and weekly hand hygiene audits. The housekeeping manager completed daily environment audits.

The service used colour coded bins in which staff disposed of different infectious waste. For example, orange bins were for fully discharged uncontaminated sharps needles. Waste disposal incidents were discussed at clinical governance meetings. This demonstrated an effective approach to infection prevention and control. It ensured compliance with established protocols and governance processes.

Staff undertook wider work with their multidisciplinary team (MDT) and community matrons to ensure patient’s community medicines were safe. Staff ensured EOLC medicines were secure and only accessible to those who needed them.

Controlled drug storage was secure. The hospice had a medicines storage room for controlled drugs and other medicines. Only appropriate clinical staff could enter through an access controlled secure door. CCTV was installed within the drug room.

Clinical staff had access to a room with emergency drugs in the event they were needed. All staff could attend mortality meetings which shared learning related to these drugs. The hospice actively used these meetings to review and enhance learning related to medicines management. This was an additional measure uncommon within the sector.

CQC reviewed the medication records for seven patients. Staff had completed all charts appropriately and considered any recorded allergies. They were paper based, clear and legible. Guidance prompts about the seven rights of medication administration were displayed which staff followed. The service shared medicine alerts for monitoring and notification with all relevant prescribing staff. CQC saw six alerts for November 2024 with descriptions and any actions which staff had taken.

Robust processes were in place to ensure medicines were managed safely. The hospice had a medicines management policy in date and action plan in place. The policy was compliance monitored through an incident report process, clinical supervision and appropriate clinical audit. Staff reviewed medicines compliance against CQC essential standards and monitored through the board of trustees. Prompt actions were taken when necessary.

The hospice had a medicines action plan, along with a Controlled Drugs Accountable Officer (CDAO) plan. The medicines management team held a forum where they discussed and reviewed all incidents and put actions into place.

Leads took prompt actions and learned lessons when medication errors were found. They also ensured medication effectiveness through a structured incident reporting process. 73 medication error incidents had occurred in the year before CQC’s assessment.The most common incident category involved controlled drugs. Actions were in place to address and reduce CD related incidents.

Staff undertook annual examinations of CD storage areas and controlled drugs audits. Hospice leads stored all medicine and CD related audit information. They used a digital performance and quality improvement scoring system. This allowed staff to access and present audits during site visits. The system further strengthened governance and transparency. The service last undertook a controlled drugs audit in November 2024. No actions or areas for improvement were required.

A pharmacist and pharmacy technician were onsite two days a week. They provided remote support by phone on the other days. They completed stock checks, medicines ordering, destruction of appropriate medicines, ward rounds and medicines reconciliation.