The Rotherham Hospice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

All managers, staff, volunteers and partners were clear about the hospice’s strategy and vision. Leaders and staff at all levels were competent, skilled and trained for their roles and responsibilities. The hospice and staff were well-led by strong leaders who embodied the cultures and values of their workforce. Leads promoted and encouraged a speak up and blame-free culture indicative to learning where staff could raise concerns. Hospice leads and staff treated everyone fairly and equitably. The hospice had a robust and positive governance and risk management culture. Leads took prompt action to address risks at all levels. Staff shared good practice and learning, and sought partnership working, collaboration and integration. Staff monitored and drove continuous improvement such as audit programmes to ensure compliance. Staff had good awareness of their environmental initiatives and impact.

This service scored 93 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff understood the hospice’s newly developed strategy and its seven aims. For example, the community outreach manager explained how their work tied in with the strategy’s objectives. Staff shared the hospice’s vision, values and strategic aims. They were proud to work for the service.

The hospice significantly invested in the development of its new strategy. This included commissioning an external research agency to gather feedback from a broad and diverse range of stakeholders. The strategy was shaped by comprehensive, community-wide engagement. This ensured it was authentic, representative, and aligned with the needs of Rotherham’s population. The hospice’s level of staff, stakeholder, and public engagement in strategy development and cultural transformation far exceeded sector standards.

Leads and staff had developed and embedded a strong, positive, open, inclusive and forward-thinking culture. Managers proactively worked to challenge the hospice’s legacy culture. This enabled staff to speak out, raise concerns and report incidents more.

Leads explained their governance framework played a pivotal role in sustaining a positive culture. An integrated governance approach aligned clinical and non-clinical staff with safeguarding, equality and diversity policies. This meant all staff could focus on mitigating risks of negative cultural practices.

Leads placed importance on ensuring everyone involved in the hospice had a positive experience. They were actively considering incorporating a formal closed culture review into their next staff surveys.

The hospice held a cultural sensitivity questionnaire shortly before CQC’s assessment. This identified areas where staff did not feel comfortable asking patients and their loved one’s questions. Training leads were developing questions based on findings to actively support staff. This demonstrated their commitment to continuous improvement in staff confidence and inclusivity.

The hospice had forged and showcased strong community connections and progressive leadership. Leads held promotional events to launch their strategic plan. One at a local cinema showed a documentary highlighting this work. As the plan was community-focused, local town councillors and council representatives had attended. The plan was available at hospice reception with a large display outlining their purpose.

The community outreach manager worked closely with local leaders to look at coproduction and learn from what others had done. They aimed to raise awareness of the hospice along with cancer, diagnosis and experience while developing new and existing relationships. They worked to address wider public misconceptions and change perceptions of what services it provided.

The hospice had just launched their new strategic plan for 2024-30 called “Living life’s wishes” – a strategy for excellence in hospice care. The strategy was based on conversations with and feedback from 656 patients, families, staff, volunteers and local partners. The strategy was evidence-based, data-driven, and directly aligned with national healthcare priorities to ensure excellence in hospice care.

The service’s vision was compassion, choice and dignity for all. Their values were caring, trust, respect, inspirational and working together. Their mission covered four objective statements to help staff achieve both.

The service had a simple vision which staff shared; to make sure everyone in Rotherham could get the palliative and end of life care they needed, wherever and however they chose.

The hospice leadership had undergone a transformation since our last inspection in March 2019. Leads had implemented a clear strategic vision (‘Living Life’s Wishes’), modernised governance structures, and ensured robust engagement at all levels. Leaders were progressive, engaged, and values driven. They were also highly visible, approachable, and supportive to all staff, trustees and volunteers. Executive directors had moved offices to be central and based close to their teams.

The hospice demonstrated an inclusive, consultative leadership culture. Medical leads were very complimentary about the chief executive officer (CEO)’s clear leadership. They saw the CEO’s progressive influence, particularly on governance, incident reporting and board-level improvements. Staff felt more involved, valued and listened to.

Leads could evidence exceptional line manager support and staff alignment. The hospice’s 2024 staff survey specifically examined line managers’ experience. Findings showed 85% of managers felt well-supported by their own line managers. 80% felt their immediate manager demonstrated the charity’s values. This showed a strong internal culture of leadership development and staff wellbeing.

Therapist staff told CQC they felt supported by hospice managers. These staff expressed strong alignment with manager’s ambitions. They said managers shared and supported their views about the services, as well as their benefits to staff, service users and their families.

Recruitment processes ensured new leads possessed the skills, experience, and values necessary for effective leadership. Leadership roles were rigorously assessed through structured interviews and competency-based evaluations. This ensured alignment with the hospice’s strategic goals.

The hospice had a fit and proper persons policy. This policy ensured governance integrity, and that continuous professional development (CPD) was actively prioritised. It applied to all directors, trustees, and senior leaders responsible for overseeing the governance, strategy, and operational leadership of the hospice. The policy ensured they all adhered to agreed standards of integrity, professionalism, and compliance.

Trustees and directors were required to complete yearly declaration of interest and insurance forms. The board reviewed forms with any potential conflicts, financial interests, or affiliations with other organisations. This ensured they made all decisions in the best interests of the hospice and its beneficiaries.

The hospice also prioritised leader’s continuous professional development (CPD). Trustees had access to training opportunities identified through skills audits. Senior staff and trustees were encouraged to attend workshops, conferences, and governance seminars.

Leads and managers developed internal talent and promoted individuals with proven leadership capabilities. The hospice had appointed a new Director of Clinical Services, who would begin in January 2025.

Leads had implemented a robust framework to support leaders throughout their roles. A new appraisal process would commence in early 2025. This would provide structured opportunities for reflection, feedback, and development planning. Leaders would have annual appraisals and monthly one-to-one meetings as part of a support framework. This demonstrated a clear commitment to ongoing leadership excellence.

Leads promoted and encouraged a speak up and blame-free culture indicative to learning where staff could raise concerns. Freedom to speak up (FTSU) training was a core element of staff’s induction program. Staff told us they could speak up and felt listened to. Managers acted on any concerns they raised.

The vast majority of 140 cases CQC received since February 2024 were positive feedback triggered by our assessment.

However, 11 of these cases were whistleblowing or people’s concerns about the service. We also received one extreme safeguarding alert from October 2024. We followed up all concerns and allegations onsite. We found these were either unsubstantiated, or managers had taken prompt appropriate action to address all issues.

The hospice had a freedom to speak up (FTSU) and whistleblowing policy. The board of trustees had overall responsibility for this policy. This was in date and reviewed every three years. The hospice’s FTSU guardian reports and process were guided by this policy, which aligned with national guidance.

The hospice was actively enhancing and strengthening their FTSU process in response to organisational changes. This related to role transitions and training, as well as increased visibility. Leads had implemented mechanisms for monitoring and continuous improvement to ensure the process was effective.

The hospice took a proactive and sector-leading approach to fostering an open, transparent, and psychologically safe working environment. The hospice conducted a specific closed culture review. Leads actively addressed the principles of this organisational review through a range of robust, embedded practices. This reflected their dedication to creating an environment where patients, staff, and volunteers felt valued and supported.

The hospice had a FTSU guardian and two champions. The guardian refreshed their training with the National Guardian’s Office annually. These champions helped staff find it easier and more comfortable to speak up. FTSU leads were advertised on posters in staff areas. Staff had a few other channels to raise concerns other than their direct line or senior manager. Staff could also access FTSU information from the staff handbook and SharePoint HR folder.

Staff told us the hospice was an inclusive place to work. The community outreach manager had undertaken a cultural competency and equity, diversity and inclusion survey. From the results they had developed cultural competency training which addressed some areas identified. This was due to start in early 2025.

The hospice was pioneering community engagement through unique initiatives. For example, multifaith initiatives invited religious leaders into the hospice and ensured culturally appropriate palliative care. The community outreach team’s dedicated engagement with minority communities had improved access to hospice services among underrepresented groups.

Leads explained how the hospice had embedded diversity and inclusion principles throughout its operations. They monitored workforce metrics related to EDI through staff surveys and internal reviews. Their recruitment and onboarding policy ensured fairness and transparency in all hiring processes. The selection process for candidates was structured and competency-based to eliminate bias. All new starters had to undertake mandatory diversity and inclusion training during their induction.

The hospice ensured a holistic approach to equality, diversity and inclusion (EDI). They had a well-established equality and diversity policy. This was ratified by the Board of Trustees and reviewed annually, ensuring compliance with the Equality Act 2010. It helped ensure all staff, trustees, volunteers, patients, and visitors were treated fairly and equitably. The policy outlined staff’s commitment to inclusion, regular training and awareness to foster a respectful culture.

The hospice integrated EDI principles when reviewing all policies and procedures. This ensured fair treatment for all employees, trustees, and volunteers, as a deeply embedded practice regardless of protected characteristics.

The hospice demonstrated continuous improvement and a proactive approach to EDI. Leads were actively developing a standalone workforce diversity policy. The policy would formalise a structured diversity audit process to identify gaps and underrepresentation. It included clearly defined goals and timelines to improve workforce diversity and inclusivity. The new policy reflected leads’ commitment to inclusive recruitment, training, and leadership development, ensuring fairness and opportunity for all staff​. It would align with the hospice’s strategic vision of "Living Life’s Wishes" and their core values of inclusivity, collaboration, compassion, and excellence. They planned to introduce this early in 2025.

The introduction of these audits, as outlined in the policy, demonstrated a commitment to measurable progress and accountability, exceeding standard expectations. This showed the hospice had a sector leading approach, taking this proactive and structured step ahead of its peers.

Hospice leads promoted budgeting visibility and accountability. For example, account reports were shared with all heads of department. Managers discussed finances at staff town hall meetings.

New governance team and management structures had been recently introduced. ‘Head of’ and ‘deputy head of’ roles were implemented. Service leads felt these senior team role changes would improve oversight and accountability.

The governance team managed a digital performance and quality improvement scoring system. The system helped leads escalate areas of non-compliance and give staff regular updates. Staff were advised of any governance changes during ‘tea and teach’ sessions. They were also issued updates in the quality matters newsletter. This improved the service’s transparency, accountability and best practices around governance.

The hospice’s board meetings were attended by the local acute trust’s consultants and doctors. This was under a service level agreement to provide clinical input. They had become more involved in the 12 months before CQC’s assessment. Hospice leads had invited their lead consultant to join the senior executive leadership team to enhance integration and governance.

Succession planning was integral to the hospice’s leadership strategy. Managers identified high-potential individuals through regular appraisals and one-to-one meetings. They would create tailored development plans.

The hospice’s sector-leading approach to governance exceeded standard practices in the charity sector. This approach reinforced strong leadership, sustainability, and governance frameworks.

Hospice staff used an electronic risk management system to support recording, reviewing and management of risks. All hospice departments had individual risk registers. All responsible risk assessment holders reviewed and updated their risk registers on the risk management system monthly. At directorate level each director had oversight for all risks in their areas of responsibility.

The hospice’s board of trustees were given a summary report, this showed key risks over a score of 9 identified across all departments, with mitigations in place to reduce risk levels.

Directors played a key role in risk oversight as part of the senior leadership team. They ensured all risks were actively managed and reported to the board of trustees​. Leads regularly reviewed risks at governance forums. They ensured concerns were escalated appropriately and mitigation strategies were implemented across the organisation.

Trustees were given the tools and knowledge necessary for their roles. The hospice introduced a structured onboarding process for new trustees in 2024. This process included a comprehensive checklist and dedicated one-to-one training with a charity governance expert. Annual skills audits were conducted to further support trustee development. The audits identified gaps and opportunities for training. The latest audit highlighted areas where targeted training could enhance governance and strategic oversight.

The hospice adhered to national and local guidance, quality statements and best practice. For example, national institute of care excellence (NICE) guidelines around end-of-life care for adults (NG142) and care of dying adults in the last days of life (NG31).

Medical leads carried out continuous clinical audits throughout the year. They summarised the last 12 months. Audit leads held mortality review meetings (MRM) with another local hospice. The hospice’s MRM standard operating procedure detailed the structured process for reviewing mortality cases. This ensured learning was captured, shared, and used to drive continuous improvement​. Leads and attendees found the learning from this partner working useful. Meetings had a clear governance structure. The hospice had clearly defined and structured audit and mortality review processes, as detailed in their procedures.

MRMs reviewed two cases monthly, with structured discussions and learning outcomes. These fed into quality and risk management processes. Any themes were identified through mortality reviews which triggered further service evaluations and audits. This ensured monitoring and quality improvement was continuous and embedded.

On our last inspection in March 2019 one of the organisation’s risk registers was not reviewed in line with policy and had not been kept up to date.

On this inspection CQC found the hospice had clear and up to date oversight of all risks filtered by department.

Leads took actions to address risks at all levels on the hospice and departmental risk registers. We reviewed the latest risk summary report from December 2024. Prompt actions relating to all the inpatient unit (IPU)’s top risks had taken place and were recorded on the register. This related to discussions with all staff about the risks of them not signing into work. All other IPU related risks but one were mitigated to a score of zero.

From January 2025 the board’s risk register would be reformatted to include only ratified risks of 12 and above.

CQC attended a clinical governance forum onsite during our assessment. This had a standard agenda which included significant safety concerns, patient experience from all forms of feedback, as well as clinical compliance and assurance items, such as incidents, risk and alerts. Attendees discussed upcoming staffing changes to senior management. CQC saw these discussions were summarised in the meeting minutes.

On our last inspection in March 2019 people’s experiences, comments and suggestions were not being used in a methodical way to drive service improvements.

On this inspection CQC found this had improved significantly. The hospice’s patient experience team invited feedback through structured surveys, verbal discussions and real-time engagement. The team gathered and acted on this patient and family feedback. They ensured lived experiences directly shaped service development.

The hospice was seen and used as a community centre by some local people. Staff hosted dedicated patient events, ensuring the hospice remained a centre of community life, not just end-of-life care. This demonstrated the hospice’s deep integration and value to the local population beyond clinical care. CQC spoke to the relative of a former inpatient who received care until their death. They continued to attend the service frequently for social activities and meals.

Hospice leads sought to simplify their referral criteria over the next few years to increase their outreach. They wanted to promote self-referrals as this would help the service benefit more people from surrounding communities.

The hospice had appointed a community outreach manager in August 2024. They had visited different communities to promote hospice services. The manager shared an example of outreach where they visited a Chinese community. They researched existing groups within the local area and contacted them. They gave a talk and highlighted the hospice’s work and services. Their visit was well received. As a result, the group planned to celebrate Chinese New Year at the service.

In March 2025 the manager organised a Ramadan experience day event to help connect local communities. This invited people to learn and understand more about Islam.

The hospice’s community outreach included multifaith and intergenerational events, and the Letters to Heaven service. This had provided significant comfort to grieving families. Staff provided complementary therapies and social work support integrated into patient and family care. They operated a hospice superstore with an integrated café to enhance public engagement.

The manager planned more community outreach events and talks. For example, one around understanding perceptions of the website with community groups.

During CQC’s assessment the manager was also due to start a local weekly radio programme. This was the first of its kind in UK hospice care, offering palliative care discussions, bereavement support, and awareness campaigns. They would host a series of discussions with the public and communities. These would educate, raise awareness, break down barriers and promote awareness of cancer, life-limiting diseases and hospice care.

Ten staff from different hospice teams had attended a recent Hospice UK conference. They welcomed the chance to network, engage and reflect on the great work achieved sector wide. This entailed lots of learning and discussions in the week before the assisted dying bill was discussed in parliament.

A support worker had raised money for the service through craft activities. This included a wreath-making class attended by over 20 people.

The hospice’s events manager promoted a wide range of events and activities. The service could offer catering and decorations. Staff shared these with patients and close relatives in the community and IPU. The manager was open to hearing patient requests and feedback about all events.

The hospice had forged links with other regional hospices to provide and share training courses, resources and opportunities.

Leads fostered collaboration and cooperation rather than competition with other regional hospice organisations. Medical leads said this engagement had improved over the past 12-18 months. For example, they explored funding commonalities and where they could combine services regionally. During CQC’s assessment, leads held conversion meetings to help a local children’s hospice transition project for 16–18-year-olds. They supported their CEO to resume clinical services and had given money to another hospice as the regional recruitment lead.

The hospice had good links into the NHS Leadership Academy. Their DCS and registered manager participated in a range of activities and leadership programmes. Examples included recruitment, delivery of NHS 360 leadership feedback and engagement in action learning sets.

The service has secured funding for a project which reviewed the experience of people aged 16-18 transitioning from children to adult services. The project was being done alongside another local children’s hospice.

The hospice’s community outreach manager was establishing an advisory board. This was a collaborative effort with a local cancer hospital and regional cancer alliance. It would include people from all marginalised groups and communities.

On our last inspection in March 2019 further work was needed to identify and remove barriers for people who could potentially find it harder to access the service.

On this inspection the hospice had appointed a community outreach manager in August 2024. This significantly strengthened the hospice’s ability to reach underrepresented groups and break down access barriers. Few hospices had this dedicated outreach role.

The hospice and fundraising teams held numerous multifaith and charity events throughout the year. This aligned with their holistic and proactive approach to EDI and embedded principles in ensuring inclusivity and community-wide engagement.

During CQC’s assessment their reception promoted several accessible events, including Christmas-themed activities open to all. This helped staff and volunteers reinforce their welcoming environment.

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

Leads had invested significantly in renewable energy solutions. This resulted in a 30% reduction in electricity consumption. This ensured staff provided a safe, sustainable, and environmentally responsible setting for patients, visitors, and staff.

The hospice roof had solar panels installed to store and save renewable energy. A five thousand litre water tank had been fitted inside, alongside a heat pump. During CQC’s assessment the service was seeing the benefits of these investments reflected in their overall energy use. This helped reduce the hospice's operational costs to prioritise frontline services.

The community outreach manager reviewed their local area’s census data to expand service provision. They particularly considered ethnicity and religion. The manager explained their patient diversity across services during CQC’s assessment was not reflective of the wider local area. This helped them better tailor hospice services to reflect the needs of more people from diverse backgrounds.

The hospice was the only one in the region actively using local census data to analyse patient demographics. This helped staff proactively tailor services to better meet the needs of the diverse communities they served. The hospice acknowledged health inequalities and disparities, and took direct action to address them, ensuring equitable access to palliative care for all.

The hospice could strongly evidence continuous learning and governance investment. They had undertaken an external governance review, proactive trustee development, and leadership in hospice governance reform.

The board of trustees had annual skills audits. These identified gaps in expertise and training needs. The annual skills audit was an active tool used whenever leads recruited to the board. This supported trustees’ development, ensured a diverse expertise mix and aligned their skills with the organisation’s strategic goals and priorities. Leads succession planning, trustee development, and governance refinement efforts exceeded those of many other charitable organisations, particularly in the hospice sector.

The hospice actively engaged in national knowledge-sharing initiatives. They were part of the end-of-life care extension of community healthcare outcomes (ECHO) programme 2024-2025. Project ECHO was a global movement supporting knowledge sharing between healthcare professionals. It formed a key part of Hospice UK’s current strategy. It facilitated peer learning across the sector. The hospice did not just participate but actively drove improvement efforts. Leads fostered regional and national collaboration on training and service enhancement. Training leads were linking with the ECHO team to arrange a series of courses, including end-of-life care.

In 2024 the hospice commissioned a full external governance review, undertaken by a leading national governance expert. The review assessed governance structures, trustee effectiveness, board decision-making, and regulatory compliance. The expert made recommendations to strengthen and refine their governance model. This was a sector leading initiative and best practice recommendation from the Charity Commission. The resulting report specifically highlighted the hospice performed at a high standard.