Zoe's Place Baby 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that children were safe and protected from avoidable harm, neglect, abuse and discrimination.

The service had a strong learning culture. When people raised concerns about safety and ideas to improve, the primary response was always to learn and improve. There was good awareness of the areas with the greatest safety risks. Solutions to risks were developed collaboratively. Managers investigated incidents thoroughly and the provider was open and transparent when things went wrong. People were protected by a strong and distinctive approach to safeguarding. Staff understood and managed risks. The facilities and equipment met the needs of people, were almost always clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well.

At our last assessment we rated this key question good. At this assessment the rating has stayed the same. This meant people were safe and protected from avoidable harm.

This service scored 84 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Safety was a top priority for everyone. There was a culture of safety and learning. This was based on openness, transparency and learning from events that had either put people and staff at risk of harm, or that had caused them harm. Risks were not overlooked or ignored.

Staff listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Staff told us they were encouraged and supported to raise concerns. They felt confident they would always be treated with compassion and understanding, and would not be blamed, or treated negatively for reporting incidents or raising concerns. They understood raising concerns helped to proactively identify and manage risks before safety events happened.

Staff told us they received feedback from incidents they reported. They also had regular learning opportunities to discuss locally reported incidents along with incidents that had occurred in other parts of the organisation. Managers attended system meetings and shared learning from their incidents there. They reported back to staff on learning from incidents taken from elsewhere in their local palliative care networks.

Lessons were learned from safety incidents and changes were made to improve patient safety. For example, there was an incident when a child put their hands into a toilet that still contained traces of the bleach used to clean it. The child was taken to hospital as a precaution and had not sustained any injuries. Hospice staff contacted the local safeguarding children's team to report the incident and to request advice about mitigating risk. Leaders made the decision to stop using bleach. The Infection prevention and control lead authorised the procurement of an alternative, nontoxic, toilet cleaner which could be used to disinfect and deodorise toilets while reducing risks to children. Learning from this incident was shared with the hospice staff, and staff within the wider organisation and the local palliative care network.

Staff told us as well as internally reporting incidents they shared information with parents if something did not go as planned. They said they typically contacted parents by phone as and when issues arose but also included details of issues or incidents on a child’s discharge form.

The service worked with families and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people needed to speak to different members of the team.

Safety and continuity of care was a priority throughout children’s care journey. This happened through a collaborative, joined-up approach to safety that involved the family and carers, along with staff and other partners in children’s care. This included referrals, admissions and discharge, and when children were moving between or accessing multiple services. Pathways were underpinned by policies to ensure safe care and treatment. For example, the rapid transfer for end of life care policy ensured the holistic needs of children were met, and their clinical needs were fully understood through the involvement of external health care professionals working with the child. The policy also ensured the cultural and religious needs of the family were taken into account when children were on an end of life pathway.

Care was delivered using an embedded care plan approach to ensure all staff knew what the care for each child should look like. Care plans were developed and revised in collaboration with parents, carers, and professionals working with the family. Care plans were reviewed a minimum of 6 monthly but more often if there was a change in the clinical or developmental needs of the child or in their social situation. There were care plans that covered every aspect of children’s care. They included, physiotherapy plans, feeding plans, speech and language plans, personal evacuation emergency plans, communication plans, care plan for the management of seizures, communication plans, sleep plans, mobility plans, skin integrity plans, and medicines plans. Children also had advanced care plans to document the family’s or child’s wishes for their care if they become seriously unwell or reach the end of their life.

To ensure continuity of care staff worked in partnership with physiotherapists, occupational therapists, and speech and language therapists to ensure children’s therapeutic needs were being met while they were at the hospice.

At the end of each session of care a discharge summary was completed. This was recorded in the child’s electronic patient record and a copy was given to the parent or carer.

The service used an electronic patient record system, but each child also had a paper file that could be accessed quickly by staff if they were away from a computer.

Prior to a baby or child being admitted for end of life care staff, in conjunction with the community team, would visit the child at home or in hospital to assess their needs and get to know the family and understand their routines. This would enable staff to provide a smooth transition from care at home to hospice care. It would also ensure staff were familiar faces to help reduce anxiety around the transition from home or hospital.

When children were receiving end of life care staff worked in partnership with the consultant paediatrician specialising in palliative care and the community paediatric clinical nurse team.

There were bereavement flow chats for staff to follow when children died to maintain safe systems of care, including after death care.

Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

There were clear safeguarding systems, processes and practices to protect children from abuse. Information about safeguarding services was readily available for staff to enable them to access safeguarding teams quickly and easily.

Staff received safeguarding training commensurate with their role. Compliance with training was consistently above the organisations target of 90%.Annual training was provided by the local safeguarding team. The local safeguarding team also provided safeguarding supervision for staff.

There was a strong understanding of safeguarding and how to take appropriate action. Staff spoke openly about their role in safeguarding, including as members of child protection core groups, looked after children’s meetings, and child in need meetings, as well as being professionals who identified and reported new and emerging safeguarding concerns. For example, staff told us about the time they reported a safeguarding concern to a local child protection team. This generated an investigation by social workers into the wider social needs of the family and the medical support required for the child. The investigation identified the family had additional needs and this enabled the provider to offer extra respite care as part of the family's contingency planning.

As a result of some safeguarding training staff added an additional question to their admission paperwork to understand if people felt safe at home. Staff told us this had proved to be a useful way of identifying additional support needs some families had. Staff met regularly to discuss families they were concerned about.

The service always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

Each child had a care needs assessment completed at the start of their care journey and at least every 6 months after that. This assessment was completed in conjunction with the child, their patents or carers, other family members, and professionals working with the family. This assessment helped create care plans to describe what each element of a child's care should look like. It was anticipated the care provided by the service would mirror or complement the care provided at home, and at school or nursey.

The assessment process highlighted potential risks. For example, risk posed to other children, staff, or to the child themselves through exhibiting challenging behaviours. Challenging behaviours are sometimes a way for a person with learning disability and or a communication difficulty to demonstrate their needs are not being met. Challenging behaviour can take the form of hurting other people, self-injury, destructive behaviours, or other behaviours like spitting or running off. Understanding risk enabled staff to develop care plans that included detailed strategies to reduce risk, use the least restrictive practice and provide care safely and consistently.

Care plans also included information for staff about how to reduce risk and when to escalate concerns to parents, medical teams, and the emergency services. During each admission for respite care children’s baseline observations were recorded and these were monitored for the duration of the episode of care. If staff noticed changes to the baseline observations they would follow the child’s care plan. This might direct staff to contact the service’s GP, or to contact parents or carers in the first instance. Staff would continue to follow the care plan if the child’s condition deteriorated, and they might, for example, contact the parents again or phone 999.

Community physiotherapists attended the first day of care provided by the service to ensure staff were fully trained to provide the therapeutic support required by each child. To support the work of the community physiotherapist the service employed a physiotherapist for 8 hours a week. Future assessment of the babies and children were undertaken by therapists at home and at the hospice.

The service used Situation, Background, Assessment, and Recommendation (SBAR), a structured tool, to communicate information about the children at shift changes to improve patient safety. SBAR structures information into 4 categories, situation, background, assessment, and recommendation to provide a clear framework for sharing information to help reduce misunderstanding and errors.

The service was fully aware of all potential risks in the care environment and controlled them well. Staff made sure equipment, facilities and technology supported the delivery of safe care.

Children were cared for in a safe environment that was designed and adapted to meet their needs. The hospice was purpose built. There was a large and spacious central atrium where children and staff spent most of the day. Most of the other rooms required by the babies and children were off the atrium, including bedrooms, the bathroom, and kitchen. A corridor separated this part of the hospice from the administrative side of the building. Although the soft play room and light sensory room were also based on the administrative side of the building.

The atrium was bright and airy and visibility clean. It was suitably furnished and contained enough equipment to keep people safe. To reduce the risk of harm to children there were stair gates in the doorway of rooms that were frequently in use, so children could not enter without the supervision of an adult.

Children slept in single rooms. Each bedroom had a mural that depicted scenes from popular children’s stories. The murals covered at least 1 whole wall. As well as a bed or cot there was enough furniture to store clothes and other belongings. There was a handwashing basin for staff in every room.

The service had a range of safe space beds and cots. These were specially designed sleep spaces for children who might have additional requirements, for example children who required oxygen or children who needed a bed with soft sides to prevent injuries. Parents told us they thought the bedrooms were beautifully decorated, the beds were safe, and their children slept well there.

The bathroom was spacious to enable movement around the freestanding bath. The bath had water jets and lights to provide therapeutic and sensory stimulation. There was a large ergonomically designed, height adjustable, changing table, so staff did not need to bend during caregiving. There were sinks set at different heights so they could be used by children of different ages. There was a handwashing sink for staff.

The garden was accessible from the atrium. The garden was fenced and contained a range of outdoor toys. The ground was artificial grass to ensure the area was easy to maintain and keep clean.

To provide a smooth and dignified transfer experience for children there were mobile and tracking hoists. Staff were trained to use the hoists. Each child who required hoisting had a detailed handling care plan that included the specific equipment, techniques, and information about the number of staff needed for their transfers. Hoists reduce physical strain and risk of injury for staff who regularly assisted with transfers.

There was accommodation for parents who wanted to stay at the hospice during their child’s stay for end of life care and/or after life care. The accommodation comprised of a self-contained apartment called the starlight suite that was situated within the main hospice building. The starlight suite could be accessed through the atrium or from the administrative side of the building. The apartment included a kitchen dining area that could be converted to a bedroom at night. There was a separate bathroom and 2 adjoining bedrooms. The first bedroom had a bed that could be used for a child up to the age of 8. The second bedroom contained a cot that could be used by a baby or infant up to about 1 year old. One bedroom was air-conditioned, the temperature could be set low enough to preserve a deceased child’s body to enable the family to spend time with their loved one, post life, while arrangements for a funeral were being made.

If babies and children had specialist equipment, for example standing frames or wheelchairs, staff requested that parents and carers bring this into the hospice for the duration of the child’s stay. Physiotherapists and occupational therapists trained staff on the use of specialist equipment so it could used therapeutically during a baby or child’s stay.

Each baby and child had an evacuation care plan to be followed in the event of fire that had been written or updated in the last 6 months.

Equipment and technology was well-maintained, used for their intended purpose and consistently supported staff to deliver safe and effective care. For example, portable appliance tests (PAT) took place annually and were last performed the week before our assessment. PATs are safety checks for portable electronic appliances to ensure compliance with health and safety regulations. All of the portable electronic appliances we looked at had stickers that showed the date the appliances were next due to be tested.

The resuscitation trolley and emergency grab bag were fully equipped and checked regularly by staff to ensure they contained all the equipment required and that it was within date.

Clinical and domestic waste bins were clearly labelled and emptied regularly. Sharps bins were stored safely.

The 5-year maintenance schedule was visible to all staff. It included names of the persons responsible for undertaking or actioning maintenance and the date when maintenance was due.

Staff were qualified, skilled and experienced, they received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

The service was designed to operate 7 days and 6 nights a week. However, it was not operating at full capacity because there were not enough nurses employed to cover those operating hours. Leaders told us since the COVID-19 pandemic there had been a national shortage of nurses. They also said the pay difference between the charitable sector and NHS meant vacant posts were harder to fill. At the time of our inspection the service was reviewing their staffing model to consider how they could improve recruitment and retention of staff. Recruitment was paused during the staffing model review.

Substantively employed staff included registered children's nurses, learning disability nurses, healthcare assistants, a part-time play leader, a part-time physiotherapist, and managers. Clinical staff were supported by a clerical team. The service also employed a part-time GP who provided on call medical cover for children having respite care. An NHS consultant paediatrician specialising in palliative care provided medical cover for children requiring palliative care at the end of their life. A team of community NHS paediatric clinical nurses supported the consultant during the admission of end of life babies and children.

There was a minimum of 1 paediatric nurse on each shift. The ratio of staff to children was calculated on the complexity of the children staying in the hospice. However, it was typically 2 nurses and 1 or 2 healthcare assistants for 3 babies or children during the daytime and 1 nurse and 1 healthcare assistant to 2 babies or children during the night. In addition to baseline staffing during the day there was sometimes a play leader on shift. The service used to roster a separate nurse to lead the day shift in addition to the nurses and care assistant establishment. However, due to low staffing numbers the service no longer routinely had a supernumerary lead nurse.

At the time of our inspection the service employed 1 bank worker, they did not use agency staff. The bank worker had been employed by the service for several years and so was familiar with the children and the service policies and procedures. Staff sickness was covered by the bank worker and managers.

Staff used an online system to complete mandatory training. The system reminded them of any new or refresher training they needed to complete. Managers monitored compliance with training and ensured staff were allocated time to complete any outstanding training requirements. The mandatory training provided to staff met the needs of staff and people accessing the service. Compliance with all modules was above the organisations target of 90%. At the time of our inspection compliance with the following training modules was 100%; safeguarding, moving and handling, infection prevention and control, prevent, food hygiene, information governance, and health and safety. Compliance with basic life support training was 92.9%, this was representative of 1 member of staff not completing their training. Compliance with competencies to use equipment was 91.5% and nurse compliance with clinical competencies was 92.9%.

All new staff and student nurses received an induction. New staff were supernumerate for their induction period. Student nurses were supernumerate for the duration of their 8 to 10 week placement at the hospice.

All staff had an annual appraisal, compliance with annual appraisals was 100%.

There was a process for managers to follow to check all staff had an up-to-date Disclosure and Barring Service check and, where applicable, had kept their nursing registration up to date.

The service assessed but did not consistently manage the risk of infection well. However, staff detected and controlled the risk of infection spread and shared concerns with appropriate agencies promptly.

The service had 2 housekeeping staff who provided 40 hours of housekeeping each week.

Staff used personal protective equipment (PPE) appropriate to the tasks they were performing. There were adequate stocks of PPE in each room. Staff followed processes to reduce healthcare-associated infections. As well as wearing PPE appropriate for the tasks they carried out staff regularly washed their hands. The hand hygiene audit measured hand washing technique and frequency of handwashing, this demonstrated 100% compliance.

Managers had overall responsibility for infection prevention and control (IPC) including reviewing the audits. Compliance with the infection prevention and control audit for March 2025 was 98.6%, which was above the organisation’s compliance target of 90%. An external IPC audit was completed in March which scored 95.8%.

Staff received annual IPC training from an external provider. Staff met every 4 months to discuss compliance with audits and to develop action plans to improve compliance when needed.

The service used signs to show when rooms had last been deep cleaned and staff told us they cleaned rooms when they had finished using them. However, there was a build-up of dirt at the side of the threshold strip between the round room and the central hospice room. This issue was resolved while we were on site.

The round room (a light sensory room off the atrium) had a sign to show the room had last been deep cleaned 11 days prior to our inspection. However, staff assured us the room had been deep cleaned 3 days before our inspection by housekeeping staff. In addition to deep cleaning staff said they had made sure the room was clean every time they finished using it which was often multiple times each day. Apart from the threshold strip the round room was visibly clean.

Not all areas of the building were easy to keep clean. The floor in one of the storage rooms off the main corridor, which belonged to an administrative team, could not be kept clean because boxes and other items were stored on the floor.

The service had regular monitoring for the presence of legionella within the water system.

The service made sure that medicines and treatments were safe and met people’s needs. However, the storage of oxygen required improvement.

Medicines could only be accessed by authorised people. The key to the medicines cupboard could only be accessed by nursing staff. Parents of children having respite care brought their child’s medication in with them, and it was stored in locked medicines cupboards or the medicines fridge. The medicines for children having end of life care were brought in by the NHS team leading their care. No other medicines were stored on site. All medicines had to be signed out by two members of staff in line with the medicines management policy. Parents and carers told us they had no concerns about medicines management.

There was a medicines board that could be viewed by all staff. The board contained details about medicines, who they belonged to and when they needed to be administered. Children had care plans that contained information about how their different medicines were administered.

Staff told us they understood medicines needed to be stored correctly and they worked as a team to ensure it was. They said a medicine that needed to be stored in the fridge once it had been made up from a powder stored in a cupboard had led to confusion for some staff who stored the made-up medicines in the cupboard. Staff identified this was because they had taken the medicine out of a cupboard, and once they made it into a liquid, they automatically returned it to the cupboard. To mitigate risk of this error continuing to happen staff introduced a sign for the fridge asking staff to check what medicines belonged there, and plastic cups to put on the top of bottles used to store liquid medicines made from powders that had signs that read ‘I am a fridge medicine’.

The care plans for medicines included plans for pain relief which was given when needed rather than at prescribed times. If a child demonstrated they were in pain as described by parents and carers in their care plan staff followed the care plan instructions. For example, they might need to contact parents prior to administering pain relief, or give pain relief after observing specific behaviours and advise parents about this when they came to pick their child up. Staff used a pain score, for example, the ‘face, legs, activity, cry, consolability’ (FLACC) behavioural pain scale to calculate the level of pain a child might be experiencing through their observations if the child lacked the ability to communicate their pain levels themselves.

Fridge and room temperature checks were performed daily to ensure medicines were being stored in line with the manufacturer’s guidance.

Medicines management audits showed good compliance with policy. The clinical governance committee report prepared for the meeting held in March 2025 showed there had been 4 medicines incidents between December 2024 to February 2025. None of the medicines incidents had involved controlled drugs, and none of the medicines incidents had been recorded as high risk. The monthly medicines management audits for December 2024 to February 2025 demonstrated an average of 93.8% compliance. This was because 2 members of staff had not consistently signed off administration of medication. An action plan had been developed to increase staff compliance with signing to say they had administered or witnessed medicines being given.

So staff could take action to protect patients from harm the service was signed up to receive alerts and recalls for medical devices and medicines.

Oxygen cylinders were stored outside in a locked storage shed. However, the cylinder storage infrastructure (walls, ceiling, floor) was not constructed of non-combustible or fire-resistant materials. The storage container did not allow for continuous ventilation to prevent a build-up of gas. The cylinders were not secured by chains or lashings. The signage on the storage container did not contain all the safety signage required to let people know about the danger of compressed gas. We raised this issue with the manager who immediately rectified these issues. They provided photographic evidence to show they had installed an oxygen cage with appropriate signage. The cylinders were securely lashed to the side of the storage cage.