Zoe's Place Baby 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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, and were free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

However, improvements were required in some governance processes. At the time of inspection, the service was in breach of its condition of registration.

The service did not seek to fully explore equality, diversity, and inclusion within the staff group. They did not produce data to explore the experiences of staff from ethnic minority backgrounds.

At our last assessment we rated this key question good. At this assessment the rating has stayed the same.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The organisational strategy was developed with recognition of and alignment to the Nursing Midwifery Council Nursing Strategy (2021), the National Framework for Local Action 2021-2026: Ambitions for Palliative and End of Life Care, and The People Plan, the National Nursing Strategy and Working Together to Safeguard Children (2018). The vision and values of the service were clear, person-centred and included, compassion, dignity, independence, respect, equality and safety. The vision was focused on supporting children and their families to live life to its fullest.

The culture of the service was person-centred. It was open, inclusive and empowering. Leaders, managers and staff had a well-developed understanding of equality, diversity and human rights, and they prioritised safe, high-quality, compassionate care for parents and for parents and carers. Staff told us the culture was focussed on, “giving children the best days we can”. Staff told us it was important to them to see parents and carers, “come back happy and refreshed because we have been able to look after their children”. One member of staff described the work the team did as, “giving families confidence to do different things, make memories and enjoy every second”.

Staff told us they enjoyed working at the service. They said they felt valued and respected and their concerns were always listened to.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders embodied the culture and values of their workforce and organisation and had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Managers led with integrity, openness, and honesty. They ensured that the organisational vision was delivered, and risks were professionally managed. The service had a clear leadership structure, so staff knew who to approach for support. Staff at all levels told us their leaders were visible and approachable. They described managers as having an, “open door policy”.

Leaders had the skills, knowledge and experience to run the service. They told us they were provided with opportunities to develop their leadership abilities. For example, they were supported to complete the Royal College of Nursing leadership course.

Staff told us they felt respected, supported and valued by their leaders. They were supported through skills development and given opportunities for growth.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders actively promoted staff empowerment to drive improvement. Leaders encouraged staff to raise concerns and promoted the value of doing so, so all staff were confident their voices would be heard.

The staff we spoke with told us they worked in a culture where speaking up was encouraged and valued. They knew about the freedom to speak up guardian and freedom to speak up champions and how to contact them should the need arise. Freedom to speak up guardians have an independent role within an organisation to listen to, support, and guide workers who feel they cannot use formal channels to raise concerns about patient care or other organisational issues. Freedom to speak up champions support the guardian by raising awareness, providing confidential advice, and signposting colleagues to the correct channels for help.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Although improvements were required to ensure the experiences of people from ethnic minority backgrounds were included.

Leaders aimed to create an inclusive working environment for staff with disabilities. Staff were encouraged to speak to managers about any reasonable adjustments they needed to improve their working lives. Managers made reasonable adjustments to support disabled staff to carry out their roles well. A member of staff with a disability told us they felt well supported by the management and wider staff team. Reasonable adjustment had been made so they could perform their duties effectively. Staff with childcare or other caring responsibilities told us reasonable adjustments had been made to help them manage their work and home life balance well.

However, leaders did not ensure there were effective and proactive ways to engage with and involve staff, with a focus on hearing the voices of all staff with protected equality characteristics and those who are excluded or marginalised, or who may be least heard within their service. For example, they did not specifically seek the views of staff from ethnic minority backgrounds in the annual people survey. So, they did not have feedback on the workplace's culture, to identify existing gaps in representation, and uncover barriers that may be faced by different employees. These insights would have allowed the service to develop targeted strategies, inform policy changes, and implement initiatives to foster a more equitable and inclusive environment.

The service had clear responsibilities, roles, systems of accountability and mostly had good governance. Staff used these to manage and deliver high-quality, sustainable care, treatment and support. Staff always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The organisation held quarterly clinical governance committee meetings. A report was prepared ahead of the meeting so all the information to be discussed was available for review by attendees ahead of the meeting. The meetings were used to look at the number and type of incidents reported and how learning had been shared, the outcome of audits, and operational risks. They were also used to review changes to national guidance that impacted on the delivery of evidence-based care and treatment. The outcomes of policy review group meetings and head of care meetings fed into the clinical governance committee meetings.

The risk register was reviewed at quarterly governance meetings. The biggest risk facing the service was staffing. Senior leaders told us since the COVID-19 pandemic they had found it difficult to recruit staff. They explained this was part of a national problem created by a shortage of nursing staff, along with the rates of pay currently offered by the organisation. The impact of staff shortages meant the hospice could not open every day of the week and so could not offer end of life care to babies and children who were in their last few days of life. To mitigate risk the service was reviewing their staffing model to improve the likelihood of recruiting new staff and retaining existing staff.

Leaders had oversight of the outcome of audits so they could ensure any actions required to improve compliance were completed. Compliance with audits was good and the findings were shared with staff so they were aware when improvements were required. Any audits that scored less than 90% had an action plan to improve performance. Data from December 2024 to February 2025 demonstrated 96.9% compliance with the health and safety audit (this included waste management fire safety and storage of hazardous substances), 96.5% compliance with infection prevention and control (this included hand hygiene, and sharps management). Compliance with child and family outcomes framework audit, record keeping audit, data protection audit, and positive handling of children audit all stood at 100%.

The provider had a process to identify incidents that would be classed as a never event or serious incident so these could be reported in accordance with legislation.

However, at the time of our inspection the service was in breach of their conditions of registration. The service was registered to provide care to babies and children from the age of 0 to 5 but was delivering care to children up to the age of 7. The current leadership team were unaware an application to vary their conditions of registration had not been made by the previous leadership team. As soon as this issue was raised with the current leadership team they made an application to vary their conditions to incorporate the care and treatment of children up to the age of 7. Leaders also introduced a new tracking tool to ensure there was good oversight of any new or proposed changes to ways of working.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

Staff and leaders engaged with people, communities, and partners to share learning with each other that resulted in continuous improvements to the service. They used these networks to identify new or innovative ideas that could lead to better outcomes for people. For example, the service was a member of their local palliative care network, and other local system working groups. These meetings were used to share best practice as well as learning from incidents.

The service was embedded in the community. The local school choir regularly visited to sing for the children.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contributed to safe, effective practice and research.

Staff told us they were encouraged to look for courses that provided developmental opportunities. Each team member had an annual budget they could access to complete training they identified as important for their learning and development. For example, a member of staff had completed at paediatric epilepsy study day.

Staff and leaders engaged with external work, including research, and embed evidence-based best-practice in the organisation. Leaders told us the service took part in research projects whenever they were invited. They also worked in partnership with other organisation who offered care to children with life limiting conditions to share learning and best practice.