Tynedale Hospice at Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

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

This meant people’s needs were met through good organisation and delivery.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The service delivered care that was person centred, with patients actively involved in planning and decision making about their care. Care plans were individualised, regularly reviewed and reflected patients’ preferences, values and goals, including physical, emotional, social and spiritual needs. Patients and families were supported and were encouraged to ask questions and participate fully in their care.

Patients told us they felt listened to, respected and involved. Where appropriate, families, carers and advocates were included in care planning and decision making, and staff ensured that patient preferences about information sharing were respected and regularly reviewed.

The service was responsive to cultural, religious and social needs. Staff asked about and recorded individual preferences, including dietary requirements, modesty and spiritual support, and adapted care accordingly. Patients were supported to maintain their cultural identity and practices, including access to chaplaincy or alternative spiritual support where desired. Interpreting services and communication aids were used to ensure patients could fully engage in their care, and staff avoided reliance on family members where this was not appropriate.

Care pathways were flexible, with arrangements made to reduce distress and support familiarity, particularly for those with cognitive or sensory needs. Relevant information, including personal preferences, risks and identified support needs, was recorded within the patient’s electronic care record. This information was shared with staff involved in delivering care to support consistency and safe practice.

The service supported patients and families to have open discussions about future care, including preferred place of care and death. These decisions were clearly documented and shared with relevant professionals to ensure continuity.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service demonstrated a good understanding of the needs of its local population and worked collaboratively with system partners to plan and deliver care. Leaders engaged with commissioners and community organisations to ensure services reflected local priorities, including supporting people with complex needs, frailty and those experiencing health inequalities. There was evidence of community engagement and responsiveness to the diverse needs of the population served.

Care was well coordinated, flexible and delivered across organisational boundaries to ensure continuity. Staff worked closely with GPs, community teams, hospitals and social care services to share information and support safe transitions. Patients with complex needs benefited from multidisciplinary input, with care plans reflecting contributions from relevant professionals and services.

Access to specialist services was available through established referral pathways, and staff described being able to obtain advice and input when needed. Bereavement support was offered to families, including ongoing support following a patient’s death, with particular consideration for children and those with additional needs.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service ensured that patients and those close to them were provided with clear, timely and accessible information about their care.

Information was available in a range of formats to meet individual needs, including support from interpreters and communication aids where required. Staff adapted their approach for patients with cognitive impairment, using simple language, repetition and involvement of carers to support understanding as far as possible. The service had systems in place to identify and record people’s information and communication needs. This was captured within the ‘Get to know me’ document, which supported staff to understand individual preferences and requirements.

However, the service recognised the need for further development to ensure consistent and structured recording within the electronic system.

Patients and families were supported with information about what to expect from the service, including how to access help, particularly if their condition changed. Clear information was provided about ongoing care, follow up and how to seek advice, including out of hours. Staff also ensured that patients and families were given sensitive and appropriate information about planning for death, post-death arrangements and available support services.

Patients were made aware of how to raise concerns and who to contact if they had questions about their care.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The service actively sought and responded to feedback from patients, families and staff to improve the quality of care provided. Feedback was gathered through a range of methods, including conversations during visits, surveys and informal discussions. Staff described a culture where listening to people’s experiences was seen as an important part of delivering person-centred care.

Patients and carers were informed about how to provide feedback or make a complaint, and information was accessible and easy to understand. Where concerns were raised, these were responded to in a timely and transparent way. Staff were aware of the complaints process and understood their role in supporting people to raise concerns.

Compliments and positive feedback were also valued and shared with staff, contributing to morale and reinforcing good practice. There was evidence that patient stories and feedback were used at different levels of the organisation, including leadership discussions, to ensure that the patient voice remained central.

We were told how in 2025, the feedback process was reviewed and standardised across all care service departments. This followed audit findings which identified inconsistencies in how feedback was collected and recorded. As a result, revised feedback forms were introduced alongside clearer governance arrangements to improve the quality, reliability and consistency of patient and carer feedback.

The service had also recently introduced a new Nursing Service Bereavement Questionnaire to provide more detailed qualitative feedback. This was intended to support service learning, reflection and ongoing development.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service demonstrated a commitment to ensuring equitable access to care, with systems in place to support timely and appropriate responses to referrals. Patients were generally able to access the service when they needed it, and staff described prioritising care based on clinical need and urgency. Leaders monitored referral activity and response times to ensure patients were reviewed promptly, with oversight mechanisms in place to identify and address any delays. The service recorded whether they first saw a patient, for nursing care, within 72 hours of referral. At the time of inspection, 92% of people were seen within 72 hours or experienced a longer wait due to their own choice. In 2025 100% of people were seen within 72 hours or experienced a longer wait due to their own choice.

Demand was managed through coordination of caseloads and prioritisation of visits, with flexibility to respond to changing patient needs. Leaders had visibility of capacity and demand pressures and made adjustments to staffing and resources where required to maintain safe and timely care delivery.

Where delays occurred, for example due to external dependencies such as availability of community services or equipment, staff escalated concerns appropriately and worked with system partners to mitigate risk.

The service demonstrated an inclusive approach to access and delivery of care. Staff were aware of potential barriers, including language, digital exclusion and social circumstances, and adapted their approach to meet individual needs.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The service demonstrated a commitment to identifying and addressing inequalities in patient experience and outcomes. Systems were in place to monitor care delivery and outcomes, with consideration given to factors such as age, disability and social circumstances. Leaders reviewed available data and feedback to identify any variation in outcomes and used this to inform service planning and improvements.

The service sought feedback from a range of patients and carers, including those from groups who may be at higher risk of poorer outcomes or discrimination. Learning from feedback, including individual experiences, was shared across the organisation and used to improve practice. Staff were able to describe how feedback had influenced changes to care delivery.

For example, we heard about the development of the dementia service and the introduction of a specialist dementia nurse role in November 2024, as well as dementia wellbeing groups and dementia cafes. This followed recognition of the increasing prevalence and complexity of dementia within the local area, alongside identified gaps in service provision. The role was informed by a review of local demographic data, stakeholder engagement and a scoping exercise to map existing dementia services, community resources and areas of unmet need across the locality.

We also heard about how feedback from patients living in a specific geographical area, gathered by staff during home visits, indicated that they felt there were limited services available locally. In response, the service established a wellbeing group within that area to improve access to support.

We were told about work undertaken by the hospice at home service to strengthen its understanding of the local community. There was evidence of awareness of health inequalities, and the service took steps to engage with different groups within the local community. This included outreach and working with partner organisations to improve awareness and access for underserved or seldom heard groups. This work aimed to inform the planning and delivery of care so that it better reflected local needs. For example, in a rural area, the service recognised that local networking and building personal relationships were important factors in effectively engaging with that community.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The service supported patients and those close to them to plan ahead and make informed choices about their care and treatment. Staff held sensitive and timely conversations about prognosis and future care, ensuring patients were given clear and honest information in a compassionate manner. One family member told us “the nurses were very honest with us- but in a kind, caring and compassionate way”. Patients and families told us they were involved when care plans changed and felt able to ask questions and discuss their preferences.

Patients were supported to express what mattered most to them, and this was reflected in personalised care plans which were shared with relevant professionals to ensure continuity. Access to emotional and spiritual support, including chaplaincy where desired, was available.