Alexander Devine Children's Hospice Service

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• 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

At our last assessment we rated this key question as good. At this assessment the rating remained the same. We found a service with a strong culture of learning, where incidents were consistently used as opportunities for reflection and improvement. Effective systems were in place to ensure safety and care was delivered within a clean, well-maintained environment that was compliant with safety standards. Staff were actively supported in their professional development and encouraged to expand their roles. Leaders promoted continuous learning and created opportunities for staff to enhance their skills, contributing to a confident, competent and forward-thinking workforce.

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.

The service had embedded a positive reporting culture in which staff felt confident and supported to raise concerns. The service had adopted the NHS Patient Safety Incident Response Framework (PSIRF) and staff understood both the policy and its practical application. A consistent electronic incident reporting system was used across inpatient, day care and community services, with training provided during staff induction. Staff described a positive, no-blame culture that encouraged reporting and learning.

Incidents were reviewed openly and systematically. A designated senior lead oversaw incident management, and all incidents were discussed at monthly staff meetings to promote shared learning and reflection. Learning arising from incidents led to tangible improvements in practice, equipment and staff training. For example, after an incident involving unavailable oxygen firebreaks, staff immediately implemented mitigating actions, ceased use of affected concentrators, and ensured replacement firebreaks were ordered and installed promptly, demonstrating a strong focus on patient safety.

The service also demonstrated a commitment to continuous improvement through incident reviews, audit activity, safeguarding discussions and feedback from families. An established audit and review processes supported learning and service development. Leaders had identified opportunities to strengthen governance oversight and were developing processes to improve the escalation of learning and assurance to trustees.

Staff consistently described an open and transparent culture. They told us they felt comfortable raising concerns and spoke positively about the organisation’s no-blame approach to incident reporting. Staff said they were “open and honest with families” and that “families were informed straight away of anything,” demonstrating an understanding of the importance of transparency and the principles of duty of candour.

Incident reporting systems were well embedded, learning was routinely shared with staff, and actions arising from incidents were clearly evidenced. While there had been no incidents meeting the statutory threshold for Duty of Candour during the reporting period, leaders recognised that the formal Duty of Candour process required further development. They had already implemented an action plan, introduced a dedicated policy and developed clearer guidance to strengthen practice in this area.

There were clear referral and admission pathways in place, and staff understood how people accessed the service and how care was coordinated with external providers. Information was routinely gathered at referral to support safe admission and ongoing care. Staff described the process as detailed, structured and which helped the team to prepare and maintain children’s safety from the beginning of their care.

The service worked collaboratively with external partners to support safe transitions between care settings. There were strong examples of shared governance and care, with evidence that the service worked with the children’s community services to deliver care when and where the child needed it. This coordination reduced the risk of fragmented care for children and their families. Families said that staff worked hard to coordinate care and communicated with other professionals involved in their child’s support.

Staff described structured processes, including daily communication and shared oversight of care delivery. For example, the clinical nurse specialists met on teams daily, the care team held a morning briefing and the team leaders from each team organised the joint rota. These arrangements supported safe handovers and continuity of care across services.

Transitions for children with higher levels of need were supported by clear escalation pathways. For end‑of‑life care in the community, there was a structured approach for end-of-life care at home. This ensured timely access to clinical advice and support. There were flexible staffing arrangements, including a shadow rota to support children and families with for end-of-life care. This further supported responsive care and safe transitions during periods of increased need.

Multidisciplinary working and working across hospice and community settings supported safe pathways. Clinical nurse specialists and paediatricians played a key role in assessment and multidisciplinary care planning. This ensured care plans were robust and informed by specialist input. Regular collaboration, including a weekly caseload meeting, partnership working and training with other hospices supported shared learning and continuity of care across organisations. Some staff said that there was an opportunity to further integrate therapy services into multidisciplinary team meetings.

There was a good awareness of safeguarding processes and clear escalation pathways. Staff understood their role in identifying risk within complex family situations and felt able to raise concerns when required. Concern could be escalated to team leaders and or the safeguarding lead. ensuring any concerns could be promptly discussed. Staff support was available when needed, including out of hours, via an on-call system so that concerns could be discussed promptly.

Safeguarding systems were supported by documentation and visibility of risks. For example, there was a flag on the care database to show if there was a safeguarding concern about a child. This supported staff to identify safeguarding issues quickly across inpatient and community settings and ensured relevant risks were clearly communicated. We found that the safeguarding policy was accessible to staff.

There was a culture where concerns were taken seriously and acted on. The service promoted a culture of openness and professional curiosity. There were processes to support safeguarding involvement, including the service’s safeguarding meeting and the service’s membership of the Safeguarding Board. This demonstrated partnership working with external agencies and advocacy for children and families and the ability to contribute to multiagency safeguarding processes. Safeguarding leadership was visible, supported staff to access advice and guidance.

Staff recognised families as experts in their child’s care and worked collaboratively to manage risks. Children and their families were actively involved in risk management through personalised care planning and ongoing communication. Families said they trusted the service and valued being encouraged to actively contribute to their child’s assessments and decision‑making. A parent said, “We get a break, with peace of mind as everything is being done to look after our child safely.” Staff also demonstrated safe practice through consistent checking and communication, for example, families said, “They double checked the medication and phoned me quickly.”

Person centred risk management enabled children to take part in meaningful activities, therapies and experiences safely. We observed care being adapted to enable participation. For example, the hydrotherapy pool had been designed to enable children with complex physical disabilities to use it safely. This was combined a detailed a risk assessment a pool emergency evacuation plan (PEEP). This demonstrated a balanced approach to risk, enabling children to enjoy positive experiences rather than restricting opportunity.

The service adjusted care in response to changes in need, supported by multidisciplinary working and partnership with external services. Families were supported to raise concerns and were involved when risks changed. Communication was open and responsive, with evidence that “I can get in touch with a nurse and they respond straight away.” This supported timely risk management and helped prevent escalation of concerns.

The purpose-built premises and grounds were well designed to meet the needs of children of all ages with complex conditions. Specialist facilities supported safe care and accessible delivery. For example, the hydrotherapy pool, sensory room and bedrooms all had hoists to ensure they were accessible. The service provided separate and adaptable indoor and outdoor spaces that enabled children and their families to spend private time together and be sociable with other families as they wished.

The service used a secure entry system for staff and visitors. These arrangements supported safe entry and exit while maintaining a welcoming environment for families.

Leaders ensured environmental risks were well managed, including the safe selection, storage, cleaning, and maintenance of toys and equipment. This supported children’s developmental needs while maintaining a clean, safe, and therapeutic environment.

High‑risk environments were actively managed to reduce risk. For example, the hydrotherapy pool was supported by CCTV, Standard operating procedure (SOP), clear safety processes, including staff trained as lifeguards and the pool side evacuation training. Additional controls were in place for the pool, for example individual risks assessments, the personal emergency evacuation plans (PEEPs) and water testing 3 times a day. Staff demonstrated awareness of these systems and processes to support safe use of specialist facilities and ensured risks were mitigated.

Staff followed clear fire‑safety procedures, and ensured extinguishers met required standards. A fire drill had been undertaken 2 months before our assessment, records showed the fire alarms were tested every week, and a fire equipment review had been undertaken 5 months before our assessment.

Staff took responsibility for maintaining a safe environment and acted promptly when risks were identified. Systems were in place to manage equipment and environmental risks, supported by regular checks and oversight.

The Shift coordinator was responsible for being the fire marshal for the day if required, and for completing the daily checklist, the daily emergency checklist, the expiry checklist for the emergency trolley equipment and the 3 monthly checklists for the defibrillator.

Staffing was organised to ensure safe care delivery, with appropriate skill mix and deployment. A locum Consultant Paediatrician worked 7 PA (programmed activity) per week. An SLA (service level agreement) was in place between the service and another local children’s hospice to provide specialist medical advice, review and symptom management support for shared community palliative care patients, development of symptom management and advance care plans and a 24/7 medical on-call service for shared community patients requiring urgent symptom management or end of life care. This helped to ensure continuity of care and timely clinical decision-making.

The nursing/ care team establishment was 3.4 Clinical Nurse Specialists (CNS), 1.8 x Team Leaders, 2.6 x Band 6, 4.9 x Band 5 and 6.2 carers/ nursing associates. There were 2 nurses and 4 Health Care Assistants (HCA) on shift daily for onsite care, and care delivery included 1:1 child to care staff ratio plus a shift coordinator. Staff worked flexibly across services, which supported continuity and responsiveness. For example, all staff worked across inpatient care and supported families in the community. This approach enabled staff to respond to changing needs and provided consistency for children and families across different settings.

The Family Support Service comprises Family Support Workers, Play Specialists, Pharmacist, Physiotherapists, Transition Lead and a Music Therapist.

Staff described escalation and support arrangements, including the senior on call process. Staffing was adapted in response to absence or increased demand, for example, staff told us that the previous week a member of staff had called in sick. The situation was managed by a senior band 5 plus support from the team lead to enable care activities to go ahead. This demonstrated a responsive approach to maintaining safe staffing levels. Although the service was operating below establishment, the team responsively maintained safe staffing levels to support safe care for children with varying levels of need, including those requiring more intensive support.

There were 22 different courses on the Mandatory and Statutory Training list (MAST). The service recorded who had completed training and a system to remind staff to complete training. A training lead ensured staff training and competency was in place. Simulation training was offered to staff to build competency and confidence in supporting children with complex health conditions. The physiotherapist was the manual handling training lead ensuring that children were supported safely.

However, during the inspection we found that compliance with some mandatory training was below 75%. This included the non-care staff training compliance for First Aid, Slips, Trips and Falls, and Stress at Work. Food Safety training compliance was 89% for direct care staff and 74% across the service.During the inspection, we spoke with the team leaders, who confirmed that they acted as the designated Fire Marshal for the day and would undertake this role in the event of a fire. All members of the care team had completed Fire Marshal/Warden training.

The service had a volunteer training action plan in place to ensure all volunteers completed the required training and remained up to date. Volunteers were only permitted to resume their role once their training requirements had been met.

Staff wellbeing and support arrangements contributed to safe staffing and safe care delivery. There were regular opportunities for supervision and reflection, including monthly team meeting including wellbeing checks and regular supervision. Most staff described a supportive culture, where people could talk easily.

However, some pressures on staffing capacity were identified across clinical and therapy staff. This impacted care service delivery at times, where the service would have to cancel community visits or day care as staff may be needed for end of life care. At the time of our assessment, the service was interviewing for 2 Band 6 posts. The service was committed to career development. For example, several recently qualified registered children’s nurses, who had been on student placement at the service whilst at university, had been employed as registered nurses and the service were supporting the inhouse development of senior leaders.

The service maintained a clean and organised environment, supported by clear processes for managing hygiene and infection risks. Personal Protective Equipment (PPE) dispensers in all care environments contained aprons, gloves and hand sanitiser and were full and tidy. Members of care staff team all wore secured individual hand sanitising gel dispensers on their uniforms and were bare below the elbows.

There were structured arrangements for waste management and cleaning, including the correct use of waste bins. Facilities such as kitchens and clinical areas were maintained safely, for example the back kitchen was locked.

Specialist environments were also managed safely. For example, the hydrotherapy facilities minimised infection risk, by testing the hydrotherapy pool water 3 times a day using recently purchased equipment. Cleaning and safety processes were monitored throughout the building.

Staff demonstrated awareness of IPC responsibilities and incorporated these into practice. Cleaning and equipment management were embedded across roles, and systems supported safe practice, including access to appropriate facilities such as accessible bins in the toilets accessed by children and their families.

The Infection, Prevention and Control policy and Toy Cleaning Policies were in date. A comprehensive IPC audit report had been undertaken 5 months before our inspection. This included the overall governance, kitchen, food preparation and feeding equipment, hand hygiene, clinical equipment, catheter management and sharps management. A cleaning schedule was in place. However, we found that at the time of our assessment not all cleaning audits were up to date. The service recognised this and had an action plan in place to ensure cleaning audits were up to date.

Medicines reconciliation was completed on admission by nursing staff and recorded on medication administration records (MARs), which were reviewed and signed by a paediatrician. Staff had access to GP and hospital electronic records to support accurate reconciliation. Children’s own medicines were checked on arrival to ensure they were correct, in date and safe to use.

Medicines were administered by trained nursing staff and recorded clearly on MAR charts. Allergies, medicine names, doses, routes of administration and additional instructions were documented. Regular and ‘when required’ medicines were clearly identified, and there were no gaps in recording.

Medicines were stored securely in locked cupboards in line with manufacturer guidance. Controlled drugs were managed safely, with appropriate storage and daily stock checks. A random check completed during the inspection found no discrepancies.

Emergency medicines, including those required for anaphylaxis, were available and routinely checked. Appropriate emergency equipment and a crash trolley were also in place. However, the service did not routinely stock naloxone despite holding opioid medicines; this was identified and actioned following inspection.

Staff received regular medicines training, and competency assessments were up to date. Staff understood their roles and responsibilities and felt confident to raise concerns. Incidents were reported, and learning was shared through governance processes, including medicines audits and team meetings. Patient safety alerts were monitored and acted upon.

The service was supported by a paediatrician and a prescribing pharmacist, providing appropriate clinical oversight of medicines management.

Risks associated with medicines were assessed and managed. For example, oxygen therapy was supported by detailed care plans and risk assessments, and body maps were used to support safe administration of topical medicines.