Michael Sobell 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

At our last assessment we rated this key question requires improvement. The service was in breach of legal regulations in relation to regulation 12 Safe care and treatment and regulation 17 Good governance. The service has made improvements and is no longer in breach of regulations. At this assessment, the rating has improved to good.

People were safe and protected from avoidable harm. This meant people were protected by an effective approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood how to raise concerns and report incidents. Staff provided examples of incidents they had raised and could tell us how they reported them. Access to the incident reporting system had improved and staff told us it was now much easier to report an incident. Leaders stated they had seen an increase in the numbers of incidents reported in the low or no harm categories in line with expectations showing staff were able to access the system more easily. The service asked staff for feedback to assure themselves the system was easier to use. Staff told them the new process was “straight forward” and the form was “easy to complete”.

Heads of department had access to a dashboard giving them oversight of any incidents raised in their department. The new dashboard showed who was responsible for taking action and meeting the deadline by a set date. This meant it was easier for leaders to manage as they had easy access to live data. We saw the dashboard and found it displayed the data in a way that made it easy to identify actions that needed to be followed up. Data showed in the last 12 months there were 105 clinical incidents and 45 non-clinical incidents of which 110 were low or no harm. The service reported no never events in the last 12 months. A never event is an incident that is preventable and should not occur if available preventative measures and national guidance are implemented.

Staff told us they received feedback after raising a concern. Once the incident reporting form had been completed, the leadership teams with oversight would include a response to the staff member who raised the incident.

The service introduced a new incident framework in line with the NHS. They worked with local partners developing new policies and adapt the patient safety incident response frameworks, so they were relevant to their specific service. The partners worked together and shared incidents and learning, meaning learning took place across the sector.

Learning was shared with staff in several ways including, weekly emails from the leadership team, at team meetings and huddles and displays around the hospice. Reflective sessions were arranged for staff after an incident or death to attend as a way of openly discussing what had happened without apportioning blame.

Staff understood duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff received training on duty of candour as part of the all staff essentials of patient safety training. The service was 92% compliant with this training, meeting the training target of 85%.

There was evidence that changes had been made as a result of staff feedback. For example, the unit had an high incident of patient falls. The service developed and implemented a new bed space audit after this was suggested by a staff member. Staff audited the space daily around a patient’s bed for trip hazards.

The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received and used to determine if the patient’s needs could be safely met by the service. The service had introduced a telephone handover during which details required for admission were clarified ensuring a transfer into the service was appropriate and a decision was made by the triage nurse to admit.

Staff supported patients to be involved in their own care. This enabled patients to maintain as much control as possible throughout their care and treatment. Staff worked with patients when moving between services, such as from an acute hospital, cancer centres, community, and the hospice. Risk assessments were person-centred and were focused upon patients’ wishes.

The hospice worked closely with other services to support patient pathways and transitions. Staff were able to access a dietician, physiotherapists and the inhouse well-being team, including mental health support.Physiotherapists actively supported patients to be able to achieve the level of movement they wanted, developing personal plans for patients at the end of their life.

The service worked closely with system colleagues including general practitioners to support safe systems of care for patients in the unit. Managers held meetings with local NHS healthcare providers to ensure safe and effective transfers of care. As the hospice was near to the local cancer centre, staff would often travel between services to ensure the transfer of care went smoothly. The service participated in a pilot funded by the local GP federation to access a mobile diagnostic service. This allowed patients to stay at the inpatient unit rather than be transported to a local hospital for diagnostic testing which was better for patients and led to a quicker diagnosis. Leaders and staff told us they were always looking at ways to improve access to care to minimise the time patients spent away from the unit and the comfort of the hospice.

The electronic patient records included areas to record information such as care plans, risk assessments, Deprivation of Liberty Safeguards (DoLS) status, information around admission, ethnicity, and preferred place of death. In the notes we reviewed, the appropriate areas were completed. It was easy for staff to see individual needs and preferences while caring for the patient.

It was especially important to the staff and leaders that patients at the end of life were able to choose their place of death. They assisted patients with the discharge process to ensure this was the case whenever possible. Staff often went above and beyond to help make this happen. For example, staff assisted a patient to repatriate overseas as this was their preferred place of death.

All patients had their preferences recorded where possible. At the weekly multidisciplinary team meeting patient deaths from the previous week were discussed, if the service had failed to achieve the patients preferred place of death. This facilitated immediate learning for the team and was acknowledged as an important part of the patients care pathway.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The safeguarding system and processes included clear roles and responsibilities, through which safeguarding risks were identified, managed and actioned by staff. The hospice had a safeguarding adults and safeguarding children policy which in date, reflected national guidance and was available for all staff. The policy included all types of abuse including domestic violence, female genital mutilation, and radicalisation. The safeguarding policy included a renewal date when the policy would be reviewed. The patient safety and governance lead received an alert from the system when policies were due to be reviewed ensuring this would not be forgotten.

Staff were trained in safeguarding and attained between level 1 – 3 dependent upon their role. Training records showed 36 of 37 eligible staff members had completed their level 3 adults safeguarding training and 8 out of 9 eligible staff members completed level 3 children’s safeguarding training.

The hospice had designated safeguarding leads and champions. We saw posters displayed showing who the leads were and contact information for the leads and the local safeguarding multi-agency hub. Staff we spoke with knew who to contact if they needed help with a safeguarding concern. The service worked in partnership with other agencies, such as the local authority, attending multidisciplinary meetings to discuss the safety of patients.

Staff knew how to make a safeguarding alert and did so when appropriate. Staff we spoke with had a clear understanding of how to identify adults and children at risk of, or suffering, significant harm and how to refer patients they had concerns over. The inpatient unit did not admit children, but children were frequent visitors and staff were able to give examples when concerns about a family, including children were raised and how the impact of additional stress on a family might impact children’s welfare.

Staff had a clear understanding of the Deprivation of Liberty Safeguards, which staff only used when in the best interest of the person. Data showed 86% of staff received training in the Mental Capacity Act (MCA) which met the providers target of 85%. The board agreed in 2025 to increase the target to 87% reflecting the ambition to achieve higher standards.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated effectively with patients so that they understood their care and treatment, including finding alternative ways to communicate with patients when necessary. Staff were aware not all patients were able to communicate their needs well, and they used tools to assist in communicating, including using pictograms when people were not able to speak or using interpreters when English was not the patients first language.

Staff enabled patients to make advance decisions when appropriate. Staff encouraged patients and their families to participate in care decisions, respecting advance wishes as well as cultural and spiritual needs. Staff completed a treatment escalation plan for all patients, which detailed the level of care a patient wanted and clearly documented the patient’s wishes.

Staff ensured that patients could access advocacy support. Staff we spoke with were aware of the sensitivities around patients care and the need for additional support. For example, the service helped patients return home, if that was their wish, by assessing the risks involved. This meant sometimes arranging support in the community, . acting on the patient’s behalf making their choices clear.

The service had reviewed how they managed and recorded patient’s pain. They had introduced a system to try and establish a base line of pain, returning within 20 minutes of medication being administered to understand if the medicine had worked and was effective for the patient. Nursing staff escalated to medical staff if the pain relief was not working as planned and prescriptions could be updated and changed earlier to try and find a more effective way of managing pain. Quarterly audits were conducted to ensure compliance with this new way of working and showed an increase in compliance. By regularly reviewing leaders were able to review the trends for example, trainees not completing the forms correctly and additional training was given.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service has premises on an NHS site, and the building was managed by NHS facilities. The inpatient unit had 14 beds available, and staff told us they were proud they had managed to increase the number from 10 to 14 beds. The beds were split between 4 bays and several side rooms meaning patients had space and privacy.

We looked at various pieces of equipment during the inspection and noted that a range of audits were undertaken to make sure equipment was safe to use. During the inspection we saw a review had been undertaken of the mobility equipment. This review identified that an additional wheelchair with more structured support for patients was needed and also a bariatric chair. Leaders had agreed a chair could be ordered and at the time of the inspection they were researching which chair was most suitable for their patients needs. Staff told us decisions on new equipment were made quickly and leaders worked with staff to identify gaps and order new equipment if needed.

The service had a range of equipment available to them to safely care for patients, including mattresses to help patients with skin integrity concerns and rehabilitation equipment to support patients achieve a level of mobility they were happy with. Staff gave examples of patients building up their strength and mobility to be able to use the bathroom on their own and support their independence, or to be able to move their arms enough to hug those close to them.

Patients had call bells within their reach and we observed staff responding quickly when they were used.

Patients and their visitors had access to various rooms and areas to spend time with each other. The bays had access to a balcony, and the doors were wide enough to push patients outside on their bed. There was also access to gardens, which a number of volunteers helped maintain. There was access to kitchen facilities for people to be able to make a hot drink or use a microwave. The service had a chef onsite to freshly prepare meals. These arrangements facilitated patient’s individual dietary needs being met.

The service maintained an equipment log. This listed all the equipment, serial numbers and who was responsible for servicing it along with dates when equipment was due to be serviced. This was reviewed monthly, the report for March 2026 showed all equipment was in date and there was no equipment in use that had not been serviced.

The building the inpatient unit was based in was part of an older estate and needed repairs. On the day of the inspection, there was a leak in the ceiling near reception. We observed the matron speaking with the trust’s estate team to arrange for it to be fixed. Leaders told us they worked well with the trust’s estates team. Leaders were aware of the issues with the estate and told us there were plans to redevelop the entrance and reception areas creating additional seating areas for staff, patients and relatives.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had a team of 5 medical staff, including 2 specialist doctors, 2 GP registrars and the medical director. Consultant cover was provided by the local NHS trust with visiting consultants attending twice a week. The service worked with the trust to forward plan when consultants left the NHS trust employment to ensure there was continuous care for patients and support for staff. All staff we spoke with told us, consultants were easy to contact when needed outside of contracted hours and they were considered as part of the team.

There were 21 WTE nursing staff which comprised of healthcare assistants (HCAs) between bands 2 – 4 and registered nurses (RNs) between bands 5 – 7. The service did not have any vacancies and staff retention was good. Leaders reported that when there have been vacancies, they had not faced any challenges with recruitment.

The service employed 1 physiotherapist and were actively recruiting for a rehabilitation assistant to join the team. Other support staff were available who worked across all the registered services of the provider, including complementary therapists and counsellors.

Staff had received and were up to date with all appropriate mandatory training. The training was appropriate for the patient group using the service, training compliance for all subjects was 94% which was above the 85% target the service had set.

The service used a staffing acuity tool to help establish the number of staff required for each shift. The current establishment was for 3 RNs and 3 HCAs on a day shift and 2 RNs and 2 HCAs on a night shift. Nursing staff we spoke with told us they felt they had sufficient numbers of staff to safely care for patients. A pool of bank staff were available to provide cover when needed and staff from other areas such as the community teams, part of a separately registered service, were included in the bank staff available. The service did not use agency staff.

A member of staff was allocated to be the admission triage nurse. As part of the triage process, they reviewed staffing levels to make sure they met the criteria before accepting any transfers into the service. Staff were supported by managers to decline a transfer if the staffing levels were not appropriate.

The service had a disclosure barring service (DBS) standard operating procedure which stated all staff, volunteers and directors whose role involved regulated activity (activity regulated by the Care Quality Commission) with adults and/or children were required to have an up-to-date DBS. This was re-checked every 3 years. Clinical workers had an enhanced DBS check and non-patient facing role had a standard check. At the time of the inspection the service was 100% compliant for enhanced and standard DBS checks.

The service participated in training staff from different educational institutions. Placements were offered to students as part of their training. We spoke with a physician associate who was on a 4-month placement, they told us they were well supported and had regular supervision. They were encouraged to participate in reflective practice like the substantive staff and were offered the opportunity to attend training sessions such as a GP training session about pain management.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had an Infection Prevention and Control policy which was in date and quoted national guidance and legislation. There were additional policies and standard operating procedures (SOP) to support this including the Isolation (Barrier) Nursing SOP.

Staff maintained equipment well and kept it clean. We saw staff take equipment away and use antibacterial wipes to clean it after patient use. The service used “I am clean stickers” and we saw equipment with stickers dated so staff were aware when it was last cleaned.

All ward areas we saw were visibly clean, and we observed cleaners onsite during the inspection maintaining the areas. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

All bays and rooms had hand washing facilities. Staff adhered to infection control principles; we observed staff handwashing after being with a patient. Staff were bare below the elbow, meaning they were not wearing jewellery and had sleeves above their elbow. The service’s Infection Prevention audit report published in February 2026 showed staff were 100% compliant bare below the elbows. Hand hygiene audit results were displayed on the unit so staff could see how important it was to maintain high standards of hand hygiene. At the time of our inspection, the results of the January audit were displayed showing 100% compliance.

We observed personal protective equipment (PPE), gloves, aprons, masks and hand gel around the unit and saw staff use and dispose of it appropriately after use. This reduced the risk of cross infection.

Clinical bins were not overflowing and they were labelled appropriately. It was clear to people using them what items should be placed in which bin.

The service reported no healthcare associated infections (HCAI) in the last 12 months. Leaders told us that while there had not been any HCAIs recently, they continued to monitor and carry out audits regularly to maintain standards. The Infection Prevention Audit Report was an annual report reviewing various IPC audits carried out over the year highlight good practice and where improvements were needed.

The IPC lead for the service attended an IPC meeting with local partners. This meant the service was aware of local trends. Through this partnership working, a recent rise in e-coli was identified and meant the service could prepare and focus on preventative measures.

The Infection Prevention Audit Report identified a number of areas for improvement, including that clinical wash basins should be wall mounted using concealed brackets. Refurbishment work was planned to take place later in the year, due to the expansion of the service, many of the risks identified would be resolved due to refurbishment works taking place and a further audit of all areas would be required.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The medicines optimisation group met quarterly. We reviewed the minutes and found it was attended by senior staff from across the service, including pharmacists who supported the service. The minutes included a summary of the discussion under the agenda points and an action list, including closed actions evidencing what improvements had been made. In the January 2026 minutes, there were 5 actions in progress and 8 new actions added to the log.

The medications incident dashboard was reviewed at the medicine’s optimisation group. The dashboard showed how many recorded incidents were about medicines. Data for quarter 3 showed there had been 13 medication incidents. The incidents were given a level of harm, ranging from between no physical harm to death. They were given an incident level score ranging from level 0, a near miss to level 6, fatal. Of the 13 incidents, 11 were considered no or low harm and scored 0 and 1. There was one level 3 and one level 4. We reviewed the investigation report for the level 4 incident and found staff had identified a risk and escalated it appropriately. Immediate action was taken to ensure the patient was safe and learning had been identified and shared with all staff.

There were appropriate policies and standard operating procedures in place to ensure safe medicines management. Medicines were stocked in a secured locked room and stored in a locked cupboard. The room had controlled access and keys to the cupboard were stored securely. We found fridge and room temperatures were recorded daily. Controlled drugs (CD) were stored in a compliant cupboard, we reviewed the controlled drug book and found this was completed appropriately with drugs signed out. Following an audit of medicines, it was found a CD drug had not been entered into the CD book as per guidance. It was identified that the drug was not missing. It had been given to a patient appropriately and recorded in the patients notes but an administration error meant it had not been recorded in the CD book. Learning from this incident was shared with staff and increased the awareness of administration errors.

We looked at various oxygen cylinders in the building and found these to be in date and fixed to the wall.

In February 2026 a deep dive of the inpatient unit was published. It highlighted key actions for 2026.. We reviewed the action plan for pharmacy and found the service had identified areas for improvement including stock management of injectables. As part of improvement plans, the service had increased the contracted hours of the pharmacist to provide additional support.

The service stored FP10s securely and were only accessible to the medical staff to prevent unauthorised use.

We reviewed patients notes and found drug charts were clear, accurate and up to date, they were signed and dated and recorded allergies clearly.