Michael Sobell 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

At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

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 evidence showed a good standard. 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.

There was a positive and inclusive culture at the service. Staff were made aware of the service’s values and philosophy through their induction and training, and we saw posters displaying the values around the unit. Staff spoke positively and enthusiastically about the service and leaders told us they were proud of their staff and what they achieved daily.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. The service was developing a new 5-year strategy and were actively seeking staff involvement engaging with them to gather their views.

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

Staff told us they thought highly of leaders. They were visible and approachable across the organisation and found them supportive. They told us leaders were passionate about the hospice and were role models. We were given different examples from different staff members telling us how leaders supported them in different ways with training, quality improvement projects and empowering them to suggest ways to improve the service.

Leaders we spoke with talked passionately about working for the hospice. The culture of the service centred on the needs and experience of the patients who used services and putting them at the centre of all they did. There were strong working relationships between teams, and all staff valued the input from colleagues.

Leaders engaged well with other providers and were due to hold a conference in June 2026, welcoming speakers from across the country and internationally, this was the 3rd time they had run the conference. Leaders were excited to host this and help the wider hospice community to come together to learn from each other.

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

The service had a named freedom to speak up (FTSU) guardian and champion. We saw posters displayed around the hospice with information about how to contact the FTSU leads and the national guardian’s office. Staff we spoke with told us they felt confident to speak up and make their voice heard. Managers were approachable and listened and all staff told us they would be happy to raise any concerns they had.

The Freedom to speak up policy had superseded the whistle blower policy. We found this was in date and used version control, describing what had changed so it was clear to staff what the update was. It referenced national guidance and provided details of external organisations for staff to contact if they wanted to raise concerns outside of the service.

Patients and carers had opportunities to give feedback on the service they received. We saw comment cards and post boxes around the service for people to provide feedback. The staff and relatives we spoke with told us they were happy to speak directly to leaders to raise any concerns they had. Relatives we spoke with told us they had raised concerns about their family members ongoing care with other providers and the impact this was having. Staff helped the family resolve these issues and the relatives told us they felt listened to and their concerns were taken seriously.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service promoted equality, diversity and inclusivity. All faiths were welcomed and celebrated. There was a recognition that staff’s cultural backgrounds and values differed and were respected to provide a diverse and inclusive workforce. Senior leaders had spent time reviewing the recruitment process to increase the diversity and skill set of the board. 5 new board members had been recruited with a wide range of skills, different experiences and different cultural backgrounds. All appointees lived locally and were representative of the patient population.

There were policies and processes in place to ensure the appointment and employment of staff was inclusive and fair. These included directions to ensure all staff were treated equally regardless of age, gender, ethnicity, sexuality and religious beliefs.

Staff we spoke with did not have any concerns about their own treatment or that of other staff. Staff understood their human rights and leaders understood their role under the Equality Act 2010.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service managed risk and performance well and systems supported leaders to have clear oversight. The hospice had systems and structures in place to ensure board oversight. These consisted of 3 committees who reported to the board of trustees, with a number of subcommittees that fed into the governance structure. Each committee approved and verified reports which went to board for review.

The service had a risk register which was reviewed regularly. Risks were identified and recorded with a target risk score and current risk score. Risk was mitigated where possible and actions recorded. Leaders understood their risks and were able to talk through the top risks and the impact on the service. The risk register was a live document meaning all risks were current.

The Quality Assurance Governance Committee Meeting met quarterly. We reviewed the minutes for the last 3 meetings and found there was a set agenda which included reviewing the actions from the previous meeting, the risks on the risk register, and performance. The service produced an annual governance and assurance report. The last report produced was in June 2025. We reviewed this and found there was evidence of ongoing learning, identifying areas of improvement and showing where improvements had been made over the previous year.

The service had clear roles and responsibilities and systems of accountability. Staff we spoke with understood reporting lines and how information was shared. There was a clear framework of what was discussed in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared. Leaders shared updates and learning with staff through a range of communications including at team meetings and staff emails, such as Feedback Friday.

Leaders benchmarked the hospice’s performance against other services to measure outcomes of care and treatment. National performance data was used as was local networks who worked together. The electronic systems used recorded audits and information was displayed in a clear way for staff to understand.

Staff understood the arrangements for working with other teams internally and externally, to meet the needs of the patients. We saw how the service worked well with the local NHS cancer centre. Staff and leaders had a proactive approach to working with partners to see how they could improve the service to benefit patients.

Information governance systems included confidentiality of patient records. We found the service had notes trolleys that were locked maintaining confidentiality. Staff could access computerised notes by logging on to systems using individual passwords meaning all access was logged.

As a charity sustainability was considered in all aspects of the service. We were told there was financial accountability and decisions were made to ensure money was used responsibly to deliver an effective and efficient service. Although working within a strict budget were an essential part of the business strategy, staff and leaders ensured they did not compromise patient care. Staff told us leaders were welcomed improvement initiatives and assessed each request for new equipment fairly, and when possible ensured sign off was quick.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The hospice worked collaboratively with partners. Training opportunities had been created working with local universities to provide placements for students. One trainee we spoke with told us this had given them invaluable experience that they would take with them throughout their career, helping them understand the importance of good care at the end of life.

The service worked closely with the local NHS trust, leaders held regular meetings with them to ensure there was a good working relationship putting patients’ needs first. The local cancer centre was on the same site as the hospice and staff worked closely with the centre providing support to patients where needed.

The hospice participated in local meetings with other hospices in the area. They came together to share information and learning. One example given to show how well they worked together, was the creation of a new patient safety incident response framework policy, that reflected end of life care services in line with the NHS. They shared ideas and created a policy together meaning they all investigated incidents in a similar way across the network.

The service participated in a staff survey that was also used by other hospices meaning they were able to bench mark responses against other hospice providers. The results found that the service scored highly in most areas and identified areas for improvement. In key engagement indicators, the service scored 84% against the national score of 83% of staff members who agreed with positive statements about the service.

The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff were given the time and support to develop opportunities for improvements and innovation. Staff could access ongoing education and one staff member we spoke with was undertaking a project about the impact on the fathers of children when their partner and mother of their children was dying. This was an area under researched with huge consequences for partners and children.

Staff used quality improvement methods and knew how to apply them. As part of supporting staff with their development, they were encouraged to start quality improvement projects. One project Coach to Care, saw the service develop a palliative care education programme for carers and family members. The service had identified there was a risk of people being asked to care for loved ones without really understanding how to do so. The aim was to provide support and build the confidence of carers in their ability to care for family members at home. The project was on course to have helped 50 people by August 2026.

Funded by the service, the medical director had developed a website providing expert information on end-of-life care and links for local services across North West London. The service had been commissioned by the local integrated care board to support healthcare workers, patients and carers across the local area. The website had 2 interfaces depending on whether the person looking for information was a patient and carer or clinician making the information available relevant to their needs.

The hospice participated in audits relevant to the service and benchmarked themselves against hospices locally. Working with the network of local hospices this allowed learning to be shared across the wider area.