Lewis-Manning Hospice Care

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

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

This meant people were safe and protected from avoidable harm.

This service scored 81 (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 demonstrated a positive learning culture, underpinned by openness, honesty and a proactive approach to safety. Leaders encouraged staff to raise concerns about patient safety and ensured these were listened to, investigated, and used as opportunities for learning and improvement.

There were clear and effective processes in place for reporting incidents and concerns. Staff were confident in using systems and gave examples of how concerns had been escalated. They also expressed confidence that managers would respond constructively, reinforcing a culture where learning from incidents was valued and supported.

Learning from incidents was used to make improvements and shared across the service in regular staff meetings. For example, following an incident where a patient sustained an injury, staff reviewed their equipment and transport needs. This resulted in the patient having the equipment they required to be safe when mobilising and communication within the staff team about the patient’s needs and how they could be met. Staff confirmed that learning was regularly discussed in weekly multidisciplinary team meetings, enabling collective understanding about patients’ needs and safe practice.

The service used patient feedback and concerns as a key source of learning. For example, when a patient’s relative raised a concern that deterioration in their condition had not been escalated appropriately, the service reviewed communication pathways between patients, relatives, the hospice and GPs. Staff described how the change in practice would ensure clearer accountability and more timely escalation of concerns, reducing risks to patients. The hospice’s response demonstrated a clear understanding of the duty of candour showing engagement and transparency between the organisation and patients while demonstrating how feedback was used to drive service wide improvements.

Opportunities for learning were embedded within clinical supervision. Staff were supported to reflect on practice, identify learning needs and make improvements. For example, following an appointment booking error, staff proactively sought supervision to reflect on the issue and develop improved ways of working. This demonstrated a psychologically safe environment where staff felt confident to be open about mistakes, seek support, and use experiences as opportunities for learning and development.

The service had established processes to manage referrals safely and ensure patients were directed to the most appropriate care pathways. There was a clear admissions pathway which included structured screening of referrals. This supported prioritisation and ensured that individuals were signposted to services that would meet their needs. The use of the Gold Standards Framework Proactive Identification Guidance strengthened this process by providing an evidence based approach to identifying patients’ phase of illness and ensuring care was aligned to their needs. Clear protocols were in place for escalating concerns, including guidance for staff on notifying GPs of patient deterioration to support coordinated and timely care.

Processes ensured that patients were contacted promptly following referral, supporting timely access to care. Initial contact was expected within 48 hours, and we saw evidence this standard was consistently met. Appointments were offered in line with patient needs. Feedback from a health care professional confirmed that referrals were handled efficiently with effective communication supporting timely access and patient safety.

The service promoted continuity of care through strong internal communication and collaborative multidisciplinary working. Daily meetings enabled information sharing between hospice services including the day hospice, hospice at home, family and bereavement services, lymphoedema and breathlessness services. This ensured that patients accessing multiple services experienced coordinated care and staff had a shared understanding of patient needs. Staff described a positive team approach, and we observed effective multidisciplinary working in practice. For example, patients attending the day hospice were able to access additional clinical input, such as specialist breathlessness support, through coordinated internal pathways. Internal referrals to complementary and psychological therapies further demonstrated a holistic and joined up approach to care.

Information systems were coordinated across organisations to ensure safe decision making and care planning. Staff had access to shared electronic patient records used by local hospitals and community services so they had information about interventions by other professionals. For example, staff were able to take account of hospital treatment when planning lymphoedema care and were aware of community interventions relating to wound care and nutrition. This oversight enabled staff to monitor patient wellbeing, identify risks and make appropriate referrals. Named links within the hospice for each primary care network supported safe transitions between services ensuring patients were seen by the right professionals at the right time and reducing the risk of gaps in care.

There were clear and effective processes to support safe discharge from the hospice. Discharge correspondence provided an overview of care delivered, current needs, and clear identification of responsibility for ongoing care. This ensured continuity and clarity for patients and professionals, reducing the risk of miscommunication or gaps in clinical oversight. These processes supported safe handover of care and ensured that all parties had access to up to date and relevant information about patients’ needs.

The hospice had effective safeguarding systems and processes in place to protect people from abuse and avoidable harm. There was a safeguarding policy supported by visible guidance such as information posters outlining how to raise concerns with the local authority safeguarding team.

Staff had appropriate knowledge and guidance to act on safeguarding concerns. Staff knew about safeguarding procedures and could recognise and report concerns. Support was available for staff from the duty nurse and safeguarding leads.

The service had a collaborative and proactive approach to safeguarding enabling people to continue safely living in their own homes. For example, staff identified concerns for a patient whose deteriorating health might impact on caring responsibilities. This was escalated to the local authority so that both the patient and their family received appropriate support to reduce risks. We also saw records where the hospice had worked in partnership with a patient and their social worker to ensure they were safe at home and provide a safe space for conversations about their care. Communication between the hospice and the patient showed sensitivity towards their circumstances and staff were proactive in checking they knew who to call if they felt unsafe.

Staff were supported to maintain their safeguarding knowledge and competence through mandatory training. Training records showed that staff completed safeguarding training for both adults and children, covering key areas such as domestic abuse, female genital mutilation, and liberty protection safeguards. Compliance with training was monitored through regular audits, and records showed that 100% of staff were up to date with their training on 31 March 2026.

The service worked collaboratively with people to understand and manage risks to their safety and wellbeing, ensuring they were involved in decisions about their care. Risk assessments were completed at the point of referral and reflected individuals’ personal circumstances including risks related to falls, personal care, and accessing their local community. These assessments supported a person-centred approach to managing risk.

Staff involved patients in meaningful conversations about risks respecting their preferences and independence. Clinical supervision records showed how staff communicated risks clearly and supported people to make informed decisions, sharing information with other professionals involved in their care.

The service actively supported people to identify and achieve personal goals safely. For example, one patient had been referred to community services to address risks related to wound care, mobility and nutrition. Access to support meant the patient felt optimistic about their future and were considering returning to activities they previously enjoyed such as swimming. Staff engaged the patient in a conversation about what support they would need to achieve this goal safely, demonstrating an empowering and collaborative approach to risk taking.

Feedback from patients indicated that they felt safe and supported when receiving care from the hospice. Comments included: “This is a place I could come and feel safe, relaxed and know I am in safe hands” and “talking to them made me feel safe and pleased I attended the clinic.” This reflected a culture where people felt listened to, involved, and supported to manage risks with respect for their independence and wellbeing.

The service did not always ensure that care and treatment were delivered in environments where risks were identified, assessed and managed to promote the safety of both patients and staff. While there were some systems to maintain a safe environment, areas for improvement were identified during the inspection.

Cleaning supplies were not always stored securely to minimise the risk of exposure or misuse. Although the risk to patients was low due to patients being supervised in these areas, this was escalated to the registered manager who took prompt action to improve storage arrangements and liaise with the cleaning company.

Checks on emergency equipment were not always completed in a way that ensured all items were complete and in date. The registered manager responded immediately by removing out of date items. There were no formal checks to ensure first aid kits were complete and contents had not expired. Checklists for the emergency trolley did not reflect which staff had completed the check to promote accountability.

Environmental risk assessments were completed before care was provided in patients’ homes. Risk assessments considered factors such as access to the property, lighting, parking, entry systems, steps and the use of mobility equipment. This supported staff to understand potential risks and plan care safely, while also promoting staff safety during visits.

Environmental risks across hospice and community clinic settings were assessed effectively. Risk assessments, completed by clinical leads, considered factors such as safe access to clinic rooms, parking, fire safety, and infection prevention and control facilities. Staff demonstrated a clear understanding of their responsibilities for maintaining a safe environment and reporting hazards. For example, staff had identified and reported a faulty paper towel dispenser with prompt action being taken to resolve the issue. This demonstrated a responsive approach to managing environmental risks.

The service ensured that medical devices were maintained safely. Regular servicing and safety checks were carried out in line with schedules, supported by clear audits demonstrating 100% compliance. For example, a light therapy machine used within the lymphoedema service was undergoing routine servicing at the time of inspection, this being known by staff and reflected in records. Equipment was labelled to show testing and servicing dates so that staff were aware it was safe to use.

The hospice demonstrated a proactive approach to staffing ensuring there were sufficient numbers of skilled staff to meet people’s needs safely. Staffing levels, turnover and sickness rates were closely monitored through committee meetings, with clear oversight from leaders. Recruitment activity was responsive and ongoing to address vacancies in a timely way, ensuring continuity and safety of care. Workforce planning reflected both current demand and anticipated future needs, supporting a sustainable staffing model.

There were safe recruitment processes to ensure only suitable staff were employed by the service. Comprehensive pre-employment checks were completed including references, Disclosure and Barring Service (DBS) checks, a full employment history, identity verification and evidence of professional registration where required. Regular audits of recruitment processes demonstrated a high level of compliance with the most recent audit in August 2025 showing 100% adherence. A central tracking system helped ensure DBS checks for staff were renewed every three years. These measures ensured that staff were safe and fit to work with patients.

Induction processes were comprehensive, personalised and designed to promote a deep understanding of the service. New staff completed mandatory training and were given opportunities to work alongside different teams across the organisation and externally. This supported a strong understanding of multidisciplinary working and care coordination. Staff described the induction as “thorough” and “very supportive”, enabling them to feel confident and competent. Opportunities for development such as shadowing and joint visits ensured staff developed skills and knowledge in a supported environment.

The service demonstrated a strong commitment to maintaining and enhancing staff competence through high quality training and continuous professional development. Mandatory and role specific training was comprehensive including nationally recognised training to support staff in delivering safe and informed care to people with learning disabilities and autistic people. Training compliance was closely monitored through regular audits, ensuring consistently high completion rates.

Staff were actively supported to develop specialist skills aligned to patient needs. For example, staff delivering lymphoedema services were supported to complete nationally recognised specialist training and ongoing recertification to maintain their competence. New staff were enrolled on specialist training ensuring they could meet patient needs safely and promptly. Development opportunities, such as clinical specialist programmes in palliative care, enabled staff to build advanced knowledge in areas including pain management, advance care planning, respiratory conditions and clinical decision making. This demonstrated commitment to a culture of continuous improvement and excellence in care.

Clinical and management supervision were embedded within practice and used effectively to support safe, high quality care. Supervision included direct observation in clinical environments, such as patient home visits, enabling assessment of staff competence and adherence to safe working practices. These sessions provided structured opportunities for reflection, feedback and identifying learning needs, ensuring continuing professional development and high standards of care delivery.

Staff consistently described a positive, supportive and collaborative working environment, where they felt valued and empowered to develop their skills. This contributed to high levels of engagement, competence and confidence among staff, directly impacting the quality and safety of care provided.

The service had systems and processes to prevent and control the risk of infection. The premises were visibly clean and well maintained, supported by a contracted service which provided regular cleaning. Cleaning standards were monitored through routine audits. Where shortfalls were identified, such as incomplete cleaning records or the need for increased attention to high level surfaces, these were addressed promptly and shared with the cleaning provider to improve standards and reduce risks.

Infection prevention and control measures were applied consistently across all sites where care was delivered in line with policy. Risk assessments included relevant information to ensure environments being used to deliver care and treatment were safe and suitable. Staff working in off-site clinics confirmed that facilities were maintained to a high standard, with essential supplies such as hand soap and paper towels readily available. Staff understood how to identify and report any concerns and were confident that issues would be resolved quickly to maintain a safe and hygienic environment.

Staff followed infection prevention and control practices to reduce the risk of cross-contamination. Personal protective equipment (PPE), including gloves and aprons, was readily available and used in line with guidance. Staff adhered to ‘bare below the elbows’ principles and we observed equipment being cleaned between patient appointments. Clinical waste was managed appropriately, with suitable disposal systems in place.

Hand hygiene practices were embedded within daily care. Staff washed their hands before and after each patient contact, following guidance displayed at handwashing stations, which were equipped with soap and paper towels. Compliance with hand hygiene was monitored through annual audits, with records showing 100% compliance in the previous year. This demonstrated adherence to IPC standards and a commitment to maintaining patient safety.

The clinical lead of palliative care services was the hospice infection prevention and control link nurse and attended quarterly meetings with with the Local Integrated Care Board to keep updated with local concerns and public health advice.

The hospice had systems and processes to support the safe and appropriate use of medicines. A medicines management policy guided staff practice and reflected the service’s role in supporting patients to manage their own medicines. Risk assessments had been completed for patients attending the day service to identify whether they wished to self-administer their medicines and were able to do so safely or required staff support. This ensured responsibility for safe storage and administration was agreed between patients and staff and clearly recorded.

The hospice empowered patients to understand and manage their medicines. This promoted patients’ safety and autonomy. For example, the hospice’s health and wellbeing programme included dedicated sessions on medicines and opportunities for patients to discuss their prescriptions with nursing staff. This enabled patients to understand the purpose and correct use of their medicines while providing opportunities to address any concerns. Staff described how these were important conversations which had enabled them to identify when a patient was taking medicines that had not been prescribed for them. This led to communication with the GP and pharmacy to review treatment and ensure safe use.

Staff delivered education to promote safe and effective medicines use. This included providing patients with guidance on correct inhaler technique and identifying when patients taking multiple medicines may benefit from a review. Staff worked collaboratively with GPs and other healthcare professionals to ensure medicines remained appropriate and were optimised to meet patients’ needs. They also acted as advocates for patients, supporting them to express preferences where medicines were not providing benefit and working with prescribers to identify suitable alternatives.

Although the hospice did not prescribe medicines, staff played an important role in recognising when patients may require specific treatments. For example, staff identified when patients might benefit from medicines such as antibiotics for cellulitis and liaised promptly with GPs to ensure timely treatment. This demonstrated a proactive approach in ensuring patients were prescribed medicines that met their needs.

The team had access to specialist knowledge and support to promote safe medicines practice. Two staff members had prescribing qualifications and provided advice to colleagues, supporting safe decision making and contributing to staff development. This included delivering training, such as a session on symptom management in December 2025, which helped ensure staff had up to date knowledge and skills to support patients.