Thames 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

Safe – 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.

The service provided care and treatment which was timely and maintained people’s welfare. There were enough staff, with the appropriate skills, training and qualifications to provide safe care. Staff understood risk management and how to escalate concerns. Medicines were mostly managed well; however, we found one expired medication and some expired equipment. We reviewed audits which showed inconsistency with patients being offered the option to wash their hands prior to dining. This was highlighted in consecutive months audits, however, improvement had not been noted.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

The service analysed themes and trends to drive improvement in patient safety and care. The service used online systems for managing and reporting incidents, eLearning and training compliance monitoring. The service investigated concerns and shared learning with the wider teams. The service was in the process of implementing the Patient Safety Incident Response Framework (PSIRF); a mandatory NHS England framework introduced to improve how healthcare services respond to safety incident by focusing on learning and improvement. This framework would further support involvement of patients and families.

Staff reported a strong learning culture across the service, they felt leaders and peers were open and transparent. Leaders promoted continuous learning by sharing lessons and outcomes through team meetings and weekly emails to staff. Learning sessions were offered to staff to support learning from shared experiences. The service held monthly mortality and morbidity meetings to discuss incidents and lessons learned to improve future care. The meetings also offered an opportunity to debrief and to celebrate positive staff efforts.

While most staff were clear about the need to be open with patients and families, some did not understand the term duty of candour, which is a legal and professional obligation requiring health and social care providers to be open and honest with patients and their families when something goes wrong with their care. We heard from leaders further training was being undertaken. We reviewed incidents and saw the duty of candour procedure applied. There was evidence of families being involved in conversations, with questions answered honestly and in understandable terms.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff understood the information and documents they required from other services to ensure patient safety was maintained; for example, patient-worn identification wristbands, safeguarding and social information, and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. A ReSPECT form records discussions between patients and clinicians, documenting a patient’s preferences and clinical recommendations for emergency care, including treatment priorities and resuscitations decisions. This information was regularly used to inform ongoing plans of care.

Staff understood the service pathways and how people were supported to access the service. There were established effective working relationships with external providers and services. Staff were knowledgeable about access and arrangements for external visitors and communicated information in a clear, appropriate and sensitive manner. This supported a smooth and efficient operational service whilst ensuring patient safety.

Leaders had developed effective partnership working with multiple external services. For example, they worked with NHS providers, schools and children’s hospices to ensure people received appropriate support. Leaders understood the challenges people faced when transitioning from child to adult services, such as the psychological impact, and were confident in providing appropriate support.

Staff told us how they maintained safe care whilst listening to patients’ preferences. For example, they carried out individual risk assessments for patients wishing to smoke. Patients accessed dedicated smoking areas and wore smoke resistant aprons for safety. The service did not allow smoking in patient rooms due to oxygen related safety. Staff could take patients outside in their beds to enjoy fresh air and a view of the scenic lake.

Staff understood the procedures to undertake following a death and told us how they completed these duties respectfully and efficiently.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

The service had named safeguarding leaders including members of the executive team and non-clinical staff. Safeguarding leads wore specific badges which made them easily identifiable. The service also had safeguarding champions. A safeguarding champion is a designated individual who promotes a safe culture and acts as a point of contact for concerns. They supported safeguarding leads, identify and share risks and ensure safeguarding is understood and implemented. Staff had clear directions on how to escalate concerns and to whom.

Current safeguarding policies were available to guide staff and volunteers if they identified or suspected abuse. These procedures included guidance for safeguarding concerns such as physical, psychological and financial abuse.

Patients and visitors had access to safeguarding leaflets on the wards, outlining types of abuse and how to report concerns.

Safeguarding was part of staff and volunteers’ induction and mandatory training. All staff and patient-facing volunteers received the appropriate level of safeguarding training for their role. For example, non-clinical administrators received level 1 training and healthcare assistants received level 2 training. Staff we spoke with could recognise the signs of abuse and knew how to raise concerns if they suspected a safeguarding concern. The staff safeguarding training completion rates were 96% for level 1 adults, 98% for level 2 adults and 100% for level 3 adults. The staff completion rates for safeguarding children training were 95% for level 1, 98% for level 2 and 100% for level 3.

There were effective systems and processes in place to keep people safe from abuse and neglect. Staff were confident to speak with service users and took time to get to know them. This helped to build a supportive environment in which concerns could be raised to a trusted member of staff if necessary. Staff were able to create patient passwords, which were key phrases or words agreed with the patient, so information was only shared with authorised callers or visitors who could provide the password. This supported the protection of people’s privacy and reduced the risk of unauthorised disclosure.

Staff recorded safeguarding concerns on the internal safeguarding log and the online incident reporting system. Safeguarding concerns were raised to the safeguarding leads who referred to the relevant local safeguarding authorities as required.

Staff we spoke with were able to clearly demonstrate their understanding of the Mental Capacity Act and how it related to the people they cared for. They were able to explain the challenges faced and the importance of informed decision making. Staff undertook mental health awareness training and overall compliance was 96%. Staff understood how ill health could cause fluctuating capacity and how to escalate any concerns. Staff understand the use of the Deprivation of Liberty Standards (DoLS) and who would be the most appropriate staff to speak with patients and their relatives about this.

The service had a lone worker policy in place for those who worked in the onsite hospice, retail spaces and in the community. Clinical staff providing care in the community undertook risk assessments. They had access to safety devices and mobile phones to maintain regular contact with the response team. Staff knew about the lone worker safety processes and who they could escalate concerns to.

The provider 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.

On admission to the inpatient unit, staff made patients and their relatives aware of additional services and how they could access them, such as physiotherapists and pastoral care. Staff told us how appropriateness of the patient was considered before offering these services, for example, a patient may be too poorly to accept physiotherapy input.

Staff completed care plans consistently and thoroughly. They included details of care needs, risks and patient preferences. Risk assessments informed personalised plans for patients, for example, falls and medicines assessments.

People were included in the review of their care. For example, when medicines were stopped, staff consulted patients and included them in these conversations. Staff recognised the importance of person-centred care and individuals having a say in how their medicines and care was managed.

Leaders shared how they wanted to empower people and not coddle them. Advance care planning conversations took place, which discussed future medical care and treatment, and the personal wishes of the patient. There was a focus on finding a balance and not fostering dependency.

The provider did not always detect and control potential risks in the inpatient care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff did not complete temperature logs for the patient’s food fridge consistently. Therefore, it was not clear food was always being safely stored, placing patients at potential risk.

We highlighted this finding to the service and heard they had recently closed one ward for refurbishment, and the ward move may have been the reason for a lack of documentation during the transition. Since our inspection, the provider told us they had implemented new processes for all food fridge temperatures to be checked and monitored.

Staff reported they had enough equipment and all the facilities worked as required. Clinical staff checked equipment before going into the community. The service completed equipment safety audits to ensure the appropriate equipment was present and working for when it was required.

A review of the environmental safety audit from October 2025 demonstrated the effective use of audit to identify gaps and ensure action was taken. This audit showed some equipment maintenance and servicing was overdue. Actions were planned to address the issues and was being monitored through the services risk map.

The service had equipped patient rooms with interactive sound systems. The systems used configured phrases where patients could trigger a hands-free call for help. This supported accessibility needs, for those who could not physically use a call bell. The sound system was also used for people to listen to music. Risk assessments had been undertaken for this technology, with risks concerning privacy and device tampering reviewed.

Staff disposed of clinical waste safely. We saw sharps bins were closed appropriately in the medicines room. Closing sharps bins is crucial for preventing injuries and the transmission of diseases. Clinical waste bins were managed by an external organisation and collected waste routinely.

We saw fire extinguishers around the site, which were all in date and regularly checked.

Clinical staff told us they completed daily room checks to ensure the environment was safe and suitable for the patient.

Access to secure areas was controlled. We saw the service had completed risk assessments to ensure people could not ‘tail-gate’ others into a controlled area.

There was dedicated parking for ambulances for a smooth access process. After 7pm, visitors entered via a controlled entry point through the ambulance entrance, where a buzzer and intercom system was in place. There was close circuit television (CCTV) in operation at both patient and staff entrances to support safety. This was organised in response to concerns highlighted by staff. They had escalated these concerns to health and safety care meetings, from which security provisions were discussed and CCTV procured.

The service had a garden of reflection, this area had seating and served as peaceful area.

The provider 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.

There was a combination of in-person and online training, with lots of refresher training available. The service had dedicated learning spaces to ensure staff undertook training in a safe space with time to complete. We heard staff found the training team accessible and helpful.

The service had a competency matrix for staff, this visual tool helped to ensure people were informed of the skills and competencies they were required to maintain.

Records confirmed the majority of staff had completed appraisals. The most recent appraisal rates showed the inpatient unit staff had 96% completed, the hospice at home team had 93%, and the wellbeing centre team had a completion rate of 100%.

The service had appropriate staffing levels. This included the inpatient unit, the community services and the nurses who supported the virtual ward. The service accessed bank staff if required. The service had no need for agency staff due to bank staff availability and staff swapping shifts to support the service.

The service had safe on call support for out of hours care. There was a nurse on call overnight and medical cover available out of hours. If there were concerns during this time, a doctor would review the patient and escalate to the consultant over the phone who would be able to support in person if required. There were processes in place to support safe and effective staffing. This included defined cut-off times for patient admissions, enabling staff to maintain safe workloads and ensure high-quality, safe care for all patients.

Staff supported each other and understood their peers’ roles. We were told doctors usually undertook responsibility for speaking with patients about their resuscitation status on admission (if appropriate). Student nurses undertook placements on the wards, they accessed support and guidance from dedicated practice supervisors.

To ensure staff teams had the right practical skills, health care assistants and nurses working in the community worked in pairs.

Volunteers formed an essential part of the staffing team. Volunteers managed certain areas of the inpatient ward, such as the kitchenette area. The service carried out appropriate recruitment checks for new volunteers. Volunteers completed the same mandatory training and induction as other staff, including face-to-face sessions.

The service recognised the impact the nature of their work could have on staff. They provided resilience training and undertook frequent debriefs. We observed a reflection meeting and saw staff recognised each other’s anxieties to deliver specific care needs.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The stock room was separate to the inpatient unit and was clean and well organised; however, we saw some large, boxed items stored directly on the floor rather than on shelving. Storing items on the floor increases the risk of contamination from dust and dirt and makes effective cleaning more difficult, which could compromise infection prevention and control practices.

Staff wore appropriate personal protective equipment (PPE) and had equipment readily available for infection prevention and management. Community staff had access to PPE to ensure they were safely prepared for their home visits.

Staff discussed patient’s infection statuses at multidisciplinary team (MDT) meetings to determine appropriateness for transfer into their care. This did not mean patients would not be accepted into the service, but extra care needs could be identified and prepared for as required.

The provider had a housekeeping service who undertook room cleaning. The environment was visibly clean, uncluttered and odour free. There was standard monitoring of the cleaning, with daily checklists completed. The service conducted regular clinical audits with areas of concern highlighted to the appropriate teams. We saw from audit documents in December 2025 and January 2026, there was inconsistency with patients being offered the option to wash their hands prior to dining. This concern was highlighted in the December 2025 audit to be discussed at the team meeting and at handovers to ensure staff were reminded of this good practice. However, in the January 2026 audit this practice was still not being evidenced.

The infection prevention and control (IPC) lead liaised regularly with the IPC team at a local NHS trust, ensuring regular access to specialist support and advice.

The provider did not always make sure that medicines and treatments were safe and metpeople’s needs, capacities and preferences.

Medicines were mostly managed well. The service stored medicines securely in locked cupboards in a keypad accessed room. Staff knew there had to be 2 members of staff together in the medicines room to ensure safe supervision of medicines.

The service had processes in place to check and audit medicines; however, we found one expired medication in the medicine’s cupboard and expired equipment in both the medicines cupboard and emergency resuscitation grab bag. The services own audits had identified concerns with the identification of out date medicines on two sequential occasions, with no clear action.

The emergency grab bag was shared between the 2 open wards. The grab bag had a checklist attached which staff completed to ensure the bag contained all necessary equipment. However, due to a misunderstanding, staff incorrectly completed this. This meant the bag contained some expired equipment and there was a risk this could impact safety or delay a response.

Information reviewed confirmed the service took steps to support the safe management of medicines, such as recording patients’ allergies, pharmacy reviews and medication compatibility checks.

Since the inspection, the service had begun to develop a more robust method to check medication expiry dates and added further checks for the grab bags.

The service had a Service Level Agreement in place for pharmacy provision with a local trust and had established a strong working relationship with them. The service received medicines from the trust. There was a pharmacist who was available onsite 4 days a week, to support the management of medicines. One day a week the pharmacist was at the local trust. Staff were aware of how to contact the pharmacist for advice and support when they were not physically present.

The service used a flagging system on electronic medicines administration records to identify people who required time-critical or treatment-specific medicines. This helped to ensure medicines were prioritised and administered appropriately, for examples for people living with epilepsy or Parkinson’s disease.

There was a safe tracing system for prescription pads. The pads were kept in a locked draw, with limited access, available only to those who required them. Staff needed to complete a password protected electronic sign in and out sheet, which meant the pads were trackable to the last user.

Staff reported medicine incidents, which the multidisciplinary team reviewed regularly in their medicines management meetings. Any learning identified from the meeting was disseminated via email for wider staff learning. Clinical staff were happy to challenge their peers regarding the active deprescribing of medicines and staff involved patients with these decisions and changes.