Thames 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question outstanding. 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.

This service scored 82 (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 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.

The service’s 2024 to 2027 strategy was available on their website, with four main priorities: to care with agility, have financial sustainability, have a supportive culture and to extend their reach into the wider community. The service discussed strategic priorities at the Strategy Implementation Group and at board meetings with the objectives reviewed regularly on the operational risk register. This assured that there was strong oversight by the relevant teams to implement strategic plans.

The strategy was developed with care at the centre of the model. To achieve their clinical strategies, the service would continue to review outcomes and key performance indicators (KPIs). However, leaders told us they were not solely target driven and they had a real focus on patient centred care.

As a registered charity, the service maintained oversight of its financial sustainability to support the continued delivery of quality care. Leaders regularly reviewed fundraising activity and promoted a shared vision of increasing community understanding of palliative care whilst challenging misconceptions. A range of initiatives were undertaken to raise both funds and awareness, strengthening engagement and support for the service. For example, a charitable walk was an inclusive fundraising event that encouraged participation from across the community at the same time as generating valuable support for the service. Staff were actively involved in these events, contributing as both as participants and volunteers.

The service’s vision was to provide quality of life to the end of life, for everyone. The service’s values were to provide care in line with compassion, ambition, respect and excellence. Staff learnt about these values as part of their induction, and the service shared any strategy updates with staff regularly. We saw staff behaved and engaged according to the service’s values.

The provider had 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 did so with integrity, openness and honesty.

The senior leadership team demonstrated a commitment to provide compassionate care to patients and their families, but also to their staff. Leaders sought feedback from their staff and acted on these.

Leaders modelled the service’s values and fostered a culture of openness and transparency. The 2025 staff survey showed that staff viewed the leadership team as effective communicators and had confidence in both the board of trustees and senior leaders.

Leaders understood their service and operated within clear reporting structures. There were succession planning arrangements for executive roles to support leadership continuity. Leadership development was promoted through programmes, workshops and coaching opportunities. These sessions supported people to enhance their skills, build professional relationships and improve their effectiveness in delivering high-quality care.

Leaders were inclusive and understood the context in which compassionate care was delivered. They could explain clearly how the teams worked to provide high quality care. Staff enjoyed working for the service and were proud of what they did. It was evident leaders were visible and approachable. They regularly undertook walkabouts, where they could engage with staff. Leaders emphasised this was not to monitor staff, but to be accessible if people wanted to speak with them.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a ‘Speaking Up’ policy, which advised and empowered people to raise concerns. The service had Freedom to Speak Up Guardians and Champions in both clinical and non-clinical roles. The freedom to speak up team would gather present an annual report which was routinely shared at the service’s board meeting. This held a transparency for people to access the most appropriate person easily. Staff were aware of the guardians they could contact if they needed to raise concerns.

The service provided opportunities for staff to speak up and ensure their voices were heard. For example, staff could provide feedback through a comment box, with the option to remain anonymous. Leaders told us they sought feedback through the annual staff survey and would reply to comments or concerns raised from this.

The service offered a ‘People’s Voice’ feedback forum, which could be accessed face to face and/or online. An example of this was when the service changed their tea bags as a result of staff feeding back that current ones were too weak.

Staff shared they were supported to speak up and would not feel fearful if they needed to do so. Line managers encouraged staff to speak up. One staff member said they were felt comfortable to raise concerns to their manager if needed.

One leader provided an example of a time where bullying behaviour was reported. The service reacted appropriately and professionally to ensure they followed procedure and supported staff. This reinforced that staff would be listened to and poor behaviours not tolerated.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service did not operate an anonymised recruitment process for reviewing prospective candidates. However, leaders reported recruitment practices were conducted in an open and non-biased way that gave equal opportunities to all applicants. As evidence of this approach, the service described an instance where a candidate progressed through the full interview process, despite not initially meeting selection expectations based on professional experience alone. The service advertised roles in many places to ensure that potential candidates were able to view the available jobs and apply. Leaders completed training which included employment laws to support building an inclusive culture.

Staff we spoke with did not have any concerns about their treatment or that of other staff. Staff felt safe to raise concerns if they needed to.

We saw evidence of an up-to-date equality, diversity and inclusion policy with training provided for staff. The service had an equality, equity, diversity and inclusion impact statement on their website. This celebrated and embraced the unique differences people brought to promote a creative and forward-thinking organisation.

In 2025, the service created an internal working group, with the aim to ensure every patient, volunteer and staff member felt safe, supported and valued. The group met regularly and supported equality, diversity and inclusion activities, helping to embed inclusive practices and ensure leaders heard the voice of staff.

The service recognised and celebrated religious festivals and cultural events throughout the year. Visible support was provided to demonstrate solidarity with colleagues. Examples of this included pin badges being worn and emails sent to staff sending celebrations. While diversity and inclusion were celebrated, the service also acknowledged the challenges and inequalities individuals may face, offering opportunities for reflection, awareness and understanding.

The provider 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The senior leadership team had oversight of the service and were actively involved with teams, including the board of trustees, clinical and non-clinical teams.

There were clear governance structures in place to support effective oversight of the service. The service had established reporting, escalation and assurance processes, which enabled leaders to monitor and manage risks appropriately. Risks and performance were regularly reviewed through governance forums and board meetings. The Board Assurance Framework (BAF) was used to track actions and outcomes, providing assurance that risks were being mitigated effectively. The BAF was taken to the board and reviewed every quarter. The board received transparent information, which supported informed decision-making and ongoing scrutiny of service quality and safety. Patient wellbeing was not lost through the governance process, with patient stories taken to quality and people committees, as well as the board, to ensure learning was shared at all levels.

Leaders had a realistic process for implementing Patient Safety Incident Response Framework (PSIRF). The service recognised that they were in the process of building a strong foundation and they did not want to rush the process and get it wrong.

The service managed risk and had an up-to-date risk register which was actively reviewed and amended. Leaders were able to explain the service’s top risks and what was in place to mitigate these.

There were processes in place to support people’s confidentiality. Documents containing sensitive information could be disposed of in confidential waste bins around the site.

Leaders had oversight of data security and safeguarded against fraud. During a national charity fraud awareness week, refresher training was provided to reinforce staff knowledge about information governance and data protection.

The service participated in a regional information sharing agreement. This supported efficient working through the safe and lawful sharing of relevant information with partner agencies.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Leaders were able to draw from their working backgrounds and previous experiences to further build strong relationships with other professionals. This professional relationship had allowed a connection where advice, practice and thoughts could be shared and discussed.

The service were level 3 regional trainers in the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process. Which focused on ReSPECT conversations held by clinical professionals. They also provided syringe driver training for care homes, with nurse consultants leading the training. Leaders were proud to provide this training, with a strong desire for sharing knowledge to better patient care. They placed value on supporting bereavement care to impact relatives and loved ones positively.

Leaders had regular communication with other hospice directors in the southeast region to share learning, policies and long-term planning which all contributed to more consistent care for patients.

The service was responsive to undertaking and providing training for not only their service, but to other services as well. For example, with other charities and hospices’, collaborative training included transitioning from child to adult services and sessions raising awareness about how to help parents prepare children for bereavement.

The hospice supported the needs of the local community and had a fundraising team to support the service. Staff proudly told us of different events they hosted, one being ‘light up a life’, which involved lighting candles for loved ones at Christmas time.

The provider 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 contributed to safe, effective practice and research.

Leaders listened and acted upon staff survey results. Some actions from the latest staff survey included recruiting more clinical staff to ensure staff and patient safety, this made the ratio 5 patients to 1 nurse. They also introduced ‘Brew and You’ sessions, allowing an approachable and accessible route to conversations with leaders.

Leaders shared how they were developing medical models and building teams for their services to provide better care for patients. This included building a medical team for the community.

The service undertook multiple projects to improve patient care. One project focused on sharing specialist knowledge of advanced care planning with care homes. This proactive approach supported the delivery of continuous, co-ordinated care in line with patients expressed wishes. It also provided targeted training and skill development for care home staff, enabling documentation to be completed by those most familiar with the individual. This ensured the service made effective use of its expertise while promoting a patient-centred approach by empowering care home staff to confidently complete the relevant documentation.

A pilot project was in progress to support local care homes and a local trust to support people who may be admitted unnecessarily to hospital. The pilot hoped to improve hospital flow, care home advance care planning, people’s quality of life and care, and the service’s reactive visits to people in the community. The project would work collaboratively with a local trust, health teams, care homes and GP surgeries.

A project was in development for the feedback process. The service was creating a webform to improve the way people could provide feedback to the service. By developing a simpler and more accessible way to provide feedback, the service hoped to create a clearer way of capturing this information, and to use it to improve the service provided.