Hospiscare

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

We reviewed governance, management and sustainability quality statement for the well-led key question. We rated this as good. At this assessment we did not look at the quality statements; shared direction and culture; capable, compassionate and inclusive leaders; freedom to speak up; learning, improvement and innovation; partnerships and communities; workforce equality, diversity and inclusion. The outstanding scores from the previous inspection in March 2016 are used to inform the scoring of these quality statements.

This service scored 96 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear roles, systems of accountability and good governance which it used to manage and deliver good quality sustainable care, treatment and support. This included regular meetings for corporate governance, care quality working team and care team leads governance meetings. There were clear and effective governance, management and accountability arrangements. The service carried out regular staff surveys and obtained regular patient feedback. Staff understood their roles and responsibilities. Managers could account for the actions, behaviours and performance of staff. Staff we spoke with stated they enjoyed working for the hospice and felt able to talk to and were supported by both their immediate line manager and the senior leadership team. The availability, integrity and confidentiality of data, records and data management systems was monitored.

The service had clear policies and processes for emergencies such as extreme weather events. The senior leadership team were planning to run simulation on certain types of emergencies to ensure plans were relevant and staff were aware of the policies, procedures and plans. The service had a business continuity plan which was last reviewed in June 2023. Any external concerns were raised through the relevant organisation quality and governance team. There was a monthly meeting with the governance lead of the local trust to manage any incidents quickly and to encourage learning from each other. Internal incidents were managed via the patient experience and safety meetings. The service was planning to implement the patient safety incident response framework in the near future.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.