Lindsey Lodge 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

We assessed 1 quality statement in the Well Led key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Lindsey Lodge Hospice 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.

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.

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.

Staff at all levels were clear about their roles and understood what they were accountable for, and to whom. The hospice held monthly quality governance meetings. We reviewed the meeting minutes for this. Topics of discussion included referrals, service and staffing updates, clinical incidents, policies, and their risk register. The service had suitable arrangements for identifying, recording, and mitigating risks. All risks were reviewed regularly at various committee meetings and the senior management team had a good understanding of these risks. The main risk was hospice funding and its complexities. The leadership team had plans and ambition to improve community services for end-of-life patients. Leaders were working on a pilot of a single leadership model between the hospice and community palliative care and end of life teams. They had identified gaps and duplications in care that they had the skills to remedy. The hospice stored and collated information digitally. There were processes to back up systems should there be a technical failing. A weekly bulletin was sent out so that staff knew of ongoing work and issues within the organisation.

The service had a clear management structure. There were 11 board trustees who met routinely 4 times yearly. The board of trustees regularly reviewed and assessed the major risks to which the hospice was exposed via use of the risk register. Financial control was aided by regular monitoring of actual performance to budgets and forecasts, and these were revised when necessary. The leadership structure consisted of the chief executive and five directors who were the medical director, the workforce consultant, the director of clinical services, the company secretary and the director of income generations. The hospice had a clear governance structure with various committees. Subcommittee meetings fed into the board meetings to ensure information was shared across all services and that staff were fully informed of any risks and safety concerns. We reviewed the minutes of the board and subcommittee meetings which were attended by the senior leadership team. They showed risk had been reviewed and escalated appropriately. The hospice collected, analysed, managed, and used information well to support all its activities, they used secure electronic systems with security safeguards. The hospice used an off-site information technology team which looked after data security and protection. There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. The hospice was committed to developing a plan to act on environmental sustainability, deliver progress on social issues and reinforce their commitment to strong governance. The hospice had a business continuity plan which served a purpose of providing both a first response and a framework under which the hospice would be managed and continue to operate under adverse circumstances.

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.