Hospice of the Good Shepherd

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 4 quality statements from this key question. We have combined the score for this area with scores based on the rating from the last inspection, which was good. Our rating for this key question is requires improvement. Staff did not always feel their own views were valued. There were some gaps in the senior and medical leadership team. The service did not always listen, and action staffs concerns regarding medical cover. Some staff we spoke with told us that a senior leader was unapproachable. During the assessment period, we were not assured the provider had effective systems in place to provide safe levels of care due the lack of RC cover, followed by the shortage of medical staffing.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they were given the opportunity to get involved with helping formulate the values the service stood for. Leaders told us staff were essential to formulating the values and used word clouds to select the values that were most important to all the staff. Staff expressed their pride in working for the service. “Our values and strategic aims 2023-2028” set out the provider’s vision, values, purpose and aims, whilst the aims were ambitious there were no key performance indicators or actions to show how the organisation would set out to measure their success within the document. We did see evidence of a strategy business operational plan 2024 – 2025 which did include RAG (Red, Amber, Green) rated strategic objectives, however for some strategic aims such as “Enabling new ways of planning for the future” the service was behind target. 77% of staff felt they understood what this charity wants to achieve as an organisation, this was below the local independent staff survey involving 32 other UK hospices with 91% in the 2024 survey. The service had performed better in this area in past surveys, previously scoring 87% in 2022. Staff did not always their views and values were listened to, in the staff survey the hospice scored below the all-hospice benchmark when asked.

The senior leadership teams spoke passionately about their values and this was reflected through policy documents. Staff we spoke with felt some the senior leaders were more visible and approachable than others. However, not all staff and managers felt supported by senior leaders. According to the staff survey, 38% of staff felt they did not have confidence in the Trustee Board, 39% did not have confidence in the Chief Executive and Leadership Team. In the same survey 40% staff answered disagree to the following statement "The Chief Executive and Leadership Team communicate effectively with staff". At the time of our inspection there were some gaps in the medical and leadership team. The new employed Director of Clinical Services was in the process of applying to be the CQC registered manager. This post was covered in the interim by the Deputy Director of Clinical Services in the interim since May 2024. There was a clear difference between teams in terms of morale and positive culture. Most teams we spoke with felt the hospice was good place to work with support in place for staff. However, at the time of our assessment it was clear that some felt unsupported in their roles. A new Clinical Director of Clinical Services had started at the service two weeks before the inspection. They had held a “meet the team” engagement session with inpatient staff. Staff, we spoke to felt positive about this level of engagement and hoped it continued.

The service had two freedom to speak up guardian’s (SUG) at the time of inspection who were available in person and contactable via email. Staff we spoke with were able to tell us how they would access SUG if they needed to. Throughout the department there were posters signposting this service. Nursing staff told us they felt comfortable raising concerns directly with their line manager or at team meetings, but knew freedom to speak up was another option. Some staff felt they were not listened to by leaders when they raised concerns over medical staffing levels. The SUG had been contacted 4 times in the last 6 months, according to board papers these issues were resolved internally. Some staff we spoke reported that not all leaders and managers were open to challenge. There was a freedom to speak out and whistleblowing policy in place. Staff could access the policy if needed. The service had a grievance procedure, and two grievances had been submitted in the last month prior to inspection. All staff and volunteers were provided with the employee handbook when starting work at the service which included the details in place for staff to follow when needing to speak up. Staff completed freedom to speak up information sessions as part of their mandatory training. The staff survey demonstrated 58% of staff felt "My views are listened to and valued", this was below the national benchmark of 66%. In the same survey 59% staff felt "my morale at work is high", this again was below the national average of 70%.

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.

Policies were accessible to staff, and they were notified when any changes were made and asked to confirm receipt. The hospice provided us with a copy of the organisational chart which had been updated in August 2024, however the date in the footer had not been updated and remained as May 2023. It was not clear from the structure of the chart who had oversight of the Specialty Doctors. On page 1 it looked like they were the responsibility of Director the Clinical Services, however, on page 3 of the document they were not referenced within the Clinical Services portfolio. Systems and processes were in place to monitor risks and outcomes, and to drive improvement. Leaders undertook reviews and audits to monitor performance. The results of these were discussed at governance meetings and shared through hospice communications such as the quality and safety bulletins and safety huddle meetings. The provider was working with the local integrated care board to prepare for the transition to a new incident reporting system. The risk register demonstrated there had been gaps in service level agreements with third party providers such as the role of a Responsible Officer. The service did not have a service level agreement with any third party to provide cover for the shortfalls in medical staffing rotas. The Medical Director had not been filled and remained vacant at time of inspection. The electronic systems to store confidential information were secure and password protected. There was a business continuity process in place that had clear actions and processes.

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.