East Lancashire 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

There was a clear leadership structure including a board of trustees, senior leaders and heads of departments. Governance processes had been strengthened and were being embedded at the time of inspection. There were committees who reported to the board. Any information was disseminated to staff in newsletters and staff meetings. This including ‘closing the loop’ information regarding any incidents. Risks were recorded on risk registers; however these did not clearly show reviews. Most staff were positive about working at the service and were proud to be there. However, recent vacancies, particularly in the clinical nurse specialist (CNS) team, had meant a reduction from seven to five day cover for CNS and additionally some staff within clinical departments had needed to take on more duties and line management responsibilities in the interim.

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.

Not all staff and managers felt supported. Of those who felt supported they reported it as a good place to work with a lot of support for staff well-being. Of those who had not felt supported they said they had considered resigning in the last few months. Senior leaders when asked about the high turnover rate said they struggled to complete with the NHS terms and conditions. Some staff said they did not always feel listened to and were sometimes afraid to speak up as they reported not all leaders and managers were open to challenge. They did not always feel confident to raise concerns with the freedom to speak up guardian (FTSUG). The head of wellbeing confirmed that staff would bring issues to them which should be raised with the FTSUG. Staff reported there was sometimes blurring of roles and responsibilities and shortages of staff caused low morale and anxiety to some teams of staff. Leaders reported that they were working with staff and had a grievance policy in place when staff felt their concerns were not being addressed. Some additional measures had been implemented to support staff. Some staff said their ideas were listened to and discussion took place on how to improve the service. The most recent staff survey, in 2023, had a response rate of 59%. There were 44% who thought that communication between different departments was effective. There were 97% of respondents who said they enjoyed their work and the people at the service and 69% said their workload was manageable. Volunteers completed a survey; there was a 38% response rate. Results were generally very positive although only 42% said they were given the opportunity to develop new skills. When grievances could not be resolved internally the provider had used independent mediation and coaching services to support staff and teams to work effectively together. Staff said the new clinical practice development facilitator role had introduced resilience based clinical supervision training which was helpful.

There was a senior leadership structure with roles and responsibilities identified. There were governance, management and accountability arrangements in place. There was an established trustee board of 11 members with four new trustee appointments that created a more diverse board. Committees included corporate governance, clinical governance and finance. There were sub-committees of health and safety, non-clinical audit and information governance, people and culture and income generation and marketing. A meeting schedule was organised for the year for all committees and sub-committees. The provider had developed an action plan to ensure robust systems in place. There was a number of actions that had been identified and were either in progress or plans made to commence, dependent on their priority, at the time of inspection. There were corporate and clinical risk registers. These included risk scores with controls and actions taken to mitigate risks, however no dates to indicate when the risk was created or review dates. Senior leaders produced quarterly board reports and shared them with heads of department. Between April 2023 and the time of the assessment the provider reported 73 incidents, although named as risks by the service, of which 69 were clinical and all but one were reported as low to moderate harm. Themes of medicines errors and pressure ulcers were identified. There were standard operating procedures (SOP), however, these did not all include any dates. They were transitioning to the patient safety incident response framework (PSIRF). We reviewed our records and noted the provider had submitted mandatory notifications to the commission. There were secure electronic systems to store confidential information that were password protected. There was external support for processes such as waste management, water testing, fire risk assessment and generator testing. There was a business continuity process, however this did not have clear actions.

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.