Hospice delighted with the results of Quality Assurance Visit

• 29 May 2025

In May 2025 the Hospice, in Shelford Bottom in Cambridge, received a visit to the Inpatient Unit, the Living Well Service and the Hospice at Home service.

The Quality Assurance visit was conducted as part of the Cambridgeshire and Peterborough Integrated Care Board (CPICB) scheduled visits for providers with an NHS contract, delivering care to the Cambridgeshire and Peterborough population.

A number of areas were inspected and successes were recognised, including:

• The Charity were awarded Silver Best Employer Accreditation (East Region) based on outstanding staff survey results.
• Electronic Prescribing System funding has been sourced, with a plan to implement by September 2025.
• The Charity has an established Family and Patient Support Team, comprising a chaplain, therapist, and social worker to provide holistic care.
• The Charity formed a multidisciplinary Admissions and Discharges Working Group to streamline patient flow and reduce unnecessary hospital admissions.

Risks and Challenges were also identified, to support future planning:

• Community demand for services has become a growing challenge, and this trend is expected to continue due to the projected increase in the aging population in the coming years.
• Ongoing changes in community re-modelling are impacting service delivery and infrastructure planning.
• Patients are often presenting for services at a late stage, limiting the Hospice’s ability to provide comprehensive end-of-life care.
• Patient records are on SystmOne and on paper (such as drug charts, care plans and other charts). The Hospice aim to get electronic prescribing in place by September however a completely electronic system will take some years as requires human resources and funding.
• The referral process is not being followed consistently by those referring into the Hospice. This does not lead to delays in admissions but can delay hospice ability to triage community patients and signpost them to the most appropriate service, sometimes this is not hospice services.
• There has been no clinical educator for the past year; however, a candidate has now been recruited for the position.

Patient Experience and feedback was collected during the visit:

• The Inpatient Unit collates feedback from patients and families and they have consistently received positive feedback.
• The Team had an opportunity to speak with one patient and family who were present visiting and shared their experience of excellent care, they mentioned the call bells were answered within seconds, family communication had been excellent, food was very good and on time and staff were very considerate and facilitate away visits as requested.

The Living Well Service Patient Experience and feedback included:

• The team lead informed the visiting member that patient feedback is very positive and demand for the service is high.
• The team are very understanding of the differing needs of patients and are aware that patients sometimes require sensitive management and that it can take time for patients to want to engage with the team and the services available.
• The atmosphere in the communal lounge was very interactive and relaxed.

The visiting team also had an opportunity to speak to staff, feedback included:

• Staff working in the living well service enjoy working at the Hospice and feel well supported and listened to.
• The team work hard to ensure that they are all supporting each other, as the job can be quite demanding due to the level of support, which is needed to be delivered, and the nature of the roles they work in.
• Staff love the work they do and feel they make a real difference to patients. This is echoed in patient feedback.
• There was freedom to speak up guardians in place and a poster was on the office wall in the office detailing who these were.
• Staff felt encouraged to bring forward new ideas and are currently working on establishing an automated advice line for patients to access, as well as considering the implementation of groups which would explore the dying process and look in more detail at symptom management with patients, so that they understand this process more clearly.
• Staff are aware of how to access policies and procedures and knew who to report any incidents or concerns to.
• All staff had completed level 2 psychological training.

The Hospice at Home and Community Services were also visited. The two teams, North and South provide specialist nursing care and support in peoples own homes or place of residence during their end of life. The team offices sit within the building at the Hospice. Staff Feedback included:

• Staff reported feeling well supported with the Senior Leadership Team (SLT) regularly checking in and knowing all staff members names.
• SLT were accessible when needed.
• Although staff reported supervisions do not happen as regularly as they should they do have regular informal touchpoint meetings and feedback.
• The Hospice at Home team reported that all their nurses had attended leadership and management training and a two-day communication course.
• Staff reported that the Education Team will source training opportunities where it is requested such as Stoma training being delivered by CPFT at the request of the hospice at home team.
• Four members of staff (two Team Leads and two nurses) collectively agreed it was a good place to work and that the charity is very supportive to their needs.
• The teams have been able to deliver an increased hours of care.
• More triage support is required.

The visiting team summarised:

• The Hospice has very good structures in place to ensure the services provided are of good quality and high standard.
• Teamwork was evidently outstanding with very positive feedback overall.
• Observed were several volunteers who were very pleasant in their tasks and evidently part of the team. They spoke with kindness and enthusiasm within the areas there were involved, for example serving patient meals in the Inpatient Unit and they have all been trained in food hygiene.

Sara Robins, Clinical Services Director and Deputy CEO commented:

“We are delighted to receive such a positive report from the ICB Quality team, that reflects our values and dedication to providing outstanding care to our patients and those who visit our Hospice. Our wonderful and committed colleagues and volunteers are what makes our Hospice special and my thanks go to all of them.”

You can read the full inspection report here.

The Charity received a full Care Quality inspection in February 2019 from the Care Quality Commission which is displayed on the Charity’s website.