Bury Hospice

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• 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 2 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. Senior leaders were able to explain the key risks and challenges faced by the service and demonstrated the experience and capability to manage them. Staff and volunteers we spoke with said they felt well supported and listened to by managers and leaders. They told us that leaders were visible, approachable and volunteers said they felt valued. Leaders had developed an action plan to make improvements identified from staff survey results. There were processes in place for the safe, effective and inclusive recruitment of leaders. Staff and leaders understood their key roles, responsibilities and accountability arrangements. All staff groups and trustees told us information on performance, risks and governance was shared. Staff participated in quality monitoring and audit processes. The service maintained a risk register and this was reviewed by trustees, senior leaders and heads of departments. The service had an organisational structure with defined roles and responsibilities. There were governance, management and accountability arrangements in place.

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.

Senior leaders were able to explain the key risks and challenges faced by the service and demonstrated the experience and capability to manage them. They explained how they worked collaboratively with partners and the actions taken to support the delivery of the service strategy and long terms goals. Staff and volunteers we spoke with said they felt well supported and listened to by managers and leaders. They said they enjoyed working for the service and that it was a good place to work. They told us that leaders were visible, approachable and volunteers said they felt valued. Some staff gave examples of when their ideas were listened to by managers and implemented to improve the service. Some staff said that they felt more supported now than in previous years. The most recent staff survey dated October 2023 had a response rate of 83% and included all staff groups such as fundraising and retail. The survey results were benchmarked against 30 participating hospices. There were 75% of staff who said they had confidence in the senior leadership team. This was slightly higher than the benchmark score of 73%. Over 90% of staff said they believed in the aims of the service and were proud of and enjoyed working there. However, 47% of staff said they had confidence in the trustee board which was lower than the benchmark score of 62%. Other areas that had low scores and below the benchmark scores included effective communication between teams and feeling stressed at work. The service had a freedom to speak up (FTSU) guardian and staff and volunteers we spoke with knew about the FTSU and whistleblowing process to raise concerns.

Leaders had developed an action plan to make improvements identified from the staff survey results. This included a new approach for regular staff communication and additional opportunities to meet with the trustees. There had been a hospice wide engagement event that included a staff discussion about well-being. The relaunch of the staff suggestion scheme was proposed by managers and senior leaders discussed staff suggestions at their bi-weekly meetings. There were examples of when staff suggestions had already been implemented. Leaders had commissioned an external governance review in March 2023 to identify any gaps and to strengthen its board and governance processes. The review looked at 9 areas including culture and behaviour, engagement and voice. The review was well balanced between what worked well and areas of concern. Leaders had developed a detailed action plan to implement the recommendations. An audit had been completed this year to assess the skills and experience of the 11 trustee board members. The audit looked at 31 sectors such as risk management, safeguarding and business development. All sectors had a trustee with experience or an expert in the field. Weekly MDT huddle meetings took place inclusive of the different services including the volunteer and fundraising service. The minutes were shared with all staff to keep them updated and included motivational and positive news. Clinical staff had requested and implemented a new initiative to acknowledge positive achievements and outcomes. There were processes in place for the safe, effective and inclusive recruitment of leaders. The recruitment process was comprehensive and competency based and leaders could access support and development. The service had a succession plan in place for leaders to ensure the continuity of key roles.

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 and leaders understood their key roles, responsibilities and accountability arrangements. Staff including volunteers and trustees told us information on performance, risks and governance was discussed during daily huddles, team meetings and shared via email or monthly board reports. Trustees told us that they also gained information from system partners for assurances around performance. Staff participated in quality monitoring and audit processes. They told us their performance was routinely monitored and they received feedback following audits to aid learning and improvement. Trustees told us that there was a clear operational plan to deliver the service strategy. They attended board meetings 5 times a year with senior leaders and said they had supervision with the chair and annual reviews. Trustees said that there was a good skill mix across the board and they felt comfortable asking challenging questions. Trustees said they had reasonable gender diversity across the board and had actively tried to recruit trustees from more diverse cultural and ethnic backgrounds. Managers understood the key risks to the service and maintained a risk register. Trustees told us that they reviewed the risk register at board meetings. Managers were aware of their responsibility to report notifiable incidents. They told us there was a system in place to ensure safety alerts were actioned and cascaded to all staff.

The service had an organisational structure with defined roles and responsibilities. There were governance, management and accountability arrangements in place. The trustee board had 11 established members including a chair. Sub-committees followed a meeting schedule throughout the year that included clinical governance, audit and regulation. Policies were managed by the board and passed by the relevant committee. Annual engagement sessions with trustees were available for staff to discuss what worked well and what could be improved. The service had a risk register that included risk scores with controls and actions taken to mitigate risks. The risks were dated and were assigned to a senior leader for ownership. The register identified the risk area such as corporate or clinical and there was a process in place for the register to be reviewed by trustees, senior leaders and heads of departments. Senior leaders produced quarterly quality data reports that included an overview of incidents, audits, complaints and patient feedback. There had been an increase in medication and falls reported between January and March 2024. Investigations had taken place with lessons learnt and education sessions. Between April and June 2024 the number of medication incidents and avoidable falls had reduced. The service had an audit schedule for both clinical and non-clinical areas. Improvement actions from clinical audits were tracked through clinical improvement plans. Learning was shared with staff through email, posters and monthly MDT incident meetings. An audit of staff files had been completed in March 2024 and reported good practice in terms of recruitment. However, some existing staff DBS checks had expired. Actions were completed in a timely manner with a new process in place to flag upcoming expiry dates and a reaudit was planned for later that year. There were secure electronic systems to store confidential information that were password protected.

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.