• Hospice service

St Margaret's Somerset Hospice - Taunton

Overall: Outstanding read more about inspection ratings

Heron Drive, Bishops Hull, Taunton, Somerset, TA1 5HA (01823) 333822

Provided and run by:
St. Margaret's Somerset Hospice

Report from 3 May 2024 assessment

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Well-led

Outstanding

Updated 12 September 2024

We rated well-led as outstanding. We assessed one quality statement on governance, management and sustainability. The service had consistently high ‘I Want Great Care’ survey results from May 2023 – May 2024. Governance was used to learn, improve and innovate. Leaders described the organisation as a learning organisation who never stopped future proofing. Staff felt that leaders were visible and provided support when needed. All staff said they had the utmost respect for the leadership team who fostered a learning culture without blame. There were regular and effective Board of Trustees’ meetings where learning was shared, as well as in-depth discussion of topics such as risks, safety, audit, culture, governance, quality and recruitment and retention of high-quality staff. There was evidence of the services’ keenness to drive and promote connections with the local health system to provide integrated care. Incidents and complaints were monitored by the audit committee and clinical governance. There were effective processes and pathways. Learning was documented along with lessons learnt which were disseminated across the organisation. All subcontracts were monitored closely with clear oversight of the renewal schedule.

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

Shared direction and culture

Score: 4

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.

Capable, compassionate and inclusive leaders

Score: 4

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.

Freedom to speak up

Score: 4

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.

Workforce equality, diversity and inclusion

Score: 4

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.

Governance, management and sustainability

Score: 4

Staff told us they felt proud to be part of the organisation. There had been lots of positive change in the executive team and the Board of Trustees. The new executive team was a strong group, who were fresh thinking with a positive approach to risk taking but always being mindful of safety. The Trustees were very engaged, and they worked together and provided support to the new clinical governance team. The leadership team participated in regular community events and were always available to talk to patients and staff. The service’s strategy for 2025/2030 included plans to diversify services and to support the patient’s journey at the earliest opportunity possible. There were plans to take the lead from and remain engaged with heads of departments, raising the voices internally of staff and patients’ experiences. Leaders discussed and planned for potential changes in assisted dying legislation in consultation with the national champion for hospices UK.

Patient’s stories were shared with the Board of Trustees at all meetings. Trustees told us they felt assured learning and improvement were ongoing. There was substantial engagement and networking with other hospices in the area, with the ICB and the local NHS Trust, also with GP forums, Marie Curie night sitters, the Hospital at Home team and national networks. The service created, led and funded a project for pressure wound prevention and wound care management at end-of-life care. This project had influenced teaching in integrated pressure prevention and complex wound care delivery and management at end-of-life care across the county. There were staff specialised in pressure prevention/fungating and malignant wounds who supported professionals and patients across Somerset. Staff with this expertise also worked closely, when necessary, with the established NHS Trust community tissue viability service.

Partnerships and communities

Score: 4

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.

Learning, improvement and innovation

Score: 4

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.