Bluebell Wood Children's 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

We rated Well-led as good. We assessed four quality statements relating to shared direction and culture, capable compassionate and inclusive leaders, freedom to speak up and governance, management and sustainability. Managers and relevant leads were clear about the hospice and service’s strategy and vision, other than those newly appointed. Leaders were capable, accountable and safely recruited. Hospice leads worked to embed a psychologically safe culture throughout the organisation. The hospice had an improving positive governance and risk management culture.

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.

Most staff felt actively engaged so their views were reflected in the planning and delivery of services and in shaping the culture. Their views were sought and acted on. For example, through all staff surveys and team days, all staff were invited to participate in cross-hospice working such as planning remembering day, other initiatives and sitting on various groups. Remembering day was when hospice staff invited deceased children's families and loved ones to celebrate their lives. Team leaders attended monthly clinical leadership team (CLT) meetings with senior managers from all areas of nursing care. They discussed and were involved with any planned changes to practice, or how to progress and develop their care or services. This was a very supportive meeting where all attendees were encouraged to voice their opinion openly in a non-judgemental space. All care team members attended weekly staff meetings on the care floor chaired by the head of care in a relaxed and open format. Staff told us these meetings helped encourage engaging conversations, manage their expectations and discuss any topics openly. Strategic leads worked hard to focus their services where they had the biggest impact on babies, children, young people and families. For example, by offering reliable short breaks, symptom management and advance care planning. The CEO’s weekly messages encouraged the shared values and promoted positive information sharing and celebrating progress, through individual or shared successes. Volunteering team staff were part of various groups including the operational management team, various governance groups, and the policy group, which they felt was fantastic for seeing increased joined-up working to shape the planning and delivery of services by incorporating volunteer's voices. Care team leads were in the process of discussing and agreeing a departmental direction and strategic plan as CQC’s assessment ended, due to the recently appointed care services director.

The hospice’s strategic leadership team (SLT) was fully quorate and operational from September 2024, led by their CEO. The team each had extensive experience of the hospice, healthcare and charity sectors. Leaders directly addressed and responded to staff concerns raised. Cultural exercises formed some of the staff away day agenda; such as whole team dynamics, respect for colleagues, their roles and how to work alongside, and table discussion sessions including where staff wanted to see the service in three years’ time. Managers were supported with ongoing training. Training included a bitesize management training programme across the employee lifecycle provided by HR. This included difficult conversations, protected characteristics and equality diversity and inclusion (EDI), as well as sickness absence management training. Leads felt the hospice had a robust recruitment process with scored interview questions. All new staff members were subject to a six-month probation period. Line managers ensured all staff had regular 1:1s and annual appraisals, training and development opportunities, and if relevant external supervision or networking. Hospice leads fostered a culture and expectation leaders should be present with their teams regularly, and the care leadership team adopted a collaborative approach to leadership, recognising their staff’s individual skill sets. The heads of department team had been refreshed since April 2023, and now included every department lead, regardless of title.

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.

We did not look at Governance, management and sustainability during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service commissioned an external independent governance review from NHS associates in 2022. This focused on getting the right structures in place. The board of trustees set up two new committees in response for improved clarity of focus. They set the terms of reference, reviewed the scheme of delegation and how they fitted together, then shared governance updates with staff. The governance officer attended a hospice working group with other regional hospices, and the Rainbows good governance group for informal discussions as well as sharing policies, ideas and best practice with other areas.

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.