Welcome to the 2025-26 Quality Account for Royal Trinity Hospice, an accurate record of our care and support activities over the last year.
In 2025 we were thrilled to receive the Hospice Team Award at the National Palliative and End of Life Care Awards. This was fitting recognition for our team, who have worked tirelessly to redesign our clinical model and embed new ways of working over the past two years. We aimed to streamline our services, be more responsive to people’s needs, introduce innovation in how we care for people, and ultimately respond to the ever-growing demand for our care. Our new clinical model is paying off: this year we supported more people than ever before to live and die well, and this is reflected throughout this report. We are now able to respond better to people in crisis, with our new Rapid Response team seeing people the same day and keeping the vast majority safely and comfortably at home and out of hospital.
Most importantly, we are hearing directly from the people receiving our care about the real difference we are making. People like Debbie, who told us:
“What struck me was how embedded Trinity is. From medication and equipment to advice and emotional support, everything is coordinated. When getting out became harder, Trinity made practical things possible making a huge difference to my sense of independence and dignity.
Beyond medical care, Trinity has offered me so much: gentle gym sessions with physios who really understand decline and adaptation; complementary therapies like massage and reflexology that give me deep relaxation; counselling that has helped me navigate fear, uncertainty and grief; and spiritual support offered in a completely inclusive way. Nothing is pushed. Everything is available.
Most importantly, they’ve cared for my husband, my children, my friends. Knowing that they will be here for my family after I die gives me enormous peace.”
Thanks to the one-off capital funding allocated by the Department for Health and Social Care,
we have made the biggest upgrade to our hospice building in years. In March 2026 we completed an extensive upgrade to the inpatient unit, the first since 2009. Each room now features state-of-the-art beds, riser-recliner chairs, and refurbished bathrooms, enabling patients to enjoy greater independence, mobility, safety, and comfort. Our treatment rooms have been upgraded to improve medication and equipment preparation and storage, and the floors have been replaced throughout the unit, contributing to improved infection prevention control and an improved environment. Behind the scenes, we have made much-needed improvements to our historic building, upgraded security and safety systems and invested in technology. These changes will contribute to improved quality and safety into the future.
For many years, Trinity has been a place that values diversity, champions inclusion and celebrates difference. In November 2025, our Hearing Loss Working Group received the Hospice UK Improving Inclusivity Award in recognition of their work to address inequalities for patients and carers with hearing loss. I am proud of the tangible improvements that this project has delivered, for people like Matthew, a deaf patient we cared for on the inpatient unit last year. He said: “They are deaf aware. One of the doctors put a doorbell on my door with a flashing light, because I couldn’t hear people knock. To have that bit of awareness around deaf people, that was lovely, and that impressed me.”
We remain incredibly grateful to our community, who is here for us just as we are here for them. We could not provide the breadth or quality of care to the number of people we do without their support and loyalty.
Emily Carter Chief Executive Officer
June 2026
1.2 About Royal Trinity Hospice
Founded in 1891, Royal Trinity Hospice is London’s oldest hospice and today remains the specialist palliative care provider for 750,000 people across seven London boroughs. This heritage gives us a deep well of trust in the communities we serve, rooted in over a century of compassionate, expert care.
Every year, we provide specialist nursing and medical care, bereavement support, therapies and welfare guidance to thousands of people across central London. We help people feel safe, understood and supported at their most vulnerable moments and provide comfort, calm and reassurance when they need it most.
We support the whole community around our patients. Families, carers, friends and loved ones can all receive support so they can cope, feel informed, and know they are not alone.
We are committed to providing equitable care for all who need it and proactively work to remove barriers among communities that traditionally do not access palliative care. Due to the success of this work, we are frequently asked to share our progress in this area with other hospices, through abstracts and presentations. Various special interest and working groups across the hospice are dedicated to improving health outcomes for some of these groups, including:
The Accessible Information Standard group
The homelessness working group
The hearing loss working group
The community inclusion group
In addition, internal and external research has identified geographies across our catchment area that are less well served by public and private transport, areas of higher socioeconomic deprivation, and disease categories and age groups that we underserve, compared to local census data. Our Community Engagement team proactively engages with these identified communities and shares learning and feedback with the clinical teams.
You did your work but way more than that, you brought kindness and care to life.
(Wandsworth End of Life Care Coordination Service)
1.3 Headline numbers 2023-2024
1.3
Our year in numbers 2025-2026
We cared for more patients than ever before 2,562
In total, 4,330 patients, carers and family members directly benefitted from our care and support
At any one time we were caring for 643 patients
There were 2,296 home visits from the Community Nursing team (not inc RRT)
427 patients in crisis, who received support from the Rapid Response team
The percentage of patients in crisis who were supported to stay at home by the Rapid Response team and avoided a hospital admission was 95%
342 patients received care in the inpatient unit
259 people received formal bereavement support and 1,467 attended bereavement support sessions
475 Carers received psychosocial/spiritual support
75% of patients who died, died in their preferred place of death
100% of respondents to our annual survey would recommend us to friends and family if they needed similar care of support and 98% of respondents felt they were treated with dignity and respect
(Inpatient unit)
Section 2: Quality of care
2.1 Patient safety
All patient-related clinical incidents are reviewed at the weekly Patient Safety Incident Response Framework (PSIRF) incident meeting, where trends are identified, and actions for improvement are monitored.
Overall themes from these incidents are then reviewed at the monthly Clinical Risk Committee meeting. Compliance with patient safety standards and how learning is shared across the organisation is overseen by the quarterly Quality Committee and Patient Services Committee, which is a Trustee-chaired committee, ensuring Board oversight.
Historically, we have published data comparing our incidents against Hospice UK’s national benchmarking data (to which we also submit our own data) in this report. Hospice UK is undertaking a review of its national benchmarking project, so no data are available this year. We look forward to reporting more on this next year.
My husband died at home and was looked after by the world’s most caring, sensible, kind, strong, hard-working, reliable and generous people. We could not be more grateful. Your people were wonderful to him, and very kind to and understanding of me and my son during those difficult weeks.
(Wandsworth End of Life Care Coordination Service)
From 2023, we have embedded the key principles of PSIRF within the hospice. Our identified patient safety priorities continue to be:
Falls
Pressure ulcers
Medication errors
Our weekly PSIRF incident meetings are well attended by representatives from across the interdisciplinary team, which has led to increased staff engagement in incident management. Having this robust process in place has enabled us to embed a culture of quality and patient safety within our clinical services.
At the end of each month, two key areas of learning are shared with the clinical teams, which has helped to improve clinical practice. For example:
implementing a change in how we measure our controlled drug liquids on the inpatient unit
improving falls prevention and management processes
highlighting the correct process for reporting pressure ulcers for both the community and the inpatient unit, including when to raise safeguarding concerns
PSIRF highlights 2025-26
Rolled out mandatory “one-off” PSIRF eLearning across clinical teams.
Reviewed how we use swarm huddles following a patient fall in the inpatient unit to make the process more robust and impactful.
Encouraged the attendance of new staff, including trustees, to the weekly incident meeting as part of their induction to the hospice.
PSIRF plans for 2026-27
Review our PSIRF policy and plan to ensure that it still reflects the needs of our patients.
Review how best to involve patients and carers in key aspects of the PSIRF process.
Analysis of Trinity safety incidents
In 2025-26, we recorded 475 clinical incidents and near misses, a slight decrease from the previous year (477). While the number of clinical incidents increased from 405 to 422, fewer near misses were reported and this increase reflects the positive reporting culture within clinical services. Reporting near misses is important because it helps us identify risks early and take actions to prevent harm. For example, if a near-miss fall is reported in the inpatient unit, we can activate the bed’s fall-prevention settings and increase comfort checks to reduce the risk of an actual fall. We will continue to monitor reporting and encourage staff to report near misses.
Clinical amber incidents increased from 57 in 202425 to 97 in 2025-26. This rise was partly due to stronger reporting by Trinity’s Community teams, whose staff have become more proactive in recording incidents. An increase in pressure ulcers present on admission to the inpatient unit and graded amber also contributed to this increase. This is discussed further in the pressure ulcer section on page 13.
Analysis of Trinity safety incidents
Health and safety incidents: green
Patient-related health and safety incidents are highlighted at the weekly PSIRF incident meeting for information purposes. At the bimonthly health and safety meeting, trends from incidents are discussed, as well as other non-clinical health and safety topics.
There has been an overall decrease in the number of health and safety incidents reported in 2025-26. The highest number of incidents related to equipment issues. We have introduced weekly health and safety walkarounds, mainly focused on the inpatient unit and attended by senior staff from the inpatient unit and facilities teams, to help identify maintenance and equipment issues. These walkarounds have led to a more robust, responsive approach to ensuring the inpatient unit environment is safe and clean, for example implementing a room handover process between housekeeping and nursing staff when a room has been prepared for use. We have an annual fire safety inspection from the London Fire Brigade, which has led us to update our door access process.
Health and safety highlights 2025-26
Completed a refurbishment of the inpatient unit, including new flooring, which has greatly improved the environment for patients and staff, including from an infection control and clinical perspective.
With guidance from the London Fire Brigade, we finalised a robust evacuation plan for the inpatient unit and rolled out training to support this for all inpatient unit nursing staff.
Health and safety improvement plans for 2026-27:
Update the evacuation training and process for the non-clinical services.
Review how we share the outcomes from health and safety audits, including the weekly walkarounds, with the clinical teams, patients and visitors to the hospice.
Analysis of Trinity safety incidents
Community team: amber
This graph highlights the amber incidents that were reported by the Community team this year. Community is an umbrella term that incorporates all care provided to people in their own home, delivered by a range of professionals across various teams.
2025-26
2024-25
Many incidents reported by the Community team related to external factors that hospice staff witnessed but were not directly involved in, for example the identification of pressure ulcers for a patient in the community on initial assessment.
Task management and escalation: incidents related to missed or delayed visits. Once identified, staff responded promptly by rearranging visits.
Caseload management: This included missed or delayed tasks, incomplete handovers to late shifts, and difficulties for internal and external stakeholders in accessing on-call CNS support. In response, the handover process was reviewed and strengthened, and staff were reminded of existing procedures.
Incorrect or contraindicated advice regarding medications: each incident was followed up individually to identify learning needs and provide further support. Staff were reminded of the process for checking medication recommendations with another colleague.
Community incident improvement highlights 2025-2026
To promote safe, effective and consistent practice, we reviewed the standard operating procedures (SOPs) for:
• anticipatory prescribing,
• medication monitoring and stock control,
• how we triage referrals, especially out of hours.
We began the rollout of a SOP for out-of-hours working for the Specialist Community Nursing team.
We introduced a process for our Royal Trinity Carers to help patients in their own homes with taking their medications.
Our plan for 2026-27
We will review how our team manages their caseloads which will result in patients and their families receiving the highest quality of care, utilising the most appropriate members of the clinical team.
We will carry out further work on our anticipatory prescribing standard operating procedure, looking at the timing of when we request essential end of life care medications which will enable us to better support patients to remain at home.
Analysis of Trinity safety incidents
Medication incidents
The largest number of reported incidents relates to medication. The hospice records both internal and external medication incidents affecting patients in our care. These incidents cover a wide range of issues, from administering the wrong dose to a broken ampoule of a controlled drug. Each incident is reviewed at the weekly PSIRF meeting, while trends are analysed at the monthly Clinical Risk and Medication Review meetings, where any further actions and learning are agreed. External incidents are fed back directly to the relevant organisation, such as the District Nursing team, referring hospital or GP practice.
Most medication incidents reported internally are related to the inpatient unit, which is the focus of this section.
Medication incidents (inpatient unit): green
This year, there has been a slight increase in the number of medication incidents reported from 249 in 2024-25 to 261 in 2025-26. Out of the 261 incidents, 257 were graded as green. There was a decrease in the number of amber incidents from 6 to 4.
Analysis of Trinity safety incidents
Medication incidents
The key trends for 2025-26 are:
Drug administration: Some incidents occurred when staff did not sign the drug chart after administering medication. When this is identified, we immediately follow up with staff to confirm whether the medication was given, helping ensure patients do not miss any doses. This category also includes cases where discarded medication was not recorded correctly. In response, we provided targeted teaching to reinforce the correct process.
Drug monitoring: Incidents in this category related to discrepancies in recording transference losses when a new bottle of a controlled drug was started, with losses exceeding the agreed threshold. Further investigation showed that the quantity in some new bottles was lower than stated on the dispensing label. To address this, we introduced specially designed rulers to measure the liquid before opening the bottle. This has strengthened the process and reduced the number of reported incidents.
Syringe drivers/opioid patches: Reports of incidents involving syringe drivers have increased, mainly where pumps stopped or ran behind schedule. To help identify problems promptly, staff check pumps every four hours, and the devices alarm if they stop. These measures help reduce delays in patients receiving their medication. We have also developed additional guidance to help staff troubleshoot issues.
Prescribing: Most of these incidents involved prescriptions with missing information, such as a prescriber’s signature, or medication not being transferred to a new chart. These issues are identified through weekday daily chart screening by the Pharmacy team or by the nurse administering the medication. As part of a quality improvement project, we redesigned the drug chart to make it clearer and easier to use.
What we did in 2025-26:
Developed a standalone process for the management of medication incidents on the inpatient unit.
Carried out a refurbishment and redesign of the treatment rooms on the inpatient unit. This has provided more surface space and better storage for medication and equipment.
Implemented electronic prescribing for non-medical prescribers in the Community team via our electronic patient record system.
Delivered further training on incident reporting, including defining incident categories more tightly to promote more robust reporting.
Our plan for 2026-27:
Introduce electronic prescribing within the inpatient unit.
Carry out a scoping exercise to inform whether we replace the current inpatient unit syringe drivers.
Roll out new pod lockers on the inpatient unit.
Analysis of Trinity safety incidents
Pressure ulcers
The multidisciplinary Tissue Viability Group meets monthly to review incident trends, discuss quality improvement projects, and consider any changes needed to guidance and policy. The group also carries out a detailed clinical review of a specific incident from both the inpatient unit and the community. This helps the team examine the care provided in more detail, highlight good practice, and identify areas for improvement to share with the relevant teams.
As a result of the Tissue Viability Group’s work this year, the Community team now reports all pressure ulcer incidents involving patients under their care. If a pressure ulcer is identified, the team ensures the patient has access to appropriate pressure-relieving equipment and pressure area care from their District Nursing team.
Pressure ulcers aquired at the hospice
The number of pressure ulcers acquired at the hospice remained in line with the previous year and made up a smaller proportion of all reported pressure ulcers. In each case, there was no further skin deterioration, and clear care plans were in place to manage the pressure ulcer. Skin changes at the end of life and the patient’s overall clinical condition contributed to the development of these ulcers, even when appropriate care measures were in place.
Over the past year, the hospice has replaced all mattresses on the inpatient unit to improve comfort and support effective pressure area care. Regular comfort checks are carried out, including repositioning where needed to help prevent further or new skin damage. Each patient’s recommended repositioning schedule is recorded on their comfort chart.
Pressure ulcers present on admission
This year, we saw a significant increase in the number of patients admitted to the hospice with pressure ulcers. This may reflect the current pressures in other healthcare settings, for example patients being cared for at home. We reviewed admission sources to identify any patterns, such as referrals from a particular ward, but found no clear trends. To ensure we have the most up-todate information at admission, we introduced a new handover sheet and nursing staff contact the admitting ward or healthcare professional for a clinical update, including a skin assessment.
What we did in 2025-26:
Provided in-person training on pressure area prevention, care and reporting on the inpatient unit during nursing staff study days which has increased staff knowledge and confidence in identifying, managing and preventing pressure ulcers.
Provided new guidance for inpatient staff on effective pressure ulcer reporting. This has led to better reporting of patients with pressure ulcers on admission.
Established links with external tissue viability services which has improved communication about care plans for patients with existing pressure ulcers on admission.
Analysis of Trinity safety incidents
Pressure ulcers
Our plan for 2026-27:
Formalise a rolling training programme for all clinical staff on key areas of pressure area management.
Review how we document pressure area care plans for both the inpatient unit and the community to ensure that they capture all the information needed to support safe and effective record keeping.
Any reported falls are discussed at the weekly PSIRF incident meeting to review why the fall occurred and agree any further actions. The Falls Group meets every two months. At this meeting, trends are analysed, and any new processes or training needs are discussed. Inpatient falls
Inpatient falls: actual and near misses
The number of falls has decreased by 21% from last year. This is the result of a series of quality improvement projects and environmental updates. Each patient has a falls risk assessment completed on admission, which helps identify the measures needed to prevent falls whilst supporting the patient in maintaining their independence and autonomy.
The new beds on the inpatient unit have a falls-prevention mode that alerts staff if the patient attempts to get out of bed. This not only helps reduce falls but also allows staff to respond faster when needed. Other new measures to help prevent falls include providing anti-slip socks and sharing each patient’s mobility plan on the mobility board in their room, which has helped raise awareness among their visitors to call for assistance if patients wish to mobilise.
What we did in 2025-26:
Reviewed how information from swarm huddles is used to manage the risk of falls on the inpatient unit.
Delivered further targeted training for staff regarding the reporting of falls and the use of bed alarms
Reviewed seating and invested in specialist recliner chairs for the inpatient unit, which have improved comfort and safety.
Included a page on falls prevention on the inpatient unit welcome pack, which is available to patients and carers in each room.
Our plan for 2026-27:
We will review post-falls management processes and train staff, to ensure we have a clear and consistent approach after a suspected or confirmed head injury from a fall.
We will develop a falls prevention and management booklet for staff to promote best practice.
Safeguarding adults
Throughout 2025-26, we upheld our commitment to safeguarding and to being a safe and effective hospice, ensuring that all children, young people and adults at risk of harm, abuse, or neglect are protected by staff who feel empowered, valued and supported. By working closely with our patients and families, we strive to achieve the best possible support and outcomes. Our safeguarding structure consists of:
Executive Lead, Safeguarding: Isatta Sisay, Director of Patient Services and Chief Nurse
Designated Safeguarding Lead: Paul Sullivan, Head of Living Well
Deputy Safeguarding Leads: Senior Social Workers within Trinity’s Patient and Family Support team
Total safeguarding concerns raisedinternal and external
No safeguarding concerns were raised directly against our clinical staff over the last year. Governance of our safeguarding process remains robust, with any safeguarding concerns regularly reviewed at our weekly PSIRF meetings and at our Clinical Risk Management Committee meetings, which provide the Board with assurance that our safeguarding duties continue to be met.
In 2025-26, we recorded 79 safeguarding concerns, which is a slight increase from the previous year (77). There was a significant increase in the number of safeguarding concerns relating to external factors that we reported this year, from 44 (202425) to 67 (2025-26). This means that 84% of the safeguarding concerns that we raised did not relate to Trinity’s care. This also reflects an improvement in our reporting following targeted teaching for clinical services, with a particular focus on safeguarding the reporting of pressure ulcers, both on the inpatient unit when patients were admitted with existing pressure ulcers and in the community.
This increase is reflected in the graph (left), which shows that the highest number of concerns reported falls under the neglect and acts of omission/self-neglect category.
In this category, 83% of reports related to pressure ulcers. By reporting these concerns, we are ensuring that patients receive appropriate care and support, with the aim of preventing further safeguarding issues.
Safeguarding adults
What we did in 2025-26:
Introduced a new Safeguarding report that is presented to the Clinical Risk Management committee.
Reviewed the content of the mandatory eLearning training for clinical staff to ensure that it promotes best practice.
Our plan for 2026-27:
Review the policy regarding safeguarding and pressure area reported to ensure it reflects the updated guidance.
Review safeguarding training requirements for the clinical team.
Freedom to Speak Up Guardians
Freedom To Speak Up Guardians provide a route to support anyone to speak up about anything they may be concerned about. We have six trained Freedom to Speak Up Guardians available to help anyone who wishes to raise something.
The hospice submits data to the National Guardian’s Office each quarter, including the number of cases brought to guardians and, within very broad definitions, what the cases were about and any issues, lessons, or takeaways. The information is also reported to Trinity’s People and Culture Committee meeting each quarter.
The total number of cases raised by staff in 2025-2026 was 12 (compared to 9 in the previous year), and issues raised included bullying, fairness, support and safety.
What we did in 2025-26:
Continued to provide support to all members of staff as and when needed.
Introduced support meeting for Guardians as required.
Our plan for 2026-27:
Ensure effective transition to NHS England oversight from the National Guardian’s Office.
Review our current cohort of Guardians, and if there is scope/ requirement for any additional Guardians.
2.2 Effective care
Outcome framework
Our quality outcomes framework measures impact, gathers feedback from those experiencing our care , and collects data that allows us to assess how well we are engaging with the communities we serve.
We continue to find ways to listen to these communities and to identify any barriers to people receiving the inclusive, responsive care that they deserve.
Core patient-centred outcome measures for palliative care (PCOMs for palliative care)
The hospice continues to use the PCOMs suite of outcome measures to describe patient status over time. These are the Integrated Palliative Care Outcome Scale (iPOS), phase of illness, and the Modified Karnofsky Performance Scale. Together, these scales enable us to provide more responsive patient-centred care based on their changing needs.
The Carer Support Needs Assessment Tool (CSNAT), which measures support needed by those caring for the patient, is used by our Patient and Family Support team and the Bartel Index for activities of daily living is used for patients on the inpatient unit. The CSNAT and the Bartel are measures used in addition to the PCOMs measures.
All patients admitted to the inpatient unit complete an iPOS, which is repeated regularly throughout admission and at discharge. If the patient dies, the Nursing team completes an iPOS following the death.
iPOS scores are discussed at inpatient interdisciplinary team (IDT) meetings and are used both to reinforce what the patient considers most important and to assign numerical scores to pressing symptoms. Over time, the score is used to monitor the patient’s clinical status and ensure any pressing issues are addressed. The Modified Karnofsky Performance Scale and the Phase of Illness Assessment Tool are used regularly during daily handover meetings to reinforce verbal updates.
In the community, the iPOS is completed at first assessment and then at any review of patient symptoms or whenever a clinical change is felt to have occurred. As with patients on the inpatient unit, the measures are used to check that issues identified by the patient are being addressed, to reinforce the impact our care is having and to prompt specific symptom review.
What we did in 2025-26:
Continued to use the iPOS for inpatients to monitor the effectiveness of care.
Introduced the use of the iPOS at the weekly community IDT.
Our plan for 2026-27:
Embed iPOS review in the community IDT
Use anonymised case reviews to reflect the quality of care given in team feedback sessions.
Outcome framework
Patient case illustrating the use of iPOS
A young man in his early forties with metastatic cancer was cared for by several hospice teams both in the community and in the inpatient unit, including the Patient and Family Support team and the Therapies team (physiotherapy, OT, Dietitian) alongside specialist community nursing, the Medical team and the Inpatient Nursing team.
The gentleman had two admissions to the inpatient unit. Prior to his first admission, his iPOS score was 30/80 and reflected significant physical symptoms, including pain. After two days on the inpatient unit, his score improved to 11/80, and he was able to return home, his preferred place of care. Several weeks later, his iPOS score had increased again to 32/80. With input from Trinity’s Specialist Community Nursing team, this improved to 29/80. Major components identified by the patient were both pain and psychological distress, and he identified that some of this was related to being at home. He was readmitted to the inpatient unit. Further scores over several weeks showed some improvement, but not to the same degree as following his initial admission. What did, however, change were the symptoms he identified as causing him the greatest concern. The iPOS allowed for directed ongoing work with all parts of the interdisciplinary team, and he died comfortably.
Spotlight on a bereavement project:
The impact of providing bereavement counselling in a natural setting
Walk-and-talk and forest bathing are becoming increasingly common ways to offer counselling outside a traditional counselling room.
We conducted a pilot scheme which explored the impact of delivering group therapy within and using nature as a co-counsellor. A group of five clients attended five two-hour sessions during autumn and winter 2025. Each session was held outside, and at the end of the pilot, feedback was positive, with attendees feeling it provided a safe environment to express and process their emotions. These sessions helped attendees learn how to use nature to support their mental health and provided opportunities to make meaningful connections with other participants. This has resulted in a second springsummer group starting this year.
Mortality review
The hospice continues to have two separate mortality reviews: one for the community and one for the inpatient unit. Both reviews focus on the quality of care given to patients once under our care and the cases are brought for review in a number of ways:
Inpatient unit: cases can be highlighted by any member of the team caring for the patient and may follow discussion at the weekly IDT. Cases may also be chosen if the length of stay for a patient was longer than average, or much shorter.
Community: cases are highlighted by any member of the team at the monthly ‘Discussion of Community Death forum’ This reflective session was introduced last year for the Community team and provides a space for staff to discuss any recent patient death, focusing on what went well, what could have gone better and any specific learning. The community mortality review also examines any patient deaths that occur in hospital.
Each case review uses a structured judgement review approach which is an evidence-based clinical case-note review method designed to standardise the evaluation of healthcare quality and allows us to review specific phases of care.
Learning from these reviews included:
Consistent development of individualised action plans for new admissions to the inpatient unit following medical assessment
Some improvement in the documentation of the effectiveness of medications, but inconsistency in this has led to an ongoing quality improvement project introducing the use of a pain scale pre- and post-medication administration
Effective communication between the hospice and external organisations (both for patients on the inpatient unit and in the community). In cases where this is not evident, specific training has been provided to teams and members of staff.
What we did in 2025-26:
Reviewed how we share with staff not only the learning but also awareness that these reviews take place.
Encouraged team members to attend reviews to understand the depth of each review and how learning is identified.
What we will do in 2026-27:
Further review the phases considered to ensure that we are maximising learning.
Increase the pool of those conducting the reviews to provide robust cover and ensure reviews can always occur monthly.
Education, learning and development
What we did in 2025-26:
Three successful cohorts graduated from our internal Management Development Programme, which has been running since 2022. This is available to both clinical and non-clinical managers, as well as aspiring managers, to better equip them when an opportunity for progression arises.
We ran various “Learning@Lunch” sessions, with themes ranging from supporting neurodiverse staff to supporting staff with visual impairments and hearing loss.
We successfully delivered phase two of our staff annual review process, ensuring all staff have a competency and behavioural based development plan designed collaboratively with their manager during one-to-one and annual reviews.
Over 50 members of staff benefited from funded development, which was aligned with their development plans.
Our plans for 2026-27:
Reduce the number of education workshops to ensure our delegate numbers remain strong per session.
Review the data from our 2025/26 training needs analysis.
Launch 360-degree feedback for both our Executive and Senior Leadership teams alongside our newly created leadership model and framework. This will ensure we upskill our leadership function to support the ever-changing needs of our people.
Clinical education and development
From August 2025 we hosted student nurse placements for 8 students:
2 3 3
We continue to offer clinical workshops to other hospices, local authorities and care homes but have seen a reduction in attendance and engagement through 2025-26, something which has fed into our plans for 2026-27.
Clinical effectiveness
Our audits, compliance checks and Quality Improvement Projects (QIPs) help us meet regulatory standards and keep improving the care we provide. The Clinical Effectiveness Committee oversees this work. The committee regularly reviews the audit programme to ensure it continues to meet the diverse demands and standards of clinical services, and that any projects are completed in a timely manner.
Clinical audits
Audits carried out this year included information governance, health and safety, pharmacy and infection prevention and control.
Clinical audits delivered this year are detailed on the following pages. A joint audit with St Christopher’s Hospice was completed and is included in the table.
I got a call from our Community Nurse, which was our first contact with Trinity. She popped round to our house and ran through all the practicalities. I had a long list of questions and I noticed as she was talking, she was answering all the questions before I asked them.
(Community)
Clinical Audit
Clinical Audit
CQC Key line of enquiry
Date
End of life care – community focus Caring April 2025
End of life careinpatient focus Caring April 2025
Mortality review of patients on the hospice’s referrals waiting list
Antimicrobials prescribing in the inpatient unit
Falls management on the inpatient unit
Pressure area care in the inpatient unit
Pressure area caresafeguarding reporting
Effective and Responsive May 2025
What we did well
Demonstrated a high standard of assessment of patients’ physical symptoms with individualised care plans.
Good practice demonstrated in recognising when a patient was approaching the end of their life and adjusting their care plan accordingly.
The hospice had a high response rate in assessing or admitting patients who were referred for end of life care.
Action plan
Amend the process of monitoring the Community team’s caseloads.
Amend the electronic patient records system to ensure we fully reflect the patient’s individualised needs and wishes for their care as they approach the end of their life.
Review the process for monitoring patients waiting for assessment or admission, and document the decision at weekends to ensure we provide a responsive service.
Safe July 2025
Significant improvement in documenting reason and length of treatment on drug charts, leading to safer prescribing practice.
Safe July 2025
Safe August 2025
Rollout of new beds with falls management systems on the inpatient unit, promoting patient safety.
Patients have clear, appropriate care plans to support the management of pressure area care.
Work continues to reiterate the importance of discussions with patients and carers about the use of antimicrobials on the inpatient unit.
Development of a falls booklet for staff, highlighting best practice in falls management.
Further work on reviewing how patients and families are involved in falls management.
Roll out a mandatory teaching programme to ensure that staff have a baseline knowledge of pressure area care and prevention.
Safe August 2025
Nutrition and hydration on the inpatient unit
Effective October 2025
This will now be merged into the yearly inpatient unit pressure area care audit. This was carried out to assess staff compliance with the updated safeguarding policy.
Implementation of individualised patient eating and drinking plans.
A review of the current menu to ensure that we are offering patients a range of options encompassing dietary, religious, and cultural preferences.
Amend the current audit to include a specific question relating to safeguarding and pressure ulcers.
Development of a swallowing assessment tool for patients on the inpatient unit.
Clinical Audit
Clinical Audit
Review of discharges from the inpatient unit
CQC Key line of enquiry Date What we did well
Safe and Effective November 2025
Welfare audit for Community team patients
Effective and Responsive November 2025
Robust referral process to District Nursing teams for patients who were discharged from the inpatient unit. This promotes a smoother transition from the hospice to the discharge destination for patients.
When the need was identified, appropriate benefit applications were promptly made.
Action plan
Ensure the discharge process flow chart reflects any updates or changes in the key elements that help facilitate a safe transfer of care.
To support proactive discussions regarding welfare concerns at the community and inpatient unit interdisciplinary team meetings.
Advance care planning in the community
Anticipatory prescribing in the community.
Joint audit with St Christophers Hospice
Responsive, Caring and Effective December 2025
Good documentation around specific aspects of advanced care planning.
Safe, Effective and Responsive January 2026
Both sites found that GP surgeries were very responsive to any requests, usually the same or following day
Further work to investigate why advance care planning discussions did not always take place and why this was not followed up at a further visit. Ensure staff discuss Universal Care Plan if appropriate.
There is a plan to continue working with St Christophers to make this an annual audit.
Community referrals to the Therapies team
Caring and Effective January 2026
Functional and nutritional status were assessed during the first contact assessment and again at regular intervals, prompting a referral to the Therapies team when appropriate.
Review and update the Therapies team referral criteria to promote ease of referrals.
Compliance checks
This year we have rolled out compliance checks across our clinical services, which are monitored quarterly at the Clinical Effectiveness Committee. Compliance checks are carried out by different members of our clinical teams and provide the opportunity to be responsive to any identified improvements.
Our current regular compliance checks are:
Pharmacy
oxygen prescribing and administration
steroid prescribing
monitoring of analgesic patches
antibiotic prescribing
quarterly controlled drug checks
expiry dates of medications check
delivery of controlled drugs between the hospital and hospice
daily chart screening
safe prescribing and administration of insulin
verbal orders
pharmacy discharge medication checks
omitted and delayed medications
Infection control
catheter care on the inpatient unit
hand hygiene on the inpatient unit and community
Royal Trinity Carers
safe disposal of sharps on the inpatient unit
vascular devices
checks on community PPE packs usage
Clinical compliance checks on the inpatient unit
blood transfusions
comfort chart checks
nightly equipment checks
use of MRASS score for patients
Clinical compliance checks in the community
Non-medical prescribing
Royal Trinity Carers medicines compliance
These checks help us demonstrate compliance with the CQC Key Lines of Enquiry. Below are some examples of the improvements we have made in response to the findings of these checks:
Providing a swifter response when medication charts have not been completed properly, both from a prescribing and a drug administration perspective.
Changing the size of personal protective equipment packs so they are easier for community staff to carry.
Redesigning the comfort charts on the inpatient unit to include room for more safety information.
Further teaching on the Modified Richmond Agitation and Sedation Scale (MRASS) score to promote use on the inpatient unit, which supports providing the patients with safe and effective care.
Quality improvement projects
During 2025-26 we undertook quality improvement projects driven by staff expertise and experience, and learning from incidents, complaints, concerns and outcomes from audits and compliance checks.
The introduction of the use of a steroid card for patients when they are discharged from the inpatient unit. This promotes safe and effective communication and handover of care.
The creation of a new booklet containing useful contacts. This is available to community patients to help them decide which service to contact for their questions or concerns.
A review of the dressings in use on the inpatient unit. This streamlined the dressings in use and gave us the opportunity to provide further education on their use.
Beginning to roll out booklets for staff that focus on key clinical areas. The booklets are to be used alongside Trinity’s current policies and include examples of best practice and further training opportunities. Following findings from the most recent mental capacity audit, the first booklet focuses on assessing mental capacity.
Rolling out a mindfulness breath and movement workshop as part of the Living Well outpatient service.
Initially I thought my own support network was enough but I began to feel professional help might be useful. The follow up was very gentle but efficient and I appreciated that it was still being offered 8 or nine months after my husband had died. I never felt rushed. My counsellor was a true friend to me who was totally relatable, open and supportive. She backed my feelings but could also offer alternative interpretations. She was absolutely brilliant. (Patient and Family Support)
What we did in 2025-26:
Continued to share audit outcomes and learning with the clinical teams, including having posters on the quality boards in the hospice.
Improved staff engagement with quality improvement projects by discussing them during quality update slots at team meetings and training days.
Our plan for 2026-27:
Develop other ways to share learning and recommendations from audits and compliance checks with both patients and other service users.
Ensure that audits and quality improvement projects are discussed at staff personal reviews and one-to-one meetings.
Continue to develop and roll out the staff booklets that focus on key clinical areas.
Research
The Research Group meets monthly and reviews all requests for collaboration from external individuals and organisations. The group also supports staff members with their own research projects. In addition, the group has taken on a role in supporting any member of staff or volunteer to submit abstracts to conferences. Four abstracts were accepted for the Hospice UK conference in 2025, and we regularly have posters accepted for other conferences, including the Palliative Care Congress run by the APM. In March, the group hosted its annual Research Awareness Event, showcasing posters from previous conferences and discussing the importance of research and how individuals can get involved. A Research Cafe is scheduled for July 2026.
The Group is now part of a hospice collaboration meeting with other local hospices, which will increase the hospice’s ability to participate in research projects, both internally and in collaboration with larger multi-site projects.
What we did in 2025-26:
Hosted internal research awareness events to continue conversations around research for everyone.
Encouraged ongoing involvement in research for all members of staff.
Our plan for 2026-27:
Develop and embed our position in local hospice research collaboration.
Showcase conference posters on our website and on internal communications boards.
2.3 Patient experience
We aim to ensure that we have processes in place to seek feedback and respond to what we hear from patients, carers, staff and stakeholders about the services we provide. This feedback enables us to respond promptly to any concerns raised, identify trends in feedback and plan for future service improvements and development.
We continue to work on ways to increase our response rates from formal patient feedback, as the response rate for 2024-25 was very low.
Patient experience of care survey
We now send this survey quarterly to increase the response rate.
This survey is sent to all patients who have used any of our clinical services. Responses are anonymous, but there is an option for respondents to include their contact details if they would like any follow-up. The survey can be completed either electronically or on paper. The survey results are analysed for key trends and shared with the clinical Heads of Service, who then agree any actions.
Patient experience of care survey 2024-25
The responses we received were largely positive, highlighting these key themes:
Kind, caring staff
Excellent spiritual support
Welcoming surroundings on the inpatient unit
Strong symptom control
Staff listened and responded promptly
“Overall, the experience was top-notch. I cannot single out anything that stood out as everything stood out.”
“Provided the best of care without fuss. Everything was carried out quietly and with good cheer.”
“Staff always wonderful. I feel it is a safe place.”
The following areas for improvement were identified from feedback themes, and a plan was made accordingly:
Theme for improvement
The environment and equipment on the inpatient unit
Discharge discussions on the inpatient unit taking place too soon
Access and length of art classes in the outpatient setting
Clearer admission criteria for the inpatient unit
More frequent contact from the Community team to check in on symptoms
What we did
In March 2026 , we completed a major refurbishment of the inpatient unit, including all rooms and clinical spaces. Upgrades were made to the flooring, furniture and bathrooms.
We completed a review into how these conversations take place and changes have been made to how we approach these. We will continue to work on this to ensure that patients feel supported when having these conversations.
We will consider whether any changes are needed to the criteria and the length of the classes offered as part of the Living Well service.
This forms part of our ongoing work looking at how we communicate about our services and what we can offer.
The Head of Service is developing a process for the team, including responsiveness criteria.
Patient experience of care survey 2025-26
The first round of the patient experience of care survey was sent in December 2025 in both physical and electronic formats. It is due to close at the end of December 2026. So far, we have sent out 451 surveys, with the next round planned for June 2026.
Carers survey
The content of this survey was reviewed and updated. This survey is sent to bereaved family members who are listed as key contacts for patients who have used any of our clinical services.
This survey opened in May 2025 and ended in May 2026. We have sent out 1,141 surveys over the last year and received 156 responses so far. An in-depth analysis of the results will take place once the survey has closed. The responses are checked monthly, which means respondents are contacted at the time if they raised any concerns to see if the issue could be resolved.
What we did in 2025-26:
Shared the patient experience of care survey 2024-25 results and actions with Heads of service.
Reviewed the content and process for the 2025-26 survey to encourage a higher response rate.
Added questions relating to meeting communication and information needs into both patient and carer surveys.
Our plans for 2026-27:
Review the results from the 2025-26 carers survey and share them with clinical teams.
Identify and implement actions from the 2025-26 carers survey.
Review the carers survey ready to send later in the year. Focus on the process to encourage a higher response rate.
Complaints and concerns
Complaints and concerns may be raised by patients, their family and friends, and other service users throughout the year. These can be submitted via our website, by post, email or in-person. In 2025-26 we have ensured that all published materials for patients and carers, including in-room signage in the inpatient unit, clearly signposts how to feed back compliments, complaints and concerns.
This year, we received and investigated eleven complaints relating to clinical services, compared to three the previous year. The key trends identified were:
Staff attitudes and behaviours
Communication - both between staff and between staff and the complainant
Responsiveness of the service
For each of these complaints, a series of recommendations were agreed. We have made the following changes in response to these recommendations:
The introduction of bedside and patient safety handovers on the inpatient unit
Delivery of tailored communication training to the community and inpatient Nursing teams
The development of a task and finish communication group to help enhance and develop different processes of how we communicate with patients and families.
A review of key operational processes in the Community team to support a more responsive service.
A review of how the hospice provides information about their services to patients, families, and other service users.
Fifty-three concerns were raised between 2025-2026, which was an increase from thirty-one the previous year. Twenty-four of these were raised through the carers survey. We contacted the person who raised each concern to offer them the opportunity for a more in-depth look into the issues they raised.
The key trends for the concerns were:
Staff behaviours
Discharge conversations
Responsiveness of services - both internal and external
Delays in referring to the hospice. This is something that we have limited amount of control over due to it being an external issue.
We have implemented the following changes in response to those concerns:
Changing how discharge conversations are held on the inpatient unit, ensuring that staff have ascertained whether the patients would like a family member present when those conversations take place.
A review of the leaflet that is given to patients and carers in the community
Complaints and concerns
What we did in 2025-26:
Established a clear process of sharing recommendations and learning with the staff directly involved in a complaint investigation.
Set up monthly recommendation reviews with the relevant Head of Service and the Associate Director of Quality.
Set up a rolling programme of complaint investigation training for all clinical managers.
Our plans for 2026-27:
Review and expand the current team of investigators
Review the training and support that is given to an investigator
Continue in the review of our process of managing complaints, focusing on further involvement of the complainant. This includes a full review of our complaints policy to ensure that we are compliant with the Accessible Information Standard and that people can both make and receive responses to complaints and concerns in their preferred format.
Compliments
We frequently receive compliments from patients, visitors, and families. These can be made verbally, via our website or in writing, which includes thank you cards, emails, and interactions through our website and social media.
When we receive compliments from patients, visitors, and families, we share them with the individual staff and teams that are mentioned. Recorded compliments are anonymised and discussed at the Clinical Risk Committee. During 2025-26 we recorded 349 written and or/ verbal compliments (compared with 209 to 2024/25).
Family, carer, relative and stakeholder comments received:
I have received outstanding bereavement support - I cannot imagine how I would have managed without it.
Thank you for taking such care of our precious mother, for supporting her during those early days when all looked so bleak. For giving her the encouragement to get up and walk again. For making her laugh. For cooking her delicious mashed potato and gravy to tempt her appetite back. For regaling her with Scottish songs, offering to do an eightsome reel and sharing memories of Edinburgh. For listening to her and allowing her time to think about the next chapter. Thank you most of all for your professionalism, advice and encouragement.
When she walked into our house that day, we were scared. When she walked out, we were reassured. It’s a core set of values that every single person at Trinity has. You realise that behind the nurses there is a core set of people with the consistent values of empathy, care, and support for the whole family. The level of reassurance is unbelievable, we really feel like every step of the way, Trinity will be there for us.
It was so reassuring to know the phone would be answered by a human, even in the early hours of a morning & what they said they would do, would be done.
As his husband I was treated exceptionally well. He needed and loved to see that. He lived as an adult through the 50s and 60s when his friends were imprisoned and persecuted for being gay, and even in the past few years he saw how some organisations dismissed our marriage as something less - his concern was often focused on that, despite his own health, and your attitudes were a constant reassurance to him on that front.
You did so much for him and were always so kind and strong for all of us. We hugely appreciated your visits and lovely way of doing your job.
Section 3: Progress against our strategic objectives
We successfully delivered the fourth year of activity against our five-year strategy with the goal “to expand our reach to all of the people in our community who would benefit from our services, through an inclusive and collaborative approach to delivery while maintaining outstanding quality and financial balance.”
In January 2026 we began the process of developing our new multi-year strategy, which will begin in April 2027. This includes in-depth consultation with the Board, Trinity staff, patients, carers, supporters and colleagues throughout the healthcare system and hospice movement. We will also complete an in-depth analysis of the data we hold of reach, responsiveness and trends in demand and delivery of care.
Objective 1
To invest in expanding our services, workforce, and facilities
What we did in 2025-26
We allocated the second year of one-off capital funding provided by HM Government to projects that have strengthened our long-term sustainability, enhanced our facilities, and improved patients’ experience of care.
As part of our environmental sustainability strategy, sustainability consultancy Neutral Home produced an action plan to support the reduction of long-term costs and environmental impact of the hospice site in Clapham.
We developed a new FREDIE (fairness, respect, engagement, diversity, inclusion, and engagement) strategy, which will guide the experience received by our patients, visitors, customers, staff, and volunteers, in keeping with our commitment to these values.
Our plans for 2026-27
We will purchase and roll out a fleet of electric vehicles for staff to use to support their community visits
We will recruit two new roles within the hospice - a Digital Educator and a Clinical Educator role.
We will continue to introduce new ways of working to support patients in the community virtually and improve efficiency and responsiveness through technology.
Objective 2:
To strengthen our collaboration with partners, utilising innovative pathways
What we did in 2025-26
We embedded the Urgent Care Record within our electronic patient record system which allow us to share key clinical information with our external stakeholders to support appropriate care and support in line with patients’ expressed wishes and preferences.
We collaborated with other hospices across London and nationally through peer networks, knowledge sharing, joint quality improvement projects, research, and clinical education. We have amplified our voices through joint projects which have resulted in successful ICB negotiations and increased awareness.
We proactively engaged with other healthcare professionals to raise awareness of our services and care by attending engagement events across our community, joining and hosting webinars, and running our regular Talk & Tour open house events.
Our plans for 2026-27
We will strengthen our relationships with local emergency departments and explore a direct pathway for patients to the hospice.
We will look to embed the London Care Records within our electronic patient record system.
We will continue to strengthen our relationships with other hospices, particularly those across London via a formalised network to share and collaborate at both a strategic and operational level and will look to formalise partnerships where there is mutual benefit in doing so.
Objective 3:
To extend our reach across all of our diverse communities-particularly those who traditionally do not access palliative and end of life services
What we did in 2025-26
We received a Hospice UK Inclusion Award for our project to improve the experience of patients, carers, staff, and volunteers who are deaf or hard of hearing. We built on this work by hosting two British Sign Language interpreted Talk & Tour open houses, delivering general awareness sessions and specific training for clinical staff and making improvements to the environment at Trinity.
We delivered and hosted over 40 workshops, events and stands throughout our community and at the hospice focusing on general awareness of Trinity and hospice care, advance care planning, and support for carers.
We trained 47 new Compassionate Neighbour volunteers and matched 44 lonely and socially isolated people approaching the end of life due to age or illness in befriending partnerships.
Our plans for 2026-27
Our Community Inclusion Group will deliver a new central knowledge intranet hub for staff to capture and access learning that informs care for our community with a focus on underserved populations and groups.
We will deliver a comprehensive project to ensure compliance with the Accessible Information Standard including updates to patient and carer information formats and education and training for staff.
Objective 4:
To make the best use of our existing workforce model and facilities, utilising digital and virtual working
What we did in 2025-26
We completed two pilot schemes with North West London ICB and South West London ICB, which made some of our inpatient beds available for fast-track Continuing Healthcare patients to access.
We began the rollout of iPLATO in the Community team to help improve efficiency with more virtual working. iPLATO integrates NHS electronic patient records systems to manage remote video/telephone consultation. Using iPLATO allows a flexible approach to patient reviews and support and improves efficiency by cutting down “lost” clinical time travelling to patients. We introduced a digital consultation process for people accessing Patient and Family Support in the community and will continue to embed these functions and roll out training to ensure usage across teams.
We have completed a range of quality improvement projects and embedded the learning from them across the organisation (see page 26).
Our plans for 2026-27
We will continue to embed iPLATO and other virtual working processes across the teams to improve responsiveness and efficiency and will recruit a Digital Educator to ensure that our workforce are confident in using all digital tools.
We will recruit a Business Analyst to review processes and identify opportunities to improve productivity and make the best use of emerging technologies.
We will roll out the use of AI tool Yarooms to promote ease of booking rooms, pool cars, and other facilities within the hospice.
Objective 5:
To ensure fundraising, retail operations and NHS income match growth in activity and associated cost
What we did in 2025-26
We secured a transformational new fairer funding deal with NHS North West London, ensuring the sustainability of care for people living in the northern part of our catchment area.
As part of our work in identifying new opportunities to generate income, we relaunched the hospice cafe to the public. Common Cause has already increased the income generated by the Cafe as well as bringing many new people into the hospice.
The Fundraising team surpassed their non-legacy fundraising target, and they achieved the highest non-legacy fundraising total in Trinity’s 135-year history with the exception of the first year of the pandemic which saw unprecedented generosity. This represents 20% growth.
Our plans for 2026-27
We will continue to lobby our NHS commissioners in South West London and South East London to ensure a fairer funding model for the care we provide to the people they serve.
We will expand Royal Trinity Hospice Retail Consultancy Services by delivering new projects for charity clients and adding to our offer.
We will continue to focus on legacy fundraising to generate a pipeline of income for the future.
Section 4: Trinity’s governance and compliance
4.1 Board of Trustees
Trinity’s Board of Trustees has ultimate responsibility for the governance and leadership of the organisation.
The Board makes strategic decisions, monitors the organisation’s performance, and ensures that it complies with its Articles of Association and applicable laws and regulations.
The Board works closely with the Chief Executive Officer and the Executive team to set our strategy and monitor performance and risk management. The Board meets quarterly and works through four board committees (People and Culture Committee, Finance and Resources Committee, Fundraising Development Committee and Patient Services Committee) and closely with the board of Trinity’s retail subsidiary.
Trustees receive no remuneration for their services, nor do they have any business or personal interest in the charity’s contracts. Trustees normally serve for a maximum of six years and are subject to re-election after three years.
(as of Jan 2026)
Board of Trustees
4.2 Care Quality Commission (CQC)
Royal Trinity Hospice is regulated by the CQC. The registered manager is the Isatta Sisay, Director of Patient Services and Chief Nurse
The named nominated individual is Mel Johnston, Associate Director of Quality The hospice was last inspected by the CQC in August 2019, where the service’s overall rating was outstanding.
4.3 Data management
Trinity has used EMIS Web as our clinical record management system since October 2022. We continue to encourage GPs within our catchment to sign our data-sharing agreement which enables patient records sharing within EMIS. NHS Smartcards allow Trinity staff access to the patient’s demographic service, thereby ensuring the use of NHS numbers for unique identifiers. We are now working with local ICBs to secure access to the London Care Record, which would further enhance interoperability.
We continue to develop a comprehensive reporting system to maintain effective clinical practices and procedures.
We are obliged to meet the standards set out in the NHS Data Security and Protection Toolkit, an online self-assessment tool that allows organisations to measure their performance against the National Data Guardian’s 10 data security standards. We completed and returned this year’s toolkit outlining our compliance before the June 2025 deadline.
Our Information Governance Committee ensures we consistently meet national requirements, reviews and oversees the implementation of information governance practices, new policies, and training. In 2025 we carried out an external audit of our Data Security and Protection Toolkit and data protection practice to ensure we meet the highest standards. The actions from this audit are being reviewed and monitored by the Information Governance Committee.
Annexe 1: The Board of Trustees and
Lead Commissioner’s Statements
Board of Trustees statement
The Board of Trustees is fully committed to the provision of a high-quality service at Royal Trinity Hospice. The hospice has a robust clinical and corporate governance structure, with members of the Board playing an active part in ensuring that Royal Trinity Hospice fulfils its mission, according to its charitable intentions and in ensuring that the organisation remains responsible and compliant in all areas of CQC registration, health and safety, employment law and other relevant legislation..
Signed Karen Proctor
Chair of the Patient Services Committee, Royal Trinity Hospice
Date: June 2026
Lead Commissioner Statement
The Commissioners have reviewed Royal Trinity Hospice’s Quality Account for 2025/6 and acknowledge the high standard of care provided. They welcome the specific priorities for 2026-7 as appropriate areas for continued improvement that link with clinical commissioning priorities.
Royal Trinity Hospice 30 Clapham Common North Side
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