St Luke's (Cheshire) Hospice

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

We looked for evidence that people received safe care and treatment. We checked patient records, the environment, equipment used, staff training and rotas to ensure people were kept safe.

Good: This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

QS Score: 3

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff we spoke with were confident about raising concerns and how to report incidents. The service had an electronic system for reporting incidents and had identified three main themes-pressure ulcers, falls and medicines. Actions had been identified to reduce these incidents, and these were monitored and reviewed by the leadership team.

We saw changes were made following incidents to improve the service. For example, staff skill mix was reviewed for each shift following a complaint which identified a shortfall on the night shift for senior support. The staffing structure was amended to ensure staff had senior support for all shifts.

Staff understood duty of candour. We saw an example where Duty of candour was applied and staff training was reviewed as policy was not followed. Duty of Candour is a legal and ethical requirement in healthcare to be open and transparent with people receiving care. It applies to every health and social care provider that CQC regulates.

The service had developed standardised templates for medical records and notes. The hospice was exploring an electronic medicine system to help strengthen accuracy and completeness of patient records.

The service used the NHS learn from patient safety events to record and analyse patient safety events. The service had completed one patient safety incident investigation at the time of our assessment. Staff were debriefed after the incident.

Quality Statement Score: 3

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and in the community.

The service worked with the local hospital and GPs to support the patients’ journey and transition between care services to enable the patients’ preferred place of death where possible.

We saw each patient had a performance score recorded for each shift to detect any deterioration.

The service provided support to people experiencing homelessness with a palliative diagnosis or deteriorating health condition. Close links with other partner agencies had been formed over many years such as social care, housing, health, drugs and alcohol teams and specialist nursing teams.

Quality Statement Score: 3

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding adults and children, knew how to make a safeguarding alert, and did this when appropriate.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff followed safe procedures for children visiting the service.

The service had support from a social worker four days a week. The safeguarding children and adults’ policy listed contact details outside of usual working hours.

We saw a deprivation of liberty safeguards (DOLs) had been applied for and implemented appropriately. Staff understood how to protect people’s human rights, including their rights under the Mental Capacity Act (MCA) and The Equality Act.

The evidence showed a good standard. The service worked with people to understand and manage risks by staff thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate.

The service completed risk assessments for patients where appropriate. These included falls, choking, venous thromboembolism (VTE) and, breathlessness, nausea and vomiting and bed rails. Staff were trained to identify people expressing discomfort or agitation and the deteriorating patient. Staff knew to escalate these to clinicians and senior staff for review. We saw examples of this during our assessment.

A falls risk assessment was completed but there was no moving and handling assessment template on the electronic system. Any moving and handling assessment completed was documented as comments. This was a shortfall in the templates available on the electronic record system and this under review for improvement.

Patients in the last few weeks or hours of life were identified using the deteriorating patient pathway. Families were supported with changes and advanced care planning conversations were followed.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The hospice premises was an old farmhouse that had had two extensions built on. There were 10 beds in total with 2 bays and 4 individual side rooms. The bathrooms were shared between patients and were across the corridor to the bays and side rooms.

We saw there was appropriate equipment which was clean and maintained. This included emergency equipment. Waste management systems and processes were in place. There was a clear and structured process for maintenance and safety checking of equipment and facilities. There were no reported delays.

Syringe drivers were maintained and used in accordance with professional recommendations. Staff had completed training and audits were completed to ensure standards were maintained.

There were arrangements for specialist equipment in the community for patient's post discharge. The service had equipment for bariatric patients.

Improvements to facilities included renovation of the pharmacy room, dining room, kitchens and bedrooms had been carried out since our last inspection. The service had a long term refurbishment plan up to 2029.

All bedrooms had been refurbished with new drawers, riser/recliner chairs, new sinks, bedding and soft furnishings.

A dedicated treatment room was available for patients and relatives to receive holistic sessions.

Fire exits and fire safety equipment was well-maintained. Fire exits were kept clear.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the time of our assessment the clinical lead had been appointed as clinical director but had not started in post. The team comprised of doctors, nurses, support workers, pharmacy staff, occupational therapy and social worker. There was no physiotherapist.

A review of staffing had been carried out following a complaint and senior nursing support was put in place for the night shift. There were processes in place to ensure there were sufficient nurses with the right skills mix based on patient acuity. Managers reviewed staffing each day and shortages were managed by using bank staff.

A monthly data report was completed for board which included staffing rates, sickness rates, staff turnover and training compliance. Staff turnover for the last 12 months was 16% as of August 2025. This was higher than planned but there had been a higher number of staff retiring.

There was adequate 24-hour medical cover 7 days a week. However, there was no second on call rota as per regional guidance. There was no Integrated Care Board funding for this service, and discussions were in progress between clinicians in Cheshire to jointly provide the second on call rota. The risk was recorded on the risk register and the service planned to have an agreement as soon as possible. There was a named consultant oversight for all patients. The medical structure was strengthened with the appointment of bank doctors to support the service.

Staff had received and were up to date with appropriate mandatory training. Basic life support training had been completed every two years, and this had been increased to every year. The service used a national recognised electronic training system, and training modules were set per staff group. Training compliance was overseen by managers and training figures were reported monthly to the board of trustees. At the time of the assessment training compliance was above 80%.

The service was supported by several volunteers. Many had volunteered at the service for many years and were knowledgeable about the service and their role.

We reviewed recruitment files and saw the required checks had been completed for staff, volunteers and trustees.

There was no physiotherapy support for the service at the time of the assessment. This was under review.

Managers provided new staff with appropriate induction.

Managers dealt with poor staff performance promptly and effectively.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. The service had infection prevention control polices and processes which were aligned to national guidance. These were audited for the day hospice and the inpatient unit using a standard template.

The service had an IPC lead and could seek microbiology advice from the local NHS Trust.

All areas were clean, had required furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that areas were cleaned regularly. We saw compliance with COSHH for hazardous substances.

Staff adhered to infection control principles, including handwashing. Hand hygiene, jewellery and uniform audits were completed with 100% compliance January 2025. Staff were trained in infection and prevention control measures.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording and disposal) and did it in line with national guidance.

Access to the pharmacy room was restricted via a swipe card system. Pharmacist support was in place with a local hospital service level agreement. The service had a service level agreement with the local hospital for stock supply and was delivered by a community pharmacy.

Allergies and weight were recorded on the patient record. People were given their medicines safely and in a timely manner.

Medicine audits were completed and improvements made to prescribing quality and standards of documentation for controlled drugs. We reviewed four medication records and found patients received pain management medicines in a timely manner. The service reviewed medicine management and made changes following updates. For example, changes were made to the starting dose of Levomepromazine (used to treat vomiting and nausea) following changes to regional and national guidance.

Patients were involved with their medicines and reviewed regularly. Anticipatory medication processes were in place.

We saw Oxygen cylinders were stored in the sluice room. This was raised with the hospice during our inspection for reconsideration. A risk assessment had been completed following a fire safety assessment.