St Luke's (Cheshire) 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

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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had a 2024-2029 strategy under pinned by the values of caring, collaboration, resourceful, excellence, respectful, honest, innovative and knowledgeable. The four strategic aims were to be employer of choice, reach out, care and support more people, be sustainable and making buildings even better.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. One of the options was to explore the possibility of a new hospice building as there was no more expansion capacity on the premises. Options were under review to assess the impact of services and finances required and available.

Leaders told us their key to success was working collaboratively with stakeholders, partners and volunteers.

The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

At the time of the assessment a new senior leadership team was in place. Staff told us they had seen improvement in leadership visibility since this had taken place.

Leaders had the skills, knowledge and experience to perform their roles.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leaders we spoke with demonstrated they understood the challenges to the service and were sensitive to the needs of the patients and loved ones whilst supporting staff to deliver a quality service.

The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

At the time of our assessment there had been no Freedom to speak up guardian for 5 months. This had been added to the hospice risk register and had action allocated to ensure the appointment progressed as quickly as possible. There was regular communication sent to staff during the gap in advising them who to contact if necessary. Following our assessment a new guardian had been appointed externally to ensure staff were able to raise concerns if they were not confident doing so internally.

We received mixed views from staff about speaking up and raising concerns. The hospice completed a speaking up survey May 2025 to gather feedback about the speaking up culture. The staff survey results showed a split response between clinical and non-clinical staff. The results showed staff were not well enough informed of where to go with issues. The hospice appointed a new freedom to speak up guardian and were addressing the structure of the freedom to speak up process.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff could work flexibly for example flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their role and responsibilities. Staff gave us examples of this during our assessment.

Staff we spoke with did not have any concerns about their own treatment or that of other staff. Staff understood their human rights and leaders understood their role under the Equality Act 2010.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had clear roles and responsibilities and systems of accountability.

The service managed risk and performance and monthly reports were sent to board for review. The service had plans for emergencies as part of their business continuity.

The hospice had systems and structures in place to ensure board oversight. These consisted of committees (estates, income generation, communications, finance and IT, human resources and patient care) that fed into the governance structure. Each committee approved and verified reports which went to board for review.

Staff undertook local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. There was a clear annual audit plan covering clinical practice of the service and evacuation procedures. Learning was identified and improvements were made. For example, the evacuation procedure audit identified staff lacked confidence with the fire panel and phone. This was added to the annual fire safety training.

The service had a risk register which was reviewed regularly. Risks were identified and recorded with a target risk score and current risk score. Risk was mitigated where possible and actions recorded.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Information governance systems included confidentiality of patient records.

Leaders we spoke with gave examples of how the governance and management systems operated. For example, meeting minutes fed into the patient care committee. If funding was required for new posts a business case was written by the management team which went to the finance committee for funding and was signed off by the full board as approved.

As a charity sustainability was considered in all aspects of the service. We were told there was financial accountability and decisions were made to ensure money was used responsibly to deliver an effective and efficient service.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service had established relationships with local services to support sharing information. A new prescribing system was in use for one partner, and the service was exploring read only access to support giving advice for patients.

The service took part in the “This is hospice care” campaign, a national initiative facilitated by Hospice UK. The campaign aimed to raise awareness of the vital role hospices play in communities and to shift the public perceptions of hospice care. The service had seen an increase in demand for hospice care and had plans to support this.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Innovations were taking place in the service. For example, workshops to support the needs of patients and carers. The service supported patients holistically with complementary therapies using them safely alongside conventional medical treatments to help patients to feel better physically, emotionally and psychologically. This included reflexology, adapted massage and Reiki.

Adapted massage techniques such as hand massage and HEARTS process (Hands-on contact, empathy, aroma, relaxation, texture and sound) were available to enhance wellbeing and utilise energies. The service planned to reach out to more people and had a vision that all people living with life limiting illness would have access to care.