QualityAccount2024-2025
StatementfromtheChiefExecutiveOfficer
KarenNutt ChiefExecutiveOfficer
WelcometotheStLuke’s(Cheshire)HospiceQualityAccountfortheyear2024/2025.Iam delightedtopresenttheseaccountsonbehalfoftheBoardofTrusteesandtheSenior ManagementTeam.Theseaccountsareanimportantpartofouraccountabilitytothe manyindividualsandgroupswhohaveaninterestinStLuke’s
OurQualityAccountprovidesyouwithasummaryofthequalityinitiativeswehave undertakenthroughoutthefinancialyear,andgivesyouahigh-leveloverviewofsomeof ourplansfor2025/2026
AsthenewChiefExecutive,IknewthatStLuke’swasaveryspecialplaceandthroughmeetingourstaffduringmyfirstfew weeksIhaveseenhowdedicatedeveryoneistoprovidingtheverybestcaretoourpatients
StLuke’shasanestablishedgovernancesystemcomprisingofanumberofsubcommitteeswhichareattendedby Trustees Thepurposeofthesecommitteesistoreviewtheperformanceandqualityofourservicesthroughadetailed monthlydatapackandreportsfromstaff
Thisyear,ourHospicehascontinuedtoprovidecompassionatecaretomorepatients,theirfamiliesandtheircarers,which takesplacethroughanumberofourservices.Oneofourprioritiesfor2024/25wastocareforandsupportmorepeople. Duringthisperiod,wehaveseenanincreaseinreferralstoourInpatientUnit,whilstalsoseeinganincreaseinthenumber ofpatientswhoaredischargedfromthehospiceprovidingthemtheopportunitytochoosetheirpreferredplaceofcare and,whereeverpossible,weaimtosupportthis.
WehavecontinuedtoseeanincreaseinreferralsintoourDayHospicewhichisavailabletopatientsandtheircarers offeringawiderangeofserviceswhichincludesWellbeingDays,Acupuncture,ComplementaryTherapy,Carers’ WorkshopsandMusicWorkshops OurDementiaserviceispartofourDayHospiceofferwhichhasseenanincreasein servicedemand;wearekeentocontinuetoexpandthisserviceasitprovidesmuchneededsupporttopatientsandtheir carers
Overthepast12monthstherehasbeenthesuccessfulimplementationofthePatientSafetyIncidentResponseFramework (PSIRF)whichourteamnowfollowwhentherehasbeenapatientsafetyincident.TheinvestmentinaQualityand Innovationleadhasenabledthistohappen,inadditiontobuildingasoundauditcycleforclinicianswhichagain contributestothequalityofcareourpatientsreceive.
Therehasbeeninvestmentinourbuildingsensuringtheyarefitforpurposetoenableustodelivercaretopatients.The diningroomrenovationwascompletedinFebruary2024andprovidesawelcomingspaceforpatients,familiesandvisitors toeat,drinkandrelaxin.Wealsorenovatedthecounsellingroomusedbythefamilysupportteam,specificallywith childrenandfamiliesuseinmind.Ithasbeenfurnishedanddecoratedtopromoteahomelyenvironmentwherechildren andyoungpeoplefeelwelcomeandrelaxedfortheircounsellingandtherapysessions Therewasalsotheinstallationof solarpanelsattheHospicewhichwillreduceenergycostswhilstproducinggreenerenergy Ourretailshopsremain importanttousandduringthepastyearwehavealsocompletedtherenovationofourStLuke’satSeventyTwoshopin Winsford
OverthenexttwelvemonthswecommittoworkinginpartnershipwithotherhealthorganisationsensuringStLuke’sis embeddedacrosstheendoflifesystemsaswebelievethiswillbenefitourpatients.
Iwouldliketothankallstaff,volunteers,ourthirdpartypartners,supportersandstakeholdersfortheircontinuedsupport onthedeliveryofthecareweprovidetoourpatientsandtheirlovedones.Ifeelinaveryprivilegedpositiontobethenew ChiefExecutiveofStLuke’sHospiceandlookforwardtoworkingwithallofourstaff,supportersandstakeholders.
Tothebestofmyknowledge,theinformationintheQualityAccountisaccurateandafairrepresentationofthequalityof healthcareservicesprovidedbyStLuke’sCheshireHospice
WhatisaQualityAccount?
ProducingaQualityAccountisarequirementoftheHealthCareAct(2009)andaccordingtothe DepartmentofHealth,QualityAccountsaimto'enhanceaccountabilitytothepublicandengagethe leadersofanorganisationintheirqualityimprovementagenda’.
ThemainpurposeoftheQualityAccountistoencourageproviderstotakearobustapproachto qualityandprovideinformationaboutthequalityoftheservicesthattheorganisationdelivers
AllprovidersofNHShealthcareservices,includingindependentorganisationssuchasStLuke’s (Cheshire)Hospice,shouldproduceaQualityAccount.Indoingsoeachprovider,ledbytheirboard,is committingtoimprovethequalityofcareitdeliverslocallyandinvitesthepublictoholdthemto account
TheQualityAccountcoverstwomainareas:
Areviewofhowweperformedlastyear,coveringthreemainareasofquality-reachouttomore people,makeourbuildingsbetterandcareforandsupportmorepeople
Asetofkeyprioritiesforimprovementnextyear.
Thepublic,patientsandotherinterestedpartiescanusetheQualityAccounttounderstand:
Whattheorganisationisdoingwell. Whereimprovementsinservicequalityarerequired.
Whattheorganisation’sprioritiesareforimprovement.
Howtheorganisationhasinvolvedpeoplewhousetheirservices,staffandotherswithaninterest intheirorganisationindeterminingtheseprioritiesforimprovement
ThevaluesofStLuke’sareattheheartofeverythingwedoandunderpinourstrategies,policiesand waysofworking.Embeddingourvaluesthroughourrecruitment,induction,trainingand communicationsalsohelpstocreatetheappropriateenvironmenttoworkinpartnershipwithothers.
AboutStLuke's(Cheshire)Hospice
InpatientUnit(IPU):TheIPUhasprovisionfor10palliativecarebeds.Theunithasadiningareacalled ‘TheFountain’whererelativescanenjoycomplimentarywater,tea,coffee,biscuitsandfruitanda conservatoryareaforpatientsandfamiliestouseforrestanddining.Theconservatoryleadsdirectlyout ontoapatioareawithcomfortableseatingwithwellstockedflowerbordersandashelteredsmoking areaforpatientstouse.Therearetablesandchairsnearthefountainatthefrontofthehospice.All outsideareasareaccessibletopatientsandtheirfamiliesduringtheirstay.Wehave4,individualuse, sideroomswhicheitheroverlookthebackpatioareaorthefrontaspectofthehospice Eachsideroom hasasink,remotecontrolledTV,radio,airconunitandriserreclinerchair.Thereare2bayswhich accommodate3bedseachwiththeirownprivacycurtains.Eachbedinthebayhasapersonaluse,over bedTVandariserreclinerchair.Thankstokinddonationsfromsupporters,wehavetwocuddlebeds whichallowfamiliestocuddletheirlovedonesandoffercomfortwhentheyneeditmost.Thebays overlookthefrontaspectofthehospice Allhospicepatientbedsareelectronicforcomfortandcanbe adjustedusingahandsetbyeitherthenurseorthepatient.Eachprofilingbedhasanairwavepressurerelievingmattress,anursecallbell,overbedtable,wardrobeanddrawerunitforpersonalbelongings. Thereare2comfortablechairsandcoffeetablesinbothbayswhichpatientsorvisitorscanuse.
Therearespecialisttoilet,bathingandshowerfacilitieswhichaccommodatephysicaldisabilitiesand promoteindependence.Thereare2comfortablevisitorroomseachwithbedsetteesforrelativestobe abletostayovernightonanindividualisedneedsbasis.Thereisasmallkitchenforaccesstoteaand coffeefacilities.Thehospicecateringteamwillalsoprovidemealsforrelativesatasmallcost.Mealsare variedandprovidedfreetoallpatients.Individualnutritionalrequirementsandpreferencesare accommodated Thereisadedicatedquietareaforreligiousrequirementsandnon-religiousspiritual careneeds,thisisavailable24hoursadayforquietreflection,prayerandreligiousservices.
AboutStLuke's(Cheshire)Hospice
Day Hospice also holds a Complementary Therapy Clinic every Tuesday at Winterley Grange, and since April2024offersComplementaryTherapysupporttopatientsintheirownhomeswhentoounwelltovisit the Day Hospice. We also operate a Befriending Service. Our unit includes a large lounge area, dining/multipurpose room, Complementary Therapy rooms and a well-established garden. Day Hospice facilitiesaresuitablefordisabledusewithaccesstoarangeofmovingandhandlingequipment.TheDay HospiceunitisalsoabaseforTheChristie'soutreachserviceonWednesdaysandFridays.
FamilySupportTeam:TheFamilySupportTeamcomprisesarangeofservicesincludingCounselling, BereavementSupport,SocialWorkSupport,SpiritualCareandChaplaincyandBenefitsAdvisorSupport. Byemployingateamthatisrichindiverseskillandknowledge,alongsideourotherkeyclinicalservices, patientsandfamiliesareabletobesupportedinanholisticmannerandinresponsivenesstotheir“total pain”experience.MuchofthesupportdeliveredbytheFamilySupportTeamistodirectusersofthe HospiceanditswiderMDTbutinsomeareassuchasBereavementSupport,thereachextendsfurtherinto ourlocalcommunity.Additionally,whilstweareanadulthospice,serviceswithintheFamilySupport Teamareequippedtoprovideemotionalandpsychologicalsupporttochildrenandyoungpeople, ensuringcompassionateandprofessionalcareisextendedtowiderfamilynetworkswhereneeded,and when.
SocialWorker:ThespecialistPalliativeCareSocialWorkercanprovidepracticalandemotionalsupport forpeoplewithlife-limitingillnessesandtheirfamilieswhoarealreadyinvolvedwithStLuke’sthrough ourDayHospiceservicesorInpatientUnit.Supportiswideranging,forexampleundertakingpersoncentredassessmentstoidentifyanycareandsupportneeds;informationandadviceaboutwaysinwhich thosecareandsupportneedscanbemet,includingreferralstohealthorsocialcareprofessionalswho cansourceappropriatecare;andprovidinginformationandadviceaboutanyconcernsyouoryourfamily mayhavewhichmayincludemakingsafeguardingreferrals.Referralstootherspecialistorganisationscan alsobemadesuchashousing,petrehomingandfinancialsupportservicesincludingCitizen’sAdviceand Macmillan.InternalreferralsforCounselling,BefriendingandComplementaryTherapyarealsoavailable. Forthosepeoplewhoarebeingdischargedfromhospiceservices,supportcanbeofferedwithsignposting toothercommunityresourcesifrequired.
AboutStLuke's(Cheshire)Hospice
OccupationalTherapy: TheOccupationalTherapyServiceprovidespalliativerehabilitationfor30hoursa week,acrosstheInpatientUnitandDayHospice,supportingpatientsandtheirfamily/carersaccessingthe hospiceforsymptommanagementandadmissionsforend-of-lifecare.TheOccupationalTherapistprovides adviceandinterventionstoenablepatientstoengageindailyandmeaningfulactivities,whichmayinvolve assessingforandprovidingequipmentandadaptations,adviceonmobilityandtransfers,managing symptoms,supporttoachievequalityoflifegoals,andpromotingindependencewhereappropriate.
TheOccupationalTherapistwillengagepatientsininterventionstobuildconfidenceandassesssafetyto returnhomeifthisisthepatient’swish.TheOccupationalTherapistwillalsosupportpatientstodevelop copingstrategiestomanagesymptomssuchasfatigue,anxiety,andbreathlessnesswhichmayimpacton theirabilitytoengageinactivities.TheOccupationalTherapistprovidesaprogrammeofeducationaltalks withintheDayHospiceWellbeingDays,includingfatiguemanagement,breathlessnessmanagement,falls prevention/management,anddevelopingemotionalresilience.Theyalsorunchair-basedexercisesto maintainfunctionalabilityandtoimprovebalanceandmobilityforpatients.Duringthisfinancialyearthe OccupationalTherapisthasundertakenaCognitiveBehavioralTherapy(CBT)inPalliativeCarecourse, facilitatedbyKathrynMannix(PalliativeCareConsultant&author),introducingCBT-basedfirstaid interventionsforpatientsaccessingthehospice.TheyhavealsobeenworkingcloselythisyearwiththeIT ManagerwithaVirtualRealityproject,tointroducetheuseofVRtothehospice Thishasinvolvedresearching thebenefitsofVRforhospicepatients,developingcriteria,apolicyandinstructionstointroduceVRsafely andeffectivelyintothehospice.
ThisyeartheoccupationaltherapisthasalsosuccessfullysetupoutpatientFatigueManagementWorkshops, whichhavebeenrunningsinceNovember2024,receivingpositivefeedbackfrompatientsonthevalueof attendingandlearninghowtomanagefatiguesymptoms.Theyarealsocurrentlyinvolvedindevelopingfalls preventionandmanagementinterventionsatthehospice,includingthedevelopmentofafallspolicyand pathway.
Befriending:TheBefriendingServiceofferscompanionshipandfriendshipfromvolunteerswhoeithervisit patientsintheirownhomesforacoupleofhourseachweek,takepatientsoutshoppingortoappointments, orkeepintouchwithpatientsonthephone,thusreducinglonelinessandisolationformanywithinthe community.Eachandeveryoneofthevolunteersmakeahugedifferencetopatients’livesandthevolunteers getasmuchoutofitasthepatientsdo.PatientsoftenrefertohavingaBefrienderas‘lettingtheoutside worldintheirhomes’andbuildagoodrelationshipwiththeirBefriender.
24-HourAdviceLine:The24hourAdviceLineprovides24hoursaday,7daysaweektelephonesupportfor patients,relatives/carersandhealthprofessionals.Thephonelineismannedbythemedicalteamand registerednurseswhowillprovideadviceandsupportand,insomecases,preventhospitaladmission.
WeekendHub:TheWeekendHubServiceofferssupportandadviceeverySaturdayandSundayfrom9am–5pmoverthetelephoneandifrequiredahomevisitcanbeprovidedforextrasupportortoprovidehandson care.Thisserviceistobridgethegapovertheweekendwhenotherservicesdonotoperate.Oftenitisto discusssymptoms,getadviceoncertainaspectofthepatient’scareorformedicationadvice.Thenurse providingtheWeekendHubServicealsohastheadviceandguidancefromtheHospice’soncallmedicalteam ifrequired.
AboutStLuke's(Cheshire)Hospice
StLuke’satHomeNightService:Wearecurrentlypausingthisserviceaswehavestruggledtorecruittoa temporaryfixedtermcontract.Thiswillallowustoengagewithstakeholdersandlookatsustainablewaysto staffthisserviceandreviewtheoutcomesofthisserviceprovision.
Benefits:TheBenefitsAdviceServiceisheretosupportpatientsknowntoStLuke’sandthewiderMDTwith welfarebenefitsadvice,andwithsourcingmeanstomaximisetheirincome.Theservicehasalsobenefitted fromcloseworkingrelationshipswithexternalservicestosupportpatientswithdebtadviceandreliefwhen needed.Beingsupportedbytheservicecansignificantlyreducefeelingsofstressandworryassociatedwith thefinancialimpactoflivingwithapalliativeillness,andqualityoflifecanbeenhancedasaresult.Supportis offeredinpersonandalsoremotely,andisresponsivetoaperson’sneeds Referralsareacceptedfrom healthcareprofessionalswithinthehospiceanditswiderMDT,andindividualsarewelcometoself-refer–if weareeverunabletoextendtheservicetoanindividual,signpostinginformationisalwaysprovidedto ensuretherighthelpandadvicecanbefound.
Lymphoedema:TheStLuke'sLymphoedemaServiceisheretotreatandsupportpatientsaged18yearsand overwithprimaryandsecondarylymphoedema.TheserviceisrunjointlybyStLuke'sHospice,Cheshire CommunityIntegratedCarePartnershipandMacmillanCancerCare.Lymphoedemaisaswellingofthe tissueswhichcanoccuranywherewithinthebody,causedbyafailureofthelymphaticsystem.Thiscanbe duetoaninheritedgeneticfault,treatmentforcancer,ortraumaasaresultofinjuryorinfection.TheSt Luke'sLymphoedemaTeamisbasedatStLuke'sHospice,butwealsohavesatelliteclinicsinAlsager,Crewe, NantwichandnewclinicsatWeaverhamandAshfieldsSurgery,coveringbothsouthCheshireandValeRoyal
Followingthefirstassessment,patientswillbeseenasclosetohomeaspossible.Whenareferralisreceived bytheteam,patientswillbeinvitedtothehospicefortheirfirstappointmenttohaveaninitialassessment,in whichadetailedhistorywillbetaken.Anindividualisedlymphoedemamanagementplanwillbedrawnup withthepatienttoincreasesupportedself-managementoftheirlymphoedema Initiallypatientsmaybeseen everyfewweeksuntiltheirlymphoedemaisstabilisedandtreatmentswillvaryfrompatienttopatient dependentontheirneeds.
Qualityandinnovation:Thepurposeofthisroleistolead,developanddriveclinicalpracticequalityacross allclinicalareasofStLuke’sHospice,whilstatalltimesworkingcollaborativelywithourhospicepartnersand ensuringthatthehospiceiscompliantwithCQCstandards
TheroleworkscloselywiththeClinicalDirectorandRegisteredManagertoensureanon-judgementaland inclusiveapproachtosupportingandenablingteamstopositivelyquestionandchallengepractice developmentopportunities,thatareofhighqualityforpatientsandcosteffective. WorkingalongsidetheDataManagerleadtoanalysequalitydataandthepatientexperience.Aswellas oversightofclinicalpoliciesandclinicalaudittomaintainandoverseequalitystandardsand recommendations,promotingasafeculturethatreflectsthehospicevaluesandbehaviours.
AsateamwecontinuetoembedthePatientSafetyIncidenceResponseFramework(PSIRF)withinthe hospice.Therehasbeenaverypositiveresponsefromallteamsmakingthisaverysuccessfulandengaging responsetoimprovingpatientsafety
Inordertosharelearningoutcomes,actionplansandhighlightwhatwearedoingwellonawiderscale,a quarterlyQualityBulletinhasbeenintroducedforstaff.
AboutStLuke's(Cheshire)Hospice
ThisyearaQualityVolunteerrolehasbeenintroduced,enablingustoengageface-to-facewithpatients andfamiliestocompletequarterlysatisfactionsurveysandpartakeintwiceyearlypatientandfamily focusgroups.Ourengagementwithserviceuserswillhelpustounderstandtheirexperiencesatthe hospiceandhowwecanimproveuponthisforpeopleinthefuture.Itwillprovidedetailedfeedbackon standardsofourservicesandcareinordertosetprioritiesfordeliveringabetterservice.
Wehavemadeimprovementstotheprocessandsystemofhowwemaintainandreviewalloftheclinical proceduraldocumentssuchaspolicies,standardoperationalproceduresandguidelines.Wehave developedaQualitymanualsystembasedonourHospiceEthos.Thisisasinglesourceofinformation whosepurposeistodescribetheframeworkapproachandprinciplesofourproceduraldocuments, ensuringcompliancewithallregulatoryrequirements
Homelessness:TheHomelessServiceworkswithindividualswhoareexperiencinghomelessnesswitha terminaldiagnosisand/orwhoareexpectedtobeintheirlastyearoflife.Homelessnessexistsin multipleforms.Terminaldiagnosiscanoftenplaceindividualsatriskofhomelessnessastheircurrent accommodationmaynolongersuittheirincreasingneeds Thoseexperiencingentrenchedhomelessness areknowntosufferdisproportionateillhealthanddifficultiesaccessingtheappropriatehealthcare services.Thiscanresultinlatediagnosisandlesstreatmentoptions.
Theageofdeathforthehomelesscommunityisoftenmuchyoungerthanthegeneralpopulationand theirdeathsareoftenunplannedwithaccesstopalliativecareuncommon ThehospiceHomeless Serviceaimstoreachouttothiscommunitywithaviewtoimproveaccommodationchoices,qualityof lifeandtosupportindividualstomakeinformedchoicesabouttheircare.Thisisensuredbyadvocacy, housingandsocialsupport,reconnectingwithlovedones,accesstohospicedayservicessuchas ComplementaryTherapiesandCounsellingServicesalongsidespecialistendoflifecare.Theseservices arealsoextendedtotheirfamilies
Additionally,supportandeducationisavailabletosupportservicesworkingwithpeopleexperiencing homelessnessandadvancedillhealth.Itsupportsthemtoidentifywhenaclient'shealthisdeteriorating ortheyareatriskofdyingandwheretogotogettheappropriatehelp.
StatementsofAssurancefromtheBoard
Thefollowingareformalstatements,undervariousheadings,thatallprovidersofNHShealthcareservices mustincludeintheirQualityAccountevenifthestatementisnotdirectlyapplicabletousasaSpecialist PalliativeCare.
OnbehalfofStLuke’sHospiceIamdelightedtoprovidethisBoardAssuranceStatementofouroversightof thequalityofourserviceprovisionasdetailedinourQualityAccount.Theongoingqualityofourclinical servicesismonitoredbi-monthlybyourPatientCareCommitteewhichinturnprovidesasummarytoeach Boardmeeting.Iamveryhappywiththelevelofdiscussion,andchallengefromboth“clinical”and“nonclinical”trusteesatbothmeetings Animportantsourceofinformationatthesemeetingsisthemonthly publicationofour“ManagementDataPack”.Overthirtypagesofmonthlyperformanceinformationis producedrangingfrombedoccupancystatisticsandDayHospiceactivitytosafeguardingincidentsand EPaCCSdataon“Preferredplaceofdeath”andotherimportantdata.Theyprovideavaluablebasisforboth informingourselvesandchallengingvariousaspectsoftheHospice’swork.
ThePatientCareCommittee,onbehalfoftheBoard,considersanddiscussesawholerangeofperformance issuesandprovidesamoredetailedopportunitytoquestionandchallengeinformationcontainedinthe ManagementData.Oneregularareaofdiscussionisthelevelofstaffingavailabletomeetourfullrangeof clinicalservices.Aprimeconcernofalltrusteesisnotonlythenumbersofstaffinposttoprovideour services,butalsotheavailabilityofanappropriaterangeofmedical,nursingandotherskills Wealso maintainacloseworkingrelationshipwithourlocalacutetrustatLeightonHospital.Discussionshavealso centredonourfutureclinicalstrategyaspartofourplanningforthefutureoftheHospiceitself Onekey discussionledtotheestablishmentofa“St.Luke’satHome”service,wherewecarriedourendoflifecare intomoreresidentialsettings.QualitygovernanceisalsoakeyconcernofallBoardmembers.
Allformalpolicieswithclinicalimplications,eitherneworforrenewal,areconsideredbythecommittee followedbyarecommendationtotheBoard Ourgovernanceisalsofulfilledbyourmonthlyreviewofall clinical“incidents”andtheiroutcomes.Wealsocloselyreviewthelevelofriskthatcouldbefacedwithin ourcareservices,makingrecommendationstominimiseallrisksasappropriate.
Oneparticularareawhichisreviewedonaregularbasisis“Medicines Management”.Inregularlyreviewingourserviceswealsotakecareful accountoftheexternalrequirementsoftheCareQualityCommissionand alsoourlocalIntegratedCareBoard.TheTrusteeBoardismadeawareof theirrequirementsandmonitorsanychangesorcorrectiveactionrequired bythestatutorybodiesandalsootherexternalorganisationssuchasthe FamcareAudits.FinallyImustrecognisetheenormousefforts,particularly ofour“frontline”staff;theyarearealcredittotheHospice
Wehavesupportedstaffinanumberofwaysandwecontinuetorecognise therealsacrificesmadebysomanyinorderthatweareabletocarefor thoseingreatestneed.Itismyprivilegetopresentthisreportonbehalfof theHospiceBoard
MikeRidley,Chairman
MikeRidley ChairmanoftheTrustees
Reviewsofourservicehelptoinformthedevelopmentandidentifytheprioritiesforfutureimprovementsat StLuke’sHospice ThehospicehasidentifiedthroughsuchreviewsthreeprioritiesforQualityImprovement for2024-2025asfollows:
PriorityONE-Reachout
During24/25
Wewillcontinuetodevelopourcommunityservicesasfollows:
Continuetoexpandthisservicetoincludeotherhospiceoutreachservicessuchascomplementary therapy
Continuewithourweekendworkingserviceanddevelopcloserlinkswithcommunityservicestoensurea seamlessandsustainableservicecanbedevelopedwithaccesstospecialistpalliativecare7daysaweek. Continuewithournightsittingserviceofferingovernightsupporttoanyonewithalifelimitingillnessand theirfamilyorcarers.
During24/25
AtStLuke’swewillcontinuethestandardsattheHospiceensuringthecareandcompassionforourpatients ismetinasuitable,safeandeffectiveenvironment.Thereareanumberofcompletedandongoingprojects fortheHospice:
WearedecoratingandrefurbishingtheNorthwichsuitecounsellingroomtomakeitmoreaccessiblefor childrenandyoungpeoplewhoattendforcounselling.
WeareredecoratinganumberofclinicalareasincludingtheLymphoedemaclinicrooms
Weplantorefurbish3ofourpatientbathrooms.
Wearecontinuingaprogrammeofredecorationandrefurbishmentofofficeandcommunalspacesto makethemamorepleasantandfriendlyenvironmentforbothstaffandfamilies
During2024/25
Wewillcontinuetoexpandandfurtherembedourexistingservicesforthosewhoarefacingbarriersto accessinghospicecareanddevelopnewservicestosupportthosewithinourcommunitywhoneedourcare: Wehavelaunchednewdrop-insessionsforcarersofpeoplelivingwithdementia.Theaimofthedropin sessionsistoofferadviceandsupportonarangeofissuesthatpeoplelivingwithdementiaandtheir familiesface
WehaveexpandedtheremitoftheLGBTQ+facilitatortonowleadonEquality,Diversion&Inclusion.They willcontinueworkingtowardstheobjectivesoutlinedwithintheNavajoCharterMarkAwardandthose outlinedwhenweretainedthechartermarkforafurther2yearsin2024.TheNavajoCharterMark recognisesthatanorganisationisworkingtoreduceinequalitiesandgivespracticaladvice,supportand assessmentofwheretheneedsoftheorganisationlie
PriorityImprovementsfor2025-26
Reviewsofourservicehelptoinformthedevelopmentandidentifytheprioritiesforfutureimprovementsat StLuke’sHospice.TheHospicehasidentifiedthroughsuchreviewsthreeprioritiesforQualityImprovement for2025-2026asfollows:
For2025/26
Wewillcontinuetodevelopourcommunityservicesasfollows:
Continuetoexpandthisservicetoincludeotherhospiceoutreachservicessuchascomplementary therapyworkinginpartnershipwithcommunityservices.
Continuewithourweekendworkingserviceanddevelopcloserlinkswithcommunityservicestoensure aseamlessandsustainableservicecanbedevelopedwithaccesstospecialistpalliativecare7daysa week.
For2025/26
AtStLuke’sweareimprovingthestandardsattheHospiceensuringthecareandcompassionforour patientsismetinasuitable,safeandeffectiveenvironment Thereareanumberofcompletedandongoing projectsfortheHospice.Thisincludes:
Weareworkingonanumberofproposalsforthehospice-anambulancestation,agardenroomlinking theIPUtoreceptionforpatientsandrelatives,refurbishmentofthecourtyardwherethefountainis,as wellaslookingatotherinternalIPUprojects,patientrooms,bathrooms,flooringanddecoration, officesandmeetingrooms
DecoratetheChapelandtheViewingRoom.
RefurbishtheoutsidesummerhouseforIPUpatientsaswellastheDayHospicesummerhouse. Replacefencingwhereneeded.
Workonoutsidefasciaandguttering.
Overallwearecontinuingaprogrammeofredecorationandrefurbishmentofofficeandcommunalspaces tomakethemamorepleasantandfriendlyenvironmentforbothstaff,volunteers,patientsandfamilies acrossthehospiceanditssites.
For2025/26
Wewillcontinuetoexpandandfurtherembedourexistingservicesforthosewhoarefacingbarriersto accessinghospicecareanddevelopnewservicestosupportthosewithinourcommunitywhoneedour care:
WewillcontinuetheworkofourDayHospiceserviceinsupportingpeoplelivingwithdementiaand theirlovedones WearehopingtoexpandtheseserviceswiththeadditionofaDementiaSpecialist Nursewhowillreachoutintothecommunitytosupportpeoplefollowingtheirdiagnosisofdementia.
WewillcontinuetheworkoutlinedinourNavajoCharterMarkinto2026workingtoimproveaccessto peoplewithpalliativecareneedsfromtheLGBTQIA+community.
ClinicalData
(Anymissingdataisduetosomeservicesonlystartingmorerecentlyandsomewherethedatareportinghas changedtobeabletoreportmoreaccurateclinicaldata.)
Allincidentsarereportedviaourelectronicincidentsystem(Vantage)bythestaffinvolvedintheincident Thereportwillthenbereviewedbyseniorstaffwheretheywillcreateanyfeedbackandactionplans. Procedures,trainingandguidanceisavailableforallstaff.Thereviewsareanon-judgementalwayto understandtheincidents,findsolutionstoimplementtoavoidanyfuturerepeatsandimprovethequalityof ourmanagement.Stepsaretakentolearnfromallincidentsandintroducemeasurestoreducefuture numbers Ifanyfurtheractionisneededstaffmembersandtheseniorleadswillactionthese
PressureUlcers:
Safeguarding:
ClinicalData
InpatientUnit:
ClinicalData
DayHospice:
ClinicalData
Befriending:
NumberofcontactsbetweenThe BefriendingCoordinator,Befriending volunteersandpatients.
Therewasagapin2024/25thatwedidn’thaveabefriendingcoordinator.
InfectionPreventionandControl
Staffandvolunteersareremainingvigilantwithgoodhygienepractices.Toreducetherisktoourpatients andtheirfamilies,staffareencouragedtowearfacemasksiftheyhavecoldsymptomsbutfeelwellenough tobeinwork.Staffarecontinuingtofollowtheguidelinesoninfectioncontroltoensureeveryoneisaware oftheexpectationsinrelationtogoodhygienepracticesandtheuseofPPE.Thehospiceseeksguidance fromthelocalinfectioncontrolteamatMCHFTwhennecessary.
EqualityandDiversity
StLuke’sHospicerecognisesandcomplieswiththeequalityrequirementsoftheEqualityAct2010. Therefore,StLuke’sHospiceisactiveinensuringfunctionsarecarriedoutwhileremainingconsciously awareoftheneedto:eliminateunlawfuldiscrimination,harassment,victimisationandanyotherconduct prohibitedbytheEqualityAct2010.
1.Advanceequalityofopportunitybetweenpeoplewhoshareaprotectedcharacteristicandpeople whodonotshareit.
2.Fostergoodrelationsbetweenpeoplewhoshareaprotectedcharacteristicandpeoplewhodonot shareit.
3.StLuke’sHospicecontinuestorecognisetheimportanceofconsistencyintheeliminationof discrimination,harassmentandvictimisation.
OurEqualityandDiversityPolicyevidencesthehospice’seffortstoensurethatno-onereceivesless favourabletreatmentonthegroundsofage,disability,gender,marriageandcivilpartnership,pregnancy ormaternity,race,religionorbelief,sexorsexualorientation Thiscommitmenttopromotingequalityand diversityisconsistentacrossorganisationalpolicy.Effortshavebeenmadetoensurethiscommitmentis explicitacrosspoliciesandisspecificallyreferencedinourDignity&RespectatWorkPolicy,AnnualLeave Policy,AppraisalPolicy,CapabilityPolicyandDisciplinaryPolicy&Procedure.Ensuringthisinclusionis consistentacrossorganisationalpolicyworkstoeliminateunlawfuldiscrimination,harassmentand victimisationwhilealsoadvancingequalityofopportunityforallthoseworkingin,visitingandusing hospiceservices.
In2022/2023StLuke’sHospicecontinuedinitsendeavourtoadvanceequalityofopportunity.Thisyear, ourhospicecontinuedtoworkcollaborativelywithfellowCheshirehospicestoextendtheimproving accesstoEndofLifeCareforLGBTQ+peopleinCheshire,aprojectoriginallyintroducedin2021 StLuke’s Hospice’scommitmenttofundingandsupportinganLGBTQ+DevelopmentFacilitatorroleallowsthe continuationinpositivechangestostaffawareness,policiesandHospicematerialsaswellasbuilding connectionswithLGBTQ+communitygroups.Forthesecondyear,ourhospicehasfocusedonproviding StLuke’sHospicestaffwithLGBTQ+awarenesstrainingandestablishingLGBTQ+Champions.Boththe trainingandChampionrolesinviteallstaff,regardlessofgenderandsexualorientation,toengagein importantconversationsaroundinclusivityandorganisationaldevelopment.Theseconversationshave alsopromptedthehospicetotakeacloserlookathowweconsiderintersectionalitywithindecision makingprocesses.Thisworkhascontinuedtobesuccessfulandhasencouragedstafftoworktogether andreviewhowinclusiveourhospicespacesandrecoursesare.
EqualityandDiversity
Toembedthis,StLuke’sHospicehasintroducedandutilisedanEqualityImpactAssessmentforallnewand reviewedpolicies.Thisworkstoensureourpolicies,practicesanddecisionsarefairandgenuinelymeetthe needsofourstaffandpatients Aswellasworkingtoensurewearenotinadvertentlydiscriminatingagainst anyprotectedgroup.Toextendthispositivework,StLuke’sHospiceintroducedacalendarofawareness campaignsforvarioustopics.Thisincludes,butisnotlimitedto,StressAwareness,Men’sHealthAwareness, DisabilityAwarenessandLGBTQ+Awarenessevents.
Thehospicehascontinuedinourcommitmenttosupportingpatientandstaffspiritualcare;withstaffbeing supportedtoutilisetheChapeltopromotetheirwellbeingwhethertheyhaveareligiousfaithornot.The promotionofhealthandwellbeinghascontinuedmorewidely,withstaffprovidedwitharangeofsupport materials/resources.Aswellasthis,wehaveMentalHealthFirstaiderstrainedandavailableasasupportive toolacrosstheorganisation.Allstaffhaveaccesstothesesupportoptions,regardlessofwhethertheydoor donotshareaprotectedcharacteristic
CareQualityCommissionReport
StLuke’sisregulatedbytheCareQualityCommission(CQC)whoseroleitistocheckthatthe servicesweprovidemeetfundamentalstandards.
StLuke’sHospicewaslastinspectedbyCQCon 21stMarch2016withtheirfullinspectionreport beingavailableat: CareQualityCommission|StLuke'sCheshireHospice|StLuke’sCheshireHospice (slhospice.co.uk)
OurlastinspectionbyCQCresultedinthefollowingratingofourservices:
InlinewithCQC'scurrentregulatoryregime,weholdregulartelephonereviewmeetingswith ourlocalinspectorwherewearealwayslookingforwaystoimprovethequalityofourcare.
StatementsonthisQualityAccount
NHSCheshireandMerseysideIntegratedCareBoard(ICB)have workedcloselywithStLuke’sHospicethroughout2024/25togain assurancethattheservicesyoudeliveraresafe,effective,and personalisedtopatients.
TheQualityAccountdemonstrateshowtheteamcontinuetodeliverexcellentserviceswhilstworking withthechallengeoffinancialstabilitywehaveseeninmuchofthehospicesectorandappreciatethe managementofthiswithanincreaseinhospiceactivityyearonyear.
Wewouldacknowledge,somedifficultdecisionsmadein2024/25andtheimpacttosomeofyourservice provision,notablyStLuke’sHomeNightServiceiscurrentlyonpauseduetoissuesinrecruitment,however wecommendyouforproactivelyusingthistimetoengagewithstakeholdersandtolookatsustainable waystostaffthisserviceandreviewtheoutcomesofthisserviceprovision.
TheprogressiveworkwithPSIRFhasbeendemonstratedinthedeliveryofthePolicyandPlanandwe appreciatethisisongoingwork.Itisidentifiedwithinthequalityaccountthatithasalreadyhada successfulimpactonhowthehospiceteamarebenefittingfromthenewapproachtoimprovingpatient safety.
Wenotethatthe2024/25prioritiesremainthesamefor2025/26.Theongoingworktoimprovethe standardsattheHospiceandensuringthecareandcompassionforpatientsismetinasuitable,safeand effectiveenvironment,wearesurethisoverallrefurbishmentworkwillgreatlyimpactthepatientsandwill enhancetheirvisitsinatimewheretheyneedtofeelmostcomfortableandsupported.
Alsocontinuingtoexpandonthecommunityserviceprovisions,theICBlookforwardtoseeingtheoutcome ofthehospicesworkandbyembeddingtheexistingservicesforthosewhoarefacingbarrierstoaccessing hospicecareanddevelopnewservicestosupportthosewithinthecommunity
Welookforwardtosupportingyouwiththeseprioritiesasyouaimtoidentifynewprioritiesfor2026/27.
StLuke’sHospicehavemadesuccessfulachievementsasanorganisation,whichwillnodoubtbenefit patients,familiesandthelocalpopulationincludingthequalityVolunteerrolethathasbeenintroduced, thisrolewillenableengagementwithpatientandfamily’susingfocusgroupstocapturefeedback.Thiswill helptounderstandpatientsandfamilies’experiencesatthehospiceandallowimprovementforthefuture.
ItiscleartoseethatStLuke’sHospiceunderstandtherichvalueofencouraginginclusivityandthisis identifiedintheopportunitytakentoworkcollaborativelywithfellowCheshirehospicestoextendthe improvingaccesstoEndofLifeCareforLGBTQ+peopleinCheshire.Thissupportingroleallowspositive changesamongststaffandbuildingconnectionswithLGBTQ+communitygroups.
StatementsonthisQualityAccount
TheHospice’sclinicalauditprogrammeshavenotbeendescribed withintheaccount,theseusuallyofferassurancesofoversightof clinicaleffectivenessandtheICBwouldliketoworkwiththe hospicethroughexistingqualitycontractmeetingtounderstand thecurrentprogrammeofwork.
Finally,theQualityAccountpatientfeedbackgivesastrongmessageofhowvaluabletheHospiceisto serviceuses,familyandfriends.Thefeedbackispositive,andtheTeamatStLuke’sHospiceshouldbe proudandcongratulatedonthesupporttheyprovidetotheircommunity.
WethankyoufortheopportunitytoreviewyourQualityAccount.Welookforwardtoworkingwithyouin 2025/26
ChrisDouglasMBE ExecutiveDirectorofNursing&Care
NHSCheshireandMerseysideICB
Throughout2023/24wehavesoughtfeedbackfrompatients,relativesandcarers WeareusingouriPadsto determinetheextenttowhichourserviceuserswouldrecommendStLuke’sHospice.
Asyoucanseeinthebelowgraph,thehospicehasachieved215completedfeedbackforms,where98%'Would Recommend’StLuke’sHospice.
HowlikelyareyoutorecommendStLuke'sservicestoyourfriendsandfamily,shouldthey needsimilarcare?
CommentsaboutStLuke’sHospiceMadebyPatientsandCarers
“Theservicehas beenoutstanding. Ilookforwardto myvisits.”
“Thestaffare wonderful.Ifeelit broughtaspark backtomyloved one.”
“Ilookforwardto comingeachweek tothetherapy.”
“Thestaffhavebeenhelpful andcaring.”
“Thankyouto everyoneforbeingso helpful,professional andsokind.”
“Staffarewonderful. Ihavereally benefittedand enjoyedcomingto StLuke’s.”
“Youdon’tfeellike you’reinahospice,it’s likeahotel.”
