St Luke's Hospice

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed one quality statement on leadership and governance. Leaders understood and embodied the culture and values of the workforce and the organisation. They had the skills and knowledge, experience and credibility to lead well. They demonstrated their integrity and honesty which was recognised by their staff. There was a clear system of governance and risk management based around delivering safe and good quality care and treatment.

This service scored 96 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff at all levels were clear about their roles and responsibilities. The hospice held monthly clinical committee meetings. . Topics of discussion included referrals, service and staffing update, clinical incidents, policies, and their risk register. The service had suitable arrangements for identifying, recording, and mitigating risks. All risks were reviewed regularly at various committee meetings and the senior management team had a thorough understanding of these risks.

The hospice had a clear governance structure with various committees. Subcommittee meetings fed into the clinical governance meetings to ensure information was shared across all services and that staff were fully informed of any risks and safety concerns. Risks were reviewed and escalated appropriately. The hospice collected, analysed, managed, and used information well to support all its activities, using secure electronic systems with security safeguards. There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. The hospice was committed to developing a plan to act on environmental sustainability, deliver progress on social issues and reinforce their commitment to strong governance. The hospice had a business continuity plan which served a purpose of providing both a first response and a framework under which the hospice may be managed and continue to operate under adverse circumstances.

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

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