Caring for People in Harrow & Brent

St Luke’s Hospice response to CQC inspection

On 6 October 2021, St Luke’s Hospice had an unannounced inspection by the Care Quality Commission (CQC). Their report commended the Hospice for many highly praised aspects of its provision, rating the two areas of ‘Caring’ and ‘Responsiveness to people’s needs’ as good and citing praise from the NHS, the London Ambulance Service, patients and their families.

However, some risks were identified around specific elements of safety and on our documentation of pain management. We state and emphasise that no patients have come to any harm because of the issues identified and that all areas of concern have already been rectified or addressed. The report, which covers the past twelve months, notes that there have been no serious incidents, that the Hospice received only one formal complaint which was fully investigated and resolved, and that patient feedback is ‘overwhelmingly positive’.

As a consequence of the report, two warning notices were issued by the CQC which has resulted in an automatic downgraded service rating of inadequate. We are sorry and deeply disappointed by the downgrade.

We have reviewed their findings and have immediately sent back evidence to address some of the concerns. We have also written to the CQC (please see our appendix). We expect another visit by the CQC within six months of this initial one, and aim to improve our rating to at least ‘good’ after this second visit. We have been addressing the issues raised and have put in place measures that go wider than the CQCs recommendations on them. These have been embedded into our daily practice. We are issuing this statement to reassure everyone that safety and excellent quality patient care are our top priorities. Our colleagues, patients and local community deserve nothing but the best, and we have tightened up our systems rapidly so that we can provide the highest level of care to the people that we serve.

Immediately following the inspection, Alpana Malde, Chief Executive of St Luke’s Hospice and Gillian Schiller, Chairman commented:
“We are pleased that the report recognises how valued we are by those who use our services but extremely disappointed with our overall downgrade. We take this very seriously and have already reviewed and improved working practises ahead of the CQC’s return visit.”

They added, “These have been exceptional times. Our staff have worked tirelessly over a prolonged period in some very difficult circumstances – even increasing our capacity by 9% last year to help relieve pressure on the NHS. We are immensely proud of everything our dedicated staff have achieved and are pleased that the inspectors have recognised our contribution to collaborative work in the community in addition to telling us that patients and families felt they received excellent care at St Luke’s.”

The Hospice maintained a tight control over Covid infections with no closures of beds as there were in many other care settings. This is testament to how seriously we take safety measures and it enabled loved ones to be with each other at the end of life throughout the pandemic. But we can do more and have made further improvements in this area.”

“In the meantime, we need our supportive community more than ever. Your encouragement is invaluable to us. What matters most to us is making every moment matter for you – and we are committed to providing the best possible service to you while we do so.”


We have written to the CQC about some contradictions between their report and their press release. Our key points are detailed below:

  1. CQC press release statement: “We found that leaders didn’t ensure staff kept up to date with all the necessary training to keep patients safe.”

Observation from the CQC report: On page 8 of the inspection report it notes that the reason staff were unable to keep up with training was “because staff were not able to attend face to face training during the COVID-19 pandemic. Staff completed electronic learning while waiting for face to face training and staff were booked for face to face training.”  We consider it is unfair to raise this as a criticism in the press release when the inspection report recognises that face to face training has not been possible due to the COVID-19 pandemic, but that e-learning has taken place instead. Whilst the inspection report refers to “Staff did not always receive and keep up-to-date with their mandatory training”, it goes on to recognise and qualify that this observation is in respect of face to face training. In doing so it acknowledges that electronic learning has been completed. Therefore the statement as currently drafted gives the misleading impression that staff were not up-to-date with all of the necessary training, which is not an accurate summary of the report’s observations and conclusions. 

  • Statement: “People’s medicines weren’t being managed properly which meant mistakes could easily be made…”

Observation: On page 11 of the inspection report it states that St Luke’s Hospice “used systems and processes to safely prescribe and record medications, but that they did not always safely  administer and store medications”. We consider the statement contradicts the inspection report and is not a fair summary of the report’s findings. The report does not refer to the risk of mistakes being easily made. The word “mistake” does not appear in the report at all. Instead, we understand the report’s findings is to focus on the storage of medicines, noting that some out of date medicines were kept in cupboards. We addressed this matter in the draft report’s findings through its fact accuracy check form submitted on 30 November 2021 which explained that staff are to follow a Medicines Management Policy which requires that all medicines are checked for expiry dates prior to administration.

In respect of the “Inspectors found” section, we make the following observations:

  • Statement: “Medicines weren’t managed safely, which may put people at risk of medication errors, which may in turn harm them.”

Observation: our comments on this statement mirror the comments in bullet point 2 above, as we consider this statement addresses the same issue raised in the inspector report.

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