Quality Account 2011 – 2012
Supporting patients and their families living with cancer
and other life-threatening diseases
2011/ 2012 Quality Account
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Statement from the Group Chief Executive
At St Giles Hospice we’re proud to consider ourselves a part of the community which we serve,
and one of our key roles as a registered charity is to make sure the community is kept informed
about everything we do.
The Board of Trustees, the Senior Management Team and all of the staff and volunteers at St Giles
are committed to providing the best possible experience for patients and their families. We aim to
achieve this by providing high quality, cost effective care underpinned by sound governance across
all aspects of the organisation.
As a result of unannounced visits undertaken during this year, no shortfalls in the service we
provide were identified by the Regulator. This reflects the commitment of all staff and volunteers
to the Hospice and the care we provide for those affected by cancer and other life threatening
illnesses.
The Hospice has worked hard to develop a culture of continuously monitoring the quality of our
services to ensure any shortfalls are identified and addressed as quickly as possible. This culture is
the responsibility of every employee and volunteer at the Hospice and their commitment to the
Hospice and the care of our service users is reflected in the assessment of the Care Quality
Commission and most importantly is evident in the responses we receive directly from our service
users.
I am responsible for the preparation and content of this report and, to the best of my knowledge,
it is an accurate and fair representation of the quality of our services.
This account considers 2011/12 and looks forward to some of our priorities in 2012/13 as we
continue to strive for improvements that benefit patients and carers and their experience of the
Hospice’s services.
Peter Holliday
Group Chief Executive
2011/ 2012 Quality Account
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Part 1
1.1 Priorities for improvement 2012/2013
St Giles Hospice remains compliant with the National Minimum Standards (2002) and has satisfied
the Care Quality Commission that criteria identified in ‘Essential standards of quality and safety’
are being met as evidenced through self assessment and via visits from CQC in July 2011 and
February 2012. As such, the Board did not have any areas of regulatory shortfall to include in the
priorities for improvement for 2012-2013 but expects and actively supports a culture of
continuous quality improvement.
The Care Quality Commission has categorised the hospice as a low risk organisation. To maintain
the Quality Risk Profile at this level, the hospice provides quarterly reports to the Care Quality
Commission. These reports are also provided to the commissioners of hospice services.
St Giles’ strategy identifies the Board’s key principles and strategic aims for the future. These aims
are dependent upon obtaining or securing the necessary funding. Three key developments to
support the strategy planned for 2012/13 are outlined below.
Implementation of a twilight Hospice at Home Service
The Hospice successfully bid for a grant of £39,000 from St James Place. This will fund, for one
year, an extension of the existing model of care for Hospice at Home (H@H) patients to
include a service providing Registered Nurse cover between the hours of 4pm - 11pm every
day. This service will greet and settle patients and families after discharge from Hospice or
hospital where their choice is to die at home. The role will provide support to district nursing
teams where they have difficulties in responding rapidly, will provide evening based care, and
mentor and support the existing night team of Healthcare Assistants (HCA) to ensure patients
remain at home should that be their wish
Integrated Hospice Community Services Model
The Hospice intends to move towards an integrated service delivery model for its community
services in 2012/13. This is to address the increasing demand for CNS and Hospice at Home
services without substantive increased investment being available, the desire to enhance
service availability 24 hours a day and further improve the co-ordination and responsiveness
of our community services. Through both service and role redesign we will be able to respond
to assessed patient and carer need in a timely way, deploying staff with the most appropriate
skill set. This will release capacity and ensure the best use of all available resources for the
benefit of patients and carers.
2011/ 2012 Quality Account
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Development of care co-ordination and advice for St Giles patients
We know that our patients turn to us, often as a first port of call, for advice and support with
any issues that they have concerning their end of life care. This is evidenced by the volume of
calls received by us each year, currently some 29,000. Some of these calls are from patients
and families not currently known to St Giles. These calls enter the organisation via a number of
routes and callers have an array of requirements ranging from simple signposting through to
advice on symptom management and psychological support. Many calls then require coordination with other services, both internal and external, in order to meet the needs of
patients and families. St Giles has the required technology to develop this service further and
create a single point of access for telephone advice, in effect a co-ordination centre for
patients and families. We are currently seeking investment to supplement service redesign to
enable us to offer an improved 7 day care co-ordination centre. This will substantially improve
efficiency of Hospice services and provide an improved response to patients and carers.
2011/ 2012 Quality Account
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1.2 Priorities for improvement 2011/2012
St Giles Hospice is fully compliant with the Care Quality Commission: Essential standards of quality
and safety. As such, the Board did not have any areas of shortfall to include in the priorities for
improvement for 2012/2013.
To meet the increasing demands of the local community, during 2011/12 St Giles identified areas
of improvement to improve care and support for patients and their families. Examples of
developments in 2011/12 are outlined below.
Widening access through Supportive Care in Day Therapies
The Family Support & Bereavement services and Complementary Therapies moved into the new
Day therapies Centre in May 2011. The refurbishment of this centre was funded by a Department
of Health grant and financial support secured from a variety of grant-making trusts. During
2011/12 a number of patient and carer programmes were piloted. In addition, the facilities have
been used by external groups for a variety of purposes. Through a restructure of the Supportive
Care Department in 2011/12 we have been able to recruit a Supportive Care Co-ordinator who
commences in July 2012. The post holder will further develop the use of volunteer and patient led
groups as well as activities for mutual education and peer support for patients and their families.
This will further increase our community engagement and break down barriers to accessing
Hospice care caused by fear and an assumption that Hospices are only for people dying of cancer.
Establishment and consolidation of St Giles Walsall inpatient service
The inpatient service commenced operation in April 2011 following a successful tender by the
Hospice. The inpatient team is now well established. Bed occupancy has increased and reflects
the expected bed occupancy according to the National Council for Palliative Care’s minimum data
set. The patient mix reflects a higher than expected percentage of non-cancer disease which we
are especially pleased about. The service is fully compliant with regulatory standards. Its quality
and audit programme demonstrates that it is providing a high standard of service and care
delivery and patient and carer feedback is excellent.
Review of inpatient respite care delivered by the Compassus Centre
A review of our inpatient respite provision was undertaken in 2011/12. We have now ensured
that we are able to meet urgent as well as planned respite needs in a more timely way. This has
meant we have been better able to respond to patient and carer need and avert potential care
crises. This ability to respond to urgent need for respite has been welcomed by patients, carers
and professionals.
2011/ 2012 Quality Account
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Implementation of the Bereavement Needs Assessment tool for inpatient services
Hospice staff had supported work at a national level to develop an evidenced based bereavement
needs assessment tool. This tool considers existing levels of resilience and support and builds on
these, as well as recognising when individuals need higher intervention levels. This was
successfully implemented in 2011/12.
2011/ 2012 Quality Account
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2
Statement of assurance from the Board
The following are a series of statements that all providers must include in their Quality Account.
Many of these statements are not directly applicable to specialist palliative care providers.
Review of services
During 2011/12 St Giles Hospice was contracted to provide six core services to the NHS:
The services were as follows:
 Clinical Nurse Specialist Community Team
 Hospice at Home services
 Day Hospice
 Outpatient care
 Lymphoedema Clinics
 In-patient care
St Giles Hospice has reviewed all the data available to them on the quality of care in all of these
services.
The income generated by various contracts for service provision to the NHS in 2011/12 represents
41.8% of the total income generated to enable the provision of these services by St Giles Hospice.
The remaining funds were generated through fundraising and the Hospice’s own subsidiary
companies working with the local community. The total value of services provided in 2011/12 was
£7,898,086.
Research
The Family Support and Bereavement Team has been involved in a research project with Keele
University to explore the different ways in which people react to bereavement and the things
which make it more or less possible to cope with the consequences of bereavement. 58 bereaved
clients have been enrolled onto the research. The data collection for the project will end in August.
Research undertaken by the Nurse Consultant in the Lymphoedema Clinic relating to application
frequency of a new lymphoedema bandaging system (Coban 2) has now been published in the
British Journal of Dermatology
The Lymphoedema Team are also involved in an ACE Study (At home Compression Evaluation) Comparison of 2 intermittent pneumatic compression pumps for home use in maintenance phase
of lymphoedema management. Interim findings will be published internationally to inform
evidence-based practice.
The Community and Hospice at Home teams and St Giles family carers have been involved in a
feasibility study to evaluate the impact of a Carer Support Needs Assessment Tool (CSNAT)
intervention in Hospice home care. The research study tests whether the CSNAT intervention
makes a difference to family carers and how. St Giles’ Hospice home care (HHC) service is one of
2011/ 2012 Quality Account
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six Hospice HHC services to use the CSNAT intervention with family carers at home. The research
team will compare carers who had usual care with those who had the CSNAT intervention by using
a postal survey of carers to find out if those who had the intervention had better health, well
being, levels of grief and feelings of being supported. The clinical teams have given feedback on
using CSNAT to the researchers with the researchers also considering if assessment frequency
made any difference. All of the learning from this study has been used to formulate a training
guide to enable services across the UK to use the CSNAT intervention in the future. The study
concluded in April 2012; however the teams continue to use CSNAT as a service improvement
initiative.
Participation in clinical audits
During 2011/12, there were no national clinical audits or national confidential enquiries covering
NHS services relate to palliative care. St Giles Hospice only provides palliative care services.
St Giles Hospice undertook a range of audits as evidence of compliance against stated standards
and criteria. Each report contained recommendations and an action plan and were reviewed by
the Clinical Governance Committee. Many of these audits used evidence based tools developed by
the National Audit Tools Group affiliated to our national body, Help the Hospices. St Giles
Hospice’s Quality & Audit Manager is a member of this national group.
The following actions have been undertaken to ensure St Giles Hospice continues to improve the
quality of healthcare provided.




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Participation in an international research study on the management of lymphoedema
Participating in a national study evaluating the use of a Carers’ Needs Assessment Tool.
Implementation of the Help the Hospices national audit tool to ensure full compliance for
the role of Accountable Officer.
The purchase of McKinley T34 syringe drivers to replace Graseby drivers in line with the
National Patient Safety Agency directive.
Investment and implementation of an e-learning suite
Development of a creative therapy area in the Compassus Centre
The Hospice implementation of version 12 of the Liverpool Care Pathway
Quality improvement and innovation goals agreed with our commissioners
St Giles Hospice’s income in 2011/12 was not conditional on achieving quality improvement and
innovation goals through the Commissioning for Quality and Innovation payment framework.
2011/ 2012 Quality Account
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What others say about us
St Giles Hospice is required to register with the Care Quality Commission and its current
registration status is unconditional and no enforcement action has been taken against St Giles
Hospice during 2011/12.
Two reviews of the Hospice were undertaken by the Care Quality Commission during 2011/12.
The first was a periodic visit within the routine schedule of planned reviews. The inspectors visited
during July and undertook a check of patients’ records, observed how people were being cared
for, talked to staff, reviewed information from stakeholders and talked to people who use
services.
The inspectors reviewed standards relating to appropriate care, protection from abuse, medicine
administration and quality monitoring. The final report was published in September 2011 and
stated that ‘St Giles Hospice - Whittington was meeting all the essential standards of quality and
safety’
The second visit was to review information held with regard to the Hospice premises at Lindridge
Road, Sutton Coldfield. The unannounced visit took place on 14 February and the inspectors
observed how people were being cared for, talked to staff and talked to people who use services.
The inspectors reviewed standards relating to appropriate care, medicine administration and
quality monitoring. The final report was published in March 2012 and stated that ‘St Giles Hospice
– Sutton Coldfield was meeting all the essential standards of quality and safety’
As a result of these visits St Giles Hospice has no corrective actions to take and is rated as low risk.
In January 2012 an announced visit was undertaken by the Assistant Director of Quality and the
Quality Manager from the Staffordshire Cluster of PCTs. The visit examined provision of services,
environment, staffing and care and treatment undertaken. The conclusion of the report was:
“Services are provided to a very high standard within the Hospice and via Hospice at
Home and the Community Specialist Team. The visit was very positive with the focus
very firmly on meeting the needs of patients and their families”
Data Quality
In accordance with agreement with the Department of Health, St Giles Hospice submits a National
Minimum Dataset (MDS) to the National Council for Palliative Care. St Giles Hospice provides the
MDS to the local PCTs.
St Giles Hospice score for 2011/12 for Information Quality and Records Management was not
assessed using the Information Governance Toolkit because this toolkit is not applicable to
palliative care.
2011/ 2012 Quality Account
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3
Quality overview
The National Council for Palliative Care: Minimum Data Sets for Palliative Care 2010/11
(This is the latest nationally available published data)
St Giles Hospice
National Median
In-Patient Unit
% New patients
89.2
89.3
% Occupancy
75.9
77.3
% Patients returning home
46.1
44.5
Average length of stay – cancer
14.8
14.4
11
St Giles Hospice
11.9
National Median
Day Hospice
% New patients – cancer
83.5
85.1
% New patients – non cancer
16.5
14.9
50.4
St Giles Hospice
59.6
National Median
Community : Clinical Nurse Specialist
% New patients
65.5
67.4
% New patients with a non-cancer diagnosis
5.5
11.4
Visits per completed series
4.7
4
Average length of stay – non cancer
% Places used
In addition to the limited number of suitable quality metrics in the national dataset for palliative
care, we have chosen to measure our performance against additional metrics identified below.
Indicator
2010/11
2009/10
2008/09
4,070
3,394
2,727
Total number of referrals not proceeding
633
653
582
Total number of patients admitted to the in-patient unit
334
307
280
% of patients who went home
46.1%
44.3%
46.2%
Number of available bed days
6,699
6,053
6,474
% Bed Occupancy
75.9%
74%
75.5%
Total number outpatient attendances
4,173
4,540
3,962
Total number of attendances by patients at the Day Hospice
1,854
2,342
2,240
Total number of new referrals to St Giles Hospice
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Indicator
2010/11
2009/10
2008/09
Total number of contacts with patients by the community service
40,840
46,198
31,553
Total number of Hospice at Home sessions provided
4,328
5,404
4,802
Total hours of Hospice at Home input
12,121
9,154
Not
collected
Total number of complaints
10
16
12
The number of complaints which were investigated and resolved in full
6
6
11
The number of complaints which were investigated, resolved but only
upheld in part
3
8
1
The number of incidents reported to RIDDOR involving patients
3
1
1
The number of incidents reported to RIDDOR involving staff
2
0
1
The number of patients known to be infected with MRSA on admission
to the in-patient unit
3
1
3
Patients infected with MRSA whilst on the in-patient unit
0
0
0
1
2
3
1
1
0
Number of patients admitted to the in-patient unit with pressure sores
67
78
57
Number of patients who developed pressure sores whilst on the
In-patient unit.
21
7
15
12.9
13.5
15.4
80
61
82
4.06
4.6
6
The number of patients known to be infected with Clostridium
difficile, Pseudomonas, Salmonella, ESBL or Klebsiella pneumonia on
admission
Patients who were diagnosed with these infections whilst on the inpatient unit.
Average length of stay on the in-patient unit (days)
Slips, trips and falls
Number of falls per occupied bed
(Number of beds multiplied by bed occupancy and divided by number of falls)
Our participation in clinical audits
Each department within St Giles Hospice is responsible for developing their forward audit
programme with the assistance and guidance of the Quality and Audit Manager. A proposed start
and finish date together with project lead is identified together with topics and standards.
The forward audit programme for each department together with Hospice wide audits – those
involving all departments and led by the Quality and Audit Manager – are then reported to the
Clinical Governance Committee.
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The Clinical Governance Committee meets quarterly and consists of four trustees – one of whom
chairs the meeting – together with the Chief Executive, Nursing Director, Business Support
Director, Medical Director (i.e. the Hospice’s Senior Management Team) and the Quality and Audit
Manager.
Clinical Audit is part of the standing agenda for each meeting. A report is tabled by the Quality
and Audit Manager identifying progress against the forward audit programme, outcome of
completed audits together with identified actions and recommendations.
Below is a selection of audits undertaken together with outcomes:
Infection Control


Re-audit of Prevention and Control of Healthcare Associated Infections (HCAI) undertaken
in June 2011. The audit reviewed the recommendations and action plan developed in June
2010 and re-audited against the Code of Practice – the outcome was 97% compliance.
To meet the rationale of effective infection control policies, process and structures to
reduce the risk of microbial contamination in everyday practice and ensure there is a
managed environment that minimises the risk of infection to patients, clients, staff and
visitors the clinical departments utilised the 12 modules developed by Help the Hospices’
National Audit Tools Group. Each department reviewed their content and suitability for
use within their clinical area. The overall average for Inpatient Unit, Day Hospice and
Lymphoedema Clinic was 87%. The findings were used to develop action plans which will
be implemented by Infection Control Champions within each area and re-audited as part of
the 2012/13 audit programme.
Medicines Management

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Self assessment audit undertaken by the Accountable Officer to evidence the discharge of
their responsibilities in the management of Controlled Drugs was undertaken in September
– the outcome evidenced 100% compliance against national regulations and legislation.
To support the Accountable Officer the following audits were undertaken by the Inpatient
Unit:
o Management of Controlled Drugs – overall compliance 93%
o Non-controlled general medicines - overall compliance 97%
o Safe and secure handling of medicines. Pharmacy led against national standards
comprising an annual audit which evidenced 100% compliance and quarterly
monitoring which averaged 80%
Documentation
The Hospice is required to keep accurate records in respect of each service user which shall
include appropriate information and documents in relation to their care and treatment. Each
clinical department is required to undertake annual audits of their documentation practice to
ensure compliance with standards. The average score across the Hospice was 87%
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What our patients say about the organisation
All departments are required to undertake an evaluation of their service which entails seeking the
views, comments and suggestions of patients and their families and carers who use the service.
The Community, Hospice at Home and Lymphoedema Teams undertake annual snapshot surveys;
Inpatient Services and Day Hospice use ‘real time’ monitoring and the Family Support and
Bereavement Team elicit views of all clients upon discharge from the service.
Community team
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Overall the feedback received was highly positive and grateful for service input by the nurse
specialist team.
Particularly gratifying was the response to the question ‘Was there anything we didn’t do that
you think we should have done for you’ – 98% of respondents indicated no.
These are just some of the comments received:
o
o
o
The support my family and I have received from the Hospice is exceptional. I have found it
very reassuring and feel very lucky to live in an area which has such a great support team.
Thank you all very, very much. We, the cancer sufferers, could not do without great people
like yourselves. God bless you all and thank you once again
Without the care and attention, kindness and understanding from all the nurses who have
seen or spoken to me I do not think I would be here today. I was in such a poor state of mind
and physical condition – they have been ‘stars’ in every way
Hospice at Home
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Overall feedback was extremely gratifying and there were no specific issues raised that require
action by the team.
100% of respondents answered ‘Yes’ to the question ‘During the time our staff are with you do
you feel they are immediately responsive to your needs?’
100% of respondents either strongly agreed (53%) or agreed (47%) with the statement ‘You
are receiving co-ordinated care from all the professionals supporting you’
These are just some of the comments received:
o
o
o
The care and support my husband (the patient) and I (his carer) have both received from our
CNS, the Hospice at Home team and the staff at St Giles Hospice has been amazing. To feel
that we have people who genuinely care about our well being at this difficult time is very
humbling and I cannot find words to express our gratitude – don’t change a thing!
St Giles Hospice at Home service has made such a difference to our lives and always such
lovely professional staff
The help and support we have received at this very difficult time has been invaluable and
most appreciated
Lymphoedema Clinic

Adult (annual survey)
 The feedback from patients was excellent – 100% of respondents indicated that they
always felt welcome when arriving at the Hospice
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94% of respondents indicated that they were very satisfied with their involvement in
planning their care
100% of respondents confirmed that they had received written information and
guidance about their swelling,
These are just some of the comments received:

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The Hospice is about as near perfect as I think it could be, you all do a wonderful job, I
would like to thank you all
All your staff are excellent
I found both clerical and clinical staff went out of their way to be helpful and arrange
as early an appointment as possible for both assessment and treatment
Children (annual survey)
 An excellent response received from the young people and their families
 100% of respondents indicated ‘always’ to the question ‘Overall, did you have
confidence in the staff who were caring for you / your child?’ and also to ‘Overall, did
you understand the explanations given to you about you / your child’s treatment and
care?’
 These are just some of the comments received:

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Always make me welcome. Always smiling and kind
You have always been very professional and caring i.e. reassuring to my child
St Giles convinced me to trust them with bandaging
A new Day Therapies Centre was opened in May 2011 – concerns were voiced regarding the
suitability of the therapy / counselling rooms in terms of dignity, respect and noise. An evaluation
was undertaken to elicit client experience when attending sessions:
Complementary Therapy

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100% of respondents strongly agreed that their privacy and dignity were always respected,
that their therapy room was clean and comfortable
Respondents were asked ‘how beneficial did you find the service overall?’ – 67% indicated
‘excellent’ with 33% indicating ‘very good’.
The final question asked if they would recommend the service to a friend – 100% of
respondents indicated yes.
Some of the comments received:
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The facilities were all modern and up to date and in a very relaxing atmosphere
From reception to therapist 100% - thank you
I have never had therapy before and I found it very relaxing and a comfort after the death of
my husband
Being introduced to St Giles has been invaluable with my mother suffering from cancer – the
relaxation has been great. I wasn’t sure if she would enjoy the sessions at the first point – it’s
not something she would normally do. However, she enjoyed it so much and looked forward
to each treatment. She doesn’t really go out very much so for her it was fantastic.
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Family Support and Bereavement

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100% of respondents indicated that their privacy and dignity were always respected and that
they were satisfied with the confidential nature of the service.
‘How beneficial did you find the service overall?’ 72% indicated excellent and 22% very good.
Some of the comments received:

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
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Had it not been for xxx I would not have been able to reach the place / be the person I am
today after the death of my husband. I have been equipped with ‘tools’ to help me find my
way in my ‘new‘ life
The service offered addresses all the issues for those of us, without a family or friends, who
may need help in the aftermath of a cruel death of a close relative or loved one
Since our introduction to St Giles my wife and I find that we are not alone with the fight
against my wife’s cancer. It is good to know that help is there when it is needed
Evaluation of support provided by specialist counsellors and dedicated support volunteers

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Were you satisfied with the confidential nature of the service?’ – 100% responded ‘Yes’
‘Were you treated in a respectful and sensitive manner’ – 100% responded ‘Yes’
‘Would you recommend this service to others?’ – 95% responded ‘Yes’
Some of the comments received:

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
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I should have requested earlier but I wanted my daughter to use the service first as I
felt her needs more important but actually we both needed help to help each other.
I can’t see you could make things any better or more comfortable. I was very
satisfied with the whole experience and I found Xx very caring. I think I would like to
meet up with him again in the future to let him see how I’m coping
I loved doing all the activities to help me remember the good things
Due to my personal situation – being able to talk things through instead of bottling
up. Our brick walls are not so supportive. My first experience of St Giles frightening.
Having visited new build, talked to people and visits I now see St Giles in a different
light. I would be content to spend my last days at St Giles or in their care at home.
Day Hospice
Bi monthly real time monitoring of patient satisfaction.
Patients were asked:

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
Have your recent visits been satisfactory?
- 95% responded ‘Always’
Do you understand the reasons for attending Day Hospice? - 76% responded ‘Always’
Do you understand what we are trying to achieve for you? - 76% responded ‘Always’
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Patients were asked to indicate their impressions of the service and its ability to meet their
on-going need.
The areas audited are:
 Environment
 Understanding how the 12 week programme works
 Confidence in staff
 Support to maintain independence
 Being involved in planning care
 Access to medical and nursing support
 Initial assessment with Doctor and Nurse
 Information received about Day Hospice and how to contact the team
 Catering and meeting dietary requirements
Overall 87% indicated ‘completely satisfied’
Following completion of their 12 week contract:

Patients were asked if they would recommend the Day Hospice to someone else 100% of
respondents indicated ‘Yes’

Patients were asked to rate the support they had received from Day Hospice: 57%
indicated that it had ‘Exceeded their expectations’ and 43% indicated that it has ‘Met
their expectations’
Inpatient Services
Real time monitoring through the use of 3 different questionnaires:
1. Patients or families / carers to complete 3 days post admission
2. Patients and families / carers to complete upon discharge
3. Families of bereaved patients
3 days post admission - questions asked
Have the first three days of your stay been
satisfactory?
Have you understood the reasons for your admission
and what we are trying to achieve for you?
Have you found the staff approachable?
Have you been given the opportunity to discuss
treatments?
Have you been able to express any concerns or
issues you may have?
Are we doing everything for you that you would wish
us to do?
If you had a complaint about the care you are
receiving, would you know what to do?
2011/ 2012 Quality Account
Compassus
Patients Families
(n = 61)
(n = 5)
Walsall
Patients Families
(n = 25)
(n = 3)
82% always
15% mostly
80% always
20% mostly
88% always
12% mostly
100%
always
76% always
24% mostly
93% always
7% mostly
84% always
16% mostly
100%
always
80% always
20% mostly
87% always
10% mostly
100%
always
88% always
12% mostly
100%
always
100%
always
85% always
13% mostly
100%
always
83% always
17% mostly
100%
always
87% always
11% mostly
100%
always
96% always
4% mostly
100%
always
58% always
25% mostly
40% always
20% mostly
70% always
13% mostly
100%
always
n/a
n/a
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What did we do

Each unit has a patient information leaflet which is given to patients and their families either
before or on admission. The leaflet contains information about the service, what will happen
during their stay, what they should bring and how to raise concerns or make suggestions. The
Compassus leaflet was updated and re-issued in December 2011.

An additional information booklet was also developed for each unit. This contains detailed
information including meal times, visiting, the environment, recreational activities and is
aimed at both the patient and their visitors.
Following discharge
Overall, did you have confidence in the staff who
were caring for you?
Overall, did you understand the explanations given to
you about your treatment and care?
Were you given the opportunity to talk to someone
about your fears and worries?
Was there anything we didn’t do that you think we
should have done for you?
Overall, how would you rate the quality of care /
treatment you received?
Compassus
(n = 12)
Walsall
(n = 16)
92% ‘Always’
8% ‘Most of the time’
83% ‘Always’
8% ‘Most of the time’
83% ‘Always’
8% ‘Most of the time’
81% ‘Always’
12% ‘Most of the time’
100% responded ‘No’
80% responded ‘No’
92% ‘Excellent’
8% ‘Fair’
94% ‘Excellent’
6% ‘Very good’
Compassus
(n = 17)
Walsall
(n = 22)
At that time, was everything done how you wanted it
done?
100% ‘Yes’
95% ‘Yes’
Was there something not done that you wanted?
100% ‘No’
95% ‘No’
Did you always feel that you knew what was going
on?
100% ‘Yes’
95% ‘Yes’
Families of bereaved patients
100% ‘Always’
100% ‘Always’
Outcome:
 All questionnaires are initially read by the Quality and Audit Manager – any immediate
concerns are fed back to either the Complaints Manager or relevant head of department for
urgent action

A quarterly report containing all responses is developed by the Quality and Audit Manager and
circulated to the Nurse Consultant, Senior Nursing Team and Nursing Director. The response
percentages can be used to benchmark the service to ensure we are maintaining high
standards or alternatively to look deeper into specific areas indicating poor performance. The
report including all the comments will then be shared with ward based staff and volunteers

The results of the real time monitoring will be reported to the Care Quality Commission and
NHS Commissioners as evidence of continual eliciting of patient and family experience.
2011/ 2012 Quality Account
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‘Thank you’ letters and cards are received by all departments across the Hospice. Below is a small
selection of those received during 2011/12:
Community:



“Just a note to say thank you for all the support and help that you gave not only to mom but to us during
her short illness. The work that you do is absolutely fantastic. We know that the support and help you gave
was very much appreciated by her.”
“I don’t know how I would manage without the help and support I receive in the community from my lovely
nurse”
“thank you from the bottom of my heart for the help and support you gave me through the hard
times...you were my rock and I am sure many more people in the future will feel the same”
Lymphoedema:


“Thank you to everyone at the Lymphoedema clinic for trying to make me look pretty”
“Thank you very much for the help and support over the last 2 years...all of you have been superstars
looking after me and I felt very honoured”
Hospice at Home:


“We couldn’t have asked for – and never expected – such professionalism, kindness and sensitivity and you
managed to bring smiles and laughter to our home each day you visited.”
“They have all made his situation so much easier to cope with and when he had got to know each one and
gained their trust he looked forward to their daily visits.”
Inpatient Services:
 ‘Words cannot express how grateful we are for the care, compassion and dignity shown to dad, and indeed



to all our family during his stay at St Giles.’
‘Just a heartfelt thank you to you all for the many kindnesses and compassion you showed to us....it has
meant so much to us’
I cannot speak too highly of my care. The staff and volunteers I came in contact with were all exceptional
in their friendliness and concern for my wellbeing at all times. My physical and mental stated improved
100% due to this stay at St Giles – thank you all so much
Feedback received through Face book:
2011/ 2012 Quality Account
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Supporting staff and volunteers to have a voice within our organisation
Employee Forum
The Hospice has taken part in a staff survey conducted by Birdsong Charity Consulting and Third
Sector magazine that enables benchmarking against other charitable Hospices.
One of the outcomes from the 2010 survey was the formation of an Employees’ forum to
encourage active participation by employees in organisational matters.
The Forum was launched in November 2011 and its purpose is to:
 Provide a medium where new ideas, policy changes and organisational issues can be
discussed freely and proactively
 Encourage communication and consultation on matters affecting the joint interests of
management and staff
 Complement existing channels of communication
 Provide an effective two way feedback mechanism in order to promote an improved
understanding and trusting relationship between management and staff
The forum is chaired by the Group Chief Executive and attended by other members of senior
management team, a representative from the Volunteer Forum and 14 employee representatives
as elected by their fellow employees.
The forum meets quarterly to discuss topics such as financial performance, economic
environment and other issues which may impact on the future direction of St Giles’ income
generation initiatives, clinical developments, areas of potential development, employment issues,
new ways of working and use of technology, training and development and health and safety.
The terms of reference and minutes of meetings are available to all staff on the Hospice intranet.
Volunteer Forum
There has been a ‘committee’ of volunteer representatives since about 2000. Over time the
number of meetings dwindled as membership decreased. When the Hospice established its
Employee Forum in 2011, it seemed a good time to revisit this body and reconstitute in line with
the Employee Forum.
The Volunteer Forum meets once every quarter, two weeks after the Employee Forum in order to
receive a report to ensure that the two committees both complement and enrich each other.
So far an informal meeting has taken place, followed by our first full session, and a member of the
forum will be joining the Hospice’s 30th Anniversary Committee.
2011/ 2012 Quality Account
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What our regulators say about the organisation
“People we spoke to, and their carers, talked enthusiastically about the care and support they
received in all areas of the service”
The unannounced visit by the Regulator recorded the following judgements:
The provider is compliant with Outcome 04: Care and welfare of people who use Services: ‘People
who use the service received appropriate care and support and the service was managed so
people felt their welfare was protected and their needs were met.’
The provider is compliant with Outcome 07: Safeguarding people who use services from abuse:
‘People who use the service felt informed when giving consent and were able to make decisions
of their choice. Information about consent was recorded to demonstrate how decisions have
been made.’
The provider is compliant with Outcome 09: Management of medicines: ‘People receiving Hospice
care benefited from systems in place to monitor medication practices to ensure they received
their prescribed medication in a safe way. The medication practices within the Hospice at Home
service is being reviewed to ensure staff have suitable training and guidance.’
The provider is compliant with Outcome 16: Assessing and monitoring the quality of service
provision: ‘There were quality assurance arrangements to formally monitor and review the
health, safety and welfare of the people who use the service.’
The Board of Trustees’ commitment to quality
The Clinical Governance Committee met on 5 May 2011, 9 August 2011, 18 October 2011 and 7
February 2012. The committee comprises 4 trustees of the main Board and the senior
management team and reports directly to the main Board.
At every meeting, held for each quarter, they consider all Accidents, Incidents and Near Misses,
Complaints, Patient Journeys, Quality & Audit reports and the quarterly report to the Care Quality
Commission.
In year they also considered the National Patient Safety Agency report on syringe drivers, Patient
Group Directives, Pressure ulcer reporting and safeguarding, Winter pressures and supportive
care, Peer Review measures and Never Events.
The Board of Trustees has demonstrated its commitment to, and responsibility for, quality by
ensuring a robust governance structure for all aspects of the organisation, with four other
governance committees meeting on a regular pattern.
2011/ 2012 Quality Account
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Annex
Staffordshire Clusters of PCTs commented:
We are pleased to comment on this Quality Account for 2011/12 which includes accounts of
patient and carer views and experiences.
Review of 2011/12
 It is pleasing to note the Hospice’s commitment to providing the best possible experience
for patients and their families and its drive for continuous quality improvement. It is clear
that these values have contributed to the positive, announced and unannounced,
inspection visits from the CQC and Commissioners during the year.
 During 2011/12 the Hospice has sought to improve access to its services by the
refurbishment of the Day Therapies Centre and the restructuring of the Supportive Care
Department. This has increased community engagement and helped address barriers to
accessing hospice care.
 Access to inpatient services has been addressed by the establishment of the St Giles
Walsall inpatient service and a review of inpatient respite provision at the Compassus
Centre. This has enabled the Hospice to respond to patient and carer need and avert
potential care crises. Both services have received positive patient and carer feedback.
 The Hospice has successfully implemented an evidence based bereavement needs
assessment tool to support work at a national level.
Priorities for 2012/13
 The Hospice has identified funding to provide a twilight Hospice at Home Service. This will
support patients to remain at home should that be their wish.
 There is an intention to move towards an integrated service delivery model for its
community services which should enable the Hospice to ensure the best use of their
available resources to meet patient and carer needs in a timely way.
 The development of a 7 day care co-ordination centre will improve the response to
patients and carers who have issues around end of life care.
Quality Overview
 The hospice has demonstrated robust process for monitoring and reporting the quality and
safety of the care they provide which includes a schedule of internal clinical audits using
national audit tools.
 The organisation is a participant in both local and national research projects and has
introduced service changes as a result of learning from a number of studies.
 The Hospice’s approach of listening to, and acting upon patient views and engaging carers,
volunteers and staff is to be praised. The Hospice uses a variety of methods to elicit patient
and carer feedback including ‘real time’ and annual surveys.
 The organisation also has both an Employee and a Volunteers Forum to encourage active
participation in organisational matters.
To the best of the commissioner’s knowledge, the information contained within this report is
accurate. (Comment approved by PCT Executives July 2012)
2011/ 2012 Quality Account
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Birmingham and Solihull Cluster of PCTs commented:
St Giles Hospice has continued to work as a major partner in delivery of Specialist Palliative care to
people in the city. St Giles clearly focus on the clinical quality priorities raised through feedback of
people who have used the service and of the population needs based on local data and
information which supports the overall Quality priorities of Birmingham and Solihull PCT Cluster.
St Giles Hospice is working jointly with colleagues within GP practices and Community services and
the local acute trusts to improve delivery of the pathway and patients journey and achieve a
collaborative and partnership where quality and safety of care can be enhanced. This is
demonstrated in their commitment to their staff, their patients and the carers and wider
community.
The amount of research and review of services demonstrates their commitment and their mind
set to pursue quality improvements as part of everyday working life.
On that basis, I support this quality account as it reflects local priorities and those of service users
and has a direct impact on the quality of service people and their families receive.
Mary Bosworth, QIPP Account Director for End of Life (comment received 17/07/2012)
Walsall Healthcare NHS Foundation Trust commented:
Having received and reviewed the Annual Quality Account, NHS Walsall feels it provides a fair
reflection of the quality of the services provided by St Giles, and to the best of our knowledge the
information included in the report is accurate.
Alan Turrell, Assistant Director of Contracting and Procurement (comment received 03/08/2012)
2011/ 2012 Quality Account
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