Quality Account
2012 – 2013
Supporting patients and
their families living with
cancer and other lifethreatening diseases
2012/ 2013 Quality Account
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Table of Contents
Page Number
Statement from the Group Chief Executive
3
Our Principles and Aims
5
Statement of directors’ responsibilities in respect of the Quality
Account
7
Priorities for improvement 2013/2014
8
Priorities for improvement 2012/2013
10
Mandated Statements
Statement of assurance from the Board
Review of services
Research
Participation in clinical audits
In Year Innovation and Quality Assurance
Quality improvement and innovation goals agreed with our
commissioners
12
12
12
12
13
13
What others say about us
16
Data Quality
19
Quality overview
19
Our participation in clinical audits
21
What our patients say about the organisation
25
Supporting staff and volunteers to have a voice within our
organisation
35
The Board of Trustees’ commitment to quality
36
2012/ 2013 Quality Account
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Statement from the Group Chief Executive
I am pleased to present our fourth Quality Account for the work of St Giles Hospice. Although we
are a charity separate from the NHS, we welcome the opportunity to prepare this report in
recognition of the financial support we receive from the NHS, and the contribution we in turn are
able to make to local NHS services. St Giles Hospice delivers specialist palliative and end of life care
for people with a progressive and life threatening illness, their families and carers. As well offering
our care to people with complex needs we provide specialist support and expertise in end of life
care to generalist services in hospitals and the community. This is enhanced by the specialised
education and training we offer to both specialist and generalist health and social care
professionals, as well as being a training placement for doctors, nursing and social work students.
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 consistent high quality, cost effective care underpinned by sound
governance across all aspects of the organisation. Our care is based on an active collaboration
with patients, their families and carers to establish their wishes and needs underpinned by expert
holistic assessment by our multi-professional teams.
St Giles hospice is answerable to several regulatory bodies in terms of our quality standards.
Following unannounced visits by the Care Quality Commission undertaken during this year we
received very positive assessments across all 3 of our sites in Lichfield, Walsall and Sutton
Coldfield. Indeed we were asked if our practice concerning the Liverpool Care Pathway could be
referred to by inspectors as exemplar practice.
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 and
opportunities for improvement addressed. This culture is the responsibility of every employee and
volunteer at the Hospice and is reflected most importantly of all in the feedback we receive
directly from the people who receive our care.
“They have accomplished more here in one week, than in months in the community. My
previous symptoms have gone. I am sleeping well. The whole set up is magnificent. The
staff are very professional"
St Giles were wonderful to my husband when he was in the Hospice; they showed him
exceptional kindness and care. They have sown the same care and kindness and support to
me as an outpatient. They can’t be praised or thanked enough
I enjoy the few hours at the Day Centre. The staff are very good and so cheerful. I didn’t
think I’d enjoy it as much. I look forward to it so much. Thanks to all the staff they are
wonderful and I appreciate their care
When admitted to St Giles I had lost the will to live. The wonderful care received restored
me fully and St Giles and its dedicated staff will never be forgotten
Our care is provided without cost to those that need it. In 2012/13 we received 36.5% funding
from the NHS, the remaining £5,709,559 was raised from the local community, this in itself being
testament to the regard in which we are held by those we serve.
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I am responsible for the preparation and content of this report, working through the Nursing
Director and Quality & Audit Manager and, to the best of my knowledge; it is an accurate and fair
representation of the quality of our services.
This account considers 2012/13 and looks forward to some of our priorities in 2013/14 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
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St Giles Hospice is this year
celebrating 30 years of service
to the community
The hospice began life at the former vicarage of St Giles
Church in Whittington, Staffordshire, opening its doors for
the first time on 12th April 1983.
With nine in-patient beds and two community nurses, the
newly-established St Giles Hospice charity cared for 167
patients during its first year.
Since then, and thanks to the continuing generosity and support of the local community, the
hospice has gone from strength to strength and in 2012, St Giles provided its wide range of
specialist caring services to nearly 4,000 people with cancer and other serious illnesses.
Nearly 90% of our care is provided in patients’ own homes across a wide area of the Midlands, as
well as at its three centres in Whittington, Sutton Coldfield and Walsall.
Today, St Giles is a centre of excellence and one of the best-known and most respected charities in
the region, with over 400 staff, over 1,000 volunteers, 30 charity shops, the most successful
hospice lottery in the UK, and over £8 million spent on providing care every year.
In recent years, the way hospices deliver their care has changed significantly. Not only are people
living longer, but the conditions people are living with towards the end of their lives are becoming
more complicated.
The challenge for St Giles is to meet the increasing demands of those we serve, not only by
continuing to provide the highest quality care, but also by ensuring these services we provide
continue to reflect the changing needs of this community
Our Principles
St Giles was founded to support patients and their families living with cancer and other lifethreatening diseases. Today we continue that work, but now caring for people with a wider variety
of conditions and earlier in their illness. All our care is based on these fundamental principles:
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Encouraging fullness of living, hope and independence by being realistic and honest
Recognising and respecting the uniqueness of every individual
Striving for equity of access to our services
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The delivery of the best possible individual care is dependent upon top quality St Giles people. We
ensure this by:
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Recruiting, developing and supporting volunteers and staff who are passionate about
patient care
Recognising the role of volunteers in both the work and culture of the hospice
Placing education and research at the core of the hospice’s work
The future of St Giles can only be assured and protected by sound governance and business
practice. We are committed to this by:
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Ensuring transparent management of the charity and its finances to achieve overall
improvement in quality of life and value for money
Collaboration, as appropriate, with other organisations involved in end of life care to
further improve patient outcomes
Maintenance of the charity’s independence as a local charity
Our Aims
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To become the preferred provider – whether alone or with others – of the care and
support of anyone in our locality affected by death or dying
To develop an in-patient facility, known as The Compassus Centre, which is regarded
nationally as a centre of excellence in the care of those with the most complex clinical
needs at the end of life
To develop and promote the nationally regarded lymphoedema service for children and
adults to ensure the continued availability of the highest possible quality of lymphoedema
care
To extend our community engagement to promote more open discussion of matters
relating to death and dying within the communities we serve
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Statement of directors’ responsibilities in respect of the Quality Account
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health
Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality
Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
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The Quality Accounts presents a balanced picture of the hospice’s performance over the period
covered;
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The performance information reported in the Quality Account is reliable and accurate;
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There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
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The data underpinning the measures of performance reported in the Quality Account is robust
and reliable, conforms to specified data quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review; and
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The Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
22/05/2013
Date
Chair
22/05/2013
Date
Chief Executive
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Part 1
1.1 Priorities for improvement 2013/2014
St Giles Hospice remains compliant with the National Minimum Standards (2002) and has been
categorised by the Care Quality Commission (CQC) as a low risk organisation. All three Hospice
sites were inspected by the CQC during 2012/13 and all received positive reports with no areas of
shortfall being identified. To maintain the Quality Risk Profile at this level, the hospice provides
quarterly reports to the CQC and also to commissioners of hospice services.
The Board of Trustees actively supports a culture of continuous quality improvement using the key
principles and strategic aims. These aims are dependent upon obtaining or securing the necessary
funding.
Three key developments to support quality improvement planned for 2013/14 are outlined below.
1. Appointment of a ‘First Contact’ Co-ordinator. This is a new post funded by the use of
reserves as supported by the Board of Trustees. This priority will impact on both
patient experience and clinical effectiveness.
How was this identified as a priority?
The hospice monitors its referrals, their outcome and response times to service delivery across all of its
clinical services. Both the inpatient unit and Specialist Palliative Care Community Team have
experienced a year on year increase in referrals and this trend is expected, in line with known
demographics, to continue. In process mapping our management of referrals we recognised that we
could substantially improve our effectiveness, responsiveness and improve the experience of patients,
carers and other professionals. In addition we continue to receive a substantial number of
inappropriate and late referrals and we believe that this is not in the interests of patient care or best
use of available resources.
What are we aiming to achieve?
We are designing a post that will be at senior clinician level who will act as the first contact point for
referral for Inpatient and Specialist Community Services. They will receive, assess and triage referrals
and be responsible for all communications associated with the referral process. This is intended to
result in more efficient and effective referral process, an improvement in the quality and timeliness of
clinical information and a speedier response time to referrals. We anticipate that this will improve the
experience of patients by improving both the quality and timeliness of communication directly from
the hospice to them.
How will progress be monitored and reported?
The post is currently being designed and recruitment during Quarter 1 is anticipated. This will be
overseen by the Nursing director in conjunction with Human Resources and monitored by the Senior
Management Team. Once the post holder is in post and the referral process redesigned and
communicated across our locality we would expect to see an improvement in the response time to
referrals as per our data monitoring processes and also by qualitative feedback from external and
internal professionals.
How will we know what we have achieved?
When we have recruited successfully to the post and by the outcomes of monitoring as described
above. We would not expect to see the full impact of this initiative during the 2013/14 period.
2012/ 2013 Quality Account
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2. Implementation of a new model for Patient Reported Outcome Measures (PROMs)
and Family Reported Outcome Measures (FROMS). This priority will impact on both
patient experience and clinical effectiveness.
How was this identified as a priority?
Meaningful outcome measures in hospice care have proved challenging, not least because of the
patient group concerned. St Giles Hospice has continually looked to develop its understanding of the
patient and family experience of its services and care but recognises that this needs to progress
further. Our collaborative relationship with another large regional hospice gave us the opportunity to
look at work they had undertaken in developing a comprehensive PROM/FROM system.
What are we aiming to achieve?
This PROM/FROM system is a comprehensive and well developed and locally evaluated system. We
believe it has the potential to give patients and families an opportunity to tell us in much richer detail
about their experience of our care and most importantly the impact that had on them and their wellbeing, quality of life and experience. In addition we will be able to review our results in comparison to
the hospice which developed them and consider any areas of discrepancy and investigate the potential
implications and opportunities for quality improvement.
How will progress be monitored and reported?
This PROM/FROM system will replace our existing methodology during 2013/14 although the results
will be reported to the Clinical Governance Committee, Board of Trustees, relevant clinical teams and
commissioners as per our existing processes. In addition we will report on the experience of
transferring this tool into our own hospice services.
How will we know what we have achieved?
We will be able to analyse the reported outcomes qualitatively and quantitatively and also identify
changes in practice that derive from this information. These will be reported as described above.
3. Systems review of Patient Information and Data
How was this identified as a priority?
Through a variety of contracting processes, grant applications and bids, internal project management
and service developments, together with the preliminary report from the Commission for the Future of
Hospice Care, we recognise that the quality of data will be critical for the hospice.
What are we aiming to achieve?
In 2013/14 we intend to undertake a systems review of Crosscare as a patient information and data
system to ensure that we use it as efficiently and effectively as possible. This will impact directly on
multi professional clinical communications, care delivery as well as improving our ability report on and
analyse our clinical activity
How will progress be monitored and reported?
The Crosscare Group, led by Dr Nial McCarron, will include clinicians, technicians and data
administrators to undertake the review. They will report to the Senior Management Team and the CEO
will in turn report the findings and recommendations to the Board of Trustees.
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1.2 Priorities for improvement 2012/2013
Review of the priorities for improvement identified in last year’s Quality Account.
Implementation of a pilot for a twilight Hospice at Home Service
Our aim was to: Extend the existing model of care for Hospice at Home (HAH) patients to include a
service providing Registered Nurse cover between the hours of 4pm - 11pm every day.
What we did: We successfully bid for a grant from St James Place for £x to fund the pilot for one year.
The grant enabled the expansion of the existing team to:
 Greet and settle patients and families after discharge from Hospice or hospital where their choice
is to die at home.
 To support district nursing teams where they have difficulties in responding rapidly
 Provide evening based care
 Mentor and support the existing night team of Healthcare Assistants (HCA) to ensure patients
remain at home should that be their wish
What was the outcome: The evaluation is currently being completed. There is both qualitative and
quantitative data to indicate that the twilight service has improved responsiveness to need, supported
safe discharge, improved co-ordination and information sharing
Provisional data from Crosscare (electronic patient record) shows the following activity for Hospice at
Home Twilight visits.
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Integrated Hospice Community Services Model
Our aim was to: Move towards an integrated service delivery model for its community services in
2012/13. We needed to address the increasing demand for CNS and Hospice at Home services without
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. In addition we were aware that
patients expected the hospice to remain in contact with them but that this being achieved by the Clinical
Nurse Specialist providing direct care was not the best use of a precious resource. By integrating the
community services we hoped to improve patient experience and better manage capacity.
What we did: Through both service and role redesign we aimed to respond to assessed patient and carer
need in a more timely way, deploying staff with the most appropriate skill set.
What was the outcome: Patients receive explanation and choice about receiving follow up contact from
the hospice when specialist palliative care nurse intervention is no longer required. This is an optional
additional contact to any the patient may receive from their primary care key worker enabling the patient
and their family to continue to receive appropriate level of support from their local hospice and our wider
support services for an interim period. This has enabled a more timely response to referral receipt and
management in our Hospice at Home service arm and is contributing to more effective case management
in the nurse specialist service arm.
Development of care co-ordination and advice for St Giles patients
Our aim was to: Create a single point of access for telephone advice. 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 co-ordination 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.
What we did: We visited other hospices and projects that had successfully implemented and evaluated a
single point of access for 24/7 advice and support for end of life care patients.
What was the outcome: On assessing various models we decided that the initial step was to appoint a
‘first Contact’ Nurse Specialist to manage and triage referrals for the community and inpatient service. In
additional we have been exploring a closer relationship with the organisation, Bridges, who have a long
history of co-ordination of palliative and supportive care.
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2
Mandated Statements
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 2012/13 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
The total value of services provided by the hospice in 2012/13 was £7,994,772. The hospice
received a contribution from the NHS equalling 36.5% of the full cost of the contracted service
provision. The remaining funds were generated through fundraising and the Hospice’s own
subsidiary companies amounting to a £5,709,559 contribution from the local community.
The Clinical Governance Committee receives a quarterly report which enables them to review the
quality of care provided by all clinical services. The committee has a standing agenda and reviews:
 Any reported accident, incident or near miss
 Drug errors
 Patient falls
 Complaints or concerns
The Clinical Governance Committee will then provide quality assurance to the Board.
Research
The Group Chief Executive of St Giles Hospice is a member of the Commission into the Future of
Hospice Care
The Family Support and Bereavement Team were involved in a research project with Keele
University in 2011/12 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. The
results of this study are being presented and published in April 2013.
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The Lymphoedema Team were 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 resulted in the study being halted as results
indicated that this treatment was not effective.
St Giles Community Manager has continued to be involved with a national research team focusing
on carer support. The learning gained from implementing Carer Support Needs Assessment Tool in
practice with St Giles home services has contributed to how training has been developed for six
additional services. This involvement continues further this year as nearly 50 other sites across the
UK receive training to implement this innovative approach to understanding and supporting
carers.
Participation in clinical audits
As an independent hospice, St Giles’ does not participate in the national NHS clinical audit
programme as there are no national clinical audits or national confidential enquiries covering NHS
services relating to palliative care. However, we regularly undertake audits, as part of our annual
forward audit programme which we select according to network, local or internal priorities.
In Year Innovation and Quality Assurance
The following actions have been undertaken to ensure St Giles Hospice continues to improve the
quality of healthcare provided. (Heads of department)
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West Midlands Nurse Managers agreed process of continuous quality monitoring with the
data being scrutinised on a quarterly basis covering areas of percentage occupancy,
pressure ulcers, slips, trips and falls, infection control, deaths and discharges.
Investment in a Clinical Nurse Specialist post for Care Homes in the Sutton Coldfield Area
Participation in a national study implementing a Carers’ Needs Assessment Tool in practice.
Implementation of the Help the Hospices national audit tool to ensure full compliance for
the role of Accountable Officer.
The successful introduction of McKinley T34 syringe drivers to replace Graseby drivers in
line with the National Patient Safety Agency directive. This was independently of the NHS
through a variety of successful grant applications.
Commenced Health Social Care Placements with local schools offering A level students
opportunity to work alongside Volunteer Ward Helpers
Link with Burton Hospital NHS Foundation Trust offering placements for acute nursing staff
both trained and untrained to offer insight into specialist palliative care
Commissioned to provide post bereavement telephone support on behalf of a local acute
trust
Green Card scheme for St Giles patients to track them when they are unexpectedly
admitted to hospital
Collaboration with HMP Sudbury regarding end of life care issues
The Hospice implementation of version 12 of the Liverpool Care Pathway together with
standard operating procedures relating to safeguards for patients and their families
ensuring transparent, multi-professional decision regarding initiation and use
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Robust monitoring of medicine management utilising Help the Hospices national audit
tools for controlled and non-controlled drugs, day to day prescribing and administration
practice of clinicians and pharmacy provision.
Development of ‘Hospice Care’ service through service redesign and integration of
community and hospice at home services.
Contribution to developing a set of core national standards for a Hospice at Home service
followed by a published article.
Raised awareness of spirituality through workshops and development of departmental
champions
Pilot project developing CNS clinic in community setting.
Transition from hand written patient information record to electronic record
Participation in a Keele University study to identify vulnerability in grief
Collaborative working with exercise facilitator and MS nurses to develop an evidence base
for the development of enablement and health promotion groups for MS patients.
Collaborative work with local council enabling support workers to respond to the needs of
young people experiencing loss and bereavement – evaluation of impact of the project
Nurse passport to support development, achievement and evidencing of core
competencies
Implementation of departmental infection control champions
Implementation of mobile lymphoedema clinics in the Cannock area
Contribution to the work of Walsall Healthcare Trust on development of DNAR
Renewal of its status as an Approved Practice Setting for medical staff
Quality improvement and innovation goals agreed with our commissioners
Birmingham Commissioners wished to implement a CQUIN (Commissioning for Quality and
Innovation payment framework) relating to patient experience. In order to prevent duplication we
used the CQUIN format to replace or integrate with our existing patient satisfaction methodology.
The goals and indicators for the hospice were as follows:
1a)
1b)
1c)
To ensure that providers have real‐time systems in place to monitor patient/carer
experience.
To demonstrate improvements in patient/carer experience
Demonstrate clear commitment from board to improve patient/carer experience
The schedule of patient surveys began in May 2012. The methodology was:
i.
Inpatient Services
a. On day 4 of admission patients / family carers to be requested to complete either
Questionnaire 1 or 2
b. On Discharge all patients given Questionnaire 3 for completion
Templates amended w/c 7th May 2012
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ii.
Day Hospice
Questionnaire given to patient monthly or 4th visit
To begin w/c 28th May 2012
iii.
Community Team
Questionnaire to be posted to percentage of case load monthly
To begin 1st June 2012
Outcome:
Inpatient Services:
Admission
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Have the first 3 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 your care
and treatments?
Have you been able to express any concerns or issues you may have?
Are we doing everything for you that you would expect us to do?
If you had a complaint about the care you are receiving,
would you know what to do?
Do you feel that the service you received could be improved?
Discharge
 Were you satisfied with the care and treatments you received?
 Did you always feel that you knew what was going on?
 Do you feel that the service you received could be improved?
86% strongly agreed
81% strongly agreed
91% strongly agreed
83% strongly agreed
80% strongly agreed
87% strongly agreed
68% strongly agreed
60% strongly disagreed
87% strongly agreed
73% strongly agreed
54% strongly disagreed
Day Hospice:
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Have your recent visits been satisfactory?
Do you understand the reasons for attending Day Hospice?
Do you understand what we are trying to achieve for you?
Do you feel that the service you are receiving could be improved?
84% strongly agreed
72% strongly agreed
74% strongly agreed
48% strongly disagreed
Community Team:
 Have you found the staff approachable?
 Have you been given the opportunity to discuss your care and treatments?
 Have you been able to express any concerns or issues you may have?
 Are we doing everything for you that you would expect us to do?
 Do you feel that the service you are receiving could be improved?
89% strongly agreed
86% strongly agreed
85% strongly agreed
85% strongly agreed
61% strongly disagreed
(A more in depth explanation of the responses received together with changes to practice and
individual response is available on page 25)
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What others say about us
St Giles Hospice is required to register with the Care Quality Commission
St Giles Hospice operates across 3 sites – Whittington, Sutton Coldfield and Walsall. All sites were
visited by the Care Quality Commission during 2012/13.
St Giles Hospice – Walsall
A routine but unannounced inspection was undertaken on 5 th November 2012 to check on the
care and welfare of people using the service.
The inspectors chose the following essential standards of quality and safety:
 Consent to care and treatment
 Care and welfare of people who use services
 Management of medicines
 Supporting workers
 Assessing and monitoring the quality of service provision
The inspectors examined personal care or treatment records of people who use the service, and
talked with people who use the service, with carers and / or family members and also with staff.
What people told the inspectors and what they found:
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The inspectors spoke at length with a person who used the service, a visiting relative and
three members of staff to obtain their views about the hospice.
Due to the nature of the needs of people living at the hospice it was not always possible to
speak directly to them to get their opinions - other methods such as questionnaires were
also used to obtain their views.
One person using the service told us, "They have accomplished more here in one week,
than in months in the community. My previous symptoms have gone. I am sleeping well.
The whole set up is magnificent. The staff are very professional".
A relative told us," I can't fault them. They always keep me updated and keep [my
relative] as comfortable as possible".
The inspectors spoke with three members of staff who told us they felt supported by their
manager and received regular training to enable them to provide specialist care.
During the inspection they observed that medications were kept safe and secure and
received reassurance that people were regularly involved in their medication reviews.
The inspectors saw that the service had effective systems in place to monitor and improve
the service and that these systems involved consulting with people using and visiting the
service.
The outcome of the inspection was that the hospice ‘Met the standard’ for all identified standards.
2012/ 2013 Quality Account
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St Giles Hospice – Whittington
A routine but unannounced inspection was undertaken on 13 th November 2012.
The inspectors chose the following essential standards of quality and safety:
 Consent to care and treatment
 Care and welfare of people who use services
 Safeguarding people who use services from abuse
 Supporting workers
 Assessing and monitoring the quality of service provision
The inspectors examined personal care or treatment records of people who use the service, and
observed how people were being cared for and talked with people who use the service, with
carers and / or family members and also with staff.
What people told the inspectors and what they found:
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The inspectors visited Compassus, the in-patient unit and the Day Hospice.
They observed that people received on-going information about their care and treatment.
The people the inspectors spoke with had given their consent to care and treatment based
on the information they received. One person said, "They explained everything". Another
person told us, "If I have a worry, they put me at ease".
They observed that people's care plans were personalised and detailed. The plans included
information about people's own priorities and preferences in respect of their care and
treatment. People told us their care was, "Brilliant". Relatives told us, "They always find
time to reassure us". People told us they felt safe at St Giles Hospice.
Staff the inspectors spoke with told us about their high level of job satisfaction. They said
they felt well supported by their managers and teams. They described the range of training
available to them which enabled them to develop their knowledge of caring for people
with a life limiting illness.
The inspectors determined that St Giles Hospice had thorough systems in place to monitor
the quality of the care and treatment provided and observed that there was continuous
monitoring of people's views about their care. We saw evidence that suggestions people
made were acted upon.
Any complaints or adverse comments were responded to. Most people who used the
service and their families were very positive about every aspect of their experience.
The outcome of the inspection was that the hospice ‘Met the standard’ for all identified standards.
St Giles Hospice – Sutton Coldfield
A routine but unannounced inspection was undertaken on 17th January 2013 to check on the care
and welfare of people using the service.
The inspectors chose the following essential standards of quality and safety:
 Respecting and involving people who use services
 Care and welfare of people who use services
2012/ 2013 Quality Account
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


Safeguarding people who use services from abuse
Supporting workers
Complaints
The inspectors examined personal care or treatment records of people who use the service,
observed how people were being cared for and talked with people who use the service and also
with staff.
What people told the inspectors and what they found:







St Giles Hospice- Sutton Coldfield is a supportive care centre for people with cancer and
other serious illnesses that impact on their quality of life. Groups held at the centre
promote physical and emotional wellbeing such as complimentary therapy and exercise
sessions.
A Lymphoedema clinic held at the centre was led by specialist nurses, this allowed people
to receive treatment locally. No personal care was being provided at the time of the
inspection.
On the day of the inspection they spoke with three members of staff, this included the
Supportive Care Coordinator and two volunteers. The inspectors also spoke with several
people who were attending a group exercise session and the facilitator for the session.
People's views and experiences were taken into account in the way that the service was
provided and delivered in relation to their care and support. People experienced care,
treatment and support that met their needs and protected their rights. One person told us,
"The service is first class".
Safeguarding procedures were in place so that staff would recognise and report any
allegations of abuse so that people were protected from the risk of harm.
People were cared for by staff who were supported to deliver safe care and treatment.
One person said, "The staff are excellent".
Comments and complaints people made were responded to appropriately.
The outcome of the inspection was that the hospice ‘Met the standard’ for all identified standards.
As a result of all these visits St Giles Hospice has no corrective actions to take and is rated as low
risk. The hospice provides a comprehensive quarterly quality report to the Care Quality
Commission to maintain this ranking.
2012/ 2013 Quality Account
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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 also provides
the MDS report and a copy of the quarterly quality report to the three local commissioning PCT
clusters.
The quality of the data outputs is reviewed monthly by Administration Leads together with Quality
and Audit Manager in order to maintain high quality patient data reporting.
Quality overview
The most recent National Minimum Dataset issued by The National Council for Palliative Care
covers the period 1st April 2011 to 31st March 2012. The data for 2012/13 has been collated but
there is no nationally available comparative data at the time of issuing this report.
St Giles Hospice
National Median
In-Patient Unit – Whittington
% New patients
89.6
90.2
% Occupancy
73.0
78.3
% Patients returning home
48.3
42.6
Average length of stay – cancer
13.2
13.4
Average length of stay – non cancer
9.6
12.6
St Giles Hospice
National Median
% New patients
100
89.1
% Occupancy
62.2
75.7
% Patients returning home
52.8
45.0
Average length of stay – cancer
10.8
12.6
Average length of stay – non cancer
10.6
11.1
St Giles Hospice
National Median
Day Hospice
% New patients – cancer
82.1
83.1
% New patients – non cancer
17.9
16.9
% Places used
53.2
57.8
St Giles Hospice
National Median
Community : Clinical Nurse Specialist
% New patients
62.5
68.8
% New patients with a non-cancer diagnosis
7.1
14.1
Visits per completed series
4.2
4.2
In-Patient Unit – Walsall (opened April 2011)
2012/ 2013 Quality Account
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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 for St Giles Hospice (2011/12 includes Walsall)
2011/12
2010/11
2009/10
4,085
4,070
3,394
694
633
653
Total number outpatient attendances
4,140
4,173
4,540
Total number of attendances by patients at the Day Hospice
2,005
1,854
2,342
47,694
40,840
46,198
Total number of Hospice at Home sessions provided
4,604
4,328
5,404
Total hours of Hospice at Home input
7,313
12,121
9,154
Total number of complaints
11
10
16
The number of complaints which were investigated and resolved in full
3
6
6
The number of complaints which were investigated, resolved but only upheld
in part
4
3
8
The number of incidents reported to RIDDOR involving patients
0
3
1
The number of incidents reported to RIDDOR involving staff
3
2
0
412
334
307
% of patients who went home
48.3%
46.1%
44.3%
Number of available bed days
7,320
6,699
6,053
% Bed Occupancy
73%
75.9%
74%
The number of patients known to be infected with MRSA on admission to the
in-patient unit
1
3
1
Patients infected with MRSA whilst on the in-patient unit
0
0
0
The number of patients known to be infected with Clostridium difficile,
Pseudomonas, Salmonella, ESBL or Klebsiella pneumonia on admission
1
1
2
Patients diagnosed with these infections whilst on the in-patient unit.
1
1
1
Number of patients admitted to the in-patient unit with pressure sores
89
67
78
Number of patients who developed pressure sores whilst on the In-patient
unit.
24
21
7
Average length of stay on the in-patient unit (days)
11.4
12.9
13.5
Slips, trips and falls
104
80
61
Total number of new referrals to St Giles Hospice
Total number of referrals not proceeding
Total number of contacts with patients by the community service
Whittington Inpatient Unit
Total number of patients admitted to in-patient unit
2012/ 2013 Quality Account
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Indicator for St Giles Hospice (2011/12 includes Walsall)
2011/12
2010/11
2009/10
7.12
4.06
4.6
197
N/a
N/a
% of patients who went home
52.8%
N/a
N/a
Number of available bed days
3,398
N/a
N/a
% Bed Occupancy
62.2%
N/a
N/a
The number of patients known to be infected with MRSA on admission to the
in-patient unit
3
N/a
N/a
Patients infected with MRSA whilst on the in-patient unit
0
N/a
N/a
1
N/a
N/a
0
N/a
N/a
Number of patients admitted to the in-patient unit with pressure sores
53
N/a
N/a
Number of patients who developed pressure sores whilst on the In-patient
unit.
34
N/a
N/a
10.7
N/a
N/a
37
N/a
N/a
4.97
N/a
N/a
Number of falls per occupied bed (Number of beds multiplied by bed
occupancy and divided by number of falls)
Walsall Inpatient Unit opened April 2011
Total number of patients admitted to in-patient unit
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 in-patient
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
The forward audit programme is developed by liaison between Nursing Director, Heads of
Department and Quality and Audit Manager. The initial programme was ratified by the Clinical
Governance Committee and circulated to The Care Quality Commission and PCT commissioners
within the April to June 2012 quarterly report.
Clinical Audit is part of the standing agenda for each Clinical Governance Committee meeting. At
each meeting the Quality and Audit Manager reports on the previous quarter’s activity identifying progress against the forward audit programme, outcome of completed audits together
with identified actions and recommendations.
2012/ 2013 Quality Account
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Below is a selection of audits undertaken together with outcomes:
Accountable Officer (AO)
A re-audit to ensure that the hospice is able to evidence that the appointment of the AO
Aim and
and the discharge of their responsibilities in the management of Controlled Drugs will meet
objective
the required regulation and legislation and that all hospice personnel involved in each stage
of the handling of CDs have been trained and / or are qualified for the tasks undertaken.
Help the Hospices National Audit Tool NATG4 reviewed:
Outcome
 The appointment of the AO
 The roles and responsibilities of the AO
 Compliance review
 Continuous quality monitoring
Follow-up
actions
Evidenced 100% compliance
To share report with Care Quality Commission, Clinical Governance Committee and
members of senior management team
To continue to monitor and review
Health Records including Moving and Handling
Clinical departments are required to undertake annual audits of their documentation
Aim and
practice to ensure compliance with standards.
objective
4 areas of practice were audited by each department:
Outcome
1. Patient record including Crosscare demographics / Patient Information Sheet
(Walsall only)
2. Departmental assessment and on-going review
3. Paper based assessments
4. Moving and handling
Follow-up
actions
Average compliance score for Hospice was 89%
Results were fed back to members of each department to raise awareness of
inconsistencies and poor practice.
Prevention and Control of Healthcare Associated Infections (HCAI) Re-audit
A re-audit to provide the hospice with evidence of compliance against The Health & Social
Aim and
Care Act 2008, Code of Practice on the Prevention and Control of Healthcare Associated
objective
Infections
Help the Hospices National Audit Tool PCI02 reviewed:
Outcome
 Management Systems
 Policies and Protocols
 Control of Environment
 Provision of Information
 Personnel - Screening, Protection & Training
Follow-up
actions
Evidenced 94.6% compliance
 Booklet covering hand hygiene, an explanation of micro-organisms, how infection is
spread, its prevention and use of isolation developed to support volunteer induction
programme
 Leaflet designed for contractors accessing clinical areas highlighting infection control
issues and respect for patients and their families
 Review of current standard operating procedures and development of a range of
training programmes looking at staff competence across all areas
 Development of mandatory education programme for 2013/14 covering hand hygiene,
isolation’ protective isolation and air borne viruses
2012/ 2013 Quality Account
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Infection Control Re-audits and Monitoring
Effective infection control policies, process and structures to reduce the risk of microbial
Aim and
contamination in everyday practice and a managed environment that minimises the risk of
objective
infection to patients, clients, staff and visitors
 Infection Prevention and Control Forum supporting clinical and non-clinical staff across
Outcome
the organisation
 Departmental Infection Control Champions undertake on-going monitoring
 Inpatient units:
o Compliance rate of 99.6% for hand hygiene
o Compliance rate of 100% for use of gloves and hand hygiene practice
 Day Hospice held ‘Hand Hygiene Awareness’ week for patients and volunteers
 Hospice at Home held teaching sessions for staff relating to hand hygiene and snapshot
audit with 90% compliance
Members
of the Infection Prevention and Control Forum together with the newly appointed
Follow-up
Infection Prevention and Control Nurse and the infection control champions will develop a
actions
robust programme of monitoring and support for the coming year
Controlled Drugs Audit (Inpatient Units)
To verify that standards are being met by the Hospice in the management of controlled
Aim and
drugs regarding compliance with current law & regulations and best practice
objective
Help the Hospices National Audit Tool 5 reviewed:
Outcome
 Adequacy of Premises / Security
 Procurement
 Examination of stock held
 CD Register (CDR), Records and Audit
 Prescribing of CD’s
 Administration of CD’s
 Destruction of CD’s
Follow-up
actions
Evidenced 97.5% compliance
Review of action plan identified:
 The signatory list has been updated
 Staff were informed of inconsistencies in documentation to raise awareness
 CD stock check has been added to the quarterly monitoring programme
 Re-audit will be undertaken September 2013
General Medicines Audit (Inpatient Units)
To provide evidence that the hospice is compliant with current legislation, regulation and
Aim and
standards relating to non-controlled medicines.
objective
Help the Hospices National Audit Tool 7 reviewed:
Outcome
 Standard Operating Procedures (SOPs)
 Purchasing and Supply of Stock Medicines
 Storage and Destruction of Medicines
 Prescribing of Medicines
 Administration of Medicines.
 Patient's Own Medicines
 Non-Medical Prescribers
Evidenced 95% compliance
2012/ 2013 Quality Account
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Follow-up
actions


Report was circulated to members of medical and nursing staff to highlight areas of
inconsistency.
Re-audit will be undertaken September 2013
Safe and Secure Handling of Medicines (Inpatient Units)
To put in place a robust system of monitoring and reporting based on current legislation,
Aim and
regulation and standards.
objective
A range of audit tools were developed to review:
Outcome
 Pharmacy provision
 CD documentation and process
 Drug Charts and TTO Forms
 Remote Prescribing
 Out of Hours medical contact
 Pharmacy intervention
 Each quarter the reports were circulated to Nurse Consultant and members of
Follow-up
Senior Nursing Team, Medical Director for dissemination to all medics, Pharmacist
actions
and Nursing Director who is also the Accountable Officer.
 The reports identified inconsistencies and recommendations
 The Pharmacy Intervention report was used to identify trends and where additional
support may be required
Nutrition and Hydration Audit
The hospice will be able to demonstrate compliance against regulated activities to:
Aim and
 Reduce the risk of poor nutrition and dehydration by encouraging and supporting
objective
people to receive adequate nutrition and hydration
 Provide choices of food and drink for people to meet their diverse needs, making
sure the feed and drink provided is nutritionally balanced and supports their health
A baseline assessment using Help the Hospices National Audit Tool TC-04 considered:
Outcome
 Organisation – policies and procedures
 Clinical Services
 Education and Training
 Service Evaluation
The
Nutrition Steering Group is supporting departments to deliver actions identified in the
Follow-up
baseline assessment to ensure that the Hospice is compliant with standards.
actions
2012/ 2013 Quality Account
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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 method varies from annual ‘snapshot’ surveys to ‘real time’ monitoring.
Community team
Method:
Each month a questionnaire was posted out to appropriate patients on the caseload of two of
the community nurses.
Over an 11 month period 261 were sent out with 159 responses received (rate of 61%)
Outcome:
The questionnaire asked ‘If you feel the service could be improved please tell us in
what way?’ Any comment received were considered by the team.



One related to planned respite. This is a service which is currently offered for 1
week Wednesday to Wednesday. The staffing levels on the inpatient unit are set
up to enable this change over to take place smoothly and currently there are no
plans to offer alternative admission day.
Another comment related to support for carer. As the questionnaire is
anonymous it was not possible to make direct contact with the specific patient
and no other form of comment or concern was received. The response however
was fed back directly to the nurses whose caseloads were evaluated to raise
awareness. The Community team introduced an evidence based Carers Support
Needs Assessment Tool in 2011 as part of their holistic assessment and approach
to supporting family carers. This assessment tool is due to be rolled out across all
hospice clinical departments in June 2013. This will therefore provide an
opportunity to refresh existing CNS as well as new team members.
One patient queried slow referral process. Usually cancer diagnosis is given to the
patient in the hospital setting where there should be a site specific cancer nurse
available to provide immediate support and advice. Often a new cancer diagnosis
does not ultimately mean that specialist palliative care services are required as
many cancers are curable or are treatable adding many years to life before any
specialist palliative needs may develop. Shortly a new additional role of referral
triage is to commence which will hopefully enhance timely contact when needed
2012/ 2013 Quality Account
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
Request for a weekly phone call. The CNS will assess each clinical situation and
agree a suitable contact timeframe with each patient. Contact is encouraged and
welcomed from any patient, family carer or professional if any changes or
deterioration occurs which we may be able to help with.

Respondents were
extremely generous in
their support for the
team.



Here is a selection:
All staff ‘go the extra mile’ in caring. Really pleased how I have been looked
after
Since I have been diagnosed my St Giles team have given me first class advice
and support and at the moment I do not think anything could be improved upon
St Giles were wonderful to my husband when he was in the Hospice; they showed
him exceptional kindness and care. They have sown the same care and kindness
and support to me as an outpatient. They can’t be praised or thanked enough
I don’t think the service you provide could be improved as I couldn’t have wished
for better treatment or care. My CNS has been not only a dedicated nurse but a
friend helping me with not just medical concerns but emotional and financial
issues
Hospice at Home
Method:
An annual survey of patients and their carers / families who are receiving end of life care /
support
20 Questionnaires were posted out to patients and their families between 13th November
2012 and 14th January 2013 – 13 responses were received (return rate of 65%)
Outcome:




Following referral to the team - 38% of patients were contacted within hours
and the remaining 62% within 1 – 3 days and respondents indicated 100%
satisfaction with response time
92% of respondents indicated that the service was ‘what they expected’
100% of respondents replied ‘Yes’ to the question ‘Did the care input by
Hospice at Home meet your needs’
77% of respondents indicated ‘Excellent’ and 33% ‘Good’ to the question
‘Overall, how would you rate the care and service provided’
The full report is available on the St Giles website -
2012/ 2013 Quality Account
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http://www.stgileshospice.com/documents/253.12ReportPatientandCarerEvaluation.pdf
These are just some of
the comments
received:



A wonderful team of care workers. Kind, considerate and most helpful. A big
thank you to all
Simply don’t think we would have coped with the last months trauma without
the help and support of all the people we met from St Giles. So many thanks.
We have found that all the staff we have had contact with have been very
pleasant and cheerful and we always feel confident in the care we receive
Lymphoedema Clinic – Adult service
Method:
An annual survey
20 questionnaires were given out with 17 returned – a response rate of 85%
Outcome:




The feedback from patients was excellent – 100% of respondents indicated
that they always felt welcome when arriving at the Hospice
88% of respondents indicated that they were very satisfied with their
involvement in planning their care
100% of respondents indicated the cleanliness of the premises as excellent and
94% rated excellent the general environment / surroundings
5 patients indicated that they did not remember receiving a patient
information leaflet – some patients have been supported by the service for
many years and their first appointment may pre-date the existence of the
leaflet.
These are just some of
the comments
received:
2012/ 2013 Quality Account
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
If it’s not broken don’t fix it
I think your service is excellent and my treatment is first class
The staff and care is always second to none
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Lymphoedema Clinic – Children’s service
Method:
An annual survey
10 questionnaires were given out with 5 returned (response rate of 50%)
Outcome:




100% of respondents answered ‘Always’ to the questions:
o ‘When you first arrived at the Hospice did you feel welcome?
o ‘Overall, did you have confidence in the staff who were caring for you /
your child?’
o ‘Did you feel staff made an effort to meet your / your child’s individual
needs and wishes’
100% of respondents answered ‘Very satisfied’ to the question ‘Overall, how
satisfied were you with your involvement in planning your / your child’s care?’
80% of respondents answered ‘Always’ and 20% ‘Most of the time’ to the
question ‘Overall, did you understand the explanations given to you about you
/ your child’s treatment and care?’
We asked respondents ‘Were you aware of what to do if you wanted to make a
complaint?’ 60% of respondents indicated that there were unsure of what to
do. Following referral all families should receive a patient information leaflet
which gives detailed instructions regarding the complaints process. Further
support is also supplied by a poster which is displayed in reception area at
Lindridge Road.
A comment received:
2012/ 2013 Quality Account

We always feel welcome and my child loves coming!
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Complementary Therapy
Method:
Outcome:
Each quarter survey sent out to clients
In December 2012 17 questionnaires were posted out to clients and 14 completed forms
received (a response rate of 82%)




Respondents were asked how they felt following their course of treatments :
92% indicated they ‘felt more relaxed’; ‘more able to cope’ and ‘improved
well-being’ – 8% indicated that they had no benefits from the treatment
93% of respondents indicated that they received adequate information
regarding their treatment
Respondents were asked about their experience with their therapist – all
indicated it as a positive experience choosing options of friendly, sensitive,
caring, informed, responsive and supportive
100% of respondents answered ‘Yes’ to the question ‘Would you
recommend this service to others

These are just some of
the comments
received:
2012/ 2013 Quality Account



Everything for me was really very good, very nice. Friendly girls who put me at
ease. Plus proved to help me very, very much – really is worthwhile
We both found the therapy beneficial and luxurious. Five star treatments thank
you
Excellent treatment and advice
I would like to say thank you for the opportunity to have these treatments and
meet lovely people
- 29 -
Family Support and Bereavement
Method:
Following completion of support each client is sent a questionnaire
Between October and March 56 evaluations were sent out with 29 returned (response rate
of 52%) Overall we received 55 completed surveys
Outcome:
Has the support you have
received from the service
made this experience of
bereavement more or less
bearable for you?
Were you satisfied with the
service provided?
Would you recommend this
service to others?

These are just some of
the comments
received:



2012/ 2013 Quality Account
I didn’t know how talking to a stranger could help me. Although I was upset
when I was there I felt better afterwards. I look at things differently now. St
Giles is a wonderful place and have helped my family a lot. We will always be
grateful for your help and support during this very sad time
I am very grateful for the service and care we received after losing my mum. Xx
was lovely always caring and supportive in what was a very difficult time for us
all and I am happy in knowing that this service is on offer to families like
ourselves that have to deal with a loss of a loved one to such a cruel disease
The service you provided was my lifeline
Service very good. It provides the companionship and someone to talk to. It is
the emptiness of bereavement is so hard to come to terms with and the people I
saw understood this
- 30 -
Day Hospice
Method:
1. Monthly real time monitoring of patient satisfaction.
2. Bi-monthly real time monitoring of patient experience
3. Evaluation of 12 week contract
Outcome for
point 1.
There were 384 attendances at Day Hospice during the evaluation period and the
response rate for completion of the monthly monitoring was 87%
The questionnaire asked ‘If you feel the service could be improved please tell us in
what way?’:
In the January and February responses there had been comments from patients
about the décor of the main lounge within the Day Hospice. St Giles applied for
Department of Health funding and were successful in their bid for monies to
transform the lounge, kitchen and craft area by a unified interior design scheme
defining the different functions of the room and adding an internet café and coffee
bar area. New furniture and soft furnishings will replace the old heavy chairs and
mobile room dividers will both allow displays of work by patients and give the
ability to change the configuration of the room easily.
Another patient commented ‘More things or occupations to entail disabled people
to participate. More communal interaction between patients’. A new Technical
Instructor has joined the Therapy Team replacing a member of staff who left
before Christmas. One of the roles of the position is to facilitate activity and craft
sessions within Day Hospice.
These are just some of the
comments received:



2012/ 2013 Quality Account
The service and support I get from the Day Hospice could not be better. All
the staff are wonderful. I just wish that everyone else who needs it could
come here to have their lives transformed
Just keep up the good work you’re doing
Everyone is doing everything to help me and I’m very pleased
- 31 -
Outcome for
point 2:
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
These are just some of the
comments received:




Outcome to
point 3
I enjoy the few hours at the Day Centre. The staff are very good and so
cheerful. I didn’t think I’d enjoy it as much. I look forward to it so much.
Thanks to all the staff they are wonderful and I appreciate their care
Everybody is very kind and supportive
No one could receive any more attention than at St Giles
You can’t improve a good thing already can you?
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:
79% indicated that it had ‘Exceeded their expectations’ and 21% indicated
that it has ‘Met their expectations’
2012/ 2013 Quality Account
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These are just some of the
comments received:



I participated in a bread making activity one week and really enjoyed it. I
exercised my fingers in a different way and saw a great end result. I would
welcome similar activities if they were available
I have received useful tips from the physio and OT. I look forward to being
in a different environment for the day. I have loaned a tri-walker which is
invaluable
Made me feel like I’m not alone and not the only one. Also gives me a break
from 4 walls at home and gives my husband a break from full time caring
Inpatient Services
Method:
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
Outcome
for point 1:
2012/ 2013 Quality Account
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Outcome
for point 2:
Outcome
for point 3:
The questionnaires asked ‘If you feel the service could be improved please tell us in
what way?’. As a result of feedback:
o Successful opening of ‘Day Space’ at Walsall for patients and their
families to relax and enjoy activities
o Purchase of separate wardrobes for a multi-bedded room
o Putting wall clocks into patient rooms
o Modification to kitchen area of ‘step down’ room to ensure clutter free
environment to assist patients who are preparing to go home
These are just some
of the comments
received:



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2012/ 2013 Quality Account
We as a family would like to thank you for all your care, love and help. Our wishes
are that when mom moves to her final days she will spend it with you
Only the entire families heartfelt thanks and admiration for the way in which the
entire hospice and its staff treated my wife and she could not and did not wish for
a better end.
My husband spent 3 weeks in hospital before transfer to St Giles. The difference
between the two is impressive. St Giles staff have so much time for my husband,
me and our children. They are really interested in improving his quality of life and
nothing is too much trouble
Everyone here goes out of their way to make dad as comfortable as possible and to
put us (his family) at ease explaining in simple (non-medical) terms about his
treatment plan. Quality of care far outweighs our expectations – thank you simply
isn’t enough – you are amazing.
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All the staff (nurses, care assistants, cleaners, chefs etc.) are all very kind and
supportive and seem to find the time to help me and talk to me and make me feel
welcome to be here
Thank you so much for all the kindness, caring and wonderful support given to the
patient, AND to us, as relatives, when we were struggling to cope in such difficult
circumstances – you all helped us deal with our emotions and find strength and
peace to carry on
When admitted to St Giles I had lost the will to live. The wonderful care received
restored me fully and St Giles and its dedicated staff will never be forgotten
Supporting staff and volunteers to have a voice within our organisation
Employee Forum
The Forum was launched in November 2011. Its purpose is to:
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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.
A member of the forum sits on the Hospice’s 30th Anniversary Committee.
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Supporting staff in their personal development
During this year the hospice supported staff in their personal development across a range of
academia:
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Non-medical prescribing
Principles of Physical Assessment
Diploma in Medical Education
European Certificate in Palliative Care
Mentorship within Health Care Setting
Independent Supplementary Nurse Prescribing
Cognitive Behavioural Therapy
Behavioural Family Therapy
Health & Social Care Change Loss & Bereavement
Leadership & Management in Health & Social Care
Introduction to negotiated learning
Development Health Assessment & Examination Skills within Clinical Practice
Research and Evidence Based Practice
The Board of Trustees’ commitment to quality
The Clinical Governance Committee comprises of 4 trustees of the main Board, all members of the
Senior Management Team and Quality and Audit Manager. The committee met quarterly as
scheduled during this period and then reported directly to the main Board.
Each meeting has a set agenda which considers all Accidents, Incidents and Near Misses,
Complaints, Patient Journeys, Quality and Audit reports and the quarterly report to the Care
Quality Commission.
In year they also considered the CQC quarterly reports, response to Assisted Dying survey, Medical
Staffing, Peer Review and Liverpool Care Pathway reporting.
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.
Inpatient Services - Provider Visit
As a result of regular monitoring of admissions and on-going treatment of patients with pressure
ulcers minor modifications were made to documentation. To ensure that the process was
transparent and robust the Chairman of the Clinical Governance Committee, who is herself a
trustee, accompanied by another trustee visited both Inpatient Units during August 2012.
The purpose of the visit was to assure that the clinical governance processes for risk management,
identification and management of pressure ulcers are robust and consistently understood and
applied in practice.
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The focus of this Provider visit is in response to the relationship between safeguarding and
pressure ulcer management, and to a noted increase in incidence reporting by our inpatient
services
The trustees were satisfied with their inspection and commented in their report:
“It was felt that the staff demonstrated their knowledge of the requirements for the prevention,
treatment, and reporting of pressure ulcers. They were able to show us the processes in action via
the completed records and the on-going monitoring that was ensuing. The patients records used
to demonstrate the processes to us had pressure ulcers and had been admitted with them
During the time we were present on the units we noted that the call bells were answered very
quickly, all the areas were clean, pleasant and we were made very welcome. The staff we
interviewed were knowledgeable, patient centred and when asked about their requirements as
regards appraisal and training needs answered very positively that these needs were met and they
were extremely happy with their working conditions”
There were two suggested items for action both of which relate to Walsall unit:
1 Printing the Nursing Holistic Assessment booklet on green paper for easy identification within
the patient record (this action was implemented immediately by Ward Clerks)
2 Provision of single wardrobes in the double rooms (this was achieved in September 2012)
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Annex
We have invited comments from local commissioners and will add to report upon receipt.
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