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I am pleased to present our fifth 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.
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.
I would like to take this opportunity to say 'thank you' for all the kindness support and comfort given to making my mum's last few hours peaceful and making my family experience over this period more bearable.
My very sincere thanks to the wonderful care and attention I have received during my stay with you.
No matter who, what or where I was I could not have been better looked after
..it was very important to my wife and myself that you gave us the opportunity to stay together and we thank you most sincerely for that consideration. We have found strength to cope and we feel without you we would have ‘lost the way forward’
I personally would like to say how fantastic you all are you gave my mom her dignity back and her self-esteem when she was at her lowest...to see mom smile left us contented
I'd just like to thank Xx from the lymphoedema service for her help with my patient. I have reviewed her in clinic today and she was thrilled with your support and recommendations. Her oedema has significantly reduced, meaning she is able to access more movement at her ankle joint and she is able to lift her leg better during gait as it doesn't feel as heavy. This has helped to improve her functional abilities and potential in physiotherapy sessions. She was all smiles!
(Comment received from Senior Physiotherapist in Neurology, Mid Staffordshire Foundation Trust)
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Thank you so much for the care and attention that you gave my father during his last days. I cannot describe how much it all meant to me. You helped dad through those very difficult days and I wish that all could have as dignified a closure on life.
I was overwhelmed at just how friendly, caring and determined you were to make my Granddad’s stay as comfortable and peaceful as possible. What was so lovely is that you talked to him like a human being and not a patient with limited time.
Our care is provided without cost to those that need it. In 2013/14 we received 37% funding from the NHS (£3,276,278), the remaining £5,577,415 was raised from the local community, this in itself being testament to the regard in which we are held by those we serve.
I am responsible for the preparation and content of this report, working through the Care 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 2013/14 and looks forward to some of our priorities in 2014/15 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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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:

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
The delivery of the best possible individua l care is dependent upon top quality St Giles people. We ensure this by:

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:
 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
During 2013/14 we have reviewed our organisational strategic aims:
St Giles Hospice is committed to offer care on the basis of need and not diagnosis. We recognise the increasing need for high quality end of life care for people living with multiple conditions and frailty as well as single diagnoses such as cancer, dementia and heart failure. In each of our strategic aims we seek partnerships with others who share our aims in order to address increasing complexity of health and social need in an environment of limited resources.
Community Services
We believe that most people prefer high quality services delivered in their own home. We will work in a way that complements statutory services and responds to the needs and expectations of our community. We will do this by matching our skills according to the assessed needs of individuals, being mindful that we must promote and maximise support and assets already available to individuals and the local community as a whole.
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Beds
We believe that the need for high quality palliative care beds will increase. We will seek innovative and fully funded options that enable us to utilise all available beds on our in-patient units and support the development of palliative care beds within our local community.
Community Engagement
We believe that patient choice, extended life expectancy and scarcity of resources mean that care will increasingly become a community activity. We will encourage local communities to build on the assets and skills they already have for good end of life care. We will actively build on the relationship between St Giles and its community to understand how we can further develop community based end of life care.
Research and Education
We believe we have a responsibility to continuously research best practice and to share this with the whole community. We will embed research into our work in the belief that all healthcare professionals have a duty to contribute to research. We will offer education and training that seeks to give patients, carers, professionals, organisations and the local community the confidence, skills and opportunities to promote good end of life care for all. We will encourage and develop the health and social care workforce of the future.
Financial sustainability
We believe that financial sustainability serves the best interests of patients by ensuring a settled workforce and an uninterrupted service. We will seek to optimise existing and new revenue streams in order to innovate whilst protecting our independence, recognising that our local community is the basis of our financial sustainability.
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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:

The Quality Accounts presents a balanced picture of the hospice’s performance over the period covered;

The performance information reported in the Quality Account is reliable and accurate;

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;

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

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
21 st May 2014 Date Chair
21 st
May 2014 Date Chief Executive
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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 2013/14 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 2014/15 are outlined below.
1.
We will seek accreditation as a Practice Development Unit and become a research active organisation
How was this identified as a priority?
In reviewing our organisational strategy during 2013/14 we concluded that we believe we have a responsibility to continuously research best practice and to share this with the whole community. We intend to embed research into our work in the belief that all healthcare professionals have a duty to contribute to research. We will offer education and training that seeks to give patients, carers, professionals, organisations and the local community the confidence, skills and opportunities to promote good end of life care for all. We will encourage and develop the health and social care workforce of the future.
What are we aiming to achieve?
We are working with Staffordshire University to develop and implement a strategy for becoming an accredited Practice Development Unit. This will be a 3 year programme. We have also committed to work with Kings College London on the IPOS international study which is to validate an outcome measures tool for palliative care.
How will progress be monitored and reported?
We will report our progress to the Clinical Governance Committee and via our Quarterly reports to CQC and Commissioners.
How will we know what we have achieved?
Both accreditation and research processes are subject to agreed milestones and reporting which will indicate both progress and achievement.
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2.
We will proactively work with partners in the primary, secondary and tertiary sectors to find solutions for non-cancer end of life care, including dementia.
How was this identified as a priority?
Following the review of our organisational strategy in 2013/14 we have restated that St Giles Hospice is committed to offer care on the basis of need and not diagnosis. The Hospice recognises that its expertise in specialist palliative care confers a responsibility to use that expertise to support improved end of life care for our whole community.
What are we aiming to achieve?
We recognise the increasing need for high quality end of life care for people living with multiple conditions and frailty as well as single diagnoses such as cancer, dementia and heart failure. In each of our strategic aims we seek partnerships with others who share our aims in order to address increasing complexity of health and social need in an environment of limited resources.
How will progress be monitored and reported?
Progress will be monitored through the Senior Management Team and the Board of Trustees. It will be reported to our regulator CQC and to Commissioners via our Quarterly reporting process. Where possible we will present our work through local, national and professional media.
How will we know what we have achieved?
All projects will have agreed key performance indicators and outcome measures to ensure we are able to demonstrate and understand their impact.
3.
The implementation of 5 Diversionary Pathways for Exacerbation of Respiratory
Conditions; Hypercalcaemia; Cellulitis management associated with Lymphoedema;
Blood Transfusion and Intravenous furosemide for patients with decompensated heart failure.
How was this identified as a priority?
By working closely with partners at Walsall Clinical Commissioning Group and Walsall Manor Hospital we identified that certain patients traditionally being treated in the acute setting could be offered an alternative pathway of care at our Inpatient Unit situated in Walsall Palliative Care Centre.
What are we aiming to achieve?
The Diversionary Pathways offer potential for an improved patient experience, speedier treatment and the release hospital capacity. They are also intended to support an improved quality of life, enable a quicker return to the person’s home and encourage advanced care planning.
How will progress be monitored and reported?
Key Performance Indicators and outcome measures have been identified and will be monitored and reported to the Clinical Commissioning Groups, Secondary Care partners and the Hospice Board via the
Clinical Governance Committee.
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Review of the priorities for improvement identified in last year’s Quality Account.
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.
Our aim was to: Create a post at senior clinician level to act as the first contact point for referral to
Inpatient and Specialist Community Services, impacting on both patient experience and clinical effectiveness. They would receive, assess and triage referrals and be responsible for all communications associated with the referral process. This would result in a more efficient and effective referral process, an improvement in the quality and timeliness of clinical information and a speedier response time to referrals. We anticipated that this will improve the experience of patients by improving both the quality and timeliness of communication directly from the hospice to them.
What we did: We successfully recruited to the post in August 2013.Internal processes were reviewed and redesigned. As a result we also seconded a staff nurse to support the volume of work involved.
What was the outcome: We are continuing to develop and refine our processes for management of referrals. However we have already seen a marked improvement in response times to patients and 75% of all referrals, regardless of urgency as indicated by the referrer, are now triaged the same day of receipt.
We are currently refining our Key Performance Indicators for this role and more robust reporting on the impact of the role will be produced during 2014/15. However we already have indications that around 7% of referred patients have no identified specialist need and these are referred back to the District Nursing
Service. Some 13% of referrals are redirected to other, more appropriate, hospice services according to their individual needs. This indicates that available resources will be used more effectively and appropriately. We are also now seeking, through service redesign and investment from the Board, to create a Referrals and Advice Centre during 2014/15.
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.
Our aim was to: develop meaningful patient and family reported outcome and experience measures across all hospice services.
During 2013/14 we wanted to implement a locally adapted methodology using a survey construction developed and evaluated by Douglas Macmillan Hospice.
What we did: We successfully rolled out the PROM and FROM programme across all core hospice services and have now collected an entire year’s data. The adapted methodology meant we were able to continuously gain feedback from patients and families about their experience of our care and the outcomes we were able to achieve.
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What was the outcome: We have been able to provide staff, Trustees, our Regulator and commissioners with more detailed information about the quality of our service than ever before. This has been used to inform processes, systems and service development. We now also have sufficient data to directly compare with the results of the other hospice. We will do this during 2014/15 and consider any discrepancies or inconsistencies in results to further enhance our learning and opportunities to further improve patient and family care.
Systems review of Patient Information and Data
Our aim was to: undertake a systems review of our electronic Crosscare patient information and data system to ensure we used it as efficiently and effectively as possible.
What are we aiming to achieve?
To maximise support for professional clinical communications and therefore care delivery as well as improving our ability report on and analyse our clinical activity.
What we did:
As we began the review it became evident that the Hospice needed to look more widely at its use of information technology to support clinical care and efficiency of services. We successfully bid for and were awarded a substantial grant to review our use of information technology and to purchase equipment to improve clinical communications and staff efficiency.
What was the outcome:
We are still progressing this extended project, supported by an outside consultancy. Smart technology is currently being implemented within our Community Team. This will enable real time access to clinical records regardless of staff location and increase staff productivity. In addition we are working on a revised single specialist assessment process which will improve inter-professional communication, reduce duplication of work and improve patient experience. The Hospice continues to work with Healthysoft (the software manufacturer) to influence the ongoing development of Crosscare to support hospice patient and service need. We are now actively seeking further external support to review data management and reporting and ongoing staff education and training to ensure the most effective use of Crosscare. This work will continue during 2014/15.
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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.
During 2013/14 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 2013/14 was £8,853,693. The hospice received a contribution from the NHS equalling 37% 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 £5,577,415 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 then provides quality assurance to the Board.
The Hospice has signed up to the National Institute for Health Research, Clinical Research Network and is currently progressing joining phase 2 of the IPOS Study (integrated palliative outcome score) led by The Cicely Saunders Institute, Kings College, London.
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 were published in a report in May last year and as a result of the project we have now integrated the AAG questionnaire (Adult Attitude to Grief) into the bereavement assessment and exploring its use as an outcome measure.
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As an independent hospice, St Giles’ has not participated in the national NHS clinical audit programme as there are currently 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.
St Giles Hospice has sent the 3 principle Clinical Commissioning Groups with which it contracts, a copy of its Quarterly Quality Report; a document prepared for our Trustee Board and our
Regulator, the Care Quality Commission. We have met regularly with these commissioners throughout the year, where the contents of these reports form the basis for discussion and review.
The reports cover key patient safety topics including the reporting, monitoring, prevention and management of: Falls; Pressure Ulcers; Accidents, Incidents & Near Misses; Safeguarding
(including where associated with Deprivation of Liberty and Mental Capacity); Infection Control;
Medicines Management; Complaints and Patient & Family Reported Outcome Measures.
In year there were no areas of concern raised which required action.
We have also shared with commissioners each CQC Compliance Report which we receive following their inspections.
The hospice also views the report and the review meetings as an opportunity to highlight the service and quality developments that have taken place which improve patient care and experience.
Clinical Effectiveness
 A rapid access pathway for patients at end of life was implemented at our Walsall inpatient service, working in close partnership with the hospital and community specialist palliative care services.
 We were awarded a grant by The St James’ Place Foundation, and with additional support from East Staffordshire CCG (Clinical Commissioning Group) have launched a project to support Care Homes with end of life care and reduce or avoid unnecessary acute stays.
 We have replaced the role of Admission and Discharge Facilitator with 2 x Admission and
Discharge Nursing Assistant posts. These posts will work with family support and the therapy team and will be trained in first level complementary therapy. The aim is also to incorporate within this role carer support offering carers skills training within our clinical skills room.

We have worked in partnership to establish a regional Advanced Nurse Practitioner Forum with Douglas Macmillan Hospice and St Giles Hospice, Walsall and Whittington.
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 We have developed a DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) training session for Day Hospice, Inpatient Services and Hospice at Home. This will enable the nursing team to undertake DNACPR orders.
 Helen Young, Nurse Consultant Lymphoedema, co-authored the British Lymphology Society
National Lymphoedema Tariff Document (2013). Developed to inform commissioning bodies on level of complexity of chronic oedema, classification categories, and level of intervention required for each category, levels of training required for each category, units of time required for each intervention and projected management pathways.
Patient Experience

The Hospice withdrew the Liverpool Care Pathway in early 2013 and has replaced it with an individualised end of life care plan.

St Giles Hospice successfully won its first local authority tender to co-produce and develop a service for carers who care for someone at end of life. Working in partnership with Douglas
Macmillan Hospice, this is an exciting project will enable us to develop support for carers, widen access to hospice support and develop a team of community based volunteers offering support. The funding is a one year pilot project from which we will be able to build a more cohesive and dedicated carers support service.

We have appointed a new staff member to lead the development of our children and young people service; this new service will extend the offer of support into the community and beyond that of hospice patients and their families. We will work with children and young people to design and build the project and are currently in the process of applying for funding for an arts project to develop some film materials.

Provision of a follow up telephone service for bereaved families following the death of a patient at Good Hope Hospital, Sutton Coldfield. This provides bereavement support for the bereaved from all 1600 adult deaths annually.
 We have undertaken an evaluation of a Group Complementary Therapy pilot utilising a focus group approach. Feedback demonstrated the value of the group in reducing isolation, enabling increased independence and providing wellbeing. The group have agreed to work to develop a
DVD to share with people during its continuation on a fortnightly basis.
 In September 2013 we re-opened the newly refurbished Day Hospice following a successful grant application to The Department of Health.
 In September 2013 we introduced a Wellbeing Day on one day per week. This offers a more flexible form of Day Therapies where patients and carers can chose their own mix of activities and therapies (group and individual) and can also book for an appointment with a hospice nurse.
 St Giles Therapy services have launched a six week programme to support our Wellbeing day on Tuesdays, with input around ‘My Meaningful Day’ exercise and wellbeing, fatigue and diet
(supported by our dietician), falls awareness, breathlessness management etc.

Arts into Health project : This was a hospice and community wide project using monies awarded by a variety of trusts to develop a major arts project. This was a new and exciting patient/public/professional community project exploring the uniqueness of people and helping our artist partners to create art based on the experiences of patients, staff and our local community.

Implementation of weekly mobile lymphoedema clinics in the Swadlincote area.
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 British Lymphology Society Award 2013 for best lymphoedema awareness week activity. Helen
Young, member of Children’s Lymphoedema Special Interest Group, facilitated the first national children’s sporting event ‘Lymphaletics’ for over 100 children and young adults with lymphoedema at Ponds Forge Stadium, Sheffield.
 Participation in PLACE - a patient led assessment of the environment of care - which specifically looks at what has been identified as important to patients and assessed by a team of assessors (which must include patients and service users) from the patient’s point of view and impressions.
Patient Safety

We have implemented the use of falls monitors in the inpatient setting where there is an assessed indication for need.

We have developed and implemented a Root Cause Analysis (RCA) tool which ascertains whether pressure ulcers were avoidable/unavoidable using key criteria.

Development of an RCA process that provides consistency in looking at whether incidents are care or service delivery problems, the toolkit also allows now a collaborative approach in looking at improving practice.

We have introduced self-appraisal by all trained nurses on their documentation as a learning tool, to enable them to appraise and ultimately improve their own practice

We have implemented a Clinical Skills training programme aligned with the Registered Nurse annual appraisal Continued Professional Development and Learning.

Renewal of our status as an Approved Practice Setting for medical staff
Other organisational developments
 St Giles Hospice supported South East Staffordshire CCG in its public engagement to support development of their End of Life Strategy by jointly facilitating a series of ‘World Cafe’ events across the community.
 In September 2013 we appointed Dr Sheila Popert to the substantive post of Consultant in
Palliative Medicine, predominantly working in Walsall
 St Giles’ refreshed strategy demonstrated that the advancement of our specialist care, the expansion of our supportive care offer and the integration of the two is critical to future success. Therefore we have implemented a revised structure to include a Head of Specialist
Services and a Head of Supportive Care Services. These posts are formed from within our existing structure and establishment. The purpose of these roles is to improve integration across services ensuring that our supportive care offer is available and designed to support our specialist patients in addition to widening access.
 Introduction of a Summer School for young people interested in a career in the caring professions

In partnership with Skills for Health we have been able to offer the QCF Framework
(Qualifications and Credit Framework) Level 2 and 3 Award in Awareness of End of Life Care

We have also delivered the Level 5 Certificate in Leading and Managing Services to Support
End of Life Care and Significant Life Events to local Care Home Managers.

Theresa Barker, Head of Education, was awarded third place in the Educator of the Year Award
2013 by the International Journal of Palliative Nursing.
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 We have launched a new ‘ What to do when someone dies’ booklet produced as a collaboration between ourselves, bereavement advice centre and RNS publications.

We have launched a Computer Social where members of the local community work as volunteers with patients, carers and staff developing computer skills.

We have appointed a Community Engagement Manager and a Community Engagement Officer to develop an asset based approach to community development. This aims to build the community’s capacity to address death and dying and end of life care and wellbeing in later life.
The implementation of a new methodology to introduce Patient reported Outcome Measures
(PROMs) and Family Related Outcome Measures (FROMs) was successfully undertaken. These results have been shared with our Regulator and Commissioners quarterly.
The questionnaires collect data retrospectively and in ‘real time’ covering experience and outcome for both patients and their families.
The following graphs have been created by analysing the responses from 526 patients and carers.
Overall during 2013/14 96% of patients and their families reported a positive experience
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Overall during 2013/14 91% of patients and their families reported a positive outcome
Overall, in 2013/14 we were able to evidence that we had an overall satisfaction with services of
93% of patients and carers
The annual report has been made available to Commissioners and to our Regulator and is available on request to the Care Director at St Giles, sarah.riches@stgileshospice.com
St Giles Hospice is required to register with the Care Quality Commission (CQC).
Each year inspections are undertaken by the CQC across all three sites - Whittington, Sutton
Coldfield and Walsall. The inspectors decide prior to the inspection the areas they wish to examine and advise staff on arrival of their requirements.
During 2013/14 all inspections were routine but unannounced.
Not chosen for inspection at this location
Date of inspection
St Giles Hospice
Walsall
06/11/2013
St Giles Hospice
Sutton Coldfield
23/01/2014
St Giles Hospice
Whittington
29/01/2014
Essential standards of quality and safety chosen:
Respecting and involving people who use services
Consent to care and treatment
Care and welfare of people who use services
Safeguarding people who use services from abuse
Cleanliness and infection control
Management of medicines
Safety and suitability of premises
Met the standard
Met the standard
Met the standard Met the standard Met the standard
Met the standard
Met the standard Met the standard
Requirements relating to workers
Supporting workers
Met the standard
Assessing and monitoring the quality of service provision Met the standard
Complaints
Met the standard
Met the standard
Met the standard
Met the standard
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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:
The inspectors spoke to patients and their families:

One person who used the service told us: "It is calm and peaceful. Staff are attentive. They come when I need them".
 One person who used the service told us: "I have been asked what my religious beliefs are".
 One person who used the service told us: "Everything has been explained to me. I know what to expect. I don't feel anxious about the care here". They told us they were involved in reviews about their care and support needs.
 A relative told us: "It is brilliant. When you press the buzzer staff are there. [My relative] gets what they need. Staff are attentive. [My relative] loved it there. It was so quiet. I would advise anyone to go there".
 One person who used the service told us: "I am very happy with the service from top to bottom. The staff are all great. They couldn't do enough for me. They went out of their way. I thought they were brilliant. I was given good information".
The inspectors spoke to staff who commented:

We spoke with staff about how they supported people who used the service to promote their independence, privacy and dignity. One member of staff told us: "We explain what we are doing and discuss things with people. We ensure people's confidentiality".

Another member of staff told us: "We take time to get to know people and their families.
We seek permission from people at every stage of their care".

We spoke with one member of staff who told us: "I love it here. We have time to give good care".

One member of staff told us: "If I had any safeguarding concerns I would report them to my manager. I get safeguarding training every year".

One member of staff told us: "I have to complete mandatory training and specific nurse training. I also have a mentoring role and support other members of staff". This meant that people were cared for, or supported by suitably qualified and skilled staff.
The inspection included examination of processes and procedures to ensure the Hospice was compliant in ‘Safeguarding people who use services from abuse’
We (CQC Inspector) saw that procedures were in place so that any incidents, allegations of abuse or any type of neglect were responded to appropriately by staff. We found that that the provider responded appropriately to any allegations or concerns about possible abuse.
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The Inspectors looked at the 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. We talked with carers and / or family members, talked with staff and reviewed information given to us by the provider.
What people told the inspectors and what they found:
The inspectors spoke to patients and their families who commented:

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. One person told us," They always ask me before they do anything".
 Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. One person told us, "The quality of care is excellent".
 Some of the people who we spoke with gave examples of how they were given the information they needed to make choices. One person told us, "I initially went to
Whittington and then I was offered the opportunity to attend the Sutton Clinic which is a lot more convenient for me".
 Another person told us, "When I go to clinic they always keep me informed of any changes".
 One person who we spoke with told us, "If I don't get seen by the same person it does not make any difference as they have all my up to date details. It's fantastic".

One person told us, "The staff really take care in marking and measuring my legs and then comparing this to previous results".

A relative told us, "The nurse we see is absolutely brilliant. If I have any concerns I discuss them with her and she will speak to the hospital consultant if needed".

We saw that the notice board at the centre contained a list of activities and events that were taking place. Some of the people who we spoke with told us how these sessions had a positive impact on them. One person said, "I get do yoga and I am part of the walking group which is really good for me as I like to stay active".

A relative told us, "We get invited to different events taking place like garden parties and sometimes the fire service visit with the fire engine which we really enjoy".

We saw that there were facilities for people to enjoy a meal and hot drinks. We saw and people that we spoke with said that they could help themselves to regular hot drinks whilst attending the centre. One person told us, "When I am attending a session, I like to have lunch from the canteen and you can have tea and coffee when you want".
 People who we spoke with were very happy with the cleanliness of the environment. One person told us, "Staff always remind us to use the hand rub before we go in and when we come out of clinic".
 A relative who we spoke with said, "It's spotless". We saw the environment was visually clean and tidy.
 Comments made by people who used the service included, "The views are beautiful" and,
"The surroundings and atmosphere is so calm and peaceful".

People and relatives who we spoke with were happy with the layout of the premises. One person told us, "The facilities are first class".
2013/ 2014 Quality Account - 19 -

The inspectors spoke to staff who commented:
 The nursing staff who we spoke with had a good understanding of infection prevention control procedures and practices and said they had received training in infection prevention and control. One member of staff who we spoke with told us, "Good hand washing is very important".
The Inspectors observed how people were being cared for, talked with people who use the service and talked with carers and / or family members. They also spoke with staff.
What people told the inspectors and what they found:
The inspectors spoke to patients and their families:
 We found care was planned and delivered to keep people safe and which promoted their wellbeing as far as was possible. One of the relatives we spoke with told us: "This is a wonderful place to be".
 Care was designed and given to ensure the person's wellbeing whatever stage of their life they were at. One person who used the service told us: "this is the best place for therapy I have ever been too". Another person told us: "They got my pain under control here".

People we spoke with told us they were able to express their fears, wishes and plans without fear or prejudice. One family we spoke with told us: "My loved one wanted to die here and the hospice made it possible for him to enjoy his last few months pain free and well looked after".

One relative we spoke with told us: "It's too painful to talk about why we are here but, this is a wonderful place to be". The also told us: "The care here is truly wonderful".
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.
If you would like to read any of the reports in full please access the Care Quality Commission website: www.cqc.org.uk
and access the section entitled ‘For the public’
2013/ 2014 Quality Account - 20 -

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 CCG clusters (Clinical Commissioning Group).
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.
The most recent National Minimum Dataset issued by The National Council for Palliative Care covers the period 1 st
April 2012 to 31 st
March 2013. We have used the national median from this data to benchmark Hospice performance. The data for 2013/14 is in the process of being collated but has not yet been published.
In-Patient Unit – Whittington
% New patients
St Giles Hospice
85.8
National Median
88.3
% Occupancy 74.4 79.1
% Patients returning home 51.6 42.7
Average length of stay – cancer 14.7 14.7
Average length of stay – non cancer 11.4 13.2
St Giles Hospice National Median
In-Patient Unit – Walsall (opened April 2011)
% New patients
% Occupancy
% Patients returning home
Average length of stay – cancer
Average length of stay – non cancer
Day Hospice
% New patients – cancer
% New patients – non cancer
88.6
60.2
51.4
88.7
77.5
56.1
12.9 12.8
8.3 10.9
St Giles Hospice National Median
71.7
28.3
76.5
23.5
47.1 57.6
% Places used
Community : Clinical Nurse Specialist
% New patients
St Giles Hospice National Median
61.2% 68.0%
% New patients with a non-cancer diagnosis
5.5% 14.5%
Visits per completed series 3.9 3.8
2013/ 2014 Quality Account - 21 -

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 onwards includes Walsall)
Total number of new referrals to St Giles Hospice
2012/13 2011/12 2010/11
4,135 4,085 4,070
Total number of referrals not proceeding
Total number outpatient attendances
Total number of attendances by patients at the Day Hospice
Total number of contacts with patients by the community service
Total number of Hospice at Home sessions provided
Total hours of Hospice at Home input
Total number of complaints
The number of complaints which were investigated and resolved in full
The number of complaints which were investigated, resolved but only upheld in part
The number of incidents reported to RIDDOR involving patients (Reporting of
Injuries, Diseases and Dangerous Occurrences Regulations)
The number of incidents reported to RIDDOR involving staff
781
4,525
1,714
694
4,140
2,005
35,483 47,694
4,948 4,604
12,265 7,313
32*
9
11
3
12
0
1
4
0
3
3
3
2
633
4,173
1,854
40,840
4,328
12,121
10
6
Compassus Inpatient Unit
Total number of patients admitted to in-patient unit
% of patients who went home
367
52.6%
412
48.3%
Number of available bed days 7,300 7,320
% Bed Occupancy
The number of patients known to be infected with MRSA on admission to the in-patient unit (Methicillin-resistant Staphylococcus aureus)
Patients infected with MRSA whilst on the in-patient unit
The number of patients known to be infected with Clostridium difficile,
Pseudomonas, Salmonella, ESBL (Extended-Spectrum Beta-Lactamases) or
Klebsiella pneumonia on admission
Patients diagnosed with these infections whilst on the in-patient unit.
Average length of stay on the in-patient unit (days)
Number of falls per occupied bed (Number of beds multiplied by bed occupancy and divided by number of falls)
2013/ 2014 Quality Account
79.3%
1
1
3
0
14.4
5.99**
73%
1
11.4
7.12
- 22 -
1
0
1 1
1
12.9
4.06
334
46.1%
6,699
75.9%
3
0

Indicator for St Giles Hospice (2011/12 onwards includes Walsall)
2012/13 2011/12 2010/11
Walsall Inpatient Unit opened April 2011
Total number of patients admitted to in-patient unit 217 197 N/a
% of patients who went home
Number of available bed days
46.5%
4,380
52.8%
3,398
N/a
N/a
% Bed Occupancy
The number of patients known to be infected with MRSA on admission to the in-patient unit
67.8%
2
62.2%
3
N/a
N/a
Patients infected with MRSA whilst on the 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)
0
0
0
0
1
0
N/a
N/a
N/a
12.21 10.7 N/a
Number of falls per occupied bed (Number of beds multiplied by bed occupancy and divided by number of falls)
3.94** 4.97 N/a
* There were a number of complaints in year regarding the patient’s geographical location and ability to access our services if 'out of area' i.e. where the General Practitioner postcode is out of our traditional catchment. We have now reviewed our response across departments to referrals and enquiries for patients who are technically 'out of area'. All referrals are considered on an individual basis; we will take from border/ out of area where patient and/or family request and where discharge can be safely facilitated. The hospice is sensitive to the public expectation of our support and conversely the critical support the public offers the hospice. In addition we believe the increase in complaints is also in part a reflection of the introduction of the PROMs and FROMs methodology has provided a more accessible route to raising a concern of complaint, which we welcome.
** Upon arrival at inpatient ward all patients are assessed for risks associated with moving and handling and falls. For those patients identified as being at risk of falling additional assessment and monitoring is undertaken. The Hospice has a specific incident form for staff to use when reporting patient falls which enable the collection of robust information to ensure that every measure possible has been undertaken to prevent re-occurrence but at the same time promote independence.
Within the incident form falls are classified as no injury, minor injury and serious injury. Minor equates to bruising and abrasions and major to trauma requiring hospitalisation and management. During 2012/13 the following statistics were reported to Trustee led Clinical Governance committee:
Whittington
Walsall
No Injury
71%
62%
Minor Injury
29%
38%
Serious Injury
0
0
2013/ 2014 Quality Account - 23 -

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 CCG commissioners within the April to June 2014 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.
Below is a selection of audits undertaken together with outcomes:
Controlled Drugs Accountable Officer (CDAO)
Aim and objective
To ensure that the hospice is able to evidence that the appointment of the Controlled Drugs
Accountable Officer and the discharge of their responsibilities in the management of
Controlled Drugs will meet the required regulation and legislation and that all hospice
Outcome 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:

Appointment of the CDAO

The roles and responsibilities of the CDAO

Annual Review by the CDAO

Continuous quality monitoring
Evidenced 100% compliance
Follow-up actions
1.
Undertake review of risk assessment accounting for the frequency of the CD stock checks
2.
Discuss exception reporting with Pharmacist at Walsall
3.
Review effectiveness of new CD destruction documentation
4.
Undertake six monthly checks on both inpatient units to support the monitoring programme
Health Records including Moving and Handling
Aim and objective
Outcome
Follow-up actions
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.
4 areas of practice were audited by each department:

Patient record including Crosscare demographics / Patient Information Sheet

(Walsall only)

Departmental assessment and on-going review

Paper based assessments
Moving and handling
Average compliance score for the Hospice was 92%
Results were fed back to members of each department to raise awareness of inconsistencies and poor practice.
2013/ 2014 Quality Account - 24 -

Prevention and Control of Healthcare Associated Infections (HCAI) Re-audit
Aim and objective
Outcome
A re-audit undertaken to ensure that the Hospice complies with The Health & Social Care
Act 2008, Code of Practice on the Prevention and Control of HCAI (Healthcare Associated
Infections)
Help the Hospices National Audit Tool PCI02 reviewed:

Management Systems

Policies and Protocols

Control of Environment

Provision of Information

Personnel - Screening, Protection & Training
Evidenced 96% compliance
Follow-up actions
1.
Infection Control Lead has worked closely with Nursing and Housekeeping Teams to create cleaning schedules which will be incorporated into the reviewed Policy. The schedules will also be incorporated into the audit and monitoring undertaken by the
Infection Control Champions.
2.
The patient information leaflets have been reviewed and updated and will be presented at the Infection Prevention and Control Forum on 13 th
May 2014 for approval.
Infection Control Re-audits and Monitoring
Aim and The hospice will have effective infection control policies, process and structures to reduce objective
Outcome 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

Infection Prevention and Control Forum supporting clinical and non-clinical staff across the organisation

Infection Control Nurse and departmental Infection Control Champions undertake ongoing monitoring

Inpatient units: o Compliance rate of 99.7% for hand hygiene practice o Compliance rate of 100% for use of gloves and hand hygiene practice o Quarterly auditing of:
 Patient areas
 Clinical rooms
 Patient bathrooms
 Patient toilets/bidets
Average compliance score of 95.66% o Yearly auditing of:
 Kitchen Areas (excluding main kitchen)
 Hand Hygiene
 Sluice / Dirty Utility
 Care of deceased patients
 Sharps
 Protective Equipment
Average compliance score of 98%

Hand Hygiene Awareness day for patients, volunteers and staff held at Lindridge Road,
Sutton Coldfield

Compliance rate of 100% for hand hygiene practice in Day Hospice
Follow-up actions
The robust audit and monitoring programme will continue to ensure that the Hospice minimises the risk of infection to patients, clients, staff and visitors.
2013/ 2014 Quality Account - 25 -

Controlled Drugs Audit (Inpatient Units)
Aim and objective
Outcome
To verify that standards are being met by the Hospice in the management of controlled drugs regarding compliance with current law & regulations and best practice
Help the Hospices National Audit Tool 5 reviewed:

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
Evidenced 97.5% compliance
Follow-up actions
Review of action plan identified:

Outcome of the audit was shared with all staff working on the inpatient units

Areas of inconsistent practice were highlighted

Continue with monitoring programme and re-audit in September 2014
General Medicines Audit (Inpatient Units)
Aim and To provide evidence that the hospice is compliant with current legislation, regulation and objective
Outcome standards relating to non-controlled medicines.
Follow-up actions
Help the Hospices National Audit Tool 7 reviewed:


Purchasing and Supply of Stock Medicines

Standard Operating Procedures (SOPs)
Storage and Destruction of Medicines

Prescribing of Medicines

Administration of Medicines.

Patient's Own Medicines

Non-Medical Prescribers
Evidenced 98% compliance

Outcome of the audit was shared with all staff working on the inpatient units

Areas of inconsistent practice were highlighted

Continue with monitoring programme and re-audit in October 2014
Safe and Secure Handling of Medicines (Inpatient Units)
Aim and objective
Outcome
Follow-up actions
To put in place a robust system of monitoring and reporting based on current legislation, regulation and standards.
A range of audit tools were developed to review:

Pharmacy provision

CD documentation and process

Drug Charts and TTO Forms (Tablets to take out)

Pharmacy intervention
Average score for monitoring on the units of 95% compliance

Each quarter the reports were circulated to Nurse Consultant and members of
Senior Nursing Team, Medical Director for dissemination to all medics, Pharmacist and Care Director who is also the Controlled Drugs Accountable Officer.

The reports identified inconsistencies and recommendations

The Pharmacy Intervention report was used to identify trends and where additional support may be required
2013/ 2014 Quality Account - 26 -

Nutrition and Hydration Audit
Aim and objective
The hospice will be able to demonstrate compliance against regulated activities to:

Reduce the risk of poor nutrition and dehydration by encouraging and supporting 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
Outcome A baseline assessment using Help the Hospices National Audit Tool TC-04 considered:

Organisation – policies and procedures

Clinical Services

Education and Training

Service Evaluation
The average score of 60% was not a reflection of the work undertaken to enable the hospice to meet the standard. The action plan had been completed but some elements of training had not been implemented therefore must score 0 in the audit.
Follow-up actions
A review of the identified actions was undertaken in February 2014 and the compliance score rose from 60% to 85% and the Hospice will be fully compliant once the Education
Programme begins in April 2014.
Departments undertake 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.
Method: Each quarter survey sent out to clients - during the year the team received 34 completed forms.
Outcome:
100% of respondents answered ‘Yes’ to the question ‘Would you recommend this service to others

Respondents were asked how they felt following their course of treatments : 100% indicated they ‘felt more relaxed’; ‘more able to cope’ and ‘improved well-being’ – there were no clients who indicated that they had no benefits from the treatment

97% 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

These are just some of the comments received:

Please keep up the good work. This has made such a difference to me just to have an hour of ‘me’ time and relax was fantastic. Thanks so much

After the therapy I felt more relaxed and slept better

I didn’t know how many sessions were available – in retrospect the most useful one was immediately after a bereavement counselling session.
Would recommend that carers are advised to have their sessions after the loss of their loved ones as 1) it makes you go out, 2) helps you to realise that you need to care for yourself and 3) extremely beneficial after counselling
2013/ 2014 Quality Account - 27 -


The care and support that St Giles offers both to the patient and their family is amazing. The complementary therapy I have received has helped me to cope better with caring for my husband through his illness

I cannot thank you enough for the kindness and care you gave me and my family. My treatments were lovely and although I find it difficult to relax they did help to calm me. This service provided a lifeline – literally – and
 gave me something to look forward to each couple of weeks. Thank you very much
I took away from the service the ability to ‘help myself’ during our day to day struggle living with cancer. Self-help is so important to me as a carer and I think necessary when sometimes feeling overwhelmed with the rest of the families concerns. My treatment has been very beneficial. Thank you.
Method:
Outcome:
Following completion of support each client is sent a questionnaire
During the year 69 evaluations were sent out with 52 returned (response rate of 75%)

89% of respondents indicated that the support they received from the service made their experience of bereavement more bearable

100% of respondents indicated that they were satisfied with the service provided

98% of respondents indicated that they would recommend the service to others

The counselling helped my wife, my boys and myself understand the illness, be realistic about the outcome and understand our and others emotions, what drove them and what was the best way to embrace them

Being able to talk openly to an outsider rather than a family member, without feeling of burdening them with your grief as well as their own.
Just having someone listening to you and not being judgemental

The lady that I saw was very understanding, never judgemental, very kind and became a friend. I could cry, laugh, say how I felt without embarrassment - without her help I would have become a total wreck

My counsellor was my help. She was gentle and compassionate. Over
These are just some of the comments received: the year I attended never once did I feel anything other than helped and supported by her. My situation became complex and every time she listened with understanding. I know, I would not be the person I am now without her help – I can now move forward

It was helpful and timely. You doubt yourself and feel selfish and cruel in your thoughts. I was made to feel that these thoughts are normal and acceptable. I felt more confident, happier and more able to care as I felt I was doing fine and able to and getting confirmation I was actually coping

I was so pleased that I attended the sessions I did. Everything we talked about sorted a lot of the problems and feelings I had going through my head. Even though I get low feelings about the losses I had and relationship problems. When these arise I can handle them almost perfectly and not get hung-up on negatives.
2013/ 2014 Quality Account - 28 -

Method: Quarterly real time monitoring of patient experience and catering - Patients were asked to indicate their impressions of the service and its ability to meet their on-going need
Patient Experience:
Outcome 
The evaluation covered areas of the service: o Environment o Understanding how the 12 week programme works o Information received about Day Hospice and how to contact the team o Access to nursing support o Being involved in planning your care o Support to maintain independence
Patients were given a scale of 1 to 5 for each question – 1 representing extremely poor up to 5 representing completely satisfied.
81% of respondents ticked 5 indicating they were completely satisfied with 17% selecting 4 on the scale.
These are just some of the comments received:

The care could not be bettered. Staff seem to know when you need any help and come to you straight away

Care and attention are excellent. Nurses and carers are very friendly and helpful and try (and succeed) to help and advice whatever problems are thrust at them. I enjoy coming and meeting all the staff and I cannot find any fault at all. My thanks go to everyone, my highlight of the week is when I come to Day Care not to be nursed

Excellent – love it here! Improving self esteem, amazing staff and made great friends. Given me a big boost thank you

Please accept my thanks for the excellent work you do. Your care is unobtrusive but is readily available when I need it. Friday in many ways is the highlight of my week – food, exercise, water colouring and companionship are all top notch
Catering:
Outcome 
100% of respondents indicated that the Day Hospice dining room was a nice place to eat in

100% of respondents indicated that their mealtime is an enjoyable experience

85% of respondents indicated that the Hospice offers enough variety on the menu
These are just some of the comments received:



Generally the standard is very good
I find it all very good.
Staff to patient ratio excellent. Very warm, welcoming atmosphere

I find nurses and carers very helpful and kind. A day I always look forward to. A big thank you. I consider my Thursday to be very special
2013/ 2014 Quality Account - 29 -

Method: Following completion of their 12 week contract:
Outcome 
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: 72% indicated that it had ‘Exceeded their expectations’ and 24% indicated that it has
‘Met their expectations’
These are just some of the comments received:

I have really enjoyed coming to the hospice as it gives me somewhere to go each week and meet people in a similar situation as myself

Everything is perfect – very friendly and as I have said before I come with a happy face and go home and look forward to next Friday

Major benefits being able to talk to people with experience and understanding who have time to listen. Very warm and welcoming atmosphere from day one. (good food)
The Hospice took part in a national staff survey run by Birdsong Charity Consulting, on behalf of
Help the Hospices.
The survey was open during June and July 2013 and 193 individuals from St Giles Hospice completed the survey, 104 paid staff and 89 volunteers. Overall 5,501 people took the survey from 42 participating hospices.
The survey asked 47 questions across 5 topics. For each question the respondent could choose
Strongly disagree, disagree, neutral, agree or strongly agree.
1. The Organisation and Communication
2. Morale and Work life balance
3. People Management
4. Development and reward
5. Other
(13)
(15)
(10)
( 8)
( 1)
Average ‘Agree’ response from St
Giles
64%
73%
67%
56%
96%
National ‘Agree’ response
64%
68%
68%
61%
95%
In 21 of the questions (45%) the Hospice scored above the National average
Overall respondents felt that St Giles did particularly well in:

Recommending St Giles as an employer

Feeling appreciated

High morale in the charity

Planning to be working here in a year’s time
2013/ 2014 Quality Account - 30 -

We didn’t score so well with
 Receipt of praise for work
 Competitive pay
There was a clear improvement in how our staff view the hospice and their roles here since the last survey in 2011 and the aim is that we will have done even better by the time of the next survey (2015).
The Employee Forum has continued in its role of providing a medium where new ideas, policy changes and organisational issues can be discussed freely and proactively in an open and honest culture.
The forum is chaired by the Group Chief Executive and attended by Deputy Chief Executive, other members of senior management team, a representative from the Volunteer Forum and 14 employee representatives as elected by their fellow employees.
Giving Volunteers a voice:
St Giles Hospice Volunteer Forum – originated 2000, reconstituted in 2012 to mirror a newlyestablished Employee Forum at which it is represented by the Voluntary Services Manager. The
Forum represents all volunteers and encourages their interest and participation in organisational matters which affect their interests. Meeting on average three times a year, this is chaired by the
Hospice Chief Executive – most recently the initial 45 minutes of each meeting have been dedicated to an area of the Hospice which is new, for example, our Care Agency and Community
Engagement.
Following in-depth updates from the Chief Executive at each meeting, he takes questions, responds and follows up. This group of nine representatives has also been part of organising and participating in annual awards functions. At present, they are considering a revised role description to look at defining their representation more clearly.
Volunteer Team Leaders Group – all volunteers are managed in their departments or teams and this group meets a couple of times a year. It enables consistency of approach to recruiting, processing and managing volunteers in a very open environment, where volunteer issues – from both perspectives – are able to be freely shared. For example, volunteer views regarding specific issues have been discussed and passed on or provided the basis to revisit aspects of their management.
Volunteer Groups Away Time/Team meetings – there is a positive attitude to ensuring volunteers are part of their teams. Recently Supportive Care Volunteers and Ward volunteers attended away time meetings to talk about their roles and what helped and hindered delivery of them.
In the case of the Ward Volunteers, a sub group is now working on revised role descriptions and a new orientation pack. Ward volunteers are also encouraged to attend multi-disciplinary team meetings every two months, with healthcare professionals and service deliverers to keep them
2013/ 2014 Quality Account - 31 -

updated and for them to provide feedback on their role delivery – these sessions are chaired by the Head of Specialist Care, documented and information circulated to all volunteer team leaders.
During this year the hospice supported staff, both in terms of financial support and study leave, in their personal development across a range of education and learning both through formal academic qualifications, training and education in a variety of formats including e-learning:

Non-medical prescribing
 Principles of Physical Assessment
 European Certificate in Palliative Care
 Mentorship within Health Care Setting
 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

Dementia Awareness

Professional Doctorate
QCF courses:
(Qualification and Credit Framework)
Elearning module topics:
Level 2 Award in Awareness of End of Life Care
Level 3 Award in Awareness of End of Life Care
Health and Safety
Fire Safety & Evacuation
Equality and Diversity
Information Governance
Safeguarding Adults
Safeguarding Children
Manual Handling
Mental Capacity Act
Conflict Resolution
Lone Working
Dementia Awareness (Clinical staff but also on request)
Safe Use of Insulin (Compassus & Walsall inpatient staff only)
Deprivation of Liberty Safeguards
The Management of Urinary Catheterisation for Adults
Food Hygiene
Control of Substances Hazardous to Health
2013/ 2014 Quality Account - 32 -

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 the Committee also considered: Clinical Excellence Awards; Out of hours, provision, A
Report on Service User involvement, Methodology for Patient and Family Reported Outcome
Measures, Root Cause Analysis (RCA) – Re: Saf T Intima cannula incident, Minimum Data Set
Report from the National Council for Palliative Care, the First Contact Nurse Specialist Role and
The Cavendish Review.
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.
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National Health Service
Clinical commissioning groups (CCGs) are NHS organisations set up by the Health and
Social Care Act 2012 to organise the delivery of NHS services in England
Do Not Attempt Cardiopulmonary Resuscitation
Root, Cause and Analysis
A framework for vocational qualifications - the Qualifications and Credit Framework
(QCF) will provide a more flexible approach to learning and enable learners to achieve
Credit for their qualifications.
M eticillin-resistant staphylococcus aureusis - a type of bacterial infection that is resistant to a number of widely used antibiotics.
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.
Employers, the self-employed and those in control of premises are required by law to report specified workplace incidents, such as work-related deaths, major injuries, 7-day injuries (those causing more than seven day’s inability to carry out normal duties), work related diseases, and dangerous occurrences (near miss accidents).
Extended Spectrum Beta-Lactamases are enzymes produced by bacteria such as
Escherichia coli ( E.coli
) and Klebsiella . These are mainly bacteria that are found normally in the human bowel, but can cause serious illness. ESBL’s can be resistance to a range of frequently used antibiotics including penicillin’s and cephalosporins As a result, infections caused by these bacteria can be difficult to treat and the prevalence of these bacteria and infections caused by them are becoming more common in both community and healthcare setting.
Healthcare Associated Infections - A hospital-acquired infection, also known as a HAI or in medical literature as a nosocomial infection, is an infection whose development is favoured by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff
Tablets to take home – medication provided to patients upon discharge
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Response dated 7 th August 2014 received from Sally
Roberts, Walsall CCG Lead Nurse on behalf of
Walsall CCG are pleased to comment on this Quality Account for 2013/14 for St Giles Hospice
Walsall.
The account details positive work that has been implemented throughout the year in relation to clinical effectiveness, patient experience and patient safety. WCCG acknowledge St Giles commitment and continuous work towards monitoring and improving quality of the services they provide.
Work undertaken by St Giles in the area of patient safety has been acknowledged, in particular the work around falls prevention and strengthening of Root Cause Analysis process which supports a collaborative approach to improving practice.
WCCG recognises that St Giles met all CQC standards following inspection and notes the positive feedback provided by CQC regarding services provided, in particular in respect of staffs experience of working at St Giles
WCCG is pleased that patients and families receive a positive experience and this is clearly evidenced through departmental evaluations and patient and family/carer surveys.
Quality indicators have been monitored through contract meetings with performance remaining consistently high throughout the year.
WCCG supports the following priorities for improvement for 2014/15 and looks forward to receiving progress reports throughout the year.

Seek accreditation as a Practice Development Unit and become a research active organisation
 Proactively work with partners in the primary, secondary and tertiary sectors to find solutions for non-cancer end of life care, including dementia
 Implementation of 5 Diversionary Pathways for Exacerbation of Respiratory Conditions;
Hypercalcaemia; Cellulitis management associated with Lymphoedema; Blood Transfusion and Intravenous furosemide for patients with decompensated heart failure.
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Response received 24 th
September 2014 from
Barbara King, Accountable Officer on behalf of
St Giles Hospice Quality Account 2013/14
Statement of assurance from Birmingham CrossCity Clinical Commissioning Group
Birmingham CrossCity CCG welcomed the opportunity to provide this statement for the 2013/14
Quality Account for St Giles Hospice. The Quality Account has been reviewed in accordance with the Department of Health guidance.
Birmingham CrossCity CCG, and its partner CGGs, are committed to ensuring that the service they commission provides the very highest of standards in respect to clinical quality, patient safety and patient experience. With this in mind we have worked closely with St Giles Hospice during the year in monitoring service delivery and reviewing performance through regular Clinical Quality Review
Group meetings which are a forum for discussing the quality of services and the safety of patient care.
Overall the Quality Account appears to be comprehensive and balanced in reflecting the activity within the Hospice during 2013/14, whilst clearly setting out the planned quality intentions for the coming year. Indeed the organisational strategic aims were extremely clear, well written and very appropriate for the service.
Generally the Quality Account was found to be very readable, and we welcome the inclusion of an abbreviation list which supports understanding for readers of this public facing document.
We welcomed the inclusion of comments made by clients and their families within the document and felt that they struck at the real heart of the hospice and the care it provides.
We also welcomed the clear statement within the Quality Account which detailed the director’s responsibilities, and feel that this was an example of good practice that all NHS Quality Accounts should include.
Whilst reviewing the Quality Account we were pleased to note some of the specific areas of work which we considered demonstrated positive developments which enhanced clinical care, service delivery and the wider patient experience. These included:

The ongoing work with Staffordshire University to develop and implement a strategy for becoming an accredited Practice Development Unit.

The ongoing work with Kings College London on the IPOS international study to validate the outcome measures tool for palliative care.
We were also pleased to note how the Hospice plans to continue their priorities for improvement during 2014-2015 and welcome the following planned developments:

The implementation of the 5 Diversionary Pathways. We agree that this work should make a great improvement to the delivery of patient focussed care.
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We welcomed the inclusion of a section of the Quality Account which focussed onto the assurances provided to NHS Commissioners which covered key issues such as patient safety, learning lessons from incidents and safeguarding arrangements including Deprivation of Liberty and Mental Capacity.
It was also positive to have confirmation of CQC inspection that have taken place during the year to confirm these issues were being robustly addressed within day-to-day practice. Additionally, in respect to preventing/ reducing avoidable harms we welcomed the positive work the hospice has undertaken in respect to tackling falls, pressure ulcers and healthcare acquired infections.
In summary, we welcomed the opportunity to comment on the 2013/14 Quality Account for St
Giles Hospice and generally consider that this report was well written and provided a balanced view of the activities within the service. As a commissioner Birmingham CrossCity CCG shall continue to work in partnership with the Hospice to support the delivery the quality agenda in
2014/15.
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