St Giles Hospice Quality Account 2019-20

St Giles Hospice
Care Quality Account

April 2019 to March 2020

















We have met with We were visited by our You can read the report on the CQC
commissioners throughout Staffordshire Commissioners website at www.cqc.org.uk/
the year, where the contents of on 7th January 2020. This location/1-129284270
these reports form the basis for visit provides assurance to
discussion and review. Staffordshire CCGs that St Giles 5.4 Clinical effectiveness
Hospice is providing safe, good
The reports cover key patient quality care to the patients of • 100% of patients who receive
safety topics including the Staffordshire. No concerns were care from our Hospice at
reporting, monitoring, prevention raised following the visit and the Home team were enabled to
and management of: visiting team thanked St Giles die at home.
Hospice for their openness
• Falls and transparency. • Overall, people who receive care
from the hospice are nearly 25%
• Pressure ulcers On 11th February 2020 we were less likely to die in hospital.
visited by our Birmingham
• Accidents Commissioners.

• Incidents and near misses CQC made their unannounced
inspection on 6th March 2019
• Safeguarding (including where until 8th March 2019. They
associated with deprivation of published the report on their
liberty and mental capacity) website on 15th January 2020 and
we were delighted to receive an
• Infection control overall ‘Outstanding’ rating.

• Medicines management

• Complaints

• Patient and family reported
outcome measures

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6. Patient safety



6.1 Safeguarding for St Giles Hospice. To assist Control advice. The Infection
with this we undertake the Prevention and Control Nurse
There were no safeguarding Infection Prevention Society’s is a member of the Infection
issues during 2019/2020 that (IPS) audits throughout the Prevention Society and Hospice
required escalating or reporting year covering both Whittington UK’s Infection Prevention and
to CQC. We continue to provide and Walsall sites along with Control Forum and also networks
staff with booster training in year Antimicrobial Audits. We regionally with other hospices
concerning the Mental Capacity undertake Hospice UK’s Health to ensure we are up to date with
Act, Deprivation of Liberty and and Social Care audit annually. best practice.
Safeguarding. We completed the The audit process is now under
Safeguarding Quality Assurance review to establish any changes 6.4 Medicines management
Audit with Birmingham and that may be required to ensure all
Solihull Clinical Commissioning areas are audited appropriately. In year we analysed our rate of
Group (BSol CCG) in 2019/2020. errors concerning medicines
Infection prevention and control administration. The error rate
An audit regarding safeguarding champions, made up of qualified was 0.04%, meaning less than 1
policies and practices was and unqualified ward staff, error per 2,000 administrations,
completed in late 2019. This was undertake monthly audits on showing our medicines
an ideal opportunity to review the handwashing, sharps boxes and administration processes and
policies and practices which were cleaning equipment. delivery are safe.
in place and highlight any further
areas for improvement. The Annual mandatory infection To ensure that the hospice
audit identified good practices prevention and control training can evidence safe working we
in safeguarding and the training is given to all our clinical staff continue to undertake four
programme which was in place. and tailored training for ward clinical audits during the year:
The audit also highlighted some volunteers and housekeepers Self-Assessment Audit for the
additional policies which needed was introduced in 2018 and Controlled Drug Accountable
developing and some further continues to be rolled out. Officer (CDAO), Controlled
work around PREVENT which Drugs, General Medicines and
has been instigated. This action Several policies and Standard Medical Gases.
plan has become one of our Operating Procedures were
priorities for 2020/2021. updated in regards to the The Medicine Management
monitoring of samples and/or group met six times during
6.2 Duty of candour possible infections carried out on 2019/2020, which acts as the
a weekly basis. delegated body for approving
There were no duty of candours recommendations in relation to
reported in 2019/2020. St Giles Hospice has a Service medicines management across
Level Agreement with University the hospice. During this time new
6.3 Prevention and Hospitals of Derby and Burton guidance on the Management
management of infection for Pathology specimens of Seizures was developed and
and Infection Prevention and approved.
Preventing, reducing and
managing infections is a priority

“The service had enough staff with the right qualifications,
skills, training and experience to keep people safe from
avoidable harm and to provide the right care and treatment.”

– CQC report, January 2020
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13. Our participation in clinical audits

Planned Audits Outcome

Self-Assessment Audit for the The audit was delayed due to the COVID-19 pandemic. The audit took

controlled Drug Accountable place in July 2020 – we audited against a nationally developed tool from

Officer (CDAO) Hospice UK and we were able to evidence 100% compliance.

Health Records including Throughout the year we averaged 96% compliance. Each quarter the
Moving and Handling results were fed back to the team highlighting both good practice and
areas for improvement. Specific areas of inconsistent practice are
regularly revisited by the senior team to support staff.

Infection Prevention We audit against the Health and Social Care Act to provide evidence
and Control that the management of our service is compliant on the prevention and
control of infections. Using an updated national tool from Hospice UK we
evidenced 100% compliance.

The robust auditing and monitoring by our Infection Control Lead and
support staff ensure that prevention is a priority within the hospice.

Highlights:

• Compliance rate of 100% for hand hygiene practice

• Quarterly auditing of patient bedrooms, bathrooms and toilets – average
compliance score of 99%

Yearly auditing comprised 17 individual audits of a range of areas
including food storage and handling; sluice, clean and dirty utility,
guidelines and policies, hand hygiene, moving and handling equipment;
management of equipment and waste management – average
compliance score of 93%.

Medicines Management Yearly audits are undertaken using national tools developed by Hospice
UK. For Controlled Drugs we averaged 99% compliance, for General
Medicines the average compliance was 96.5% and for Medical Gases
the average compliance was 97.5%.

To ensure we remain vigilant we audit quarterly using tools developed
by our palliative care pharmacist. Overall we averaged 92% compliance
during the year.

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14. Supporting staff and our community


to have a voice within our organisation



The Care Quality Commission patients, staff, the public and During 2019/2020 we sought
stated in their report that “There local organisations to plan and feedback from staff and
were consistently high levels manage appropriate services volunteers via a survey called
of constructive engagement and collaborated with partner Birdsong, supported by Hospice
with staff and people who organisations effectively”. UK, and in which 37 hospices
used services. Rigorous and across the UK participated in.
constructive challenge from This year staff, volunteers and This enabled us to benchmark
people who used services, the service users were critical in our outcomes.
public and stakeholders was helping us develop our ‘Patients
welcomed and seen as a vital way of the Future’ strategy through The outcomes were shared with
of holding services to account. a number of listening and staff and volunteers and an
The service engaged well with engagement events. action plan was reported to our
Board and to commissioners.

Overall comparison with the All Hospices benchmark
St Giles Hospice 2019 total agree comparison with All Hospices 2019

Worse, 2

Same, 22 Better, 23

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