St Giles Hospice Quality Account 2017/2018 St Giles Hospice 2017-18 Quality Account | Page 19

programme is shared internally with
Trustees and Clinical Governance
Committee and externally with our
commissioning groups. The hospice
recognises the importance of audit
in influencing and monitoring good
practice. Involvement of frontline
staff is recognised as essential to
raise awareness of ways to improve.
Planned Audits Outcome
Self-Assessment Audit for
the Controlled Drug Ac-
countable Officer (CDAO) Audited against a nationally developed tool from HospiceUK we were able to
evidence 99% compliance.
Health Records including
Moving and Handling Throughout the year we averaged 93% compliance – each quarter the
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
and Control We audit against the Health and Social Care Act to provide evidence that the
management of our service is compliant on the prevention and control of
infections. Using an updated national tool from HospiceUK we evidenced 99%
compliance. The re-audit identified an area of policy which needed updating.
Diligent auditing and monitoring by the Infection Control Lead and support
staff ensure 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 96.5%
•
Yearly auditing comprised 31 individual audits of a range of areas
including kitchen, food storage and handling; sluice, clean and dirty utility,
laundry; care of deceased patients, sharps, protective, respiratory and moving
and handling equipment; public areas; staff health; offices within clinical
areas and visitors’ accommodation – average compliance score of 92%
Medicines
Management Yearly audits are undertaken using national tools developed by HospiceUK. For
controlled drugs we averaged 97.5% compliance and for general medicines 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
93% compliance during the year.
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