How We Maintain and our Standards
EXTERNAL REGULATION
Care Quality Commission
The Hospice is regulated by the Care Quality Commission, who requires us to appoint a Registered Manager who has the relevant qualifications, experience and expertise to undertake the role. The Registered Manager at our Hospice is Mrs Linda Smout, Director of Clinical Services.
Each year our Hospice is required to complete and return a Self Assessment form. We are regularly inspected by the Care Quality Commission; the outcomes of both self assessment and physical inspection are published on the Care Quality Commission web site.
It is part of our Registration requirement to provide an Information Booklet for our patients and their families. We publish information on the range of services provided in our Bedside Book, our service specific leaflets and our website. Our Statement of Purpose is also available on request. This states our service aims and objectives, where these services are provided and how we will meet our service users’ needs.
Primary Care Trust
The Hospice is required to meet the Key Performance Indicators within the Service Level Agreement it has in place with the Primary Care Trust for the provision of services.
Charity Commission
The Charity Commission also identifies a Governance Framework for Charities which is based around having a clear purpose and direction, effective management, fitness for purpose, learning and improving, sound financial practices, accountability and transparency. The Hospice is required to provide evidence to the Charity commission of the above.
INTERNAL REGULATION
The Hospice has in place a framework for Good Governance which allows the continual monitoring of the quality and safety of the services it provides. Its aim is to create an environment in which excellence in clinical care will flourish. Using a systematic approach the Hospice is able to identify risk, and maintain and improve the quality of patient care delivered within our health care setting
Audit
The Quality Assurance Team complete monthly audits covering all aspects of the clinical service provision and the outcomes are shared with the remainder of the professional team. The audit process enables us to ensure:
- High quality care
- Continuous improvement and the safeguarding of our high standards
- That our patients remain our main priority
- That our service is patient outcome focused
- A safe patient environment
- A safe and healthy environment for our staff and volunteers to work in.
Patient and Carer Surveys
The Quality Assurance Team ask our patients and their carers to participate in quarterly Satisfaction Surveys, the results of which are analysed and used to inform service improvements. They are available for viewing in the Main Reception area at the Hospice. Copies are also available on request.
Risk Management
- In line with regulatory requirements the Hospice has a Risk Register which is subject to ongoing monitoring through various internal meeting structures. This Hospice is committed to continuous service improvement and uses this register to proactively manage risk and provide evidence of A safe patient environmentservice outcomes.
Safeguarding
The Hospice is committed to Safeguarding its Service Users, Staff and Visitors. It has robust policies and procedures in place to support this and these are subject to ongoing monitoring and review.
If you require further information about any of the above please contact The Quality Assurance Team, Gaynor Ashton or Graham Ellams at the Hospice on 01928 719454/712728 or via the following E mail addresses.