St Giles Hospice Quality Account 2018/2019 St Giles Hospice 2018-19 Quality Account | Page 20

13. Our participation in clinical audits
Planned Audits Outcome
Self-Assessment Audit for the
controlled Drug Accountable
Officer (CDAO) Audited against a nationally developed tool from Hospice UK we were
able to evidence 100% compliance.
Health Records including
Moving and Handling Throughout the year we averaged 96% 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 Hospice UK
we evidenced 98% compliance. The re-audit identified that information
provided to patients and the public needed to include the importance of
appropriate use of antimicrobials.
Diligent auditing and monitoring by Infection Control Lead and support
staff ensure prevention is a priority within the hospice:
Highlights:
• Compliance rate of 100% for hand hygiene practice
• Q
 uarterly auditing of patient bedrooms, bathrooms and toilets – average
compliance score of 99%
Yearly auditing comprised 24 individual audits of a range of areas
including kitchen, food storage and handling: sluice, clean and dirty
utility, laundry; sharps, protective, respiratory and moving and handling
equipment: public areas: staff health – average compliance score of 93%
Medicines Management
Yearly audits are undertaken using national tools developed by Hospice
UK. For Controlled Drugs we averaged 98.5% compliance, for General
Medicines the average compliance was 97.5% and for Medical Gases the
average compliance was 91.5%
To ensure we remain vigilant we audit quarterly using tools developed
by our palliative care pharmacist – overall we averaged 93% compliance
during the year.
20