Quality & Governance
To ensure we maintain a high quality of care, St Andrew’s Hospice has a comprehensive Quality and Governance structure in place which is responsible for ensuring there is a systematic approach to maintaining and improving the quality of patient care within the Hospice. The responsibility for overseeing this process sits with the Integrated Governance Committee which is chaired by the Chief Executive, Joy Farquharson.
For further information on our Quality & Governance department, please call Wendy Cowper on 01236 766951 or contact us online.
Download Vision 2030 here.
St Andrew’s Hospice has an internal framework through which, as a voluntary sector provider of Hospice and Specialist Palliative Care, we can demonstrate accountability for and ensure continuous improvement in the quality of our services for patients and their families. Our Quality Governance Framework aims to safeguard high standards of care and creating an environment in which excellence of care will flourish by:
- Coordinating improvement within St Andrew’s Hospice in all its departments, concentrating on the core values of human dignity, compassion, justice, quality and advocacy
- Promote equity of service provision and specialist palliative care education for patients and staff in Lanarkshire
- Provide support and direction to staff with key responsibility for Governance, including Risk Management, in the following areas: Health and Safety, Information Governance, Infection Control, Medicines Management, Care of Children and Vulnerable Adults, Audit and Staff Governance
- Promoting clinical audit and critical incident reporting as valuable tools to monitor and improve existing practice
- Overseeing and monitoring progress in order to ensure that lessons are learned from complaints, adverse incidents and enquiries for the benefit of clinical services
- Reviewing outcomes of care against local and national standards and guidelines with particular reference to Health Improvement Scotland
- Ensuring service user participation incorporated into service provision.
St Andrew’s Hospice promotes a positive culture of actively seeking and acting upon the views of the people it serves and works with to continually improve the service it provides. The Hospice employs a number of policies and strategies to satisfy that end including the use of:
- a robust Concerns and Complaints Resolution Policy,
- an active User Experience Strategy and
- a User Involvement Strategy.
St Andrew’s Hospice regularly consults all users of its services including’ inpatients, outpatients and visitors about the services provided and their experience of using them. From the results, action plans are drawn up to resolve any issues which may be identified. Information obtained from these surveys are fed back to the relevant departments as well as being shared on the Engagement & Feedback Noticeboard located near the entrance to the ward.
Patients and visitors are also welcome to submit any comments or suggestions by completing our ‘Comments, Suggestions and Complaints’ forms which can be found at reception. They may also be submitted via our Contact Us form.
St Andrew’s Hospice has always been committed to ensuring we provide high quality care to all the patients and families who require to utilise our services.
We are regulated by Healthcare Improvement Scotland (HIS) who undertake unannounced visits to the hospice to ensure we are meeting the National Standards.
Inspectors undertook the last inspection in January 2024.
Read the full report here.
Integrated Governance Committee
The Integrated Governance Committee (IGC) meets 4 times per year and membership of the Integrated Governance Committee comprises:
- Chief Executive (Chair)
- Deputy Chief Executive / Head of Clinical Services
- Lead Consultant
- Quality and Governance Manager
- Head of Social Work, Counselling & Support Services
- Consultant in Palliative Care
- Clinical Risk, Audit and Quality Committee Chair
- Infection Control Committee Chair
- Health and Safety Committee Chair
- Information Governance Committee Chair
- User Experience Committee Chair
- Head of People
- Lay Representative
The St Andrew’s IGC receives and discusses formal reports from each subcommittee chair and is responsible for ratifying all policies and approving the annual audit plan. All Clinical and Non Clinical incidents are reported to the IGC via the relevant committees as well as any comments, suggestions or complaints.
The Minutes of the IGC meetings, together with policy documents are shared with the Board of Trustees.
Here are St Andrew’s Hospice’s 2024/25 year end accounts: Click here to download.
St Andrew’s Hospice aims to take an honest and open approach with users of our services, and when things go wrong with care or treatment provided to service users, we inform them and other relevant persons and provide them with: support, truthful information and when appropriate, a written apology. Within the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016, provisions are included in relation to Duty of Candour.
Principles of Candour exist in many organisations and within professional codes of conduct and what is expected of staff who work in health and social care. The Act introduces a statutory duty of Candour on health, care and social work services from 1st April 2018.
Please click here to view our annual Duty of Candour report.
Zero Tolerance Statement
At St Andrew’s Hospice, we are dedicated to upholding a safe, compassionate, and
respectful environment for all patients, families, staff, volunteers, and visitors. We
operate a zero tolerance approach toward any form of abuse, bullying, harassment
including sexual harassment, discrimination, or aggression
We Do Not Tolerate:
- Verbal threats or abusive language
- Physical violence or intimidation
- Bullying, harassment, sexual harassment or malicious behaviour
- Any form of discrimination including racism, sexism, homophobia, or ableism
- Damage to hospice property or disruptive actions
Such behaviours undermine the values of dignity and care we strive to uphold and
will be dealt with firmly and appropriately.
Mutual Respect & Compassion
We ask that all members of our hospice community:
- Treat one another with courtesy, empathy, and kindness
- Respect the privacy and wellbeing of patients and families
- Engage in honest and constructive communication
Action & Accountability
Incidents will be thoroughly investigated and may lead to consequences including
removal from the premises, reporting to authorities, or internal disciplinary measures.
Our top priority is the safety and comfort of everyone within our care.
Together, we will continue to foster an environment where compassion prevails, and
every individual feels safe and supported.