• Quality & Governance

Quality & Governance

St Andrew’s Hospice Quality & Governance Framework
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 and 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, Infection Control, Medicines Management, Care of Children and Vulnerable Adults, Audit and  Staff Governance.
  • Producing a Quality Development Plan at three year intervals, which is  agreed in consultation with the Hospice Board of Trustees, which supports the concurrent Hospice Operating Plan
  • 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.

To ensure we maintain a high quality of care, the 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, Bruce High.

For further information on our Quality & Governance department please call Joy Farquharson on  01236 772015 or contact us online.

Engagement & Feedback

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 “Patient Satisfaction Strategy and
  • a “User Involvement Strategy”.

St Andrew’s Hospice regularly consults all users of its services including inpatients, visitors and day hospice patients 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 outside the Dove Cafe within the Hospice .

Visitor Satisfaction Survey feedback

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 or next to the Engagement and Feedback Noticeboard beside the Dove Cafe. They may also be submitted via our Contact Us form.

HIS Inspections

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 April 2018. The inspection was based on nine domains which look at all aspects of the organisation including; Care, Leadership, Environment, Governance and Participation. These nine domains are broadly grouped under three headings relating to:

  1. Outcomes and impact
  2. Service delivery, and
  3. Vision and leadership.

As part of the change to their inspection methodology, HIS have changed their scoring system from a 6 point scale to a 4 point scale. Although HIS inspected and reported against all 9 Domains of their Framework, they only publish grades for the following 3 indicators.

Quality Indicator St Andrew’s Hospice Grade
2.1 – Patients and service user experience 4-Exceptional
5.1 – Safe delivery of care, and 3-Good
9.4 – Leadership of improvement and change. 3-Good

Patients and families spoken to during the inspection reported the following:

‘They look at [patient’s name] as a person, not an illness. It’s all very dignified. They make the unbearable, bearable. Nothing is a bother for the staff.’

 Staff spoken to during the inspection said:

‘I love the patient contact and variety of work, it is important to us all that the patients are well looked after’

To view the full report, please visit

Integrated Governance Committee

Integrated Governance Committee

The Integrated Governance Committee(IGC) meets 6 times per year and membership of the Integrated Governance Committee comprises:

  • Chief Executive(Chair)
  • Acting Deputy Chief Executive: Governance & Service Development
  • Acting Deputy Chief Executive: Clinical Services
  • Lead Consultant
  • Director of Mission
  • Quality and Governance Manager
  • Head of Pastoral Care and Education
  • Consultant in Palliative Care
  • Clinical Risk & Audit Committee Chair
  • Infection Control Committee Chair
  • Health and Safety Committee Chair
  • Medicines Management Committee Chair
  • Information Governance Committee Chair
  • Risk Management Committee Chair
  • Patient Satisfaction Committee Chair.
  • Human Resources Manager
  • AHP Representative
  • Lay Representative

Integrated Governance Structure

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.