Welcome to our Always on Quality Performance reporting page. Here you can see how we’re doing in providing services to donors and where we’re working to improve.

The year is divided into four quarters. This report concerns quarter 4 2024/25 (January, February and March).

More information about how our services are doing can be found in our full Quality & Safety Quarterly Report.

Patient Experience

At Velindre Cancer Service, we want to hear about your experiences. That’s why we use our patient survey system to gather feedback from patients in three simple ways: 

• At dedicated kiosks throughout our hospital 
• On tablets provided by our friendly volunteers and staff 
• By scanning QR codes posted around the building 

We share the survey results with our leadership team and different departments, making sure your feedback goes into our quarterly and annual reports. By listening to what you tell us, we can celebrate our successes, find ways to make positive improvements to our services. 

We look for patterns in the feedback so we can understand what our patients need and experience. Then we create improvement plans to address any concerns. Your voice helps shape our services and drives meaningful change across our organisation.

We review areas where the feedback is less than 100% to ensure we improve our services based on what our patients tell us.
 
The “You Said, We Did” boards are placed around the hospital which shows feedback from patients and how the Cancer Service has responded. This wording will be changed to “We asked, you said and together we have”.
 

You Said	We Did
“Convenient access to light refreshments for patients & companions.”	There is a plan to re-open the coffee shop in Radio Therapy.
“Unclear signage indicating baby-changing facilities.”	Added baby-changing signs to toilet doors.
“Waited 1 1/2 hours in Outpatients for a blood test.”	We are sorry and are undertaking a review of ways of working to reduce the wait.
“Could the lights be turned out earlier.”	We aim to turn the lights off at 10pm but depending on the business this may vary.
“Bookings sometimes get confused wrong appointment times.”	This issue has been highlighted to the appropriate department.
“More patient toilets in new hospital.”	The new Velindre Cancer Centre will have more patient toilets.
“Unclear signage indicating baby-changing facilities.”	Added baby-changing signs to toiler doors.
“Need early access to leaflets & more info about the process & how it works.”	We have started a full audit & review all patient information leaflets, following which we will make any improvements identified as needed
“Bookings sometimes get confused wrong appointment times.”	We have escalated this issue to the Bookings Team and an improvement plan is under development.
“A tea or coffee machine for out of hours would be great.”	While we don’t currently have provision for patients to buy a hot drink out of hours, all patients and companions are welcome to request a hot drink from staff members.

 

Wall of Thanks

Every month our Wall of Thanks intranet page is updated with the latest heartfelt messages that have been shared with us by patients. The messages recognise the amazing difference our staff make.

 

Complaints

We always aim to provide the very best care, but we know sometimes things might not go as well as they should. If you're unhappy with any aspect of our care or service, we want to hear from you - your feedback helps us improve.

How to raise a concern:

• Talk to us in person

You can speak to a member of staff who will share your concern with the Concerns Team.

• Phone or write to us

Phone: 02920 196161

Email: handlingconcernsvelindre@wales.nhs.uk

Executive Director of Nursing, Allied Health Professionals and Health Sciences
Trust Headquarters
2 Charnwood Court
Heol Billingsley
Parc Nantgarw
Cardiff
CF15 7QZ

• Ask a member of staff for support - we're here to help you through the process

We follow the Wales Putting Things Right guidelines, which means:

• We'll acknowledge your concern promptly

• We'll investigate thoroughly

• We'll be open and honest about what we find

• We'll tell you what we're doing to make things better

Between January and March 2025, we received 30 complaints – that’s around 0.04% of patient attendances. While this is a small number, each concern matters to us and helps us learn how to improve our care and services. 2 complaints were reopened, because complainants did not feel satisfied with their final response. In person meetings are offered and the complaint are under review.

• 22 complaints managed as Early Resolution - within 2 working days

• 8 complaints managed formally under the Welsh Putting Things Right regulations

• 2 complaints reopened, indicating that complaints were managed satisfactorily.

 

Based on your feedback, we have made the following changes:

• Waits whilst in the Outpatient Department: Two new clinic rooms have been made available, and the clinic templates have been reviewed to ensure that clinic time and space is being optimised.
• Reminded staff of the importance of always ensuring professionalism when speaking to patient or families.
• Reinforcing the opportunity to discuss unexpected scan reports with a radiologist before discussing with the patient.
• Reinforcing with staff the processes around communicating appointment information to ensure the patient is notified in a timely manner.
• Learning from recent complaints has been shared with all departments of Velindre Cancer Service via a ‘speedy cascade’ – a method of rapidly sharing important information with staff.

 

Incident reporting

We work hard to keep everyone safe and provide the best care possible. That’s why we encourage our staff to report any incidents—or even near misses—through our incident management system. Once an incident is reported, we:

• Investigate straight away to see what went wrong 
• Resolve any immediate concerns 
• Identify and fix the root causes to prevent recurrence 

We also share lessons learned with the entire organisation, and we watch for trends that can guide improvements at local and wider levels. If an incident causes moderate or higher harm, we conduct a detailed review and investigation to ensure we’re doing all we can to keep our patients and staff safe.

 

 

Themes noted:

• Use of email for communicating urgent medical information.
  • A task and finish group has been established and work is ongoing to develop new ways of working, including the use of new technologies.
• Improvements are required in the process for ensuring all blood test results are reviewed in a timely manner.
  • A task and finish group has been established and work is ongoing to develop new processes and ways of working.
• Improvements are required in how our electronic clinical systems interface with one another. We are exploring technological solutions to these issues.
• For some staff, knowledge and education around Granulocyte Colony Stimulating Factor medications needed to be enhanced
  • Training and education is being provided by the Education Team
• Improvements are required in the transferring of acutely unwell patients between departments within Velindre Cancer Centre
• Training and education will be provided to staff.