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HALTON HAVEN HOSPICE QUALITY ACCOUNT
2014/15
Halton Haven Hospice offers a patient centred and patient
led approach to the provision of Palliative Care. Physical,
psychological, spiritual, emotional and social needs are
met with sensitivity regardless of colour, creed or social
standing. Patient’s views are respected and needs
identified in consultation with them and their families.
Chairman’s Statement 2
What is a Quality Account 3
Introduction to Halton Haven Hospice 4
Statements of Assurance from the Board 6
Review of Quality Performance Priorities 2013 9
Feedback from Patients and Relatives 12
Clinical Governance Overview 19
Care Quality Commission Report 24
Equality and Diversity 25
Community Engagement 28
Priorities for Improvement 2014 32
Statements on this Quality Account 36
Opportunity to Provide Feedback 38
1.1.1.1. ContentsContentsContentsContents
2. 2. 2. 2. Chairman’s StatementChairman’s StatementChairman’s StatementChairman’s Statement
I am very pleased to endorse the 2014 Quality Account for Halton Haven Hospice. After reading
the account I am sure you will see that quality is at the heart of everything we do and that the
Board of Trustees, staff and volunteers have a commitment to ensuring that the highest standard
of specialist palliative care is delivered to local people in need of our services.
This commitment is demonstrated not only through our approach to corporate and clinical
governance; but also through our everyday service provision. Our measure of quality is not
solely based on meeting clinical targets but on providing a service that treats patients and their
families with dignity and respect during what is often a very difficult time. We hope that you find
all of this reflected in our Quality Account.
Over the past twelve months, I am proud to say that we achieved the targets that we set for
ourselves in the 2013 quality account and I feel confident that we will go onto replicate this
success with our new priorities for the year ahead.
We have also achieved great success in many other areas including patient satisfaction,
fundraising, community engagement and during our Care Quality Commission Inspection that
took place in July 2013; during which we were assessed as fully compliant with all of the
inspected standards and outcomes. I would also like to draw special attention to our newest
project, which includes the new Family Support Centre and ‘Men’s Shed’, all of which have
been designed to further increase the quality and reach of our services for people across the
Borough.
Despite the current economic climate, the Hospice has continued to be able to provide a high
quality, cost effective, specialist service to patients and their families. Together with the Board of
Trustees, I would like to thank all of our Staff and Volunteers for their achievements in providing
this quality of service during 2013 - 2014. The provision of high quality care is paramount. It is
central to what we believe; it is the basis of our reputation and it helps us to secure the financial
support we receive from the NHS and the public, upon which we rely.
I, as Chair of Halton Haven Hospice Trustees, am responsible for the preparation of this report
and its contents, and to the best of my knowledge the information contained therein is
accurate and a fair representation of the quality of the NHS healthcare services provided by
Halton Haven Hospice.
Neil Townsend
Chair of Halton Haven Hospice Trustees
3. 3. 3. 3. What is a Quality Account?What is a Quality Account?What is a Quality Account?What is a Quality Account?
There is a requirement of the Health Care Act (2009) that all providers of NHS healthcare
services should produce a Quality Account, including independent organisations. According to
the Department of Health, ‘Quality Accounts aim to enhance accountability to the public and
engage the leaders of an organisation in their quality improvement agenda’. They provide
information about the quality of the services that the organisation delivers.
Quality Accounts are annual reports to the public about the quality of NHS healthcare services
an organisation provides and their main purpose is to encourage providers to take a robust
approach to quality. By publishing their Quality Account each provider, led by their Board, is
committing to improve the quality of care it delivers locally and invites the public to hold them
to account.
The Quality Account covers two main areas;
• A review of how we performed last year, covering three main areas of quality; patient
safety, patient experience and clinical effectiveness
• A set of key priorities for improvement next year and plans for how we aim to achieve
that improvement
The public, patients and other interested parties will use the Quality Account to understand;
• What an organisation is doing well
• Where improvements in service quality are required
• What the organisation’s priorities for improvement are for the coming years
• How the organisation has involved people who use their services, staff and others with an
interest in their organisation in determining these priorities for improvement
For further information about Quality Accounts please visit;
http://www.nhs.uk/aboutNHSChoices/professionals/healthandcareprofessionals/qualityaccount
s/pages/about-quality-acounts.aspx
Our Vision
We will continue to be the leading provider of specialist palliative care for the
people of Halton
We will provide our special kind of caring with compassion and humanity to meet
and support the choices our patients make
We will use our expertise to enhance the experience of patients in other care
settings
Halton Haven Hospice is a registered charity with its origins in the vision of one man,
Dom Valdez. Activity started on our present site in 1981. The first element of the
Hospice was the unit which is now our Day Hospice lounge and this was followed by
the adjoining Inglenook in 1986. The Inpatient Unit was built in the early 1990s with
the Amanda Edwards Unit following, which was the last element of the Hospice and
is now an integral part of our Day Hospice.
Halton Haven Hospice is a single story building which underwent a full refurbishment
programme during the period 2010/2012. This has resulted in substantial
development of the original structure of the Hospice and we are now well placed to
meet the challenges of the future, in providing high quality Specialist Palliative Care
for the community of Halton.
The Hospice In-Patient Unit is registered with the Care Quality Commission and has
provision for twelve palliative care beds. The In-Patient Unit has a comfortable
lounge leading directly into a conservatory and then out into the well-developed
garden areas. In-Patient bedrooms have en-suite facilities, with some having an en-
suite shower and additional space to accommodate patients with physical
disabilities. All rooms have remote control television, radio, CD player and an electric
fan. There is a specialist bathing and shower room to enable patient choice. A
comfortable visitor’s room, with access to tea and coffee making facilities, is
available. The Hospice has made provision of a dedicated Quiet Room available
twenty four hours a day for quiet reflection, prayer and religious services.
The Day Hospice is licensed to accommodate up to twelve patients per day. It has a
comfortable lounge, access to a well presented dining area, activities,
Complementary Therapy and Physiotherapy rooms and access to established
garden areas. Day Hospice has its own toilet and shower facilities, which are
suitable for disabled use. A patient call system is available within all patient areas.
One day a week the Day Hospice facilities are utilised as a Specialist Outpatient
Clinic.
Our patients are cared for in a clean, comfortable, safe and smoke free
environment and treated with respect and sensitivity to their individual needs and
abilities.
4.4.4.4. Introduction to Halton Haven HospiceIntroduction to Halton Haven HospiceIntroduction to Halton Haven HospiceIntroduction to Halton Haven Hospice
Members of Hospice staff are responsive to all patients and their relatives, providing
the appropriate support to ensure the optimum quality of life during their stay with
us.
The Hospice’s key objectives are to;
• Provide a flexible and adaptive approach to Palliative Care Services.
• Provide expert care at the highest standard achievable, thereby enhancing
the quality of life for patients faced with life limiting illnesses.
• Respect patient choice and autonomy. We are mindful of the individuals
need for dignity, independence and privacy.
• Respect and acknowledge individual spiritual and religious beliefs.
• Provide a system of support which enables the person to live as actively as
possible and supports the family and other carers.
• Work in conjunction with other professionals in order to provide a seamless
service.
• Ensure care is provided by a team who have undergone appropriate
Specialist Palliative Care training.
• Contribute to the education and development of the Hospice’s own staff
and to the local palliative care education programmes.
• Evaluate and improve our services through analysis of feedback from
patients, relatives, and other professionals.
Halton Haven Hospice aims to provide care to all our patients to a standard of
excellence which embraces fundamental principles of best practice. This will be
evaluated and evidenced through quality control and risk management systems.
5.5.5.5.
6. 6. 6. 6. Statements of AssurancesStatements of AssurancesStatements of AssurancesStatements of Assurances from the Boardfrom the Boardfrom the Boardfrom the Board
The following are formal statements, under various headings that all providers of NHS healthcare
services must include in their Quality Account, even though many of the statements are not
directly applicable to us as a Specialist Palliative Care provider.
Review of Services
During 2013/14 Halton Haven Hospice provided Specialist Palliative Care Services to the NHS.
Halton Haven Hospice has reviewed all the data available to us on the quality of care in these
NHS services.
The income generated by the NHS services reviewed in 2013/14 represents 50% of the total
income generated from the provision of NHS services by Halton Haven Hospice for 2013/14. This
50% represents only part of the funding required to provide services at Halton Haven Hospice;
the remaining 50% of income is generated through fundraising and the generosity of the local
community.
Participation in Clinical Audits:
During 2013/14 NO national clinical audits and NO national confidential enquiries covered NHS
services that Halton Haven Hospice provides.
During that period Halton Haven Hospice participated in 0% national clinical audits and 0%
national confidential enquiries of the national clinical audits and national confidential enquiries
which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Halton Haven Hospice was
eligible to participate in during 2013/14 was NONE.
Research
The number of patients receiving NHS services provided by Halton Haven Hospice in 2013/14
that were recruited during that period to participate in research approved by a research ethics
committee was NONE. The Hospice would be open to participate in research projects subject to
eligibility.
7.7.7.7.
Use of the CQUIN Payment Framework
A proportion of Halton Haven Hospice’s income in 2013-2014 was NOT conditional on achieving
quality improvement and innovation goals agreed between Halton Haven Hospice and the
commissioning body they entered into a contract, agreement or arrangement with for the provision
of NHS services, through the Commissioning for Quality and Innovation payment framework.
Care Quality Commission (CQC)
Halton Haven Hospice is required to register with the Care Quality Commission and its current
registration status is Independent Hospice for Adults. It is registered to provide the following regulated
activities:
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury
Halton Haven Hospice has the following conditions on registration:
• The establishment is registered for the provision of supportive and palliative care services.
• The establishment will provide overnight treatment to a maximum of 12 (twelve) persons aged
18 (eighteen) years or over.
• The establishment may provide day services for 12 (twelve) patients at any one time for
patients aged 18 (eighteen) years or over.
• The prior written approval of the Care Quality Commission must be obtained at least 4 (four)
weeks in advance if providing any treatment or service not detailed in the Statement of
Purpose.
The CQC has not taken enforcement action against Halton Haven Hospice during 2013/14.
Halton Haven Hospice has not participated in special reviews or investigations by the CQC during
2013/14.
Halton Haven Hospice was inspected by CQC on the 25th of July 2013 and was found to be
compliant with standards and outcomes.
8.8.8.8. Data Quality
Halton Haven Hospice did not submit records during 2013/14 to the Secondary Uses Service for
inclusion in the Hospital Episode Statistics which are included in the latest published data.
Information Governance Toolkit Attainment Levels
The Halton Haven Hospice Information Governance Assessment Report overall score for 2014 - 2015
is 66% and is graded Green (satisfactory), meaning that we achieved Attainment Level 2 or above
on all requirements (Version 8 or after).
The Information Quality and Records Management attainment levels assessed within the
Information Governance Toolkit (IGT) provide an overall measure of the quality of data systems,
standards and processes within an organisation. Halton Haven Hospice was required to use the IGT
to assess its information governance management as a condition on gaining an N3 connection
even though this assessment is not otherwise applicable to Palliative Care Services.
The Information Governance Toolkit is available on the Connecting for Health website
www.igt.connectingforhealth.nhs.uk
Clinical Coding Error Rate
Halton Haven Hospice was not subject to the Payment by Results clinical coding audit during
2013/14 by the Audit Commission.
9.9.9.9. Review of Priorities 2013Review of Priorities 2013Review of Priorities 2013Review of Priorities 2013
During the year 2013 – 2014 Halton Haven Hospice set priorities for improvement in the areas of;
• Patient Safety
• Patient Experience
• Clinical Effectiveness
In this section we review our Quality Performance in meeting the targets we set for ourselves.
PRIORITY ONE
Patient Safety
Our goal was to further develop education and training at the Hospice
THIS GOAL HAS BEEN ACHIEVED
Halton Haven Hospice wanted to ensure that all members of clinical staff have the requisite
knowledge, training and skills to deliver safe and effective care. The Hospice also aimed to
provide staff with the opportunity to plan and set goals for their career, so that they have direction
and a way of measuring personal success, which is motivating. Being motivated allows our staff to
be proactive rather than reactive to events and can ensure that they are in a position to
effectively deal with the challenges that can be presented in providing end of life care. Halton
Haven Hospice believes that this results in enhanced safety and positive experiences for our
patients and their carers.
The Hospice also wanted to better coordinate the delivery of our experience and expertise to
develop the ways in which we engage with people who can use or need what we have to offer.
This can also help improve the safety and experience of people who are not directly referred to
the Hospice for care from our core services.
Halton Haven Hospice has met this goal by appointing a Lead Nurse for Education and Training
and through the training schedule that is now being implemented by our new Advanced Care
Planner.
The Lead Nurse for Education and Training is now responsible for the Hospices internal and external
clinical education and training programmes, which have been implemented across the clinical
staffing structure. Delivery, attendance and feedback are all closely monitored and training is
now being delivered proactively, rather than reactively. In addition to this, the Advanced Care
Planner has implemented a comprehensive training schedule, targeting outside agencies and
carers for people at the end of their life. This too is monitored closely for delivery, attendance and
feedback.
10.10.10.10.
PRIORITY TWO
Clinical Effectiveness
Our goal was to look at the prevalence an incidence of Lymphoedema in palliative care
patients in the community of Halton
THIS GOAL HAS BEEN ACHIEVED
In 2012/2013, Halton Haven Hospice identified the need to look at the prevalence and
incidence of Lymphoedema in palliative care patients in the community of Halton. The
prevalence and incidence of Lymphoedema has been difficult to determine as it was a
relatively newly-recognised condition with no agreed definition that could often be
misdiagnosed or confused with other conditions. This, in turn, resulted in many patients in the
United Kingdom having problems accessing specialist services and treatment. Therefore, our
goal was to ensure that this is not the case for Halton’s patients with palliative care needs.
The Hospice aimed to obtain funding in order to set up a Specialist Lymphoedema Service
for patients with palliative care needs. Lymphoedema specialists would be able to provide
support and give advice to both patients and professionals, obtain and disseminate
Lymphoedema information and provide our patients with the best possible care and
treatment.
Halton Haven Hospice has achieved this goal. More specifically, the business case for a
proposed Bridgewater - wide Lymphoedema service was discussed by the Business
Development Group meeting at Bridgewater NHS on December 11th 2013 and this has since
been approved. This model includes the location of two beds at Halton Haven Hospice for
specialist interventions such as Multi-Layer Bandaging.
This specialist service will allow patients to be diagnosed and treated more quickly than may
otherwise be the case and will ensure access for patients with palliative care needs to a
‘whole package of care’ for Lymphoedema. The service will also relieve some of the burden
on inexperienced practitioners and on physiotherapists across Halton, while setting a
benchmark of best practice for the rest of the country.
11.11.11.11.
PRIORITY THREE
Patient Experience
Our goal was to develop a service at Halton Haven Hospice that will encourage more of the
male population of Halton who have had a bereavement to access the service
THIS GOAL HAS BEEN ACHIEVED
Halton Haven Hospice understands that it can be very difficult for bereaved men to feel able
to access support services. Most men have learned from our culture that they don’t talk
about feelings and emotions and there has been little encouragement for men to take an
interest in their own health and well-being. Because of this many men’s health suffers, they
drink more, take more risks and they suffer more from isolation, loneliness and depression.
Bereavement in particular is a problem that men often try and fail to successfully deal with on
their own.
In response to this Halton Haven Hospice aimed to secure funding for a ‘Men’s Shed’. The
Men’s Shed Project started in Australia in 1996 and has since spread to other countries. It is a
project that looks to utilise an updated version of the shed in the backyard, that has long
been a part of our culture, as a place where men can be in a familiar environment, doing
familiar things in a friendly and relaxed way with other men. The Hospice recognised that the
creation of a Men’s Shed for Halton would be a step towards supporting men of all ages by
providing an environment in which men can share their skills, experience and feelings in a
way that feels more natural to them.
Halton Haven Hospice has achieved this goal. Thanks to a successful bid to the Department
of Health the Hospice is now building a new Family Support Centre so that our families have
first class facilities in which to be supported. And part of this building is a space especially for
men – a “Men’s Shed”.
Men’s Shed will offer groups of men the opportunity to share the tools and resources they
need to work on projects of their own choosing at their own pace and in a safe, friendly and
inclusive environment. It will be a place of skill-sharing and informal learning, of individual
pursuits and community projects, of purpose, achievement and social interaction. It is a
place of leisure where men come together to work, while simultaneously improving their
health and wellbeing.
The Men’s Shed at Halton Haven Hospice is a first for the Hospice movement and is another
example of how, here in Halton, we can innovate nationally.
12. 12. 12. 12. Feedback from Patients and RelativesFeedback from Patients and RelativesFeedback from Patients and RelativesFeedback from Patients and Relatives
Halton Haven Hospice surveys its patients and their relatives on a regular basis in order to get
feedback from them on the services that we provide. This enables continuous evaluation of
what the people who use our services think about what we do well and what we might be
able to do better. The questionnaire we ask to be completed seeks opinion on;
• Whether or not Hospice facilities are of a good standard
• Whether or not the information we provide is sufficient to allow patients to make
informed decisions and choices.
• Whether or not patients felt involved in the medical assessment process that they
undergo. This includes the issue of consent and whether or not adequate explanations
are given prior to assessment or the provision of care.
• Whether or not people feel safe in the Hospice environment
• Whether or not we treat people who come to the Hospice with the dignity and respect
they expect and deserve especially with regard to personal views, values and beliefs.
• Whether or not we meet people’s privacy needs
The Hospice also now incorporates the Family and Friends test into its Patient/Carer Survey to
establish how likely people are to recommend our services to others who may require similar
care and treatment to themselves or their family member.
In addition to this we also now give respondents the opportunity to state their name and
contact details on the questionnaire so that they can be contacted about any feedback that
may need following up on.
With the quarterly analysis of returned questionnaires we are able to identify areas where
improvement to service delivery may be required or to identify any significant trends.
13.13.13.13. Patient and Carer Surveys for the Period
1st February 2013 – 31st January 2014
2013 - 2014 2012 - 2013
No. of questionnaires sent
out
150
133
No. of Questionnaires
returned
65
70
Return Rate
43%
53%
At the beginning of the year the response rate had dropped to 31%, much lower than the
Hospice hopes for. In response to this we changed the questions to make them easier to
understand, more relevant to the services that we provide and perhaps most significantly we
aimed to make them more relevant to the things that matter to our patients and their families. In
addition to this, we also now give respondents the opportunity to complete an easy read version
of the questionnaire instead of the standard version. Both copies are sent to each individual to
give them the choice of which they feel more comfortable completing. Combined this has seen
the return rate increase during the course of the year, a trend that is now continuing into 2014.
14.14.14.14.
2013 - 2014 2012 - 2013
No. of Patients that
responded
28%
21%
No. of Relatives that
responded
72%
79%
No. of other people that
responded
0%
0%
Due to the nature of the services provided at Halton Haven Hospice we always have a higher
response rate from relatives of deceased patients than from patients themselves.
2013 - 2014 2012 - 2013
No. of respondents who
said that they saw
information on services,
advice and a service
user guide available for
them
94%
88%
As can be seen there has been an increase in the number of respondents who confirmed that
they saw the information that the Hospice makes available for patients. We have made
increased efforts over the past year to ensure that things such as infection control advice is
seen by patients and visitors and improved results are starting to be seen. Over the last year we
have also reviewed the Service User Guide (Bedside Book) to ensure that all information a
patient could need is to hand. A copy of each bedside Book, along with an easy read version,
is now available in every room and in the communal areas.
15.15.15.15.
2013 - 2014 2012 - 2013
No. of respondents who said
that they felt the patient,
where possible, consented
to their medical
assessments and care
94%
93%
Halton Haven Hospice makes every possible effort to gain patient consent for everything we do
and to involve patients in their care. It is important to note here that of the 6% of respondents
that did not answer ‘yes’ to this question only one person stated that they had not given
consent; while the others did not answer the question. While the Hospice would obviously like
this to be 100%, we do recognise that sometimes when relatives answer this question (as is the
case here) they do not always feel as involved as they would like to be. It is also common for
relatives to feel like they should have been asked to consent, when I truth the patient has the
capacity to make decisions for themselves and so the families are not always asked for their
consent.
2013 - 2014 2012 - 2013
No of respondents who said
that they felt their medical
assessments resulted in
care that met the patient’s
needs.
96.5%
94%
Of those that did not answer yes to this question, only one relative stated that they felt the care
needs of the patient were not met. The remaining percentage is made up of people who did
not answer the question at all. As with the previous question we would obviously prefer this to
be 100% but we understand that sometimes people would hope that we can do more than we
actually can.
16.16.16.16.
2013 - 2014 2012 - 2013
No of respondents who said
that the Hospice facilities
were either excellent or
good
99%
100%
No of respondents who said
that the Hospice food was
either excellent or good
98%
94%
No of respondents who said
that cleanliness at the
Hospice was either
excellent or good
100%
100%
No of respondents who said
that staff at the Hospice
were either excellent or
good
100%
100%
With regards to facilities there is a slight reduction in satisfaction among our respondents,
however this equates to one person who stated that the facilities were ‘fair’. There were no
negative responses. We are pleased to note that satisfaction with our food has increased. Of
the respondents who answered this question 100% remain satisfied with the cleanliness of the
building and with the staff.
With regards to facilities, one person commented ;
“Smoking issue. Smokers location unacceptable. Needs to be away from the building. Could
smell smoke in conservatory and dining room. Unable to sit outside because of the smokers.”
In response to this the Hospice has constructed a purpose built smoking shelter, away from the
conservatory, which is where smokers visiting the Hospice used to stand. Smokers are now
encouraged to use the shelter, which is no longer visible from the dining room and lounge.
17.17.17.17.
In May 2013 we added a ‘Family and Friends Test’ section to our questionnaire to establish how
likely the respondents are to recommend our services to others. Results from May 2013 to January
2014 were as follows;
Extremely
Likely
Likely Neither Likely
or Unlikely
Unlikely Extremely
Unlikely
Don’t
Know
How likely are you to
recommend our Hospice
to friends and family if
they need similar care or
treatment?
98%
2%
0%
0%
0%
0%
We are delighted to report that 100% of respondents to our patient and carer questionnaire stated
that they would recommend our services to family and friends should they need similar treatment.
18.18.18.18.
A Sample of Comments made by Patients and Carers
“I went in wanting to be put out of my misery. I came out wanting to fight for my life.”
“Everyone 1st class”
“The care and attention that my husband and I received was second to none. The word
excellent does not seem to say enough.”
“All the staff were very helpful and respectful. They could not do enough. They were wonderful.”
“Loved how they spoke to the patient, even though she was in a coma.”
“Everyone, from nursing staff, doctors and cleaners made me feel comfortable and upbeat. Can’t
thank them enough.”
“Angels in uniforms, bless you all xx. Dedicated, friendly and caring couldn’t have asked for more”
“The kindness and friendliness of all the staff was wonderful. I can’t thank them enough it’s like
home from home”
“My Mum was the patient who sadly died at the Hospice. She was a retired nurse and she
commented about the Hospice ‘This is how nursing should be’ and ‘this is how nursing was in my
day’. In four years in and out of hospital she has never said this about anywhere else, so this is high
praise indeed for a marvellous place.”
“I have been told I might not have very long to live but miracles do happen so I request to be a
patient at the Haven I did not want to go to hospital or stay at home so I chose the Haven. I could
not have made a better choice. Every one of the staff are marvellous it’s like being at home with
all my friends around me and I feel happy and relaxed. You all deserve medals. Thank you for
making me happy and relaxed in the last few months I have left? God bless you all”
‘Although Mum did not eat anything, the staff very kindly made sandwiches / toast for us as a
family – nothing was too much trouble for them’
19.19.19.19. Clinical Governance OverviewClinical Governance OverviewClinical Governance OverviewClinical Governance Overview
Halton Haven Hospice recognises its responsibility to provide a governance framework outlining
organisational and individual accountability through which the quality and safety of the services
it provides can be constantly monitored and improved. The Hospice is committed to creating
an environment where continual learning takes place and excellence in clinical care can
flourish. The Hospice will strive to put into place efficient systems of management and processes
of continual assessment and change within the organisation to enable patients to receive safe
and effective care of the highest quality.
Our Clinical Governance Overview looks at a variety of areas that we determine to be specific
indicators of quality and outcomes for all who use services at the Hospice. This includes;
• Complaints
• Incidents
• Infection Control
• Safeguarding
• MHRA Alerts
• Audits and Associate Actions
• Policy Reviews
• CQC Notifications
• Patient/Carer Surveys
Complaints
Formal Written Complaints
2013 - 2014
2012 - 2013
Total 1 0
Number Upheld 0 0
Number Unsubstantiated 1 0
Number Ongoing 0 0
One family wrote in to us during 2013 – 2014 to complain about the Hospice. Following a thorough
investigation this was found to be unsubstantiated.
The Hospice also met informally with a small number of service users and their families who wished to talk
about specific concerns throughout the year. These discussions were not followed up with formal
complaints.
20.20.20.20.
Healthcare Associated Infections
2013 - 2014
2012 - 2013
INFECTIONS DEVELOPED AFTER ADMISSION
TO THE HOSPICE
0
0
The Hospice is proud to maintain its record of not developing healthcare associated infections. The Hospice
takes infection control and cleaning standards very seriously with regular training and audit to ensure the
safety and wellbeing of everyone at the Hospice.
Incidents
2013 - 2014
2012 - 2013
Never Events 0 0
Serious Untoward Incidents 0 0
Clinical Incidents 3 10
Non Clinical Incidents 1 7
Health and Safety Incidents 11 9
Information Security Incidents 0 0
Other Incidents 1 0
The Hospice is pleased to report a significant decrease in the number of clinical incidents, although
we would obviously prefer the figure to be zero. The three clinical incidents were as follows;
• Incorrect dosage of MST given to a patient (70mgs instead of 80mgs). Also resulted in a
discrepancy with stock reconciliation. No adverse effect to patient. Full investigation
completed.
• Overdose of controlled drug given to a patient. No adverse effect. Members of staff involved
were suspended from administering drugs until assessed as competent to do so. Full
investigation completed.
• Medication error. No adverse effect. Members of staff involved were suspended from
administering drugs until assessed as competent to do so. Full investigation completed.
21.21.21.21.
All non-clinical incidents, health and safety incidents and other incidents involved members of
staff and not patients. One of the Health and Safety Incidents was reportable to RIDDOR,
when a staff member hurt her foot and subsequently took more than a week off work.
MHRA Alerts
2013 - 2014
2012 - 2013
Alerts Requiring
Action by the
Hospice
2
3
Over the last year there have been two alerts from MHRA, which have required the Hospice to
take action. The alerts were dealt with promptly and did not result in any incidents. One was
for a urinalysis diagnostic strip, which needed to be monitored for effectiveness. The second
was for suction canisters and liners. New parts were ordered and the faulty ones returned, this
was followed by a visit from the Rep from the company to ensure that the equipment was
functional to standard.
Safeguarding
2013 - 2014
2012 - 2013
Safeguarding
Procedures Initiated
by the Hospice
4
1
The Head of Clinical Services, who is also the Registered Manager made four safeguarding
notifications during 2013 – 2014.
Members of staff have completed in house safeguarding training, delivered by the Registered
Manager and have also met with two representatives from the Care Quality Commission to
discuss safeguarding at the Hospice.
22.22.22.22.
Pressure Sores
2013 - 2014
2012 - 2013
Pressure Sores
Developed at the
Hospice
5
6
In the last year the Hospice cared for five patients who developed a pressure sore following their
admission. This is an improvement from the previous year, but we would ideally prefer it if the reported
figure was zero. This is an improvement on the previous year but also more than we would wish. Whilst
it is recognised that, due to multiple factors, patients in the later stages of their life are at increased
risk of skin break down, the Hospice will continue to review and audit its processes with the aim of
reducing this incidence even further.
On admission to the the Hospice all patients are assessed for skin integrity and risk using the Waterlow
2005 risk assesment tool. Where damage to skin is identified the Hospice uses the EPUA 1999 Pressure
Sore Grading Tool as below. These tools allow a potential breakdown of skin to be identified and
prevented under certain circumstances. Following an admission reassessment of skin integrity is
continuous and there are clear lines of responsibility and accountability in place to facilitate this
process.
Pressure Sore Grading (EPUAP,1999)
Grade 1: Non blanchable erythema of intact skin. Discolouration of the skin,
warmth, oedema, indurations or hardness may also be used as indicators
particularly on individuals with darker skin.
Grade 2: Partial thickness skin loss involving epidermis, dermis or both. The ulcer is
superficial and presents clinically as an abrasion or blister.
Grade 3: Full thickness skin loss involving damage to or necrosis of, subcutaneous
tissue that may extend down to, but not through underlying fascia.
Grade 4: Extensive destruction, tissue necrosis or damage to muscle, bone or
supporting structures with or without full thickness skin loss.
The five pressure sores developed at the Hospice over the past year were investigated, analysed and
graded as follows:
• 2 pressure sore at Grade 1
• 3 pressure sores at Grade 2
23.23.23.23.
Audits
Members of staff at Halton Haven Hospice have conducted internal audits throughout the year
within the following areas;
• Medication
• Medical Officer Recording
• Liverpool Care Pathway
• Case Notes
• Accidents
• Bedrails
• Water
• Incidents
• Infection Control
• Health and Safety
• Mattresses
• Spiritual Care
• Pressure Sores
The Hospice adheres to a comprehensive audit schedule, within which audits are completed
monthly, quarterly or annually. Audits are used to determine whether good practice is being
delivered at the Hospice and results are used to populate the risk register. Findings from the audits
are disseminated to all relevant staff for review, and if necessary action.
Policies and Procedures
The work of Halton Haven Hospice is underpinned by a wide variety of policies and procedures,
which are divided into the following categories;
• Operational
• Clinical
• Medicines
• Health and Safety
• Human Resources
Policies and procedures are developed as and when required. They are then subsequently
reviewed as part of a three year review schedule. Members of Halton Haven staff are required to
adhere to policies and procedures at all times in order to minimise any potential risks to the patients,
other staff members or the Hospice as a whole. All policies and procedure are discussed at the
Hospice Clinical Governance Meeting and are ratified by the appropriate member of the Senior
Management Team.
24. 24. 24. 24. Care Quality CommissionCare Quality CommissionCare Quality CommissionCare Quality Commission ReportReportReportReport
The Hospice is regulated by the Care Quality Commission (CQC) and it is their job to check that the
services we provide meet essential standards.
The Care Quality Commission last inspected the Hospice on the 25th of July 2013. This was a routine,
unannounced inspection that looked at the following standards;
• Consent to care and treatment
• Care and welfare of people who use services
• Cleanliness and infection control
• Supporting workers
• Records
Following the inspection the Hospice was found to have met all of the standards and the
subsequent report to verify this was published in August 2013. A summary of the findings can be
found below;
How we carried out this inspection
We looked at the personal care or treatment records of people who use the service, carried out a
visit on 25 July 2013, observed how people were being cared for and checked how people were
cared for at each stage of their treatment and care. We talked with people who use the service,
talked with carers and/or family members and talked with staff.
What people told us and what we found
Patient’s confirmed they were pleased with the standard of care they received from all the staff.
Patients told us nursing staff and medical staff were available at all times for support and to answer
questions they had. They were overall very positive about the care and attention they were
receiving. They made various positive comments such as, ‘we couldn’t be any better cared for the
staff are wonderful’ and ‘the staff are fantastic they discuss everything with you’.
Infection control procedures were in place to ensure continued good standards of hygiene which
helped to minimise risks to patients.
We looked at a number of records regarding the ongoing management of the Hospice to ensure
patient safety. Records seen were kept secure, accurate, fit for purpose and managed effectively
to protect the safety and wellbeing of the patients and others.
The Hospice had a variety of information leaflets about the service available throughout the
building including the reception area. The manager had displayed the results of a recent patient
survey in reception to share with everyone the results of what people had told them. They also had
a patient comment box for anyone to make suggestions about the service at any time during their
stay. These initiatives helped to keep everyone informed about the Hospice and also tried to
include people’s comments and suggestions in the ongoing development of the Hospice.
The full report is available at www.cqc.org.uk
25. 25. 25. 25. Equality and DiversityEquality and DiversityEquality and DiversityEquality and Diversity
It is a requirement of the Equality Act (2010) that Halton Haven Hospice demonstrates due regard for
the following three aims;
1. Eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited
by the Act
2. Advance equality of opportunity between people who share a protected characteristic and
people who do not share it
3. Foster good relations between people who share a protected characteristic and people
who do not share it
In addition to this, the Hospice works towards a specific and measurable set of equality objectives
and publishes all of the information here, as part of the quality account.
Demonstration of Due Regard
1. Eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited
by the Act
Halton Haven Hospice recognises that while we cannot solve the problems of discrimination within
wider society, we aim to take practical steps to minimize the potential of it occurring within our own
organisation.
To help us to achieve this, we acknowledge our responsibility to equality and diversity and to adhere
to the various Acts of Parliament and the European Union that governs this. The Hospice is
committed to promoting equality, embracing diversity and views fair treatment not only as a legal
duty but as a moral responsibility and business imperative. We are committed to providing equality
for all, with our services being open to all sections of the local community and by having a
workforce that is representative of the communities from which it is drawn. Halton Haven Hospice
will not tolerate any kind of direct or indirect discrimination, harassment or oppressive practices and
is committed to eliminating these wherever possible.
To actively demonstrate commitment to this, the Hospice has a number of equality and diversity
policies in place for both staff and service users. There is also a comprehensive equality impact
assessment within each of the Hospices policies and procedures. Any breach of Hospice policies
and procedures is taken very seriously and can lead to disciplinary action and possible dismissal.
In addition to this, the Hospice adheres to a robust recruitment system which aims to ensure fair
treatment for all and all Hospice employees will attend in house equality and diversity training.
26.26.26.26.
2. Advance equality of opportunity between people who share a protected characteristic and
people who do not share it
At Halton Haven Hospice no one, staff or service user, receives less favourable treatment on the
grounds of disability, gender, age, religion or belief, race, sexual orientation, gender reassignment,
marriage and civil partnership status, pregnancy and maternity status, nationality, caring
responsibilities, political opinion or part time/fixed term working status. Furthermore, no one is
disadvantaged by unjustifiable provisions, criteria or practices. This commitment extends to all
areas of employment e.g. recruitment and selection, pay, benefits and other terms and conditions
of employment; supervision and performance, appraisal, opportunities for promotion/transfer,
access to training, discipline and dismissal (including redundancy and retirement) and also to all
areas of our service provision.
It is the policy of Halton Haven Hospice to recruit and promote people on the basis of their suitability
for the role, as defined by a comprehensive and up to date job description and person
specification. Vacancies are advertised to the widest possible audience and utilise sources that, as
far as is reasonably practicable, ensure that all sections of the community have the opportunity to
apply. All applicants for employment or volunteering vacancies receive an equal opportunities
monitoring form as part of the recruitment process.
If under-representation of any particular group (e.g. disabled people, people from ethnic minorities
or people of a certain gender or age) is found we will, where appropriate, make every effort to:
• Include a statement in our job advertisements, positively encouraging people from those
groups to apply;
• Ensure our job advertisements reach them;
• Consider using targeted or specialist media for our job advertisements;
• Consult specialist agencies, such as Job Centre Plus, for advice;
• Make sure the criteria for selection are entirely job-related;
• Review and revise the organisation’s policies, practices and procedures; and consider taking
positive action to provide training specifically for under-represented groups
In line with current legislation, Halton Haven Hospice reserves the right to take positive action that
will help or encourage people who share a protected characteristic to gain employment or benefit
from service provision on an equal basis to those who do not share a protected characteristic.
27.27.27.27.
3. Foster good relations between people who share a protected characteristic and people who
do not share it
In addition to all of the details noted above, the Hospice provides ‘Spiritual Care’ training to make
staff aware of the different spiritual needs of patients and their families from varying cultures and
religions. It is hoped that this increased awareness and understanding leads to better relationships
and more positive outcomes for all concerned.
The Hospice also has a policy and procedure in place to make sure that the kitchen is aware of
the dietary requirements of each patient whatever their personal needs, whether this is due to
allergies, intolerances, cultural or religious requirements or simply due to personal preference.
Equality Objectives 2013 – 2017
It is a requirement of the Equality Act (2010) that Halton Haven Hospice works towards a specific
and measurable set of equality objectives every four years. Between April 2013 and March 2017
the Hospice will work towards the following three targets;
• To actively recruit male nurses, as this group are currently under represented within both the
In –patient and Day Hospice services.
• To continue to promote the work of the Hospice across the local community in ways that
are accessible to as many people as possible.
• To continue to provide the highest quality palliative care services to people from the local
community, irrespective of the absence or presence of protected characteristics.
28. 28. 28. 28. Community EngagementCommunity EngagementCommunity EngagementCommunity Engagement
Community Engagement continues to be, and always will be, an important activity for the
Hospice. Halton Haven Hospice provides a Core Service for the community of Halton which
includes the In - Patient Unit and Day Hospice. These core activities provide multi – disciplinary
treatment and support for patients and their families referred for direct service provision.
It is our belief and our commitment that the role of the Hospice extends beyond the provision of
beds and our core services, with Halton Haven Hospice looking to engage with the local
community in the following ways:
• Information
• Consultation
• Involvement
• Collaboration
• Empowerment
Information
Halton Haven Hospice aims to be a local source of expert, balanced and objective information on
end of life care issues such as hospice care, serious illness, advanced care planning and
bereavement.
Consultation
The Hospice always encourages community feedback about its practice. This includes concerns,
aspirations, evaluation and analysis. We endeavour to use this consultation to inform service
delivery wherever possible.
Involvement
The Hospice works with the community of Halton to encourage feedback and to ensure it is being
understood and reflected in service delivery. We look to the community to assess the effectiveness
of our service delivery.
Collaboration
The Hospice works in partnership with the local community to make decisions about end of life
care. This includes developing alternative approaches as required and identifying preferred
solutions.
Empowerment
Final decision making about end of life care is placed with the community. The Hospice transfers
professional knowledge and enables community members to make their own informed decisions
about what they want in respect to service needs.
29.29.29.29.
Halton Haven Hospice combines many aspects of community engagement to provide the
underpinning framework for its activities in Halton. The Hospice’s commitment to community
engagement can be demonstrated in the following examples of activity from the past year;
Advanced Care Planner
Throughout this past year the Advance Care Planning team has acted as a pivotal link in providing
support and education on the delicate issues surrounding end of life care planning. The team has
encouraged professionals to share their knowledge of Advanced Care Planning tools that support
people and their families who are living with a terminal illness in Halton, with the aim of helping to
provide choice at end of life.
This work has also included working in the community to help improve end of life care through
education and training, co-ordination between services, raising awareness of end of life issues
amongst other professionals in the Borough, improving working across organisational boundaries,
supporting the implementation of all recognised end of life care tools and looking to ensure that
the tools are available and in use in the right settings, for the benefit of the patients and their
carers in Halton. The team has worked with health and social care professionals in the local
community who deliver end of life care to help ensure that best practice is always available.
Drop in Centres for Bereavement Support
Halton Haven’s Family Support Team offers one to one bereavement support to the community of
Halton. However, we are aware that not everyone who is bereaved requires one to one support
and with this in mind we have bereavement drop-in support groups, which have continued to be
available throughout 2013 – 2014. The groups aim to offer peer support to group members in a safe
and friendly environment which helps to build a sense of belonging, confidence and
empowerment, things often lost following bereavement. Anyone can attend the groups and no
previous connection with the Hospice is required. Over the past year the groups have been hugely
successful and will continue to provide this service into the future.
Patient and Carer Support Groups
Over the past year the Hospice has been running two individual support groups, one for patients
and one for carers, to provide each the space and time to talk, ask questions, to share their
experience, to relax or just take a little bit of time out from their usual routine. The groups are a
means for the Hospice to offer and deliver to patients and carers in Halton help, information and
advice on things such as looking after yourself, financial matters, welfare rights, employment rights
for carers, legal issues such as power of attorney, lasting powers and wills, stress management,
symptom management advice and spiritual and emotional support. The groups have been well
attended and will continue to be available throughout the coming year.
30.30.30.30.
Dying Matters Events
The Hospice once again, this past year, took part in the annual, national “Dying Matters” week event.
The aim of this is to try to change public knowledge, attitudes and behaviours towards dying, death
and bereavement. Talking about death doesn't bring death closer; it’s about planning for life and
without communication and understanding death and terminal illness can be a lonely and stressful
experience, both for the person who is dying and for their friends and family. The Hospice took part in
awareness raising of these issues at events across the Borough, which helps in getting across these
messages and gets people thinking and talking about death and dying, particularly what their own
wishes at that time might be.
Relationship with Media
Halton Haven Hospice continues to have a very good relationship with the local media and as a result
of this the Hospices activities are extremely well represented in the local press. This is an important
relationship for the Hospice as it provides a means for getting our messages across to the local
community. The Hospice also utilises the internet through the use of the Hospice website and online
social media sites such as “Facebook” to ensure the Hospice message reaches the widest possible
audience.
Relationship with Halton Borough Council
The Hospice has continued to enjoy close collaboration with Halton Borough Council this year with
visits from the Chief Executive, the Leader of the Council and a number of other elected members.
Relationship with Clinical Commissioning Group
Halton Haven Hospice has developed an excellent working relationship with Halton Clinical
Commissioning Group (CCG). The Hospice has been fully represented at all the public engagement
events held by the CCG during 2013 – 2014. The importance of a continuing collaborative relationship
with Halton Clinical Commissioning Group is recognised by the Hospice to enable the successful
delivery of specialist palliative care services to the people of Halton.
Hospice Shops and Recycling Centre
The Halton Haven Hospice shops in Runcorn, Widnes and Frodsham and the recycling centre in
Runcorn continue to provide the local community with a means of recycling unwanted household
items. The activities of all of these outlets have again been a great success over the year, continuing
to raising money for the Hospice and providing opportunities for bargains for the local community.
31.31.31.31.
Hospice Volunteers
The past year has seen Halton Haven Hospice continue to recognise and value the contribution
that the local community makes to the delivery of Hospice services in a voluntary capacity. The
general public, friends and relatives have provided help in many areas which allows us to provide
care to service users. The Hospice encourages the involvement of individuals from the local
community who wish to work with the Hospice in a voluntary capacity and looks forward to
engaging with more people in this way over the coming year.
Hospice Organised Events
The local community of Halton is a joint funder of Hospice services through participation and
involvement in the many Hospice organised events and fundraising activities that have taken
place throughout the past year. The raising of money to help fund services gives people in the
community the opportunity to work together with us and provides a sense of involvement and
ownership in those who have generously taken part.
Patient and Carer Representative on Clinical Governance Committee
The Hospice has recently recruited a new patient/carer representative to speak to our patients,
gather anecdotal feedback and to attend the Hospice Clinical Governance Meetings. This is an
important role that gives patients and their families the opportunity to voice their opinions about
Halton Haven Hospice and the services we provide. This role includes the patient/carer
representative talking to patients and their families about their experiences of the Hospice, listening
to their views about the service and then representing these views at the Hospice Clinical
Governance Committee Meetings. It is hoped that this ensures that patient/carer views are heard
within a forum which can take action upon them as appropriate.
Halton Haven Hospice aims to continue with its community engagement activities over the coming
year and will look to engage with and involve an ever greater number of local people in what we
do. It is our aim to show people that this is their Hospice and that the local community can be
proud of what has been achieved over the years as a result of their contributions.
32.32.32.32. Priorities for Improvement 2014Priorities for Improvement 2014Priorities for Improvement 2014Priorities for Improvement 2014----2222015015015015
Halton Haven Hospice continually reviews services and seeks to improve and develop them
whenever and wherever we can. The Hospice has a strategy which is developed in consultation
with patients, public, staff and other professionals. The strategy, supported by annual business
plans, outlines our vision for the future of the Hospice in ensuring that we continue to meet patient
and carer needs at end of life.
Everyone with a stake in the Hospice working together is fundamental to the delivery of our
strategy and two way communication between all Hospice teams, the Hospice Management,
the Board of Trustees and others is essential to ensure service delivery is monitored through Clinical
and Corporate Governance mechanisms such as audit, project reports, activity data collection,
feedback from patient and carer surveys and meetings with commissioners of services.
Throughout 2013 - 2014 our reviews of service provision have identified and informed the
development of our priorities for the year 2014 - 2015. We have discussed our priorities taking into
consideration national and local policy, as well as those issues which are of concern to our service
users, our staff and our partners. However, Halton Haven Hospice is a small organisation with
limited resources and while wanting to challenge ourselves and push for continual improvements,
we are mindful that the goals we set are achievable and that new initiatives can be delivered to
a high standard and be sustainable in the long term.
Halton Haven Hospice has over the past year identified three Priorities for Quality Improvement for
2014 – 2015, one in each the following categories:
• Patient Safety
• Clinical Effectiveness
• Patient Experience
33.33.33.33. PRIORITY ONE
Patient Safety
Produce an audit framework focussing on patient outcomes
It is our aim this coming year to develop the way in which we audit patient outcomes.
Audit is integral to the clinical governance structure of the Hospice as it helps to inform our
everyday service provision as well as our underpinning structures; thus making continual
improvement and expansion in this area vital to our continued success.
As part of our comprehensive audit schedule we currently audit the wide variety of paperwork
that is produced when caring for an individual and their family. However, such audits focus on the
documentation and whether it has been completed correctly by our team here at the Hospice.
While we understand that this is very important, in the future we would like to broaden our
approach to audits and look at the actual outcomes for our patients not only in relation to their
medical treatment but also regarding the holistic support package that we provide. In doing this
we hope to further improve upon the quality and depth of the services that we offer to ensure that
our patients and their families receive the best possible care and support at all times.
We aim to achieve this goal by developing a new audit tool at the Hospice that enables the staff
team to establish whether or not outcomes are being met for patients and their families. Action
plans can then be drawn from this and implemented in a timely and appropriate way.
Progress will be monitored over the coming year by the Chief Executive Officer, the Hospice’s
Clinical Director and the Head of Clinical Services. Findings and action points will be discussed with
the Board of Trustees and the wider team as a whole.
34.34.34.34.
PRIORITY TWO
Patient Experience
Advertise and promote Men’s Shed
Following a successful bid to the Department of Health Halton Haven Hospice has almost
completed the building of a new Family Support Centre so that our families have first class
facilities in which to be supported. And part of this building is a space especially for men – a
“Men’s Shed”.
Men’s Shed will offer groups of men the opportunity to share the tools and resources they need
to work on projects of their own choosing at their own pace and in a safe, friendly and inclusive
environment. It will be a place of skill-sharing and informal learning, of individual pursuits and
community projects, of purpose, achievement and social interaction. It is a place of leisure
where men come together to work, while simultaneously improving their health and wellbeing.
The Men’s Shed at Halton Haven Hospice is a first for the Hospice movement and is another
example of how, here in Halton, we can innovate nationally.
Over the coming year, the Hospice aims to advertise and promote the ‘Men’s Shed’ in order to
build a sustainable core of service beneficiaries. In doing this, Halton Haven Hospice hopes to
alleviate some of the pressures that men face, especially following a bereavement. Halton
Haven Hospice understands that it can be very difficult for bereaved men to feel able to
access support services. Most men have learned from our culture that they don’t talk about
feelings and emotions and there has been little encouragement for men to take an interest in
their own health and well-being. Because of this many men’s health suffers, they drink more,
take more risks and they suffer more from isolation, loneliness and depression. Bereavement in
particular is a problem that men often try and fail to successfully deal with on their own.
Halton Haven Hospice will promote the ‘Men’s Shed’ using local media, social networking and
local events. This will be achieved by the fundraising team who have a proven track record of
successful public relations campaigns in the area. Success in this area will be evident through
the development of a core group of beneficiaries accessing this new service.
Progress will be monitored over the coming year by the Chief Executive Officer, the Family
Support Manager and the Senior Management Team as a whole.
35.35.35.35.
PRIORITY THREE
Clinical Effectiveness
Support the provision of a Lymphoedema service
Halton Haven Hospice’s business case for a proposed Bridgewater - wide Lymphoedema service
was discussed by the Business Development Group meeting at Bridgewater NHS on December
11th 2013 and has since been approved.
This specialist service will allow patients to be diagnosed and treated more quickly than may
otherwise be the case and will ensure access for patients with palliative care needs to a ‘whole
package of care’ for Lymphoedema. Lymphoedema specialists will be able to provide support
and give advice to both patients and professionals, obtain and disseminate Lymphoedema
information and provide our patients with the best possible care and treatment. The service will
also relieve some of the burden on inexperienced practitioners and on physiotherapists across
Halton, while setting a benchmark of best practice for the rest of the country.
In 2013/14 we aim to further support Bridgewater Community NHS Trust’s provision of the
Lymphoedema Service. In doing this we will make provision for two dedicated beds at the
Hospice for specialist interventions such as Multi-Layer Bandaging; and will also offer an
increased number of available sessions with the Consultant in Palliative Care. To achieve this,
the Hospice will work closely with all relevant partners to develop a comprehensive and relevant
implementation plan that sees this service rolled out across the entirety of the Bridgewater
footprint.
Progress will be monitored over the coming year by the Chief Executive Officer, the Hospice’s
Clinical Director and the Head of Clinical Services.
36.36.36.36. Statements on this Quality AccountStatements on this Quality AccountStatements on this Quality AccountStatements on this Quality Account
Halton Haven Hospice has received comments on this Quality Account from the following
organisations:
• Healthwatch Halton
• Halton Clinical Commissioning Group
Healthwatch Halton Statement on the
Quality Account of Halton Haven 2013-14
Healthwatch Halton appreciates Halton Haven’s commitment to producing the report, when there is no
statutory requirement to do so and members welcomed the opportunity to comment on your Quality
Account for the year 2013-14.
The Account is clear, easy to read and informative.
We are pleased to note that last year’s priorities have been achieved, but we would like some statistics
related to meeting the goals.
We welcome the overall decrease in clinical incidents but following our comments last year, we cannot
see if there has been training in medicines’ management.
Members applaud the efforts of the Trust to involve service users, staff and partners in informing the
choice of priorities for 2014-15.
The Haven is to be congratulated once again on its continued involvement with the local community and
businesses that not only take part in fund-raising activities but also provide volunteers who give their
time to support the Haven.
We welcome the progress of the ‘Men’s Shed’ project and look forward to hearing of people’s
experiences of using this service.
During the past year, Healthwatch Halton has continued working closely with the Advanced Care
Planning Team and we value the commitment shown to improving end-of-life care for the residents of
Halton. We look forward to further developing this good working relationship in 2014-15.
37.37.37.37.
Halton Clinical Commissioning Group Statement on the
Quality Account of Halton Haven 2013-14
Dear Viv
Many thanks for submission of the Quality Account for 2013-2014 and for the presentation to local
stakeholders on 6th May 2014. This letter provides the response from NHS Halton CCG to your
Quality Account.
Although the CCG has been a fully authorised body for just 12 we have I believe had a good working
relationship prior to authorisation and since. NHS Halton CCG is the commissioner for the Halton
Haven Hospice contract and scrutiny of the key quality indictors in the Quality Schedule and other
contractual requirements is managed through the CCG, the processes are proving to be both effective
and useful.
NHS Halton welcomes the work delivered by the provider in relation to improving clinical leadership
and congratulates you on your successes in the area. The CCG notes the delivery against your
planned improvements targets. NHS Halton CCG is also pleased to note the delivery against the other
commissioner requirements and the very positive from patients and families regarding care received.
NHS Halton CCG notes that the hospice has received very positive feedback from the Care Quality
Commission in relation to the recent inspection.
NHS Halton CCG are pleased to see the planned Quality Priorities for 2014/2015 and we look forward
to working with the hospice through 2014/15, helping to improve the quality of services for our patients
through the NHS contractual mechanisms and the review and management of Serious Incidents,
applying good governance and ensuring lessons are learnt throughout the hospice.
Yours sincerely
Jan Snoddon
Chief Nurse/Quality Lead
NHS Halton CCG
38383838. Feedback. Feedback. Feedback. Feedback
Feedback about our Quality Account is very welcome. If you have any comments or queries
please do not hesitate to contact;
Chair of Trustees
Halton Haven Hospice
Barnfield Avenue
Murdishaw
Runcorn
Cheshire
WA7 6EP