quality account 2015/16 - nhs · 2015. 7. 28. · a quality account is an annual report to the...

QUALITY ACCOUNT 2015/16

1 St. John’s Hospice North Lancashire & South Lakes is a Charitable Incorporated Organisation

registered in England with charity number 1157030

Our Vision

Putting local patients and families at the heart of everything we do, we will ensure that on the journey towards the end of life, we provide the right care,

in the right place, at the right time

Our Values:

Care – We will provide 1st class care, delivered by competent people who

put the patient at the heart of all we do Compassion – We will treat everyone with respect, dignity and empathy Collaboration – We will work with others to ensure that patients and families receive the best end of life care possible Charity – We will provide care free of charge to patients and families and will connect with our local communities so that they continue to finance our present and our future

• Celebration – We will celebrate the abilities of the people we care for, however limited they may be. When people are bereaved, we will support them to celebrate the lives of the people they have lost

St John’s Hospice

Built by the people, for the people



Part 1

Chi ef Execut ive’s St at ement

It gives me great pleasure to present this Quality Account for St John’s Hospice. In this account our aim is to show how the Hospice measures quality, involves patients, carers and staff and strives to always look for areas where we can improve our care.

A Quality Account is an annual report to the public from providers of NHS healthcare about the quality of services they deliver. It is important to note that St John’s Hospice only receives around 30% of its funding from the NHS; the rest (£2.7million) is donated by the local community. The majority of services described in this document are funded by charitable donation rather than by the NHS.

Quality sits at the centre of all that the Hospice does. Our vision is that everyone in our catchment area of South Lakeland, parts of North Yorkshire and all of North Lancashire with any life-limiting condition will have high quality care and support at the end of their life in the right place, at the right time.

We asked patients, families, volunteers and staff to sum up in one word what St John’s means to them. Their key words can be seen here:



Our Corporate and Clinical Governance structures ensure that we have both the systems and processes in place to maintain a viable and responsible business, whilst ensuring that our services are of the highest quality and meet the aspirations of our vision. Our services are subject to unannounced inspections at any time.

On the 13th February 2014, the Care Quality Commission (CQC) conducted an unannounced inspection of the Hospice. A CQC Inspector and an “expert inspector” specialising in Governance attended. They spent a full day speaking to patients, families and staff and scrutinising records and documentation. The Hospice was judged to be fully compliant in all areas inspected. They said:

“We found there were good systems and processes in place to monitor the quality of the service being provided. Staff told us this was underpinned by an open

reporting culture and strong leadership.”

As I write this account, we await inspection under the new CQC regime for Hospice services. Responsibility for inspecting Hospices will move from the NHS to the Adult Social Care Directorate. I am responsible for the preparation of this report and its contents. To the best of my knowledge, the information contained in this Quality Account is accurate and a fair representation of the quality of healthcare services provided by our Hospice.

Sue McGraw

Chief Executive

30th March 2015



Part 2

Priorities for Improvement 2015/16

The priorities for improvement we have identified for 2015/16 are set out below. Our focus for the year ahead will be on reaching more people and increasing our impact. Our priorities have been developed in conjunction with feedback from our VOICE group (Valued Opinions in Care Excellence.) The VOICE group is made up of patients, family members and Volunteers, all of whom have had recent experience of Hospice services. In addition, the Quality Account has been to our Staff Forum for consultation. We have expressed our priorities in terms of the three domains of quality:

• Patient safety • Clinical effectiveness • Patient experience

Priority 1 –Patient Experience Review the Provision of Spiritual Care and Equality and Inclusion

How was this priority identified? St John’s Hospice was founded almost 30 years ago. Whilst our Christian heritage is treasured by some of our supporters, this approach no longer fully reflects the demographics of the community we serve. Indeed, our history and heritage is often a barrier for certain sectors of our community. The vast majority of our patients identify themselves as having no faith or to be of a non-practicing Christian background.

The provision of spiritual care for patients and families has been discussed at Board level for a number of years. Many hospices still employ a Hospice Chaplain. Last year the Board of Trustees made the decision to move away from the Chaplaincy model. A temporary post, “Spiritual Care Coordinator” was piloted for 6 months. The role of the Spiritual Care Coordinator was to reach out into community and faith groups to establish links with volunteers who could be called upon when needed. This model has proved to be so effective, the Board of Trustees made the post substantive in December 2014.



To continue the development of spiritual care provision, in April 2015 the CEO commissioned a “visual audit” of the Hospice building with regards to Equality & inclusion. This audit was carried out by the Head of Equality & Inclusion from the Lancashire and Midlands Commissioning Support unit. In summary the recommendations were that:

1. To develop a more inclusive atmosphere, we should consider moving the cross on the outer wall of the Chapel to another less prominent position.

2. Identify a suitable location for a multi-faith room/space for quiet reflection. The findings of the report were discussed on the 28th April 2015 with the hospice VOICE group. The group suggested a number of suitable locations. One suggestion was to develop a garden room in the central courtyard of the Hospice, subject to grant funding. Over the next 12 months we will work with volunteers from demographically significant faith groups and the VOICE group to identify a suitable, inclusive space for quiet reflection.

How will progress be monitored and reported?

• The VOICE group will monitor the development of this project • Progress will be reported via the Care, Quality & Services Sub-Committee of

the Board • Feedback and consultation will be undertaken with key faith groups from

our local communities

How was this priority identified?

Dementia care is an increasingly important strategic consideration for palliative and end of life care providers. The anticipated changes in population size, age and related morbidity and mortality indicate dementia will call for increasing levels of health and social care, including end of life care. Dementia is now one of the biggest global public health challenges facing our generation. Over 35 million people worldwide are currently living with a diagnosis of dementia. This is projected to double by 2030 and more than triple by 2050.

Priority 2 – Clinical Effectiveness, Patient Experience & Patient Safety

Develop a Dementia Friendly Ward Environment



Dementia is now acknowledged as a life limiting condition with most dementias being progressive in nature and no curative treatment to date. If St John’s Hospice is to respond to the needs of its community in coming years, the infrastructure of the building and the skills of our staff must be developed to meet this need. In March 2015 the Hospice VOICE group was asked to conduct a review of the ward and its associated areas. Many of their comments and observations mirror guidance from The King’s Fund on developing dementia-friendly in-patient units “Enhancing the Healing Environment” for example, the group would like a complete review of signage on the ward. They considered current signage to be confusing, sometimes missing and out of date. The group suggested an update of the reception/nurses station at the centre of the ward, again mirroring The King’s Fund recommendations regarding best practice. It is our ambition to apply for grant funding to update the ward over the next 12 months. Whilst there is no doubt about the skills and level of care our staff provide for patients at the end of life, we do feel that more in depth skills training in dementia care would enhance our practice. Our Education Team are working in partnership with the University of Cumbria to develop an accredited Dementia Skills module of a palliative care certificate. It is our intention over the next 12 months to enhance the training of all our staff in this area and to provide training to health and social care colleagues in the community. The St. James’s Place Charitable Foundation is currently inviting hospices to bid via a grant programme to fund projects for hospice-enabled dementia care. St John’s Hospice has made a bid to employ a dementia nurse trained in the use of the Namaste model. The Namaste Care programme was developed by Professor Joyce Simard in the USA in 2003. ‘Namaste’ is the Indian greeting meaning ‘to honour the spirit within’. The care programme was developed to meet the needs of people with advanced dementia for human contact, sensory stimulation and meaningful activity. Namaste Care seeks to engage people with advanced dementia through sensory input, comfort and pleasure. Namaste combines compassionate nursing care with music, therapeutic touch, colour, food treats and scents. Families are supported to acknowledge the progression of dementia in the positive context of seeking to provide quality of life. We will know if our bid has been successful in June 2015.

How will progress be monitored and reported?

• The VOICE group will be actively involved in monitoring physical improvements on the ward.



• The Care, Quality & Services Sub-committee of the Board will receive regular update reports

• Progress will be reported quarterly to the full Board of Trustees

How was this priority identified? In the next 12 months we will review all our engagement and consultation channels. This will include: the work of the VOICE group, patient and family surveys, incident reports, comments, compliments and complaints, the use of suggestions boxes, Staff Forum, feedback received on social media and more traditional channels. We will work with Hospice UK, the umbrella organisation for hospices to ensure that our engagement and consultation processes are at the leading edge of good practice. How will progress be monitored and reported? • Review the current consultation and engagement strategies • Develop a task and finish group comprising of Trustees and key staff to

consider new methods gathering feedback • The Care, Quality & Services Sub-committee will receive regular update reports • Progress will be reported quarterly to the full Board of Trustees

Priority 4 – Effectiveness

Develop Volunteer-led Services to Reach more People and Increase Impact

How was this priority identified? Volunteers have been at the heart of service delivery in the Hospice for 30 years. The rise of regulatory requirements and health & safety culture has meant that we have restricted the roles we may have traditionally allowed volunteers to fulfil. In the next 12 months we will pilot a number of volunteer projects that will allow us to test how far volunteers may still be involved in some aspects of clinical and social care. For

Priority 3 – Effectiveness & Patient Experience

Conduct a Review of Engagement and Consultation Processes and Procedures.



example, we have received grant funding to fund a post that will focus on the use of volunteers in traditionally clinical roles on the ward. We have received funding from The Prime Ministers Challenge Fund to develop a network of “Hospice Neighbours”; their role will be to support people who place large amounts of demand on the wider health and social system. We will review the provision of Day Hospice care. Volunteers are actively involved in the day-to-day running of this service, it is our intention over the next 12 months to establish a “positive living” drop-in programme that will be delivered, not only at the Hospice, but also in community settings.

How will progress be monitored and reported? • Project managers will report progress to the Care, Quality & Service Sub-

committee • Progress will be reported quarterly to the full Board of Trustees

Review of 2013/14 Priorities for Improvement

Develop a Workforce that is Fit for the Future

Review Working in consultation with staff, a complete review of shifts, working patterns and ward management was undertaken in the previous year. The aim of the review was to ensure that patients and families received consistent and safe care. All staff now work on a rotating shift pattern to ensure that the skills of our team are shared and up to date. A complete review of competencies was undertaken and is still ongoing. Induction for care staff has been updated and extended and in the next 12 months all new care staff will complete the “Care Certificate” as part of their induction and probationary period. Mandatory training for the Clinical Team has been reviewed. Developments in our Education Team mean that we are now able to offer a mix of on-line and face-to-face training, some of which will be accredited by the University of Cumbria.



Conduct a Food & Nutrition Review across the Hospice

Review The demise of the Liverpool Care Pathway in 2013 prompted the Hospice to review the provision of food and hydration to patients at the end of life. The CEO commissioned an audit which included surveys of patients and families’ views and considered the skills of our catering team.

The Head of Nursing & Quality has commissioned support from University Hospitals Morecambe Bay Trust (UHMBT) Dietetics Team. They will visit the Hospice once a month to provide help and advice to the Catering Team. In addition the Head of the Catering & Hospitality School at Kendal College is advising the Catering Team with regards to menu planning and nutritional content. We obtained a grant of £5,000 from the Foundation of Nursing Studies (FoNS) to develop a new role – Nutritional Support Worker. The purpose of this role is to highlight the importance of meeting patients’ likes and nutritional needs on the ward.

Our patient & family surveys still indicate that the quality of our food is very good however, the Hospice is determined to ensure that our provision of food and nutrition is supported by a strong evidence base and keeps abreast of new techniques and guidance. Our volunteers continue to develop our Hospice allotment. Between May and October, much of the fruit and vegetables we require is grown on-site. The volunteer gardeners will be actively encouraged to meet and work with our partners from the dietetics team at UHMBT and from Kendal College.

St. John’s Hospice North Lancashire & South Lakes is a Charitable Incorporated Organisation registered in England with charity number 1157030

10

Adoption of an Electronic Record System to Ensure Patients Receive Safe, Effective Patient Care.

Review EMIS Web was chosen as the preferred electronic patient record system. EMIS is used by all our GP Practices and the majority of the Community Nursing Teams. It was felt that the adoption of the same system would enable us to safely and effectively admit, treat and discharge patients. The implementation of the system has taken 12 months. Monthly project management meetings have taken place with representatives from the Hospice, UHMBT, the Locality GP with responsibility for I.T. and with other healthcare colleagues as required. Whilst the process has taken longer than anticipated, we are pleased to report that the Hospice went “live” on EMIS on 27th April 2015. Early indications show that our thorough project management and training provision has been of great benefit to the team who seem to have made such a major transition smoothly.

Part 2 (Continued) Statements of Assurance from the Board

Quality Accounts have a series of statements that MUST be included. Many of these statements do not apply to St John’s Hospice. Explanations of these statements are given where appropriate and are prefaced by the words: “MANDATORY STATEMENT”.

During 2014/15, St John’s Hospice provided the following services:

• In Patient Unit • Hospice at Home Service • Day Hospice • Family Support and Bereavement Service • COPD/MND/Parkinsons Support Groups • Education and Training – Including 6 Steps to Success programme with Care

Homes and domiciliary agencies. • Education and Training – Including Lancaster University GP trainees, GPSTRs

from the Lancaster University Medical School, Nurses and Occupational Therapists from UCLAN and University of Cumbria


11

• Out Patient Clinics • Physiotherapy, Occupational Therapy, Social Work and Lymphoedema Services

Charitable donations support 70% of this work, the remaining 30% comes from the NHS.

MANDATORY STATEMENT – St John’s Hospice has reviewed all the data available to them on the quality of care in all these NHS services.

Participation in Clinical Audits

The following are examples of audits (both clinical and non-clinical) conducted within the Hospice in 2014/15:

• Nursing Uniform • Hand Hygiene • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) & Preferred

Priorities of Care (PPC) documentation • Spiritual Care • Controlled Drugs Accountable Officer • Information Governance Compliance • Record keeping • Education Audit

We were also active participants in the regional Lidocaine audit for the North West Palliative Care Audit Group. Some positive outcomes have been achieved from this year’s audit activity; headline themes being:

• Controlled Drugs – progress has been made as initial audits in 2013-14 focussed on physical storage and improved management of the Controlled Drug keys/fob locks. This year we have been able to drill down on quality issues such as improved monitoring systems ensuring appropriate signatures are exact and up to date.

• Record Keeping – audit activity in this area highlighted the need for improved record keeping. This applied to both clinical and non-clinical information such as spiritual care preferences. This has led to the introduction of record keeping within our annual Clinical Mandatory Training Programme and will be further supported by the introduction of electronic clinical record keeping EMIS which has been implemented in May 2015.


12

• Education – a Resource Room has been identified and is available to Medical, Nursing & Allied Health Students to access journals and use our available workspace to access e-resources and internet/intranet.

Research

MANDATORY STATEMENT - The number of patients receiving NHS services provided

or sub- contracted by St John’s Hospice in 2014/15 that were recruited during that

period to participate in research approved by a research ethics committee was

NONE.

13 St. John’s Hospice North Lancashire & South Lakes is a Charitable Incorporated Organisation registered in England with

charity number 1157030

Use of the CQUIN Payment Framework

The Hospice at Home Hub was asked to work on the CQUIN framework below, results are

indicated, all goals were achieved.

Goal Number

Goal Name Description of Goal

Goal weighting (% of CQUIN scheme available)

Expected financial value of Goal (£)

Quality Domain (Safety, Effectiveness Patient Experience or Innovation)

H@H Hub Response

1 Friend and Family Test

Develop and pilot family & carer survey in year

50.00%

£1,440.50

Patient Experience

Completed, although this will continue.

2

NHS Safety Thermometer

Locally develop implementation of safety tools applicable to the service

0.00%

£0.00

0

N/A

3 Dementia

All staff undertake Dementia awareness training

50.00%

£1,440.50

Effectiveness

Completed.

4 VTE

Training to identify, assess and manage treatment of VTE, where appropriate in year

0.00%

£0.00

Patient Experience

N/A

Total

100.00%

MANDATORY STATEMENT - £2881.00 of St John’s Hospice NHS income in 2014/15 was conditional on

achieving CQUIN targets as outlined above. All targets were achieved.



Statement from the Care Quality Commission (CQC)

St John’s Hospice is required to register with the CQC; we are registered to carry out the following regulated activities:

Treatment of disease, disorder or injury Diagnostic and screening processes Transport services, triage and medical advice provided remotely

St John’s Hospice has the following conditions on registration:

Only treat people over 18 years old Only accommodate a maximum of 20 in-patients

The CQC has not taken any enforcement action against St John’s Hospice during 2014/15.

Our most recent CQC inspection took place on 13th February 2014. Two inspectors made an

unannounced visit to the Hospice. The Inspectors’ overview of the Inspection was as follows:

“We spoke with a range of people about the hospice. They included the registered manager, staff members, volunteers, patients, relatives and visitors. We also asked for the views of

external agencies in order to gain a balanced overview of what people experienced using St John’s Hospice. We spoke with patients and relatives. They told us they could express their

views and were involved in making decisions about their care. They told us they felt listened to when discussing their care needs. Staff confirmed to us they also involved relatives, where possible to ensure people received the right care and support. We spent time in all areas of the hospice, including the day centre and in-patient unit. This helped us to observe the daily routines and gain an insight into how people's care and support was being managed. Staff

treated people with respect and ensured their privacy when supporting them. They provided support or attention as people requested it. We spoke with people about the care and

support they received. They said they were happy with the care and support being provided. We looked at how the service was being staffed and reviewed staff training and supervision. We saw there were sufficient staff on each shift with a range of skills and experience. Staff

told us they felt supported, had regular meetings with their manager, and their training was kept up to date. We found there were good systems and processes in place to monitor the

quality of the service being provided. Staff told us they felt this was underpinned by an open reporting culture and strong leadership.”

Areas inspected were:

Treating people with respect and involving them in their care Providing care, treatment & support that meets people's needs Caring for people safely & protecting them from harm Staffing Management

All areas inspected fully met CQC standards.



Data Quality

MANDATORY STATEMENT - St John’s Hospice did not submit records during 2014/15 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data.

However, St John’s Hospice does submit data to the Minimum Data Set (MDS) for Specialist Palliative Care services collected by the National Council for Palliative Care on an annual basis, with the aim of providing an accurate picture of Hospice and Specialist Palliative Care service activity. Data taken from the MDS is reported in section 3, Review of quality Performance.

Information Governance Toolkit

St John’s Hospice Information Governance Assessment Report overall score for 2014/15 was 85%. This has been audited and verified by the Information Governance Team at the Health & Social Care Information Centre.

Clinical Coding Error

MANDATORY STATEMENT – St John’s Hospice was not subject to the payment by results clinical coding audit during 2014/15



Part 3

Review of Quality Performance

In this section, we have chosen to provide data benchmarking St John’s Hospice with figures from the National Council for Palliative Care Minimum Data Set, (MDS.) The MDS is the only national benchmarking tool for Hospices.

In Patient Unit

2014/15 2013/14 2012/13

Total number of patients

278 295 293

Number of new

patients

235

258

259

% Occupancy

75%

77%

74%

Location after end of

stay (N.B. Figures do not total because some

patients were admitted more than once.)

173-Deaths

139-Home

8-Care Home

3-Acute Hospital

20-Other

159-Deaths

152-Home

16-Care Home

3-Acute Hospital

22-Other

161-Deaths

169-Home

7-Care Home

4-Acute Hospital

9-Other

Average length of stay (in days)

14

13.4

15.4

Hospice at Home/CNS

2014/15 2013/14 2012/13

Total number of

patients

527

541

315 Total number of visits

face to face

13,572

12,327

4,902

Total number of telephone calls

12,756

10,302

4,722

% of people who died at home

92% 85% 92%

Average length of care (in days)

61.5 43 25.9



Day Hospice

2014/15 2013/14 2012/13

Total number of patients

163 147 140

% new patients

60% 66% 69%

Average period of attendance (in days)

73.5 80.5 85

Family Support and Bereavement Service

2014/15 2013/14 2012/13

Total service users 502 420 456

Number of whom formal support ended

423 344 391

Average length of support (in days)

67.3 45.4 47

Feedback from Staff

An annual staff satisfaction survey is conducted. The top three statements that staff agreed with were:

If a friend or relative needed treatment, I would be happy with the standard of care provided by the Hospice – 96%

I enjoy the work I do – 94%

I am proud to work for St John’s Hospice – 96%



Feedback from Patients, Families and Carers

Feedback from patients, families and carers is one of the most important ways for us to understand and improve the services we provide.

We often receive comments and compliments by letter or email, here is a montage of some of them:

We never forget that the sign above the door here reads “built by the people for the people”. Putting patients and families at the heart of what we do is fundamental for the Hospice.

We have very few complaints – formal or informal. However, in 2014/15 one family complained about the attitude of a member of our night staff team. We responded to this by conducting a thorough investigation, providing additional skills training for the team member, changing shift patterns to rotate people through days and nights. The person who made the complaint was invited to join our VOICE group and we are pleased to report that she has now become a member.



Surveys

Our volunteers conduct patient surveys on the Ward. This year, comments have been almost 100% positive.

As part of our contract with the CCG, we are required to survey bereaved families for our Hospice at Home service. Again, responses have been overwhelmingly positive.

Complaints 2014/15

Complaints are all monitored by the relevant member of Senior Management Team, clinical complaints are discussed at the Care , Quality & Services Committee and are reported to the full Board of Trustees.

Complaints Number

Total number received 2

Total number of complaints upheld in full 2

Total number of complaints upheld in part 0

Total number of complaints not upheld 0

Opportunities to give Feedback on this Quality Account

We welcome feedback on our Quality Account. If you have any comments, please email:

[email protected]

Or write to: Sue McGraw CEO St John’s Hospice Slyne Rd Lancaster LA2 6ST

mailto:[email protected]



Annex

Comments from Healthwatch North Lancashire Healthwatch Lancashire were unable to provide a comment on our Quality Account this year.

Comments from North Lancashire CCG “I think the report is an excellent reflection of the level of consideration you have given to leading and developing the Hospice and the staff are to be commended on their hard work and commitment.” Commissioning Manager, Lancashire North CCG

quality account 2015/16 - nhs · 2015. 7. 28. · a quality account is an annual report to the...

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