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Quality Account 2017-2018

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Contents Page

Chief Executive Statement of Quality 3

Who we are and What we do

Our Purpose 4

Our Aim 4

Services provided by St peter’s Hospice 2017-18 5

Service Delivery Statistics 6

What we have achieved 2017-18

Priority 1 - Clinical Effectiveness and Patient Experience 7

Priority 2— Effectiveness 8

Priority 3— Safety 9

Other achievements

CNS Out of Hours Service 9-10

Psychological Triage Professional (PTP) 11

Advice Line 11—12

Practice Educator Role 12

Volunteer Resources 12

Quality Assurance

Serious Incident Reporting 13

Infection Prevention and Control 13

Audit 13

Flu Vaccination 14

Sign Up to Safety 14

Medication Safety 14

Clinical Audits and Practice Improvement 15

Duty of Candour 15

Clinical Incidents 15—16

Complaints 16

Education 16—17

Data Quality 17

Information Governance 17

Planning undertaken for the NEW General Data Protection Regulations 18

User Involvement

Carer & Family Satisfaction—IWGC, User Feedback, Social Media 19—20

Monitoring

Internal and External —Trustees and Commissioners 21—22

Aims and Priorities for Improvement 2018-19 23

New Build 24

Board of Trustees’ commitment to quality 25

Care Quality Commission (CQC) 25

Appendices

Sign up to Safety 26

Audits & Surveys 27

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Chief Executive St Peter’s Hospice Statement of Quality This Quality Account is for our patients, their families and friends, the general public as well

as the local NHS organisations.

It is of note that only twenty-five per cent of our care costs are provided by the NHS and

the remainder of our funding is from charitable donations.

The aim of this report is to give clear information about the quality of our services to

demonstrate that our patients can feel safe and well cared for, that all of our services are

of a very high standard and that the NHS is receiving very good value for money.

We could not give such high standards of care without our hardworking staff and over 1500

volunteers, and together with the Board of Trustees, I would like to thank them all for their

support.

Our Director of Patient Care, Medical Director and all clinical managers are responsible for

the preparation of this report and its content. To the best of my knowledge, the information

in the Quality Account is accurate and a fair representation of the quality of health care

services provided by St Peter’s Hospice.

Our focus is, and always will be, our patients, their families and carers and therefore we

actively continue to seek the views of all who access our services in order to ensure we

maintain the highest standards of quality.

Simon Caraffi

Chief Executive

St Peter’s Hospice, Bristol

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Who we are and what we do.

Our purpose (Mission statement)

To provide care and support for adult patients, families and carers in our community living

with life limiting illnesses in order to improve the quality of their living and dying. We do this

working closely with other health and social care providers.

Our aim (Vision)

St Peter’s Hospice will play a leading role in the development and delivery of the best possi-

ble care and support services for adult patients, families and carers living with life limiting

illness in our community.

St Peter’s Hospice (SPH) is Bristol’s only adult hospice. We have been looking after people in

our area (greater Bristol, South Gloucestershire, part of North Somerset and the Chew Valley

area of Bath and North East Somerset) for 40 years. Our commitment is to contribute to im-

proving the quality of life of patients with life limiting illnesses while extending care and sup-

port to their families and loved ones. Our main building is at Brentry but our Community

Nurse Specialist team have bases in Staple Hill, Long Ashton, Brentry and Yate making it

easier for us to provide accessible care and support across this large geographical area.

Who we are and what we do.

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Who we are and what we do.

Services provided by

St Peter’s Hospice 2017-18

We deliver the following services exceeding the service level specifications agreed with the

NHS. The NHS contributes 25% of our overall funding.

Triage Service:

All patients referred to the hospice are triaged by a registered nurse to ensure that SPH is right for their needs and the patient is directed to the right service.

Inpatient Unit (IPU):

In October 2017 we temporarily relocated our Inpatient Unit to a site within a new Care Home complex in Keynsham (The Chocolate Quarter-St Monica Trust) whilst we rebuild the IPU at our Brentry site. This is due to complete late Autumn 2018. During this period we

are running 10 beds, and will then re-open the new IPU with 15 single rooms.

24hr Advice Line:

Offering specialist palliative care advice to healthcare professionals, patients and carers 24 hours a day. This became a partially commissioned service by the NHS in 2016/17.

Day Services:

Up to 20 patients daily, 4 days per week. Patients attend for a day a week for a 12 week period. Fatigue and Breathlessness programme x 1 group a week.

This service will temporarily move to the Garden Rooms in May 18 due to the rebuild- when 14 places will be available daily.

Complementary Therapy:

A service offering massage, aromatherapy and reflexology to inpatients, Day Hospice patients and via an outpatient clinic.

Physiotherapy/Occupational Therapy:

To help patients maintain a good quality of life for as long as possible.

Hospice at Home:

Delivering hands on care to patients at end of life in their own homes, and offer a small amount of respite care.

Community Nurse Specialist Service:

Providing advice, support and symptom control. A CNS also works at the weekend and on Bank Holidays to respond to patients who are identified (by the Advice Line) to

need urgent assessment.

Medical Team:

Consultant led team covering the Inpatient Unit, Day Hospice, Community and 1 session a week with the UHB Palliative Care Team.

Patient & Family Support (PFS) Services:

Provide social, emotional and spiritual support for patients, families and carers. This service includes social work, psychological support, spiritual and bereavement care.

St Peter’s Hospice monitors all services on a monthly basis through collecting of data

on number of patients seen, face to face contacts and telephone contacts.

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Who we are and what we do.

Service Delivery Statistics 2017-18

15% increase in unique referrals; 2150 (2016-17) to 2474 in 2017-18.

Hospice at Home team have increased direct care hours by 17%

from 13600 (2016-17) to 16374 in 2017-18.

Advice Line calls received to service increased by 33% from 2989 (2016-17)

to 4473 in 2017-18.

New data breakdown of all our Patient Family Support Services included

for the first time this year.

Increase in patients with a non-cancer diagnosis from 15.2 % (2016-17)

to 22.6 % of total patients (2017-18).

Service Development

We have successfully transferred and adapted all Inpatient Services to the

temporary rented Keynsham site and were successfully inspected by CQC in

order to open the new location.

We now have EMIS data sharing agreements with GPs, BCH, SIRONA and

One Care. This is having a very positive impact on patient care.

We have embedded CNS 7 day working, which supports complex community

patient need at weekends and Bank Holidays. 218 patients have benefited

from this OOH service during 2017/18.

We have continued to develop our pressure injury and falls prevention work

and worked closely with the BNSSG Multi-Agency Strategy for the Prevention

and Management of Pressure Injuries.

We have developed a new Patient Information group, it ensures we have

agreed the documentation we offer patients and have a clear development

process for internal patient information. We ask patients from Day Hospice to

review new literature to ensure it is patient friendly.

We have successfully implemented a new role; Psychological Triage

Practitioner (PTP) to the IPU. This role was developed because of the complex

psychological issues experienced by many of our patients and their family

members. The PTP role directly supports patients but also clinical staff in

developing psychological care plans to ensure there is a consistent approach

to meeting patient needs.

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What we have achieved 2017-18

We had 3 areas prioritised for improvement this year:

Priorities for improvement set for 2017/18

Why was this seen as a priority?

2017/18 saw the temporary relocation of the Inpatient Unit in order to rebuild the IPU at the

Brentry site. The Brentry building is 20 years old and the original layout of predominantly

shared rooms was no longer fit for our patients’ needs. Care needs have become more com-

plex and patients and their families benefit from individual en-suite rooms to offer them the

privacy and dignity they require.

Significant work has gone into planning the new IPU, and in finding a temporary site for the

12 months needed to rebuild it. This site was found in Keynsham within a new build Care

Home owned by St Monica Trust; we are renting half a floor of the Care Home. We needed to

adapt the Care Home design to be fit for hospice purposes. We modified rooms to make them

into Clinical Rooms for medication storage and to meet CQC requirements, build an equip-

ment store and adapted a bedroom to be a ‘Quiet Room’ to allow our social workers and ther-

apists to meet with families. Another room was converted to become a Ward Office, and sig-

nificant IT infrastructure was needed to be able to use our Electronic Patient Record system,

EMIS, on site. Phone systems were piggybacked from the Brentry site, so we could continue

to transfer calls across the organisation, and switch the Advice Line service over to the tem-

porary site overnight. This necessary infrastructure work meant that we only had space for 10

patient rooms, a reduction from the 15 we had been running. Our aim is to keep the same

quality of care throughout this period.

Volunteers have amended their roles to support us; volunteer drivers picking up Pharmacy

staff from NBT and transporting them daily to Keynsham. Volunteers covering the IPU recep-

tion in the evenings, transporting clinical samples (with training), and making many adapta-

tions to ensure all the small touches, such as flowers across the unit, continue to be deliv-

ered.

There have been challenges working as part of a very large new site especially as it opens.

The car parking was difficult for visitors in the first few months as building work continued on

the wider site and parking rules changed week by week. The team have supported families

and wider visitors to ensure they park correctly (the site charges for parking); producing writ-

ten information, and supporting them in remembering to move their cars if they are staying

for long periods.

Visibility into the bedrooms is also quite restricted due to the design of the build, and again

the team have adapted by purchasing sensor equipment to alert staff when vulnerable

patients are beginning to move (with patient consent), and increased the frequency that

patients are checked by the nursing team.

The impact of this significant work has not just affected the team directly working in the

Inpatient Unit. Our clinical teams have had to work differently across the whole organisation.

Staff have had to timetable themselves across Day Hospice (still functioning at Brentry), the

IPU in Keynsham, and to cover community patients. Space at the Brentry site has been at a

premium, as we continue to run our many other hospice services. We have moved a Clinical

Nurse Specialist Team to Westbury on Trym GP surgery where we have rented space for a

year. Our psychological therapists have rented rooms at the Penny Brohn Centre, and volun-

teer drivers have supported clients by driving them there.

Priority 1- Clinical effectiveness and patient experience.

This involved the temporary relocation of our Inpatient Unit

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What we have achieved 2017-18

As this report is written we are 6 months into the relocation and the IPU is functioning well.

We opened the site on the 16th October and built up patient numbers over those first 3 weeks.

So far in the 28 weeks we have been open we have cared for 119 patients, with 1279 occupied

bed days. During this period satisfaction with care has remained high with I Want Great Care

reviews scoring an average of 4.9/5.0.

‘Everything was amazing’.

‘All the staff from caring, cleaners, nursing, Drs, volunteers, social workers

O/T's - everyone has been so invested in getting me home’.

‘An amazing bunch of people you have who brought me back from the brink.

Thank you will never be enough’.

Priority 2 - Effectiveness

In 2017/18 we aimed to increase the roll out of our new Electronic Patient Record

EMIS across our services and increase data sharing with external services.

We have continued to develop the use of EMIS within our services.

Hospice at Home

All Registered Nurses now have iPads with EMIS mobile. The majority of Hospice at Home

Health Care Assistants have now been trained in both the use of EMIS and the iPad. This has

involved the development of specific templates to support documentation of the care given

by these teams, which has added to the quality and detail of their documentation. There has

been a delay by EMIS in developing the new updated EMIS Mobile app- but we hope the

whole team will be using this by July 2018.

The Inpatient Unit

Health Care Assistants have been upskilling their IT ability ready for EMIS training.

This training has been slightly delayed due to both the relocation and the decision to review

the current IPU nursing care plans. This new documentation needs to be piloted in paper

form before new templates are developed within EMIS; the HCA’s will then be trained to use

these specific templates.

Data sharing with external services has also increased in the last 12 months.

We now data share with approx. 95% of GP services, Bristol Community Health, SIRONA,

North Somerset Community Partnership and the GP Out of Hours Services One Care. We

hope to be able to link with Connecting Care in 2018. Our staff and external health care

professionals find the ability to see each other’s care records hugely beneficial and time

saving.

A SPH Consultant is involved in the BNSSG working group rolling out an End of Life Care Reg-

ister (EPaCCs) and we hope to join this in Phase 2 of the roll out in 2018/19. Currently we

are supporting this by informing the GP to update via their access to the Register.

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What we have achieved 2017-18

Priority 3 - Safety

In 2017/18 we planned to review our current falls assessment and develop a new

integrated Falls Bundle.

Significant work has occurred in relation to reviewing our Falls Risk Assessment and Care

Plan. These have been developed in line with the NICE Clinical Guidelines ‘Falls in older peo-

ple’ and , ‘Falls in older people: assessing risk and prevention’. The new paperwork was

piloted in February-March and has now been rolled out.

Over the year we have had 53 falls over 3828 occupied bed days. Of the 53 falls only 1

scored as moderate harm (the other 52 were no or low harm); this patient fell and chipped a

bone in their elbow. A high percentage of our patients are at a high risk of falls, and it is at

times a balance to support independence and reduce risk; there is continued dialogue and

assessment between patients and staff in order to manage this.

The temporary relocated site has less visibility into patient rooms than a hospice built envi-

ronment, and there was an increase in falls as the team started working there (Quarter 3=

19 falls). Bed and chair sensors have now been purchased to support patients who some-

times forget to ask for help with mobilising, and the nursing team promote very regular

checks (half hourly) for other patients to ensure any needs can be anticipated. For patients

at very high risk we support them with one to one nursing. All extra support is implemented

with patient and family consent and understanding, or if they lack capacity, via a Best Inter-

ests assessment. On occasions this will lead to a Deprivation of Liberty Safeguarding applica-

tion.

Other achievements in 2017/18

Whilst the IPU rebuild and relocation has been a dominant project in 17/18 that will continue

into 18/19, there have been other areas where we have developed in the year.

CNS Out of Hours Service

In October 2016 a Clinical Nurse Specialist Out Of Hours (CNS OOH) service for urgent pallia-

tive care assessment was piloted. An evaluation after the initial 6 months showed that the

service was highly rated in meeting the needs of the 52 patients referred. The positive

patient outcomes were measured as effective management of complex need, achieving a

higher than hospice average preferred place of death, avoiding inappropriate hospital admis-

sions and conversely promoting appropriate hospice admissions.

During 2017/18 the CNS OOH service provision has doubled with 218 patients benefitting

from this service. This is mainly due to widening the referral criteria to include those requir-

ing a more proactive approach to prevent crises. The CNS’s are now providing a specialist

advice and support over the phone in addition to face to face visits which means they can

provide the service to more patients and families.

A hospice MDT meeting has been introduced on each weekend or BH morning to discuss ur-

gent need and to plan the most appropriate response. This includes the CNS, on call Medic,

Advice line Nurse and Hospice at Home nurse, and decisions are made as to which service

will best fit the patients need.

The principles of this model of CNS OOH working will be transferred into the working week in

2018/19 as part of the development of a dedicated response CNS role. The main aims will be

to provide a responsive, effective and person-centred service for patients who flag as ‘urgent’

when referred to the hospice, or for unanticipated crisis of existing patients’ that would

benefit from immediate response. A poster showcasing this work was accepted at the 2018

Hospice UK Conference.

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What we have achieved 2017-18

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What we have achieved 2017-18

Psychological Triage Professional (PTP)

In October 2017 a new role was introduced to support both inpatients and Inpatient Unit

staff. This we believe is a unique post that SPH developed due to the complex psychological

needs of some patients and family members. This distress can further complicate the process

of trying to manage the physical symptoms of a patient’s illness such as their breathlessness

or pain.

Often the responsibility to manage this distress has fallen on clinicians who do not feel

equipped, or are conflicted by clinical duties, to provide the necessary support. The PTP role

now offers direct psychological intervention to patients and their families. A result of these

interventions is reduction in the level of psychological distress being held by the ward staff.

There is a sense at ward level that the PTP role has helped reduce stress levels amongst staff

on the IPU.

Interventions can range from simply listening, normalising experiences or referring a family

member to one of our psychotherapists. Some patients however need more complex ongoing

intervention whilst on the IPU. This might involve working with an individual’s sense of exis-

tential crisis, or might be supporting someone with already complex mental health as they

seek to manage the challenges of a life limiting illness.

The role has seen increased referrals, month by month (63 patients referred resulting in 260

face to face or telephone consultations in the first 5 months), as well as the development of a

multidisciplinary culture when dealing with psychological distress. One outcome of the PTP

role is that areas of need are now clearer and this has greatly informed future planning and

long term aspiration for St. Peter’s psychological services.

Advice Line

The Advice Line service offers 24/7 specialist palliative care advice to patients and carers, but

also to many health care professionals in relation to symptom control and medication advice.

This is likely to reduce escalating symptom issues, GP call outs and therefore

emergency admissions.

2017/18 has shown an increase of 33% calls from last year’s figures:

2016/17= 2989, 2017/18= 4473,

At the request of the CCG we completed a more detailed report of the calls for one month:

August 17. This highlighted that we report on the calls coming in but not the significant on-

going calls that the teams make to ensure that a patient’s issue is resolved, which on occa-

sions can be multiple. The summary of the month’s findings are below:

25% of all calls received were from GP’s

41% of calls involved referral to senior medical/ consultant input.

Over half of all calls were received out of hours but less than 10% of total calls required

further out of hours GP input.

Over two thirds of calls were fully resolved with advice given at the time of call.

Approximately one third of all calls resulted in further hospice or healthcare input,

including 14 unplanned hospice admissions but only 2 hospital admissions.

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What we have achieved 2017-18

Several of the calls taken during that month demonstrated intensive input from the hospice,

an example being one that involved 11 phone calls in total and took 200 minutes of medical

time in relation to complex symptom management of agitation and seizures. Without this

intense input it is very likely the patient would have been transferred to hospital.

This data clearly shows how the Advice Line service supports the delivery of high quality care

for patients, 24 hours a day, 365 days a year. It supports both families and health care profes-

sionals by providing timely specialist palliative care advice, enabling where at all possible for

patients to remain in the most appropriate place of care.

Practice Educator Role

The provision of clinical skills training continues to grow. This training is organised and facili-

tated by the Practice Assessor and Practice Facilitator. These 2 roles work across all clinical

areas with the aim of providing and facilitating clinical skills training. The 2 staff members

also support staff undertaking the Care Certificate and Qualifications Credit Framework;

oversee student nurse placements and help with the orientation of new clinical staff.

The Practice Facilitator and Assessor deliver two day clinical skills workshops for our

Healthcare assistants from the Inpatient Unit and Hospice at Home team, covering skills such

as; catheter care, stoma care, pressure area care, syringe pumps, diabetes and blood glu-

cose monitoring. The training consists of knowledge sessions followed by simulation assess-

ment with the aim of assessing skills, knowledge and behaviours.

The registered nurses receive male catheterisation, blood transfusion and syringe pump

training. Intravenous Therapy training is delivered in house: this consists of a one day train-

ing programme followed by workshops and competency assessment in practice.

Registered Nurse Verification of an Expected Death training has been re-developed we have

enrolled in an external Aseptic Non Touch Technique eLearning packages. This training also

requires practical competency assessment before staff can practise.

We have recently engaged in some collaborative working with Dorothy House Hospice in the

delivery of clinical skills for Health Care Assistants. Feedback from staff suggests being

alongside another organisation was not only enjoyable but beneficial in exchanging ideas and

building relationships. This is something that we hope to explore further over the next year.

Volunteer Resources

Volunteering and volunteers are an integral and vital part of St Peter’s Hospice. With approxi-

mately 20 different roles covering clinical, retail and commercial operations, our 1500 volun-

teers contribute over £2million of in-kind support. Over 2017/18 Hospice based volunteers

have donated nearly 30,000 hours of their time.

Due to the rebuild of the Inpatient Unit, Brentry based volunteers have been redeployed to

the Keynsham site, continued on a reduced rota at Brentry or been stood down pending reo-

pening later in 2018. The gap in normal volunteer provision has allowed us to focus on up-

dating DBS checks, renew statutory and mandatory training as well as planning for new and

expanded roles.

This year has also seen an expansion in our community based Hospice Neighbour Network.

Neighbours volunteers provide non-clinical practical and emotional support to patients in their

own home. Tasks include respite for carers, companionship to reduce loneliness and isolation,

accompanying patients to out-patient appointments, shopping, household chores & garden-

ing. With over 60 volunteers covering almost the whole of Bristol and Avon area, we feel this

service has added significant value and complements our clinical community teams.

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Quality Assurance 2017-18

Infection Prevention and Control

The Hospice continues to develop its Infection Prevention and Control (IP&C) knowledge and

practice throughout the organisation. The Infection Prevention and Control Lead Nurse is 0.6

WTE and leads a team of IPC Link Nurses who help to support and maintain standards of

IP&C in the Clinical Teams across the Hospice. The IPC Lead trains all new clinical staff to

the organisation including the volunteer workforce in IPC especially effective handwashing.

The IP&C Lead networks and information gathers by attending local, regional and national

meetings and conferences. We continue to have good connections and support from the IP&C

Teams at UBHT and North Bristol Trust.

Outbreaks

We have had no outbreak episodes this year. There was only one patient admitted with a

known infection over the last 12 months. The patient was nursed in a single room and there

was no spread of infection. 5 Patients were isolated with suspected infection. All 5 patients

were nursed in single rooms, stool samples were sent and results were negative and isolation

was stopped.

Training provided by the IPC Lead

Infection Prevention and Control Orientation is provided for all clinical staff within two

weeks of commencing work at the Hospice.

The Hospice provides yearly face to face training & e learning to facilitate learning and

practice and to meet statutory requirement.

Provide regular Infection Prevention and Control sessions at Volunteer Orientation

Days.

Serious Incident (SI) Reporting

There was one drug error and one significant near miss drug error reported to the CCG Quali-

ty Team in 17/18. There was no noticeable harm to the patient who received the drug error,

but there was potential for harm so we reported fully to the CCG Quality Team and completed

an RCA. The patient lacked capacity (being cared for under a DoLS); the family were fully in-

formed of the error and full apology given. Reported to CCG and also safeguarding.

The significant near miss involved the calculation of opioids by nursing staff when giving ad-

vice to other health care professionals. This has resulted in change of practice in both the IPU

and CNS Teams in relation to advice given relating to complex opioid calculations. The clini-

cal, pharmacy and education team have developed a new more challenging annual drug cal-

culation test for these teams who are frequently involved in complex regimes. The patient did

not actually receive an incorrect dose of medication- there was no harm. The family were in-

formed of the near miss and a full apology given. RCA report sent to the CCG Quality Team.

We have reported 10 grade 3/4/ungradable pressure injuries to the CCG Quality Teams and

CQC in the 12 month period- all assessed as unavoidable.

Audit

The Annual IP&C Audit of IPU, Day Hospice, Main Kitchen and Coffee Shop, a Sharps, hand

hygiene and uniform audit has been undertaken and any changes needed have been imple-

mented. Monthly hand audits on IPU and DH continue. This has continued to improve and the

results on average are 93% -100% over the last year. The standard is 95%. Yearly one to

one hand wash observation and assessments has helped with this improvement.

Quality Assurance 2017-18

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Quality Assurance 2017-18

Flu Vaccination

An in-house flu vaccination campaign was facilitated again this year by the Infection Preven-

tion and Control Lead Nurse. Clinics were held on various days and after community team

meetings to ensure all those who wished to be vaccinated had easy access. There continues

to be a small but steady increase in the uptake of vaccinations.

Sign up to Safety

In December 2017 we Signed up to Safety, an NHS England initiative to listen to patients

and staff to ensure we deliver harm free effective care.

St Peter’s Hospice made 5 pledges to work on throughout the year, all of which are in pro-

gress (see Appendix 1).

Medication Safety

The hospice uses large volumes of complex drugs and we are continually reviewing our pro-

cesses and training to minimise risk. To support staff knowledge we have devised a poster

called Medication Matters that succinctly highlights key points for the nursing team to be

aware of. If there have been any errors or issues we will put the learning points from the in-

cident into the poster. It is devised by our Pharmacist and Quality Manager.

Below is an example of our February and March issue:

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Quality Assurance 2017-18

Clinical Audits and Practice Improvement

We continue each year to develop our Quality Assurance through Clinical Audit; to ascertain

whether we are meeting our set standards and looking for practice changes if not. We have

conducted the following surveys and audits across our clinical services resulting in many

areas of practice improvement. Please see appendix 2 for further details.

Duty of Candour

St Peter’s Hospice always aims to be open and transparent in our care. We have an open cul-

ture of reporting incidents, and being honest if we make errors in relation to care, however

small. Staff understand that incident reporting and near miss reporting allow for practice im-

provement and service development and are always encouraged to report any concerns. Any

‘Serious Incidents’ or near misses are investigated thoroughly and discussed with the patient

and family. When there has been any error in our care we will always acknowledge this and

apologise for it, explaining what our reporting mechanisms are, and letting them know how

we plan to learn from the incident. We report any Serious Incident to the Clinical Commis-

sioning Group (CCG), Quality Team and Care Quality Commission (CQC) via a statutory noti-

fication. We liaise with the Quality team if we have any queries and need advice.

All complaints are managed in line with the Duty of Candour, and where possible we aim to

meet the complainant in person to ensure we give them the opportunity to fully express their

concerns and receive an apology in person.

Clinical incidents

IPU Clinical Incidents 2017-18 2017/18

Falls Q1 Q2 Q3 Q4 Total

No harm 9 5 11 6 31

Low harm 7 6 7 1 21

Moderate harm 0 0 1 0 1

Severe 0 0 0 0 0

Pressure Injuries during Admission Q1 Q2 Q3 Q4

Grade 1 & 2 19 17 9 13 58

Grade 3 & 4 2 1 0 1 4

Ungradable 3 0 0 3 6

Totals 68

Pressure Injuries ON Admission - acquired before admission Q1 Q2 Q3 Q4

Grade 1 & 2 12 14 13 19 58

Grade 3 & 4 7 3 4 4 18

Ungradable 2 1 0 1 4

Totals 80

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Quality Assurance 2017-18

The table above details clinical incidents reported across the organisation. We have had no

incidents resulting in severe harm in the year.

A lot of work has gone into reducing pressure injury development this year and we have had

no pressure injuries that have been assessed as ‘unavoidable’. We have a very frail cohort of

patients, many who come in with existing pressure injuries at Grade 2 and above and who

score as ‘very high risk’ of developing pressure injuries. We are an active part of the BNSSG

Multi-Agency Strategy for the Prevention and Management of Pressure Injuries. All Grade 3, 4

and ungradable Pressure Injuries are reported to CQC. A quarterly report of all unavoidable

Pressure Injuries and documentation of ongoing practice improvement is sent to the CCG

Quality Team. If we have an avoidable Grade 3 pressure injury a full RCA is completed for the

CCG.

Complaints

Total for 2017/18 = 9, 5 written and 4 verbal.

2 involved care given in the Community , 3 to care in the IPU, 1 related to medical process

related to a clinical intervention, 1 related to Hospice at Home, 1 to the triage process, and one

related to the relocation of the Psychological Therapy services.

Each complaint has been investigated and where possible we have had direct meetings with

the complainant to apologise in person and fully understand their concerns.

2 of the complaints involved joint agencies; a community provider, and an acute trust so

these investigations have been managed in a collaborative fashion.

When appropriate we have changed practice to ensure that we improve on our care, this has

included work with a trust to develop a more comprehensive pathway for patients undergoing

a saddle block procedure, developing a visitors leaflet for the IPU and supporting staff in

being more assertive when needed. We have had one complaint that can be directly linked to

our change of location.

All complaints were dealt with as per our complaints policy and all but one fully resolved

within 20 working days. The exception was not under our direct control.

Education 2017/18

As in previous years, the Education department has continued to develop its delivery of

external and internal education and training.

Some funding was received from commissioners to provide ongoing training and education.

Bristol CCG Care Home Support Team commissioned a workshop series for unregistered

support workers. It allowed for 6x 1.5hr sessions around Anticipatory Prescribing in Care

Homes; this education was well evaluated and provided in total to approximately 150 staff.

The team also lead 5 x 1 hour workshops with a total of 100 attendees at the Bristol Care

Homes Conference (Bristol CCG).

Sirona have funded places on a number of courses including the Introduction to Syringe

Pump and Advanced Syringe Pump training, Professional End of Life Care Series, 3 Day RN &

HCA Programmes.

In North Somerset we have delivered a bespoke Loss and Bereavement day and other staff

have attended study days and courses within our training programme.

17

Quality Assurance 2017-18

We continue to deliver training to health and social care staff working for South Gloucester-

shire Council: MCA Planning ahead x 3 sessions (in total around 36 attendees), Understanding

Loss in End of Life Care, and Providing Care and Comfort at End of Life.

There has been a decrease in numbers attending Higher Education modules for 2017-18 (402)

in comparison to 16/17 (599); this represents the discontinuation of contracted places funded

by Health Education England. Whilst each individual module run has attracted good numbers

(consistent with numbers attracted prior to the funding availability), in 2016-17 an additional

run was requested to accommodate the funded places, this was not required for 2017-18.

However the department have increased their higher education profile by being asked to

provide end of life care sessions within other modules run at UWE (including Cancer, COPD,

Care of the Older Person and pre-registered nursing programme end of life care and

Respiratory Care choice modules).

Other department activities have seen the ‘Professional End of Life Series’ relaunched with

good uptake. We continue to participate in the GP Training programme; we delivered 2 half

days with content supported by the medical team, 2x full days for ST 1 and 2 (18 attendees to

both days) and ST3 x1 ½ day (43 attendees).

We have worked with the Bristol Dementia Wellbeing Service (CCG commissioned); the team

were invited to lead one of the sessions on the staff development day (60 attendees). We also

delivered sessions to a Bristol support group on Living with Secondary Breast Cancer (x 2),

pain management and palliative care.

The team have supported Volunteer training with ‘I don’t know what to say’ study days around

having difficult conversations and further dates will be run later in the year to facilitate the

change in volunteer role on the inpatient unit.

Data Quality

SPH provides a quarterly patient activity report in an agreed format to the local NHS

Commissioners as well as an annual report as agreed in our NHS Community contract. Key

patient service data is presented on a dashboard to quarterly Board meetings of trustees.

Our clinical data is benchmarked both regionally and nationally against other hospices,

through Hospice UK.

Information Governance

Our score in 2017/18, against the NHS Information Governance Toolkit, was 73% which

achieves the required standard for our organisation and is an increase of 7% on last year’s

submission. Our Information Management Group continues to develop and support our Infor-

mation Governance policies and processes. We continue to optimise and improve our Elec-

tronic Patient Record System EMIS Web, through the uptake of new functionality and output

of richer data. Data sharing with GPs and Community partners has further expanded in the

last year and has enhanced our patient care.

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Quality Assurance 2017-18

Planning undertaken for the new General Data Protection Regulations’

Our preparation for GDPR started in 2017. We undertook information security and data

protection internal audits to confirm our current security and compliance arrangements.

We then performed an assessment of our readiness for GDPR within the areas of governance,

risk management, requirement for a DPO, roles and responsibilities, contracts, privacy

notices, policies and procedures, information systems and data subjects rights.

Examples of activities undertaken to date include:

Creation of an Information Management Group, led by the SIRO with

members including the Caldicott Guardian and the Information Asset Owners.

Activities of the group include reviews of data flow maps, access, data

retention as well as risk assessments and regular review of incidents.

Decision not to appoint a DPO and map out the requirements of the DPO

and ensure that activities are covered by a suitable role within the

Organisation.

Appoint an administrator whose role includes support for the SIRO and

the IMG.

Training and awareness for SIRO, CG and IAO’s; course-led and

bespoke workshops. Staff communications to raise awareness.

Achieve toolkit compliance.

Review of policies and procedures as well as drafting new ones.

Revise our patch management programme from monthly to weekly.

Penetration testing.

A review of some privacy notices.

Identification of devices not encrypted.

Work continues in order to achieve full compliance and includes

A review of all privacy notices.

Review and amendment of contract clauses.

Review of staff job descriptions.

Complete encryption project.

We are aiming for compliance during 2018.

19

User Involvement 2017-18

Carer & Family Satisfaction—User feedback

I Want Great Care (iWGC)

St Peter’s Hospice uses a range of approaches to measure satisfaction. The main measure is

via “I Want Great Care” (iWGC). There are 8 other regional hospices using this service who

meet regularly to discuss results and best practice. Our reviews are available online at

www.iwantgreatcare.org and we continue to be reviewed favourably.

We use the same questionnaires for all services in order to maintain a standardised approach

that is comparable to the work of others. However, we approach patients and other service

users in several ways in order to gain their feedback: for example volunteers support pa-

tients on the IPU who are too ill to write things down, questionnaires are sent by post, or giv-

en out in group settings and they are always available around our buildings. iWGC report

monthly to St Peter’s Hospice on each service area and also give an overview. The monthly

overview is displayed on Noticeboards around the Hospice.

Although we receive the reports on these areas, the raw data from iWGC collates the infor-

mation by 3 distinct categories, IPU = Inpatient unit, Community = includes Hospice at

Home and the Community Team & Outpatients = includes Day Services, Complementary

Therapy, FAB, PFS - Bereavement, Social Work, Arts Psychotherapy.

iWGC Reviews

The total number of reviews received this year is 486. This is a 16.2% decrease, most of

which we believe is due to our temporary change of location and reduction to 10 beds. Our

inpatient unit returns were significantly lower (50%) than previous years. We continue to

exceed our yearly target of 400 responses (see Appendix 3).

19% of the replies were from males, 47% from females and 34% gender was unknown.

We regularly monitor responses and alert service leads if there are any comments that could

cause concern, or demonstrate where we could generally improve on current standards.

93% of responses were ‘Extremely likely to recommend’, 5% were ‘likely to recommend’ 2% were blank with 1 response ‘Unlikely to recommend’ which occurred in quarter 2.

How likely are you to Recommend Our Services to your friends & family?

20

User Involvement 2017-18

Service Area Response Rate 2017/18

Number of IWGC Returns 2017/18 2016/17

486 580

User involvement

We also frequently ask our users to support the development of our services. Recent exam-

ples include collecting views re the décor for the new Inpatient unit and patient preference

when choosing new nursing uniforms. We frequently ask patients in Day Hospice to give us

feedback on Patient Information leaflets we are developing, and we have also asked Day

Hospice patients if they would be willing to support researchers who are looking at the future

ReSPECT forms.

St Peter’s Hospice Social Media

We also receive frequent reviews via social media, including Facebook, Twitter and our

Website. Any concerns raised via social media are directly reported to the appropriate Senior

Manager for review and actioned as necessary.

My husband, who died on Sunday, and myself. Received the best care possible throughout his

entire illness with your wonderful care and help. I was able to keep him at home where he waited

to be, and he died peacefully with me by his side. Thank you from the bottom of my heart for

everything you all did for us both.

I have been to the day centre 12 times this is my last time. I would recommend it for

treatment to anyone.

21

Monitoring 2017-18

Internal

Board of Trustees Provider visits

Our trustees are appointed to ensure good governance of the hospice. In order to ensure

they review the quality of treatment and care offered they visit the hospice at least every 6

months on an unannounced visit. The visits are conducted by 2 trustees, who base their visit

on the care patients receive, interviewing staff members, and looking at the care environ-

ment and inspecting the records of any complaints. The outcomes of the visit are recorded in

a report which is sent to the other Trustees, Chief Executive, and Director of Patient Care.

The report is also discussed in the next Board meeting.

We have had two visits in 2017, one at our Long Ashton site and one at our IPU Keynsham

site both of which were very positive.

Monitoring

External

Care Quality Commission (CQC)

We were inspected by Care Quality Commission (CQC) in March 2016 and the final report was

published in June 2016. We have had no further inspections.

The inspection focuses on 5 key questions of the service:

Are they safe?

Are they effective?

Are they caring?

Are they responsive to people’s needs?

Are they well led?

We are very pleased to say that we received ‘Good’ in all 5 domains and the report was very

complimentary about the care we deliver.

22

Monitoring 2017-18

Commissioners

We meet quarterly with our commissioners to discuss service delivery and compliance with

the contract. We also report any serious incidents to the CCG Quality Team, completing

RCA’s as necessary. The Medical Director and Director of Patient Care both attend the BNSSG

End of Life Care Board which is chaired by the CCG.

Please read the full report at http://www.cqc.org.uk/ and then enter St Peter’s Hospice

in the search box.

23

Aims and Priorities for Improvement 2018-19

Aims for 2018/19

Our Priorities for improvement

Our main priorities for improvement in 2018/19 are:

Priorities for improvement 2018/19

Priority 1- Patient Experience

In 2018/19 the Inpatient Unit will move back to the

Brentry site and occupy the new build.

The new IPU has been designed with patient and family

experience as the main priority, with a modern design al-

lowing for patient privacy and family comfort. The rebuild,

planning and purchasing of new equipment will continue in

2018/19 with patients moving into the new build late

2018.

Priority 2 – Safety

In 2018/19 the hospice moves under ‘Healthcare’ in rela-

tion to CQC inspections. Due to the growing size of the

clinical team and the increasing Governance demand, SPH

will appoint a Deputy Director of Patient Care to lead on

Clinical Governance and become the new CQC Registered

Manager.

This will allow for the development of a small team includ-

ing the Quality Manager and Practice Educators to support

the workforce in patient safety and clinical effectiveness.

The team will benchmark our current practice against the

new healthcare regulations and develop an action plan to

ensure we are compliant.

Priority 3 – Effectiveness

In 2018/19 we will develop a Response Clinical Nurse Spe-

cialist role. 2 nurses will be employed to support urgent

referrals within 24 hours and offer urgent assessment that

are flagged through the Advice line. This will expand on

our successful current weekend working model. We will

capture the data to measure the effectiveness of this role.

Priority 4—Patient Experience

In 2018/19 we will scope a new strategy to support carers.

This will support carers across the organisation, and where

led by the PFS Team will be the responsibility of all.

Commissioning for Quality and Innovation (CQUIN) 2018/19

This year it has been agreed between the commissioners and St Peter’s Hospice that there

will be no CQUIN Programme.

24

Aims and Priorities for Improvement 2018-19

Our New Hospice Build in development

The Board of Trustees’ commitment to quality

The Board of Trustees is fully committed to delivering high quality services to all our patients

whether in the community or at the hospice site. Our trustees are actively involved in moni-

toring the health and safety of patients, the standards of care, feedback from patients includ-

ing complaints, and plans for future service development. They do this by carrying out regu-

lar unannounced visits, receiving regular reports on all these aspects of care and discussing

them at Clinical Services Committee and full Board meetings.

We have continued, and will continue, to deliver service developments in accordance with our

2016-21 strategy. In 2017/18 we commenced the complete rebuild of our In Patient Unit in

order to modernise our facilities. This required the temporary relocation of the unit to an al-

ternative site in Keynsham, south Bristol. This resulted in a reduction in the number of beds

we could offer to 10, and required significant staff effort to effect the move but we have

managed to maintain the same quality of care in these temporary surroundings. Other ser-

vices based at our principal site have also been disrupted by the building programme but we

have continued to deliver them to the normal high standard. At the end of 2018 we will be

fully reoccupying our newly rebuilt main site at Brentry, including returning the In Patient

Unit from its temporary location.

The Board is confident that the care and treatment provided by St Peter’s Hospice is of a high

quality and cost effective.

Care Quality Commission (CQC)

St Peter’s Hospice is inspected by CQC. Inspections are planned to check whether the provid-

er is meeting the legal requirements and regulations associated with the Health and Social

Care Act 2008, to look at the overall quality of the service, and to provide a rating for the

service under the Care Act 2014. We were last inspected in March 2016.

In April 2018 St Peter’s Hospice moves under healthcare inspection with CQC. This will in-

volve a higher level of interaction with CQC and regular reporting and site meetings.

St Peter’s Hospice welcomes this new model of interaction and the learning it can offer.

St Peter’s Hospice is CQC registered to deliver the following regulated activities: Treatment of disease, disorder or injury and Personal Care under the Health and Social Care Act 2008.

Chris Benson Anjali Mullick

Director of Patient Care Medical Director

St Peter’s Hospice St Peter’s Hospice

25

St Peters Hospice QUALITY ACCOUNT

Statement from Bristol, North Somerset and South Gloucestershire

(BNSSG) Clinical Commissioning Group CCG

BNSSG CCG welcomes the Quality Account which provides a fitting reflection on the

quality performance during 2017/18. The data presented has been reviewed and is

in line with data provided and reviewed through the review of quarterly quality and

performance reports.

The CCG has worked closely with St Peter’s Hospice throughout 2017/18 to gain

assurances that the services delivered was safe, effective and personalised to service

users. We acknowledge and are pleased to note that the three 2017/18

priorities have all been achieved.

BNSSG CCG is pleased to note St Peter’s Hospice has excellent Infection Control

measures in place with no outbreaks documented in 2017/18.

The CCG continue to work with it’s providers to prevent Fall’s and Pressure Ulcer

deterioration and note the Hospice actively contribute to the BNSSG Multi-Agency

Strategy Group, where all learning becomes an embedded process within the

provider facilities.

The CCG is informed of all the Serious Incidents (SI) reported and is pleased to note

that there have been no Never Events reported in this current year. Full root cause

analysis investigations have been undertaken by the Hospice for all SI`s reported, in

line with national policy, and all reports and action plans have been scrutinised by the

CCG. The CCG will continue to work with the provider to ensure that assurance is

provided of embedding the learning into the organisation and sharing learning across

BNSSG.

St Peter’s Hospice is commended for their continual focus on Patient Safety in the

In-Patient Unit (IPU) during the transition between the Care Home complex in

Keynsham (The Chocolate Quarter-St Monica Trust) whilst construction of a new IPU

at the Brentry site.

26

Appendices

Sign up to Safety Appendix 1

1. Putting safety first. Commit to helping people work safely.

We will:-

Develop a more systematic approach to assessing risk and planning care to prevent patient falls

Ensure we develop an organisational culture of working safely and promote a shared responsibility towards this

Ensure the development of our new Inpatient Unit is focussed around patient safety, focussing on being dementia friendly, and ensuring all new equipment and the environment is geared to-wards patient safety and comfort.

2. Continually learning. Listen and act on what we are hearing in our conversations with our staff, pa-

tients and families.

We will:-

Continue to review every incident and near miss to ensure we can learn from them

Ensure staff are fully involved in contributing to solutions to incidents and accidents and that wider learning is shared across all clinical teams, not just the team it in-volved

Develop regular staff bulletins to support learning, engage staff and encourage them to contribute to the culture of working safely

Encourage collaboration with patients and families post incidents to ensure we also learn from them, in how we can improve our practice, and help educate patients to also reduce their own risk of harm.

3. Being honest. Create an environment where staff, patients, families can have open and honest con-

versations about what went wrong and what went well, free from judgement and be treated with kind-

ness.

We will :-

Always be open and transparent with all patients and their families when there are

involved in any patient safety incidences.

Always encourage staff to be open and honest about mistakes and be supportive of

them when they occur, we will encourage them to reflect to help us improve on our

care and processes.

Always see incidents as an opportunity for shared learning and practice improve-

ment.

Respond openly to all complaints and ensure we feedback what we have learnt and any chang-es in practice from investigating an incident.

4. Collaborating. Create opportunities for conversations where all staff, regardless of their role or posi-

tion can share what they know about working safely to help others learn.

We will:-

Continue to be active partners in the BNSSG Pressure Injury Board, developing

standards and sharing knowledge and resources to support both patient, their

carer’s and health care professionals

Work with other hospices both regionally and nationally to share knowledge of In-

fection Prevention and Control procedures and implement best practice locally

Continue to develop our clinical competencies across the clinical workforce- collaborating with other hospices when able.

5. Being supportive. Really listen to each other when support is needed and act on what has been said.

Create opportunities to celebrate success and spread joy.

We will:

Learn and celebrate when things go well and not just focus on errors.

Regularly share with the wider teams positive feedback from patient and relatives

about excellent care.

Focus on specific safety priorities annually; ensuring staff have the time and resources to work on these priorities.

27

Appendices

Audits & Surveys Appendix 2

Clinical Surveys/Audits 2017/18

Subject/Title Mth

Audit of IPU Observation charts June 2017

Audit of CQC Statutory Notifications of ‘death of a person using the service’ Jul 2017

CNS Workload Review Aug 2017

Bereavement Volunteer Survey Aug 2017

Audit of the BNSSG Community Drug Chart Sept 2017

IPU VTE Risk Assessment Audit Oct 2017

Audit of Medication Discharge Charts against prescribing standards Oct 2017

CNS Response from Access to Initial Patient Assessment Nov 2017

IPU Antibiotic Prescribing Audit Nov 2017

Audit – 3 identifiers on all patient documentation internal & external. Jan 2018

Mouth Care Documentation Audit Jan 2018

Audit of Clinical Staff Uniforms Jan 2018

Re Audit of Patient Demographics and Equality Monitoring Jan 2018

Audit of Patient Demographics and Equality Monitoring Jan 2018

CNS Response Time from Triage to Initial Assessment Jan 2018

Audit of Controlled Drug Management Jan 2018

Spot Audit of Key Elements of IPU Prescribing Guidelines. Mar 2018

IPU VTE Assessment Audit Mar 2018

Controlled Drug Reconciliation Audit quarterly

Monthly Audits of Hand Washing across Clinical Services ongoing

Audit of Kitchen and Coffee Shop March 2018

28

V2—BNSSG addition—Oct 2018