Quality Account
High quality care for all
Reporting period: 1st April 2014 to 31st March 2015
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Patients and Carers’ Feedback
“Thank you for all the care and compassion that you provided for X, you are all by far
the Angels of Ashgate, I always knew X was in safe hands and had the very best
possible care”
“We would like to wish everyone a big heartfelt thank you. The kindness and care you
provided for X was sensitive and passionate. The generosity and support you showed
towards us all went far above and beyond all expectations and for this we are truly
grateful. Everybody really did go the extra mile ensuring mum was comfortable and
reassured. She wanted for nothing”
“A big thank you to each and every one of you. You made our mum’s last few days
comfortable and peaceful and she loved you all. Nothing was too much trouble for
either our mum or our family”
“To all the staff at Ashgate Hospice, it is simply impossible to express my thanks to
each and every one of you for caring so lovingly for X. Whilst she only spent a few
weeks with you I know how safe, calm and happy she felt in your care’. As a family,
you made every day a little easier to cope with and we took strength from this to help
us through the difficult times then and what we knew was ahead’’
(received from the relatives of patients on the hospice ward)
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Chief Executive’s Statement
Ashgate Hospicecare continues as an independent charity, and company limited by
Guarantee. The hospice is governed by a Board of Trustees and is now in its 27th
year of operation. Ashgate Hospicecare has recently refreshed its name and
branding to reflect the full range of services and settings in which support is offered.
The Hospice prides itself on delivering the highest quality Specialist Palliative and
End of Life care in multiple settings, including patients own homes, to the population
of North Derbyshire. I remain confident that quality continues to be at the centre of
our smooth running, and is what drives our governance arrangements. We are
thrilled with the CQC ‘Outstanding’ rating that we achieved in 2014 – this reflects the
team effort of all of the hardworking, compassionate staff and volunteers who are
central to this hospice.
Overall, we continue to monitor our performance, to benchmark and to make
improvements where necessary. We also continue to put the needs of our patients
and their families and carers at the centre of everything that we do; always aiming to
treat people as individuals and with compassion, dignity and respect.
We are keen to share our expertise with others in order to promote excellence in
Palliative and End of Life care across the health, social and care home sector. We
know that that the hospice has a significant and positive role to play locally,
regionally and nationally in terms of influencing the quality of care that is provided in
other settings. We continue to be forward looking, ‘seeking out’ opportunities for
collaboration and partnership working locally and beyond.
The financial climate for third sector organisations continues to be challenging.
Operating costs are rising year on year, due to increasing demand and in fact
referrals to all hospice clinical teams were up by 7% in 2014. Despite these
challenges, which we know all health and social care organisations face, we
continue to provide a comprehensive range of high quality, cost effective services to
our community. I am confident that we offer significant social return on investment,
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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both in terms of the care that is provided and subsidised through voluntary income,
and through the opportunities that exist at Ashgate Hospice for people to volunteer.
I would like to acknowledge and thank everybody who supports, volunteers and
works at the Hospice; everyone’s contribution is acknowledged and genuinely
appreciated. The consistently excellent patient feedback that we receive, our CQC
‘Outstanding’ rating, and our low turnover of staff and volunteers, enables me to
confidently offer assurance to North Derbyshire and Hardwick CCG’s on the quality
of the services that we provide.
I am confident that to the best of my knowledge, the information reported in this
Quality Account is an accurate and fair representation of the healthcare services
provided by Ashgate Hospicecare.
Lucy Nickson
Chief Executive May 2015
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Section 1
Improvement priorities
Priorities for improvement 2015-2016
The hospice participated in the Wave 2 pilot inspection from the Care Quality
Commission in August 2014. The inspection was very comprehensive and included
scrutiny of the community service, the volunteer service, the therapy service, as well
as the day hospice, ward, catering and other more standard areas of inspection.
The CQC have confirmed that the hospice achieved an overall outstanding award in
the following areas:

Care

Well Led

Responsiveness
The hospice achieved a good award in the following areas:

Safe

Effective
The hospice does not therefore have any areas of shortfall to include in the priorities
for improvement from 2014-2015.
In developing the strategic plan for the hospice, particular attention was paid to the
changing commissioning landscape within health and social care organisations, and
the influence that would have on hospice services. We looked at how the hospice
could extend its services to meet the needs of the local population, enabling people
to receive care in the place of their choice.
The top three quality improvement priorities for 2015 to 2016 are as follows:
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Future planning - Priority 1
“Improve our environment to help those patients with dementia”
We are seeing an increasing number of patients with dementia at the hospice; and whilst
the ward and day hospice are good environments for most patients, there are some
aspects that could be improved for those patients with dementia
We have recently joined the Derbyshire Dementia Action Alliance, and have identified two
members of staff who will act as dementia champions for both the ward and day hospice.
Any good practice identified in this Alliance will be brought back to the hospice setting to
improve the environment for our patients
We have already planned to change the colour scheme in certain areas of the ward and
day hospice, to clearly identify the difference between the rooms, the corridors and the
WC and bathrooms. Currently all of these areas are painted in one colour.
Future planning - Priority 2
“Reduce the numbers of patients who fall in our care”
We have been part of a national benchmarking scheme which is related to three key
quality indicators. One of the indicators ‘reducing patient falls’, requires us to record the
number and severity of falls that our patients have whilst in our care at the hospice. We
report on every fall, near miss and slump into this benchmarking scheme, and in the last 6
months that we are reporting slightly more falls by comparison with other hospices of a
similar size.
As a result, we plan to analyse this information further in order to identify any possible
trends or themes.
The time the fall occurred, the medical condition of the patient, the type of room they were
in will all be considered as possible contributory factors, and will be considered in terms of
likely impact on falls prevention. We plan to increase staff awareness and understanding
of falls prevention by using national evidence and tools, with the aim of reducing the
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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number of falls in the next year.
We will develop a falls group to include a range of professionals (physiotherapist, doctor,
nurse, quality and audit manager and patient representative) so that we ensure we have
analysed and put into place measures to reduce falls in the hospice.
Future planning - Priority 3
“Recruit to Head of Governance and Patient Safety post”
Due to developments and changes in how care providing organisations are expected to
offer assurance and performance information to regulators, commissioners and the public;
the hospice has identified the need to increase capacity and expertise in clinical
governance and patient safety.
As such a new role, ‘Head of Governance and Patient Safety’ has been developed to
address this. The aim is to enable further development of our clinical governance
intelligence, and to stretch ourselves in terms of audit and analysis of quality and patient
safety information. Our medium to long term aim is to ensure improvements are identified
then implemented wherever they are needed.
Always mindful of the cost of the administration elements of hospice care, we are
delighted to have been able to create this role as a result of change in other departments;
there is therefore no additional financial impact to the hospice, which is extremely positive.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Progress against the improvement priorities identified in 2014-2015
Throughout 2014-2015, the hospice had a number of initiatives to enable it to offer a
more comprehensive service to the local community, and progress against the
quality improvement priorities is discussed below.
Progress made from Improvement Priority 1:
“Using national comparisons of our care in preventing falls, pressure
ulcers and in medicines management”
We now have a full year of information from this national hospice benchmarking scheme.
We are delighted to report that although we consistently see higher occupancy levels
than in other hospices of the same or similar size, we have fewer medication errors and
fewer patients developing pressure ulcers that could be avoided, whilst in our care.
The benchmarking information has shown us that we have a slightly higher number of
patients who fall on the ward, compared to the same or similar sized hospices. No
Patients who fell while in our care suffered only minor harm or no harm at all. Minor
harm might include a small graze on an elbow for example. Irrespective of low or no
harm status, as a result of all falls we are very keen to understand the data so that we
can assess any trends or common themes. This will enable us to ensure that if
improvements are needed, they can be put in place immediately.
NB: Anecdotally, our rate of falls may be a result of the high numbers of very sick and
frail patients that we care for on our In-patient Unit. .
This national benchmarking data is extremely important to us and enables us to take an
objective look at the areas that we may need to improve on.
Progress made against Improvement Priority 2:
“Staff development for the future”
Since last year we have provided more education and training to staff overall, we have
also included specific training for venepuncture skills (taking blood), male catheterisation
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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and intravenous antibiotic therapy. All staff has had additional training on dementia
awareness and information governance. We have invested in more computer terminals
and spent time delivering more computer skills training.
For staff in the community and in the local hospital, who work at a higher professional
level, we have a programme in place to enable them to undertake Non Medical
Prescribing and advanced clinical skills assessment skills. Two members of staff every
year will undertake these advanced training programmes, so that all staff are competent
in these areas in the years to come.
All members of the Hospice at Home team have undergone additional training on taking a
blood pressure and pulse and urine testing and delivering specialist feeds. This has
enhanced their function overall and enables the team to do more for our patients who are
at home.
The staff report feeling motivated, supported and very enthusiastic following the hospice
investment in this specific training.
Progress made against Improvement Priority 3:
“Extending our reach into the community to see more patients”
We are delighted to report that the North Derbyshire Clinical Commissioning group has
agreed to fund two key areas of service provision recurrently:

An additional £108,054 per year has been agreed for the Hospice at Home team,
as a direct result of the excellent service and level of support that this team give to
our patients and their loved ones in the community.

A third Specialist Palliative Care Consultant whose particular focus will be to
support patients and their families in the community and support the delivery of
additional specialist education to professionals across the health and social care
community
We continue to work with Commissioners in developing our services further.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Section 2 - Mandated Statements
Statements of assurance from the board
The following are a series of statements that all providers must include in their
Quality Account.
Review of services
During 1st April 2014 to 31st March 2015, Ashgate Hospice provided the following
services:

In-Patient Unit

Day Hospice

Lymphoedema service

Hospice at Home – N Derbyshire Community

Palliative Care Clinical Nurse Specialist – N Derbyshire Community

Palliative Care Clinical Nurse Specialist in-reach service (into local acute
hospital)

Therapy services (inpatient, day unit and community) – occupational therapy,
physiotherapy and Complementary Therapy

Patient and Family Support (Bereavement) Service

Spiritual care

Specialist Education and Training (health community, local universities)
Ashgate Hospice Healthcare Governance Committee receives regular reports,
which enable them to review the quality of care provided by all clinical services.
This group meets quarterly, and is a subcommittee of the Board. A quarterly report
from this group is submitted to the Board of Trustees
Participation in national clinical audits
During 2014/15, Ashgate Hospice did not participate in any national clinical audits
other than the Hospice UK clinical benchmarking scheme relating to the number of
falls, avoidable pressure ulcers and medication errors
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Research
In November 2014 two clinical nurse specialists published their research into ‘The
Role and Organisation of Community Palliative Specialist Nursing Teams Working in
Rural England’ in the British Journal of Community Nursing.
Quality improvement and innovation goals agreed with our
commissioners
The goals and indicators for the hospice as required by the commissioners were as
follows:
Goal 1
To ensure that all front line staff has all the necessary skills,
knowledge and attitudes related to the care of the dying
Goal 2
To ensure that all individuals approaching the end of life are
offered a care plan
Goal 3
The hospice should have mechanism for auditing and reviewing
quality of end of life care.
Goal 4
Relatives involved in end of life care decisions to the extent that
they and the patient wish
Goal 5
Undertake surveys on how services have benefited users and
carers
Goal 6
Highlight main achievements and successes during the year
Goal 7
Report on the number of complaints and how they were
resolved
Goal 8
Report on activity relating to day unit, ward, community palliative
clinical nurse specialists
What others say about us
Ashgate Hospice is required to register with the Care Quality Commission
The Care Quality Commission’s last inspection of August and September last year
rated Ashgate Hospicecare as Outstanding overall and in three key lines of enquiry:
care, responsiveness and well led: and good in effective and safe.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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The registered manager for Ashgate Hospice is the Director of Clinical Services and
our regulated activities are: treatment of disease, disorder and injury, surgical
procedures, diagnostic and screening procedures, nursing care, and personal care.
Data quality
During 2014/15 the quality of information from the electronic patient record has been
of a consistently high quality which has enabled us to report more accurately on
activity and outcomes
The hospice submitted the Information Governance tool kit on 31 st March 2015, and
is complaint at level 2
The hospice also recruited a part time information governance lead to provide a
dedicated focus on matters relating to data and information governance across the
hospice.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Section 3 Quality overview
Comparison with previous year’s data sets
The most recent Dataset covers the period 1st April 2014 to 31st March 2015.
Ashgate Hospice data for 2013-14 have been collated and compared below.
Community: Palliative Care Clinical Nurse Specialist
Community Specialist Palliative Care data
The hospice sees the community team as providing a significant role in improving
the quality, accessibility, flexibility and integration of palliative and end of life (EOL)
care in our catchment area.
Full year 2013/14 face to face contacts = 1,867
Non face to face contacts = 4,338
Full year 2014/15 face to face contacts = 1,735
Non face to face contacts = 6,716
“I would like to thank you and your team for all the love and support you gave to X
and myself. Without your help I don’t think I would have been able to manage as it
was my dearest wish for him to be at home’’
“On behalf of our family and friends we would like to thank all of the staff at Ashgate
for your kindness care and attention paid to our beloved X. The service is
invaluable’’
Quotes from patients relatives
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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HOSPITAL CNS (in reach service to Chesterfield Royal Hospital Foundation
Trust)
Full year 2013/14 face to face contacts = 4,321
Full year 2014/15 face to face contacts = 3,592
This small team based at Chesterfield Royal work across all wards and settings
where patients may be at the end of their life, or who are in the palliative stage of
their illness. They are provided by Ashgate Hospice and work very closely with the
consultant and other medical staff as part of a team delivering specialist palliative
care to the acute hospital
’’Cannot fault the care given to my husband at a very difficult time. The support
given to me and my family could not have been better’’
’’Absolute and total respect for everyone concerned with X’s care and treatment.
Worth their weight in gold‘’
Quotes from patients relatives
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Hospice at Home
2013/14 face to face contacts = 1,930
Non face to face contacts = 411
2014/15 face to face contacts = 2,298
Non face to face contacts = 1,244
The Hospice at Home team provide support and care to patients and families across
North Derbyshire predominantly in the last 3 months of life. The team will deliver
supportive care and personal care as required, and based on need. The length of
intervention is variable and each contact can last for half a day or more; again
depending on need. The team work in collaboration with other agencies (social care,
health and other third sector) and in partnership with families. Having received
recurrent funding this year for two extra posts, our intention is to work with
commissioners and other providers to develop this concept further to a 7 day
service, if possible
‘’I can’t tell you the pleasure it gave me and peace of mind knowing my husband
was safe’’
‘’They have the gift of listening, gently making suggestions and putting us at ease. It
has made it seem possible no matter what may happen’’
Big thank you to all in the at Home Team, you do a wonderful job. The service has
been absolutely invaluable’’
Quotes from patients carers and relatives
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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In-Patient Unit
ACTIVITY LEVELS - 2014/2015
IN-PATIENT
UNIT
Available Bed
days
Occupied Bed
days
Total Admissions
Av Length of stay
Apr
May
Jun
Jul
Aug Sep
Oct
Nov
Dec
Jan
Feb
Mar
ACT
630
651
630
651
651
630
651
651
651
651
588
651
7686
611
617
612
567
580
569
593
603
620
637
526
628
7163
34
36
41
44
37
35
30
27
34
38
38
39
433
19.7 16.7 14.6 13.5 13.5
19
19.8 24.1 19.4 14.8 17.5 14.3
17.24
Discharges Total
10
14
18
14
17
12
15
9
14
15
9
13
160
Deaths
21
23
24
28
26
18
15
16
18
28
21
31
269
The hospice has a specialist community team, who cover the North Derbyshire area
and include clinical nurse specialists, occupational therapists and physiotherapists,
Hospice at Home team, all of whom are supported by three medical consultants. As
a result, patients are managed in their home environment, or alternative place of
care, for as long as possible. If the need arises for an in-patient admission, the
hospice is committed to supporting patients to return to their home, or alternative
place of care, as soon as their symptoms have been managed; or care for them at
the hospice for as long as is needed.
This is in accordance with the charity’s aims to offer comprehensive specialist
palliative care service to adults in north Derbyshire with progressive, advanced
disease and a limited life expectancy,
The Length of Stay and the effective use of the admission and discharge criteria
enable the timely admission of patients needing specialist in-patient palliative care.
The percentage occupancy remains high for this hospice at 93% for 2014/15,
which is considerably higher than the national median value of 80%. The inpatient
unit has an average waiting list of 1-2 patients per day, though a high percentage
of patients are admitted on the day of referral, or the day after. The additional 4
beds funded by the CCG have been extremely well utilised.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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‘’All my needs have easily been met. I was highly embarrassed at first, not being
able to do things and having to have very personal care if you know what I mean.
However staff put me at so much ease I don't feel embarrassed anymore, it is
wonderful.’’
Feedback from one of our patients who was admitted to our IPU and
discharged home with help of other services of Ashgate
Day Hospice
Activity Levels 2014/2015
DAY
HOSPICE
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
ACT
Referrals
19
21
15
26
19
19
24
26
18
17
18
30
252
Attendances
199
218
202
209
207
188
235
212
223
150
210
210
2463
Nonattendees
30
32
16
23
20
28
32
20
22
18
20
33
294
7%
10%
9%
9%
9%
11%
9%
14%
11%
1
3
6
4
9
0
5
1
56
% DNA
IPU attendees
13% 13%
6
4
13% 12%
8
9
During 2014 and 2015 the day hospice underwent a 15 step challenge. This is a
systematic way of assessing the patient experience and was carried out by a
Trustee, a patient and a health care assistant. The area was looked at with fresh
eyes and recommendations were made for improving the environment and
experience for patients. The board approved the recommendations and work is
underway to improve the facilities, decoration and layout of the room. Feedback
from the patients who attend the day hospice is extremely positive.
‘’Feel physically better and more confident. Find it therapeutic, pleased my wife can
have some time to herself’’
‘’It has been the best 12 weeks coming here I didn’t know what to expect but it has
helped me so much’’
Patients’ feedback
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Lymphoedema Service
During 2013 and 2014 the team received 307 referrals
During 2014 and 2015 the team received 377 referrals
This service is consultant led and supported by a small team (3 staff) who deliver
out patient service and occasionally, home based care, across N Derbyshire. The
team work in collaboration with other health and social care providers, and aim to
deliver specialist training.
‘’I would like to say how beneficial I have found the regular sessions. Thank you all
for treating me with much kindness, you are brilliant’’
‘’This is an impressively good service; I am one very thankful patient. Thank you for
how much you have helped me’’
‘’I was confident that the standard of care would be high once I heard that it was
hospice based’’
Patients’ feedback
Therapy Service
All therapy services are provided on the ward, in the day hospice and into the
community across North Derbyshire, with the majority of their work carried out in the
community. The service work with cancer and non cancer patients and work
collaboratively with other health and social care providers across north Derbyshire.
Approximately 689 pieces of specialist equipment were provided to patients from
Ashgate Therapy service during last year
This service received additional recurrent funding from the commissioning group this
year to employ a full time additional occupational therapist to enhance the Hospice
at Home team and increase the support we can offer in the community.
‘’I just wanted to thank the team for your help with my dad in the last few weeks of
his life. His pain was managed successfully thanks to your suggestions and the
hospital bed proved to be essential for his last 9 days’’
‘’Just a note to say thank you for all your help and support both at home and at the
day centre. I appreciate everything the team of physio’s and OT’s did for X’’
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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‘’Thank you for all your support and kindness shown to me whilst looking after X,
your help and support kept me going so I would like to say one big thank you.’’
‘’The Therapy team have been a great help in the care for my mum. Whatever
problem we have encountered in her care, they have listened, advised and have
dealt with our problem professionally, with an extremely caring attitude.’’
‘’Absolutely delighted with everything, which is helping to make difficult times
easier.’’
Patient and carer views 2014/15
Patient and Family Support (Bereavement) Service
One of the Charity’s aims is to offer professional advice and support to families and
carers during the patient’s illness and during the initial stages of bereavement.
Between 1st April 2014 and 31st March 2015 the service received 301 referrals, and
provided 807 telephone advice and support contacts to patients and carers. Patients
and carers were supported through a variety of interventions such as bereavement
support group (1 session per week for 6 weeks), home visits, and support from an
art therapist (evidenced as particularly useful when working with children or those
with language difficulties).
‘’Just knowing there was always a friendly, objective ear whenever I needed it
without always telling my family my fears. It allowed me to remain strong for them’’
‘’They listened and tried to show me maybe there was a different way of looking at
things and yes more than anything it has given me a new way of coping with my
anxiousness’’
‘’Thank you for your support. Your service is invaluable, excellent service caring for
the whole family’’
Selection of comments from service users
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Chaplaincy
Ashgate hospice employs a full time chaplain to provide spiritual care and support to
the patients and carers as an integral part of the holistic care. On average there are
40 contacts per week. Part of the role is in providing post bereavement support,
leading groups and working with the family support and bereavement team. As the
hospice has grown in size the work of the chaplain has increased and the board of
trustees have committed to supporting this department with additional funding to
employ an additional part time chaplain.
’The kindness and personal support you gave will always be remembered and
appreciated and I know X values the times he spent with you too, he loved to tell us
when he had been to the Chapel at the Hospice!’’
I wanted to say that it has been such a pleasure to get to know you. Your
sensitivity, peace and gentleness are wonderful and you carry something so
precious – God’s presence.
‘’Talking about death and bereavement is very difficult because students at that age
vary so much in terms of maturity and exposure to death or friends who are grieving,
but I thought you did this really well, asking them to reflect about what a grieving
person might want. Thank you for giving up your time for us’’
Quotes from relatives cards and feedback from external teaching sessions to
the Chaplain
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Quality indicators:
Prevention and management of pressure ulcers
Between 1st April 2014 and 31st March 2015, 433 patients were admitted to the IPU.
A Waterlow score was determined for all patients. Of the number admitted 130
pressure ulcers were graded on patient admission. All pressure ulcers, and areas at
risk of developing into a pressure ulcer, were given a grading using the EPUAP
classification system. All patients had a documented care plan, which includes
monitoring on an ongoing basis. Preventative measures were put in place for all
patients, such as pressure relieving mattresses and cushions. Collaborative working
with DCHS tissue viability team supports our staff in the latest prevention and
treatment of vulnerable patients. In addition, during 2014 the hospice purchased
additional training for all clinical staff in the prevention and management of pressure
ulcers. This has been very well received and will be followed up with an audit this
year to evidence the learning into practise.
One case was reported to the CQC during this time, and developed because a
patient refused the recommended treatment and advice.
Prevention and management of patient falls
Between 1st April 2014 and 31st March 2015 there were 111 patient falls, none of
which were serious and needed no treatment or minor first aid only. This is an area,
as with all hospice settings, where we expect to see a high level of falls. All patients
have a falls risk assessment on admission, and preventative measures are put in
place following the assessment. Following a fall the risk assessment is reviewed
and further measures are implemented if necessary. Many patients are frail and
confused in the hospice setting and we therefore ensure high staffing levels are in
place. We plan to do a piece of work this year to analyse the falls in more detail to
identify trends and themes, for example the time the fall occurred, the medical
condition of the patient, whether they are in a multi bedded bay or single room, and
assess whether this is having a negative impact on the prevention of falls. We
would like to increase staff awareness and understanding of falls prevention using
national evidence and tools in order to reduce the number of falls in the next year.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Mandatory training
96% staff attendance at mandatory training days: topics include:
Fire, infection control, safeguarding, moving and handling, information governance,
health and safety and resuscitation as core elements, with additional specific clinical
topics planned following appraisal and training needs analysis. (For example:
nutrition, dementia awareness, and communication).
Infection prevention and control
Between 1st April 2014 and 31st March 2015 none of our patients developed MRSA
or C Difficile whilst in the ward.
Our participation in clinical audits
To ensure that the hospice is providing a consistently high quality service, we
undertake our own clinical audits, using national audit tools developed specifically
for hospices, which have been peer reviewed and quality assessed. This allows us
to monitor the quality of care being provided in a systematic way and creates a
framework by which we can review this information and make improvements where
needed.
Each year, the Clinical Governance Committee approves the audit schedule for the
coming year. Priorities are selected in accordance with what is required by our
regulators and any areas where a formal audit would inform the risk management
processes within the hospice.
Through the Clinical Governance report, which is shared with the Health Care
Governance Committee, the Board of Directors is kept fully informed about the audit
results and any identified shortfalls. Through this process, the Board has received
an assurance of the quality of the services provided.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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The following audits were completed between 1st April 2014 and 31st March 2015.
Audit Title
Audit Compliance
Audit Comments
Infection Control Audit (Code of Practice)
96% (up 5.4% from previous
year)
This audit has to be completed
annually and was carried out
in August and September 2014
Management of Controlled drugs
100% (up 1.2% from previous
year)
This audit has to be completed
annually to provide evidence
to support the self assessment
by the Accountable Officer and
was carried out in November
2014. The hospice was fully
compliant with the legal
requirements
Controlled Drugs - Accountable Officer
100% (same as previous year)
This audit has to be completed
annually to provide evidence
to support the self assessment
by the Accountable Officer and
was carried out in November
2014. The hospice was fully
compliant with the legal
requirements
General Medicine Audit
97% (up 7% from previous year)
Safeguarding Audit (requested for
Quality Schedule requirements)
100% - fully compliant
This audit was carried out in
July 2014 and the hospice was
found to be fully compliant
with the required standards
Nutrition and Hydration Audit
59% (new audit to 2014/15)
This audit was carried out in
April and May 2014. After this
audit a detailed action plan
was written with a follow up
audit planned for June 2015.
All actions from this audit are
now completed.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
This audit was carried out in
December 2014 and has
demonstrated significant
improvement
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IPU Admission and Initial Assessment
Audit
84% (new audit to 2014/15)
This audit was carried out in
June 2014. All actions were
completed in 2014/15.
Day Hospice Admission and Initial
Assessment Audit
95% (new audit to 2014/15)
This audit was carried out in
June 2014. All actions were
carried out in 2014/1.
Pain Management Audit
54% (new audit to 2014/15)
This audit was carried out in
October 2014. A detailed
action plan was written with a
follow up audit planned for
August 2015. All actions from
this audit are now completed
What our staff says about the organisation
Ashgate hospice values the opinions of the staff regarding the quality of the service
provided and views are currently captured through a number of methods; staff panel
representatives, newsletters, informal drop in sessions with staff and members of
the Senior Management Team, and staff meetings. During 2014 the hospice
participated in the national Birdsong Survey, and the survey is due to be repeated
each year. Each directorate has looked at the results in detail, developed an action
plan and worked with the staff to improve areas that had been identified. The key
themes were shared with the Board of Trustees.
The Board of Trustees’ commitment to quality
The Board of Trustees is fully committed to the quality agenda. The hospice has a
well established governance structure, with members of the Board having an active
role in ensuring that the hospice provides a consistently high quality service. There
were two additions to the Board of Trustees in 2014, both with clinical and NHS
backgrounds. A further two new Trustees have been appointed in 2015. These
additions ensure a robust ‘check and balance’, and enquiry, into the quality of
services that we provide.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Annex A
Quality Account 2014/2015
Ashgate Hospice
Commissioner Statement
General Comments
NHS North Derbyshire Clinical Commissioning Group (NDCCG) is responsible for
providing the commissioner statement on the quality account provided by Ashgate
Hospice and in doing so has provided NHS Hardwick Clinical Commissioning
Group, with the opportunity to make comments and contribute to the commissioner
statement. NDCCG can confirm that Ashgate Hospice has produced a Quality
Account that is open and robust and that the information provided appears to be
accurate and representative of the information available to NDCCG through contract
monitoring and quality assurance processes during the year.
Measuring and Improving Performance
The Quality Account describes the quality of services provided this year by Ashgate
Hospicecare measured against national, regional and local standards.
Last year Ashgate Hospicecare detailed 3 improvement priorities, these were “to
use national comparisons of our care in preventing falls, pressure ulcers and
medicines management”, “staff development for the future” and “extend our reach
into the community to see more patients”. It is clear from the Quality Account that
marked progress has been made in all of these areas. In particular the
developments within the Hospice at Home team has made a significant difference in
supporting families and enabling people to stay at home at the end of their lives if it
was their choice to do so.
NDCCG support the 3 future planning priorities outlined within this report:
 “Improve our environment to help those patients with dementia”
 “Reduce the numbers of patients who fall in our care”
 “Recruit to Head of Governance and Patient Safety post … in order to
develop intelligence and stretch ourselves in terms of audit and analysis of
quality and patient safety information”.
We would like to congratulate Ashgate Hospicecare on being rated as ‘Outstanding’
overall following a Care Quality Commission inspection in September 2014 and on 3
key lines of enquiry: care, responsiveness and well led. Also for the 2 ‘Good’ ratings
on the remaining indicators: effective and safe.
The Hospice has continued to demonstrate good results in relation to infection
control and there have been no incidences of patients developing C Difficile or
MRSA while on the ward. Across the 12 months, the hospice has had one incidence
of a pressure ulcer developing in their care. The CCG support the focus on falls
prevention for the coming year given the slight increase in their incidence over the
past 6 months.
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Additional comments
The Quality Account is an annual report to the public that aims to demonstrate that
the Hospice is assessing quality across the healthcare services provided. The
Quality Account is patient friendly and is enhanced by the patient comments and
feedback which are throughout and clearly demonstrate that the Hospice is
providing a comprehensive range of palliative and end of life care in a variety of
settings.
The Hospice has worked collaboratively with commissioners and all key
stakeholders to ensure patients receive high quality care in the right care setting.
NHS North Derbyshire Clinical Commissioning Group and associate commissioners
look forward to continuing to work with the Hospice to commission and deliver this
high quality patient care.
Jayne Stringfellow
Chief Nurse & Quality Officer
On behalf of NHS North Derbyshire Clinical Commissioning Group
5th June 2015
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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Annex B
Press release by the Care Quality Commission
regarding their last inspection of Ashgate Hospicecare
Hospice in Derbyshire is rated as Outstanding by the Care Quality
Commission.
The Care Quality Commission has found the quality of care provided by Ashgate Hospice in
Chesterfield to be Outstanding following an inspection carried out in August 2014.
Ashgate Hospice is an independent registered charity for the delivery of care and treatment
for people across the community of North Derbyshire.
Inspectors found staff were caring and compassionate and people were being provided with
safe, responsive, caring, effective and well led care. A full report of the inspection has been
published today: http://www.cqc.org.uk/location/1-121816895
Under CQC’s new programme of inspections, all adult social care services are being given a
rating according to whether they are safe, effective, caring, responsive and well led.
The report on Ashgate Hospice highlights innovative and creative practice used by staff and
a clear commitment by managers to continually improve. All of the people receiving care
inspectors spoke with were highly complementary about the care and treatment provided and
the clean, pleasant hospital inpatient environment.
Staff worked with people and their families on an individual basis, to agree their care,
involvement and support and to enable them to live as full a life as possible. People were
supported to receive end of life care that met with their
needs and wishes to achieve a private, dignified and pain free death.
Sue Howard, Interim Deputy Chief Inspector of Adult Social Care in CQC’s Central
region, said:
“We found that people receiving care at Ashgate Hospice and their relatives were
overwhelmingly positive about the quality of their care.
“Inspectors found many examples of the home’s management implementing innovative
approaches to ensure care was delivered to a high standard.
“These included managers supporting staff to undertake relevant research and development,
to ensure best practice and make improvements when required.
“We were impressed by the service’s commitment to supporting people before, and after
death. People were treated with the utmost care and compassion and were enabled to live as
full a life as possible. People, their families and staff mattered and their views about the care
and treatment provided were sought, respected and acted on”.
Andrea Sutcliffe, Chief Inspector of Adult Social Care, said:
“The quality of care which our inspectors found here was exceptional and I am very pleased
that we can celebrate the hospice’s achievements.
“An outstanding service is the result of a tremendous amount of hard work and commitment.
I would like to thank and congratulate everyone involved.”
Ashgate Hospicecare Quality Account – Anna Baker – May 2015
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