COMPTON HOSPICE
QUALITY ACCOUNTS 2014/2015
Our Purpose
Compton Hospice is committed to providing quality palliative
and end-of-life care to people with incurable conditions and
frailty and providing support to their families.
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Compton Hospice Registered Charity: 512387
Statement from our Chief Executive, Ron Middleton
It gives me great pleasure to present this Quality Account for
Compton Hospice. This report reviews progress against our priorities
described in last year’s account and sets out some of our key quality
priorities to improve services for patients and families in the coming
year.
The aim of this report is to give clear information about the quality
of our services so that the people using them can feel safe and well
cared for, that their families and friends are reassured that all of our
services are of a very high standard and value for money. Public trust
and satisfaction with our service is essential.
The hospice is an independent charity (registered number 512387)
and is constituted as a company limited by guarantee (registered
number 1607631). The charity is run by a board of Trustees who are
also Directors of the Company.
Compton Hospice continues to be a highly respected organisation providing palliative care to patients over
the age of 18, which extends to families and carers. Our care is provided without cost to those that need it.
The hospice has been established for 32 years and is recognised as a leader and innovator in the provision
of palliative care.
The Hospice provides palliative care services to patients from Wolverhampton, South Staffordshire,
Walsall, Dudley, Sandwell and Shropshire. Approximately one third of funding has been provided from the
six Clinical Commissioning Groups that we work with. The remaining funding is provided through voluntary
donations from members of the public, other fundraising activities carried out by the hospice, the
operation of 25 retail charity shops, and a weekly lottery company and legacy income.
Our eligibility criteria make no distinction for any group irrespective of ethnicity, religion, disability or
sexual orientation. Our clinical and fundraising teams continue to work hard to promote hospice care to
the whole of the areas we serve to ensure equity of access.
The last year has been extremely busy and we have made great progress in achieving our priorities, but we
have also seen other achievements. For example I am extremely proud to announce that our In-Patient
Unit (IPU) received the Inaugural Sue Pembrey Award for a project they implemented through the
Foundation of Nursing Studies. The project considered the benefit of providing Healthcare Assistants (HCA)
to complete second medication checks which has improved the timeliness of symptom management for
patients whilst on the IPU.
We continue to work in partnership with a number or organisations including Mary Stevens Hospice,
Beacon Centre for the Blind and have strong links with The Royal Wolverhampton Hospitals NHS Trust in
particular through our medical provision.
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Compton Hospice Registered Charity: 512387
I would particularly like to thank all our staff and volunteers for their continued commitment and
achievements during the last twelve months. We could not give such high standards of care without our
hardworking staff and volunteers.
To the best of my knowledge, the information reported in this Quality Account is accurate and a fair
representation of the quality of healthcare services provided by Compton Hospice. The safety, experience
and outcomes for all those using our services are of paramount importance to us, and whilst we believe
that the care we deliver is of the highest quality, we also recognise that there is always room for
improvement and are fully committed to continually reviewing our services to ensure that our services are
safe and that our patients always receive the care they need.
The document has been forwarded and commented upon by Wolverhampton City CCG (our Lead CCG).
Ron Middleton, Chief Executive
June 2015
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Compton Hospice Registered Charity: 512387
About Compton Hospice
The History of Compton Hospice
Compton Hall, along with its stables, coach houses, yard,
servants' quarters and lodge, was built between 1840 and
1850 and is set in four-and-a-half acres of woodland and
gardens.
After housing evacuees during the war, it became a home
for nurses working at the Midlands County Eye Infirmary.
When this provision was no longer needed, a health
council working group, led by Councillor Stephen Morton,
petitioned for it to be used as a care facility for
terminally-ill patients.
With help from National Cancer Relief, the Regional Health Authority and Wolverhampton Rotary, a
staggering £454,000 was raised, making the necessary building works possible to transform the old hall
into a 16-bed unit. Compton Hospice welcomed its first patients in February 1982 and was officially opened
by the Duchess of Kent on November 9th 1982.
2015 at Compton Hospice
Compton Hospice has been open for 32 years and in this time has cared for in excess of 22,000 patients,
our catchment area covers predominately the Wolverhampton area, reaching out to South Staffordshire,
Dudley, Walsall, Sandwell and Shropshire.
Compton Hospice has an in-patient unit set in the grounds; the in-patient unit was completely refurbished
in 2011 and now provides 18 single purpose built rooms with en-suite facilities.
Compton Hospice also operates outpatient facilities which include:

Day centre on-site which is registered for up to 16 patients per day

Community Nurse Team

Hospice at Home Team

Lymphoedema Clinic.
Both in-patient and community teams are supported by a team of medical staff, physiotherapists, social
workers, spiritual care and bereavement service.
Compton Hospice has an education department which delivers a wide range of courses for Health
Professionals up to Masters Degree level.
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Compton Hospice Registered Charity: 512387
Our Purpose
Compton Hospice is committed to providing quality palliative and end-of-life care to people with incurable
conditions and frailty and providing support to their families.
Our Values
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We believe the patient and their family come first
Our focus is on excellence of care
We value diversity
We value and recognise the contribution of all our people and promote the importance of their
professional development
We believe in team working
We believe in equal opportunities for all
We strive to maintain our good reputation
We value open, honest, transparent communication
We believe in sharing responsibility appropriately
We value evidence based and continuous improvement
We believe we should share our knowledge and expertise with other
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Compton Hospice Registered Charity: 512387
Statement of Trustees’ responsibilities in respect of the Quality Account
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year.
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
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the Quality Account presents a balanced picture of the Hospice’s performance over the reporting
period;
the performance information reported in the Quality Account is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to confirm
that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and
the Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Account.
Date
Signature
Chairperson
Date
Signature
Chief Executive
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Compton Hospice Registered Charity: 512387
Part 1 Priorities for Improvement
1.1
Looking Forward: Priorities for Quality Improvement 2015/16
Compton Hospice has developed an overall five year operational strategy for 2015 – 2019; Our Strategic
Aims include to:

Through the development of our resources maximise our capacity and extend our reach across the
seven day week to meet the increasing end-of-life care requirements of our community based on
need rather than diagnosis;

Develop expertise in the health and social care workforce who care for those in the last years of life
through education and training;

Maximise the effectiveness of limited resources across the health and social care economy by
forming partnerships whenever possible with others whose aims and values are congruent to ours.
We have identified various quality initiatives for the coming year; those detailed below are a summary of
our priority quality initiatives.
Our Quality Improvement Priorities for 2015/16
Safety Priority
Quality Priority
How will we
measure?
To reduce the risk of patients falling whilst on our in-patient unit.
Incident data.
In-patient dashboard.
Benchmarking using National Council for Palliative Care: Minimum Datasets.
Performance measures against timeliness of initial and subsequent falls assessments.
Performance measures against timeliness of initial and subsequent falls assessments.
How will we do
this?
Audit of care plans and risk assessments.
 Develop and implement a falls policy on our in-patient unit
 Use investigation tools to review falls incidents to identify learning
 Network with other hospices to share learning and good practice
 Engage with the falls prevention service in Wolverhampton
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Compton Hospice Registered Charity: 512387
Safety Priority
Quality Priority
How will we
measure?
We want to strengthen our systems for monitoring and improving
prevention and control
Performance data relating to infection prevention and control
infection
In-patient dashboard
Revised policy embedded
Attendance at network meetings
Training data
Attendance at network meetings
How will we do
this?
Training data
 Revise our infection control policy
 Review our infection prevention and control audit plan
 Review our infection and prevention control training
 Develop an annual infection prevention and control improvement plan
 Engage with our partners and experts infection prevention and control
 Participate in local infection prevention group
Safety Priority
Quality Priority
How will we
measure?
We want to review our mandatory training programme for all staff to ensure that it
is fit for purpose
Training evaluation feedback
Training compliance data
How will we do
this?
Supervision and appraisals
 A working group will oversee a review of mandatory training
 The working group will develop a mandatory training matrix for clinical and
non-clinical staff
 Source alternative methods of training provision to support core training
 Link training and competency to staffs annual appraisal
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Compton Hospice Registered Charity: 512387
Patience Experience Priority
Quality Priority
How will we
measure?
We want to improve the way in which we engage and seek views from our patients
and carers of the services that we provide.
Ratified strategy and implementation plan.
Each service will be represented by patient experience champions.
How will we do
this?
Annual report relating to patient experience that details how we use information
gathered to improve services for our patients and carers.
Develop a 5 year patient experience strategy which will set out our commitment to
seeking views on our services and methods that we will use to do this.
Identify patient experience champions throughout the hospice including Board level.
Actively listen to views to improve our services.
Develop patient and carer outcome measures using:
 Carer Support Needs Assessment Tool
 Palliative Care Outcome Scale Tool
Patience Experience Priority
Quality Priority
How will we
measure?
Wolverhampton is a multi-cultural and multi-faith city, we therefore want to change
our emphasis from religious to spiritual care
Training data
Patient and family feedback
How will we do
this?
Links with religious leaders in our local community
 Revise our core training program for staff
 Provide monthly support sessions for volunteers including mandatory training
relating to spiritual care
 Chaplaincy Team will become Spiritual Care Team
 The sanctuary will be reconfigured to provide a peaceful spiritual space to
offer sanctuary for those of religious faith and none
 Invest in resources that are important to the religious practice of other faiths
 Engage with religious leaders in our local community
Effectiveness Priority
Quality Priority
How will we
measure?
We want to extend our community service provision to better serve the population
we cover.
Attendance will be measured through our activity data.
Patient and carer experience reports.
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Compton Hospice Registered Charity: 512387
How will we do
this?
Workforce data.
 Increase community nursing team by 50%
 Increase education provided to patients and staff in nursing homes
 Implement the electronic record system
 Increase support offered to carers through collaborative working with social
workers
 Development of Clinical Nurse Specialist Out-patient clinics
 Increase the use of our day centre through education with staff and
promotion with our patients
Effectiveness Priority
Quality Priority
How will we
measure?
To implement a rehabilitative palliative approach within our in-patient unit across
the multi-disciplinary team to optimise patient function and wellbeing and to enable
them to live as independently and fully as possible, with choice and autonomy, within
the limitations of advancing illness.
Length of stay data
Audit of care plans
How will we do
this?
Patient feedback
 Integrate rehabilitation, enablement, self-management and self-care into our
model of care
 Utilise a multi-disciplinary team approach
 Include patients and relatives in care planning
 Revise care plans to include patient goals, priorities, and limitations
Effectiveness Priority
Quality Priority
How will we
measure?
How will we do
this?
We want to review our audit programme to ensure that we select appropriate audits
and improve our services as a result of audits.
Number of completed audits
Monitor through Clinical Audit & Guidelines Group
 Review the process for identifying audits
 Maintain a comprehensive audit program
 Strengthen the way in which we evaluate and implement the learning from
audits
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Compton Hospice Registered Charity: 512387
1.2
Looking Back: What did we achieve in 2014/15?
Our Quality Priorities for 2014/15
Patient Experience Priority
Quality Priority
What did we want
to achieve?
What did we do?
Improvements to outpatient facilities.
We wanted to build a new orangery for patients and visitors with funding from a
specific legacy. We sought to create an area away from the individual in-patient
rooms for patients and families to enjoy the view of the gardens in peaceful and
welcoming accommodation.
We also wanted to relocate the doctors’ office to a purpose built room directly
adjacent to the Orangery, thus releasing additional space to allow extension of the
new reception area.
 Installed the orangery extension to the ward area
 Installed a lift in out-patient area
What was our
outcome?
 Relocated doctor’s office
The creation of the orangery has provided an additional area for patients and visitors
which gives access into the hospice grounds and gardens, patients and relatives
utilise this area for family activities such as picnics and quiet time to enjoy the fresh
air.
Effectiveness Priority
Quality Priority
What did we want
to achieve?
What did we do?
Improvement in the admission, length of stay and discharge process of the in-patient
unit.
Currently the systems for admitting patients and indeed their ultimate discharge did
not support consistent achievement of performance indicators set by the Board of
Trustees and senior management in respect of occupancy and length of stay.
We wanted to bring about changes in working practices and how we communicate
with patients and their families before admission to better achieve these
performance indicators.
 Appointed a Liaison Nurse for the in-patient unit to co-ordinate, lead and
facilitate effective and timely discharges.
 Strengthened admission process between the Acute Hospital and In-patient
What was our
outcome?
Unit.
Improving length of stay remains one of our strategic objectives and priorities for the
following year.
The Liaison Nurse has strengthened processes in respect of discharge and has
integrated discharge documentation into the Electronic Patient Administration
System.
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Compton Hospice Registered Charity: 512387
Safety Priority
Quality Priority
What did we want
to achieve?
What did we do?
Implementation of the Electronic Patient Administration System (CrossCare).
We wanted to create a patient electronic record system for use across all clinical
services that is fully compliant with the Data Protection Act 1998 and Information
Governance requirements.
 Worked with service leads to ensure that the CrossCare system meets the
requirements of the service and is fit for purpose
 Implemented the electronic record system in all clinical areas, making
refinements at each stage of the project
 Provided training to staff
 Created reporting and audit mechanisms within the system
What was our
outcome?
The project to implement CrossCare is a long term vision which spans across 3 years,
we have key milestones within the project, and the project will continue into
2015/16.
To date the system has been implemented across all clinical areas; however some
services are not yet using the system to the full potential.
Cross care has provided us with:
 Access to accurate information
 Timely access to information regarding patients care and treatment
 Access to comprehensive information
Effective working through enhanced exchange of information between services
Effectiveness Priority
Quality Priority
What did we want
to achieve?
Development of services aligned to the In-patient Unit.
 Implement an assessment tool that allows us to assess the level of nursing
staff required per shift, and develop a flexible workforce to achieve safe
staffing levels

Strategies to manage risks associated with patient safety

What did we do?
Improve documentation of care
 Implemented an evidenced based tool to identify required staffing
establishment
 Increased establishment on in-patient unit
 Developed a crib sheet that has been recognised as good practice and
adopted by other hospices
 Introduced shift rotation
What was our
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The use of an evidence based tool to assess the level of staff needed on the in-patient
Compton Hospice Registered Charity: 512387
outcome?
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unit each day has meant that we can be sure that we have the right amount of staff
with the appropriate knowledge, skills and competence to provide high quality care
to our patients every day. The introduction of the tool means that we can be flexible
and revise our workforce to meet the needs of the service on a shift by shift basis.
Compton Hospice Registered Charity: 512387
Part 2 Statements of Assurance
Compton Hospice is required to register with and is regulated by the Care Quality Commission (CQC) and
its current registration status is unconditional. The CQC has not taken enforcement action against
Compton Hospice during 2014/2015.
The most recent CQC inspection was November 2013, the results of this inspection were extremely
positive with all standards being met with no action required due to any areas being highlighted as being of
concern.
2.1
Mandated Statements
The following are a series of statements that all providers must include in their Quality Account. Many of
these statements are not directly applicable to specialist palliative care providers.
Review of services
During 2014/15 Compton Hospice was contracted to provide six core services to the NHS:
The services were as follows:
 Clinical Nurse Specialist Community Team
 Hospice at Home services
 Day Hospice
 Outpatient care
 Lymphoedema Clinics
 In-patient care
 Bereavement Service
What this means
The hospice received a contribution from the NHS equalling 36% of the full cost of the contracted
service provision. The remaining funds were generated by contributions from the local community
through fundraising and the Hospice’s own subsidiary companies.
The Clinical Issues Committee meets bi-monthly to develop and monitor the work of the clinical services at
Compton Hospice; the Committee informs the Chief Executive and Board of Trustees on clinical issues
within the hospice through the Development and Governance Group. The Pharmacy Committee directly
reports to the Clinical Issues Committee.
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Compton Hospice Registered Charity: 512387
The Clinical Issues Committee:
 Reviews developments in palliative care including the national and local End of Life Care Strategies,
appropriate research, audit and clinical guidelines.
 Develops quality indicators
 Monitors clinical incidents and complaints and makes appropriate recommendations to inform
practice
 Recommend task and finish groups for key work areas as required
What this means
Delivering the very highest quality of care is at the heart of everything we do, our Board seek assurance
through the Board meetings that this high standard of care is consistently delivered, the Board
challenge where they identify improvements may be required and monitor and remedial action
required.
We meet twice a year with our lead commissioners to review performance and provide assurance
relating to:
 Quality of care
 Effectiveness of Service
 Experience of those using our services
No concerns have been raised at these meetings.
2.2
Participation in Clinical Audits
As an independent hospice, Compton Hospice does not participate in the national NHS clinical audit
programme as there are no national clinical audits or national confidential enquiries covering NHS services
relating to palliative care. However, we regularly undertake audits, as part of our annual forward audit
programme which we select according to network, local or internal priorities.
What this means
As a provider of specialist palliative care Compton Hospice was not eligible to participate in any national
clinical audits or national confidential enquiries, however to ensure high quality of services a local audit
plan is established. Where necessary local action plans for improvement are developed.
The number of patients receiving NHS services provided or sub-contracted by Compton Hospice in
2014/2015 that were recruited during that period to participate in research approved by a research ethics
committee was 0. There was no appropriate, national, ethically approved research in palliative care in
which the hospice could participate.
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Compton Hospice Registered Charity: 512387
2.4
Use of CQUIN Payment Framework
The contract for Compton Hospice NHS income for 2014/15 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation payment
framework.
2.5
Data Quality
Compton Hospice did not submit records during 2014/2015 to the Secondary Uses Service for inclusion in
the Hospital Episode Statistics.
In accordance with agreement with the Department of Health, Compton Hospice submits a National
Minimum Dataset (MDS) to the National Council for Palliative Care. This information is detailed in section
3.
2.6
Information Governance
Compton Hospice’s score for 2014/2015 for information Quality and Records Management was not
assessed using the Information Governance Toolkit. This toolkit is not applicable to palliative care.
2.7
Payment by Results
Compton Hospice was not subject to the Payment by Results clinical coding audit during 2014/2015 by the
Audit Commission
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Compton Hospice Registered Charity: 512387
Part 3 Review of Quality Performance
3.1 The National Council for Palliative Care: Minimum Datasets April 2014 – March
2015
The National Council for Palliative Care: Minimum Datasets are the only annual data collection to cover
patient activity in specialist services in the voluntary sector; the aim is to provide an accurate picture of
hospice and specialist palliative care service activity. It allows us to benchmark our services with other
similar hospices.
We submit data for our In-patient Service and Hospice at Home Service.
3.2
Compton Hospice Quality Performance Information 2014/15
Activity
Referral Information
The total number of patients referred to our services between April 1 st 2014 and March 31st 2015 was
1,758.Our patients predominately live in Wolverhampton; they are referred to our services by their GP,
District Nurse and Hospital or Community Consultant.
Referral activity is shown in the tables below; the majority of our referrals continue to be from residents of
Wolverhampton. We have seen an increase in our referrals in comparison to the previous year.
The number of patients referred by Commissioning Group is tabled below.
Patients referred by Clinical Commissioning Group Area (Total 1,758)
Number of referrals
Area
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Wolverhampt
112
91
104
101
85
on
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
102
112
112
98
95
118
138
Dudley
3
7
7
5
5
5
7
7
2
4
7
3
Sandwell
2
0
3
0
1
3
3
1
3
1
3
5
Walsall
2
3
2
1
2
0
1
2
3
4
4
3
30
20
33
20
23
29
30
25
30
25
32
36
Shropshire
8
2
3
3
2
4
5
0
1
4
2
7
Others
1
South
Staffordshire
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Compton Hospice Registered Charity: 512387
Length of Stay Information
Activity relating to our In-patient Unit is detailed in the table below; reducing average length of stay is one
of our quality priorities for improvement this coming year.
In-patient Unit Activity
Activity
Area
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
262
286
256
174
191
225
329
259
238
306
299
367
Dudley
11
6
5
32
69
6
42
44
70
68
59
33
Sandwell
12
0
12
36
47
48
18
0
13
0
10
32
Walsall
14
30
17
0
2
10
0
0
0
35
28
31
Staffs
111
54
91
141
88
96
102
110
124
33
25
23
28
19
12
23
20
3
0
4
12
0
0
20
438
395
393
406
417
388
491
417
457
442
421
506
15
15
11
12
17
13
17
17
16
12
14
20
Wolverhamp
ton
Shropshire
Total
Occupied
Bed Days
Average
Length of
stay (days)
3.3
Updates from our Services
Clinical Nurse Specialist Community Team
We have a team of specialist palliative care nurses that provide holistic assessment of our patients, and
their family’s needs, identifying any physical, psychological, spiritual or social needs.
The team work closely with other health and social care professionals to help patients and their families
coping with adjusting to living with a life limiting illness. The emphasis is on maximising the quality of life
of the patient and their family.
Clinical Nurse Specialist Community Team key achievements
 Continued training and development for staff to ensure we have a highly skilled and competent
workforce
 Participated in a partnership project with Macmillan Cancer to facilitate provision of seamless
and high quality care for offenders with palliative and end of life care needs
 Implemented the Integrated Patient Care Outcome Scale (IPOS) to capture how input from the
team has improved outcomes for patients
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Compton Hospice Registered Charity: 512387
Hospice at Home Services
Our hospice at home service aims to do exactly that - bringing hospice care into the home environment.
It enables patients with a life limiting illness to be cared for at the end of their life in their own home and
works alongside other community teams to provide health and social care and emotional support for the
patient and the family.
Hospice at Home Team key achievements?
 We continue to provide support to the In-patient Unit and Day Therapy Centre
 We provide day support service to South Staffordshire, and have extended this to the entire
catchment area when there is available capacity
 We have increased our operational hours for the day support service to 07.30am – 9.30pm and
can now offer support 24 hours per day, 7 days per week
Day Hospice
Compton Hospice Woods Centre provides a holistic service to help maintain a sense of independence, wellbeing and quality of life whilst adapting to advanced illness. Each patient has an individual program to
address patients concerns which may include therapies and services such as pain and symptom control,
relaxation therapies and confidence building.
Day Hospice key achievements
 We have integrated with Community, In-patient Unit and Day Therapy Centre
 Our patients attend the day centre whilst an in-patient which supports the transition from inpatient to home, this forms part of the preparation for discharge.
Physiotherapy Service
The physiotherapy service aims to improve patients’ quality of life by promoting independence and helping
people adapt to their changing condition. Physiotherapy aims to make the most of peoples abilities,
physical, psychological and emotional, to keep them as independent as possible.
We work in patients’ own homes, day therapy, out-patients and in-patients.
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Compton Hospice Registered Charity: 512387
Physiotherapy Service key achievements
 We received excellent feedback through the audit of our breathlessness self-help service.
 90% of patients receiving the breathlessness self-help service felt that they had learned
something new about managing breathlessness and 94% felt better able to manage their
breathlessness.
 The service is a key member of the regional project which is reviewing end of life care for
patients with Chronic Obstructive Pulmonary Disease.
Lymphoedema Clinics
The lymphoedema service at Compton set up in 1996 has continued to grow and is now one of the largest
specialist lymphoedema units in the UK treating around 200 adults per week.
Lymphoedema Clinic key achievements
 We have invested in technology to ensure we are able to measure outcomes effectively for
those suffering from trunkal/head and neck oedema
 We have improved the quality of life questionnaire to ensure we are able to treat patients
holistically
 We continue to register approximately 250 new patients each year.
 We have a nurse on the in-patient unit with specialist Lymphoedema skills which has improved
the service to in-patients
 We have developed group clinics for patients referred to the service who are low priority to give
advice on self-management of Lymphoedema
 Staff have successfully completed various levels of education such to
 We continue to be instrumental in developing Lymphoedema care on a national scale through
specific degree modules developed and provided through Compton hospice Education Centre
In-patient care
The in-patient unit (IPU) continues to deliver the high quality care which exceeds expectations of our
patients and families.
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Compton Hospice Registered Charity: 512387
Inpatient Unit key achievements
 We have continued to train and develop our staff to ensure we have a highly skilled and
competent workforce
 We have improved risk management processes to support continual learning
 We are listening to what our patients say about our care to improve for the future
 We are piloting the electronic record system
 We are embedding “Time to Care”
 We have strengthened the discharge process with introduction of the Discharge Liaison Nurse
role
 We participated in the Foundation of Nursing Studies (FoN’s) Project and were awarded the
Inaugural Sue Pembrey Award for our work to train healthcare assistants to second check
medication
Bereavement Services
The bereavement services continue to offer support and counselling to relatives after the death of a loved
one, which can be individual or group sessions, provided at the hospice or in families own homes. We also
provide a specialist bereavement service for children.
Bereavement Services key achievements
 5 bereavement visitors for adults and 2 volunteers for children were trained in September 2014.
 There is a drop in coffee morning held monthly which has been extremely successful and is
continuing to grow, the group offers a safe place to meet other people who are also grieving.
The coffee morning is led by the bereavement visitors.
 The Bereavement Coordinator has assessed and benchmarked the bereavement service against
the new bereavement service standards.
 Scoping work in terms of children’s bereavement services has been completed and a proposal
has been developed to expand the children’s bereavement service.
3.4
Quality Indicators
Quality is central to everything that we do. In addition to national quality indicators we have chosen to
measure our performance against the following:
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Compton Hospice Registered Charity: 512387
 What our patients and families say about us
 How we monitor and use safety information to make improvements – falls, meds errors, pressure
ulcers, infections, safety alerts, safeguarding
 How we make sure that our staff are skilled and competent to work in the hospice
 How we review our systems and processes and make changes to the way we work
 How we prevent and control infection
Complaints and Concerns
During the year our complaints procedure has been reviewed and updated.
Sometimes we hear feedback that helps us to learn and improve the way we work.
In 2014/15 we received four complaints, one was not related to our clinical services, however related to
our Compton Hospice Promotions Service, the complaint was responded to and the issue was resolved.
Three complaints related to Compton Hospice Clinical Services, these were fully investigated, although this
is only a small number of complaints they generally indicated a perceived lack of communication, further
training has been targeted where necessary to prevent reoccurrence.
All complaints were responded to and resolved within 20 working days.
Compliments
We receive compliments in various ways, sometimes by letter or card, other times by talking to patients or
families. Compliments help reinforce positive messages to our population and staff about the work that we
do.
A snap shot of compliments received are provided in the comments section below.
Safety Information
We encourage an open and transparent culture where reporting of accidents and incidents provides us
with an opportunity to identify where we can make improvements.
Whilst extremely small in numbers our top 3 incidents reported relate to:

Patients falling

Patients developing a pressure ulcers
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Compton Hospice Registered Charity: 512387

Medication Incidents
There were no incidents which resulted in serious harm, most incidents result in no harm, and one fall
resulted in moderate harm; however we take the opportunity to review care provided to ensure that we
continually learn from incidents and use the information to improve our services.
We recognised that preventing patients falling was a high priority and we have included this as our priority
for 2015/16.
Education and Training
Compton Hospice has an established education centre that provides training for staff that directly relates
to patient care.
Local Audits
We have undertaken various audits and surveys during 2014/15; we have an audit group which:
 Monitors progress against our annual audit plan
 Reviews the outcome of completed audits
 Oversees the implementation of actions
Outcomes from completed audits are shared with staff through the audit presentation meeting, multidisciplinary reviews and team meetings.
Infection Prevention and Control
The Infection Prevention Nurse oversees the hospices work program in relation to infection prevention and
control; this includes a program of audits such as environmental audit, sharps audit and handwashing
audit, the infection prevention nurse also acts as a port for advice and support for clinical staff.
We want to strengthen our work program and arrangements relating to infection prevention and control in
the coming year, this is one of our safety quality improvement indicators for 2015/16.
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Compton Hospice Registered Charity: 512387
3.6
What people say about our service?
What patients and their families say about our service?
In-patient Unit
“To all the lovely people at Compton Hospice who made our mothers last few months as comfortable as
possible and provided us with support, we want to thank you so much.”
“I don’t have sufficient words to express my gratitude for all the care you gave my husband. Doctors, nurses
and volunteers – you are a special family.”
Hospice at Home Services
“Words can’t describe how overwhelmed we are with the outstanding service; all members of the team
have provided. Very caring, compassionate and treated my mother as their own.”
“I felt reassured going to bed knowing my husband was having professional care throughout the night.”
Lymphoedema Clinic
“My thanks go to the nurses at Compton Cedars for their constant monitoring of my Lymphoedema.”
“I have found the service amazing. The Nursing staff are a credit to the service. Always pleasant and
cheerful, able to sit and have a chat with a cup of tea if required. Lots of useful advice for continuing
treatments and personal to individual patient.”
The building itself since its refurbishment is a very serene and relaxed area, always clean. Ladies in
reception always recognise patients on sight, making it a very personal appointment.”
What our Staff say about our Service
“I have been privileged to work at Compton Hospice alongside dedicated and caring staff. I am proud to
have been associated with the modern hospice movement and this hospice in particular and to be able to
boast and speak with great pride of the amazing work which we do. I am constantly humbled to be witness
to the special care given lovingly and freely, to our patients and their families.”
What our Volunteers say about our Service
“I just love it!”
What our Trustees say
“The Board of Trustees of Compton Hospice is fully committed to prioritising the quality of patient and
family care and continued development of services developing services in line with the needs of our patients
and their families and friends and our updated strategy.
“To this extent we have invested in our nursing and medical workforce to expand our community services,
which recognises our aim to deliver palliative care to patients in need in the most appropriate location. We
appreciate that people will not always want to be cared for in our In-Patient Unit; this investment affords
people choices about where they wish to be cared for.
“We are pleased to introduce our new quality improvement plans for 2015/16 in this quality account which
support our persistent drive to improve the quality of services.
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Compton Hospice Registered Charity: 512387
“The Board is confident that the care and treatment provided by Compton Hospice is of a high quality, is
cost effective, and can be sustained in the foreseeable future, and they fully endorse this Quality Account.”
C J Harris
Chairman – Compton Hospice Board of Trustees
What our Comissioners say about our Service
Quality Account 2014/15 – Commissioner Statement
Thank you for sharing the Quality Accounts with the CCG for 2014/15, we
as a commissioner value receipt of these and the opportunity to comment
and congratulate you on the progress you have made and your vision for
2015/16 that seeks to improve services for patients.
The achievements outlined in the quality accounts for services particularly Physiotherapy, Hospice at Home
Team, Day Hospice, Lymphoedema Clinic and Bereavement Service confirm many successes.
The on-going commitment of Compton Hospice to provide quality palliative and end of life care is testimony
to the achievements we recognise from 2014/15 including:•
Quality improvements in out-patient facilities including an orangery extension to the ward area
along with a lift and relocation of the doctor’s office. These changes have enabled patients and their visitors
have access to the grounds and gardens.
•
Improvements to the admission, length of stay and discharge process in the in-patient unit through
improved processes and documentation that is now electronic.
•
Implementation of the Electronic Patient Administration System has enabled access to accurate
information, access to each patient’s care & treatment and the ability to exchange information efficiently
between services.
•
Services have been developed and aligned with the in-patient unit through utilising a staffing
establishment tool, increased staffing on the in-patient unit and use of a crib sheet that is also being used in
other hospices.
We recognise that the CCG are one of a number of stakeholders working with Compton Hospice, CQC have
not visited in year nor have they taken any enforcement action. Delivery of very high quality care is a
priority for the Board who seek assurance that this is consistently achieved. The CCG maintain regular
contact and meet periodically to ensure those standards are being maintained. We were impressed with
the Hospice at Home Service reviewed during February 2015, this confirmed the level of rigour that is given
to ensuring high quality care is provided to patients in the community.
In 2015/16 the priorities for quality improvement are to maximise capacity and extend reach across the
seven day week, development expertise in health and social care workforce and maximise effectiveness of
the limited resources available.
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Compton Hospice Registered Charity: 512387
Quality initiatives will include reducing the risk of patients falling, infection prevention and control,
undertake a review of mandatory training for all staff, engage and seek views from our patients and carers
and to change emphasis from religious to spiritual care. The CCG are confident in the hospice’s ability to
sustain the standards already being achieved and to embrace the challenges that their priorities for
2015/16 will bring.
The CCG developed an End of Life Care Strategy in August 2014, with its partner organisations including
Royal Wolverhampton Trust and Compton Hospice. We are now looking to refresh this strategy to reflect
the national guidance Ambitions for Palliative and End of Life Care: A national framework for local action
2015-2020 which has been developed by the National Palliative and End of Life Care Partnership. This
framework has at its heart 6 ambitions for developing End of Life Care. These are:
1
Each person is seen as an individual
2
Each person gets fair access to care
3
Maximising comfort and wellbeing
4
Care is coordinated
5
All staff are prepared to care
6
Each community is prepared to help
We will work together to ensure that locally the 6 ambitions for developing end of life care are fundamental
to our commissioning and desire to secure the highest quality of care for our patients.
Yours sincerely
Dr Helen Hibbs
Chief Officer
Wolverhampton Clinical Commissioning Group
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Compton Hospice Registered Charity: 512387