Sections
Part 1: Introduction by Chief Executive - Alison Stevens
Board of Trustees Commitment to Quality
Part 2: Priorities for Improvement & Statements of Assurance From the Board (in regulations)
Future priorities for improvement - 2015 – 2016
Priorities for improvement from 2014 – 2015
Mandatory Statements of Assurance from the Board
The Francis Report & Farleigh Hospice
Part 3: Review of quality performance
Farleigh Hospice Quality Performance Information 2014 -2015
Quality Markers we have chosen to measure
Other quality initiatives
What people say about our organisation
Statement from mid Essex Clinical Commissioning Group
Statement from Healthwatch Essex
Appendix A – Audits completed April 2014 – March 2015
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Farleigh Hospice Quality Account 2014-2015 1
Welcome to our fourth Quality Account. This report is for our patients, their families and friends, our supporters, the general public and mid
Essex Clinical Commissioning Group, who part fund our services. The aim of this report is to give clear information about the quality of our services so that patients feel safe and well cared for and their carers and families are supported and reassured that all of our services are of a very high standard and well governed at all levels throughout the organisation.
We have commenced a process to review the structure of governance in Farleigh Hospice and have identified this as one of our key priorities for the coming year. We are keen to ensure that the many ways that we have in place to achieve all of the required standards of care and service delivery are connected and that we are clear and transparent in our actions to continually learn from our mistakes and improve services.
We are developing a Learning and Development Strategy for our staff and the implementation of this is a key priority, as we believe that through ongoing training of our staff and volunteers we will be able to achieve high standards of care and support.
We undertake satisfaction surveys, policy reviews and have a comprehensive audit programme to ensure high quality care. We have recruited and trained 12 Care Quality Commission champions from across the organisation to carry out observational visits to review all aspects of our work, talking to staff, volunteers and users of our service to ensure we maintain the NHS fundamental standards of care.
I wish to thank all of our staff and volunteers for their ongoing hard work and commitment to Farleigh
Hospice and to our local community and NHS funders for their continuing support.
This Quality Account follows the model requirement set out in the regulations by the Department of
Health. To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality of healthcare provided by Farleigh Hospice.
Alison Stevens RN, DipHSM, MA
Chief Executive
For any queries, comments or any further information please email us at: comments@farleighhospice.org
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2 Farleigh Hospice Quality Account 2014-2015
The trustees are required under the Health Act 2009 to prepare a Quality Account for each financial year as Farleigh Hospice is part funded by the NHS. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act
2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National
Health Service (Quality Accounts) Amendment Regulations 2011).
In preparing the Quality Account, the trustees are required to take steps to satisfy themselves that:
The Quality Accounts presents a balanced picture of the hospice’s performance over the period covered;
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 trustees confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account.
Signature - Keith Andrew, Chairman of the Board of Trustees
Date
Signature - Alison Stevens, Chief Executive
Date www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 3
Farleigh Hospice Strategic Plan - ’Your Hospice and the Next Four Years - 2014- 2018’ outlines our vision moving forward which is of a community in which anyone affected by life limiting illness or bereavement has access to skilled compassionate care and support at the right time for them and in a place of their choice. There is still much to do to maintain existing services and to improve them so that they are flexible enough to respond to people’s changing needs.
This quality account mainly considers quality issues within the provision of clinical care and relevant support services necessary to provide this care. It does not fully take into account the fundraising and administrative functions of the organisation.
The Board of Trustees is committed to the delivery of high quality care which is safe, effective and meets the needs of people who use our services and to support the continuous development and improvement of these services.
These priorities have been developed through consultation with people who use our services including patients, carers, staff and volunteers.
The priorities we have selected will impact directly on each of the three domains of quality:-
● ● Patient safety
● ● Clinical effectiveness
● ● Patient experience.
Looking forward Farleigh Hospice confirms that the top five quality improvement priorities for
2015- 2016 to be:-
The introduction and development of a new Farleigh Hospice Welcome Service, which will provide a flexible team of trained volunteers to welcome, guide, signpost and support all visitors to Farleigh Hospice and other Information Service locations www.farleighhospice.org info@farleighhospice.org 3

4 Farleigh Hospice Quality Account 2014-2015
Why was this priority identified?
In 2009 the Lantern Suite was opened as part of the development of the Information Service. It also included counselling and treatment rooms. Recently the function of the Lantern Suite has changed with the increase in the Therapy & Wellbeing, Psychosocial and the Bereavement Support Services Teams.
This has resulted in an increased number of people using the facilities in the evenings, at weekends as well as during the day. It was also recognised that as more people come to the hospice there is a need to not only acknowledge them when they arrive but also to ensure they get to their destination by giving one to one support where we can. This cannot currently be provided by the reception team. The aim will be to develop a team of volunteers whose role will be to welcome, guide and support all visitors and to separate out administration tasks associated with the reception function.
How will this be achieved?
A Welcome Team Project Coordinator will be appointed who will be involved in developing a Volunteer
Role profile and be responsible for the recruitment, induction, training and organising of over 40 Welcome
Volunteers for the service.
The Hotel Services Manager, who is currently responsible for the reception team will carry out a full review of the current duties of the reception team.
The Hotel Services Manager and the Welcome Team Project Coordinator will agree which roles will remain with the Welcome Team and which will be allocated elsewhere.
How will this be monitored?
The Welcome Team will be part of the Information Service and will provide regular feedback to the
Independent Living Team manager. It is planned to start the implementation of the new service in May
2015 with the Welcome Team Project Coordinator providing a project review update after six months for the Senior Management Team. This will include reporting on a thorough risk assessment with associated action plans to ensure the Welcome Service is safe, effective and fit for purpose.
To develop and implement a 3 year Learning & Development Strategy for Farleigh
Hospice to ensure quality services are delivered by staff and volunteers who are supported to develop appropriate skills, knowledge and competencies
Why was this priority identified?
In previous years the hospice developed an annual Learning & Development plan with action plans to be worked on over the year. Following the Francis Report recommendations and the introduction of a variety of learning and development opportunities especially for unqualified staff e.g. Care Certificate,
Qualification & Credit Framework (QCF), apprenticeships, it was felt there was a need to take a more long term strategic approach. The strategy, working alongside the Training Matrix already developed should provide a good basis for all staff and volunteers learning & development needs
How will this be achieved? www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 5
Establish a Task & Finish group to write the Learning & Development Strategy drawing members from across the hospice.
Review current relevant legislation and best practice relevant to the organisation to reference and include in the strategy
Develop a draft Learning and Development Strategy including overarching strategic objectives which will form the basis to develop an annual work plan. The draft strategy will be discussed and ratified at all
Governance Committees.
How will this be monitored?
The Education and Training Group will develop the annual work plan and be responsible for its implementation. They will provide a progress report to the quarterly Corporate Governance Committee meetings.
To develop and introduce a new Staff Induction and Training Manual for clinical staff to support them in their roles.
Why was this priority identified?
Clinical staff are appointed throughout the year but as, overall, the staff group is quite small, Mandatory
Training is usually only provided twice a year. As this training is an essential part of induction new staff cannot wait for long periods before they receive this training. To overcome this issue and ensure we have safe, competent and effective staff it is proposed to develop a training manual which covers the basic information new staff will require in relation to the mandatory training required for their role.
Currently a manager’s induction checklist exists and many departments also have a local induction. The induction element of the Clinical Staff Induction and Training Manual will be further developed to be up to date and collate the items that all clinical staff need to be aware of, with departments then developing local induction that meets all requirements without duplication.
How will this be achieved?
The training manual will be based on the mandatory training requirements for individual roles and involve the new staff members reading relevant documents answering questionnaires and arranging to meet relevant key staff. As each stage is completed this will be signed off by a senior member of staff.
How will this be monitored?
Completion of each section of the induction manual will be recorded in the staff members training record.
The training records will be reviewed to ensure that all new staff have completed their mandatory training required for their role. As part of the NHS Contract Local Quality Requirements we are asked to report on staff trained and in date on a quarterly basis.
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6 Farleigh Hospice Quality Account 2014-2015
To establish a working group to develop and deliver projects using ‘LEAN’ techniques to support environmentally friendly practices across the hospice.
Why was this priority identified?
As part of the NHS Contract we are required to evidence environmentally friendly practices especially carbon reduction. A group of staff are interested to take these ideas forward and make use of ‘LEAN’ techniques to review current processes in relation to waste management and energy efficiency.
How will this be achieved?
A working group will be set up, led by a ‘LEAN’ Adviser, to develop a work plan with projected cost savings initially on the Chelmsford site but with the expectation of spreading to other Farleigh Hospice sites.
How will this be monitored?.
The working group will meet regularly with information being fed back to Heads of Department meetings and monthly ‘LEAN’ Team reports.
To review and strengthen the Farleigh Hospice governance framework, including operational groups, to be able to evidence ‘good’ governance in all areas of the hospice.
Why was this priority identified?
The Board felt that the current Governance group and structure needed to have a more robust framework with clear levels of accountability and responsibility identified to ensure good governance for the organisation. This is essential for Board assurance of good practice and as evidence for the NHS
Contract and the Charity Commission.
How will this be achieved?
The current structure will be reviewed and proposals developed to strengthen the Governance framework including the relationships with work groups and identify any gaps in the framework. The proposal will be reviewed by the Senior Management Team and the Board of Trustees who will agree the final framework.
A chart depicting communications and relationships across the framework will be agreed.
How will this be monitored?
The development of the new framework will be noted in minutes of meetings where the structure is scussed and the development of the new chart shared across the organisation. A reporting schedule will www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 7 be agreed with an annual Governance Report to the Board of the work of the Governance Framework.
The Farleigh Hospice Board of Trustees will monitor and report on progress through a variety of methods including:-
● ● Annual General Meeting of the Company
● ● Annual Review and Audited Report and Accounts
● ● Events such as Open Days, Volunteers Days
● ● Farleigh Hospice Lantern, Farleigh Focus and other periodic communications
● ● Quality Accounts and Annual Governance reports
● ● Quality and Audit Activity reports and Patient Surveys
● ● Updates posted on the Farleigh Intranet and Farleigh Web site
● ● Trustee Provider visits
The aim of the Quality Account is to not only look forward by setting future priorities for improvements but to also look back and evidence achievements on priorities for improvement from the previous year.
In last year’s report we set out four priorities for improvements for our services. All the areas identified were specifically selected as they would impact directly on the care our patients and carers received, either through improving patient safety, clinical effectiveness or the patient’s experience.
To widen access to our services through a review of our referral criteria and processes to be able to reach out to those who may have issues and concerns at an early stage in their illness.
● ● Following the consultation process and development of the new Farleigh Hospice Strategy ‘Your
Hospice and the Next Four Years 2014 - 2018’ one of the objectives in the strategy was ‘To widen access to Farleigh Hospice services’.
● ● Farleigh Hospice has endeavoured to widen access to its services to reach out to those affected by life limiting illnesses. The aim was to look at how we make sure that everyone who could benefit from our services can do so by thinking creatively about how we work, whilst retaining the excellent services we currently provide. To help facilitate this several initiatives were developed over the review period.
● Review of the referral criteria - A steering group was set up to review the referral criteria and process by which people access services. This was achieved with the policy and criteria www.farleighhospice.org info@farleighhospice.org 7

8 Farleigh Hospice Quality Account 2014-2015 updated prior to the pilot of the Coordination Project starting in January 2015. This has made referral and self referral much easier. The future aim is to have secure online referral to all services.
● Piloting a Coordination project - The aim of this project was to coordinate end of life care to provide advice and support to those affected by progressive, life limiting conditions to enable them to be cared for in the setting of their choice This was achieved by offering an advice line for anyone to call which offers support, advice and access to urgent care should it be needed.
The Coordination Project Is already demonstrating success and it is hoped that when the pilot is complete the service will become an integral part of Farleigh Hospice Services
● Further Development of the Information Service – The introduction of the Pop up Pod (PUP) which is a small display unit which is easy to transport and erect. It offers more opportunities and ways for people in the community to get direct access to information and advice on issues and or concerns relating to life limiting illnesses. This has enabled the Information Service to reach venues that are too small or not accessible to the Hospice Outreach Project vehicle, including music festivals, increasing the number who accessed the service in the review period.
● Development of the Palliative Rehabilitation Model – The opening of the Rehabilitation space at Farleigh in Chelmsford has offered more opportunities for people to access exercise programmes tailored to their needs. An increase in the number of groups available to patients, carers and the bereaved through more flexible use of the facilities at both Farleigh in
Chelmsford and Maldon has further increased the number of people accessing Farleigh Hospice services. (see Priority 4 Development of a Rehabilitation Model )
● ● Widening access can be evidenced in the total number of people i.e. patients, carers and bereaved, cared for by Farleigh Hospice in the last year which was 3,105, an increase on the previous year of
11.6%. The increase in people cared for is primarily carers and the bereaved. The expansion of the
Information Service and its availability and accessibility has increased the number of people cared for by the hospice. Although currently the Information Service contacts have not been included in the total number of people cared for by the hospice, as detailed above, had they been included this would have added an additional 5,447 people giving a total of 8,552 and last year the total being 7,742.
To develop a consistent and clear message about our current and future services by reviewing our mission, vision and core values and how we communicate with service users and other stakeholders.
● ● Following the consultation process and development of the new Farleigh Hospice Strategy ‘Your
Hospice and the Next Four Years 2014 - 2018’ one of the objectives in the strategy was:-
‘To be clear about our message’.
● ● It was decided to help achieve this objective we should go back to basics. A review of our literature www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 9 showed we had several documents – the Promise, Aims & Objectives, Philosophy and Mission. It was felt there were too many documents duplicating the same information so it was decided to ‘LEAN’ the process..
● ● The Heads of Departments took part in 2 workshops looking at creating a clearer message sharing thoughts and ideas from their teams. As part of this it was agreed to review and strengthen the Farleigh
Hospice Mission and develop a Vision and Core Values statements to provide a consistent and clear message about who we are and what we do.
● ● The Heads of Departments updated the current Mission statement, developed a new Vision Statement and created a draft list of words which described Our Core Values
● ● Key to this was agreeing the core values for the hospice which would be shared and owned by all staff and volunteers. Following a wider organisational consultation process the final Core Values were agreed and along with the Mission and Vision statements agreed by the Senior Management Team and the Board of Trustees. The discussions also included agreeing how to promote the agreed Vision,
Mission and Core Values with all stakeholders.
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Farleigh Hospice Quality Account 2014-2015
● ● The three documents are now widely available to staff and volunteers internally and externally on the website and are being incorporated into several documents such as the Annual Review and form part of all staff and volunteers induction.
The introduction and rollout of ‘‘SystmOne’’ which will be our new electronic patient record system to improve communication and information sharing between the hospice and NHS services e.g. District Nurses, GPs and hospitals.
How was this priority identified?
● ● During 2013 – 14 Farleigh Hospice achieved connection to the ‘N3’ NHS broadband and the
Information Technology and Clinical Teams carried out the preparatory work for the introduction of a new electronic care records management system called ‘‘SystmOne’’ replacing iCare and paper patient records, and also providing a range of additional benefits for service users and staff at Farleigh
Hospice. The new system is designed to make the work of clinical staff much more effective, with patient notes being stored electronically in one place for all the healthcare professionals caring for that patient to access. It is also designed to improve the sharing of information and enhance the quality and consistency of patient records. The aim being a more joined up approach to providing care across health and social care organisations with GPs, NHS teams and associated healthcare organisations www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 11 all working securely with a single set of patient records. “‘SystmOne’ is also linked to the NHS ‘national spine’- meaning any administrative patient details, such as changes of address, are immediately highlighted for correction, and the system is specially designed to protect the confidentiality of clinical information.
● ● Prior to the ‘going live’ with “SystmOne”’ in April 2014 a programme of staff training was undertaken to ensure clinical and administrative staff understood the new system and were able to access and use the new electronic patient record. As part of the development plan, ‘Champions ‘ and ‘Super Users’ were identified who have been able to support staff using the system as well as new staff joining the teams.
● ● A ‘User forum’ was established to review, problem solve and customise the system to meet identified needs. This group has met regularly and fed back to the Heads of Departments and the Senior
Management Team.
● ● A “SystmOne” notes audit was carried out by the Clinical Heads of Departments which highlighted that some staff were recording information in other parts of the patient record and not in the Holistic
Template. A full action plan was developed and has been followed up by the Clinical Heads. It is planned to repeat the audit in September 2015.
● ● A ‘Template Review Forum’ was established to look at forms used in the system and this has streamlined the main assessment and recording tool – the Holistic Template– to reduce duplication of information and clarify where it can be found in the system
● ● A dedicated Helpdesk was also created to help resolve technical issues.
● ● The Clinical Information Co-ordinator has been able to use data from “SystmOne” to create the annual
Statistical report about the services Farleigh Hospice has provided in the reporting year. ( see Part 3
Review of Quality Performance )
● ● The development of the new system has enabled ongoing monitoring of the patient, carer and bereavement services provided by Farleigh Hospice and is aiding future planning to meet local needs.
To further develop the Independent Living Team using a rehabilitation model. This will include the opening of a new Rehabilitation space at North Court Road in Chelmsford and also patient and carers workshops in both Chelmsford and Maldon.
● ● The UK’s population is growing and this is partly due to improved medical management of illnesses.
With treatment advances, comes improved survivorship and, as a result, people are now living with symptoms, side effects and disabilities that are a lasting legacy of their survival. This means a different approach is needed to support people who are living with a life limiting illness which affects every aspect of a person’s life, as well as those around them
● ● National guidelines recommend that rehabilitation should be an intrinsic part of palliative care and that patients should receive an active and planned approach to rehabilitation that involves assessment, www.farleighhospice.org info@farleighhospice.org 11

12 Farleigh Hospice Quality Account 2014-2015 goal setting, care planning and evaluation.
● ● Farleigh Hospice’s Independent Living Team (ILT) focus is rehabilitation, enablement and wellbeing, which is delivered by professionals including Complementary Therapists, Physiotherapists,
Occupational Therapists and Therapy Assistants. Thanks to a grant from the Department of Health, the Independent Living Team was able to start offering a brand new opportunity to empower patients and enable them to actively participate in their own management. This was made possible through a new gym area which has been developed at the North Court Road site in Chelmsford. This new rehabilitation space has provided more opportunities for regular physical exercise, education, and other activities to improve physical and mental wellbeing.
● ● The space accommodates a range of equipment including a Wii, treadmill, steps, exercise bikes, weights and gym balls, which patients use under the care and guidance of the ILT team. The aim of the space is to help patients, at all stages of their illness, to improve functionality and ultimately maintain their independence. Through positive psychological support and improved function, patients’ quality of life can be improved and dispel the myth that the Hospice is only for care at the end of life. Patients are able to be referred by Farleigh Hospice clinical staff for Palliative Rehabilitation
‘I come away from my sessions feeling tired, but in a positive and rewarding way.’
‘Life is for living and that is exactly what I am doing!’
● ● The reopening of Farleigh in Maldon and Day Care moving to be part of the Independent Living
Team offered the opportunity to review groups and other rehabilitation activities offered. Two group review meetings were held involving ILT staff and others interested in being involved in developing this new approach. This was the beginning of an ongoing process to look at how Farleigh Hospice organizes groups and day services. A rolling programme of events for patients and carers has now been developed to offer a variety of opportunities in the Chelmsford and Maldon facilities as well as the community.
● ● The manager of the ILT service has used her experience and research to support the development of Palliative Rehabilitation and is planning on presenting a poster about her work at The European
Association of Palliative Care conference, in Copenhagen in May 2015
● ● The referral criteria for the inpatient unit has also been reviewed and now includes admission for rehabilitation which is complimented by the development of the Garden Room which is a self contained room supporting different levels of independence.
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Farleigh Hospice Quality Account 2014-2015 13
The following are statements that all providers must include in their Quality Account. Many of these statements are not directly applicable to specialist palliative care providers and therefore explanations of what these statements mean are also given.
During 2014 - 2015 Farleigh Hospice provided the following specialist palliative care services:-
● ● In-Patient Unit – 10 beds
● ● Day Hospice – at Chelmsford & Maldon – 90 places per week.
● ● Clinical Outpatients
● ● Contact Team – Advice line and urgent response service (pilot from January 2015)
● ● Community services – including Hospice @ Home, Farleigh Clinical Nurse Specialists, physiotherapists, occupational therapists, social workers
● ● Counselling
● ● Carer Support
● ● Well Being Services – creative therapies, chiropody, hairdressing, complementary therapies
● ● Information and ‘drop in’ services at the Lantern Suite in Chelmsford, on the HOP (Hospice Outreach
Project) vehicle and Pop Up Pod in the community and the Information ‘Pod’ at Broomfield Hospital run in partnership with Broomfield Hospital and Macmillan Cancer Support
● ● Chaplaincy
● ● Bereavement support for children, young people and adults
● ● Education and Training
Farleigh Hospice is an independent charity which provides all services free of charge.
The income generated from the NHS in 2014 - 2015 represented 45% of the overall costs of service delivery with the remaining income to fund our services coming from voluntary charitable donations, legacies, events, corporate and community fundraising, hospice shops and lottery.
Although 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.
● ● During 2014 – 2015 as no National Clinical Audits (NCAs) or Clinical Outcome Review Programmes
(CORPs) (previously Confidential Enquiries) covered NHS services provided by Farleigh Hospice,. it was not eligible to participate in any of these activities and therefore there is no information to submit.
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14 Farleigh Hospice Quality Account 2014-2015
As a provider of specialist palliative care Farleigh Hospice was not eligible to participate in any of the National Clinical Audits (NCAs) or Clinical Outcome Review Programmes
(CORPs) (previously Confidential Enquiries). This is because none of the 2014 - 2015 audits or reviews related to specialist palliative care. The hospice will also not be eligible to take part in any National Clinical Audit (NCAs) in 2015 – 2016 for the same reasons.
To ensure a high quality of services an annual audit programme has been established and a variety of quality and audit activities were undertaken using nationally agreed formats often specifically developed for hospice care as well as locally developed audit tools. For all these audits undertaken, where necessary, local action plans for improvements were developed, and in general they will be re-audited within the next 12 months to check for compliance and where relevant improvements. This has enabled us to monitor the quality of services and make improvements where needed. The reports of 78 local audits were reviewed by the Farleigh Hospice Governance Committees of which 70 related to clinical care and relevant support services necessary to provide this care and evidence compliance.
Details of audits completed in 2014 – 2015, to improve the quality of services, can be seen in Appendix A.
The number of patients receiving NHS services provided by Farleigh Hospice in 2014-15 that were recruited during that period to participate in research approved by a research ethics committee was
NONE. There were no appropriate national, ethically approved research studies in palliative care in which we could participate during this period.
No Commissioning for Quality and Innovation (CQUIN) sums formed part of the NHS contract for 2014 –
2015.
Farleigh Hospice in Chelmsford and Farleigh Hospice in Maldon are required to register with the Care
Quality Commission and in the reporting year were registered to provide the following regulated activity:-
● ● Personal care
● ● Treatment of disease, disorder or injury
Farleigh Hospice is subject to periodic reviews by the Care Quality Commission and the last on-site inspection was in July 2013 at Farleigh Hospice in Chelmsford. Farleigh Hospice in Maldon was not subject to a review as the facility was closed as a result of flooding from August 2013 reopening in April
2014. Farleigh Hospice was fully compliant with all the Essential Standards of Quality and Safety as set out in Care Quality Commission (Registration) Regulations 2009 and the Health & Social Care Act 2008
(Regulated Activities) Regulations 2010. The CQC has not taken any enforcement action during 2014 –
2015. Farleigh Hospice has not participated in any special reviews or investigations by the CQC in this period.
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Farleigh Hospice Quality Account 2014-2015 15
Farleigh Hospice did not submit records during 2014-15 to the Secondary Users service for inclusion in the Hospital Episode Statistics which are included in the latest published data.
This is because Farleigh Hospice is not eligible to participate in this scheme. In the absence of this we have our own system in place to collect and monitor data through the electronic patient records SystmOne (see Priorities for Improvement 3, 2014 – 2015) specialist palliative care activity.
Farleigh Hospice submitted its Information Governance Toolkit assessment version 12 in March 2014 to Mid Essex Clinical Commissioning Group and the Health & Social Care Information Centre (HSCIC).
The outcome from both organisations was satisfactory for this year’s IG Toolkit and we again passed the required standard. Overall, the Farleigh Hospice IGT score for 2014-15 was graded at 67% (Satisfactory), achieving a Satisfactory grade across all the assessed IGT sections and rated at Level Two for 27 out of the 29 requirement groups, Level Three for one of the requirement groups and the remaining requirement group was identified as Not Relevant. This current assessment covered a larger number of compliance criteria in each group, as well as covering new areas such as smartcards/RA activities.
The final phase of the IGT assessment is the independent audit by the HSCIC Team; to validate the responses submitted and the associated supporting evidence. The outcome of this final assessment was that the Farleigh Hospice submission was approved by the HSCIC without any further information or
Improvement Plans being needed.
‘N3’ (fast broadband networking service within the NHS) computer connection improves access to diagnostic test results carried out by the NHS. Results will be more easily accessible for medical staff, leading to quicker decisions regarding treatment of patients.
This is also a requirement for connection and use of ‘SystmOne’ the electronic patient record system which went live on 1st April 2014.
Farleigh Hospice was not subject to the Payment by Results clinical coding audit during 2014– 2015 by the Audit Commission.
There is currently no payment tariff for specialist palliative care services.
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16 Farleigh Hospice Quality Account 2014-2015
The Francis Report (2013) made 290 recommendations of which 102 were relevant to Farleigh Hospice.
For the 102 recommendations that apply to Farleigh Hospice a detailed report and action plan was written and presented to the Board of Trustees in February 2014 to demonstrate full compliance or areas for further improvement. The action plan has now been completed and has been signed off.
If you would like a copy of the completed action plan please email us at : comments@farleighhospice.org
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Farleigh Hospice Quality Account 2014-2015 17
Detailed below is data about services provided by Farleigh Hospice relating to the review period April
2014 to March 2015.
The total number of people i.e. patients, carers and bereaved, cared for by Farleigh Hospice in the last year was 3105 an increase on the previous year of 11.6%. The increase in people cared for is primarily carers and the bereaved.
The expansion of the Information Service and its availability and accessibility has increased the number of people cared for by the hospice. Although currently the Information Service contacts have not been included in the total number of people cared for by the hospice, as shown in the chart above, had they been included this would have added an additional 5,447 people giving a total of 8,552. Last year the total was 7,742.
The number of patient referrals and new patients to the hospice was 1,397 slightly higher than last year.
Hospital referrals continue to be the highest source of referrals. Overall the total number of patients cared for by the hospice was 1,746 an increase on the previous year
Farleigh Hospice has always provided end of life care for cancer and non cancer patients and over the last few years there has been a slight increase in the number of non cancer patients accessing hospice services – in the review period 13.7% of referrals had a non cancer diagnosis.
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18 Farleigh Hospice Quality Account 2014-2015
74% of all patients achieved their PPC, 7% of patients did not achieve their PPC and 19% did not have a recorded PPC.
The workload in the Inpatient Unit (IPU) has been variable over the year with the total admissions being
296 which are lower than the previous year which was 320. Of these 244 were ‘first’ admissions to the inpatient unit.
There were 21 unavailable bed days on the IPU due to redecoration and dependency.
Bed occupancy was 76.7% higher than the previous year of 68.7%. There is rarely a waiting list for admissions.
31.8% of admissions to the IPU were from hospital, an increase from the previous year of 18.7%
The average length of stay was 8.2 days showing an increase from last year of 7.8 days.
IPU admissions were 9.5% of the hospice workload. This is less than last year and reflects the greater use of the community services including Hospice @ Home.
The newly formed Contact Team consist of Community Nurse Specialists, a consultant and administrators who offer an advice line and an urgent response service. There has been a significant increase in the number of call received since the pilot service launched.
The Farleigh Hospice Community Specialist Nursing Team continued to face high workloads. The nursing team carried out 3,006 visits which was less than the previous year, 3,376 but this was due in part to staff taking time out to undertake the Nurse Prescribing training
The Hospice at Home team provided 6680 care hours in patients homes to 381 patients. The team now has 2 registered nurses working alongside the Healthcare assistants. The trend for the amount of time spent on each visit is increasing reflecting the increasing needs of some patients. www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 19
The Day Hospices in Chelmsford and Maldon saw a total of 396 patients of which 175 were new to Day
Hospice. This totalled 3300 attendances over the year.
The work of the Allied Health Professionals Team has increased with an increase in group work e.g. arts, crafts, creative writing, outdoor group, providing patients and carers with choice and access to activities.
This has resulted in a significant increase in the number of people accessing groups.
A Welfare Benefits Adviser role has offered additional, much needed support to patients and carers.
The information service saw 5,447 people at various venues across mid Essex an increase in the number of people to whom we were able to provide advice and support. The Information ‘Pod’ in the atrium at
Broomfield Hospital, Chelmsford saw 2867. The Lantern Suite team, in Chelmsford, had 1,170 people visit over the year and the Hospice Outreach Project (HOP) vehicle visited a variety of locations across mid Essex staff met with 932. The introduction of the Pop up Pod (PUP) has increased the opportunities to provide advice and support in smaller venues. www.farleighhospice.org info@farleighhospice.org 19

20 Farleigh Hospice Quality Account 2014-2015
The mid Essex adult bereavement service – ‘Circle’, was not only available to provide support for the bereaved families and carers of hospice patients but also to other bereaved adults in mid Essex who were appropriate for the service. The service provided one to one support sessions, Bereavement Counselling sessions, groups as well as telephone support.
The Yo-Yo Project which is a pre and post bereavement service for children and young people provided individual, group and telephone support over the year with a high proportion of sessions being delivered in the community, not in the hospice, to meet family choice.
Sessional counsellors have been used to support counsellors, student counsellors and volunteers to help meet the increased demand in both adult and children’s services.
In 2014 – 2015 Farleigh Hospice was required to report to Mid Essex Clinical Commissioning group on the quality of its services via the NHS Standard Contract. The hospice reported quarterly evidencing compliance against National and Locally Defined Quality Measures.
Quality is at the heart of everything we do. In addition to the data about services provided by Farleigh
Hospice relating to the review period we have chosen to measure our performance against the following:-
● ● Complaints, Concerns & Compliments
● ● Safety Information
● ● Infections & Pressure Ulcers
● ● Local Audits
● ● Other Quality Initiatives - Connecting with our Community
● ● What others say – Connecting with our Community
The management of complaints is in line with the Farleigh Hospice Policy 1.11 Complaints – Statement and Procedure. 21 complaints were received between April 2014 and March 2015 and of those 12 related to clinical care. The other complaints received related the shops and fundraising activities. www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 21
Last year also included the logging of ‘Concerns’ which were dealt with in an informal manner. 12 concerns were also raised and of these 5 related to clinical care.
All complaints are categorised, following completion of an investigation, as green, amber or red based on the seriousness and likelihood of the issue to recur. The outcome of the complaint is agreed – Not
Upheld, Partially Upheld, Upheld and the theme of the complaint e.g. – clinical care, communication, attitudes, fundraising issues are also recorded to monitor trends.
Total number of complaints related to patient/family care 12
Total number of these which were upheld 5
Total number of these which were partially upheld
Main theme from complaints
Total Number of complaints related to non patient/family care
Total number of these which were upheld
8
Communication
9
5
Total number of these which were partially upheld 4
Main theme from complaints Communication
All complaints were fully investigated and appropriate actions taken. All complaints and concerns were discussed by the Senior Management Team to ensure they were correctly dealt with and to facilitate organisational learning. This information was fed back to the relevant teams and resulted in some processes being reviewed and updated, policies amended, additional training provided to staff and awareness raised of the need for effective communication between staff and across teams.
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22 Farleigh Hospice Quality Account 2014-2015
Although the number of complaints was small the number of compliments was significantly higher as evidenced through letters and cards from families and carers, comments in the annual Patient Satisfaction
Surveys and customer feedback in our shops.
General risk assessments are in place to address health & safety hazards in all areas of the organisation.
Additionally, Control of Substances Hazardous to Health (COSHH) risk assessments have been carried out for all hazardous substances. The policy was also updated to reflect the changes in COSHH symbols which were replaced by international symbols on substances from December 2010, and will be replaced on mixtures from 1st June 2015. All risk assessments are reviewed at least annually or sooner if circumstances change.
For the period 1st April 2014 to 31st March 2015 there were 46 health & safety related incidents reported involving staff, volunteers, visitors and members of the public. In 20 of the reported incidents no injury was sustained, of the 26 incidents where injuries were sustained 25 were classed as minor and 1 was classed as medium. Of the injuries, 1 was reported to the Health & Safety Executive, which was a manual handling incident involving a member of staff. As can be seen from the chart below, manual handling was the most common cause of injury.
For the period 1st April 2014 to 31st March 2015 there were 64 clinical incidents, 52 of which were patient falls. 2 Serious Untoward Incidents required reporting to the Clinical Commissioning Group and Care
Quality Commission. The incidents were fully investigated and reported on within agreed timescales.
A Root Cause Analysis was carried out and action plans developed all of which have been completed.
There was no serious consequence for the patients involved.
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Farleigh Hospice Quality Account 2014-2015 23
Of the 52 patient falls, 13 resulted in minor injuries. All were fully investigated which included a review of the Falls Risk assessments and if required an update of the Falls Management Plans
The patient falls were categorised, as follows:-
Medication Adverse Events are audited on a quarterly basis.
In 2014 – 2015 40 medication related incidents occurred of which 6 were near misses. There were no serious consequences to patients from any of these incidents.
All were investigated and, where necessary, corrective action was taken.
The majority were due to human error and a need for increased vigilance by clinical staff. All audit results were shared with the clinical team and additional training carried out to raise awareness of the issues.
The hospice reviewed and actioned relevant alerts received from the Central Alerting System including drug safety alerts from the Medicines and Healthcare Products Regulatory Agency and Medical Devices
Alerts – 78 alerts were reviewed of which 17 were relevant to the hospice and appropriate action taken when relevant.
Infections and pressure ulcers cause pain and distress to patients and families and have cost implications to organisations. Infections and pressure ulcers are monitored on an on-going basis by the Manager of the Inpatient Unit. Whether they are acquired or not at Farleigh Hospice they will still be reported to
Farleigh Hospice’s Clinical Governance Group, Mid Essex Clinical Commissioning Group and the Care
Quality Commission. Infections are also reported to the Farleigh Hospice Infection Control Team on a quarterly basis.
Information relating to the incidence of Patient Infections and Pressure Ulcers is collated into an annual audit. There continues to be a very low number of infections and pressure ulcers acquired at the hospice. www.farleighhospice.org info@farleighhospice.org 23

24 Farleigh Hospice Quality Account 2014-2015
There were 14 reported infections during the period compared to 18 the previous year. 1 patient was identified with 2 separate organisms. None of the 14 reported infections were acquired at Farleigh
Hospice and 13 were from patients admitted to the Inpatient Unit and 1 reported at Farleigh in Maldon.
Patient Infection 2014 - 2015
Unit
Inpatient Unit
Day Hospice
No. of Cases
13
1
No. on admission
13
1
No. Acquired At Farleigh
0
0
Totals 14 14 0
There were 64 reported pressure ulcers during this period compared to 45 the previous year. All were from patients admitted to the Inpatient Unit. Although there was an increase in the number of reported pressure ulcers, the number acquired in the hospice was 6 which were all unavoidable due to patient choice and physical condition at the end of life. 8 patients had a pressure ulcer on transfer from hospital and 50 on transfer from the community.
Unit No. of Cases No. on admission No. Acquired At Farleigh
Inpatient Unit 64 58 6*
*Three of the six patients refused high specification pressure relieving equipment despite being informed www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 25 of the risks
Pressure ulcers are graded to provide a consistent approach to detecting the different severities of ulcers from a Grade 1 (redness) through to a Grade 4 (extensive tissue damage).
The Pressure ulcers reported during this period were:-
Grade 1 - 13 Grade 2 - 49 Grade 3 - 0 Grade 4 - 2
Of these the six hospice acquired pressure ulcers were – Grade 1 – 1, Grade 2 - 5
Farleigh Hospice took part in the pilot of the Help the Hospices (now Hospice UK) National Hospice
Inpatient Safety Benchmarking tool in 2013 – 2014 and continued to take part in this benchmarking exercise in 2014 - 2015. The tool records information on patient falls, pressure ulcers and medication incidents. Information is submitted monthly to Hospice UK who collate the information and benchmark the organisation against similar size hospices. Farleigh Hospice compares favourably with other hospices of a similar size. The information is also used to evidence patient safety and compliance for the Care Quality
Commission – ‘Is it safe?’ – the provider learns from any safety incidents that have occurred and changes practice in response (2013). The hospice will be continuing to record information on this tool and it is anticipated that there will be a web based version available in 2015.
Farleigh Hospice updated its policies on Safeguarding Vulnerable Adults and Children, Mental Capacity
Act (MCA) and Deprivation of Liberties Safeguards (DoLS) to reflect changes in legislation and for the
NHS Contract. The hospice’s Safeguarding /.DoLS /Prevent lead provides advice and training for all clinical staff on induction and annually on these policies. www.farleighhospice.org info@farleighhospice.org 25

26 Farleigh Hospice Quality Account 2014-2015
In the review period there were 6 incidents reported through the Information Security Incidents process.
In 4 of those cases there were no apparent data losses and therefore they were not formally reported, but all were seen as potential breaches and treated as such in the associated Senior Information Risk Owner reports. These 4 were linked to SystmOne issues with the loss of smart cards or computer screens left unlocked. 2 incidents were reported as Caldicott issues as detailed below.
The Caldicott Guardian is a senior person within an organisation responsible for protecting the confidentiality of patient information and enabling appropriate information-sharing. They provide an oversight to ensure that the highest practicable standards for handling patient identifiable information are employed, and are responsible for ensuring that their organisation adheres to the Caldicott principles. The role of Caldicott Guardian at Farleigh Hospice is carried out by the Chief Executive.
In the review period 12 issues were raised with the Caldicott Guardian, all of which have been investigated and closed. The main issue related to requests for access to patient records. 6 related to
SystmOne relating to sharing of information and information entered in error, one such incident required reporting to the Clinical Commissioning Group and Care Quality Commission. (see above – Patient
Incidents)
To ensure a high quality of services a variety of audits were undertaken using nationally agreed formats often specifically developed for hospice care as well as locally developed audit tools. This has enabled us to monitor the quality of services and make improvement where needed.
The Quality & Audit Activity programme for 2013 - 2014 had 74 local reports and all action plans from these reports have been completed.
In 2014 – 15 the reports from 78 local audits were reviewed by the Farleigh Hospice Governance group of which 70 related to clinical care and relevant support services necessary to provide this care and evidence compliance. www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 27
1 Respecting and involving people who use services
2 Consent to care and treatment
4 Care and welfare of people who use services
5 Meeting nutritional needs
6 Cooperating with other providers
7 Safeguarding people who use services from abuse
8 Cleanliness and infection control
9 Management of medicines
10 Safety and suitability of premises
11 Safety, availability and suitability of equipment
12 Requirements relating to workers
13 Staffing
14 Supporting staff
16 Assessing and monitoring quality of services
17 Complaints
20 Notification of other incidents
21 Records
24 Requirements relating to registered managers www.farleighhospice.org info@farleighhospice.org 27

28 Farleigh Hospice Quality Account 2014-2015
Action plans were developed as a result of these audits to improve the quality of services provided. The outcomes from the audits were reviewed by the Governance Group on a regular basis and in their Annual
Governance report.
Details of audits completed in 2014 – 2015 can be seen in Appendix A
The Quality Account was discussed and reviewed by Farleigh Hospice Clinical & Corporate Governance committees which include senior managers, Trustees, and the Quality Improvement Lead. The task of writing the report was designated to the Quality Improvement Lead and Chief Executive.
Discussion then took place within the Senior Management team regarding the key priorities for improvement for 2015 – 2016 following suggestions from Heads of Departments and the Multi
Departmental Quality Assurance group. Four were selected and after consultation with staff, patients, carers, volunteers and the public, it was agreed to include all four in the report. An additional idea was suggested and this was also included.
“We certainly agree with the list” comment from Service User
The list of priorities was agreed to be Welcome Service, Learning & Development Strategy, Clinical
Staff Induction and Training Manual, Go Green Group, Review and Strengthening of the Governance
Framework.
A final draft of the Quality Account was then completed and circulated to the Governance Committees and Board of Trustees for discussion and comment and it was distributed externally to the mid Essex
Clinical Commission Group; Healthwatch Essex and the Health & Wellbeing Board, Essex. Comments received have been included in this report prior to it being published on the NHS Choices website.
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Farleigh Hospice Quality Account 2014-2015 29
In April 2014 Farleigh Hospice was pleased to launch its new Strategic Plan which sets out what the hospice aims to concentrate on between 2014 and 2018. The formation of this plan was a real team effort, with input being received from supporters, public surveys and external healthcare professionals, alongside listening to the opinions of patients, carers, staff and volunteers. The responses received demonstrated strong support for the plan. As part of the launch of the new Strategic Plan, a number of
‘road shows’ were held by the Chief Executive across mid Essex which provided an opportunity for people to come along and hear more about the objectives and ask any questions they might have.
● ● To widen access to Farleigh Hospice’s services and reach all those affected by life limiting illnesses who wish to access our caring services
● ● To coordinate care and contribute towards improving services provided to local people affected by life limiting illnesses in mid Essex
● ● To be clear in the message about what we offer
● ● To use resources effectively and efficiently
● ● To maximise income to ensure service sustainability and enable further development
● ● To engage with our local community and further develop our role within the community.
● ● Copies of the Strategic Plan are available to view on our website www.farleighhospice.org
In April 2014, Farleigh’s Maldon based Day Hospice reopened, following a flood in August 2013. The building had to be fully dried out and redecorated. Good can come from bad and the flood enabled the team, including patients and their carers, to meet up and discuss how they would like the Day Hospice to look and what the building should be used for in the future. A grant from the Department of Health enabled a refit of the kitchen creating a professionally designed, stainless steel workspace making catering so much easier at the hospice and enabling patient groups to use the space for sessions. The www.farleighhospice.org info@farleighhospice.org 29

30 Farleigh Hospice Quality Account 2014-2015 high ceilings were lowered and atmospheric lighting installed to make the main room more homely. The flooring was changed and, alongside the new colour coordinated furniture, now gives a modern and clean environment for patients, their carers and staff alike.
New clinical groups and counselling sessions are now being offered in the newly refurbished facilities
(See Priorities for Improvement 4 Development of a Rehabilitation Model)
After months of preparation and planning, our patients, carers and clinical teams are now reaping the rewards of an electronic care records management system called ‘SystmOne’ which went live at the hospice in April. With patient notes being stored electronically in one place for all of the healthcare professionals involved in a person’s care to access, the new system brings a range of benefits to our clinical team and service users alike.
On being referred to Farleigh Hospice, patients and carers will be asked if they wish to consent to give their permission to the hospice to access their GP practice records.
The benefits of sharing information electronically include:
● ● Prompt access to relevant information which will lead to fewer delays in the provision of somebody’s care
● ● Information will always be up-to-date and consistent
● ● Improved communication between the healthcare professionals who are involved in a patients’ care
● ● Reduced risk of things being missed
● ● Less duplication and more efficient use of Farleigh Hospice’s clinical and administrative time
The implementation of SystmOne is also part of the ongoing process for Farleigh Hospice to become a more paperless and environmentally friendly organisation. ( See Part 2 Priorities for Improvement 3:
Introduction and rollout of ‘‘SystmOne’’)
To support its Strategic Objective ‘To widen access to services’, Farleigh Hospice secured additional funding from our Clinical Commissioning Group (CCG), to set up a pilot project which allowed the hospice to further enhance the essential services it provides. The Coordination Project went live in January 2015 which has enabled Farleigh Hospice to reach even more people affected by life limiting illnesses across mid Essex and, through taking a lead in coordinating their care, help to ensure that they receive the best end of life care possible. This was achieved by offering an advice line for anyone to call which offers support, advice and access to urgent care should it be needed.
The benefits of this major development include:-
● ● Early & equitable access to end of life care services
● ● Referral and signposting to the right services, based on need
● ● Care wishes being recorded in one place, resulting in a higher chance of a patient’s wishes, choices and priorities being fulfilled
● ● Consented sharing of information with other healthcare providers to reduce the number of times a www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 31 patient has to reiterate their wishes and improve coordination of care
● ● A reduction of unwanted or unnecessary intervention and treatments
● ● A reduction of unwanted or unnecessary hospital admissions
With patients consent, the Team will also store information about anyone from the mid Essex area who is expected to be within the last year of their life on an Advance Care Register. This register will contain important information about where the patient might wish to be cared for, their next of kin and any clinical information that might be useful in an out of hours crisis. Keeping this information up to date and making it available to services such as NHS 111 and the Ambulance Service, will make care more streamlined, especially in emergencies, and mean that correct information is to hand and unnecessary admissions into hospital can be significantly reduced.
The Coordination Project is already demonstrating success and it is hoped that when the pilot is complete the service will become an integral part of Farleigh Hospice Services
In June 2014 a very special collaboration came about between Farleigh Hospice and City of Chelmsford
Mencap. As part of the year’s Disability Awareness Week, the two charities were put in touch to work closely together and raise the awareness of each other’s services and reaching members of the wider community. Over the year this relationship has grown from strength to strength, with the Information
Service hosting Mencap representatives on both the HOP and the Pod and Mencap inviting our
Information Service to join them at the V Festival in Hylands Park!
A group of 14-15 students from Mencap have also been giving a helping hand at the North Court Road site in Chelmsford. The group have been coming in fortnightly to prepare for a very special and much needed vegetable garden. When finished, the area will be used to cultivate home-grown vegetables which will be used by our kitchen staff. Under the guidance of the Maintenance Team, the students have cleared the plot in preparation for the garden, worked on planning and designing a new vegetable garden, art trail and sculpture to take pride of place in the grounds.
In September 2013, working in partnership with Macmillan Cancer Support and Mid Essex Health Trust
(MEHT), the Information Pod based at Broomfield Hospital was launched. In 2014 the Information
Service Team were invited to attend a black tie gala event at Hylands House for the second annual Mid
Essex Hospital Trust OSCAs awards as they had been nominated for an award. The OSCAs recognise and celebrate ‘Outstanding Service and Care’ delivered to mid Essex patients. Trust staff are invited to www.farleighhospice.org info@farleighhospice.org 31

32 Farleigh Hospice Quality Account 2014-2015 nominate a colleague, team, or member of staff, who they think deserves to be recognised for outstanding service and care.
There had been over 1100 nominations for the OSCAs this year and the information service was awarded runners up in the ‘Going the Extra Mile’ category. A massive surprise and a huge honour for the information service team
The Farleigh Hospice Information service was launched in 2008 with the Hospice Outreach Project
(HOP). Since then the Information Service has grown and expanded and has been working hard to widen its reach and offer information, support and advice to even more people, by collaborating with other organisations
The Information Service Team has been working with even more organisations in order to reach out to more people in need of our support. In January 2014 they took part in a collaborative working in action with Boots in Lakeside, Macmillan Cancer Support, St Luke’s Hospice and Southend Hospital. It was a great opportunity for the different services to signpost to each other and was so successful that another
Boots, Macmillan and Farleigh Hospice event was planned for April in Boots in Chelmsford.
As well as joining together with other organisations for special events, there are also other guests lined up to join the HOP vehicle, such as Age UK, MS Society and ‘Heart and Sole’ - Chelmsford’s Health Walk
Scheme set up by Chelmsford City Council and Provide.”
The Senior Management Team has prepared a draft Collaboration strategy to support the Farleigh
Hospice 2014-18 strategic plan. Areas of collaboration include working more closely with Mid Essex
Hospital Trust (MEHT) with representation on acute hospital working groups to improve End of Life Care
(EOLC) in the hospital setting. Also working in collaboration with GP’s and Provide, NHS Community services to identify areas of overlap and gaps in service provision and how these might be addressed in the future. The Chief Executive leads on the Health, Wellbeing and Social Care Workstream, a sub-group of the Essex Voluntary and Community Services Alliance. This combined group of charities providing support for people across Essex have prepared a draft set of core outcomes relevant to service users across all areas of health and social care. This is a work in progress and is being discussed with local government and commissioning groups.
Farleigh Hospice managers and senior staff work collaboratively where possible with other charities including hospices in - service delivery and design where possible.
Each year, Farleigh Hospice is proud to take part in ‘Dignity Action Day’ – a national initiative that takes place annually and serves as an opportunity for health and social care workers, plus members of the public, to uphold people’s rights to dignity in care. This year, once again, our staff and volunteers were invited to wear red to mark the special occasion Farleigh Hospice now has ‘Dignity Champions’ in all clinical areas. They believe dignity is a concept everyone must keep close to their hearts. The Inpatient
Unit invited people to attend small workshops which evidenced how they how they support the concept in their practice and how it can be applied.
This year, the Yo-Yo Team who provide pre and post bereavement support for children and young adults www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 33 created a Memory Tree those, they are currently supporting, to create and display personal messages remembering their loved ones. The Memory Tree started as part of ‘A Time to Remember’ service, when a number of families that have been, or still are, part of the Yo-Yo Project were invited to attend. The messages were written on individual leaves which were then added to the tree, creating a collage of colourful special messages. Not wanting to hide this beautiful and very emotive creation away, the tree was placed in the Sanctuary for anyone to read and add to.
A poster presented by two Farleigh Hospice Occupational Therapists, entitled ‘Motor Neurone Disease and the Installation and Use of Stair lifts’ achieved a Highly Commended rosette at the College of
Occupational Therapist conference in Brighton. The Quality Improvement Lead, also presented a poster –
Clinical Supervision in a Hospice Setting.
Both posters attracted a lot of interest and discussion, which has continued after the conference. It is good to know that Farleigh Hospice has impacted on thinking. The conference was also an opportunity to catch up on current clinical practice, new aids and equipment and friends and colleagues. It was a really great experience and all came back inspired and full of great new ideas.
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34 Farleigh Hospice Quality Account 2014-2015
It is essential to know what people say about our organisation especially as we widen access to our services and facilities and work to further connect with our local community. Many different approaches were used, formal and informal, over the year to get feedback to provide quality information for the NHS
Contact, review of current services to monitor ongoing quality improvements and review new services.
These included:-
● ● Patient Satisfaction Inpatient Unit
● ● Patient Satisfaction Survey Day Hospice Chelmsford
● ● Patient Satisfaction Survey Day Hospice Maldon
● ● Hospice At Home Relatives/ Carers Survey
● ● Independent Practitioner – Welfare Benefits Adviser
● ● Independent Practitioner – Community Specialist Nurses
● ● Client Satisfaction – Circle Adult Bereavement Counselling
● ● Staff Survey
Every year Farleigh Hospice conducts surveys which focus on the quality of care being delivered. The surveys are carried out by the Independent Service User Facilitator, and are completed throughout the year by interviewing patients during their stay on the IPU or at the Day Hospices. Overall the responses about all these services were positive and affirming:- www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 35
Patients in IPU were asked if they had any suggestions to help us improve our services, - all felt there was nothing they could suggest and as the service we provide is already so good.
Overall experience in the inpatient unit:-
‘100% excellent ‘
‘Wonderful, even my dog was allowed to visit me’
All felt the cleanliness of the hospice, its outlook and environment were ‘Very Good’ or ’Excellent’
‘everything shipshape and clean’
‘the towels smell lovely’
‘pristine!’
When asked if they felt their relatives and visitors were well looked after, 99% said always, one patient had had no visitors during their stay.
‘my wife stayed over and on our son’s 13th birthday all the family came in, marvellous!’
Would you recommend Farleigh hospice to a friend? – Everyone said, ‘Yes’.
46% of patients had concerns before their first visit to the Day Hospice They felt it might be a ‘sad place’ ,
‘people sitting round depressed’ , ‘full of sick and dying people’ . One patient said – ‘thought it might be morbid but used Google to see it on line via the website and realised it wasn’t !’
People commented that once they got over their apprehension and visited they saw the place in a positive and completely different light
Overall experience in both Day Hospices: ‘100% excellent’
Comments about the Welfare Benefits Advice
In 2014 a Welfare Benefits Adviser post was created as part of the Psychosocial Team and it was felt it would be useful to get feedback on this new service. A short survey was carried out which demonstrated that all people interviewed who had used the service were 100% satisfied with the advice they received and that they were treated with respect and courteously.
When asked how the service had improved their circumstances people replied ‘It was brilliant support and with really sound advice’
Any other comments ‘No, Farleigh seems to cover everything’
Farleigh Hospice provides a dedicated service to carers which aims to offer support to carers of hospice patients across mid Essex and prevent them from feeling alone and isolated. At Farleigh Hospice we continue to recognise the vital role carers play throughout the year by providing them with their own support service.
The Carers Coordinator and one of the Occupational Therapy Team have also been running HOPE (Help to Overcome Problems Effectively) courses for carers and patients with the support from specially trained volunteers. The aim of the course is to help people who have got a life limiting illness or for those caring www.farleighhospice.org info@farleighhospice.org 35

36 Farleigh Hospice Quality Account 2014-2015 for someone with a life limiting illness to get on with life during the illness and throughout treatment.
The HOPE course emphasises the strengths people already possess and looks at how to make the most of them. This course can play an important role in helping people who are living with a life limiting illness to find new ways to regain confidence.
The feedback from the courses so far has been very positive with reports that participants have felt more
‘confident’ , more ‘positive’ .
‘With help, support and laughter, I have been lifted out of a dark place to be reacquainted with myself’
Carers ‘drop ins’, ‘pamper’ days and candle lit dinners, barge trips are held throughout the year as part of ongoing support and these are popular and well supported.
In 2014 Farleigh Hospice took part again in an annual staff satisfaction survey for Hospices, delivered by
Birdsong Charity Consulting in conjunction with Hospice UK (formally Help the Hospices). Each hospice receives a benchmarked report that compares its results with the other hospices, other third sector responses and previous survey results.
The response rate was 59% (122 staff).
Overall high levels of satisfaction were expressed by staff in the survey.
General satisfaction can be gauged by these answers
‘I would recommend this charity as an employer.’ 84% Farleigh Hospice - 71% All Hospices
‘I feel appreciated.’ 84% Farleigh Hospice - 71% All Hospices
Not only are these high scores, but these scores were higher percentages than all other hospices in the survey
Some areas were highlighted which it was felt required further action
‘ I receive sufficient training/development to enable me to do my job well.’ 64% Farleigh Hospice - 69% All
Hospices
‘I am happy with the personal development opportunities here.’ 52% Farleigh Hospice - 57% All Hospices
These responses prompted the hospice to look at developing a Learning & Development strategy and a Clinical Staff Induction & Training Manual to support training and personal development (see Part 2:
Future Priorities for Improvement 2 and 3 )
In 2013 an additional statement was added and this was included again in 2014:-
‘If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation’ the response in 2013 and 2014 was that 97% agreed. In 2014 in the NHS the overall score from all organisations in response to the same question was 76%.
It is planned to take part in the survey in 2015 as it is useful to have data to benchmark against.
www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 37
Volunteers play a key role in all services at Farleigh Hospice and we are always looking for more. This year to support a recruitment drive the hospice produced a video – ‘Farleigh Hospice needs YOU’ which starred volunteers talking about their roles and what volunteering for the hospice meant to them. There was no shortage of people ’volunteering’ to be stars in the video and it received several shares on
Facebook and over 300 views on YouTube within a short time after the launch and prompted enquires about volunteering. If you would like to view the video it is available on www.farleighhospice.org/ farleighneedsyou
Two Trustee Provider visits took place in 2014 at roughly six monthly intervals which involved trustees visiting facilities and interviewing staff, patients and volunteers and checking that services comply with relevant regulations. The aim is to provide Trustees with an opportunity to inspect and monitor services and feedback on behalf of the board. Both visits focused on patient care. The June 2014 visit focused on a review of The Day Hospices in Chelmsford and Maldon and the November on Community services.
New policy guidelines for these visits were introduced in August 2014 and used to structure the visit in
November. Both visits evidenced excellent care and support. One family in the community commented
‘I can’t believe the help we are being given’ . A patient attending the Day Hospice was full of praise and commented that they ‘Did not want anything done differently’ . There was evidence of good leadership and that staff felt valued for their knowledge & expertise. www.farleighhospice.org info@farleighhospice.org 37

38 Farleigh Hospice Quality Account 2014-2015
Only one issue was raised requiring action within a month and this related to reliability of mobile phone in the community which was acknowledged by the Senior Management Team and actioned. Other concerns regarding the future of Day Hospice services, access to IPU beds and the need for better communication or understanding of the work of different teams were raised with the Senior Management Team as part of the action plans from the visit which were responded to and followed up.
The most recent onsite inspection was carried out by the Care Quality Commission in July 2013 at
Farleigh Hospice in Chelmsford. This was a routine unannounced inspection to check that essential standards of quality and safety were being met. All standards assessed were fully met.
No recent inspection has been carried out at Farleigh Hospice in Maldon as the Day Hospice was closed in August 2013 due to flooding and did not reopen until April 2014.
www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 39
Mid Essex Clinical Commissioning Group (MECCG) is the main NHS Commissioner contributing to services provided by Farleigh Hospice and as such is required to comment on its Quality Account.
Unfortunately, this Quality Account was not received in time to enable due process to be carried out to ensure the accuracy, fair interpretation and representation of services provided.
However, MECCG would like to congratulate the Hospice on the success of setting up the care coordination service, which supports colleagues in the wider healthcare system to highlight patients with a life limiting condition earlier in their journey, so that their care can be planned more proactively and their wishes made clear as regards PPC/PPD and other concerns.
MECCG looks forward to continuing its work with Farleigh Hospice in the coming year.
Carol Anderson
Director of Nursing and Quality
Mid Essex Clinical Commissioning Group
June 2015 www.farleighhospice.org info@farleighhospice.org 39

40 Farleigh Hospice Quality Account 2014-2015
Healthwatch Essex is an independent voice for the people of Essex, helping to shape and improve local health and social care services. We believe that people who use health and social care services and their lived experience should be at the heart of the NHS and social care services.
Although we have not undertaken any specific work with Farleigh Hospice over the past year, from our reading of the Quality Account we are pleased to note that Farleigh Hospice actively engages service users and families about the services they receive. In addition, the Hospice receives praise from service users and their families for the high quality services and invaluable support it provides. For example, the
2014 Farleigh Hospice Patient Survey asked 12 people about their experiences on the Inpatient Unit.
Overall, feedback was positive - all said they felt listened to, treated with respect and dignity, and had been given choice about their care. Additionally, all those surveyed rated their overall experience on the
Inpatient Unit as excellent.
The Hospices priorities for 2015-16, include the development of a new Welcome Service to further improve the experience of services users, carers and families. The new service will be designed to welcome, guide, signpost and support all visitors to Farleigh Hospice.
Healthwatch Essex believes that lived experience should be at the heart of services, and believes that listening to the voice and lived experience of patients, service users, carers, and the wider population, is a vital component of providing good quality care. We are pleased to acknowledge the work Farleigh
Hospice undertakes in this regard.
www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 41
A copy of the Farleigh Hospice Quality Account 2014 – 2015 was forwarded to the Health & Wellbeing
Board, Essex but we did not receive any comments at the time of publication www.farleighhospice.org info@farleighhospice.org 41

Farleigh Hospice Quality Account 2014-2015 42
Aug-14
Aug-14
Aug-14
Aug-14
Aug-14
Aug-14
Aug-14
Sep-14
Sep-14
Apr-14
May-14
May-14
Jun-14
Jun-14
Jun-14
Jul-14
Jul-14
Jul-14
Jul-14
Jul-14
Jul-14
Jul-14
Jul-14
Aug-14
Aug-14
Date Reports
Apr-14
Apr-14
Apr-14
Infections and Pressure Ulcers April 13 - March 14
Medication Adverse Events Jan - March 2014
Verbal Orders in IPU Oct - Dec 13 & Jan - March 14
IT User Survey
Health, Safety & Environmental Report 2013 - 2014
Complaints report 2013 - 2014
Falls in IPU
Client satisfaction -Circle Bereavement Counselling
H @ H Relative / Carer Survey 2011 - 2013
Legacy Pledger
Medication Adverse Events April - June 2014
Verbal Orders
Gift Aid Fundraising
YoYo Project Waiting Times
Infection Control Lantern Suite 2014
Department
Clinical
Clinical
Clinical
IT
Health & Safety
Quality
Clinical
Clinical
Clinical
Fundraising
Clinical
Clinical
Fundraising
Clinical
Clinical
Food Hygiene Standards Farleigh in Maldon 2014
Independent Practitioner - Welfare Benefits Advice 2014
Clinical
Clinical
Planned Preventative Maintenance North Court Rd Jan - June 2014 Maintenance
Reactive Maintenance North Court Road Jan - June 2014 Maintenance
Planned Preventative Maintenance Retail & Lottery Jan - June 2014 Maintenance
Reactive Maintenance Retail & Lottery Jan - June 2014 Maintenance
RAG Report Medical Outpatients Jan - July 2014
Infection Control IPU 2014
Medical
Clinical
Triage - re-referral audit
Clinical Key performance Indicators 2013 - 2014
Audit of Audits 2014
Internal Audit 2014
Triage response times to referrals
Clinical
Clinical
Quality
Quality
Clinical www.farleighhospice.org info@farleighhospice.org 01245 457300

Farleigh Hospice Quality Account 2014-2015 43
Oct-14
Oct-14
Oct-14
Nov-14
Nov-14
Nov-14
Dec-14
Dec-14
Date Reports
Oct-14 Infection Control FiM
Oct-14 Medication Adverse Events July - Sept 2014
Oct-14
Oct-14
Oct-14
Oct-14
Verbal Orders July - Sept 2014
Welcome Nurse Checklist 2014
Information Pod first annual report 2013/14
SystmOne Notes Audit
Health & Social Care Act 2008 Infection Control Compliance
Independent Practitioner Community Nursing
Money Laundering
Mattress Audit
Summer Grand Prize Draw - Lottery 2014
Mouth Care
Patient Satisfaction Survey IPU 2014
Welcome events evaluation 2014
Jan-15
Jan-15
Jan-15
Jan-15
Jan-15
Jan-15
Jan-15
Jan-15
Jan-15
Jan-15
Dec-14
Dec-14
Board Review 2014 Executive Summary
Internal Clinical Supervision evaluation
Dec-14 DNACPR
Dec-14 Response Times: Circle Adult Bereavement Service
Jan-15
Jan-15
Jan-15
Jan-15
Hospice @ Home, achievement of PPC
Controlled Drugs Audits, Accountable Officer
Management of Controlled Drugs IPU
Planned Preventative Maintenance NCR July - Dec 2014
Reactive Maintenance NCR July - Dec 2014
Board/SMT
Quality
Medical
Clinical
Clinical
Clinical
Clinical
Maintenance
Planned Preventative Maintenance Retail & Lottery July - Dec 2014 Maintenance
Reactive Maintenance Retail & Lottery July - Dec 2014
Planned Preventative Maintenance FiM July - Dec 2014
Reactive Maintenance FiM July - Dec 2014
Verbal Orders IPU Oct - Dec 2014
Omitted & Delayed Medication Nov - Dec 2014
Medication Adverse Events Oct - Dec 2014
Walk for life evaluation 2014
Walk for Life 2014 - PR & Marketing audit
Maintenance
Maintenance
Maintenance
Maintenance
Clinical
Clinical
Clinical
Fundraising
PR & Marketing
Department
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Finance
Clinical
PR Marketing
Clinical
Clinical
HR www.farleighhospice.org info@farleighhospice.org 43

44 Farleigh Hospice Quality Account 2014-2015
Feb-15
Feb-15
Feb-15
Mar-15
Mar-15
Mar-15
Mar-15
Mar-15
Mar-15
Mar-15
Date Reports
Feb-15 Cleaning in FiC
Feb-15
Feb-15
Feb-15
Cleaning in IPU
Cleaning in Lantern Suite
Cleaning in FiM
Feb-15
Feb-15
Feb-15
Feb-15
Healthshield survey & review
Staff Survey 2014
Patient Satisfaction Survey FiC 2014
Patient Satisfaction Survey FiM 2014
Health & Safety Campaign 2014 Evaluation
Client Satisfaction - Circle Bereavement Counselling Service
Commode Environmental Audit
Internal Controls Checklist Finance CC8 Charity Commission
Gift Aid Fundraising April - Sept 2014
Light up a Life (Hospice UK LUPAL survey)
IG Toolkit submission
National Charity Shops Survey 2014
Legacy Audit
Patient ID Bands
If you would like further details of the above reports please contact –
Quality Improvement Lead at : susan.bridger@farleighhospice.org
Department
Hotel Services
Hotel Services
Hotel Services
Hotel Services
HR
HR
Clinical
Clinical
Health & Safety
Clinical
Clinical
Finance
Finance
Fundraising
IT
Fundraising
Fundraising
Clinical www.farleighhospice.org info@farleighhospice.org 01245 457300