Halton Haven Hospice
Quality Account
2015
1
Contents
OUR VISION, MISSION AND AIMS
3
CHAIRMANS STATEMENT
4
WHAT IS A QUALITY ACCOUNT
5
STATEMENTS OF ASSURANCE FROM THE BOARD
6
REVIEW OF QUALITY PERFORMANCE PRIORITIES 2014/15
8
FEEDBACK FROM PATIENTS AND RELATIVES
10
CLINICAL GOVERNANCE OVERVIEW
17
CARE QUALITY COMMISSION REPORT
21
EQUALITY AND DIVERSITY
22
COMMUNITY ENGAGEMENT
24
PRIORITIES FOR IMPROVEMENT 2015
28
STATEMENTS ON THIS QUALITY ACCOUNT
31
OPPORTUNITY TO PROVIDE FEEDBACK
33
2
Halton Haven Hospice
Our Vision:
•
People of Halton facing life limiting illness will have quality of life and dignity in death
Our Mission:
•
To care for people living with life limiting illness by providing safe, specialist end of life
care and supporting their families. We will lead and inspire excellent care wherever
people choose to die
Our Aims:
•
To provide and develop quality and cost effective end of life services for the people
of Halton
•
To sustain and develop Hospice services that are fit for the future
•
To promote the excellence of the work of the Hospice and celebrate success
We Will Deliver This By:
•
Valuing and developing our people
•
Making the most efficient use of our resources
3
Statement from the Chair of Trustees
On behalf of our Board of Trustees and the Executive Management Team I have
pleasure in presenting the annual Quality Account for Halton Haven Hospice.
I, as Chair of Halton Haven Hospice Trustees, am responsible for the preparation of this
report and its contents, and to the best of my knowledge the information contained
therein is accurate and a fair representation of the quality of the NHS healthcare
services provided by Halton Haven Hospice.
This is the fourth Quality Account we have produced and we hope that it provides a
summary of what we have been doing over the last year to improve our services. We
are always delighted to have any feedback on the document itself, or indeed our
services in general, so please do feel free to get in touch.
Quality is central to the care that we provide. The Hospice has developed a strong
framework in both corporate and clinical governance and has a culture of
continuous quality monitoring, in which any shortfalls are identified and acted upon
quickly. We recognise there will always be challenges but will continue to strive for the
highest quality in the care that is provided, putting our patients, their families, friends
and carers at the heart of everything we do.
Together with the Board of Trustees, our thanks must go to not only our staff and
volunteers, who work tirelessly to provide high quality services, but also to our faithful
and committed supporters, who enable us to raise the necessary funds to provide our
services free of charge to patients and their families.
Neil Townsend
Chair of Halton Haven Hospice Trustees
4
What Is a Quality Account?
Producing a Quality Account is a requirement of the Health Care Act (2009) and according
to the Department of Health, ‘Quality Accounts aim to enhance accountability to the public
and engage the leaders of an organisation in their quality improvement agenda’.
The Quality Account should provide information about the quality of the services that the
organisation delivers and their main purpose is to encourage providers to take a robust
approach to quality.
All providers of NHS healthcare services, including independent organisations such as Halton
Haven Hospice, should produce a Quality Account and in doing so each provider, led by their
Board, is committing to improve the quality of care it delivers locally and invites the public to
hold them to account.
The Quality Account covers two main areas;
•
A review of how we performed last year, covering three main areas of quality; patient
safety, patient experience and clinical effectiveness
•
A set of key priorities for improvement next year and plans for how we aim to achieve
that improvement
The public, patients and other interested parties will use the Quality Account to understand;
•
What an organisation is doing well
•
Where improvements in service quality are required
•
What the organisation’s priorities for improvement are for the coming year
•
How the organisation has involved people who use their services, staff and others with
an interest in their organisation in determining these priorities for improvement
5
Statements of Assurance from the Board
The following are formal statements, under various headings that all providers of NHS
healthcare services must include in their Quality Account, even though many of the
statements are not directly applicable to us as a Specialist Palliative Care provider.
Review of Services
During 2014/15 Halton Haven Hospice provided Specialist Palliative Care Services to the NHS.
Halton Haven Hospice has reviewed all the data available to us on the quality of care in these
NHS services.
The income generated by the NHS services reviewed in 2014/15 represents 60% of the total
income generated from the provision of NHS services by Halton Haven Hospice for 2014/15.
This 60% represents only part of the funding required to provide services at Halton Haven
Hospice; the remaining 40% of income is generated through fundraising and the generosity of
the local community.
Participation in Clinical Audits
During 2014/15 NO national clinical audits and NO national confidential enquiries covered NHS
services that Halton Haven Hospice provides.
During that period Halton Haven Hospice participated in 0% national clinical audits and 0%
national confidential enquiries of the national clinical audits and national confidential
enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Halton Haven Hospice was
eligible to participate in during 2014/15 was NONE.
Research
The number of patients receiving NHS services provided by Halton Haven Hospice in 2014/15
that were recruited during that period to participate in research approved by a research
ethics committee was NONE. The Hospice would be open to participate in research projects
subject to eligibility.
Use of the CQUIN Payment Framework
A proportion of Halton Haven Hospice’s income in 2014/2015 was NOT conditional on
achieving quality improvement and innovation goals agreed between Halton Haven Hospice
and the commissioning bodies they entered into a contract, agreement or arrangement with
for the provision of NHS services, through the Commissioning for Quality and Innovation
payment framework.
6
Care Quality Commission (CQC)
Halton Haven Hospice is required to register with the Care Quality Commission and its current
registration status is Independent Hospice for Adults. It is registered to provide the following
regulated activities:
•
Diagnostic and screening procedures
•
Treatment of disease, disorder or injury
Halton Haven Hospice has the following conditions on registration:
•
The establishment is registered for the provision of supportive and palliative care
services.
•
The establishment will provide overnight treatment to a maximum of 12 (twelve)
persons aged 18 (eighteen) years or over.
•
The establishment may provide day services for 12 (twelve) patients at any one time
for patients aged 18 (eighteen) years or over.
•
The prior written approval of the Care Quality Commission must be obtained at least 4
(four) weeks in advance if providing any treatment or service not detailed in the
Statement of Purpose.
The CQC has not taken enforcement action against Halton Haven Hospice during 2014/15.
Halton Haven Hospice has not participated in special reviews or investigations by the CQC
during 2014/15.
Halton Haven Hospice was last inspected by CQC on the 25th of July 2013 and was found to
be compliant with inspected standards and outcomes.
Data Quality
Halton Haven Hospice did not submit records during 2014/15 to the Secondary Uses Service for
inclusion in the Hospital Episode Statistics which are included in the latest published data.
Information Governance Toolkit Attainment Levels
The current Halton Haven Hospice Information Governance Assessment Report overall score
for 66% and is graded Green (satisfactory), meaning that we achieved Attainment Level 2 or
above on all requirements (Version 8 or after).
The Information Quality and Records Management attainment levels assessed within the
Information Governance Toolkit (IGT) provide an overall measure of the quality of data
systems, standards and processes within an organisation.
The Information Governance Toolkit is available on the Connecting for Health website
www.igt.connectingforhealth.nhs.uk
Clinical Coding Error Rate
Halton Haven Hospice was not subject to the Payment by Results clinical coding audit during
2014/15 by the Audit Commission.
7
Review of Priorities 2014 - 2015
During the year 2014 – 2015 Halton Haven Hospice set priorities for improvement in the areas
of;
•
Patient Safety - Our priority was to develop and expand the Hospice’s audit framework
•
Patient Experience - Our priority was to advertise and promote Men’s Shed
•
Clinical Effectiveness - Our priority was to support the provision of a Lymphoedema
Service
In this section we provide a brief review of the previous year priorities.
Patient Safety
Over the past year the Hospice Quality Assurance Team set about looking at what audits had
been done historically and identified areas of service provision that had previously not been
audited. This included an expansion of Clinical Audits within the Hospice to identify whether or
not we were meeting the standards set out in the Merseyside and Cheshire Palliative Care
Network Audit Group Standards and Guidelines. An audit programme looking at these
standards was instigated and will continue into the future to ensure compliance.
The Hospice has also been working at ensuring that we are ready for the Care Quality
Commission’s (CQC) new inspection programme against the new Regulations and
Fundamental Standards, which will look to identify whether patients at the Hospice are safe,
whether the care we provide is effective, whether we are caring and responsive to people’s
needs and whether the Hospice is well led. CQC’s consultation period on their new inspection
programme has now concluded and the Hospice Quality Assurance Team has been
developing audit tools that can mirror what the CQC Key Lines of Enquiry will be. These audit
tools are now ready for use and will be able to provide outcome assessments for the Hospice
into the future.
The Patient and Carer Surveys done by the Hospice were reviewed this past year so that the
questionnaires we use look to gain feedback that is more reflective of patient outcomes than
has previously been the case. The surveys now ask questions that mirror the CQC safe,
effective, caring and well led lines of enquiry.
As well as reviewing our existing survey we have expanded the surveys we do at the Hospice
to now include Day Hospice Patients and also Complementary Therapy Clients in separate
surveys to get feedback on their views of those particular services.
The Quality Assurance Team have also been working on developing a Patient Diary for use in
Day Hospice. The Patient Diary seeks to gain feedback from patients on their experience of
referral to Day Hospice procedures, the admission and discharge procedures at Day Hospice
and also on their experience of attendance during each of their 12 week admission. The
Patient Diaries have been produced and are currently being piloted by a number of patients.
The pilot period will provide us information on how well this initiative works and allows an
opportunity to fine tune the Diaries for future use.
The Hospice has also recruited a new Patient and Carer Representative who attends the
Hospice to visit patients on the In-Patient Unit, in Day Hospice and at the Patient and Carer
Support Groups. The Patient and Carer Representative talks to people within these services to
gain anecdotal feedback of outcomes and provide patients and carers a voice within the
Hospice’s governance structures.
We feel that the review of our audit structure and the expansion of auditing within the Hospice
will benefit Patient safety and enhance future outcomes for patients and their Carers.
8
Patient Experience
Having successfully initiated the idea of the Men’s Shed Project within the Hospice with much
support and enthusiasm for the concept, it was time this past year to put that concept into
practice.
Men’s Shed offers bereaved men in Halton the opportunity to share the tools and resources
they need to work on projects of their own choosing, at their own pace and in a safe, friendly
and inclusive environment. It is a place of skill-sharing and informal learning, of individual
pursuits and community projects, of purpose, achievement and social interaction. It is a place
of leisure where bereaved men can come together to work, while simultaneously improving
their health and wellbeing.
Following the building of our new Family Support Centre, which incorporates the new Men’s
Shed Project, the Hospice set about promoting this ground-breaking initiative within the
borough of Halton.
We have used various methods of communication to introduce and promote the new service
we are providing to the people of Halton and we are happy to be able to report that Men’s
Shed is already showing signs of becoming a huge success and will have positive outcomes
for bereaved men in the borough.
This past year, since the service was officially opened, has seen Men’s Shed grow to the point
where it is now barely being contained within the Family Support Centre it was initially housed
in and the Hospice has been working to expand the space provided for the service within the
Hospice grounds. We believe we have done the ground work this past year, which is now
enabling a sustainable core of service beneficiaries and in doing this Halton Haven Hospice
hopes to alleviate some of the pressures that men in the borough face following a
bereavement.
The Hospice understands that it can be very difficult for bereaved men to feel able to access
support services. Most men having learned from our culture not to talk about feelings and
emotions and there has been little encouragement for men to take an interest in their own
health and well-being. Because of this many men’s health suffers, they drink more, take more
risks and they suffer more from isolation, loneliness and depression. Bereavement in particular
is a problem that men often try and fail to successfully deal with on their own.
The Men’s Shed at Halton Haven is currently supporting 60 men through difficult periods of their
lives. It has extended the range of services offered by Halton Haven Hospice and is improving
the experience of our service users beyond the scope of what we have previously been able
to offer.
Thanks to generous support from Area Forum Funding, the Hospice is now able build upon the
very positive start the Men’s Shed has had this past year with the addition of a purpose built
20ft by 30ft workshop, which will allow us to accommodate and support more men into the
future.
Clinical Effectiveness
Halton Haven Hospice prioritised supporting the development of a Lymphoedema Service, to
be made available across the Bridgewater footprint, during 2014 – 2015. The Hospice provided
the business case for this development and earmarked spaces to provide 2 patient rooms to
be used for such a service. Bridgewater Community NHS Trust took the case forward to the
local Clinical Commissioning Group (CCG), but given the financial pressures which CCGs are
currently under, the proposal is unlikely now to be adopted in 2015 – 2016.
However, the Hospice remains committed to working with partners to provide a
Lymphoedema Service and will remain open to discussions on this project in the future.
9
Feedback from Patients and Relatives
Patient and Carer Surveys
We are pleased to be able to report that this past year we have introduced an Easy Read
version of our Patient and Carer Survey Questionnaire to accompany the Standard version we
have historically sent out to our Service Users.
Throughout the past year we have sent out both the Standard and Easy Read questionnaires
to each patient or their family, as appropriate. This initiative was to facilitate giving a choice,
through which potential respondents could provide feedback on Halton Haven Hospice
services using the questionnaire that was most suited to them.
It was also identified that this initiative may help to increase the return rate on our Patient and
Carer Survey and provide us with even more useful feedback on our services than we might
have otherwise received.
Since their introduction 17 of the 69 returned questionnaires have been in the Easy Read
format. This is 25% of the returned total and is likely to have contributed to the 12% increase in
Return Rate on the previous year, as seen in the table below.
No. of patients/Families sent
questionnaires
No. of Questionnaires
returned
Return Rate
2014
2013
2012
130
150
133
69
65
70
(Standard plus Easy
Read
Questionnaires)
(Standard
Questionnaires Only)
(Standard
Questionnaires Only)
55%
43%
53%
The percentages of Patients and Relatives who complete our Survey Questionnaire continues
to be fairly consistent.
The nature of the service we provide means that we will always get substantially more
feedback from relatives than from Patients on these Surveys, as the table below shows.
10
No. of Patients that
responded
2014
2013
2012
21%
28%
21%
72%
79%
0%
0%
(Standard plus Easy
Read Questionnaires)
79%
No. of Relatives that
responded
(Standard plus Easy
Read Questionnaires)
0%
No. of other people that
responded
(Standard plus Easy
Read Questionnaires)
The Easy Read version of our questionnaire asks questions that look to gain feedback on the
same areas of our service provision as the Standard version of the questionnaire.
We have presented in the tables below the collated responses from both versions of the
questionnaire.
The percentages shown are the average of the percentages we saw on each of the three
surveys completed in 2014 and also the average from the surveys done in the previous two
years for comparison.
The Hospice is keen to ensure that Service Users are provided with appropriate leaflets,
booklets and guides, which enables them to make informed choices about their care. As seen
below, a small number of respondents stated that they had not been aware of information
leaflets in the Hospice, however some of these also stated that they were so preoccupied with
attending to their loved ones at a very stressful time that they just may not remember having
seen them.
No. of respondents who
said that they saw
information on services,
advice and a service user
guide available for them
2014
2013
2012
Standard
Questionnaires
94%
94%
88%
Easy Read
84%
Questionnaires
The Hospice was not using the Easy
Read Version of the patient and
carer survey questionnaire during
this period
11
It is important that the Hospice gains patient consent for their assessments and the care they
receive.
In 2014 we are pleased to be able to say that we continue to score highly in gaining consent,
with one respondent not answering this question but saying they could not answer it as they
did not know.
No. of respondents who said
that they felt the patient,
where possible, consented
to their medical assessments
and care
2014
2013
2012
Standard
Questionnaires
94%
94%
93%
Easy Read
100%
Questionnaires
The Hospice was not using the
Easy Read Version of the patient
and carer survey questionnaire
during this period
Having provided Service Users with appropriate information to enable them to make informed
decisions and sought their consent for the care we provide, the Hospice looks to find out if
patients and their families are happy with the standard of service they have then received.
Everyone at the Hospice is delighted with the 100% positive response to this question.
No of respondents who said
that they felt their medical
assessments resulted in care
that met the patient’s needs.
2014
2013
2012
Standard
Questionnaires
100%
96.5%
94%
Easy Read
100%
Questionnaires
The Hospice was not using the
Easy Read Version of the patient
and carer survey questionnaire
during this period
We want to know what our Service Users think of our facilities, the food we serve to them, the
cleanliness of the Hospice environment and the standard of the staff who look after them.
In each area except Food, and on both Standard and Easy Read Questionnaires, we are
pleased to report a 100% satisfaction rate.
12
However, 14% of respondents who replied using the Standard questionnaire and 8% who
replied using the Easy Read Questionnaire, did not rate the food as being either excellent or
good. This equates to a total of 8 respondents across the year, 6 of whom commented that
they could not comment or rate the food as they did not have experience of it.
No of respondents who said
that the Hospice facilities
were either excellent or
good
2014
2013
2012
Standard
Questionnaires
100%
99%
100%
Easy Read
100%
Questionnaires
No of respondents who said
that the Hospice food was
either excellent or good
Standard
Questionnaires
86%
Easy Read
92%
Questionnaires
No of respondents who said
that cleanliness at the
Hospice was either excellent
or good
Standard
Questionnaires
100%
Easy Read
100%
Questionnaires
No of respondents who said
that staff at the Hospice
were either excellent or
good
Standard
Questionnaires
100%
Easy Read
100%
Questionnaires
The Hospice was not using the
Easy Read Version of the
patient and carer survey
questionnaire during this period
98%
94%
The Hospice was not using the
Easy Read Version of the
patient and carer survey
questionnaire during this period
100%
100%
The Hospice was not using the
Easy Read Version of the
patient and carer survey
questionnaire during this period
100%
100%
The Hospice was not using the
Easy Read Version of the
patient and carer survey
questionnaire during this period
Our survey then enquires as to whether the Service User would subsequently be likely to
recommend us to others if they needed similar care or treatment.
In 2014, 8% of respondents who completed an Easy Read Questionnaire, did not answer this
particular question, hence the 92% Extremely Likely score. Otherwise 100% of respondents who
answered the question would be “Extremely Likely” to recommend us.
13
Standard
Questionnaire
Extremely
Likely
Likely
Neither
Likely or
Unlikely
Unlikely
Extremely
Unlikely
Don’t
Know
100%
0%
0%
0%
0%
0%
92%
0%
0%
0%
0%
0%
98%
2%
0%
0%
0%
0%
2014
Easy Read
Are respondents
likely to
recommend our
Hospice to friends
and family if they
need similar care
or treatment?
Questionnaire
Standard
Questionnaire
2013
Easy Read
Questionnaire
2012
The Hospice was not using the Easy Read Version of the patient
and carer survey questionnaire during this period
This question was not asked on our patient and carer survey
questionnaire during this period
A Sample of Comments made by Patients and Carers
“The service and staff were faultless. I could not have wished for better”
“Staff are wonderful. Couldn’t get through this without the Hospice”
“Respect and privacy along with all round care were excellent. As a nurse myself I have
never observed or experienced care at this high level”
“I was deeply touched overall by the level of care provided to my Dad, even after his death
the nurse treated him with utmost dignity”
“Your staff are caring and compassionate and made my Father’s last days comfortable and
peaceful. Thank you”
14
“My Mother spent one week in the Hospice, first visit and she passed away one week later. I
spent six days with her and could not have asked for anything more in my Mother’s final
days”
“You made the unbearable, bearable. You were patient and non-judgmental when we
became stressed and I became agitated and I’m very grateful for that”
“I tell everyone how wonderful the Haven is. It is well named as it is a Haven for patients and
family. God bless all”
“I appreciate the Hospice staff and facilities. The example the staff set should be bottled and
sold to the hospitals to show them how to treat patients and care for them”
“It is a wonderful place, I have no complaints and can’t fault it. Can’t fault the food, nothing.
Wonderful place”
“I could not praise the staff enough. XXX was well looked after and the whole family was
cared for. The room was very comfortable. Thank you all once again”
“The staff were wonderful and nothing was too much trouble. I was very well cared for in
mind and body and I feel very privileged I was able to stay there. What a wonderful place”
“I was very grateful that Daddy didn’t die in the Hospital, they needed to be more open
about his health as they never really said he was dying. The Hospice helped me greatly”
“It’s a pity that more money isn’t coming to you. What a wonderful place.”
“It is a lovely place. So glad my husband saw sense and went to the Hospice. He went
peacefully”
“Mum said the haven was her cloud, her little piece of heaven. You can’t top that.”
“My husband, brother and friend have all passed in the Hospice. Couldn’t fault anything.
They are all kind and caring. I call them angels”
“Your service is excellent. I couldn’t find anything to improve your service, it is superb.”
“My wife chose to end her days at the Hospice. I thank God she did. She died peacefully
and my family were well looked after.”
“First class care. So much so my father wished to end his days here in a safe, caring
environment, where he and his family knew he would receive first rate care and attention”
“All of the staff went way beyond their duty. I will never stop praising them for the way they
looked after ******”
“Please continue with the special care that gives patients a boost when everything is so
sad”
“Halton Haven is an extremely well managed facility and service, which provided an
excellence in care rarely found these days. Sincere thanks to all the staff”
“There is not one thing I can think of to improve your service. Excellent.”
“I felt comfortable at the Hospice and felt I could go to a quiet place and if I needed
comfort it would be there.”
15
Comments made that initiated a response from the Hospice this past year
“It was lovely that my brother-in-law’s room had access to outside, although I thought the
room itself was quite drab. Only a little observation.”
“The décor is a little tired, but this did not detract from the care, which was fabulous”
The above two comments inspired us to embark on an already identified redecorating project
within the Hospice In-Patient area a little sooner than we had planned, with the aim of
refreshing the rooms and giving them a more contemporary feel. Eight of the twelve Patient
rooms have been completed to date, with the remaining four rooms due to be refurbished in
the near future. Since this project started we have not had any adverse comments about the
Patient Rooms.
“There was no vegetarian option for the main meal”
“Food could be a little more exciting to encourage those who can to eat more”
The Hospice is aware that when it comes to food everyone’s tastes and expectations are
different and even though we would like 100% of survey respondents to say that the food we
serve is excellent or good it is perhaps unrealistic for us to expect to achieve that.
“When in extreme pain medication needs to be given sooner as they are locked away”
The Patient comment above was an observation on the administration of Controlled Drugs at
the Hospice, which legislation, regulations and guidance dictate must be safely locked away.
When Nursing Staff at the Hospice are aware that a Patient is in pain and in need of
medication, they act immediately to administer what is necessary to that Patient. However,
administering a Controlled Drug takes a little longer than a Non-Controlled Drug and this
comment made us aware that maybe not all Patients are aware of this or the reasons why.
We have always encouraged Patients to tell us as soon as possible when they need
medication, so that we can alleviate their symptoms as fast as we can. In light of this comment
Nursing Staff also now explain to Patients the need for Controlled Drugs to be locked safely
away and that they should not let pain or other symptoms become too bad before requesting
such medicines, due to the short amount of extra time it takes to administer them.
“Maybe the beds could be a bit wider (I am comparing to hospital beds)”
“Ensure that longer beds are available immediately for tall patients. My **** was six foot four
inches tall. He was accommodated, but what if another tall patient had come in at the
same time”
Since these comments were made during the past year, the Hospice has replaced 6 of the 12
beds on the In-Patient unit with new bigger beds that can appropriately and comfortably
accommodate Patients. It is hoped that we can raise the necessary funding to replace the
remaining 6 beds during the coming year.
16
Clinical Governance Overview
Halton Haven Hospice recognises its responsibility to provide a governance framework
outlining organisational and individual accountability through which the quality and safety of
the services it provides can be constantly monitored and improved.
The Hospice is committed to creating an environment where continual learning takes place
and excellence in clinical care can flourish. The Hospice has in place efficient systems of
management and processes of continual assessment and change within the organisation to
enable patients to receive safe and effective care of the highest quality.
Our Clinical Governance Overview looks at a variety of areas that we determine to be
indicators of quality:
Complaints
2014
2013
2012
Total
0
1
0
Number Upheld
0
0
0
Number Unsubstantiated
0
1
0
Number Ongoing
0
0
0
The Hospice recognises its responsibility to reflect on complaints and to commit to positive
change where required. It is the policy of the Hospice to address all complaints in a timely
manner and to, wherever reasonably practicable, provide a satisfactory outcome for the
complainant.
Over the past year the Hospice was not in receipt of any complaints about any aspects of the
service we provide.
Healthcare Associated Infections
Infections Developed After
Admission To The Hospice
2014
2013
2012
0
0
0
Once again the Hospice is proud to maintain its record of not developing healthcare
associated infections. However, as reported below, there was one instance of a patient being
transferred to the Hospice with a pre-existing MRSA infection, which did not result in any spread
of infection to other patients.
17
The Hospice takes infection control and cleaning standards very seriously, with regular training
and audit to ensure the safety and wellbeing of everyone at the Hospice.
The Hospice has recently taken the decision not to renew its Service Level Agreement with
Mersey Care NHS Trust for the provision of Infection Control Services and would like to thank
the Trust’s Infection Control Team for their support over a number of years. Infection control will
now be managed in-house with appropriate advice and support from the Three Boroughs
Public Health Infection Control Group, whose meetings the Hospice will attend and report to.
Incidents
2014
2013
2012
Never Events
0
0
0
Serious Untoward Incidents
0
0
0
Clinical Incidents
36
3
10
Non Clinical Incidents
0
1
7
Health and Safety Incidents
4
11
9
Information Security Incidents
2
0
0
This past year has seen a change in the way the Hospice reports Patient Accidents, which
includes slips, trips and falls. These have previously been reported separately from Clinical
Incidents, but this past year saw the Hospice change reporting procedures to include these
accidents in the Clinical Incidents Reporting Procedures. This explains the seemingly large
increase in Clinical Incidents at the Hospice during the past year as 27 of the 36 Clinical
Incidents reported above were patient slips, trips or falls, which were previously reported as
Accidents within the Hospice rather than Clinical Incidents.
The 27 Patient slips, trips or falls did not result in any major injury for any Patient or require
RIDDOR reporting procedures to be initiated by the Hospice.
The other Clinical Incidents include:
•
•
•
medication errors,
an incident involving a blood transfusion,
an incident when a Patient was transferred to the Hospice with a pre-existing MRSA
infection, which was not communicated to us on transfer.
None of these incidents resulted in any patient coming to harm and there was no spread of
infection.
The medication errors were all appropriately reported as Safeguarding concerns to the Local
Authority Safeguarding Team. Action plans following medication errors were put in place by
the Hospice to help reduce the risk of repeat and these were also communicated to the Local
Authority Safeguarding Team, who did not feel it was then necessary to initiate any further
actions.
18
The Health and Safety Incidents were minor accidents Patients had whilst in-patients at the
Hospice, resulting in minor injuries such as grazes or bruises. No RIDDOR reporting was necessary
following these accidents.
The 2 Information Security Incidents were near misses and did not result in any breach of
Confidentiality or further Data Protection issues. Measures were put into place following the
incidents to help reduce risk of repeat.
Safeguarding
Safeguarding Procedures
Initiated by the Hospice
2014
2013
2012
6
4
1
The Director of Care and Operational Services, who is also the Registered Manager at the
Hospice, made six notifications to the Local Authority Safeguarding Team during 2014 – 2015.
These notifications were in respect medication errors at the Hospice and also Deprivation of
Liberty Safeguard applications.
Action plans put in place by the Hospice following medication errors, to help reduce the risk
of repeat, were communicated to the Local Authority Safeguarding Team, who did not feel it
was then necessary to initiate any further actions.
The increased number of safeguarding procedures initiated by the Hospice are a result of the
Hospice having a more robust understanding of safeguarding issues and responsibilities in
regard to reporting, which we feel increases the safety of patients at Halton Haven Hospice.
Medicines and Healthcare Products Regulatory Agency (MHRA) Alerts
Alerts Requiring Action by the
Hospice
2014
2013
2012
0
2
3
The Hospice has in place systems to receive and take action on MHRA alerts as required. Over
the last year there were many alerts received from MHRA, none of which resulted in the
Hospice being required to take action to rectify any problems with medicines or medical
devices used at the Hospice.
There has, however, been 1 NHS England Patient Safety Alert requiring action by the Hospice.
This was a Stage One: Warning regarding risk of asphyxiation by accidental ingestion of
fluid/food thickening powder.
The Hospice does use thickening powders and following receipt of this alert has put into place
appropriate measures to reduce the risks of accidental ingestion by patients.
19
Audits
The Hospice conducts internally initiated audits of various areas of service provision as part of
our clinical governance framework. There is an audit schedule within which audits are
completed on a monthly, quarterly or annually basis.
Audits are used to determine whether good practice is being delivered at the Hospice and
results would be used to populate the Hospice Risk Register as appropriate.
Members of staff at Halton Haven Hospice have conducted internal audits throughout the
past year within the following areas;
•
•
•
•
•
•
•
•
•
•
•
Medication
Medical Officer Recording
Case Notes
Data Protection
Accidents
Infection Control
Food Standards
Health and Safety
Mattresses
Spiritual Care
A Programme of various Clinical Audit against Merseyside and Cheshire Palliative Care
Network Audit Group Standards and Guidelines.
We are pleased to be able to report that audits conducted over the past year have not
resulted in any major action plans.
Policies and Procedures
Halton Haven Hospice has developed a policy review schedule, which looks to ensure that all
policies and procedures at the Hospice are updated and maintained in a timely manner, to
keep them contemporaneous with current, relevant legislation, standards and guidelines.
The policy review schedule is managed by the Hospice Quality Assurance Team, who have,
over the past year, ensured that each month the scheduled policies have been reviewed and
appropriately updated. Our Schedule is intended to be somewhat flexible in order to ensure
that it is responsive to changes in legislation.
During this period the Quality Assurance Team have introduced Policy Review Alerts. Each
month these Alerts are distributed amongst Hospice Teams to be cascaded down to individual
staff. The Alerts give information on which policies have been reviewed and updated each
month and highlight new Policies that staff need to make themselves aware of.
This past year has seen a major review of all the Hospice’s Medicines Policies and Procedures
to bring them all into one overarching Medicines Policy. This Policy is currently going through
our ratification process and it is hoped will be ready to be rolled out very shortly.
Another project this past year has seen the Quality Assurance Team working to producing Easy
Read versions of a number of our Policies in order to make them accessible to the largest
number of people possible.
All policies and procedure are discussed at the Hospice Clinical Governance Meetings and
are further ratified by appropriate members of the Executive Management Team.
Halton Haven Hospice staff are required to adhere to policies and procedures at all times in
order to minimise any potential risks to the patients, other staff members or the Hospice as a
whole.
20
Care Quality Commission Report
The Hospice is regulated by the Care Quality Commission (CQC) and it is their job to check
that the services we provide meet essential standards.
During the reporting period covered by this Quality Account Halton Haven Hospice has not
been inspected by CQC.
The Care Quality Commission last inspected the Hospice on the 25th of July 2013. This was a
routine, unannounced inspection that looked at the following standards;
•
•
•
•
•
Consent to care and treatment
Care and welfare of people who use services
Cleanliness and infection control
Supporting workers
Records
Following the inspection in 2013 the Hospice was found to have met all of the inspected
standards and the subsequent report to verify this was published in August 2013. A summary
of the findings can be found below;
How we carried out this inspection:
We looked at the personal care or treatment records of people who use the service, carried out a visit
on 25 July 2013, observed how people were being cared for and checked how people were cared for
at each stage of their treatment and care. We talked with people who use the service, talked with carers
and/or family members and talked with staff.
What people told us and what we found:
Patient’s confirmed they were pleased with the standard of care they received from all the staff. Patients
told us nursing staff and medical staff were available at all times for support and to answer questions they
had. They were overall very positive about the care and attention they were receiving. They made
various positive comments such as, ‘we couldn’t be any better cared for the staff are wonderful’ and
‘the staff are fantastic they discuss everything with you’.
Infection control procedures were in place to ensure continued good standards of hygiene which helped
to minimise risks to patients.
We looked at a number of records regarding the ongoing management of the Hospice to ensure patient
safety. Records seen were kept secure, accurate, fit for purpose and managed effectively to protect the
safety and wellbeing of the patients and others.
The Hospice had a variety of information leaflets about the service available throughout the building
including the reception area. The manager had displayed the results of a recent patient survey in
reception to share with everyone the results of what people had told them. They also had a patient
comment box for anyone to make suggestions about the service at any time during their stay. These
initiatives helped to keep everyone informed about the Hospice and also tried to include people’s
comments and suggestions in the ongoing development of the Hospice.
The full report is available at www.cqc.org.uk
21
Equality and Diversity
It is a requirement of the Equality Act (2010) that Halton Haven Hospice demonstrates due
regard for the following three aims;
1. Eliminate unlawful discrimination, harassment, victimisation and any other conduct
prohibited by the Act.
2. Advance equality of opportunity between people who share a protected
characteristic and people who do not share it.
3. Foster good relations between people who share a protected characteristic and
people who do not share it.
Demonstration of Due Regard
1.
Eliminate unlawful discrimination, harassment, victimisation and any other conduct
prohibited by the Act
Halton Haven Hospice recognises that while we cannot solve the problems of discrimination
within wider society, we aim to take practical steps to minimize the potential of it occurring
within our own organisation.
To help us to achieve this, we acknowledge our responsibility to equality and diversity and to
adhere to the various Acts of Parliament and the European Union that governs this. The
Hospice is committed to promoting equality, embracing diversity and views fair treatment not
only as a legal duty but as a moral responsibility and business imperative. We are committed
to providing equality for all, with our services being open to all sections of the local community
and by having a workforce that is representative of the communities from which it is drawn.
Halton Haven Hospice will not tolerate any kind of direct or indirect discrimination, harassment
or oppressive practices and is committed to eliminating these wherever possible.
To actively demonstrate commitment to this, the Hospice has a number of equality and
diversity policies in place for both staff and service users. There is also a comprehensive equality
impact assessment within each of the Hospices policies and procedures. Any breach of
Hospice policies and procedures is taken very seriously and can lead to disciplinary action and
possible dismissal.
In addition to this, the Hospice adheres to a robust recruitment system which aims to ensure
fair treatment for all and all Hospice employees will attend in house equality and diversity
training.
2.
Advance equality of opportunity between people who share a protected characteristic
and people who do not share it.
At Halton Haven Hospice no one, staff or service user, receives less favourable treatment on
the grounds of disability, gender, age, religion or belief, race, sexual orientation, gender
reassignment, marriage and civil partnership status, pregnancy and maternity status,
nationality, caring responsibilities, political opinion or part time/fixed term working status.
Furthermore, no one is disadvantaged by unjustifiable provisions, criteria or practices. This
commitment extends to all areas of employment e.g. recruitment and selection, pay, benefits
and other terms and conditions of employment; supervision and performance, appraisal,
opportunities for promotion/transfer, access to training, discipline and dismissal (including
redundancy and retirement) and also to all areas of our service provision.
22
It is the policy of Halton Haven Hospice to recruit and promote people on the basis of their
suitability for the role, as defined by a comprehensive and up to date job description and
person specification. Vacancies are advertised to the widest possible audience and utilise
sources that, as far as is reasonably practicable, ensure that all sections of the community
have the opportunity to apply. All applicants for employment or volunteering vacancies
receive an equal opportunities monitoring form as part of the recruitment process.
If under-representation of any particular group (e.g. disabled people, people from ethnic
minorities or people of a certain gender or age) is found we will, where appropriate, make
every effort to:
•
Include a statement in our job advertisements, positively encouraging people from
those groups to apply;
•
Ensure our job advertisements reach them;
•
Consider using targeted or specialist media for our job advertisements;
•
Consult specialist agencies, such as Job Centre Plus, for advice;
•
Make sure the criteria for selection are entirely job-related;
•
Review and revise the organisation’s policies, practices and procedures; and consider
taking positive action to provide training specifically for under-represented groups
In line with current legislation, Halton Haven Hospice reserves the right to take positive action
that will help or encourage people who share a protected characteristic to gain employment
or benefit from service provision on an equal basis to those who do not share a protected
characteristic.
3.
Foster good relations between people who share a protected characteristic and people
who do not share it.
In addition to all of the details noted above, the Hospice provides ‘Spiritual Care’ training to
make staff aware of the different spiritual needs of patients and their families from varying
cultures and religions. It is hoped that this increased awareness and understanding leads to
better relationships and more positive outcomes for all concerned.
The Hospice also has a policy and procedure in place to make sure that the kitchen is aware
of the dietary requirements of each patient whatever their personal needs, whether this is due
to allergies, intolerances, cultural or religious requirements or simply due to personal
preference.
Equality Objectives 2013 – 2017
It is a requirement of the Equality Act (2010) that Halton Haven Hospice works towards a
specific and measurable set of equality objectives every four years. Between April 2013 and
March 2017 the Hospice will work towards the following three targets;
•
•
•
To actively recruit more male nurses, as this group are currently under represented
within both the In–patient and Day Hospice services.
To continue to promote the work of the Hospice across the local community in ways
that are accessible to as many people as possible.
To continue to provide the highest quality palliative care services to people from the
local community, irrespective of the absence or presence of protected characteristics.
23
Community Engagement
As always Community Engagement is an important activity for Halton Haven Hospice. The
Hospice provides a core service for the community of Halton, which includes Specialist
Palliative Care and End of Life Care through the In - Patient Unit and Day Hospice. These offer
multi – disciplinary treatment and support for patients and their families referred for direct
service provision.
However, it is our belief and our commitment that the role of the Hospice extends beyond the
provision of our core services, with Halton Haven Hospice looking to engage with the local
community through information, consultation, involvement, collaboration and empowerment.
Halton Haven Hospice uses these aspects of community engagement to provide the
underpinning framework for its activities in the local community.
We aim to be the local source of expert, balanced and objective information on end of life
care issues and through consultation with stakeholders, working in partnership and through
collaboration, empower the local community to make informed decisions on end of life care.
Working together we can identify concerns and aspirations and develop preferred solutions.
The following are examples of how we have taken the work of the Hospice out into the local
community and engaged with the people of Halton;
Advanced Care Planning
The Advance Care Planning Team is a pivotal link in providing support and education on the
issues surrounding end of life care planning. The team encourages professionals to share their
knowledge of Advanced Care Planning tools that support people and their families who are
living with a terminal illness in Halton, with the aim of helping to provide choice at end of life.
This work includes working in the community to help improve end of life care through:
•
•
•
•
•
•
Education and training
Co-ordination between services
Raising awareness of end of life issues amongst other professionals in the Borough,
Improving working across organisational boundaries
Supporting the implementation of all recognised end of life care tools
Looking to ensure that the tools are available and in use in the right settings, for the
benefit of the patients and their carers in Halton.
The team has worked with health and social care professionals in the local community who
deliver end of life care to help ensure best practice.
Bereavement Support Drop In Centres
Halton Haven’s Family Support Team offers one to one bereavement support to the families
that use our service. However, we are aware that not everyone who is bereaved requires one
to one support and we, therefore, facilitate bereavement drop-in support groups. These
groups aim to offer peer support to group members in a safe and friendly environment, which
helps to build a sense of belonging, confidence and empowerment, things often lost following
bereavement.
24
Patient and Carer Support Groups
The Hospice’s Family Support Team also run Support Groups, for both patients and carers, to
provide each the space and time to talk, ask questions, to share their experience, to relax or
just take a little bit of time out from their usual routine.
These Patient and Carer led groups are a means for the Hospice to offer and deliver help,
information and advice on things such as looking after yourself, financial matters, welfare
rights, employment rights for carers, legal issues such as power of attorney, lasting powers and
wills, stress management, symptom management advice and spiritual and emotional support.
Dying Matters Events
The Hospice continues to support the annual, national “Dying Matters” week events that took
place in Halton. The aim of this is to try to change public knowledge, attitudes and behaviours
towards dying, death and bereavement.
We do not believe that talking about these things brings death closer; our message being that
it’s about planning for life and without communication and understanding death and terminal
illness can be a lonely and stressful experience, both for the person who is dying and for their
friends and family.
The Hospice is keen to play its part in raising awareness of this and hopefully get local people
thinking and talking about death and dying, particularly about what their own wishes at that
time might be.
Men’s Shed
The Hospice’s Men’s Shed has been one of our priorities over this past year. Having successfully
set this service up within our new Family Support Centre, we wanted then to ensure that it was
utilised by as many men as possible who might need it.
Men’s Shed is a fairly new concept in this country and we have set up the first within a Hospice
in the UK. It is intended to be a place where bereaved men have time and space to reflect
and think, to interact with other men going through similar experiences, in a way that is natural
to them. This can have huge health benefits and meet the unanswered needs bereavement
brings to men.
It is hoped that the Men’s Shed within Halton Haven can give men in the local community
renewed purpose following the death of their loved ones. We have provided a review of how
this new service is doing in the “Review of Priorities 2014 – 2015” section of this Quality Account.
Relationship with Media
Halton Haven Hospice continues to have a very good relationship with the local media and
as a result of this Hospices activities are well represented in the local press. This is an important
relationship for the Hospice as it provides a means for getting our messages across to the local
community and encouraging involvement.
The Hospice also utilises the internet through the use of the Hospice website and online social
media sites such as “Facebook” to ensure the Hospice’s messages reach the widest possible
audience.
25
Relationship with Halton Borough Council
The Hospice has continued to enjoy a good, supportive relationship with Halton Borough
Council. Elected members have been invited to visit the Hospice each month and Officers of
the Council have given valuable, practical support in running events, such as the Santa Dash.
Relationship with Halton Clinical Commissioning Group
The Hospice and Halton Clinical Commissioning Group (CCG) continued to work closely and
collaboratively during 2014/2015. Aside from regular quarterly commissioning meetings the
Hospice has been involved in a number of CCG projects including:
• CCC public engagement events
• NHS Improving Quality Initiative
• CCG radio shows on Halton Radio
Particularly welcome has been the CCGs continued support for and close interest in our
innovative Men’s Shed project.
Hospice Shops and Recycling Centre
The Halton Haven Hospice shops in Runcorn, Widnes and Frodsham and the recycling centre
in Runcorn continue to provide the local community with a means of recycling unwanted
items. These retail outlets extend the Hospices presence in the community and provide links
through which local people can engage with us.
The shops are of course a valuable fundraising activity for the Hospice, but they also fulfil a
social role in providing sometimes much needed opportunities for retail bargains in the local
community. They are also providing volunteering opportunities for local people, which can
help to reduce isolation for many within the Borough.
Hospice Volunteers
Halton Haven Hospice has always recognised and valued the contribution that the local
community makes to the delivery of Hospice services in a voluntary capacity. The general
public, patient’s relatives and friends have provided help and support as volunteers in many
areas of the Hospice since it was originally founded, which has contributed to allowing us to
provide much needed end of life care to the community of Halton.
The Hospice encourages the involvement of individuals from the local community who wish to
work with the Hospice in a voluntary capacity and looks forward to engaging with more
people in this way for many years to come.
Patient and Carer Representative
The Hospice has recently recruited a new volunteer patient/carer representative, whose role
within the Hospice community is to gather anecdotal feedback, through talking to Patients
and Carers at the Hospice and representing their views within the Hospice’s Governance
framework. This is an important role that gives patients and their families another way through
which to voice their opinions about Halton Haven Hospice and the services we provide. It is
intended that this will help to ensure that patient/carer views are heard within a forum which
can take action upon them as appropriate and the Hospice can improve the quality of its
services.
26
Hospice Organised Events
We view the local community of Halton as being a joint funder of Hospice services through
participation and involvement in the many Hospice organised events and fundraising activities
that take place throughout each year.
The raising of money to help fund services gives people in the local community the opportunity
to work together with us and provides a sense of involvement and ownership in those who
have generously taken part.
There were many successful events and activities over the past year and through our
Fundraising and Events Team the Hospice looks forward to organising more exciting activities
throughout the coming year.
Halton Haven Hospice aims to continue with its community engagement activities over the
coming year and will look to engage with and involve an ever greater number of local people
in what we do.
It is our aim to show people that this is their Hospice, to which they can contribute in many
ways and be proud of what we achieve together.
27
Priorities for Improvement 2015-2016
Constant reviews of service provision help to identify and inform the development of priorities
for future improvement at Halton Haven Hospice, which takes into account national and local
policy, concerns and aspirations of our service users, our staff and our partners, along with
statutory obligations.
Halton Haven Hospice has identified three Priorities for Quality Improvement for 2015 – 2016 as
follows:
PRIORITY ONE - Patient Safety - Introduction of an E-Learning Programme for Staff
E-learning is increasingly used in healthcare training, education and practice development,
with the technologies used in this method being able to enhance the learning opportunities
for those involved. E-learning may be unable to provide some types of necessary learning
experience, but research suggests that the technologies commonly used as part of online
learning can help in ways that face to face teaching sometimes cannot.
There is no single agreed definition of e-learning, but it generally refers to internet based forms
of learning, rather than face to face interaction and where traditional methods of learning are
supported by online resources. The properties intrinsic to the technologies used in e-learning
allow for more flexibility and can provide a safe environment where learning can take place
and mistakes can be made without harming patients.
This coming year Halton Haven Hospice plans to introduce an e-learning programme for staff
into its existing Training and Education Programme, to run alongside the successful face to
face learning that already takes place. This will help to achieve our aim of providing staff with
even further opportunities for development and the enhancing education and training of staff,
which will benefit the safety of patients at the Hospice.
The introduction of e-learning at the Hospice will be managed through our Training and
Education Department, who will source the most appropriate programmes and will monitor
the success of the project over the coming year.
PRIORITY TWO - Patient Experience - Taking the “15 Step Challenge”
15 Step Challenge was identified by the Hospice, via the “NHS Institute for Innovation and
Improvement”, as a means of gaining more feedback on Patient experience of our service. It
specifically looks at first impressions and was originally developed as a reaction to a comment
a Hospital Patient’s mother made, as follows:
“I can tell what kind of care my daughter is going to get within
15 steps of walking on to a ward”
The Hospital where this took place decided it wanted to rise to the challenge and developed
a tool / resource along with patients, service users, carers, relatives, volunteers, staff, governors
and senior leaders, to help look at care in a variety of settings through the eyes of patients and
service users, which could capture what good quality care looks, sounds and feels like.
Halton Haven intends to introduce this initiative at the Hospice this coming year to gain
feedback on what peoples first impressions of us are.
28
First impressions count:
• First impressions give us our initial feeling about any situation. When we first arrive on
a ward, does it inspire confidence in the care that we are about to receive?
• What makes us trust a care environment? What makes us feel that we will be safe
and cared for?
• What are the first clues to high quality care?
• What does “good” look, feel, sound and smell like?
The 15 Steps Challenge can help staff, patients and others to work together to identify
improvements that can be made to enhance patient experience at the Hospice. The idea is
to see the Hospice as if through a patient’s eyes. Does the environment build confidence and
trust? The Challenge Teams will gather impressions for feedback to us focussing on the
following areas:
•
Welcoming
•
Safe
•
Caring and Involving
•
Well organised and calm
The 15 Step Challenge tool contains a guide to help structure observations of the environment,
which is underpinned by the Care Quality Commission’s Fundamental Standards. The
Challenge Team will walk around and observe the environment, observe interaction with
patients, and talk to patients and visitors to get their views and impressions. They will also talk
to and ask questions of staff.
After the walk around, the 15 Steps Challenge team feeds back to the Hospice what their first
impressions were, both positives and recommendations. Feedback will focus on good practice
to share, and areas for improvement. We hope to highlight what is working well and what
might be done to improve first impressions and increase patient confidence.
This feedback can:
• be used to help hear how patients view the Hospice and care, bringing a stronger
patient voice into the care that we provide.
• identify areas for improvement from a patient perspective, which will support better
patient experience
•
identify issues in advance of CQC inspections
•
support continuous improvement.
It is intended that The Challenge is repeated on a regular basis to ensure that improvements
are being progressed. Action Plans developed as a result of 15 Step Challenges will be
monitored and reported upon by the Hospice Quality Assurance Team.
29
PRIORITY THREE - Clinical Effectiveness – Work alongside Halton Clinical Commissioning Group
to Facilitate the Implementation of EMIS Clinical Systems at Halton Haven Hospice.
“EMIS clinical systems are already used by over 5,000 healthcare organisations across the UK,
from GP practices and out-of-hours services, to community care and sexual health services.
By using the same system, everyone can access the same information about their patients no matter where they are treated - making the prospect of integrated care a reality. With
over 25 years' experience of working with the NHS, we're entrusted with over 40 million
patient records. We also have one of the largest support and training teams, with more than
350 staff supporting our customers.” From EMIS website.
EMIS clinical systems are already in use by GP surgeries throughout the Borough of Halton and,
along with Halton Clinical Commissioning Group, the Hospice has identified that using the
same system at the Hospice would increase clinical effectiveness and enhance Patient care,
not just at Halton Haven but within the Borough.
Using EMIS at the Hospice would provide an easy and intuitive system through which real time
patient data was available to our clinical team and to other health professionals involved in a
Patient’s care within Halton, enabling informed clinical decisions to be made in an enhanced,
efficient and effective manner.
To achieve this we will work with Halton Clinical Commissioning Group to facilitate the
implementation of EMIS here at Halton Haven.
This project will be monitored by the Hospice Executive Management Team.
30
Statements on This Quality Account
The following organisations were offered the opportunity to comment on this Quality Account:
•
Healthwatch Halton
•
Health Policy and Performance Board
•
Halton Clinical Commissioning Group
At the time of publication Halton Haven Hospice has received the following statements on this
Quality Account:
Healthwatch Halton Statement on the
Quality Account of Halton Haven 2015
Healthwatch Halton appreciates Halton Haven’s commitment to producing the report and
members welcomed the opportunity to comment on your Quality Account for the year 201415.
The Account is clear, easy to follow and informative.
We are pleased to note that most of last year’s priorities have been achieved, but as
mentioned last year, we would have welcomed a simple table, preferably colour-coded, to
say whether the priorities were fully met; partially met or not met, together with some statistics
or narrative demonstrating progress.
Last year members approved the innovative idea of a ‘Men’s Shed’ and we are pleased to
hear of the project’s success during the past year. We note that the proposed Lymphoedema
service was unfortunately not funded, but we welcome the Haven’s continued commitment
to working with partners to develop this service in future.
The increase in clinical incidents, explained by a change of reporting procedures, still
contained a number of medication errors, which concerned us, but we are pleased to note,
that they were reported and acted on to the satisfaction of the Local Safeguarding Team.
The work carried out by the Haven to elicit and then act on feedback from patients and carers
is to be applauded as is the development of an ‘easy-read’ version of the patient & carer
survey. We also appreciate the Quality Assurance Team producing Easy Read versions of the
organisation’s policies.
We acknowledge the excellent response from patients and carers on their satisfaction with the
services Halton Haven Hospice provides.
Members applaud the efforts of the Trust to involve service users, staff and partners in informing
the choice of priorities for 2015-16.We note the choice of priorities and hope the
implementation of the EMIS Clinical System will enhance patient care, not just at the Haven,
but throughout the Borough.
The Haven is to be congratulated again on its continued involvement with the local
community and businesses that not only take part in fund-raising activities but also provide
volunteers who give their time to support the Haven.
Yours sincerely,
Doreen Shotton
QA Lead – Healthwatch Halton.
31
Health Policy and Performance Board Statement on the
Quality Account of Halton Haven 2015
Further to receiving a copy of your draft Quality Accounts, I am writing with the Health Policy
and Performance Board comments. The Health Policy and Performance Board particularly
noted the following key areas:
During the year 2014/15 the Trust identified a number of priorities to be achieved during this
year. The Board noted the following:
•
Patient Safety – The Board were pleased that the Hospice had recruited a new
Patient and Carer Representative who attends the Hospice to visit patients on the InPatient Unit, Day Hospice and at the Patient and Carer Support Groups. This is a
good development and the Board will be interested to hear progress in this area.
•
Patient Experience – The Board were pleased to note the success that the Men’s Shed
at Halton Haven is having, supporting 60 men through difficult periods of their lives.
From Area Forum Funding, the Board are pleased to hear that the Hospice is now able
build upon the Men’s Shed initiative with the addition of a purpose built 20ft by 30ft
workshop, so that more men can be supported in the future.
•
Clinical Effectiveness – The Board were disappointed to note that the Hospice’s
business case for the development of a Lymphoedema Service to the CCG was not
successful for this year. It is good to note that the Hospice remains committed to
working with partners to provide this Service and remains open to discussions on this
project in the future.
The Board are pleased to note the following Improvement Priorities for 2015 – 2016:
•
Patient Safety - Introduction of an E-Learning Programme for Staff – the Board were
pleased to note the introduction of the e-learning programme for staff, in conjunction
with the face-to-face training and development that already exists. E-learning can be
a good addition to other delivery methods of training.
•
Patient Experience - Taking the “15 Step Challenge” – The Board were really interested
to hear of the new initiative being implemented this year where people’s first
impressions, e.g. within their first 15 steps into the Hospice are captured. The Board feels
that this will be an important tool to help future continuous improvement at the hospice
and bringing a stronger patient voice into the care that is provided.
•
Clinical Effectiveness – Work alongside Halton Clinical Commissioning Group to
Facilitate the Implementation of EMIS Clinical Systems at Halton Haven Hospice – the
Board were pleased to note the developmental work with the NHS Halton CCG in terms
of the EMIS clinical system. This not only shows good joint working, but also consistency
across the borough with the use of the system.
The Board would like to thank Halton Haven Hospice for the opportunity to comment on these
Quality Accounts.
Yours sincerely,
Councillor Joan Lowe
Chair, Health Policy and Performance Board
32
Feedback
Feedback about our Quality Account is very welcome. If you have any comments or
queries please do not hesitate to contact;
Chair of Trustees
Halton Haven Hospice
Barnfield Avenue
Murdishaw
Runcorn
Cheshire
WA7 6EP
33