Hartlepool Hospice Ltd is the trading name of Hartlepool & District Hospice
Alice House, Wells Avenue, Hartlepool, TS24 9DA
Telephone: 01429 855555 * Email: enquiries@hartlepoolhospice.co.uk * Website: www.hartlepoolhospice.co.uk
CONTENTS
PART 1: STATEMENTS OF QUALITY FROM THE CHIEF EXECUTIVE & CHAIRMAN
3
PART 2: PRIORITIES FOR IMPROVEMENT 2015/2016
STATEMENT OF ASSURANCE FROM THE BOARD
5
AND
MANDATORY
2.1
INTRODUCTION
5
2.2
FUTURE IMPROVEMENT ASPIRATION 2015/2016
6
2.2.1 Priority 1 – Patient Safety
2.2.2 Priority 2 – Clinical Effectiveness
2.2.3 Priority 3 – Patient Experience
6
7
8
PROGRESS ON IMPROVEMENT PRIORITIES FOR 2015/2016
9
2.3
2.3.1
2.3.2
2.3.3
2.3.4
2.4
Priority 1 – Clinical Effectiveness, Patient Experience
Priority 2 – Clinical Effectiveness, Patient Experience
Priority 3 – Patient Experience, Clinical Effectiveness, Patient Experience
Priority 4 – Patient Safety, Clinical Effectiveness
9
10
11
12
MANDATORY STATEMENT OF ASSURANCE FROM THE BOARD
12
2.4.1
2.4.2
2.4.3
2.4.4
2.4.5
2.4.6
2.4.7
2.4.8
13
13
13
13
14
14
14
15
Review of Services
Participation in Clinical Audit
Research
CQUIN Payment Framework
Statement from Care Quality Commission
Data Quality
Information Governance Toolkit Attainment
Clinical Coding Error Rate
PART 3: REVIEW OF QUALITY PERFORMANCE
15
3.1
PATIENT SAFETY
15
3.1.1 Incident Report and Risk Management
15
CLINICAL EFFECTIVENESS
17
3.2.1 Hospice Performance Against National Council for Palliative Care
Minimum Dataset
3.2.2 Key Performance Indicators
3.2.3 Local Audits
3.2.4 Clinical Governance
17
PATIENT, CARER, STAFF & VOLUNTEER EXPERIENCE
20
3.3.1
3.3.2
3.3.3
3.3.4
3.3.5
3.3.6
3.3.7
3.3.8
3.3.9
3.3.10
3.3.11
20
20
20
20
20
21
21
22
23
23
23
3.2
3.3
3.4
Staff Experience
Sickness & Absences
Staff Satisfaction
Mandatory Training
Clinical Supervision
Board Development
Volunteers’ Experience
Education & Training
Awards
Complaints
Other Comments from Partners & Stakeholders
SUPPORTING STATEMENTS FROM PARTNERS & STAKEHOLDERS
Hartlepool & District Hospice Quality Accounts 2014/2015
18
19
19
25
Page 2 of 27
PART 1: STATEMENTS OF QUALITY FROM THE CHIEF EXECUTIVE AND
CHAIRMAN
CHIEF EXECUTIVE’S STATEMENT
Hartlepool & District Hospice strive to work with commissioners and other
providers to ensure that the wider health needs of the community are met
either through Hospice specific innovations or through partnership working.
This year sees the completion of major building works that have enabled a
range of new services to be delivered in appropriate and complementary
facilities for both cancer and non-cancer patients.
Hartlepool & District Hospice is a Consultant led specialist palliative care unit
which provides training and supervision to a whole range of health
professionals including Specialist Trainees, GP Trainees, Junior Doctors (F2),
Student Nurses, Counsellors and other allied health professionals. This level
of expertise ensures that the most complex patients are cared for in an
environment that meets both their and their family’s holistic needs and
supports care in a range of settings. Our expertise ensures service users are
prevented from unnecessary hospital admissions and are able to achieve their
Preferred Place of Care (PPC).
2015 saw the completion of a three year strategy and the new strategy focuses
on three major service objectives which encompass all Hospice activities,
ensuring that patients receive excellent compassionate care.
Hartlepool & District Hospice is also available as an expert resource for all
other providers to call on for advice, training and guidance to ensure a high
quality of care for all regardless of place of delivery.
These Quality Accounts have been prepared taking into account the views of
the Board of Trustees and service users and their families. The Hospice is
committed to using innovative practice to develop its services and work in true
partnership with our commissioners, local community and other healthcare
providers to ensure that patients and their families receive outstanding
palliative and end of life care.
Tracy Woodall
Chief Executive
May 2015
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 3 of 27
CHAIRMAN’S STATMENT
On behalf of the Board of Trustees at Hartlepool & District Hospice, I am happy
to endorse these Quality Accounts and pledge our commitment to the
continuous improvement of clinical services.
I am fully involved with activities at the Hospice and work closely with the
Senior Management Team to drive strategic and operational activities for the
benefit of members of our communities who may need to use our services for
a variety of reasons.
I am confident that the care that is delivered at the Hospice reflects our values
of dignity and compassion and is a beacon of excellence for anyone who
wishes to learn from us or work in partnership with us.
The Hospice has changed and grown over the last year and as such has been
able to provide a much larger range of services and support to patients who
would not traditionally use Hospice facilities. In my view and that of the Board
of Trustees this is our way of thanking the amazing people and businesses of
Hartlepool and East Durham who support us financially and enable this
wonderful place to provide care for people at their most difficult times.
We look forward to continuing this provision in the year ahead and making a
difference to people’s lives.
Ray Priestman
Chair of Trustees
May 2015
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 4 of 27
PART 2: PRIORITIES FOR IMPROVEMENT 2015/16 AND
STATEMENT OF ASSURANCE FROM THE BOARD
2.1
MANDATORY
INTRODUCTION
Hartlepool & District Hospice was established in 1980 as a local charity
delivering specialist palliative care to individuals affected by life limiting
illnesses within the local communities of Hartlepool and East Durham. The
Hospice is Consultant led and supported by a Multi-Disciplinary Team of
professionals who provide patients with individualised care, whilst promoting
and maintaining the best quality of life possible.
The services are designed to meet the health care needs of the local
community and include:






Inpatient Unit
Day Hospice
Outpatients Clinics
Counselling & Support Services
Therapeutic Services
24 hr Helpline
NICE Guidelines 2004 (Improving Supportive & Palliative Care for Adults
with Cancer) state that providers should offer a range of services that meet
the individual’s physical, environmental, spiritual and social support and
improve quality of life. The Hospice ensures that patients and their families
receive excellent care from diagnosis to post bereavement which is based
around their holistic needs. This is achieved through a whole range of
services for both cancer and non-cancer patients, promoting the philosophy
of living life to the full.
It is the Hospice’s Vision to ensure that ‘every person, to the last moment of
their life has the right to dignity, respect, support and care’ and our Mission
‘to provide services that add value to life and make a difference to patients
and their families’.
As the future of Hospice care evolves in the constantly changing health
environment, we have developed working relationships that ensure cross
organisational integration and representation through different working
groups to identify pressures and inadequacies in the healthcare system and
to generate innovative solutions to patient service problems.
The Quality Accounts will demonstrate the standard of service delivery and
innovative practice implemented in partnership with the local Clinical
Commissioning Groups (NHS Hartlepool & Stockton-on-Tees CCG and
Durham, Dales, Easington & Sedgefield CCG) during 2014/15. The Hospice
has developed a new Strategy for 2015 to 2018 which will underpin our
future priorities.
Please note that the Quality Accounts do not include non-clinical quality
initiatives, such as fundraising, administration and finance.
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 5 of 27
2.2
FUTURE IMPROVEMENT ASPIRATIONS 2015/16
The Hospice has developed the following improvement aspirations with the
involvement of service users including patients, their carers and volunteers
and this is demonstrated within the three domains of quality; namely Patient
Safety, Clinical Effectiveness and Patient Experience.
2.2.1
Priority 1 – Patient Safety
To improve the standards of medicine safety.
2.2.1.1 How the priority was identified
Patient safety is high on the government and local commissioning partners’
agendas. The Hospice will be undertaking the CQUIN indicator for medicine
safety during 2015/16 which, based on an analysis of clinical incidents, has
been identified as an area to improve best practice.
2.2.1.2 How the priority will be achieved
The Hospice will ensure that reconciliation of medications is carried out
within 24 hours of the patient being admitted. This will include a formal
checking process utilising a reconciliation tool to cross reference the
patient’s medication. The reconciliation tool once completed will have
performed three separate checks, minimising the risk of errors involving
medications. It will ensure that the patient is receiving all of the medications
prescribed prior to being admitted, if appropriate and that they are prescribed
at the correct dose.
Improvements will also be made around obtaining a patient’s allergy status
and this will be documented appropriately. There will also be a commitment
to a reduction of omitted doses of medication including medicine
optimisation.
2.2.1.3 How the priority will be measured
A quarterly audit will be conducted on the reconciliation tool to identify that
every patient has been reviewed on admission. The Hospice will be working
towards an improvement target of 100% of patients having a reconciliation
starting within 24 hours and a 100% reduction in missed transcriptions.
Audits will be conducted and comparisons made to the previous year’s data
in relation to the patient’s allergy status and omitted doses of medication.
The audits will be governed through the Medicines Management Group and
agreed changes to practice within the clinical areas implemented to improve
best practice. This will also apply to the use of a baseline assessment tool
for medicines optimisation which will underpin the NICE Medicine Practice
Guidelines.
2.2.2
Priority 2 – Clinical Effectiveness
To create a sustainable programme of clinical best practice through the
introduction of LINK Nurses.
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 6 of 27
2.2.2.1 How the priority was identified
As a small independent Hospice, it is vital that we ensure our clinical staff
maintain a sound knowledge and understanding of clinical best practice to
deliver a high standard of quality care. It is not only the responsibility of the
organisation but also of individual professionals under their Code of
Professional Conduct to ensure the safe and effective delivery of care. The
Hospice is committed to ensuring best practice in all clinical activities by
keeping up-to-date with current research and changes in clinical
management in palliative care.
2.2.2.2 How the priority will be achieved
A LINK Nurse framework will be developed which will identify professionals
who have expressed an interest in a speciality and a formal link to specialist
team members. Each member of the Nursing Team will become a LINK
professional for a specific area, which will fall under the three areas of
clinical tasks, interventions and healthcare advancements. This may include
areas such as catheterisation, dressings and tissue viability, chemotherapy
or advancements in illness progression such as motor neuron disease. The
LINK professional will be required to communicate with other healthcare
professionals to seek updates, advice and support where required. The LINK
professional will be expected to research areas to improve practice and
share information within the Clinical Team. This will be demonstrated
through creating a resource file, presenting findings at the Clinical
Governance Group or conducting short teaching sessions.
2.2.2.3 How the priority will be measured
The Hospice will create a matrix of LINK professionals which will be
supported by an action plan and monitored by a Clinical Manager. The
matrix will be updated in each quarter to identify any changes in practice and
to ensure that evidence has been communicated with the appropriate
professionals and minuted with the appropriate governance group. The
matrix will be utilised when conducting the individual LINK professional’s
contact meetings and appraisals to ensure that they are achieving their
objectives. The LINK professionals’ matrix will become a regular item on the
Clinical Governance Agenda to ensure that all recommendations for
improvements in best practice are discussed, agreed and reviewed.
2.2.3
Priority 3 – Patient Experience
To improve the Hospice journey for dementia patients.
2.2.3.1 How the priority was identified
Dementia is currently high on the government agenda, with only 42% of the
estimated 670,000 people in England affected by dementia being formally
diagnosed. The Hospice recognises that dementia is a palliative diagnosis
and with the increase in diagnosis, alongside of other palliative diseases, it is
essential that our practice reflects best practice and current research to
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 7 of 27
maintain high standards of care to patients who may have a diagnosis of
dementia.
The Hospice recognises its responsibility in supporting the community to
identify patients with undiagnosed dementia, to ensure that they receive the
appropriate care and treatment that both they and their families require. It is
also essential that staff are trained to identify the difference between when
patients are cognitively impaired from other causes, including delirium and
depression.
The Hospice acknowledges that there is a requirement to improve
knowledge around dementia care and promote Hospice services that
support patients with a dementia illness.
2.2.3.2 How the priority will be achieved
At the beginning of 2014, the Hospice implemented the dementia screening
tool into practice to find, assess, investigate and refer (FAIR) all patients who
access Hospice services, excluding anyone who already has a formal
diagnosis of dementia.
The Hospice has appointed a Lead Nurse for Dementia who during the next
12 months will co-ordinate mandatory training sessions for all clinical staff
through the rolling programme of clinical education on the care and
assessment of potential and actual dementia patients. All clinical staff will
achieve a minimum qualification in dementia at level 3.
The Hospice will also provide signposting and guidance information for
carers of patients diagnosed with dementia.
To ensure that the Hospice increases the awareness of dementia being a
palliative diagnosis, Hospice staff will network with other providers,
professionals, stakeholders and external networking forums. Education will
also be provided to potential referrers around the appropriateness of patients
with dementia accessing a range of Hospice services.
2.2.3.3 How the priority will be measured
To ensure that the Hospice achieves this priority, quarterly reporting will take
place as part of the CQUIN indicator for Dementia to NHS Hartlepool &
Stockton-on-Tess Clinical Commissioning Group and Durham Dales,
Easington and Sedgefield Clinical Commissioning Group. Progress will be
measured and monitored against an agreed action plan with both CCG’s.
Evidence will also be supported through monthly dementia audits.
Feedback will also be measured from carers of patients with dementia to
measure the level of support they receive through a short questionnaire.
This will also identify whether they have been given the Hospice leaflet on
supporting a patient with dementia.
The Hospice will audit and record the amount of patients who access
Hospice services with a formal diagnosis of dementia. This will help us to
identify if there has been an improvement in the level of referrals received to
care for patients with a dementia diagnosis and at what stage during their
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 8 of 27
diagnosis we began providing care for them. This will enable us identify if
the individual with a diagnosis of dementia is accessing Hospice services for
dementia or another primary palliative diagnosis. This again will help us to
shape our services to meet the needs of our local communities in relation to
caring for patient with a dementia diagnosis.
2.3
PROGRESS ON IMPROVEMENT PRIORITIES FOR 2014/15
The quality improvement priorities for the previous year are reported on
below.
2.3.1
Priority 1
(Quality Domain: Clinical Effectiveness, Patient Experience)
Work with health and social care partners to fully support local
communities to receive care closest to home.
2.3.1.1 What we have achieved
NHS Hartlepool & Stockton-on-Tees Clinical Commissioning Group and
Hartlepool Borough Council constantly work towards improving care within
both residential and nursing homes for patients who are approaching the end
of life. One of the challenges is to prevent inappropriate hospital admissions
and achieve the patients’ Preferred Place of Care (PPC). NHS Hartlepool &
Stockton-on-Tees CCG have provided funding to support the Hospice
delivering an educational programme to care homes which have a
particularly high admission rate for patients who are approaching the end of
life and are failing to meet their preferences for dying.
The education programme allows the Hospice to share its expertise and
knowledge and support more patients and families, making a difference to
their journey as they approach the end of life. The programme continues to
be delivered but a review of the statistics around end of life care and the
admission of patients dying in the acute setting is being carried out by NHS
Hartlepool & Stockton-on-Tees Clinical Commissioning Group. This will
demonstrate if the programme of education has supported care home staff in
making appropriate decisions around the patient care needs. It has also
enabled the Hospice to promote its 24 hour Helpline, which care home staff
can access to support them with decision making.
Achievements to date include:
 We have provided 14 sessions of the education programme to 8 care
homes and 69 members of staff have accessed the training.
 We have educated staff on how to recognise the signs a patient who is
approaching the end of life.
 We have identified some of the issues and challenges which our local
care homes are facing and have reported this back to the CCG’s, making
recommendations on ways to improve procedures.
 We have created new networking opportunities for care homes.
 We have promoted the Hospice’s 24 hour Helpline for future support.
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 9 of 27
2.3.1.2 How we will continue to improve
The Hospice is currently reviewing the education programme and providing
feedback to the CCG’s. There is evidence to suggest that there is a further
requirement to provide more consistent training and facilitated support within
care homes to enable a continuous improvement in the standards of end of
life care. This would allow the staff to identify in practice the signs of a
deteriorating and dying patient and the process for making individualised
choices for patients, ensuring a positive experience for them and their
families. The Hospice will continue to support the care homes with the 24
hour Helpline.
2.3.2
Priority 2
(Quality Domain: Clinical Effectiveness and Patient Experience)
Be proactive in addressing high morbidity illnesses and support
patients and their carers to fulfil their lives.
2.3.2.1 What we have achieved
In response to the CCG and the Acute Trust identifying a significant amount
of inappropriate admissions to the acute setting for patients with anxiety
related breathlessness, the Hospice developed a six week programme to
support patients and their carers with a respiratory diagnosis, for example
COPD (Chronic Obstructive Pulmonary Disease). The purpose of the
programme was to educate the participants on how to manage their
symptoms, decrease anxiety and identify other support services pertinent to
their needs. The programme also consisted of access to complementary
therapies, both group and individual counselling sessions, nursing support
and evening telephone comfort calls from trained staff to provide
reassurance and an avoidance of an admission.
After completing 12 months of the programme, the data collated
demonstrated a significant reduction in admissions to A&E and acute beds
with patients who have a chronic respiratory diagnosis. Patient assessments
and feedback showed a significant reduction in anxiety and an even more
significant improvement in their morbidity and quality of life and a sounder
understanding of what their diagnosis meant for them and their families.
2.3.2.2 How we will continue to improve
The Hospice has demonstrated that the programme has enabled patients to
take control of their disease and how to ensure that their physical health and
their wellbeing is maintained. On reflection, the data demonstrates a need
for future support for patients and families affected by a respiratory disease
to continue to reduce inappropriate admissions. The Hospice is currently in
discussions with the local commissioners to continue working in partnership
to provide this innovative service during 2015/16. Further recommendations
would be to conduct an audit of the impact upon primary care of this
programme, i.e. reduced GP appointments and community nursing
interventions.
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 10 of 27
2.3.3
Priority 3
(Quality Domain:
Experience)
Patient Safety, Clinical Effectiveness and Patient
Develop our facilities to respond to the increasing need for more
complex and longer term care as the only Consultant led and medical
training establishment in the area.
2.3.3.1 What we have achieved
The Hospice is seeing an increase in individuals being diagnosed with a
palliative illness. Due to the advances in clinical expertise these diagnosis
are often being made much earlier than previously. This is also having an
impact on an individual’s acceptance of living with a palliative illness. Much
of our feedback at the Hospice demonstrates a reduction in patients’ fear of
accessing Hospice services due to initially accessing services available
through the Holistic Wellbeing Centre.
In 2013 the Hospice was successful in being awarded a Department of
Health Capital Development Programme grant to develop the patient care
environment. The grant was used to erect a single story Holistic Wellbeing
Centre, providing a range of Day Care, Outpatient, Counselling and
Therapeutic Support Services to the local communities of Hartlepool and
East Durham, ensuring that patients remain independent and empowered to
lead on their own care with the support of the Hospice.
The Holistic Wellbeing Centre was officially opened in May 2014, when the
new facilities were embraced by its service users who feel that those first
steps into the Hospice are less daunting and the stigma of Hospice care has
been reduced, as the appearance of the building is warm and inviting and
although located in the Hospice grounds it is not directly attached.
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 11 of 27
2.3.3.2 How we will continue to improve
The building has leant itself to creating and delivering more innovative and
patient specific programmes, such as the breathlessness support
programme. It allows the Hospice to develop pathways that support both
cancer and non-cancer palliative opportunities in partnership with other
healthcare professionals to address future healthcare developments.
2.3.4
Priority 4
(Quality Domain: Patient Safety, Clinical Effectiveness)
Ensure Hospice Values are upheld regardless of where they are
delivered.
2.3.4.1 What we have achieved
Hartlepool & District Hospice are committed to the training and development
of its staff, ensuring that the quality of care that is provided is delivered with
excellence. The Hospice encourages all staff to be strong leaders,
supporting them to be involved in innovative practice and implementing
change for best practice. The Hospice continues to invest in leadership
training for every member of staff. Throughout this training staff learn more
about themselves and their individual leadership behaviours and types, but
also that of their colleagues. This supports the Hospice to identify all the
strengths of its employees and how each member of the team can
complement their colleagues and the services which we deliver. Through
strong leadership we ensure that every member of staff is committed to the
delivery of compassionate and dignified care.
2.3.4.2 How we will continue to improve
Clinical staff will continue to be educated via the Hospice’s rolling
programme of clinical education, which is designed to meet the current
needs of the Clinical Team and the individuals within this working group.
Supervision, appraisals, incidents and previous practice areas of
improvement will be identified and educational sessions will be built into the
rolling programme of clinical education to ensure that all clinicians have the
opportunity to improve their own individual practice and apply best practice
into the clinical areas across the organisation. All staff within the Hospice
receive induction training which ensures that our values are upheld
regardless of position.
2.4
MANDATORY STATEMENT OF ASSURANCE FROM THE BOARD
The following statements must be provided within the Quality Accounts by all
providers. Many of these statements are not directly applicable to specialist
palliative care providers including Hartlepool & District Hospice, therefore
explanations of what these mean are given.
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 12 of 27
2.4.1
Review of Services
During the reporting period 2014/2015 Hartlepool & District Hospice provided
the following services to the NHS:
 8 Bedded Inpatient Unit
 Day Hospice
 Outpatient Clinics
 Complementary Therapies
 Counselling Support Service
 24 hr Helpline
 Physiotherapy
 Occupational Therapy
 Chaplaincy
The income generated by the NHS services reviewed in 2014/15 represents
22% of the total income generated from the provision of NHS services by
Hartlepool & District Hospice for 2014/2015.
This means that the remaining 78% of the overall costs of service delivery is
fundraised by the Hospice from voluntary charitable donations, legacies,
Hospice shops, Hospice lottery, events and community fundraising.
2.4.2
Participation in Clinical Audit
During 2014/2015 0 national clinical audits and 0 national confidential
enquiries covered NHS services that Hartlepool & District Hospice provides.
During 2014/2015 Hartlepool & District Hospice participated in 0% national
clinical audits and 0% national confidential enquiries of the national clinical
audit and national confidential enquiries as it was not eligible to do so.
2.4.3
Research
The number of patients receiving NHS services provided or sub contracted
by Hartlepool & District Hospice in 2014/2015 that were recruited during that
period to participate in research approved by a research ethics committee
was 0.
2.4.4
CQUIN Payment Framework
Hartlepool & District Hospice’s income for 2014/2015 was conditional on
achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation (CQUIN) payment framework.
The Hospice completed the following CQUIN indicators, which represented
2.5% of the overall contract value:
NHS Hartlepool & Stockton-on-Tees CCG
 Safety Thermometer
 Friends & Family Test
 Local Patient Experience (Questionnaire)
 Dementia & Delirium
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 13 of 27
Durham Dales, Easington & Sedgefield CCG
 Safety Thermometer
 Friends & Family Test
 Patient Safety (Reduction in Pressure Ulcers/Damage)
2.4.5
Statement from Care Quality Commission
Hartlepool & District Hospice is required to register with the Care Quality
Commission and it is currently registered to carry out the following regulated
activities:
 Treatment of disease, disorder or injury.
 Diagnostic and screening procedures.
Hartlepool & District Hospice is registered with the following conditions:
 To accommodate up to a maximum of 10 patients overnight.
 To provide a service for people over the age of 18 years old.
 The registered provider’s regulated activity is managed by a Registered
Manager.
 The provider location where regulated activity can be carried out is:
Alice House, Wells Avenue, Hartlepool, TS24 9DA.
The Care Quality Commission has not taken any enforcement actions
against Hartlepool & District Hospice during 2014/2015. There have been
no special reviews or investigations carried out by the Care Quality
Commission during this reporting period.
The Hospice received an unannounced inspection by the Care Quality
Commission on 23 March 2015. At the time of preparing the Quality
Accounts, the Hospice was waiting to receive the formal report and rating
from the inspection, however positive feedback was given at the time of
inspection to management on the five domains of inspection; namely safe,
effective, caring, responsive and well led.
2.4.6
Data Quality
Hartlepool & District Hospice did not submit records during 2014/2015 to the
Secondary Uses Service for inclusion in the Hospital Episode Statistics
which are included in the latest published data.
Although Hartlepool & District Hospice was not eligible to participate in the
above scheme, the Hospice continues to participate in the National Council
for Palliative Care Minimum Dataset.
2.4.7
Information Governance Toolkit Attainment
Hartlepool & District Hospice’s Information Governance Assessment Report
achieved and overall reporting score for 2014/2015 of 80% and was graded
satisfactory. The score had increased from the previous year’s score of
72%.
The Information Governance Group will take forward the action plan formed
from the audit toolkit covering 2014/2015 to make further improvements and
improve the level of compliance.
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 14 of 27
2.4.8
Clinical Coding Error Rate
Hartlepool & District Hospice was not subject to the Payment by Results
clinical coding audit during 2014/2015 by the Audit Commission.
PART 3: REVIEW OF QUALITY PERFORMANCE
Hartlepool & District Hospice has considered the three domains of Patient
Safety, Clinical Effectiveness and Patient, Carers, Staff and Volunteer
Experience within these accounts during the reporting period of 2014/2015.
3.1
PATIENT SAFETY
3.1.1
Incident Report and Risk Assessment
Hartlepool & District Hospice have clear policies and procedures in place to
ensure that incidents are reported in an appropriate manner and that all
incidents reported result in lessons being learnt and practice improved. The
Hospice staff are committed to reporting any incidents, including near
misses. Risk assessments are conducted to minimise the event of an
incident occurring and to maintain the safety of both patients and staff.
The table below shows that there were a total of 54 clinical incidents in
2014/2015. These ranged from falls/patient safety, drug errors and near
misses. Staff at the Hospice practice in a transparent manner and ensure
that all incidents or potential incidents are reported to improve the quality of
the services we deliver. None of the incidents reported during this period
resulted in a patient coming to serious harm. 50% of the errors involving
drugs were that of measurements and have been collated for record
purposes but have no implications for patient care; this is considered best
practice and recommended by the Controlled Drug Local Intelligence
Network (CDLIN). Medicine safety will be prioritised during period 2015/2016
when the Hospice will work to improve reconciliation of three areas
highlighted through reporting which include utilising a reconciliation check
tool, an improvement in reporting patients allergy status and a reduction in
omissions of medication (see item 2.2.2).
35
30
25
20
15
10
5
0
Drugs
Falls
Hartlepool & District Hospice Quality Accounts 2014/2015
Others
Page 15 of 27
3.1.1.1 Falls
The pie chart below demonstrates the falls which took place when a patient
was trying to independently use the toilet/shower facilities, where equipment
was involved or where a patient may have been confused and potentially
contributed towards the fall taking place.
The Hospice has invested in falls prevention equipment to support patients
and staff in the avoidance of a fall taking place. This includes chair and bed
alarm pads which will alert staff if a patient is trying to mobilise and may
require some assistance.
3.1.1.2 Pressure Ulcers/Damage
In 2014/2015 Hartlepool & District Hospice completed the CQUIN indicator
to improve pressure ulcers/damage. The Hospice has demonstrated a 20%
reduction in the development of new pressure ulcers. This was achieved
through identifying areas of improvement for best practice and accessing
support from appropriate specialists. The risk assessment documentation
was reviewed to reflect the patients and their symptoms that access Hospice
services. Trust grant applications have funded the purchase of new beds
and air mattresses for the Inpatient Unit.
3.1.1.3 Infection Control
During 2014/2015 there were 0 acquired Hospice infections, however the
Hospice cared for 4 patients who had a Hospital acquired infection. These
were acquired prior to admission to the Hospice and infection control
measures were implemented to prevent further cross-infection and to ensure
that the patients received high standards of care.
The Hospice receives six-monthly infection control inspections from an
external professional who conducted an audit and report on the findings
which made recommendations for improvement in practice. During this
reporting period the Hospice was 95% compliant for the environment and
although the fabric footstools were highlighted as a concern, the
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 16 of 27
recommended action was that the Hospice could continue to use them with
appropriate steam cleaning in between patients. The Hospice was found to
be 100% compliance for both Hand Hygiene and Standard Precautions.
Audit Area
Environment
Hand Hygiene
Standard Precautions
Compliance
95%
100%
100%
3.1.1.4 Safety Thermometer
During 2014/2015 the Hospice submitted monthly submissions for the Safety
Thermometer to the Health and Social Care Information Centre. The Safety
Thermometer is a mandatory CQUIN Indicator which takes a ‘snapshot’
measure of pre-determined domains across the clinical area on a set day
each month.
3.2
CLINICAL EFFECTIVENESS
3.2.1
Hospice Performance against National Council for Palliative Care
Minimum Dataset
The Hospice collates statistical information on patient activity for inclusion in
the National Council for Palliative Care’s Minimum Dataset, which enables
comparison of local data to the national average. The table below shows the
Hospice’s Inpatient Unit performance measured against the NCPC Minimum
Dataset.
INPATIENT UNIT
Total
01/04/12 to
31/03/13
Total
01/04/13
to 31/03/14
Total
01/04/2014
to 31/03/15
* National
Median
Admissions
239
242
231
-
First Admission
181
179
180
-
71.4%
76.7%
80.2%
75.4%
8.5
9.2
10.1
12.3
% Died
43.7%
42.1%
42.2%
55.3%
% Discharges
56.3%
57.9%
57.8%
44.7%
Cancer %
90.0%
88.0%
87.0%
87.4%
Non Cancer %
10.0%
12.0%
13.0%
12.6%
% Bed Occupancy
Average Length of Stay (Days)
* (National Median data extracted from The National Council for Palliative Care, MDS Report 2012/13)
The data reflects that the Hospice remains below the national average length
of stay. The Hospice continues to support patients to achieve their Preferred
Place of Care (PPC) which is demonstrated through a higher than national
average discharge rate and a lower than national average Hospice death
rate. Cancer and non-cancer diagnosis continue to remain in line with the
national average.
The Hospice has recently conducted a study to understand the types of
referrals received to ensure that demand is met. This identified that the
majority of Hospice referrals were for symptom management and that there
was an increasing demand for complex specialist palliative care. As a
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 17 of 27
Consultant led specialist palliative care unit, the Hospice expects to see the
demand increase for complex specialist intervention.
3.2.2
Key Performance Indicators
The Hospice submits quarterly reports on Key Performance Indicators to
meet contractual requirements with NHS Hartlepool & Stockton-on-Tees
CCG and Durham Dales, Easington & Sedgefield CCG. A summary of the
performance data for the accounting period can be seen below.
3.2.2.1 NHS Hartlepool & Stockton-on-Tees CCG
Measure
Threshold
Performance
Q1
Performance
Q2
Performance
Q3
Performance
Q4
Time from Inpatient
referral to decision to
admit/not to admit.
Number of Inpatients
who have been
OFFERED an
ACP/Deciding Rights.
Number of Inpatients
RECEIVING an
ACP/Deciding Rights.
Inpatient bed
availability.
Inpatient bed
occupancy.
% of Day Hospice/
Outpatients receiving
a care plan.
Time from Day
Hospice/Outpatient
referral to
assessment.
90%
within 2
hours
90%
89.7%
100%
97.0%
100%
100%
97.0%
97.0%
100%
90%
75.9%
66.7%
81.8%
100%
95%
100%
83.7%
100%
100%
85%
66.1%
115.4%
71.6%
57.6%
100%
100%
100%
100%
100%
>=90%
within 7
days
37.5%
15.4%
35.7%
0%
3.2.2.2 Durham Dales, Easington & Sedgefield CCG
Measure
Threshold
Performance
Q1
Performance
Q2
Performance
Q3
Performance
Q4
Time from Inpatient
referral to decision to
admit/not to admit.
Number of Inpatients
who have been
OFFERED an
ACP/Deciding Rights.
Number of Inpatients
who RECEIVED an
ACP/Deciding Rights.
Inpatient bed
availability.
Inpatient bed
occupancy.
% of Day Hospice/
Outpatients receiving
a care plan.
Time from Day
Hospice/Outpatient
referral to
assessment.
90%
within 2
hours
90%
85.7%
100%
92.9%
100%
100%
100%
100%
100%
90%
85.7%
100%
85.7%
88.9%
100%
100%
100%
100%
100%
85%
69.2%
10.4%
77.2%
42.2%
100%
100%
100%
100%
100%
>=90%
within 7
days
100%
100%
0%
100%
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 18 of 27
3.2.3
Local Audits
The Hospice has an Audit Sub Group who ensure that current clinical issues
and practices are explored and audited. Nationally agreed organisational
audit tools, such as Hospice UK, are used to support the Hospice in
capturing the appropriate detail to benchmark its expectations of the services
it delivers. The audits support and monitor the quality of these services and
also identify where there are areas for improvement and change to best
practice. Hartlepool & District Hospice ensures that the results of audits and
the recommendations to improve practice are approved by the Clinical
Governance Group and shared with all clinical staff.
All clinical audits are reviewed and monitored by the Audit Sub Group via an
action plan to demonstrate a 360 degree approach to improving practice.
The following clinical audits are currently being conducted at the Hospice:


















Pressure Ulcers
Diagnostic Assessment Tools for Anxiety and Depression
Infection Control (Internal and External)
Hand Hygiene
Referral to Hospice Services
Medicine Management
Controlled Drugs and Controlled Drugs Register
FP10
Patient Experience
Clinical Incidents
Oral Hygiene
Falls
Bedrails
Deciding Right
Consent to Treatment
Hospice Helpline
Thromboprophylaxis
Documentation
The Hospice continues to review its auditing processes and ensures that
audits are conducted for an appropriate purpose and that evidence is
provided to quantify the quality of the services delivered.
3.2.4
Clinical Governance
The Clinical Governance Group steer the quality of clinical services within
the Hospice and the framework allows us to demonstrate safe, effective and
patient led services by a well led group of multi professionals. The Clinical
Governance Group reports to the Board of Trustees and covers all aspects
of patient related care.
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 19 of 27
3.3
PATIENT, CARER, STAFF & VOLUNTEER EXPERIENCE
3.3.1
Staff Experience
Hartlepool & District Hospice are committed to the welfare of its staff. The
National Quality Board (NQB) Report ‘how to ensure the right people, with
the right skills, are in the right place at the right time’ (published 19
November 2013) and the Government’s commitments set out in ‘Hard
Truths’ (see also ‘Hard Truths Commitments Regarding the Publishing of
Staffing Data’, NHS England and Care Quality Commission) form the basis
for the Hospice’s Workforce Assurance Report which is prepared and
submitted to commissioners on a six-monthly basis.
The Workforce Assurance Report focuses on sickness and absences,
training, education and appraisals.
3.3.2
Sickness and Absences
Staff sickness is minimised through effective management, providing support
to staff to keep healthy and ensuring that their wellbeing is maintained. Staff
that are identified as having significantly high episodes of sickness are
monitored closely via sickness review meetings. They remain under review
until they are six months clear of any episodes of sickness. This is to ensure
that casual sickness remains at a minimum but also to ensure staff have a
pathway to access support which may prevent further episodes of sickness.
STAFF SICKNESS RATES
2030.50 hours absence from
53614.50 contracted hours across the Hospice
3.3.3
Hospice %
2014/2015
National
Voluntary
Sector Average
3.79%
5.03%
Staff Satisfaction
An annual staff satisfaction survey is given to all staff members to complete.
The survey reflects their work and home life balance and their experience as
a Hospice employee. The returns during 2014/2015 demonstrated a high
level of job satisfaction for staff (100%) and all recommendations that were
made by staff have been fully explored, actioned and changes implemented
where appropriate.
3.3.4
Mandatory Training
All staff are required to undertake mandatory training to ensure the safe and
effective delivery of care. The Human Resources Department manage all
staff inductions and annual training to meet compliance with the Care Quality
Commission and regulatory legislation.
3.3.5
Clinical Supervision
The Hospice facilitated leadership training for all Hospice staff during
2014/2015. Staff were also offered the opportunity for 1:1 supervision with a
Volunteer Occupational Development Consultant who provides techniques to
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 20 of 27
change practice, support to steer concerns, guidance with time management
and personal development.
It is standard practice for clinical staff to receive clinical supervision from
their Line Manager but there are also opportunities for specialist practitioners
to have prescribing supervision. Any staff that may require additional support
in practice are supported with on the job clinical supervision. External
supervision is provided for specific roles such as Counsellors.
3.3.6
Board Development
The Hospice holds a public Annual General Meeting, which takes place
every September. This is delivered by the Chair of Trustees in partnership
with the Board of Trustees and the Senior Management Team. This gives
the opportunity to present to the public and Hospice employees a reflection
of the previous financial year and future aspirations for service
improvements.
The Board of Trustees undertake annual re-election to ensure that they
remain appropriate panel members and provide a range of skills and
expertise. The vote is agreed at the Annual General Meeting by the Hospice
Members.
The Hospice has a well-structured and strong Senior Management Team
who compliment and support the Chief Executive to steer services in a
positive direction.
The following roles are in place within the Hospice to ensure regulatory
compliance is achieved:












3.3.7
Chief Executive
Deputy Chief Executive
Registered Manager (Care Quality Commission)
Accountable Officer (Care Quality Commission)
Nominated Individual (Care Quality Commission)
Responsible Individual
Caldicott Guardian
Senior Risk Information Officer
Accountable Emergency Officer
Safeguarding & Prevent Lead
Information Governance Lead
Mental Capacity & Deprivation of Liberty Lead
Volunteers’ Experience
There are 195 volunteers working throughout the organisation, 41 of which
work within the clinical areas; namely Inpatient Unit, Day Hospice,
Counselling,
Catering
&
Housekeeping,
Reception/Administration,
Gardening and Driving.
All volunteers are required to attend an induction in the area they will be
working. They are also required to undertake mandatory training which
supports them and ensures that safety is maintained when conducting their
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 21 of 27
role. All volunteers are expected to abide by the Hospice’s Policies and
Procedures and implement the Hospice’s Vision, Mission, Values and
Strategic Objectives.
The Hospice engages with other voluntary organisations that assist
unemployed people to develop skills to support them back into employment.
Income generation departments depend heavily on the support of volunteers
to secure events, raise awareness and increase resources to support
patients and their families to receive the high quality care which the Hospice
is renowned for. The Hospice is highly appreciative of its volunteer support
and ensures that they are made aware of the results of their hard work.
Feedback from volunteers includes the following comments:
“For the last 5 years I have been a volunteer in one of the Hospice’s shops.
I was invited to look around the Hospice and see what my contribution
towards patient care was. It’s rewarding to see the money we raise being
put into patient care.”
“I was a volunteer in the Inpatient Unit and I loved every minute I was there,
you are all truly wonderful, god bless”.
3.3.8
Education & Training
Hartlepool & District Hospice are driving education and training forward and
are committed to providing it both internally and externally. In 2014/2015 all
staff have had access to leadership training and clinical staff attended two
rolling programmes of clinical education (see item 2.3.4.2). The Hospice has
invested in government agenda items such as advanced training in
safeguarding for clinical staff.
It is paramount that the Hospice continues to explore new opportunities to
increase knowledge of the future of health and hospice care. The Hospice is
currently represented on the following steering groups:









Specialist Palliative Multi-Disciplinary Team, North Tees & Hartlepool
NHS Trust
Elderly & Facility Group, NHS Hartlepool & Stockton-on-Tees Clinical
Commissioning Group
Health & Wellbeing Board (representing voluntary sector), NHS
Hartlepool & Stockton-on-Tees CCG
Controlled Drug Local Intelligence Network (CDLIN), NHS North of
England Commissioning Support
Hospice Review Meetings (Durham Area), NHS North of England
Commissioning Support
End of Life & Palliative Care Group, Durham Dales, Easington &
Sedgefield CCG
Independent Registered Managers’ Group, North East Cancer Network
Senior Nurse Leaders Network, NHS North of England Commissioning
Support
Journal Club
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 22 of 27
As a Consultant led specialist palliative care unit we offer training and
support to Foundation Doctors. We also provide placements for Specialist
Registrar Trainees who are training to become Consultants in Palliative Care
and offer placements to GP Trainees who require additional experience in
caring for patients with a palliative diagnosis. This continues to support the
Hospice in promoting its services to potential referrers and builds on
partnership working.
3.3.9
Awards
The Hospice feels that it is vital that staff are rewarded for their efforts and
especially when they have achieved a personal professional achievement.
These achievements are noted at the Hospice’s Annual General Meeting.
Staff vote annually for their colleagues to be recognised for their
achievements and awards are given to two members of staff at the Annual
General Meeting, one clinical and one non-clinical member of staff.
The Chief Executive’s award is also presented at the Annual General
Meeting. This award reflects a drive to changing practice within the
organisation and innovation for service delivery.
In June 2014, Hartlepool & District Hospice were presented with Hartlepool’s
The Best of Health Award for Team of the Year. This was a great
achievement for the Clinical Team at the Hospice who strive to make a
difference to the patients and the community it serves.
3.3.10
Complaints
Hartlepool & District Hospice seeks feedback from service users, staff and
stakeholders. This feedback supports the Hospice in shaping its services
and implementing changes where they are deemed appropriate. Service
users are made aware of how to log a formal complaint through a variety of
means such as the Hospice’s Complaints Policy & Procedure which is
included in all Patient & Visitors’ Information Files and the Compliments,
Comments & Concerns Leaflet which is displayed in all public areas. The
Hospice’s complaints literature also advertises external stakeholders such as
the local Clinical Commissioning Groups, Care Quality Commission and
Local Authorities who can be approached with any concerns in relation to the
Hospice.
The Hospice maintains a Complaints Register and during 2014/15 there
were 7 complaints (mainly non-clinical), all of which were resolved.
3.3.11 Other Comments from Partners & Stakeholders
A selection of comments received are listed below:
“To all the team at Hartlepool Hospice Inpatients we just want to say a big
THANK YOU to each and every one of you that looked after our mam/wife.
We couldn’t have made her final few days comfortable and pain free
without your help and support!! You are all fantastic in the job you do and
we really appreciate all the support you gave to us all during our difficult
time.”
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 23 of 27
“Thank you for your wonderful letter, xxxxx enjoyed coming to Alice
House so this enabled me to have respite and to recharge my batteries.
The last few days of xxxxx life helped my family to spend some quality
time with him. xxxxx knew he was dying hence the reason for not coming
home. Your staff were absolutely wonderful giving him respect, dignity and
most importantly caring for me and my family. Nothing was any bother
which made it easier for us all. The nurses were with my son and when he
took his last breath, they were so kind and gentle, this helped us through it
and made his passing so easy. They also prepared him in his clothes so
that some of the family could come and pay their last respects. My family
and I would like to thank you all for your support and care through a very
difficult time.”
“Thank you to all you lovely ladies who helped care for our lovely Dad. The
care and devotion was second to none, nothing was a trouble to you. Also
thank you to the Doctor for the reassurance he gave my dad. We will
always sponsor the Hospice as we now know how much it takes to run it.
Forever grateful. God bless you all.”
“We would not forgive ourselves if we did not write to say Thank You but
we didn’t think any words could possibly be adequate to express our
feelings and gratitude to you all. So THANK YOU so very much for your
care and support. We appreciated everything you did for my husband/dad.
He is free now…… no more suffering. Bless you all.”
“A big thank you to all the staff who looked after our ‘nana’. She really
appreciated it and it meant a lot to us. Thanks.”
“We would like to thank each and every one of you who gave so much
care to xxxxx. As a family we were so relieved when he was brought to the
Hospice. All we prayed for was for him to have peaceful surroundings
when it came the time for him to pass. We could not have asked for
anything better than the care he received and also us as a family. You
made the last few days with my husband, our dad, granda, brother in law
and uncle the best we could have wished for, the time was so precious to
us. Thank you.”
“Thank you very much for all the love and support you gave to my mum
and all the family. We would have found it very hard to look after her to the
same standard of comfort and attention had she been at home. All your
excellent care was much appreciated.”
“I would like to say a very big thank you to everyone who looked after my
mum recently. Mum received the best care and I know this brought her
great comfort, as well as myself and my family and mum's friends. Mum
was so lucky to be looked after by such a caring team as I was too on my
daily visits. Thank you all so much, continue with your great work.”
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 24 of 27
3.4
SUPPORTING STATEMENTS FROM PARTNERS & STAKEHOLDERS
Supporting statements are being sought from the following partners and
stakeholders and will be included in the Quality Accounts when they are
received:






NHS Hartlepool & Stockton-on-Tees CCG
Durham Dales, Easington & Sedgefield CCG
NHS Hartlepool & Stockton-on-Tees CCG’s Health & Wellbeing Board
(representing voluntary sector)
Healthwatch
Hartlepool Borough Council
Durham County Council
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 25 of 27
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 26 of 27
Councillor Christopher Akers-Belcher
Leader of Hartlepool Borough Council
Tel: 01429 284142
Civic Centre
Hartlepool
TS24 8AY
www.hartlepool.gov.uk
Our Ref: CAB/
Your Ref:
Contact Email: leader@hartlepool.gov.uk
29 June 2015
TO: Tracy Woodall, Chief Executive
Hartlepool and District Hospice
Alice House
Wells Avenue
Hartlepool
TS24 9DA
Dear Tracy
On behalf of the Frail Older People Project Group, Healthwatch and Hartlepool
Borough Council, I welcome the opportunity to provide a statement, for inclusion
within Hartlepool and District Hospice’s Quality Accounts.
As Chair of Hartlepool Borough Council’s Health and Wellbeing Board, I welcome
the Chief Executive’s role on the Board, as the Voluntary and Community Sector
representative, which has brought a new perspective to the discussions and debate
at the Board meetings.
The Hospice has been represented in multi agency work (alongside the Council and
health partners) to address system resilience and improve care pathways for frail
older people. The provision of training for care homes regarding end of life care is
expected to have a positive impact in terms of reducing avoidable hospital
admissions and will potentially support the delivery of the Better Care Fund plan.
Yours sincerely
Councillor Christopher Akers-Belcher
LEADER – HARTLEPOOL BOROUGH COUNCIL
Hartlepool & District Hospice Quality Accounts 2014/2015
Page 27 of 27