Annual Quality Account
April 2014 – March 2015
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Keech Hospice Quality Accounts 2014 - 2015
Table of Contents
Table of Contents .................................................................................................................................................................................................................... 2
Report from the Chief Executive Officer................................................................................................................................................................................ 4
Our vision................................................................................................................................................................................................................................ 5
Report from the Clinical Director............................................................................................................................................................................................ 5
Objectives ............................................................................................................................................................................................................................... 7
Objective 1 – Providing excellent care ................................................................................................................................................................................... 7
Objective 2 – Wider reach ...................................................................................................................................................................................................... 9
Objective 3 – Right choices .................................................................................................................................................................................................. 10
Objective 4 – Value for money ............................................................................................................................................................................................. 10
Objective 5 – Working together ............................................................................................................................................................................................ 11
Priorities for improvement and statements of assurance from the board................................................................................................................................ 12
1a. Priorities for improvement in 2015 – 2016 (Adults and Childrens) ............................................................................................................................... 12
1b. Progress against Priorities for Improvement in 2014 – 2015 .......................................................................................................................................... 14
2. Review of services .......................................................................................................................................................................................................... 16
3. Participation in Clinical Audit........................................................................................................................................................................................ 17
4. Research ......................................................................................................................................................................................................................... 17
5. Use of CQUIN payment framework ............................................................................................................................................................................... 18
6. Statement on the Care Quality Commission .................................................................................................................................................................. 18
7. Data Quality ................................................................................................................................................................................................................... 18
8. Information Governance Toolkit .................................................................................................................................................................................... 19
9. Clinical coding error rate ................................................................................................................................................................................................ 19
10. Organisational Structure ............................................................................................................................................................................................. 20
ADULT SERVICES ..................................................................................................................................................................................................................... 21
11. Adult Service Statistics ............................................................................................................................................................................................... 22
Adult Inpatient Analysis ........................................................................................................................................................................................................ 22
Breakdown of patients using the service in 2013/14 ............................................................................................................................................................ 22
Keech Palliative Care Centre Patient Analysis ...................................................................................................................................................................... 23
Other activity undertaken by Adult Services ......................................................................................................................................................................... 25
12. Infection Control ............................................................................................................................................................................................................. 26
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13. Safeguarding ............................................................................................................................................................................................................... 26
CHILDREN’S SERVICES ........................................................................................................................................................................................................... 27
14. Children’s Service Statistics ........................................................................................................................................................................................ 28
Children’s In-patient Unit activity statistics ......................................................................................................................................................................... 28
Total BME in 2014/15 = 30%............................................................................................................................................................................................... 28
Children’s Community Activity ............................................................................................................................................................................................ 29
Children’s Service Day Support activity statistics................................................................................................................................................................ 29
15. Accidents, Incidents, Complaints and Compliments ................................................................................................................................................... 30
Accidents ............................................................................................................................................................................................................................... 30
Incidents ................................................................................................................................................................................................................................ 31
Complaints ............................................................................................................................................................................................................................ 32
Compliments received ........................................................................................................................................................................................................... 33
16. Quality and Compliance .............................................................................................................................................................................................. 35
Standard of Care ................................................................................................................................................................................................................... 35
Care Quality Commission (CQC) ................................................................................................................................................................................. 35
Accreditation ..................................................................................................................................................................................................................... 35
Provider Visit ..................................................................................................................................................................................................................... 35
Summary of 2014/15 Audits & Surveys ............................................................................................................................................................................... 37
Research ................................................................................................................................................................................................................................ 38
17. Feedback from Our NHS Commissioners:..................................................................................................................................................................... 39
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Keech Hospice Quality Accounts 2014 - 2015
Report from the Chief Executive Officer
Together with the Board of Trustees, I would like to thank all our staff and volunteers for their achievements over the
past year. Despite the current economic climate, the Hospice has continued to increase the number of people it
supports, providing a wide range of services whilst remaining financially sound.
At Keech Hospice we strive to continually deliver safe and innovative services, whilst giving reassurance that the
organisation as a whole has patient care and quality at its core. The safety, experience and outcomes for all our
patients and those close to them are of paramount importance to us. We continue to actively seek the views of
everyone who comes into contact with our services to enable us to gain insight into the care people want and the
quality they expect.
Over the past year we have been reviewing our strategic direction and developing a new 5-year strategy 2015-2020, which is outlined in more
detail later in this report. We have also restructured our Governance and Management Structure, which is outlined on page 20.
I am responsible for the preparation of this report and its contents. To the best of my knowledge, the information reported in this Quality
Account is accurate and a fair representation of the quality of healthcare services provided by our Hospice.
Mike Keel
Chief Executive Officer
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Our vision
Our Vision is that High quality Palliative care is available to all who need it in our community.
Our Mission statement:
We will be the patients’ champion,
We will seek out all the people that need palliative care, ensure their needs are assessed and ensure that they are
addressed in the way they choose.
We will be the voice of palliative care in our community
By doing this the charity will be supporting the health, social and educational services to meet their obligations
Report from the Clinical Director
Keech Hospice Care provides specialist palliative care to Adults in Luton and South Bedfordshire and Children from
all of Bedfordshire, Hertfordshire and Milton Keynes. We pride ourselves on not just delivering care to cancer
patients but also in supporting adults and children with Long Term Conditions and with a palliative need.
Our aim is to develop new models of care and support that respond to the changing needs of patients, families and
carers; help patients live life to the full; and, when the time comes, to die in their place of choice. We will ensure our
services dovetail with the NHS, local authorities, care homes, schools and children’s respite facilities; to give
patients and families the best services. Our ambition is to provide more services closer to home and ensure our
beds are utilised to the maximum benefit for our most complex patients requiring specialist care.
We will embrace change but we will not compromise on our values or lose what Keech stands for. In short; we will stay true to ourselves.
Keech believes there is always room for improvement and we will continue to find improvements not only in what we do but also in care other
providers give at the end of life. We will do this by influencing and supporting everyone to improve Palliative and End of Life care.
Our strategic themes are:
1. Providing Excellent Care – to ensure that patient’s, children and families receive outstanding care from all they come into contact with.
2. Wider Reach – To lead the provision of Community services in order to ensure that excellent care is delivered to patients in their own
home (or care home)
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3. Right Choices – To ensure that the preferred place of care for all patients and families is recorded and communicated across the whole
health system.
4. Value for money – To ensure better value for money across our hospice services
5. Working together – To build on and develop further partnerships with health and social care professionals in our area
Care Update.
It has been a very busy year. There have been many successes such as increases in number of beneficiaries in all areas despite the
challenges of the building works and staffing shortages, full credit must be given to the care staff who have worked extremely hard to keep up
this performance. The main challenges have been staffing shortages particularly on the adult IPU and Children’s Community Team. These
shortages have been created by an unprecedented number of staff on maternity leave and sickness.
Headline performance 2014/15:
Adult Inpatient Unit new admissions increased by 11%, total patients increased by 9%, average length of stay down to 11.5 days.
Children’s Inpatient Unit new admissions increased by 12%, total patients increased by 8% average length of stay down to 2.58 days.
KPCC total patients increased by 11%, attendances up by 15%.
MCCT registered 695 patients; our challenge will now be how to offer these new patients Keech services.
Children’s Community Team increased families supported by 5%, visits increased by 23% and deaths supported at home increased by 33%.
Children’s Day Support increased number of patients by 77%, attendances up 88%. This reflects the new approach to Day Support and the
movement of one of the IPU nurses to lead this important service.
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Objectives
Achievements and highlights from 2014/15 were monitored against our previous strategic objectives:
Objective 1 – Providing excellent care
To ensure that patients, children and families receive outstanding care from all who come into contact with.
•
Palliative Rehabilitation Service: a project application has been submitted and we await confirmation of funding, from
Macmillan, to deliver the service. This will support 0.6wte posts for both a physiotherapist and an occupational therapist. They
will lead exercise and well being programmes as well as symptom specific clinics. The fatigue management programme
continues, with the fourth programme planned. The project also identified the need for patient information, specifically for
patients with non malignant disease. We were lucky enough to receive funding from a trust to change a under utilised space in
KPCC to a patient information area.
•
Non-malignant MDT’s - The three Non-malignant Palliative MDT’s (Respiratory , Motor Neurone Disease (MND) and Heart
Failure) are continuing to be successful in planning patients care within secondary, primary, health & social care and hospice
care. These meetings are proving to facilitate better proactive joined-up patient care and ultimately avoiding unnecessary
hospital admission. The hope is to obtain funding to develop the MND MDT into a Rare Neuro MDT.
Rare Palliative Neurological Conditions – We were delighted to receive the news that we had a successful application for East of
England NTI action learning set to establish a Co-production way of working in developing service in rare palliative neurological
diseases. This is a great opportunity for Keech hospice care to network with other services and work with other charitable
organisations –Motor Neurone Disease Association and PSP Association. We have now completed the first actions learning set
and are working with patients, carers and all care services to establish’ what a good service looks like’. An educational event for
all professional we be held at Keech in the next quarter and we are working together to set up this training event with community
services.
Outreach Palliative Non-malignant Respiratory Programme/Pilot. We were delighted to receive our first proof of the article being
published in May (2015) edition of the European Journal of Palliative Care. This is a great achievement for Keech to get their
work published in such a well recognised journal.
Breath of Hope Group / User Group - The Breath of Hope Support Group was originally formed as a monthly support group for
patients and carers following the Respiratory Outreach Programme. It has gone from strength to strength, with the group
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contributing to the meeting agendas, and it has now progressed into a user group for Keech hospice care. The group has
recently reviewed and commented on the new Adult Service leaflets and the Patient & Public Involvement Strategy and their
suggestions have been taken forward and acted upon.
Clinical Supervision - The Clinical Development Lead for the Adult Service and the Adult IPU Senior Sister have been working
together on planning the roll out of clinical supervision for all care team staff. A planning day has commenced and we are now in
the process of formulating all the staff support in the care service in order to create a monthly programme. Individual reflection
session, guided meditation and clinical supervision are accessible to all the care team at request.
•
The Luton Paediatric Palliative MDT’s continue to run monthly and are well attended by both Health and Social Care
colleagues. The MDT’s continue to be chaired by the Keech Clinical Development Lead along with the paediatric palliative care
teaching program at the Luton and Dunstable Hospital. Implementation of the Paediatric Palliative Care Strategy for Luton
continues. The working party has developed a leaflet and parent held record for families. These have been funded through the
joint commissioner and are currently awaiting print.
•
Keech staff, Neonatal and Midwifery colleagues at the Luton & Dunstable Hospital, the joint Children’s Commissioner for Luton
and CHUMS have reinstated the Neonatal End of Life Pathway that ran as a pilot several years ago. This work is currently
ongoing.
•
The Children’s Inpatient Unit have a new care plan for inpatient care. A new draft document is currently out for consultation
internally.
Supportive Care Service.
•
The new bereavement training continues and the feedback on the evaluation forms has been positive.
•
The Silver Lining group number 22 closed in October after two years of support. This was a well attended group who continue to
support each other away from Keech hospice care. Evaluation feedback forms have also been received back from this group.
There was an 80% response rate, the majority of which were extremely positive.
•
Patient Safety Strategy: We continue to implement the Patient Safety Strategy with safety thermometer visits. The results of
these have been presented in poster format. All areas have far exceeded the benchmark score of 80% however as always we
strive to improve our service to patients and recommendations are being followed up.
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•
Adult In-patient Unit: The unit staff have worked hard under challenging staffing issues this year .We continue to work closely
with the Macmillan team so that we can offer our patients a seamless service. It has been noted that the complexity of our
patients has increased.
•
Children’s In-patient Unit: Following building works funded through a Department of Health capital grant, the new care area is
now complete and being fully utilised. We just await funding for the garden/courtyard which has been designed by families and
the team. The team are working hard on developing dependency scores and competencies, training and care plans so that we
can care for children with TPN feeding. This has led to some great work with the Luton and Dunstable hospital with staff going
into the hospital to develop their competencies.
•
Medical Team Update: In 2014/15 we introduced a new approach to the medical cover of the Children's Service, with a junior
doctor based on the unit. This is working very well. Dr Ranjith Joseph, Consultant Paediatrician joined our team through a joint
arrangement with the L&D hospital and is now settled and offering clinics to our families, it has been a great asset to have his
support. Working relationships with the L&D hospital go from strength to strength and we are exploring other ways of working
together.
•
Following a new reporting framework and subsequent increase in reporting of falls, we will be placing an emphasis on monitoring
and improving this area of care.
Objective 2 – Wider reach
To ensure that care is delivered fairly and equitably to all our local population, and to lead the provision of community services to ensure that
excellent care is delivered to patients in their own home (or care home).
•
My Care Co-ordination Team (MCCT): The team are focusing on promoting the service within our local hospital to ensure all
patients receive information and access to MCCT. Further details on MCCT can be found on page 25.
•
Keech Palliative Care Centre (KPCC) has been monitoring patients’ palliative outcome scores for some time. The team are
keen to use this data to develop their service and skills. KPCC now has an Ascitic Drainage Pathway; this service is for
malignant disease patients who are well enough to attend KPCC as out-patients. Patients will attend KPCC for medical
assessment and their pre-paracentisis venepuncture and then attend within 24/48 hours for drainage of ascites. There continues
to be a regular need for patients accessing the service for blood transfusion and bisphosphonate infusion and from February
2015 KPCC started running a venepuncture clinic on a Monday afternoon for routine Pre-Bisphosphonate Infusion Venepuncture
as the number of patients requiring this service is growing. They will also continue to see patients for urgent venepuncture on
Mondays and as required throughout the week.
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•
Education of others:
The Practice Educator continues to deliver the ABC End of Life Training to nursing home staff. The aim is to deliver an intensive
learning programme to the home for approx. 3 months whilst monitoring their admissions to hospital and reviewing their
practices when a death occurs within their home.
•
We have been working closely with Cambridge Community Services; staff at Keech continues to assist with delivery of training
from the Luton Cancer and Palliative Care Education Programme.
•
An In House Education Programme has started and has been well received by nursing staff, attendance so far has been
excellent.
Objective 3 – Right choices
To ensure that the preferred place of care for all patients and families is recorded and communicated across the whole health system.
•
In 2014/15 we updated our electronic patient record database, Systmone, with a Gold Standard Framework template which
enables us to record information about patient preferences (e.g. place of death). Any update recorded on this template can be
seen by other selected providers, regardless of who has made the entry.
•
To further enhance the GSF template our Head of Care is working with Luton CCG , Bedfordshire CCG, CCS, SEPT to develop
a GSF template that all can use with a range of links, and printable drop downs. It also includes an easy electronic referral to My
Care Co-ordination Team.
Objective 4 – Value for money
To ensure better value for money across all our hospice services.
During 2014/15 statutory funding increased by 5.84%
NHS Commissioned activity during 2014/15, especially Adult Inpatients, has remained high; however, funding from some CCGs is not
reflecting the activity or complexity of care provided. We therefore continue to raise this issue with commissioners formally at our quarterly
contract review meetings.
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Objective 5 – Working together
To build on and develop further partnerships with health and social care professionals in our area.
•
We continue to work with Luton and Hertfordshire Transition Leads looking at the smooth transition for young adults from children’s
services to adult service
•
We are partners within the Luton dementia co-production project, which aims to identify the issues causing carer crisis/breakdown
•
Our relationship with the Luton and Dunstable Hospital continues to remain strong. Examples of working together are the development
of an SLA for our doctors' revalidation, Paediatric Consultant sessions at the hospice and support in the development of individualised
care plans for the dying patient to be used in hospital wards.
•
We continue to have representation at the Bedfordshire and Hertfordshire cancer and end of life forum, working collaboratively with
other hospices and NHS partners to develop protocols and pathways that can be used in all settings.
•
The Clinical Director is now an Associate of the National Council for Palliative Care and has been asked to comment on a new
approach to compassionate employers.
Whilst it has been a challenging year, to date the team have worked extremely hard and continue to be motivated to care for our local
community.
Our strategic themes from 2015/16 are:
1.
2.
3.
4.
5.
6.
To deliver excellent palliative care.
To educate, communicate and influence others to deliver excellent palliative care by sharing our experience and expertise. To educate
the public about death and dying.
To be well funded so we maximise organisational impact
To be well governed and led
To maximise our people resource (staff and volunteers)
To use business intelligence to further our aims
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Priorities for improvement and statements of assurance from the board
The Board of Trustees is committed to the delivery of high quality care that is safe, effective and provides patients and carers with a
positive experience.
1a. Priorities for improvement in 2015 – 2016 (Adults and Childrens)
To Deliver Excellent Care:
Priority 1:
Target:
How was this identified as a priority?
How will this priority be achieved?
How will progress be monitored?
Priority 2:
To develop Palliative Rehabilitation Services as part of our universal specialist offer to patients with
long term conditions.
Recruit additional staff in response to a successful funding application, for physiotherapy and
occupational therapy staff.
Keech hospice care Strategy 2015-2020
Funding application submitted and approved.
Successful recruitment of OT & physiotherapy staff
Offering of service
% increase of adult patients accessing services.
Target:
Enhance Supportive Care and Bereavement services as part of our universal specialist offer to
family members
Produce strategy for Supportive Care.
How was this identified as a priority?
Keech Hospice Care Strategy 2015-2020
How will this priority be achieved?
Completed and approved Supportive Care Strategy with implementation plan.
% increase of family members accessing supportive care and bereavement services.
How will progress be monitored?
Progress reported bi-monthly to the Clinical Managers Team meetings (CMT)
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Priority 3:
Increase our capacity to care for more people by expanding our services into the community so all
patients and families in our catchment area, who want a community based service, have access to
full specialist palliative care support, wherever they need it.
Target:
Explore models and devise business plan for adult Hospice in the Home team.
How was this identified as a priority?
Keech hospice care Strategy 2015-2020
How will this priority be achieved?
Plan devised and approved by Board of Trustees
How will progress be monitored?
Progress reported bi-monthly to the Clinical Managers Team meetings (CMT)
Educate & Communicate:
Priority 4:
Increasing the range and quantity of education, training and research opportunities through a
learning hub model to deliver these both internally and externally; clinical and non-clinical.
Target:
Scope and develop an implementation plan for a new commercial venture for an education service
for Keech. Where possible in partnership with an academic institution.
How was this identified as a priority?
Keech hospice care Strategy 2015-2020
How will this priority be achieved?
Scoping exercise and Implementation Plan developed.
How will progress be monitored?
Progress reported bi-monthly to the Clinical Managers Team meetings (CMT)
To maximise our people resource (staff and volunteers):
Priority 5:
To ensure we have the full Multidiscipline Team in the right numbers with the right competencies to
be recognised as a Specialist Service
Full MDT in place
Target:
How was this identified as a priority?
Keech Hospice Care Strategy 2015-2020
How will this priority be achieved?
Capacity and delivery plan against NICE guidance
How will progress be monitored?
SMT to the Board
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1b. Progress against Priorities for Improvement in 2014 – 2015
Providing Excellent Care:
Progress in 14/15
Priority 1:
To increase the range of services provided within the community to those with malignant and non-malignant conditions.
Target:
To scope and explore the needs of children and families and develop a
community support model.
To increase the number of adults we see in their normal place of
residence
A review was completed in Hertfordshire, which included
patients, families and professionals to explore the support
needs and identify proposals for moving forward.
Palliative care support workers made 190 visits/calls to
patients in the community and there were 38 hospital
avoidances.
Wider Reach:
Priority 2:
Target:
Ensure access to services for patients with non-malignant disease and palliative rehabilitation needs
Develop outreach programmes for those with respiratory diseases,
Respiratory/COPD outreach programmes have run
heart failure outreach and rare neurological conditions.
successfully in 14/15 and an article was written submitted for
publication in 2015/16. The fatigue management programme
also ran.
Rehabilitation scoping exercise was completed and plan to
move forward identified.
Value for Money:
Priority 3
Target:
Develop a ‘Cost of Care Model’ and review our hospice tariffs, to ensure an efficient and effective cost and income base.
To develop a statutory income strategy financial framework that can be
A ‘Cost of Care’ model spreadsheet has been developed and is
populated to provide accurate costs for individual services provided.
used when costing services for trust applications or service
commissioning
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Working Together:
Priority 4
Target:
Progress in 14/15
Explore opportunities to develop a collaborative research programme and service improvement plan, offering palliative care
education and resources to colleagues in the health economy, to ensure best practice is offered everywhere.
Establish formal relationship with Higher Education Institute
Keech is part of the Health Education England consultation on
end of life training.
Work continues with the University of Bedfordshire, although
we recognise that we are not as far forward as we would have
hoped.
Keech is also discussing learning opportunities with the
National Council for Palliative Care to improve learning.
Patient Safety, Patient Experience and Clinical Effectiveness
Priority 4:
Target:
To obtain meaningful patient and public feedback and use to shape services
To establish two Patient & Public Involvement Participation Groups (one Keech has established a ‘Patient and Public Involvement
for adults and one for children’s services). This group will work within an Committee’, which reviews all feedback received from patients
agreed Terms of Reference to provide a focus within the charity for
and the public and considers actions required to continually
involvement and debate. The panel will determine priorities for targeted improve our services.
patient surveys and involvement.
The annual Stakeholder and Partner Meeting, on review, was
To hold an annual Stakeholder and Partner Meeting (around
considered not the best approach and we have therefore
October), at which time ideas for service development and how
agreed to move forward engaging on specific areas and
services should be shaped to address patient and public
engaging users in this way i.e. PLACE surveys. Children
feedback will be discussed with commissioners.
informed the new build designs, Breath of Hope group
reviewed patient literature etc.
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2. Review of services
During 2014/15 Keech Hospice Care provided the following specialist palliative care services to the NHS:
Adult Service
• Inpatient unit
• Palliative Care Centre
• Care Co-ordination Services
• Drug Therapies
Children’s Service
• Inpatient unit
• Day Support
• Community Nursing Team
In addition we have also provided the following services through charitable funding:
• Hospice at Home
• Complementary Therapy
• Music Therapy
• Family and Carer support
• Bereavement Care
• Spiritual Care
• Hydrotherapy pool
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3. Participation in Clinical Audit
•
During 2014/15 no national clinical audits or confidential enquiries covered NHS services that Keech Hospice Care provides
•
During 2014/15 Keech Hospice Care participated in no national clinical audits and no confidential enquiries of the national clinical
audits and national confidential enquiries as it was not eligible to participate in. However we ensured that key audits were completed
using nationally recognised excellence audit tools for hospices developed by Help the Hospices.
•
The national clinical audits and national confidential enquiries that Keech Hospice Care participated in during 2013/14 are as follows:
N/A
•
The national clinical audits and national confidential enquiries that Keech Hospice Care participated in and for which data collection was
completed during 2014/15 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the
number of registered cases required by the terms of that audit or enquiry: N/A
•
The reports of 0 national clinical audits were reviewed by the provider in 2014/15. This is because there were no national clinical audits
relevant to the work of Keech Hospice Care.
•
Keech Hospice Care was not eligible in 2014/15 to participate in any national clinical audits or national confidential enquiries and
therefore there is no information to submit.
•
The local clinical audits that were reviewed in 2014/15 are listed further in the document.
•
Keech Hospice Care submits an annual National Minimum Data Set to the National Council of Palliative Care and uses nationally
approved audit tools (Help the Hospices) to audit Infection Control, General Medication and Controlled Drugs. Since 2009 we have
achieved the status of accredited Hospice with CHKS. This is a quality assurance accreditation which is tailored to Hospice services.
4. Research
The number of patients receiving NHS services provided or sub-contracted by Keech Hospice Care in 2014/15 that were recruited
during that period to participate in research approved by a research ethics committee was NONE.
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5. Use of CQUIN payment framework
A proportion of Keech Hospice Care income in 2014/15 was conditional on achieving quality improvement and innovation goals as
specified by our Commissioning Partners and the agreed CQUIN’s where achieved in 2014/15.
6. Statement on the Care Quality Commission
Keech Hospice Care is required to register with the Care Quality Commission and is currently registered to carry out the regulated
activities:




Treatment of disease, disorder or injury
Accommodation for persons who require nursing or personal care
Nursing Care
Personal Care
There are no restrictions on our registration.
The Care Quality Commission has not taken any enforcement action against Keech Hospice Care in 2014/15.
Keech Hospice Care has not participated in any special reviews or investigations by the Care Quality Commission in 2014/15.
7. Data Quality
Keech Hospice Care did not submit records during 2014/15 to the Secondary Users Services for inclusion in the Hospital Episodes
Statistics which are included in the latest published date because it is not eligible to participate in this scheme. We do however have our
own system for monitoring the quality of data.
We continue to use SystmOne, electronic patient record system, which is also used by many healthcare professionals in the community
meaning that we can share information from and with other services (with given consent from the patient). SystmOne is also linked with
the NHS spine which makes for an easier registration process when a patient is referred into the service, it also means that our doctors
are able to access test results online.
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8. Information Governance Toolkit
Keech Hospice Care achieved 70% using version 12 of the Information Governance Assessment Report for 2014/15: This is well above
the 66% we are expected/required to score.
9. Clinical coding error rate
Keech Hospice was not subject to the Payment By Results clinical coding Audit during 2014/15 undertaken by the audit commission.
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10. Organisational Structure
Keech Hospice Care – Governance and Management Structure
Council of Management
Audit & Risk Committee
Clinical Management Team
Clinical Audit Group
Senior Management Team
Operational Management Team
Risk Management and Health and Safety Committee
Medical Gases Committee
Information Governance Steering Group
Education Group
Drugs and Therapeutics
Committee
Infection Control Group
Notes Audit Group
Patient and Public Involvement
Steering Group
Children's Service
Steering Group
Representatives of Employee
Safety Committee
Moving and Handling Group
Legend
– Governance
Joint Consultative Committee
– Management
Widening Access Group
– Operational
Staff Forum
– Consultation
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ADULT SERVICES
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11. Adult Service Statistics
Total number of patients seen was 474 in 2014/15 (against 468 in 2013/14)
Adult Inpatient Analysis
Emotional Support,
36
Total bed nights used April – March = 1740
132 patients used IPU, of which 84 died.
End of Life, 353
Pain/Symptom
Management, 1351
Out of the 84 patients who died on the Adult In-patient
Unit:
• 46 were referred for end of life care
• 38 were referred for pain/symptom management
In total 55 referrals were received for end of life care. Out of
these:
• 46 patients died on the unit
• 1 was discharged to a nursing home
• 1 patient was discharged home but later came back and
died on the unit (counted in the 39 above)
• 4 were still resident on the adult in-patient unit at the
end of quarter 4
• 3 were discharged home
These patients were on the unit for a combined total of 353 bed
nights.
Breakdown of patients using the service in 2013/14
Total BME 2014/15 = 18.9%
Total BME 2013/14 = 16.6%
Local BME 35%
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Keech Hospice Quality Accounts 2014 - 15
Keech Palliative Care Centre Patient Analysis
Total patients seen in KPPC was 238 in 2014/15 (an increase on the 215 seen in 2013/14)
The graph below shows which Palliative Care Centre services patients have accessed:
250
In addition to our work in KPCC, for Luton
patients we have provided:
200
33 Blood Transfusions
3 Hormone Implants
77 Infusions
11 Paracentisis Assessments
150
100
50
0
Patients
Nurse Led Clinic
Full Day
Drop In
Doctors Clinic
Methadone
Clinic
209
127
94
71
17
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Keech Hospice Quality Accounts 2014 - 15
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Keech Hospice Quality Accounts 2014 - 15
Supportive Care Services
Number of Sessions:
Art therapy activity statistics
2013/14
Adult Children
74
132
2014/15
Adult
Children
163
189
Complementary therapy activity statistics
710
144
646
229
Music therapy activity statistics
121
17
268
184
Social work activity statistics
672
158
958
88
Hospice at Home activity statistics (patients)
149
0
141
0
Bereavement service activity statistics
354
295
321
447
Other activity undertaken by Adult Services
Out of Hours Nursing Visits and Telephone Advice Line (Adult Service)
Visits/Phone calls 531 (an increase on 473 in 2013/14)
My Care Co-ordination Activity
Total number of registrations:
Deaths:
Discharges:
Average length of time on caseload:
Number of hospital avoidances:
695 (103 of whom were already known to Keech)
332
27
76 days (for those who were discharged or died).
38
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Keech Hospice Quality Accounts 2014 - 15
12. Infection Control
Required
For
CQC
13.
2012/13
2013/14
2014/15
The no. of patients known to be infected
with MRSA on admission to the unit
The no. of patients known to be infected
with MRSA whilst on the in-patient unit
1
1
1
0
0
0
The no. of patients admitted to the unit with
C-difficile
The no. of patients infected with C-difficile
while on the in-patient unit
1
0
2
0
0
0
The no. of patients known to be infected
with an alert on admission
The no. of patients who contracted an alert
organism infection whilst on the unit (if
known)
0
0
2
0
0
0
2012/13
2013/14
2014/15
The no. of CQC reportable safeguarding
issues
0
1
2
The no. of non-CQC reportable
safeguarding issues
1
3
13*
Safeguarding
Required
For
CCG/
CQC
*There was an increase in the number of non-CQC reportable safeguarding issues due to a new system for reporting introduced and as training given,
more forms have been submitted.
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Keech Hospice Quality Accounts 2014 - 15
CHILDREN’S SERVICES
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Keech Hospice Quality Accounts 2014 - 15
14.
Children’s Service Statistics
Children's Service
Total number of children using the service was 255 in 14/15 (against 244 in 13/14)
Children’s In-patient Unit activity statistics
Hospital
Transition, 37
End of
Life,
44
81 patients used IPU. This is an increase on the
75 patients last year.
Total bed nights used April 2014 – March 2015
= 703
The figures shown in the chart represent bed
nights used. Occupancy % is down for April –
March due to building works which were taking
place during that time.
Short breaks accounted for 75% of the bed nights
used
Hospital
Transition/EOL, 72
72 nights were used for 1 young adult who
initially came in for a hospital transition stay, this
changed during her stay to become end of life
care
Symptom/Pain
Management, 24
Short Break, 526
44 nights accounted for end of life care for 8
children (these do not include the child above)
In addition to the 703 nights shown on this chart
the Meadow Suite was used by 12 families for a
total of 36 nights
Total BME in 2014/15 = 30%
Total BME in 2013/14 – 25%
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Keech Hospice Quality Accounts 2014 - 15
Children’s Community Activity
Total families supported 244 (14/15), an increase on 2013/14 activity of 232.
Number of visits provided 1353 (14/15), an increase on 2013/14 activity of 1101.
Deaths supported in the community were 24 (14/15), an increase on the 18 supported last year.
399
267
177
114
110
39
Condition
Specific…
8
End of Life
Care
9
Bereavement
(Pre)
41
Clinical
Intervention
Second in
attendance
Professionals
Mtgs
Assessment
42
Bereavement
(Post)
83
Symptom
Control
Day therapy
team
Care Planning
64
Psychosocial
450
400
350
300
250
200
150
100
50
0
Children’s Service Day Support activity statistics
Total number of attendances in 2014/15 was 760 (a significant increase on the 522 in 2013/14). This reflects the new approach to Day
Support and the movement, in year, of one of the IPU nurses to lead this important service.
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Keech Hospice Quality Accounts 2014 - 15
15.
Accidents, Incidents, Complaints and Compliments
(Hospice Wide Statistics):
Accidents
2012/13
Adult IPU
Palliative Care Centre
Children's IPU
2013/14
2014/15
Patient (Falls)
15
11
21
Patient (Accidents)
2
1
1
Care Staff
5
6
8
Patient (Falls)
1
0
1
Patient (Accidents)
2
1
3
Care Staff
3
0
2
Patient (Falls)
0
0
2
Patient (Accidents)
3
1
6
Care Staff
4
4
2
35
24
46
Reportable Accidents
Number of accidents reported to RIDOOR = 2
Number of accidents reported to CQC = 2
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Keech Hospice Quality Accounts 2014 - 15
Incidents
Medication Incidents
Total received YTD
2013/14
2014/15
Medication Incidents (Direct patient care – Adults )
0
11
Medication Incidents (Non patient care – Adults )
2
12
Medication Incident (Third Party – Adults)
2
13
Medication Incidents (Direct patient care – Children )
2
2
Medication Incidents (non patient care – Children )
2
4
Medication Incidents (Third Party – Children )
0
1
Total
8
43
Medication Incident Risk Scores Quarter 4
Incident
1
SUI
2
LIN
20-25
13-19
Inherent Risk
8-12
4-7
Direct patients care – Adults
Non patient care – Adults
Third party – Adults
0
0
0
0
0
0
3
Direct patient care – Children
Non patient care – Children
0
0
0
0
1
1
1-3
Not scored
1
1
1
1
SUI = Serious Untoward Incident which must be reported to the Clinical Commissioning Groups and the Care Quality Commission
LIN = Local Intelligence Network. Medication Incidents involving controlled drugs are reported on a quarterly basis by our Accountable Officer (Liz Searle) to the Local Intelligence
Network
2
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Keech Hospice Quality Accounts 2014 - 15
Other Incidents
Total received YTD
2013/14
2014/15
Hospice - Care
Patient Care – (A)
Patient Care – (C)
Patient Care – (OP)
Patient Safety/Security
Potential Safeguarding – (A)
Potential Safeguarding – (C)
Potential Safeguarding – (HP)
Privacy and Dignity
Abusive/Aggressive behaviour (A)
Maintenance/Equipment
Bereavement Care – (A)
Bereavement Care – (OP)
Other – care
1
2
1
5
1
1
0
1
1
1
0
0
1
3
3
6
6
1
1
2
2
4
3
1
1
1
Hospice – Non Care
27
44
Retail
25
20
Total incidents
67
98
(A)= Adult Service (C) = Children’s Service
(OP) = Other Provider
(HP) = Hydrotherapy Pool
Complaints
2112/13
2013/14
Reportable Complaints
2014/15
Patient Care – Adult (Verbal)
0
1*
2
Patient Care – Adult (Written)
0
0
2
Patient Care – Children (Verbal)
2
0
2
Patient Care – Children (Written)
3
1
3
5
2
9
Number of complaints reported to CQC = 0
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Keech Hospice Quality Accounts 2014 - 15
Compliments received
“Thank you for the wonderful care
you provided to my wife, it was
her wish to spend her final days at
Keech and I feel so honoured that
this was fulfilled. I particularly
thank the nurse who took me and
my family under her wing when
my wife was entering the final
stages of her life and the period
immediately afterwards”
(Adults)
“Keech has made a real difference
to our lives, we could not ask for
better support”
“There is nowhere safer, more
secure or more caring. We feel
100% relaxed when our child is in
your care” (Children)
“Keech is such a valuable place for
us; I don’t know what I would do
without it! All nurses are so nice and
caring. I wish I lived there because
the support they give is just
amazing” (Children)
“Excellent staff at Keech, they know
our son and they care for him with
love and kindness. We feel
completely confident in their ability
to look after him” (Children)
“My wife always looked forward to her Tuesday visits and
despite her fragile health was undoubtedly much improved
when I collected her at 3pm” (Adult)
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Keech Hospice Quality Accounts 2014 - 15
Friends & Family
A requirement of our commissioners is that we ask our users to complete a friends and family questionnaire. Year to date 244 questionnaires
were given out and 90 responses received back.
We asked the question:
How likely are you to
recommend Keech
Hospice Care to friends
and family if they
needed similar
treatment or care>
Extremely Likely
Adults Service
31/63 Returned
(49%)
Children’s Service
26/118 (22%)
Returned
Likely
Neither likely nor
not likely
Unlikely
Extremely unlikely
98%
2%
0
0
0
93%
7%
0
0
0
00
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Keech Hospice Quality Accounts 2014 - 15
16. Quality and Compliance
Standard of Care
Care Quality Commission (CQC)
We have not yet been inspected by the Care Quality Commission.
Notifications made to the Care Quality Commission between April – March:
 Serious Injury = 3 (2 fractures & 1 grade 3 pressure ulcer)
 7 notifications have been made for Deprivation of Liberty of adult patients.
Accreditation
Our accreditation is due to expire in November 2015. We have received an enquiry from CHKS as to whether we would be renewing our
accreditation, this would mean revisiting all of the standards, re-submitting evidence and another site visit next November. After discussion the
Senior Management Team have agreed that as we are currently working towards the Gold Standards Accreditation we will not be renewing
with CHKS this time round however it is not ruled out for the future.
Provider Visit
Provider visits conducted by Trustees have been taking place quarterly. Throughout the year they have visited the following departments::






Children’s IPU
Adult IPU
Palliative Care Centre
My Care Co-ordination Team
Finance
Marketing and Communications






Supportive Care
Fundraising
Children’s Community
Housekeeping
Catering
HR, Training and Volunteers
Feedback is generally good. An action plan is drawn up following each visit.
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Keech Hospice Quality Accounts 2014 - 15
Safety Thermometer
Adult IPU, Children’s IPU and KPCC continue to conduct monthly safety checks in their areas, concentrating on infection control issues and
patient safety. The results of these are sent to the Clinical Director and Head of Care.
The Clinical Director and Quality and Compliance Manager conduct quarterly quality and safety checks which includes review of the
medication books and stock checks, discussing with staff outcomes around any incidents, accidents and complaints (also sharing
compliments received) and talking to patients and visitors about their experience. The results of these are shared with the respective teams
via a ‘Safety Thermometer Awareness Poster’.
Positive reports have been received from staff about this process.
Workplace Inspections
Quarterly workplace inspections continue to take place and are conducted by the Health and Safety Co-ordinator, a member of the Quality
and Compliance team and a Representative of Employee Safety (ROES), a member of the admin team records any issues or concerns raised
by staff. The last workplace inspection took place on 5th March 2015, no major concerns were raised.
Clinical Audits Conducted:
The following table has been taken from our Clinical Audit Calendar for 2014/15 and shows our progress with the audits on the calendar for
the period April 2014 – March 2015. Audit and compliance is a standing agenda item for the Audit and Risk Committee which meets quarterly.
The Clinical Audit Group meet quarterly. The group are presented with reports from any new audits and review the progress made against
action plans from previous audits.
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Keech Hospice Quality Accounts 2014 - 15
Summary of 2014/15 Audits & Surveys:
Month
Audit Title
Planned completion date
April
Patient Accident Audit (for period April 13- March 14)
Complete
Complaints Audit (for period April 13 - March 14)
Complete
Notes Audit
Re Audit - Infection Control (Adults)
Complete
Complete
Re Audit - Infection Control (Children)
Complete
Infection Control Audit KPCC
Complete
Pain Assessment Audit (Children)
Self Administration of Medicines (KPCC)
Complete
Complete
July
Pain Management Audit (Adult)
Complete
August
General Medicines Audit - CIPU
Complete
General Medicines Audit - KPCC
Complete
General Medicines Audit - AIPU
Complete
Re Audit - Use of Methadone
Complete
Controlled Drugs Audit - CIPU
Complete
Controlled Drugs Audit - KPCC
Controlled Drugs Audit - AIPU
Complete
Complete
Practicing Privileges Audit
Complete
Notes Audit
Complete
Medical Gases Audit
Complete
Care Plan Audit (Children's Service)
Complete
November
December
Use of Steroids Audit (Adults)
Completion of Moving and Handling Forms
Complete
Complete
January
Patient and Family Experience Survey
Complete
June
Sept
October
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Keech Hospice Quality Accounts 2014 - 15
Month
Audit Title
Planned completion date
Complete
March
Bereavement Care Survey (Results of Bereavement Visitor
Questionnaire and Silver Lining Questionnaire)
Consent Audit
Complete
Surveys
Adult Service patient experience Survey
Carer Experience Survey
Family Experience Survey
Patient Accident Audit
Research
In 2014/15 Keech Hospice Care did not take part in any research. However, this is an area we are interested in pursuing as set out in our
priorities for 2015/16.
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Keech Hospice Quality Accounts 2014 - 15
17.
Feedback from Our NHS Commissioners:
1) East and North Herts CCG (ENHCCG) has reviewed the information provided by Keech Hospice and we believe this is a true reflection of
performance during 2014/15, based on the information submitted during the year as part of the on-going quality monitoring process.
During 2014-15 Keech Hospice continued to deliver high quality care to the children of Hertfordshire. The Quality Account clearly sets out
achievement against the priorities set for 2014/15 and demonstrates continued quality improvement. The hospice has a strong emphasis
on proactive development and identification of new ways of working with partners to improve the quality of service for patients. In addition,
they proactively maintain their involvement and influence in relation to the palliative care strategy.
The quality of service provided is evident through the positive feedback received from patients and relatives from Friends and Family
questionnaire throughout the year. The priorities set out for 2015-16 build upon the successes of 2014-15 and demonstrate a commitment
to all round quality improvement. The priorities are supported and embedded into the Hospice care strategy. During 2015-16 the CCG looks
forward to building on the relationship already developed with the hospice to ensure open dialogue and continued quality improvement for
the population of Hertfordshire.
East & North Herts Clinical Commissioning Group
2) “Herts Valleys CCG sees Keech Hospice Care as a key partner in the delivery of integrated end of life care to young people in West
Hertfordshire. We value the regular and open communication that we have, and are committed to working with Keech to continue to deliver
a high quality and much valued service to our population.
During 2014/15 Keech Hospice Care continued to provide high quality care, prioritising patient safety, clinical effectiveness and enhancing
the experience of patients and their families.
Looking forward to 15/16, Herts Valleys CCG is delighted to continue to work closely with Keech as a key partner in helping us to achieve
our End of Life Strategy. The strategy reflects the aims of both organisations to continually improve, and to provide high quality end of life
care to the local community.”
Commissioning Team, Herts Valley Clinical Commissioning Group
3) “In line with the NHS (Quality Accounts) Regulations 2011, NHS Luton Clinical Commissioning Group have reviewed the information
contained within the Quality Account to provide a comment as requested by Keech Hospice.
The account is well presented and provides an overview of the services provided.
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Keech Hospice Quality Accounts 2014 - 15
The account appears to be an honest reflection of the previous year, both with the challenges faced and the progress made with the
2014/15 priorities.
We are pleased to see the focus of the 2015/16 priorities following our feedback also includes children’s services and Luton Clinical
Commissioning Group look forward to supporting Keech Hospice in achieving quality improvements within year.
Luton Clinical Commissioning Group are keen to see Keech Hospice further develop in partnership with other organisations and achieve a
high quality service to the patients of Luton, understanding the financial constraints they work within.”
David Foord, Director of Quality & Clinical Governance, Luton Clinical Commissioning Group
4) Thank you for forwarding a copy of the Quality Account for Keech Hospice Care to the Milton Keynes Commissioning Group (CCG) which
has been read with interest.
We are pleased that Keech Hospice Care has continued to work alongside MKCCG to sustain and further improve the quality of their
service. It is helpful to see the achievements and highlights to demonstrate progress against the previous strategic objectives.
It is positive to see that Keech Hospice Care are embracing the safety agenda through schemes based upon safety thermometer principles
and the robust ongoing audit and survey programme.
In addition to the Annual Quality Account MKCCG is pleased to have received regular and timely quarterly Quality Reports which have
provided more detailed qualitative and quantitative information and demonstrated changes and improvements made as a result of incidents
or complaints, which has been positive to see.
MKCCG can confirm, to the best of our knowledge, that the Quality Account contains accurate and transparent information in relation to the
range of services provided and the quality of services that Keech Hospice Care provide.
During 2015/16 MKCCG looks forward to working collaboratively with Keech Hospice Care to further understand the priorities for
improvement for 2015/16.
Jill Wilkinson, Director of Nursing & Quality, Milton Keynes Clinical Commissioning Group
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Keech Hospice Quality Accounts 2014 - 15
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Keech Hospice Quality Accounts 2014 - 15