Page
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LOROS vision, mission, values and behaviours
1
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Our Aims
2
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Patient story
3
Part 1
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Statement on quality from Chief Executive
4
Part 2
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Priorities for Improvement 2015/16 - future planning
5-10
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Statements of Assurance from the Board
11
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Review of Services (Mandatory Statement)
11
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Participation in Clinical Audits (Mandatory Statement)
12-14
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Research (Mandatory Statement)
15
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Goals Agreed with Commissioners (Mandatory Statement)
16
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What Others Say About Us (the Provider) (Mandatory Statement)
16
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CQC Inspection Visit
17
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Data Quality (Mandatory Statement)
18
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Information Governance Toolkit (Mandatory Statement)
18
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Clinical Coding Error Rate
18
Part 3
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Report on Review of Quality Performance (2014/15)
19-25
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Clinical Dashboard
26-35
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Clinical Data
36-43
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Feedback from Patients/Families
43-60
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Feedback from Hospice staff
61
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The Board of Trustees Commitment to Quality
62
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Written Statements by other bodies
63
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Glossary of Terms
64
VISION
(Our long term aspiration for our society)
Everyone with an incurable illness has the right to excellent
care. This should value and respect their uniqueness and their
own choices. People should be enabled to live and die with dignity and with appropriate and compassionate support for them
and their loved ones.
MISSION
(Our goals and activities in working towards our Vision)
LOROS is a charity whose aim is to enhance the quality of life of
adult patients with cancer, progressive neurological conditions
and end-stage organ failure for whom curative treatment is no
longer possible. Patients are treated at the hospice and in the
community based upon clinical need, regardless of background
and the ability to pay.
LOROS specialises in holistic, multidisciplinary care, focused on
the whole person and including family and carers. The care given takes into account the patients’ physical, psychological, social and spiritual needs as well as their own choices. Family
members are supported in adjusting to loss and bereavement.
LOROS contributes to the education and training of its own and
other health and social care professionals and of volunteers. The
charity is also committed to research in order to improve the
understanding and practice of palliative care.
VALUES & BEHAVIOURS
(How we will strive to be)
L
FOCUSED
PROFESSIONA
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in our attitude and everything we do
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on patients, families and carers whilst
listening, learning and adapting to their
diverse needs
in working together and with others
RATIVE

ONATE
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STED
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COLLABO
COMPASSI
TRU
in providing care and responding sensitively
to requests for support
within our organisation and by our
community
Our Aims
Patients and families are at the heart of everything we do
In caring for you and supporting your family, we will:
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Treat you with dignity, respect, compassion and sensitivity
Deliver care that is focussed on your individual needs and wishes
Respond to your physical, psychological, social and spiritual needs
Communicate effectively with you
Promote your wellbeing and as much independence as possible
Provide you with high quality and safe care
Respect your cultural needs
Listen to your views and learn from them, to continually improve our services
Recruit competent, trained staff and volunteers who you can trust
Support the development of staff and volunteers both within LOROS and externally
through education, training and research
Work as one team within LOROS
Be professional in our attitude and behaviours
Work in partnership with other organisations involved in your care
Be open to external influences and ideas to improve the care we deliver
Do everything we can to enhance your quality of life
Chief Executive
Director of Care Services
Lead Clinician
Eamonn Downs was just 44 when he died in March 2013, less than
a year after being told he had a brain tumour. During his last
months with his wife, Jo, and baby son, Evan, who is now two,
LOROS provided immeasurable support to the whole family. Here,
Jo tells how the hospice helped her through.
When Eamonn was diagnosed, we were told then that his tumour
was grade 4, the worst it could be. We were put in touch with
LOROS pretty quickly as he was on a lot of medication, so at first a
CNS (community nurse specialist) would visit us at home to support
him with that. Then we were told about the counselling service. We
did that together and the support was invaluable. Eamonn was a
very private man, very independent, but being able to talk with
someone gave me a sense of what he was going through, his
frustrations, and also his wishes for the future as well. I’m so
grateful that we got the counselling and that we got it early on,
when Eamonn was reasonably well, as the tumour affected his
ability to communicate in the end. I’m so glad they got to know him
and understand him. In October-time, Eamonn had a week’s respite. He had lots of complications with the tumour and we found out
he had osteoporosis — he was in agony. The consultant at LOROS
really listened and supported us getting appointments at hospital
for him. Eamonn went back to LOROS in January 2013. He came
home after a few weeks but it wasn’t long before he went back. He
died at LOROS, and I know it was the best place he could have
been.
I spent many nights at the hospice with Eamonn. Our son was only
one when it was all happening so it was incredibly difficult, but they
were so accommodating, making everything as normal as possible.
I’d order takeaways and Eamonn would have a can of beer sometimes. Every Thursday, when he was up to it, his friend would take
him to the pub. Eamonn and I were very close and in love, and he
was a very romantic man. We celebrated our anniversary at
LOROS and on Valentine’s Day, he made me a heart of flowers. He
wouldn’t have been able to do that himself, by that point, and it
meant so much that they’d helped.
Eamonn was a strong character. He wanted to protect me right to
the very end and I think LOROS helped him do that. They gave him
the feeling that he still had some control over his life. And they
helped me cope, too. I carried on using the counselling service and
that only stopped earlier this year.
If we hadn’t had LOROS, I don’t think I would have been able to
cope. I don’t know how I would have got through. I really can’t
praise them highly enough.
LOROS is an independent charity that provides palliative care and support to
around 2,500 people each year a cross Leicester, Leicestershire and Rutland. It
is of particular significance that this Quality Account is written in the charity’s thirtieth anniversary year. Whilst it is my first year as the Chief Executive Officer I
know that this is a time at which we are particularly proud of the organisation’s
achievements and its ongoing dedication to providing the very highest standards
of care.
Patients are offered our services based upon clinical need and independent of
gender, race, colour, religion or the ability to pay. All services provided by
LOROS are free of charge due to the collaboration of funding from both the NHS
and the generosity of the local community. Fundraising contributes over 65% of
the monies necessary to sustain and develop the hospice.
The passion and commitment of the Trustees, staff team and volunteers drives a
culture that strives for continuous improvement. This is partly achieved through
inviting, capturing and acting upon feedback from patients and their families.
Other focussed activities that enable service improvement are the use of data to
aid the review of efficiency and effectiveness and also the energy and resource
that LOROS dedicates to workforce development and research.
It is reassuring for me to be able to confirm that the Priorities stated in last year’s
account have been successfully progressed with positive outcomes. In looking
forward to the period 2015/2016 LOROS will continue to focus its energies to provide a service of outstanding quality and during this time has committed to a number of key priorities under the headings of patient safety, clinical effectiveness
and patient experience.
A large number of people have contributed to this Quality Account, most notably
the Director of Care Services and Clinical Governance/Compliance Lead.
The LOROS Board of Trustees reviewed and approved this Quality Account in
June 2015.
To the best of my knowledge, the information contained in this document is
accurate.
John Knight, Chief Executive Officer
We have identified areas for improvement in the coming year, under each of the domains of quality set out in the Department of
Health Report:- High Quality Care for All, Patient Safety, Clinical
Effectiveness and Patient Experience.
Patient Safety
Priority one - Pressure Ulcer Management
LOROS has been actively participating in a number of groups
working at both an operational and strategic level across LLR in
support of a national drive to eliminate all pressure ulcers within
every care settings. As part of this work a pressure ulcer campaign
is taking place to help raise awareness amongst service users and
the general public about pressure area management. LOROS will
be participating in this campaign by utilising posters and leaflets
agreed by the group and undertaking a series of manned campaign
days within the hospice to promote the issue of pressure area management and provide additional verbal advice to patients, families
and visitors.
The hospice continues to submit pressure ulcer data nationally as
part of the Hospice UK Inpatient Safety benchmarking project and
is further analysing this data via a midlands wide hospice senior
nursing and quality group to identify trends and areas of good practice that can potentially be implemented locally.
The internal validation process at the hospice has been further developed and from April LOROS has begun to use LLR agreed
codes to identify the cause of avoidable pressure ulcers (PUs) to
help highlight trends that can be further explored by the operational
group. As numbers are relatively small at the hospice unavoidable
PUs are also going to be classified using these codes to identify if
they are fit for purpose for coding and identifying themes for all PUs
in the longer term.
To help support this work LOROS has increased the hours of the
Tissue Viability lead nurse from 12 to 15. The outcome of the
above work is a proposed further reduction in the number of
hospice acquired PUs.
Priority two - Falls Management
Participating in the National Hospice UK Inpatient Safety Benchmarking project has also provided the opportunity to build some
local intelligence in relation to the incidence of falls.
It has highlighted that whilst patients of all ages fall, certain risk
factors are more common in younger people (including trip hazards, faints, fits, acute illness), but falls are most likely to occur in
older patients, and they are much more likely to experience serious
injury.
Further work is now required to analyse the falls incidence data in
more detail and compare performance between hospices of a
similar size and patient mix. Collating data over a twelve month
period has enabled the identification of trends and themes to better
inform clinical practice and make positive improvements to patient
care. Participation in the Midlands wide nursing and quality group
will provide further opportunity to scrutinise this data and share
successful interventions from other units to help inform service
development at LOROS. There will be a multi-disciplinary approach
to this priority with input from the medical teams and allied health
professionals.
The outcome from this work is a predicted reduction in the
number of falls within the in-patient unit during 2015/16 and
improved strategies to manage patients at high risk of falls.
Priority three - Medication Administration Competencies
LOROS is very aware that to ensure safe and effective administration of medicines it is essential that Registered Nurses maintain
and constantly update their knowledge and skills. Following on
from the introduction of clinical competencies for hospice nursing
staff a new bespoke administration of medicines training package
is being implemented at LOROS to provide support to Registered
Nurses in the safe administration of medicines, helping to maintain
high standards of practice and ensuring a consistent approach to
the management of medicines administration incidents.
This training package aims to provide an opportunity for Registered
Nurses to analyse their practice, learn from incidents and subsequently improve their skills, providing them with education and support in their role in the safe administration of medicines.
The outcome is that all Registered Nurses will have successfully completed this training package by April 2016 and a further reduction in administration errors.
Clinical Effectiveness
Priority One – Further implementation of the integrated palliative outcome scale (IPOS)
IPOS is a validated tool used to measure the difference a service is
making for patients, and is being used nationally across hospice
and palliative care services. It works by asking patients to rate their
physical and psychological symptoms, as well as family concerns
and information needs. These scores are then compared over time,
to see where support is needed most and if subsequent interventions have actually helped.
Following the successful pilot in the Day Therapy service, over the
next year LOROS will be extending the use of the IPOS to patients
on the in-patient unit, out-patient clinics and when seen at home by
the community nurse specialist team. By utilising this tool more
widely the hospice can better identify patients’ perspectives on
what matters to them and see if the services provided have been
able to make a positive difference.
An innovation this year will be automating how the data is collected
from the document the patients fill in, so that there is a clearer
overview of where services are performing well, and also where
improvements are required. This will also help the clinical staff to
be more objective about which patients are managing well without
intense support, and also those who need a greater level of input.
Another development is enabling staff to use SystmOne, our electronic patient record, in settings outside of the hospice, for instance
when visiting patients at home. Having the latest information available and being able to see what other services are providing can be
very helpful in caring for patients and reduce duplication and miscommunication between healthcare professionals. Outcomes from
this priority will be tangible evidence of where LOROS services have made a positive difference to patients and improved communication to support better patient care.
Priority two – Progressing Strategic Priorities
Following a Board of Trustees development day a number of strategic
priorities have been identified and are being progressed via five work
streams led by a member of the senior management committee and supported by a number of trustees. Two of these work streams will have a
direct impact on the effectiveness of LOROS services moving forward,
those being ‘exploring our service scope’ and ‘reviewing our in-patient
service’.
They will take into account financial challenges, the external landscape,
the drive to support as many people as possible across LLR and the ability to clearly articulate the hospices offer to our local community (which
includes our service users, our supporters, those who refer to us and the
commissioners). The outcomes from these areas of work are to identify the most effective and sustainable service model for the future.
Other strategic priorities are cross cutting and relate to workforce development (including volunteers), data collection and voluntary income generation.
Patient Experience
Priority one – Information and feedback
To improve general communication with our service users and to address
recommendations from the Francis report and the hospices patients’ satisfaction survey, LOROS will be introducing information and feedback
boards in a number of sites around the hospice.
These boards will include our recently developed 'Our Aims' document
(included in this year’s Quality Account) which outlines what patients and
their families can expect when accessing LOROS services. It will also
display the process to follow if they wish to raise concerns or complaints
regarding any of the services at the hospice. In addition it will display various forms of feedback that we have received from patients and their families and any actions that have been implemented to address concerns or
areas for improvement. These will be updated on a monthly basis. On the
in-patient and day therapy unit it will also display photographs of the nursing uniforms and the senior nursing team to enable patients and families
to clearly identify each person’s role. The outcome of this priority will
be better informed patients, families and visitors and tangible evidence of promoting a ‘duty of candour’ within the hospice.
Priority two – Advance care planning within an integrated care
pathway
For LOROS to contribute to the wider healthcare local priorities of
increasing the quality and uptake of advance care planning and enhancing the services that provide support for people who are dying
at home. LOROS is working as a member of the End of Life ‘Better
Care Together’ Group to address these priorities in a joined up way
across the many organisations providing care across Leicester,
Leicestershire and Rutland. The overall outcome of this partnership working is to help provide seamless end of life care for all
patients regardless of care setting or diagnosis.
The following are a series of statements that all providers must include in their Quality Account.
Many of these statements are not directly applicable to palliative care providers. Please note
that the wording of these statements is prescribed.
Review of Services (Mandatory Statement)
During 2014/15 LOROS has provided for NHS England and the local community:
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In-patient Unit
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Day Therapy Service
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Outpatients and domiciliary palliative medicine consultant visits
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Community palliative care nurse specialist service
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Home visiting
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Counselling
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Lymphoedema Clinic service (cancer and non-cancer)
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Complementary Therapy
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Education Service
NB - the hospice at home service is not provided by LOROS
LOROS has reviewed all of the data available to them on the quality of care in all of these services (NHS services). The income generated by NHS England Services reviewed in 2014/15
represents one third of the total expenditure incurred in the provision of services by LOROS for
the reporting period 2014/15.
During the period 2014/15 there have been no national clinical audits and no confidential enquiries relating to the services that LOROS provides. During this period LOROS did not participate in any national clinical audits and national confidential enquiries.
We do however regularly undertake audits which we select according to national, local or internal priorities. Audits are mapped to the CQC Five Essential Domains and the Commissioners
Quality Schedule.
Medication related audit results are reported to the Therapeutic Committee and all others are
reported to the Clinical Governance Steering Group. The Board of Trustees receive regular audit reports identifying areas for improvement, the number of audits showing full compliance and
examples of undertaking clinical audits. In addition, an annual clinical audit report is produced
In March of each year outlining all activity for the previous twelve month period.
122 standard clinical audits were undertaken in the period 2014-2015, 93 of these showed full
compliance. An action plan with time frame included are completed for all audits which require
improvements.
Audit examples of good practice identified:
7th July 2014 - Management of Controlled Drugs - Main Ward
Compliance against standards:
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Subtopic 1: Adequacy of premises/security - 100%
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Subtopic 2: Procurement - 100%
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Subtopic 3: Examination of stock held - 100%
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Subtopic 4: CD register, records and audit - 100%
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Subtopic 4b: CD register, records and audit - 100%
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Subtopic 5: Prescribing of CDs patient’s medication chart - 100%
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Subtopic 5b: TTO’s - 100%
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Subtopic 6: Administration of CDs - 90% (patients informed consent when drugs are being administered is
not obtained. This has been discussed previously and agreed at the Therapeutic Committee)
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Subtopic 7a: Destruction of CDs - 100%
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Subtopic 7b: Destruction of CDs - 100%
August 2014 - Maintaining Privacy, Dignity and Confidentiality - Observational Audit (Main Ward)
100% compliance in the following standards:
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Do not disturb signs are in place on closed curtains
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Staff request permission before entering room/curtained bed space
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Patients are suitably covered/dressed at all times
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Private areas are available for patients and visitors
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Staff telephone conversations cannot be overheard
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Computer screens cannot be viewed by visitors
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Computers are not left logged on and unattended showing confidential information on the screen
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Smart cards are not left unattended in computers
13th August 2014 - Acupuncture Consent Audit—Physiotherapy Team
100% compliance
All 12 patients computerised records examined showed that consent forms have been fully completed
Examples of Improvement made as a result of audit processes
20th May 2014 - Consent to Blood Transfusions
80% compliance. (58% in January 2014)
20th May 2014 - Infection Prevention and Control - 5 Moments of Hand Hygiene (Main
Ward)
91% compliance. (88% in March 2014)
21st May 2014 - Infection Prevention and Control - Willow Wing (Environment)
81% compliance. (75% in April 2014)
LOROS is actively developing opportunities to improve and challenge the provision of palliative care from its
broadest perspective. Research in 2014/15 has included:
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Withdrawal of ventilation in people with Motor Neurone Disease (MND) –exploration of the experiences of
family and health professionals.
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How nurses working within an inpatient adult palliative care unit identify children, aged 18 years and under, in
need of additional support when they have a parent who is expected to die.
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Decision making by surgeons and anaesthetists in the care of the frail elderly.
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VerDIs: Video based research around doctor-patient interactions
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The needs of young people with a parent who is dying
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Decision-making concerning genetically inherited cancers
Research has been disseminated through presentations at both National and International Conferences; including the Motor Neurone Disease Association’s International Symposium on ALS (Amyotrophic lateral sclerosis)/
MND in December 2014, which was held in Brussels.
LOROS has adopted the Research Governance Framework for the NHS and this is overseen by the Hospice
Research Committee.
Future research continues to be focussed on the following areas:
1. Innovation in palliative care
2. Diversity and disadvantage
3. Education including communication skills
4. Lymphoedema
5. End of life decision making and advance care planning
Research participant figures :
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Withdrawal of ventilation at the request of a patient with MND = total 67 (a mix of healthcare professionals
and bereaved carers, most of whom were staff or participants not related to LOROS)
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How do nurses working within an inpatient adult palliative care unit identify children, aged 18 years and
under, in need of additional support when they have a parent who is expected to die? = 14 (LOROS
Healthcare professionals)
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VerDIs (Phase I): Video analysis of patient doctor consultations = 70
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The needs of young people with a parent who is dying = 3
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Decision-making concerning genetically inherited cancers = 13 (LOROS healthcare professionals)
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Patient/carer participants in 2014/15 = 74
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Healthcare Professionals in 2014/15= 103
Professor Christina Faull, Consultant in Palliative Medicine and lead for Research at LOROS, also Co-Chairs the
DMU and LOROS Centre for the Promotion of Excellence in Palliative Care (CPEP).
Goals Agreed with Commissioners (Mandatory Statement)
LOROS’ NHS England 2014/15 was not conditional on achieving quality improvement and
innovation goals through the Commissioning for Quality and Innovation (CQUIN) Payment
Framework, because LOROS is not contractually part of the CQUIN scheme. We are
awaiting revision of our quality schedule and key performance indicators for the period
2015/16 to be agreed by the West Leicester Clinical Commissioning Group.
What Others Say About Us (the Provider) (Mandatory Statement)
LOROS is required to register with the Care Quality Commission (CQC) and its current
registration is as a provider of the following regulated activities.
The Leicestershire & Rutland Organisation for the Relief of Suffering has the following
conditions of registration that apply.
1.
Diagnostic screening procedures
The Registered Provider must ensure that the regulated activity, diagnostic and
screening procedures is managed by an individual who is registered as a manager in
respect of the activity, as carried on at or from the locations LOROS The Leicester
shire and Rutland Hospice.
2.
Treatment of disease, disorder or injury
The Registered Provider must ensure that the regulated activity treatment of disease,
disorder or injury is managed by an individual who is registered as a manager in
respect of the activity, as carried on at or from the locations LOROS The Leicester
shire and Rutland Hospice.
Additional conditions that apply at LOROS Hospice:
1., The Registered Provider must only accommodate a maximum of 32 service users at
LOROS The Leicestershire & Rutland Hospice.
The Care Quality Commission has not taken enforcement action against LOROS during the
period 2014/15
The organisation was last inspected by the CQC on 7th September 2013. The following
standards were met:
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Treating people with respect and involving them in their care.
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Providing care, treatment and support that meets people’s needs.
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Caring for people safely and protecting them from harm.
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Staffing.
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Quality and suitability of management.
Data Quality (Mandatory Statement)
LOROS did not submit records during 2014/15 to the Secondary Users Service for inclusion
in the Hospital Episode Statistics which are included in the latest published data.
In accordance with the Department of Health, LOROS has submitted a National Minimum
Dataset (MDS) to the National Council of Palliative Care.
The Hospice regularly quality assures the data provided to the CCG’s (bed occupancy;
length of stay; preferred place of death for Inpatient Unit; DNACPR status of inpatients;
serious untoward incidents; patients diagnosed with infections during admission; safeguarding concerns; telephone advice line usage, and referral details for various hospice
services).
Information Governance (IG) Toolkit (Mandatory Statement)
LOROS has developed all relevant documentation and undertaken the appropriate staff
training to achieve level 2 compliance of the Connecting for Health’s IG Toolkit assessment.
This compliance provides assurance to our patients and the general public that personal
data is being dealt with safely and securely.
The Hospices Information Governance Assessment Report Version 11 overall score for 1st
April 2014 - 31st March 2015 was 66% - Level 2.
Clinical Coding Error Rate
LOROS was not subject to the Payment by Results clinical coding audit during the period
2014-2015 by the Audit Commission.
Review of Priorities 2014-2015
Priority 1 - Patient Safety: Patient Safety Metrics
Three key aspects of patient safety are falls, medication errors and pressure ulcers. There is a
drive nationally to make improvements in all of these areas. LOROS is committed to ensuring
this happens to provide re-assurance to our patients, the Care Quality Commission (CQC) and
the local commissioners (CCGs.)
We have implemented a number of initiatives in the last few years to help improve care in these
areas including the appointment of a Tissue Viability Lead Nurse and the introduction of noninterrupted medication rounds. This year we are planning to revise our nursing care plan which
incorporates a falls assessment to ensure a robust Multi-Disciplinary Team (MDT) approach,
which will help minimise the risk of falls.
To support us in on-going improvement in these areas, LOROS will participate in a national
benchmarking patient safety metrics project coordinated by Help the Hospices, sharing data on
falls, pressure ulcers and medication errors. Approximately 100 hospices are taking part, helping
to build national intelligence in relation to patient safety issues and enabling the sharing of good
practice and service improvement initiatives. This will be invaluable for LOROS enabling us to
review our practices against other units, identifying where we are performing well and also
where further improvements are possible.
Outcomes should include a reduction in the number of incidents and on-going improvements in
service delivery.
Update
LOROS began participating in the national benchmarking initiative coordinated by Hospice UK in
April 2014. Once this project has been completed and the results published we will be able to
consider the overall findings in relation to our patient activity and dependency. The Initial results
have highlighted that our incidence of pressure ulcers and medication incidents are less that the
national average, however, the incidence of falls within the inpatient unit is higher than the average of all participating hospices. As a result, further detailed work is being undertaken to establish any trend and themes in this area and this work will be progressed in 2015/16.
As with any multi centre data collection we do need to take into consideration contributing factors when assessing any outcomes from this work, such as how and what types of incidents are
being reported in other units. This data is however a helpful resource and will enable us to identify areas of potential good practise that the hospice can implement locally to improve patient
care.
Priority 2 – Introducing robust patient outcome measurement
Being able to demonstrate tangible outcomes for patients in relation to the impact LOROS services has on their care, continues to be a challenge. It is important that whatever tool is used it
can be easily integrated into clinical practice and that health professionals use the data to improve patient care. It therefore needs to be part of the assessment and on-going care planning
process.
The Integrated Palliative Outcome Scale (IPOS) is a validated tool that has been used in a number of palliative care services to capture the outcomes for patients. LOROS is implementing the
tool initially in the Day Therapy service with a view to rolling it out to other care services following an evaluation after three months.
This information will be used alongside activity and patient experience data to give a comprehensive overview of the standard of care provided at the hospice and again identify areas that
need development or investment.
Update
A pilot utilising the IPOS tool took place in the day therapy service from April – October 2014.
Patients found the tool easy to complete and it has helped to identify concerns that the staff
have then reviewed with patients and planned care to help address these concerns. Forms are
completed every six weeks and the outcomes to date show that there has been an overall reduction in the severity of concerns during attendance at day therapy.
It has proved challenging to collate the data and this has been undertaken manually to date.
The hospice is now investigating ways of collating the data electronically to enable us to roll out
the use of IPOS to other departments, ensuring we are able to use the data collected to improve
patient care and evidence that the care LOROS provides results in positive outcomes for our patients.
Priority 3 - Care during the last days of life – moving on from the LCP
Following the recent national independent review of the Liverpool Care Pathway, the LCP has
been phased out in all care settings across the country by July 2014. In line with the recommendations LOROS is no longer using the LCP. When it is recognised that a patient is dying this is
now being referred to as ‘the Dying Phase’ which is in line with the four phases of end of life care
identified during the palliative care funding review – stable, unstable, deteriorating and dying.
The Leadership Alliance for the Care of Dying People, who have the responsibility for taking forward the recommendations from the review, stated in January 2014 that there would not be a replacement for the LCP but that there will be some guiding principles that all care providers should
follow. This will support consistency in approach and ensure that the way in which a dying person
is cared for, including the goals and key aspects of their care, is focussed around the individual,
in line with their needs and preferences and developed and delivered in consultation with them,
wherever possible, and/or their family.
LOROS will provide care during the dying phase in line with these guiding principles (as is current best practice) and will not have a separate end of life plan or pathway.
LOROS is working closely with other key providers, predominately University Hospitals of Leicester (UHL) and Leicestershire Partnership Trust (LPT) to try and develop as consistent approach
as possible during this transition. Once the final guiding principles are published it is envisaged
that providers will continue to work collaboratively to ensure patients receive consistent, high
quality end of life care irrespective of the care setting. Nationally the CQC will focus more on end
of life care during 2014/15 and NICE (National Institute for Health and Care Excellence) are planning on developing new guidelines on the care of dying adults which are expected to be published in 2016. This should result in greater clarity for care providers in the future and a mechanism for demonstrating clear outcomes in relation to end of life.
During the interim LOROS will liaise closely with the Clinical Commissioning Groups to ensure
that the hospice is able to provide appropriate data to demonstrate the provision of high quality
end of life care.
Priority 3 - Care during the last days of life – moving on from the LCP
Update
The LCP was phased out as planned in July 2014. New guidelines were introduced at the hospice based on the 5 key priority areas for the care of people in the last days or hours of life, which
were devised by the national advisory group.
These principles have been incorporated into our electronic care planning documentation on
SystmOne. Staff have received training in relation to the five key priority areas, including assessing patients and documenting care.
Once a patient is diagnosed at being in the Dying Phase he/her care needs are assessed by the
multi-disciplinary team with input from the patient and/or their family and the appropriate care
plans put in place. These are then reviewed on a daily basis and altered accordingly to meet
each patient's individual needs.
These guidelines have been produced in collaboration with other key providers, predominately
University Hospitals of Leicester (UHL) and Leicestershire Partnership Trust (LPT).
An audit tool is currently being developed in relation to the care provided in the last few days of
life to ensure LOROS can demonstrate the effectiveness of the care it delivers to patients at this
time.
Priority 4
Patient Experience: Developing a more outward feeling service to meet the needs of more
patients, families and carers
LOROS currently cares for approximately 2,500 patients per year. A great deal of care provision
is delivered at the hospice itself and to increase our reach in the coming year there is a drive to
increase the breadth and scope of service provision.
We have recently reviewed our Family Support Service and to enable it to grow and develop
over the coming years the service has been reconfigured to separate home visiting and bereavement services. The home visiting service will be supported by an increased number of volunteers to enable us to deliver services to a much greater number of patients.
Initial ideas for service development within home visiting include helping to support patients in
the last few days of life within their own homes, by providing reassurance and support to family
members and providing practical support for carers such as shopping or walking the dog as
these are often things that make a big difference to families but that other agencies no longer
offer.
Within bereavement services we are planning to establish bereavement support groups, both at
the hospice and out in local communities. These will provide much needed support for a greater
number of people including the relatives of patients who have died at home or in another health
care setting such as UHL.
There are a number of out-reach services that LOROS would like to offer to patients who may
not wish to come to the hospice and/or who would prefer to access services in their local community. These may include complementary therapy, lymphoedema and patient information and/
or welfare advice. To help deliver these services we are trying to secure funding to establish a
mobile bus which can be taken to a number of different venues.
We are also hoping to again work in partnership with Macmillan Cancer Support in the coming
year to develop a project to help improve the access and care of patients who may not traditionally receive palliative care services such as prisoners, travellers and the homeless. We would
also like to continue increasing the support we provide to local BME communities.
If we are successful in establishing some of these services, the positive impact for patients
would include greater and easier access to our services and improved care, particularly for the
under-represented patients from these groups.
Priority 4
Patient Experience: Developing a more outward feeling service to meet the needs of more
patients, families and carers
Update
The new Home Visiting service was launched in March 2015. To date there are over 20 volunteers supporting this service, all of which have undertaken a robust training programme. LOROS
has successfully secured external grant money to help implement a volunteer service to support
patients and families at home in the last few days of life (Volunteers at End of Life) . A project
group has recently been established and this work will be piloted with support from GP practices
in the East CCG.
Two bereavement support groups have recently been established with a view to developing
more in 2015/16 with a number outreaching into the local community. The first of which will be
set up in the Birstall area supported by funding from a local cancer support group.
To date LOROS has been unable to secure funding to progress the other proposed initiatives to
take services out into the community. The hospice will continue to seek funding opportunities in
2015/16 as strongly believe that these are important service developments that LOROS wishes
to deliver across LLR. This includes the aspiration to improve the care of people who do not traditionally access hospice services. This work will continue to be driven forward with support from
the senior management committee.
Quality Overview - Review of Quality Performance
LOROS is a specialist palliative care provider which also provides a portfolio of educational
events that can be accessed by external service providers across Leicester, Leicestershire and
Rutland and beyond, enabling the specialist knowledge and expertise to be shared to improve
the care of other patients with palliative and end of life care needs.
The quality and performance of the services delivered at LOROS are reviewed in several ways.
Each year the Lead Clinical Commissioning Group (CCG) undertakes a quality visit to measure
compliance against a number of quality measures. The Care Quality Commission undertakes at
least one unannounced visit each year, measuring compliance against five key questions:
Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive to people’s needs?

Is the service well led?
Outcomes from a number of Key Performance Indicators (KPIs) are reported regularly in a clinical dashboard internally to the Board of Trustees and externally to the lead CCG. In addition, in
accordance with the Department of Health (DH) LOROS submits a National Minimum Dataset to
the National Council for Palliative Care.
Quality Visit
The last CCG inspection took place in August 2013.
Ward Admissions by CCG Apr 14 - Mar15
193
30%
Respite Admissions by CCG Apr 14 - Mar 15
23
25%
237
36%
32
35%
36
40%
219
34%
East Leicestershire & Rutland
West Leicestershire
Leicester City
Total number of admissions for year 13/14 was 819, the number of admissions for year 14/15 was 749.
Apr 14
May 14
Jun 14
Aug 14
Oct 14
Nov 14
Dec 14
Mar 15
MRSA
MRSA Bac
CDT
BBI
VRE
Serious Untoward Incidents Reported to the CCG Apr 14 – Mar 15
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
x2 single patient
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
Category 3 Pressure Ulcer hospice acquired
Avoidable
Closed
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
x2 single patient
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
Unexplained death
Closed
Closed
Category 3 Pressure Ulcer hospice acquired
Unavoidable
Closed
Patients Diagnosed with infections during admission
Apr 14 May 14 Jun 14 Jul 14
Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Mar 15
0
0
0
0
0
Definitions: MRSA – Meticillin-resistant staphybcoccusaureus MRSA Bac – Meticillin-resistant staphybcoccusaureus Bacteraemia
CDT – Clostridium difficile toxin BBI – Blood borne infection VRE – Vancomycin-resistant enterococci
0
0
0
0
0
Actual Safeguarding Concerns
5
Adults
Children
MCA Assessments
DoLs
4
3
2
1
0
Apr-14 May-14 Jun-14
Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Definitions: MCA Assessments – Mental Capacity Act Assessments, DoLs – Deprivation of Liberty
120
Telephone Advice Line - Total number of calls April – March 15 =785
Caller ID
100
NB: Some calls recorded
without date/time and
therefore unable to
classify.
80
60
40
20
0
GP
Comm
Nurse
Hospital
Doctor
Hospital
Nurse
Other
Not
complete
d
88
56
46
7
8
7
4
10
74
41
29
6
10
11
2
Oct-Dec 14
11
98
31
28
1
11
16
1
Jan-Mar 15
7
72
30
44
6
8
10
1
Patient
Carer
/Relative
Apr-Jun 14
11
Jul-Sep 14
Time call was taken
180
160
Outcomes
140
120
Normal
hours
181
25%
Out of
hours
553
75%
100
80
60
40
69% of all calls
20
0
Advice
given
Refer to GP
Admit to
Hospice
Refer to
Hospital
Apr-Jun 14
Jul-Sep 14
Refer to DN
Refer to
CNS
Refer to
H@H
164
34
14
127
31
14
6
4
4
1
8
2
1
Oct-Dec 14
135
38
0
11
7
1
5
Jan-Mar 15
119
34
2
16
7
2
3
1
Written Compliments/Complaints for all Care Services April 14 – Mar 15
Compliments
418
Complaints
taken resulted in
advice being
given by LOROS
staff.
12
D A Y T H E R A P Y S E R V I C E - Open 4 Days per week (Mon/Wed/Thur/Fri) 15 Places available per day
Day Therapy Service Referrals by CCG
Apr 14 - Mar 15
88
36%
Day Therapy Service Attendances by CCG
Apr 14 - Mar 15
72
29%
86
35%
East Leicestershire & Rutland
447
26%
569
34%
671
40%
West Leicestershire
Leicester City
Total number of referrals for year 13/14 was 257, the number of referrals for year 14/15 was 249.
Total number of attendances for year 13/14 was 1631, the number of attendances for year 14/15 was 1687.
O U T P A T I E N T C L I N I C S incl MND (Consultant and Nurse Clinics), Neurology, Pain
Management, Help with Breathlessness (Consultant/Enablement Service), Hypnotherapy Clinics and
Enablement Service (incl Acupuncture)
Outpatient Appointments
by CCG Apr 14 - Mar 15
237
29%
241
30%
334
41%
East Leicestershire & Rutland
400
350
300
250
200
150
100
50
0
Outpatient Appointments by
Clinic Type Apr 14 - Mar 15
337
124
West Leicestershire
160
61
21
79
14
19
Leicester City
Outpatient Referrals by CCG
Apr 14 - Mar 15
118
31%
109
29%
152
40%
NB: Outpatient data includes Enablement Team and Acupuncture and MND Nurse Clinics from August 2014
Total number of referrals for year 13/14 was 256, the number of referrals for year 14/15 was 382.
Total number of appointments for year 13/14 was 518, the number of appointments for year 14/15 was 815.
COMMUNITY NURSE SPECIALIST
CNS Visits by CCG Apr 14 - Mar 15
CNS Referrals by CCG Apr 14 - Mar 15
137
14%
354
11%
787
26%
279
28%
577
58%
TEAM
1925
63%
East Leicestershire & Rutland
West Leicestershire
Leicester City
Total number of referrals for year 13/14 was 995, the number of referrals for year 14/15 was 994.
Total number of visits for year 13/14 was 3408, the number of visits for year 14/15 was 3072.
KPI - Preferred Place of Death Achieved
for Patients who die and are known to a
LOROS CNS
75%
Mar-15
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
79%
100%
79%
85%
90%
78%
84%
90%
92%
86%
76%
0%
20%
40%
60%
80%
100%
% Achievement for April 14 - Mar 15 = 84%
LYMPHOEDEMA SERVICE
Lymphoedema Referrals by CCG
Apr 14 - Mar 15
Lymphoedema Appointments by CCG
Apr 14 - Mar 15
458
28%
113
32%
105
30%
136
38%
East Leicestershire & Rutland
569
34%
625
38%
West Leicestershire
Leicester City
Total number of referrals for year 13/14 was 309, the number of referrals for year 14/15 was 384.
Total number of appointments for year 13/14 was 1814, the number of visits for year 14/15 was 1735.
COUNSELLING SERVICE
Counselling Service Referrals by CCG
Apr 14 - Mar 15
101
25%
Counselling Service Sessions by CCG
Apr 14 - Mar 15
436
28%
154
37%
562
36%
157
38%
East Leicestershire & Rutland
560
36%
West Leicestershire
Leicester City
Total number of referrals for year 13/14 was 357, the number of referrals for year 14/15 was 419.
Total number of sessions for year 13/14 was 1763, the number of sessions for year 14/15 was 1587.
COMPLEMENTARY THERAPY
Complementary Therapy Referrals by CCG
Apr 14 - Mar 15
125
29%
Complementary Therapy Appointments by
CCG Apr 14 - Mar 15
150
24%
145
33%
167
38%
East Leicestershire & Rutland
233
37%
248
39%
West Leicestershire
Leicester City
Total number of referrals for year 13/14 was 429, the number of referrals for year 14/15 was 445.
Total number of sessions for year 13/14 was 638, the number of sessions for year 14/15 was 635.
CULTURAL SUPPORT WORKER
Cultural Support Worker Referrals by CCG
Apr 14 - Mar 15 - Macmillan/
LOROS CNS
2
Cultural Support Worker Visits by CCG
Apr 14 - Mar 15 Macmillan/
3
LOROS CNS
2%
3%
66
97%
164
98%
East Leicestershire & Rutland
West Leicestershire
Referrals to CSW by Macmillan Nurses and
LOROS Community Nurse Specialists
LOROS CNS
Joint visits attended by CSW for Macmillan
Nurses and LOROS Community Nurse
Specialists
35
Macmillan
LOROS CNS
32
0
10
20
Cultural Support Worker Facilitating
Communication for Patients
6
accessing other LOROS services
4%
Apr 14 - Mar 15
129
94%
30
2
2%
Leicester City
73
Macmillan
40
93
0
20
40
60
80
100
National Survey of Patient Activity Data for Specialist Palliative Care Services
(MDS Report summary for the year 2012-2013)
This is the most recent MDS report data which we have
LOROS Comparisons:
Inpatient Unit:
144 units responded (76%)
Nat Survey 12/13
LOROS 12/13
0.2%
0.18%
25 - 64
30%
37%
65 - 84
56%
54%
85 and over
13%
9%
84%
89%
Cancer
87%
85%
Non-Cancer
13%
15%
16.2 (Units with over 25 beds)
12
45%
56%
75.4%
79%
21.1
24.8
3.9
3
Age
Under 25
Ethnicity1
White British
Diagnosis
Average Length of Stay
Admissions Ending in Discharge
% Bed Occupancy (midnight)
Throughput (Adm per bed per year)
Turnover (Interval between adms)
in days
National Survey of Patient Activity Data for Specialist Palliative Care Services
(MDS Report summary for the year 2012-2013)
This is the most recent MDS report data which we have
LOROS Comparisons:
Daycare:
148 units responded (73%)
Nat Survey 12/13
LOROS 12/13
55.2
54.4
0.18%
0%
25 - 64
31%
31%
65 - 84
57%
51%
85 and over
12%
17%
Male
44%
38%
56%
62%
89%
91%
Cancer
77%
72%
Non-Cancer
23%
28%
Average caseload
Age
Under 25
Female
Ethnicity
1
White British
Diagnosis
Average length of care2
Avg no of sessions per year per unit
Avg no of places per session3
% use of available places
172 days (6M)
137 days
216
146
14.8
17
75.5%
54.7%
1
Not including records where ethnicity not recorded/unclear.
2
57% of patients attended for 90 days or fewer while 20% attended between 91 and 180 days and 23% attended
for more than 180 days. Defining length of care as days between referral date and discharge date. (LOROS 57%
90 days or fewer/19% greater than 180 days).
3
During this accounting period LOROS services changed from 20 places per session to 17 per session at the hospice
and 14 at Loughborough hospital.
National Survey of Patient Activity Data for Specialist Palliative Care Services
(MDS Report summary for the year 2012-2013)
This is the most recent MDS report data which we have
LOROS Comparisons:
Community Services:
There was a 65% response rate overall with 183 units (out of 281) identifying themselves as
Home Care Services.
Nat Survey 12/13
LOROS 12/13
0.28%
0.14%
25 - 64
26%
22%
65 - 84
56%
56%
17%
22%
86%
85%
Cancer
84%
91%
Non-Cancer
16%
9%
4.4
4.8
Age
Under 25
85 and over
Ethnicity
1
White British
Diagnosis
Average number of visits per patient
Deaths as a % of deaths and discharges
Home deaths as a % of all deaths
5
Average length of care
Average number of people visited per team6
59.5%
45%
111 days
222.5
52%
4
73%
82 days
714
4
This figure may be artificially high for LOROS as during the accounting period the recording of place of death was
not robust. There were a high number of deaths where place of death was not recorded and therefore not included. This has since been addressed and place of death for CNS patients is now routinely recorded.
5
68% of patients had a length of care of less than 90 days and 16% for more than 180 days. (LOROS 72% 90
days or fewer/10% greater than 180 days).
6
Checked with Adrian Jones, Information Analyst at the NCPC who confirmed that this figure was the average number of people visited per team and not a caseload number as reported in previous years.
National Survey of Patient Activity Data for Specialist Palliative Care Services
(MDS Report summary for the year 2012-2013)
This is the most recent MDS report data which we have
LOROS Comparisons:
Outpatients:
50% response rate considered to be still too low. LOROS Comparisons using all appointments
across all services - Medical Outpatients (including Pain Clinic/MND Clinic), Enablement Clinic,
Day Therapy (Manor Croft) Lymphoedema, Complementary Therapy and Counselling.
Nat Survey
12/13
LOROS 12/13
Age
Under 25
0.79%
1%
25 - 64
45%
48%
65 - 84
47%
44%
8%
7%
90%
87%
Cancer
72%
46%
Non-Cancer
28%
54%
85 and over
Ethnicity1
White British
Diagnosis7
7
The figures for LOROS include Lymphoedema, Counselling and Complementary Therapy services which see a high
number of relatives and patients with a non-Cancer primary diagnosis of Lymphoedema. These are currently reported in ‘All other non-Cancer diagnoses’, and therefore will increase the Non-Cancer figure.
2013/14
2012/13
2011/
12
2010/11
2098
1888
1847
1616
1697
Total number of admissions to Inpatient
Unit (IPU)
749
819
769
797
730
% of admissions ending in discharge
51%
61%
56%
55%
54%
% occupancy
73
(M)/79
75
(M)/83
79(M)/86
83
(M)/90
73(M)/80
Average Length of stay on the IPU
(days) midnight figure
11
11
12
14
13
Total number of medical outpatient attendances including Manor Croft and
Domiciliary
1313
806
552
509
528
Total number of Lymphoedema outpatient attendances inc. Consultant Lymphoedema clinics
1735
1809
2071
2316
2623
Total number of Enablement Team
Therapy Clinic attendances including Acupuncture sessions
583
318
144
99
117
Total number of Complementary Therapy Outpatient sessions not including
Ward activity
883
996
582
780
937
Total number of attendances by patients
at Day Therapy Unit
1686
1631
1448
1829
1830
3109
3417
3287
3578
3394
19
-
-
12
3
3
4
10
8
2
1
1
9
Indicator
2014/15
Total number of new referrals
Total number of contacts with patients
by the CNS Team
Total number of clinical complaints (3
relating to UHL)
Total number of written clinical complaints (3 relating to UHL)
The number of clinical complaints that
were founded
-
-
Indicator
2014/15
2013/14
2012/13
2011/12
2010/11
The number of clinical complaints which were unfounded
6 (2
relating to
UHL)
1
2
3
1
The number of written compliments
689
419
404
346
N/A
The number of drug incidents
57
63
36
41
44
The number of near miss drug incidents
24
52
90
50
25
Slips, trips and falls (patients only)
114
116
109
115
109
0
2
0
1
2
The number of patients known to be infected with MRSA
on admission to the IPU
1
9
1
4
5
Patients infected with MRSA whilst on the IPU
0
0
1
0
1
The number of patients known to be infected with Clostridium difficile, Pseudomonas, Salmonella, ESBL or
Klebsiella pneumonia on admission
14
8
4
2
2
Patients who contracted these infections whilst on the IPU
1
1
5
2
0
Number of Patients admitted to the IPU with pressure ulcers
97
117
55
-
81
Number which were Grade 3 or 4
21
35
15
10
25
Number of Patients who developed pressure ulcers whilst
on the IPU
29
39
21
-
25
Number which were Grade 3 or 4
12
4
6
2
2
12
8
6
3
0
0
0
-
-
-
The number of patients who experience a fracture or other serious injury as a result of a fall
(from 2011 onwards all fractures are classified as Serious
Incidents)
The total number of serious patient safety incidents or
serious incidents
(inc. pressure ulcers of grade 3 and 4 developed at
LOROS and fractures)
Number of (NHS) Never Events
For the period April 2014-March 2015 the following information details the complaints we have
received:

Total number of clinical complaints = 19

Number of written clinical complaints = 12

Number of complaints regarding patient care at LOROS = 7 written, 4 verbal

Number of complaints regarding problems with admission from UHL = 2

Other clinical but not related to patient care at LOROS (excluding UHL) = 6

Number of founded overall = 8

Number of unfounded—6 (inc. 2 from UHL as LOROS did not prevent admission)
All complaints are taken seriously, thoroughly investigated and acknowledged to the person
making the complaint. They are also reported to the Clinical Governance Steering Group. Once
the investigation has been completed the findings are shared with the complainant and the
appropriate actions taken with the relevant staff. A register of complaints is kept along with a
register of compliments.
During the past 12 months, the number of incidents reported has remained the same as the
previous year. There has been no harm as a result of these incidents. A proactive reporting
culture supports staff to report all incidents including near misses. All incident forms are initially
reviewed by the relevant head of department and learning points noted and fed back to the
appropriate teams to action. The forms are also seen by the Facilities and Operations Manager
who is responsible for Health and Safety at LOROS, the Head of Inpatients Services and the
Director of Care Services. All incidents are logged and reported on a quarterly basis to the
Clinical Governance Steering Group and any further actions identified.
During the past 12 months the number of drug incidents and near misses have decreased.
Drug incidents are discussed at the Therapeutics Committee and areas for improvement
identified and subsequently actioned. In addition, incidents relating to controlled drugs are
reported quarterly to the Local Intelligence Network. Accountable Officers from all relevant
healthcare providers across LLR are members of this group which provides an external
governance process regarding the management of controlled drugs.
There have been an increase in the number of patients admitted to the IPU with a infection
during 2014/2015 however; the number of patients contracting infections during admission was
extremely low. LOROS continues to proactively address infection prevention across the
organisation.
All category 3 and 4 pressure ulcers are recorded and reported to the CCG immediately, either
on admission or if they develop following admission to the IPU. The number of patients
admitted to the IPU with pressure ulcers has fallen including category 3 or 4. The number of
patients who developed pressure ulcers whilst on the IPU has also fallen, however the number
of category 3 pressure ulcers in this group have increased. Following the recruitment of a tissue
viability lead nurse there has been more accurate categorisation of pressure ulcers. LOROS
senior staff are part of the membership of the LLR pressure ulcer group.
Nursing team members over the past year have completed Essential for Role training in
pressure ulcers.
For the period April 2014-March 2015 LOROS has continued to report on the occurrence of any
relevant (NHS) Never Events. There have been none reported in 2014/15.
Feedback from patients and carers is one of the most important ways in which LOROS
measures the quality of care we give. We receive many compliments and positive comments
from patients and families. Here is a selection from recent surveys and “Tell Us What You
Think” forms.
Excellent professional
care
We feel confident that
we could leave our
daughter in safe hands
Everyone has a smile
Since arriving I have felt
very safe and at peace
with myself. I feel lucky
to have LOROS as a final
resting place
Excellent care,
thoughtful and
sensitive
I have been overwhelmed by the kindness
of the staff
You did so much for
me it’s hard to put into
words
Mum didn’t want for
anything during her staywe can’t fault any of her
care
Exceptional
compassion, nothing is
too much trouble
Can’t fault a thing
What Our Patients Say about the Organisation
LOROS values the views of our patients and carers and activity engages with users of our services in a number of
ways. Patients are encouraged to give on-going feedback through a variety of approaches such as Patient Satisfaction Questionnaires, ’Tell Us What You Think’ forms or joining one of our groups such as the patient and carer
participation group, patient information group or reader’s panel. The ‘Tell Us What You Think’ feedback is collated
at the end of each month and displayed at the hospice for patients, carers, staff and visitors to see. This includes
positive comments plus any actions that have been put in place to address suggested improvements to our services.
Within the last year we have introduced a new initiative which gives our patients and families the opportunity to provide feedback through an additional mechanism – ‘Small Things Make a Big Difference’.
As an organisation we recognise that the big things like funding and thinking needs to be addressed to ensure everyone receives good care at the end of life, but we are told often that it’s the small things that make a big difference.
Staff have been briefed about the concept, small cards have been produced which asks ‘what small thing did
LOROS do that made a big difference for you’. Completed cards are collated monthly, displayed and feature on our
website.
Patient Satisfaction Questionnaires
A comprehensive Patient Satisfaction Questionnaire is distributed annually across all departments. A total of 284
questionnaires were handed out to patients/carers during June 2014 and 153 were returned giving a response rate
of 54%.
Patient and Carer Participation Group
Membership of patients and carers continues to grow which spans age and diversity. The role of chair and vice
chair has been successfully taken up by 2 ex-carers. The group continues to meet with appointed staff members
and continues to provide valuable insight, knowledge and experience at a consultative level, which continues to
help shape our services.
During the past year we have given the patients and carer members the opportunity to have a more direct involvement with the organisation, this has been through the introduction of the 5 Senses Survey. Training on the survey
has been provided and to date we have undertaken 2 surveys and have a planned rolling programme.
The involvement of volunteer patients and carers has led to a more accurate and rounded assessment and findings
from the survey have already led to improve the patient experience. For example, noisy metal tea trolleys have
been replaced with quieter plastic ones in day therapy. Feedback has been well received and appreciated by staff
and led to action plans being developed in collaborative meaningful ways with our volunteer patients and carers and
staff. One volunteer commented:
“Taking part in the 5 Senses Survey was a good experience as it enabled me to consider the various aspects of the
environment with a heightened sense of detail. It was very interesting how much I picked up when focussing and
paying attention to things using all the 5 Senses and reinforced the fact that the little things can make a big difference to how an environment appears and is experienced”.
This initiative has proved extremely beneficial in supporting our patient experience agenda.
Patient Information Group/Readers Panel
The readers’ panel continues to meet to review new and revised LOROS information leaflets. The panel reviews
the language used, the layout and presentation and assesses its appropriateness for the targeted audience. The
readers’ panel works alongside the patient information group, which meets bi-monthly at the hospice to review patient literature, ensuring it is available to, and meets the needs, of all groups, including those hard to reach. Within
the last year we have completed the review of all LOROS patient information factsheets.
“The Care We Provide” leaflet has been distributed externally to raise awareness of the services provided. To date
these are located within GP surgeries, UHL hospitals, Coping with Cancer, Age UK and all LOROS shops. The
uptake of these will be monitored over the coming year.
FAMCARE 2014 Action Plan
A service evaluation of bereaved relatives’ satisfaction with end of life care. Project lead: Dr
Luke Feathers.
Methodology
Duration of service evaluation: 1st August 2014 to 30th September 2014
Covers deaths on the inpatient unit from 1st June 2014 to 30th August 2014 and deaths at
home.
(NB. Coding provided by the association unfortunately did not differentiate the two different
teams; this was not uncovered until the data analysis was returned).
The FAM care tool was sent with a generic covering letter and a returned free post envelope to
the association of palliative medicine.
49 questionnaires were sent out from the inpatient unit and 42 from the CNS team. 36 questionnaires were returned (40% response rate).
Results
In general terms our results compare well with the national benchmark data and confirm we are
providing comparable high quality care. Our relatively small sample size where one questionnaire returned represents 2.8%, means caution should be exercised in over-interpreting any differences compared to the national data.
Verbatim comments received
LOROS CNS was very good, District nurse was exceedingly helpful and supportive. Getting in touch with a
district nurse via the call centre was basically impossible, service is useless, all you get is a message saying
everyone is busy. A complete non-starter. Arranging some help for me in looking after my wife was again a
non-starter. An appointment for someone to call and see us re providing me with some help was scheduled for
after my wife died!
Verbatim comments received continued/...
The palliative care my wife and my family received was excellent from the LOROS nurses, all the district nurses, the care staff from Bosworth Care Team and Doctor from Barwell Medical Centre. Every time anything was
needed they were there no question. Even though the outcome of the care was the sad loss of my wife, I’m
glad her last few weeks at home was as good as it could have been. Thanks again.
We were very satisfied with the care given.
There were two nurses on the Red team at LOROS, Leicester that were exceptional, along with a nursing assistant. They were fantastic to mum and to us. We feel that this should be recognised. Thank you.
My wife passed away with dignity and without pain while in the care of the Blue team. At the end they phoned
me in the middle of the night, so that me and our daughter could be with her. Although my wife was probably
unaware of our presence, we will be forever thankful for that precious moment. My praise of LOROS cannot be
high enough.
Although my husband had had cancer for 7 years it only became difficult in the last few weeks. After 3 weeks in
hospital he only lived 1 week. During that time his care was good.
A lot of the questions do not really apply because xxxx did not want outside help as such, so we did most of it
ourselves, but we were kept aware at all times about drugs and anything else xxxx needed as in equipment, we
had everything we asked for and needed. Help was only a phone call away and xxxx passed away quite unexpectedly really, but as I say up to that point we had lots of help and advice to keep xxxx as comfortable as possible. We had no complaints.
Everyone involved were so kind and considerate in the way they dealt with dad and us. Also everyone was
very professional. Thanks seems so insignificant for all that they did. I am so glad things have changed to this
way of caring, so different to how we were treated 17 years ago in similar circumstances.
Every consideration was shown to both my husband, the patient and to me, his wife. We welcomed the visits of
the nurse specialist, who showed us both help and compassion.
A very big “thank you” from the whole family for the support provided to my wife and ourselves during her 4½
year illness. The care and attention provided principally by CNS nurse was outstanding and it was extremely
comforting to know she was there for us all. Thank you.
For the purpose of reporting this year, internally we have compared our combined LOROS results to the national
hospice inpatient data and national homecare data by working out the average of both data sets and comparing this
to our own. In future years the comparison will be more accurate as we will know the proportion of returns for each
service.
284 questionnaires were distributed to patients and/or carers accessing clinical services from 16th June – 14th July.
The results below represent data from all clinical departments. Data from individual services is available on request. 153 completed questionnaires were returned giving a response rate of 54%. A 100% satisfaction rate was
achieved.
2013’s results are in black, 2014’s in red
Who completed the survey?
57%
Patient

Did you receive any patient/carer information from LOROS?
– 86% (47%)

If yes, was it:
62%
29%
Next-of-kin
26%
Given by a member of staff – 95% (new question)
8%
Carer
4%
Relative/Friend
7%
1%
Other
Picked up from the information point – 4% (new question)
5%
1%

96% felt that the leaflets were given at the right time. (93%)

97% felt that the leaflet was easy to understand (96%)

96% found the leaflets helpful. (97%)
The following questions were asked
about the care received:
N/A
Did the staff introduce themselves in a warm
and courteous manner?
1%
Did staff explain what they were doing and
why they were doing it?
Did you find a member of staff to talk to
about your worries and fears if needed?
2%
Never
Some
of the
time
Most
of the
time
4%
3%
1%
3%
1%
12%
9%
The staff listened to you and responded to
your needs without being rushed?
2%
Did you have confidence and trust in the
staff?
2%
Did staff tell you who to contact if you were
worried about your condition after you left
the hospice?
26%
Were staff helpful and supportive in meeting
your individual needs?
6%
Were you treated with courtesy and respect?
The staff member explained the reasons for
the treatment or action in a way that you
could understand?
3%
5%
5%
6%
8%
2%
1%
10%
2%
1%
10%
11%
3%
76%
78%
6%
5%
81%
94%
6%
4%
3%
1%
2%
1%
3%
90%
95%
8%
5%
1%
88%
66%
9%
7%
5%
67%
87%
8%
2%
5%
87%
96%
4%
8%
4%
10%
89%
82%
4%
20%
90%
92%
3%
9%
You, your family and friends were involved
as much as you wanted them to be in decisions about your care and treatment?
96%
1%
1%
Always
1%
91%
88%
7%
82%
12%
Were you given enough privacy and dignity
when discussion your condition or being ex-
2%
10%
Were you offered a copy of the letter sent to your GP
following your outpatient appointment? *medical outpatients only*
1%
(Sample only one patient)
Poor
How did you find the variety of food?
How did you find the quality of the food?
Yes
No
Unsure
59%
16%
25%
61%
13%
26%
Good
Excellent
Acceptable
2%
How did you find the hospitality of the
catering staff?
88%
1%
If you were unhappy with any aspect of our
services, would you know how to complain?
Yes – 100% (67%)
The following questions were asked
about catering:
87%
21%
77%
21%
3%
3%
3%
3%
32%
5%
79%
62%
40%
27%
5%
56%
67%
53%
42%
Yes
81%
If you had any cultural/special dietary needs do you feel these were met?
No
19%
100%
Poor
Acceptable
2%
How did you find the cleanliness of the
premises and overall environment?
Good
7%
Excellent
91%
95%
5%
Poor
Overall, how would you rate the care and
support you received?
Acceptable
Good
12%
Excellent
88%
97%
3%
How likely are you to recommend our services to friends/family if they needed similar
treatment?
Extremely likely
Likely
Neither likely or unlikely
Unlikely
Extremely unlikely
Don’t know
92% (93%)
8% (3%)
(1%)
(1%)
Additional comments received on improving the services accessed:
“I
spent many long hours sitting my husband’s room, wanting to spend as much time as possible with him. During these hours I found it difficult to make sure I ate well, as it would mean I
would have to go home. The canteen had sandwiches but may I suggest some small meat
pies or pastries, also vegetarian options of these. I ate badly while I looked after him”
“After the counselling service has ended there should be an extended drop-in group session
for bereaved people as alternative providers fall short all round”
“Sometimes food is cold or lukewarm and dried up”
“I felt sometimes that as the wife of the patient I didn’t always know what the plan was regarding care and medication as my husband was not able to communicate properly”
“Level of noise in the corridors needs to be kept lower”
“The only issue we had was with the privacy and respect on the ward when the curtains were
drawn and the patient was dying, other visitors were sometimes oblivious to the distress their
noisy behaviour caused”
“Felt overwhelmed when visited by several different professionals on arriving in day therapy on
a Friday. I also experienced 2-3 abrupt comments from the volunteer on the reception desk”
“An automated system of sending text/email to patients would reduce paper and postage
costs”
“Automated text/email prior to appointments to remind patients re appointments”
“Please have a high 4” toilet seat in disabled toilet for arthritic people”
“Waiting time for appointments to attend was a long time”
“Access to meditation, simple yoga e.g movement and breathing, reiki, reflexology”
Respondents were asked if there was anything good about the services that
they would like to highlight:
*Please note that this is only a selection of comments due to the vast amount
received*
“I found both of the MND nurses excellent and feel very safe with them looking after
my needs – good service”
“Everyone has a smile”
“The time people gave even when they were so busy, the general caring personality of all staff that were involved”
“We felt confident that we could leave our daughter in safe hands”
“Genuine support within a warm and friendly environment”
“All services were very good but especially the counselling services. The counsellor I see regularly is very good, very patient, understanding and I look forward to my
session with her
“The care and compassion of the team they would get me whatever I wanted especially particular foods I felt like”
“The bubble baths were special for me making me feel all nice and clean. This
made me very happy”
Do you have any additional comments on improving the services you accessed?
““I spent many long hours sitting my hus-
Response from Head Chef
band’s room, wanting to spend as much time
as possible with him. During these hours I
found it difficult to make sure I ate well, as it
would mean I would have to go home. The
canteen had sandwiches but may I suggest
some small meat pies or pastries, also vegetarian options of these. I ate badly while I
looked after him”
Although our main area of care is for the patient, we do offer
meals to relatives who are staying overnight or if we are made
aware that a relative is spending a lot of time here we will
offer meals at the discretion of the Nurse in Charge. It is
difficult to gauge though unless the relative asks if they are
able to have meals, in which case they are directed to ask a
member of the team looking after their relative, as the meals
are organised by the Nurse in Charge, who will inform the
Catering department.
Response from Counselling & Psychological Support
Services Manager
“After the counselling service has ended
there should be an extended drop-in group
session for bereaved people as alternative
providers fall short all round”
We acknowledge that counselling is a useful but time limited
resource and we agreed that after counselling has ended,
there are still areas where our clients would benefit from other
or further support. Where a client requires extra support, we
provide information on other organisations or services in the
area, where individuals can access support for their specific
needs e.g. other voluntary organisations, GP services,
support groups.
Further to specific feedback from clients from the counselling
service the team have focussed on exploring how we can
increase our “resource” for 2014-15 and we are looking to
scope what additional services would be of value to our
clients now and in the future. We are in the process of
recruiting volunteers to support counselling and bereavement
services, which would enable us to work in new areas. For
example, we are working on a number of objectives that
include; recruiting and developing volunteers, piloting a
bereavement support group, scoping the offering of other
types of groups for patients/carers and considering new areas
of work through opportunities to work in partnership with other
organisations in Leicester, Leicestershire and Rutland.
Response from Head Chef
“Sometimes food is cold or lukewarm and
dried up”
Temperature of food is checked on cooking service and end
of service. Please accept my apologies for this; however
we would encourage feedback immediately in order to
rectify this.
Response from Ward Manager
“I felt sometimes that as the wife of the patient
I didn’t always know what the plan was regarding care and medication as my husband was
not able to communicate properly”
During the admission process, every effort is made to
include family members with regards to the plan of care and
any changes to medication, especially if the patient has
communication difficulties. On a daily basis the medical
team and nursing teams are available to talk about care and
medication. This information and details of the times of
consultant ward rounds is available within the patient
information folder situated at each bedside. I apologise that
this wasn’t your experience and this will be communicated
at all nursing team meetings and the weekly consultant and
doctors’ meetings.
Response from Ward Manager
“Level of noise in the corridors needs to be
kept lower”
With regards to noise levels we do try to minimise traffic
through the ward, but we do need to respond to the needs
of families of all generations to visit. Many families
comment that it’s lovely to hear life continuing around them.
Our policy states that after 10pm, only close members of
family should visit. We also encourage our visitors to talk to
us about any concerns, and if a particular area was too
noisy, we would move the patient if there was capacity.
Response from Ward Manager
“The only issue we had was with the privacy
and respect on the ward when the curtains
were drawn and the patient was dying, other
visitors were sometimes oblivious to the distress their noisy behaviour caused”
If we were aware that a family were distressed in the bay,
we would move the patient if there was a room available
and they consented. It’s very difficult to judge as the other
patient’s in the bay may also be distressed by events that
they have little knowledge of behind curtains and of course
we would not disclose confidential information to other
patients
Response from Head of Day Care and Community
Services
Following this comment we have discussed with the DT
team and plan to:
“Felt overwhelmed when visited by several different professionals on arriving in day therapy
on a Friday. I also experienced 2-3 abrupt comments from the volunteer on the reception desk”
Explain to all patients during their assessment appointment that the environment in DT is busy and the multidisciplinary model of care means that they may see different members of the team throughout the day. Explain to
patients that if they feel tired or don’t wish to see team
members just to let one of the nurses know.
Talk to all team members (including Volunteers) about
trying to ensure that patients don’t feel overwhelmed as
they come into the unit whilst still ensuring that they are
introduced to the team in a timely manner.
Liaise with Inpatient unit re information on different members of staff uniforms and plan to include this in the DT
patient information folder when it is developed or consider
a ‘photo board’.
The need for a more spacious lounge and single consultation rooms has been fed into the plans for the possible
future development of the DT space which should help the
feeling of being overwhelmed.
Response from Lymphoedema Services Manager
“An automated system of sending text/email to
patients would reduce paper and postage costs”
This is not seen as an efficient way of contacting patients.
It would be necessary to set up a separate email account
that did not accept incoming messages to prevent the admin team being flooded with requests and queries from
the public.
Confidentiality could not be ensured.
People change internet provider and email addresses may
change.
We would need a separate record of which patients
wished to be contacted by email or by post. This would
create more work for the admin team. This suggestion is
not viable to take forward.
Response from Lymphoedema Services Manager
“Automated text/email prior to appointments to remind patients re
appointments”
SMS messaging has been on the SystmOne development list for
some time. I have emailed SystmOne Lead again to ask if this can be
implemented as soon as possible. To implement this there will be a
cost implication, at this point we do not know what this is.
Response from Lymphoedema Services Manager
Discussed with enablement team member, further exploration of appropriate way forward needed.
“Please have a high 4” toilet seat in
disabled toilet for arthritic people”
A risk assessment would need to be carried out for individual patients
The toilets in the disabled facilities are 2 inches higher than normal
toilets
It may be possible for an individual patient to use the closimatt toilet in
day therapy on request, to discuss further with Shindy.
The need for access to raised toilets for outpatient clinics can be considered in any expansion plans.
Response from Lymphoedema Services Manager
All referrals are prioritised, with cancer patients taking precedence.
We frequently require more information from the referrer. This may
lead to a delay in the patient being offered an appointment.
“Waiting time for appointments to
attend was a long-time”
Some patients request an appointment for a particular day or time.
Accommodating these requests may lead to a delay in being seen.
In the future automated text messages reminding patients to attend
their appointment may reduce the number of DNA’s. This will lead to
more appointments being available.
Response from Head of Day Care and Community
Services
“Access to meditation, simple yoga e.g. movement and breathing, reiki, reflexology”
We have a complementary therapy service at LOROS
which provides various evidence based treatments such
as aromatherapy, reflexology, and massage. We are unable to provide Reiki at LOROS currently however the local
branch of the MND Association provides funding of £150
per person with MND which can be put towards any privately sourced complementary therapy of a person’s
choice. Both of these services can be accessed via the
MND Clinical nurse specialist.
We currently provide group relaxation and visualisation
and arm chair yoga sessions within Day therapy on an ad
hoc basis and I will discuss the possibility of some meditation sessions and whether these group sessions could be
opened up to others to access with the team.
Response from Volunteer Services Co-Ordinator
“I experienced 2-3 abrupt comments from the
volunteer on the reception desks”
Our volunteers ask everyone to sign in the visitor book
and also need to ask the purpose of their visit for example
maybe attending a clinic appointment or day therapy.
However this comment will be raised at the next reception
meting to be held in October. Volunteers will be reminded
about the importance of good communication”
Actions as a result of a drop in compliance
The following questions were asked
about catering:
Poor
How did you find the quality of the food?
Good
2%
21%
3%
3%
32%
3%
3%
How did you find the hospitality of the
catering staff?
How did you find the variety of food?
Acceptable
Excellent
77%
21%
5%
40%
27%
5%
79%
62%
56%
67%
42%
Responsible for
Results have been shared with Facilities & Operations Manager and will
be taken to the nutritional group for discussion by Jane Pickard, Head of InPatient Services on Monday, 17 November 2014. JP will provide a response and action plan as a result of this.
Patient Experience Lead to look at the Tell Us What You Think comments
over the past 12 months particularly relating to any issues raised relating to
food and provide this to the nutritional group.
Head of Inpatient
Services/
53%
Timescale
Dec 2014
Facilities and
Operations Manager
Patient Experience
Lead
Oct 2014
Analysis completed – over the past 12 months no issues relating to food
has been highlighted in the Tell Us What You Think comments. Patient
Experience Lead to share with Head of Inpatient Services.
Update – December 2014
Head chef has conducted subsequent audits that showed patients were
happy with the variety and quality of food. The audit tool is currently being
reviewed and has been shared at the nutrition and hydration group. The
work of this group is to be shared at the next Patient and Carer Participation
Group in March 2015
Head of Inpatient
Services
A patient and carer representative will be identified to join the nutrition group
as a member
Patient Experience
Lead
March 2015
Feb 2015
Actions as a result of a drop in compliance
The following questions were asked about the
care received:
Did staff tell you who to contact if you were
worried about your condition after you left the
Head of In-Patient Services to develop a card for patients
and carers to be given on discharge. This will include telephone numbers and who to contact on discharge.
Update – December 2014
Card currently being developed to align with other initiatives which is part of the discharge process
N/A
26%
20%
Never
2%
Some
of the
time
1%
3%
Most
of the
time
5%
1%
Always
66%
9%
Responsible
for
Head of Inpatient
Services
Timescale
Head of Inpatient
Services
February 2015
Dec 2014
67%
Actions as a result of a drop in compliance
If you were unhappy with any aspect of our services, would you know how to complain?
Yes
59%
No
16%
61%
Unsure
25%
13%
26%
Patient Experience Lead to liaise with Head of In-Patient Services
regarding “Our Aims” document. How to raise comments and
complaints will feature underneath this and be on display throughout organisation.
Responsible for
Timescale
Patient Experience
Lead
Dec 2014
What our staff say about the organisation
Staff feedback is obtained through team meetings, our Heads of Department forum,
Chief Executive’s forum and through staff surveys. In 2014 LOROS did not participate in the
anonymous Birdsong survey through Hospice UK. It is anticipated that the organisation will be
participating in this survey in 2015.
A sample of issues raised by inpatient unit staff in the 2013 Birdsong survey and the actions
devised to address these follows:
Topic
Action/Outcome
Introduce a ‘nurse in charge’
badge
Badges are now being worn to clearly identify who is the nurse
in charge for all staff, patients and families
Visible education support is
required on the ward

Education link person has been allocated to each nursing
team

The links have been working clinically with the teams they
are aligned to and have attending team meetings

Time for reflection is made available in the first part of the
weekly team meetings

Soul space which is facilitated by the chaplaincy team is
also offered monthly
Time for reflection is needed in
team meetings

Review staffing levels to
cover peak times such as
twilight hours.

Staffing levels and skill mix has been reviewed to ensure
relevant members of staff are on duty each shift to cover
different levels of patient dependency

Have a floating member of
the team to support the
prompt answering of call
bells.

Housekeeping hours have been increased to support late
shifts

Use of bank staff have been reviewed to explore different
hours of cover to support times of increased activity
Sessions on self-management in 
stressful situations to be
considered
The chaplain and counselling and psychological services
manager have delivered these sessions at nursing teams
away day.
The Board is fully committed to ensuring the provision of the highest quality of care to patients
and their families, to ensure the organisation achieve its mission. The hospice has an established governance structure, with members of the Board having an active role in a number of
groups, committees and service development initiatives to ensure LOROS provides all of its services in accordance to its Statement of Purpose. This has recently been updated and is publically displayed within the hospice.
The Board of Trustees receive regular written and verbal updates at each Board meeting in relation to care services including feedback from patients and carers and outcomes from clinical audits, incorporating those which have led to improvements in service provision. They also receive
the outcomes of any unannounced visits by the Care Quality Commission (CQC) and the Quality
Visits undertaken by the Clinical Commissioning Groups (CCG).
Trustees sit on a number of internal groups, such as Clinical Governance and Inclusivity and
regularly attend events at the hospice, which gives them the opportunity to meet staff, volunteers, families and carers and personally receive feedback regarding the quality of the services
provided.
The Board is confident that the care and treatment provided by LOROS is of a high standard
and is cost effective.
The LOROS Quality Account was approved by the Board of Trustees in June 2015. On behalf of
the Board of Trustees I hereby certify that I believe the contents of the LOROS Quality Account
to be a true statement of fact.
John Feehally
Chair of Board of Trustees
June 2015
The LOROS Quality Account 2014-2015 was sent to the following organisations:

Leicester City Clinical Commissioning Group

West Leicestershire Clinical Commissioning Group

East Leicestershire and Rutland Clinical Commissioning Group

Healthwatch Leicestershire

Healthwatch Rutland

Leicester, Leicestershire and Rutland Better Care Together Workstream

Health and Well Being Board
Comments have been invited, at the time of finalising this report none have been received.
CCG
- Clinical Commissioning Group
CNS
- Clinical Nurse Specialist
CPEP
- Centre for Promotion of Excellence in Palliative Care
CQC
- Care Quality Commission
CQUIN
- Commissioning for Quality and Innovation
DMU
- De Montfort University
GP
- General Practitioner
IPU
- In-Patient Unit
IPOS
- Integrated Palliative Outcome Scale
KPI
- Key Performance Indicator
LLR
- Leicester, Leicestershire and Rutland
LPT
- Leicestershire Partnership Trust
NICE
- National Institute for Health and Care Excellence
PPD
- Preferred Place of Death
MDS
- Minimum Data Set
MND
- Motor Neurone Disease
NHS
- National Health Service
UHL
- University Hospitals of Leicester