Quality Account 2015
Our care places the patient at the centre of everything we do.
Contents
Part 1 - Introduction
3
1.1
1.2
1.3
1.4
3
4
4
5
1.5
1.6
1.7
1.8
“Our mission is to deliver,
champion, and teach, high
quality care and choice for
those with a terminal illness.
We will do this through the
creation of a sustainable centre
of excellence, improving quality
of life and personal experience.”
Chief Executive’s Statement
Introduction to this Quality Account
Overall Statement of Purpose
Responsibility towards patients, families
and friends
Other responsibilities
Specific aims
Our Services
Our Ethos
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5
6
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Part 2 - Priorities for Improvement
8
2.1
2.2
8
14
Priorities for improvement 2014-2015
Priorities for improvement 2015-2016
Part 3 - Statements of Assurance from the
Board of Trustees
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3.1
3.2
3.3
3.4
Overview of Quality Performance
Review of Services
Income Generation
Participation in Clinical Audits
Participation in National Clinical Audits
Participation in Local Audits
3.5 Research
3.6 CQUIN goals agreed with commissioners
3.7 What others say about Rotherham Hospice
3.8 Reviews and investigations by CQC
3.9 Data Quality
3.10 Information Governance Toolkit Attainment
3.11 Clinical Coding Error Rate
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17
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Part 4 - NHS Framework Domains 1 - 5
31
Part 5 - Supporting Statements
32
5.1
Statement from Rotherham Clinical
Commissioning Group (Rotherham CCG)
32
5.2
Statement from Rotherham Health and
Wellbeing Board
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30
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Part 1 - Introduction
1.1 Chief Executive Statement
On behalf of the Board of Trustees and the Executive Team, I am
pleased to present the Quality Account for Rotherham Hospice
for 2014/15.
Our Vision is excellence in care for all those throughout Rotherham
affected by a terminal illness. Rotherham Hospice aims to be the
keystone of all the health and social services that together provide
end of life and palliative care in Rotherham. The quality of life of
patients together with their families and carers is at the centre of
everything we do. We have four Strategic Objectives, set out in our
three year Strategic Plan:
1. High quality services valued widely for their compassion
and accessibility
2. Recognition by the community, stakeholders and partners of
the Hospice ‘added value’ to end of life care
3. Long term financial strength and ‘independence’ that
allows innovation
4. Staff skills and attitudes that are highly respected by the wider
health and care network
Quality is at the heart of every action and task within each strategic
objective. This enables us to live up to the high standards expected
of the Hospice.
The Board of Trustees is committed to excellence in care and to
evidence our clinical capability and the highest standards of
compliance across all of our services. They have put in place a
strong strategic and governance framework. This is reviewed to
ensure that it is fit for purpose. This framework consists of the main
Board and Trustee meetings and the Board Committees of Clinical
Strategy, Finance and Resources, Marketing and Communications
and Human Resources. I, as the Chief Executive, provide the
assurance to the Board that the appropriate processes and
procedures are working well. These consist mainly of the Clinical
Governance and Corporate Governance Groups, including Patient
Safety and Clinical Risk Management Group, Quality and Clinical
Effectiveness Group and Best Practice Group.
I am also grateful to the Rotherham Clinical Commissioning Group
(RCCG) for their continued commissioning of our services and the
financial support through this contract. I am proud of the RCCG
support for the Hospice, the recognition of the good outcomes
we achieve and their commitment to developing services of the
highest quality for end of life care throughout Rotherham.
As part of our contractual requirements the Hospice has achieved
level 2 for the Information Governance Statement of Compliance
toolkit and has completed the work required around NHS Protect
and Prevent.
The Board and Executive Team would like to thank our patients, their
families and carers for their feedback. We listen to their views,
comments and suggestions and reflect on how our services could
improve. The Board and Executive Team would also like to thank our
dedicated team of staff and volunteers. The high standards of care
achieved by Rotherham Hospice are only possible through their
hard work and commitment to improve the quality of care provided.
The following are a list of statements made by service
users and/or their families:
Day Therapies:
“It is so much easier to come to the Day Hospice for his transfusion. It is also much better
than having to travel to Sheffield particularly when he is feeling poorly and really great
that I can stay and be involved in other things with him”.
Traditional Day Hospice:
“Thank you for all the support & friendship you gave to our brother. Attending Day
Hospice every Wednesday was the highlight of his week, he always spoke highly of the
attention and care you all gave. Thanks you for your help and the happy memories”.
IPU:
“Thank you! We saw an insight into what goes on in the Hospice and cannot praise you
enough for what you do to make the remaining time of patient’s lives as comfortable,
painless and serene as can possibly be”.
Volunteers:
“To all the wonderful volunteers – forever grateful to you all”.
Community Team:
“Heartfelt thanks for your excellent care and the compassion shown to our mum we feel
privileged that she spent her last hours with you. Thank you for taking away her pain
and giving us time to spend with her in her last days”.
General:
“The Hospice is an absolute asset to Rotherham. Staff are amazing”.
Bereavement Support:
“I found it a comfort to speak to someone else who’s lost someone that was dear to them.
The first session since losing my brother and found it to be really constructive and
helpful being able to talk to helpers and other bereaved people about all topics and not
feeling guilty. Thank You”.
Carer Support:
“Thank you all so much for the care and devotion you showed my husband. A very
special thank you for the caring support for myself, thank you for your ongoing support”.
Therapies:
“I was amazed at how fabulous the treatment was. I felt truly relaxed and calm and that
is not in my character”.
“I didn’t feel much at the time but that night I slept and for the following few days I felt
so clam tranquil and stress free”.
I am responsible for this Quality Account. I believe that
the information presented is a true and fair representation
of the quality of the healthcare services provided by
Rotherham Hospice.
Christopher Duff
Chief Executive
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1.2 Introduction to this Quality
Account
1.3 Overall Statement
of Purpose
Since April 2010, all providers of NHS
commissioned healthcare services have been
required to produce an annual Quality Account.
The purpose of Rotherham Hospice is to enhance
the quality of life of patients and those important to
them through specialist palliative care services and
education. The Hospice is committed to achieving
this by providing services for patients during the
changing phases of their illness. We will offer a
well-co-ordinated, multi-professional and ‘seamless’
service, which integrates the Hospice specialist
palliative care services with primary, secondary and
tertiary health care services, other voluntary and
independent agencies, social services and, in the
case of children and young people, education
services.
Rotherham Hospice presents this Quality Account
as its annual report to the public, as a provider of
NHS commissioned healthcare services. In line with
national requirements it exercises our
accountability to service users, stakeholders and
the broader public and demonstrates how all
aspects of the organisation has engaged in our
quality improvement agenda, reflecting the three
domains of quality: patient safety, clinical
effectiveness and patient experience.
This quality account is both retrospective and
forward looking, providing a review of services
delivered throughout 2014/15, explaining what
is being delivered well and where service
improvement can be made. It also looks forward,
describing key priorities for improvement
throughout 2015/16.
Finally this quality account demonstrates the
engagement of service users, key stakeholders, staff
and others with an interest in the organisation in
determining the quality of our services and the
priorities for improvement in the future.
For further information on the content of this or
any previous Rotherham Hospice Quality Account,
please see the NHS Choices website:
http://www.nhs.uk/aboutNHSChoices/professional
s/healthandcareprofessionals/qualityaccounts/Pages/about-quality-accounts.aspx
Our approach will be non-judgemental and nondiscriminatory. We consider it equally important to
give support to those who care for our patients,
whether they are professional carers, members of
the family or friends.
Our Vision and Mission statements are:
“Our vision is excellence in care for all those throughout
Rotherham affected by a terminal illness.”
“Our mission is to deliver, champion, and teach, high quality
care and choice for those with a terminal illness. We will do
this through the creation of a sustainable centre of excellence,
improving quality of life and personal experience.”
It is the aim of Rotherham Hospice to ensure
that all staff working within the Hospice and
associated services are fully engaged and
empowered to provide high quality care. In addition,
that all patients receiving care from the Hospice and
associated services, receive a high quality service
that is safe, effective, caring, responsive to patient
needs and well-led.
Our care places the patient at the centre of everything we do.
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1.4 Responsibility towards
patients, families and friends
Patients, families and friends will be treated as
individuals with compassion, humility, honesty and
love. We will listen to them and, whenever possible,
involve them in decisions about patient treatment.
Their preferences, beliefs and customs will be
respected and their complete privacy and dignity
assured through the use of single rooms, screens,
discrete interview rooms and heightened
awareness by staff of these requirements.
The needs of patients at different stages of their
illness will always be taken into account. There is
no charge to patients or their families for use of
our services.
1.5 Other Responsibilities
The community generously contributes a great
deal of money, time and effort to sustain our work.
We must use these resources wisely, prudently and
effectively.
1.6 Specific Aims
Our aims are to:
• Provide supportive and palliative care for adults
with a terminal illness regardless of age,
disability, gender reassignment, pregnancy and
maternity, race, religion or belief, gender, sexual
orientation or civil partnerships.
• Encourage patients to maintain their identity,
dignity and independence.
• Provide a welcoming and homely environment
to all.
• Facilitate effective, meaningful communication
between patients, staff and significant others
through a multidisciplinary team approach.
• See the patient as a unique individual and plan
with them their care management, whilst
promoting their independence.
• Nurture the patient’s feelings of self worth and
promote a sense of still being able to actively
live life.
• Support patients and their families in decision
making and adapting to changes throughout
their illness.
• Offer a continuation of care and support
through the initial stages of loss and
bereavement.
• Maintain standards of the highest quality,
supporting staff and volunteers’ personal and
professional development.
• Work together in developing an environment
based on support and mutual respect.
• Provide education and information to
Rotherham healthcare professionals and the
general public regarding palliative care issues.
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1.7 Our Services
1.8 Our Ethos
Rotherham Hospice offers a range of services that
respond to local need. We strive to provide a
homely, welcoming environment, placing
significant emphasis on an individual’s dignity,
privacy and comfort.
We believe interaction with families and carers is
very important to those in our care, and we
actively encourage an open visiting policy. Family
members and carers are also more than welcome
to use the family overnight accommodation,
reclining chairs in patient rooms and beverage and
snack facilities on offer, should they wish to stay.
We ensure that patients can stay in touch with
loved ones through the use of telephones and
wireless internet facilities in the patient areas.
The Hospice delivers this care through the
following services:
• Inpatient Unit – consisting of 14 single Inpatient
bedrooms all with en-suite facilities including
capacity for bariatric care.
• Day Hospice – providing 15 places a day 4 days
a week (excluding bank holidays) for Traditional
“holistic day care” and 2 days a week providing
day therapies, including Lymphoedema,
Transfusion Services, Medical Outpatients,
Nursing Assessment and Triage, and Health and
Well-being groups.
Transport for patients to and from the Hospice is
also provided.
• Community Care – through the Hospice
Community Team which provides Clinical Nurse
Specialists covering all of the Rotherham
Borough, a 24/7 Advice Line and a Hospice at
Home team delivering Hospice care in a patients
place of residence.
• Patient and Family Support Services – including
Occupational Therapy, Physiotherapy,
Complementary Therapy, Counselling and
Bereavement Support and a Child Bereavement
Support Group.
The views and opinions of those using our service
are very important to the Hospice. Members of
staff seek comments and suggestions through
patient and carer experience surveys that are
provided during a patients stay on our Inpatient
Unit or on discharge. Patients and families are also
encouraged to share their views verbally or in
writing to staff. A leaflet with further information
is available from reception, and the complaints
procedure will be discussed with patients and
families on admission to the Hospice. In the first
instance, those wishing to raise a concern are
requested to contact either the Head of Inpatient
Unit and Day Therapies or the Clinical Services
Director, who is the Registered Manager.
Patients and carers can find out more about the
services the Hospice offers and how the charity
operates by reading the Patient and Visitor
Information Booklet provided on admission and
leaflets available in the Hospice and on our
website. Our members of staff will also discuss
topics during the patient’s admission or
attendance and on a daily basis as the need arises.
Our website www.rotherhamhospice.org.uk also
provides further information for patients and
families.
Our care places the patient at the centre of everything we do.
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7
Part 2 - Priorities for Improvement
2.1 Looking Back: achievement against our Priorities for
Improvement for 2014/15
During 2013/14 the Hospice identified a number of quality improvements that could be made across
clinical services. In selecting our 3 key priorities for improvement in 2014/15 we were mindful of national
and local policy as well as those issues which were of concern to our service users, our workforce, our
partners and our Trustees.
The 3 key priorities for quality improvement that were identified for 2014/15 were selected for their
impact on patient safety, clinical effectiveness and patient experience.
Priority One – The redesign of Day Hospice to create a Day Therapies
and Treatment Service
(Addressing clinical effectiveness and patient experience)
Standard
Performance against this priority
Through the introduction of Day Therapy and
Treatment Services, all patients and families attending
Day Hospice Services will be able to access a full range
of holistic care and support treatments to prevent
unnecessary duplication in community practitioner
interventions and avoidable hospital admissions.
The Day Hospice has been redesigned to allow the
introduction of Day Therapies and Treatments as well
as broader health and Well-being programs.
Where appropriate, patients, families and carers will
be able to access wellbeing services to optimise their
ability to maintain independence and enable them
to make informed choices about their care.
How was this priority identified?
This priority was identified through feedback from
patients, family members and carers who expressed
their concerns that duplicate appointments were
needed for patients to see additional palliative care
staff as well as attend Traditional Day Hospice.
It was also identified in conjunction with
commissioners and other key stakeholders in order
to reduce avoidable hospital admissions for simple
day therapies and treatments.
This information has been explored through broader
staff discussions to inform an overall redesign of Day
Hospice Services.
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This has seen overall Day Hospice increase from 5 days
per week to 6 days per week but seen the Traditional
Day Hospice reduce to 4 days a week. This has
provided capacity for the introduction of a
lymphoedema clinic, complementary therapy clinic,
carer’s drop in and support group, bereavement
support group, exercise group and relaxation group.
It has also allowed the introduction of clinical
assessment sessions, increased outpatient clinics
and outpatient transfusion services.
Day Therapies now also facilitate numerous
counselling and bereavement support sessions as
part of a holistic support program.
Further work is still underway to fully implement
the health and well being programs both as single
sessions and as part of an ongoing wellbeing program
to look at understanding conditions, symptom
management, advance decision making and
coordination of care.
What people told us about these
improvements
Service user feedback:
Professional feedback
“It is so much easier to come to the Day Hospice for his
transfusion. It is also much better than having to travel to
Sheffield particularly when he is feeling poorly and really great
that I can stay and be involved in other things with him”
(Therapy Services)
“It is great to be able to access many different services that can
support a patient and their family as they travel through their
journey” (GP)
“I enjoy the steady pace of the exercise class. The exercises help
with my balance, so my walking is improved” (Exercise Class)
“I have enjoyed taking part in all Day Hospice activities but have
benefited most from the relaxation group. The group has helped
me learn more about relaxation techniques and
how to plan a more relaxed lifestyle” (Relaxation Group)
“At first I felt guilty to receive any treatments but now I am really
glad to take the time out and have relaxation, feeling an
emotional release is also a major benefit as it has helped me
with the grieving process” (Complementary Therapy)
“It helped to ease my aches and pains”
(Complementary Therapy)
“Service redesign helps us to improve services and offer choice to
patients and their families. It also helps us to ensure good value
for money” (GP-CCG)
“Excellent program, covering balance, strength, stretching and
coordination. Really good atmosphere, everyone enjoying
themselves” (Visiting Physiotherapist)
It is important to note that not all feedback has
been positive in relation to these changes. This
feedback will therefore be considered as part of
the ongoing development and improvement of
Day Therapies.
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Priority Two – The Introduction of a menu of bespoke carer support
packages to enable increased engagement by carers and improved
carer experience.
(Addressing clinical effectiveness and patient experience)
Standard
All patients, families and carers will receive the support
and advice they require to maintain family carer
responsibilities and understand the services and
support networks that are available locally.
All services have access to and provide new patients
with carer’s information, increasing awareness and
understanding of the issues faced and how to
access help.
All carers will be offered support services that meet
their requirements and involve their loved ones in
services.
Finally 2014/15 has seen the introduction of a carers
drop in service and carers weekly support program.
These are still in their infancy but growing in strength.
How was this priority identified?
Through the delivery of CQUIN 1 during 2013/14,
it was identified that almost 100% of our Hospice
patients have either an informal or formal carer who
supports them at home. The CQUIN data also
demonstrated that although carers want to receive
advice and support, the support they require is
very varied.
What people told us about
these improvements
Carers have also provided some information on the
specific types of service they would like to receive.
This has led to the staged development of a menu
of carer support packages that will be implemented
throughout 2014/15 as part of a broader clinical
services redesign.
Performance against this priority
2014/15 has seen the introduction of a more robust
data collection tool for identifying formal carers who
want or need support. This tool has been integrated
into care assessments and is recorded electronically
to improve data quality.
This has seen an increase in carers being referred for
formal support including counselling, pre
bereavement support and advice and information.
The service is coordinated and facilitates links with
other networks of support that carers can access.
The service is also able to support whole families,
linking with other Hospice and broader
community services.
Our care places the patient at the centre of everything we do.
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Service user feedback:
“Nice to know someone cares about us while we are caring for
our loved ones”.
“Provides somewhere to go where I can say things I cannot
say anywhere else”.
“It helps me when I come here as it helps me to think that I
also help others that are going through caring for a loved one”.
“It helps being in a group talking and listening to others. Gives
me a bit of respite”.
“It helps me feel able to cope”.
“Nice to be around others in similar situation”.
Professional feedback:
“Good to have something to offer to carers as well as care for
the patient” (GP).
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Priority Three – The introduction of a four tier counselling and
support service
(Addressing patient experience)
Standard
How was this priority identified?
All patients and families accessing Hospice services
will receive care and support that is mindful of their
holistic health, including their emotional and
psychological wellbeing.
This priority was identified through patient, family
and staff feedback and overall service redesign
benchmarking data form 2013/14 demonstrating
where activity and demand within the service were
not being met.
This will see the formal introduction of a tiered
Psychology and Counselling Service, providing
appropriate support to patients and their families
across levels 1-4.
This will also provide an up skilled workforce with
increased ability to engage in complex
communication with patients and families. This service
redesign also allows for robust governance in this area,
providing supervision and reflection in line with
national requirements.
By introducing allocated counselling and carer
support time, improved outcomes for carers and
families will also be achieved.
Staff training needs analysis also demonstrated
where core level two staff did not always have the
confidence and competence to provide structured
support using nationally recognised tools.
This was also influenced by the requirements of the
cancer peer review.
Performance against this priority
The introduction of a dedicated nurse counsellor has
seen hugely positive changes in this service with an
increase in capacity overall with 144 patients
supported through the service during 2014/15. This is
a direct increase of 156% (based on 56 patients seen
through 2013/14).
Referral to first contact time has also been improved
with an average of 26% of patients waiting longer
than 5 days in 2013/14 and by quarter 4 of 2014/15
the percentage of patients who waited longer than 5
days was reduced to 0%.
The service has developed links with GP practices and
local mental health services to strengthen the holistic
support provided to all those receiving counselling
support.
Eleven Level 2 nurses have received training
throughout 2014/15 and continue to receive
supervision to deliver the psychological element of
their role. This has not had an expected decrease in
referral but has raised awareness and increase referral
at this stage.
All staff have received training on “Compassion in
practice” and will be considering compassionate
behaviours as an integral part of their ongoing
development.
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What people told us about
these improvements
Service user feedback:
“I am so glad my husband came to counselling sessions he is
getting such a lot from it”.
“It provides an opportunity to off load”.
“It is good to be able to come and say what I want without
Judgement”.
“It is great to have a single point of contact so that you know
you can contact someone who will be at the other end of the
phone”.
Professional Feedback:
“It is great to have more confidence when dealing with
difficult situations” (level 2 nurse)
“Much easier to be able to refer someone having someone
around all of the time” (CNS)
“The introduction of nurse counsellor enables us to provide a
much better service. Patients and their families are now able
to access service quickly and are able to build relationships in
a relaxed environment where they are able to speak freely”
(Staff member)
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2.2 Looking Forward at Priorities for Improvement during 2015/16
Throughout 2014/15 we have utilised feedback from stakeholders in the Hospice and identified 3 key quality
improvements that need to be made throughout 2015/16. In selecting these priorities we have been mindful
of national and local policy as well as those issues which were of concern to all our stakeholders, including
service users, our workforce, our partners and our Trustees.
The priorities for quality improvement that have been identified for 2015/16 have been selected for their
impact on patient safety, clinical effectiveness and patient experience.
Priority One – Enhancement of the Hospice @ Home Service to include 24
hour service provision, the introduction of a Domiciliary Care Service and
an improved Community Volunteering Service (Hospice Neighbours).
(Addressing clinical effectiveness and patient/carer experience)
Standard
To ensure that the Hospice @ Home service provision
across Rotherham is accessible by all who need it. This
would improve end of life care provision and
coordination creating sustainability and increased
quality and effectiveness for everyone who needs it.
How was this priority identified?
This priority was identified through feedback from
patients, family members and carers who expressed
frustration and disappointment in the duplication of
services involved with individual families.
Finally it will see the increase in service capacity to
allow 24 hour service provision in collaboration with
Marie Curie.
Monitoring and reporting methods
It was also identified in conjunction with
commissioners and other key stakeholders in order
to reduce avoidable hospital admissions and enable
patients to receive care in their preferred place.
The project will be monitored through the collection
and analysis of service activity data, service user
feedback surveys, and the measurement of patient
and carer outcomes.
This priority was also identified as an integral part of
the independent evaluation and validation stages of
the redesign of Specialist Palliative Care Services and
End of Life Care Services across the borough.
This data will be collected and presented on a
monthly basis to the Quality and Clinical Effectiveness
Group to allow the service to be further developed in
a way that continues to meet the needs of its users.
How will this priority be achieved?
This information will then be reported to the
Clinical Commissioning Group as part of a broader
quality matrix.
This priority will be achieved through the provision
of a multi professional service that can provide all
aspects of care to patients and their families at the
end of life. It will also provide a responsive service to
those in crisis therefore preventing unnecessary
hospital admission.
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The enhanced team will see the introduction of a
domiciliary (support service) to add value to the
existing health care services provided by the current
Hospice @ Home Team. It will also see the increase
in community volunteering and look at methods of
exploring the scope of volunteering activities to
provide bespoke support to individual families.
Priority Two – Identification and Implementation of both national
and locally defined EOLC Outcome measures
(Addressing clinical effectiveness and patient experience)
Standard
Patient Related Outcome Measures (PROMS) and
Family Related Outcome Measures (FROMS) have
formed part of national service evaluation for some
time now. Although these are recognised as
essential tools to measuring service quality and
effectiveness, in the field of Palliative / End of Life
Care it is also important to have an understanding of
what patients and their families are feeling physically
and emotionally.
This priority will see the development and
introduction of locally agreed – service level
palliative care outcome measures, ensuring that all
of the above is addressed when measuring both
quality and effectiveness of service interventions.
How was this priority identified?
Measurement of physical symptoms such as pain is
well established, but practitioners in palliative care
challenge these assessments sometimes with the
argument that feedback from the patient on how
they are feeling today is more important than a
numerical score on a symptom scale.
Some staff have been using the Integrated Palliative
Care Outcome Scale (IPOS) with good effect and
other services feel that this not suitable for the
variety of services that the Hospice provides.
Due to service changes the national IPOS tool is no
longer suitable to be used as a generic tool,
particularly within the health and well being
programs.
This work will also consider the changes in national
outcome measures for palliative care before finally
agreeing a way forward.
Finally the work will look at the implementation
of the agreed outcome measures into every day
practice, providing practitioners with practical tools
that are easily interpreted, understood and
delivered.
Monitoring and reporting methods
This priority will be measured in phases as follows:
Phase 1: Establishment of the group, including
multidisciplinary representation, frequency of
meeting and terms of reference for the work. This is
to be achieved before the end of quarter 2.
Phase 2: The development of outcomes including
consideration of national requirements and best
practice. This is to be achieved before the end of
quarter 3.
Phase 3: Concept testing across a variety of services
This will be achieved during quarter 3/4.
Phase 4: Implementation of the outcomes into
practice. This will be achieved during quarter 4.
Performance against this priority will be measured
as part of the clinical governance framework and
reporting will be through the Quality and Clinical
Effective Group on a quarterly basis.
How will this priority be achieved?
This priority will be achieved through the
development of a task and finish group to explore
the concept of palliative outcome measures further.
This work will then be concept tested across a
variety of Hospice services allowing us to develop
local outcome measures that are suitable for the
types of services and interventions that we provided.
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Priority Three – Introduction of “Schwartz Rounds” as a robust staff
resilience model
(Addressing patient experience)
Standard
How will this priority be achieved?
Following the Francis enquiry, the Kings Fund piloted
“Schwartz Rounds” until 2013. Since 2013 “The Point of
Care Foundation” have been delivering the Schwartz
Rounds Program as an evidenced based tool for
supporting Staff Resilience in health care organisation.
This priority will be achieved in line with the national
research requirements for Schwartz rounds. The
project has an appointed Medical and Psychology
lead and is being supported by the Executive Team
and Board.
Schwartz rounds are also credited with developing
and strengthening organisational culture and values
leading to improved standards of quality and
compassion
Lead staff will receive appropriate training and
support to enable them to establish and deliver the
program. This will include the development of a local,
organisational steering group that will drive this
project forward across the coming year.
This priority will see the introduction of Schwartz
Rounds for all Hospice staff. This will in turn lead to
improvements in staff morale, resilience, reduced
sickness and absence and overall commitment to
both the organisation and caring overall.
(Jocelyn Cornwell & Joanna Goodrich, Dublin
April 2012)
How was this priority identified?
This priority has been identified through changes in
demographic trends across Hospice services. These
have shown a sustainable increase in the complexity
and number of patients accessing and receiving
support, particularly within the Inpatient Unit.
In conjunction with changes to staffing and an
extensive service redesign program, staff morale has
been lower than it has previously and staff are
struggling more to sustain their ability to deal with
their caring environment on a day to day basis.
Therefore the introduction of Schwartz Rounds will
enhance other service changes that have been made
and support a robust process of clinical supervision.
When completed multidisciplinary groups will
commence and run on a monthly basis.
The focus of these rounds will be on the human
dimension of care. Staff will have an opportunity
to share their experiences, thoughts and feelings
on thought-provoking topics drawn from actual
patient cases.
Staff will then be encouraged to give and receive
feedback.
Monitoring and reporting methods
This priority will be measured in phases as follows:
Phase 1: Training for lead staff and the establishment
of the steering group to be achieved before the end
of quarter 2.
Phase 2: Rounds to commence before the end
of quarter 3.
Participation in the national audit and evaluation of
Schwartz Rounds will run across the year, supported
by Macmillan and The Point of Care Foundation.
Performance against this priority will be measured
as part of the clinical governance framework and
reporting will be through the Quality and Clinical
Effective Group on a quarterly basis.
16
Part 3 - Statements of assurance from
the Board of Trustees
3.1 Statements of assurance
from the board
The following are a series of statements that all
providers must include in their Quality Account.
Many of these statements are not directly
applicable to specialist palliative care or End of
Life Care providers, especially Hospices.
3.2 Review of services
During 2014/15 Rotherham Hospice provided the
following services:
• Inpatient Unit - consisting of 14 single Inpatient
bedrooms all with en-suite facilities including
capacity for bariatric care.
• Day Services - providing 15 places a day 4 days
a week (excluding bank holidays) for Traditional
“holistic day care” and 2 days a week providing
day therapies, including Lymphoedema,
Transfusion services, Medical Outpatients,
nursing assessment and triage, and Health and
well being groups.
Transport for patients to and from the Hospice
is also provided.
• Hospice Community Team including Clinical
Nurse Specialist Services and Hospice at Home
(Rapid response) services
• Bereavement services, Carers support,
Chaplaincy services and Children’s Bereavement
Support Group
• Therapy services, including, Complementary,
Physiotherapy and Occupational therapy and
Psychological support services.
Rotherham Hospice has reviewed all the data
available to them on the quality of care and
efficiency across all of these services and used this
information to facilitate service improvements and
or demonstrate commissioner and regulatory
compliance.
3.3 Income generation
Rotherham Hospice is commissioned via the NHS
Standard Contract, to deliver NHS End of Life Care
and Specialist Palliative Care Services on behalf of
Rotherham Clinical Commissioning Group. The
income generated by the NHS services reviewed
in 2014/15 represents 100% of the total income
generated from the provision of NHS services by
Rotherham Hospice for 2014/15. The overall
income generated from the NHS contract
represents 56% income for the Hospice for
the same year.
3.4 Participation in clinical
audits
National clinical audits and national
confidential enquiries
During the period 2014/15 Rotherham Hospice
was not eligible to participate in any national
clinical audits or national confidential enquiries.
As Rotherham Hospice was ineligible to participate
in any national clinical audits and national
confidential enquiries there is no list or number
of cases submitted to any audit or enquiry as a
percentage of the number of registered cases.
This is because none of the 2014/15 audits or
enquiries related to EOLC or specialist palliative
care. The Hospice will also not be eligible to take
part in any national audit or confidential enquiry
in 2015/16 for the same reason.
Although the Hospice did not have the
opportunity to participate in national clinical
audits throughout 2014/15, internally the
following local clinical audits were conducted.
17
Local Clinical audits
Rotherham Hospice has conducted and or reviewed 12 local clinical audits during 2014/15 as follows:
Audit
Lead
April
2014
Feb March
May June July Aug Sept Oct
Nov Dec Jan
2014 2014 2014 2014 2014 2014 2014 2014 2015 2015 2015
Clinical Services Director/
Medicines Management
and Controlled Drugs Audit Pharmacy Lead
Audit of Safeguarding
Processes
Clinical Services
Director/Social Worker
Clinical Services
Audit of Mental Capacity
Act (MCA) and Deprivation Director/Social Worker
of Liberty Safeguards (DOLs)
processes (SCie Guidance)
NHS Safety Thermometer Monthly
Clinical Services
Director/IPU – Day
Therapies Lead
Additional Safety
Thermometer assessment
markers – Weekly
Clinical Services
Director/IPU – Day
Therapies Lead
Internal Records Audit Monthly
IPU – Day Therapies
Lead/Clinical Governance
Facilitator
Patient Experience Audits Quarterly
Clinical Services Director
/Data Analyst
IPU Sister & IPC Lead/Day
Infection, Prevention &
Control: General inspection, Hospice
Sharps audit, Hand Washing
audit, (ESSENTIAL STEPS)
PLACE Assessment
CSD/SS Manager and
Clinical Governance
Groups
Audit of Non-medical
prescribing practices
Head of Community
Services/Pharmacy Lead
Head of Patient and
Audit of newly
Family Support Services
implemented 4 tier
counselling and psychology
Audit of the effectiveness
and experience of the
newly implemented
Wellbeing Groups
Head of IPU and Day
Therapies/ AHP Staff
These Audits have then informed local action or service improvements plans and assisted in
identifying key priority areas for the coming year.
A sample of the findings of the above audits is provided as follows
Our care places the patient at the centre of everything we do.
18
Audit Summary – Safety Thermometer
including additional assessment markers
Over the past year, 2014-2015, the Safety
Thermometer Harm free percentage has never
fallen below 85%. Predominantly this number has
consistently been above 90%.
Due to the small number of patients in each
sample, the percentage of harm free care is
affected quickly by any identification of harm.
The Day Hospice had 100% of harm free patients
in each of the 12 months across the year..
Within the Inpatient Unit, 90% of harms were
pressure sores, with two thirds of those being a
category 2 sore and one third being a category 3
sore. All of these sores were developed prior to
accessing Hospice care.
The percentage of patients where there is written
evidence of continuing assessment has not fallen
below 95% in any month. In 5 of the 12 months,
this percentage was 100%. This demonstrates
consistent Best Practice in assessing and
reassessing risk.
Audit Summary - Infection, Prevention &
Control: General inspection, Sharps audit, Hand
washing audit, (ESSENTIAL STEPS)
The audits in relation to Infection Prevention and
Control were carried out monthly. These included
external audits by the specialist team at the local
foundation trust and internal audits by the support
service manager and senior clinical staff.
Senior staff performed the Essential Steps Audits
looking at:
1. Compliance with our Uniform policy requiring
staff to be “Bare below the elbows”.
2. Hand washing and the use of Personal
protective equipment and the application of
good aseptic technique.
3. Save disposal of sharps
4. Catheter Care
5. Enteral Feeding
All of this data was collated and submitted as part
of local area data so that a comparison report
could be prepared. Although this comparison is
measured against an acute trust, the Hospice
performance was consistently exemplary.
Participation in this audit helps to maintain
standards and support Best Practice
19
Hygiene Code: Statement of Compliance for 2014/15
Section 21 of the Health and Social Care Act 2008, places a statutory requirement on organisations to
comply with the regulatory requirements for Cleanliness and Infection Control (Regulation 12 HSCA –
Revised 2010)
The regulatory requirements cover 10 specific areas and form the Code of Practice to which Health and
Social Care Organisations should adhere. The following is Rotherham Hospices, statement of compliance
against the 10 criteria listed in the code:
Compliance Performance against criteria
Criteria
1. The Hospice routinely screens all patients admitted to the Inpatient Unit for MRSA and uses an
Inter-Trust Transfer Form to allow identification of any patients moving within the local
healthcare system.
We have full electronic access to receive laboratory reports from other trusts
and have 24 hour access to laboratory services for screening and assessment.
2. The Hospice has a number of processes in place for assessing cleanliness and infection control
processes including the annual PLACE assessment, monthly self assessments and quarterly
external cleanliness audits. All of these have been positive across the year. This has seen 0%
infections acquired at the Hospice during 2014/15.
3. Information on hand hygiene and the need for good infection Control processes is visible in all
areas, particularly the Inpatient Unit.
Information on Barrier Nursing or other appropriate information is given to families as required.
4. Appropriate signage is used to identify where infected patients are being Barrier Nursed (in
line with local identification policies).
Staff are made aware at MDT of any IPC requirements for individual patients.
5. MRSA screening is performed on all patients on admission (unless they are too unwell – EOLC)
The Hospice has access to electronic laboratory reports and Medical cover so all patients can
have timely review and any to treatment can be made as required.
6. All staff and volunteers are aware of the importance of Infection Control and this is
emphasised through training and development processes. These include audit and
compliance processes, annual staff training and staff workbooks. Infection Control is also
highlighted as an integral part of staff contracts.
7. All patients on the Inpatient unit are nursed in single rooms. Therapies on the Day Unt are
provided in clinical rooms as required.
8. The Hospice has a contractual agreement with the local Foundation Trust for the supply of
Laboratory Services. This includes the collection and transportation of samples from the
Hospice, twice daily.
9. The Hospice works to policies and procedures developed and agreed in line with national and
local guidance. It also has a contractual agreement with the local Foundation Trust for the
supply of services related to infection prevention and control. The Hospice conducts
individual patient risk assessments and formulises personal care plans to support patients and
their families as required.
10. All staff at the Hospice have appropriate Occupational Health Screening prior to employment.
For clinical staff this includes antibody screening and inoculations as required. The Hospice also
offers staff Flu jabs annually. The Hospice Sickness and Absence policy requires 48 hours
infection free before return to work.
20
Our care places the patient at the centre of everything we do.
We are committed to providing the highest standard of
specialist palliative care for patients and families affected
by a terminal illness over the age of 18.
21
3.5 Research
The number of patients receiving NHS services
provided or sub-contracted by Rotherham Hospice
in 2014/15 that were recruited during that period
to participate in formal research approved by a
research ethics committee was 5.
Rotherham Hospice has participated in two
research projects during 2014/15.
These are as follows:
University of West Scotland, Lead Researcher
Stevens E. (NHS ethics approval)
Title: The Impact of Specialist Palliative Day
Services on the quality of life, wellbeing and mood
of attendees.
3.6 Quality improvement and
innovation goals agreed with our
Commissioners/ CQUIN payment
framework
Purpose: To discover if attending Day Hospice is
beneficial to those living at home with serious
illness.
Rotherham Hospice NHS income in 2014/15 was
conditional on achieving quality
improvement and innovation goals through the
Commissioning for Quality and
Innovation payment framework.
Aim: To produce evidence on whether Day
Hospice Services have affected attendee’s quality
of life and feelings of wellbeing.
CQUIN Measure 1:
Friends and Family Test (FFT)
5 patients have been recruited to this study during
2014/15. This study ended on November 2014
What Participation Entails: Completion of
monthly questionnaires in conjunction with
weekly brief discussions.
University of Hull, Principal Investigator
leading the Network is Dr David Kennedy
Title: ‘Crossing Over: New Narratives of Death’
Purpose: To explore how objects become the
focus for stories of remembering. In particular this
group is trying to understand the role objects play
in caring for people at the end of their lives. They
are considering how objects are a feature of daily
life in the Rotherham Hospice Day Unit, and
exploring specifically how they shape relationships
staff and volunteers have with patients and how
they remember them.
Aim: The group has been working creatively using
objects from the past and present to share stories
and write collaborative poetry to explore the
above ideas and provide evidence as to their
importance.
22
What Participation Entails: The ‘Crossing Over’
Network is an international, interdisciplinary network
of researchers and practitioners from different fields.
It is funded under the Arts and Humanities Research
Council (AHRC) Research Networking Scheme.
Working Group: Objects and Narratives. This has
seen Hospice Day Unit staff and volunteers
participate in the project as a learning opportunity.
This project has not directly involved patients.
The Friends and Family Test is a quick, consistent,
standardised patient experience indicator that
provides a simple, easily understandable metric
based on near time experience, which is
comparable from a patient’s point of view and can
act as a benchmark for organisations.
The Friends and Family Test (FFT) enables the public
to compare healthcare services, identify those who
are performing well and allow other organisations
to improve their services.
CQUIN Measure 1
Progress Summary
All service patient and family feedback
questionnaires now include the FFT general
question and these are collated to provide feedback
on a monthly basis through the clinical governance
system. These are now an integral part of the data
suite for submission as part of broader contract
monitoring. (IPU – 100%, H@H – 100%, CNS –
98.8%). Our staff survey was conducted as an
isolated study this year, showing 100% of staff would
recommend Hospice services to a friend or family
member if required.
CQUIN Measure 2
NHS Patient Safety Thermometer
CQUIN Measure 3
Carer Support Programs
To reduce harm. The power of the NHS Safety
Thermometer lies in allowing frontline teams to
measure how safe their services are and to deliver
improvement locally
Following an agreed assessment the Hospice will
provide a variety of support options which are
appropriate to support to carers, in order that
they can continue to care for the patient.
Particular emphasis will be placed on those carers
where the patient has expressed a wish to be
cared for at home and those who find traditional
support difficult to access. This will be considered
in line with the Hospice redesign.
Collection and submission of data on patient harm
using the National Patient Safety Thermometer
CQUIN Measure 2
Progress Summary
The new national minimum percentage
achievement of “Harm Free care” is set at 95%. The
Hospice continues to achieve a very high standard
with an average of 92% harm free care recorded
throughout 2014/15. This is below the attainment
level of 95% but is supported by 100% assessment
and care management records (as reported in other
areas of the data suite). It is important to consider
the size of the Hospice when comparing this data
as just 1 incident has the ability to reduce the
percentage by more than 5%.
CQUIN Measure 3
Progress Summary
In line with agreed improvements, throughout
2014/15 the carer assessment form has been
made an integral part of the initial care
assessment and admission process and is now
captured electronically to prevent distorted data.
This has seen an improvement in the level of data
available.
2014/15 has also seen the introduction of more
services to support carers, including drop
sessions, counselling/pre bereavement support.
All of these CQUIN measures were achieved in
full, however further work is still being taken
forward in relation to carer support services to
enhance services further in 2015/16.
23
3.7 What others say about us
As a learning organisation, Rotherham Hospice is
keen to engage all service users and key
stakeholders in feedback to support service
improvement and increase quality and experience.
With this in mind the organisation has robust
networking systems in place with local strategic
partners to ensure we receive feedback which can
facilitate service improvement by strengthening
what we do well and learning from situations
where we did not meet expectation.
The Hospice also has a number of working groups
which include representation from external
organisations these include our Equality and
Diversity group, PLACE assessment group and our
Nutrition and Catering Forum.
Finally feedback is sought in the form of service
user satisfaction surveys helping us to gain
information from patient, family members and
carers about the care that they received and their
experience overall. These surveys have helped us
to understand how our services are perceived by
the people who use them. Learning from the
comments made has enabled us to acknowledge
where shortfalls in service provision exist and
make positive service changes for the future.
24
Selections of these comments are listed below:
From Hospice at Home and Community CNS Team;
“I feel it is an absolute Godsend and I can honestly say I really
don't know how we would be managing without this wonderful
team of people. Thank you so, so much.”
“We as a family cannot say enough good about this service.
They make a terrible situation a bearable one and made my
mum very happy right to the end. We feel we can't think how
we would have managed without it. There is no other service as
needed as this one is. If we couldn't have had this service our
memories would have been very different.”
“They provided invaluable support for all family members and
the highest standard of medical care for our mum. They became
part of our family and helped us all to cope with every stage of
our family's personal tragedy.”
“Grateful thanks for wonderful care given to..... in his final
weeks of life and also the great support given to his wife.”
“Thanking for all kindness, consideration and support the team
provided, not only for..... but for the family. They all brought a
ray of sunshine and laughter to our lives and cheered.....up no
end in his final weeks.”
“For the care and kindness they showed to my husband, we can
never thank you enough, without your help I could have never
kept him at home.”
From Day Hospice;
From Carers;
“Day care is absolutely invaluable as meeting others is helpful,
and makes it easier to access medical care.”
“When I came I was really down and I feel much better, uplifted
and understood. Supported even now my husband has died.”
“Fantastic place to attend and very beneficial”
“I am very emotional but feel safe to cry and supported.”
“Only thing missing, access to internet”
“I can say things here that I can’t say anywhere else.”
“Our sincere thanks for all the care and devotion you showed to
.....in his short time with you. He really appreciated the time he
spent with you.”
“Nice to be around people that are in a similar situation.”
“.......came home from the Hospice today absolutely full of it! He
had really enjoyed the day, the food and the company. It was
marvellous to see him so enthused and happy. I would like to
thank you and your colleagues for everything you do to bring a
little bit of happiness and enjoyment to ...... declining years.”
“It always helps me when I come here. Comes every week and it
helps her to think she also helps others that are going through
caring for a loved one.”
“It has helped being in a group listening to others and realising
that I get a bit of respite looking after Mum by going home.
Others have it 24/7.”
From Inpatient Unit;
“Feel able to control my anger and feel more capable to cope.”
“The care and consideration we all received, especially in the
time after her death was a huge comfort to us so thank you.”
“I look forward to coming.”
“Words cannot describe how thankful we are to you all for the
amazing support you gave our family and ....”
“Thank you, we saw an insight into what goes on in the Hospice
and cannot praise you enough for what you do to make the
remaining time of patients’ lives as comfortable, painless and
serene as can possible be.”
“To everyone at the Hospice who helped my husband during his
last days, you really made a difference to both of us.”
“Totally able to let out emotions, talk about happy moments.”
From Bereavement Support Service;
“She showed such understanding at such a sad time in my life
following the death of my wife. I looked forward to every visit
and I am feeling better in my approach to the situation.”
“Big thank you, took on board what you said and it helps.”
“Thank you for our chats, help and support you have given over
the last few months.”
25
3.8 Care Quality
Commission (CQC)
Rotherham Hospice is registered with and
regulated by the Care Quality Commission and
its current registration status is approved and
unconditional. Rotherham Hospice has no
conditions on registration and registration is
approved as follows:
Rotherham Hospice Trust is registered in respect
of 4 Regulated Activities:
• Accommodation for persons who require
nursing or personal care
• Diagnostic and screening procedures
• Transport services, triage and medical advice
provided remotely
• Treatment of disease, disorder or injury
Regulation also states that:
• Services can only be provided to people 18
years of age and over (with exception for
children’s bereavement support only)
• A maximum number of 14 patients can reside
in the Inpatient Unit at any one time
Rotherham Hospice has not participated in any
special reviews or investigations by the CQC
during 2014/15.
The Care Quality Commission has not taken
enforcement action against Rotherham Hospice
during the period April 2014-March 2015.
26
Throughout 2014/15 Rotherham Hospice has
undertaken ongoing self-assessment of its
compliance against all 28 CQC domains and in turn
the Health and Social Care Act 2008 and Care
Quality Commission Registration Regulations 2009.
This enabled the organisation to understand its level
of compliance and identify any areas for further
improvement which will be implemented through
the governance framework.
The Health and Social Care Act 2008, revised in 2012
under Regulation 8, has seen the introduction of the
11 Fundamental Standards. These standards
describe the essential standards of quality and
safety that people who use health and adult social
care services have a right to expect. These 11
standards will be scrutinised at future inspections
to determine the standard of care in relation to five
key lines of enquiry.
Safe, Effective, Caring, Responsive, Well-Led
As part of an unannounced CQC compliance
inspection on Monday 21st July2014, the following
standards were considered and outcomes achieved:
This inspection was carried out under the previous
inspection regime.
Standard
Care and welfare of people who use services
(Outcome 4)
Providers ensure effective, safe and appropriate,
personalised care, treatment and support through
coordinated assessment, planning and delivery. People
who use services have safe and appropriate care,
treatment and support because their individual needs
are established from when they are referred or begin
to use the service.
Cleanliness and infection control (Outcome 8)
Providers of services comply with the requirements of
regulation 12, with regard to the Code of Practice for
Health and Adult Social Care on the prevention and
control of infections and related guidance.
Safety and suitability of premises (Outcome 10)
People who use services and others who work in or
visit the premises can be confident that in relation to
design and layout the provider understands their
responsibility in relation to statutory requirements and
best practice and is able to demonstrate compliance
across each of these areas whilst maintaining an
environment that is homely, welcoming and clinically
fit for purpose.
Assessing and monitoring the quality of service
provision (Outcome 16)
Providers will lead effectively to manage risk and have
appropriate systems for gathering, recording and
evaluating accurate information about the quality and
safety of the care, treatment and support the service
provides, and the outcomes it achieves.
Records (Outcome 21)
People who use services can be confident that their
personal records for their care, treatment and support
are properly managed because the service has clear
procedures that are followed in practice, monitored
and reviewed, to ensure personalised records and
medical records are kept and maintained for each
person who uses the service.
Compliance
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
27
Overall Comments:
Verbal feedback on the inspection visit was very positive overall, across all
of the domains considered with particular positive feedback on the
passion and compassion of staff that had been observed.
The Inspector felt that many areas demonstrated “Best Practice” particularly
in encouraging feedback through surveys, comments, compliments and
complaints. The ability to respond to and learn from complaints was also
recognised.
In the absence of the new CQC process, the inspector was extremely keen
to include weighting on the views of patients, carers, volunteers, visitors
and staff. She was also interested in the external views of other
stakeholders and considered collaborative partnership arrangements.
The overall inspection was considered in line with the five new assessment
criteria requiring organisations to demonstrate that they are Safe, Effective,
Caring, Responsive to People’s Needs, Well-led
28
Feedback
Care and welfare of people who use services (Outcome 4)
No negative feedback was received, Patient feedback was very positive and the interactions between
staff and patients were considered to be exemplary with clear evidence of the passion and
compassion of staff.
The inspector felt that all patients’ needs were being met to a very high standard and that their wishes
were considered in all aspects of care.
The inspector commented repeatedly on the atmosphere of the environment and care delivery overall.
Cleanliness and infection control (Outcome 8)
Training records and staff training handbooks were considered and the inspector felt that staff were
trained in relation to IPC to a high standard. The inspector felt that the Infection Control Lead was very
knowledgeable in her role and responsibilities.
Systems were observed and it was felt that staff understood the principles of infection control and
demonstrated this well in their daily practice.
Although the Hospice is not required to make an annual statement in relation to the “Hygiene Code”,
the inspector suggested that as so much work had been undertaken and robust evidence already
exists, that compiling a statement to include in our Annual Quality Account may be beneficial.
See section 3.4 – participation in audits
Safety and suitability of premises (Outcome 10)
Overall the inspector felt that the premises were utilised very well given the space and layout of
the facility. The inspector was pleased to see a number of quiet or breakout areas for people to use.
The gardens and grounds were described as a “fantastic facility” and the inspector felt that the rooms
were spacious and used to their full potential.
The PLACE audit was considered to be very positive and the audits that feed into this process were
also acknowledged as robust.
Assessing and monitoring the quality of service provision (Outcome 16)
The audit plan was considered and felt to be a good proactive management tool, the inspector was
also very positive about the use of patient and family feedback questionnaires to inform quality and
service improvement. The complaints observed were felt to be thoroughly investigated and responded
to accordingly, including changes to practice where required.
The inspector did point out that the CQC is no longer able to receive escalations in relation to complaints and
therefore the wording on information leaflets and posters needs to be reviewed accordingly.
This has been completed.
Records (Outcome 21)
The organisation was complemented on their challenge of the request of the inspector to review
patient records in an open clinical area. The inspector was impressed by the robust nature of record
keeping including completion, sharing and storage and felt that records were clear, detailed and up to
date and able to be followed through.
The inspector felt that staff training in relation to information governance was very good and this was
demonstrated by individual staff when they were questioned.
Monthly records audits were also considered to be best practice.
Summary
Overall this was an extremely positive visit. The inspector reiterated her need to drive home the
“Atmosphere” of the organisation and voiced that she felt so strongly she would strive to capture
this in her written report.
29
3.9 Data Quality
Rotherham Hospice did not submit records during
2014/15 to the Secondary Users Service for inclusion
in the Hospital Episode Statistics which are included
in the latest published data. This is due to
ineligibility to take part in the scheme.
However, in the absence of this we have a local
system in place for monitoring the quality of data
and the use of the electronic Patient Information
System, SystmOne. This provides monthly
information on data quality and ensures accuracy
in recording and reporting mechanisms.
Monthly data quality performance
for 2014/15 is as follows:
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
93.58%
96.87%
95.24%
94.58%
92.74%
91.50%
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
93.85%
96.37%
95.10%
96.10%
95.29%
95.08%
Commissioning data quality targets stand at 90%.
Therefore compliance has been consistently
achieved throughout the year.
3.10 Information Governance
Toolkit attainment levels
Throughout 2014/15 the Hospice has maintained
the relevant framework documentation, polices,
training, and security infrastructure to be able to
demonstrate an attainment of 67% at level 2
compliance with NHS Connecting for Health’s
Information Governance standards, ensuring we
provide service users, key stakeholders, staff and
others with an interest in the organisation with the
confidence that their information is dealt with
efficiently, safely and securely.
The Hospice has completed and submitted its
annual Information Governance Statement of
Compliance in accordance with National
Information Standards and CQC requirements.
Statement from and external IGSOC auditor:
Rotherham Hospice has an excellent approach to
the areas which the Information Governance
Toolkit covers, with best practices obvious across
the different areas of the organisation. The SIRO
and Caldicott Guardian roles have both been
allocated and the incumbents trained, staff training
is comprehensive with use of the HSCIC modules
and in- house training. Support from a structured
set up of committees and groups, all with
reporting mechanisms and robust terms of
reference means that all elements of IG
programme are on board.
The auditor, was able to reassure the SIRO, that the
Hospice was an assured IGT Level 2, Green and
Satisfactory.
3.11 Clinical Coding Error Rate
Rotherham Hospice was not subject to the Audit
Commissions, Payment by Results clinical coding
audit during 2013/14.
30
Part 4 - NHS Framework Domains 1 - 5
The core indicators are listed in the table below. The
numbering scheme used in the table corresponds with
the numbering of the indicators in the Regulation 4
Schedule within the Quality Accounts Regulations.
Prescribed information
Some of the indicators are not relevant to the Hospice.
Trusts are only required to report on indicators that are
relevant to the services that they provide or subcontract in the reporting period therefore some areas
have been shaded as not relevant.
Achievement
Response
Regulations 12-18 (Domains 1-3) are not applicable to Rotherham Hospice for the reporting period 2014/15.
19. The percentage of patients aged:
(i) 0 to 14; and
(ii) 15 or over,
readmitted to a hospital which forms
part of the trust within 28 days of
being discharged from a hospital
which forms part of the trust during
the reporting period.
9.5% (35) of patients were
readmitted to Hospice services (IPU)
within 28 days of discharge. This is a
decrease of 2.2% from 2013/14
where the figure was 11.7% (44
patients).
The Rotherham Hospice considers that this data is as described
for the following reasons: Changes in patient conditions and
the issues with procuring appropriate domiciliary provision for
some patients on discharge.
The Rotherham Hospice has taken the following actions to
improve this and so the quality of its services, by: The
introduction of 48 hour emergency discharge cover from the
Hospice @ Home service to ensure all discharges are safe and
effective in the patients home environment.
20. The trust’s responsiveness to the
personal needs of its patients during
the reporting period.
The Trust does not have actual %
data on its responsiveness to
patients and their families at this
time. However the Hospice can
evidence its ability to assess, plan
and coordinate care in a responsive
manner. This is also evident from
the organisations response to
incidents and complaints, ensuring
learning and service improvement
occurs as a result of its findings.
The Rotherham Hospice considers that this data is as described
for the following reasons: The Hospice is not required to submit
this data to the HSCIC as routine reporting.
21. The percentage of staff employed by, Q4 = 100%
or under contract to, the trust during
the reporting period who would
recommend the trust as a provider
of care to their family or friends.
The Rotherham Hospice considers that this data is as described
for the following reasons: Staff are happy with the type and
quality of service that the trust provides.
Regulations 22-23 (Domains 2,4 &5) are not applicable to Rotherham Hospice for the reporting period 2014/15.
21.1 This indicator is not a statutory
requirement.
The trust's score from a single
question survey which asks patients
whether they would recommend the
NHS service they have received to
friends and family who need similar
treatment or care.
IPU – annual average 100%
Day Therapies (reception) – annual
average 98.8%
CNS Service – annual average 97.4%
H@H – annual average 98.3%
The Rotherham Hospice considers that this data is as described
for the following reasons: Patients and families are generally
happy with the care and support that they receive.
The Rotherham Hospice has taken the following actions to
improve this and so the quality of its services, by: Improving
the variety and accessibility of services that are available by the
Hospice and by placing itself centrally to coordinate EOLC
thereby improving experience.
24. The rate per 100,000 bed days of
cases of C.difficile infection reported
within the trust amongst patients
aged 2 or over during the reporting
period.
0 patients were reported to have
C.difficile infection during 2014/15.
The Rotherham Hospice considers that this data is as described
for the following reasons: High value is placed on infection
control principles and all patients are nursed in single rooms.
25. The number and, where available,
rate of patient safety incidents
reported within the trust during the
reporting period, and the number
and percentage of such patient
safety incidents that resulted in
severe harm or death.
The trust reported the following
clinical incidents overall in 2014/15
with 2 relating to patient safety and
being escalated as Serious Incidents
due to their potential for harm.
No incidents resulted in serious
harm or death of a patient.
Please see our statement re the Hygiene Code in section 3.4)
Q1 = 19
Q3 = 34
Q2 = 22
Q4 = 19
The Rotherham Hospice considers that this data is as described
for the following reasons: Although this number seems high, it
demonstrates the trusts ethos of valuing the reporting of
incidents as learning opportunities. These range from no injury
falls and equipment issues to medicine management issues.
The Rotherham Hospice has taken the following actions to
improve this and so the quality of its services, by: Introducing
robust systems of assessment and planning to ensure care is
delivered safely, effectively and free from harm. It has also
implemented improved systems for medicines management
training and supervision.
It is not possible for the Hospice to report comparatively as it does not submit data to
the Health and Social Care Information Centre (HSCIC).
31
Part 5
Supporting Statements
5.1 Rotherham Clinical Commissioning
Group (Rotherham CCG)
Rotherham CCG is encouraged by the continuing focus on
quality by the Hospice. This is embodied in the 4 key strategic
objectives which focus on high quality services that ‘add value’
to end of life care. Ensuring service delivery from a base of long
term financial strength and ‘independence’, provided by staff
with skills and attitudes that are highly respected by the wider
health and care network.
The Hospice has progressed well against the 3 key priorities for
quality improvement that were identified for 2014/15. The Day
Hospice has been redesigned to allow the introduction of day
therapies and treatments as well as broader health and
wellbeing programs. A more robust data collection tool has
been introduced for identifying formal carers who want or need
support. And a four tier counselling and support service has
been introduced. In all cases service users and professionals
feedback has been very positive.
The CCG welcomes the three key quality improvement priorities
that the Hospice has identified for 2015/16. These build on
improving the scope of the services being provided, developing
robust ways of measuring patient outcomes and further
enhancement of staff resilience. These will all help to strengthen
the quality of the service that the Hospice provides to the benefit
of patients and their families in Rotherham.
The CCG looks forward to a continued positive relationship
with the Hospice over the coming year.
Dr Avanthi Gunasekera
GP EOLC Commissioning Lead
Rotherham CCG
32
5.2 Rotherham Health and
Wellbeing Board
The Health and Wellbeing Board are very appreciative of the
work Rotherham Hospice carries out for its local residents.
Offering end of life care requires dedication and sensitivity
from services to support families through this often difficult
period. The Health and Wellbeing Board will continue to
work with partners to ensure the highest standard of care
is achieved for all of Rotherham residents.
Councillor David Roche
Chair of Rotherham Health
& Wellbeing Board.
www.rotherhamhospice.org.uk
33
Rotherham Hospice, Broom Road
Rotherham, South Yorkshire S60 2SW
Tel: 01709 308900
www.rotherhamhospice.org.uk
A Registered Charity.
A Company Limited by Guarantee.
Registered Address: Broom Road, Rotherham, S60 2SW
Company Registration No: 2234222
Registered Charity No: 700356
Our care places the patient at the centre of everything we do.