SPRINGHILL HOSPICE
QUALITY ACCOUNT
2014 - 2015
Springhill Hospice (Rochdale)
Broad Lane
Rochdale
OL16 4PZ
Registered Charity No: 701798
www.springhill.org.uk
Incorporated as a Company Limited by Guarantee No 2325905
1
Springhill Hospice
“Making every moment count”
“On behalf of the whole family, thank you
for your expert and dedicated care of my
mum, ensuring she was comfortable at the
end of her life. We very much appreciated the
compassion and kindness shown, not just to
my mum, but to the whole family during my
mum’s last days”
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QUALITY ACCOUNT 2014 - 2015
TABLE OF CONTENTS
Page
Statement on Quality from the Chief Executive
4
About us

Statement of Philosophy
5
Priorities for improvement 2015/16
6
Progress on priorities for improvement 2013/15
9
Statement of assurance from the Board

Review of services

Research

Participation in clinical audits

Learning from clinical incidents

Management of complaints, concerns, comments
and suggestions

Goals agreed with Commissioners
11
11
11
13
14
14
What others say about Springhill Hospice

Statements from the Care Quality Commission

Statements from others we work with
14
16
Data quality
17
Safeguarding
18
Quality overview
18
What Our Patients and their Families say about Springhill Hospice

Inpatient Unit

Specialist Community services (including Specialist Nursing,
Hospice at Home and Night Sitting service)

Counselling and Bereavement services

Day Hospice service

Letters and cards of support from patients and families
19
20
20
21
21
22
Comment from the Clinical Commissioning Group
Comment from Healthwatch (Rochdale)
Comment from the Overview Scrutiny Committee
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QUALITY ACCOUNT 2014 - 2015
STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
I am delighted to present this Quality Account for Springhill Hospice.
As an organisation, we continually strive to offer the best possible service to our patients and
their families at all times ensuring a high quality and individualised approach.
As you read through this report, you will see that our services have expanded and grown
considerably responding to local and national demands. Our new community service was
launched in 2014, and it is pleasing to see an increase in the number of patients and families
we are able to care for in the place of their choosing.
It is testament to the hard work and dedication of Trustees, Staff and Volunteers who deliver
our services that we have met and indeed exceeded our key priorities for previous years, at the
same time as undertaking some significant service development.
This quality account is intended to demonstrate to all who read it, that our Hospice provides a
high quality service, where patients and their families will receive the very best standards of
care possible.
I confirm that to the best of my knowledge, the information contained within this Quality
Account is a true and accurate reflection of quality at Springhill Hospice.
Julie Halliwell
Chief Executive
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QUALITY ACCOUNT 2014 - 2015
ABOUT US
Springhill Hospice offers specialist palliative care services to patients with life-limiting illnesses
and emotional and psychological support for their families. Hospice services include a 16-bed
Inpatient Unit, where patients are admitted for end of life care, symptom management and
respite; Day Hospice where patients can access psychological, complementary and creative
therapies; Lymphoedema clinic, Counselling and Bereavement services and a 24 hour specialist
palliative care advice line for patients, families and healthcare professionals. We also offer
Specialist Palliative Care and End of Life Community Services consisting of a Consultant led
Medical service, Specialist Nursing service, Hospice at Home service for patients at the end of
life, a Night sitting service, Physiotherapy, Social Work, Counselling and Spiritual Support.
STATEMENT OF PHILOSOPY
As a specialist palliative care unit, Springhill Hospice:
provides the highest standard of physical, psychological, emotional and spiritual care for
patients and their families, friends and carers.

encourages patients to maintain independence and control, and to make informed
choices, whilst respecting privacy and dignity.

offers advice and support from the time of referral, throughout the illness and into the
bereavement period.

offers post bereavement therapies, psychotherapy and counselling.

offers information and education to patients, families, friends, carers and professionals, to
promote a high standard of palliative care across the community.

respects all cultural, religious and personal beliefs, placing the emphasis of care on
individual need.

audits and reviews the services it provides to ensure appropriate clinical standards are
maintained and services are delivered effectively.
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QUALITY ACCOUNT 2014 - 2015
PRIORITIES FOR IMPROVEMENT 2015/16
Springhill Hospice is fully compliant with the Care Quality Commission (Registration)
Regulations: Essential Standards of Quality and Safety and with the Health and Social Care Act,
2008. As such, the Board did not have any areas of shortfall to include in its priorities for
improvement for 2015/16.
Within the Hospice Strategy 2010-15 (Building on Success), the Board laid a strong emphasis
on quality and development in the following 5 core elements:





giving patients a choice – Hospice at Home initiative
improving quality and information – patient information systems
increasing income generation – diversifying income streams
developing the workforce – workforce analysis and joint working initiatives
education for all - improving knowledge and skills
From this strategy the Board and Executive Management Team have identified several key
priorities relating to the development of services with an emphasis on quality and ensuring the
3 elements of quality: patient safety, clinical effectiveness and patient/family experience. Key
priorities for 2015/16 relating to quality are as follows:
Future Planning Priority 1
Successful implementation and delivery of the Integrated Community Specialist
Palliative Care and End of Life Care service
The Integrated Community Specialist Palliative Care and End of Life service was subject to
procurement in October 2013 and we were delighted to be chosen to provide this service.
The implementation of the service has proven to be the most challenging service development
since the Hospice opened its doors in 1989.
The integrated service is led by a Consultant in Specialist Palliative Care and has a team of 10
Specialist Palliative Care Nurses who provide a service to patients and families 7 days a week
from 8:00am to 8:00pm Monday to Friday, 8:00am to 4:00pm Saturday, Sunday and Bank
holidays.
Our Hospice at Home team also form part of this service, working 7 days from 8:00am to
10:00pm and we are working in partnership with Marie Curie Nursing Services to provide a
night sitting service for patients at the end of life.
The team is further strengthened by input from our Palliative Care Physiotherapist and Social
Worker, Counselling and Spiritual services and Volunteer Community Services.
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QUALITY ACCOUNT 2014 - 2015
Our challenge now is to embed these services into our local community, better supporting
patients and families, reducing the number of inappropriate admissions to hospital, caring for
patients in the place of their choice and supporting their families.
We are working closely with our commissioners to embed the service into the local community
health environment, working with GPs, District Nurses and social care providers to raise
awareness of palliative and end of life issues, to ensure our new service makes a difference to
patients and families.
Future Planning Priority 2
Implementation of the Individualised Plan of Care and Support for the Dying
Patient
The Individualised Plan of Care is a Department of Health initiative developed to support
practitioners in all settings to provide a high standard of care for patients at the end of life.
The Care Plan is to be used to record the individualised care delivered to the dying person in
the last days and hours of their lives and support their families, carers and those close to
them.
Effective communication, compassion and kindness a well as clear documentation are key to
delivering good clinical care in all circumstances and meeting the needs of the person and
their family and carers.
Springhill Hospice will be central to the implementation of this new care plan. Funding has
been made available from the Strategic Clinical Network through ‘Multi Professional Education
& Training’ funding to recruit a nurse on a 12 month fixed term contract to work alongside
the Hospice Education Lead to roll our the document across Hospice, Community and Care
Home settings.
The effective use of this tool will improve the standard of care given to patients at the end of
life and the support given to their families.
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QUALITY ACCOUNT 2014 - 2015
Future Planning Priority 3
Provision of Specialist Palliative Care and End of Life Education to Community
Practitioners and Care Home staff across Heywood, Middleton and Rochdale
When developing the Springhill Hospice Community service model we identified a need to
improve the availability of Specialist Palliative Care education to all community generalist
practitioners across Heywood, Middleton and Rochdale.
We are aware that many patients and families do not access Hospice services and are cared
for by General Practitioners, District Nurses and other practitioners in the community.
Education and training is essential to develop the knowledge and skills of these practitioners to
enable them to care for these patients and to afford them palliative care and end of life care of
the highest standard.
We have recruited an Education Lead to work closely with our colleagues in the community to
increase their knowledge and skills, competence and confidence, in order for them to care for
patients appropriately.
The Education Lead delivers programmes of learning for all practitioners in a flexible way to
best meet the needs of the study group. Workshops and study days are held both here at
Springhill Hospice and in their workplace.
The Education Lead has also developed a ‘Palliative Care Passport’ for Care Home and
Domiciliary Care staff to address the fundamental palliative care skills they need to care for
dying patients and support families.
Future Planning Priority 4
Community Volunteer Support Service
As part of our new Specialist Palliative Care service we are currently working towards the
provision of volunteer support in the Community.
In addition to Specialist medical and nursing needs we have identified that some patients and
families also need more fundamental support with everyday living.
From this year, patients and families will be further supported by our volunteer service who
will offer additional services to patients and families ie, companion service, volunteer drivers,
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QUALITY ACCOUNT 2014 - 2015
gardeners and even dog-walking
PROGRESS ON PRIORITIES FOR IMPROVEMENT 2013/15
The following areas were identified as Key Priorities for 2013/15:
Key Priority 1
Hospice at Home Service – secure recurrent funding from Pilot year
As the Springhill Hospice at Home service approached the end of its pilot year in 2013 it was
clear from activity data and stakeholder feedback that the service was evaluating well and
clearly making a difference to our patients and families.
In order to secure future recurrent funding we worked closely with the Clinical Commissioning
Group to embed this service within the Heywood, Middleton and Rochdale CCG End of Life
Strategy (Adults) 2012/13 – 2015/16.
HMR CCG subsequently included the Hospice at Home service within its model for an
Integrated Community Specialist Palliative Care and End of Life Care service.
Springhill Hospice was successful in the bid for this service which commenced in July 2014.
Key Priority 2
Implement Recommendations from recent Governance Review
During 2014, the Board began working through a series of recommendation following an
independent review of Governance undertaken in 2013.
A self assessment survey was undertaken in order to identify any deficiencies in the make-up
of the Board. 4 additional Trustees were appointed through a process of open recruitment.
An induction programme has been developed for new Trustees and is currently being trialled.
It is intended that a formal appraisal system be introduced for all Trustees in order to review
performance, attendance and contribution.
Further work is being undertaken to review the role and duties of the Board, its Committee
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QUALITY ACCOUNT 2014 - 2015
Structures and how Trustees organise their business.
Key Priority 3
“Digging Deep and Expanding Horizons” - Refurbishment of Patient Areas –
Department of Health Improvement Grant, 2013
Springhill Hospice was awarded a significant grant from the Department of Health Grant
Awards Scheme. Over 2013/14 we were able to make the following improvements:





refurbishment of the Day Hospice unit and therapy rooms
provision of sheltered external seating areas for patients and families
development of a ‘therapeutic’ vegetable garden
improvements to our laundry provision and staff changing facilities
improvements to a patient bathroom and ward treatment room
The DoH funding enabled us to progress our plans to improve the quality of facilities and the
care environment for our patients and families.
Key Priority 4
Expansion of Hospice Bereavement Services
In December 2012 we were approached by the Clinical Commissioning Group to consider the
potential for widening access to our Hospice Bereavement Service.
Previously the Bereavement Service had been limited to families, friends and carers of patients
who had been known to Springhill. A pilot service was launched in February 2013 enabling
Health and Social care practitioners to refer clients to our Bereavement service regardless of
prior contact with the Hospice.
Bereavement support is offered at a variety of levels dependent upon identified need. The
service consists of counselling, one-to-one bereavement support, weekly/monthly bereavement
support groups and grief workshops.
The service has evaluated well and we are delighted that, from the initial pilot year, Heywood,
Middleton and Rochdale Clinical commissioning Group have commissioned the Springhill Hospice
Bereavement Service for a further 3 years to 2017.
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QUALITY ACCOUNT 2014 - 2015
STATEMENT 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 providers.
REVIEW OF SERVICES
During 2014/15 Springhill Hospice has provided the following NHS services:
Inpatient services
Day Hospice services
Outpatient services
Psychological & Supportive Care services
Community Specialist Palliative Care Medical and Nursing services
Community Physiotherapy, Social Work, Counselling and Spiritual Care services
Hospice at Home service
Night Sitting service
Lymphoedema service
Bereavement service
24 hour Advice Line service
Springhill Hospice has reviewed all the data available on the quality of care in all of these
services.
Springhill Hospice Specialist Palliative Care and End of Life integrated Community Service
receives 100% funding from Heywood, Middleton and Rochdale Clinical Commissioning Group.
The service is subject to a Standard NHS Contract for 3 years to June 2017.
For other Hospice services, the income generated by a variety of contracts and agreements with
the NHS represents approximately 31% of the total income generated to enable the provision of
these services by Springhill Hospice. The remaining funds were generated through fundraising
and the Hospice’s own subsidiary companies working with the local community.
RESEARCH
Springhill Hospice has not participated in the any research studies in 2014/15:
PARTICIPATION IN CLINICAL AUDITS
During 2014/15 there were no national clinical audits or national confidential enquiries covering
NHS services relating to palliative care. Springhill Hospice only provides palliative care services.
During 2014/15 Springhill Hospice undertook a number of clinical audits. Audit tools are
developed to measure compliance with Hospice policy and Standard Operational Procedures,
which in turn reflect our commitment to ensure compliance with the Care Quality Commission
Fundamental Standards.
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QUALITY ACCOUNT 2014 - 2015
Audit Subject
Admission and
management of referrals
(Jan 15)
Student and work
placement (Feb 15)
Clinical documentation –
Nursing (IPU) (Mar 15)
Clinical Documentation –
Spiritual and Pastoral Care
(July 14)
Management of Medicines –
storage (Oct 14)
Management of Medicines –
administration (Mar 14)
Outcome
Audit identified a high level of compliance to policy across all clinical
areas with evidence of regular ongoing communication with referrer and
patients/families.
Audit indicated some improvement required in records held for work
placement students – addressed.
Audit indicated some areas for improvement in relation to review of
assessments and care plans - addressed.
Audit indicated the need to introduce a spiritual assessment tool on
admissions – addressed.
Food safety (Feb 14)
Audit indicated some improvement needed in the availability of training
records and improvement in attendance at mandatory training –
addressed.
Audit indicated a need for improvement in recording maintenance of
certain equipment - addressed. Annual maintenance schedule in place.
All standards fully met. Audit indicated no areas of concern.
All standards fully met indicating a high level of compliance with policy.
Maintenance of medical
equipment (Feb 14)
Patient transport (Mar 14)
Management of medicines
– syringe driver (May 14)
Management of medicines
– Independent prescribing
Jan 15)
Management of medicines
– ordering and receipt (Jan
14)
Management of medicines
– disposal (Nov 14)
Education, training and
development (Oct 14)
Preferred priorities for care
(Mar 14)
Staff dress code and
uniform (Dec 14)
Audit indicated the need for improvement in the storage of patient’s own
medication in individual cabinets – addressed.
Audit indicated the need for some improvement in documentation addressed.
Audit indicated a high standard of prescribing practice.
Audit indicated some improvement needed in the recording of drugs
received into the Hospice – addressed.
Audit indicated a need for improvement in the recording of drugs for
destruction – addressed. Remaining standards fully met indicating a
good standard of compliance with policy.
Audit indicated some improvement in the numbers of staff attending
mandatory training sessions – addressed.
All audit standards fully met. Medical documentation recording all
significant interactions with patient and families in relation to advance
care planning and choice.
Audit indicated some minor breaches of uniform policy – addressed.
In addition to the clinical audits listed above, the Hospice has also undertaken audits in relation
to non-clinical areas relating to our support services, administration, finance and income
services.
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QUALITY ACCOUNT 2014 - 2015
LEARNING FROM CLINICAL INCIDENTS
Springhill Hospice encourages an open approach to reporting all incidents, both clinical and
non-clinical. All incidents are reported, investigated and managed immediately and incident
reports subsequently collated and reported through the Hospice Risk Management sub
committee and Governance Committee. All incidents are categorised according to the incident
area and level of risk. Where the incident involves a patient fall, this will then be subject to a
risk assessment and appropriate action taken. Any significant injury will be reported
appropriately to the Care Quality Commission as a statutory notification and reported to the
Health and Safety Executive (RIDDOR) as appropriate. All incidents relating to controlled drugs
will be reported by the Hospice Accountable officer for Controlled Drugs (AO) to the
Accountable Officer of the CCG via the Local Intelligence Network.
Reported incidents are often the catalyst for change, both in clinical practice and in policy.
The following incidents were reported in 2014/15:
Category
Clinical
incidents
A1
A2
A3
Falls/injuries
B1
B2
Indicator
B3
Other
incidents
C1
C2
C3
Drug
incidents
D1
D2
D3
D4
Pressure
ulcers
P1
P2
No of incidents
Directly affects patient either by action or omission
Potential to affect patient
No potential to affect patient
14
7
1
Significant injury - patient
Minor injury
3
30
No injury sustained
43
Direct affect to individual/organisation ie theft, damage
Potential to affect individual/organisation
No potential risk identified
9
9
0
Directly affects patient either by action or omission
Potential to affect patient
No potential risk to patient but deviation from policy
Accidental spillages
12
23
10
17
Hospice acquired pressure ulcer
Community/hospital acquired pressure ulcer identified on
admission
Total number of reported incidents
0
4
Patient
Staff
Volunteer
Patient
Staff
Volunteer
Visitor
13 (falls 10)
13
4
37 (falls 35)
5
0
1
182
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QUALITY ACCOUNT 2014 - 2015
MANAGEMENT OF COMPLAINTS, CONCERNS, COMMENTS AND SUGGESTIONS
Springhill Hospice encourages feedback in a variety of ways from patients, families, staff,
volunteers and visitors.
Comments/suggestions boxes are available in the Reception area, Inpatient Unit and Day
Hospice unit. Comments and suggestions are reported through the Operational Management
team meetings.
Feedback from patients and families are also encouraged through a variety of feedback cards,
satisfaction surveys and questionnaires, reported through the Clinical Standards sub committee
and Governance Committee.
Complaints are managed through policy and an annual audit of the complaints procedure is
undertaken. All complaints received are taken extremely seriously, thoroughly investigated and
a response to the complainant made in writing. Even in cases where the complaint has not
been upheld we strongly believe that we can always learn from the experiences of others where
their perception of Hospice services is less than satisfactory. The Hospice received the
following complaints in 2014/15:
Total
Total
Total
Total
number
number
number
number
of
of
of
of
complaints received
clinical complaints
non-clinical complaints
complaints resolved within timeframe
10
2
8
10
GOALS AGREED WITH COMMISSIONERS
Use of the CQUIN payment framework
Under the terms of the NHS Standard Contract, Springhill Hospice income in 2014/15 is
conditional on achieving quality improvement and innovation goals through the Commissioning
for Quality and Innovation payment framework. Because Springhill Hospice has only recently
entered into an NHS National Standard Contract it has been agreed with commissioners that, in
year 2 of the contract, the Hospice will negotiate and enter into an agreed CQUIN Scheme.
WHAT OTHERS SAY ABOUT SPRINGHILL HOSPICE
Statements from the CQC
Springhill Hospice is required to register with the Care Quality Commission and its current
registration status is unconditional. The Care Quality Commission has not taken enforcement
action against Springhill Hospice during 2014/15.
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QUALITY ACCOUNT 2014 - 2015
Springhill Hospice has not participated in any special reviews or investigations by the CQC
during the reporting period.
Springhill Hospice was subject to a routine inspection by the Care Quality Commission in
October 2013. The following standards were inspected and found to be fully met:
1.
Respecting and involving people who use services
“During this visit we looked at the care records of two patients to see if they had been
involved in decisions relating to their care, support and treatment. It was clear from the
information contained within the care plans that patients had been involved in the
planning of their care. The care plans contained information which demonstrated that
patients were encouraged to be as independent as possible. They also contained
information to show that patients had their right to privacy, to make choices, and to give
consent to their care and treatment, respected.”
2.
Care and welfare of people who use services
“During our visit we spoke with two of the patients on the Inpatient Unit and asked them
to tell us how they felt they were being cared for. Comments made included ‘the staff are
brilliant’ and ‘very kind, very caring and they are looking after me very well. We looked at
the nursing care plans of two patients. The care plans contained sufficient information to
show how patients were to be supported and cared for.”
3.
Meeting nutritional needs
“The menus showed that, in addition to homemade soup, there was always a good choice
of main meal and dessert. Throughout the day we saw that hot and cold drinks were
made available. Patients and their visitors were always asked what they would like to
drink and home made cakes were served during afternoon tea. The cook was very
knowledgeable about special diets that patients may need and was aware of how to fortify
foods to improve a patient’s nutrition.”
4.
Requirements relating to workers
“We looked at three staff personnel files. They contained proof of identity, application
forms that documented a full employment history, a medical questionnaire and two
professional references. There was evidence to show that criminal record checks (CRBs)
had been undertaken. We were shown the robust system that was in place for checking
that nurses, medical staff and other professionals employed by the Hospice, remained
registered with the relevant professional body.”
5.
Supporting workers
“We were shown the training plan that was in place for all the staff. It showed staff had
received the essential training necessary to safely care for and support patients and their
relatives. We spoke with two staff members who told us they felt very supported. One
staff member told us they received their main support from within their own team.
Another staff member told us that, because of the unique professional role they undertook
within the Hospice, access to the relevant professional support for them had been sought
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QUALITY ACCOUNT 2014 - 2015
from an outside source. Staff also told us they received plenty of training to enable them
to do their job safely and maintain their skills.”
Summary of inspection
“Arrangements were in place to help ensure patients were treated in a respectful, dignified way
and were involved in the making of decisions about their care, support and treatment.”
“Patients’ care records contained enough information to show how they were to be supported
and cared for.”
“The patients were provided with a choice of suitable and nutritious food and hydration to
ensure their nutritional needs were met.”
“Arrangements were in place to ensure the patients were cared for by skilled and experienced
staff that were safely recruited.”
“Patients were cared for by staff that were properly trained, supported and supervised.”
STATEMENTS FROM OTHERS WE WORK WITH
“We have enjoyed a long relationship with Springhill Hospice, which has been additionally
strengthened during the last year since the development of the Community Service. It is
pleasing to see that the Hospice has recruited an Educationalist, who is able to support the
delivery of End of Life Care within GP practices. AS GPs we are able to readily access support
and advice from Hospice doctors and other clinical staff as required, which is beneficial for both
professionals and patients alike. I have nothing but praise for the Hospice at Home team who
have cared for a number of patients from our practice. The Hospice team is professional in its
approach, but ensure that their professionalism is supported by a compassion and true
understanding of what the patients and families are experiencing at a very difficult time.
Springhill Hospice really is the Jewel in Rochdale's crown”.
General Practitioner
HMR
“I would like to send my sincere gratitude to you and your team for all the support you gave to
me and thank you for your patience each time I rang on behalf of my client. In our line of work
we come across people who express a wish to die in their own home. For whatever reasons
sometimes this seems to be overlooked. I sincerely hope your (Hospice at Home) service can
grow and continue”.
Independent Mental Capacity Advocacy (IMCA) service
MIND (Rochdale and District)
“I would like to express a huge thank you for the wonderful help and support that Hospice at
Home gave to us. Many people could not even comprehend how important the support that
your team is able to give. As the manager of a busy care home I welcomed the opportunity to
take on board your help. It was wonderful to see that, along with my carers, your team were
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QUALITY ACCOUNT 2014 - 2015
not only passionate about what they do, but showed that their love to others is unconditional in
their hour of need, and we wish to thank you for that”.
Manager
Residential Care Home
Middleton
“I have been a District Nurse in Rochdale for many years and have always been a great
supporter of the services Springhill Hospice provides. Over the years many of my patients have
benefitted from the services provided on the Hospice inpatient unit, Day Hospice and
Counselling service. More recently some of my patients have been supported by the Hospice at
Home service and Community team and I have been able to work alongside the team from
Springhill to care for patients at the end of life and support their families. Working in
partnership with the Hospice and ensuring good lines of communication has ensured a first
class service for my patients”
District Nurse
Rochdale
DATA QUALITY
In accordance with agreement with the Department of Health, Springhill Hospice submits a
National Minimum Dataset (MDS) to the National Council for Palliative Care.
Springhill Hospice is not required to and did not submit records during 2014/15 to the
Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the
latest published data.
Springhill Hospice was not subject to Payment by Results clinical coding audit during 2014/15
by the Audit Commission.
Springhill Hospice undertakes to ensure that information is managed appropriately with regard
to confidentiality, and privacy of individuals, in line with statutory requirements including, but
not limited to, the Data Protection Act 1998.
The Hospice complies with all requirements made by the Care Quality Commission and other
statutory bodies requiring information to contribute to national health care studies and data
sets. In line with these requirements, an Information Sharing Protocol is in place with The
Christie NHS Foundation Trust, Pennine Care NHS Foundation Trust, Heywood, Middleton and
Rochdale CCG, Bury CCG, Oldham CCG and North Manchester CCG (CCGs signed as PCTs) for
secure information sharing. The signed documentation is held in a central file by the Director of
Corporate Services.
The Hospice actively completes the Health and Social Care Information Centre Managed
Information Governance Toolkit annual assessment. For the 2014/15 (Version12) assessment
the Hospice approved and submitted an attainment of 66% (satisfactory), which included the
achievement of at least the minimum level two compliance for all criteria.
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QUALITY ACCOUNT 2014 - 2015
The Hospice ensures that records are retained for the required statutory periods, including
health records, employment records and financial records.
Compliance with Statutory Requirements
Care Quality Commission C29, C31
Data Protection Act 1998
Access to Health Records Act 1990 (with regard to information held about patients who are
deceased)
Caldicott Committee Report (December 1997)
The Hospice undertakes annual audits of documentation and information management and
security to ensure data integrity.
All staff are required to undertake annual training in Information Management & Confidentiality.
SAFEGUARDING
In accordance with the NHS contract, Springhill Hospice has submitted the Safeguarding selfassessment toolkit with Rochdale Metropolitan Borough Safeguarding Board, demonstrating full
compliance across all areas for 2014/15.
All Hospice staff have received training in respect of Safeguarding Vulnerable Adults, Mental
Capacity and Deprivation of Liberty Safeguarding.
QUALITY OVERVIEW
In July 2014 Springhill Hospice introduced the iCare patient information system. The iCare
system is used for recording medical, demographic and statistical information which is shared
between professionals involved in the patient’s care and used to evaluate services. All clinical
staff have access to, and contribute to, the system. Icare is also used to collate patient data in
terms of reports for our Commissioners and for Minimum Data set recording for NCPC.
As iCare was introduced in July 2014, only part year data is available. For the period 1.7.14 –
31.3.15 (9 months) activity as follows:
INPATIENT UNIT
Total number of admissions
Total number of discharges
Total number of deaths in Hospice
1 July 2014 – 31 March 2015
256
146
110
MEDICAL OUT-PATIENTS
Total number of patients referred
1 July 2014 – 31 March 2015
23
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QUALITY ACCOUNT 2014 - 2015
Total number of contacts
43
DAY HOSPICE
Total number of patients referred
1 July 2014 – 31 March 2015
131
SPECIALIST COMMUNITY SERVICE
Total number of patients referred
Medical Consultant visits
Specialist Nurse visits
Physiotherapy visits
Social Worker visits
Counsellor visits
Chaplain visits
Complementary Therapist visits
Current caseload
1 July 2014 – 31 March 2015
551
39
2525
294
81
48
36
37
219 (37 on hold)
HOSPICE AT HOME
Total number of patients/families referred
Total number of H@H visits
1 July 2014 – 31 March 2015
167
1766
NIGHT SITTING SERVICE
Total number of referrals
Total number of Hospice night sits
Total number of Marie Curie night sits
1 July 2014 – 31 March 2015
74
186
513
24 HOUR SPECIALIST PALLIATIVE
CARE ADVICE LINE
Total number of calls received
1 July 2014 – 31 March 2015
LYMPHOEDEMA SERVICE
Total number of referrals to service
Total number of interventions
Current caseload
1 July 2014 – 31 March 2015
12
72
74
PSYCHOLOGICAL SERVICES
Total number of referrals to services
Number of counselling interventions (1-2-1)
Number of bereavement interventions (1-2-1)
1 July 2014 – 31 March 2015
392
487
608
58
WHAT OUR PATIENTS AND THEIR FAMILIES SAY ABOUT SPRINGHILL HOSPICE
Springhill Hospice’s feedback programme is designed to elicit information about the care and
services received by patients and families from their individual perspective. A variety of
feedback cards have been developed to capture the experience of patients and their relatives
and friends, across the Inpatient unit, Day hospice unit and community service settings. The
cards, based on the concept of the ‘family and friends test’ have been designed to be easy to
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QUALITY ACCOUNT 2014 - 2015
complete and to capture, from the perspective of the patient or family member … “What did we
do well?” and “What could we do better?”
Inpatient Unit
Feedback cards are given out to, and made available to, our patients and their relatives and
friends.
The responses indicate a high level of satisfaction with the Inpatient Unit services. Typical
comments from respondents include:
“We have nothing but praises for every single member of staff we have had contact with. We
know our Mum is receiving the highest standard of care”
“The staff have supported the whole family. Thank you”
“Would highly recommend to anyone in the same situation”
Specialist Community Services (including Specialist Nursing, Hospice at Home and
Night Sitting service)
Our Specialist Nurses include a feedback card in the patient information pack which is left with
the patient at their home. Feedback cards are posted out to the family members of patients
who have died whilst under the care of our Hospice at Home service and also to patients in
receipt of our Night Sitting service.
All responses, without exception, indicate an exceptionally high level of satisfaction with the
service. Typical comments from families include:
“Very grateful for the help and support. I could not have been treated any better”
“Oaklands (Care home) felt very privileged to have the support from everyone at Springhill.
The care and support received was excellent. We felt supported with the difficulties that were
faced at the end of life”
“Staff always helpful and respectful”
“All night sitting support carers have been excellent, giving me total confidence and trust to
leave my father-in-law overnight”
“Thank you for the support you have given; the night sitting service means I and my husband
can have some sleep to enable the ongoing 24/7 care we are giving during my father’s illness”
“I didn’t have to ask for anything – all services were offered”
“When our nurse came to see us for the first time, she instantly became a very important
person to us”
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QUALITY ACCOUNT 2014 - 2015
“Fantastic, responsive service. Gave support and expert advice when needed. Professional and
empathetic staff”
Counselling and Bereavement services
As part of our ongoing evaluation of services, periodic satisfaction questionnaires are sent out
to clients who been in receipt of the Counselling service and Bereavement service.
Comments from the questionnaires include:
Counselling
“The counselling literally saved me from my own destructive and painful experiences. It
repaired something within me which I believed was beyond repairing”
“Counselling has made me realise that I’m a lot stronger and able to cope with situations than I
ever thought I could”
“It has helped me cope with my diagnosis and I am less fearful of the future”
Bereavement support
“Was feeling lighter hearted, & that there was light at the end of a very long tunnel”
“I’m able to cope now before I felt life was too much”
“Realising that I do have control over what I do and I can choose how I respond”
“I couldn’t have done it without you”
“I don’t know how it happened but before counselling I was suicidal and afterwards I
approached life with a smile”
Day Hospice service
Feedback from patients who are in receipt of our Day Hospice service include the following
comments:
“A wonderful experience and first class service”
“I love the craft work. The staff treat us well”
“I was made to feel very welcome”
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QUALITY ACCOUNT 2014 - 2015
Letters of Support from Families and Thank You Cards
In addition to periodic surveys and questionnaires we also continue to receive many cards of
thanks and support from patients and families across all services.
Typical comments include:
“We cannot express our feelings of gratitude enough, and there are no words to thank the
team adequately”
“My Dad’s Palliative Care Nurse was incredibly supportive and the Hospice at Home team
exceeded all our expectations. We miss our Dad immensely but are reassured and supported
by the fact that the end of life care he received was exceptional”
“Thanks a million to you all for your kindness and compassion. We could not have managed
without you. May God bless you all”
“Just a note to say how grateful we are for your care of my husband during his last two weeks.
We really appreciated your empathy, professionalism and support”
“Thank you for making such a terrible time a little bit better with all your help and support”
Springhill Hospice Quality Account 2014/15 has been forwarded to the following bodies for
comment:



Heywood, Middleton and Rochdale Clinical Commissioning Group (CCG)
LINK – Healthwatch (Rochdale)
Overview and Scrutiny Committee, Rochdale Metropolitan Borough Council
Comments received from Heywood, Middleton and Rochdale CCG include:
“Thank you for asking us to comment on your draft Quality account for 2014/15. We were
please to read the detailed Quality Account which demonstrated the Hospice’s on-going
commitment and dedication to improving quality of services offered. Quality and safety of
services is of paramount importance to HMR CCG (“the CCG), and thus we have welcomed the
opportunity to comment on your Quality Account.
The information contained within the Quality Account reflects the performance on quality
reported to the CCG at monthly meetings with the CCG and at quarterly contract meetings.
These meetings enable discussions about all aspects of end of life care and facilitate excellent
relationships between CCG and Hospice staff.
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QUALITY ACCOUNT 2014 - 2015
Continuous quality improvement is a priority for the CCG. KPIs have been jointly discussed and
agreed through the contract meetings, with KPIs in the process of being developed for Year 2
of the contract.
The CCG is committed to incentivising providers to deliver high quality innovative care through
the use of “CQUIN” schemes. We are looking for a quality based CQUIN concentrating on the
development of Staff, Patient and family satisfaction, looking at service user/carer survey
processes and developing and delivering quality data from these by the end of contract year 2.
This will be discussed and worked up with the Hospice during 2015/16.
It is pleasing to note the progress made against the identified priorities for improvements
during 2013/15, particularly the implementation of the Hospice at Home service following an
initial pilot. Anecdotal patient feedback has been extremely positive and review of data clearly
demonstrates that patients receiving the service are far more likely to be managed in the
community.
We recognise the commitment to good governance and note the Hospice has begun working
through the series of recommendations made following an independent review of Governance
in 2013.
We welcome the expansion of the Bereavement Service to cover all adults living in the borough
of Rochdale, particularly as there is a wide range of support forms and it is open to adults prior
to bereavement up to 12-month post bereavement dependent upon need. We note that user
feedback has been excellent.
We support the identified priorities for 2015/16 particularly in the work which the Hospice is
undertaking with the CCG to ultimately achieve an appropriate 24/7 Integrated Community
Specialist Palliative Care and End of Life Care service. We recognise the progress and success
of the service to date encompassing all aspects of support and care for the patient and family
and liaison with a wide range of services such as GP surgeries, emergency services, Coroners
office, Social Services, Community and Secondary health providers, community groups and the
wider population of the Rochdale Borough.
The provision of high quality individualised end of life care is priority for the CCG and we are
pleased that the implementation of the Individualised Plan of Care and Support for the Dying
Patient is a priority for the Hospice in 2015/16. We note this work will be supported by the
recruitment of a nurse on a 12 month fixed term contract to lead on the roll out of the
document across Hospice, community and Care Home settings.
The involvement of Springhill Hospice in our wide range of community and clinical education
opportunities is a crucial contributor to the overall success of the Integrated Community End of
Life and Palliative Care Service. The willingness of the Hospice to get involved in the education
sessions for GPs, District Nurses, and other community staff to use Springhill meetings to meet
with other stakeholders has been central to building/developing relationships in order to have
improved/joined up care for our patients.
We also note that there is specific training available to Community Nursing staff from a clinical
perspective such as the symptom and pain control modules and 24/7 advice line for
patients/carers and clinicians manned by the Hospice Ward Nurses and Doctors.
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QUALITY ACCOUNT 2014 - 2015
We are pleased to note that the Hospice recognises the value of patient/service user feedback
and the opportunities for improving practice through learning from complaints and incidents.
Moving forwards, we would like to receive examples of how learning from feedback, complaints
and incidents has been used to drive service improvements and enhance the provision of high
quality care.
Overall, we support the significant quality improvements achieved and look forward to working
with the Hospice to further develop high quality services for our population in 2015/16. Also,
Commissioners acknowledge the dedication and care provided by the staff at the Hospice to
local people and feel confident that the Hospice has identified the right quality improvement
priority areas to focus on in the coming year.
We endorse the quality improvements achieved and look forward to working with you in the
future.”
Chief Officer – HMR CCG
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