ST ANDREW’S
HOSPICE
Our Vision
Providing excellence and choice for everyone
affected by a life-limiting illness
Making Each Day Count
QUALITY ACCOUNT 2015-2016
Contents Page
St Andrew’s Hospice Mission Statement
Part1
Chief Executives Statement
Part 2
Monitoring and Reporting of the Priorities for
Improvement 2014-2015
2.2 Priority 1 - Patient Experience
Providing Care in the Patients Home
2.3 Priority 2 – Clinical Effectiveness
2.3a Continue to develop Day Therapy services to ensure that they meet
the needs of the patients and their families
2.3b Increase and develop medical provision within the wider Palliative
and End of Life Care Partnership to provide care at the point of need
2.4 Priority 3 - Patient Safety
2.4a Ensure that the premises are fit for purpose and offer a therapeutic
environment to deliver a high standard of care to patients and their
families
2.4b Explore the use of patient safety parameters to analyse and evidence
the high standard of care provided
Part 3
Priorities for Improvement 2015-2016
3.2 Priority 1 - Patient Experience
3.2a Increase, develop and evaluate the provision of catering services to
patients, staff and visitors, including members of the public
3.2b Raise the awareness of Hospice services to improve the
understanding of and access to care for people nearing the end of their
life and to increase the engagement to support the sustainability of
hospice services
3.3 Priority 2 – Clinical Effectiveness
3.3a Develop and implement a locality wide integrated assessment tool
for palliative and end of life care patients
3.3b Continue to develop Day Therapy Services within both Adult and
Children’s Services to ensure that they support the needs of patients and
their families
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3.3c To improve the quality and methods of collecting data to inform
quality, efficiencies and productivity
3.4 Priority 3 - Patient Safety
3.4a Ensure the premises are fit for purpose and offer a therapeutic
environment to deliver a high standard of care to patients and their
families
Part 4
Statements of Assurance from the Board of Directors
4.1 Reviews by the Care Quality Commission
4.2 National Minimum Data Sets (MDS) and Data Comparison for Children’s
Services
4.3 Review of Services
4.4 Participation in Clinical Audits, National Confidential Enquiries and
Research
4.5 Quality Markers- What we have chosen to measure?
4.6 What others say about St Andrew’s Hospice?
Part 5
Supporting Statements
5.1 Statement from North East Lincolnshire Clinical Commissioning Group.
5.2 Statement from St Andrew’s Hospice Patient Representatives
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St Andrew’s Hospice Mission Statement
“St Andrew’s Hospice will strive to make each day count for people of all
ages with life limiting illnesses and to support those who care for them.”
To ensure that we achieve our mission:
We will offer specialist palliative care which is flexible to the needs of patients with
progressive disease, where curative treatment is no longer possible.
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We will act with openness, honesty and sensitivity, to respect the rights of all
patients to make decisions based on informed choice and to include families and
close others in decision-making where appropriate.
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We will commit to provide a physical, spiritual, psychological and social approach
(holistic) to all care; delivered by a multi skilled team to promote the quality of life of
patients, families and close others.
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We will work together with everyone involved in the patients’ care (lay carers and
professional staff), recognising and respecting their contribution to ensure an
integrated, seamless service is provided and sign up to Together for Short Lives and
Royal College of Nursing/Royal College of General Practitioners Patients Charters.
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We will continue to care for family and close others following bereavement, in a
sensitive and supportive environment.
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We will provide continuing education and training opportunities for all staff and
volunteers in order to develop commitment, expertise, specialism, innovation and
the sharing of knowledge. We will also offer placement opportunities to students of
all disciplines.
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We will ensure the quality and standard of service is of a consistently high level,
undertaking regular internal and external audits and responding to changing needs.
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We will maintain confidentiality and demonstrate that we can be trusted.
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We will maintain an environment that is uplifting, comfortable, friendly and patientcentred.
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We will make the best use of our resources, providing the highest quality of care in
the most cost-effective and efficient way possible.
Approved at April 2009 Board meeting
Acknowledgement to TREE Group for their input to this document
Reviewed July 2012
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Part 1:
Statement from the Chief Executive
On behalf of our Board of Directors and the Senior Management Team I have pleasure in
presenting our annual Quality Account Report for St Andrew’s Hospice.
Quality is central to the care that we provide. The Hospice has developed a strong
framework in both corporate and clinical governance and has a culture of continuous quality
monitoring, in which any shortfalls are identified and acted upon swiftly. Our Patient &
Carer Involvement Group are represented within our governance framework and play a key
role in communicating feedback and offering advice to ensure that all our services and
activities are responsive and deliver on quality.
Our redevelopment, which commenced in 2014, continues, and even though we are behind
schedule, which often happens with a scheme of this size, I am pleased to report that we
began the move into Phase I at the end of March 2015 and that Phase II has commenced
with a completion date at the end of 2015. Currently we have not opened the additional
four adult beds, as we wanted to ensure that staff were inducted to the new building to
enable them to be confident with the new facilities. We are also negotiating with our local
commissioning group regarding funding for the additional beds. We are hoping to open the
beds within the next few months. Throughout all these building works we have managed to
keep the in-patient unit open which has been difficult at times, however I am pleased to
report that all staff have ‘pulled together’ in true team spirit, to ensure that the highest
standards of care have continued to be delivered, with limited disruption to patient services.
We are a registered charity which provides specialist palliative care to people of any age
(children and adults) living with a life-limiting or life-threatening illness. We make no charge
to patients or their families/carers for the services we deliver. We care not only for the
person who is ill, but for the whole family, friends and carers. We respect the patient’s
dignity and strive to enable the patient to achieve their personal goals and priorities.
We provide a range of specialist palliative care services that include:
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An 8 bedded Adult In-patient Unit (to open a further 4 beds 2015)
A 4 bedded Children’s & Young Peoples Unit
Day Therapy within both units
Special bedroom (within Children’s & Young Peoples Unit)
A Lymphoedema Service
Complementary Therapies
Chaplaincy
Creativity
Carers Support
Physiotherapy
Bereavement Support (pre & post)
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An out of hours telephone advice line for professionals
All services are supported by a multi-disciplinary team of professionals, including a
Consultant in Palliative Medicine, Speciality Doctors and Nursing Teams, who are, in turn,
supported by the wider team of dedicated staff who work or volunteer at the Hospice
providing catering, household and administrative functions. Excellence in quality requires a
team approach. All local service providers whose core role is to provide palliative and endof-life services are based at the hospice and the new building has enable us to further
integrate due to the design of spaces – we now house all staff together in an open office
which has enabled interagency working to further flourish which in turn ensures a more
seamless service for patients and their families.
Our services are monitored by the Care Quality Commission as well as by our local
commissioning organisation – North East Lincolnshire Clinical Commissioning Group
(CCG). We are also measured against National Cancer Peer Review Quality Standards, as
well as Fire and Environmental Inspections. In March 2015 we had an unannounced
inspection by the Care Quality Commission under the new inspection regime. This is the
first time that we have been inspected in this way, and the CQC uses five key lines of
enquiry in relation to inspection of services: these are
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Are they safe?
Are they effective?
Are they caring?
Are they responsive to people’s needs
Are they well-led?
We received an overall rating of Good, and were awarded good in all categories except for
caring where were we were judged to be outstanding. This is a tribute to the hard work of
every member of staff working for St Andrew’s Hospice; therefore I would like to take this
opportunity to thank all of our staff and volunteers for their achievements over the past
year. Despite the current economic climate, the Hospice has continued to provide a high
quality service and remain financially sound. We have achieved this by providing high quality,
cost-effective services to our patients, their families, friends and carers. Our team continues
to strive for excellence in all they deliver.
Feedback from the community we serve is very important to us, therefore we undertake an
annual satisfaction survey, as well as encouraging feedback from patients/families and carers
as they are receiving care/services.
We recognise there will always be challenges and will continue to strive for the highest
quality in all care provided, putting our patients, their families, friends and carers at the
heart of everything we do.
Alison Carlisle
Chief Executive
15th May 2015
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Part 2:
2.1
Monitoring and Reporting of the identified Priorities for Improvement
2014-2015
Five priorities were identified within the 2014-2015 Quality Accounts relating to Patient
Experience, Clinical Effectiveness and Patient Safety. The progress of these priorities is
reported below:
2.2
Priority 1: Providing care in the patients’ home
Actions/Progress
This priority was divided in to the development of services for Adult and Children’s
Services.
Adult Services
The Strategic Lead for Palliative and End of Life Care was identified as the project lead to
take this initiative forward. Having already established the Haven Team, who provide
palliative and end of life care to patients in their own home, 24 hours per day 7 days per
week, it was agreed St Andrew’s Hospice would develop the existing hospice volunteer role
into a community volunteer scheme, to provide practical help with everyday tasks, assisting
those patients who want to remain at home.
8 volunteers have now been trained and allocated patients to visit in their own homes. The
volunteers and patients have been matched by similar interests, life experiences and shared
views and a number of visits have taken place not only in the patient’s home, but the
patients have also been supported with outings to various places including the library, the
GP practice, their local church as well as visits to the hospice. The purpose of these
supported visits is to increase participation and extend access in other community activities.
Support is provided for the volunteer, by the Senior Therapy Lead as well as volunteers
being buddied up together to provide peer support. The feedback indicates the patients
value this service, reporting a reduction in isolation, increased confidence and access to
other services as part of their local community. The Senior Therapy Lead is now looking at
expanding this service for bereaved people.
Children’s Services
Having being awarded the funding to provide a Senior Nurse and Advanced Nursing
Assistant, a Senior Nurse-Community Lead was appointed in April 2014. Policies,
procedures and a competency framework have all been developed and are all now in place
to support the nursing team to provide care in the child’s home. This care is provided by
the existing children’s services team, who work on an in-reach/outreach basis between the
hospice and child’s home environment, providing the opportunity for staff to develop their
skills further, ensuring continuity of care and maintaining existing relationships.
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Over the last year, the Children’s Community Service has cared for 14 children and their
families, providing nearly 200 visits. This service has enabled one child to achieve their
preferred place of care and die at home. It has also provided care and support when families
have experienced crisis, accompanied children and their families to hospital appointments, as
well as visiting children admitted to local and regional hospitals. The Senior Nurse is now
also the lead for advanced care planning, undertaking regular reviews of these plans and is
undertaking the non-medical prescribing course to further support her role. The service has
enabled children to engage with other services, including encouraging attendance at the
Hospice. Some families are now accepting home care, who previously would not entertain
this service. Future developments for this service include expansion into the wider
catchment areas of Lincolnshire and Hull, a volunteer befriending scheme to sit alongside
the home care, developing anticipatory drugs for children and providing palliative and end of
life care training and education.
2.3
Priority 2: Continue to develop Day Therapy Services within both Adult
and Children’s Services to ensure that they support the needs of patients
and their families
Actions/Progress:
The review into the current adult day therapy services has continued, with a working group
made up of patients, their family and carers, staff and volunteers looking at how we can
improve the services provided. All members have visited other hospice services to look at
different service models that provide mixed social and medical approaches to Day Therapy.
Through this work, we have introduced a small number of new sessions that patients can
choose to attend, such as drop in relaxation, a breathe-well clinic and exploring spirituality.
Having recently relocated into the new hospice building, we are continuing to develop these
sessions by extending further the ‘menu’ of activities provided, and this objective has been
included within our 2015-2016 priorities.
The review in Children’s Services has commenced and we are assessing the provision of
individualised effective care and social activities. Day care for a child is different as it
provides an alternative to a nursery/school/college placement, and as such attending for the
whole day is of great value to the parents. Following changes in the team we have seen an
increase in attendances for day care and all children and young people now have an activities
plan to ensure individualised care is being provided. With the relocation of Adult Services,
and the provision of a dedicated creativity area, there is more integration of care and a
wider availability of activities provided. Similar to the Adult priority, this objective will carry
over to the next year for a full evaluation of the services provided.
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2.3b
Increase and develop medical provision within the wider Palliative and
End of Life Partnership to provide care at the point of need
Actions/Progress:
Following the approval of the Hospice Board to increase the hours available to the Medical
Team and the amalgamation of the existing medical provision provided to partner services,
we appointed three additional doctors to this team. This service now provides seven day
support to patients receiving palliative and end of life care services through a Monday to
Friday sessional basis with a supporting rota to provide weekend cover. Support is provided
not only to the Hospice Adult and Children’s Services, but to Macmillan and Haven Teams,
as well as advisory support to GPs within the locality. Working alongside the Consultant in
Palliative Medicine, support is also being provided to the local acute trust.
The increase in resources has enabled patients to have more choice over where they are
cared for, reduced inappropriate admissions to the local hospital, provided more medical
support to patients living within care homes and provided an equitable service 7 days per
week, 365 days per year.
Funding as now been awarded for a further pilot project to review the Out of Hours
provision, to look to offering medical support at any time of the day/night for palliative and
end of life care patients.
2.4
Priority 3: Ensure the premises are fit for purpose and offer a
therapeutic environment to deliver a high standard of care to patients
and their families
Actions/Progress:
Phase one is now complete, providing a purpose built inpatient unit increasing the number
of beds from 8 to 12 (all en-suite) for adult patients, a large day services building with
dedicated creativity and consultation rooms to assist with the expansion of services and
increased space to accommodate all services providing palliative and end of life care within
one working area. Patients, staff and volunteers were involved with the colour and design of
the rooms and selecting furniture and equipment, suitable for their needs. We have
successfully relocated all services into the new environment and have received positive
feedback from patients, their families, visitors, staff and volunteers.
As this objective is still in progress with the development of Phase Two, the Health and
Wellbeing Unit we have included it within our 2015-2016 priorities.
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2.4b Explore the use of patient safety parameters to analyse and evidence the
high standard of care provided
Actions/Progress:
We have submitted data as part of Hospice UK national Hospice Inpatient Safety
Benchmarking project. The metrics measured were falls, pressure ulcers and drug errors.
Data was collected in both adult and children’s inpatient units, and our data was discussed
through the Hospice Clinical and Governance meetings. We are waiting for the
benchmarking report for the full year’s data but results from the first 3 quarters of the year
from the 108 hospices participating in this project indicate very low incidence of all three
metrics, with our data comparing slightly higher on falls and medication errors but lower on
pressure ulcers reported. We will be participating in the 2015-2016 data collection and on
receipt of the annual report we will analyse our data, producing a plan for the necessary
actions indicated.
We have also introduced the Edmonton Symptom Assessment System within the Adult
Inpatient Unit. This assessment utilises a set of scores by which the patient identifies the
severity of their symptom(s). Assessment on how the patient perceives their symptoms is
undertaken on day one and reviewed on day 4 and every 4 days thereafter. There is an
expectation we will see an improvement in the score reported by the patient on their
perception of their symptoms. By day four, in most cases we are seeing an improvement in
the patient’s perception of their symptoms. We have seen increased focus towards the
management of symptoms due to the tangible data on which an assessment is based,
providing an opportunity to explore further management options to relieve symptoms.
We have introduced The Traffic Light System for the prevention or further deterioration of
pressure damage for those patients presenting with tissue damage on admission to the
hospice. This initiative has been introduced to all inpatient services across the locality. This
tool recognises the level of risk to the patient and influences the subsequent management
plan. This system identifies all patients at risk, with the majority of hospice patients being
rated amber to red. The supporting management plans inform the necessary plan of care
and outcome assessments and by following this system, gives us confidence we are providing
the best supportive management for these patients with existing pressure damage and
minimising the risk of any avoidable pressure damage being acquired at the hospice.
The Adult Services Manager is now going on to explore the range of safety measures
designed specifically for patients with dementia.
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Part 3:
3.1
Identified Priorities for Improvement 2015-2016
The Board and Senior Management Team are in the process of finalising their Strategic Plan
to cover the period 2015-2018. Through this work we have identified the following
priorities to be taken forward over the next twelve months. These priorities include the
continuing developments of two of last year’s objectives. The priorities set for this year
impact directly on each of the three priority areas - patient experience, clinical effectiveness
and patient safety.
3.2
Priority 1:
Patient Experience
3.2a
Increase, develop and evaluate the provision of catering services to
patients, staff and visitors, including members of the public
How was this identified as a priority?
Through the recent hospice redevelopment, opportunity arose to improve the facility for
the provision of catering services. The Catering Manager worked closely with the catering
equipment suppliers to develop a fit for purpose kitchen and designed a new servery facility.
With the new facilities available it was clear the existing model of providing meals needed
reviewing and developing in order to improve the patient experience, provide additional
services to accommodate visitors and staff and utilise the new facilities to their potential.
There has been a recent emphasis in the literature on nutrition as an important factor in the
quality of life of palliative care patients. Adequate nutrition is essential, not only to meet
physiological requirements, but also because it has additional psychological, spiritual, social,
and cultural benefits for patients and their family or carers. Having the ability to choose
what they would like to eat, when, where and with whom they would like to eat it often
helps a patient to maintain their nutritional requirements and improves their quality of life.
How will the priority be achieved?
We are investing in our catering department in order to expand our service to patients.
Primarily this will mean that an improved, wider selection of the daily lunch menu will be
offered to each inpatient and will be served by a member of the clinical staff in a portion size
that meets the patient’s requirements. This will enable clinical staff to monitor the
nutritional levels of their patients and, with the purchase of a heated serving trolley, has the
benefit of allowing the patient to see and smell the lunch items rather than having to order
in advance and thus retaining real choice. Breakfast and Dinner will also be selected from
improved menus in the patient’s bedroom.
Within the new inpatient bedrooms, there is provision for the patient to sit at a small dining
table to eat their meals, with space enough for one or two family members to join them.
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This facility provides privacy and replaces the need for the patient to eat their meals in their
bed.
There will are also be an additional two places where the patient can eat. Firstly in the new
severy/dining area in the hub of the main building which is a busy, light and airy space where
day service patients, visitors and staff also eat or, if they wish more privacy and less hustle
and bustle, in a smaller dining area within the inpatient unit. This is providing choice and a
change of scenery for the patient as well as the possibility of social interaction with other
patients, their families or staff.
Secondly, the provision of the servery counter will also improve the experience of the day
service patients, visitors and staff attending the Hospice. Whereas previously they had to
order their lunch, at least an hour in advance from a limited list of meals and only had access
to food during the hours of 12-1.30pm, they will be able to choose and help themselves to a
variety of lunchtime main meals as well as ordering and purchasing snacks from 8.30-5pm.
Once we have established the service during these hours the aim will be to extend these
hours further into the evening to increase the provision.
How will progress be monitored and reported?
Progress will be monitored by the following:
 Feedback from patients and their family, carers or visitors
 Increase in the number of meals provided
 Development of a wide choice of available meals on the menu
 Increase in number of visitors, including members of the public, linking in directly
with the next priority.
3.2b Raise the awareness of Hospice services to improve the understanding of
and access to care for people nearing the end of their life and to increase the
engagement to support the sustainability of hospice services
How was this identified as a priority?
Help the Hospices has described hospice care as ‘community engaged palliative and end of
life care in all settings for patients, families and carers.’ The Commission into the Future of
Hospice Care 2013 endorses this definition, recognising the distinctive nature of the
connection that hospices have with their local communities to shape, fund and deliver its
care.
It was reported through the Commission that people want better access to information and
more help to enable them to use this information to inform their decisions about care at
the end of life. They feel this would help them take greater control of their situation and
they believed that hospices could do more to help with this. Although importantly, their
request for more information was not limited to just choices about care, but also extending
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to wanting to know more about giving to the hospice and volunteering to help with its
work.
Due to the negative perception of hospices, one challenge we experience is informing
potential patients, their family and carers, professionals and members of the public about the
care and support, provided by the hospice, and encouraging patients nearing the end of their
life and their family and carers to access these hospice services. Another challenge we
experience with the limited public engagement is the on-going struggle to raise sufficient
support to deliver these services.
How will the priority be achieved?
Improved Public engagement
During a recent consultation with a national company we have engaged to advise the
organisation on rebranding, it became clear that the messages and language we use are
contributing to the negative views of the reality of what hospices actually do.
Our aspirations for the future are to market the refreshed brand both locally and
throughout the wider catchment area. All publicity and supporting material throughout the
hospice will be written to reaffirm the positivity which is at the heart of all the hospice does.
As an organisation we rely on charitable funding for 88% of our running costs and as such a
consistent message needs to be disseminated to all our stakeholders, which includes patients
and their families.
Improved collaboration between the Income Generation Team and Clinical Teams
It is increasingly difficult to generate income, and we have protected our patients and their
families from the realities of the cost of the care we provide free of charge. As such, the
very people and their families who may wish to contribute if they are financially able have no
understanding of the cost of care. This ethos has been at the heart of the hospice
movement ethically to ensure those who cannot afford to contribute do not feel
compromised. However with increasing financial support made available to individuals to
cover the cost of care this is something we need to address.
The Income Generation & Marketing team are working with the clinical multidisciplinary
team to roll out “Tribute Funds” to encourage families to raise money year on year in
memory of someone who was cared for at the hospice. This year we aim to recruit 10
families and aspire to raise £50,000.
As a wider team, we are also developing a process whereby we achieve consent to mail
patients and their family and carers, to ensure they have the opportunity to support the
work of the hospice if they wish to.
Fundraising and marketing information will be displayed throughout the hospice to
encourage involvement by patients, their families and visitors.
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Developing new funding streams
Over the forthcoming year we are looking to explore the possibility of a formal partnership
with a local undertaker. This, we believe, will not only provide a better service for families
by supporting them in the immediate period after the death of their loved one but will
generate additional income for the sustainability of hospice services
How will progress be monitored and reported?
Progress will be monitored by the following:
 The increase in engagement and support from individuals and organisations both in
North East Lincolnshire and in the wider catchment area we serve for children’s
services
 Analysing the success of the Tribute Funds as well as increased donations and
patient/family involvement in events organised by the hospice.
3.3
Priority 2:
Clinical Effectiveness
3.3a
Develop and implement a locality wide integrated assessment tool for
palliative and end of life care patients
How was this identified as a priority?
Hospices are not the only providers of palliative and end of life care. Within North East
Lincolnshire, we work as part of a formal partnership with other palliative care service
providers of Care Plus Group, Macmillan and Marie Curie and alongside other core services
to augment our own skills and services to meet the needs of people in our care. We can
learn much from our colleagues in other specialities and can provide more holistic and
seamless care when we work closely together to support individuals with multiple needs.
There are also challenges when services work together and one identified through a recent
video published by NHS England was patients’ having to unnecessarily repeat themselves
every time a new team or service becomes involved with their care. By developing and
implementing an integrated assessment tool, accessed electronically through a coordinated
care system, we should be better able to deliver fast access to services, effective treatment
options, respect for the patient’s preferences, support for continuing self-care and the
appropriate level of involvement of family and carers. We should also prevent duplication,
providing more efficient services.
How will the priority be achieved?
Care Plus Group has recently introduced an integrated assessment tool for use by their
health and social care community services, including community nursing, rapid response
intermediate care at home and palliative care teams. Working with these services, the
Partnership aims to adapt this tool to facilitate widening its use to effectively assess the
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holistic needs of palliative care patients. It is envisaged the patient’s assessment will be
accessed by all services to improve communication and data quality, reduce repetition of
assessment and effectively inform of the preferences and care needs of the patient including
advanced care planning.
How will progress be monitored and reported?
Progress will be monitored by the following:
 Successful adaption of the existing tool to effectively assess the palliative care needs
of patients
 Improved feedback from the patients in relation to their experience of assessment
and accessing services
 Improved communication between services caring for palliative care patients, by the
effective completion of the assessment tool
3.3b Continue to develop Day Therapy Services within both Adult and
Children’s Services to ensure that they support the needs of patients and
their families
How was this identified as a priority?
This objective was identified as a priority last year and the development work is on-going, as
discussed earlier.
How will the priority be achieved?
The review into current adult day services will continue, with the development of a wide
‘menu’ of therapeutic group work and sessions for patients and carers to access delivered
not only by Hospice staff but also utilising the skills from within the partnership. Other
approaches will be explored, for example, an appointment system or an option to book
onto this group work. This will be trialled before being finally implemented into the service.
Patient, carers, staff and volunteers will continue to shape services through the working
group and will also be part of the formal evaluation following implementation of the new
model.
Within Children’s Services it is proposed to fully evaluate day services provided through
feedback from children and young people accessing the services as well as their parents.
This feedback will help develop services further to meet the individualised needs of these
patients.
How will progress be monitored and reported?
Progress will be monitored by the following:
 Increase in number of referrals to both adult and children’s day services
 Increase in attendance to both day services
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3.3c
Development and implementation of a ‘menu’ of services and activities to be
provided to patients and their families within both Adult and Children’s Services
Feedback from adults and children accessing services
To improve the quality and methods of collecting data to inform quality,
efficiencies and productivity
How was this identified as a priority?
Year on year we are facing the increasing challenge of collecting data to assist with the
reporting of activity, performance and quality through the lack of development in our
systems and processes to support this data collection. Historically data was, and in some
areas still is, collected by a nurse or a therapist counting patient and carer activity from a
number of sources and working out the final results on a calculator. Not only is this time
consuming, but poses a real challenge to the quality of the data being submitted.
We are now recording patients care and carers support through the use of StystmOne, as
well as booking patients in for inpatient care, day therapy and outpatient appointments. We
are aware this system can support us far more, especially in relation to the collection of
data, but time and knowledge are preventing this development.
How will the priority be achieved?
We have successfully sourced support from our partnership organisation, Care Plus Group,
to review the data we are collecting, the processes and quality of our data collection and to
assist in the improvement of these processes with the use of the systems we have in place.
Through this review we will highlight what areas of our service we are actually reporting on,
agree what data we need to report and identify gaps in our data collection, in order to
successfully submit required reports, as well as utilise our data further to assess quality and
productivity to improve and develop patient care and services.
How will progress be monitored and reported?
Progress will be monitored by the following:
 Full review of what data is being collected, what data is required: identifying any
areas not being reported on
 Implementation of processes to improve the collection of data
 Decrease in time spent collecting data
 Increased confidence in the reliability of the data being produced
3.4
Priority 3:
Patient Safety
3.4a
Ensure the premises are fit for purpose and offer a therapeutic
environment to deliver a high standard of care to patients and their
families
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How was this identified as a priority?
This objective was identified as a priority last year and the redevelopment work is on-going
with phase two.
How will the priority be achieved?
Phase II of the redevelopment, a Health and Wellbeing unit, has commenced with a
completion date of November 2015. This area is designed as a spa-like environment with
therapy rooms for complementary therapy and lymphoedema services, a gym and
hydrotherapy swim spa for physiotherapy, rehabilitative exercise and other fun activities and
a hair dressing and nail room. The existing Serenity Room is also being relocated to the rear
garden of the Health and Wellbeing unit. This garden room is a quiet space to promote
peace, tranquillity and an opportunity for reflection, away from the hustle and bustle of the
main hospice buildings. There will also be meeting rooms and conference facilities on the
first floor to meet our own needs, as well as those of the local community.
Patients, their families and carers, staff and volunteers will be involved in the colour and
design of the rooms, and the furniture and equipment to be purchased.
How will progress be monitored and reported?
Progress will be monitored by the following:



Successful completion of phase II
Smooth relocation of services from the existing building to the Health and Wellbeing
Unit
Feedback from patients, their families and carers, staff and volunteers
16
Part 4:
4.1
Statements of Assurance from the Board of Directors
Reviews by the Care Quality Commission
St Andrew’s Hospice is required to register with the Care Quality Commission (CQC) and
is currently registered to undertake the following regulated activities:



Treatment of disease, disorder or injury
Diagnostic and screening procedures
Transport services, triage and medical advice provided remotely
The Regulated Activity may only be carried out in the following location:
St Andrew’s Hospice, Peaks Lane, Grimsby, North East Lincolnshire, DN32 9RP
The CQC has not taken any enforcement action against St Andrew’s Hospice during 20142015.
St Andrew’s Hospice has not participated in any special reviews or investigations by the
CQC during 2014-2015.
St Andrew’s Hospice, Adult and Children’s Services, received an unannounced inspection by
the CQC on 17th & 18th March 2015. The Hospice was reviewed against the five key
questions asked of all services:
 Are they safe?
 Are they effective?
 Are they caring?
 Are they responsive to people's needs?
 Are they well-led?
St Andrew’s Hospice was given an overall rating of good and no sanctions or requirements
were made by the CQC following the inspection.
17
“People told us they felt safe in the service, they were well looked after and there was enough
staff to support them. Comments included, “Generally they are straight down when you ring
the bell”, “Yes, I feel safe; I’ve had no falls in here”, “They couldn’t do anything better”, and
“Yes, the staff look after me.”."(Care Quality Commission Report 2015)
“People told us they were happy with the care and treatment they received. They also said
they enjoyed the meals provided. Comments included, “Medical staff are fabulous and so
helpful and responsive to my requirements”, “The doctors come around and they know what I
want”, “The nursing and care staff are wonderful and they often call in to see me for a chat
and to make sure that everything is alright for me”, “The food is wonderful and presented just
how I like it”, “The food is very good; they fetch a sheet daily and you put down want you
want; there is plenty to eat and drink” and “They put a jug of fresh water there every day.”
We spoke with one older child in-patient who told us they were very happy with the nursing
staff and confirmed they looked after him well. They said, “They (staff) always give me my
favourite food, chips, and they are very good.” (Care Quality Commission Report 2015)
“People told us staff provided person-centred care. They also said there were activities and
therapies for them to take up if they wished. People knew how to make a complaint and
confirmed they felt able to raise concerns if required. Comments included, “I have a special bed
and mattress to stop me from getting sore”, “They keep a record of what I drink and what
passes through”, “I have no complaints whatsoever but if I had I’m sure it would be dealt with”
4.2
National
Minimum
(MDS)
figures
and “There
are things
to do but Data
I preferSet
to sit
and watch
television; my family visit most days. I
can’t think of anything they could do better.” One person described how they had been given a
high risk pendant to wear around their neck in case of falls so they can alert staff when
required but remain independent." (Care Quality Commission Report 2015)
4.2 National Data Comparisons
We have chosen to present information from the National Council for Palliative Care
(NCPC): Minimum Data Sets (MDS) which is the only information collected nationally on
adult hospice activity, with 149 hospices participating. The completed reports are published
eight to ten months following the submission of the data, which explains why the figures
appear to report on a year behind. The figures below provide information on the activity
and outcomes of care of patients and bereaved family/carers.
Based on our return we have been included in the small unit category for inpatients and day
therapy services (fewer than 11 beds/fewer than 111 patients), medium unit category for
bereavement support (between 114 to 262 service users) and outpatients classified as a
large unit (more than 316 patients).
18
Adult Inpatient Unit
Adult In Patient Services
2012-2013
Small unit – fewer than 11
beds
St Andrew’s
National
Hospice
Median
Total number of patients
% New patients
% Re-referred patients
% Occupancy
Average length of stay (nights)
% Inpatient stays ending in
discharge
% Patients aged 25-64yrs
% Patients over 84yrs
% Patients with non-cancer
diagnosis
2013-2014
Small unit – fewer than 11
beds
St Andrew’s
National
Hospice
Median
147
78.2%
18.3%
78.4%
16.6
62.7%
166
89.0%
7.8%
76.2%
11.15
49.8%
174
82.8%
13.8%
74.0%
17
58.9%
171
90.3%
5.8%
78.8%
17.8
48.2%
32.2%
12.2%
19.0%
30%
12.1%
8.3%
29.3%
12.1%
19.5%
30.1%
11.7%
11.0%
The number of In Patient stays ending in discharge continues to be much higher than the
national average, albeit slightly lower than the previous year, with nearly 59% of admissions
ending in discharge. This could be due to the provision of respite and having a proactive
approach to discharge planning.
The occupancy has reduced slightly from the previous year and has moved below the
national average. With only eight beds, there are variations in our occupancy where we can
be fully occupied one day and following death or discharge have available beds the next.
However we find once we have informed a professional that we have no available beds, they
don’t referrer for a number of days/weeks, even with plenty of encouragement and
explanation. Also having identified beds for respite care can be difficult when managing
occupancy, as we don’t have as much flexibility/availability with the current number of beds.
It is hoped with four additional beds that we will be able to improve the management of the
variation in occupancy.
The number of patients with a non-cancer diagnosis has risen slightly for 2013-14, remaining
significantly above the national average.
Adult Day Therapy Unit
Adult Day Therapy
2012-2013
Small unit – fewer than 111
patients
St Andrew’s
National
Hospice
Median
Total patients accessing
% New patients
% Patients aged 25-64yrs
105
50.5%
24.5%
83
61.7%
25.4%
19
2013-2014
Medium unit – between 112 180 patients
St Andrew’s
National
Hospice
Median
118
31.4%
28.8%
144
63%
26.9%
% Patients over 84yrs
Day therapy attendances
% Places used
% Patients with non-cancer
diagnosis
7.5%
1915
78.6%
17%
11.1%
1010
56.9%
19.1%
6.8%
1585
64.1%
29.7%
12.4%
1614
54.4%
25%
Due to the slight increase in the number of patients accessing Day Therapy, we have been
included within the category for Medium Unit for 2013-14, albeit the number of attendances
has fallen from the previous year. As previously identified, we are currently reviewing Day
Therapy provision as feedback has identified we are not meeting the needs of all patients,
and also in response to the down turn in the number of patients attending the service.
There continues to be a fall in numbers of patients over the age of 84 years accessing Day
Therapy. This could be due to the model of care currently provided, the length of the day
and the reduction in transport available. Through the Day Therapy review, we are also
reviewing the wider provision of transport as well as offering more groups/appointment
based attendances.
Similar to the Inpatient Unit, we have identified an increase in patients attending with a noncancer diagnosis. Through the Day Therapy review, we are also looking at how we can
better support patients with longer term neurological conditions and Dementia.
Adult Outpatients
Adult Outpatients
2012-2013
Large unit – more than 316
patients
St Andrew’s
National
Hospice
Median
Total patients accessing
% New patients
% Patients aged 25-64yrs
% Patients over 84yrs
Outpatient clinic attendances
Attendances per patient
% patients with non-cancer
diagnosis
355
34.6%
52.0%
6.5%
1367
3.9
16.3%
513
39.9%
40.3%
8.0%
1202
1.9
14.9%
2013-2014
Large unit – more than 316
patients
St Andrew’s
National
Hospice
Median
358
36.0%
49.4%
3.9%
1271
3.6
15.4%
632
42.5%
43.6%
7.5%
1570
2.4
19.8%
Again, as a hospice we only just fit within the large category due to the number of patients
attending for outpatients appointments, whereas for all other departments/categories we
are classed as a small/medium unit, so for this aspect of the MDS we are compared against
much larger organisations than ours.
Through the redevelopment and Day Therapy review, we are looking into the possibility of
providing more outpatient clinics with palliative care professionals and also assessing the
20
feasibility of relocating some of the outpatients clinics from the local acute trust to utilise
the new facilities, preventing patients having to attend hospital for these appointments
Bereavement Support
Bereavement Support
2012-2013
Small unit – fewer than 114
service users
St Andrew’s
National
Hospice
Median
Total people accessing
% New people
% People aged 25-64yrs
% People aged 65-84yrs
% Patients over 84yrs
Total contacts
% contacts group sessions
% deceased patients with noncancer diagnosis
95
56.8%
40.7%
24.1%
0.0%
512
39.3%
38.9%
70
69.1%
48%
23.1%
1.6%
366
10.7%
9.3%
2013-2014
medium unit – between 114
to 262 service users
St Andrew’s
National
Hospice
Median
159
60.4%
47.2%
27.0%
1.9%
356
44.4%
28.3%
159
70.8%
54.1%
23.8%
1.0%
1092
6.9%
8.5%
We have continued to see an increase in the number of people accessing the bereavement
support service. This is due to the implementation of a formal case management approach
which includes a level of provision for all family members and carers.
Even though we have seen a marked fall in the total contacts there continued to be an
increase in the percentage of contacts via group sessions, which remains significantly higher
than the national average. This may be due to us now giving family members the
opportunity of declining a follow up contact and empowering them to contact us when they
need support. Following feedback on this approach and the request for more group
sessions, we have seen a continual growth in the attendance at group sessions.
It is disappointing to note again even though there has been a slight increase, both as an
individual hospice and the national average there are so few people over the age of 84
accessing bereavement support services. This may be due to a generational view, the
difficulty in accessing services, the cultural expectation that they don’t need support or that
our current services don’t meet the needs of this group of society.
Data comparison for Children’s Services
It is disappointing to report that there has been no national data collected for children’s
hospice services, similar to the MDS for adult hospices, for a number of years. It is therefore
a challenge to benchmark against other children’s hospices in relation to activity and service
provision. For the purpose of this report, a comparison will be made between the previous
21
three years of activity data for St Andrew’s Children’s Hospice, identifying improvements or
challenges faced.
Children & Young Persons Services
2012-2013
2013-2014
Number of children
supporting
% of children aged below
2 years
% of children aged above
16 years
2014-2015
85
101
81
6%
8%
4%
26%
27%
23%
Total bed nights available
1005
1448
1427
% Occupancy of Beds
92%
99%
95%
Total number of
admissions
311
409
440
% Occupancy of Day Care
75%
64%
79%
5 children / 53
nights
5 children / 31
nights
4 children / 29
nights
Special Room usage
(number of children/
number of nights)
There has been a notable fall in the number of children we are supporting. This is due to a
number of reasons from a fall in referrals, to the number of children we have reviewed and
subsequently discharged – including those who have reached the age of 25 years. As
identified within the priorities for this year, we are also finding some quality issues in the
data we have/are collecting and on reflection we have identified statistical errors associated
with this data.
There has been a slight fall in the number of beds available due to the building of the new
hospice building. Also as part of this redevelopment the family rooms and special bedroom
were unavailable for most of the year. One room was closed for the family of a diseased
child, who indicated they wanted to stay, but in fact went home. The room was closed in
case they changed their minds and wanted to return and stay.
On commencing the review of Day Care Services, it is pleasing to see the increase in
occupancy for this year. Looking at data for the early part of 2015-16 it is anticipated this
figure will continue to increase in next year’s report.
4.3
Review of Services
All providers must include the following statements in their Quality Accounts. Many of these
statements are not directly applicable to specialist palliative care providers and therefore,
where appropriate, further explanation of the meaning of certain statements is provided.
22
During 2014-2015, St Andrew’s Hospice supported North East Lincolnshire Clinical
Commissioning Group’s commissioning priorities with regard to the provision of specialist
palliative care. The following services were provided:










Adult, Children’s & Young People’s In Patient Units
Adult, Children’s & Young People’s Day Therapy
Lymphoedema
Physiotherapy
Complementary Therapies
Creative Therapy
Pre and Post Bereavement Support/Counselling
Patient Forum
Carer’s Group
Out of hours advice line for professionals
All of the above are supported by a multi-professional team employed by the Hospice.
The income generated by the NHS services provided by St Andrew’s Hospice and reviewed
in 2014-2015 represents 100% of the total income generated from the provision of NHS
services by St Andrew’s Hospice for the reporting period 2013-2014.
What this means:
St Andrew’s Hospice is currently funded through an NHS grant and fundraising activity. The grant
allocated by North East Lincolnshire Clinical Commissioning Group represents approximately 10% of
3.2
Participation in Clinical Audits, National Confidential Enquiries
the Hospice’s total income. The remaining income is generated through fundraising, public
donations,
shops, lotteryinactivity
andAudits,
investments.
The level
of the NHS grant
means that
all services
3.4
Participation
Clinical
National
Confidential
Enquiries
and
delivered
by the Hospice are substantially funded from charitable funds with the NHS funding a small
Research
proportion of the current services provided.
4.4
Participation in Clinical Audits, National Confidential Enquiries and
Research
During 2014-2015 there were no clinical audits or national confidential enquiries covering
NHS services relating to palliative care. St Andrew’s Hospice only provides palliative care,
therefore were ineligible to participate.
During 2014-2015, St Andrew’s Hospice did not directly participate in any research studies.
Following the appointment of a Professional Development and Quality Lead a review was
undertaken in relation to the Hospice’s Audit agenda, including the staff’s understanding of
audit and how they perceived it related to their roles. It was clear the knowledge base
varied significantly throughout the organisation, not only between clinical and non-clinical
23
departments but also within the teams themselves, dependant on the staff member’s
knowledge and previous experiences of audit.
Through discussion, the Senior Management Strategy Team (SMST) agreed to suspend the
current audit programme and developed a new approach and process which included the
introduction of Hospice-wide mandatory audit training. To enable all staff to understand the
importance of this process and what the Hospice aimed to achieve from it, it was re-named
Quality Improvement and Monitoring.
Following the completion of this training a new programme of audits has been developed,
led by nominated representatives within all departments, and will be monitored through the
SMST. A summary of this will be included within 2016-2017 Quality Accounts.
4.5
Quality Markers – What we have chosen to measure
Accidents 2014-2015
The number of trips and falls within an Adult Hospice/Palliative Care Unit is 5.7-6.2 falls per
occupied bed per year (Goodridge, 2002; Pearse, 2004), therefore the range is 45.1-49 falls
within the Hospice for 2014-2015.
Accidents
Trips & Falls
2012-2013
46
2013-2014
33
2014-15
25
In 2014-2015 one patient accident was reportable to HSE under RIDDOR.
Patients are assessed using a falls risk assessment tool to identify any potential risks and
action is taken to ensure that patients are safe whilst in our care. Clinical staff receive
training in identifying how to manage patients who are at risk of falling, including recognising
indicators and triggers which can affect a patient’s balance. We are really pleased with the
continued reduction in falls.
Within St Andrew’s Hospice we support our patients to continue to be as independent as
their illness allows. Although many of our patients are weak and vulnerable the majority
wish to retain their independence for as long as is possible. This however increases the risk
of accidents occurring. Our philosophy is to support patients while allowing them the
freedom to move around the Hospice.
Patient Safety Incidents
Indicator
No of Patients
admitted to the Inpatient Unit with
2012-2013
2013-2014
Patient Safety Incidents
22
34
24
2014-15
22
pressure damage
No of Patients who
developed pressure
damage whilst in the
In-patient Unit
No of medication
errors
No of Significant
Events
15
12
8
25
30
34
14
18
13
of which 2 were positive
events
of which 1 was a
positive events
No of Complaints
No of Clinical Complaints
No of Non-clinical
Complaints
2012-2013
2
8
2013-2014
1
10
2014-15
1
2
The Hospice receives many letters and cards of thanks. The number of compliments far
outweighs the number of complaints.
The Chief Executive and Senior Management Team are accessible via email and contact
details are available on the Hospice website, making the Hospice Management Team
accessible to everyone.
4.6
What Others Say About St Andrew’s Hospice
What our Staff Say
From our recent CQC inspection our staff said:
“I love working at the hospice; it is a breath of fresh air and has a lovely, calm atmosphere”,
and “There is time to speak to the patients.”
“I feel very supported by management; there are on call arrangements to support staff”,
“There is a good training available for staff”, “You can raise concerns and they would be
addressed”, “I feel the structure of management would deal with issues”, “We are able to
challenge each other”, and “There is good team work approach.”
Following previous involvement with the Help the Hospices/Birdsong Hospice Staff Survey a
further in-house survey was undertaken which provided a deeper understanding into the
two sections which fell below our benchmark of 70%. These were staff morale and work life
balance, and development and reward. This enabled us to develop a number of new
initiatives including:
25



a new Contribution and Development Review framework. (CDR) process of which
we are launching this year
introduction of flexible benefits
development of a staff support and wellbeing policy
We will also be participating, as planned in the Birdsong Hospice Staff Survey in 2016.
Levels of engagement are very important to the Hospice as a high level of staff
engagement/satisfaction results in high standards of patient care, reduced absenteeism and
organisational effectiveness.
Employees Whom
Tendered Resignation
Staff Absence (excluding
bereavement/carer leave)
2012-2013
12.6%
2013-2014
12.3%
2014-2015
15.85%
3.03%
2.39%
3.92%
2014-2015 showed a substantial increase in long term absence and this equates for in excess
of 60% of all absences.
4.7
What others say about St Andrew’s Hospice
Feedback from patients, family, carers and supporters:
Cash For Kids: “Great meeting with @HelpStAndrews doing fantastic work and we cannot wait
to work together.”
“Nine five-star Facebook ratings”
[Name] gave the hospice a 5-star rating and commented: “Amazing place cared for my son for a
number of years in children's unit then went on to use adult unit they cared for my son in his final
days with such care and dignity can never thank them enough a place I will always support it will
always be close my heart.”
(Comments from Social Media)
“Staff always polite and helpful. Plenty to choose from and plenty of sizes.”
“Great organisation – well done. Great shop very polite.”
“Lovely shop, excellent display and good counter display!”
“Had great time trying dresses. Had good help, no fantastic help. Brought two dresses for
wedding. Will tell everyone about here. Staff second to none.”
(Comments from Retail comments books)
“An inspirational, interesting and informed visit. Thank you.”
“Thank you for the loving care shown to mum [Name] whilst in for her weeks respite. She
especially loves her baths. You shouldn’t change a thing, you are all doing a fantastic job – keep
up the good work. Thank you!!”
(Comments from Reception Comments Book) 26
“Sorry it has taken a few weeks for me to put pen to paper but this isn’t as easy as I had
anticipated. Where do you find the right words to say how much we appreciate the Hospice and
what it meant to mum and our family? The care and support given to our lovely mum, [Name],
and my brother, myself and our respective families is, and has been, second to none. Would you
please pass on our sincere thanks to all the doctors, nurses, carers and all staff involved over the
years and especially towards the end. We know that mum is now in a good place, at peace and
together with dad but whilst she was still here you all made her illness bearable and she always
had hope. On behalf of us all, my heartfelt thanks [Name]”.
(Comments from Thank You cards)
“To everyone, we would like to thank everyone at the Hospice for all the kindness shown to our
lovely daughter, sister and wife [Name]. You all made a very sad and distressing time easier for
us and gave [Name] dignity and peace. Thank you so much [Names]”.
(Comments from Thank You cards)
St Andrew’s Hospice values the feedback it receives from patients, their families and carers,
as this is an important way in which the organisation can identify issues, resolve problems
and improve the quality of the care we provide.
Feedback is gathered in a number of different ways. Questionnaires are sent out following
access to services, information on complaints, letters of thanks, and comments in feedback
books within the clinical and communal areas are collated, comments from social media
postings and verbal conversations are also gathered and feedback is also collected through a
volunteer specifically appointed for this role. The results from all of the above are all
reported and analysed through Hospice Governance.
Results from the Inpatient and Day Unit patient questionnaires indicate that overall patients
utilising both of these services were satisfied with their care. The process for admission,
and discharge including the information received before and during their stays all rated
highly with an average of 90% being satisfied with the above. Patients who had attended Day
services prior to an inpatient stay indicated that they felt more prepared.
We offer bereavement support to relatives/carers of patients who have accessed services
from the Hospice. Views are sought from those who have accessed this support on the
care and services received by the patient in the last months of their loved one’s life. The
survey also looks at the care the Hospice provided to family and friends. The results from
the survey undertaken in 2014/2015 show that the patient’s privacy and dignity were
respected at all times and that 81% of the family/carers felt strongly that they were kept
informed throughout the patients time at the hospice and that everything was explained in a
language they understood.
We host TREE group (patient and carer involvement) meetings 3 times a year for
patients/families and carers as we believe it is important to include patients/families and
carers in the development of services at the Hospice. As the hospice has been undergoing a
27
large redevelopment project, patients/families and carers have been instrumental in shaping
this work by attending workshops and visiting other hospices to bring ideas back which has
helped inform some of the changes made. The second phase is now underway and again
there will be engagement with the service user group.
Part 5:
5.1
Supporting Statements
Statement from North East Lincolnshire Clinical Commissioning Group
St Andrews Hospice continues to build on its partnership with other agencies in the delivery
of the North East Lincolnshire End of Life Care strategy. It moves towards an integrated
Palliative and End of Life care provision with the other majority provider Care Plus Group
and has spent the last year working cohesively with providers and commissioners, in our
“shift to the left” moving services from Acute environments to the community, this has
been underpinned by the wonderful redevelopment which has enabled not only more
Integrated Care Provision to be offered to People with a life limiting condition but with the
current refocus of the utilisation of the inpatient unit, will provide an alternative
environment for people away from Hospital care.
The CCG remain committed to supporting St Andrews Hospice as a key provider within
North East Lincolnshire and thank them for their contribution to the health and wellbeing of
the residents of North East Lincolnshire.
5.2
Statement from St Andrew’s Hospice Patient Representatives
The identified priorities for 2015-2016 have been discussed with a representation of
patients attending St Andrew’s Hospice. All patients agreed with the identified priorities and
there was a lot of discussion around how they all interlinked to underpin the wider
development of the partnership working. There was an interest in the on-going changes to
Day Therapy and also the integrated assessment tool.
28