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Introduction
As Chair of Trustees of St Catherine’s Hospice, it gives me great pleasure to introduce this
year's Quality Account.
This has been my first full year as Chair and it has been a year of significant change at St
Catherine's Hospice, with the appointment of a new Chief Executive, Giles Tomsett and
Director of Care Services, Penny Jones.
St Catherine's Hospice has always enjoyed an excellent reputation locally as a provider of
high quality end of life care services and we continue to seek to strengthen our reach and
range of services building on our mission to lead the community in support of all those facing
death and bereavement. Like many other organisations however, while we receive fantastic
affirmation from our patients and their families about our care, we know that we can do more
to truly provide assurance that ALL facets of our service and our support arrangements are
genuinely patient-centred and fully grounded in enabling us to be the organisation that we
aspire to be. To make this more robust, we have made a significant investment into
demonstrating our commitment to quality 'from ward to board' this year.
This has included a comprehensive review of governance across the organisation, and the
setting up of four new board committees to scrutinise various aspects from clinical quality
and safety to resources, remuneration and board development. At the same time, I am
delighted to report that the Senior Management Team has made a commitment to introduce
a hospice wide, externally accredited Quality Management System and has appointed a
Quality and Information Manager to co-ordinate the quality agenda across all aspects of the
hospice.
Significant progress has been made with respect to gathering feedback from staff and
service users in a more systematic way, and using this to inform plans and service design. It
was fantastic for the Board of Trustees to hear the 'patient voice' when the new Service User
Engagement Coordinator fed back the initial results of our new Friends and Family Test. I
am also delighted to report that St Catherine's Hospice maintained its status as an Investors
in People accredited organisation following external re-assessment in March. We look
forward to much more in 2015-16 and in strengthening the role of our over 800 volunteers
who underpin what we do each and every day.
It is down to the dedication of our staff and volunteers that we ensure our patients and their
families get the best care that they deserve at this difficult time and we are continuing to
invest in building their skills to strive constantly for excellence.
This report is a reflection of the journey we are on to provide more and deeper evidence that
the experiences of patients and their families are the best they can be. We are committed to
continuous improvement and the steps we have taken this year reflect the feedback from
patients and their families who are at the centre of everything we do.
I hope the information presented in the Quality Account gives you a sense of the
organisation and its dedication to its role in end of life care.
Simon Turpitt
Chair of Trustees
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Part One - Report on 2014/15 Improvements
We identified a number of quality improvements to achieve in 2014/15. Here we report on
the progress we have made in these areas.
Introduction of new governance structures, processes and controls
Following a comprehensive review involving trustees and the leadership team, a new
governance structure for the Hospice has been established. Four new board groups have
been set up including one that has specific responsibility for scrutinising quality. This is
supported by a Quality & Safety Committee, which has a membership of trustees and staff.
This committee is responsible for developing and delivering an integrated quality, safety and
risk management programme for the whole organisation, and for providing assurance to the
Board that high standards of care are provided by the hospice at all times.
The following groups have been set up as part of the new governance framework, and report
monthly to the Quality & Safety Committee in order to provide pan hospice reporting on all
quality matters:
Information Governance Group - to ensure the Hospice has effective policies and
management arrangements covering all aspects of Information Governance in line with
current legislation, NHS guidance and professional codes of practice
Clinical Leads Group - to advance clinical practice and ensure a consistent approach to
clinical care and management across all Hospice services
Medicines Management Group - to ensure that medicines are managed safely, securely and
cost-effectively, and in accordance with legal requirements, local guidance and best practice
Health & Safety Group - to establish and maintain standards of health, safety and welfare in
keeping with legal requirements and in accordance with the organisation policy
Research Group - to enable and promote the Hospice to be a 'research active hospice',
ensuring any research undertaken is in line with best practice, and promotes evidencebased practice in all clinical services.
Clinical Audit Group - to inspire, motivate and support staff to participate in clinical audit,
contributing to improved patient safety and clinical effectiveness.
Learning & Development Group - to ensure the Hospice identifies and meets the learning
and development needs of staff, to create and maintain a skilled and effective workforce.
Specific quality initiatives that have been undertaken this year include:


the development and roll out of a comprehensive pan-organisation complaints policy
and procedure, that ensures all complaints and concerns are handled in a prompt,
professional and consistent manner; and that learning from these events are shared
and used to identify and embed improvements.
the introduction of a web-based software application to improve management of
incidents.
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Implementation of 'Patient Led Assessment of Care Environment' assessments
This year we invited a team of assessors (which included service users) to carry out our first
PLACE assessment, a national initiative to evidence patients are treated with care,
compassion and dignity, in a clean and safe environment. The results showed that we meet
a good standard. There were a number of suggestions for further improvements which have
been actioned. We will be repeating the PLACE assessment in 2015 as part of our
commitment to continuous improvement and service user involvement.
Strengthening our involvement in research
Last year we recognised the need to establish a more formal research culture at St
Catherine's Hospice. During this year we have:
- established a research policy and procedures
- nominated a lead for research
- created a research nurse post
- participated in multiple research studies (eg SEED - Supporting Excellence in End of life
care in Dementia)
This is helping St Catherine's Hospice to follow best practice and ensure our care is
evidence-based.
Development of an outcomes and evidence framework
Following the development of a comprehensive set of outcomes for St Catherine's Hospice
in 2014,
we have started to use a range of measures and tools to enable us to define and assess the
quality and impact of our services. These include:
- VOICES questionnaire (to collect bereaved people's views on the quality of care provided
to a friend or relative at the end of life)
- Friends & Family Test (real time feedback on quality of services)
- Well-being Star (to define and assess progress against patients' own wellbeing goals).
Create new post of Quality & Information Manager
The Quality & Information Manager post was created in June 2014 and is a pan-hospice,
non-clinical role. So far, improvements have been implemented in complaints and incident
management, service user engagement, information governance, and in data management
and quality.
Implementation of a Hub
In May 2014 the pilot of a nurse lead Triage service commenced as the precursor to the
development of an integrated central service hub providing a single point of contact for all
incoming calls from patients, carers and healthcare professionals. The Triage service has
become well established and now over 2500 inbound calls are received each month. The
service is to be expanded in 2015 into a Care Co-ordination Centre and the range of
information, and advice services provided by telephone will also be reviewed in order to
provide more holistic care to a more diverse patient group including the frail elderly.
Hospice website re-design
Work is progressing on this project and the new website will offer more interactive
functionality and ensure better communication with all our stakeholders. We have extended
the timeframe for completion to 2015/16. This is to ensure the website supports our recent
service redesign and to allow for a coordinated launch with our new brand.
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Part Two - Priorities for Improvement 2015/16
St Catherine's Hospice is committed to the delivery of high quality care and has identified an
ambitious programme of work during 2015/16 to deliver improvements across all areas of
the Hospice. Driving this will be the development of a pan hospice quality management
system.
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Part Three - Partnerships & Collaboration
At St Catherine's Hospice we recognise that integrated whole systems working is the best
way to deliver excellent care for patients. In 2014 we have built more effective relationships
through closer collaboration with a number of organisations locally and the following
examples illustrate this:
Our clinicians now work with palliative care colleagues at Surrey and Sussex Healthcare, our
local acute hospital in Redhill. This has improved co-ordination of care and lead to increased
opportunities for shared learning.
Our Education team co-ordinated a bid with other local hospices to provide compassion
training and were awarded the contract as preferred supplier by Health Education Kent,
Surrey and Sussex. So far sessions have been delivered to 1500 people and further training
will be provided in 2015.
Our Dementia Working Group has developed a range of relationships with local
organisations working to raise awareness and understanding of people with dementia and
was highlighted by the Alzheimer’s Society through their national awards. We are proud to
be members of the award winning Dementia Friendly Crawley initiative.
We continue to work closely with our Clinical Commissioning Groups and are grateful for the
support and collaboration they continue to offer St Catherine's Hospice:
- NHS Coastal West Sussex CCG
- NHS Crawley
- NHS East Surrey CCG
- NHS High Weald Lewes Havens CCG
- NHS Horsham and Mid Sussex CCG
- NHS Surrey Downs CCG
We have valued the opportunity to work more closely with other hospices in our region, both
to explore the potential for joint initiatives and to share and learn from each other's work.
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Part Four - Monitoring Activity
Figures submitted to the Minimum Dataset Project
Hospice figures:
2013/14
In-patient
Location before admission:
from home
from care home
from hospital - acute
from hospital - community
Average length of stay (all patients)
Completed stays - total discharged and deaths:
Location after end of stay:
died
home
care home
hospital acute
hospital - community
2014/15
260
3
123
1
13 days
387
244
8
115
4
14 days
371
249
110
23
4
1
234
108
25
2
1
Day Therapy:
new patients
total patients
.. of which cancer/malignant diagnosis
.. of which other diagnosis
138
197
166
31
167
235
187
48
Community:
new patients
total patients
.. of which cancer/malignant diagnosis
.. of which other diagnosis
Deaths:
at home
at care home
at hospice
at community hospital
at acute hospital
other
Length of care episode (ave)
1,199
1,827
1,424
399
1,080
368
292
216
13
188
3
162.8 days
1,248
1,837
1,376
456
1,117
329
366
200
27
185
10
159.4 days
Patient and Family Support Team:
total referrals
new assessments
total sessions delivered
731
532
2,540
7
701
485
3,074
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