St Elizabeth Hospice
Quality Account
2014 - 2015
‘I would like to express our sincere thanks for all the support you provided for our mother.
She really enjoyed her visits to the Hospice for reflexology from when she was first ill and
only had praise for the excellent facilities.
However, we really came to experience just how excellent the services you provide are once
my mother was in her last couple of months at home. It is hard to express to others the
difference it made having the daily help from the Hospice team as well as such kind and
experienced nurses at the end of the phone 24 hours a day. It helped my mum to feel well
looked after and it helped us as a family to care for her at home as she wished.’
Our last Care Quality Commission visit was in January 2014
We have had no visit during the period of this Quality Account
St Elizabeth Hospice
565 Foxhall Rd
Ipswich
Suffolk
IP3 8LX
www.stelizabethhospice.org.uk
Registered Charity Number: 289154
This Quality Account was endorsed by the St Elizabeth Hospice Board of Trustees on
5th March 2015
1
Framework for Quality Accounts
Quality Accounts aim to improve organisational accountability to the public and engage
boards in the quality improvements agenda for an organisation.
LEADS TO
Public accountability
Leadership engaged with improvement of
quality of services
There is a legal requirement under the Health Act 2009, for St Elizabeth Hospice, as a
provider of NHS services, to produce a Quality Account.
2
Contents Page
Page
Information about St Elizabeth Hospice
Front Cover
Part 1 –Statement on Quality
4
Our Purpose, Vision and Principles
4
Statement on quality on behalf of the Chief Executive
5
Part 2 – Priorities for improvement and statements of assurance
from the Board
6
2.1
Priorities for improvement 2015-2016
6
2.2
Priorities for improvement 2014-2015
11
2.3
Statement of Assurance from the Board of Trustees
14
2.3.1
Review of Services
14
2.3.2
Participation in National Clinical Audits
15
2.3.3
Participation in Local Audits
16
2.3.4
Research
17
2.3.5
Goals agreed with commissioners – use of the
CQUIN Payment Framework
17
2.3.6
What others say about St Elizabeth Hospice
17
2.3.7
Data Quality
2.3.7.1 Information Governance Toolkit Attainment
17
2.3.7.2 Clinical Coding Error Rate
17
Part 3 – Review of Quality Performance April 2014 - March 2015
3.1
18
Quality Overview
3.1.1
St Elizabeth Hospice governance policy statement
18
3.1.2
Quality Overview
20
3.2
Who has been involved?
23
3.3
Statements provided by Commissioning CCG, Healthwatch and OSCS
24
3
Part 1: Statement on Quality
Our Vision
“Improving life for people living with a progressive illness”
Objectives and Activities
To further develop the high quality specialist and palliative care we provide for the people of
Suffolk, Great Yarmouth, Waveney and surrounding areas.
Our statement of purpose is
St Elizabeth Hospice aims to improve life for people living with a progressive
illness by:

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

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Providing multi-disciplinary holistic specialist and dedicated palliative care services to
patients, their families and carers.
Working alongside other statutory and voluntary agencies to provide specialist and
dedicated palliative care, in a timely manner, where the patient wishes to be.
Acting as a resource to the local community regarding general and specialist
palliative care to increase confidence and competence in improving life for people
living with a progressive illness.
Providing care that respects the choices made by patients and their families so that
patients are treated in their preferred place and die in their place of choice where
possible.
Working towards equitable provision of all services, leading to increased use of
services by people with non-malignant progressive disease, and those from seldomheard communities.
Feb 2015
All of the above goals will be monitored through quantitative and qualitative data collection
and audit processes.
4
Statement on quality on behalf of the Chief Executive
I would like to thank all volunteers and staff for another wonderful year in which we provided
a responsive and high quality service to patients and their families of Suffolk, Great
Yarmouth, Waveney and surrounding areas.
Patient and family feedback, sought through surveys, comment cards, the Partnership Group
and our website, demonstrates high user satisfaction. We strive for a non-blame culture
which acknowledges the need to constantly improve and learn from episodes of care that
have not gone as well as wished for and put right any errors made. This year we have
increased our standards in the management of falls prevention, ensured staff receive the
training they need to perform their roles safely and efficiently and responded to staffing
issues, such as vacancies and absenteeism which can impact on patient care.
We have finished a large extension and refurbishment project on the Day Unit in Ipswich.
This will enable us to see more people and offer more services to our patients as the
demand for them rises over the coming years; in an environment which is fully suited to the
need of patients and that supports a rehabilitative model and promotes independence, which
in turns promotes a higher quality of life.
The Hospice has had a change in Chief Executive this last year. Jane Petit retired in May
2014 and Mark Millar joined as Acting Chief Executive in January 2015.
I can confirm that I am responsible for overseeing the preparation of this report and its
contents. To the best of my knowledge, the information reported in this Quality Account is
accurate and a fair representation of the quality of healthcare services provided by our
Hospice.
Verity Jolly,
Director of Patient Services and Registered Manager
5
Part 2 - Priorities for improvement and statements of assurance from the board
2.1 Priorities for improvement 2015-2016
Areas for improvement for 2015-16 are set out below.
They have been selected because of the impact they will have on patient safety, clinical
effectiveness and patient experience.
2.1.1 Patient Safety
Priority One
Electronic communication of medications and information on discharge
Recent audits and feedback has highlighted that some key information could be conveyed to
community or hospital teams more quickly and effectively.
A computerised method of producing both discharge letters and discharge medication
prescriptions will reduce these problems.
How this priority was decided
Recent audits and feedback from healthcare professionals has highlighted that some key
information on patients’ management and progress during an inpatient stay could be
conveyed to community or hospital teams more quickly and effectively. Minimum standards
for producing a discharge summary are generally met using information recorded on the
handwritten discharge medication prescription but it is felt that the ease of reading and
completeness of this could be improved on.
As discharge medication lists are handwritten, the information is not always as clear as it
could be for Pharmacy purposes or for recording medication lists for future review. This is
due to carbon copies being scanned to the iCare computer system. As discharge medication
is requested in a handwritten form, any alterations or adjustments are difficult to track and
can be time consuming.
A separate list of medication is routinely created by nursing staff for patient/relatives use.
This duplicates work and creates a risk of differences between the two versions of discharge
medication advice. A computerised method of producing both discharge letters and
discharge medication prescriptions (TTOs) and a clear protocol for their use will remove or
reduce these problems, improving communication with external professionals in addition to
optimising safety, effectiveness and efficiency.
The use of electronic prescribing systems for the Hospice was considered but: evidence
confirming its efficacy compared to risks for Hospices is limited; and the timescale for
investigation, procurement and implementation would be difficult to determine. As this will
take a considerable amount of time, progress on electronic prescribing will be reported in the
next Quality Account, if progress is made, but will need to be explored over the next few
years, depending on external factors and success of this priority.
How the priority will be achieved
A new Word based template for TTOs, incorporating drop down boxes of standardised
options has been produced and is currently being trialled. Feedback from Pharmacy,
Hospice staff and patients will be used to optimise this process.
6
A new electronic form for discharge letters using the Hospice patient records computer
system (iCare) will be produced and trialled. Clear written procedures for the production of
TTOs and discharge letters have been produced
How progress will be monitored and reported
An audit of ‘time to discharge letter’ will be repeated. Assessment of the new procedures
using feedback from Pharmacy, doctors, patients, and nurses will be collated by a Hospice
medical consultant and reviewed by the Medical Director.
The results of this process and the feedback will be overseen by the Quality, Improvement
and Assurance governance group, which reports to the Patient Services Committee.
Priority Two
The use of Hoists in the Inpatient Unit (IPU)
In the last refurbishment of the IPU, we installed an overhead hoist in each bay that could be
used for all four beds. Those now need to be replaced. We wish to ensure we purchase
replacements that are safe and comfortable and are easy to use for staff.
How was the Priority decided
The IPU has 18 beds, six of which are in single rooms and the rest in three, four bedded
bays. The bays are serviced with its own overhead hoist and each bay has one hoist to be
used across the four beds.
The biggest problem with the hoist currently being used is that it has to be moved around the
bay, so patients either wait or need to use a portable hoist, and this movement has led to
equipment failure, causing problems to both patients and nurses.
Therefore a decision has been made to replace the hoists, but a few at a time so that we can
try out the replacements and ensure we have the best equipment before committing to all
18, if we decide to have each bed serviced by its own hoist.
How the priority will be achieved
The range of hoists available has been researched and there is a plan to purchase a new
brand to try in a bay. This will replace the equipment that has needed repairing, and will not
be serviceable for very long. The IPU staff will monitor patient satisfaction and ease of use.
The new equipment will be review around safety and patient satisfaction, with a view of
further purchases of hoists to adequately service the IPU.
How will progress be monitored and reported
Patients will be asked for their feedback and any incidents or complaints monitored around
the use of the hoists. Staff using the trialled equipment will be asked for their view on ease of
use and observations of patient experience. Any concerns of safety issues will be taken to
the Health and Safety Group, and appropriate action taken, if required. Consideration of the
patient environment, with the new equipment present, will be taken.
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Progress will be monitored at the Quality, Improvement and Assurance Group and fed in to
the Patient Services Committee, which is Trustee led. Decisions to replace all hoists in the
IPU will be made based on the above.
2.1.2 Patient Experience
Priority Three
7 Day a week service
To review our current service, investigate areas of expansion and to look at offering more
services across seven days if appropriate, to meet service demand and needs of patients.
How was the priority decided
In the Patient Services Group we have been exploring the need for 7 day a week working
across departments. Doctors, nurses, Healthcare Assistants and the Spiritual care team are
available 7 days a week. What is the need for the Emotional wellbeing team and the
Therapists to be also?
Currently most referrals, received by the Emotional Wellbeing Team (Family Support
workers - Social workers, Art and Music Therapists, Counsellors and Bereavement Coordinator) are for emotional support for patients and their families. The minimum response
time for these referrals is three days. The reasoning behind this is that what may be deemed
as emergency situations are the responsibility of statutory organisations and there are duty
systems in place to deal with them as they arise, for example child or adult safeguarding or
issues relating to mental health e.g. psychotic episodes, suicide attempts.
Because of bank holiday weekends, in particular, response time can be longer than three
days. There is also some discussion to be had around the skills and knowledge this team
have which could support the larger multi-professional team that is currently unavailable at
weekends and on Bank holidays.
The Therapy team, (Physiotherapists, Occupational Therapists and Complementary
Therapists), also work Monday to Friday currently. However some patients are admitted to
the ward for rehabilitation, and do not receive the same level of support they have during
weekdays. We also have a large and newly equipped gym, which could be utilised every
day.
How the priority will be achieved
We appreciate that patient need continues over all days regardless of weekends so will be
considering:
 The needs of patients and families that would better be served seven days a week
without delay
 How would those needs be met? i.e. by improving the skills of those already working; or
making all disciplines available in person or on the phone or by having an on-call system
We would consider how this would fit into the paid and volunteer teams and the provision of
more information leaflets.
We would also consider how to gain the most benefit from our large Day Services Unit. By
providing additional services, e.g. running groups at the weekend, increasing the number of
services and therefore patient choice and capacity. This could reduce waiting times on
weekday services.
8
We will consider more partnership working, as we have good experience of this. We can
increase service provision by working closely with other providers. For example Active Lives
provide falls prevention groups to our patients, while we provide the venue.
How will progress be monitored and reported
The Patient Services Group will lead the project and report at its meetings. A work plan will
be agreed and a project lead assigned. This will then be reported to the Patient Services
Committee which is Trustee led and supported by membership of the Partnership Group
(patient represented group). Activity reports will be made available, as required, and audits
and patient surveys supported by the Quality, Improvement and Assurance group.
9
2.1.3 Patient Effectiveness and Patient Experience
Priority Four
The implementation of Patient Related Outcome Measures
There is a need to demonstrate the quality of care that we provide. This is ever more
required by our potential patient population as well as our donors and commissioners.
The best people to judge the service that we provide is the people who receive it. This is
validated by the annual VOICES survey as a useful data source and should be incorporated
into local performance management structures. Also the DH (2009) paper as part of the End
Of Life Strategy “Quality Markers and Measures for EoLC” also recommends the
development of local Patient Reported Outcome Measures (PROMs) for EoLC.
How this priority was decided
Patients and their families who receive our care have a right to provide feedback and input
into that service provision. They also have a right to inform if what is being provided is of the
standard that they want. Both national drivers, as well as encouragement from the board of
trustees and our local CCG commissioners have led us to consider objective ways of
measuring our impact on the people that we serve.
Although we do already measure our service by other means such as activity data, key
performance indicators, audits and surveys, Patient Related Outcome Measures (PROM)
are regarded as being important measures of the service provided especially in end of life
care.
The PROM should measure that:
 Pain and other symptoms should be controlled effectively
 The individual, carers and family should feel well supported
 The individual, carers and family should feel confident in the skills and knowledge of
their health and social care professionals
 The individual, carers and family should know who to contact in an emergency
 The individual should be able to die in their place of choice
In this year we will focus on the first three measures suggested.
How the priority will be achieved
The patient version of the integrated Palliative Care Outcome Score (iPOS) will be
implemented. It will be introduced into one service area i.e. the day service, both day care
and outpatients first. Thereafter it will be introduced into the IPU and finally into the
community.
Initially it will be used in day care and embedded into the eight week programme of care that
is provided. By the end of the programme of care, the iPOS will have been done at least on
initial assessment and at the end of the programme on a minimum of 50% of eligible patients
attending. It will also be introduced into the Outpatient clinics initially and at each visit to the
clinic. Again this will be achieved on 50% of all eligible patients reviewed in clinic.
After three months of embedding and training, it will then be implemented into the ward. It
will be done by patients on admission (who are able) and again two days prior to discharge.
The intention will be to achieve this on at least 50% of eligible patients admitted.
The next service where iPOS will be implemented is in the community team visits, either in
the home or care homes (where appropriate).
10
How progress will be monitored and reported
Staff will attend training from the developers of the tool so that they are able to be champion
the implementation into the services. Day Care is the initial area to implement as they
already have been using the older version of iPOS. These trained staff will then oversee the
implementation process by training staff and supporting them as well.
The patient services group, as well as the senior clinical group that meet quarterly, will
monitor the implementation of this tool. The leads will provide progress reports to the groups
and ensure that a schedule is followed to implement into the various service areas. Any
issues will be identified and managed within the senior clinical team.
The implementation and efficacy of the iPOS will be reviewed and some aspects audited in
each area to determine whether it is working and also its benefits.
These outcomes will be reported to the Patient services committee which is a Trustee
Committee.
2.2 Achievement of Priorities for Improvement 2014-2015
2.2.1 Patient Safety
Priority One
Falls Prevention Programme
The Hospice is participating in the Ipswich and East Suffolk Clinical Commissioning Group
Strategy and Nice Guidelines and Standards, in falls prevention. Also in the Help the
Hospices benchmarking project.
Hospice patients are all to be assessed on their risk of falls and offered advice and care
when they are found at risk. We will also ensure all staff and volunteers are knowledgeable
Areas for improvement identified for 2013-2014 were set out below.
in the prevention of falls and actively support people to prevent falls and injury.
Patient safety and wellbeing is always the highest priority. The Governance Committee
monitors incidents, including falls, and need to make certain everything is being done to
prevent patient injury.
New NICE guidance - Falls, Assessment and prevention of falls in older people, June 2013,
states people aged 65 and older have the highest risk of falling, causing distress, pain,
injury, loss of independence and mortality. The guideline is aimed at people, mainly 65 plus
but also people aged 50-64 who are admitted to hospital judged to be at a higher risk of
falling because of an underlying condition.
In September 2013, the Integrated Falls Pathway Development Group arose as a Task and
Finish group. Its objectives are:
 To reduce admissions
 To reduce fragility fractures
 To increase the percentage of falls assessments
 To increase the speed at which they are undertaken
 To reduce mortality and morbidity
 To reduce the associated costs (financial and human)
The lead is the Clinical Commissioning Group and the other stakeholders include:
Geriatricians, Therapists, ambulance service, implementation managers, social care,
commissioners, health and voluntary sector; the Hospice and Suffolk Family Carers.
11
The group will propose a service spanning across many different providers, which agree a
process of assessment and implementation of care and documentation.
We believe the principles of risk assessment and care for those at risk will apply to most of
our patients, regardless of age, because of the complexity of their illness and frailty.
Risk assessments are routine for patients who have fallen on the Inpatient Unit in the
Hospice. We now plan to introduce an improved method of assessment for all patients
whether in the community, Day Units or Inpatient Unit.
2014-15 We:
 Reviewed and updated the falls risk assessment on the IPU and made it more userfriendly ensuring all teams e.g. medical, therapy and nursing, are involved in the
assessment
 Devised risk assessments for those using the gym at risk of falling to ensure
adequate staffing levels and support
 Provided training to staff on falls prevention and the management of falls
 Now have a more fully equipped gym to manage patients who are at risk of falls or
have fallen to receive rehabilitation in a safe environment
 Use a more efficient way of recording fall incidents via iCare to ensure teams are
aware of incidents that occur
 Have all our beds in the Inpatient Unit able to lower their height, reducing the risk of
injury from patients falling from the bed
 Agreed partnership working with an external organisation who run a successful falls
programme to host this at the Hospice.
 Attended external Falls meetings to keep up to date
 Offer 1:1 and group palliative rehabilitation on a weekly basis
Did we achieve these improvements?
 We have improved both our assessments which identify those at risk of falls, and
services to help prevent or reduce falls
 We have identified the need to look at replicating falls risks assessments across all
services including day services and the community
 We saw a significant reduction in falls from patients getting in and out of bed. (OctMarch 14 =49 bed falls, April –Sept 14 =27 bed falls, Oct –Dec 14 =4 bed falls NB 3
months only)
 We have up-skilled our staff to be proactive to falls management and will continue to
do so
2.2.2 Patient Experience and Clinical Effectiveness
Priority Two
Development of Transitional Care
To work with young people, their families and other providers to ensure patients feel
supported when moving from children services to St Elizabeth Hospice (adult) services
The Hospice is registered for patients from the age of 14 and above in recognition of the
difficulties which can be faced by young people moving from children’s to adult services.
There is a need for specific support at this time as the focus of adult and children’s services
can be very different and this can cause worry and concern for the young people and their
families.
12
The Hospice therefore wishes to work more closely with other providers to offer support
during what can be a stressful period in their lives.
2014-15 We:
 Saw a significant increase in the numbers of young people using our services
 Strengthened our working relationships with East Anglia Children’s Hospice (EACH)
 Received six referrals for young adults under the age of nineteen and shared care
with the EACH as part of the transition process. Further referrals have been received
from those who had missed out on the transition time, prior to the start of the project,
so collectively the Hospice is currently providing support to sixteen young adults.
 Held two open events for young people and their families enabling them to visit the
Hospice informally for a fun day and introducing them to the building and staff
The open events have enabled the Hospice to engage with young people and their
families, to listen to what support they feel they need during transition into adult
Hospice services. The feedback has included the need for socially inclusive peer
support for young adults, the opportunity for parent peer support and short break
respite
 Ran a new monthly young adult group which started with seven young people and
continues to grow. Again the group is run in partnership with EACH and with the
paediatric nurses from the hospital. The group is for patients and families to share
and support and to receive services, e.g. music therapy, use of the gym and
complementary therapies. This supports young people transitioning from potentially
very different services in a gradual and easy way
 Are developing the process for offering short breaks
Did we achieve these improvements?
 We have rapidly developed this service and the demand continues to grow. St
Elizabeth Hospice is leading the way in transitional care and our knowledge and
experience is being sought across the country
2.2.3 Patient Experience
Priority Three
Skill mix review and role development in the community team
To review the roles and skills of those providing care to patients in the community. In
particular, look at developing new volunteer roles and the roles of the Community
Healthcare Assistants. Consider the option of having registered nurses based in the
community, who are not working to Clinical Specialist level
The community nursing team comprises of three teams; Clinical Nurse Specialists, Hospice
at Home Clinical Nurse Specialists and Community Healthcare Assistants. There is also a
volunteer role which supports people at home, often providing company and support to
people enabling family carers to leave the home for short periods of time.
The Community Healthcare Assistants are trained to a minimum level of NVQ II. The carers
often have to manage unplanned events when they make a visit, as the patients they are
caring for are usually very ill and near the end of their lives.
The Clinical Nurse Specialist team are registered nurses who are trained to degree and
masters level and work at a specialist level. They have identified elements of their role which
is not classed as specialist, and therefore could be undertaken by other skilled staff.
The review will look at the skills and experience of those attending patients in their own
homes and how volunteers can further enhance the service provision.
13
2014-15 We:
 Employed a Service Transformation Manager to review the community service and
support change
 Provided training so that the Community Healthcare Assistants could complete
competencies in drug handling to assist those in the community needing support to take
their drugs
 Provided a Volunteer Sitting Service which supports patients in their homes
 Have introduced both band 5 and band 6 Registered Nursing posts. This has increased
the establishment. This has resulted in better use of nurses skills and expertise, directing
care at the level required. It also increases the skills and knowledge of the Band 5 and 6
Registered nurses which support succession planning and as one role rotates within the
Inpatient unit, helps to up-skill those working on the ward too
 Have introduced thirty additional administration hours a week, to support the advice line
at the busiest times. This has improved the service by reducing the risk of losing calls and
ensuring a timely and effective response, especially to patients in distress or in pain
Did we achieve these improvements?
 We have changed the skill mix of the team and this will continue to develop over this
coming year too
 We have increased the capacity of the teams to be more responsive to patient need
2.3. Statement of Assurance from the Board of Trustees
St Elizabeth Hospice is constantly aiming to improve quality of care and services to patients
and their families. It demonstrates this through its Governance structure. It has a culture of
openness and learning by its mistakes and not apportioning blame.
The following are statements that all providers must include in their Quality Account. Many
of these statements are not directly applicable to specialist palliative care providers.
2.3.1 Review of Services
During 2014-2015 St Elizabeth Hospice provided and/or subcontracted the following NHS
services:






Inpatient Unit
Day Service Unit
Hospice at Home
Community Clinical Nurse Specialists and Healthcare Assistant
Family Support services, including bereavement service, Art and Music Therapists
and Chaplaincy team
Therapy services, including Lymphoedema, Complementary, Physiotherapy and
Occupational therapy
St Elizabeth Hospice has reviewed all the data available to it on the quality of care of these
NHS Services.
The income generated from the NHS in relation to services reviewed in April 2014 - March
2015 represents 26% of the total income generated for the provision of these NHS services
by St Elizabeth Hospice for that period.
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2.3.2 Participation in National Clinical Audits
As a provider of specialist palliative care, St Elizabeth Hospice is not eligible to participate in
any of the national clinical audits or national confidential enquiries as they did not relate to
specialist palliative care. We will also not be participating in them next year for the same
reason. (Mandatory statement).
15
2.3.3 Participation in Local Audits
The schedule below shows the local audits that St Elizabeth Hospice will carry out in 201516
Audit Diary Chart 2015/16
Abbreviation Table
H@H – Hospice at Home
SUI’s – Sudden Untoward Incidents
IPU- Inpatient Unit
FSW – Family Support Workers
SLA – Service Level Agreement
CQC – Care Quality Commission
DC – Day Care
Spec R – Specialty Registrar
Coloured boxes with initials represent the members of staff in charge of audit
IPU (rolling)
Apr
15
AO
Drug (quarterly)
VJ
Medical (x 3)
H@H (rolling)
May
15
Jun
15
Aug
15
Sep
15
VJ
SHO
Oct
15
AO
Nov
15
Dec
15
AO
AO
Jan
16
AO
VJ
VJ
AO
SH
O
AO
AO
AO
SHO
Staff Survey (annual)
Feb
16
Mar
16
SMT
Community Audit (rolling)
AO
Incidents – Patients
(6 monthly)
Incidents – Non-patients (6
monthly)
Complaints, Compliments
concerns (monthly)
Discharge (bi annual)
Documentation
(6 monthly)
Education/Training (annual)
LL
Day Care (rolling)
AO
Controlled Drug Audit
VJ
AO
LL
AO
ST
ST
ST
ST
AO
ST
ST
ST
ST
ST
ST
ST
ST
LL
CNS
FS
W
SA Edu
AO
AO
AO
VJ
Bereavement Feedback
AO
Infection Control Report
IPU/D
C
CQC Evidence
IPU/D
C
IPU/
DC
AO
Quality Account
VJ
Diet & Nutrition
Help the Hospice – Quality
Metrics (Falls, Pressure Ulcers,
Medication Incidents
Jul
15
AO
Additio
nal
Audits
May
be
AO
Nec
es.
ZJ
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2.3.4. Research
There were no patients receiving NHS services provided or subcontracted by St Elizabeth
Hospice in 2014-2015 recruited to participate in research approved by a research ethics
committee. (Mandatory statement).
There have not been any national research projects in palliative care in which our patients
were asked to participate.
2.3.5. Goals Agreed with Commissioners
St Elizabeth Hospice’s income in 2015-2016 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework because it is a third-sector organisation. It was therefore not eligible to
take part. (Mandatory statement).
2.3.6. What others say about St Elizabeth Hospice
2.3.6.1 No CQC inspection during this period
2.3.7. Data Quality
St Elizabeth Hospice did not submit records during 2014-2015 to the Secondary Uses
Service for inclusion in the Hospital Episode Statistics which are included in the latest
published data. (Mandatory statement).
This is because we are not required to submit data to this system.
2.3.7.1 Information governance
St Elizabeth Hospice did not hold a formal contract with NHS Suffolk for 2014-2015 for
Information Quality and Records Management, assessed using the Information Governance
Toolkit version. (Mandatory statement). The Hospice achieved level 2 compliance during the
year.
2.3.7.2 Clinical coding
St Elizabeth Hospice was not subject to the Payment by Results clinical coding audit during
2014 - 2015 by the Audit Commission. (Mandatory statement).
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Part 3 Review of Quality Performance
3.1 Quality Overview
3.1.1 St Elizabeth Hospice governance policy statement;
The organisation aims to ensure the overall direction, effectiveness, supervision and
accountability of the organisation by putting in place a system and processes which:
 Achieves continuous quality improvements by identifying and instigating best
practice, learning through mistakes, and creating an environment in which
excellence can flourish
 Ensures compliance with relevant regulations and legislation
 Ensures efficacy and effectiveness
 Ensures that the charity meets its objects as outlined in the Memorandum of
Association
The Quality Assurance and Improvement Group has a rolling audit programme as well as
the ability to prioritise new audits if this response is required.
The Partnership Group
The Partnership Group has now been established for nine years this year. During this time
the groups representation with both patients and carers with the addition of Hospice
professional staff on the committee has engaged the group to look at many suggestions and
obstacles that have challenged the group.
Unfortunately during 2014 the group lost two of its members who were very well thought of
and this did affect the group considerably. On a positive note two new patient members
joined and they have both been very proactive and this has been excellent for the group.
The Partnership Group is always actively trying to recruit new members to ensure that we
have an equal voice on the committee in representing patients and carers but also to be able
to assist in tasks that the Hospice ask us do help with.
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Achievements:
•
•
•
•
•
Introduction of a trial of New TV remote controls on the IPU
Involved in the design discussions of the new Day Unit
Review of Complementary Therapy treatments
Looked at Talking Apps on iPads/tablets for patients who have trouble communicating
Acquired Hospice maintenance to devise and aid to the flushing mechanism on the toilets
on IPU as patients were finding it difficult to flush the toilet with the push button system this was very successful for staff as well and has been rolled out to all the toilets in the
Hospice
• Initiated contact with non-cancer support groups: for patients in the Hospice to liaise with;
to obtain information to devise a newsletter for the intranet and for Hospice
staff/volunteers to read and receive information on patient support services for the many
non-cancer patients the Hospice treat
• Writing a blog to be shared on the Hospice website and Facebook page
• Relocation of a Donation Box on IPU
Action plan 2015
This year this group has decided to select only a couple of main objectives for the period of
2015. This is due to the membership of the group and also because we found we dealt with
more "ad hoc" issues bought to the group needing our attention during 2014, taking up the
groups time.
Therefore our plans are:
• To discuss and develop with the Day Care team a "drop-in" service in the new Day Care
reception area for patients, carers and family to meet and discuss any issues that the
Partnership Group could take forward with the relevant Hospice department(s)
• To continue with our non-cancer newsletter and Intranet information source
• To continue with regular updates for the blog and Facebook
• Recruit new members to the Committee
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• To take on any "Ad hoc" issues that the Partnership Group feel necessary to bring to the
Hospice attention.
The Partnership Group still strives to continue to promote a proactive partnership with
Hospice departments and Management and in 2014 the group underwent an exercise to
strengthen those ties with a better understanding and co-operation. To this end the
Partnership Group will provide the listening ear in overcoming issues that we feel effect
patients and carers.
Ian Ewers-Larose MInstLM
Chair of the Partnership Group
St Elizabeth Hospice, 27th January 2015
The Accountable Officer is also the Registered Manager and a member of the Locality
Intelligence Network group. She monitors drugs incidents, makes three monthly Drug
incident reports and assesses the storage, destruction and use of controlled drugs formally
every six months.
Each Directorate has a risk register which is updated regularly. Risk assessments and
incidents are raised at the Health and Safety Group.
The Hospice has its own Responsible Officer, Dr Kelvin Bengtson. All doctors are now
expected to be appraised on a regular annual basis and then revalidated every 5 years. All
systems and processes are in place to ensure that this happens.
3.1.2 Quality overview
In 2014-2015 St Elizabeth cared for 2128 patients and their families across the range of
services.
This is a selection of patient and carer comments on our services
Hospice at Home audit
 65-85% of responders (over three surveys) stated the service enabled their relative
to remain at home
 High majority had no problems making contact with the team
 “The team were very supportive and more than helpful. Thank you.”
“I could never have looked after my husband at home on my own, I shall always be
so grateful that I could with the help of all your brilliant team. Thank you.”
“My family and I were totally amazed at the wonderfully caring service we received.
The nurses who attended were so very kind and supportive all the way through.”
“I pleaded for the patient to be admitted (patient died at home)”
“Without their prompt attendance and support my husband would have had to go into
hospital and would have died there. Both myself, my husband and my family would
have been very unhappy if that had happened. Instead he was able to pass away
peacefully in my arms in his own bed.”
“On occasions contacting/speaking to somebody on the night shift was quite hard as
the H@H team were very busy.”
 100% of all relatives found the service cared with respect and the team were helpful
Community Nurse Specialist Feedback Audit
 90% of patients felt the service was introduced to them at the right time
 85% of patients felt the service met their expectations
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

Very satisfied with the service, no improvement suggested in nine replies
“Would like to thank the CNS who instigated trial and follow up of the service.”
“Nurse is trustworthy - I am sure they will prolong my life.”
“Writing on behalf of my husband to say how very lucky we are to get this support,
nothing is too much trouble, someone to talk to in our hour of need, service is
wonderful, thank you.”
Fears expressed by one responder as allocated nurse has been unwell for some time
and they are worried in case they should need urgent help or advice
Day Care Survey
 “I do enjoy the day centre, especially the company. The food is always good.”
“I was unaware that there were services available at the Hospice as a day
visitor.....thoroughly enjoy my time there.”
“It may be necessary in future to have help with transport as my disease progresses.
The greatest benefit I have received is the taking away of being so isolated, not only
physically but importantly for me, mentally.”
 100% of patients replying felt they were treated with dignity and respect. 84% felt
treated as an individual
 100% of patients stated the attitude of staff working at the Day Care Centres as
excellent
Complaints and compliments
All complaints received at St Elizabeth Hospice are taken seriously, fully investigated and
processed as laid out in our complaints procedure.
We received (52 from 1.4.14 - 31.12.14) complaints throughout the year, covering all patient
services, retail, volunteers and support staff all of which, with the exception of one were
resolved satisfactorily and within the time scales laid out in our policy and procedures. The
outstanding complaint could not be resolved locally and was referred to the Health Service
Ombudsman for review.
With effect from 1.12.14 a revised system for service user feedback was rolled out in order
to more accurately reflect the type of feedback received, using the categories: compliment,
comment, concern and complaint.
In the same period we received (209 from 1.4.14 - 31.12.14) compliments, covering all
patient services, retail, volunteers and support staff. Two extracts are reproduced below:
“I would like to take this opportunity to thank doctors, staff and volunteers at St Elizabeth on
behalf of my wife and myself for the professional care and kindness you have all given so
freely.
“My wife has always had a special confidence in you (Dr B) from your first meeting. She
knew it would be a difficult time for us to come to the Hospice at the end of her illness, but
the knowledge and trust she had in you and the members of the team made that decision
easy for D and me. May I make special mention of Pauline, Sarah and Peter whose
dedication, care and kindness to D and our family went that extra mile. There are many
others I would like to mention but sadly their names elude me, but not my heartfelt thanks. I
would ask you to please pass on my gratitude to all.”
“Dear Dr B I write to express the gratitude of myself and my family for all the kindness and
care given to my darling wife while she was in the Hospice recently. She died peacefully in
her sleep early on Tuesday morning. Will you please pass on these expressions of gratitude
to all the doctors and nursing staff there. In addition, a very special thank you to the team of
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nurses who attended her at home with such wonderful care, they were lovely to her. We had
never had any experience of Hospice care before and the general happy atmosphere so
good for the patients, is a credit to all the medical staff and volunteers who give their
services.”
Quality Markers we have chosen to measure
In order to inform the governance process St Elizabeth Hospice monitors outcomes across
six different areas of the Hospice work monthly, using recognised tools and national
benchmarking data.
This enables the Board to look at areas of development over a period of twelve months to
monitor progress and identify actions for any areas of concern.
The Hospice has outcome Key Performance Indicators relating to Inpatient Unit and
assessing outcome of pain, psychological, spiritual and social interventions. We also ask
when collecting this data, if the patients feels they were treated as a person, and would
recommend us to their families and friends.
Domain
Outcome
Tools
Patient experience
Relief of Symptoms
-
Meeting patient’s needs
-
Patient Choice
Achievement of
preferred place for care
-
Patient safety
Maintain a safe
environment
-
Effective workforce
Employer of choice
Financial sustainability
Financial health
-
Organisational
effectiveness
Widening access
-
Use of resources
-
audit of complaints and
compliments
audit of preferred priorities for care
audit of advance care plans
ensuring patients are part of the
decision making process by
checking capacity and obtaining
consent for every intervention and
documenting it
audit of patient accidents
audit of drug incidents
audit of hospital acquired infections
audit of complaints, concerns and
complements
implementation of regulations
regarding Deprivation of Liberty
staff retention
working days lost due to sickness
investment in training and education
staff survey
no blame culture
audited accounts
increase in patients with non-cancer
diagnosis
expansion of geographical area
uptake of day care places
time in service
expansion to providing care closer
to the patient such as satellite
clinics
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3.2 Who has been involved






Chief Executive Officer
Senior Management Team
o Director of Patient Services
o Medical Director
o Director of Corporate Services
o Director of Income Generation and Marketing
Quality and Improvement Group
Partnership group
Governance Committee
Board of Trustees
3.3 Statements Provided from Commissioning CCG, Healthwatch and OSCS
The following statements were made in response to receiving this Quality Account.
Ipswich and East Suffolk Clinical Commissioning Group
Ipswich and East Suffolk Clinical Commissioning Group, as the commissioning organisation for
St Elizabeth Hospice, confirm that the Hospice has consulted and invited comment regarding the
Quality Account for 2014/2015. This has occurred within the agreed timeframe and the CCG is
satisfied that the Quality Account incorporates all the mandated elements required.
The CCG has reviewed the Quality Account data to assess reliability and validity and to the best
of our knowledge consider that the data is accurate. The information contained within the Quality
Account is reflective of both the challenges and achievements within the Hospice over the
previous 12 month period. The priorities identified within the account for the year ahead reflect
and support local priorities. Ipswich and East Suffolk Clinical Commissioning Group is currently
working with clinicians and managers from the Hospice and with local service users to continue
to improve services to ensure quality, safety, clinical effectiveness and good patient/carer
experience is delivered across the organisation.
This Quality Account demonstrates the commitment of the Hospice to improve services. The
Clinical Commissioning Group endorses the publication of this account.
Barbara McLean
Chief Nursing Officer
Suffolk Health Scrutiny Committee
The Suffolk Health Scrutiny Committee does not intend to comment individually on the NHS
Quality Accounts for 2015. This should in no way be taken as a negative response. The
Committee has, in the main, been content with the engagement of local healthcare providers
in its work over the past year. The Committee has taken the view that it would be
appropriate for Healthwatch Suffolk to consider the content of the Quality Accounts in light of
views and comments received from patients and local residents, and comment
accordingly.
County Councillor Michael Ladd
On behalf of the Suffolk Health Scrutiny Committee
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HealthWatch
Healthwatch Suffolk has the roll to produce a statement on whether or not we consider,
based on the views of local people and other information that we have access to on the
provider, the QA report is a fair reflection of the full range of services provided. Healthwatch
Suffolk has not received any comments about St Elizabeth Hospice this year and therefore
will not be able to produce a statement.
Please continue to send us future Quality Accounts as we may gather feedback on the
service over the coming years.
Jenny Ward
Information Services Officer
If you have any feedback on this document, please email our enquiries line on
enquiries@stelizabethHospice.org.uk or visit our website www.stelizabethHospice.org.uk
and complete our form for comments, compliments or complaints, which is found in the
Contact Us section.
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