St Gemma’s Hospice
Quality Account
2014/15
What a wonderful, calm, gorgeous place.
“
My Dad’s final hours were just so peaceful and I could
not have wished for any better care for him.
”
CONTENTS
PART ONE
PART ONE
Statement on Quality from the Chief Executive .................................................................................................
1
Vision, Purpose and Values ...............................................................................................................................
2
PART TWO
Priorities for Improvement 2015/2016 ................................................................................................................ 3
Statements Relating to the Quality of the Services Provided ............................................................................ 6
Statement of Assurance from the Board ............................................................................................................
6
Review of Services ............................................................................................................................................. 7
Statements from the Care Quality Commission .................................................................................................
10
PART THREE
Priorities for Improvement 2014/15 .................................................................................................................... 12
Review of Quality Performance .......................................................................................................................... 17
Patient and Family Experience of the Hospice ................................................................................................... 22
Staff Experience of Working at the Hospice .......................................................................................................
25
PART FOUR
Statements from:
Leeds South and East Clinical Commissioning Group ....................................................................................... 26
Healthwatch Leeds ............................................................................................................................................. 27
Appendix, References, Glossary and Further Information .................................................................................
Quality Account 2014/2015
28
Statement on Quality from the
Chief Executive
Welcome to our Quality Account, which outlines
some of the key quality improvements we have
delivered in 2014/15 and the priorities we have set
for clinical improvement in 2015/16.
St Gemma’s Hospice provides and promotes
the highest quality palliative and end of life care,
education and research. We strive to meet the
complex and changing needs and preferences
of people with a terminal illness and support their
families and carers. Through education and
research, our Academic Unit of Palliative Care, in
partnership with the University of Leeds, enables us
to improve care and support for all, not only those
who receive services directly from St Gemma’s.
Last year we set out three priorities for improvement
in our Quality Account. We made significant steps
to deliver those priorities. We improved the care
we provide to patients with cognitive impairment or
communication difficulties with the introduction of
new tools, additional staff training and the creation
of two special interest groups. We expanded our
specialist palliative care community nursing service
so that patients living at home as well as care
professionals can this specialist support every day
of the week. We also provided enhanced training to
ward based nursing staff providing telephone advice
to patients and professionals outside normal working
hours, including overnight.
Delivering improvements is not always easy; one
of our priorities for 2014/15 was meeting the needs
of patients with an increased risk of falls. We have
taken significant steps to meet this priority but
work has been delayed due to nursing recruitment
challenges, a national issue. There is more work we
need to do in this area and we have retained this as
a priority area for the coming year.
Alongside falls prevention work, in 2015/16 we will
focus on enhancing support for young people and
measuring clinical outcomes for patients. Both of
these objectives will shape our services and ensure
we continue to respond to changing patient and
family needs.
Our priorities as set out in the Quality Account are
not the only areas of service development. With
funding from the NHS we commissioned and
supported four dedicated beds for people near
the end of life in Green Acres Nursing Home. We
improved engagement and involvement with our
staff and volunteers who maintain the quality of
care delivered day by day. We also completed
improvements to our Hospice environment, so that it
continues to be a welcoming and safe place for all.
In this, the Hospice’s 36th year, we remain hugely
grateful to our supporters who have continued to
provide us with the majority of funds needed to care
for local people. Although not part of the NHS, we
receive a welcome financial contribution from them
and work closely in partnership with commissioners
and providers to improve care for people in Leeds.
St Gemma’s maintains a robust clinical governance
framework. We review and progressively build on
our assurance and reporting of clinical outcomes
and seek to capture effective data. We seek
continuous improvement, informed by feedback
from patients and families, learning from incidents
and complaints quickly and openly, undertaking a
programme of clinical audits and monitoring a range
of key performance indicators.
This year’s Quality Account has been prepared by
our Director of Nursing with support from the clinical
teams. The Hospice Leadership Team has been
closely involved in setting our priorities for quality
improvement and in delivering improvements on
the ground. The Board of Trustees has endorsed
our Quality Account and I am able to confirm that
the information contained in this
document is, to the best of my
knowledge, accurate.
Kerry Jackson
Chief Executive
Quality Account 2014/2015
1
PART TWO
St Gemma’s Hospice: Vision, Purpose and Values
Our Vision:
The needs of people living with a terminal illness and those close to them are
met with care, compassion and skill
Our Purpose:
St Gemma’s Hospice acknowledges the value of life and the importance of
dignity in death. We provide and promote the highest quality palliative and
end of life care, education and research
Our Values:
Caring - Treating each person with kindness, empathy, compassion
and respect
Aspiring - Continually learning and developing; striving for excellence
in everything we do
Professional - Delivering high standards through team work, a skilled
workforce and good governance
2
Quality Account 2014/2015
Priorities for Improvement
1st April 2015 - 31st March 2016
At St Gemma’s we continually review our services
and act on the information we receive from patients
and carers as well as the views of our staff.
The St Gemma’s Clinical Strategy is in line with the
Leeds End of Life Care Strategy (June 2014) which
takes account of the need and preferences of the
local population.
Clinical and support teams are fundamental to the
delivery of our strategy and business plans. Delivery
is achieved through effective team working and
communication between front line teams, the Hospice
Leadership Team and the Board of Trustees. Each
year the Hospice holds a Staff Conference; in 2014
this focused on the Hospice Vision and Values
which were developed in consultation with staff and
volunteers, patients and carers. The Chief Executive
ensures delivery is monitored through mechanisms
such as audit and project reports, activity data and
feedback from patients and carers.
Our Quality Account priorities are in line with the
Hospice Clinical Strategy, take account of patient and
carer feedback received and build on any incidents
or clinical governance issues which were medium
to high level risk or have demonstrated a trend. The
Quality Account firstly addresses the priorities for the
forthcoming year 2015/16 (Part 2) and then reflects
on the progress made against the priorities in the
previous year 2014/15 (part 3).
Quality Account 2014/2015
3
Priority 1: Patient Safety
Management of patient falls
Falls were a key priority for the Hospice in 2014/15.
A significant amount of work was undertaken to
develop a falls assessment tool which aligned to the
NICE Guideline: Preventing Falls for Older People.
The Hospice supports patients to live well until they
die, which often involves taking risks. If patients want
to walk and have the ability to do so, we will support
them to do this. Falls are the most common clinical
incident at St Gemma’s; although the majority of
falls do not result in physical injury, they can have a
significant psychological impact, reducing a person’s
confidence and belief in their own ability.
• Review by the MDT falls group to evaluate the
impact of the above in June 2015
• Ongoing review of current literature to ensure the
pathway remains in line with best practice and
effective
• In-depth analysis of all falls occurring in the
Hospice, including a case review on patients who
have fallen repeatedly
• Further development of the pathway with the
St Gemma’s Community Team who will work
alongside District Nurses to ensure co-ordinated
care
The current management of falls was reviewed
in 2014/15 including assessment, training,
documentation and evaluation. The new assessment
tool was introduced in January 2015 and we now
wish to evaluate its impact; therefore we have
decided, based on current incident data and impact
on patients, to continue to seek to meet the needs of
patients with an increased risk of falls as our patient
safety priority.
Our formal evaluation will establish if the assessment
is fit for purpose and ensure that clinical teams are
confident in using and acting upon the assessment in
practice.
Our key targets are as follows:
• Reduce the number of patient falls to be in line
with or below the Hospice UK benchmarking falls
average for 25 beds and over: 12.4 falls per 1000
occupied bed days; the Hospice is currently at
14.2 falls per 1000 occupied bed days
• Compliance with our new In-Patient falls
documentation measured through audit and
including:
• Falls assesment for 100% of patients
• Falls Management plan developed for all patients
where risks are identified
• Reviews Management Plan, including undertaking of additional assessments,at least
once per week or more often if a patient has fallen
• Use of post falls assessment tools to support
improvement, effective clinical documentation and
incident reporting
4
Quality Account 2014/2015
Priority 2: Patient Experience
Enhancing support for young people
The Hospice is constantly learning and developing;
our patient experience priority has been developed
as a result of a review of complaints received in
2014/15 which highlighted complex family situations
which can impact on communication within the
family and with health and social care professionals.
Often the focus of care is directed at supporting
adults; we want to ensure we support all family
members, including children and young adults in the
pre and post bereavement phase.
The Hospice has invested in its social care provision;
we recently recruited two young people’s workers in
addition to highly trained volunteers. This investment
will provide a consistent, sustainable service which
will be developed during 2015/16.
With this investment we aim to support 10% more
young people via a range of activities including one
to one counselling, group events and joint working
with other agencies in order to support young people
when someone they love is dying or when they are
bereaved.
We also want children and young adults to shape
our services; in April 2015 we will launch the Young
People’s User Group to engage, value and empower
the young people to define the service they need.
This forum will give young people between the ages
of 9 and 17 the opportunity to build life and social
skills by working with and supporting their peers.
We also plan to engage with other third sector
providers, communities and schools to facilitate
integrated support opportunities for bereaved young
people and their carers.
Our key targets are as follows:
• Launch Young People’s User Group 9-17 year
olds in April 2015
• Reach 10% more young people
during 2015/16
• Increase the level of third sector integration,
through an increase in schools, community
groups and youth work by at least 10%
Priority 3: Clinical Effectiveness
Measuring palliative care outcomes
Understanding the impact of care on patients and
families allows hospices to improve their services.
Measuring the impact of palliative care is a
challenge, as was highlighted in the recent national
Palliative Care Funding Review. In our Hospice
Strategy we have identified the need to seek
improved outcome measures to ensure our service
is responsive to changing patient need.
Comparable, credible measures were sought
that could inform patient care for those currently
receiving care and also shape the future of palliative
care nationally by having comparable data sets.
The Cecily Saunders institute and Kings Fund
have developed the Outcome Assessment and
Complexity Collaborative (OACC) initiative, which
aims to implement outcome measures in palliative
care. There are six OACC outcome measures which
are aligned to the National Minimum Data Set and
also the national Palliative Care Funding Review.
The Hospice will be adopting OACC during 2015/16;
other hospices have indicated they will also be
taking this forward. It is anticipated that OACC will
allow us to better understand the impact of palliative
care on patients and their families and shape our
future services.
Our key targets are as follows:
• Staff to understand the value of measuring
care – through training and monitoring usage of
outcome measures in practice
• Develop patient/ family information sheets
explaining the outcome measures
• Enable electronic data collection
• Introduce four out of the six outcome measures
by December 2015
• For 80% of patients receiving care on the InPatient Unit to have three measures at two points
in time and for these to be discussed during part
of MDT meetings
• For the phase of illness measure to be part of
Community and Day Hospice MDT meetings
Quality Account 2014/2015
5
Statements Relating to the Quality of the Services Provided
Review of Services
Statement of Assurance from the Board
During 2014/15 St Gemma’s Hospice
provided the following services:
The Board of Trustees is assured by the progress made in 2014/15 and supports the quality improvements
planned for 2015/16. The Board is committed to the provision of high quality care for patients, families and staff
across all Hospice services.
The Trustees undertake unannounced quality assurance visits of patient services; the frequency of these has
been increased and the visits will engage every Board member over time. Trustees have visited the Inpatient
Unit and the Day Hospice. Patients and families are asked if they are willing to speak to Trustees to share their
experience of care. Trustees also gather staff views. This assists Trustees to understand the core business of
the Hospice and gives the Board assurance of the quality of care provided. The most recent visit took place in
February 2015. The service was deemed as excellent.
The Board of Trustees will continue to monitor the progress against the priorities for quality improvement, as
well as additional quality monitoring information such as key performance indicators, complaints and incidents
and the clinical risk register through the Clinical Governance Committee, a joint committee of Trustees and
Directors.
•
In-Patient Care (32 Beds) which provides 24
hour care and support by a team of specialist
staff.
•
Day Hospice (up to 14 places per day)
which gives patients extra support to manage
symptoms, gain confidence at home and
maximise quality of life.
•
Out-Patients Service at the main Hospice site
and at two community clinics. These provide
a consultation with a Doctor, Clinical Nurse
Specialist or Therapist.
•
Community Services, which provide specialist
support and advice in a patient’s home.
•
Chairman of the Board of Trustees
Our services are provided by a multi-disciplinary
team comprising:
•
Doctors including medical consultants.
•
Nurses and Healthcare Assistants
•
Therapies to support independence and
promote comfort including:
• Physiotherapy
• Occupational therapy
• Dietetics
• Complementary therapy
• Creative arts
•
6
Quality Account 2014/2015
Community Nurse led beds in a Nursing Home
supporting patients nearing the end of life.
Social Workers and Discharge Support
Worker provide specialist support and
counselling to patients and families and friends.
•
Spiritual Care services supporting patients and
their families.
•
Bereavement services for adults and children.
•
Support services providing cleaning, catering
and laundry services for patients.
The Hospice, in partnership with the University
of Leeds, hosts the Academic Unit of Palliative
Care (AUPC). This unit undertakes national and
international clinical research, monitors and seeks
to develop the quality of services through linking
research into clinical practice. The AUPC also
provides education and training for both Hospice
and external staff.
The Hospice provides palliative and end of life care
to the population of Leeds; our community services
provide care to patients in east Leeds and patients
from a wider catchment area are cared for within
our In-Patient Unit and Day Hospice. The Young
People’s Bereavement Service is city wide. We also
undertake some adult bereavement support work
for the wider population of Leeds, directly funded by
NHS commissioners.
In the following review there are statements (in
italics) required by regulation which have to be
included in the report. There are also a number of
statements which are not applicable to the Hospice.
These are listed in the Appendix.
St Gemma’s Hospice has reviewed all the data
available to us on the quality of care in all of these
services.
Financial Considerations
The income received from the NHS in 2014/15
represents 28% of the total income generated by St
Gemma’s Hospice in 2014/15.
The Hospice receives funding from the NHS Leeds
Clinical Commissioning Groups as a contribution
to the overall cost of service provision. 100% of the
financial support we receive from the NHS is spent
directly on patient services.
The running costs of St Gemma’s are forecast to be
£9.7 million in 2015/16. The majority of this has to
be funded through donations, legacies, fundraising
initiatives and our chain of charity shops.
We review all our services on an ongoing basis to
ensure we are delivering them as efficiently as we
can and that we spend our money wisely. This
is particularly important in light of the challenging
economic climate we have faced in recent times.
Expert care for our patients and their families
remains our priority.
Quality Account 2014/2015
7
Service Evaluation
Participation in Clinical Audit
Our focus is continually on improving the quality of
life for patients and their families, ensuring a positive
experience of our care, and treating and caring for
people in a safe environment.
The new regulatory assessment framework
from the Care Quality Commission
(CQC) is built around 5 key lines
of enquiry (KLOE): is the service
safe, caring, responsive,
effective and well led. This
fits well with the ethos of the
Hospice and has shaped
how we demonstrate that
the Hospice provides
appropriate care to patients
and families. We are
committed to using the Quality
Standard for End of Life Care
from the National Institute for
Health and Care Excellence (NICE)
as the basis for audit criteria in order
to assess and improve the quality of care we
provide.
The Clinical Effectiveness Group at the Hospice
oversees a programme of audit which includes
the use of national audit tools and
locally designed tools. There is a
multidisciplinary approach to audit
with dissemination of reports,
monitoring of action plans and
re-audit where necessary.
The reports of local clinical
audits have been reviewed
for 2014/15 and the Hospice
intends to take a number
of actions as identified in
the examples in Table 1 to
improve the quality of care.
The majority are re-audits which
demonstrates our commitment to
continuous quality improvement.
Table 1
Audit
Issues identified and resulting
actions to be taken
2014 / 15 2013 / 14
Controlled Drugs (CD)*
100%
93%
Continued monitoring to uphold standards
Positive Patient Identification
92.5%
99%
96%
100%
Surname not written in uppercase, preceding first
name on a number of bands – further spot checks
continue
*Hospice UK audit tool – single rooms do not have a
dedicated hand hygiene sink. The only available sinks
are in bathrooms for patient use. Sinks are located
outside the rooms in the corridors
Continued monitoring to uphold standards
Infection Control – Hand
hygiene
Accountable Officer*
100%
100%
Re-audit Management of
Sharps*
92%
92%
Re-audit Mouth Care
Documentation
90%
80%
Nutrition Audit
88%
N/A
Signing and dating of sharps bins and adherence to
procedure for drawing up multiple drugs - further spot
checks to continue
Diagram of mouth to be completed. A re-audit will
take place in Quarter 1 2015/16
Further information to be recorded on current dietary
requirements. A re-audit will take place in Quarter 1
2015/16
* National audit tools devised by Help the Hospices (the UK charity supporting hospices)
Patient Related Outcome Measures (PROMS)
A review of medical sevices
During 2014/15 a review of domiciliary medical
services for the previous 12 months was undertaken.
Domiciliary Visits (DV) may be viewed as a
‘consultant ward in the community’.
Our review identified that patients visited had highly
complex needs, which could not be addressed by a
Community Clinical Nurse Specialist (CNS) and / or
GP alone. The most common reasons for requesting
a DV were difficult symptom management or
decision making.
Patients visited were highly symptomatic, having a
median of six problems and with all patients having
at least one physical problem (median 3) and over
three quarters having information, psychological and
carer needs. Patients with non-malignant disease
represented 20% of patients visited which is in line
with Hospice referral rates, suggesting that patients
with non cancer are no more likely to be seen than
those with cancer. There was a tendency to visit
younger patients with 46% of visits to patients aged
under 65 compared to 22% of overall Hospice
referrals being for patients aged under 65.
Most patients received one visit (79%) but a small
number with highly complex needs received multiple
visits which are important for symptom control,
patient continuity, confidence and CNS/ GP support.
Domiciliary visits contribute to the patient achieving
their preferred place of care with 60% of the patients
achieving their aim of dying at home.
We reviewed the time taken for each DV; currently
visits take approximately two hours, including
preparation prior to the visit, one hour with the
patient, travel and the recording of the visit. There
is no data to allow bench marking of DVs across
UK Hospices, however studies have in Austria and
America recommend allowing up to an hour for a
new referral.
The Hospice continues to use the DV model but
recognises it is time intensive. The team continues
to monitor the frequency and responsiveness of
DVs and aims to gather more outcome data. The
Outcome Assessment and Complexity Collaborative
(OACC) project as referred to in priority 3 2015/16
provides a framework to measure the impact of DVs
on patients and their families.
Participation in Research
The Academic Unit of Palliative Care (AUPC) led by
Professor Mike Bennett has continued participating
in high quality research projects, all of which are
included in the National Institute for Health Research
(NIHR) portfolio. Some of these studies are led from
St Gemma’s Hospice and some are in collaboration
with national and international researchers.
The SMARTE study (Self-Management of Pain and
Related Treatments at the End of Life) launched in
October 2014. This study is funded by a grant from
the Health Technology Assessment Programme, with
Professor Bennett as Chief Investigator. The study
aims to develop support systems for patients and
carers to manage their pain medicines.
Research projects led by the AUPC and undertaken
at both St Gemma’s Hospice and Sue Ryder
Wheatfields Hospice have resulted in the recruitment
(participation) of 158 patients, six carers and 14 staff
between April 2014 and March 2015.
When Cure is Not Likely is a project undertaken
with University College London to assess the care
needs of younger adults (aged 24 - 40) with a
diagnosis of incurable cancer.
Examples of projects undertaken in the past year
include:
The IMPACCT programme (Improving the
Management of Pain from Cancer in the Community)
has continued to build on the previous year’s
studies to develop an educational pain toolkit and
an electronic pain assessment tool, which are both
currently being evaluated by patients and carers in
further studies.
The findings from the research are being shared
nationally, with 15 papers accepted for publication
from the research team, a number of which related
to the IMPACCT or SONIC programme.
The Hospice has previously used the St Christopher Index of Patient Priorities. This is now part of a wider piece
of work progressed as a Quality Account priority for 2015/16. Further information is available in part 2, priority 3.
8
Quality Account 2014/2015
Quality Account 2014/2015
9
Delivery of City Wide Education
Graduate Certificate Course: This year the AUPC at
St. Gemma’s Hospice has renewed its collaborative
agreement with the University of Leeds School of
Healthcare. The Graduate Certificate in Palliative
Care has continued to run successfully with the
intake of students for 2014/2015. For 2015/2016 the
AUPC is developing a Post Graduate Certificate in
Palliative Care to be delivered in collaboration with
the University of Leeds School of Healthcare Studies.
This will give participants credits at Masters level. One
module from the Graduate Certificate will continue
to run for pre-registration students, giving them an
introduction to the principles of palliative care.
City Wide Education: Over the last year St Gemma’s
AUPC has hosted and been the main provider in
delivering palliative and end of life care education to
various health care professionals across the city. This
has included delivering training in communication
skills / starting conversations about end of life to over
200 District Nurses, community nurses and care home
staff; running a successful master class in symptom
management at the end of life to 23 GPs and also
carrying out practice based sessions for GPs. The
team has delivered sessions to over 70 Out of Hours
GPs on symptom management. The AUPC has run
the QELCA programme (Quality End of Life Care
for All) for four senior nurses from Leeds Teaching
Hospitals NHS Trust; this programme consists of
nurses spending a week at the hospice – two days in
the class room and three days working in the specialist
end of life setting.
Evaluations from these sessions showed that by
the end of the course GPs felt most able to manage
common symptoms experienced by palliative care
patients and to prescribe appropriate and adequate
pain control medication. The largest improvement in
communication skills was the ability to discuss the
patient’s own death and answer difficult questions like
‘how long have I got to live?’ They felt more able to
discuss issues of death and dying.
Statements from the Care Quality Commission (CQC)
St Gemma’s Hospice is required to register with the
Care Quality Commission and its current registration is
for the following regulated activities
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury
St Gemma’s Hospice has the following conditions on
registration:
Data Quality
The Hospice deployed SystmOne (S1) in April 2010.
This system supports an electronic patient record
which can be shared with other external users of the
system, for example General Practitioners and District
Nurses. The Hospice is part of the Leeds Electronic
Palliative Care Coordination System (EPaCCS) sharing
Information Governance
St Gemma’s Hospice’s score for 2014/15 for
Information Quality and Records Management,
assessed using the Information Governance Toolkit
version 12, is 66% which means the Hospice is fully
compliant at level 2, the required national standard.
We are also compliant in several areas at level 3.
key information, with the patient’s consent, about their
preferences at end of life. The Hospice has internal
arrangements to monitor the quality of the data. The
system uses the NHS number as the key identifier for
patient records. The Hospice is to be part of Leeds
Care Record as this is implemented across the city.
The Hospice continues to monitor handling of Personal
Identifiable Data against the standards in the
Information Governance Statement of Compliance.
The Hospice, in improving patient safety, continues to
develop the electronic patient record and continues
to focus on becoming “paperlite” in all departments.
The Hospice has shared records in accordance with
the Data Protection Act and has in place Data Sharing
Agreements.
• Only treat people over 18 years of age
• Only accommodate a maximum of 34 In-Patients
St Gemma’s Hospice is subject to periodic review by
the Care Quality Commission and the last review was
an unannounced routine inspection on 4th December
2013.
The areas reviewed by the CQC and its assessment of our compliance are as follows:
Standards of treating people with respect and involving them in their care
Standards of providing care, treatment and support that meets people’s needs
Standards of caring for people safely and protecting them from harm
Standards of staffing
Standards of quality and suitability of management
The Hospice submitted the Provider Information Response to the Care Quality Commission on 5th December
2014 and continues to provide, and further develop, safe, caring, effective, responsive and well led care,
upholding the fundamental standards, including Duty of Candour.
The latest report is available on the Hospice website
http://www.st-gemma.co.uk/
or on the CQC website
http://www.cqc.org.uk/node/280579
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Quality Account 2014/2015
Quality Account 2014/2015
11
PART THREE
Priorities for Improvement
1st April 2014 – 31st March 2015
Priority 1: Patient Safety
Ensuring the Hospice meets the needs of
patients with an increased risk of falls
Patient falls were identified as a key area of focus
in 2014/15 due to the rise in the number of falls
across the In-Patient Unit. The Hospice aims to
maximise patient independence and privacy whist
upholding patient safety. The Hospice is part of
Hospice UK Bench Marking scheme where levels
of falls are compared with over 90 Hospices
nationally (9 of which are over 25 beds and
provide a closer comparison to St Gemma’s).
•
A robust quality measure will be developed
to ensure compliance with standards and
quality of care in relation to falls.
Result: The risk assessment and supporting
tools were launched in January 2015. The
Ward Sisters are monitoring daily but a formal
evaluation is yet to take place. This is planned
for 2015/16.
Ensuring the Hospice meets the needs of
people who have or may develop difficulty
communicating their needs due to dysphasia,
cognitive impairment or extreme frailty
•
12
Initial development of a
community and Day Hospice falls
risk assessment
Result: This was introduced in the
Day Hospice with supporting tools.
For patients in the community District
Nurses lead on falls assessment; the
St Gemma’s community team liaised
with district nurses where they identified
patients who were at a high risk of falling.
Quality Account 2014/2015
Development of general training session
which aimed at helping staff to understand
behaviour. This forms the basis of
understanding the difficulties experienced
by patients
Result: A full day training workshop on
‘The Experience of Cognitive Impairment’
was delivered on two separate occasions
and attended by 19 members of Hospice
staff. Members of Mindset took part in the
delivery of this workshop. There was positive
feedback from the staff who attended. The
project has been outlined and the use of the
‘Helping us understand you’ booklet and
resources have been promoted to a further
13 staff during their attendance at mandatory
clinical update training sessions..
•
75% of all patients will have a preferred
place of care recorded and 85% will have a
preferred place of death recorded (or noted
why the discussion was inappropriate)
Result: 78% of in-patients had a preferred
place of death recorded
90% of Healthcare Assistants trained and
using S1
Result: All members of this staff group have
“read” access but “write” access on hold due
to delayed roll out
The targets were as follows:
•
Delivery of this project was delayed in 2014/15.
Although some progress was made, falls continue
to be the highest cause of clinical incidents across
the In-Patient Unit. As a result this will continue to
be a priority in 2015/16 with a full evaluation of the
outcomes.
IPU tool will be embedded and further tools
developed which are fit for purpose in the
Day Hospice and community settings
Result: Assessment documentation including
risk assessment and information pack was
introduced to both wards in January
2015. Patient, patient information
leaflets were developed and made
available to all patients and families.
Initial implementation of the project
has taken longer than originally
planned due to staffing recruitment
challenges
•
This was an area of priority in 2014/15 because
increasing numbers of Hospice patients
experience difficulties in communicating their
needs. The Hospice had an established group
of clinicians – ‘Mindset’ - who had previously
developed resources and led teaching sessions
to guide other professionals. There was a need to
look at how national resources could be adapted
to meet the needs of palliative and end of life care
patients to ensure that staff were able to use the
tools in practice.
The key targets for 2014/15 were:
•
The use of the ‘Helping us Understand You’
booklet and the resources will be evaluated
in May 2015 through focus group discussions
with families and staff
Priority 2: Patient Experience
•
Development of the ‘Helping us understand
you’ booklet.
Result: The ‘Helping us understand you’
booklet has been developed in consultation
with members of the Hospice Mindset
Group and the wider clinical teams. Two
patients and a carer also gave their views.
Discussions with the patients, the carer and
staff gave information on how this booklet
may be most effectively implemented.
Staff trained to use new resources to
support the patient experience
Result: The ‘Helping us understand you’
booklet was launched on 23rd February
2015 and is available for use by patients on
the In-Patient Unit, in the community and in
Day Services. Mindset members have been
identified as ‘Champions’ to support the
roll-out of the ‘Helping us understand you’
booklet and to encourage the appropriate
use of the resources. Posters and information
leaflets were provided for staff to promote
effective implementation. An information
poster was exhibited for patients and carers
to highlight its value in supporting
patient-centred care.
•
A number of resources have been acquired
to support communication, reminiscence and
relaxation. These include books, DVDs,
fibre-optic lights and objects of interest.
Quality Account 2014/2015
13
•
Development of two special interest groups
comprising: Staff trained in supportive
communication
Result: A one day bespoke training
programme on supportive communication
techniques will be delivered at St. Gemma’s
Hospice on two separate occasions on the
20th May and 10th June 2015. The teaching
will be delivered by someone who is both
a speech and language therapist and a
dementia care trainer from the University of
Bradford, School of Dementia Studies. The
following topics will be covered:
• How people communicate
• Types of communication difficulties
• Using Total Communication techniques to engage people with communication difficulties
• How to use communication aides and
tablet technology to engage with people with
communication difficulties.
Members of St. Gemma’s Hospice staff
who attend will be invited to form a special
interest group to embed supportive
communication techniques in practice.
•
14
Staff trained in use of the DisDAT tool
Result: Training on the DisDAT tool is being
rolled out. It has currently been
delivered to the community
team. There are plans to
disseminate this training
through various groups
of clinicians including
the doctors, senior
sisters, Day Services
and therapies. Small
group teaching
sessions will also
take place on the
In-Patient Unit for
ward staff. The
use of supportive
communication
techniques and
the DisDAT will be
evaluated through focus
group sessions with staff in
November 2015.
Overall implementation of this
objective has been successful; steps
taken in 2014/15 will be evaluated and built
upon in 2015/16, and subsequent years.
Priority 3: Clinical Effectiveness
Assuring the quality of out of hours advice
and information provided by the Hospice to
patients, carers and healthcare professionals
This was a priority in 2014/15; although out of
hours telephone advice was available through the
St Gemma’s Nurse in Charge, there was variation
in the advice given. In addition, there were no
face to face specialist palliative care services
in the community at weekends. The targets for
2014/15 were:
•
From April 2014 a Community Clinical
Nurse Specialist will work 8.30am-5pm
at weekends and bank holidays offering
telephone advice and will visit patients if
needed
Result: The Community Palliative Care
Service was enhanced in April 2014,
with support from the Leeds Clinical
Commissioning Groups. A Clinical Nurse
Specialist (CNS) now works every weekend
and bank holidays, 8.30am to 5pm. Support
continues to be provided by the medical
Consultant on call when required. The
Community and Day Hospice team leaves
details of patients to be contacted
for support and advice over the
weekend, patients referred
to the service on a Friday
can be contacted if they
have urgent needs,
home assessments
and reviews can
be undertaken if
required, calls
regarding patients
not already known
to the service are
received.
This has enabled
a much more
comprehensive and
equitable service to
be provided to patients,
families and professionals.
It is a proactive rather than
reactive service and the CNS can visit
when needed as well as offer a telephone
service. The Hospice In-Patient nurses who
previously took phone calls have more time
to care for patients on the wards.
Quality Account 2014/2015
•
The enhanced community weekend service
will be evaluated
Result: An evaluation of the service was
undertaken by Healthwatch Leeds, an
independent organisation which seeks and
represents the views of people who use
health services. They contacted 42 people,
by phone, who had used the St Gemma’s
weekend service. The evaluation found the
service to be of a very high standard and
invaluable for a range of people coping with
emotional and stressful circumstances.
The main benefits identified were:
• Emotional e.g. reassuring, reduces
anxiety and feelings of isolation
• Family and carers support e.g. emotional
and financial
• Pain management and advice e.g.
medication advice, visit to assess, nurses
writing prescriptions
• Choice and involvement e.g. listening,
inclusion in decision making
• Gateway to other services e.g. contacting
other services, providing information
Key themes were identified in four main
areas:
• How easy the access to the service was.
• It offered a ‘one stop’ approach which
greatly reduced anxiety of callers as the
CNS would get the support needed for
them rather than them having to seek
themselves and navigate confusing
systems and find numbers etc.
• Support was available regarding a
wide range of issues.
• Hospice Staff were found to be
caring, knowledgeable and
professional.
The benefits of the service are clear to those
who use it but also to the CNSs themselves
and other colleagues
•
A training needs analysis of ward nurses
who manage out of hours calls will be
undertaken in November 2014
Result: The nurses on the In-Patient Unit are
the first contact for callers to the Hospice
in the evening and overnight. It is therefore
important to ensure they have the training
and support to enable them to provide
the care needed. In-practice training has
been provided by one of the St Gemma’s
Community Clinical Nurse Specialists to the
In-Patient nursing staff. This has included
time discussing needs and monitoring the
standard of responses to callers. Training
has been provided on a one to one or small
group basis, based on the areas the nurses
identified and using examples of calls
received and discussing the best way to deal
with these and resources available including
symptom control guidance. Out of the 25
nurses who take on this advice role 23 (92%)
have now received the training. This will be
continued on an ongoing basis.
Patient/ carer comments
included:
‘Stops us from feeling isolated,
we know there is always help/
advice available.’
‘Not having to go to an NHS
hospital. Being able to get
specialist advice and help from
a hospice. Being treated as an
individual.’
‘Brilliant - I think I would have had a nervous
breakdown. One telephone call - solves
problems.’
Quality Account 2014/2015
15
•
A secondment programme for In-Patient
nurses will start from September 2014
that will enhance knowledge and skills
of community services and the needs of
families at home. They will move into the
community and Day Hospice team for a
month with specific objectives
Result: An additional way to develop staff
to enable them to give advice was identified
as a secondment programme from the InPatient Unit in to the Community and Day
Services team. Funding was identified within
the Hospice budget to increase the In-Patient
nursing establishment by one full time nurse.
The programme has been developed with a
four week programme of activities planned
and clear outcomes. However, unfortunately
it has not been possible to start this as yet
due to difficulties in recruiting nurses up to
the new establishment levels; the shortage
of qualified nurses is a national issue and not
unique to the Hospice. Despite this, some
nurses have spent a day with the team. It is
hoped the secondment programme can start
in September 2015.
•
•
The current resource folder containing
information will be developed further by
September 2014
Result: A resource file has been developed
for the In-Patient Unit containing flow charts
regarding the main symptoms experienced
by patients and information regarding
medication and how this can be accessed
and used in community.
Competencies for Out of Hours assessment
by staff will be further developed
Result: The Hospice has been working with
Skills for Health to develop competencies
for nurses. It has been valuable to use the
expertise of this organisation. The first draft of
the competencies has now been developed
and these are being considered by the
Hospice.
Overall, significant progress has been made
to meet the key aims within this priority. The
weekend service has been very valuable and
of a high standard. Work is well underway to
develop the nurses on the In-Patient Unit and
clear plans are in progress to continue this.
Review of Quality Performance
The Hospice is committed to continuous quality
improvement with leadership focused on
professional development for the clinical teams,
service improvements for the patients, planning,
prioritising and ensuring best use of resources.
The Hospice supports informed patient choice and
strives to deliver care where the patient wishes to be;
either in their own home or care home with Specialist
Nurse and Medical Consultant support or in the InPatient Unit.
Reporting systems are in place to ensure
robust governance arrangements. The Clinical
Effectiveness Group incorporating clinical audit
Table 2
Review of Hospice Data
and practice enquiry is part of the Academic Unit
of Palliative Care; this will work during 2015/16
with a new Quality Assurance Group. The Quality
Assurance Group will report to the Hospice Clinical
Governance Committee which in turn reports to the
Board of Trustees.
Monitoring Activity - A Review of
Hospice Data
Hospice data is regularly submitted to Leeds South
and East Clinical Commissioning Group.
2014 / 2015
2013 / 2014
Change %
1,043
1,018
2
% cancer diagnosis (new referrals)
78
82
-4
% non-cancer diagnosis (new referrals)
22
18
4
Number of admissions
541
564
-4
Average length of stay (days)
14.6
14.1
4
1,328
1,178
13
74
67
7
4,196
3,913
7
794
654
21
413
419
-1
1,321
1,223
8
745
425
75
2,531
2,714
-7
Data collection
error
2,689
Unable to report
Overall Service – Patient Care
First referrals to In-Patient Unit, Community and Day Hospice
In-Patient Unit
Day Hospice
Attendances
% places used
Community
Community Nurse Specialist and Advance Nurse Practitioner
face to face consultations
Medical face to face consultations
Clinical Support Services
Social Work referrals
Adult bereavement contacts
Young People’s Bereavement Service contacts
Complementary therapy contacts
Physiotherapy, occupational therapy and dietetics contacts
Overall activity has increased across the Hospice in 2014/15 particularly in Community, Day Services and
across Bereavement Support. Overall referrals have been stable and there has been a slight reduction in the
number of admissions. The In-Patient Unit has had to reduce bed capacity during the year due to nursing
shortages. Nationally nursing recruitment has been a challenge, the situation is improving and we anticipate
being at full establishment by June 2015. The number of non-cancer patients accessing hospice services
continues to increase in line with the Hospice strategy; of widening access to all patients who have palliative
and end of life care needs.
16
Quality Account 2014/2015
Quality Account 2014/2015
17
The demand for community services continues to
grow and is line with the national end of life care
strategy. Out of hours support, a priority in 2014/15
Quality Account is now significantly improved; 7
day a week Clinical Nurse Specialist Service was
introduced. Healthwatch evaluated this new service.
The evaluation showed the positive impact it had on
patients and families (for further information see part
3, priority 3). A number of patients who are dying do
not have specialist palliative care needs but do not
wish to die in hospital and need a level of support
that cannot be provided in their own home.
The Hospice has commissioned
four end of life care beds in the
Greenacres Nursing Home,
with support of the CCG.
This is pilot project has
identified new ways of
supporting high quality
care for patients in the
community, through
sharing knowledge
and skills.
Day Hospice has
attendance has
increased with
occupancy averaging
74%. This increase was
anticipated in 2013/14
report. The rehabilitation
programme has been well
received by patients with
physiotherapy leading exercise
classes and a cycling challenge on the
exercise bike inspired by the Tour de France.
Bereavements services are now fully staffed and has
seen a 75% increase in the number of contacts for the
Young People’s Service. We are wanting to extend
this further hence a priority for 2015/16. The further
development of this service is a priority for 2015/16;
engaging young people with shaping the service,
increasing community facing work and continue to
raise awareness of the service enabling access for
a greater number of young people. The Hospice has
continued to support CRUSE clients, these figures are
not included in our general statistics.
Our complementary therapy service has seen a
reduction in service this was due to staffing issues
which has since been resolved. The level of service
contacts has risen in Quarter 3 and Quarter 4. The
service continues to be highly valued by patients and
carers.
18
The physiotherapy, occupational therapy and dietetic
data have shown some anomalies that indicate data
entry issues. The contact figure generated cannot be
validated and is not included.
Key Quality Indicators (KQI)
Assurance of the quality of patient care through
multiple measures is central to patient safety and
promoting a positive patient experience.
The Hospice has an extensive range of
KQIs; those of greatest significance
are set out in Table 3. Information
for KQIs is gained primarily from
the patient’s electronic record,
incident reports and laboratory
reports for infection incidents.
The Hospice has worked
Hospice UK and is now part
of a national benchmarking
programme with over 90
adult hospices, nine of which
are comparable in size to St
Gemma’s. The tool focuses
on pressure ulcers, slips,
trips, falls and medication
incidents.
The Hospice promotes an open
reporting system, recognising that
patient safety is everybody’s business.
It supports and upholds the Duty of
Candour, and will continue to inform and
involve patients and families in understanding any
errors or incidents that have resulted in patient harm
under Hospice care.
Table 3
Key Quality Indicator (KQI)
2014 / 2015
2013 / 2014
Five priorities of care – number of patients with a personalised care plan for care of
the dying
66%
66%
Number of patients achieving preferred place of care/ death (where preferred place
recorded)
73%
71%
Total number of complaints
8
9
Number of complaints fully upheld
1
2
Number of complains partially upheld
2
5
Number of complaints not upheld
5
2
Internal drug incidents
31
30
Internal drug incidents - near misses
4
11
110
108
Number of patients developing pressure ulcers Grade 2
77
73
Number of patients developing pressure ulcers Grade 3
1
2
Number of patients admitted with MRSA
0
1
Number of patients who developed MRSA during admission
0
0
Number of patients admitted with clostridium difficile
1
0
Number of in-patients who developed clostridium difficile during admission
1*
0
Complaints
Patient Safety
Number of slips, trips and falls
Key Quality Indicator (KQI)
*not known whether acquired or transferred
The majority of incidents in the Hospice are near
misses; this means there has been no patient harm
and a potential incident has been avoided due to
a risk being identified before an incident occurred.
Lessons from near misses are shared and practice
modified as a result. The Hospice works with other
health and social care organisations where an
incident has been reported to or observed by the
Hospice and warrants further investigation. All
incidents are discussed by the Clinical Risk Group
and a report submitted to the Clinical Governance
Committee where further recommendations may be
added to the agreed
Quality Account 2014/2015
Quality Account 2014/2015
19
KQI – Personalised care plan for the
dying patient
The Hospice has been acting on the
recommendations of the Neuberger report ‘ More
care, less pathway’ (DH 2013) and the subsequent
publication ‘One chance to get it right’ (DH 2014)
promoting the five priorities of care; recognise,
communicate, involve, support plan and do.
Further developments are planned as the Hospice
is working with other providers across Leeds to
implement a consistent approach to care planning
and recording in the last days of life across the
city. The Hospice is part of the electronic palliative
care coordination system (EPaCCS) which allows a
patient’s wishes about end of life care to be shared
with other providers with the patients consent.
KQI – Preferred Place of Care/ Death
The Hospice supports patients to achieve their
preferred place of care. Recording a patient’s
wishes and sharing those with the patient’s family
where the patient gives their consent, is becoming
integral to practice. Sometimes we cannot meet the
patient’s preferred place of care, for example where
a patient wishes to be in a Hospice but we have no
beds available. On average two thirds of our
patients whose wishes were recorded achieved their
preferred place of care / death.
KQI- Clinical Complaints
During 2014/15 we received eight clinical
complaints, of the eight complaints one was
owned by another health care provider however
St Gemma’s had been involved in one episode of
care and were asked to respond and account for
the actions taken. One complaint was fully upheld.
The Hospice found there had been a failure in
procedure and a GP had not received information
in a timely way. The Hospice revised systems and
this has prevented a recurrence. Two complaints
were partially upheld and both included elements of
poor communication. Our communications training
is a high priority for the Hospice and is developed
year on year. We have fully investigated all the
complaints received and responded in detail. We
regret that anyone feels that have not received
a high standard of care from the Hospice. We
treat complaints as important for the continuous
improvement of our services and we seek to learn
from the feedback we receive.
KQI - Pressure Ulcers
KQI - Internal Drug Errors/ Near Misses
The Hospice manages a high volume of patients’
medicines, including controlled drugs. On average
over 3000 controlled drug checks are undertaken in
a three month period (a quarter) across the Hospice.
All drug errors are graded; 0 = near miss through to
level 6 = Fatality. The highest grade of internal error
in 2014/15 was level 2 (1 error). This indicates an
incident has occurred with minor injury/ observation
required. The level of patient related drug incidents
is similar to 2013/14. The Hospice captures external
incidents but only reports on internal incidents for
the purpose of the Quality Account. The majority of
incidents were level 1 (86%); these relate to minor
errors where there was no harm to the patient. All
incidents are taken seriously and by acting on the
low grade incidents the Hospice seeks to learn
lessons and prevent serious incidents occurring.
The Hospice detects a significant number of external
errors (9). These are errors which are caused
by another organisation such as a chemist, GP
practice, hospitals or community services. We share
such errors with the external organisation and where
appropriate offer support, for example through
training.
KQI – Slips Trips and Falls
The level of slips trips and fall has remained at a
similar level to 2013/14. Falls were a Quality Account
priority in 2014-15. It is positive that the levels of
falls have not significantly increased however it is
believed a lot more can be done to reduce the level
of falls. Because we have not seen a reduction in
the number of falls it has remained our patient safety
priority for 2015/16 as is discussed further in part 2
and 3.
20
Quality Account 2014/2015
The number of patients who have acquired a Grade
2 pressure ulcer whilst under Hospice care is 77;
this is slightly higher than last year, however there
has been a reduction in the number of Grade 3
ulcers. The Hospice reviews all Grade 2 ulcers as
to whether they were avoidable. An assessment
is made of whether all appropriate measures were
taken to avoid a pressure sore including - patient
assessed within six hours of admission, care plan
instigated including positioning, nutritional needs
and appropriate equipment used to reduce risk,
a wound care plan was in place where the sore
required a dressing. The numbers of avoidable
and unavoidable sores are reported to Hospice UK
as part of a national bench marking programme.
Of the 77 sores recorded seven were found to be
avoidable. Of the 70 remaining sores all appropriate
measures had been taken.
The Hospice is now taking part in a research project
– using PURPOSE T (a risk assessment framework)
to see if there are any further additional actions that
can be taken. PURPOSE T incorporates key risk
factors (including skin status and pain) and makes a
distinction between patients who have no pressure
ulcers but are at risk and require primary prevention,
and those patients who have an existing pressure
ulcer or scarring from a previous pressure ulcer who
require secondary prevention and treatment.
KQI - Infection rates
Infection rates continue to remain low in the Hospice.
A bare below the elbow policy is in place across
the In-Patient Unit. Patients who are admitted with
infections are nursed in a single room. It is not
always possible to identify if patients have acquired
an infection at the Hospice or were admitted with the
infection in situ; patients are not routinely screened
for infection upon admission. Infection control
training is part of mandatory training; hand hygiene
is continually promoted and monitored through
audits with all staff and visitors throughout the
Hospice.
Benchmarking – Falls, Medication
Incidents and Pressure Ulcers
The Hospice is part of Hospice UK national
benchmarking programme with over 90 hospices
participating. The Hospice is benchmarked against
other Hospices who have 25 beds or more (11
hospices). The Hospice has shown over the 12
months that it is below average on number of
pressure sores and drug errors but slightly above
average on falls. The benchmarking has led to a
series of tele-hospice conference calls to compare
and share best practice.
Quality Account 2014/2015
21
Feedback from the Young People’s Bereavement Service
Patient and Family Experience of the Feedback received in 2014/15
The In-Patient Unit introduced the friends and
family test, which it shared with Healthwatch Leeds
prior to launching. A group of volunteers have been
trained and visit the Hospice monthly, meeting with
patients and family members to complete the survey.
Volunteers commenced in November 2014 and to
date 24 questionnaires have been completed, 20
by patients and four by family members or friends.
100% of respondents said they would if the need
arose wish to be cared for by St Gemma’s and
87.5% rated care as excellent. Respondents are
asked if there is anything they would prefer us to
do differently and is there anything we can improve
upon. The comments are very positive; the points
raised are generally addressed in real time so we
can improve the immediate experience for patients.
thing that
o
n
is
e
r
e
Th
ging. My
n
a
h
c
s
e
ir
requ
ed
eing follow
b
e
r
a
s
e
is
wish
ppy with th
a
h
m
a
I
and
“
”
The men
“
u, sometim
see
es
There is
nothing to
improve,
is
everything
excellent
“
”
ms to hav
,
e ‘complic
dishes on
ated’
. Howeve
r, if he
does not
like a dish
there is
no proble
m
This
”
has been
addresse
new Chef
d with the
and there
is
a
n
alternative
plain men
u available
.
“Don’t want my family contacted through the night if
blood sugar drops” (fedback to Ward Nurse).
“Nothing, apart from being able to smell cigarette
smoke from smoking room”.
Community patients - formal evaluation by
Healthwatch
Many positive comments have been received. These
included:
Brilliant - I think I
would have had a
nervous breakdown. One
telephone call - solves
problems
“
”
Someone
“
to
spea
k with – I
really nee
ded
emotiona
l
support
The young people’s service has grown this year with
the appointment of two Young People’s Bereavement
Workers. This allows a wider reach to support young
people and their families in coping with their grief.
With the support of our volunteers, we offer one to
one sessions, group events and work with schools
and community groups to support young people.
Our partnership work with four local schools has
included working with learning mentors and teachers
to support younger children with bereavement
issues, advising about materials and techniques to
use.
Events for young people this year included an Easter
eggstravaganza, Children’s Day to Remember, a
Drama Workshop, Pantomime, Christmas celebration
and two 10 pin bowling trips. The ages of the
children have been between 3 and 16 years, hence
the variety. Children express emotions differently;
normalising interactions and meeting others is very
important for them in understanding their own grief
and starting to enjoy life again.
We ask young people and families for feedback
following each event, some responses include:
”
e call,
n
o
h
p
le
One te olved our
“which res urance
ss
y. Rea elpful
t
e
i
x
n
a
very h
given, g it was
knowin le
”
availab
Other comments included
‘Staff have shown so much care & kindness. Patient
feels as soon as she puts a foot inside the Hospice
she feels better. Staff can’t do enough and are
always there.’
hank god
T
“
you were
there ”
The smoking rooms have now been closed, although
there is smoking provision outside.
erful,
Staff are all wond
“co
nsiderate & caring.
Food - both for patients &
in the Bistro is very good
”
22
Quality Account 2014/2015
Quality Account 2014/2015
23
Spiritual Care Service
Staff Experience of Working at the Hospice
The Hospice provides spiritual support, helping
patients and families during highly emotional times
in their lives. St Gemma’s supports patients and
families of all faiths and beliefs and those who have
no faith. Monthly memorial services are offered
to all friends and families to allow them to fondly
remember their loved ones. The Memorial Services
has been attended by 809 family members in
the past year. Feedback following the services
continued to affirm that this aspect of our care is
very well received. The comments included:
‘It was beautiful occasion. A memorial service that
gave me peace.
Hearing my husband’s name and taking the candle
to be lit was very poignant, even though I have lit
other candles for him since his death.’
‘All the prayers and the readings and the address
were so appropriate and also helped afterwards.’
‘It was wonderful. There is very little more that I can
say. His name being read out and my grandson
went up to light his candle because he was so close
to my brother and I know he has now accepted that
he has gone but at least not forgotten and I was so
proud.’
Adult Bereavement Support
We are supported by eight Volunteer Counsellors
who support our two Adult Bereavement Counsellors
to offer one to one counselling; currently we are
offering this one to one counselling service to 78
people.
investigating the appetite for developing further
support groups.
We continue to support 24 people at our monthly
Bereavement Support Group which is facilitated
by our Counsellors with the help of some of the
bereavement volunteers. This year we will be
“Without you I wouldn’t be where I am right now.
Thank you for helping me. So glad there’s people
like you to help when you think you can’t go on”
Feedback from adult bereavement clients has
included:
Engagement with the Public by the Hospice
St Gemma’s continues to work hard to engage
and communicate with the Leeds community. The
Hospice involves and interacts with the public in
a variety of ways.
The Hospice also carries out high
profile advertising campaigns,
including bus adverts, to promote
areas of our work such as
research into pain management
via the Academic Unit of Palliative
Care.
Digital communications remain
an important part of our
communications mix. The
St Gemma’s website is visited
by around 8,000 people per
month, we interact with over
10,000 people daily via our
social media platforms and
we engage with over 10,000
supporters per week via email.
We continue to use traditional
marketing tools too, including
sending an informative newsletter
about our work and developments to
around 40,000 supporters three times a year.
We frequently review and update our information
leaflets and DVD in line with feedback we receive
24
from patients, supporters or the public. We maintain
relationships with key healthcare professionals
across the region to promote access to our
information and services.
St Gemma’s supports the national
Dying Matters awareness week
in May. We use the campaign to
engage with the community about
death, dying and bereavement and
encourage discussions across different
forums and within diverse groups across the
community. For example, we continue to carry out
educational sessions with school children, provide
bereavement support groups and communicate with
churches and multi-faith groups.
Quality Account 2014/2015
Staff turnover in 2014 was 19.49% (18% in 2013)
and sickness absence was 5.79 % (6.4% in 2013).
Throughout this period St Gemma’s Hospice
continued to experience an increased level of
change which continued to impact on staff turnover.
Sickness absence has now begun to improve.
St Gemma’s purpose, vision and values;
commencing a review of terms and conditions
of employment; redefining the management and
leadership within the Hospice and starting to identify
increased opportunities for cross team working
across the organisation.
Staff have access to an Occupational Health
Service, complementary therapy service and clinical
supervision. Communication within the Hospice is
supported by a monthly staff bulletin, a quarterly
question time with the Chief Executive and at bimonthly meetings of the Employee Consultation
Group.
Staff are supported with an internal education
programme. 96% of clinical staff attended
mandatory training in 2013/14. The following are
some examples of the additional opportunities
which have been available to staff in the last twelve
months: Cognitive therapy, falls assessment,
non-invasive ventilation and oxygen management,
advance care planning, Leaders and people
programme, managing time and prioritisation and
Helping people to learn.
The Hospice has a robust system in place for
raising concerns with a Whistleblowing Policy and
procedure available to every member of staff –
employee and volunteer.
During 2014 staff engagement has been an
important area of focus in helping to build a
committed and high performing workforce. During
the year St Gemma’s has undertaken three key
staff engagement exercises: Investors in People
Accreditation, staff survey and one to one meetings
between staff and the Chief Executive. These
initiatives highlighted that staff are highly motivated
to see the Hospice succeed and feel very strongly
that the organisation is committed to patient care.
Also highlighted was that most employees believed
that the Hospice effectively communicated its goals
to them and that they were clear about what was
expected of them in their roles.
Other developments have included refocusing the
strategic direction of the Hospice; redeveloping
The annual Hospice Conference was held in June
2014, this focused on vision and values. This was
a highly interactive conference, engaging clinical
and non clinical staff in what the values mean to
them, their role and the Hospice. Staff are supported
to attend external training and to continue their
professional development in degree level studies.
The next steps are:
• Provide opportunities for cross team working and
joint team collaboration
• Build on our existing training and development
provision
• Increase our focussed volunteer opportunities
• Finalise and embed our Values and Behaviours
framework
Quality Account 2014/2015
25
PART FOUR
Statement from NHS Leeds South and East Clinical
Commissioning Group
Leeds South and East Clinical Commissioning Group (CCG) welcomes the opportunity to comment on
St Gemma’s quality account for 2014/15. Leeds South & East Clinical Commissioning Group is providing this
narrative on behalf of all three Leeds Commissioning Groups including Leeds West CCG and Leeds North
CCG. We have reviewed the account and we believe that the information published, that is also provided as
part of the contractual agreement, is accurate. We are supportive of the priorities that have been proposed for
the forthcoming year, and pleased to note the specification of standards and key target measures.
In November 2013 the Government published its response to Sir Robert Francis’s report into the events
at Mid-Staffordshire hospital. This report, entitled ‘Hard Truths’, accepted the vast majority of Sir Robert’s
recommendations and confirmed the need to focus on high quality health care. It is crucial that commissioners
and providers work together to ensure this.
We are therefore pleased to see that the organisations priorities focus on the elements of quality, namely
clinical effectiveness, patient safety and patient experience. We would like to acknowledge that the document
is well written, easy to read, interesting and informative. We would also like to acknowledge that Health watch
were invited to undertake an independent review, evidencing that as an organisation, St Gemma’s practices
openness and candour.
Statement from Leeds Healthwatch
Introduction
Healthwatch Leeds hosted a session for all the organisations providing NHS services in Leeds who are required
to provide annual Quality Accounts and have invited Healthwatch Leeds to comment on them as a part of their
statutory duty. Each organisation was invited to present their account with a focus on accessibility, evidence
of links between patient feedback or engagement and priorities, the measures of planned improvement and
progress and benchmarking. Healthwatch volunteers were also invited to identify areas of good practice.
As the actual copies of the QA were not provided by everyone, a general recommendation is to produce a more
accessible summary, possibly in easy read that has a focus on the issues identified as important and influenced
by patients, service users or their carers.
Healthwatch Leeds comments for the Quality Account
St Gemma’s Hospice Quality accounts show a clear link between their engagement with patients, carers
and staff and their priorities for improving care. There are examples of evaluation and supported feedback
including work to improve the engagement of young people. There is evidence of benchmarking linking to
the improvement priorities. Examples of good practice include patient outcome measures and work to avoid
hospital admissions when they are not the best choice for the patient. We welcome the way the hospice has
taken on board the Healthwatch comments from the previous accounts and continued to improve their Quality
Accounts.
We are pleased to note the level of assurance undertaken by the Board of Trustees to understand the Hospices
core business and provide the Board with assurance of the quality of the care provided, through a range of
quality visits.
It is pleasing to see that St Gemma’s is part of the National Hospice UK Benchmarking Group, which provides
useful insight and comparative understanding. We are particularly interested in the falls and pressure ulcer
work which is taking place at St Gemma’s and pleased to see this continues to be a high priority for 2015/16.
We are pleased and interested to note the ongoing commitment to research and development activity and
the level of education delivered both within the organisation and to system partners, this corroborates the
organisations commitment to high quality care in line with the recent Francis recommendations and professional
standards. It is of particular interest to see that St Gemma’s host the Academic Unit of Palliative Care (AUPC) in
partnership with the University of Leeds.
We are concerned to note the increase in drug incidence, grade 2 pressure sores and slips, trips and falls,
however we note that the organisation is actively reviewing practice in order to learn, which is reflected in the
improvement priorities for 2015/16.
It is noted that the number of complaints have reduced in 2014/15, although the number of complaints not
upheld has doubled. This is concerning as these are issues that have been perceived by patients / carers,
where there experience was not as they would have expected it to be. However we do acknowledge that
St Gemma’s continues to engage with service users and the public and it is particularly pleasing to note that
2015/16 priorities are based on themes/trends identified through the investigation of complaints received in
2014/15.
We continue to have a positive relationship with St Gemma’s Hospice and we look forward to working with them
in 2015/16 with the aim of delivering the highest standards of patient centred, palliative care.
26
Quality Account 2014/2015
Quality Account 2014/2015
27
Appendix 1
Glossary
• The following are required by law to be included in the Quality Account. They currently do
not apply to the Hospice.
CQC
Care Quality Commission
This is the independent regulator of health and social care in England. It regulates health and
adult social care services provided by the NHS, local authorities, private companies or voluntary
organisations.
www.cqc.org.uk
EPaCCS
Electronic Palliative Care Co-ordination System
EPaCCS provides a shared locality record for healthcare professionals. It allows rapid access
across care boundaries to key information about an individual approaching the end of life
including their expressed preferences of care.
GSF
Gold Standards Framework
GSF is a systematic evidence based approach to optimising the care of patients nearing the end
of life by generalist providers.
NICE
National Institute for Health and Care Excellence
NICE provides guidance which helps health and social care professionals to deliver the best
possible care based on the best available evidence.
www.nice.org.uk
• The number of national clinical audits and the number of national confidential enquiries
• The proportion of income conditional on achieving quality improvement and innovation
goals agreed through the Commissioning for Quality and Innovation payment framework.
• The Hospice was not subject to the Payment by Results clinical coding audit during
2013/14 by the Audit Commission.
• Records submitted to the Secondary Uses service for inclusion in the Hospital Episode
Statistics.
References
Department of Health (2014) One Chance to Get it Right
Department of Health (2013) More Care, Less Pathway: A Review of the Liverpool Care Pathway. (Chaired by
Baroness Julia Neuberger) Williams Lea (London)
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.
pdf
Further information
For further information about this Quality Account please contact the Quality Manager (0113 218 5500)
Department of Health (2008) End of Life Care Strategy: Promoting High Quality Care for all Adults at the End of
Life. The Stationery Office, London.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_086345.
pdf
National Institute for Health and Clinical Excellence (2011) Quality Standard for end of life care for adults
http://www.nice.org.uk/media/EE7/57/EoLCFinalQS.pdf
Information for patients - http://www.nice.org.uk/media/E9C/A9/EndOfLifeCarePatientInfo.pdf
NICE Clinical Guideline (CG) 161 Preventing Falls in Older People (2013)
http://guidance.nice.org.uk/CG161
Report of the Mid Staffordshire NHS Foundation Trust (2013) (Chaired by Robert Francis QC) The Stationery
Office: London
http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf
Sibbald RG, Krasner DL, Lutz JB et al (2009) The SCALE Expert Panel: Skin Changes at Life’s End. Final
Consensus
http://www.epuap.org/scale-skin-changes-at-lifes-end/
28
Quality Account 2014/2015
Quality Account 2014/2015
29
St Gemma’s Hospice is a local, independent charity,
providing expert medical and nursing care to thousands of
local people every year – all free of charge to patients and
their families.
If you would like more information about our work, please contact us:
Website: www.st-gemma.co.uk
Email:postmaster@st-gemma.co.uk
Hospice Reception: 329 Harrogate Road
Moortown
Leeds, LS17 6QD
www.twitter.com/stgemmashospice
www.facebook.com/st.g.hospice
Registered Charity No. 1015941
0113 218 5500