Quality Account 2014/15
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Contents
PART ONE
Statement on Quality from the Chief Executive.............................................................................5
Statement on Governance and Public Benefit……………..…………………………………………………………...7
PART TWO
Priorities for Improvement 2015/2016..........................................................................................9
Review of Services.........................................................................................................................18
Care Quality Commission (CQC) Inspection...................................................................................21
PART THREE
Priorities for Improvement 2014/2015 .....................................................................................23
Review of Quality Performance..................................................................................................29
PART FOUR
Statements from:
Sheffield Healthier Communities and Adult Social Care Scrutiny Committee Board................32
Sheffield Clinical Commissioning Group ...................................................................................34
Sheffield Healthwatch ...............................................................................................................35
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Part one:
Chief Executive’s statement
On behalf of St Luke’s Executive Team and the Board of Trustees, it gives me great
pleasure to present this, the fourth quality account for St Luke’s Hospice. This account
gives us the opportunity to provide information on how we delivered last year’s priority
areas and how we measure and gain assurance about the quality of our services, and to
identify the quality actions we intend to implement during the coming twelve months.
Over the last year St Luke’s has built upon the achievements of recent years which
culminated in the official opening of our new In Patient Centre in 2014. Our focus for the
future is to develop St Luke’s activities within the community – in homes and nursing
homes – where the majority of our patients and their families spend their time. It is
important that – as well as providing excellence in day and in-patient care – we provide
the very best support to people dealing with end-of-life challenges in their home setting.
To this end, we completely changed the structure of our community specialist palliative
care nursing team in 2014, bringing new skills and expanding services. We are
particularly proud to have developed a new Rapid Response service which provides
medical and nursing support to patients and families facing crisis at home – and for
whom the only alternative might have been hospital admission, which would add to
trauma and discomfort, as well as tying up hospital resources. This new service has
quickly become an important part of the local health support for patients at home.
We’ve also launched some innovative pilot schemes, looking at nutritional and laundry
support for patients at home, and also developing a new ‘community volunteer’ scheme
which will act as ‘eyes and ears’ for patients in the community and supplement our
clinical care directly – as well as tackling important issues such as loneliness and social
isolation.
All of these new schemes have been launched and piloted from our own resources,
because we believe that by being innovative we will find better ways to care. We’re also
excited to be involved with a new multi-partner project to look at the use of technology to
more effectively support palliative care in the community, with support from the Nursing
Technology Fund.
Having concluded the new building work for the In Patient Centre, we’ve just completed
the transformation of our gardens to make them accessible to all our patients and
families, year round, and to bring the benefits of the outdoor environment to all that need
it. This completes the physical renewal of St Luke’s at our home – Little Common Lane –
which has been an enormous task.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Chief Executive’s statement… continued
Importantly, throughout these changes, the quality of our care always comes first and
foremost. St Luke’s has been heavily involved in the development of the new Care
Quality Commission inspection process for Hospices, and we’re delighted that following
our own extensive inspection we received an overall rating of ‘Good’ based on five
individual ‘good’ assessments from the key lines of enquiry. That we achieved this result
whilst undergoing a significant transformation and change process is very pleasing and
testament to all the staff and volunteers here. I would like to thank everyone involved.
St Luke’s has always been very proud of the care it delivers, but is never complacent and
is always seeking ways to do things better and improve. In deciding our priority quality
improvements, we have listened to our patients, relatives, carers, employees and
volunteers as well as welcoming views from external agencies such as Sheffield
Healthwatch.
The Board of Trustees are fully focused on maintaining and improving the quality and
extent of care we give, and base the decisions they make on managing risk and serving
our beneficiaries. This is reflected in St Luke’s approach to Corporate and Healthcare
Governance which, in conjunction with operational groups, enables me to give assurance
to our Board that the appropriate processes and procedures are in place to underpin our
activities and that these are regularly monitored and reviewed using key quality and
performance indicators.
Despite the current economic climate, the hospice has continued to provide high quality
services to its beneficiaries and remains financially viable, thanks to generous support
from our local community which each year helps us raise c.£5m to supplement our NHS
funding and ensure St Luke’s can stay open. NHS funding still only covers about 29% of
the total income required to ensure St Luke’s can provide its services each year. We
have received some comfort from a two-year guarantee of funding from NHS Sheffield
between 2014 and 2016, and we hope that a further multiple-year arrangement can
succeed it. However, as a charity we are suffering from the zero-inflation that has kept
our NHS funding at a flat monetary amount for five years whilst our cost base and
demand levels have been rising.
During 2014-15 St Luke’s succeeded in reaching its notional target levels for In Patient
activity included within our NHS contract. More than that, we believe that our contribution
to end-of-life care services in Sheffield is fundamental to the overall delivery of care in
our city, and we are delighted that our NHS Commissioners have reflected this in their
contract with us.
I am responsible for 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 St Luke’s Hospice for the
people of Sheffield.
Peter Hartland
Chief Executive
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Statement on Governance and Public Benefit
St Luke’s Hospice is a registered charity, number 254402, as well as a company
incorporated in England and Wales. It is independent and has no legal connection with
other hospices in the UK.
Governance of St Luke’s Hospice is the responsibility of the members of the Board of
Trustees, who serve in an unpaid capacity. New members are appointed with a view to
ensuring that the Board of Trustees contains an appropriate balance of experience
relevant to the requirements of the operations of St Luke’s Hospice.
The Board of Trustees has delegated a monitoring function to Committees, which
comprise a number of members of the Board of Trustees, members of the Executive and
Management Group and, when appropriate, external members who are selected for their
particular expertise and appointed through approval by the Board.
First line leadership of the hospice is provided by the Chief Executive, who is charged to
ensure that St Luke’s Hospice is run as a cost-effective charity while providing the best
possible care for patients and relatives. The Chief Executive is supported by an
Executive Team, which comprises the Deputy Chief Executive (covering patient service
areas), Director of Medicine and a Director of Finance and Corporate Services. The
Executive Team is supported by a clear and accountable organisation structure including
a Management Group, and other Heads of Department. The emphasis is on leadership,
accountability and empowerment.
Governance and Risk Management Arrangements
St Luke’s Hospice has developed an approach to good governance, which embraces
both clinical and non-clinical risks. St Luke’s Risk Management Strategy embraces a
number of elements.
(a)
Clinical Governance - St Luke’s Hospice has Clinical Governance arrangements
modelled on guidance and good practice within the NHS. Clinical Governance is
defined as the framework through which St Luke’s Hospice will ensure continuous
improvement in the quality of services for patients. This process is overseen by the
Healthcare Governance Committee.
(b)
Non-clinical Risk Management - The Resource and Finance Committee takes
lead responsibility for non-clinical and business risk.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Statement on Governance and Public Benefit continued
(c)
The Board of Trustees - oversees St Luke’s Hospice Risk Management Strategy,
and is involved in the evaluation of our risk environment via the risk register, the
assessment of risk appetite, and the approval of the annual risk action plan. The
Board works in conjunction with the Healthcare Governance Committee, the
Resource and Finance Committee, and the Executive Team in the delivery of the
Risk Management Strategy. During the year there has been continued development
of the strategy and the formulation of processes and monitoring systems. The Chief
Executive has lead responsibility for the development of this approach.
(d)
Financial Control - the Resource and Finance Committee monitors the application
of good financial control and places reliance on the work of St Luke’s Hospice’s
auditors. The Honorary Treasurer provides support and advice in matters of
financial strategy and reporting.
Public benefit
In planning and delivering our services and activities, the trustees and management of St
Luke’s Hospice have given due regard to the need to ensure that the Hospice provides
public benefit – following the Charity Commission’s guidance on these matters.
St Luke’s Hospice’s charitable objectives, and our annual declaration of activities and
achievements (publicly available from the Charities Commission and Companies House)
demonstrate that the hospice provides a vital and free-to-access service to all people in
the city of Sheffield, clearly meeting the requirements of the public benefit test – a charity
providing benefits for the public, and supported by the public.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Part two:
Priorities for improvement
1 April 2015 - 31 March 2016
Priority 1 — Improving access
St Luke’s Hospice was one of the first hospices to be opened in England outside London
and the extensive works identified in past quality accounts have described how the
patient care facilities and gardens have been developed to enhance and improve patient,
carer and relative experiences whilst providing a working environment for our staff and
volunteers that supports the delivery of high quality care.
When evaluating patient comments from the patient safety walkrounds and comments
made by Healthwatch volunteers as part of the Patient Led Assessment of the Care
Environment, in conjunction with the Board of Trustees and Executives’ vision for St
Luke’s in the 21st century, it was recognised that there was a need to improve access
and develop a truly welcoming environment for patients attending the In Patient Centre
and Therapies and Rehabilitation Centre on their arrival and improve way-finding for
carers and relatives.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Improving access… continued
The main objectives for the proposed scheme are to 
Ensure ease of access for all

Improve privacy and dignity by providing natural screening

Improve access safety with defined and well lit walkways

Create an excellent first impression that inspires confidence in care as described in
the fifteen steps challenge, introduced as one of the last quality account priorities.

Improve local environmental control
We will monitor the impact made by this scheme by 
Formal and informal patient and user feedback

Reports from the fifteen steps challenge patient safety walkrounds

Feedback from Healthwatch Sheffield, including the results of Patient Led
Assessment of the Care Environment.
“An amazing place
and I do not know
what me and my
family would have
done without it ”
“I felt welcomed
and cared for from
the moment
I arrived”
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Priority 2 — Community Engagement and Volunteering
St Luke’s Hospice fully appreciates that it could not provide the quality care and services
it does without the tireless work of its 700 plus volunteers across a whole range of
activities.
It also seeks to play a full part in not only enhancing its services to patients but also in
recognising the important role it can fulfil as a community partner to other developmental
organisations.
One example of this is the Young Volunteers Project, which is a year 12/13 apprenticestyle consultancy project lasting 12 weeks, that seeks to introduce young people to
volunteering by providing opportunity for personal development, thus ensuring a positive
experience and lasting benefits for all parties involved.
Those taking part will be able to use the experience as evidence for university
applications, The Duke of Edinburgh Gold Scheme and CVs as part of job applications.
At the same time it is important to identify areas where volunteers can play a full and
active part in improving the patient experience by developing enhanced work streams,
underpinned by robust training and governance arrangements.
A lot of work has already started including 
Working with Voluntary Action Sheffield to develop a quality marker in volunteering
for Sheffield.

A contract with the Department for Work and Pensions and Interserve to find quality
opportunities for mandatory, voluntary and community work placements with a
target to retain a minimum of 30% as volunteers at the end of the programme.

Partnering the National Citizenship Service to provide 16/17 year olds with
community social action projects.

Student engagement with Sheffield Hallam University around community perception
of St Luke’s Hospice.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Priority 2 — Community Engagement and Volunteering ...continued
St Luke’s Hospice will further 
Identify and develop enhanced opportunities for volunteers to support and assist on
the In Patient Centre and in the community.

Maintain and strengthen links with local colleges seeking BTEC placements.

Form links with local schools to offer insight and support to pupils undertaking
health and social care studies.
With regard to the Young Volunteers Project, St Luke’s Hospice will 
Work with local education establishments to identify appropriate students who
aspire to careers in health and social care.

Develop a clear brief, which allows the students to work as a team on a project
related to promoting Allied Health Practitioner services including Occupational
Therapy, Physiotherapy, Wellbeing Services, Social Work and Bereavement
Services.

Provide project objectives, terms of reference, governance arrangements and
mentorship support.
The end result will help ensure our patients, carers and relatives have a better
understanding of the range of services available and how these can enhance their
experience.
One particularly exciting initiative is to develop a group of Community Patient Support
Volunteers. These volunteers will not provide any clinical support but are to be seen as
‘expert friends’ who are matched to patients in a stable stage of their illness that still
require a level of monitoring.
The volunteers role will be to empower patients, improve social contact and promote
activity whilst at the same time giving regard to issues such as general appearance,
wellbeing or even just comments the patient may make. These and other prompts can
give early indications that more specialist help is needed and the volunteers provide
another pair of eyes and ears, with clear guidance on any untoward circumstances, to
ensure that the patients community nurse key worker is informed.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Priority 2 — Community Engagement and Volunteering ...continued
To ensure appropriate governance arrangements are in place potential volunteers will be
subject to initial interview, disclosure and barring scheme check, a full training
programme, a second interview and remain completely connected to the patients key
worker during their defined contact time with the patient.
The initiative is being supported by Sheffield Clinical Commissioning Group who have
granted £90,000 from the systems resilience fund
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Priority 3 - Food and Laundry Services
St Luke’s community team provides comprehensive clinical help and support to patients
in their own home.
Sometimes they recognise that patients and their families are having difficulties and
would benefit from extra support, particularly in dealing with increased laundry
requirements and ensuring patients’ dietary needs are adequately met.
These circumstances often occur when the families concerned do not have extended
family support
In order to help meet these needs, where appropriately identified and following
discussions with the patient and family, St Luke’s will offer the following two pilot
schemes 
A collection, washing, ironing and return laundry service of a community patient’s
bed linen or, where the household may have limited supplies of bed linen, fresh
supplies of hospice bed linen will be provided and collected. This service will be
particularly valuable for patients who may be incontinent and will free up quality
time for the carers to spend with their loved ones.

A delivery service of food freshly prepared from the hospice catering department
which has been matched to the patient’s wants and needs.
Both these services will be provided free of charge or any other cost to the patient or
family.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Priority 4 - Patient Dependency
St Luke’s aim is to ensure that patients are always cared for by staff and volunteers who
have the right experience and skills to provide them with high quality care.
It is also important to ensure that the mix of grades of staff, i.e. qualified nurses and support
staff and volunteers, is sufficient to maintain patient treatment, comfort and safety.
The ethos of St Luke’s is to provide individualised care that is planned and delivered in
conjunction with the patient. The level of care needed and the dependency of individual
patients can therefore impact upon the number and the grade of staff required on a shift by
shift basis.
To achieve the principle of having the right persons with the right skills in the right place at
the right time St Luke’s will

Build upon work already being undertaken within the NHS.

Develop and pilot a patient dependency toolkit.

Ensure policies and processes to escalate patient dependency and staffing concerns
to the Executive Team and the Board of Trustees are robust.
This work will be monitored by the Healthcare Compliance Group and reported to the
Healthcare Governance Committee.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Priority 5 - Enhanced Community Palliative Support Services - EnComPaSS
During 2014/15 327 patients were admitted to the In Patient Centre for palliative or end of
life care. In the same period of time the St Luke’s Hospice community team of doctors and
nurses provided ongoing care and support to 5,787 patients.
As part of its community service development St Luke’s Executive Team has asked itself
three key questions. These are 
How can access to palliative care services be improved?

How can it be ensured that assessment, documentation and caseload management is
consistent, efficient and effective?

What are the best ways to make sure there is continuity for patients at the end of life?
As a result of this self examination St Luke’s will develop and pilot the following three
schemes 
Enhanced assessment, documentation and case load management utilising remote IT
systems.

Development of individual patient/carer web pages.

Reaching out to more patients and carers by the development of delegated specialist
nursing activity to registered nurses, assistant practitioners, carers and patients.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Priority 5 - Enhanced Community Palliative Support Services…. continued
Using technology, one Senior Nurse is able to monitor multiple patients in their own homes
from a remote setting, providing direction to Community Nurses who are already in the
patient’s home, working with the patient and their families. Each Community Nurse is trained
to observe and report patients’ signs and symptoms via a smartphone linked through a
secure clinical portal for real time assessment by the Senior Nurse. The Senior Nurse
becomes the eyes, hands and ears of the Community Nurse.
This will improve quality of care for some of Sheffield’s most fragile end of life patients. It will
also reduce hospital admissions and unnecessary visits to hospital, helping to keep more
end of life patients at home for as long as possible.
St Luke’s has been awarded £250k from the NHS England Nursing Technology Fund in
order to develop the technology and training required to fully integrate all aspects of
EnComPaSS into the hospice. And we are working closely with Sensory Technologies and
CLARHC Yorkshire and Humber, with partnerships including the University of Sheffield and
Western University Canada.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Review of services
In the following review there are a number of statements required by regulations which
have to be included in the report. These are highlighted in italics.
Some statements required by regulation are not applicable St Luke’s.
During 2014-15 St Luke’s Hospice provided the following services:

A 20-bedded In Patient Centre, consisting of fourteen single rooms and two threebedded multi occupancy rooms, which provides 24 hour care and support by a team
of specialist staff.

A Therapies and Rehabilitation Centre which provides medical, clinical and
therapeutic day care services from Monday to Friday to give patients extra support
to manage symptoms, be cared for at home and maximise their life quality.

A Community Nursing Team who provide a Rapid Response Service for crisis
support at home and specialist support, guidance and advice to:
- Patients and families at home
- District Nurses
- General Practitioners
- Nursing homes

Therapy services to support independence and promote comfort including:
- Physiotherapy
- Occupational Therapy
- Wellbeing Services and complementary therapies
- Nurse and doctor led clinics
- Group work including circuit fitness and fatigue management

A Social Work team who provide specialised support and guidance to patients and
their families.

Bereavement Services who provide specialised support and counselling services.

Spiritual Care Services supporting patients and their families.

A Service User Coordinator who works with patients and families to ensure their
needs are being met and to ensure their full involvement in service developments.

An oral history service that allows patients to make an audio recording of their life
story.
St Luke’s Hospice has reviewed all the data available to us on the quality of care in all of
these services.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Financial considerations
Our NHS contract funding in 2013-14 provided 24% of the total recurrent income required
to run St Luke’s services during the year with 76% of income being self-generated by St
Luke’s through fundraising and other activities.
The normal day to day running costs of St Luke’s for 2014/15 were £7.4m.
More than £5m must be raised to cover these costs through donations, legacies,
fundraising initiatives and our chain of charity shops. We rely on a wide variety of
donations, from those who simply donate money, to those who proactively go out and
raise money on behalf of St Luke’s. Thousands of people across the city donate in a
large or small way each year. The small fundraising team support donors wherever
possible, driving income from a wide variety of income streams.
Through the constant application of sound business principles and responsiveness to an
ever changing financial and regulatory landscape we ensure that we deliver our services
as efficiently as possible. We ensure that our costs - both staff and non staff - are
managed effectively and are under our control. We seek to develop collaborative
partnerships within the healthcare and business community. We continue to identify and
exploit future income streams, through the expansion of our retail chain and through the
ever more creative and innovative efforts of our Fundraising team.
As a charity we continually strive to move forward, maximising the use of our resources
to benefit the community and add quality to life for all - patients, families, friends, carers,
employees and volunteers. The importance of providing care centred on the needs of the
patient and their family, supported by employees and volunteers who are valued and
respected, is central to the future development of St Luke’s Hospice. All our key strategic
aims have been built around this central theme and underpin our main aim of ‘Adding
Quality to Life’.
Our contract with the NHS through the CCG is a major element of our funding, but has
been of a fixed monetary value for a number of years. We set notional targets with the
CCG for activity each year, but it is recognised that St Luke’s is only partially funded
through the NHS and delivers, through its unique ability to generate funding and
voluntary support from the people of Sheffield, a service that has an economic value
significantly larger than the funding provided by the state would ever allow.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Research, audits and service evaluations
The hospice recognises the importance of clinical audits and is committed to full
participation in relevant studies. During 2014/15, no national clinical audits and no
national confidential enquiries covered NHS services relating to palliative care. St Luke’s
Hospice only provides palliative care.
National research
St Luke’s recognises the importance of research in helping to improve and develop
services and quality care for patients and is fully committed to participating in appropriate
studies. However during 2014/15 there were no appropriate, national, ethically approved
research studies in palliative care in which we could participate.
The number of patients receiving NHS services provided or sub-contracted by St Luke’s
Hospice in 2014/15 that were recruited during that period to participate in research
approved by a research ethics committee was nil.
Local audits, research and service evaluations
Whilst not involved in national audits, the hospice has a comprehensive register and
programme of local audits, research and service evaluation, a range of which are
mandated as part of a rolling programme. These include 
Infection Control

Medical Records

Advance Care Planning

Oxygen Prescribing

Drug Cards

Psychological Assessment
To promote audit, research and service evaluations, the hospice has developed a simple
handbook to assist proposers through the required stages.
All trainee doctors who have placements at St Luke’s are required to undertake an audit
as part of a quality improvement programme.
All proposed audits, research projects and service evaluations follow a structured
process for approval within the hospice governance arrangements, and the results,
recommendations and action plans are presented to the Healthcare Compliance Group
and the Healthcare Governance Committee, which is a sub group of the Board of
Trustees, that monitor progress against any identified actions.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Care Quality Commission Inspection
St Luke’s is required to register with the Care Quality Commission and its current
registration is for the following regulated activities:

diagnostic and screening services

treatment of disease, disorder or injury

providing supportive and palliative care for adults
The Care Quality Commission has not taken enforcement action against St Luke’s
Hospice during 2014/15.
St Luke’s Hospice has not participated in any special reviews or investigations by the
Care Quality Commission during 2014/15.
The hospice is subject to periodic review by the Care Quality Commission and
participated in the pilot programme of changes to how the Care Quality Commission
undertook their unannounced inspection which took place on the 12th and 13th August
2014.
The inspection involved a lead inspector, a specialist expert and a lay expert examining
the service against five key questions Key Question
Is the service safe?------------
Good
Is the service effective?------------
Good
Is the service caring?------------
Good
Is the service responsive?----------- Good
Is the service well-led? ------------
Good
Overall rating for St Luke’s Hospice --------- Good
The Care Quality Commission report confirmed that St Luke’s was meeting the required
standards and that no remedial measures were required. The full report can be found at
the following website www.cqc.org.uk/public/news/our-latest-reports
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Care Quality Commission inspection continued
What Patients and the Care Quality Commission Said
Patients told the inspector that they were happy with care at St Luke’s and that there was
a strong sense of support, with people receiving care which was centred on their
individual needs.
The following are observations and statements included in the Care Quality
Commission’s report:
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Part Three:
Priorities for improvement
1 April 2013 - 31 March 2014
Priority 1 — Rapid Response Services
Following a successful pilot of a Rapid Response Service, the Community Nursing
Service at St Luke’s Hospice has been through an extensive review and restructure to
facilitate the growth and development of the direct delivery and influence of the hospice
services to patients in their own homes.
The Rapid Response Service was a key element of the redesign of this service given the
positive impact seen during the pilot phase, and the restructure process has given
opportunity to develop an appropriate role profile and specification for the nursing roles.
The model of delivery has also been restructured to introduce clear leadership with a
lead Rapid Response Nurse to deliver the elements of advanced practice required, such
as clinical examination skills and prescribing, and to provide the leadership for a 7 day
service, develop the operational framework for the service for direct referrals, and
facilitate internal escalation of patients who need a same day response.
In October 2014 there were 84 Rapid Response visits delivered by one specialist nurse.
We have now appointed an additional 2 nurses to work in this service.
In 2012 – 2013 there were 61 face to face Consultant home visits. By developing the
integrated model and increasing the medical resource for the service we can
demonstrate the following improvements - From July 2013 – July 2014 there were 161
Consultant and supervised Specialist Registrar home visits which allowed people to
remain in their preferred place of care.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
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Priorities for improvement
Priority 2 - The oral history project
The oral history service at St Luke’s Hospice offers patients the opportunity to make an
audio recording, with most choosing to tell their life story. Patients are guided through an
interview by a trained interviewer, and the interview is recorded onto an audio CD.
Patients receive a copy of their recording on CD and can request extra copies for friends
and family.
To date, 74 patients have made 131 recordings (some choose to record more than one
interview). There are 8 active volunteers who carry out the interviews, along with the
service user co-ordinator.
In 2013/14 we participated in a study carried out by the University of Sheffield to
investigate the impact on patients and relatives of recording oral history in palliative care.
The study provided clear evidence that both patients and bereaved relatives benefited
from the service. One other finding was that patients and relatives often wished that the
patient had made their recording earlier, before factors such as fatigue and voice or
breathing changes had an impact on the recording. To remedy this, we are now able to
offer the service to our patients in the community, whose illness may be at an earlier
stage than our day and in-patients. Volunteers can visit a patient at home, or we can
make hospice transport available to bring the patient in to the hospice. Additionally, we
have partnered with colleagues in the oral history service at the Palliative Care Unit, to
enable their volunteers to carry out oral history interviews with our patients who live near
their Unit.
We continue to receive anecdotal evidence about the benefit of the service from patients,
relatives, and staff. Below is a quote from a bereaved relative who had requested some
extra copies of her late husband’s oral history CDs.
“How can I ever thank you enough for the wonderful CDs of my husband … I have his
voice forever, how very lucky I am to have such precious moments listening to him.
Thank you so very much. You really do a good service to relatives on the sad occasion. I
shall never forget your kindness at a time when it is needed”.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 24
Priorities for improvement
Priority 3 - The fifteen steps challenge (patient safety walkrounds)
The NHS Institute for Innovation and Improvement developed the Fifteen Steps
Challenge as a means of understanding quality from a patient’s perspective, following a
statement from a mother who said “I can tell what kind of care my daughter is going to
get within fifteen steps of walking on to a ward.”
The challenge toolkit is a series of questions and prompts to test what first impressions
patients, relatives, carers and visitors may have of the organisation. It considers four
main areas. Is the area:

welcoming?

safe?

caring and involving?

well organised and calm?
St Luke’s Hospice developed a question set based upon the 15 steps challenge model,
and a staff information leaflet. A number of drop in and structured presentations further
promoted the challenge amongst staff and volunteers.
Four patient safety walkrounds have been completed, three on the In Patient Centre at
various times of the day, and one on the Therapies and Rehabilitation Centre.
Each walkround involves a patient, a clinically focused member of the Board of Trustees,
the Deputy Chief Executive, a member of staff from another area, administrative support
and the risk management coordinator.
Patients are fully briefed before undertaking the patient safety walkrounds and all
participants sign off the report and any recommendations, usually within seven days of
the walkround.
As a result of the walkrounds a number of improvements have been made to signage,
toilet accessories, patient appointment systems, access, clinical reception and flooring.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 25
Priorities for improvement
Priority 4 - Just One Thing
Following the completion of our environmental satisfaction survey in 2014, the hospice
wanted an ongoing way of gathering feedback from service users. The Service User Coordinator has created and implemented a postcard scheme. The postcard asks patients
and relatives what one thing they would change about the hospice if they could. We have
found that in previous surveys, participants frequently struggled to make constructive
criticism, but that asking them for one suggestion often elicited a useful response.
The postcard is offered to in-patients and their families, as well as patients attending the
hospice’s day centre, by the Service User Co-ordinator and Service User Involvement
volunteers, and cards are also available in the hospice’s public areas. It has proved a
popular way of making suggestions. Since the scheme was launched in May 2014, 139
suggestions have been received – some of these were compliments, but many were
constructive suggestions for improvement. We have been able to act on some
suggestions quickly, for example:
-
-
-
An in-patient wanted to have a film night with his children and needed a way of
playing DVDs through the TV in his room. We purchased a DVD player the same
day and installed it in the patient’s room. The DVD player is now available to any
other patient who wishes to use it.
Some patients reported difficulty operating their in-room lighting in the dark when
they woke in the night. We trialled a touch-operated bedside light with one patient,
who found it to be of great benefit. We are now purchasing several more of these
lights for patients who would benefit from them.
Patients in the shared rooms found the toilet roll holders in their en-suite
bathrooms difficult to operate and awkward to reach. We purchased some free
standing toilet roll holders to try out, and patients have found these a great
improvement.
Other suggestions need more consideration, for example because they require more
resources or because the benefits might be uncertain – for example, some in-patients
requested a full length mirror in their rooms, but those with body image issues said that
they might find this a hindrance. To debate these issues we have set up a User
Feedback Forum. Our first forum ran in November 2014 and comprised the Service User
Co-ordinator, a Service User Involvement volunteer, our Deputy Chief Executive, our
Head of Hotel Services (since many of the comments related to environmental factors)
and a patient representative. We discussed all the suggestions received in the previous
quarter and decided which could be implemented.
We plan to communicate all suggestions implemented to patients and relatives via a ‘you
said, we did’ poster, where we will also set out why certain other suggestions were not
able to be put into place. We also plan to run the forum on a regular basis and also seek
a carer/relative representative to attend.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 26
Priorities for improvement
Priority 5 - Grounds and Gardens
St Luke’s Hospice has always recognised the importance of having a sensorily
stimulating but tranquil outside space for patients and their families.
The proposed project for the grounds and gardens have been completed providing just
such a space with a balance of grassed areas, plants, wild flowers, social spaces and a
green roof garden room.
At the same time the layout of the car park and garden in relation to the main hospice
building has been reconfigured to ensure better access and outlook for patients and
improved parking for relatives and visitors. This also reduces our impact on our
neighbours by reducing on-street parking.
The following photographs show what the grounds and gardens now look like.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 27
Priorities for improvement
Priority 5 - Grounds and Gardens
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 28
Review of quality performance
St Luke’s Hospice is committed to a process of continuous quality improvement, with the
Executive focus being on professional development and competencies for the clinical
teams; service evaluations and improvements for patients; planning; prioritising, and
ensuring the best use of resources.
The hospice seeks to support patient choice and, where possible, deliver care where the
patient wishes to be; either in their own home supported by Specialist Palliative Care
Community Nurses or within the In Patient Centre.
The hospice has robust governance arrangements to review and monitor performance
quality through its Healthcare Development and Healthcare Compliance groups using a
range of key quality indicators and clinical dashboards. These groups report to the
Healthcare Governance Committee which in turn reports to the Board of Trustees.
Key quality indicators
We also have a range of activity levels and quality indicators agreed with Sheffield
Clinical Commissioning Group that underpin a quality service. Quarterly and performance
meetings with Sheffield Clinical Commissioning Group provide an external assurance
that our quality performance is satisfactory.
The hospice continues to capture and submit data, using the Patient Safety
Thermometer, to the Heath and Social Care Information Centre as part of the Harm Free
Care initiative and has completed the first twelve months of a Hospice UK programme for
national benchmarking in relation to patient safety and quality.
St Luke’s submits annual data to the National Council for Palliative Care and Hospice UK
to enable comparisons with other specialist care services, both locally and nationally, and
assist care commissioners to understand the needs of the people in the area in relation
to palliative care.
The final report from the National Council for Palliative Care is available on the following
website: www.ncpc.org.uk/mds
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 29
Review of quality performance continued
Key quality indicators
The hospice dashboard contains the following key quality indicators:

drug incidents

clinical incidents

hospice acquired infections

activity

end of life care

ethnicity

patient safety thermometer and harm free care
2.5% of St Luke’s Hospice’s income in 2014/15 was conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework. Formal status and quality monitoring reports are provided to the
commissioners each quarter. All these indicators are monitored by the Hospice Executive
and reported via its governance arrangements.
Hospice activity
2012/13
2013/14
2014/15
Available Bed Days
Bed Occupancy
7297
87.2%
6472
92.2%
7300
85.0%
Admissions
323
301
327
2747
274
1988
298
1797
247
1319
3881
1483
5249
1534
5787
Indicator
In Patient Unit
Therapies and
Rehabilitation Centre
Day Care Attendances
New Patients
Community Team
New Patients
Community Visits
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 30
Review of quality performance continued
Help the Hospices National Benchmarking Programme
The above programme focuses on all incidents that occur relating to patient falls, drug
incidents and pressure ulcers. St Luke’s has participated in the programme over the past
12 months and has subsequently committed to participate over the next twelve months.
The programme will provide a direct comparison against like sized hospices, currently 28
organisations, and give a national average of all participating hospices, currently 110
organisations.
Opportunities for learning
St Luke’s Hospice is always keen to take every opportunity to improve the quality of
service that it provides and places a great deal of emphasis on patient, family and carer
feedback. This is reflected within the work of the Service User Coordinator, satisfaction
surveys, audit reports, inspection reports and through the formal and informal
management of incidents, complaints, comments and compliments.
In line with good practice we make every attempt to resolve concerns at a local level and
during the twelve months covered by this quality account St Luke’s received only one
written complaint. During the same period 166 formal letters of compliment were
received, as well as many hundreds of appreciation cards which are shared locally but
not collated centrally.
All policies, including incident management and compliments, comments and complaints
are subject to an annual check.
Two patient related incidents were considered serious enough to be subject to reporting
to external agencies including the Care Quality Commission and Sheffield Clinical
Commissioning Group. Both incidents were investigated fully and as a result changes
were made to our internal security, incident escalation and our clinical documentation
training.
Lessons learned from one of the incidents has been shared locally and nationally with
other healthcare providers.
As commissioners of the service, Sheffield Clinical Commissioning Group were involved
in all actions taken and were happy that all appropriate actions had been implemented.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 31
What other people say about us.
E.mail: cate.mcdonald@sheffield.gov.uk
Tel: (0114) 273 5588 (office)
Our Ref: CMcD/vm230615
Date: 23rd June 2015
Cate McDonald- Chair
Healthier Communities & Adult Social Care
Scrutiny & Policy Development
Councillor for Gleadless Valley Ward
C/o Members Support
Town Hall
Sheffield S1 2HH
Mr Peter Hartland
Chief Executive
St Lukes’s Hospice
Little Common Lane
Abbey Lane
Sheffield S11 9NE
Dear Mr Hartland
St Luke’s Hospice, Sheffield Quality Account 2014/15
Thank you for sending a copy of the above. I am writing as Chair of the Healthier Communities and Adult Social Care
Scrutiny Committee to comment on it. I can see that the Hospice continues to develop its services to patients and
their families. As a local councillor I receive nothing but praise about the service. However I welcome the results of
the Care Quality Commission inspection in August 2014 which provides external assurance of the quality of care
provided by St Luke’s.
2014/15 Priorities
I am pleased to note the progress that St Luke’s Hospice has made on the priorities for improvement it set last year.
It is good to see the improvement of service delivery to people in their own homes and to see the resulting increase
in the number of home visits. I was also impressed by the ‘Just One Thing’ way of gathering feedback: this appears
to be a quick and effective way on getting service feedback which can be quickly implemented.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 32
What other people say about us.
2015/16 Priorities for Improvement
I welcome the priorities which you have set out: these seem an appropriate continuation of previous developments.
I am particularly pleased to hear about the acquisition of Clifford House to create a new Centre for Palliative Care. I
am also impressed by the volunteer support which contributes so much to the quality of care which you are able to
offer. The introduction of outreach laundry and catering pilot schemes are interesting developments and I look
forward to hearing about the outcome of these.
The only area which I feel is missing is how St Luke’s Hospice end of life support addresses the diverse needs of our
multicultural community. It would be good if you could include this in a future report.
Thank you again for giving me the opportunity to comment.
Yours sincerely
Councillor Cate McDonald
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 33
What other people say about us.
Sheffield Clinical Commissioning Group
St Luke’s Hospice Quality Account 2014/15
Statement from NHS Sheffield Clinical Commissioning Group
NHS Sheffield Clinical Commissioning Group (CCG) continues to recognise and appreciate the
high quality of the care which St Luke’s Hospice provides as part of the overall programme of
care for people at end of life in Sheffield. Following the successful development of the new in
patient centre, we commend St Luke’s Hospice for moving the focus for developments to
support to patients and their families in the community with the changed structure of the
community specialist palliative nursing team and the Rapid Response service providing significant
support to people dealing with end of life challenges in their own homes. The resultant services
show St Luke’s Hospice to be healthcare innovators in the city, providing both alternative models
of care and new services but also as technology innovators with the possibility that their learning
may be applied more widely in community services in Sheffield. Finally we must make mention
of the newly transformed gardens which will provide a tranquil setting to be enjoyed by patient
and their families.
The CCG has maintained its funding commitment in 2015/16 and looks forward to continuing to
work with the hospice in its role both as a provider of care and as a champion for quality
improvement for end of life care in Sheffield.
Submitted by Beverly Ryton on behalf of:
Kevin Clifford
Chief Nurse
and
Robert Carter
Senior Contracts and Commissioning Manager
NHS Sheffield Clinical Commissioning Group
June 17th 2015
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 34
What other people say about us.
Healthwatch Sheffield
Healthwatch Sheffield Response to St. Luke's Quality Account 2014/15
Healthwatch Sheffield are pleased to be able to comment on this Quality Account, and as in
previous years, would like to commend St.Luke’s for their attempts to make this account as easy
to read as possible in both its language and layout.
We note the organisation’s ambitious priorities for 2015/16, and are aware that we are named
as a body who will contribute to monitoring the impact of any changes. We are happy to work
with the organisation through our continued partnership working and collaboration on PLACE
assessments. We particularly look forward to hearing more about the pilot EnComPaSS scheme,
as we feel this has the potential to offer significant positive change for not only the organisation
but the wider community.
We understand the unique funding position the organisation finds itself in, and continue to keep
a watchful eye on this as we are well aware of the implications of any loss of voluntary
contributions.
St Luke’s feedback indicates that they have made good progress on all of their priorities for last
year, and several of these priorities also appear to feed into those selected for this year.
We thank the organisation for their continued clear lines of communication and positive working
relationship, and look forward to this continuing in 2015/16.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 35
Chief Executive letter to the Chair of Sheffield Healthier Communities and Adult
Social Care Scrutiny Committee Board
30 June 2015
Cllr C McDonald
Healthier Communities & Adult Social Care
Scrutiny & Policy Development
Councillor for Gleadless Valley Ward
C/o Members Support
Town Hall
Sheffield
S1 2HH
Dear Cllr McDonald
Thank you for your recent letter in respect of St Luke’s Quality Account 2014/15 and your very kind
comments. We appreciate you taking the time to write with your feedback.
We recognise the validity of your observation regarding Sheffield’s multicultural community and I would
like to assure you that St Luke’s team respects the needs of all those we care for, irrespective of faith or
cultural background. I confirm that we have a programme of support in place to address these issues and,
in all our work, ensure that the diverse needs of our patients and loved ones are taken into
consideration. For example, when developing our new facilities we consulted with all sections of the
community to advise us of their needs as they approached the end of their life. We are also actively
engaged in research into the barriers which exist in accessing care, and how we can address them,
working with other partners across the city.
We appreciate that our Quality Account does not currently refer to these issues, and unfortunately the
deadline for submission means that it would be difficult to amend the current document – hence this
letter. However, please be assured that we will incorporate how we are addressing these needs into
future reports.
St Luke’s Hospice, Sheffield: Quality Account 2014/15
page 36