St Teresa’s Hospice
The Darlington & District Hospice Movement
Quality Account for the Year 2014/2015
St Teresa’s Hospice, The Woodlands, Woodland Road, Darlington, DL3 7UA | (01325) 254321
www.darlingtonhospice.org.uk
PART 1
CHIEF EXECUTIVE’S STATEMENT
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PART 2 PRIORITIES FOR IMPROVEMENT 2015/16 AND MANDATORY STATEMENT OF ASSURANCE
FROM THE BOARD
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2.1
2.2
2.3
2.4
PART 3
3.1
3.2
3.3
3.4
INTRODUCTION
FUTURE IMPROVEMENT ASPIRATIONS FOR 2015/2016
PROGRESS ON IMPROVEMENT ASPIRATIONS FOR 2014/2015
MANDATORY STATEMENT OF ASSURANCE FROM THE BOARD
REVIEW OF QUALITY PERFORMANCE 2014/15
PATIENT SAFETY
CLINICAL EFFECTIVENESS
2014/15 PATIENT, CARER, STAFF AND VOLUNTEER EXPERIENCE
OTHER COMMENTS FROM PARTNERS & STAKEHOLDERS
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4
10
14
17
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19
28
34
SUPPORTING STATEMENTS
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ST TERESA’S HOSPICE QUALITY ACCOUNT 2014-15
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THE BOARD OF TRUSTEES STATEMENT
ENDORSEMENT BY SENIOR DIRECTORS
DARLINGTON CLINICAL COMMISSIONING GROUP STATEMENT
HAMBLETON, RICHMONDSHIRE & WHITBY CLINICAL COMMISSIONING GROUP STATEMENT
COMMENT FROM HEALTHWATCH, DARLINGTON
COMMENT FROM HEALTH & PARTNERSHIPS SCRUTINY COMMITTEE, DARLINGTON
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36
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2
Part 1
Chief Executive’s Statement
I am pleased to present the Quality Account for St Teresa’s Hospice 2014-15.
The Quality Account looks back on the progress we have made during the past year, and also
outlines future aspirations to improve services for patients and families.
The Darlington & District Hospice Movement, also known as St Teresa’s Hospice is an independent
charity (registered number 518394) and Company limited by guarantee (registered number 2080756).
The Board of Trustees is responsible over all for Governance of the Charity.
The Strategic Management Team of 6, led by the Chief Executive, is comprised of CEO, Director of
Clinical Services, Finance Director, Head of Nursing, Education Manager and Operations Manager.
St Teresa’s Hospice is a highly-regarded and well-loved organisation and we continually strive to
provide care of the highest standard. The support we receive from the business community, from
clubs and organisations, and from private individuals in the community is wonderful, and is a tribute
to the hard work and dedication of the Board of Trustees, and our wonderful staff and volunteer team.
Through this Quality Account, we have the opportunity to show all stakeholders our commitment to
quality as intrinsic to everything we do. Our culture of continuous review and improvement through
Clinical Governance ensures continuous quality monitoring, so that any shortfalls are speedily
identified, reported, rectified and learned from, to improve future practice. We strive constantly to
remain up to date and respond to changing needs, from the recommendations in the Neuberger
Report and Care of the Dying Framework, to meeting the revised standards which are inspected by
the Care Quality Commission. Excellent patient care remains at the heart of everything we do.
It is widely known that, in the next 20 years, Hospice Care is set to increase dramatically as Britain’s
older population increases. The number of young adults with life limiting conditions is also on the
increase and there is evidence that growing numbers of young people with highly complex needs are
moving from children’s services into adult care, however adult services may not be ideal or adaptable
for their age range or conditions. Following a full needs assessment, the Hospice’s major building
development programme will help to address this changing demographic, providing services which
can help more people, with more complex needs, in the most appropriate setting.
(see 2.2 Aspirations 1. and 3.)
This Quality Account is written in consultation with service users, and the Hospice team, and is
endorsed by our Board of Trustees, whose members enthusiastically support quality improvement; to
the best of my knowledge, I confirm it as a true and accurate assessment.
Jane Bradshaw
Chief Executive
3
Part 2
Priorities for Improvement 2015/16
Mandatory Statement of Assurance from the Board
2.1
and
Introduction
All of the work that St Teresa’s Hospice does is inspired by needs of people affected by a palliative or
life limiting illness. This includes patients themselves, their loved ones referred to throughout the
remainder of the document as carers and the general public who may look to us for support around
Public Health issues associated with palliative care. The Hospice has worked hard over recent years
embedding a culture of continuous improvement. But we are not complacent and strive not only to
maintain our exceptionally high standards today but to keep moving forwards, being innovative and
developing our services so that we can meet needs in the future of an ever changing population
demographic but also to keep apace of the changes in the commissioning landscape.
The following quality improvements you are about to read, and reports on quality performance,
pertain only to clinical care and relevant support services necessary to provide care. The report does
not take into account fundraising and administrative functions of the organisation where separate
quality initiatives are employed.
The Board of Trustees and Senior Management of St Teresa’s Hospice are committed to the delivery
of high quality care which is safe, clinically effective and provides the best possible patient experience.
2.2
Future Improvement Aspirations for 2015/2016
The following improvement aspirations have been developed with staff teams and people who use
our services including patients, carers and volunteers and are detailed across the domains of patient
safety, patient experience and clinical effectiveness.
Improvement Aspiration 1:
To build a purpose built, 10 bedded In Patient Unit
Quality Domain- Patient Safety, Patient Experience, Clinical Effectiveness
How was this aspiration identified?
The population is growing alongside changing demographics with an expected increase in life
expectancy. By 2020 over 40% of the Darlington population will be over 50 years and 10% will be over
75 years. With a rise in life expectancy it is also expected that more people will have co-morbidities
and will suffer with complex illnesses related to older age, such as Dementia, nationally it is widely
recognised that a third of over 85 year olds will suffer from Dementia. The annual death rate is growing
and is expected to rise steeply from 2016; this will have a corresponding rise in the numbers of people
requiring palliative and end of life care.
The Hospice carried out a local needs assessment in July 2013, identifying the need for more In-patient
beds for Darlington and District catchment area. The Cancer Care Alliance in 2005 carried out a needs
4
assessment identifying the need for additional beds and the current (draft) North Eastern Cancer
network wide needs assessment indicates that based on epidemiology, demographics and socioeconomic factors, considering a population of Darlington alone of 105,584 (St Teresa’s Hospice serves
Darlington and District including patients from Durham Dales Clinical Commissioning Group and
Hambleton, Richmondshire and Whitby Clinical Commissioning Group) there should be between 8.610.6 In-patient beds.
Furthermore, the current 6 bedded In Patient Unit although offering consistently high quality services
also poses some barriers to care due to accessibility and limitations of the Grade 2 listed building. The
In Patient Unit is on the first floor, with a split level landing giving stretcher access to only 3 bedrooms.
There is frequently a waiting list in operation as patients can only be admitted to the upper floor either
if they are mobile or in a wheelchair.
The Care Quality Commission on every visit has raised concerns regarding the open landing, comments
that were also flagged in an independent audit of the Hospice for a Dementia friendly environment.
Patients who are confused, agitated or wandering cannot be admitted to the upper floor, again
limiting the number of referrals that can be accepted and taking into account expected rise in
incidence of dementia, this will be exacerbated in coming years. In addition, the very high ceilings
potentially pose an infection control risk due to difficulties in cleaning.
Fire risk assessments support the need for a purpose built unit. Currently in the event of a fire,
palliative or end of life patients would need to exit the building in a “toboggan”, down 2 flights of
stairs.
Patients have also commented on the heat and ventilation in the rooms and although all bedrooms
have en-suites, only patients on the upper floor can access the bathroom (unless mobile). Carers and
relatives, who may be struggling to deal with what is happening to a loved one, have access only to a
very small room which doubles up as a staff room. Staff have very little space to work away from
patients, or to discuss patient care and access to computers can be difficult which together can at
times compromise patient care.
Patients who have sadly died whilst at the Hospice currently exit the building via the stretcher lift and
through a link corridor, which does not offer the optimum dignity and privacy.
How will it be achieved?
During 2014/2015 St Teresa’s Hospice submitted a planning application to develop a purpose designed
10 bedded In Patient Unit on the Woodlands site. The planning permission was approved in November
2014. Each of the ground floor bedrooms will have an en-suite and access to the gardens. All rooms
will be uniform in size and shape, with more natural light and proper ventilation, with improved access
for patients using mobility aids. The whole unit will offer privacy and dignity to all patients during
their entire stay with us and have a separate area for relatives and carers to use if they wish. Overall
the aim is to achieve a superior facility that will provide significant improvements in the physical
environment for patients, carers and staff, enable improved patient safety and patient experience and
delivery of high quality clinical effective care. During 15/16 we are ready to deliver our ambitious plan
in line with the following milestones:
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Identify Project Construction Management business*
April 2015
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Site Preparation
Commence Build Programme
Commence Capital Fundraising Campaign
Practical Completion Date and Handover
Internal Furnishing
Commission Unit
May 2015
June 2015
October 2015
February 2016
March 2016
31st March 2016
*Building client engages an external consultant to plan, manage and coordinate the whole project
How will it be monitored and measured?
Weekly site meetings with the site manager and monthly project team meetings, with bimonthly
reports into the Board of Trustees.
Improvement Aspiration 2:
To develop a comprehensive, Hospice based Lymphoedema Service
Quality Domain- Patient Safety, Clinical Effectiveness, Patient Experience
Lymphoedema is a chronic inflammatory disease developed following obstruction or failure of the
lymphatic system, resulting in swelling of limbs, trunk, head and neck, breast or genitalia. It can be
classified as Primary (intrinsic defects of the Lymphatic system) or Secondary (due to extrinsic damage
surgery, infection or disease). Lymphoedema services in Darlington have been unstable for many
years, and there has historically been a lack of substantive funding. Impacts on patients suffering with
Lymphoedema can be catastrophic including pain, cellulitis, significantly swollen and infected limbs,
impacts on body image and mental health and in some cases amputation.
How was this aspiration identified?
The need for a dedicated, comprehensive Lymphoedema service was identified primarily by patients.
GP’s have supported the development of the Lymphoedema proposal via the GP End of Life Care Leads
forum hosted at the Hospice. Lymphoedema is on the Hospice clinical risk register and is also a locality
priority. The development of the proposal has been in partnership with County Durham and
Darlington Foundation Trust.
How will it be achieved?
There has been commitment from all partner organisations to develop the Lymphoedema service.
Patients can expect to be treated at the optimum time to prevent deterioration of their condition
therefore avoiding avoidable use of antibiotics and hospital admissions. A dedicated Lymphoedema
practitioner will deliver the clinic supported by Health Care Assistants. The referral pathway will be
developed enabling GP’s to refer direct to the clinic. A key worker training course for District Nurses
will be established enabling them to identify and support housebound patients in their own home. A
patient self-management support group will help patients to manage their condition themselves
providing independence and improve patient experience. Getting to know patients and managing
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their care through the clinic effectively will improve patient safety and clinical effectiveness and should
also avoid unnecessary hospital admissions.
The Lymphoedema practitioner will develop networks within the locality to enable a rich knowledge
base at the Hospice and develop improved inter-organisational links supporting seamless patient care
delivery.
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Appoint Practitioner
2 day per week clinic provision commence
Key Worker course
Develop self-management programme
Key worker course
Service evaluation and commissioning discussions commence
June 2015
June 2015
August 2015
October 2015
January 2015
January 2015
How will it be monitored and measured?
Progress against key milestones will be monitored at the Quarterly Clinical Governance Sub
Committee.
Improvement Aspiration 3:
To explore the role of St Teresa’s Hospice in Transitional Care
Quality Domain- Patient Experience
How was this aspiration identified?
St Teresa’s Hospice is registered to provide services to patients age 18 and above. In 2013, a 17 year
old Darlington resident was referred to the Hospice by the paediatric palliative care team at James
Cook University Hospital. Unfortunately, as the patient was underage we were unable to provide care
until the patient reached 18 years of age, although the Family Support Team were able to support her
family.
The population of young people with life limiting conditions is growing and it is vital that their needs
are addressed and planned for as they transition into adulthood. Together for Short Lives have begun
to raise the profile of the need for better transition services nationally and the local Palliative and End
of Life Steering group have also identified this as a priority.
St Teresa’s Hospice has always been a pioneering Hospice, and our drive is to meet patient needs as
safely and clinically effectively as possible. Therefore, the Hospice is keen to explore how and if we
may serve this growing patient population and importantly how we can support them to achieve their
ongoing wishes and hopes for their future and their care as they live with their life limiting illness.
How will it be achieved?
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Link/Network Local Paediatric Network
Join local CCG group
June 2015
June 2015
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Ascertain local baseline
Ascertain locally available services
Ascertain what young people need from Hospice Services
Recommendations for the Hospice relating to Transition
October 2015
October 2015
February 2015
March 2015
How will it be monitored and measured?
Progress against key milestones will be monitored at the Quarterly Clinical Governance Sub
Committee.
Improvement Aspiration 4:
To develop Day Hospice Satellite for North Yorkshire patients
Quality Domain- Patient Safety, Patient Experience, Clinical Effectiveness
How was this aspiration identified?
Evaluation of the Day Hospice Satellite has proven how beneficial the service is to patients, their carer
and also a useful resource for health care professionals to offer to patients. However, data analysis
and discussion with health care professionals indicated that only some patients in the Hospice
catchment are able to access the service because of travel constraints due to their ambulatory oxygen
supply.
How will it be achieved?
The Hospice will develop a Day Hospice Satellite service for 10 patients located in Scorton or
Richmond. The Patients will be able to access the “CHOICES” programme on a morning. In addition 6
patients will be able to access the 8 week respiratory programme which will rotate around three
localities within North Yorkshire.
Milestones will include:
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Agreement of Programme with Commissioners
Identify Venue
Equipment procurement and set up at venue
Service Promotion
Commence CHOICES Programme
Commence Respiratory Programme
1
Commence Respiratory Programme
2
Commence Respiratory Programme
3
Service Evaluation and negotiation with commissioners
May 2015
May 2015
June 2015
June 2015
June 2015
July 2015
October 2015
January 2016
January 2016
How will it be monitored?
Monitoring of the Day Hospice Satellite will be via the Clinical Governance Group which meets
quarterly.
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How will progress be monitored and reported on for all future improvement aspirations
2015/2016?
St Teresa’s Hospice Board of Trustees will monitor and report on progress through a variety of
methods including:
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Annual return to the Charity Commission
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Annual review and audited reports and accounts
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Quality Account and reports to Clinical Governance Sub Committee
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Annual General Meeting
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Hospice Newsletter and other publications
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Events, such as open days
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2.3
Progress on Improvement Aspirations for 2014/2015
The purpose of the Quality Account is to not only set out future improvement aspirations but to also
evidence achievements on aspirations for improvement for the previous year.
In last year’s report we set out 4 aspirations for improvements for our services. All aspirations were
specifically selected as they would directly impact on the care our patients and carers received,
through improving patient safety, clinical effectiveness or the patient’s experience.
The quality improvement aspirations for the previous year were:
2014/15 - Aspiration 1:
To build a purpose built, 10 bedded In Patient Unit
Quality Domain- Patient Safety, Patient Experience, Clinical Effectiveness
This aspiration during 14/15 represented the first stage of this important development for the
Hospice, it continues to be an aspiration for 15/16. The needs analysis completed in 2013 highlighted
the changing demographics in Darlington and District, with a significant increase in death rate
expected from 2016, an ageing population who will have co-morbidities and require more complex
care, both culminating in increased need for Palliative and End of Life Care. The current 6 bedded In
Patient Unit, will not be sufficient to meet these needs.
Furthermore, the existing In Patient Unit although offering consistently high quality services also poses
some barriers to care due to accessibility and limitations of the Grade 2 listed building. The In Patient
Unit is on the first floor, with a split level landing giving stretcher access to only 3 bedrooms. There is
frequently a waiting list in operation as patients can only be admitted to the upper floor either if they
are mobile or in a wheelchair.
What we have achieved:
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Development of architects plans, staff consultation
Submission of architects drawings and planning application
Decision on planning application- resubmission required -DELAYED
Identify and engage company for Design and Build Scheme-DELAYED
Consultation and engagement with local stakeholders
Commence Capital Campaign for interior outfitting
Commence building within 2015/2016
April 2014
End of May 2014
November 2014
March/April 2015
May2014-April 2015
July 2014
May 2015
How we will continue to improve:
Unexpected delays were incurred due to delays in the agreement of the planning application which
necessitated slight design amendments and resubmission of plans before planning permission was
granted. Furthermore, tender returns were over budget and a value engineering process was required
before successfully appointing a building firm. The builder has now been commissioned and the build
programme will commence in May 2015.
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2014/15 - Aspiration 2: To develop leadership on the In Patient Unit and to
have a named nurse responsible for each patient on the In Patient Unit and
Day Hospice
Quality Domain- Patient Safety, Clinical Effectiveness
What we have achieved:
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Re-structure of the 2 Band 6 Registered Nurse posts so that one post holder can focus on
operational management and the other provide clinical leadership
Recruitment to the vacant Band 6 post
Named nurse allocated to every patient on IPU, who takes responsibility and accountability
for patients in their care
Every day the named nurse introduces themselves to the patient and writes their name on
the board in the patient bedroom, and leads on care delivery for their patients
The named nurse is present at ward rounds and ward level discussions about patient care
The named nurse responsible for ensuring handover to the clinician at the MDT
Significant review and development of nursing shift handover process ensuring that factual,
up to date clinical information is passed on between shifts (enhanced SBAR tool), named nurse
is responsible for their patient hand over at the end of each shift
Significantly improved transparency to the public with staffing levels displayed alongside the
name of senior nurse on shift at ward level, updated twice daily
Production of bi-annual staffing report which triangulates staffing levels, occupancy and
patient harms
How we will continue to improve:
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RGN Core Competencies are under development, draft version includes further areas for
development of nurse leadership
The comprehensive Clinical Governance work plan is designed to support development of
nurse leadership across all staff grades
Visible introduction of Compassion in Practice through delivery of Clinical Governance work
plan action areas
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2014/15 - Aspiration 3: To transform Day Hospice services to offer a range of
services to meet patient needs and ensure we reach as many patients as
possible
Quality Domain- Patient Experience Clinical Effectiveness
Key objectives for the transformation process were to increase the REACH of our services to noncancer patients, and to improve patient experience. Significant progress has been made and
transformation is embedded.
What we have achieved:
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Away Day to agree transformation objectives with team
Appointment of Team Leader post for transformation
Staff and patient evaluation pre service transformation
Commenced Neurological MDT at Hospice for Darlington Patients’
Commenced CHOICES programme, Neurology Clinic, Respiratory Clinic
Heart Failure Clinic, Complementary Therapy outpatients
Service promotional activity, GP’s, District Nurses, Macmillan Nurses,
Respiratory CNS, Heart Failure CNS and Support Groups
Commenced Satellite Day Hospice pilot for North Yorkshire
Service evaluation- excellent evaluation for CHOICES, disease specific
clinics and Day Hospice Satellite
Service evaluation- Day Hospice Satellite
May 2014
July 2014
June 2014
June 2014
July 2014
July 2014
Oct 2014
Nov 2014
Jan 2015
How we will continue to improve:
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Develop lead nurse role in Day Hospice
Work with North Yorkshire Commissioners to develop Day Hospice Satellite for 2015/2016
Introduce RGN core competencies into Day Hospice
Review Health Care Assistant role to look at extended practice and responsibilities
2014/15 - Aspiration 4: To develop a Clinical Risk Management Framework
Quality Domain- Patient Safety
Patient safety is our top priority at the Hospice. Significant work has been undertaken in key risk areas
such as patient falls and pressure ulcer management and our approach to monitoring risk has also
improved. In August 2014, the Clinical Commissioning Group undertook a Hospice visit incorporating
reviews of patient safety around medicines management, infection control and patient experience,
the feedback following the visit was excellent.
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What we have achieved:
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Introduction of clinical risk register, reviewed quarterly
May 2014
Review and improved Pressure Ulcer Management- annual monitoring
and improvement plan developed as part of CQuIN
April 2014
Review and improved Falls Management- annual monitoring
and improvement plan developed as part of CQuIN
April 2014
Progressed with introduction of electronic incident reporting system – under development
How we will continue to improve:
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Review and develop the Business Continuity Policy
Fully introduce single incident reporting system
Develop a “Whole Hospice” approach to risk management.
Develop Clinical Audit to include both processes and outcomes in patient care
Introduce a Patient Related Outcome Measure -PROM
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2.4
Mandatory Statement of Assurance from the Board
The following statements must be provided within the Quality Account by all providers. Many of these
statements are not directly applicable to specialist palliative care providers including St Teresa’s
Hospice, therefore explanations of what these mean are given.
2.4.1 Review of Services
During the reporting period 2014/2015 St Teresa’s Hospice, Darlington provided the following services
to the NHS:
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6 Bedded In Patient Unit
Day Therapy Service
Hospice at Home
Rapid Response Service
Lymphoedema Services
Family Support (including welfare benefits)
Complementary Therapies
During the reporting period 2014/2015 St Teresa’s Hospice, provided or sub contracted 7 NHS services
(no funding received for Complementary Therapies). The Hospice has reviewed all the data available
to them on the quality of these NHS Services.
The income generated by the NHS services reviewed in 2014/2015 represents 100 per cent of the total
income generated from the provision of NHS services by St Teresa’s Hospice, Darlington for
2014/2015. The income generated represents approximately 30% of the overall costs of running these
services.
What this means:
St Teresa’s Hospice is an independent Charity which provides all services free of charge. The income
generated from the NHS (Darlington Clinical Commissioning Group and Hambleton, Richmondshire
and Whitby Clinical Commissioning Group) in 2014/2015 represents approximately 30% of the overall
costs of service delivery, with the remaining income to fund our services from voluntary charitable
donations, legacies, Hospice shops, the One Wish Lottery, events and community fundraising.
St Teresa’s Hospice for the accounting period 2014/2015 signed an NHS contract with Darlington CCG,
and a voluntary sector grant with Hambleton, Richmondshire and Whitby CCG, similar arrangements
are in place for 2015/2016. Contracts for Rapid Response (partnership service St Teresa’s Hospice and
Marie Curie) have rolled over as part of a pilot project and are due to expire in March 2016.
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2.4.2 Participation in Clinical Audit
During 2014/2015 no national clinical audits or confidential enquiries covered NHS services provided
by St Teresa’s Hospice.
During 2014/2015 St Teresa’s Hospice participated in no national clinical audit and no confidential
enquiries of the national clinical audits and national confidential enquiries as it was not eligible to do
so.
The national clinical audits and national confidential enquiries that St Teresa’s Hospice was eligible to
participate in during 2014/2015 was none.
The national audits and national confidential enquiries that St Teresa’s Hospice participated in, for
which data collection was completed during 2014/2015, are listed below alongside the number of
cases submitted to each audit or enquiry as a percentage of the number of registered cases required
by the terms of audit or enquiry.
St Teresa’s Hospice was not eligible to participate; therefore, there is no information to submit or list
here.
What this means:
St Teresa’s Hospice as a provider of palliative care was not eligible to participate in any national audit
or confidential enquires as these have not pertained to palliative care during the accounting period
St Teresa’s Hospice has not reviewed any national or local audits during 2014/2015 and therefore has
no actions to implement
2.4.3 Research
The number of patients receiving NHS services provided or sub-contracted by St Teresa’s Hospice in
2014/2015 that were recruited during that period to participate in research approved by an ethics
committee was none. There was no appropriate, nationally, ethically approved research studies in
palliative care in which St Teresa’s Hospice could participate.
2.4.4 CQUIN Payment Framework
Darlington CCG St Teresa’s Hospice NHS income in 2014/2015 was conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation payment
framework for 3 elements within the contract. The 3 CQuINS represented 2.5% of the overall contract
value. (CQuIN measures included Friends and Family Test, Patient Safety and Day Hospice
Transformation). The Hospice has qualified for full payment of all 3 CQuINS.
Hambleton, Richmondshire and Whitby - St Teresa’s Hospice NHS income in 2014/2015 was not
conditional on achieving quality improvement and innovation goals through the Commissioning for
Quality and Innovation payment framework because it had a voluntary sector grant in place.
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2.4.5 Statement for the Care Quality Commission
St Teresa’s Hospice is required to register with the Care Quality Commission and its current
registration status is for the following regulated activities:
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Diagnostic and screening procedures
Treatment of Disease, disorder or injury
Personal Care
St Teresa’s Hospice is registered with the following conditions:
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Services are provided for people over 18 years old
The maximum of 6 patients may be accommodated overnight
Notification in writing must be provided to the Care Quality Commission at least one month
prior to providing treatment or services not detailed in the Statement of Purpose
St Teresa’s Hospice is subject to periodic and unplanned reviews by the Care Quality Commission
(CQC), the last on-site inspection was in December 2013. St Teresa’s Hospice was fully compliant with
all the essential standards of Quality and Safety as set out in the Care Quality Commission registration
and the Health and Social Care Act. The CQC has not taken any enforcement action during 2014-2015
and St Teresa’s Hospice has not participated in any special reviews or investigations by the CQC in this
time period. The CQC has issued new regulations and the Hospice category “Adult Social Care Services:
Hospice Services”. The Hospice has baselined current activity against new regulations and a
development plan is in place in readiness for the new inspection process.
2.4.6 Data Quality
St Teresa’s Hospice did not submit records during 2014/2015 to the Secondary Users Service for
inclusion in the Hospital Episode Statistics.
What this means:
St Teresa’s Hospice is not eligible to participate in the scheme. In the absence of this we have our own
system in place to collect and monitor data through the electronic patient information system,
SystmOne. St Teresa’s Hospice also submits data to the National Minimum Dataset for Specialist
Palliative Care Services collected by the National Council for Palliative Care on an annual basis.
2.4.7 Information Governance Toolkit Attainment
St Teresa’s Hospice participated in completion of the Information Governance Toolkit in 2014/2015,
the outcome was satisfactory and an appropriate action plan for improvements has been developed
which is timetabled for review on an annual basis. All clinical staff have completed annual top ups for
information governance as part of mandatory training.
2.4.8 Clinical Coding Error Rate
St Teresa’s Hospice was not subject to the Payment by Results clinical coding audit during 2014/2015
by the audit commission.
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Part 3
Review of Quality Performance 2014/15
The review of Quality at St Teresa’s Hospice can be considered across the three domains of Patient
Safety, Clinical Effectiveness and Patient, Staff and Volunteer Experience. The following information
provides information on these areas during the accounting period 2014/2015.
3.1
Patient Safety
Risk Assessments
Risk assessments are carried out as part of everyday practice, are reviewed at least annually, and are
in place to address health and safety hazards in all areas of the organisation. Additionally COSHH risk
assessments have been carried out for hazardous substances. CAS alerts monitoring system in place.
Incident Reporting
For the period 1st April 2014-31st March 2015 there were 61 health and safety and clinical incidents
reported. All In Patient Unit incidents are reported via Safeguard System (incidents involving NHS Staff
on the In Patient Unit) and also reported via internal governance processes and reviewed and
monitored by the Clinical Governance sub group. The number of incidents has increased since the last
reporting year, however, the Clinical Governance Sub-committee view this as a significant
development as all staff are now aware of their responsibility and accountability in reporting and
subsequent investigation of incidents.
Table 1 Demonstrating Clinical Incidents during Accounting Period 2014/2015
Clinical Incident
Number
Slips, trips, falls and accidents - patients
8
Slips, trips, falls and accidents – staff and 4
volunteers, and visitors
Pressure ulcers
10
Infections
0
Drug errors and adverse effects
2
Incidents relating to medication
6
Other clinical incidents
16
Other non-clinical incidents
9
Information Governance
6
17
Slips, trips, falls and accidents- Patients
There were 8 incidents involving patients, none of which resulted in major injury requiring reporting
to the Care Quality Commission Health and Safety Executive or North East Commissioning Support
Unit. 8 were patient falls, (4 patient falls in the In Patient Unit, 1 patient fall when taken home and fell
in the street, 1 patient fall in Day Hospice, 1 patient fall in doorway of Woodlands Reception, 1 H@H
patient fell out of bed).
Slips, trips, falls and accidents- Staff, Volunteers and Visitors
There were 4 health and safety incidents reported involving staff, volunteers and members of the
public. 1 incident involved member of staff with swollen face, lips and eyes watering, cause unknown.
1 paper cut, 1 incident involved boiling water leaking from thermos missing patient’s legs, 1 incident
staff cut hand on glass, no serious injury was sustained during any accident.
Pressure Ulcers
Infections and pressure ulcers cause pain and distress to patients and families. Improvement work has
taken place over the past 12 months on identification of pressure ulcers and it is acknowledged that
this is an ongoing training requirement for the Hospice. 10 pressure ulcers were recorded, 7 patients
were recorded to be admitted with existing pressure ulcers, the remaining 3 were investigated and
were unavoidable.
Infections
There were no hospital acquired infections during the accounting period.
Incidents relating to medication
There were 6 incidents relating to medication, (1 where medication was written up incorrectly by
Darlington Memorial Hospital, 1 discrepancy in total amount when destroying controlled drugs, three
where syringe drivers was faulty, 1 patient arrived with no drug chart therefore no regular medication
could be administered until GP arrived).
Drug Errors
There were 2 drug errors; both were investigated fully and improvements in practice implemented,
both still within safe prescribing limits of administered medications.
Safety Thermometer
St Teresa’s Hospice has completed the patient safety thermometer for the past 12 months and
reported its findings nationally to the Department of Health. The Safety thermometer is a “snapshot”
measure taken across pre-determined domains on the same day each month. During April 2014March 2015 time period, the following harms were recorded in domains measured.
Clinical
Area
IPU
18
Pressure
Ulcer
5
Catheter &
UTI
5
VTE
Falls
0
0
3.2
Clinical Effectiveness
Many components contribute to demonstrating clinical effectiveness including quantitative data,
Key performance indicators, audit and an overarching, strong clinical governance steer.
Data collection at St Teresa’s Hospice has developed significantly over recent years due to the
installation of SystmOne patient information system. However, reporting continues to be a
challenge due to the design of original data inputting templates, this has been acknowledged and
addressed and as a consequence over coming months confidence in data will grow so that dual
recording mechanisms can stop and the Hospice can rely on a “paper-light” system. All
departments are now paper light except IPU (paper systems are reduced, however are still
necessary for Medication Charts and some patient held information such as DNACPR forms). During
14/15 the Data Quality manager has perfected data collection, however, when comparing previous
years data, it has been recognised that there are some inaccuracies and that in some areas statistics
have been counted twice.
Hospice Performance against National Council for Palliative Care Minimum Dataset
The Hospice collects statistical information on activity and submits this to the National Council for
Palliative Care for inclusion in a National Minimum Dataset (MDS). This allows comparison of local
data to the national average similar sized Hospices. The following table displays performance of St
Teresa’s Hospice to the National MDS from the previous reporting year, as the actual data for this
accounting period will not be available until September 2015.
Comparing St Teresa’s Hospice to the National Minimum Dataset
Area
Inpatient
Services
Total number of
Patients
Total
New
Patients
Re-referred
Patients
Average
Bed
Occupancy
Cancer Diagnosis
(%)
Non
Cancer
Diagnosis (%)
Average length of
stay (days)
Died in Hospice
(%)
Discharge care
home (%)
Discharge acute
(%)
St Teresa’s
Hospice
2011/2012
St Teresa’s
Hospice
2012/2013
St Teresa’s
Hospice
2013/2014
St Teresa’s
Hospice
2014/2015
Nat’l Min. Data
Set 2012/13
181
141
134
106
-
122
131
128
93
-
14
6
6
11
-
86%
64%
69%
55%
75%
82%
84%
83%
83%
87%
18%
13%
11%
17%
11%
7.7
8.1
8.6
11.42
13.4
40%
46%
51%
63%
55%
1%
5%
4%
3.7%
4%
2%
2.5%
5.50%
4.7%
2%
19
Area
Discharge home
(%)
St Teresa’s
Hospice
2011/2012
St Teresa’s
Hospice
2012/2013
St Teresa’s
Hospice
2013/2014
St Teresa’s
Hospice
2014/2015
Nat’l Min. Data
Set 2012/13
49%
33%
35%
26.4%
38%
Other
Day Therapy
Total number of
Patients treated
Number of New
Patients
Total
Days
available places
Total
Places
attended
Total
Places
booked DNA
Average length of
care (days)*
Cancer Diagnosis
(%)
Non
Cancer
Diagnosis (%)
Hospice at Home
Total Number of
Patients treated
0%
13.5%
5%
1.8%
1%
146
121
129
129
-
80
54
70
81
-
3920
3840
3900
3240
-
1947
1852
1794
1578
-
794
847
873
637
-
300
326
287.5
226
183
80%
65%
62%
64%
78.%
20%
17%
36%
36%
18%
184
182
196
101
-
New Patients
Patients died in
Hospice (%)
Patients died at
Home
(%)
(achieving PPC)
Patients
died
acute
or
Community
Cancer Diagnosis
Hospital
(%)
(%)
132
132
137
94
-
15%
12%
22.50%
2%
-
68%
68%
65%
95%
49.8%
1%
0
0
2%
24%
52%
55%
53.50%
78%
80%
48%
45%
40%
22%
16%
127
120
88
37.8
115
Non
Cancer
Diagnosis (%)
Length of Care
(days)
*Day Hospice Transformation 14/15 figure represents CHOICES Programme only
In Patient Unit
During the accounting period the Hospice had a total of 106 patients on the In Patient Unit, 93 of
which were new referrals. Bed occupancy was 55%, which was lower than the MDS at national
average of 75%. 83% of the In-patient population were treated having a cancer diagnosis compared
to the MDS of 87%, this figure has remained stable for several years. Average length of stay was
11.4 days, an increase on previous years but is shorter than the national average of 13.6 days which
also includes planned respite which we do not currently offer due to limitations on capacity. The
number of patients dying in the Hospice is also higher than national average at 63% compared to
the MDS of 55%. The majority of referrals were for symptom management followed by End of Life
Care. The overall picture demonstrates that patients are coming into the Hospice and staying
20
longer than previous years and also more patients are choosing the Hospice at the end of life,
suggesting we are seeing more complex patients. Although our occupancy is lower than previous
years, we have had a waiting list in operation throughout the year on many occasions. It can be
suggested that the longer length of stay and the reason for referral have significance in relation to
occupancy, as only mobile/wheelchair patients can be admitted into the upper first floor of the
building as the stretcher lift provides access only to the lower first floor, the data suggests a more
poorly cohort of patients have been accessing the service and whilst occupancy appears low, we
could not admit more patients possibly due to limitations of the building. (There has been a waiting
list in operation on several occasions when we have only had 3 patients on IPU as we cannot admit
stretcher patients to upper first floor).
Bar Chart demonstrating Reason for Referral to In Patient Unit 2014-2015
Reason for Referral to IPU
45
40
35
30
25
20
15
10
5
0
Qtr 1
Qtr 2
Symtpon Control
Qtr 3
End of Life
Crisis Respite
Qtr 4
Not recorded
Day Hospice
The Day Hospice has undergone transformation during the accounting period. The Day Hospice
now includes the pioneering CHOICES programme, 3 days per week and disease specific clinics, 2
days per week (Neurology, Respiratory, Heart Failure).
The total number of places for CHOICES was 3240, with an attendance rate of 1578. However,
attendance to Day Hospice overall was 4798, a significant increase on total attendances when
compared to previous accounting period when total attendances were 1794. Individual patient
attendances to Day Hospice increased from 129 patients in 13/14 to 358 patients during 14/15.
Average length of care was longer than the national average of 183 days with Hospice average
length of care being 226 days for CHOICES programme, however, we expect this to come in line
with national average as the CHOICES programme is embedded (operates on a 12 week
programme).
21
In CHOICES programme 64% of patients had a cancer diagnosis, however, looking at Day Hospice
overall the non-cancer population accounts for 41% of the total population. The Day Hospice
transformation has achieved its aim of improving access and REACH to non-cancer patients.
Service evaluation has been extremely positive from all patients attending.
Hospice at Home
The Hospice at Home service supported 101 patients during the accounting period, 94 of these
patients were new referrals. In addition, there was a further 30 referrals to the service, taking
referral rate to 132, however, no action could be taken due to either the patient dying before first
visit, declining the service or service being at capacity. 95% of those patients supported who
reported home as their preferred place of care, were supported to die at home compared to a
national average of 50%. Again the Hospice was able to support non-cancer patients extremely
well with 22% of total patients having a non-cancer diagnosis compared to a national average of
16%.
Bar chart showing total Hospice at Home Hours of Care provided 2013/2014 Hospice at
Home no of visits provided
No of Visits
100
80
60
40
20
0
22
General Information
The total number of patients accessing all services in the graph below appears to be less than previous
years. However, in reality in previous years, data quality was less accurate, patients were counted
every time they accessed a different service. 2014/2015 represents individual patients.
Bar Chart of Total number of people accessing our services cumulatively (Patients,
Carers and Bereaved)
Individual Patients
900
800
700
600
500
400
300
200
100
0
2010/11
2011/12
2012/13
2013/14
2014/15
The bar chart below actually demonstrates that overall patient referrals across all services have
remained fairly static.
Bar Chart of Total number of people accessing Hospice by service type
No of Patients Accessing Each Service
400
350
300
250
200
150
100
50
0
2010/11
IPU
2011/12
Day Hospice
2012/13
Hospice at Home
2013/14
Family Support
2014/15
OP
NB During 14/15 outpatients are included with Day Hospice activity due to transformation.
23
The bar chart, shows an apparent reduction in IPU, Hospice at Home and FST however, in reality
this is not the case but more accurate data collection has allowed us to count actual patients,
avoiding duplicate counting when a patient accesses more than one service. The Bar Chart does
demonstrate the enormous success of Day Hospice.
Key Performance Indicators (KPI) 2014-2015
The Hospice reports quarterly on Key Performance Indicators to meet contractual requirements.
A summary of the performance for the accounting period can be seen below. Performance against
KPI has been excellent in the majority of areas where there are shortfalls explanations are
provided.
24
Measure
Time for In-patient referral to
decision to admit/not to
admit
Number of Inpatients who
have been offered an
Advance Care Plan
Threshold
90% within 2
hrs
Q1
92%
Q2
92%
Q3
97%
Q4
100%
Notes
90%
0%
86%
86%
80%
Number of inpatients who
are on Liverpool Care
Pathway or equivalent at
time of death
Inpatient bed availability (i.e.
are all beds available for usenot vacant beds)
Inpatient bed occupancy
90%
22%
0%
0%
0%
ACP are not
appropriate for
patients
admitted for
End of Life
Care
LCP Phased
out July 2014
95%
85%
91.5%
78%
88%
Maintenance
work accounts
for reduction
85%
55%
59%
62%
64.5%
Explanation
provided in
detail above
% Of Day
Hospice/Outpatients
receiving a care plan
Time from Day
Hospice/outpatient referral
to assessment
100%
100%
100%
100% 100%
>90% within
7 days
100%
100%
83%
Hospice at Home- record
made as to whether patient
has an Advanced Care Plan
Hospice at Home- referral for
assessment made to key
worker within 24 hours for
those patients who don’t
need an Advance Care Plan
100%
100%
100%
100% 100%
>95%
100%
100%
94%
50%
70%
Changes to
“assessment
day” as part of
Transformatio
n
Shortfall when
RGN has
completed ACP
rather than
referring to
DN- but an
improvement
for pt.
Measure
Hospice at home- number of
patients who the service are
facilitating nursing care at
their time of death whose
referred place of care is
achieved
Family Support team and
Bereavement – client to be
contacted within 7 working
days of receipt of referral
Family Support team and
Bereavement- client
assessment to commence
within 15 working days of
receipt of referral
Family support team and
Bereavement- written
assessment of needs and
action plan agreed with
client
Family support team and
Bereavement- family and
friends of deceased to be
supplied with
information/card about the
bereavement service within
7 days of the service being
notified
Family support team and
Bereavement- Hospice to
have an individual service
action plan with clear
objectives and delivery dates
Threshold
>85% by 31st
March 2014
Q1
100%
Q2
91%
Q3
Q4
100% 75%
>95%
100%
98%
97%
98%
>95%
80%
96%
94%
97%
100%
100%
100%
100% 100%
100%
96%
100%
100% 94.5%
100%
100%
100%
100% 100%
Notes
25
Patient related Outcomes
The Hospice is in the process of introducing patient related outcome measures. This means measuring
the efficacy of their care. The MYCAW tool allows a patient to score their “problem” for example pain,
or nausea prior to treatment and following a course of 6 treatments. The Graph below demonstrates
that every patient using MYCAW receiving acupuncture has improved significantly as a direct result of
treatment received. A broader range of patient related outcome measures will be introduced during
15/16.
Complementary Therapy MYCAW Scoring
Local Audit
To ensure high quality of services audit is important and the annual audit programme is now well
established using nationally agreed formats such as Help the Hospice audit tools and also locally
developed audit tools. For audits undertaken, action plans for improvement are developed, and
monitored by the clinical governance sub group. This enables us to monitor quality and make
improvements where needed. All clinical staff are encouraged to participate in at least 1 audit per
annum and audit is on every staff meeting agenda. The audit programme for the forthcoming year
will focus on patient outcomes as well as processes.
Clinical Governance
There is a strong culture of continuous improvement at the Hospice. Clinical Governance systems
and processes have dramatically improved and the Hospice has a Clinical Governance Sub strategy
with a dedicated annual work plan, performance managed by the Clinical Governance subcommittee of the Board of Trustees. The work plan, updated annually focuses on key areas of
improvement, across patient safety, clinical effectiveness and patient experience.
26
Safeguarding
All clinical staff have received safeguarding training appropriate to their required level. Deprivation
of Liberty training has also been delivered and annual refresher training planned.
Other Quality Initiatives 2014-15
During the accounting period the additional Quality Initiatives have been introduced:
Development days- Quarterly development days for In Patient staff have been established, these
are themed education and training days which focus on either patient safety or clinical
effectiveness. Every member of the IPU team attends (IPU covered by bank staff).
Care of Dying Patient –The Hospice has taken part in the North East pilot for the “Care of the
Dying Patient”. The documentation is intended to replace the Liverpool Care Pathway and the
Hospice will introduce the new documentation internally and cascade training locally to GP’s,
District Nurses etc.
Patient handover- The patient handover documentation and processes has been reviewed and
improved
Patient Discharge – Patient Discharge process has been reviewed and improved
Medicines Management – The Hospice procurement of medicines has been reviewed in light of
new MHRA guidance. A new system is under negotiation.
Deprivation of Liberty Safeguards – DOLS- The Hospice reacted quickly to new national guidance
regarding DOLS and has trained every appropriate staff member.
Protected Learning Event for GP’s- All Darlington practices attended a PLT in Palliative Care
during April 2015, the programme was designed to provide education in symptom management
at the end of life and to develop a strategic vision for integrated working.
27
3.3
2014/15
Patient, Carer, Staff and Volunteer Experience
Staff Experience
Staff experience is measured in three ways:



Accurate monitoring, reporting and review of sickness levels
Confidential annual staff experience survey
Line management support including 1:1 contact meetings and annual Appraisal process.
Hospice Staff Sickness levels
The reporting system for staff sickness in all departments is now firmly established and a report
produced quarterly for the HR Sub Committee of the Board of Trustees and monthly updates
provided to department heads. Capability procedures and sickness monitoring systems enable
any worrying trends to be identified; however, there are no current trend alerts. The average
sickness rate was 4.42% per wte.
Confidential Annual Staff Experience Survey
An annual staff experience survey was carried out with an 85% response rate. Overall, staff
morale displays no worrying trends.
Line Management and Appraisal
The Hospice ensures all staff regularly meet with their line manager for contact meetings and
have an annual appraisal, 100% of staff received an annual appraisal during 2014/2015. The
Hospice management also operates a vital open door policy.
Clinical Supervision
All clinical staff are offered the opportunity to partake in clinical supervision and this is a firmly
established practice. During the accounting period, this has also been extended to administrative
staff, recognising that they can also have potentially distressing conversations with patients and
their families. Clinical supervised practice is reviewed annually to ensure it is effective, and as a
result of this year’s review a new supervisor has been identified.
Board Development
The Hospice Board of Trustees is currently going through a Board Development programme and new
members have been elected onto the Board.
The Hospice has a strong management structure in place with a Chief Executive Officer with delegated
responsibility from the Board who is supported by a Deputy CEO/Director of Clinical Services and
Finance Director, additional members of the Strategic Management Team include the Operations
Manager, Head of Nursing and Education Manager.
The following officers are also in place:
 Anti-fraud officer (Hospice Trustee)
 Caldicott Guardian, (CEO) responsible for safeguarding patient information
28




2 Privacy officers (CEO & Deputy CEO/Director of Clinical Services)
Accountable Emergency Officer (CEO)
Prevent Lead (Hospice Trustee)
Accountable Officer for medications, (Hospice Education Manager)
Volunteer Experience
Throughout the year we have held 4 induction courses for prospective volunteers who wish to help at
the Hospice, this has totalled 60 people, and most of those who attend do go on and contribute in
some way at the Hospice as a volunteer. We have been delighted to welcome volunteers into the In
Patient Unit, Day Hospice, kitchen, driving, complementary therapies or the shops and warehouse.
Some of the volunteers are students either from Sixth Form College, Gap year students or Access
students or newly retired people as well as others who are looking for a fulfilling volunteer role at this
stage in their life.
In addition to the induction courses we have also held extended visits for 22 Sixth Form students who
are looking towards a career in the medical profession. Following the visits, those who wish to pursue
volunteering are offered the opportunity to attend the induction course and there are opportunities
for them to help on the In Patient Unit either at teatime or at weekends.
We have held an education programme for volunteers, this covered Food Hygiene, Moving and
Handling, Fire training and an update on services offered by the Hospice.
We have also started a programme of visits for shop volunteers so that they can see the Hospice and
hear and understand the range of work that goes on for patients with life limiting illnesses so they can
inform customers and people in their communities about our work and the opportunities that are
available for those in need.
Education and Training






Induction - The Hospice continues to develop the induction programme and the Education
Manager is developing a standard operating procedure for all managers to follow when
inducting staff.
GP and student placements - GPs access the Hospice for palliative care placements whilst
completing the Diploma in Palliative Medicine, and medical, nursing and social work
students are present throughout the year.
Palliative Care Core Competencies – Core competencies for Health Care Assistants are in
place and are being developed for Registered Nurses and will be introduced during the
summer 2015.
Journal Club- A monthly journal club runs with different departments taking a lead, an
“article library” has also been introduced to improve staff research awareness.
Dementia Awareness - Is continuing to be a high priority with the aim that all clinical staff
access the advanced Alzheimer’s accredited training. The Hospice is also part of a support
group developed with other Hospices to share best practice.
Volunteer Training has been introduced in the last year for all Hospice based volunteers. In
addition, three volunteers have been trained in Moving and Handling skills to enable them
29





to support the Neurological Clinic. All volunteers have also been given an opportunity to
complete the dementia awareness workbook and have received training on hand hygiene,
equality and diversity, fire training, updates on clinical services and much more.
The Family Support Team run an extensive programme of education for all their volunteers
in areas such as attachment theory, creative writing, grief loss, bereavement and
mindfulness. There is a continuous programme of personal development and supervision.
The FST also continue to support schools as requested.
Mandatory Training- There is a programme of mandatory training in place and identified
mandatory training mapped to specific roles. All clinical and non-clinical staff now undertake
Dementia Awareness Training, as part of the mandatory training.
Education in Care Homes - We have commenced education in Care Homes in partnership
with Teesside University around palliative care.
Management Training Programme- Our second six month management training course is
underway and will finish in May 2015. This enables the development of management and
leadership skills for department heads.
The Complementary Therapy lead has completed his BSc in complementary therapy and the
Nurse Consultant has started an MSc in Health and Social Care Studies (End of Life Care). We
have several Health Care Assistants completing an Introduction to Palliative Care, for People
with Cancer and Long Term Conditions, at Teesside University (run by the Hospice Education
Manager). All staff have appraisals where education needs are identified and mapped
against Hospice Strategy.
Awards and Complaints






The Hospice has the 'two ticks' positive about disability symbol, which is awarded by Jobcentre
Plus to employers who have made commitments to employ, keep and develop the abilities of
disabled staff (renewed annually on submission of return).
The Hospice is awarded the FRSB symbol, being regulated by the Fundraising Standards Board:
the regulator of charity fundraising in the UK (renewed annually on submission of return).
Several volunteers received awards at the last Evolution Darlington (volunteer bureau)
presentations.
The Hospice was awarded the 5 star Food Hygiene Award by Environmental Health Feb/March
2015.
The Hospice was highlighted in Hospice UK (formerly Help the Hospices) Dementia Project as
a beacon Hospice of good practice for Dementia Care.
The Hospice receives many letters of thanks and recommendations from patients and families
which are celebrated with staff teams.
Complaints are seen by the Hospice as an integral part of service improvement as they provide
valuable feedback about the quality of service we are providing. Complaints are rarely received. In
the reporting period, 2014/2015 no patient complaints were received. However, the Hospice does
have a complaints process in place. Serious Untoward Incidents and Never Events would be reported
to both the Care Quality Commission and Clinical Commissioning Groups.
30
Patient and Service User Satisfaction
St Teresa’s Hospice continues to invest significant time in exploring patient and service user
experience over the past year. User feedback has been sought in a variety of ways including the
following:






Patient Questionnaires
Carer Questionnaires
Semi-Structured Interviews
Focus Groups
Suggestion Boxes
Use of patient outcome measures e.g. MYCAW
Additional, volunteered information is also recorded from comments, thank you cards, letters and
feedback on the Hospice website. All of the methods of seeking patient and carer feedback have been
valuable, but one of the most valuable has been semi-structured interviews, conducted by a Hospice
Trustee; feedback has enabled us to improve patient care almost instantaneously. All comments are
discussed at the monthly Strategic Management meeting, and “what you said, what we did”
developed for example;
What you said- Carer indicated
difficult to drop off patient
What you said- Patients
requested Wifi
What we did- Made a “no
parking area, drop off only
adjacent to reception”
What we did- Provided Wifi
access in IPU lounge
What you said- Patient
requested music in
treatment room
What we did – Music
available now in all
treatment rooms
Comments from the Inpatient Unit:
“I am eternally grateful for the absolutely wonderful way in which you looked
after her and made her departure from this world so peaceful.”
“Just a big “thank you” to all the staff who cared for xxxx during his brief
admission 21st/22nd October. The care he received was excellent and he was
able to die peacefully surrounded by staff who provided excellent care”
Comments from the Day Hospice:
“Thank you all for keeping me alive, you are all lovely people.”
“Thank you so much for your kindness and friendship and for looking after me
so well in the time I have been at St Teresa’s”.
31
Comments from Hospice at Home:
“.. being able to rest at night knowing mum was safe was invaluable and helped
us cope with whatever came along during the day!”.
“With grateful thanks for the services you have provided, without which I
myself may have succumbed. Will remember you forever”.
Comments from Family Support:
“I have really appreciated the time during our sessions to reflect on, and try to
make sense of so many things. I know there is no ‘quick fix’ but I think now I
can face whatever the future holds, with all its up and downs.”
“Thank you for helping me about my Grandad”
The following letter was received during Q4 and has been included as it clearly outlines the value of
what the Hospice delivers to patients and families, across all our service areas and our effectiveness
and working across organisational boundaries to deliver seamless patient care.
XXX was diagnosed with pancreatic cancer in mid-June 2013 and eventually had major surgery at the Freeman
Hospital, Newcastle, on 3rd of August followed by a 24 week course of chemotherapy at Darlington Memorial
Hospital starting on 30th October once the surgical wound had healed sufficiently.
Treatment ended on 2nd April 2014 but we learned on 18th of June that the disease had returned at the bed of
the earlier surgery. XXX was offered palliative radiotherapy/chemotherapy which she declined.
XXX wish was that she should be cared for at home for as long as that was a realistic option and we managed
to achieve this with the help and support of or GP surgery and the district and Macmillan nurses until what
turned out to be the last 6 days of her life.
She had also been previously referred to St Theresa’s Hospice and following an introductory visit XXX attended
some counselling sessions and the day unit once but then declined any further participation. Her decision was
not made because of any concerns about the quality of either activity but rather because visiting the Hospice
reminded her of the stark reality of the state of her health and the terminal prognosis, realities that she was
determined should not dominate what remained of her life.
The Hospice arranged weekly home visits by a member of the family support team. Stephen always arrived on
time and XXX looked forward very much to his visits which we both found of great help.
We also had a visit from Helen, head of Hospice Care at Home, who detailed the at home and in-patient
facilities and services provided by the Hospice.
During the week of Monday 16th September, XXX condition began to deteriorate more rapidly and because
she had become disorientated and somewhat delirious by Sunday 21 st I arranged a doctor visit via 111. He
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diagnosed possible urinary tract infection and prescribed antibiotics but her condition continued to deteriorate
and following an early morning 111 call on Tuesday 23rd a nurse visited late morning to assess XXX.
Helen visited about 2 hours later. She indicated that a bed would be available in the In Patient Unit and that
transport would arrive within an hour to take XXX to the Hospice.
Once admitted, XXX received care that I can only describe as truly exceptional, delivered by a team of amazing
professionals clearly skilled in caring for terminally ill patients in what I would class as a haven of peace and
tranquillity. Her admission to the Hospice lifted an enormous burden from my shoulders.
Within 2 days the team had achieved control over XXX symptoms. She became very settled spending
progressively less time awake until she died peacefully on Monday September 29 th.
I was fully briefed about the care plan when XXX was admitted and was fully informed throughout her stay. I
discussed the situation with members of the Hospice team each morning, during each day and last thing at
night before I left the premises.
Although XXX was the main focus of the team’s attention, there was also a very keen interest in how I was
coping and that continues today.
At no time did I have even the slightest concern about the quality of XXX care. Although the outcome was
sadly inevitable, I remain eternally indebted to St Theresa’s Hospice for the superb care provided to my late
wife.”
Patient Questionnaires and Evaluations
During 2014/2015, the Friends and Family test has been introduced. We received 111 responses and
of these 103 patients reported they would be extremely likely to recommend our service to Friends
and Family. The following bar chart demonstrates both improvements made over the year in
distribution and return of the questionnaires following improved engagement with service leads, and
the overwhelmingly positive response highlighted in returns.
FFT Distribution and Responses 2014/15
70
60
50
40
No Distributed
30
No of Responses
20
No of "Extremely Likely"
10
0
Quarter 2
Quarter 3
Quarter 4
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3.4
Other Comments from Partners & Stakeholders
Partnership Working with CDDFT, Jane Haywood, Clinical Director Adults and Integrated
Services:
“The district nursing staff work closely in partnership with St Teresa’s to improve
the quality of life, for those patients living with a life limiting illness. Together
with the hospice the community nursing team undertakes;
 Emergency Health Care Planning
 DNACPR
 Advanced care planning.
 Shared care of patients
Wherever possible we provide integrated services to ensure the highest quality of
care”
Partnership-working with Macmillan, Andrea Williams, Service Development Manager:
“Macmillan Cancer Support has worked in partnership with St Teresa’s Hospice
now for 2 ½ years and have co-created therapy and assistant posts to support
people affected with cancer. The partnership has been hugely beneficial to
patients as the national and local Charities have worked together to develop
measurable, key patient outcomes. The Day Hospice transformation over the
past year has allowed even more patients to benefit from the rehabilitation
model of care. The investment Macmillan has made in the service has been
beneficial and it is great to see ongoing progress”
Partnership-working Macmillan Team, North Yorkshire, Jane Bond Macmillan Nurse:
“From a personal and professional perspective the service supports me in
knowing that patients and carers truly have a multidisciplinary team around
them, giving more opportunities to identify and address concerns and provide
additional and/or alternative support to the Macmillan Community Service
Partnership-working with Marie Curie Karen Torley, Divisional General Manager, NE:
“The development of the Darlington Community Rapid Response Service is
testament to the effective partnership working between St Teresa’s Hospice and
Marie Curie. This is an innovative project which has influenced other provision
and demonstrates the efficacy of local and national charity partnership work.”
St Teresa’s Hospice Comment (extract from our Quality Assurance Policy)
All feedback is invaluable. We encourage positive comments and we ensure that service users are
aware of how to make complaints. We see these feedback mechanisms as providing vital intelligence
to help us to learn and to continuously improve our services at St Teresa’s Hospice.
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Supporting Statements
St Teresa’s Hospice Quality Account 2014-15
The Board of Trustees Statement
As we approach our 30th Anniversary year, this Quality Account document is evidence of the
ongoing commitment of St Teresa's Hospice to deliver safe, effective, patient-centred end of life and
palliative care, that is timely, efficient and equitable. It demonstrates also the ongoing commitment
of our organisation to move with the times, to respond to changing demographics and to identify
unmet needs in our community and having done so, to make every possible effort to fulfil those
needs. The development of our new purpose built in-patient unit, improvements in day hospice care
and the delivery of a satellite day-hospice service in North Yorkshire are just a few examples of this
commitment in action.
This Quality Account also reflects the commitment of St Teresa's Hospice to the delivery of an
holistic model of care, the hallmark of the Hospice Movement; ensuring that compassion takes
centre stage in our care and giving our patients and their families the time and support they need.
The value placed on our services by those we serve is reflected in the amazing feedback and
practical support we receive from the local community in fundraising and volunteering for the
hospice.
The Board of Trustees remains confident that the robust organisational framework that has been
established by our Chief Executive and Senior Management Team will ensure that we are successful
in achieving our aims and Board members are further assured by actively participating in corporate
and clinical governance activities.
Dr Harry Byrne, Chairman
Endorsement by Senior Directors
We the undersigned confirm this Quality Account as a true and accurate assessment of the
standards at St Teresa’s Hospice:
Dr Harry Byrne
Jane Bradshaw
Chairman, Board of Trustees
Chief Executive
Victoria Ashley
Nicola Myers
Director of Clinical Services
Finance Director
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Darlington Clinical Commissioning Group Statement
Statement from Darlington Clinical Commissioning Group for St Teresa’s Hospice Quality
Account 2014/15.
The CCG welcomes the opportunity to review and comment on the Quality Account for St Teresa’s
hospice for 2014/15 and would like to offer the following commentary.
As commissioners, Darlington Clinical Commissioning Group (CCG) is committed to commissioning
high quality services from St Teresa’s Hospice and take seriously their responsibility to ensure that
patients’ needs are met by the provision of safe, high quality services and that the views and
expectations of patients and the public are listened to and acted upon.
Overall the CCG felt that the report was excellent, well written and presented in a meaningful way for
both stakeholders and users and provides an accurate representation of the services provided during
2014/15 within the Hospice.
We recognise the work that the Hospice has undertaken to drive quality improvements throughout the
year particularly around patient experience, clinical effectiveness and patient safety. The changes
implemented as a result of patient and carer feedback, in particular the inclusion of this feedback
within the monthly Strategic Management meetings is to be commended.
The Hospice’s structured approach to governance and quality improvement is demonstrated by the
development of the two lead nurse roles with clearly defined responsibility for clinical leadership and
operational management. We further welcome the continued compliance with the commissioning for
quality and innovation (CQUIN) schemes agreed with ourselves throughout 2014/15.
The CCG is pleased to see the progress made in embedding clinical risk management processes
within the Hospice and supports the work undertaken to improve staff awareness of incident reporting
procedures. The introduction of a named nurse allocated to each patient is viewed as a positive step
towards ensuring professional accountability and continuity of care is maintained. The CCG also
acknowledges the data quality improvements that are being realised following the implementation of
SystmOne.
Darlington Clinical Commissioning Group (CCG) welcome the specific priorities for 2015/16
highlighted in the report and feel that they are appropriate areas to target for continued improvement.
The CCG look forward to continuing to work in partnership with the Hospice to assure the quality of
services commissioned in 2015/16.
Lisa Tempest
Chief Finance and Operating Officer
Darlington CCG
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Hambleton, Richmondshire & Whitby Clinical Commissioning Group
Statement
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Comment from Healthwatch, Darlington
Feedback from Healthwatch Darlington on St Teresa’s Hospice Quality Accounts
2014-2015.
These comments are on behalf of the Healthwatch Darlington Limited Board and
active volunteers.
Healthwatch Darlington have welcomed the opportunity to comment on the Quality
Account and look forward to an active involvement in the coming year. We are
pleased to note the accounts have been written in a very open and honest manner
and are easily understandable for the public.
Healthwatch Darlington members have been pleased to see a lot of progress has
been made towards the previous Aspirations in particular the work around patient
safety and experience.
Under the Patient Safety section of the Account we are happy to note that no falls
had resulted in major injury and there had been zero avoidable pressure ulcers
during the reporting year. It is comforting to note that where incidents are reported
and investigated, plans for improvement are applied.
Healthwatch Darlington is pleased to note such high figures under the Key
Performance Indicators (KPI’s) section of the document.
The group were happy to read about the support and training given to volunteers
and the awards received by them. Again, we are happy to note the staff support
and experience, and applaud the 100% appraisal monitoring and the operation of a
vital open door policy.
The comments received about the service are inspirational and we have heard
nothing but positive things from local residents.
Healthwatch Darlington agree with all of the aspirations for the upcoming year and
look forward to observing the development of the 10 bedded inpatient unit.
Thank you for involving Healthwatch Darlington in the Quality Account, we look
forward to working with St Teresa’s Hospice in 2015-2016.
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Comment from Health & Partnerships Scrutiny Committee, Darlington
Health and Partnership Scrutiny Committee
Response to St. Teresa’s Hospice Quality Accounts 2014/15
Health and Partnerships Scrutiny Committee is happy to respond to the Quality Accounts which are
comprehensive and written so as to be easily understood by the public.
The inclusion of comments from parents and carers is good and reflects the excellent care provided by
staff and volunteers.
Future Improvement/Aspirations for 2015/16
1. The Committee is pleased to note the continuing aspiration to provide a purpose built 10 bedded
Patient Unit. The Hospice is planning for future needs of patients, taking into consideration
demographic changes and the limitations and challenges of the existing building. We wish them
well and hope they are successful in commissioning this Unit by April 2016.
2. We welcome the aspiration to develop a comprehensive, Hospice based Lymphoedema service.
It seem that this service has been somewhat fragmented and we are pleased to note the
commitment to work with partners to provide a more streamlined service, with a dedicated
Lymphoedema Practitioner, referral pathway for GP’s, training, a patient self-management group
and development of networks within the locality.
We feel that this will provide a much better patient experience as well as potentially reducing
hospital admissions.
3. This refers to exploring the role of St Teresa’s Hospice in Transitional Care. The Committee is
pleased that this has been identified as a priority to meet the needs and support younger people.
Committee would welcome the opportunity to consider recommendations when the report
becomes available.
4. The Committee notes the aspiration to develop a Day Hospice Satellite for North Yorkshire
Patients which will give them access to beneficial services closer to home.
The Committee has considered the evidence presented in respect of the Aspirations for 2014/15 and
has made the following comments:1. The plan to provide the 10-bedded purpose-built In Patient Unit is on track and this aspiration will
continue into 2015/16.
2. We are happy to note that the aspiration to have a named nurse for each patient within the In
Patient Unit has been achieved and indeed the Hospice seems to have gone above and beyond
the original ambition.
3. We note the significant progress made in the range of services offered to non-cancer patients and
are pleased that the Hospice recognises the needs of patients with other life limiting conditions.
4. This Committee notes the progress made in Clinical Risk Management and the proposals for the
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future including Patient Related Outcome Measure (PROM).
Finally, the Hospice is to be commended on achieving full payment of 3 CQuINS – Friends and Family
Test, Patient Safety and Day Hospice Transformation.
Councillor Wendy Newall,
Chair, Health and Partnerships Scrutiny Committee
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St Teresa’s Hospice | The Woodlands | Woodland Road | Darlington | DL3 7UA
01325 254321 | enquiries@darlingtonhospice.org.uk
www.darlingtonhospice.org.uk
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