Title
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Part 1
Chief Executive’s Summary
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Part 2
Quality Improvement Priorities
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2.1
Priorities for improvement 2014/15
4
2.1.1
To reduce the incidence of falls as compared to 2014/15
4
2.1.2
To evaluate clinical care using validated outcome measurements
4
2.1.3
To ensure patients’ and relatives’ views of care are captured at the time of care
5
2.2
Feedback on priorities for improvement 2013/14
5
2.2.1
To improve patient safety
5
2.2.2
To demonstrate the effectiveness of clinical care through use of outcome measurements
5
2.2.4
To improve our understanding of the patient experience of our hospice services through gathering real time
feedback from patients
To monitor and improve accuracy of health record keeping to improve safety and ensure accurate reporting
2.3
Statements of assurance from the board relating to the quality of NHS services provided
6
2.3.1
Review of services
6
2.3.2
Participation in clinical audits
7
2.3.3
Accountable Officer for controlled drugs
8
2.4
Summary of published audit, research or academic studies during 2013/14
8
2.4.1
Research
8
2.4.2
Summary of research engagement and activity
8
2.4.3
Research studies
9
2.4.4
Presentations at research meetings
9
2.4.5
Research publications
9
2.4.6
Staff members Involved in external teaching on research degrees 2014-2015
9
2.4.7
Other related research activities
9
2.5
Statements from the CQC
9
2.6
Registered provider visits
10
2.7
Data quality
10
Part 3
Review of Quality Performance
11
3.1
Embedding a new clinical governance structure
11
3.1.2
Clinical risk
11
3.1.3
Clinical effectiveness
11
3.1.4
Patient experience
11
3.1.5
Infection control
12
3.1.6
Medicines management
12
3.1.7
Complaints
13
3.1.8
Health and safety
13
3.1.9
Information governance
13
3.1.10
Psychosocial care
13
3.1.11
Staff support
13
3.1.12
Learning and development
13
3.2
Patient safety
13
3.3
Patient experience
16
3.3.1
CQC comments
17
3.3.2
Feedback from those who experience care provided by St Wilfrid’s Hospice
17
2.2.3
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Chief Executive’s Summary
Our vision is of a community where people talk openly about dying, live well until the end of their life and where
nobody dies alone afraid or in pain. St Wilfrid’s Hospice is a local charity founded in
1982. The charity exists to support, empower and care for people at the end of life, to
influence the quality of end of life care in all settings and to encourage the wider
community to be concerned about the issues of death, dying and loss. The 1,000
patients supported by St Wilfrid’s Hospice each year all have progressive, advanced and
life limiting disease. Patients are referred by their General Practitioner or healthcare
practitioner with problems that may include uncontrolled pain, vomiting,
breathlessness, fatigue, anxiety or low mood. Patients may also have practical and or
family concerns. Care is delivered by a specialist team that includes Consultants in
Palliative Medicine, specialist nurses, physiotherapists, occupational therapists and
social workers as well as a Chaplain and nearly 600 volunteers. The services provided
include a 15 bed short stay inpatient unit, an occupational therapy-led Wellbeing
Centre, a seven day a week Hospice at Home service including a night sitting service, a
24/7 nurse run advice and support service and a counselling and bereavement service.
Services were inspected by the Care Quality Commission in 2014 and were rated as outstanding.
This set of Quality Accounts were prepared by senior clinicians leading the Patient Safety, Patient Experience and
Clinical Effectiveness work streams that are part of the charity’s clinical governance structure. These Quality
Accounts have been approved by the Clinical Governance Committee which is a sub-committee of the Board of
Trustees of St Wilfrid’s Hospice. To the best of my knowledge, the information presented in this set of Quality
Accounts is a fair and accurate representation of the care provided by St Wilfrid’s Hospice Eastbourne.
Kara Bishop
Chief Executive
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Quality Improvement Priorities
St Wilfrid’s Hospice has declared itself compliant as part of the registration process with the Care Quality
Commission (CQC) to comply with the Health and Social Care Act 2008 (Regulations 2010). In February 2015 the
hospice was awarded a rating of Outstanding by the Care Quality Commission, following an unannounced
inspection in August 2014.
2.1
Priorities for improvement 2014/15
2.1.1
To reduce the incidence of falls as compared to 2014/15
Why
a.
During 2014/15 falls incidence increased. Whilst measures have been taken to analyse causes and
implement change these are at an early stage and require on-going scrutiny.
b.
St Wilfrid’s Hospice has had above average falls incidence in 2014/15 when compared to similar sized units
through Hospice UK national benchmarking.
c.
The patient population being cared for within the In-Patient Unit (IPU) comprise a high risk group and falls
are a significant risk.
Implementation and measurement
d.
Continue to participate in national benchmarking through Hospice UK and to be at or below the average
number of falls for the hospice size category.
d.
Further review the assessment of falls risk for admission to IPU.
e.
Report falls incidence as a clinical key performance indicator (KPI) ensuring monitoring, awareness and
engagement.
f.
Review and analyse incidents and highlight areas for practice changes and learning.
2.1.2
To evaluate clinical care using validated outcome measurements
Why
a.
During 2013/14 great progress was made to introduce an outcome measure within some aspects of the
hospice services. Concentration is now required to build on this achievement to embed change.
b.
Evidence based care is key to demonstrating the effectiveness of hospice services and enables us to
communicate outcomes and is one way to show quality.
c.
Measurement of care using validated outcomes allows comparison of St Wilfrid’s Hospice care to other
hospice services.
Implementation and measurement
d.
Use of validated outcome measurements will be a clinical KPI for 2015/16 ensuring inter-professional
engagement and analyses.
e.
St Wilfrid’s Hospice will share its learning of outcome measurement through presentation at a key
palliative care conference.
f.
Training and practice development in use of outcome measurements will continue to improve knowledge
and skills.
g.
The use of validated outcome measurement will be reportable by the end of this reporting year.
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2.1.3
To ensure patients’ and relatives’ views of care are captured at the time of care
Why
a.
Improving understanding of the patient experience of our hospice services through gathering real time feed
back from patients was a quality improvement priority for 2014/15 which we did not achieve due to senior
staff changes within the hospice.
b.
Patients’ views on care is one aspect of information which can demonstrate quality of care
c.
The hospice is committed to improving the experience of carers.
Implementation and measurement
d.
Undertake work to identify best practice and validated tools to capture views of care.
e.
Improve knowledge and skills in gaining and interpreting views of care through training and awareness.
f.
To begin collecting views of care within hospice services by the end of the reporting year.
2.2
Feedback on priorities for improvement 2014/15
This section details the activity undertaken in response to the quality improvement priorities described in the
previous year’s Quality Accounts.
2.2.1
To improve patient safety

St Wilfrid’s Hospice took part in the national benchmarking of patient safety metrics organised by Hospice UK.

During the reporting year five additional beds were opened on the In-Patient Unit. This increased
opportunities for incidents. Due to the increase in beds it is not helpful to compare activity for the previous
year. Medication errors were a clinical key performance indicator for the hospice and discussed monthly at
its Clinical Leader Forum and reported to the Board of Trustees bi-monthly for scrutiny.

The process of incident reporting was reviewed through the clinical governance structure and a revised
incident form created to ensure all data required to investigate incidents or near misses was captured.

The annual mandatory clinical update training sessions on medicine management and has been reviewed to
increase focus on preventing harm and the session on moving and handling changed to include falls
prevention awareness.
2.2.2
To demonstrate the effectiveness of clinical care through use of outcome measurements

Nationally recognised and validated outcome measurement tools were reviewed through literature searches
and study days. The integrated Palliative Outcome Score (iPOS) was decided by clinical effectiveness as the
most beneficial. In this year the iPOS was itself recognised nationally as a recommended tool for use in
palliative care settings confirming this was the right tool to adopt.

The iPOS is part of a suite of measures that has been highlighted through the Outcome Assessment and
Complexity Collaborative (OACC) and has been taken up by the National Council of Palliative Care for future
use in Minimum Dataset reporting.

Other outcome measurements continue to be used in Wellbeing and within the Therapy team where their
use is established. These include: Distress Thermometer in Wellbeing and Therapeutic Outcome
Measurement Score (TOMS) in physiotherapy. The iPOS will be taken up by all departments as the key
measure of outcome across all settings.
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
Through the year we were able to pilot the use of iPOS in the outpatient setting primarily to assess user
experience. A user survey suggested patients were happy to use it and it actually improved the quality of
assessment.

To ensure iPOS was integrated into practice the scoring was embedded into our electronic patient record
(Crosscare). On discussion with other units using outcome measures this was seen as a great innovation.

The Inpatient Unit (IPU) was chosen to implement full use of iPOS including a review period. A flow chart
was created and all staff were trained in its use.

To encourage debate and reflective learning a monthly forum was set up for all staff interested called the
Outcome Measurement Group (OMG).

The actual reporting of iPOS through Crosscare was not achieved due to the departure of the Clinical
Information Manager in December 2014. This final task of the project will become a quality improvement
priority for the coming year. In the interim an audit of its use in IPU including a review of outcome changes
will be implemented.
2.2.3

To improve our understanding of the patient experience of our hospice services through gathering
real time feedback from patients
Due to senior staff changes within the organisation this priority was not met. It will form a quality
improvement priority for 2015/16. Further activity undertaken to engage with patients and carer’s is
described in the Patient Experience Group report later in section .
2.2.4
To monitor and improve accuracy of health record keeping to improve safety and ensure accurate
reporting

The accident, incident and near miss reporting process was reviewed to improve the categories to better
identify clinical information governance incidents. The initial stage has been implemented with on-going
work required to ensure clarity and detail of the nature of incidents.

Quarterly reporting of incidents related to health record keeping was provided to the Clinical Governance
and Board of Trustees.

Themes identified through incident reporting led to targeted one to one staff support in use of the electronic
patient record.

During the review period the requirement for all clinical staff to attend the annual mandatory training days
including a Crosscare session has continued. The mandatory training year runs September to May and at the
time of the report eighty percent of all those required will have attended, with the further twenty percent
attending in the first two months of the reporting year 2015/16.
2.3
Statements of assurance from the board relating to the quality of NHS services provided
The following are a series of statements that all providers must include in their Quality Accounts. Not all of these
statements are directly applicable to specialist palliative care, including hospice providers.
2.3.1
Review of services
During 2014/15 St Wilfrid’s Hospice provided the following services:
a.
Inpatient care within our Inpatient Unit (IPU) with 307 admissions. The number of beds within IPU increased
to 15 in December 2014.
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b.
Care to patients within their own home and usual place of residence, including care homes, through our
Hospice at Home team and Advanced Nurse Practitioner with 10,470 contacts.
c.
Day care services to patients in Wellbeing supported 252 new patients.
d.
The hospice piloted a new Triage service providing 24/7 telephone advice and support to patients, their
relatives and carers, and health professionals. The service was made permanent from 1st March 2015. In
the six months of the pilot, 4,217 calls were dealt with.
The hospice saw an increase in clinical activity during the reporting year. Although there was a noticeable increase
in falls, other patient safety incidents did not increase.
St Wilfrid’s Hospice has reviewed all the data available to it on the quality of care across these services. The
income generated by the NHS services reviewed in 2014/15 represents 14% of the total income generated from
the provision of services by the hospice for 2014/15.
2.3.2
Participation in clinical audits
a. National audits and confidential enquiries
During 2014/15 there were no national clinical audits and no national confidential enquiries covering NHSrelated services that St Wilfrid’s Hospice provides. St Wilfrid’s Hospice was not eligible to participate in any
national clinical audits or national confidential enquiries during 2014/15.
b. Local clinical audits
The reports of local clinical audits were reviewed by the hospice in 2014/15 and St Wilfrid’s Hospice
intends to take actions to improve the quality of health care as a result of these audits. The following table
describes this activity:
Audit subject
Outcome
Completion of the carers’ assessment on the
IPU
Staff training needs identified and changes to
electronic patient record highlighted for action.
Email communication Audit
Staff training need identified and planned reaudit to identify specific departmental needs
Mattress setting on the IPU
Training needs identified; changes made to
current documentation. Plan to purchase
weighing scales and prompted valuable
discussion regarding weighing patients in the
hospice setting with potential for a research
question
Pressure ulcer care
Changes to current documentation and
formation of the Pressure Ulcer Group. Training
need identified around the reporting of high
End of life documentation on the IPU
Identified changes required on electronic
patient record to guide care and accurately
document communication. Prompted
discussion regarding phase of illness which will
inform further work in the hospice’s Clinical
Effectiveness Group.
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Improvement to storage and infection
control measures
Improved awareness demonstrating 95%
compliance
Safe waste management
Hand washing
Infection control practice with medical
devices
Changes in procedures of cleaning medical
devices
100 % compliance with polices and
procedures
Improved procedures for storage of food
and patient aids
Demonstrated compliance with storage
and disposal of controlled drugs
Handling and disposal of linen
Audit of the patient environment
Controlled drugs audit
Audit identified time management issues
and considered how environmental
changes will impact on future practice
Medicines Management medication times
in relation to administration
2.3.3
Accountable officer for controlled drugs
The Advanced Nurse Practitioner at St Wilfrid’s Hospice continues with the Accountable Officer role and
has undertaken regular audits of stock and patient named controlled drugs to ensure they are correct and
used in accordance with national protocols. All deceased patient records are checked to ensure
appropriate use of the drugs. Contact has continued with the Controlled Drug Liaison Officer for Sussex
Police who destroys all controlled drugs which are no longer required and advises on environmental
aspects of controlled drug storage. Due to the hard work and vigilance of the clinical managers the
number of incidents involving controlled drugs has decreased in the last year.
2.3.4
Research
No patients receiving NHS services provided or sub-contracted by St Wilfrid’s Hospice in 2014/15 were
recruited during that period to participate in research approved by a research ethics committee.
St Wilfrid’s Hospice is committed to evidence based care and during the reporting period has reviewed
and strengthened its approach to ensuring evidenced based care is embedded within the hospice,
through the clinical governance structure.
2.4
Summary of published audit, research or academic studies during 2014/15
2.4.1
Research
St Wilfrid’s Hospice has not recruited patients to any National Portfolio Research studies between April
2014 and March 2015.
2.4.2
Summary of research engagement and activity
St Wilfrid’s Hospice continues to be engaged in palliative care research in the year 2014/15 and has
started recruitment to a regional Kent, Surrey and Sussex research study.
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2.4.3
Research studies
St Wilfrid’s Hospice has been involved in the following research studies:
a. OaSis1 Study: St Wilfrid’s Hospice has been involved as a participant recruitment centre in a regional KSS
study entitled OaSiS 1 (which is being run by the Royal Surrey County Hospital, Guildford). This study
examines the prevalence of oral symptoms in patients with advanced cancer and we are currently
recruiting through our IPU.
b. OPT-Care Neuro: We have gathered and submitted service data as part of the mapping exercise for
inclusion in the Opt-Care Neuro study. This study is being run out of the Cicely Saunders Institute, Kings
College London and is a National Institute of Health Research (NIHR) funded study which evaluates the
clinical and cost-effectiveness of Short-term Integrated Palliative Care Services (SIPC) to OPTimise CARE for
people with advanced long term neurological conditions.
Individual research

Karen Clarke (Deputy Chief Executive) has started the research phase of her PhD. The study has gained ethical
approval via the Faculty of Health and Medicine Research Ethics Committee (FHMREC) at Lancaster University. The
working title is “Integrating rehabilitation into palliative care”.

Lara Cowley (Lead Physiotherapist) has been developing her thesis as part of her MSc in Physiotherapy,
Brighton University examining patient experience post-discharge from exercise classes in the hospice. The study is
currently going through ethical approval.

Eirian Levell (Hospice at Home Nurse Manager) has completed her BSc in Professional Practice January 2015.
2.4.4
Presentations at research meetings
There have been no presentations at research meetings. Karen Clarke, Deputy CEO presented a parallel
session at the Hospice UK national conference in Leeds on the subject of ‘maximising the potential of
hospice volunteers to add value to your local community'.
2.4.5
Research publications
No publications were submitted in the reporting year.
2.4.6
Staff members involved in external teaching on research degrees 2014-2015:
No staff members were involved in external teaching on research degrees this year.
2.4.7
Other related research activities
Dr Farida Malik continues to co-lead the Sussex Palliative Care Research Specialty Group (SPCRSG). She is
also a member of the Kent, Surrey and Sussex (KSS) Palliative Care Regional Research Specialty Group and
co-organised and chaired a study day for the regional group, which was held at the University of Brighton
in September 2014. The study day covered the challenges and ethics of undertaking research in patients
who lack capacity in relation to older people with dementia and in palliative care. The second part of the
day covered the KSS Clinical Research Network and Division 5 and how to improve palliative care
recruitment to National Institute of Health Research clinical trials. It had Royal College of Physicians
Continuous Professional Development accreditation.
2.5
Statements from the CQC
St Wilfrid’s Hospice is required to register with the Care Quality Commission and its current status is as
registered to provide treatment of disease, disorder or injury and diagnostic and screening procedures. The
CQC has not taken enforcement action against St Wilfrid’s Hospice during 2014/15. St Wilfrid’s Hospice was
inspected by the CQC in August 2014 under the new model of inspection and awarded an Outstanding
rating.
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2.6
Registered provider visits
During the reporting period there were no registered provider visits.
2.7
Data quality
Good data quality underpins the effective delivery of patient care and is essential if improvements in quality of care
are to be made. Improving data quality, which includes the quality of ethnicity and other equality data, will thus
improve patient care and improve value for money. During 2014/15 St Wilfrid’s Hospice has continued to monitor
and scrutinize its data quality through its Clinical Leaders Forum and Clinical Governance structure. The hospice
submitted a satisfactory Information Governance toolkit assessment in March 2015.
St Wilfrid’s Hospice, in accordance with agreement with the Department of Health, submits a National Minimum
Data Set (MDS) to the National Council for Palliative Care. The hospice has been accredited to access and has maintained an N3 community of interest network (COIN) connection which required the satisfaction of 19 requirements
as specified in the NHS Information Governance toolkit for voluntary services.
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Review of Quality Performance
3.1
Maintaining a strong clinical governance structure
The Clinical Governance Committee at St Wilfrid’s Hospice is based on the three pillars described in the clinical
governance toolkit: patient safety, clinical effectiveness and patient experience. Three sub-groups exist leading
on these areas with broad staff membership, reporting on a quarterly basis to the Clinical Governance
Committee, chaired by the Chief Executive.
During 2014/15 the senior management structure was reviewed. The posts of Nursing Director and Family and
Patient Support Director were created to strengthen the clinical involvement at executive level.
The clinical governance framework in the hospice covers all areas focusing on patient care, described in the
following section.
3.1.2
Clinical risk
St Wilfrid’s Hospice has a strong process of managing accidents, incidents and near misses (AINM). The
incident reporting process was reviewed and changes implemented during the reporting year. Patient
safety data is reported in detail in a subsequent section of this document.
3.1.3
Clinical effectiveness
Oversight of audit is incorporated within the Clinical Effectiveness group. Work to implement and develop
the use of outcome measurement has been described in section 2.2.2.
3.1.4
Patient experience
St Wilfrid’s Patients Forum, an active and well-established group of current patients facilitated by the
Deputy Chief Executive, continued to meet on a monthly basis and influenced patient service
developments.
The following summary describes activity from the hospice’s Patient Experience Group during the
reporting year:

Patient Led Assessments of the Care Environment (PLACE) were undertaken for the first time in June 2014
and the results, published in late August, demonstrated that improvements could be made by providing
patients with a written menu each day and offering more condiments. Menus are now available for
patients and the choice of condiments has been increased.

Following consultation with the Wellbeing Steering Group, Patients Forum and Patient Experience Group it
was agreed, with the clinical directors, that the hospice would install a leaflet rack in the Orchard Lounge
containing information that might be of use to carers and that other more general leaflets would be
available in the counselling rooms. The Wellbeing team has also developed self-help guides for coping with
breathlessness and fatigue for patients to use at home.

Members of the Patients Forum were consulted and concluded that they were satisfied with the way that
the hospice engaged with patients, and gathered their feedback, but that this should be reviewed on a
regular basis.
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
The IPU Nurse Managers plan to implement the ‘Carers Support Needs Assessment Tool’ (CSNAT) following a
successful introduction in Wellbeing and Hospice at Home. Work will continue into 2015/16. Feedback is also
being gathered from carers about access to respite facilities at the hospice and the benefit (or otherwise) to
them. The Learning and Development Manager is planning a half day workshop, in 2015 for groups of up to
12 clinical staff to include:
3.1.5

Café –style session where carers talk about their experience

Focus on CSNAT – why is it important? What will it tell us? Who will it benefit?

Case studies – good and not so good practice

Communication skills
Infection control
The hospice has an Infection Control Group chaired by the IPU Nurse Manager meeting every six weeks.
Membership includes clinical and non clinical staff. All Infection control policy and procedures have been re
viewed and amended to reflect evidence based practices.
The Front of House Manager is involved in monthly environmental audits with clinical staff. This ensures high
standards within the environment focused on reducing the risk of infection, enhancing patient safety and
employee well being. Findings from the audits are discussed at the infection control meetings and action
plans devised. Positive feedback has been gained from the patient questionnaires on the cleanliness of the
IPU. The CQC inspection report stated: “the hospice had a clean and well maintained environment which
allowed people to move around freely without risk of harm.”
The hospice has not reported any incidents relating to hospice-acquired infections during the reporting year.
3.1.6
Medicines management
There has been a 15% reduction in drug incidents for 2014/2015 compared to 2013/2014. (34 compared to
40), a notable achievement with the increase in patient activity and opportunities for harm. Teaching
sessions of the Medicines Management for clinical updates have been extended. Within the reporting year,
new medication and syringe driver charts have been introduced promoting greater patient choice by allowing
flexibility of when medication is administrated. St Wilfrid’s Hospice is part of a national bench marking on
medication incidents, enabling comparison with hospices of similar size.
The CQC inspection report for St Wilfrid’s Hospice states:

There are established forums to review medicines safety, identifying and reducing risk in relation to their
management.

Good reporting culture regarding medication errors or near misses.

Errors reported had been investigated in a timely manner and actions put in place to prevent them from
recurring.

Staff managed people’s medicines safely and had the skills to work with medicines used in palliative care.
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3.1.7
Complaints
The hospice has continued to address any concerns or complaints. The Patient Experience Group oversees
the management of complaints and reports to the Clinical Governance Board. The hospice actively
encourages feedback and has an established policy and procedure to deal with complaints. During the
reporting year there were two complaints received related to clinical care, which prompted reviews of the
discharge process and significant investment and improvement to the hospice’s 24/7 response to advice
and support via telephone.
3.1.8
Health and safety
The hospice has a well-established Health and Safety Committee chaired by the Chief Executive which
meets on a quarterly basis. A new liquefied medical piped gas system has been successfully implemented
in 2014-15 to ensure consistent oxygen availability for patients within the hospice.
3.1.9
Information governance
Mandatory staff training on information governance is in place, with protected time for staff to complete
the on line e learning refresher module of the information governance toolkit. The target of 100%
compliance for this training has not been met and will continue to be monitored by the Patient Safety
Group.
3.1.10
Psychosocial care
Reflective Review sessions are an established focus for staff and volunteers and encourage critical review
and learning. The senior management structure within the hospice was reviewed in the reporting year and
the post of Family and Patient Support Director created and successfully filled. This will strengthen and
improve the psycho-social care to patients and carers. In addition a new post of Social Worker was created
and successfully recruited to. The hospice has provided a programme of training on Compassion
Awareness in collaboration with Health Education England to improve compassion and dignity in care
across all settings across the local area.
3.1.11
Staff support
St Wilfrid’s Hospice recognises the value of staff support and development in order to provide safe,
effective care. During the reporting year the hospice undertook a pilot of group supervision for staff which
had highly positive evaluation. The next step will be to use the information gained in the pilot to develop
achievable and sustainable supervision across the hospice. The hospice was rated Outstanding for the
domain ‘is the service well-led’ in its CQC inspection.
3.1.12
Learning and development
There has been a full programme of training during 2014-15 for both hospice staff and external health and
social care organisations and groups. The two day clinical mandatory training, which was reviewed last
year, has been successfully embedded. It involves interactive, practical and theoretical sessions, along with
on line learning modules, including E-Elca and E -Learning for health. The in-house education programme
has sessions appropriate for all clinical staff and combined with the mandatory training ensures staff are
fully trained to offer safe and effective patient care.
3.2
Patient safety
Patient safety is a key domain of quality and when patients receive care from St Wilfrid’s Hospice there is a
commitment to ensure a safe environment which causes no harm. The hospice has a culture of openness
and transparency and encourages reporting of accidents, incidents and near misses. These are
investigated to ensure lessons are learned, recommendations made and all appropriate actions
implemented.
St Wilfrid’s Hospice participated in the Hospice UK national benchmarking pilot on quality measures for
medication, falls and pressure ulcer incidents enabling comparison with national hospice care.
13
The following section is a summary of patient safety data:
14

97% of incidents caused no or low harm.

Despite a 50% increase in the number of beds on IPU there was a 15% reduction in the number of medication
incidents.

For level 1 or above incidents only, the hospice reported 21 in the year 2014/15 as opposed to a national
average of 23 for hospice IPUs of a similar size.
15

95% of falls resulted in no or low harm.

There was a 53% increase in the number of falls as compared to the previous year. There was an increase in
the number of IPU beds across the reporting year from 10 to 15.

A multi-professional falls prevention task and finish group was formed to address the issue. Actions included
education and awareness of falls prevention management, improved information on reporting, purchase and
use of sensor pads and perching stools and protected rest time after lunch.

Bed occupancy is a variable which may affect falls activity: St Wilfrid’s Hospice bed occupancy in the reporting year has been 91% as opposed to the national average for similar sized hospices of 78%.

A deeper analysis of activity identified diagnosis as a key risk for falls with brain disease and confusion contributing to multiple falls. Incident forms have been modified to capture information on diagnosis.

Assumptions were made that the patient dependency had increased and needs become more complex, potentially contributing to increased falls. A working group has been formed to implement dependency scoring
within IPU based on the multi-factorial, nationally implemented, safer nursing toolkit.

Improving falls management will be a key improvement priority for 2015/16.
Pressure ulcers
One pressure ulcer was reported in the year 2014/15. This is against a national average for similar sized hospices
of 15. A pressure ulcer group has been formed in the reporting year. In addition, the pressure ulcer assessment
tool has been reviewed and a new tool introduced.
Infection control
There have been six incidents reported in the category of infection control in the reporting year. Infection control
has been discussed in further detail in section 3.1.5.
3.3
Patient experience
Patient questionnaires are collated monthly and service managers required to respond to comments with actions
where indicated. Throughout 2014/15, 152 questionnaires were completed representing a 30% return rate.
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3.3.1
CQC comments
The report in to the CQC inspection undertaken in August 2014 includes many highly positive comments
and can be viewed in full at: http://www.cqc.org.uk/location/1-999808672#accordion-1
The inspection team commented that “people and their families were involved in the planning of care and
were treated with kindness and compassion with due regard to their privacy and dignity”
3.3.2
Feedback from those who experience care provided by St Wilfrid’s Hospice
The following comments were made by two relatives whose loved ones died at home supported by the
Hospice at Home team:
“We send our heartfelt gratitude for all the unwavering support and kindness shown to all of us. Without
your dedication, help and advice, these past few months would have been much harder. Because of your
involvement we were able to keep our mum at home ‘til the end, which was where she was happiest, with
her family.”
“Thank you to all the Hospice at Home nurses who came out to help myself and my family to allow my father
to die peacefully and with dignity at home in his own bed with my mum beside him and all his five children
and grandchildren with him. You are a special bunch!”
Completed June 2015
Author: Colin Twomey
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St Wilfrid’s Hospice (Eastbourne)
1 Broadwater Way
Eastbourne
East Sussex BN22 9PZ
01323 434200
www.stwhospice.org
stwhospice
@stwilfridstweet
Registered Charity Number: 283686
Registered Company Number: 1594410
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