Contents
Page number
Introduction by Chief Executive
3
Who We Are and What We Do
Hospice Services
Our purpose, values, strategic priorities
Review of last year’s quality improvements
National Clinical Audits and National Confidential Enquiries
Data Quality
Research
4
5
6
8
8
9
Quality Overview of Services
Overall Services
Inpatient Unit
Palliative Day Services
Rehabilitation team
Carers support
Hospice at Home
Community team
Practice Educator for care homes
Bereavement service
Education
10
10
11
12
12
12
13
13
14
15
Quality Markers
Review of quality performance
What patients and families say about the services
at St Wilfrid’s Hospice
User involvement
What others say about St Wilfrid’s Hospice
What our staff and volunteers say about the organisation
Priorities for improvement for 2014/15
Quality improvement and innovation goals agreed by
our commissioners
The Board of Trustees commitment to quality
Statements from local Healthwatch and Clinical
Commissioning Group
2
16
19
21
22
23
25
26
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27
Introduction by Chief Executive
On behalf of myself and the Board of Trustees, I am delighted to
introduce our Quality Account for the year
April 2014 - March 2015.
St Wilfrid's Hospice Chichester, as a local charity has been
providing high quality specialist palliative and end of life care to
people in need since 1987. The majority of our patients are cared for at home and this
year the average number of patients being supported at any one time increased to
235, an increase of 38% in the last three years. We continue to support people at
home, in local nursing and care homes, in hospital and at the Hospice. We are not part
of the NHS, although we work collaboratively with its services and we provide our care
free of charge, relying on public donations to ensure as many people as possible
receive our care. We receive a grant from the NHS which meets 12% of our annual
costs.
This report shows the actions we have taken over the last year to improve our services
so that we continue to provide high quality and cost effective patient care. We thank all
the staff and volunteers for their high quality work and commitment and hope that they
are proud of our achievements as detailed in the report. We are always looking for
better ways of delivering our services and ways in which we can develop and improve;
despite very high levels of satisfaction with our services there is always room to do
more. We are committed to further development of our much needed services to meet
the growing needs of those in our community who could benefit from our expert care.
St Wilfrid's has a well-established and effective clinical governance function,
incorporating a quality and audit programme, which acts as the driver for continuous
improvement in the quality of patient care. The views, experiences and outcomes for
patients and their families are paramount to quality improvement and are of great
importance to us. Questionnaires, surveys and feedback cards are just some of the
ways we listen. From this we are able to learn, develop and improve the services we
provide.
Thank you to the many and varied supporters of the vital work of the Hospice; without
this support we would not be able to deliver our services which make such a
significant difference to those in need of them. I am responsible for overseeing the
preparation of this report and its contents. To the best of my knowledge, the
information reported in this Quality Account is accurate and a fair representation of the
quality of healthcare services provided by our Hospice.
Thank you for your interest in the work of St Wilfrid's Hospice.
Alison Moorey, Chief Executive
3
Who We Are and What We Do
This section includes information that all providers must include in their Quality
Account. (Some of the information does not directly apply to Specialist Palliative Care
providers).
The purpose of St Wilfrid’s Hospice is to relieve the suffering of people with cancer
and other terminal conditions and support families, carers and friends including the
provision of bereavement support.
In December 2015 following discussions with staff, volunteers and other key
stakeholders the Board of Trustees agreed to our new Purpose, revised Values,
Strategic Priorities and Headlines for 2015-20.
Hospice services
During 2014 -2015 St Wilfrid’s Hospice provided the following services to NHS
patients and families:
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Inpatient care
Palliative Day Services
Hospice at Home
Community Team, including Doctors, Clinical Nurse Specialists, Chaplaincy,
Psychosocial Team and Volunteers
Physiotherapy and Occupational therapy
Complementary therapy
Support in local hospitals, nursing and care homes
Bereavement service
Education
St Wilfrid’s Hospice Audit Group regularly reviews feedback from patients, relatives,
carers, staff and volunteers on the quality of care provided within all of these services
for NHS patients. The Audit Group reports this feedback to the Governance subcommittee of the Board and relevant Senior Staff.
St Wilfrid’s Hospice is funded through an NHS grant, fundraising and retail activity.
The income generated from the NHS represented approximately 12% of the overall
running costs of the Hospice 2014 -2015. The remaining income is generated through
legacies (gifts in Wills), generous support from our local community, retail, fundraising
and investments.
4
Our purpose, values and strategic priorities
Agreed statement
Purpose
Our purpose is to provide high quality specialist
palliative and end of life care in our community, in
collaboration with the NHS and other local services
People focused – meeting needs with tailored care
and support
Excellence – striving for quality and innovation in all
that we do
Values
Compassion – responding to others with
understanding and a desire to help
Accountability – acting with responsibility and
transparency to those we serve
Collaboration – working in partnership and cooperation with others
1. Deliver services
Develop and enhance the provision of high quality
specialist palliative and end of life care services.
3 Strategic Priorities
and Headlines
2. Communicate and educate
Share our knowledge and expertise to increase
impact, awareness and understanding of our work.
3. Raise funds and manage resources wisely
Raise funds and use our resources (human, financial
and physical) to fulfil our purpose.
5
Review of last year’s quality improvements (2014-2015)
Improvement Priority 1: Development of Palliative Day Services
A working group was set up led by our Palliative Day Services Leader and Palliative
Medicine Consultant to establish a new service for patients who have a chronic illness
that is life-limiting and causes distressing symptoms.
The Orchard Supportive Care Clinic (OSCC) started in November 2014, on Monday
afternoons. It has an independent referral process which is not limited by prognosis; all
assessments are made by a SWH Medical Consultant or Clinical Nurse Specialist
(CNS).
In collaboration with the patient and involving a professional team an individual
package of interventions is tailored to needs, which might include individual
appointments or groups, with the aim of promoting resilience and management of
symptoms.
A part-time staff nurse was recruited to oversee patents attending the clinic and free
up time for the Palliative Day Services Leader to work on strategic development.
Further monitoring and patient feedback is ongoing.
Since the OSCC has started; 18 referrals have been received, 2 patients have been
referred on to the CNS team for ongoing support and one patient has completed the
Advance Care Planning course.
Improvement Priority 2: Joint funding for End of Life Care Project Manager
position within the Coastal West Sussex Commissioning Group
As from 1st April 2013 the Coastal West Sussex Commissioning Group (CCG)
assumed its full responsibilities under the changes in the structure of the NHS.
Following an analysis of end of life care by the CCG and based on sound working
relationships, a two year part-time End of Life Care Programme Lead position has
been jointly funded by the CCG, St Barnabas and St Wilfrid’s Hospice on a three day a
week basis.
The purpose of this initiative is to improve end of life care in the wider community and
establish closer working with the CCG, demonstrating commitment from both hospices
to benefit the community as a whole.
The funding commenced for a two year period from October 2014 however the
stakeholder group has been meeting since July 2014. The group, chaired by the CCG
Lead, represents all stakeholders across statutory and voluntary health and social
care organisations in Coastal West Sussex and has met on a monthly basis.
6
The overarching aim of the EoL redesign project is to address the identified inequities
in access to care at the end of life, to raise the profile of end of life care and to ensure
the most efficient and appropriate use of available resources in order to improve the
patient and carer experience at the end of life.
Key achievements in the period:
 Engaging widely and inclusively with key stakeholders.
 Ensuring and maintaining Patient and public engagement (PPE)
 Agreeing the bespoke ‘collaborative model for EOLC for CWS’
 Managing effective and open communications and relationships
The focus of the next stage of the work will be the development of the business case
for the centralised EOLC co-ordination component of the model.
Improvement Priority 3: Enhancing dementia awareness
In support of an Alzheimer’s Society initiative (funded by the Cabinet Office and
Department of Health) our Education department at provided opportunities for the
general public to become a ‘Dementia Friend’. As a consequence of this initiative, all
staff at SWH had the opportunity to become a ‘Dementia Friend’ as part of this year’s
in-house training.
The aim of this initiative was ‘to create dementia-friendly communities and improve
everyone’s understanding of the needs of people with dementia and how we can help’.
These sessions are facilitated by three staff and two volunteers from SWH who have
trained to be Dementia Champions.
This initiative continues and although attendance at the Dementia Friends session at
the end of In House training was optional we know there was a positive response
amongst those who did stay. We continue to offer these sessions to the general public
and although the guidelines are that no formal attendance records are kept we
envisage that at least 200 members of the general public have crossed our threshold
for these awareness sessions.
7
National Clinical Audits and National Confidential Enquiries
For 2014-2015 no national clinical audits or national confidential enquiries covered
NHS services relating to palliative care. St Wilfrid’s Hospice only provides palliative
care and carries out internal clinical audits throughout the year as part of our service
provision.
Data Quality
St Wilfrid’s Hospice submitted a partial response to the National Minimum Data Set
2014-2015. Extracting the clinical activity data from SystmOne has continued to be
challenging but good progress was made this year.
The Governance sub-committee of the Board will continue to review the data outputs
in order to improve the quality of patient data reporting.
St Wilfrid’s Hospice takes the safety of their patients very seriously and in the past
year has been involved in auditing and benchmarking the results of different areas of
the care given.
The benchmarking tool the Hospice used has been developed by Hospice UK and
concentrates on some of the key indicators of patient safety: falls, pressure ulcers and
medication incidents. Each quarter relevant data collated is submitted and sent to be
benchmarked against a hospice of the same size.
This has enabled the Hospice to share, compare and learn from other hospices by
relating their performance to others and identify where improvements can be made.
Results showed:
 the Hospice’s bed occupancy rate was higher in relation to others in our group.
 patient falls increased between April 2014 to March 2015, which related to high
patient activity
 the percentage of patients developing pressure injuries was very low to minimal
 medication incidents were at level 1 and 2 where the error did not reach the
patient
8
Research
The Board of Trustees and Management Team supported our involvement with a
Longitudinal National Evaluation of Schwartz® Center Rounds.
In March 2015 we took part in Phase 1 of a national research project which aims to
evaluate Schwartz® Centre Rounds; it is funded by the National Institute of Health
Research, and led by Professor Jill Maben. Ethical approval for this study was given
by the University of Sheffield.
The first phase was a mapping phase, the aim being that information was collected
from every organisation that is currently running Schwartz® Rounds (about 80
organisations). The chair of our Schwartz® Center Rounds completed a data
collection form, and participated in a short telephone interview following approval from
the Hospice ethics forum. Although we are a relatively small organisation we were
seriously considered for Phase 2 of the study following the telephone interview which
was described as “a rich and insightful interview”.
In recent months our attendance figures at the Rounds have varied, we have reduced
the number of Rounds to six per year and it was decided by the national research
team that we would not be selected in the first wave of the Phase 2 study. It was
however suggested that we might be selected as “a potential ethnography only site” in
the second wave and that discussions with regard to the feasibility and
appropriateness of this would take place in September after another two rounds gives
us further attendance data.
9
Quality Overview of Services
Overall services
There were 850 patient referrals received in the year, an increase of 13% from the
previous year. An increase of 23% in referral numbers in two years demonstrates the
growing need for our services and the clinical team has worked with great commitment
to address these needs and maintain excellent standards of care. The average
number of patients being supported at any one time has increased from 170 in 201112 to 235 in 2014-15, an increase of 38%. However the rapid increase in referrals
does mean our services are becoming over-stretched on increasingly more occasions.
We are looking at ways to increase our efficiency to cope with this change, but
recognise that sometimes we are not able to respond as quickly as patients and
families would like.
Overall Service Activity
2014/2015
2013/2014
Total referrals
850
740
Non-cancer or non-MND referrals
151
95
Self-referrals
39
19
14,341
13,491
TOTAL referrals since 1987
Care has continued to be focused upon meeting individual needs and wishes; for most
people this means care close to or in their own homes. Evidence of improving access
to our services is seen in the growing number of referrals received directly from
patients and families and the further growth in the proportion of referrals of patients
with diseases other than cancer and motor neurone disease from 13% to 18% in the
year.
We now take ‘self-referrals’ i.e. patient/family/carer phone asking for referral to our
services, this is an increasingly successful referral route.
Inpatient Unit
The Inpatient Unit supports many patients and their families providing symptom
control, end of life care and pre-planned admission for patients so their carers can
have a break. There is a doctor on-call 24 hours a day providing support to the
inpatient team and our patients in the community.
IPU Clinical Activity
2014/2015
2013/2014
323
302
2
2
% of bed occupancy
82%
84%
Average (mean) stay (days)
13.3
15.0
Ward discharges
123
125
Non-cancer/non MND admissions
24
27
Inpatient admissions
Average (median) wait for admission (days)
10
Palliative Day Services
Day Hospice
The Day Hospice continues to support patients and their carers two days a week. The
staff provide holistic care and interventions to address physical, psychological, spiritual
and social symptoms. Patients have access to other members of the multi-disciplinary
team if required. Complementary therapies, including relaxation and mindfulness, and
are provided by volunteers. Reiki and reflexology are most popular, especially with
carers, and Art Therapy involves two students from University of Chichester. Our
Complementary Therapy Co-Ordinator now undertakes home visits. There are
opportunities to meet others in similar circumstances, enjoy structured activities or
relax in a supportive calm environment.
Orchard Centre
The Orchard Centre and Cafe is open every Wednesday allowing patients and their
family/carers to drop-in for various activities and clinics with members of the
multidisciplinary team. This initiative often serves as a gentle introduction to the other
services the Hospice can provide and lunch is available in a relaxed, friendly and safe
environment.
Feedback from patients and carers is sought to continually review and improve the
service we offer.
Orchard Supportive Care Clinic
In November 2014 this new stand-alone service was started for patients who have a
chronic illness that is life-limiting and causes distressing symptoms. There is an
independent referral process which is not limited by prognosis and, in collaboration
with the patient and involving a professional team, an individual package of
interventions is tailored to manage the following symptoms in association with lifelimiting illness:
 Fatigue
 Refractory and chronic breathlessness
 Pain (excluding chronic pain conditions)
 Cachexia
 Psychological distress-including anxiety, panic, depression, insomnia
 Oral symptoms
 Nausea and vomiting
 Bowel symptoms
Group sessions for patients and their carer also include:
 Advance care planning
 Goal setting
 Fatigue, Anxiety, Panic and eating issues
 Exercise/Circuit Group
 Mindfulness/Relaxation/Complementary Therapies
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Rehabilitation Team
The aim of the rehabilitation service is to help patients achieve their maximum
potential of functional independence and gain relief from distressing symptoms.
The Physiotherapy and Occupational therapy services work closely together and with
other local Community Rehabilitation teams to ensure good communication and team
work between all services, both voluntary and statutory.
Palliative Physiotherapy and Occupational therapy can help with assessments of daily
living and includes advice and support with mobility issues/muscle strengthening,
energy conservation, managing fatigue / breathlessness, relaxation training and
coping with anxiety.
Various group sessions include: exercise groups to music, anxiety management and
relaxation groups, all of which enable patients to have some practical tips and advice
on managing their illness, as well as the social aspect of meeting other people.
Carers Support
On the last Wednesday of every month we work in partnership with Carers Support
West Sussex to deliver an information session to carers. The aim is to offer
information and support to all those caring for someone under the care of the Hospice.
Hospice at Home
The Hospice at Home (H@H) service operates 24 hours a day, 7 days a week and is
involved in the last few days of life or in response to a palliative care crisis. H@H
offers patients care at home, including personal and emotional nursing care, support
with symptom control and support for carers and their families. This often facilitates
patients’ preferences to remain at home in their final days.
Clinical activity
2014/2015
2013/2014
Referrals to H@H
256
240
Deaths at home with H@H involvement
116
113
% Patients that achieved their preferred
place of death (where known)
78%
97%
A rapid response service is also available, with the aim of delivering hands-on care
within three hours of the request, whenever resources allow.
The service works collaboratively with all other health, social care and voluntary
service providers as required.
12
The numbers of referrals made to Hospice at Home have increased as the service
develops. A closer working relationship with Continuing Health Care has been
established and funding has been obtained towards the cost of care for some of our
patients at the end of life.
Community Team
The number of patients supported by the Community Team continues to increase.
They work in close association with the patient’s General Practitioner and the
Community Nursing team. The majority of the ten Clinical Nurse Specialists are
independent nurse prescribers, providing symptom control, advance care planning,
psychological care and bereavement support at the patient’s home or in outpatient
clinics.
Clinical activity
2014/2015
2013/2014
New patients seen
699
Comparative data
not available
% of deaths at home or a care home
52%
51%
It is excellent that a greater number of patients have been able to die at home with our
support.
Work is ongoing to improve the information derived from the SystmOne database. This
is proving to be challenging particularly where entry of comprehensive patient data
requires ongoing training and supervision. New dedicated staff have been employed
to improve the quality of data entry, training for existing and new staff, as well as
working on further data interrogation.
Practice Educator for care homes
This post was established in March 2014 to provide support to care homes for patients
at the end of life and other achievements include:
 Database of all care homes including Learning Disability and Mental Health
homes
 Increased confidence in care provision at the End Of Life
 Delivery of a 3 day Admission Avoidance Course (multi-disciplinary) for care
homes in conjunction with St Barnabas Hospice
 Development of our own programme/s for end of life care education for local
use
 Follow up and support after education sessions
 Short 1.5 day course for carers
13
Bereavement service
Bereavement care is co-ordinated by the Psychosocial Team, working with the
Chaplains and a team of 29 Hospice Visitors. The Hospice Visitors are a team of
volunteers who attended an in house training course and receive regular supervision
from the Psychosocial Team.
Relatives and friends of people who have died under the care of the Hospice (whether
they have died in the Hospice, the hospital, at home or in a nursing/care home)
receive a letter and booklet approximately four weeks after death. This explains the
support that is available and who to contact if they would like support. This information
is sent to every person the patient has identified as significant to them. Approximately
two weeks after this relatives and friends are called to see if they have received the
information and whether they feel they would like some support.
The Bereavement Service offers one to one counselling or emotional support, family
group therapy and three bereavement groups.
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Safe Haven - a group for people who have recently been bereaved
Open House - a drop-in group which gives people the opportunity to meet
others in a similar situation to exchange information and coping strategies.
Support is available from staff for those who wish to talk on an individual basis
or feel they need specialised support
Walk and Talk Group - these are guided walks for bereaved relatives under
the care of the Hospice. The one to two mile walks are on easy going, flat
surfaces beginning and ending at the same place.
The Psychosocial Team offer the opportunity to explore concerns, anxieties or feeling
that may be troubling. This support can be for individuals, couples or family groups
and is also there for children who are facing the death of someone significant in their
lives.
Examples of difficult situations may include;
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Receiving bad news and adjusting to living with life-limiting illnesses
Communication difficulties between couples
Choices around treatment and quality of life
Coping strategies for difficult situations
Families struggling to communicate with each other
Carers struggling and wondering where to turn next
Helping families to support children and young people at home
Explaining to schools what is happening
Working directly with children
Finding other sources of help and support as required
14
Support is also given to find an appropriate advocate for; complex benefit
entitlements, grants for essential items, other services needed within the home and
housing needs.
Education
The Education department of SWH has been very active since the offset and for more
than a decade has delivered university accredited courses, presently with Greenwich
University, alongside a selection of other longitudinal courses and study days. The
courses offered relate to palliative and end of life care and complementary therapies
and have included:
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Dementia Friends Sessions
Compassion Awareness
Sage &Thyme Communication skills
Courses for care home staff
Commissioned education e.g. for paramedics
Evaluations
Excellent
Good
Average
Poor
Overall ratings from all course students
74%
26%
0%
0%
There are two permanent lecturers and a Practice Educator for care homes
who are versed in the delivery of university accredited modules, marking and exam
board preparation. The Board of Trustees and Management Team see the Education
department as a core extension of the Hospice’s in reach into the community. The
vision and values of the Education department echo those of the Hospice itself.
15
Quality Markers
Review of quality performance
We have chosen to measure our performance against the following metrics:
Indicator
Complaints
Total number of formal clinical complaints
Total number of formal non-clinical complaints
Number resolved satisfactorily
Total number of adverse comments clinical
Total number of adverse comments non-clinical
Thank you letters
Written thank you cards/letters received
Patient safety incidents
Number of serious patient safety incidents
Number of patient falls on IPU
Patient safety incidents (infection)
Number of patients known to become infected with MRSA
whilst on the Inpatient Unit
Number of patients known to become infected with
C-difficile whilst on the Inpatient Unit
2014/
2015
2013/
2014
3
0
3
12
11
3
6
9
n/a
n/a
320
240
0
64
0
52
0
0
1
0
Formal complaints and adverse comments are uncommon but can provide useful
insights into how services are perceived. Most complaints and adverse comments do
not directly suggest changes but themes are collated and learning points addressed
and planned by the clinical teams and a report presented to the Governance
Committee.
Throughout the year staff have been trained to respond effectively to adverse
comments from users. The clinical teams have reviewed all complaints and adverse
comments and have made changes to processes and practices where appropriate.
These have included:
 Ensuring a senior ward nurse joins the Consultant ward rounds on the inpatient
unit to improve communication
 Development of a leaflet to guide relatives and carers when it is necessary to
plan a transfer of their loved one from the Inpatient Unit to a nursing or care
home
 Review of processes in response to patient falls and implementation of
associated training for nursing staff
 Training for staff in dealing with calls received out of normal working hours
The increased number of patient falls is being looked into. Falls management and
delirium training was provided to all clinical staff during 2014/2015 and as a
16
consequence further work will be undertaken by the multi-disciplinary team in fall
assessment and management .
The Governance Committee carried out a formal review of the recommendations
made in the Francis Report published in response to the failings of the Mid
Staffordshire NHS Trust. The Committee was satisfied that the required processes
and actions are in place to assure the Trustees of the safety and quality of services.
This is reviewed on an annual basis by the Governance Committee.
Clinical Audits 2014 – 2015
To ensure that we are continually meeting standards and providing a consistently high
quality service, St Wilfrid’s has an audit programme in place. The programme allows
us to monitor the quality of service in a systematic way, identifying areas for audit in
the coming year. It creates a framework where we can review this information and
make improvements where needed. Quarterly Governance meetings provide a forum
to monitor quality of care and discuss audit and quality evaluation results.
Recommendations are made and action plans developed.
A sample of clinical audits completed at St Wilfrid’s Hospice 2014-2015:
Audit
Findings, recommendations and actions
Infection Control Inpatient Unit
January 2015
Overall compliance 100%. Results fed back to appropriate
departments. No recommendations included. Repeat audit in
12 months.
Confidentiality
May 2014
No complaints or incidents in relation to actual or potential
breaches of confidentiality in the last month.
Controls were in place to ensure only authorised people are
able to access confidential information.
Recommendations included:
 Remind all staff to lock their workstations
 Leavers to be removed from IT system/photocopier
 Staff encouraged to pre- speed dial when faxing to
avoid wrong numbers being dialled.
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Referral to first
contact audit
March 15
Overall compliance 96%; For 100% of all urgent referrals to
have a contact within 2 working days and routine/ non urgent
referrals to have a contact within 5 working days.
Lone Worker
December 2014
Compliance was much improved. Lone Workers are much
better at reporting in when visits have finished and the system
is working well.
The Hospice has an Audit Action Log to ensure recommendations from all the audits
undertaken at St Wilfrid’s Hospice have been carried out and monitors when a repeat
audit is required.
The Hospice has an Audit schedule planned for each year; this is planned by the Audit
group. On some occasions an audit may need to be repeated if and when a problem is
identified.
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What patients and families say about the services they receive at St Wilfrid’s
Hospice.
The views and experiences of patients and their families are important to the Hospice
and enable us to look at how we can learn, develop and improve the services we
provide. The Hospice undertakes a series of questionnaires, surveys and carers
groups on a regular basis as detailed below:
Inpatient Survey
The Inpatient Survey is on-going throughout the year; volunteers are involved with
giving out and collecting the surveys to patients. Feedback has been extremely
positive.
A sample of results and comments are as follows from the last two quarters:
Question
Total questionnaires received
Nov - Jan
15
Feb - April Nov - Jan Feb - April
15
15
15
27
21
Yes
Yes
Do the staff involved in your care
explain what they are doing?
100%
90%
0%
5%
Do you have confidence in the staff
who are caring for you?
100%
100%
0%
0%
Do you feel the staff make an effort
to meet your individual needs and
wishes?
96%
95%
4%
5%
Do you feel you are treated with
respect?
96%
95%
4%
5%
Would you know what to do if you
were dissatisfied about something
85%
95%
4%
0%
Has your admission to the Hospice
been helpful so far?
96%
90%
4%
10%
Not
Not
answered answered
There has been improvement in the score around knowing what to do if dissatisfied.
The nursing team continues to ensure that an information folder is accessible in each
patient’s room and point out the relevant paragraph on their admission.
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Comments from the Inpatient Survey (November 2014 – April 2015)
“First class service throughout”
”Nothing is too much trouble for all the staff and volunteers”
“I believe in them, the staff are absolutely brilliant”
“I have felt less anxious since being here.”
“The dignity and respect I have received.”
Trustee Visit
In April 2015, two of the SWH Trustees visited the Inpatient Unit to gain an insight into
ward routines, including mealtimes and the nursing handover. The Trustees also
observed how the team worked together, communicated between staff, volunteers and
patients, and observed the general cleanliness of the ward environment. The Trustees’
report was presented to the Board of Trustees Governance Committee and distributed
amongst the staff.
Unreserved praise was expressed to the Trustees by two patients for the quality and
variety of food and beverages provided. The café in the Day Hospice had just opened
for use and was obviously a welcome and appreciated facility.
The Trustees noted the combination of a 24/7 facility and a high proportion of part-time
staff necessitates very high standards of organisation and communication to ensure
appropriate continuity of patient (and family) care and that clear evidence that this
requirement is understood, given high priority and is effective.
The Trustees final comments stated “we weren’t surprised that the relatives of one of
the patients (who had come from Spain, for three weeks, to visit her) were stunned by
the standards of the Hospice as a whole”.
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Feedback from people who have received bereavement support:
Comments from bereavement group attendees 2014-2015
“It is really helpful being with people in the same position”
“It’s safe to cry”
“You don’t have to explain yourself – it’s understood why you are here”
User involvement
St Wilfrid’s Hospice believes that all areas of Hospice activity should reflect the
principles of user involvement. Rather than devolve this responsibility onto a small
group of people, all departments are expected to seek and act on the views of users
they encounter. User feedback is sought in a variety of ways ranging from
questionnaires to informal remarks.
Design of services
A major initiative has been prompted by feedback experienced by one of the Hospice
consultants. Whilst involved in discharging (from Hospice services) patients with
longer than anticipated prognoses and in not taking on patients with uncertain
prognoses, some patients voiced how they felt they fell into a gap of service provision
between acute specialties and Hospice care. They wanted to receive expertise in
symptom control and the multidisciplinary approach of the Hospice. They did not feel
their GP could meet this need. Out of these conversations, other staff’s experiences in
palliative day services and from previous experiences of supportive care in other
settings, came the plan to launch a supportive care clinic. In November 2014 the
Orchard Supportive Care Clinic was opened.
Questionnaires
The regular In-patient questionnaire continued to provide overwhelmingly positive
feedback. There were some negative comments about details of the catering service
to which the catering manager and ward sister have responded by designing several
improvements to the service, especially around keeping food hot:


If patients have requested soup and a main meal, the soup is served to the
patient 10 minutes before the main meal which remains stored in the heated
trolley
Designated auxiliaries have been trained to act as ‘mealtime co-ordinators’ to
ensure that all meals are given out. Blue trays are used to indicate meals that
will require a nurse to take into the room (e.g. the patient may need sitting up,
require help with feeding or aids such as a feeding bib etc.). Food is served on
black trays to patients who do not need such help
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
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Volunteers have been trained to help with feeding and providing companionship
for patients who want company
After each meal, the nurses record what the patients have managed to eat. The
reason why a meal was not eaten is also recorded enabling the ward sister to
feedback any catering issues to the catering manager
Informal initiative
Following the ‘My name is….’ campaign, patients were asked if they would value
having the names of the doctors and nurses looking after them displayed in their
rooms. As a result, relevant names are displayed on a laminated sheet in each room.
What others say about St Wilfrid’s Hospice
St Wilfrid’s Hospice is registered with the Care Quality Commission, the regulatory
body that ensures that we meet our legal obligation in all aspects of care.
In January 2015 the CQC implemented a new regime for inspection and regulation,
our last unannounced routine inspection was in October 2013; the Care Quality
Commission inspector looked at the treatment records, observed how people were
being cared for, talked to staff, reviewed information from stakeholders and talked to
people who use our services.
The inspector looked at documents and patient records and observed the care being
provided to people. They wrote: “We saw very good care with real attention to detail
and respect for people’s wishes.” All the staff the inspector spoke to were very happy
in their work and described ‘the joy and privilege of having the time, resources and
support to care for people properly’.
Patients spoke about the food being ‘good and they make it easy for me to eat. I need
easily digestible food and they can’t do enough for me’.
In the report it says: “There are enough qualified, skilled and experienced staff to meet
people’s needs; we spoke to one person who said: ‘they seldom have to press the bell
as there were so many staff or volunteers present that someone was always watching
and waiting to help’.
The inspector wrote: “People are made aware of the complaints system because it is
displayed and accessible to everyone using the Hospice”. One person said: “They are
so good at sorting things out as soon as you mention something.”
The inspector was shown records of people being cared for and commented: “The
records were very comprehensive and contained all the information to be able to
provide appropriate care to each person.”
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The Care Quality Commission inspection report of October 2013 also
included these comments from patients they met:
“It’s funny, I came here because I am dying but I haven’t been so happy in
years. I have people popping in for a chat all the time. It’s lovely.”
“I am treated with 100% respect, dignity and the care is extremely good.
I couldn’t fault it. Yes, they are able to cater for all my needs.”
“Nothing was too much trouble.”
A copy of this report is on St Wilfrid’s Hospice website.
What our staff and volunteers say about the organisation
Our last staff survey was undertaken during June and July 2013. The survey was run
by Birdsong Charity Consulting, on behalf of Help The Hospices and It was agreed to
repeat the same survey after two years and monitor informal feedback from staff forum
and senior staff group in the meantime.
As a consequence of issues raised and the comments and feedback received from the
staff in 2013, the following actions have been undertaken and work is ongoing in these
areas:






The Board of Trustees and Management Team continue to discuss how to
resolve issues related to space/facilities and parking. After extensive research a
planning application for a new Hospice building in the Bosham area was
submitted in May 2015
Line managers to lead the process of succession planning for their department.
It was noted that this will remain an issue while low turnover continues
Format of the senior staff group has been reviewed and implemented
Clinical strategy group have involved staff regarding future developments
Staff have been reminded there is a process to follow to request changes to
work hours and patterns.
Line manager training implemented for newly appointed and current line
managers and will be ongoing annually
The Staff Forum met four times in 2014-2015 and some of the subjects covered
included:

Reviewing the draft new Hospice strategy – provided feedback to the
Management Team
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


Hospice Care Week – discussed how to get more Hospice staff involved and
fed back to Hospice Care Week working group
Departmental profiles in Vista – suggested these as a means of improving
communication throughout the Hospice
Reviewed the following policies; Gift Acceptance and Anti-Bribery, Sabbatical
Leave, Expenses policy, Psychological well-being - provided feedback to the
Management Team
Staff Forum members still very much enjoy being asked for their opinions and
providing feedback to the Management Team and Human Resource Committee and
look forward to more opportunities like this in future, in particular they look forward to
being involved in discussion regarding the new Hospice.
The Human Resource Committee meets quarterly and monitors key indicators which
include staff sickness, pension membership, volunteer turnover and staff turnover.
Staff turnover ( including Retail)
Jan –Dec 2014
Jan –Dec 2013
8.4% (10.79 FTE)
14.6% (18.52 FTE)
Volunteer Annual Review
Our last survey of our Volunteers was
undertaken in December 2014, (excluding
shop volunteers).
Out of 267 volunteers, 135 surveys were
returned (51% return rate).
A sample of the feedback received is as follows:
Questions
Yes
Are you satisfied with your current role?
133
Is the support and training offered adequate?
134
Do you feel valued by members of staff at the Hospice?
134
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The Volunteer Forum has continued to be a success now running for 2½ years and
meets up every 6 weeks to discuss developments at the Hospice with 22 members
from across all departments of the Hospice and Retail.
We have continued to recruit and train more volunteers with numbers of current
volunteers at an all-time high (total of 291 at the Hospice). This has enabled us to
expand the IPU Meet & Greet role to cover weekends and for volunteers to help assist
our Rehabilitation team in the new Exercise/Relaxation sessions for patients.
What volunteers say about working at St Wilfrid’s Hospice
– volunteer survey 2014-2015
“It is a privilege to volunteer at the hospice and particularly to be able to
practice complementary therapies to patients, carers and bereaved. It’s a
joy to be able to help people in some small way, to be there for them,
and be a listening ear”
“I feel valued and supported”
“Sense of belonging and community, it has made me feel more fulfilled
and adds a balance to my working/family life. Provokes reflection and
consideration of others”
Priorities for improvement for 2015 – 2016
Future Planning Priority 1: Adapt ways of working to enable clinicians to
address growing number of referrals.
There were 850 patient referrals received in 2014-2015, an increase of 13% from the
previous year and a 23% increase in two years, demonstrating the growing need for
our services and clinical teams to address these needs.
New initiatives and creative working is required to meet a noticeable increase in
referrals; during the year the clinical leads group will review processes and systems to
identity changes that will assist the team to meet increased needs within existing
resources.
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Future Planning Priority 2: To provide the facilities to meet the pressing current
and future demands for our services.
To design a new purpose-built hospice to meet future patient and family needs by:
 securing funds to achieve our goal
 improving and enhancing Palliative Day Services
 provision of 4 additional Inpatient beds with the possibility to increase by 2 more
beds at a future point if required,
 providing sufficient parking
 working closely with our community, key partners and agencies
 maintaining current services and facilities during the development of the new
hospice
Future Planning Priority 3: Continue to work in collaboration with Coastal West
Sussex CCG End of Life care stakeholder group
St Barnabas, St Wilfrid’s and CWS CCG will continue to jointly fund the End of Life
Care Lead post for the End of Life Care redesign project on a three day a week basis
until October 2016.
The stakeholder group will continue using a collaborative approach to developing the
business case for centralised co-ordination of end of life care and this will mean that
the stakeholder group will continue to meet on a monthly basis.
The current plan is to complete the business case for presentation, discussion and
approval at the September 2015 CCG Clinical Commissioning Executive.
Quality improvement and innovation goals agreed by our commissioners
St Wilfrid’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.
The Board of Trustees commitment to quality
The Board are fully committed and supportive of the provision of a high quality clinical
service which they place at the heart of all decisions they make about the Hospice and
its strategic development. The Hospice has a well-established governance structure,
with members of the Board having an active role in ensuring that the Hospice provides
a high quality service.
The Board of Trustees meets formally every other month and in the intervening
months receives updates and presentations from clinical and other staff to enhance
their understanding and awareness of our services. The Management Team ensure
that the Board are kept informed of all relevant information with regard to clinical
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services. All the above ensure that the Board have a ‘real feel’ for the level of care
provided. The Board are confident that the care and treatment of patients is safe, cost
effective and of a high standard.
Statements from local Healthwatch and Clinical Commissioning Group
Healthwatch West Sussex thanked the Hospice for our offer to become involved in our
Quality Account (QA) this year. However, Healthwatch West Sussex stated it focuses
its limited resources on QAs provided by large NHS providers with whom it has
continuous contact and allocated liaison volunteers.
Healthwatch commended the Hospice in its drive towards transparency of reporting on
the quality of services and noted our positive Care Quality Commission inspection
outcomes in 2013.
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