Quality Account 2014 –15
Our quality performance,
initiatives and priorities
Contents
Quality Account 2014–15
Our quality performance,
initiatives and priorities
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Part one: our priorities for quality
Position and status on quality
Part two: our priorities for improvement
Our progress against our priorities for improvement
Priority 1: Service user experience
Priority 2: Service user safety
Priority 3: Effectiveness
Priority 4: Effectiveness
Priority 5: Effectiveness
Priority 6: Effectiveness
Part three: indicators
Service user experience
Safety
Effectivness
Part four: annexes
Annex 1: Legal requirements
Annex 2: Statements from Lead Clinical Commissioning Groups
Annex 3: Feedback from service user group - Acorns
Annex 4: National service offering
Sue Ryder – Quality Account 2014–15
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Part one: our priorities for quality
Position and status on quality
Joint statement from our Chief Executive and the Chairman of Trustees
Welcome to our annual Quality Account, a summary of our performance against selected
quality measures for 2014–15 and our initiatives and measures for 2015–16. This is our sixth
account and each year we use the account to celebrate some of the year’s achievements in
healthcare.
Working towards a national service offer
The aim of the Sue Ryder national service offer is to give
people true choice, personalisation and control over how and
where they are supported by making a defined list of services
available to all people accessing our specialist palliative and
neurological care. Each defined service line is detailed in a
service specification which formalises our qualitative
expectations i.e. what makes incredible care.
We’re also using the money raised by Morrisons customers
and colleagues to set up new community services and family
support teams, ensuring people facing life-limiting conditions
receive the best possible care. In Oxfordshire, seven day
community nurse specialists are already caring for people with
life-limiting conditions in their own homes, whilst in West
Yorkshire, complementary therapists are now able to deliver
treatments in local communities.
The list of services has been developed by crossorganisational Sue Ryder professionals, and has been
reviewed and agreed by our Health and Social Care
Subcommittee. You can view the services in our national
offer in Annex 4. New services launched in 2014-15 include
an expanded homecare service in Scotland, the development
of a clinical nurse specialist team at our Nettlebed Hospice,
and the introduction of a Hospice at Home service at
Leckhampton Court Hospice. We’ve also now completed the
construction of our new purpose-built Thorpe Hall Hospice.
End of life befriending service
The Cabinet Office awarded £237,776 to Sue Ryder in
December 2014 to help us deliver an end of life befriending
service providing vital support for people and their families
across England.
Our charity partner, Morrisons
When someone is dying, questions and emotions can be
overwhelming. So it’s comforting to know support is only a
click away.
Thanks to the generous support of our charity partner
Morrisons, from May 2015 Sue Ryder is able to help more
people and their loved ones than ever before who are facing
life-limiting conditions, through our new Online Community.
Whether someone just wants to take a look, feels ready to join
the conversation or ask a question, they’ll be able to join us
from their mobile phone, tablet or computer 24 hours a day to
access:
• free practical information
• expert advice
• support from people with similar experiences
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Sue Ryder – Quality Account 2014–15
With this funding, we’ll be able to replicate the successful
end of life befriending service that we already offer in West
Berkshire across other sites in West Yorkshire, Peterborough,
Bedfordshire, Leeds and Cheltenham. Trained Volunteers
will provide companionship and emotional support, as well
as practical support to help people reconnect with their
own communities.
Working in partnership with Dynamic Healthcare
Systems
VitruCare is a digital health service enabling patients living with
life-limiting conditions to record decisions about their
healthcare, plan for the future and keep in touch with their
support team using a computer, tablet or smartphone. Having
obtained funding from NHS England’s Small Business
Research Initiative, Sue Ryder and Dynamic Health Systems
are working in partnership to pilot the service across three
areas supported by Sue Ryder hospices:
• Airedale/Wharfedale/Craven/Bradford (Manorlands
Hospice)
• Leeds (Wheatfields Hospice)
• Bedfordshire (St John’s Hospice)
‘Dying doesn’t work 9 to 5’ campaign
We are campaigning to ensure terminally ill people and their
carers have immediate access to dedicated 24/7 co-ordinated
expert support from a helpline. We hope this will stop the fear,
isolation and distress that many people and their families are
facing when services are not available out of hours.
We want to push forward on what comprehensive end of life
services and support look like, so we’re asking the public to
sign our petition to ensure 24-hour expert support and coordination is available to everyone. We have received a huge
response to this request.
Sue Ryder – Quality Account 2014–15
We hope you find our Quality Account useful. We welcome
suggestions for future accounts. The Quality Account and the
information it contains is accurate at the time of print; it has
been reviewed via our internal governance structure and is
true to the best of our knowledge.
Heidi Travis
Chief Executive
Roger Paffard
Chairman of Trustees
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Part one: our priorities for quality
We have incredible colleagues and volunteers who
demonstrated our values through the Sue Ryder
Incredible People Awards 2014
1. Do the right thing
Carmella Miller is volunteer manager and lead facilitator for
11 community Synergy Dementia Cafés spread across Suffolk
with a team of facilitators and assistants working for her. In
addition, she took on a temporary lead role for the Suffolk
Dementia Helpline, overseeing the rota for volunteers,
particularly those who work from home in the evenings.
All of the volunteer teams managed by this exceptional young
woman feel well supported and speak very warmly of her; she
makes time for every individual and maintains a professional
relationship, ensuring that they all feel valued and fulfilled.
2. Push the boundaries
Dr Linda Wilson, an inspiring medical consultant at Manorlands
Hospice, has been instrumental in the development of a
dedicated phone line providing out of hours palliative support
and guidance for patients, carers and professionals in Airedale,
Wharfedale, Craven and Bradford. The Gold Line service is
manned by trained and experienced staff in the Telehealth
Hub at Airedale Hospital.
3. Make the future together
Volunteers Ted Nickson, Michael Johnson and Geraldine
Woodruff join the Cuerden Hall Neurological Care Centre
activities team every Friday. Starting with a good catch-up and
a brew, they ask what the residents want to do and then help
them to join in. They help with dinners, assisting residents with
their lunches, clearing up, and providing entertainment.
Afternoons are filled with word searches and a quiz that one of
the team has prepared. They are a marvellous addition to our
volunteering team; patient, considerate, organised, and so
eager to help in any way that they can.
In response to the award, Michael said “I feel humbled to think
that you can receive an award for something you love doing. I
am amazed at the resilience and cheerfulness of people living
under very difficult circumstances. I feel it a privilege to have
the opportunity to work with so many lovely people. Long may
it continue.”
Linda demonstrated great passion, commitment and tenacity
in working with key stakeholders to establish this service.
Our vision
We aspire to create a world where
everyone has access to personalised
and compassionate care.
Our values
At Sue Ryder we’re passionate about
giving people the care they want,
that’s why we always aim to:
1. Do the right thing
2. Push the boundaries
3. Make the future together
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Sue Ryder – Quality Account 2014–15
Our service map
Head Office
1. Central Office, London
Registered Office
2. Sudbury Office, Sudbury
Aberdeen
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3.
4.
5.
6.
7.
8.
9.
Palliative Care
Sue Ryder – Manorlands Hospice, West Yorkshire
Sue Ryder – Wheatfields Hospice, West Yorkshire
Sue Ryder – Thorpe Hall Hospice, Peterborough
Sue Ryder – St John’s Hospice, Bedfordshire
Sue Ryder – Nettlebed Hospice, Oxfordshire
Sue Ryder – Leckhampton Court Hospice, Cheltenham
Sue Ryder – Duchess of Kent Hospice, Reading
10.
11.
12.
13.
14.
Complex neurological care
Sue Ryder – Dee View Court, Aberdeen
Sue Ryder – Holme Hall, East Yorkshire
Sue Ryder – The Chantry, Suffolk
Sue Ryder – Stagenhoe, Hertfordshire
Sue Ryder – Cuerden Hall, Lancashire
Elderly & dementia (residential care)
15. Sue Ryder – Birchley Hall, Merseyside
Homecare services (in Scotland)
16. Angus Homecare
17. Stirling Homecare
Supported living
18. Supported Living Unit, Suffolk
19. Supported Living Unit, Aberdeen
Leeds
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4
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Other services
20. Doncaster Community Services, Doncaster
21. PEPS service, Bedfordshire
22. Dementia Helpline, Suffolk
Liverpool
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20
Nottingham
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Birmingham
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6
8
13
Oxford
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2
12
22
London
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Sue Ryder – Quality Account 2014–15
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Part two: our priorities for improvement
Our progress against our priorities for improvement 2014-15
The priorities for 2014-15 were:
Priority 1
Service user experience
To embed the use of electronic devices to gain real-time feedback
from people who use our services
Priority 2
Service user safety
To manage the risk of harm from falls
Priority 3
Effectiveness
To continue to develop and then measure the activity standard
Priority 4
Effectiveness
To develop our strategy for education and training
Priority 5
Effectiveness
To deliver an accredited development programme for non-registered
clinical staff (our healthcare assistants)
Priority 6
Effectiveness
To improve and measure the quality of our end of life care
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Sue Ryder – Quality Account 2014–15
The priorities for 2015-16 are:
Priority 1
Service user safety
To implement and embed the new falls strategy with reference to
the implementation plan:
• supporting and training staff on the use of the new falls risk
assessment tool
• audit and evaluation of care records to ensure assessment tools
are fully utilised
• monitoring all falls and ensuring harm is reduced in all
circumstances
Priority 2
Effectiveness
To develop our leadership programme for our clinical and non clinical
workforce, linking to the national RCN programme when this is relaunched later in 2015.
To evaluate the leadership programme offered during 2015 which is a
joint programme with other Sue Ryder directorates
Priority 3
Effectiveness
To review the learning from the pilot sites to further implement the
use of electronic feedback across all sites.
To develop our service user strategy with agreed national aims which
link to local implementation plans.
Priority 4
Service user experience
To implement local service user involvement plans across each
healthcare site.
• Launch national service user strategy.
• Recruit member of Trustee Board with special interest in service
user involvement.
• Recruit volunteer ambassadors via our service user group to
influence national campaigns and policy.
Priority 5
Effectiveness
To review our pressure ulcer prevention policy and monitoring
systems.
• Increase staff education and training on pressure ulcers prevention
in palliative care services.
• Undertake detailed investigation of any pressure ulcer
development of grade 2 and above.
Sue Ryder – Quality Account 2014–15
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Part two: our priorities for improvement
Priority 1: Service user experience
To embed the use of electronic devices to gain real-time feedback from
people who use our services
We said we would: purchase, pilot and begin to use devices
for real-time feedback across all our services.
We said we would: train volunteers to support service users
to use devices for feedback.
We did. Working with Elephant Kiosks, in 2014 we developed
a pilot project to run across two hospice sites using both
hand-held tablets and Elephant Kiosks to collect real-time
feedback. The aim of the project was to evaluate whether
collecting this feedback supports meaningful and ongoing
engagement of service users. After consultation with service
representatives the stand-alone kiosks were removed from
the project (though remaining a possibility for the future) with
use of hand-held tablets the preferred option.
We did. A protocol for use of the devices was developed and
a training plan for volunteers was put in place at the two pilot
sites. Having a trained group of volunteers, using a common
script and approach enables Sue Ryder to be certain of the
quality of the feedback collected. The pilot showed that
services users, families and the recruited volunteers found
the devices easy to use.
A working group supported and directed the pilot,
recognising a variety of approaches were necessary. The
working group was responsible for collating questions to ask,
agreeing the processes for collection and interrogation of
data and evaluating the pilot’s success. The pilot showed that
collecting real-time feedback does support meaningful and
ongoing engagement of service users, making sure we
remain person-centered by creating and using the data
collected to influence the commissioners of services and as
credible evidence for inspectors. For example, the free text
boxes allowed detailed feedback identifying that the night
staff were noisy at times, enabling the service manager to
discuss this with the service user and staff to make an
immediate improvement.
Authority for roll out has been given and a budget set, an
implementation plan has been created and roll out across all
sites will be completed by December 2015.
We said we would: look at the use of real-time feedback for
audits.
We did. The use of real-time feedback in audits is being
explored. The potential is seen for the tablet devices to make
audits of the care environment, experience of mealtimes and
presence of infection prevention measures a straightforward
process. This is being developed slowly to make sure of a
thorough evaluation.
“Every week I see the nurse to
have my symptoms and
medication assessed and any
problems are sorted
immediately. The Sue Ryder
doctors and nurses work well
with other NHS services too.”
Richard, patient at Duchess of Kent Hospice.
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Sue Ryder – Quality Account 2014–15
Establishing if resident
dependency outstrips
resources
Shirley, Head of Care at neurological care centre The Chantry,
undertook a project to establish the answer to a question
raised by a service user: ‘Does resident dependency outstrip
staffing resources?’
She and the practice educator conducted an observational
exercise over a four week period to monitor if processes were
being followed. Shirley shadowed clinical staff, focusing on
Sue Ryder – Quality Account 2014–15
observing residents’ care, handover, allocations, rota
management and medication rounds. The practice educator
focused on mealtimes, the shared lounge and observations of
care.
The exercise identified that during shifts, workloads did
outweigh the resources available to deliver care. Through
discussion with the service manager, a recommendation was
put forward to change allocation of workload to provide
equity and consistency of care based on complexity of need.
This included increasing staffing levels by two support
workers on each shift during the day and one support worker
at night. A hostess role was also introduced at mealtime
pressure points to improve the mealtime experience.
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Part two: our priorities for improvement
Priority 2: Service user safety
To manage the risk of harm from falls
We said we would: write a falls risk management strategy
and implementation plan.
We said we would: evaluate the success of the strategy
through incident review and a newly developed core audit.
We did. We carried out a literature search which identified
common risk factors, risks associated with different care
settings and interventions designed to prevent falls. This
informed development of a falls risk management strategy
and implementation plan along with reference to NICE
guidance and the Patient Safety First Guidance on how to
reduce harm from falls. Following consultation at the Quality
Action Group in December 2014, we agreed the falls risk
management strategy.
We did. We developed a falls risk audit based on the falls risk
management policy and tested compliance with policy
across all of our services during May and June 2014. We then
developed action plans across all of our services in response
to the falls risk audit.
We also developed our specialist review approach to
presenting an overview of falls incidents to the Healthcare
Governance Committee to include assurance from each of
our services of their response to identified trends.
We said we would: deliver priority areas of the
implementation plan.
We did. We piloted a numerical falls risk assessment with one
of our hospices which identified that a multifactorial risk
assessment would be the best approach to assessing risk
going forward. This, along with the recommendations
identified within the falls risk management strategy and
implementation plan, informed revision of our falls risk
management policy to include:
• guidance on how to report falls
• a new multifactorial falls risk assessment
• a post-falls protocol
• more guidance regarding environmental risk assessment
• a requirement to carry out a root cause analysis
investigation where there is serious harm
“The friendly staff work together
with input from volunteers
providing fun activities.
Interacting with other patients
in a similar situation and sharing
stories is very enjoyable.”
Roy, a Nettlebed day hospice patient.
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Sue Ryder – Quality Account 2014–15
Part two: our priorities for improvement
Priority 3: Effectiveness
To continue to develop and then measure the activity standard
We said we would: launch B-Active, our activity standard.
We did. We bought staff and service users together to
identify the differences in the activities offered at each of our
hospices and neurological centres. We then used this to
agree a set of standard activities which should be available
everywhere as well as identifying some initial improvements
to the activities already on offer.
To communicate what was agreed, we developed a B-Active
Standards leaflet setting out the activities service users would
like to see offered and how they would like to see these
delivered. A newly appointed occupational therapist in one of
our neurological services will collaborate in the next stages of
the standard setting and evaluation process.
We said we would: support activity co-ordinators to make
service improvements in line with the standard.
We did. Activity co-ordinators across all of our services have
been involved with the meetings to review the draft of the
activity standards. This has included bringing our palliative
and neurological activity teams together to hear about how
activities differed and learn from each other. Training
opportunities were also discussed and shared. They will
continue to be fully involved in the development of the
activity standards framework, supported by the Quality Team
to check their activities against these standards, identify any
areas of improvement and achieve their improvement plans
where in place.
We said we would: develop a themed survey to evaluate the
success and impact of the project based on
recommendations by our national service user advisory
group: Acorns.
We did. An evaluation document is being written using the
principles of person-centred planning. This priority is being
completed working closely with the quality manger and data
analyst working on Priority 1: service user experience.
Services will be asked to evaluate current activity
programmes with full service user involvement. This will
produce an action plan for change which will be part of the
services’ Quality Improvement Plan. Service user feedback will
continue to influence service provision, particularly in our
neurological care settings. Activity within palliative services
continues to be very closely monitored by commissioners
and CQC inspection.
We said we would: continue to consult with Acorns on the
delivery of meaningful activities.
We did. The Acorns team have been fully involved in
progressing this priority. They have signed off the standards
and B-Active Standards leaflet and have been brought fully up
to date on progress against the work plan. A number of
service users involved in activities but not on the Acorns
group were also asked to comment on the draft leaflet and
the draft version of the service standards.
The final version of the standards, after involvement of the
newly-appointed occupational therapist, and B-Active
standards leaflet will be passed through Acorns in April and
introduced to all services mid-2015.
e
B – Activ ndards
a
Activity st
Sue Ryder – Quality Account 2014–15
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Part two: our priorities for improvement
Priority 4: Effectiveness
To develop our strategy for education and training
We said we would: develop a three-year strategy for
learning and development across healthcare. This has
been superseded by an organisational Learning and
Development strategy.
We did. A cross-organisational learning strategy has been
developed by the Organisational and People Development
Team working in partnership with key directorates. The
strategy supports the delivery of the five year plan and
strategic goals. The themes have been identified as:
• on-boarding and induction
• improving management capability
• building leadership capability
• core skills development for all
• improved use and access to learning and development
resources
• income generation
We said we would: put in place an implementation plan for
each of the strands which support healthcare delivery.
We did. This organisational strategy was approved by the
Executive Leadership Team. There is an organisational
development plan which is reviewed annually and refocuses
priorities to keep momentum against key organisation needs.
An implementation plan has been put together to meet the
needs of healthcare staff based on local learning needs
analysis and feedback from each centre into the central
Organisational and People Development Team.
We said we would: agree a process for measuring and
monitoring plans and actions.
We did. The success of this strategy and the effectiveness of
ongoing operational activity can only be determined through
effective dialogue with people in our organisation and
systematic measures of performance. This will be through a
range of engagement and measurement methods and
activities.
Engagement activities will include:
• commitment from the health and social care Learning and
Development Workforce Group to lead local
implementation plans for education
• organisational development of key skills, across all
directorates
• continued working in partnership with staff for the
development of policies and guidance to ensure that
these reflect their needs
• staff surveys as a form of evaluation and monitoring
“Sue Ryder was able to
co-ordinate my care so I didn’t
need to go to different doctor’s
appointments. When I was
admitted they managed to
keep my symptoms under
control and I was able to go
home. They look after my wife
as well, she regularly goes to
the carers’ support group and
really enjoys it.”
Chris, patient at Manorlands Hospice
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Sue Ryder – Quality Account 2014–15
Improving communication
between day and night shifts
Staff nurse Janina, at neurological care centre Stagenhoe,
identified that communication between day and night staff
was not as good as it could be, with important information
not always being passed on. An in-depth quality visit and spot
checks by the practice educator confirmed her observation,
so Janina made some suggestions for improvement.
management to provide internet access for all night staff and
preparing a night staff communication folder to be shared
with other units, giving them the opportunity to pass on
things that are important to the day staff when they do not
get the opportunity to see or speak to them.
These measures helped to ensure that night staff are not
missed out from communication of important issues, helping
them to feel more included in what’s happening in the centre
and to feel more valued.
This included introducing a night staff (including bank staff)
managerial supervision list and monthly meetings, asking
Sue Ryder – Quality Account 2014–15
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Part two: our priorities for improvement
Priority 5: Effectiveness
To deliver an accredited development programme for non-registered clinical staff
We said we would: develop a programme based on the 6 Cs
of Nursing (care, compassion, competence, communication,
courage, commitment) to be delivered over the course of a
year, recognising that leadership happens at the point of care.
We did. The Francis report and Cavendish review both
identified the need to develop a workforce that supports
system-wide improvements in patient care and experience
across all healthcare providers. There was particular emphasis
on developing the skills of support workers and healthcare
assistants in leadership and management, alongside their
clinical skills.
This fitted well with the Chief Nursing Officer’s 6 Cs of Nursing,
an initiative which was developed as a vision and strategy for
nursing to make a difference. The module was designed to
equip students with the knowledge and skills to translate
the 6 Cs into practice; empowering them to lead in the delivery
of compassionate, competent, evidence-based care.
We said we would: seek accreditation for the course.
We did. After careful deliberation the module was named
Delivering Compassionate Care. It was presented to the
accreditation board of University of West London in June 2014
by Jo Kerridge who worked tirelessly to put this module
together. It was agreed / approved at the first presentation
with only one minor change.
We said we would: start the recruitment process for the first
cohort.
We did. Recruitment started for the first cohort in July 2014
and the actual module started to run in September 2014. At
least 30 of our unregistered clinical workforce enrolled onto
the course. The course is being run by our local Practice
Educators across three areas:
• Nettlebed Hospice / Leckhampton Court Hospice
• St John’s Hospice / Thorpe Hall Hospice
• Cuerden Hall Neurological Care Centre
“We have been able to
contribute our views on the
recent refurbishment, have
helped to get wi-fi and
appropriate laptop computers
for the patients, established a
memory garden and sent a
delegation to address a
parliamentary sub-committee.”
Dr John Roth, on behalf of the Duchess of Kent Hospice
user group
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Sue Ryder – Quality Account 2014–15
Our healthcare assistant course
Prior to commencing the six study days for
this module, we delivered a study skills day
to familiarise the students with the
requirements for writing and studying at a
higher education (HE) level. This proved to
be the most challenging aspect of the
course for the delegates.
‘The six study days were themed around the 6 Cs and the
content identified in the module study guide, and were
delivered by the education teams in each area. This enabled
the workshops to be locally driven, and the relevance to their
workplace made more explicit for the students. It also allowed
for collaborative working with colleagues from other local
centres; something which was identified as being of great
value by the students themselves.
outcomes. A pass mark will give them 20 academic credits at
HE level 4, which is foundation degree level. Not all the
students will achieve this, and some have withdrawn from
completing the full module. However, the students who
decided not to submit have still attended some or all of the
study days, and this has been hugely beneficial to their
professional development.
‘The education teams plan to meet to review the module once
the marking has been completed. It is hoped to deliver the
module again in 2015, but changes will need to be made to
make it more manageable from an administrative view. There
will also be a recommendation that it is also opened more
widely to Sue Ryder HCAs who only want to attend the study
days, as the learning from these workshops is just as valuable
as that achieved by academic study, and will make the module
more accessible to those who may struggle with this aspect of
a course.’
Jo Kerridge, Delivering Compassionate Care module leader
‘The assessment for this module consisted of three
assignments which reflected on the students’ own practice,
and demonstrated achievement of the module learning
Sue Ryder – Quality Account 2014–15
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Part two: our priorities for improvement
Priority 6: Effectiveness
To improve and measure the quality of our end of life care
We said we would: update our end of life care policy based
on recommendations from the Leadership Alliance for Care of
Dying People
We did. We updated our end of life care policy with reference
to the Leadership Alliance for the Care of Dying People
(LACDP)’s publication: One chance to get it right. The policy
now has a link to the quick reference guides for staff based on
the five priority areas (recognise, communicate, involve,
support, plan and do). The approach now taken in policy is to
have an individualised care plan. We agreed this revised end of
life care policy at the Healthcare Governance Committee in
October 2014.
We said we would: continue to implement person-centred
care plans across our hospices
We did. We implemented a new approach to person-centred
care planning across our hospices which has led to a further
review of our approach. Following observations made during
quality team visits we worked with nursing teams at hospices
to look afresh at the Sue Ryder-designed care plans to see
how further refinement could make them more personcentred.
We said we would: widen our use of the End of Life Care
Quality Assessment Tool (ELCQuA) from Public Health England
We did. We supported all of our Hospices to join the ELCQuA
website which will help us to plan our priorities for end of life
care, monitor compliance with the NICE Quality Standard for
End of Life Care and benchmark ourselves against other
similar services.
We identified gaps in our data sources that would
demonstrate compliance against the standards and have
taken measures to rectify this through the development of our
surveys and core audits. We piloted a newly developed ‘after
death audit’ in two hospices. This audit tool is designed to test
our compliance with standards relating to end of life care.
“In my old nursing home they
didn’t understand Huntington’s.
I didn’t smile anymore and I’d
lost a lot of weight. Shortly after I
came to Holme Hall I took up
dancing. That shocked my sons
the most – they were amazed at
the change in me.”
Graham, resident at Holme Hall Neurological Care Centre.
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Sue Ryder – Quality Account 2014–15
Improving communication
Staff nurse Joanne aimed to improve sharing of information,
ideas and knowledge between units at neurological care
centre Stagenhoe by putting in place a regular monthly
trained staff meeting. First she discussed the idea with
colleagues and the head of care, asking for their input
and ideas.
There were some challenges to overcome including setting
a date and time for meetings within a busy shift, finding a
suitable venue, encouraging staff who were not on duty to
Sue Ryder – Quality Account 2014–15
attend and finding someone willing to take and distribute
minutes of meetings in her absence.
After two initial meetings the response from colleagues has
been positive overall with some areas of improvement also
noted. Trained staff are now more up to date with how other
units are running and the individual needs of all the clients in
the centre. This has increased confidence in staff when
working on a different unit, improving client care. Clients are
aware that their opinions matter and that they can influence
change within the care centre.
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Part three: indicators
1. Service user experience – all users
Service user experience is measured within the annual service user surveys in the following ways:
• percentage of service users who rated overall care as ‘Good’ or ‘Excellent’
• percentage of service users who responded ‘Yes, completely’ or ‘Yes, mostly’
that overall they were treated with respect and dignity
• percentage of service users who responded ‘Yes’ when asked if they
would recommend the service to family and friends (neuro and homecare services only)
• NHS Net Promoter Score which measures how likely service users are to
recommend the service to family and friends (hospices only)
1.1 Neurological care 2014-15
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
2013-14
79%
92%
64%
90%
78%
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
2014-15
89%
100%
87%
77%
95%
2013-14
86%
92%
71%
91%
68%
2014-15
89%
100%
88%
84%
95%
Percentage of people
likely to recommend the service
2013-14
77%
100%
86%
84%
82%
2014-15
89%
100%
93%
100%
94%
1.2 Palliative care 2014-15
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
Leckhampton Court
Manorlands
Nettlebed
St Johns
Thorpe Hall
Duchess of Kent (West Berkshire services)
Wheatfields
2013-14
96%
100%
100%
100%
98%
100%
100%
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
2014-15
100%
100%
100%
98%
98%
97%
100%
2013-14
96%
100%
100%
100%
97%
100%
100%
2014-15
94%
100%
97%
98%
98%
97%
100%
NHS Net Promoter Score
2013-14
90
100
98
n/a*
91
92
91
2014-15
84
94
95
100
91
83
100
*St John’s did not include the net promoter score within the survey they sent out to patients in 2013-14.
1.3 Community support and homecare services 2014-15
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
Angus Homecare
Stirling Homecare
20
Sue Ryder – Quality Account 2014–15
2013-14
94%
88%
2014-15
97%
77%
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
2013-14
88%
96%
2014-15
99%
96%
Percentage of service users
likely to recommend the service
2013-14
100%
99%
2014-15
98%
95%
Part three: indicators
1. Service user experience – all users
1.4 Formal complaints about care
Complaints 2014-15
We define a formal complaint as ‘an expression of discontent to which a response is required’. With reference to our complaints
policy, the complaint is considered formal when it is received orally, in writing or electronically and cannot be resolved within 24hours of receipt. There were 18 formal complaints about care during 2014–2015. The target in the complaints policy for the
initial holding response to complaints is three working days. Where the complaint was initially received by a service, and where
the complaint was by a named complainant, 100% were acknowledged within the timescale. The target in the complaints
policy for the final written response to a complaint is 20 working days; however the policy does acknowledge that in some
instances this is not possible. This would usually be where the investigation is complex. In these cases all services aim to maintain
contact with the complainant, giving a report of progress. In all cases this standard was met within 20 working days.
Neurological care
Centre
Stagenhoe
Formal complaints
2013-14
Formal complaints
2014-15
Acknowledged
within three days
Responded to
in 20 days
0
3
3
2
Upheld/
not upheld
Partialy upheld
upheld 2
not upheld 1
Holme Hall
The Chantry
Dee View Court
Cureden
0
0
0
0
1
0
1
1
1
agreed extension 0
1
1
1
upheld 1
Formal complaints
2013-14
Formal complaints
2014-15
Acknowledged
within three days
Responded to
in 20 days
Upheld/
not upheld
Partialy upheld
Nettlebed
0
3
1
2
2
agreed extension 1
2
upheld 2
Manorlands
3
holding 1
3
1
Palliative care
Centre
3
upheld 2
not upheld 1
St John’s
Wheatfields
Thorpe Hall
Leckhampton
Duchess of Kent
0
0
2
1
2
2
1
1
1
1
2
1
1
1
1
2
1
agreed extension 1
1
1
upheld 2
1
1
1
1
There are no recorded complaints from any of our community support and homecare services across 2014-15
The themes are very important from complaints to assist in learning and to improve the overall experience for individuals using
our services, these included communication to relatives, staff attitudes/behaviours, full respite experience, environment,
bureaucracy/ non-care processes, care which did not meet the expectations of the family.
Changes made
• Local policy and procedural review for respite admissions: these have been updated and reviewed.
• Procedural review, clarifying communication to family members regarding preferred contact details and times to ring certain
numbers (land line rather than mobile or vise versa ) for all hospices.
• Local procedural clarification of contacting funeral directors when the family preference is not recorded.
• Review of volunteer recruitment and support and supervision.
• Written information on local facilities for families staying overnight within hospice setting.
Sue Ryder – Quality Account 2014–15
21
Part three: indicators
2. Safety
2.1 Number of incidents affecting service users 2014-15
Neurological care*
Palliative care
Homecare
2013-14
2014-15
2013-14
2014-15
2013-14
2014-15
0
0
0
0
0
1***
0
1
0
0
0
0
4
7
7
1
0
3
0
1
1
1
0
0
Number of incidents resulting in death**
Number of incidents resulting in
permanent or long-term harm
Number of service user slips, trips
or falls resulting in hospital visit
Number of reports under RIDDOR
*Excludes Birchley Hall
** Incidents resulting in death 2014/15 are recorded for Chantry, Angus and Stirling – in each case the service user was found dead rather than the death being a result of care so
these are not shown above.
*** Four incidents at Wheatfields were recorded as permanent or long-term harm for 2013/14 relating to pressure damage but this was incorrectly recorded.
2.2 Number of medicines incidents 2014-15
Neurological care
Centre
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
Minimum harm, person required extra
observation or minor treatment
Moderate (short term) harm –
person required further treatment
1
2
4
1
1
0
0
1
0
1
Minimum harm, person required extra
observation or minor treatment
Moderate (short term) harm –
person required further treatment
1
5
6
3
5
4
5
0
0
1
0
0
3
0
Minimum harm, person required extra
observation or minor treatment
Moderate (short term) harm –
person required further treatment
0
0
0
0
Palliative care
Centre
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Duchess of Kent (West Berkshire services)
Wheatfields
Homecare services
Service
Angus Homecare
Stirling Homecare
22
Sue Ryder – Quality Account 2014–15
Part three: indicators
2. Safety
2.3 Regulatory inspection results
Neurological care
In England the CQC has changed the way inspections are undertaken and moved to a rating scale – because of this move some
of our inspection results are based on the previous system of compliant or non-compliant whilst others have been inspected
under the new system.
Holme Hall
Birchley
Date
of last check from CQC
Overall rating
requires
improvement
Is the
service safe
Is the
service effective
Is the
service caring
Is the
service
responsive
Is the
service well led
2/1/15
Requires
improvement
Good
Requires
improvement
Good
Good
Requires
improvement
20/4/15
Good
Good
Good
Good
Good
Good
Standards of
caring for people
safely and
protecting them
from harm
Standards of
staffing
Standards of
management
The following services have not been assessed under the new inspection process
Centre
The Chantry
Cuerden Hall
Stagenhoe
Fourways Suffolk
Sue Ryder – Quality Account 2014–15
Date
of last check from CQC
Standards of
treating people
with respect and
involving them
Standards of
providing care
treatment and
support which
meets peoples
needs
9/8/13
18/10/13
6/12/13
23/11/13
23
Part three: indicators
2. Safety
Palliative care
In England the CQC has changed the way inspections are undertaken and moved to a rating scale – because of this move some
of our inspection results are based on the previous system of compliant or non-compliant whilst others have been inspected
under the new system.
Date
of last check from CQC
Inspected
under new process
– overall rating
Is the
service safe
Is the
service effective
Is the
service caring
Is the
service
responsive
Is the
service well led
2/1/15
Good
Requires
improvement
Requires
improvement
Outstanding
Good
Good
Standards of
staffing
Standards of
management
Nettlebed
The following services have not been assessed under the new inspection process
Centre
Date
of last check from CQC
Leckhampton Court
Manorlands
St John’s
Thorpe Hall
Duchess of Kent
Wheatfields
Standards of
treating people
with respect and
involving them
Standards of
providing care
treatment and
support which
meets peoples
needs
Standards of
caring for people
safely and
protecting them
from harm
11/2/14
17/06/14
21/11/13
20/9/13
14/03/15
31/1/14
Scottish services
Care Inspectorate in Scotland.
Centre
Dee View Court
Centre
House 7 – Dee View Court
Service
Angus Homecare
Stirling Homecare
24
Sue Ryder – Quality Account 2014–15
Date of last
quality visit
Quality of care
and support
Quality of
environment
Quality of
staffing
Quality of
management
and leadership
19/5/14
5 Very Good
6 Excellent
5 Very Good
6 Excellent
Date of last
quality visit
Quality of care
and support
Quality of
environment
Quality of
staffing
Quality of
management
and leadership
10/11/14
4 Good
Not assessed
4 Good
4 Good
Date of last
quality visit
Quality of care
and support
Quality of
environment
Quality of
staffing
Quality of
management
and leadership
21/1/15
28/4/14
6 Excellent
6 Excellent
Not assessed
Not assessed
6 Excellent
6 Excellent
6 Excellent
5 Very Good
Part three: indicators
3. Effectiveness
3.1 Number of Healthcare Acquired Infections (HCAI) 2014-15
Neurological care*
Clostridium difficile
Norovirus
MRSA (infection)
MRSA (colonised)
ESBL (infection)
ESBL (colonised)
Hepatitis (A, B or C)
Tuberculosis
Influenza
Total
Palliative care
Total
Acquired within
own service
Acquired external
to service
Acquired within
own service
Acquired external
to service
Acquired within
own service
2013 - 14
Acquired within
own service
2014 - 15
1
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
1
2
0
0
1
0
0
0
0
0
3
11
0
4
3
1
0
5
0
0
24
2
0
0
0
0
0
0
0
0
2
3
0
0
1
0
0
0
0
0
4
*Excludes Birchley Hall
Number of Healthcare Acquired Infections (HCAI) acquired within own service
2013–2014
2
4
2014–2015
3.2 Number of Healthcare Acquired Infections (HCAI) by service 2014-15
Neurological care
Centre
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
Total
Clostridium
difficile
Norovirus
1
0
0
1
0
2
0
0
0
0
0
0
Clostridium
difficile
Norovirus
0
3
0
1
2
2
5
13
0
0
0
0
0
0
0
0
MRSA I
MRSA C
ESBL
ESBL
(infection) (colonised) (infection) (colonised)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Hepatitis Tuberculosis Influenza
(A,B or C)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Palliative care
Centre
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Duchess of Kent (West Berkshire services)
Wheatfields
Total
Sue Ryder – Quality Account 2014–15
MRSA I
MRSA C
ESBL I
ESBL (C
(infection) (colonised) (infection) (colonised)
0
0
0
0
2
2
0
4
1
0
0
0
0
0
3
4
0
1
0
0
0
0
0
1
0
0
0
0
0
0
0
0
Hepatitis Tuberculosis Influenza
(A,B or C)
0
1
1
0
0
3
0
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
25
Part three: indicators
3. Effectiveness
3.3 Pressure ulcers 2014-15
Data now includes only grade 2 and above
Total pressure ulcers 2014-15
Acquired within
own service
2013 - 14
Acquired external
to service
2013 - 14
Acquired within
own service
2014 - 15
Acquired external
to service
2014 - 15
10
92
9
207
11
122
8
260
Neurological care
Palliative care
Number of pressure ulcers acquired within own service
(Neurological)
Number of pressure ulcers acquired within own service
(Palliative)
2013–2014
2013–2014
2014–2015
10
11
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
2
7
7
7
7
7
7
7
7
7
7
92
122
2014–2015
7
7
7
7
7
7
7
3
Neurological care
Centre
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
Total
Acquired within
own service
2013 - 14
Acquired external
to service
2013 - 14
Acquired within
own service
2014 - 15
Acquired external
to service
2014 - 15
3
0
2
3
2
10
1
0
0
3
5
9
5
0
3
1
2
11
1
0
1
2
4
8
Acquired within
own service
2013 - 14
Acquired external
to service
2013 - 14
Acquired within
own service
2014 - 15
Acquired external
to service
2014 - 15
11
9
23
11
7
14
17
92
32
21
23
40
27
32
32
207
11
19
16
17
12
33
14
122
10
51
45
51
36
28
39
260
Palliative care
Centre
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Duchess of Kent (West Berkshire services)
Wheatfields
Total
26
Sue Ryder – Quality Account 2014–15
Part four: annexes
Annex 1
There is a legal requirement to report on this section
During the period of this report, 1 April 2014 to 31 March 2015, Sue Ryder provided NHSfunded community care services in our hospices and some care centres and NHS-funded
nursing care in most of our centres. Sue Ryder had seven adult inpatient units within hospices,
eight day hospices, one Hospice at Home service, three community nursing services, and five
care homes with nursing. In addition to these services we also delivered care within one care
home without nursing, two supported living services.
Sue Ryder has reviewed all the data available to it on the quality of care in all of the above services.
The percentage of NHS funding is variable depending on the nature of the service and ranges from 35% to 90% of the total cost
of providing the service. The shortfall is met from Sue Ryder charitable income.
The income generated by the NHS services reviewed in the period 1 April 2014 to 31 March 2015 represents 100% of the total
income generated from the provision of NHS services by Sue Ryder for the period 1 April 2013 to 31 March 2014.
During the period from 1 April 2014 to 31 March 2015 there were no national clinical audits or national confidential enquiries
covering the NHS services that Sue Ryder provides. Sue Ryder sets an annual core audit programme that runs from April to
March each year.
The core audit programme is risk-driven, and for hospices and neurological care centres includes record keeping, medicines
management, falls prevention, manual handling, pressure ulcer assessment and management, care at end of life (neurological
centres), infection prevention and control including environmental and hand hygiene audit. The monitoring, reporting and
actions following these audits ensure care delivery is safe and effective. Each service reports audit findings into their local
internal Quality Improvement Group. The Healthcare Governance Committee for Sue Ryder receives a twice-yearly overview of
audit results and actions taken in response. Learning from audits is summarised and shared across health and social care via
learning for safety memos.
From 1 April 2014 to 31 March 2015 Sue Ryder was not eligible to participate in national clinical audits.
Out of the eight studies approved from April 2014, the following studies recruited participants since April 2014:
exploring patients’ views and opinions on physical activity and what they would like to achieve: pilot interviews to inform the
development of a new physical activity program at Wheatfields Hospice (approved in March 2013 but recruited participants
from April 2014). Site: Wheatfields Hospice. Recruited: 12 participants.
A multi-centre, non-interventional investigation of the relationship between pain intensity numeric rating scale scores and
health status, as assessed with the EQ-5D, in patients with cancer-related chronic pain (not completed; 280 participants
recruited internationally out of a total of 330). Site: Leckhampton Court Hospice. Recruited: 57 participants.
Photo making in hospice: can the process of constructing images restore the changed self-image that accompanies the
diagnosis of a life-limiting condition? Site: Leckhampton Court Hospice. Recruited: 8 participants.
The views of nurses on the implementation of single nurse controlled drug administration in Specialist Palliative Care Units
(SPCUs). Sites: St John’s Hospice, Thorpe Hall Hopsice. Recruited: 10 participants.
Sue Ryder income in this reporting period for three hospices was conditional on achieving quality improvement and innovation
goals through the Commissioning for Quality and Innovation payment agreed via local commissioning groups.
Sue Ryder – Quality Account 2014–15
27
Part four: annexes
Annex 1
There is a legal requirement to report on this section
Sue Ryder is required to register with the Care Quality Commission and the Scottish Care Inspectorate. Conditions of registration
include the management by an individual who is registered as a manager in respect of that activity at all locations and maximum
number of beds for its services in the following regulated activities:
• accommodation for people who require nursing or personal care
• diagnostic and screening procedures
• personal care
• transport services, triage and medical advice provided remotely
• treatment of disease, disorder or injury
Sue Ryder has not participated in any special reviews or investigations by the CQC during the reporting period.
Sue Ryder was not required to submit records during the period from 1 April 2014 to 31 March 2015 to the secondary uses
service for inclusion in the hospital episode statistics.
Sue Ryder is eligible to be scored for the period April 2014 to 31 March 2015 for information quality and records management,
assessed using the Information Governance (IG) toolkit. The eligibility to be scored this year is due to a change in our
organisation type and amendments to the IG toolkit. Previously the only option that was available to Sue Ryder, when first taking
NHS services, was as a ‘Commercial Third Party’. This did not focus on information quality and records management. Last year a
new organisation type within the IG toolkit, ‘NHS Business Partner’, was introduced and Sue Ryder submitted evidence based on
self assessment for attainment level one (amber).
Sue Ryder was not subject to the Audit Commission’s payment by results clinical coding audit during the period 1 April 2014 to
31 March 2015.
Sue Ryder will be taking appropriate actions to improve data quality through:
• increased awareness in the importance of reporting
• training, including how to use our documentation templates
• identifying trends through a balanced scorecard reporting system
• ‘learning for safety’ memos for when systems and processes change
Some of the people we support may be local authority funded, depending on their needs.
Sue Ryder has a Monitor licence to provide NHS-funded services from 1 April 2014 onwards. None of Sue Ryder’s services have
been designated as commissioner requested services.
28
Sue Ryder – Quality Account 2014–15
Part four: annexes
Annex 2
Statements from Lead Clinical Commissioning Groups (CCG), Commissioning support units (CSU), the Overview
and Scrutiny Committee (OSC) and Health and Wellbeing Boards.
Feedback from the Leeds South and East Clinical Commissioning Group
Dear Helen,
Re: CCG response to draft quality account
Thank you for the opportunity to review and provide a response to your Quality Account for 2014/15. We have sought views from
a range of stakeholders and clinicians, and our response is as follows:
Leeds South and East Clinical Commissioning Group (CCG) welcomes the opportunity to comment on Sue Ryder Quality Account
for 2014/15. Leeds South & East Clinical Commissioning Group is providing this narrative on behalf of all three Leeds
Commissioning Groups including Leeds West CCG and Leeds North CCG.
We have reviewed the account and we believe that the information published, that is also provided as part of the contractual
agreement, is accurate. We are supportive of the priorities that have been proposed for the forthcoming year.
In November 2013 the Government published its response to Sir Robert Francis’s report into the events at Mid-Staffordshire
Hospital. This report, entitled ‘Hard Truths’, accepted the vast majority of Sir Robert’s recommendations and confirmed the need to
focus on high quality healthcare. It is crucial that commissioners and providers work together to ensure this.
We would like to thank you for the individual service summary for Wheatfields Hospice; which was felt to be extremely useful. This
clearly evidences the active engagement in improving clinical practice, supporting patients and informing NHS England about
end of life care. It would have been helpful for more detail to have been provided to review as part of the individual local summary.
We are pleased to note the focused work undertaken to better understand falls risks. We acknowledge that the number of
incidents resulting in harm have significantly reduced from 203/14 data, which appears to correlate with the organisations falls
risk management strategy and implementation plan, which was introduced in 2014.
It is pleasing to note the collaborative partnerships and external education programmes which have continued to grow and
develop in 2014/15 and we are supportive of your plans to deliver more palliative care education programmes for GPs and Care
Homes in 2015/16.
It is concerning to note that the number of pressure ulcers acquired within palliative care services has increased since 2013-14,
with significant increases being reported for the Wheatfields and Duchess of Kent centres. Previous Quality Accounts show that
overall there has been a year on year increase since 2011-12 and we have expressed our concern in relation to this increase in
previous comments. We would have liked to have seen an active plan to reduce this within 2015/16 plans. In addition to the four
main Sue Ryder priorities for 2015/16, we support Wheatfields’ additional priority to focus on further improvements in pressure
ulcer prevention.
We continue to have a positive relationship with Wheatfields and we look forward to working with them in 2015/16 with the aim
of delivering the highest standards of patient-centred, palliative care.
Ellie Monkhouse
Director of Nursing and Quality, Leeds North CCG, Director of Nursing and Quality, Leeds South and East CCG
Sue Ryder – Quality Account 2014–15
29
Part four: annexes
Annex 2
Statements from Lead Clinical Commissioning Groups (CCG), Commissioning support units (CSU), the Overview
and Scrutiny Committee (OSC) and Health and Wellbeing Boards.
Our response to the comments we received:
Thank you for the considered feedback, this is the first time we have produced local summaries and this was in direct response
to the feedback from Leeds CCG last year- we will continue to develop greater detail in the summaries in response to your
feedback.
The upward trend in pressure damage has been noted and we also recognise that there has been an increasing upward trend of
pressure ulcers identified on admission to the service.
Following our review across all sites we have noted that we are seeing pressure damage in non-traditional sites, such as ears and
bridges of noses, therefore next years Quality account will outline pressure ulcer development by position on the body, as part
of the improvement plans at Wheatfields we will look at RCA for each ulcer developed.
Helen Ankrett, Wheatfields Hospice Director
Feedback from Healthwatch Leeds
Feedback on the 2014-2015 Quality Account
Wheatfield’s Hospice, Leeds
Introduction
Healthwatch Leeds hosted a session for all the organisations providing NHS services in Leeds who are required to provide
annual Quality Accounts and have invited Healthwatch Leeds to comment on them as a part of their statutory duty. Each
organisation was invited to present their account with a focus on accessibility, evidence of links between patient feedback or
engagement and priorities, the measures of planned improvement and progress and benchmarking. Healthwatch volunteers
were also invited to identify areas of good practice. As the actual copies of the QA were not provided by everyone, a general
recommendation is to produce a more accessible summary, possibly in easy read that has a focus on the issues identified as
important and influenced by patients, service users or their carers.
Healthwatch Leeds comments for the Quality Account
Wheatfield’s Hospice is owned by Sue Ryder, a national provider that produces a corporate Quality Account. A part of the
corporate template was shared, there were references to improvements identified through patient and carer engagement and
improvement priorities relating to patient care. Benchmarking takes place and there are examples of good practice for
example through supported engagement and developing volunteer roles. Following the feedback last year the hospice is now
committed to providing a local section that will relate to Leeds, this is a positive development. The table presented for the
national priorities was not very accessible due to font size and the corporate colour scheme, the provider may wish to consider
a larger bold print or a more accessible summary.
Our response to the comments we received:
Thank you for the feedback - we note the general recommendation regarding summaries and easy read version. This is our
first year producing a local summary and we will continue to develop this based on local feedback. Please note that all of our
publications are available in alternative formats on request. I have noted your comments regarding the table presented, our
final summary and full publication of the Quality Account has addressed this.
Helen Ankrett, Wheatfields Hospice Director
30
Sue Ryder – Quality Account 2014–15
Part four: annexes
Annex 2
Statements from Lead Clinical Commissioning Groups (CCG), Commissioning support units (CSU), the Overview
and Scrutiny Committee (OSC) and Health and Wellbeing Boards.
Feedback from Bedfordshire Clinical Commissioning Group
Dear Mike
I realised belatedly that your email did not include Vanda Prutton and Maria Laffan at the Quality Team so I have emailed the QA
statement to them.
Vanda will need to offer you formal feedback qualitatively.
My observation will be that whilst there is indication of very good work, it would be useful to have evidence that the Quality Team
can review the findings against.
Furthermore, it would be useful to have St. John’s feedback for ongoing work and changes to practice to reduce further
likelihood of reoccurance, e.g. the pressure ulcer findings.
Tom Shyu,
Senior Contracts Manager,
Bedfordshire Clinical Commissioning Group,
Our response to the comments we received:
Thank you for the feedback. This is the first year completing local summaries and I will certainly use this feedback to further
develop these. The data from St Johns includes the last five years’ figures, pressure ulcer identification has consistently improved
and the upward trend is both for patients admitted to the service and those acquiring pressure ulcers in the service. We have
seen an upward trend in pressure ulcer development in non-traditional sites, such as ears and bridges of noses, therefore next
year’s Quality Account will outline pressure ulcer development by position on the body, as part of the improvement plans at St
John’s we will look at RCA for each ulcer developed.
Mike Coward, St John’s Hospice Director
Feedback from NHS Bradford Districts CCG
Dear Lizzie,
Thanks for sharing these documents. Overall I am sure you are very pleased with your ‘results’, feedback from the patients and
carers and CQC inspection. Please pass on my thanks for your continued hard work and dedication to all your staff. We can pick
up one or two items in the report I know you will be working on next time we meet. Well done.
Rob O'Connell
Head of Integrated & Continuing Healthcare
NHS Bradford Districts CCG
Our response to the comments we received:
Thank you for this feedback, we are delighted with the feedback from patients and families and look forward to the coming year
and our ongoing plans for continued improvement, particularly supporting more individuals via our new befriending service.
Lizzie Procter, Manorlands Hospice Director
Sue Ryder – Quality Account 2014–15
31
Part four: annexes
Annex 3
Feedback from Acorns 21 April 2015
The group welcomed the Quality Account and feel that the local summaries are a welcome addition. The group were also
pleased to see progress on the real-time feedback, but outlined that the falls risk management strategy must be linked to
personalisation and the right of individuals to take risks in maintaining independence. The Acorns group also would like to
acknowledge the work undertaken around the service user strategy development. They highlighted that the local
implementation plans could be strengthened further by identifying and working with service users to have ambassador-type
roles as link to strengthening our national voice in policy and campaigns.
Response from Chief Nurse
Thank you for the considered review of our Quality Account, I have strengthened our priority area for service user strategy to
reflect your feedback. The Falls Strategy and associated policy does include personalised approaches to managing falls risk but
this will be an area we will monitor over the coming year and report back to Acorns at the November meeting.
32
Sue Ryder – Quality Account 2014–15
Part four: annexes
Annex 4
National service offer for palliative care (service lines)
Providing access to psychology
Inpatient services:
• 24/7 admissions through a range of access points and
inclusive of the ‘hard to reach’
• beds managed by both consultants and community nurses
• offering physiotherapy, OT, complementary therapies, social
workers and a chaplaincy
• delivering individual programmes of care linked to personal
goals and performances
24 hour co-ordinated palliative care advice:
• signposting advice and guidance
• support for individuals to navigate the system
• ‘one stop’ nurse clinics
Hospice at Home:
• enabling by technology (eg. self management applications)
• domiciliary visits
• medical and family support
Befriending:
• maximised by the use of volunteers
Bereavement services:
• development of a ‘best practice’ breavement model
Providing transition for young adults
Transport services
7/7 CNS service:
• community nurse prescribers
• delivering choice across the range of community services
Day therapy:
• delivering flexible, responsive ‘packages’ tailored to
individual need
• out patients
• specific clinics, ‘pop in’ visits
• long term conditions programmes
• delivering the lymphedema service nationally
• medical outpatients with interventions
Patient co-ordination:
• PEPS type service
• delivering co-ordinated and seamless access and transition
through all services and settings
Hospital and care home in reach service:
Respite service:
• as an extension of carer support
• offering a range of options: inpatient, day provision, night
sleepers
Carer and family support:
• bereavement, spiritual and social
Sue Ryder – Quality Account 2014–15
33
Part four: annexes
Annex 4
National service offer for neurological care
(service lines)
Complex care – residential:
• support for challenging behaviour via links to
mental health teams
• behaviour psychology provision
• slow stream rehabilitation
• ventilated/respiratory support
• support for more complex needs (abi)
• physiotherapy, occupational, speech and language
therapies
• providing social and recreational activities that
enhance well being and quality of life
• medical and pharmacy services
• EOL care
Neuro community nurse specialists:
• care services
• advice and co-ordination
Patient co-ordination:
• PEPS type service
• delivering co-ordinated and seamless access and transition
through all services and settings
24/7 day service provision
Specialist day services
Condition specific re-ablement programmes
Provide specialist outreach services
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Sue Ryder – Quality Account 2014–15
Self managment and preventative programmes:
• telehealth
• telemedicine
• community services
Respite provision:
• clients home
• resdidential centre
Rapid response
Befriending:
• escort service
• family/carer support service
Care co-ordination service
Supported living
Community day services
• neuro cafes
• dementia service/cafes
35
Sue Ryder provides incredible hospice and neurological care for people
facing a frightening, life-changing diagnosis. It’s not just expert medical care
we provide. It’s the emotional support and practical things we take care of
too. We do whatever we can to be a safety net for our patients and their
loved ones at the most difficult time of their lives.
Not only do we treat more conditions than any other UK charity in our
hospices, neurological care centres and out in the community; we also
campaign to improve the lives of people living with them. We see the person,
not the condition, taking time to understand the small things that help that
person live the fullest life they can.
For more information about Sue Ryder
call: 0845 050 1953
email: healthandsocialcare@sueryder.org
visit: www.sueryder.org
/SueRyderNational
@sue_ryder
This document is available in alternative formats on request.
Sue Ryder is a charity registered in England and Wales (1052076) and in Scotland (SC039578).
Ref. No. 03956 © Sue Ryder. June 2015..