Quality Account
2014 -15
Mission Statement
Teesside Hospice Care Foundation (THCF) is committed to enhancing the quality
of life of those suffering from life limiting illness, offering specialist palliative care
and support to patients and their carers in the belief that each person is entitled to
dignity and choice within the best provision of care.
Teesside Hospice
1, Northgate Road, Linthorpe,
Middlesbrough,
TS5 5NW
Registered Charity Number - 512875
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“As ever, the Hospice and all their staff were beyond reproach. The Hospice are a
beacon of professionalism, their care and commitment. Both myself and my family
are indebted to you all.” Patient comment – Inpatient Unit Satisfaction Survey
2014/15
“First impression when walking into the building was the feeling of comfort and
relaxing atmosphere. The staff and volunteers are warm and welcoming and will do
anything that is asked of them with pleasure.” Patient comment – Day Hospice
Satisfaction Survey 2014/15
“The lymphoedema clinic is excellent. Staff are friendly, approachable, and
knowledgeable and are highly skilled. The whole team always have time for you.”
Patient comment – Community Lymphoedema Satisfaction Survey 2014/15
The best thing about Teesside hospice was:“The caring nature of ALL the staff involved in my wife's care and the support given
to the family. They all lived up to your motto.”
“The way things were put together to give a total comprehensive and very caring
attitude to … and I from the moment of walking through the doors. We couldn't have
hoped in our wildest dreams for anything better. You all pulled together as a lovely
caring team. Well done all of you! And thanks from the bottom of our hearts!”
“Every member of staff are wonderful! Everyone took the time to get to know my dad
and myself and support us and nothing was too much trouble. They truly are amazing
people and thank you so much for everything”. Bereaved Carer 2014/15
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PART 1
Statement from Chief Executive
Teesside Hospice Care Foundation is committed to delivering the best possible experience for
patients and their families. Through the Hospice’s Consultant led multi professional team we
aim to provide the highest standard of specialist palliative care we can achieve.
We are committed to continuous improvement within the Specialist Palliative Care we deliver.
This Quality Account will hopefully demonstrate the level of commitment we have to deliver,
review and improve the quality of the service we provide to patients and their families that
access our services. We rely on the feedback from patients and families who use our services.
The Care Quality Commission made an unannounced inspection to the Hospice in January
2014. The report on this inspection did not identify any areas where remedial action was
required, nor were any recommendations or suggestions made.
The Board of Trustees continues to oversee the corporate governance of the organisation,
with various sub committees having trustee representation. Policy review and new
documentation is developed with the inclusion of the appropriate management and staff.
We receive 32% funding from the NHS but rely heavily on our Trading Company together with
the very generous support of local businesses and supporters to make up the remaining 68%
of the required funding. Legacy income is not a guaranteed source of income but is needed to
ensure the Hospice has vital reserves going forward. Teesside Hospice is a local Charity based
in Middlesbrough. Throughout 2014 / 15 the Hospice has continued to ensure strong financial
stability.
I would like to thank all staff, volunteers and supporters for their dedication in contributing to
make our patients and families have the best experience of palliative care we can deliver.
To the best of my knowledge the details within these accounts reflects an accurate and a fair
representation of the quality of care provided by Teesside Hospice.
Maureen Thompson
Chief Executive
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PART 2
Looking ahead: Key priorities for improvement for 2015/16
2.1 Introduction
Teesside Hospice Care Foundation (THCF) was established in 1982 as a specialist
palliative care centre to enhance the quality of life of those suffering from life limiting
illnesses. It offers Consultant led specialist palliative care and support to patients and
their carers.
Our aim is to provide the relief of complex symptoms with regard to physical, social,
psychological and spiritual aspects of patient/family care, thus enabling them to return
home or to another care environment. The majority of care to patients, families and
carers focuses upon pain and symptom control and end of life care.
An annual patient survey is
undertaken and managed by THCF
Clinical Audit Group. The outcome of
the survey is shared with the Clinical
Governance Committee, Council of
Management Trustees and
summaries of the survey are
displayed as posters in each
department to inform patients, their
families and other visitors to the
organisation of the outcome of the
survey.
A carer support programme is established alongside the Day Hospice Service and
where possible patient and carer views are sought prior to specific changes or service
developments.
In January 2014, Teesside Hospice satisfied the Care Quality Commission (CQC) that
standards are being met through both self-assessment and an unplanned CQC
inspection. The CQC inspection was extremely successful and Teesside Hospice was
deemed fully compliant. We are in the process of submitting the Provider Information
Return (PIR) to the CQC and await an unannounced inspection in the coming months
as part of the ongoing CQC inspection process.
Teesside Hospice monitors the quality of care that is provided across the organisation
via its Clinical Governance Committee. The importance of providing quality care is
underlined by the membership of the committee which includes the organisations most
senior clinicians, the Director of Patient Services and representatives from the Board.
The Hospice’s catchment area is predominately Middlesbrough, Redcar and Cleveland
areas however, we are also contracted to provide a specialist community
lymphoedema service to patients from the North and South CCG areas.
A major capital improvement programme was completed in March 2015 funded jointly
by the Department of Health and the Hospice. All areas and departments of the
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Hospice were upgraded, with the main reception area and an extension to the Inpatient
Unit being the most significant developments.
2.2
Improvement Aspirations
Aspiration 1 - Patient Safety
Why
choose the
it asquality
a priority?
To improve
of the patient hand over process on the Inpatient
Unit.
Why choose this as a priority?
Poorly structured, verbal handovers have been identified as a common source of
patient related errors in continuity of care, evidence recommends the standardisation
of the handover process to include structured checklists and protocols.
The Nursing and Midwifery Council (2009) highlight good record keeping and
communication as an integral part of practice and essential to the provision of safe and
effective care. The primary purpose of nurse handover is the clear exchange of
information from the outgoing nurses to the incoming nurses to enable the latter to
nurse appropriately.
To further improve the quality of the patient handover process the use of the Situation,
Background, Assessment and Recommendation (SBAR) evidence based tool will be
reviewed. It is recommended by the NHS and the World Health Organisation. SBAR
will be used to frame clinical discussions and form the structure of the handover. This
will aim to focus, clarify and avoid repetition of information shared between nursing
shifts and the multi-disciplinary team.
How will this priority be achieved?
The Inpatient Unit Sister has recently undertaken her nursing degree and identified a
need to improve nursing hand over on the unit through this academic work.
 A small group of staff will form a group to work on the SBAR tool.
 A pilot of the new tool will be undertaken over a 3 month period and evaluated.
Consideration will also be given to the supportive and debriefing function of the
handover for staff as the emotional demands on staff working with palliative care
patients are well-documented.
How will this priority be measured?
The audit evaluation will be reviewed in terms of staff satisfaction, effectiveness and
clarity of information and communication as a result of the nursing handover process.
This will be shared with the senior team and members of the multi-disciplinary team
prior to a decision being made regarding changes to the verbal handover process.
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Aspiration 2 – Clinical Effectiveness
To ensure that End of Life Care provided to patients at Teesside Hospice is
patient centred, high quality and in accordance with the recent review of
end of life care, ‘One Chance to get it Right’.
Why choose this priority?
An independent review of the Liverpool Care Pathway (LCP) conducted by Baroness
Julia Neuberger and published in July 2013 concluded that the LCP should be phased
out. Following this, the Leadership Alliance for the Care of the Dying People published
‘One Chance to Get it Right’. This sets out the approach to caring for dying people that
healthcare organisations and staff should adopt in England. The approach focuses on
achieving five priority areas for care: Recognition, Communication, Shared decisionmaking, Exploring other’s needs and Individualisation.
Teesside Hospice prides itself on delivering individualised, patient centred, high quality
end of life care and as a result we want to be sure we are achieving this.
How will this be achieved?
We have developed a new patient centred, individualised care plan (Assessment, Care
and Treatment in the last days of life – ACT), to be used for patients who we recognise
may die within the next few days or hours. The plan of care is individual to each patient,
involving the patient themselves and those identified as being important to them e.g.
family, carers. It has been developed using the 5 priorities of care at its core. The ACT
document is currently being piloted. During the pilot all staff are encouraged to
feedback their thoughts and comments regarding their experience of using the new
care plan.
How will this be measured?
An audit tool has been created with criteria developed from the ‘5 Priority Areas’ from
the Leadership Alliance for Care of Dying People’s report ‘One Chance to get it Right’.
A retrospective audit has taken place looking at documentation prior to the introduction
of the ACT document and also an initial prospective re-audit to assess changes in
documentation and care resulting from the use of our new ACT care plan has been
undertaken.
 Ongoing evaluation and review continues and a further audit to complete the
audit cycle will take place.
 A report on the pilot including audit results and staff feedback regarding end of
life care and the documentation of this will be completed.
 We plan to have End of Life Care as one of the topics for our ‘Awareness
Education Program’ in the coming months when results of the pilot can be
cascaded to staff.
 Feedback from bereaved carers continues to be another important way for us
to monitor the quality of end of life care and the experience of relatives of
patients who have died at the hospice.
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Aspiration 3 – Patient Experience
Increase the social interaction of Inpatient Unit and Day Hospice patients
and families.
Why choose it as a priority?
We strive to continually improve the standard of care for patients and their families by
listening to the stories of their experiences. We also receive feedback through surveys,
suggestion boxes and user forums. It was identified that a dedicated communal area
within the Inpatient Unit was needed for patients and their families. Previously we had
a small family room but this was not situated near the Inpatient Unit and therefore was
used infrequently.
Some examples of the feedback were:“We found the family room rather unwelcoming – blinds drawn, poor décor and lighting,
no flowers or tissues”.
“Better facilities for relatives needed i.e. extra family room, beds to sleep in, microwave
etc.”
“Increased awareness of family room and its purpose”.
Also during a User Forum one lady recalled how she found it difficult to eat and drink
in her partner’s room when he was no longer able to eat or drink and would have loved
to have a place to go with all the family.
“A room that families can use as a slightly more social element where families can
escape for a little bit …..have a more open access where families can go in and sit and
have a cup of coffee or a little chat.”
“I felt I was isolated, no one to discuss things with”
As part of the capital improvement bid funded jointly by the Department of Health and
Teesside Hospice it was decided that the provision of a new family room for patients
and families with bathroom and kitchen / dining facilities was a priority and became an
important focus of the bid. The aim of this room was to:
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Increase social interaction between patients and families.
Avoid social isolation of patients.
Create an area where families can spend time together.
Encourage socialisation between Day Hospice and Inpatient Unit patients
How will this priority be achieved?
The new family room has now been built and named the Rowan Room by patients and
significant progress has been made towards achieving its aims. Further work is still
required to ensure it is used to its full potential and the future plans include:7
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New activity projects
Joint IPU and Day Hospice activity sessions
Families will be encouraged to use the room on an evening or weekend to have
family time together away from the patient bedroom
Encourage patients to spend time out of their room where possible to socialise
with other patients i.e. meal times, morning coffee and cake etc.
How will this priority be measured?
This priority will be measured by reviewing the Patient Satisfaction Surveys and
having it as the subject of a User Forum session to ask patients and carers whether
they felt the room was being used to its full potential and if they were using the
facilities.
Those involved in specific
planned activity sessions in
the Rowan Room will be
asked to give their
feedback through an
evaluation form.
Staff will also be surveyed
as to the use of the room by
patients and family and to
comment on the effect of
having this facility.
2.3
Statements of Assurance from the Board - (Formal statements required
by the Department of Health)
The following are statements under various headings that all providers of NHS
healthcare services must include in their Quality Account, even though many of the
statements are not directly applicable to Teesside Hospice.
a. Review of Services
During the reporting period 2014/15 Teesside Hospice provided the following
Specialist Palliative Care Services to the NHS:
•
•
•
•
•
Inpatient Unit – 10 beds
Day Hospice Services
Specialist Community Lymphoedema Services
Medical Out Patient Services
Adult and Children’s Bereavement Counselling Service
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Teesside Hospice has reviewed
all the data available to us in
terms of the quality of care
delivered. Activity data is
provided to the Commissioners
of these services on a quarterly
basis and is reviewed at
quarterly meetings with the
Commissioner, Chief Executive
(CE) and Director of Patient
Services (DPS).
The income generated by the NHS services reviewed by this quality account
represents 32% of the total income generated from the provision of NHS services by
Teesside Hospice for 2014/15. This 32% represents only part of the funding required
to provide services at Teesside Hospice.
The remaining 68% of income is
generated through fundraising, charity
shops income, lottery activity and
investment income and we are
dependent on the generosity of the
local community in sustaining this
income. The NHS contract means that
all services delivered by Teesside
Hospice are partly funded by the NHS
and partly funded from charitable funds.
b. Participation in Clinical Audit
During 2014/15, there were no national clinical audits and no national confidential
enquiries covering NHS services relating to palliative care. Therefore, during that
period Teesside Hospice was not eligible to participate in any national clinical audits
and national confidential enquiries.
c. Research
The number of patients receiving NHS services provided by Teesside Hospice in
2014/15 that were recruited during that period to participate in research approved by
a research ethics committee was ZERO. There was no appropriate, national, ethically
approved research studies in palliative care in which we could participate.
d. Commissioning for Quality and Innovation (CQuIN) Payment Framework
A proportion of Teesside Hospice’s NHS income in 2014/15 was conditional on
achieving quality improvement and innovation goals agreed between Teesside
Hospice and the commissioning CCG. The improvement conditions that were agreed
were:
• NHS Safety Thermometer - collecting data and demonstrating a reduction in the
incidence of pressure ulcers, falls and urinary infection in patients with a
catheter
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•
Undertaking a local patient experience survey and implementing actions
resulting from the survey and including Friends and Family Test in the survey.
The two CQuIN measures represent 2.5% of the overall contract value with both being
successfully achieved with full payment.
e. The Care Quality Commission
Teesside Hospice is required to register with the Care Quality Commission and its
current registration status is for the following regulated activities:
•
•
•
Treatment of disease, disorder or injury
Diagnostic and screening procedures
Transport services, triage and medical advice provided remotely
Teesside Hospice is registered with the following conditions:
•
•
•
Services are provided for people over 18 years old
The maximum of 10 patients may be accommodated overnight
Notification in writing must be provided to the Care Quality Commission at
least one month prior to providing treatment or services not detailed in the
Statement of Purpose
The last unannounced routine inspection of Teesside Hospice took place on 6th
January 2014. The report on this inspection did not identify any areas where remedial
action was required, nor were any recommendations or suggestions made. Teesside
Hospice has not participated in any special reviews or investigations by the Care
Quality Commission in 2014/15.
f. Data Quality
Teesside Hospice did not submit records during 2014/15 to the Secondary Users
service for inclusion in the Hospital Episode Statistics which are included in the latest
published data. Teesside Hospice is not eligible to participate in the scheme.
g. Information Governance Toolkit attainment levels
Teesside Hospice has an information sharing agreement with South Tees NHS Trust,
whereby we have a remote access provision to patient IT systems. We also store
patient information on our own network. All organisations that have either direct or
indirect access to Health and Social Care Information Centre (HSCIC) Services must
complete an annual Information Governance Toolkit Assessment. It is in a selfassessment format. We have successfully submitted our voluntary sector organisation
self-assessment for 2014/15 achieving a pass level 2 on all applicable requirements.
We have developed a completion plan for next year which aims to move to level 3
(maximum score) where feasible.
h. Clinical Coding Error Rate
Teesside Hospice was not subject to the ‘Payment by Results’ clinical coding audit by
the Audit Commission during 2014/15.
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Part 3
Review of Quality Performance
The quality improvements outlined in the 2014/15 Quality Account have all been
satisfactorily achieved, however, in all areas continuous improvement is planned. The
Board of Trustees has been in full support of the improvement areas over the past year
and has received regular reports on progress. Services users have been consulted
with where appropriate.
3.1 Improvement Priority 1 (Patient Safety)
To reduce the number of patient falls
Falls are identified, as a significant problem in the elderly and frail patient populations.
Therefore, as the number of older adults with cancer increases in the future, the
prevention of falls in this population is even more critical. Reduction of falls is an
ongoing priority for THCF reflecting the importance that the organisation places on this.
THCF has reviewed the process we follow regarding falls. As a result we have
introduced an adapted version of the Hospice UK tool. This is to ensure that an
evidence-based and more effective process is followed in the management and
prevention of falls in the Inpatient Unit and Day Hospice care setting.
Data collected by THCF regarding incidents of falls has demonstrated a reduction in
falls since the introduction of the new tool however, we have only collected this data
since January 2014 and more data will need to be collated before we can attribute this
improvement to the new tool. However, a recent audit of this tool has demonstrated a
continued improvement in the assessment of patients at risk and the effectiveness of
prevention. The tool has supported the nursing team in using the information gathered
to introduce preventative measures at the earliest opportunity. The tool helps the
nursing team to identify the appropriate intervention such as the new sensor pads on
either patient’s beds or chairs and to consider the need for hourly monitoring of
patients.
Falls are one of the 3 safety indicators that the hospice UK collect data on, to support
hospices across the UK to benchmark their practice. THCF have been part of this pilot
and this is now an ongoing process, the data is collated giving a national and hospice
category average which has demonstrated excellent results for THCF.
Furthermore, we have introduced a comprehensive care plan which identifies key fall
risk factors and have included the incident report form as part of the process. This
ensures that the circumstances of any fall are described completely and meaningfully
in order to analyse and use reports of falls to learn about contributing factors.
3.2
Improvement Priority 2 (Clinical Effectiveness)
To increase accessibility and awareness of the acupuncture service and its
benefits to patients in the holistic management of symptoms, within the Day
Care and Inpatient services ensuring that the delivery of acupuncture to patients
is beneficial and improves their quality of life.
The acupuncture service at THCF now has 2 qualified practitioners, who work across
the Day Hospice service and Inpatient services which allows for greater accessibility.
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The Medical Practitioner has been able to promote the use of acupuncture in the
Inpatient Unit by educating staff on the symptoms/conditions which can be treated by
acupuncture and also by directly identifying patients who may benefit. Having 2
practitioners has also allowed for a cross-over of patients who can then be followed up
within each setting.
The annual Acupuncture Audit was undertaken in
September 2014, using statistical analysis of patient uptake
and the MYCAW (Measure Yourself Concerns and
Wellbeing) assessment tool to measure the effectiveness of
treatments on symptoms and well-being. The audit
demonstrated that there has been a 21% increase in the
number of patients treated across both services, with a 41%
increase in patients treated within the Inpatient unit. The
number of treatments given across the services increased
by 38%.
The MYCAW score for symptoms, measured that there was
an average change in symptoms of -2.57, this correlates
with an improvement in symptoms (a change of 1.5 or more
is considered to be significant). The range of change in
symptoms was from 0 to -4. The average change in Well-being score was -1.83. It is
important to take into consideration that many of the patients treated had advanced
disease and the acupuncture successfully treated specific symptoms but other
problems arose which impaired general well-being. The results of the audit have been
shared with the Medical and Nursing staff and to the Clinical Audit Group.
3.3 Improvement Priority 3 (Patient Experience)
To improve the experience of Day Care Patients by introducing a new
individualised programme of support
A six week programme of support called the ‘Be in Charge’ (BIC) group was piloted as
an alternative to the traditional model of Day Hospice and was developed from the
review of Day Hospice services that involved patients, carers and professionals.
The programme was delivered by a multi-professional team and involved sessions
such as anatomy of the lungs & breathing techniques; coping with sleep problems;
fatigue & exercise tolerance; modifying your diet & food preparation; coping with
anxiety to 12 patients. The programme provided education, information, practical
advice and support to patients on ways to manage their own symptoms, education on
new skills and coping strategies to help reduce and manage exacerbations and action
to take in the event of sudden worsening of condition.
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The BIC programme was delivered by a skilled
workforce experienced in supporting patients
with long term conditions and their varied and
complex
needs
and
more
specifically
experienced in identifying when patients are
approaching end of life and in supporting
discussions around patient’s priorities and
preferences of care and death.
The BIC group was well-designed and delivered
a self-management programme which demonstrated improvements in clinical
symptoms, improvement in attitudes and behaviours and improved quality of life.
Evaluations forms were given to patients on the last session of the six week
programme and results were collated and supplemented by qualitative information
from patients at each of the 6 sessions. In total 11 completed evaluation forms were
returned 92% return rate.
All patients who attended also completed a Holistic Assessment Tool (HAT) prior to
attending the group and afterwards to try and assess what benefit the group had made
to their needs. The patient scored their concerns on a scale of 1-10 (10 meaning great
distress). The average reduction in distress was -2.5 at the end of the session.
Overall, the results were extremely positive identifying that the BIC group was a real
success. Most patients found the sessions beneficial. The HAT identified that out of
the 29 concerns identified by patients before the start of the group 23 had shown
improvement by the end which is a remarkable achievement.
A proposal has been put forward to the CCG for funding to continue this programme
as an alternative model for new patients referred into the service.
3.4
2014/15 Performance
a. What patients and families say about the services they receive
We value the feedback we receive from patients and families as an important aspect
of how we can identify issues, resolve problems and improve the quality of the care
Teesside Hospice provides.
As part of our commitment to ensuring patients and families have a voice we give a
survey to all appropriate patients discharged from the Inpatient Unit and send a survey
to the family of patients who die in our care. A patient survey is also given to all Day
Hospice and Lymphoedema Service patients. The results of these surveys are collated
and shared with Trustees, staff/volunteers and patients/carers by PowerPoint or poster
presentations. The surveys are anonymous but where concerns are raised and people
identify themselves this is followed up in a timely manner to resolve the issue and to
learn from what has gone wrong.
The Bereavement Counselling service gives all clients an evaluation sheet and this
was reported in September 2014. Since this report all new referrals are now discussed
at a weekly assessment meeting and appointments given which has resulted in clients
being seen more promptly.
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The lymphoedema team undertook a 3 monthly analysis of a questionnaire given to all
discharged patients in that period and this was reported in Feb 2014. This has resulted
in all patients being sent a printed map of how to get to the Hospice in their appointment
letters and the plan to put a google map link on to our website.
The In Patient (IPU) & Day Hospice Survey - Summary of Results
The annual IPU Satisfaction Survey from April 2014 – March 2015 had a response rate
of 49% (75 out of 152 patients).
Some of the key findings from this report were:

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100% patients stated they were always or most of the time treated with respect.
100% patients felt their privacy was always or most of the time respected.
100% patients were always or most of the time satisfied with the response when
they needed to ask for assistance.
98% patients felt supported in making decisions about their care either always
or most of the time.
97% patients felt very satisfied or satisfied with their involvement in planning
their care.
100% patients stated staff introduced themselves either always or most of the
time.
100% patients stated staff always or most of the time explained what they were
doing prior to any procedure.
97% patients felt they always or most of the time understood explanations given
to them regarding their treatment and care.
100% patients stated staff always or most of the time made an effort to meet
their individual wishes.
97% patients felt the general environment and surroundings were either
excellent or good.
86% patients stated they were offered verbal or written feedback following
MDT meeting
Patients are invited to “Comment on anything you were particularly happy with or
unhappy with giving an example if possible, as this will help to improve our service for
patients in the future”. A selection of responses are included below:
All staff were caring, they helped me improve. I was very happy with the care I
received and couldn't ask for better care.
From day one my mind was put at ease by the professional attitude of all staff
members from the junior to senior.
Nursing staff give 100% to the patients and will go out of their way to help with
anything.
As ever, the Hospice and all their staff were beyond reproach. The Hospice are a
beacon of professionalism, their care and commitment. Both myself and my family
are indebted to you all.
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I have been looking for something to criticise but I've been completely satisfied so
I'm afraid I can't offer up any new ideas to improve things. Sorry.
The staff in every discipline have been amazing. I cannot speak highly enough of
the care me and my family have received.
Unhappy with wearing a sling in the bath/shower but did ask about this and was
removed on request.
Every member of staff have time to listen and are trying hard to get the correct pain
relief. I feel *** is safe when I'm not there especially during the night when the staff
put a sensor in his room so they know if he is moving around with pain and can't
reach his buzzer.
From the cleaners, volunteers, nurses, doctors, physio everyone who works in this
Hospice including main people I forgot, cooks 100% wonderful.
The Day Hospice Satisfaction Survey – Summary of Results
The survey was undertaken from April 2014 – March 2015 and had a response rate of
71% (79 out of 111 patients). Some of the key findings from this report are as follows:
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100% patients stated they were always or most of the time treated with respect.
100% patients felt their privacy was always or most of the time respected.
100% patients stated staff always or most of the time made an effort to meet
their individual wishes.
100% patients felt the general environment and surroundings were either
excellent or good.
100% patients felt very satisfied or satisfied with their involvement in planning
their care.
100% patients stated staff always or most of the time explained what they were
doing prior to any procedure.
100% patients rated helpfulness of volunteers as either excellent or good.
100% patients rated standard of Nursing Care as either excellent or good.
100% patients felt the standard of the room furnishings / comfort were either
excellent or good.
100% patients felt the cleanliness of the Hospice was either excellent or good.
100% patients felt the comfort of hospice transport was either excellent or
good.
100% patients felt the punctuality of hospice drivers was either excellent or
good.
100% patients felt they were able to ask questions about their care either
always or most of the time.
99% patients felt they always or most of the time understood explanations given
to them regarding their treatment and care.
99% patients rated helpfulness of reception staff as either excellent or good.
99% patients rated the standard of Medical Care and emotional support as
either excellent or good.
Patients are invited to “Comment on anything you were particularly happy with or
unhappy with giving an example if possible, as this will help to improve our service for
patients in the future”. A selection of responses are included below:
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I think the nurses and volunteers are really nice and friendly and always polite
The initial introduction to the group settled any miss givings I held about joining the
group.
The welcome you get when you first arrive. Had totally different opinion of hospice
before I came. Have settled down to love coming
Relieved at how soon felt welcome and accepted in the community by staff,
volunteers and members. I noticed that each person made a point of showing
acceptance to a new member.
First impression when walking into the building was the feeling of comfort and
relaxing atmosphere. The staff and volunteers are warm and welcoming and will do
anything that is asked of them with pleasure.
Support and help with anything. We, as I mean me had a few black moods, but I now
look forward to Monday’s, from being picked up by … and … in ambulance to going
back home. It is a good day and will be sorry when comes to an end. Special
mentions in dispatches to many.
The staff and volunteers made my weekly day visit very happy. I am just sorry my 6
weeks has expired. It has flown by and something I will miss is the staff who made
my visits so enjoyable.
The Bereaved Carers Survey- Summary of Results
The annual Bereaved Carers survey from (Jan 2014 – Dec 2014) had a response rate
49% (37 out of 75 sent out to carers).
From previous research, bereaved carers were found to be the most open to providing
feedback on hospice facilities and services. Therefore, a questionnaire was devised
with user involvement as a way of evaluating services and increasing levels of user
involvement in the future. Questionnaires are posted out 8 weeks following the death
of the patient – this was the advisory period given by members of the focus group.
Some of the key findings from this report are:




100% bereaved carers stated they would definitely recommend this service to
a member of their family or friends.
100% bereaved carers rated standard of Medical Care was excellent.
100% bereaved carers rated standard of Nursing Care, emotional support,
Physiotherapy, Dietetic Support, Chaplaincy / Spiritual Care, Complimentary
Therapies, Hairdressing, food service/menu choice, room furnishing / comfort
and room cleaning as either excellent or good.
100% bereaved carers rated helpfulness of reception staff and volunteers as
either excellent or good.
97% bereaved carers rated the standard of catering as either excellent or
good.
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

95% bereaved carers rated standard of Occupational Therapy as either
excellent or good.
92% bereaved carers rated standard of Social Work Support was either
excellent or good.
Those completing the survey were also asked “What was the best thing about
Teesside Hospice” and “Have you any thoughts that might help other patients and
families using the hospice in the future?” Numerous comments were received and a
selection are detailed below.
“Amount of time given to my mother by the medical team. Truly amazing the lengths
& breadths they went to in adjusting the medications to alleviate her symptoms. The
presentation, quality & variety of food, excellent, exemplary - lovely the way the
food was brought at a pace to suit my mother not all at once – excellent. Delightful
when some of the cooks came to visit Mum. Finally being allowed the total freedom
to be and care for my mum which she expressly wanted me to do. I am so grateful
to have been able to do all that I did. Her named nurse was so understanding and
caring towards me”.
“Caring. Calm and peaceful environment. We much appreciated kindness at a
difficult time”.
“Every member of staff are wonderful! Everyone took the time to get to know my
Dad and myself and support us and nothing was too much trouble. They truly are
amazing people and thank you so much for everything”.
“Everyone is very caring. Nothing was too hard to try to meet my wife's needs and
everything was done to give her the best quality of life whilst in the Hospice.
Everything was explained clearly to myself and I was never left in the dark as to
what was happening to my wife’s care plan from day to day.”
……. truly got us through this life
changing time and we will be
forever grateful to them. Day Care
fantastic … in inpatients gave me
the strength to say my goodbye to
Dad and the whole experience was
wonderful, peaceful, dignified. ….chef most respectful kind man”
“The privacy and respect my
husband received during the short
stay he had with you was very
touching for myself and my daughter. His last moments he had were painfully sad but
left this world with all our love in his heart”.
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Key projects / outcomes
In the last 12 months the CGC and its sub groups have been actively working on a
number of projects and initiatives:

End of the Liverpool Care Pathway (LCP)
The senior clinical team led a project to ensure that we have taken account of the
recommendations of the Neuberger Review, More Care Less Pathway. Whilst we
are very confident in the quality of end of life care given at Teesside Hospice we
need to ensure that appropriate documentation supports this delivery and to that
end we drafted an ‘Assessment, Care and Treatment in the Last Days of Life’
document. This was introduced prior to the deadline date of 1st July for the phasing
out of the LCP nationally.

The Clinical Audit Group
The Audit Group have met 11 times from April 2014 to March 2015. It has been
well attended within that time with regular attendance from the Audit & Education
Facilitator, Consultant, Associate Specialist, Director of Patient services, Clinical
Team Leader, IPU & Day Hospice Sisters, Medical Secretary and a representative
from Bereavement Counselling, AHP team and nursing staff. We are hoping to
get a regular representative from Lymphoedema this year.
The audit group facilitated the usual audit programme but there were a number of
new audits undertaken this year. These included the clinical waste audit, a COSHH
audit including every department in the hospice, new administration of medicines
audit of the whole organisation, a complete audit cycle for end of life care,
Transmucosal Fentanyl use, review of the use of analgesia in neuropathic pain
and an evaluation of the Be in Charge pilot group. The creation of an MDT audit
is underway.
The audit group facilitated a large project creating new patient leaflets for Hospice
specific information. This included the creation of a new Welcome Pack for all
Inpatients and a bereavement pack given to all families whose loved one died at
the Hospice. This project finished April/May 2014 but there is now a system in
place to ensure yearly review of all these leaflets.
The audit group completed the patient experience report for 2014 – 2015 and
ensured quarterly information for contract local quality requirements were
undertaken each quarter throughout the year.

Staff Support / Clinical Supervision
Following the summary of the staff support focus groups and reflective practice
session, an action plan was drawn up in February 2014. As it was evident that this
was not going to be a ‘one size fits all’ solution, a variety of projects were
recommended and implemented.
Both Day Care and IPU have introduced the opportunity for staff to debrief and
discuss complex situations on a regular basis as part of handover and end of day
de-brief. If there are times when an objective facilitator is required, it was
suggested Sarah Ramsden, Chaplain would be appropriate. It was also suggested
to have a regular opportunity after the weekly MDT for staff to remember everyone
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who had died and also be given the opportunity to reflect on their care and any
issues that staff wanted to raise.
Regular reflective practice sessions are held which are open to all staff who can
bring issues pertinent to their work. Further particular needs pertinent to differing
departments were to be identified on an individual basis at appraisal by line
managers throughout the organisation, and as a result regular Administration
meetings have been implemented.
A weekly 15 minute ‘Breathing Space’ was piloted from January 2015 until March
2015 by the Chaplain and Head of Counselling. This has recently been reviewed
as a very positive form of support and it is intended for it to continue.
A leaflet has been produced by our Chaplain for all staff highlighting all the support
which is available at the hospice. Staff receive a lot of informal support from
colleagues and line managers and the subject of more formal supervision is to be
reviewed in the future if necessary.

Enhancing the environment for patients with dementia and cognitive
impairment
THCF applied for a grant in October 2013 and were successful in obtaining
£10,000. The particular focus for the Rank Foundation Grant is to enhance the
environment for patients with dementia and cognitive impairment. The aim was to
create a calming environment by making a number of changes. The existing nurse
call system which is currently an audible alarm was changed to a non-audible
system; the bedrooms were redecorated in toned down colours and signage was
reviewed and improved.
 Information technology for patients – A grant application was submitted to the
Towergate Charitable Foundation to improve communication for patients with
verbal impairment and also access to information for patients attending the Day
Hospice and Inpatient Unit. As a result we have purchased a Lite Writer and 2
more iPad’s.
 IMProVE – End of Life Commissioning Group
THCF submitted applications for 4 projects to be funded. These are:
o BIC - Be in Charge Day Care project
o Out Patient Cognitive Behavioral Therapy Service
o C4C - Carers Group
o ABC - Anticipatory Bereavement Counselling
These submissions were supported by the Board of Trustees and to date we are
awaiting the outcome.
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The Board of Trustees Statement
The Board of Trustees is fully committed to the provision of a high quality service at
Teesside Hospice.
The Hospice has a well-established clinical and corporate governance structure, with
members of the Board playing an active part in ensuring that Teesside Hospice fulfils
its mission, according to its charitable intentions and in ensuring that the organisation
remains responsible and compliant in all areas of CQC registration, health and safety,
employment law and other relevant legislation.
This Quality Account was approved 16th June 2015
Signed
Professor Brian Footitt OBE, Chairman, Board of Trustees of Teesside Hospice
Care Foundation
Healthwatch Middlesbrough
Catalyst House
27 Yarm Road
Stockton on Tees
TS18 3NJ
Tel 01642 688312
healthwatchstockton@pcp.uk.net
www.healthwatchstocktonontees.co.uk
Click here to enter text.
Mr Brian Footitt OBE
Teesside Hospice
1 Northgate Road, Linthorpe,
Middlesbrough
TS5 5NW
22nd June 2015
Dear Brian,
Teesside Hospice Quality Account 2014/15
Thank you for your email dated 17th June 2015, providing the opportunity for
Healthwatch Middlesbrough to make comment on Teesside Hospice Quality Account
2014/15.
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The Quality Account was circulated to the Healthwatch Middlesbrough Executive
Board for comments. The chair of Healthwatch Middlesbrough, board members and
staff were all offered the opportunity to comment and feedback.
Overall, Healthwatch Middlesbrough welcomes the opportunity to respond to the
Quality Account and would hope it will continue to reflect the views the residents.
It is clear from the report that you value the opinions of your patients and carers
and we applaud the active way in which you involve them in helping shape future
services and improvements for example the redecoration and improvements of the
family room.
Yours sincerely
Paul Crawshaw
Healthwatch Middlesbrough Chair
Statement from NHS South Tees Clinical Commissioning Group (ST CCG) for
the Teesside Hospice Quality Account 2014/15.
The CCG welcomes the opportunity to review and comment on the Quality Account
for Teesside Hospice for 2014/15 and would like to offer the following commentary.
NHS South Tees Clinical Commissioning Group (CCG) is committed to
commissioning high quality services from Teesside Hospice and take seriously their
responsibility to ensure that patients’ needs are met by the provision of safe, high
quality services and that the views and expectations of patients and the public are
listened to and acted upon.
Overall the CCG feels that the report is well written and presented in a meaningful
way for both stakeholders and users and provides an accurate representation of the
services delivered during 2014/15 within the Hospice.
We recognise the significant work that the Hospice has undertaken to drive quality
improvements throughout the year, particularly in relation to reducing patient falls,
with a focus on prevention, risk management and comprehensive care planning. The
benefits expressed by patients, through the introduction of a pilot individualised
programme of support, demonstrates the Hospice’s commitment to test innovative
and new ways of improving patient experience.
The CCG supports the priorities for 2015/16, specifically the focus on improving the
quality of patient handovers, through the adoption of an evidence based tool.
We also commend the commitment to delivering the expectations of ‘One Chance to
Get it Right’, in relation to end of life care; building on existing practice which
positively promotes and is underpinned by individualised, patient centred
approaches.
The CCG looks forward to continuing to work in partnership with the Hospice to
assure the quality of services commissioned in 2015/16.
Amanda Hume
Chief Officer
NHS South Tees Clinical Commissioning Group
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