Wirral Hospice St John’s
Quality Account 2014/15
Serving our Community
Wirral Hospice St John’s
Mount Road
Higher Bebington
Wirral, CH63 6JE
Registered Charity No.510643
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Quality Account 2014/15
“It is a privilege to
have a loved one
cared for in the
Hospice. It is an
amazing place and
has a very special
place in the heart
of my family”
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Quality Account 2014/15
CONTENTS
SECTION 1: Statement on Quality
page
Statement on Quality from the Chief Executive
4
Wirral Hospice St John’s Core Values
5
Philosophy of Care
6
SECTION 2: Priorities for Improvement 2015/16
 Patient Safety
 Clinical Effectiveness
 Patient Experience
7
8
9
Statutory Information and Statements relating to the Quality of Services
Statement of Assurance from the Board
10
Review of Services
10
Participation in Clinical Audits
11
Quality Improvement and innovation goals agreed with our commissioners
11
What others say about us
11
Data Quality
13
SECTION 3: Quality Overview
Priorities for improvement 2014/15
14
Review of Quality Performance
14
Monitoring patient activity
18
Clinical Audits
22
Key Performance (Quality) Indicators
24
What our patients and families say about the organisation
26
Statements from Clinical Commissioning Groups
29
Statement from Health Watch
29
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Quality Account 2014/15
SECTION 1:
STATEMENT ON QUALITY
From Chief Executive
At Wirral Hospice St John’s, we endeavour to meet the physical, psychological, social and
spiritual needs of those with progressive illness, and support their loved ones and carers
without discrimination.
In order to achieve these high ideals, and to meet the standards set out in the updating of
national policies, all members of the Hospice staff undergo continuous scrutiny and training.
Areas which need further attention to achieve the highest standards are being addressed.
During the time covered by this Quality Account, a substantial building project was completed
and commissioned. This included integrated team accommodation, allowing for the
introduction of an Information Point, and, most importantly, creating facilities that allow for
greater integration of Hospice services with those of other service providers such as
counsellors, therapists and social workers. Our Hospice at Home service was expanded with
an increase in the number of visits undertaken, and the installation of SystmOne patient
information system, an integral IT system. It has been a time of extraordinary change at our
Hospice.
Palliative and end of life care is an area of healthcare which is constantly changing, particularly
as its focus broadens out from cancer to other non-cancer conditions. Our Board of Trustees
take a robust view on the maintenance of the highest standards with regard to clinical
governance and audits, so that, as soon as a need is identified, improvements can be
implemented quickly.
This is the first formal Quality Account undertaken by Wirral Hospice St John’s. In preparing
for it, we identified three quality priorities: patient safety, particularly relating to tissue viability;
clinical effectiveness, particularly relating to improvement in medicine management; and
patient experience, where processes were developed, reviewed and updated to enable
patients and carers to express their views. These priorities have been fully tested during the
year. I confirm that, to the best of my knowledge, the information contained within this Quality
Account is a true and accurate account of quality at Wirral Hospice St John’s.
We actively seek the views of our patients, their families and carers, and our staff so that we
can continually monitor and improve our standards
.
Julie Gorry Chief Executive
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Quality Account 2014/15
Wirral Hospice St John’s Core Values
Promoting mutual respect for everybody, maintaining dignity at all times and ensuring the
strictest confidentiality.
Respect


A feeling of deep admiration for someone or something elicited by their abilities,
qualities or achievements
Due regard for the feelings, wishes or rights of others


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I always consider peoples’ views and listen to understand their perspective
I always respond to requests in a timely manner
I always recognise people and take time to ensure they are attended to
I welcome and greet patients, families, supporters and visitors ensuring they
know who I am and what the next steps are
Dignity

The state or quality of being worthy of honour or respect
 I always put the patient, families, carers, supporters and visitors first in
everything I do
 I ensure patients/colleagues are treated with dignity, ensuring their privacy and
confidentiality are respected
Developing relationships built on trust and acting with the utmost integrity in everything that
we do.
Trust

Firm belief in the reliability, truth or ability of someone or something
 I always think the best of someone
 I advise others when things go wrong
 I maintain competency to ensure I am providing the best quality of care and or
customer/user service at all times
 I always deliver on what I promise
 I always work in partnership to ensure everyone’s choices are heard on all
occasions.
Integrity

The quality of being honest and displaying strong moral principles
 I always uphold a consistent approach
 I am committed to ensure the best quality of care and, or, customer/user service
and getting it right every time
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Quality Account 2014/15
Encouraging open, clear communication throughout the Hospice, ensuring that everybody
feels they are being listened to and their opinions respected.
Open

Allowing unrestricted access, not closed or blocked
Clear


Easy to perceive, understand or interpret
Transparent, unclouded
Communication

The imparting or exchanging of information by speaking, writing or using some other
medium
 I go out of my way to ensure I always keep people informed to the best of my
ability
 I always listen to others and seek to understand others views
 I listen and respond to all patients, colleagues and users feedback in a timely
manner
 My communication style is clear, concise and is adapted to the particular
person/audience
Recognising that we are one team made up of committed, dedicated employees and
volunteers who are working together to ensure the highest standards of care.
One
 A single person or entity
Team


A group of players with a common purpose
Two or more people working together

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I always act in the best interests of the Hospice, putting my own interests second
I always work to support the Hospices/departments common goals
I always look at how to make things work
I always adopt a positive attitude and a can do approach
I spend time working with colleagues to understand how I can help them within
my role
The Core Values are underpinned by the Hospice’s obligation to uphold all legal and
regulatory requirements.
Philosophy of Care
The aim of Wirral Hospice St John’s is to warmly welcome people with progressive illness
which has failed to respond to curative treatment, into the quiet calm of a highly professional,
caring atmosphere which ‘comforts always’ both them and those who are important to them.
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Quality Account 2014/15
SECTION 2:
PRIORITIES FOR IMPROVEMENT 2015-2016
The priorities for quality improvements identified for 2015/16 are set out below.
2a. Priorities for Improvement 2015/16
Patient Safety
PRIORITY 1
Improvement in Safeguarding and issues surrounding Mental Capacity and Deprivation
of Liberty Safeguards
How was this identified as a priority?
Mandatory Training highlighted gaps in staff understanding of what is required from a
safeguarding point of view when a patient is admitted to the Hospice
This priority for improvement will be achieved by:
Regular training on the Mental Capacity Act and Deprivation Of Liberty Safeguards
(DOLS) and Safeguarding procedures in addition to mandatory training
 Establishment of a Safeguarding forum
Safeguarding Forum
Purpose – the core purpose of the group will be to ensure patient safety in relation to any
issues around safeguarding. This would include both adult and child safeguarding of patients,
carers and families accessing the Hospice’s services, Deprivation of Liberty safeguards
(DOL’s), the Mental Capacity Act and any other issues in relation to safeguarding.
The Group will assume responsibility for the development of best practice in relation to
safeguarding through the sharing of information and effective communication.
The Group will aim:1. To ensure best practice through the development and update of policies that include
current evidence and legislation
2. To ensure any new information or amendment to policy is communicated effectively
and to ensure plans are developed that ensure ongoing competency in all staff
3. To ensure that robust audit plans are in place to ensure policies are being applied in
practice
4. To ensure training and development is relevant, evidence based and effective.
5. To discuss clinical cases in relation to any safeguarding cases with the purpose of
learning from experience, reviewing and disseminating any areas of good practice or
improvement
6. To ensure Safeguarding issues are raised at Board level through regular reporting to
the Clinical Governance group
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Quality Account 2014/15
How will progress be monitored and reported?
 Progress with this objective to be reported regularly to Clinical Governance group
 Clinical audit
 Clinical Policy process
Clinical effectiveness
PRIORITY 2
Care of people with dementia
How was this identified as a priority?
Caring for patients with dementia is a national priority and end of life care for patients with
dementia is an area of increasing focus for hospices. Dementia is now acknowledged as a life
limiting condition with most dementia being progressive in nature and no curative treatment to
date. Estimations of deaths attributable to dementia within the UK are at around 66,000 per
year.
Improving end of life care for people with dementia has been the focus of UK policy and
guidance for over a decade now. However, we still see many examples where people with
dementia do not have fair access to palliative and end of life care services and support; or in
their family or carers’ access of bereavement support after their death. A difficulty for services,
such as hospices, is in understanding what it is they can offer to this group of people and
when. Hospice UK 2015 : A guide to help hospices establish care for people with dementia,
their families and carers
Hospice UK in partnership with Hope for Home identified some key priorities in relation to
caring for patients with dementia at the end of their life. These include:

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a corporate commitment to engage with the agenda of dementia care
efforts to establish new partnerships
creativity in the provision of care and services to meet the specific needs of people with
dementia
an evidence-based approach to care and the care environment
investment in training of staff and volunteers
At Wirral Hospice St John’s there is a need to establish our position in relation to caring for
patients with dementia who have specialist palliative care needs. This has been identified as a
priority for 2015/16.
This priority for improvement will be achieved by:
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The establishment of a working group
Identification of areas for improvement in the management of patients with dementia
Review of the physical environment in relation to the findings of the Patient Led
Assessment of the Care Environment (PLACE) assessment (completed April 2015)
Establishment of link nurses roles
Identification of training needs for all staff and volunteers and provision of required
training
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Quality Account 2014/15
How will progress be monitored and reported?
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Progress with this objective will be reported regularly to the Clinical Governance group.
Actions required following the PLACE assessment to be implemented by Senior and
Departmental managers.
Action plans to be updated and reviewed regularly by departmental managers.
Patient Experience
PRIORITY 3
To review all patient information to ensure that people who use the Hospice services
have accessible, current and comprehensive information about the services we provide
when they need it.
How was this identified as a priority?
Over the last twelve months it has become apparent that there are a considerable number of
leaflets that were either out of date or misleading in their content. Responses from our patient
satisfaction surveys suggested that not all patients were receiving the necessary information
on admission or at other key times during their time at the Hospice.
This priority for improvement will be achieved by the following:


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A review of all patient information leaflets currently utilised.to ensure they are up to
date and accurate. This will be achieved in conjunction with the Patient Focus group.
A review of how and when patients and their families are given information, written or
verbal and how this could be improved.
Identification of any information leaflets that may need to be developed
Consideration of the introduction of patient information folders for use on the In-patient
unit.
How will progress be monitored and reported?


Progress with this objective to be reported regularly to the Clinical Governance group
Patient, Carers and Visitors’ engagement process.
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Quality Account 2014/15
2b Statement of Assurances from the Board and Statutory Information
The following are statements that all providers must include in their Quality Account.
Statement of Assurance from the Board
“The Board of Trustees supports the Quality objectives agreed for 2015-16. The Board is
committed to high quality care for patients and their families throughout all areas of the
Hospice.
The Trustees undertake unannounced visits to the Hospice on a regular basis. Patients and
families are asked whether they are willing to participate in these visits by sharing their views
on the services they have received. The Trustees also speak with staff and volunteers to
ascertain their views. These visits help the Trustees to gain a greater understanding of the
clinical services provided and gives the Board assurance of the quality of care. The most
recent visit took place in January 2015, with its main focus being on CQC Outcome 1
highlighting how the Hospice ensures patients are involved with the services and are treated
with dignity and respect at all times. Comments received from patients and families
interviewed were very positive.
The Board of Trustees will continue to monitor progress against the priorities for improvement,
in addition to our other quality monitoring processes including Key performance Indicators,
complaints and incidents, and the clinical risk register through the Clinical Governance group
and monthly Board meetings.”
Dr P.J.R Cuthbertson MBE
Chairman
Review of Services
During 2014/15, Wirral Hospice St John’s provided the following services:
In-patient services (16 beds – providing 24 hour care and support)

Out-patient Services
Clinics -Providing consultation with Consultants in Palliative Medicine, Therapists and
Counsellor.
Day Therapy (12 places on 4 days a week)
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Hospice at Home
Bereavement and family support
PAIL (Professionals’ Palliative Advice and Information Line).
Patient Carer and Family Advice and Information Line
Wirral Hospice has reviewed all of the data available to them on the quality of care in all of
these services.
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Quality Account 2014/15
Financial
The income received from the NHS services reviewed in 2014/15 represents 35.1 % of the
total income generated by Wirral Hospice St John’s for 2014/15. The income generated from
the NHS represents approximately 49.3 % of the overall running costs of the Hospice. The
Hospice receives funding from Wirral Clinical Commissioning Group as a contribution to the
overall cost of service provision. 100% of the financial support from the NHS goes towards
patient services. All services are reviewed on an on-going basis to ensure we are providing
them as efficiently as possible.
Participation in clinical audits
During 2014/15, Wirral Hospice St John’s was not eligible to participate in any of the national
clinical audits or national confidential enquiries, because none of the audits or enquiries
related to palliative care.
The Hospice clinical audit programme for 2014/15 included audits on medicine management,
infection prevention and control, slips, trips and falls, documentation, bereavement support,
patient environment, exercise classes, dementia, admission process, and bereaved relatives’
satisfaction with the end of life care provided. In addition, Wirral Hospice St John’s
participated in the Palliative Care Regional Audit programme.
Research
The number of patients receiving NHS services provided by Wirral Hospice St John’s in
2014/15 that were recruited during that period to participate in research approved by a
research ethics committee was NONE. There were no national, ethically approved research
studies in palliative care in which we could participate.
Quality Improvement and Innovation goals agreed with our commissioners
Wirral Hospice’s income in 2014/15 was not conditional on achieving quality improvement and
innovation goals through the commissioning for quality and innovation Framework. Because it
is a third sector organisation it was therefore not able to take part.
What others say about us
Wirral Hospice St John’s is required to register with the Care Quality Commission (CQC) and
its current registration is for the following regulated activities:

Treatment of disease, disorder or injury
Diagnostic and Screening procedures
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Quality Account 2014/15
Wirral Hospice St John’s has the following conditions on registration:


The organisation is registered for the provision of supportive and Palliative care
services
Provides overnight accommodation and treatment for a maximum 16 adults aged 18
years or over
The Hospice provides Day Therapy services for 12 adults per day 4 days a week
Wirral Hospice St John’s is subject to periodic reviews by the Care Quality Commission (CQC)
The CQC has not taken any enforcement action against Wirral Hospice St John’s during
2014/15.The CQC has not carried out any inspection of Wirral Hospice during 2014/15.
During December 2013, the CQC carried out an un-announced inspection and found that the
Hospice was fully compliant with the following standards:Outcome 4 Care and Welfare of people who use the services
People should get safe and appropriate care that meets their needs and supports
their rights.
Patients said their care and treatment was agreed with them on admission and that any
changes in treatment were discussed with them and any changes to the care plan were always
agreed before being implemented. They also said the doctors and nurses were always
available and willing to discuss any aspects of their treatment at any time.
Staff members were knowledgeable about the patients’ needs and we observed staff
supported people in a very dignified, caring and respectful manner.
Outcome 5 Meeting nutritional needs
Food and drink should meet people’s individual dietary needs.
Patients told us that the food was very good and they could have whatever they wanted to eat
or drink at any time. One patient said “The food is great and they always ask you what you
want”.
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Quality Account 2014/15
Patients and relatives also told us that they enjoyed the café facility as it enabled them to
spend time with their family members away from the ward.
Outcome 9: Management of medicines
People should be given the medicines they need when they need them and in a safe
way.
When patients went home from the Hospice they were provided with two week’s supply of
medication and a personalised patient information sheet listing their medication with directions
and information on what each medication was for. A nurse or the Pharmacist went through this
with the patient or their carer. The patients we spoke to told us they received their medicines at
times that they needed them and they were never kept waiting for pain relief.
Outcome 21: Records
People’s personal records, including medical records, should be accurate and kept safe
and confidential.
People were protected from the risks of unsafe or inappropriate care and treatment because
appropriate records were maintained.
Outcome 12: Staffing
There should be enough members of staff to keep people safe and meet their health and
welfare needs.
The Hospice employs a range of health and social care staff to meet the patients’ physical,
psychological and social needs. Patients .and families were extremely complimentary about
the staff “Everyone’s very pleasant and helpful” “They’re very attentive” “”They couldn’t do
anything more” “Call bells are answered promptly”.
Data Quality
Wirral Hospice is not required to submit records to the Secondary Uses service for inclusion in
the Hospital Episode Statistics. In accordance with the Department of Health it submits
National Minimum Dataset (MDS) to the National Council for Palliative Care annually.
During 2014/15, the Hospice has been in the process of implementing electronic patient
records by way of SystmOne. All staff have received in-house training in the use of this system
and ongoing training will continue in the coming months.
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Quality Account 2014/15
SECTION 3:
QUALITY OVERVIEW
Review of quality performance
This section looks at:
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Quality priorities for 2014/15
Data and information about the number of patients who use our services
How we monitor the quality of care we provide
What patients and families say about us
What our regulators say about us
3.1 Review of quality priorities for 2014/15
The following highlight key areas in which the organisation has demonstrated and improved the
quality of care for patients and their families in 2014/2015.
PATIENT SAFETY
Tissue Viability
How was this identified as a priority?
Wirral Hospice St John’s aims to treat people in a safe environment and protect them from
avoidable harm, maintaining high standards of skin care to minimise the risk of pressure area
development. The clinical management recognised that more robust tissue viability procedures
were required.
Progress to date:
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A working group was established comprising Tissue Viability Link nurses. This group is
now meeting monthly
This group has reviewed all existing documentation relating to tissue viability including
wound charts and patient care plans
A new electronic wound chart has been developed as part of SystmOne
Incident reporting of pressure ulcers Grade 2 and above is now implemented
Photographic records of all wounds are now completed on admission
The following will continue to be a priority in the next twelve months:


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On-going education of staff in the management and prevention of pressure ulcers
Audit of all pressure ulcers Grade 2 and above on a monthly basis
Patient Information leaflet on skin care to be developed
Monitoring and review


Progress will be monitored by on-going review of the incidence of pressure ulcers
Action plans and progress will be reported to the clinical team and senior managers
meetings on a monthly basis
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Quality Account 2014/15
CLINICAL EFFECTIVENESS
Improvement in Medicine Management
How was this identified as a priority?
There had been a significant increase in the number of medicine incidents over the previous
twelve months. A large number of these had involved omissions of medicines. The Pharmacist
and Clinical managers were concerned that not all staff had received sufficient medicine
management training on induction.
Progress to date:
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A comprehensive review of all medicine management processes ensuring that all staff
are familiar with current policies and procedures.
Medicine management training has been provided for regular bank and agency staff
The Induction programme for clinical staff has been reviewed to ensure that all staff are
aware of the medicine management processes that are utilised within the hospice.
The Pharmacist has developed competencies for all trained staff.
On-going medicine management training updates have been provided.
Mandatory training in medicines management has included Local Involvement Network
(LIN) for controlled drugs representation, highlighting the importance of comprehensive
documentation.
How will progress continue to be monitored and reported?
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Number of incidents
Audit programme
Competency programme and training attendance
Monthly reports to the Hospice Drugs and Therapeutics Group
PATIENT EXPERIENCE
Review, update and develop processes for patients and carers to express their views
and be more involved in service developments
How was this identified as a priority?
Patient comments and views on the Hospice services had been sought on a regular basis, to
ensure that the Hospice was providing the care that is needed. It had been noted however that
there were only a relatively small number of completed Patient Satisfaction surveys and
comment forms returned. There was no central forum for patients and carers to come together
and discuss services and put forward ideas and views, enabling them to have a greater say in
further developments to services.
Progress to date:
 Review and re-design all Patient Satisfaction surveys for both In-patients and Outpatients/Day Therapy
 Volunteers to be trained to assist patients and families in completing satisfaction
surveys
 Establishment of a “Have your Say” Patient and Carer Focus Group
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Quality Account 2014/15
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Development of links with local Health-Watch and the completion of a Patient- Led
Assessment of the Care Environment (PLACE) Programme
Provision of a Carer Drop-In facility
Patient Stories
.
Patient Focus Group
A formal integrated user partnership was introduced in 2013/14 and this year has continued to
engage with our service users and staff to gain better understanding of the needs of patients
and carers. They have been instrumental in the new-building programme with provision of
ideas/suggestions on colours, design, furnishings for the Outpatient department.
Patient Satisfaction
We have invested significant time in exploring patient and service user experience over the
past year. Patient Satisfaction surveys for all areas of Hospice services have been reviewed
and amended.
User feedback has been sought in a variety of ways including the following:
•
•
•
•
•
Patient questionnaires
Face- to- face discussions with patients/families through service visits
Focus group meetings
Suggestion boxes
Bereavement care questionnaires
No negative feedback was received with the majority of feedback being extremely positive.
A number of Volunteers have been trained in assisting people who use the services in
completion of the satisfaction surveys. This has led to a significant increase in the number of
comments received.
Patient Stories
During the last twelve months, we have also drafted a number of “Patient Stories”, interviewing
people who use the services and asking them to give us more detailed accounts of their
experiences in using Hospice services. These anonymised stories have been shared with the
Board of Trustees to give them greater insight into patients’ views on the care they have
received.
Comments Log
Any negative comments are now logged by the Quality team and referred on to the relevant
manager for any actions required.
How will progress be monitored and reported?

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Audit of number of surveys returned/completed
Patient and carer interviews
Weekly Service Visit Reports (by Registered Manager)
Attendance at “Have your Say” group meetings
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Quality Account 2014/15
Other quality improvement areas in 2014/15
Nutrition and Hydration Group
This group was established to ensure that people using our services were receiving good
nutritional care and that our staff were fully aware of patients’ nutritional requirements.
Actions have included:
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A review of the nutritional assessment tool used on admission.
Provision of food for in-patients after hours – fresh fruit, snacks, sandwiches.
Development of a Hospice policy for nutritional care.
Staff training, both clinical and catering staff on the nutritional needs of our patients
Establishment of a Patient Focus Group, facilitated by the Dietician, to give patients and
carers greater understanding of the need for good nutrition.
Enforcement of protected meal-times
Patients being encouraged to eat their meals together in the patient’s dining room
Further work in the coming months will involve the establishment of patient menus and the
design of a patient leaflet on nutrition.
Patient Information Point
As part of the Department of Health grant awarded to Wirral Hospice St John’s, a new patient
information point has been established. Manned by Hospice volunteers it provides an easily
accessible, light and welcoming space, close to the Hospice’s main reception area for people
to gain information on services available, signposting as appropriate to other agencies,
financial matters etc.
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Quality Account 2014/15
3.2 Monitoring patient activity
The Hospice submits annual returns to the National Council for Palliative care (NCPC)
Minimum Data Sets.
Patient Activity
In-patients (16 beds)
2013/14
2014/15
Total number of admissions
321
242
% Occupancy
85%
89%
Mean Length of stay (Days)
15.59
16.93
Total number of discharges
174(54%)
114(47%)
% urgent referrals within standard(Admission
within 2days)
99%
97%
% of routine referrals within standard(Admission
within 5 days )
97%
88%
Wirral Hospice St John’s has 16 in-patient beds, of which 7 are single rooms and there are
three, three-bedded bays. The unit has a large bright patient and visitor lounge with dining
facilities, relatives’ room and easy access to patio areas and gardens
Patients are admitted for short term interventions following assessment by the multiprofessional team (MPT) whose needs cannot be met by specialist palliative care providers
elsewhere. Patients are admitted under the care of the Palliative Care Consultant.
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Quality Account 2014/15
Multi-professional team meetings are held once a week. All patients are discussed and a
management plan devised so as to address their complex symptoms and needs. In addition
patients are reviewed daily by a doctor and twice weekly by a Consultant.
Discharge planning commences at the point of (or even prior to) admission, and discharge
occurs once the patient’s specialist palliative care needs have been addressed.. The average
length of stay is two weeks.
Patients and their families are also able to
make use of the restaurant facilities available
in the Hospice”hub” providing an informal
meeting place away from the ward
environment. Patients are also encouraged to
eat their meals in the patients’ lounge, should
they feel well enough.
Relatives of patients admitted to the In-patient Unit are able to stay overnight in a designated
relative’s room.
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Quality Account 2014/15
Day Therapy ( 48 places per week)
2013-14
2014-15
Total number of available places
2460
2448
Total number of allocated places
2362
2457
% attendance of available places
65%
64%
Mean length of stay (days)
54.41days
51.77 days
Day Therapy services are available on four days a week in a purpose built unit for 12 patients
per day, provided by a specialist multi-professional team, working alongside patients and their
families to enable them to live well with a life-limiting disease. Patients attend Day Therapy for
a maximum of 8 weekly sessions during which they may access, aromatherapy, creative
therapy, Occupational Therapy, Physiotherapy, Relaxation, exercise classes, breathlessness
management, anxiety management, fatigue management, counselling, support with advance
care planning and benefits advice.
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Quality Account 2014/15
Out-patients
2013-14
2014-15
Total number of referrals
559
544
New appointments
434
323
Out-patient clinics are provided by a team of Consultants in Palliative Medicine, Bereavement
Counsellors and an aromatherapist. Services are for patients under the care of the Primary Health
Care teams requiring medical access to the wider multi professional specialist palliative care
service through the specialist palliative care MDT.
Hospice at Home
2013/14
2014/15
Total number of referrals
476
501
Accompanied Discharge
54
36
Hospice at Day
327
406
Hospice at night
95
59
Total number of deaths
331
158
Total number of deaths at home
239(72%)
123 (78%)
2014/15 is the third year of a pilot Hospice at Home service provided by the Hospice. Wirral
Clinical Commissioning Group has continued to support the Hospice in 2014/15 in the delivery of
Hospice at Home services for all Wirral residents.
The Hospice at Home team continues to provide quality end of life care to patients wishing to
remain at home, providing practical and emotional support to patients, families and carers in a
variety of ways. Evaluation from service users, families and healthcare professionals provides
positive qualitative feedback (see section 3.5).
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Quality Account 2014/15
3.3 Clinical Audit
To ensure that we are continually meeting standards and providing a consistently high quality of
service, Wirral Hospice St John’s has an annual Audit Plan comprising audits on a variety of
topics. Our audit programme reviews the effectiveness of our clinical care.
A sample of clinical audits completed over the last 12 months
Audit subject
Dementia
environmental
audit
Admission
processes
PLACE
assessment
(Patient Led
Assessment of
the Care
Environment)
Rationale/ Outcome of Audit
Actions/recommendations
Following on from Dementia
Awareness Week and introduction of
the PLACE assessment this audit
made several recommendations for
improvements to the Hospice
environment in relation to Dementia.
An action plan was
devised to address
patient environment and
soft furnishings in
relation to dementia
patients’ care.
The audit was undertaken to
ascertain compliance with
completion of admission
documentation. The audit highlighted
some gaps in completion of
assessment tools.
Communicated to staff.
Audit carried out by patient
representatives and Health-Watch.
Audit findings:
Food :
88.87%,
Cleanliness :
100%
Condition, appearance
and maintenance: 95.16%
Privacy, Dignity
and Well-being:
95.74%
Dementia:
82.12%
Recommendation for
further staff training in
recording of
assessments on new
electronic system.
Actions will be mainly
focused on improvements in
provision for Dementia
patients (One of our
priority improvements for
2015/16). Re-audit 12
months
:
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Quality Account 2014/15
Infection
Prevention and
Controlcompliance with
code of practice
and policy.
Monthly audits carried out against all
23 infection prevention and control
policies have highlighted the
following improvements required in :Pathway documentation completion
Cleaning rotas and checklist
Laundry procedures
Staff communication via
Team Brief
Training updates as
required by Infection
Control Lead.
Continue to audit
monthly
‘Bare below the elbow’ policy and
hand hygiene.
FAMcare11(Family
satisfaction with
end of life care
provided by
specialist
palliative care
services)
Service evaluation of care in the last
days of life, benchmarked against
other hospices. In total 16 hospice
in-patient units, 10 home care teams
and 12 hospital support teams
participated. Questionnaires were
sent to 27 relatives of patients who
had died at Wirral Hospice.
Respondents were either satisfied or
very satisfied with all domains of
care perceived as relevant to them
and their family member. In 15 out of
17 domains (88%) the proportion of
very satisfied responses was greater
at Wirral Hospice than for hospice inpatient care nationally. In addition,
many positive free text comments
were received.
Results disseminated to
all staff and recognition
given to their tireless
work in easing the
distress of patients and
their loved ones at such
a difficult time
Controlled Drug
Accountable
Officer(CDAO)
audit
CDAO audits (quarterly) against
Standing operating procedures/policy
compliance in relation to ordering,
transportation, storage,
administration, documentation and
destruction of controlled drugs (CDs).
Discussed at Drugs and
Therapeutic group
meetings
Requisition audits (monthly) to
ensure transparency and reduce
scope for CD diversion. Actions
required in relation to:Documentation in CD Register,
Omissions of codes, CD ordering
and use of calibration bottles.
Audits continue quarterly
and monthly
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Quality Account 2014/15
Communicated to
clinical teams
3.4 Key Performance (Quality) Indicators
Key performance(Quality)Indicators
2013/14
2014/15
6(actual)
1(actual)
1(potential)
2(potential)
Number of Medicine Incidents*
101
161*
Number of slips, trips and falls
39
67
Number of patients admitted with MRSA
2
5
Number of patients acquiring MRSA during
admission
0
0
Number of patients who developed
Clostridium Difficile during admission
0
0
Complaints
Total number of complaints
Patient Safety
Infection Prevention and Control
Complaints received throughout the year did not relate to patient care but concerned
dissatisfaction with a patient’s relative wishing to have a memorial at the Hospice which is not
encouraged. Wirral Hospice treats any complaints or dissatisfaction as important, seeking to
learn from feedback from the people who use our services.
Patient safety
Medicine Incidents*
Medicine management continues to be a priority for us. Wirral Hospice has a robust reporting
process for medicine incidents to ensure a constant review of practice. All incidents relating to
the management of medicines are strictly recorded to ensure patient safety, that lessons are
learned and to reduce the risk of recurrence. In accordance with the CQC classification of
medicine incidents in the Provider Information Return, 11 out of the 161 are reportable as
medicine associated incidents – Omissions, too much/too little or duplication, wrong medicine,
wrong person, wrongly recorded or wrongly administered. The remainder are medicine
incidents that are not directly related to patient care or well-being that have been identified by
our rigorous reporting processes. For example 131 of the 161incidents reported were due to
the omission of an initial or code, and others involved storage and delivery. The numbers and
types of incidents will continue to be highlighted and reviewed at the monthly Drugs and
Therapeutics group meetings. Training has been provided for regular bank and agency staff, in
addition to the mandatory sessions and regular updates for all staff annually. The Pharmacist
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Quality Account 2014/15
has developed competencies for all trained staff which are to be implemented shortly and will
be mandatory
Slips, Trips and Falls
The Hospice has a Slips, Trips and Falls multi-professional group who meet.quarterly to review
all incidents involving slips, trips and falls and to consider and implement any necessary
actions to prevent further mishaps. The Hospice Falls Policy has been developed and the
group are looking at easier ways of completing falls care plans on the new electronic patient
records system.
Infection Prevention and control
Infection rates continue to remain low. Patients are assessed prior to admission in compliance
with our infection prevention and control admission, transfer and discharge policy. Patients are
also routinely screened for infection on admission.
Staff training in infection prevention and control is part of our mandatory training programme
and hand-hygiene is continually promoted throughout the Hospice.
The Infection Control lead carries out regular audits against the 23 policies, including
responsibilities, hygiene, clinical care and procedures, laboratory specimens, linen laundry,
cleaning/decontamination, sharps, isolation procedures and charity shops. Action plans are
devised and communicated to managers, staff and volunteers monthly.
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Quality Account 2014/15
What our patients and families say about the organisation
Patient Satisfaction surveys, Comment Forms and face- to- face interviews are utilised
throughout all clinical areas of the Hospice including In-patients, Out-patients, Day Therapy
and Hospice at Home to ascertain patient and family views on our services and any
suggestions they may have for improvement.
Responses and any actions taken are communicated to patients and families within the
Hospice via the information notice boards.
“As a family, we were treated
with great tenderness and
consideration and despite the
sad circumstances we have been
left with such wonderful
memories of our time spent with
you all at the Hospice. He
couldn’t have been in better
hands.”
“Thank you for the
wonderful care given
to my son and for
the support and
comfort given to the
whole family”
“My wife’s treatment
and care was second
to none. The
palliative care team,
no the palliative care
family, were both
professional and
empathetic to every
physical, emotional
and psychological
need that my father
and our family had”
“A special thanks to
the cooks for
fabulous meals”
“It is a privilege to
have a loved one
cared for in the
Hospice. It is an
amazing place
and has a very
special place in
the heart of my
family”
“On my visits to the
Hospice to be with my
daughter, I was very
impressed with the
treatment and tender care
provided through her
weeks of pain and
suffering. My heartfelt
thanks to everyone at the
Hospice for providing such
a wonderful environment
for people in their
desperate hour of need”
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Quality Account 2014/15
“There is nowhere that I
know of, or could be a
better place for people with
a terminal illness. You all
work as a well-run team
from doctors to cleaners.
No wonder so many people
feel the need to help in the
Hospice “
“You made my mum feel safe
and that’s all we can ask.
Thank you for your care and
kindness. She loved her time
at the Hospice – nothing was
too much trouble when asking
for that extra cuppa or a
chat.”
“To each and every
member of staff – you’ve
done it again! I came into
the Hospice very poorly,
and here I am going
home feeling really, really
well and that’s all down to
you all as a team. As a
team, you would win the
Hospice World Cup!
Thanks for everything.”
How did Hospice at Home help?
“Just wanted to say a
huge thank you for the
care and support your
team gave to mum in
her final weeks. The
service you provide is
second to none. Your
carers always went that
extra mile”
“Your interventions
made such a difference
to our Dad. You all do a
fantastic job”
“Thank you to the Hospice at
Home staff who spent time
caring for my son. You are all a
wonderful extension of the
amazing support given to
families throughout the Hospice”
“The night service was
absolutely fantastic. The
support and kindness they
gave my partner was
wonderful. It put him at ease
and made him as comfortable
as they could. It helped me
and my son to get some sleep.
Words cannot express what
you have done for us”
“The Hospice at Home team have
supplied several significant benefits. It
quickly became clear that due to their
compassion, skills and caring
professionalism, their presence gave my
mother both emotional support and
wonderful company. The service in my
opinion is of a very high standard.It is
difficult to know how it can be improved”
“They helped me with my
journey home, showed me
my meds, gave me
information, phone
numbers, etc. Lady who
brought me home was
lovely”
“The service helped tremendously
in providing much needed respite
care to our family as well as
providing support and reassurance to both myself and my
elderly mother”
“Allowed us to keep a
promise made to my
Dad about helping
him to die at home”
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Quality Account 2014/15
Bereavement support service
The Hospice offers bereavement support both individually and in a group.
The bereavement group comprises members whose partner or spouse have died. It is an open
group that meets fortnightly, enabling people to join at any time. It is important that the Hospice
establishes whether the group is meeting its aims and objectives and to this end a
questionnaire has been devised, relatively short in nature, in order to maximise uptake.
The following are some of the comments received this year both about the bereavement
group and the individual bereavement support offered:How did bereavement support help?
‘It’s difficult to express
how important the
meetings were to me. I
know that I could call if I
needed to – very reassuring’
“Thank you -your
support was
invaluable, knowing I
could off load to you
confidentially kept
me from feeling as if
I was going slightly
mad at times. It is a
long road but the
support you gave me
has made it easier to
travel along”
“I was made to feel at ease
straightaway and it is a safe
and comfortable environment.
I have really benefited from
this service. I received
excellent support and care”
“I thought that I was
strong enough to cope or I
could just talk to friends.
Having had counselling
and seen first -hand how
valuable it is, I have
recommended it to friends
and colleagues who have
experienced
bereavement”
“Everything was
planned in at my pace.
I never felt rushed or
"
“Very happy with my
treatment at the Hospice
from all the wonderful
staff and obviously a
special thank you to the
bereavement counsellor
who kept me going
through a difficult period”
under pressure and it
made me feel safe to
have that level of
support”
“I felt I was treated
respectfully and really
listened to”
“Overall feedback is very positive and most importantly
the service is meeting individual needs and enabling
them to build a new and different life, the principal aim of
our service. It is reassuring that our bereavement work,
which is often challenging and requires lots of patience
from the bereavement team, is enabling those who
have lost a loved one to progress with their lives.”
Bereavement Support Co-ordinator
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Quality Account 2014/15
“ An appointment was
arranged with a
doctor for me to
discuss some medical
queries, with the
opportunity to discuss
a range of issues”
Statement from Clinical Commissioning Group
Comments have been requested from Wirral Clinical Commissioning Group (CCG) and are
awaited.
Statement from Healthwatch
Healthwatch Wirral would like to thank Wirral Hospice St John’s for the opportunity to comment
on their Quality Account for 2014/15
The Hospice core values were impressive and totally relevant and it was good to note that
patient care, wishes and needs are at the forefront.
Priorities for Improvement 2015/16
The 3 priorities were noted and we look forward to receiving the quarterly reviews on progress
against these priorities.
Review of Quality Priorities for 2014/15
It was positive to note that:Tissue Viability




A more robust tissue viability procedure has been introduced to protect people from
avoidable harm and to maintain high standards of skin care to minimise the risk of
pressure area development.
The ongoing education of staff in the management and prevention of pressure ulcers.
Monthly Audits of pressure ulcers Grade 2 and above.
Action plans and progress will be reported to the clinical team and senior managers
monthly.
Medicines Management

There has been a comprehensive review of all medicines management processes and
training to ensure staff are familiar with current policies and procedures.
Patient Experience



User feedback has been sought in a variety of ways
No negative feedback has been received with the majority being very positive.
The introduction of ‘The Hub’ and the Patient Information Point
Nutrition and Hydration

The establishment of a Nutrition and Hydration Group to ensure that people receive
good nutritional care.
Hospice at Home
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Quality Account 2014/15

The Hospice at Home Project team continues to provide quality support to patients.
Key Performance Indicators
Healthwatch were disappointed to see the number of medicine incidents and slips, trips and
falls had increased. However, it was positive to note the appropriate steps being put in place to
manage these issues.
We would welcome more information and details of outcome measures that the Hospice will
monitor against.
Patient Satisfaction
It was pleasing to note the positive comments from patients at the end of the report and the
fact that any responses or action from patient satisfaction surveys are communicated to
patients and families via the information notice boards.
Finally
Overall the Quality Account was positive.
Healthwatch Wirral has enjoyed working alongside the Hospice including supporting the
Patient-led assessments of the care environment (PLACE) and Wirral End of Life Charter. We
recognise the value in our relationship and have utilised the functions, duties and powers of
Healthwatch to provide challenge and assurances. We appreciate the opportunity to
comment on the report as a "critical friend" and look forward to working with the Hospice to
support the implementation of the Quality Account and strategic plans.
Karen Prior
Healthwatch Wirral Manager
On behalf of Healthwatch Wirral
June 2015
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Quality Account 2014/15