Quality Account 2009 – 2010
‘The team at St. Helena Hospice is exactly what a “team” of
skilled and caring people should be.’
Quote from family of patient who used Hospice at Home, Hospice Nurse
Specialist and Inpatient Services 2009.
Part 1
Chief Executive’s Statement
On behalf of myself and the Board of Trustees, I would like to thank all of our staff
and volunteers for their achievements over the past year. Despite the current
economic climate, the hospice has continued to provide high quality services to an
increased number of patients and remains financially sound, thanks to generous
support from our local community. In particular, numbers of patients served in the
community have grown hugely and our team made 13,987 home visits in the year
reported.
Quality is high on the agenda for the hospice. St. Helena Hospice is a leader and
innovator in the hospice movement and has now committed to becoming an
accredited Practice Development Unit (PDU) through Leeds University.
Once again this year, our regulators have assessed the treatment and care provided
by the hospice as being of high quality. Following submission of our self-assessment
in July 2009, the Care Quality Commission identified no shortfalls in the services
provided by the hospice. This is a tribute to the hard work of every member of staff
working for St. Helena Hospice. The hospice has a culture of continuous quality
monitoring, in which any shortfalls are identified and acted upon quickly.
The safety, experiences and outcomes for patients and their families are of
paramount importance to us all at St Helena Hospice. Our services users are an
embedded element of continuous development, represented on the Board and on
our Clinical Governance Group. Through effective clinical governance, the Hospice
audit group, the fully established and integrated User Partnership Group and the
PDU process the organisation will continue to focus on the quality of the services
provided.
I am responsible for the preparation of this report and its contents. To the best of my
knowledge, the information reported in this Quality Account is accurate and a fair
representation of the quality of healthcare services provided by our hospice.
Rosy Stamp
Chief Executive
24th May 2010
1.1 Priorities for improvement 2010-2011
St. Helena Hospice is fully compliant with the National Minimum Standards (2002)
and has satisfied the Care Quality Commission that standards are being met through
self assessment over the last year. As such, the Board did not have any areas of
regulatory shortfall to include in the priorities for improvement for 2010-2011.
The Board looked at how the hospice could extend and improve its services to better
meet the needs of the local population. The Board then looked at development
opportunities for service improvement.
Following consultation with the staff and the User Partnership Group St. Helena
Hospice confirm the top three quality improvement priorities for 2010 to 2011 to be:
Future planning Priority 1
Upgraded patient facilities in the Colchester Day Centre
The hospice has been awarded a grant from the Department of Health to support
this project.
The project will increase the space for patients and allow easier access to the centre
for disabled service users.
This facility will play a significant role in improving the quality, accessibility and
flexibility of the service and allow St. Helena to provide palliative and end of life
(EOL) care to a wider group of people in North East Essex.
Measures:
Feedback from building survey six months after completion using ASPECT tool.
Increased range of patients able to access the building.
AEDAT tool.
Future planning Priority 2
Roll out of the new patient notes
The Hospice identified through audit that the current notes needed to be reviewed. A
notes committee was established. The group have devised a new notes system
based on CQC requirements, audit and research. Training for this documentation
has been rolled out across the organisation. The notes went ‘live’ in May 2010.
Measure:
The Hospice audit group will audit these notes against the Help the Hospices
National Audit tool in six months with an aim of reaching 100% compliance.
Future planning Priority 3
Increased engagement with service users.
St. Helena Hospice already has an active and integrated user partnership group. The
group write, distribute and analysis the annual patient satisfaction survey and are
consulted on all developments. However, the Hospice would like to have further
engagement from all services users. New focus groups will be established with
invitations for all service users and their families to attend.
Measures:
Focus group is established
Patients and families coming forward to represent their views
User Partnership to contribute to Annual Report 2010
Future planning Priority 4
Feedback from Volunteers
St Helena Hospice has recently set up a Volunteer Forum with representatives from
volunteer roles across the organisation. The aim is for this Forum to give volunteers
a greater voice within the organisation and for areas of concern to be raised in a
structured way. The Forum has started to report to the Chief Executive. In summer
2010 the first Volunteer Survey at St. Helena Hospice will be carried out.
Measures:
Volunteers coming forward to represent their area
Forum takes place
Volunteer survey shows that communication is good
Fewer complaints from volunteers
1.2
Priorities for improvement 2009-2010
St Helena Hospice is fully compliant with the National Minimum Standards (2002).
As such, the Board did not have any areas of shortfall to include in the priorities for
improvement for 2009-2010.
All plans for improvement took into consideration sustainability due to the current
economic constraints and have been identified through direct patient involvement. As
far as possible, we have discussed all initiatives with the hospice’s User Partnership
group.
The quality improvement priorities for 2009-2010 were as follows:
Improvement Priority 1
Hospital Palliative Care Team
Cancer Peer review, and the Essex Cancer Network identified a shortfall in the
Hospital Specialist Palliative Care service. The hospice has been working with the
local health community to address this shortfall. Priority was given to the
appointment of a hospital-based consultant and an increase of 4 hospital based
Nurse Specialist posts. In addition St. Helena Hospice has a vacant consultant post;
recruitment for the two consultant posts will be done jointly with the Acute Trust.
Hospital-based post:
Approval to the establishment of the hospital-based consultant and hospital nurse
specialist posts post was given in February 2010.
The Hospice has supported acute trust colleagues in the recruitment to the Nurse
Specialist posts.
The hospice consultant and the hospital-based consultant will work as a team, with
the new consultant providing cover at the hospice. St. Helena Hospice has worked
with the acute trust to ensure NHS contracts are in place for all consultants to ensure
recruitment and retention of a scarce professional group.
The outcomes of having these posts in place will be evaluated by providing a dataset
to the PCT. It is expected that the number of deaths in hospital will reduce and the
number of deaths at home or in the patients’ Preferred Place of Care will increase.
Improvement Priority 2
NICE Compliance
The twelve key priority areas of NICE Guidance was set to be implemented by
December 2009. St Helena Hospice set up a Quality and Standards group made up
of senior clinicians from across the Hospice to ensure that the Hospice was in a
position to meet all of the relevant guidance.
Training was provided for all clinical staff within the Hospice on NICE Guidance and
other national and regional drivers i.e. End of Life Care Strategy; Towards the Best
Together.
The outcome of this training will be evaluated when the new notes are audited by
checking that keys areas of guidance are documented and evaluated.
Improvement Priority 3
Seven day working for Hospice Nurse Specialists
In line with NICE guidance St. Helena Hospice recognised the need for 7 day
working the Hospice Nurse Specialists. A six month pilot of 7 day working was run by
the Hospice. This proved successful and demonstrated a reduction in the number of
palliative care patients admitted to Hospital at weekends.
A business case was made and approved by North East Essex PCT to increase the
number of nurses in the service in order to continue 7 day working. This funding was
originally ring fenced for this post but is this year incorporated into the main grant.
The outcome of this initiative can be seen through the number of admissions to
hospital for palliative care patients that are avoided over the weekends
Part 2
Statements of assurance from the board
The following are a series of statements that all providers must include in their
Quality Account. Many of these statements are not directly applicable to specialist
palliative care providers.
1.1 Review of services
During 2009/10 St. Helena Hospice provided five NHS services.
The services were as follows:
•
•
•
•
•
In-Patient Unit
Day Services
Out Patients
Hospice at Home
Hospice Nurse Specialist Service
St Helena Hospice has reviewed all the data available to them on the quality of care
in all of these services.
1.2 Income generated
The income generated by the NHS services reviewed in 2009/10 represents 100 per
cent of the total income generated from the provision of NHS services by St. Helena
Hospice for 2009/10. The income generated from the NHS represents approximately
32% of the overall cost of running these services.
2 Participation in clinical audits
During 2009/10, no national clinical audits and no national confidential enquiries
covered NHS services relating to palliative care. St Helena Hospice only provides
palliative care.
2.1 Eligibility to participate in national confidential enquiries
During that period St Helena Hospice was not eligible to participate in any national
clinical audits and national confidential enquiries.
2.2 /2.3/ 2.4/2.5 National clinical audits and national confidential enquiries.
The national clinical audits and national confidential enquiries that St. Helena
Hospice was eligible to participate in during 2009/10 are as follows:
None.
As St. Helena Hospice was ineligible to participate in any national clinical audits and
national confidential enquiries there is no list or number of cases submitted to any
audit or enquiry as a percentage of the number of registered cases required by the
terms of the audit or enquiry.
2.6/2.7/2.8 Local Clinical audits
The reports of 5 local clinical audits were reviewed by St. Helena Hospice during
2009/10 and St. Helena Hospice intends to take the following actions to improve the
quality of healthcare provided:
•
•
•
Improve documentation around discharge planning.
Monitor falls to ensure that all risks have been identified and minimised
Monitor and evaluate the new patient documentation that has been
implemented in the last month.
3 Research
The number of patients receiving NHS services provided or sub-contracted by St
Helena Hospice in 2009/10 that were recruited during that period to participate in
research approved by a research ethics committee was 0. There was no appropriate,
national, ethically approved research studies in palliative care in which we could
participate.
During 2009/10 St. Helena Hospice received a grant for a two year research project
into caring for people with dementia. The work for this project has received ethical
approval and is being undertaken by a member of the Education team, Dr Kate
Powis.
4/4.1/4.2 Quality improvement and innovation goals agreed with our
commissioners
St Helena Hospice income in 2009/10 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation payment framework because with the exception of the Hospice at Home
Service the NHS only pays for 39% of the patient services provided by St. Helena
Hospice.
5/ 5.1What others say about us
St. Helena Hospice is required to register with the Care Quality Commission and its
current registration status is unconditional. St. Helena Hospice has no conditions on
registration. The Care Quality Commission has not taken any enforcement action
against St. Helena Hospice during 2009/10.
6/6.1 Periodic reviews by the CQC
St. Helena Hospice is subject to periodic reviews by the Care Quality Commission
and the last review was self assessment in July 2009. The CQC’s assessment of St.
Helena Hospice was that the review was the establishment was assessed as not
needing an inspection.
7/7.1 Reviews and investigations by CQC
St. Helena Hospice has not participated in any special reviews or investigations by
the CQC during 2009/10.
8-10 These sections are not applicable to St. Helena Hospice.
Part 3
Quality overview
The National Minimum Dataset figures for 2009/10 compare six months figures for
St. Helena Hospice against 12 months figures for other Hospices. However, even
against these figures it is clear that the throughput for the inpatient unit is higher than
the national average and occupancy is on a par with the national median values.
The number of day service patients attending St. Helena the first six months is equal
to the national median for the whole year.
Our Home Care service saw 114 more patients in six months than the national
median for the whole year and the St Helena Hospice team made 13,987 home visits
during the year. The service supported double the number of deaths in care homes
during the six month period than the national average for the whole year and
supported 158 deaths at home in six months compared to the national median of 120
in the whole year. In six months our bereavement service saw double the national
median for the whole year and our outpatient service saw 206 patients in six months
compared to 234 as the national median for the entire year.
St. Helena Hospice worked with 1,907 patients in the year 2009/10. Once the initial
referral is received patients are assessed by the multi-disciplinary referral team each
working day and an assessment is arranged in the appropriate setting for that patient
and their family. Once this assessment takes place in conjunction with the patient
and family a decision about which of the Hospice services will best meet the needs
of the individual is made. Ongoing review of patients by qualified professionals takes
place regardless of the services they are using
The Hospice receives many commendations from patients and families, a small
number of complaints are received each year (4 last year). Commendations are
welcomed and celebrated at Clinical Governance as well as in the individual teams.
Complaints are taken extremely seriously; they are thoroughly investigated, reported
on (anonymised) at Clinical Governance and to Trustees and reported to the CQC
on an annual basis. Immediate action is taken to rectify any shortfalls or concerns
identified.
St. Helena Hospice carries out an annual patient survey. This is written, distributed
and analysed by the User Partnership group. Copies of the last survey can be found
on our website using the following link:
www.sthelenahospice.org.uk/PatientSurveys.cfm
In the last year the Chair of our User Partnership group and a long standing Hospice
Nurse Specialist were nominated by St. Helena for the prestigious International
Journal of Palliative Nursing Awards.
Ken Aldred was nominated and came second in the Service User/Carer/Volunteer of
the Year category and Lauren Smith was nominated and came third in the Palliative
Care Nurse of the Year award.
St Helena Hospice strives to meet the individual needs of patients and families using
our services and will continue to do so.
Supporting statements
NHS North East Essex PCT Commissioners
The PCT consider that the statement contains accurate and up to date information.
This quality account report communicates that St Helena Hospice are committed to
continually improving the patient and carer experience.
The PCT is particularly pleased to see the section on priorities for improvement in
2010/11 which includes increasing engagement with service users and improving
communication with volunteers. This area is particularly relevant to your services
and we hope that you will see the benefits of this work during the coming year.
We are delighted that your application to the Department of Health has resulted in
the grant being awarded to upgrade your facilities in the Colchester Day Centre. The
improved patient facilities will no doubt contribute to the quality and accessibility of
the service provided from the day centre.
There is a clear message throughout this Quality Account report of the organisations
responsiveness to quality, and this is recognised in your submission to the Care
Quality Commission resulting in fully meeting the national minimum standards.
We fully support your aspiration to undertake further clinical audits including
improving the documentation around discharge planning. We would like you to
consider how to ensure a robust clinical audit programme is undertaken with
consistent clinical engagement.
It is appreciated that the year ahead will be a challenging one for your organisation
due to the current economic climate, and we are committed to supporting you to
maintain and improve the quality of your services to our population.
Sam Hepplewhite on behalf of NHS NEE PCT
Essex Health Overview and Scrutiny Committee
The Essex HOSC has had no dealings with the Hospice during 2009/10, although
the Director of Inpatient Services has liaised with the Secretary of the HOSC whilst
preparing this report. The Secretary is aware of the work of the Hospice, having
visited the premises in another capacity during the year, and is aware that the
Hospice and its work is well respected within the county.
The HOSC welcomes the Hospice’s assurances that it complies with all National
Minimum Standards and it supports the planning priorities proposed by the Board.
Due to the specialist work of the Hospice it looks unlikely that the Essex HOSC will
be heavily involved with its work in the future unless any specific issues or problems
are bought to the HOSC’s attention.
Graham Redgwell on behalf of Essex Health Overview and Scrutiny Committee
Essex and Southend Local Involvement Committee
During 2009/10 the Essex and Southend LINk has had no dealings with St. Helena
Hospice, although the Director of Inpatient Services has liaised with the LINk whilst
preparing this Quality Account. The Essex and Southend LINk is aware of the work
of the Hospice and have contacted the North East Locality group members to give
feedback on the Quality Account for 2009/10.
The Essex and Southend LINk supports the future planning priorities to improve
patient care areas in the Colchester Day Centre. During 2010/11 the Essex and
Southend LINk will become more engaged with the work of St. Helena Hospice
through the Hospice User Partnership group.
Sharon Cohen on behalf of Essex and Southend Local Involvement Network