The Martlets Hospice
Quality Accounts 2010-2011
Part 1
Chief Executive Statement
Welcome to our first annual Quality Account report.
This provides you with a summary of our performance against selected quality
measures for 2010/11 and our initiatives and priorities for 2011/12.
The Martlets Hospice is highly committed to quality improvements at all levels of
its services. We have developed this approach to quality over many years and
have worked hard to embed a culture of clinical improvement within all our
services. This report demonstrates that quality is high on the agenda for the
Hospice and also demonstrates our continued commitment to ensuring that our
patients receive the best possible care.
Within the clinical practice of the Hospice
there is a culture of continuous quality
improvement, in which shortfalls or complaints
are identified and acted upon quickly. The
Patient Satisfaction Survey is one of the
mechanisms we use to identify those areas of
required improvement.
The Clinical Governance Group is made up of
representatives from all of the services and
monitors closely all matters relating to clinical
effectiveness. Clinical audits and learning
outcomes are undertaken and disseminated
by this group.
In addition the Clinical
Governance Sub-Committee of the Board of
Trustees maintains a watchful overview of all
these clinical governance and quality improvement processes.
A crucial pillar in the Martlets commitment to quality is the Education Service
which, is funded by the Charity. This delivers a comprehensive range of training
to our own staff and is also actively engaged in delivering training on all aspects
of palliative and end-of-life care to a whole range of external professionals.
Degree modules, Advanced Communication Skills, Liverpool Care Pathway,
seminars for Medical Students, Dementia training, are amongst the many topics
our staff deliver.
I am very pleased to have the opportunity to convey all that we are trying to
achieve and to confirm my personal commitment to continuous improvement.
Caroline Lower
Chief Executive
9th June 2011
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Part 2
Looking Forward: Priorities for improvement 2011 – 2012.
2.1 Priorities for improvement
Throughout 2010-2011 we identified and developed our priorities for the year
2011-2012. In selecting our priorities we have been mindful of national and local
policy as well as those issues which are of concern to our service users, our
workforce, our partners and our Trustees.
Following our assessment the top priorities for the year 2011-2012 are set out
below:Priority 1: Formation of a volunteer’s involvement group
Priority 2: Decreasing the number of patient falls
Priority 3: Improving documentation of health records through the introduction of
an Electronic Patient Records (EPR) system
Priority 1:
Formation of a volunteer’s involvement group
To provide a forum for communication to consult with and involve hospice
volunteer representatives.
How was this identified as a priority?
Volunteers are an integral part of any hospice team and they bring to the
hospice an amazing wealth of skills and experiences. A volunteer involvement
group would act as a sounding board for volunteer opinion and views, a meeting
place to consider issues of mutual concern and to provide an opportunity for
volunteers to raise topics where they would like to see change.
How will this be achieved?
A volunteer involvement group will be formed with representatives from across
the hospice. A chair person and secretary would be elected. A hospice manager
would be part of the group to bring information to the group and to communicate
back to senior managers.
Priority 2:
Decreasing the number of patient falls
The Hospice is committed to providing a safe environment to patients, staff and
visitors. The aim of this initiative is to provide practical guidance to managers
and staff in order to minimise the risk of harm and maintain patients and staff
safety.
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How was this identified as a priority?
The need to review the number of patient falls was highlighted through the
Clinical Governance Group. Quality of life and maintaining independence for as
long as possible is important to most patients near the end of their lives. The
balance between supporting the independence of a patient and minimising risk
requires a careful balance.
How will this be achieved?
A guidance document will be introduced to guide staff with the prevention,
assessment and recording of falls. We need to accurately record all falls for to
identify areas for improvement. The current accident form will be updated with
some specific areas designated to patient falls. The information that we collect
from this form is intended to help identify avoidable risks so that preventative
action can be implemented.
Priority 3:
Improving the delivery of patient care through the successful introduction
of an Electronic Patient Records (EPR) system.
An electronic health record is a digital version of an individual’s medical record.
How was this identified as a priority?
Electronic health records can be accessible by a health care provider anywhere
and at any time. Because they can be accessed when and wherever needed
they ultimately improve the delivery of healthcare by making the sharing of vital
information between healthcare providers more efficient.
How will this be achieved?
A project group has been formed to coordinate the implementation of electronic
patient records. There is a phased implementation plan with full implementation
throughout the hospice’s clinical areas by November 2011.
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2.2 Looking back: Priorities for improvement 2010 – 2011
Following our assessment the top priorities for the year 2010-2011 were as
follows:
Priority 1: Improvement of the Hospice In-Patient facilities
Priority 2: Introduction of new syringe drivers
Priority 3: Identifying complaints/dissatisfactions
Priority 1:
Improvement of the Hospice In-Patient facilities
It is essential that the Hospice In-Patient area provides a pleasant environment
for patients, visitors and staff. An attractive, soothing environment aids the
overall feeling of well-being in a person. It is well researched that a healing
environment can have positive effects on the experience of pain and other
distressing symptoms. As well as being pleasant for the patients and families,
the unit also needs to be a practical working area so that staff can deliver safe
patient care.
How was this identified as a priority?
The hospice was built in 1997 and despite most of the areas having regular
painting and decorating the areas were looking distinctly tired. There had also
been feedback from patients, carers and staff that the rooms themselves were
quite draughty which were not solved by our DIY attempts.
How was this achieved?
In 2010 the hospice was awarded a grant from the Department of Health to
support improvements to the In-Patient area of the hospice. The whole of the InPatient Unit was updated including curtains, improved lighting, flooring, doors
and windows.
A new room providing space for therapeutic activities and a larger, more
accessible spiritual space were added to the existing building. Many more
storage areas were also created thus enabling equipment and clutter to be
stored out of sight ensuring safe, clear passageways and rooms.
Priority 2:
Introduction of new syringe drivers
The hospice, in line with most other hospices, has been using the same
ambulatory syringe drivers for a number of years.
How was this identified as a priority?
The National Patient Safety Agency has highlighted some of the limitations and
risks associated with the use of this type of syringe driver.
How was this achieved?
Brighton and Hove Primary Care Trust allocated funds for the Hospice to
purchase 22 new syringe drivers with additional safety features.
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Priority 3:
Identifying complaints/dissatisfactions
The hospice receives very few complaints or expressions of dissatisfaction,
however, it is important to review and identify areas for improvement from the
few that we do receive.
How was this identified as a priority?
The recording of formal complaints have always been part of a more formal
process, however, what has not always been recorded is the verbal and often
impromptu expressions of dissatisfaction. Following discussions at the Clinical
Governance Group it was identified that dissatisfactions should also be recorded
so that improvements could be made were indicated.
How was this achieved?
All expressions of dissatisfaction and complaints are now recorded no matter if
they are verbal or written, big or small.
Part 3
Statement of assurance
The following are statements that all providers must include in their Quality
Account. Many of these statements are not directly applicable to palliative care
providers and therefore explanations of what these statements mean are also
given.
3.1 Review of Services
During 2010-2011 the Martlets Hospice provided the following services through
its main clinical areas listed below:
In-Patient Unit
Hospice at Home
Day Hospice
Bereavement Support Services
Outpatient Breathing Clinic
The Martlets Hospice has reviewed all the data available to them on the quality
of care in all of these services.
3.2 Income generated
The income generated by the NHS represents approximately 27% of the overall
cost of running these services.
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3.3 Participation in Clinical Audit
During 2010-2011 no national clinical audits or confidential enquiries covered
NHS services provided by the Martlets Hospice. The Martlets Hospice only
provides palliative care.
During the period the Martlets Hospice participated in no (0%) national clinical
audits and no (0%) confidential enquiries of the national clinical audits and
national confidential enquiries it was eligible to participate in.
The national clinical audits and national confidential enquiries that the Martlets
Hospice was eligible to participate in during 2010-2011 are as follows: None
The national clinical audits and national confidential enquiries that the Martlets
Hospice participated in during 2010-2011 are as follows: None
The Martlets Hospice was not eligible in 2010-2011 to participate in any national
clinical audits or national confidential enquiries and therefore there is no
information to submit. As a provider of specialist palliative care the Martlets
Hospice is not eligible to participate in any of the national clinical audits or
national confidential enquiries. This is because none of the 2010-2011 audits or
enquiries related to specialist palliative care.
The Hospice will also not be eligible to take part in any national audit or
confidential enquiry in 2011-2012 for the same reason.
3.4 Local Clinical Audits
Clinical audits have taken place within the Martlets Hospice; these form part of
the annual audit cycle programme. The monitoring, reporting and actions
following these audits ensure care delivery that is safe and effective. The clinical
audit cycle includes audits around documentation, medicine management,
pressure ulcer management, infection control and care of the dying audit.
Where indicated changes are implemented at an individual, team or service
level and further monitoring is part of the cycle.
3.5 Research
The number of patients receiving NHS services provided or subcontracted by
the Martlets Hospice in 2010/11 that were recruited during that period to
participate in research approved by a research ethics committee was: None.
3.6 Use of the CQUIN payment framework
The Martlets Hospice income in 2010/11 was not conditional on achieving
quality improvement and innovation goals through the Commissioning for
Quality and Innovation payment framework because it is a third sector
organisation and as such was not eligible to participate in this scheme during
the reporting period.
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3.7 The Care Quality Commission
The Martlets Hospice is required to register with the Care Quality Commission.
The Martlets Hospice is required to undertake regulated activities at the
following location The Martlets Hospice, Wayfield Avenue, Hove, East Sussex.
BN3 7LW.
The Martlets Hospice is subject to periodic reviews by the Care Quality
Commission and the last on-site inspection was June 2009. This was followed
by the re-registration process as required by all healthcare providers and
registration was confirmed in January 2011.
The Martlets Hospice has not participated in any special reviews or
investigations by the Care Quality Commission during 2010-2011.
3.7 Data Quality
The Martlets Hospice did not submit records during 2010-2011 to the Secondary
Users service for inclusion in the Hospital Episode Statistics which are included
in the latest published data. The Martlets Hospice is not eligible to participate in
this scheme.
However the Martlets Hospice does submit data to the Minimum Data Set
(MDS) for Specialist Palliative Care Services collected by National Council of
Palliative Care on a yearly basis, with the aim of providing an accurate picture of
hospice and specialist palliative care service activity.
It is anticipated that the introduction of an Electronic Patient Records System
during 2011-2012 should improve the overall quality of collected data.
3.8 Clinical coding error rate
The Martlets Hospice was not subject to the payment by results clinical coding
audit during 2010-2011 by the Audit Commission.
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Part 4
Quality overview
In 2009-2010 the In-Patient Unit cared for 244 patients. 88% of these patients
had a cancer diagnosis and 37% of patients were under 65 years of age.
“Even though your time with our Dad was short we would like to thank you for
the support and comfort you gave him. His wish was to be with you and I can
understand why. You made sure he was as comfortable as possible and for that
we are truly grateful.”
In 2009-2010 the Day Hospice cared for 206 patients. Over the year patients
made 1,781 visits to the Day Hospice. 70% of patients were aged 64 years or
over.
“My wife and I wish to express how very appreciative we are of all the loving
care, help and support we have received from the staff at the Martlets Hospice.
Attending the day Hospice has added another dimension to my life and is
helping me to cope with a very difficult and frustrating condition.”
In 2009-2010 the Hospice at Home service cared for 245 patients. 80% had an
advanced cancer diagnosis.
“There are too many to name you all but I wanted to thank you so much for all
you did for my wife and the support you gave me and the girls. Without you we
couldn’t have kept her at home, which was her wish, and we were so pleased
we could.”
In 2009-2010 the bereavement service supported 254 people. 10 bereavement
volunteers visited families in their own home.
“I just wanted to express how much I have appreciated your kindness and
support over the last very difficult year. Without your regular input I do not know
how I would have faced it all.”
The Hospice receives many commendations from patients and families.
Commendations are welcomed and celebrated at the Clinical Governance
Group as well as in the individual team meetings or informally at nursing staff
handovers.
Complaints are taken extremely seriously and we try and learn from complaints.
Complaints are thoroughly investigated and reported at the Clinical Governance
Group meeting, to the Board of Trustees and the Care Quality Commission.
Immediate action is taken to rectify any shortfalls or concerns identified.
The Martlets Hospice places a high value on feedback from those who use our
services. Feedback is gained from a variety of sources including patients, carers
and other professionals. Feedback through questionnaires is reported on and is
reviewed by the clinical team involved and the Clinical Governance Group.
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The Martlets Hospice strives to meet the individual needs of patients and
families using our services and will continue to do so.
Supporting statements
As outlined in the regulations, this document has been sent to the Brighton and
Hove; Local Involvement Network (LINk), Overview and Scrutiny Committee
(OSC) and lead commissioning Primary Care Trust (PCT) for comment.
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