Quality Accounts 2011 - 2012
Farleigh Hospice exists to meet the needs of local people affected by
life limiting illnesses and to support those who have been bereaved.
Through the ongoing generosity of the mid Essex population we
provide a range of high quality services totally free of charge. By
giving people choice and involvement in the care they receive we
make a real difference when and where it matters most.
“I truly appreciate all you do for so many. Keep on keeping on.” –
a supporter
Quality Accounts 2011 - 2012
CONTENTS
Sections
Page
Part 1: Introduction by Chief Executive Janet Doghan
3
Part 2: Priorities for Improvement & Statements of Assurance from the
Board (in regulations)
Future priorities for improvement - 2012 – 2013
4
Priorities for improvement from 2011 – 2012
9
Mandatory Statements of assurance from the board
13
Part 3: Review of quality performance
National Council for Palliative Care: Minimum Data Sets – 2010 – 2011
17
Farleigh Hospice Quality Performance Information 2011 -2012
18
Quality Markers we have chosen to measure
20
Other quality initiatives
24
What people say about our organisation
26
Statement from North Essex PCT Cluster
30
Statement from Essex Health Overview & Scrutiny Committee
32
Statement from Essex & Southend Local Involvement Network
33
Appendix A – Audits completed April 2011 – March 2012
35
2
Part 1
Introduction by Chief Executive
Farleigh Hospice has received NHS income under a Service Level Agreement for the
year 2011-12 from NHS Mid Essex. It follows that I am responsible for the preparation
of this report and its contents; a duty which I am more than happy to undertake for two
reasons. First, it gives me the opportunity to report on our extensive governance
programme within Farleigh Hospice. Secondly it gives me a public platform on which to
formally thank the PCT for the financial support which Farleigh Hospice has received.
Farleigh Hospice services have been developed in close collaboration with our PCT
commissioners and in accordance with the joint End of Life Care Strategy 2009-14. We
are proud of our relationship with the PCT which has facilitated the development of
quality hospice services and we are keen to establish a similarly effective relationship
with the Mid Essex Clinical Commissioning Group.
We also owe a debt of gratitude to our many loyal supporters who give generously of
their time, skills and money. As a charity Farleigh Hospice is dependent upon a number
of different sources of income including donations and gifts in wills, fundraising, shops,
and a weekly lottery. These voluntary sources of income are just as vital as the NHS
funding.
I chair regular meetings of the Hospice's Governance Group where trustees, senior
managers and the independent service user facilitator rigorously debate, challenge and
add value to the quality programme. Our aim is to ensure on behalf of the Board of
Trustees that a framework exists through which Farleigh Hospice is accountable for
continuously improving the quality of services and safeguarding high standards of care
by creating an environment in which excellence in clinical care will flourish. In addition,
the group can provide a safe forum for exploring management issues which may impact
upon quality of care. In May 2011 we were joined by a dedicated part time lead for
Quality Improvement which has enabled a more focused and co-ordinated approach to
quality across the whole charity.
This Quality Account follows the model requirement set out in the regulations. To the
best of my knowledge, the information reported in this Quality Account is accurate and a
fair representation of the quality of healthcare provided by Farleigh Hospice.
Janet Doghan MIHM DipHSM
Chief Executive
For any queries, comments or any further information please email us at:
comments@farleighhospice.org
3
Part 2
Priorities for Improvement and Statements of Assurance from the
Board (in regulations)
Introduction
Farleigh Hospice Strategic Plan - ’Your Hospice and the Next Three Years’- 2011- 2014
outlines our vision moving forward which is, as always, inspired by the needs of people
affected by a life limiting illness. There is still much to do to maintain existing services
and to improve them so that they are flexible enough to respond to people's changing
needs.
This quality account only considers quality issues within the provision of clinical care
and relevant support services necessary to provide this care. This does not take into
account the fundraising and administrative functions of the organisation where separate
quality initiatives are employed.
Future priorities for improvement - 2012 – 2013
The Board of Trustees is committed to the delivery of high quality care which is safe,
effective and meets the needs of people who use our services and to support the
continuous development and improvement of these services.
These priorities have been developed through consultation with people who use our
services including patients, carers, staff and volunteers.
The priorities we have selected will impact directly on each of the three domains of
quality:patient safety
clinical effectiveness
patient experience.
Looking forward Farleigh Hospice confirms that the top four quality improvement
priorities for 2012- 2013 to be:-
Future improvement priority 1
Evaluation of the Hospice @ Home service in Mid Essex
Quality Domain: - Patient Experience
The Hospice @ Home service for Mid Essex was introduced in February 2011 and we
aim to evaluate this service to establish a clear understanding of activity, patient
outcomes, patient & carers’ views, health professionals’ views and future resource
requirements.
4
How was this priority identified?
As a new service it is important that it provides the most efficient and effective service to
people who use it. The service evaluation will help us look at what we do and what we
could do better based on the feedback we receive.
How will this be achieved?
This will be achieved by setting up systems to collect:Information from individuals using the service over the 12 month period.
Quantitative data on care given.
Records of achievement of the Preferred Priorities for Care (PPC).
How will progress be monitored?
The information will be collated quarterly with recommendations reviewed and with a
final report being prepared by March 2013.
Future improvement priority 2
Development of a Staff Training Matrix for Mandatory Training
Quality Domain: - Patient Safety
All staff involved in patient care undergo mandatory training, which is appropriate to
their role, as part of their induction and relevant update training. We aim to ensure
that the training provided is right for the post and therefore want to review and
improve on what we currently do. The development of the training matrix will clarify
training requirements for each individual post. We believe this will be for the benefit of
all patients.
How was this priority identified?
This was identified as a priority following CQC evidence gathering and agreed by Heads
of Departments at Farleigh Hospice who felt that as the hospice grows and more roles
are being introduced that there is a need for clarification of requirements for mandatory
training for individual roles.
How will this be achieved?
This will be achieved through the establishment of an Education and Training Group
which will be tasked with developing a training matrix through discussion with Heads of
Department. Once completed the mandatory training requirement for individual posts
will be included in job descriptions to ensure staff are aware of the requirements for their
role.
5
How will progress be monitored?
Progress on this priority will be monitored through Human Resources and Heads of
Department. The Education and Training Group will be responsible for the development
and implementation of the training matrix.
Future improvement priority 3
Provision of efficient and effective service following a review of
clinical services using the ‘LEAN’ process
Quality Domain: - Clinical Effectiveness
Farleigh Hospice aims to provide the most efficient and effective services. We recently
undertook a review of the patient pathway using the ‘LEAN’ process ('LEAN' is a
process which involves staff in critically reviewing current work practices to eliminate
wasteful processes or those that do not add value to clinical care). Following this
process, we now want to review the impact on our services to see what has been
achieved.
How was this priority identified?
Farleigh Hospice continually strives to provide the most efficient and streamlined
services possible, right across the organisation. The Senior Management Team (SMT)
and the ‘LEAN’ facilitators decided to ‘LEAN’ the patient pathway as this involved the
whole multi professional team and would therefore be a good information source to
‘LEAN’/review. By assessing three main principles which focus on identifying areas
where there are problems or interruptions to the flow of work, the ‘LEAN’ process
enabled our clinical departments to consider how they go about delivering a more
effective service, both within their working environment and when meeting the needs of
patients, families and carers. Following this process we feel it is important to evaluate
the impact this has had on our services.
How will this be achieved?
The ‘LEAN’ training has commenced and there have been several update meetings to
discuss change processes. Progress on agreed projects will be regularly reviewed, staff
views on the effectiveness of the change processes will be sought and patient activity
will be reviewed and compared against previous activity. Moving forward ‘LEAN’
champions will be identified who can co-ordinate and motivate others to ‘LEAN’ their
work processes.
How will this be monitored?
Regular update meetings, reports to SMT and regular updating of information boards
established to provide focus and feedback for staff. Reports on the impact of the ‘LEAN’
processes will be on going.
6
Future improvement priority 4
Connection to NHS ‘N3’ broadband network computer service to
improve clinical communication
Quality Domain: - Clinical Effectiveness
In order for us to provide the best care we need to work closely with our NHS
colleagues. One way to do this is to have an ‘N3’ (fast broadband networking service
within the NHS) computer connection which will improve our access to diagnostic test
results carried out by the NHS.
How was this priority identified?
Access to the results of diagnostic tests carried out by the NHS – pathology and
radiology are not readily available to hospice staff when patients are referred to our
services. This can impact on the speed of decisions regarding treatment which can be
detrimental to patient care. Furthermore, a lot of staff time is wasted obtaining test
results by other means. As manual transcription of telephoned information is recognised
as a patient safety issue eliminating this through access to the ‘N3’ connection will be a
major safety improvement and improve clinical effectiveness.
How will this be achieved?
Successful completion of the Information Governance (IG) Toolkit achieving levels 2 in
a variety of areas - systems, services, policies and procedures are required to evidence
compliance.
Successfully securing funding to provide the broadband connections in Chelmsford and
Maldon.
How will this be monitored?
The Information Governance Steering group will be responsible for ensuring the
completion of the IG Toolkit, its submission to the PCT and ongoing compliance.
7
How will progress be monitored for all future priority improvements –
2012 - 2013?
The Farleigh Hospice Board of Trustees will monitor and report on progress through a
variety of methods including:Annual return to the Charity Commission
Annual Review and audited Report and Accounts
Quality Accounts and Annual Governance report
Annual audits and patient surveys
Annual General Meetings of the Company
Farleigh Hospice News and other periodic communications
Updates posted on the Farleigh Intranet and Farleigh Web site
Events such as Open Days and Medical Staff open evenings
8
Priorities for improvement from 2011 – 2012
The aim of the Quality Account is to not only set future priority improvements but to also
evidence achievements on priorities for improvement from the previous year.
In last year’s report we set out five priorities for improvements for our services. All the
areas identified were specifically selected as they would impact directly on the care our
patients and carers received, either through improving patient safety, clinical
effectiveness or the patient’s experience.
The quality improvements for the previous year - 2011 -2012 were:-
Priority 1
Develop a Hospice @ Home service in Mid Essex
Quality Domain: - Clinical Effectiveness, Patient Experience
Standard - To set up a Hospice @ Home service in Mid Essex in line with
government guidance (End of Life Strategy 2008) and the views of the majority of our
patients.
In line with government guidance (End of Life Strategy 2008) and the views of the
majority of our patients and carers we have set up the Hospice @ Home service
which was launched in February 2011 and is available throughout the Chelmsford,
Maldon and Braintree districts. This provides a service 7 days a week (8.00 – 22.00)
with Marie Curie Cancer Care providing night support.
The establishment and development of this service has enabled people to return
home and stay there, if this is their wish, by facilitating discharge and providing
quick response and respite care at home.
The service has been audited to review the initial impact on other hospice services
and response to patients’ Preferred Priorities of Care (PPC) document as well as
patients/carers and other professionals' views of the service. The audit was carried
out over a seven month period between 1 st February 2011 and 31st August 2011
with questionnaires being sent to the primary carer/relative of the deceased
individual between four and five weeks after their bereavement. The results of the
audit showed that overall there was a positive response to the questions
demonstrating a high level of satisfaction with the services provided by the Hospice
@ Home service: 95% of respondents felt their loved one had achieved their PPC.
9
As a new service it is important that it provides the most efficient and effective
service to people who use it. It is planned to carry out a service evaluation to help
us look at what we are doing well and what we could do better based on the
feedback we receive. (See Future Improvement Priority 1 2012 – 2013 above).
Priority 2
Establish an annual audit cycle to evidence quality improvements
across the organisation
Quality Domain: - Patient Safety, Clinical Effectiveness & Patient Experience
Standard - To establish quality assurance systems and an annual audit cycle to
evidence quality improvements across the organisation.
The appointment of a Quality Improvement Lead in May 2011 has enabled a more
focused and coordinated approach to quality activity and quality improvement
across the organisation.
A Multi Departmental Quality Assurance (MDQA) group and regular meeting
structure has been established to develop and monitor quality activity including the
development of an annual audit programme.
An Annual Audit programme was developed for 2011 – 2012. To support this
activity Audit Proposal and Report templates were developed along with an audit
process flowchart.
A structure to review and follow up action plans for audit to monitor quality
improvements was introduced.
A Quality Improvement Plan 2011 – 2012 was developed. The annual plan
described the improvement actions for all parts of the organisation and
achievements on action plans were reviewed with 95% being achieved.
Progress was monitored through the completed audits, MDQA meeting minutes and
quarterly report to the Governance Group.
Priority 3
Develop proposals to extend bereavement support services for
adults across the whole of Mid Essex
Quality Domain: - Clinical Effectiveness & Patient Experience
Standard - To develop a proposal to expand the current bereavement service for
adults to non Farleigh Hospice patients across Mid Essex.
.
10
The Bereavement Service at Farleigh Hospice has been successful in supporting
bereaved relatives and friends of patients who were involved with Farleigh Hospice.
Farleigh Hospice also provides county wide bereavement support for children and
young people (The Yo-Yo Bereavement project). A gap in service provision was
identified for bereaved adults in Mid Essex where there was no connection with
Farleigh Hospice services.
A proposal was developed and submitted to seek funding to expand the current
bereavement service for adults to non Farleigh Hospice patients across Mid Essex.
Funding was agreed and the new service – ‘CIRCLE’: Adult Bereavement Support –
started on 1st May 2012. A new counsellor has been appointed and volunteers are
currently being recruited and trained. It is planned to audit this new service as part
of the audit programme for 2012 -2013.
Priority 4
The development of multi-purpose space for rehabilitation within the
existing Inpatient Unit.
Quality Domain: - Clinical Effectiveness & Patient Experience
Standard - To develop a self contained rehabilitation suite in the Inpatient Unit to
assist patients and families to adapt their lifestyles to enable them to spend as much
time as possible together in their own home. The suite will also be available for respite
care ensuring patients maintain their levels of independence and for assessing
patients prior to discharge, thereby reducing the need for home visits by staff.
.
. As more people living with life limiting illness choose to spend as much time as
possible in their own homes an ever increasing area of our work involves assisting
patients and their families to adapt their lifestyles and their homes to facilitate this
choice.
A proposal was developed and submitted to fund the conversion of a three bedded
room in the In Patient unit into a self contained rehabilitation suite. An application for
funding to a charitable trust was successful to fund the building work and an
additional private gift provided furniture for the suite.
The basic building work for the suite has been completed and it is likely the suite will
be ready for use once the furniture has arrived.
The suite will be available for respite care ensuring patients maintain their levels of
independence and for assessing patients prior to discharge, thereby reducing the
need for home visits by Occupational Therapy and Physiotherapy staff.
11
A system for monitoring the use of this new facility will be put in place. The benefits
of the suite will be evaluated a year after the suite is fully operational.
Priority 5
Participation in Dying Matters campaigns and events to change
attitudes and raise public awareness about death and dying
Quality Domain: - Clinical Effectiveness and Patient Experience
Standard - To participate in this national campaign to change attitudes and raise
professional and public awareness about death and dying including collaboration with
GPs and other professionals through educational and other events.
The Dying Matters national campaign is encouraging people to talk about their
wishes for their end of their life care. Recent research reveals the majority of people
– about 70 per cent – would prefer to die at home, but about 60 per cent actually die
in hospital, in many cases, unnecessarily. Additionally while about three-quarters of
people report feeling confident about planning for the end of their life, less than a
third have actually discussed their wishes around dying.
Farleigh Hospice is participating in this national campaign to change attitudes and
raise professional and public awareness about death and dying including
collaboration with GPs and other professionals through educational events.
A Dying Matters Steering group was established with the aim of bringing together
relevant organisations to promote public awareness of ‘Dying Matters’ across Mid
Essex.
A programme of events has been developed, to promote this national campaign,
taking place across Chelmsford, Maldon and Braintree districts including events
during the Dying Matters week in May 2012.
12
Mandatory Statements of Assurance from the Board
The following are statements that all providers must include in their Quality Account.
Many of these statements are not directly applicable to specialist palliative care
providers and therefore explanations of what these statement mean are also given.
Review of services
During 2011 - 2012 Farleigh Hospice provided the following specialist palliative care
services:In-Patient Unit – 10 beds
Day Hospice – at Chelmsford & Maldon – 90 places per week
Nurse led clinics
Out Patients
Community services – including Hospice @ Home, Farleigh Nurse Specialists,
Hospice Outreach Project (HOP), physiotherapists, occupational therapists, social
workers
Counselling
Carer Support
Well Being Services – creative therapies, chiropody, hairdressing, complementary
therapies
Information and ‘drop in’ services
Chaplaincy
Bereavement support ( included services for children, young people and adults)
Education and Training
What this means
Farleigh Hospice is an independent charity which provides all services free of charge.
The income generated from the NHS in 2011/2012 represented 47% of the overall
costs of service delivery with the remaining income to fund our services coming from
voluntary charitable donations, legacies, hospice shops and lottery, events, corporate
and community fundraising.
Participation in clinical audits
Although 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.
13
During 2011 - 2012 no national clinical audits or confidential enquiries covered NHS
services provided by Farleigh Hospice. As Farleigh Hospice only provides palliative
care it was not eligible to participate in any of the above activities.
During that period Farleigh Hospice participated in no national clinical audits and no
confidential enquiries of the national clinical audits and national confidential
enquiries it was not eligible to participate in any.
The national clinical audits and national confidential enquiries that Farleigh Hospice
was eligible to participate in are as follows: NONE.
The national clinical audits and national confidential enquiries that Farleigh Hospice
participated in are as follows: NONE.
The national clinical audits and national confidential enquiries that Farleigh Hospice
participated in and for which data collection was completed are listed below
alongside the number of cases submitted to each audit or enquiry as a percentage
of the number of registered cases required by the terms of that audit or enquiry.
NONE.
Farleigh Hospice was not eligible to participate in any national clinical audits or
national confidential enquiries and therefore there is no information to submit.
What this means
As a provider of specialist palliative care Farleigh Hospice was not eligible to
participate in any of the national clinical audits or national confidential enquiries. This is
because none of the 2011 - 2012 audits or enquiries related to specialist palliative
care. The hospice will also not be eligible to take part in any national clinical audit in
2012 – 2013 for the same reasons.
Local audits
To ensure a high quality of services an annual audit programme has been established
(see above Improvement Priority 2 from 2011 - 2012 ) and a variety of audits were
undertaken using nationally agreed formats often specifically developed for hospice
care as well as locally developed audit tools. For all these audits undertaken, where
necessary, local action plans for improvements were developed, and in general they will
be re-audited within the next 12 months to check for improvements. This has enabled
us to monitor the quality of services and make improvement where needed. The reports
of 52 local audits were reviewed by the Farleigh Hospice Governance group of which 48
related to clinical care.
Details of audits completed in 2011 – 2012, to improve the quality of services, can be
seen in Appendix A
14
Research
The number of patients receiving NHS services provided by Farleigh Hospice in 20112012 that were recruited during that period to participate in research approved by a
research ethics committee was NONE. There were no appropriate national, ethically
approved research studies in palliative care in which we could participate during this
period.
Use of CQUIN payment framework
The Service Level Agreement for Farleigh Hospice NHS income in 2011 – 2012
included a Commissioning for Quality and Innovation (CQUIN) sum in respect of the
reduction in hospital deaths as a direct result of the Hospice @ Home service.
Statements from CQC
Farleigh Hospice in Chelmsford and Farleigh Hospice in Maldon are required to register
with the Care Quality Commission and are currently registered to provide the following
regulated activity:Personal care,
Treatment of disease, disorder or injury
They are fully compliant with the Essential Standards of Quality and Safety as set out in
Care Quality Commission (Registration) Regulations 2009 and the Health & Social Care
Act 2008 (Regulated Activities) Regulations 2010. These standards were met through
self assessment in 2009. Farleigh has no conditions attached to registration and the
CQC has not taken any enforcement action during 2011 – 2012. Farleigh has not
participated in any special reviews or investigations by the CQC in this period.
Data Quality
Farleigh Hospice did not submit records during 2011-2012 to the Secondary Users
service for inclusion in the Hospital Episode Statistics which are included in the latest
published data.
Why is this?
This is because Farleigh Hospice is not eligible to participate in this scheme. In the
absence of this we have our own system in place to collect and monitor data through
the electronic patient information system iCare.
Farleigh Hospice also submits data to the Minimum Data Set (MDS) for Specialist
Palliative Care Services collected by National Council for Palliative Care on an annual
basis with the aim of providing an accurate picture of hospice and specialist palliative
care activity.
15
Information Governance Toolkit
Farleigh Hospice submitted its Information Governance Toolkit assessment version 9 in
March 2012 to Mid Essex PCT and NHS Connecting for Health for review. The outcome
from both organisations was satisfactory with sufficient compliance to support the
application for an ‘N3’ connection.
What this means
‘N3’ (fast broadband networking service within the NHS) computer connection will
improve access to diagnostic test results carried out by the NHS. Results will be more
easily accessible for medical staff, leading to quicker decisions regarding treatment of
patients. This is a Future Improvement Priority 4 for 2012 - 2013
Clinical coding error rate
Farleigh Hospice was not subject to the Payment by Results clinical coding audit during
2011 – 2012 by the Audit Commission.
Why is this?
There is currently no payment tariff for palliative care services.
16
Part 3 - Review of Quality Performance
The National Council for Palliative Care: Minimum Data Sets – 2010 – 2011
The figures below provide information on the activity and outcomes of care for patients
in 2010 – 2011 compared to the median for other similar hospice services prepared by
the National Council for Palliative Care. (NCPC)
This information is however for the previous year not the reporting year as the
NCPC dataset for 2011– 2012 will not be available until September 2012
2010 - 2011
Farleigh
Hospice
NCPC National
Median
Number/%
283
255
90.1%
11.0%
68.4%
55.0%
6.92
Number/%
219
198
89.6%
8.1%
77.9%
55.9%
12
202
120
59.4%
13.3%
2426
53.3%
134.9
233
152
65.6%
14.0%
2282
60.9%
149.7
1001
665
66.4%
15.2%
50%
134.9
1324
913
67.4%
11.4%
44%
149.7
1470
722
49.1%
3784
749
51.0%
552
373
65.7%
2269
333
60.0%
42
26
61.9%
11.5%
41*
1772*
48
30
67.5%
7.6%
2.5
104
Inpatient Services
Total number of patients
Total number of new patients
% New patients
% New patients – non cancer diagnosis
% Occupancy
% Inpatient stay ending in death
Average length of stay ( days )
Day Care
Total number of patients
Total number of new patients
% New patients
% New patients – non cancer diagnosis
Total Day Care Attendances
% Places used
Average length of attendance
Home Care
Total number of patients
Total Number of new patients
% New patients
% New patients – non cancer diagnosis
% of patients who died at home
Average length of care ( days )
Bereavement
Total Service Users
Total number of new service users
% New referrals
Total number of contacts
Total number discharged
% discharged
Out Patients
Total number of patients
Total number of new patients
% New patients
% New patients – non cancer diagnosis
Average attendance per patient ( days )
Total outpatient clinic attendances
* These figures include outpatient group attendances such as ‘Easibreathe’ groups
17
Farleigh Hospice Quality Performance Information 2011 -2012
Detailed below is data about services provided by Farleigh Hospice relating to the
period April 2011 to March 2012.
General Information
The total number of patients cared for by Farleigh Hospice increased by 9% and is now
the highest it has ever been – 2,060 compared with1,891 in 2010 – 2011.
The total number of referrals to the hospice was 1,090 an increase of 2% on last year.
The number of new patients in the last year was 1,011 which is an increase of 4% on
last year. Referrals from the local hospital were 13% higher but self referrals were at
their lowest ever, possibly because the hospital teams are referring patients to the
hospice before discharge.
Farleigh Hospice has always provided end of life care for cancer and non cancer
patients and over the last few years there has been a slow increase in the number of
non cancer patients accessing hospice services – 15% of patients in 2011 – 2012
compared to 11.5% in 2010 – 2011.
Inpatient Care
In the Inpatient Unit (IPU) the average length of stay for patients was 8.7 days. The
workload on the Inpatient Unit has been variable over the year. Admission numbers
were down 18% which may be due to the introduction of the Hospice at Home (H@H)
service in February 2011. The Preferred Priorities of Care (PPC) also continues to have
an impact on the Inpatient Unit. There was a rise in the number of people being
admitted in the last few days of life with Farleigh Hospice as their preferred choice, 10%
of patients dying on the day of admission. 17% of all admissions are from hospital which
probably reflects patient/family wishes to die in the hospice rather than the hospital.
Overall these factors have contributed to the low length of stay.
There is rarely a waiting list for people to come in and the average time from referral to
being admitted was 2 days. Longer times from referral to admission are often at the
patient’s request/preference. Bed occupancy was 73%.
IPU admissions were about 14% of the hospice workload. This is lower than last year again possibly due to the impact of the Hospice at Home (H@H) service.
Farleigh Hospice Nurse Specialists
The Farleigh Hospice Community Nursing Team had some staff changes in the year. In
December an additional specialist nurse was appointed to ease the pressure on the
team resulting from seven day working. This post and possibly the results of the
‘LEAN’ process on the patient pathway has helped increase the workload activity with
the community team making 3,547 visits in the year an increase of 43%.
18
The number of new patients was 595 the highest number ever and 14% up on last year.
Hospice @ Home (H@H)
The Hospice @ Home service was set up in February 2012. The service received 366
referrals carrying out 6,270 visits from April 2011 to March 2012. The service was
audited to review the initial impact on other hospice services and response to patients’
Preferred Priorities of Care (PPC) document. The results showed that overall there was
a high level of satisfaction with the services provided by the Hospice @ Home team:
95% of respondents felt their loved one had achieved their PPC.
Day Hospice
The day hospices in Chelmsford and Maldon had 2,335 patient attendances. There
were 160 new day care patients in this year, 18% increase on last year. Patients are
however often referred very late in their illness pathway and non attendances are high
although this non attendance rate is lower than the average for similar hospices as
noted in the National Minimum dataset.
Bereavement support
The bereavement team provides a service for adults linked to Farleigh Hospice and a
district wide service - The Yo-Yo project - helping children and young people prepare
and deal with loss. The team continued to provide an extensive service with sessional
counsellors being used to help meet the increased demand for bereavement
counselling in both adult and children’s services. The total number of bereaved
supported by the service was 1,430. The total number of new referrals in the year was
715. In May 2012 the adult service was expanded to be district wide.
19
Quality Markers we have chosen to measure
In addition to the number of suitable quality measures in the national data set for
palliative care, we have chosen to measure our performance against the following:Complaints & Compliments
Safety Information
Infections & Pressure Ulcers
Education & Training
Local Audits
Other Quality Initiatives
What others say about our organisation
Complaints & Compliments
Any complaints made were fully investigated and appropriate action taken. All
complaints were discussed by the Senior Management Team to facilitate organisational
learning. A review of the complaints management system took place in the review
period and resulted in the introduction of a new complaints management system. All
complaints are now categorised following completion of an investigation as green,
amber or red based on the seriousness and likelihood of the issue to recur. The
outcome of the complaint – Not Upheld, Partially Upheld, Upheld and theme of the
complaint e.g. – Clinical Care, Shop, Lottery, Fundraising, Administration are also
recorded to monitor trends
Complaints 2011 – 2012
Total number of complaints related to patient/family care
Total number of these which were upheld
Themes for upheld complaints
10
5
Communication
A total of 29 complaints were received with 10 related to patient/family care. Two audits
were carried out as a result of complaints to review practice – Independent Practitioner
Audit and Discharge –Review of TTO forms. (To take home medication forms).Action
plans were developed to address issues raised.
Although the number of complaints was small the number of compliments was
significantly higher as evidenced through letters and cards from families and carers and
in the annual Patient Satisfaction Surveys. In a recent review over a one month period
231 compliments were received which over a year could amount to over 2770
compliments.
Over 50% were made verbally in person or by telephone, 35% were cards, letter,
emails, and gifts. Over 46% were compliments about patient care including the
chaplaincy service and the catering service.
20
Safety information
Accidents, Incidents, Near Misses
For this period there were a total of 103 reported accidents / incidents (46 injury and 57
non injury), as detailed below.
Total
Near
Miss
Incidents
Minor
Medium
Major
Total
Patients
42
26
1
1
70
Employee’s
10
11
5
0
26
Visitors
2
1
0
0
3
Volunteers
3
1
0
0
4
Total
57
39
6
1
103
58 incidents were patient falls which were categorised in line with Health & Safety
Executive reporting requirements as follows:
Near Miss
Minor
Medium
Major
Total
35
21
1
1
58
One incident categorised as major was reported to the Care Quality Commission and a
Route Cause Analysis of the incident was carried out by the hospice.
Medication related incidents –
There were 32 incidents –
28 medication adverse events
4 medication errors
All were investigated and, where necessary, corrective action was taken. There were no
serious consequences to patients from any of these incidents. Audits of these
medication related incidents are carried out quarterly.
Safety Alerts
The hospice reviewed and actioned relevant alerts received from the Central Alerting
System including drug safety alerts from the Medicines and Healthcare products
Regulatory Agency and Medical Devices Alerts – Action was taken in relation to 48
medical device alerts which were relevant to the hospice.
Patient Infections and Pressure Ulcers
Infections and pressure ulcers are monitored on an on-going basis by the Manager of
the Inpatient Unit and reported to Farleigh Hospice’s Governance Group and the Care
Quality Commission. Infections are also reported to the Infection Control Team on a
quarterly basis.
Information relating to the incidence of Patient Infections and Pressure Ulcers is collated
into an annual audit. There continues to be a very low number of infections and
21
pressure ulcers acquired at the hospice. There was a slight increase in reported
infection from last year but the likelihood is that none were acquired at Farleigh
Hospice. There was a decrease in the number of reported pressure ulcers and once
again a very low number were acquired at the hospice.
Patient Infection 2011 -2012
Unit
No Cases
No on admission
No Acquired At Farleigh
Inpatient Unit/Day
12*
3
3
Hospice
* 3 were of unknown origin i.e. patients had symptoms and were investigated whilst in
the IPU. However, it is probable that the infections were present on admission.
Pressure Ulcers 2011 - 2012
Unit
No Cases
No on admission
No Acquired At Farleigh
Inpatient Unit
21
19
2*
Day Hospice Maldon
7
7
0
Day Hospice
0
0
0
Chelmsford
* 2 patients developed ulcers while in the IPU but refused preventative measures
despite being informed of the risks.
Education & Training - Palliative and End of life care
Education and training focused on palliative and end of life care was delivered by
hospice staff to IPU and community staff as well as staff from residential care homes,
community hospitals, nursing homes, community nurses and GPs. These were short
sessions and study days at Farleigh Hospice as well as outreach sessions in the
community.
Palliative Care Essentials study days – these all day events took place at Farleigh
Hospice, Chelmsford covering a variety of palliative and end of life care issues. The
target audience was community and care home staff as well as new Farleigh Hospice
staff.
Micro teaching sessions – these events took place at Farleigh Hospice and in a
variety of community settings covering a variety of palliative and end of life care
issues. The length of sessions was dependant on the topic.
Outreach Palliative Education programme – these events took place in a variety of
community settings with the teaching being taken to community hospitals, care
homes, care agencies and community nurses workplaces.
22
Palliative Link meetings – these events were aimed to maintain positive links with
interested care homes providing opportunities to discuss topical palliative care issues
and share good practice.
General practitioner palliative care education sessions – Clinical and Education staff
at Farleigh Hospice facilitated two palliative care education afternoons for trainees
and General Practitioners.
A medical open evening was also organised to raise awareness of the work of the
hospice. See Other Quality Initiatives below for more details.
There are plans to continue and increase this education work to the wider community in
2012 – 2013.
Education & Training - Palliative and End of Life Care 2010 -2011
Type of Event
Palliative care essentials
study days
Micro Teaching sessions –
1 - 4 hours sessions
Outreach Palliative
Education programme
Palliative links meetings
Total No
of events
Staff targeted
Total No
Attended
17
Community and care home staff and
new Farleigh Hospice staff
315
22
Farleigh & Community Staff
145
13*
Community hospital, care home, care
agency & community nursing staff
67
5**
Care home and nursing home staff.
25
* 7 planned meetings were cancelled due to work related issues for attendees
**2 planned meetings were cancelled due to work related issues for attendees
Local audits
To ensure a high quality of services a variety of audits were undertaken using nationally
agreed formats often specifically developed for hospice care as well as locally
developed audit tools. This has enabled us to monitor the quality of services and make
improvement where needed.
The reports of 52 local audits were completed with 48 relating to clinical care. See
Appendix A for details of completed audits. Action plans have been developed as a
result of these audits to improve the quality of healthcare provided. The outcomes from
the audits were reviewed by the Governance Group on a regular basis and in their
Annual Governance report.
23
Other quality initiatives
Dignity Action Day
Farleigh Hospice is passionate and committed to providing the highest level of dignity in
everything we do and this plays a dual role across the hospice. In the care and support
we provide to our service users, as well as by actively promoting dignity within the
whole organisation.
In order to promote dignity on a national level up and down the country, ‘Dignity Action
Day’ aims to give everyone the opportunity to contribute to upholding people’s rights to
dignity in care. For the third year running Farleigh Hospice showed its support of this UK
initiative. Staff and volunteers across the whole organisation wore red as an expression
of their commitment to dignity.
An audit was also carried out using the “Dignity on the Ward “audit tool. The audit tool is
based on the recording of observations within the Five Key Themes:patient environment,
privacy, dignity and modesty,
communication with patients,
promoting individual needs
staff training in privacy, dignity & promoting individual needs
In the standards covered in the audit, (83%) scored a band 1 (standard fully achieved –
no further action required with 17% a band 2 (standard achieved – minor improvement
is required.) Action plans were developed to address these issues for minor
improvement.
“On an ongoing basis we promote dignity each and every day through
hands on patient care, through supporting and educating the nurses
with yearly training, with policies, by auditing dignity in care and also
through the dignity challenge which has been set out by the
Department of Health.”
Quote from a member of IPU nursing staff.
Medical Open Evening
In February 2012 Farleigh Hospice held its first ever medical open evening as part of an
on-going initiative to increase awareness within the local medical community of the
services provided by Farleigh Hospice. The aim of the event was to fully engage with
GPs and Hospital Consultants, showcase all of our services, and provide an opportunity
for them to meet members of the Farleigh Hospice team.
All GP’s in the Mid Essex area (which includes 53 practices) as well as all Practice
Managers, Hospital Consultants, members of Mid Essex Healthcare Trust (MEHT) and
the Cancer Board were invited to attend the event. 26 people attended on the night and
24
enjoyed a virtual tour of the Inpatient Unit on DVD, a hosted tour of the other patient
care areas of the hospice, refreshments and a chance to meet the Trustees and
members of the Clinical, Medical and Senior Management Teams.
“Overall the evening went very well,…. On the night we received
lots of positive feedback and comments about the services
we provide, the building, the event organisation and
Farleigh Hospice in general”.
Quote from the Event Manager
Everyone was given a ‘take home pack’ which included information regarding the
hospices services, our referral system and the DVD”. The Medical Open Evening is part
of Farleigh Hospice’s ongoing initiative to improve end of life care for the people of Mid
Essex.
Lantern Suite
The Lantern Suite opened in April 2011 to provide facilities for a range of services
aimed at supporting patients, families and carers. Inside the Lantern Suite our new
Information Centre gives anyone who is ill, bereaved, or worried about someone who is,
the opportunity to just ‘drop-in’ for professional information, support and advice. Staff
and volunteers can help people access the wider hospice team, or signpost them to the
most appropriate service.
Inpatient Unit awards special Certificates of Excellence
As part of the celebrations for International Nurses’ Day senior nurses awarded some of
the Inpatient Unit Nurses with special Certificates of Excellence. These included
Excellence in Documentation; Excellence in Health and Safety; Excellence in Caring;
Excellence in Innovation; Calm in a Crisis; Excellent attendance; and Always willing to
cover a shift.
Farleigh Focus
Focus is a monthly news letter for staff and volunteers which provides information and
celebrates the achievements of all aspects of the hospice. It also provides an
opportunity for patients, carers, staff and volunteers to comment on the work of the
hospice.
IPU “Graffiti” Comments Board
The graffiti board was introduced in the Inpatient Unit several years ago to enable
members of the team to comment anonymously on any issue or area within the IPU that
could potentially be improved upon or changed for the benefit of patients and/or carers.
Because of its success we now have a permanent white board in the handover room
and comments and responses are made on a monthly basis. The comments over the
25
year have been diverse from suggestions for speciality training, improving patient
experience, making better use of space to requests for more beakers. Not everything is
possible but each comment is given a response and a monthly report is compiled
detailing this information.
What people say about our organisation
During the forthcoming year it is proposed that we work with patients, their families and
the wider public to understand what, for them, is the most important information that will
help them to make a decision on the quality of the services being provided.
Patients Every year Farleigh Hospice conducts surveys which focus on the quality of care being
delivered. The surveys are carried out by the Independent Service User Facilitator, and
are completed throughout the year by interviewing patients during their stay on the IPU
or at the Day Hospices. Overall the responses about the services were positive and
affirming:Comments on the IPU:‘…, it’s an unbelievably good place to be when you are unwell’’
‘’This place cannot be bettered, I came in here frightened and
scared of dying - now I know it’s not just for that - can’t be bettered.’’
Comments on the Day Hospice
“This is the best day of the week for me.”
“Can’t think of anything you could do to improve it.”
“I feel so lucky to be able to come here – if I think
about having to leave I feel quite tearful.”
Comments on things we could do better:IPU
‘’Would have liked to mix with others more and
had communal music.’’
‘’Could never finish my meal and had to apologise most days’’
‘’Not eating very much so asked for half size portion
and it was perfect.’’
Day Hospice
“Gentle exercise would be good as I can’t get
down the gym anymore.”
26
The feedback showed a high level of satisfaction with the services. No significant issues
were reported and some positive suggestions were made for improvements and
recommendations were agreed and action plans developed to address these. Two
audits were carried out following the IPU survey to review the role of the Welcome
Nurse and information given to patients on admission and Patient Meal Portion sizes as
some felt the portions were too large. Relevant changes were made following these
audits.
When asked ‘What makes a good Nurse?’
All patients were really thoughtful about this question and typically the responses were:IPU
“Listening - they all listen and respond with accuracy.”
“Compassion and care - all the nurses here have it.”
“Care - make you feel like you are at home and a real person.”
“Caring - and not to leave you on your own too long,
which never happens here.”
Day Hospice
“No matter who you are, all the Nurses here are
ready to give you a smile.”
“Professionalism is a serious matter, but with a good
sense of humour. The atmosphere they create makes it
a joy to attend and it’s not a bit like most people’s
concept of what a Hospice is like.”
“Talk to you in a way that you would talk yourself and
if you have a problem they attend to it straight away.”
“Having time to listen to you, prepared to be hands
on and help whenever necessary.”
Staff
All staff are regularly surveyed to seek their views with the next survey planned for 2012
– 2013.
An annual clinical supervision survey was carried out with positive responses:“Supervision is invaluable to me.”
“I enjoy supervision because I feel in control of the agenda –
it is my time to use for the ultimate benefit of clients.”
27
Trustees Two Trustee Provider visits took place in 2011 – 2012 at roughly six monthly intervals
which involved trustees visiting facilities and interviewing staff, patients and volunteers
and checking that our services comply with relevant regulations. Reports from each of
the visits were discussed at the Governance Group. The comments were positive with
no issues requiring immediate resolution. Action plans were developed to address minor
issues which were followed up and concluded by the Senior Management Team. As
usual with such visits the Trustees were impressed with the quality of the service
delivered, the commitment of the staff and volunteers who were interviewed and the
positive feedback from patients.
Volunteers Volunteers are an integral part of Farleigh Hospice and we supported the annual
‘National Volunteers Week’ and ran a Volunteers day in recognition of their valued work.
“As a new volunteer it was a great opportunity to find out
about the services Farleigh Hospice offers and meet other
volunteers. The talks from the carers were especially moving
and emphasised for me why I have chosen to volunteer for
Farleigh Hospice”
- Comment from volunteer who attended Volunteers Day.
A volunteer satisfaction survey was also carried out. Overall the results demonstrated a
high level of satisfaction from the volunteers with their roles, support and information
received facilities and working environment. It also demonstrated a high level of
commitment with over 50 % having worked at Farleigh Hospice for 3 -5 years and over
35% for 11 years plus.
“Farleigh is a lovely place to work. All the staff are so
appreciative of volunteers. The work is so rewarding.”
Carers Farleigh Hospice provides a dedicated service which aims to offer as much support as
possible to carers of hospice patients across Mid Essex and prevent them from feeling
alone and isolated. At Farleigh Hospice we continue to recognise the vital role carers
play throughout the year by providing them with a special support service. The hospice
also supported the annual National Carers Week with a variety of events including
pamper and information days and a barge trip. This year we gave Carers’ Week a
theme which was ‘The True Face of Carers’. A total of around 150 carers attended the
different activities and they all enjoyed the opportunity to have some much needed
respite from their usual day-to-day lives. The week was a resounding success with lots
of positive feedback received throughout the 5 days
28
“Very relaxing, just what I needed, thank you all so much.”
“Excellent, thank you for the opportunity to meet others
in my position”
Following feedback we have continued to organise pamper days and coffee mornings
throughout the year.
29
Statement from North Essex PCT Cluster
31 May 2012
Janet Doghan
Chief Executive Officer
Farleigh Hospice
North Court Road
Chelmsford
Essex
CM1 7FH
Dear Janet
NHS North Essex PCT response to Farleigh Hospice Quality Account for 2011 to
2012
This is the final year that Quality Accounts are being commented on by NHS North
Essex Cluster. The Cluster welcomes this Quality Account as a commitment to an open
and honest dialogue with the public regarding the quality of care provided by Farleigh
Hospice.
Assurance from the PCT is required to ensure that the information in this Quality
Account is accurate, fairly interpreted, and representative of the range of services
delivered.
Though the PCT are commenting on a draft version of this Quality Account, it is pleased
to be able to assure the accuracy of the content in general. The PCT is however unable
to assure all data reported, as some is yet to be reported.
You describe processes to monitor your own progress through the year including the
involvement of the Trustees, these appear robust. You give an outline summary of
actions taken in the past twelve months and your vision for year to come. You provide
information on activities you have used to involve people in your services including the
Dignity Action Day and Medical Open Evening. We are pleased to note the comments
made by those who use your service.
Your priorities for improvement in 2011 – 2012 have been supported by the North Essex
PCT Cluster through the agreement of CQUIN schemes which provide financial
incentives to improve quality. You have made clear links between all targets and how
you have made progress and how this has been measured. Data on how much has
been achieved is not included although we note that monitoring reports are sent to our
30
commissioner at quarterly intervals in accordance with the Service Level Agreement.
We recognise that you are an independent charity providing services free of charge part
funded by the NHS.
We note your work to deliver services which meet the End of Life Strategy 2008 and the
Gold Standard Framework, including the development of the Hospice at Home service.
This is seen to have made progress and we note your intentions to further develop this.
We note the positive effect that has been recorded by people and their families you
have cared for. We also note that you have developed a quality assurance system and
annual audit cycle to deliver quality improvements across the organisation. Further that
you have extended your bereavement service, a rehabilitation suite and have been
involved in national campaign to change attitudes to death and dying. We commend the
work you have undertaken.
You give a comprehensive description of your participation in and learning from clinical
audit, although there were no relevant national audits for you to participate in.
In your report there is information about your performance in respect of data quality we
note that you are taking action to improve data quality, and have developed a minimum
data set. We also note that that you were involved in the completion of the Information
Governance Tool Kit and that you were assessed as 'Satisfactory'. You have provided
an overview of your activity giving comprehensive information which compares your
activity to others across the country who provide similar services.
Your strategic priorities for improvement in 2012 – 2013 are:
1.
2.
3.
4.
Evaluation of the Hospice at Home Service in Mid-Essex
Staff Training Matrix for Mandatory training
Review of Services using 'Lean' process
Connection to NHS 'N3' broadband network to improve clinical communication
You describe your decision making process and those you have involved. We note you
have also described the processes for monitoring and assuring the progress of your
work in these areas.
In conclusion the North Essex PCT Cluster considers Farleigh Hospice Quality
Accounts for 2011 to 2012 as providing an accurate and balanced picture of key issues
in the reporting period. The PCT encourages the organisation to continue to implement
the multiple and wide-ranging efforts and initiatives to improve and be innovative in its
delivery of quality in the services delivered.
Yours sincerely
Denise Hagel
Interim Director of Nursing
North Essex Cluster
31
Statement from Essex Health Overview and Scrutiny Committees
6th June 2012
RE: Farleigh Hospice Quality Account 2011 -2012
Detailed below the formal response from the Essex Health Overview and Scrutiny
Committee (HOSC):Thank you for the opportunity to comments on the Quality Accounts for 2011/12.
The Essex HOSC rarely has dealings with a Hospice. However, it is well aware of
the important role they carry out and the long tradition of support of hospices by
Essex residents. The Committee’s chairman is, himself, the Chief Executive of a
Hospice. The HOSC has also commented on End of Life strategies in use in the
county, so is aware of the issues involved.
The HOSC has received a number of Accounts from hospices in this round and has
noted a number of common themes, which this document also includes. It
particularly welcomes the work Farleigh is undertaking on the Hospice at Home and
Bereavement Support Services initiatives – the end of the life of one individual does
affect many others and these initiatives display a recognition of that fact.
The HOSC will be invited to receive an update on the work of the hospices in Essex
at one of its meetings in 2012/13.
Graham Redgwell
(Secretary to the Essex HOSC)
PO Box 11
County Hall
Chelmsford
CM1 1LX
32
Statement from Essex & Southend Local Involvement Network
Farleigh Hospice Quality Account 2011-12 submission by Mid Essex Locality,
Essex & Southend LINk
“Essex & Southend LINk (E&S LINk) is divided into five Locality Groups. Its Mid Essex
Locality Group covers Chelmsford Borough, Maldon District and Braintree District and
so is the Group which relates to Farleigh Hospice and is responsible for this statement.
During 2012/13 E&S LINk looks forward to developing a good working relationship with
Farleigh Hospice as a ‘critical friend’. It hopes this will include invitations to attend and
contribute to Board and other executive group meetings and that there will be a smooth
transition of this to Essex (Local) HealthWatch in April 2013.
Formalised arrangements, as enjoyed by us with other commissioners and providers,
will enable E&S LINk, and Essex HealthWatch in due course, to gain information and
understanding and provide the opportunity to press the case for patients and public. The
attitude of staff and clinical practice are the matters of most concern to patients and
public about health care services. The Dignity & Respect agenda must be at the heart of
everything Farleigh Hospice does.
Farleigh Hospice must be at the forefront of the development of End of Life Care, home
and community care in the next few years as healthcare moves as much as possible
away from acute hospital treatment to treatment at home and in the community. It is
good to see that patients, their families and carers place their gratitude on record for the
care they receive from Farleigh.
As we have had little contact to date with Farleigh Hospice it is not possible for us to
comment in any detail about its past performance other than to say that this Hospice
enjoys an excellent reputation in the local community which is reflected in the financial
and moral support given. A senior representative of Farleigh has agreed to attend and
speak at our next meeting on 5 July 2012 which we welcome and hope will be the start
of a mutually fruitful developing relationship.
Turning to the Priorities set for 2012-13, all of which we would like to see specifically
quantified, transparently monitored and publicly reported:
33
Not only would we like to see the Hospice@Home service in Mid Essex
evaluated but also reviewed, developed as appropriate to the results of the
evaluation and increased;
The development of a Staff Training Matrix for Mandatory Training and
establishment of an Education & Training Group are timely; we would expect
this to extend beyond statutory and regulatory mandatory training to include: the
Dignity & Respect agenda; patient/public/’customer’ service; induction of new
permanent, bank and agency staff in all roles; and, effective engagement with
health and social care partners;
Clinical effectiveness is a fundamental requirement and continuing close
attention to service efficiency and effectiveness is a necessity; patient
pathways and experience need to be constantly assessed, by Executives, NonExecutives and outside monitors; the Board must lead Farleigh as a learning
organisation and patient stories should be an agenda item at all Board meetings;
Connection to the NHS ‘N3’ broadband network computer service will improve
patient care by speeding up diagnostics and decisions about treatment.
Other issues:
We would like to see Farleigh Hospice develop and deliver a Patient & Public
Involvement & Engagement Strategy and would like to help with this; we hope
that will lead to a formal arrangement for engagement with E&S LINk and then
Essex HealthWatch;
We would like to see Farleigh Hospice develop and deliver its own PALS (Patient
Advice & Liaison Service) in line with other healthcare providers; and
We would like to see Farleigh Hospice bring its compliments, complaints and
incident reporting in line with other health care providers so that there is
transparency about the numbers and nature of Compliments, Complaints,
Serious Incidents and Never Events; close attention should continue to be
given to reducing the numbers of accidents/incidents, patient falls, medication
related incidents, medical device alerts, inpatient acquired infections (with
specific attention to and reporting of MRSA and C Diff) and pressure ulcers
(which should be measured on the 1-4 scale).
Farleigh Hospice patients and the public in Mid Essex want it to aspire to be, and
become, the best provider of inpatient and community hospice care in Essex, the East
of England and the country.”
______________________________________________________________________
Thank you. It is because you care that we can
Farleigh Hospice, North Court Road, Chelmsford, Essex, CM1 7FH
Charity Registration No 284670
34
Appendix A
Audits completed April 2011 – March 2012
Date
Apr-11
Audit
Controlled Drugs (CDs) – Audit on the Inpatient unit
Apr-11
Destruction of Controlled Drugs – Advise given to patients/carers in the
community
May-11
Apr-11
May-11
May-11
May-11
Jun-11
Jul-11
Jul-11
Jun-11
Jun-11
Jun-11
Jun-11
Jul-11
Jul-11
Jul-11
Aug-11
Oct-11
Dec-11
Dec-11
Dec-11
Jan-12
Jan-12
Jan-12
Jan-12
Oct-11
Jan-12
Jan-12
Jan-12
Jan-12
Jan-12
Patient Identification Bands
IT Systems Survey
In Patient Unit Infection Control Audit
Farleigh in Chelmsford Day Hospice – Cleaning Audit
In Patient Unit – Cleaning Audit
Basic Documentation of patients notes
Omitted and Delayed Medication - 01/04/11 to 30/06/11
Controlled Drugs – Help the Hospice audit tool
Carers Week Survey feedback
Farleigh in Maldon Day Hospice - Infection Control Audit
Triage - Re-referrals
Lantern Suite – Infection Control Audit
Farleigh in Maldon Day Hospice - Cleaning Audit
IT Helpdesk on time report
Medication Adverse Events - 01/04/11 to 30/06/11
Patient Identification Bands – re audit
Controlled Drugs (CDs) – re audit
In Patient Unit Patient Satisfaction Survey
Welcome Nurse Checklist
Patients’ Meal Portion Sizes
Welcome to Farleigh Hospice events feedback
Farleigh in Maldon Day Hospice – Cleaning Audit
Food Hygiene Standards – Chelmsford
Basic Documentation of patients notes
Medication Adverse Events – 01/07/11 to 30/09/11
Medication Adverse Events - 01/10/11 to 31/12/11
Independent Practitioner Audit
Liverpool Care Pathway documentation
Patient Survey – Farleigh in Chelmsford Day Hospice
Patient Survey – Farleigh in Maldon Day Hospice
35
Date
Jan-12
Jan-12
Jan-12
Jan-12
Feb-12
Dec-11
Feb-12
Dec-12
Dec-12
Jan-12
Feb-12
Feb-12
Feb-12
Feb-12
Mar-12
Mar-12
Mar-12
Mar-12
Mar-12
Mar-12
Audit
Volunteers day Evaluation
Gift Aid - Fundraising
Lantern Suite Environmental Audit
Controlled Drugs (CDs) – Re audit of one item on the Inpatient unit
Dignity on the IPU
Volunteer Satisfaction Survey 2011
Speed of response to donations
Farleigh in Chelmsford Day Hospice – Cleaning Audit
In Patient Unit – Cleaning Audit
Lantern Suite – Cleaning Audit
Cycle for Life 2011 Evaluation
In Patient Unit (TTOs) to take out medication forms
Omitted and Delayed Medication - 01/07/11 to 30/09/11
Omitted and Delayed Medication - 01/10/11 to 31/12/11
Light up a Life (LUPAL) – Help the Hospices survey 2011
Clinical Supervision
Infections and pressure Ulcers April 2011 – March 2012
Hospice @ Home - Carers survey
Omitted and Delayed Medication - 01/01/12 to 31/03/12
Medication Adverse Events - 01/01/12 to 31/03/12
If you would like further details of the outcomes of the above audits please contact:
susanbridger@farleighhospice.org
36