QUALITY ACCOUNT
2012
Philosophy of Care
Halton Haven Hospice offers a patient centred and patient led approach to the
provision of Palliative Care. Physical, psychological, spiritual, emotional and
social needs are met with sensitivity regardless of colour, creed or social
standing. Patient’s views are respected and needs identified in consultation with
them and their families.
CONTENTS
•
Statement from the Chair of Halton Haven Hospice Trustees
•
About this Quality Account
•
Introduction to Halton Haven Hospice
•
Statements of Assurance from the Board
(Formal Statements required by The Department Of Health)
•
Review Of Quality Performance Priorities 2011-2012
•
Feedback from Patients and Relatives on Services
•
Staff Quality Improvements Survey
•
Clinical Governance Overview 2011 – 2012
•
Community Engagement Review
•
Priorities for Improvement 2012 – 2013
•
Statements on Halton Haven Hospice’s Quality Account
•
Opportunity to Provide Feedback on this Quality Account
2
CHAIR OF HALTON HAVEN HOSPICE
TRUSTEE’S STATEMENT
I am very pleased to present the first annual Quality Account for Halton Haven
Hospice. The quality of our services is at the heart of our Hospice and our quality
framework and monitoring systems have been developed, and are actively
reviewed, in order to provide us with a culture of continuous improvement, in
which any shortfalls are identified and acted upon quickly.
In this Quality Account, I and the Board of Trustees are delighted to have the
opportunity to highlight some of the priority activities we have been engaged in
here at Halton Haven Hospice, which have improved the Patient and Carer
experience over the past year. We also look forward to the next twelve months
with priority goals set for continued improvement and development.
Our measure of quality is not solely based on meeting clinical targets, though
these are very important. Our aim is to provide a human service that provides a
high level of dignity and respect to the people of Halton we serve during very
difficult times in their lives, and it is hoped that this is reflected in our Quality
Account.
It does need to be acknowledged that over the past year Patients, Carers,
Visitors and indeed Staff have had to endure a fair amount of disruption to the
Hospice environment, as refurbishment work in many areas has taken place. The
Board of Trustees would like to thank everyone who has had to live and work
around ongoing reconstruction of the building during this period for their
understanding and patience. The current refurbishment has now been
completed and I am sure you will see from our Quality Account that the
improvements have resulted in a Hospice that is better equipped to provide a
high quality service to the people of Halton for many years to come.
Despite the current economic climate, the Hospice has continued to be able to
provide a high quality, cost effective, specialist service to patients and their
families. Together with the Board of Trustees, I would like to thank all of our Staff
and Volunteers for their achievements in providing this quality of service during
2011 – 2012.
I, as Chair of Halton Haven Hospice Trustees, am responsible for the preparation
of this report and its contents, and to the best of my knowledge the information
contained therein is accurate and a fair representation of the quality of the NHS
healthcare services provided by Halton Haven Hospice.
Carole Gibbard
Chair of Halton Haven Hospice Trustees
3
ABOUT THIS QUALITY ACCOUNT
ABOUT THIS QUALITY ACCOUNT
There is a requirement of the Health Care Act 2009 that all providers of NHS
healthcare services should produce a Quality Account, including independent
organisations. According to the Department for Health, “Quality Accounts aim to
enhance accountability to the public and engage the leaders of an
organisation in their quality improvement agenda.’’ They provide information
about the quality of the services which that organisation delivers.
Quality Accounts are annual reports to the public about the quality of NHS
healthcare services an organisation provides and their main purpose is to
encourage providers to take a robust approach to quality. By publishing their
Quality Account each provider, led by their Board, is committing to improve the
quality of care it delivers locally and invites the public to hold them to account.
The Quality Account covers two main areas:
•
A review of how we performed last year, covering the three main areas of
quality: Patient Safety, Patient Experience and Clinical Effectiveness.
•
A set of key priorities for improvement next year and plans for how we will
measure that improvement.
The Public, Patients and others with an interest, will use a Quality Account to
understand:
•
What an organisation is doing well;
•
Where improvements in service quality are required;
•
What the organisation’s priorities for improvement are for the coming
year; and,
•
How the organisation has involved people who use their services, staff,
and others with an interest in their organisation in determining these
priorities for improvement.
For further details around Quality Accounts, please see the NHS Choices website:
http://www.nhs.uk/aboutNHSChoices/professionals/healthandcareprofessionals/
qualityaccounts/Pages/about-quality-accounts.aspx
INTRODUCTION TO BARNET COMMUNITY
4
INTRODUCTION TO HALTON HAVEN HOSPICE
Our Vision
We will continue to be the leading provider of specialist palliative care for
the people of Halton
We will provide our special kind of caring with compassion and humanity
to meet and support the choices our patients make
We will use our expertise to enhance the experience of patients in other
care settings
Halton Haven Hospice is a registered charity with its origins in the vision of one
man, Dom Valdez. Activity started on our present site in 1981. The first element of
the Hospice was the unit which is now our Day Hospice lounge and this was
followed by the adjoining Inglenook in 1986. The Inpatient Unit was built in the
early 1990s with the Amanda Edwards Unit following, which was the last element
of the Hospice and is now an integral part of our Day Hospice.
Halton Haven Hospice is a single story building which underwent a full
refurbishment programme during the period 2010/2012. This has resulted in
substantial development of the original structure of the Hospice and we are now
well placed to meet the challenges of the future, in providing high quality
Specialist Palliative Care for the community of Halton.
The Hospice In-Patient Unit is registered with the Care Quality Commission and
has provision for twelve palliative care beds. The In-Patient Unit has a
comfortable lounge leading directly into a conservatory and then out into the
well developed garden areas. In-Patient bedrooms have en-suite facilities, with
some having an en-suite shower and additional space to accommodate
patients with physical disabilities. All rooms have remote control television, radio,
CD player and an electric fan. There is a specialist bathing and shower room to
enable patient choice. A comfortable visitor’s room, with access to tea and
coffee making facilities, is available.
The Hospice has made provision of a
dedicated Quiet Room available twenty four hours a day for quiet reflection,
prayer and religious services.
5
The Day Hospice is licensed to accommodate up to twelve patients per day. It
has a comfortable lounge, access to a well presented dining area, activities,
Complementary Therapy and Physiotherapy rooms and access to established
garden areas. Day Hospice has its own toilet and shower facilities, which are
suitable for disabled use. A patient call system is available within all patient
areas. One day a week the Day Hospice facilities are utilised as a Specialist
Outpatient Clinic.
Our patients are cared for in a clean, comfortable, safe and smoke free
environment and treated with respect and sensitivity to their individual needs
and abilities. Staff are responsive to all patients and their relatives, providing the
appropriate support to ensure the optimum quality of life during their stay with us.
The Hospice’s key objectives are to;
•
Provide a flexible and adaptive approach to Palliative Care Services.
•
Provide expert care at the highest standard achievable, thereby
enhancing the quality of life for patients faced with life limiting illnesses.
•
Respect patient choice and autonomy. We are mindful of the individuals
need for dignity, independence and privacy.
•
Respect and acknowledge individual spiritual and religious beliefs.
•
Provide a system of support which enables the person to live as actively as
possible and supports the family and other carers.
•
Work in conjunction with other professionals in order to provide a seamless
service.
•
Ensure care is provided by a team who have undergone appropriate
Specialist Palliative Care training.
•
Contribute to the education and development of the Hospice’s own staff
and to the local palliative care education programmes.
•
Evaluate and improve our services through analysis of feedback from
patients, relatives, other professionals and staff questionnaires.
Halton Haven Hospice aims to provide care to all our patients to a standard of
excellence which embraces fundamental principles of best practice, and that
this will be evaluated and evidenced through quality control and risk
management systems.
6
STATEMENTS OF ASSURANCE
FROM THE BOARD
(FORMAL STATEMENTS REQUIRED BY THE DEPARTMENT OF HEALTH)
The following are statements under various headings that all providers of NHS
healthcare services must include in their Quality Account, even though many of
the statements are not directly applicable to us as a Specialist Palliative Care
provider.
Review of Services
During 2011/12 Halton Haven Hospice provided Specialist Palliative Care Services
to the NHS.
Halton Haven Hospice has reviewed all the data available to us on the quality of
care in these NHS services.
The income generated by the NHS services reviewed in 2011/12 represents 42 %
of the total income generated from the provision of NHS services by Halton
Haven Hospice for 2011/12. This 42% represents only part of the funding required
to provide services at Halton Haven Hospice; the remaining 58% of income is
generated through fundraising and the generosity of the local community.
Participation in Clinical Audits:
During 2011/12 NO national clinical audits and NO national confidential enquiries
covered NHS services that Halton Haven Hospice provides.”
During that period Halton Haven Hospice participated in 0% national clinical
audits and 0% national confidential enquiries of the national clinical audits and
national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Halton Haven
Hospice was eligible to participate in during 2011/12 was NONE.
Research
The number of patients receiving NHS services provided by Halton Haven
Hospice in 2011/12 that were recruited during that period to participate in
research approved by a research ethics committee was NONE. The Hospice
would be open to participate in research projects subject to eligibility.
7
Use of the CQUIN Payment Framework
A proportion of Halton Haven Hospice’s income in 2011-2012 was conditional on
achieving quality improvement and innovation goals agreed between Halton
Haven Hospice and the commissioning PCT they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
The improvement conditions that were agreed were as follows:
•
Halton Haven Hospice was to provide 24 hour medical cover for patients
at the Hospice.
•
Halton Haven Hospice was to make preparations to become a Consultant
led service.
•
Halton Haven Hospice was to make preparations to extend the Clinical IT
system.
These three conditions have been met over the past 12 months
Care Quality Commission (CQC)
Halton Haven Hospice is required to register with the Care Quality Commission
and its current registration status is independent Hospice for Adults. It is registered
to provide the following regulated activities:
•
•
Diagnostic and screening procedures
Treatment of disease, disorder or injury
Halton Haven Hospice has the following conditions on registration:
•
•
•
•
The establishment is registered for the provision of supportive and
palliative care services.
The establishment will provide overnight treatment to a maximum of 12
(twelve) persons aged 18 (eighteen) years or over.
The establishment may provide day services for 12 (twelve) patients at
any one time for patients aged 18 (eighteen) years or over.
The prior written approval of the Care Quality Commission must be
obtained at least 4 (four) weeks in advance if providing any treatment or
service not detailed in the Statement of Purpose.
The CQC has not taken enforcement action against Halton Haven Hospice
during 2011/12.
Halton Haven Hospice has not participated in special reviews or investigations by
the CQC during 2011/12.
Halton Haven Hospice was inspected by CQC on 23rd November 2011 and was
found to be compliant with standards and outcomes.
8
Data Quality
Halton Haven Hospice did not submit records during 2011/12 to the Secondary
Uses Service for inclusion in the Hospital Episode Statistics which are included in
the latest published data.
Information Governance Toolkit Attainment Levels
Halton Haven Hospice did not use the Information Governance Toolkit to assess
its information governance management as this is not applicable to Palliative
Care Services.
Clinical Coding Error Rate
Halton Haven Hospice was not subject to the Payment by Results clinical coding
audit during 2011/12 by the Audit Commission.
9
REVIEW OF QUALITY PERFORMANCE
PRIORITIES 2011-2012
During the year 2011 – 2012 Halton Haven Hospice set priorities for improvement
in the areas of Patient Safety, Clinical Effectiveness and Patient Experience. In
this section we review our Quality Performance in meeting the targets we set for
ourselves.
• PRIORITY ONE
PATIENT SAFETY
Halton Haven Hospice’s Priority for Patient Safety for
the Year 2011 – 2012 was to ensure the provision
of 24 hour Medical Cover.
THIS GOAL HAS BEEN MET
Prior to 2011-2012 the Hospice operated with an out of hours agreement with
Devon Doctors that if required we could contact them to attend the Hospice to
assess the needs of a patient. During the course of this agreement there was
actually never the need to contact Devon Doctors to request a visit due to a
good will arrangement with our own Medical officers being organised who
would visit when requested. This was supported by improved assessment,
appropriate anticipatory prescribing and availability of out of hours telephone
support. This was however an informal arrangement.
It was agreed, in the interest of improved patient safety at the Hospice, to
prioritise making formal this arrangement with our Medical Officers. Throughout
the year a change in working conditions was discussed with the Medical Team
and agreement was reached to commence 24 hour medical cover by our own
Medical Officers in January 2012.
This has enabled Nursing Staff to have access to Medical Officers who know the
patients at the Hospice and whom have Specialist Palliative Care knowledge
and experience at any time throughout the day or night, thus ensuring that
patients receive the best possible care and experience possible.
10
• PRIORITY TWO
CLINICAL EFFECTIVENESS
Halton Haven Hospice’s Priority for Clinical Effectiveness for the
Year 2011 – 2012 was to establish a Quality Assurance Team
within the Hospice.
THIS GOAL HAS BEEN MET
The Hospice Directors identified the need to evidence patient and carer
outcomes and to ensure the achievement of continual quality improvement at
Halton Haven Hospice. To facilitate this it was determined that it would be
beneficial to develop a Quality Assurance Team.
In April 2011 two Quality Assurance Officers were recruited and were in post
ready to begin the work of setting up and putting into place the tools through
which quality service delivery could be continually assessed.
Throughout the year much has been instigated and achieved by the Quality
Assurance Team. Audits, Patient and Carer Surveys, Staff Surveys, Policy and
Procedure reviews, Documentation reviews, Risk Management, analysis of
events, identification of training needs, reporting to the Clinical Governance
Group and much more has contributed to the Hospice being in a better position
to be able to monitor the services provided, evidence the quality of those
services, identify any shortfalls and advise on changes to service delivery where
evidence proves it may be necessary or appropriate to do so.
Being able to do this enables the Hospice to improve Clinical Effectiveness and
ensure that patients receive the best possible care, with the aim of meeting their
expected outcomes.
11
• PRIORITY THREE
PATIENT EXPERIENCE
Halton Haven Hospice’s Priority for Patient Experience for the
Year 2011 – 2012 was to complete a
refurbishment of the Hospice building.
THIS GOAL HAS BEEN MET
Halton Haven Hospice is a single storey building situated in Runcorn, Cheshire
and has been established since 1981. The Hospice has undergone significant
changes to service provision over the past 32 years and it was felt that the
building was in need of refurbishment in order to keep up with those changes.
The aim of the refurbishment project was to improve the environment at the
Hospice, to enhance patient experience and to facilitate the further
development of services for the local people of Halton with Palliative Care
needs.
Some of the changes the refurbishment has enabled include:
•
A new conservatory where the doors slide back to allow a feeling of
being outdoors whilst being inside.
12
•
Four larger rooms with bigger en-suites to allow greater independence for
wheelchair users and to accommodate those with larger families. This was
a direct result of verbal patient feedback.
•
Three rooms now with patio doors leading onto the garden which allows
for a better experience for patients with breathing difficulties. Again this
came from patient feedback.
•
There is now a larger shower room and a larger bath room with a new
Hydrotherapy bath, both of which have enhanced patient experience.
13
•
All other rooms have been refurbished to bring about an environment that
is modern, homely and comfortable.
•
We also have a refreshed Visitors Room where patient’s families and
friends can take time out, make themselves refreshments and relax a little.
The refurbished building was officially opened by Andrew Lansley MP, Secretary
of State for Health, in 2011 and the improved and extended building has
enabled the increase of support services already available, with greater access
to Day Hospice, In-Patient Unit, Out-Patient Clinic, Complementary Therapies,
Physiotherapy, Family Support Team and Patient and Carer Support Groups.
Feedback from service users and staff on the refurbishment has been very
positive and complimentary and we are confident that the changes have, and
will into the future, benefit anyone who visits the Hospice.
14
FEEDBACK FROM PATIENTS
AND RELATIVES ON SERVICES
Halton Haven Hospice surveys its patients and their relatives on a regular basis in
order to get feedback from them on the services that we provide, to enable
continuous evaluation of what the people who use our services think about what
we do well and what we might be able to do better. The questionnaire seeks
opinion on:
•
Whether or not the information we provide is sufficient to allow patients to
make informed decisions and choices.
•
Whether or not patients felt involved in the medical assessment process
that they undergo.
•
Whether or not the care that we provided met the patient’s expected
outcome.
•
Whether or not we treat people who come to the Hospice with the dignity
and respect they expect and deserve.
With the quarterly analysis of returned questionnaires we would be able to
identify areas where improvement to service delivery may be required or to
identify any significant trends.
PATIENT AND CARER SURVEYS FOR THE PERIOD
1ST FEBRUARY 2011 – 31st JANUARY 2012
No. of questionnaires sent out :
Questionnaire completed
by
Which Services Were
114
No. returned :
Patient : 22%
In Patients :
Relative :
85%
64
77%
Day Hospice :
Return Rate :
Friend / Other Visitor : 1%
20%
Accessed by Respondents
Physiotherapy : 9%
15
56%
Family Support: 20%
Complementary
Therapy
: 22%
Chaplaincy
: 16%
Was an information leaflet
on the service accessed
seen
YES :
How many of those that saw
the leaflet found it useful
YES :
How many respondents saw
the Infection Control Leaflet
YES :
How many respondents
who saw it found the
Infection Control Leaflet
useful
YES :
97%
100%
81%
100%
NO :
2%
NO REPLY:
1%
NO :
0%
NO :
17%
NO REPLY:
2%
NO :
0%
Excellent
Good
Fair
No Reply
Staff
98%
2%
-
-
How did respondents
Facilities
97%
3%
-
-
rate our services
Food
72%
22%
-
6%
Cleanliness of
Building
98%
2%
-
-
How many of
respondents saw the
bedside information
booklet
YES :
83%
NO :
16
9%
N/A :
8%
How many of the
respondents who saw
the bedside
information booklet
found it useful
YES :
Of the respondents
how many said that
they consented to their
initial assessments
YES :
Of the respondents
how many said that
they felt involved in
their initial assessment
YES :
Of the respondents
how many said that
they were satisfied that
their assessments
resulted in care that
met their needs
YES :
Of the respondents
how many said that
staff explained how
they could be involved
in the ongoing review
of their care
YES :
98%
NO :
94%
92%
NO :
0%
NO REPLY:
2%
0%
NOT ASKED :
0%
NOT SURE :
2%
NO REPLY:
4%
NO :
6%
NO REPLY:
2%
98%
NO :
2%
89%
NO :
6%
NOT APPLICABLE:
2%
NO REPLY:
3%
17
Of the respondents
who said it was not
explained to them,
how many would have
liked to have been
involved in the
ongoing reviews of
their care
YES :
Of the respondents
how many thought that
staff respected their
personal views, values
and beliefs
YES :
Of the relatives that
replied how many said
that their needs were
discussed with them
YES :
Of the relatives that
replied how many
were satisfied that their
own needs were met
YES :
0%
97%
92%
96%
18
NO :
75%
NO REPLY :
25%
NO :
0%
NO REPLY:
3%
NO :
2%
NO REPLY:
6%
NO :
0%
NO REPLY:
4%
In reviewing the results of the Patient and Carer Surveys the Hospice set a
benchmark of 85% and where this was not achieved for any of the areas
surveyed the Hospice was able to determine any actions that may be necessary
for the future.
When analysing the results for the year it is apparent that 81% of respondents say
that they saw the Infection Control Information leaflet that we provide. However,
the Hospice was aware of this earlier in the year and made Infection Control
Information more prominent throughout the Hospice. The latest of the quarterly
Surveys, completed at the end of January 2012, showed that 92% of respondents
said that they saw the Infection Control Information, which is an improvement
the Hospice hopes to see continued throughout this year.
The Hospice believes that the control of infection risks is critical to the quality of
the services provided and maintaining the safety and welfare of all patients,
visitors and staff by ensuring that advice and appropriate information is easily
accessible to all is crucial in this objective.
83% of respondents reported that they saw the Bedside Information Booklet
(Service User Guide), which is lower than the 85% benchmark. However, 8% of
respondents reported that they didn’t see the Booklet as it was Not Applicable to
them, due to them accessing services other than the In-Patient unit. Therefore
the number of respondents the Bedside Booklet was relevant to who saw it
actually exceeds the benchmark.
Even though this falls within the benchmark we believe it is possible to improve
and the Hospice will make efforts to display the Booklet more prominently. This is
important as we wish to give as much information as possible to our patients, and
their families and carers in order that they are able to make informed decisions
and choices during their stay at Halton Haven Hospice.
The surveys identified that 72% of respondents believed the food served at the
Hospice was excellent and 22% believed the food was good. Although below
the benchmark, together the scores total 94% and no respondents indicated
that the food was poor.
To ensure continued improvement the Hospice Catering team have planned
further nutritional and dietary training and will be reviewing their menu plans to
ensure greater variety and choice.
19
The following quotations have been taken directly from the returned
Patient / Carer questionnaires received during 2011-2012
“Prioritising all the right things to provide excellent service”
“Staff took time to discuss everything, taking everyone’s feelings into account
supporting all the family members individually.”
“Although a very sad time we are left with memories to cherish, the staff made it
a special time for us all”
“Each family member was made to feel special and involved from the day of
admission onwards”
“Can’t rate the service highly enough! Only ever heard good things about the
Haven from anyone who has spoken about it.”
“The Hospice is extremely well run – standards are rated excellent, can’t go any
higher.”
“Just to say thank you for the love and care shown to my husband and family.
You are such wonderful, dedicated people during such sad times in our lives.”
“…was treated royally. Care was wonderful; the staff could not have done any
more.”
“Standards of care received, help, advice and much needed support were all
there when we needed it.”
“Halton Haven and all the staff are a brilliant help to families. I cannot say
enough about the Haven; it is a lovely, special place”
“The staff at all levels or whichever their job descriptions were absolutely
marvellous.”
“The care and professionalism were excellent”
“Respected my husband’s views entirely, even when it made their own job
harder. Much appreciated as he had little control over his illness”
“Sadly my husband has died, but I have nothing but praise and appreciation for
all at Halton Haven. Their presence in our life at such a traumatic time has been
invaluable.”
“On the day my father passed away the nurses on duty that day were most
helpful. Nothing could be faulted.”
“Our whole experience of the Hospice has been above and beyond the service
we expected.”
20
STAFF QUALITY IMPROVEMENTS SURVEY
Hospice staff were surveyed to determine what they thought had been the most
significant quality improvements they had seen at the Hospice over the previous
year. The responses have been collated and are presented below:
•
Responders believe the refurbishment of the Hospice has had significant
impact on quality improvement and has enhanced patient experience.
•
Responders believe the Quality Audits have supported and evidenced
improved clinical effectiveness and monitoring of services
•
Responders believe 24 hour medical cover is significant and has resulted
in improved patient safety
•
Responders believe the addition of a Social Worker to the Family support
team is an asset to quality service for patients and their families
•
Responders believe the introduction of a new Menu selection system for
patients has made a significant difference for patients by emphasising
and enhancing patient choice.
•
Other comments from respondents included:
-
Dedicated Doctor for Day Hospice has strengthened the provision
of Medical Care at the Hospice.
-
The instigation of Patient and Carer Surveys has provided useful
feedback on our services, allowing us to see what our patients and
their carers think of the services that we provide.
-
Provision of Outpatient Clinic has broadened the services that the
Hospice provides for patients in the community of Halton.
-
Documentation changes in Patient Notes have made them more
user friendly and therefore the quality of documentation has
improved.
-
Access to University Training Course Modules for Staff and more
mandatory training within the Hospice has provided staff with
increased learning opportunities that will help to increase and
maintain their skills and support quality improvement.
-
Perceived increased Professionalism within the Hospice, which has
been achieved without losing the warm and friendly environment
the Hospice prides itself on.
This feedback from staff, we feel, goes towards evidencing that our Priorities for
Improvement for 2011-2012 have been achieved and the benefits of those
improvements are now being experienced. It also shows what has been done at
Halton Haven Hospice beyond the Priorities set for last year.
21
Hospice staff were also asked in the survey where they thought we could
achieve further quality improvements in the coming year. The responses have
been collated and are presented below:
•
Responders believe more specialist training i.e. symptom management,
verification of death etc, it would support quality improvement.
•
In house training strategy and plan for other than mandatory training.
•
Further N.V.Q. training for Health Care Assistants.
•
Discharge planning – It is felt that a Discharge Co-ordinator position would
benefit patients greatly.
•
In house Occupational Therapist would also help to improve the
discharge process for patients.
•
Increase Qualified Nurse Bank and reduction in staff turnover.
•
Introduce Hospice at Home at some point in the future which would take
Hospice services further into the community and improve the care that
could be provided to patients in their own homes/Preferred Place of
Care.
•
Improve communication.
•
Improve menu choices to reduce repetition of meals and less use of
packet soups and desserts.
•
Increase public and professional awareness of the Hospice and its
Services.
•
Telephone Advice Helpline for the use of other Professionals in the
community would be a step forward in utilising the expertise in Palliative
Care that can be found at the Hospice.
•
Improved Patient access to IT could facilitate better channels of
communication for patients with their families and friends while they were
staying at the Hospice.
•
Patient rest times each afternoon where visiting would be limited.
Halton Haven Hospice will utilise these suggestions from staff to form part of the
basis for discussion when developing the Hospice business plan and setting
Priorities for Quality Improvements for the forthcoming year. There are some that
the Hospice is already preparing to put into place, such as a telephone advice
line for other professionals.
Whilst it may not be practicable to include all employee suggestions in the
forthcoming year priorities, every effort will be made to make progress in as
many of these areas as possible.
22
CLINICAL GOVERNANCE OVERVIEW
COVERING PERIOD-1ST APRIL 2011 to 31ST MARCH 2012
This Clinical Governance overview looks at areas that we determine are specific
indicators of quality and outcomes for all who use services at the Hospice.
COMPLAINTS
TOTAL NUMBER OF COMPLAINTS
1
WRITTEN COMPLAINTS
TOTAL
0
NUMBER UPHELD:
0
NUMBER UNSUBSTATIATED:
0
NUMBER ONGOING:
0
VERBAL COMPLAINTS
TOTAL
1
NUMBER UPHELD:
0
NUMBER UNSUBSTATIATED:
1
NUMBER ONGOING:
0
The one complaint that was received during this reporting period was discussed
with the complainant and was found to be unsubstantiated. The discussion was
concluded to the satisfaction of the complainant. Halton Haven Hospice takes
all complaints very seriously and they are always thoroughly investigated. The
Hospice endorses a culture of continuous improvement in which we constantly
review the quality of the services provided and any shortfalls identified are acted
upon quickly. Any complaints that we receive are looked at in this light, with the
aim of providing the complainant with a satisfactory outcome and learning
where we can to improve in what we do.
23
INFECTION CONTROL
HEALTHCARE
ASSOCIATED
INFECTIONS:
0
Halton Haven Hospice takes infection control extremely seriously and adheres to
all of the relevevant legislation, standards and guidelines with the aim of
minimising the risk of infection to all. During this reporting period there were no
infections identified that had developed after admission.
MHRA ALERTS
ALERTS THAT
HAVE
REQUIRED
ACTION:
0
Halton Haven Hospice receives alerts from the Medicines and Healthcare
Regulatory Agency which inform us of any problems with equipment or
medicines that we need to be aware of which might impact upon health and
safety at the Hospice. During this reporting period none of the alerts were
relevent to anything that we use at the Hospice and therefore no actions were
necessary.
SAFEGUARDING
Director of Clinical Services initiated one Safeguarding Procedure on behalf of
one patient during this reporting period.
Halton Haven Hospice is committed to protecting vulnerable adults and children
from abuse. Vulnerable adults and children may be abused by a wide range of
people including relatives and family members, professional staff, paid care
workers, volunteers, other service users, neighbours, friends and associates,
people who deliberately exploit vulnerable people and strangers. The Hospice
will take any report or concern of abuse very seriously and will initiate
Safeguarding Procedures where approriate to do so, as was the case in one
instance during the past year.
24
PRESSURE SORES
PRESSURE
SORES
DEVELOPED
AT THE
HOSPICE
AFTER
ADMISSION:
7
Over the previous year the Hospice had seven patients who developed a
pressure sore after being admitted.
On admission to the a Hospice all patients are assessed for skin integrity and risk
using the Waterlow 2005 risk assesment tool. Where damage to skin is identified
the Hospice uses the EPUA 1999 Pressure Sore Grading Tool as below. These tools
allow a potential breakdown of skin to be identified and prevented under
certain circumstances. Following an admission reassessment of skin integrity is
continuous and there are clear lines of responsibility and accountability in place
to facilitate this process.
PRESSURE SORE GRADING (EPUAP,1999)
GRADE 1: Non blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema,
indurations or hardness may also be used as indicators particularly on individuals with darker skin.
GRADE 2: Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and
presents clinically as an abrasion or blister.
GRADE 3: Full thickness skin loss involving damage to or necrosis of, subcutaneous tissue that may
extend down to, but not through underlying fascia.
GRADE 4: Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures with
or without full thickness skin loss.
The seven pressure sores developed at the Hospice were investigated, analysed
and graded as follows:
5 at grade 1 : Records evidence that full risk assessments were undertaken,
appropriate interventions and eqiupment was used and these pressure sores
(reddened areas in these cases) were a direct result of the deteriorating
condition of the patients.
1 at grade 2 : Records evidence that full risk assessments were completed and
discussed with the patient who declined the use of the appropriately assessed
pressure relieving mattress. The patient was made fully aware of the risk of
significant tissue damage as a result of not consenting.
25
1 at grade 3 : Records evidence that full risk assessments were completed and
discussed with the patient who declined the use of the appropriately assessed
pressure relieving mattress and nursing interventions to relieve pressure. The
patient was made fully aware of the risk of significant tissue damage as a result
of not consenting to interventions.
The seven pressure sores represent 4.6% of the total admissions for the whole
year. However, the anaysis shows that only two patients, 1.3% of admissions, had
a pressure sore where the skin was not intact, as indicated above.
Whilst it is recognised that, due to multiple factors, patients in the later stages of
their life are at increased risk of skin break down, the Hospice will continue to
review and audit its processes with the aim of reducing this incidence further.
POLICIES AND PROCEDURES
All Policies and Procedures have been reviewed and updated as scheduled.
New policies are being developed when identified as being required.
Halton Haven Hospice has a wide range of Policies and Procedures organised in
the following categories:
•
Operational Policies and Procedures
•
Clinical Policies and Procedures
•
Medicines Policies and Procedures
•
Health and Safety Policies and Procedures
•
Human Resources Policies and Procedures
Policies and Procedures are reviewed monthly to ensure that they are kept up to
date with corresponding legislation, standards and guidlines. Staff are required
to adhere to these Policies and Procedures to minimise any risks to patient safety.
26
INCIDENTS
TYPE OF INCIDENT
QUANTITY
COMMENT
CLINICAL INCIDENTS / NEAR MISSES:
1
A patient in Day Hospice gave
another patient some of their
own medication. The incident
was identified and dealt with
quickly with no adverse effect to
the patient who took the
medication.
The dangers of taking
unprescribed medication has
been stressed to all Day Hospice
Patients and they have been
advised that they should not
give their own medication to
anyone else. This is being
monitored closely.
NON CLINICAL INCIDENTS / NEAR MISSES:
1
MEDICAL DEVICE INCIDENTS / NEAR
MISSES:
0
MEDICINE RELATED INCIDENTS / NEAR
MISSES:
5
This was an incident where there
was a bed rail entrapment. No
injury to patients was sustained.
Following this all non integral bed
rails have been taken out of use.
Beds with integral bed rails are
still used with guidelines for use
being strictly adhered to and
monitored.
There were three instances
where there were missed doses
of controlled drugs, one instance
where an incorrect dose of a
controlled drug administered
and one instance where a NonPrescribed drug was
administered. All of these
incidents were quickly identified
and there was no adverse
effects to the patients involved.
Further training for staff on
administration of medicines and
strict monitoring of and
adherence to Policy and
Procedures are to be used to
minimise the risk of medicine
related incidents.
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TYPE OF INCIDENT
QUANTITY
FIRE INCIDENTS:
0
SECURITY INCIDENTS:
0
INFORMATION SECURITY INCIDENTS:
0
VIOLENCE / AGRESSION INCIDENTS:
0
PATIENT ACCIDENTS RESULTING IN
SERIOUS INJURY:
0
STAFF ACCIDENTS:
5
COMMENT
There were four incidents where
staff sustained a back injury.
There is adequate euipment in
place for staff use and training
has previously been provided
however, further manual
handling training will be used to
minimise the risk of this occuring.
There was one incident where a
member of staff slipped on ice in
the Hospice car park. This has
resulted in the instigation of more
extensive gritting of the car park
when conditions indicate this to
be necessary.
RIDDOR REPORTS
1
OTHER INCIDENTS:
0
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This was regarding the slip on ice
in the Hospice car park. No
further investigation was
instigated.
ANNUAL ANALYSIS OF MONTHLY HOSPICE AUDITS
AUDIT
PERCENTAGE
IMPROVEMENT FROM 1ST
APRIL 2011 TO 31ST
MARCH 2012
ACCIDENT AUDITS
+38%
PRESSURE SORE AUDITS
+55%
CASE NOTE AUDITS
+6%
SPIRITUAL CARE AUDITS
+25%
LIVERPOOL CARE
PATHWAY AUDITS
+1.25%
MEDICATION AUDITS
+9%
INFECTION CONTROL
AUDITS
+14%
PERCENTAGE
IMPROVEMENT FROM 1ST
JANUARY 2012 TO 31ST
MARCH 2012
MEDICAL OFFICER CASE
NOTE AUDITS
-13.5%
PRESCRIBER MEDICATION
ADMINISTRATION
RECORD AUDITS
-5.6%
Analysis of the monthly audits carried out throughout the past year shows that in
many cases there have been improvements made following feedback to staff
on the results and findings.
Monthly feedback is viewed positively and the identification of problems is
followed up with action plans for rectification. This may include things such as
training, documentation changes or revised Policy and Procedures.
As can be seen, however, there are a couple of areas where we need more
work to improve performance and during the forthcoming year work will
continue with the Clinical Team to improve adherence to standards in these and
all other areas.
Continued monthly audit will monitor progress and feedback to the team, along
with remedial measures as necessary, will aim to facilitate improvements.
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COMMUNITY ENGAGEMENT REVIEW
As mentioned earlier only 42% of the funding required to provide NHS healthcare
services at Halton Haven Hospice this past year actually came from the NHS. The
remaining 58% had to be generated by the Hospice and we have a dedicated
team working to raise the income required to ensure the continuation of the
Specialist Palliative Care services we provide for the community of Halton.
During the past year our Events and Fundraising Teams have been busy initiating
new and exciting ways to engage with people that not only benefits the Hospice
financially but helps to create an enhanced sense of togetherness amongst
disparate elements of the local community. Taking part in these events has seen
people working together, in fun ways, towards a common goal and has
provided a real sense of achievement and involvement with Halton Haven
Hospice in those who have generously taken part.
Many of the event participants have first hand experience of the services we
provide and they have been very keen to do what they can to make sure the
Hospice is able to continue its work into the future.
Thanks must go to everyone who joined in and contributed to the success we
have had in community engagement over the past year. Without the help of
everyone who got involved and volunteered their time, effort and financial
support we would not have been able to raise the money needed to provide
the services that many people in Halton rely upon.
Some of the Year’s Highlights Include
Santa Dash
In collaboration with Halton Borough Council, Halton Haven Hospice organised
its first 5k Santa Dash in December 2011. Hundreds of local people took part in
the fun run through Runcorn and Widnes dressed in Santa Suits. The Runcorn and
Widnes Silver Jubilee Bridge was closed especially for the event, allowing runners
to cross it as part of the celebrations for the bridges 50th anniversary. The Santa
Dash looks set to become an iconic event in the borough of Halton as people
take part in such a magical event during the Christmas period.
30
Twilight Walk
The 2011 Twilight Walk was a great success again with walkers setting off from the
Stobart Stadium in Widnes, heading to Runcorn Town Hall, and returning on the
10k route. The start of the event was brought forward by one hour to allow more
children to take part this year and it was good to see many local families taking
part along with local businesses and Hospice Staff.
Abba in the Park
In August 2011 the Hospice organised another great Abba in the Park party in
Frodsham. Over 200 guests attended and were entertained by the national
ABBA tribute band Abba Fever. The band had guests dancing the night away in
true Abba style, many of whom forgot about the cold weather and came in
fancy dress! Guests from all ages attended the event including many families,
couples, a hen party and a couple of birthday parties too.
31
30th Birthday Celebrations and Awards Evening
As part of the Hospices 30th Birthday celebrations the Hospice Awards Evening
was created to thank the people of Halton who have supported the Charity over
the past thirty years. The invitations went to local businesses, community groups,
and individual fundraisers without whose continued support the Hospice would
struggle to find the £2.2 million needed each year for running costs. This event
was to thank everyone for their continued fundraising and support for the
Hospice.
Shops and Recycling Unit
Halton Haven Hospice has shops in Runcorn, Widnes and Frodsham, along with a
recycling unit in Runcorn. Apart from the normal clothes and bric-a-brac, all of
our shops specialise in good quality donated furniture. The Runcorn Shop has a
dedicated Bridal floor, the Widnes Shop is like a department store covering two
floors and in Frodsham the shop specialises in particularly high quality furniture.
The new recycling centre takes unwanted clothes, metal or wood and turns
them into cash for the Hospice! All of these outlets have been a great success
over the year, continuing to raising money for the Hospice and providing
opportunities for bargains for the local community.
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National Charity Times Award
In 2011 Halton Haven Hospice was recognised for its work with Halton Housing
Trust when they jointly won the national Charity Times Corporate Community
Local Involvement Award. This was in recognition of the way the two
organisations work together for the benefit of people across Runcorn and
Widnes. Halton Housing Trust, which owns and manages 6,100 homes across
Runcorn and Widnes, asks employees to vote on which Charity they would
like to support each year and they have consistently chosen the Hospice over
the past five years. As a result the two organisations have co-operated on many
projects which have gone towards making a difference to the lives of many
patients and their families.
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PRIORITIES FOR IMPROVEMENT 2012 – 2013
At Halton Haven Hospice we continually review our services and seek to improve
and develop them. The Hospice has a three year strategy, developed in
consultation with patients, public and staff, which is supported by annual
business plans. The strategy and plans outline our future vision in ensuring that we
continue to meet patient and carer needs at end of life and how we will
achieve this.
Clinical and Support teams are fundamental to the delivery of the strategy and
two way communication between all teams, the Hospice Management and the
Board of Trustees ensures delivery is monitored through mechanisms such as
audit and project reports, activity data and feedback from patient and carer
surveys.
Throughout 2011 - 2012 we identified and developed our priorities for the year
2012 - 2013. We have selected our priorities being mindful of national and local
policy, as well as those issues which are of concern to our service users, our staff
and our Partners.
Halton Haven Hospice has identified three Priorities for Quality Improvement for
2012 – 2013, one in each the following categories.
•
Patient Safety
•
Clinical Effectiveness and
•
Patient Experience
These priorities are set out below:
34
• PATIENT SAFETY
PRIORITY ONE
To increase the Medical establishment at the Hospice to
ensure robust staffing arrangements are in place to meet
future service developments arising as a result of the
appointment of the Consultant in Palliative Medicine.
HOW WAS PRIORITY ONE IDENTIFIED?
This was identified through discussions during the planning of the Hospice’s
Clinical and Educational Strategy, where it was recognised that the formal
appointment of the Hospice’s Consultant in Palliative Medicine would bring with
it not only benefits but additional commitments through increased education
delivery and service expansion.
HOW WILL PRIORITY ONE BE ACHIEVED?
The Hospice will need to source the income to finance the appointment of
additional Medical Officers to complement the existing establishment.
Following this there will be a need to utilise the existing Hospice Policy and
Procedures for Staff Recruitment.
HOW WILL PROGRESS OF PRIORITY ONE BE MONITORED AND REPORTED?
This will be monitored by the Hospice Directors in consultation with the Consultant
in Palliative Medicine and reported to the Board of Trustees.
35
• CLINICAL EFFECTIVENESS
PRIORITY TWO
To gain N3 connection for all key clinical staff, which
would allow the Hospice IT systems to be connected with
the Hospital IT systems. This will facilitate direct and
speedy access to laboratory and radiology investigation
results for our patients.
HOW WAS PRIORITY TWO IDENTIFIED?
To make preparations to extend the Clinical IT system was a condition of PCT
funding for the previous year and investigatory work into the Hospice’s needs
and how it might financed was instigated. Risk assessments had identified the
need for systems of accessing laboratory and radiology results to be more robust
and responsive, which would enable the Clinical Team to initiate treatment for
patients in a timelier manner, thus facilitating enhanced clinical effectiveness.
HOW WILL PRIORITY TWO BE ACHIEVED?
Funding for this project has already been sourced and we now need to work
with British Telecom to put into place the necessary equipment and systems to
enable N3 connection for the Hospice. Once the relevant hardware and
software is available there will then be a need for a training programme for the
staff that will use the system. The Hospice intends to work with Warrington
General Hospital whose staff will provide the relevant training over the coming
year.
HOW WILL PROGRESS OF PRIORITY TWO BE MONITORED AND REPORTED?
This is a high priority for the Hospice and responsibility for the project lies with the
Hospice’s Director of Corporate Services who will monitor and report progress
through the Clinical Governance Group.
36
• PATIENT EXPERIENCE
PRIORITY THREE
Improvement of the patient discharge pathway to
facilitate choice and maximise opportunities for our
patients to have their preferred place of care.
HOW WAS PRIORITY THREE IDENTIFIED?
It had been identified at the weekly Hospice’s Multi-Disciplinary Team meetings
that discharges for patients were often delayed for a number of reasons. These
reasons include delays in funding approval, delays in Occupational Therapy
assessments and delivery of appropriate equipment for patients and lack of
appropriate Care Home Places for patients for whom discharge home was not
an appropriate option or choice.
HOW WILL PRIORITY THREE BE ACHIEVED?
The Hospice will be looking to dedicate a member of the Nursing Team to
Discharge Co-ordination with the task of working with the Family Support Team
and End of Life Care Facilitator to liaise and improve links with any services that
are relevant to the discharge of patients to an appropriate place of care for
their needs. It is hoped that this will improve the experience of patients by
enabling them to, more rapidly, be in a place of care that they need or wish to
be.
HOW WILL PROGRESS OF PRIORITY THREE BE MONITORED AND REPORTED?
This will be monitored at Clinical Meetings and the Clinical Governance Group.
The Discharge Co-ordinator will maintain appropriate statistics of outcomes for
presentation and discussion at these meetings. Patient and Carer Surveys will
also be used to assess patient satisfaction with the discharge pathway.
37
STATEMENTS ON HALTON HAVEN HOSPICE’S
QUALITY ACCOUNT 2012
As indicated in the regulations, this Halton Haven Hospice Quality Account has
been submitted to the commissioning Primary Care Trust, St Helens and Halton
LINk and the local Overview and Scrutiny Committee for their comments on our
report.
Below we have included the comments received from these organisations.
Comments from Primary Care Trust
“Halton Haven has made excellent progress developing its expanding service
delivery to meet more complex patient's needs. It is anticipated that the service
will continue to implement all agreed service outcomes in 2012. Halton Haven
has collaborated with local end of life services to ensure NICE guidelines are met
and continue to be an important provider locally in the delivery of end of life
care.”
Jennifer Owen
Commissioning Programme Manager
Halton- Clinical Commissioning Group
Comments from Halton LINk
“Halton LINk welcomed Halton Haven’s commitment to share the report and
members appreciated the opportunity to comment on your Quality Account for
the year 2011-12.
The Account is clear, informative and the data easy to understand.
Halton LINK appreciates that Halton Haven Hospice undertakes monthly audits in
order to identify any problems; good practice and highlight issues for staff
training.
We also welcome the use of regular surveys to capture feedback from patients
and relatives, which is used to improve services.
The extensive refurbishment carried out by the Haven, has led to a much
improved environment, as reflected in feedback from patients, families and staff.
The patient’s experience has been enhanced giving more choice, privacy and
better facilities for patients and their families.
We are pleased to note that no incidents of infection have occurred and that
the Haven is controlling the incidents of pressure sores wherever possible.
38
Members welcome the developments to increase the medical establishment to
support the palliative consultant and look forward to IT developments that will
benefit both patients and staff.
We support increased partnership working initiatives to facilitate the choice in
the discharge procedure.
The Haven is to be congratulated on involving the local community to take part
in activities to raise extra funding that is used to improve services.
The Halton LINk is pleased to see that the goals for 2011-12 were achieved and
will watch with interest in how the Haven will address their priorities in 2012-13.
During the past year, Halton LINk has had the opportunity to work with staff from
the Haven and we appreciate the commitment shown to improving end-of-life
care for the residents of Halton. We look forward to building on this good working
relationship in 2012-13.”
Doreen Shotton
LINk Board Member – Halton LINk Lead for Quality Accounts.
Comments from Overview and Scrutiny Committee
(Health Policy and Performance Board)
“Thank you for the opportunity to comment on your Quality Account. The Health
Policy and Performance Board have particularly noted the following key areas:
In 2011/12, the Hospice identified three Quality priorities to be achieved during
this year. The Board was pleased to see that the Hospice successfully met each
goal. In particular, the Board were pleased to note the refurbishment to the
building which has increased patient experience at the Hospice.
The Board notes that the Hospice undertook a Patient and Carer Survey for the
period 1st February 2011 to 31st January 2012 and that improvements in access to
Hospice information leaflets have been recorded. Food served at the Hospice
came below the benchmark figure of 85%, but the Board are pleased to note
that the Hospice Catering team have planned further nutritional and dietary
training, and will be reviewing their menu plans. The Board observed the
quotations taken directly from the patient/carer questionnaires and were happy
to read such positive comments about the Hospice.
The Board were pleased to note that a Staff Quality Improvement Survey had
been carried out to determine the staff’s view of the most significant quality
improvements at the Hospice as well as where they thought the Hospice could
achieve further quality improvements. The Board felt that the use of this
information to inform future business planning and setting of future quality
improvements was a good resource to use and encourage staff involvement of
such things.
39
Looking at the Clinical Governance overview for the Hospice, the Board were
pleased to note the following during the period 1st April 2011 to 31st March 2012:
•
•
•
only one verbal complaint had been received;
no incidences of healthcare associated infections were recorded; and
no Medicines and Healthcare Regulatory Agency alerts that required action.
There were seven incidences of pressure sores that had developed at the
Hospice following admission, but the Board notes that all were investigated and
analysed and that full risk assessments had been undertaken.
The Board notes that Halton Haven has been able to identify three priorities for
Quality Improvement for 2012-2013 that will demonstrate improvements in
patient safety, clinical effectiveness and patient experience. The three quality
priorities are:
•
•
•
Patient Safety - To increase the medical establishment at the Hospice to
ensure robust staffing arrangements are in place to meet future service
developments arising as a result of the appointment of the Consultant in
Palliative Medicine.
Clinical Effectiveness – To gain N3 connection for all key clinical staff, this
would allow the Hospice IT systems to be connected with the Hospital IT
systems. This will facilitate direct and speedy access to laboratory and
radiology investigation results for our patients.
Patient Experience – Improvement of the patient discharge pathway to
facilitate choice and maximise opportunities for our patients to have their
preferred place of care.
The Board welcomes these quality priorities and the benefits these will bring to
the overall experience a patient and carers receive when in the Hospice.”
Cllr Ellen Cargill
Chair, Health Policy and Performance Board
40
OPPORTUNITY TO PROVIDE FEEDBACK ON
THIS QUALITY ACCOUNT
Feedback on this Quality Account is very welcome. If you would like to do this,
please write to:
Chair of Trustees,
Halton Haven Hospice,
Barnfield Avenue,
Murdishaw,
Runcorn,
Cheshire,
WA7 6EP.
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