Overgate Hospice Quality Account for
2011/2012
Mission Statement:
Overgate Hospice is a charity providing specialist palliative care for the people
of Calderdale living with a life limiting illness.
Philosophy of care
o We care for the whole person and their family, friends and carers.
o We respect patients’ priorities and strive to enable them to achieve
their personal goals.
We Value
o The support of our community through fundraising and volunteering
and in all aspects of hospice life.
o Team work and Professionalism
o Diversity in our staff, volunteers and all those we care for.
Overgate Hospice
30 Hullen Edge Road
Elland
West Yorkshire
HX5 0QY
Registered Charity No: 511619
Part 1:
Statement from the Chief Executive
I have pleasure in presenting our first Quality Account Report for Overgate
Hospice. In previous years we have presented an Annual Review which sets
out what we have achieved during the year and our plans for the future. We
are now required to report about the quality of the services that we provide in
the format of a Quality Account.
You will know that quality is central to the care we provide. We are a charity
that provides specialist palliative care for the people of Calderdale living with a
life limiting illnesses. We care for the whole person and their family, friends
and carers; we respect patients’ priorities and strive to enable them to achieve
their personal goals.
We value:
The support of our community through fundraising and volunteering
and in all aspects of hospice life.
Team work and Professionalism
Diversity in our staff, volunteers and all those we care for.
Quality services are defined by looking at patient safety, the effectiveness of
treatments that patients receive and their feedback about the care provided.
This report provides information on each of these definitions in separate
chapters.
We provide a range of specialist palliative care services that include:
A 12 bedded Inpatient unit
Day Hospice
Social Work
Complementary Therapies
Bereavement Counselling
Spiritual care
Physiotherapy
Carers Support
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An Out of Hours telephone advice line for professionals
Our services are monitored by the Care Quality Commission as well as by our
local commissioning organisation – NHS Calderdale. We are also currently
preparing for all our services to be measured against National Cancer Peer
Review Quality Standards.
Feedback from the community that we serve is important to us so we
undertake an annual satisfaction survey as well as encouraging feedback
from patients/families and their carers as they are receiving care.
We have nearly 31 years of experience in hospice care and we are looking to
the future to consider how we can meet the growing demand for our services.
We are working with local partner organisations to agree how we can better
work together to strengthen community provision as we know more people
towards the end of life want to die at home but they need support around
them to enable this to happen.
I hope you find this report interesting and I would like to thank you for all your
support over the years – because you care we can.
Janet Cawtheray
Chief Executive
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Part 2: Priorities for improvement and statements of
assurance from the Board of Trustees 2012 – 2013
1. Improvement
The Board of Trustees continues to support the continuous development and
improvement of hospice services to ensure that the care and support provided evolve
to meet patient and carer needs.
The priorities for quality improvement identified for 2012/13 are set out below. These
priorities have been identified in conjunction with patients and carers, staff and
stakeholders. The priorities we have selected will impact directly on each of the
three priority areas:
patient safety
clinical effectiveness and
patient experience.
Future planning priority one: Patient Safety
Introduction of a new Falls Policy the FRASE - Fall Risk Assessment Score in
the Elderly Assessment tool
Research shows that there is significant morbidity and mortality due to falls on
inpatient units, including serious head injuries, spinal injuries and fractures. These
can be reduced by primary and secondary prevention of falls, and by reducing harm
after falls.
Minimising fall risks can benefit all people at the hospice, including patients, visitors,
volunteers and staff.
As hospice patients have advanced life-limiting illnesses it will not always be
appropriate to send a patient to hospital for treatment or investigation should a fall
occur. However the needs and wishes of patients should be assessed individually,
as some patients may have a prognosis and quality of life that would warrant
investigation and treatment, especially if this reduces pain (eg internal fixation of
fractures if the patient is systemically well enough).
All patients admitted to the hospice will be assessed using the FRASE within 24
hours of being admitted.
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How was this identified as a priority?
This was identified as a priority following the hospice’s audit on accidents and the
increasing frailty and complex condition of patients treated. The audit suggested a
need to improve the initial and continuing assessment of those patients at greater
risk of trips and falls. The introduction of a recognised assessment tool to support
frail and vulnerable patients was considered a priority by the multi-disciplinary team.
How will this priority be achieved?
The FRASE tool was introduced into the clinical areas by the Senior Nurse in March
2012 who supported staff training needs, produced guidance documents and the
assessment tool. Ongoing training is provided as part of mandatory Manual Handling
and any additional training needs will be met by the Manual Handling key trainers,
with the support of the Senior Nurse.
The hospice has purchased further supplies of seat and bed alarms which indicate
when a patient who has been assessed at risk of a fall or trip, gets up unaided from
either their chair or bed. The alarm receivers are carried by named members of the
caring team: should the alarm be activated, the person carrying the receiver will be
required to check and assist the patient.
If a fall or trip occurs, a record of the accident will be completed giving details of who,
where, how, why and what occurred. The report will then be forwarded to the Clinical
Services Manager for information and any further action if necessary.
How will progress be monitored and reported?
Progress will be monitored through audit of The Reportable Accident forms which are
passed to the Clinical Services Manager for scrutiny and storage.
All accidents involving patients are reported on (anonymously) at the monthly Clinical
Governance meeting and these are then passed to the Manual Handling team for
further discussion and review of practice.
Audit of the Reportable Accidents is usually performed annually or more frequently if
it is felt necessary. Due to the introduction of the FRASE tool an audit will be
performed after 6 months of implementation (September/October 2012) in order to
assess the impact and determine whether further actions are required to reduce the
impact of falls.
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Future planning priority two: Clinical Effectiveness
Strengthening community provision
How was this identified as a priority?
Overgate Hospice, as a lead specialist provider locally, has been provided with some
non recurrent money from Calderdale PCT to work with other end of life care
providers to develop a business case which will demonstrate to the PCT how we can
strengthen local services.
The partner organisations are Marie Curie, Calderdale Care Scheme, Calderdale
Social Services, Calderdale and Huddersfield Foundation Trust (acute and
community nursing services), including the involvement of Dr David Wild who is a GP
in Hebden Bridge and an associate member of the shadow Clinical Commissioning
Group.
All of the above providers currently deliver excellent services but it is felt we could all
provide a better service for patients and their families if we work together in
collaboration to offer an integrated approach. It is clear that together we have a vast
amount of knowledge of what works well and what needs to be improved, including
additional capacity, new services, better co-ordination, training and education and
better information.
The context we are working with is that:
 Demand for specialist palliative care is going to increase as a result of the
UK’s ageing population: the number of deaths per year is expected to rise by
17% between 2012 and 2030.
 In addition, many people will be dying at an older age and will therefore be
likely to have more complex needs and multiple co-morbidities as they near
the end of their lives
 Community services are central to the health agenda and a key area of focus
for the NHS
 The ongoing reform agenda signals a shift in focus from acute care to primary
and community based care for patients
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 Calderdale has a higher than average number of people reaching the end of
their lives in a hospice compared to the national average – 6.4% compared to
5.2% nationally. However with the number of deaths expected to rise by 17%
up to 2030, joint work is needed to plan how to meet this increased demand
in an appropriate and sensitive manner.
 More people die in hospital in Calderdale 57.7% compared with national
average of 56.7% (3245 people).
 It is clear that if community services are central to the health agenda, then
there needs to be a big shift from a hospital focus to enable more people to
be supported, in line with their wishes, in dying at home or within the hospice.
At Overgate we know that the projected increase in numbers of people dying each
year will result in a smaller percentage being able to access hospice care in
Calderdale unless alternative hospice services can be developed. We aim to explore
potential service models to enable hospice care to be delivered in the community.
This work is an exciting opportunity for Overgate Hospice to work in partnership with
other local providers and agree what contribution we can make. A Hospice at Home
service has been discussed for some time but we need to develop a proposal with
our partners
How will this priority be achieved?
The PCT funding has allowed Overgate Hospice to purchase project management
support to develop a proposal for Calderdale to improve local services. We have
identified a project lead that is going to consult with staff in the hospice and within the
other partner organisations to determine what is needed locally.
In addition, the project lead will research evidence from the literature and other
models across the country, so that as much information as possible is available to
inform an effective service model for Calderdale.
How will progress be monitored and reported?
Progress will be monitored by the project steering group that we have set up. A
business case will be developed for consideration by NHS Calderdale/Clinical
Commissioning Group. If the business case is successful, a service level agreement
will be established with the local commissioners.
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Future planning priority three: Patient Experience
Increased engagement with Day Hospice Service Users
How was this identified as a priority?
Following the recent extension and refurbishment of Day Hospice which was funded
through the Department of Health’s Capital Grant in 2010/11, the services which
Overgate Hospice provides as part of Day Hospice provision were reviewed to
ensure that they are as effective as possible.
An Away Day took place on 4th May 2012. Day Hospice patients, carers, volunteers
and staff were invited to attend and discuss what Day Hospice meant to them, what
they liked, what they disliked and what they would like to be considered as part of the
service in the future.
The day was well attended with 10 patients, 4 carers, 15 volunteers and 10 staff
members. The event was facilitated by an experienced facilitator and a report was
prepared on the feedback received.
How will this priority be achieved?
The report has been sent to the Senior Management Team (SMT) at the Hospice for
further discussion at Board level. A copy of the report has been forwarded to the
patients, carers, volunteers and staff who attended the day, for their information.
A Service User Forum is planned, involving users from the Day Hospice and the
Inpatient Unit, to enable information to be passed between all parties concerned.
How will progress be monitored and reported?
The SMT will organise meetings with staff to develop an action plan to meet the
issues identified in the report and to inform the Hospice’s 5 year strategy.
There will be consultation with service users as part of the planning, development
and implementation of any changes or introduction of new services within the Day
Hospice. Their input will remain crucial to the developments implemented and the
introduction of a Service User Group can now be explored for the future on the back
of this successful event.
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2. Statement of Assurance from the Board
All providers must include the following statements in their Quality Accounts. Many
of these statements are not directly applicable to specialist palliative care providers,
and therefore, where appropriate, further explanation of the meaning of certain
statements is also provided.
2a. Review of Services
During 2011/12 Overgate Hospice supported NHS Calderdale’s commissioning
priorities with regard to the provision of specialist palliative care. The following
services were provided:
 Inpatient Unit
 Day Hospice
 Social Work
 Physiotherapy
 Bereavement/Counselling
 Carers’ Group
 Out of hours advice line for professionals
NHS Calderdale supported Overgate Hospice with over 25% of its core running
costs. In order for Overgate Hospice to provide its full range of services, the
remaining funding was generated through fundraising, shops, lottery activity and
investments.
2b. Participation in Clinical Audit
During 2011/12 Overgate Hospice did not participate in any national clinical audits.
2c. Research
During 2011/12 Overgate Hospice did not participate in research approved by a
research ethic committee.
2d. Care Quality Commission
Overgate Hospice is required to register with Care Quality Commission (CQC) and is
currently registered to undertake the following regulated activities:
 Treatment of disease, disorder or injury
 Diagnostic & screening procedures
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The CQC did not attach any conditions of registration for Overgate Hospice.
The Regulated Activity may only be carried out on the following location:
Overgate Hospice, 30 Hullen Edge Road, Elland, West Yorkshire, HX5 0QY
The CQC has not taken any enforcement action against Overgate Hospice during
2011/12
Overgate Hospice has not participated in any special reviews or investigations by
CQC during 2011/12
Overgate Hospice was inspected by the CQC on 24th November 2011 as part of their
routine schedule of planned reviews. Overgate Hospice was reviewed against the
following CQC standards:
 Outcome 01: People should be treated with respect, involved in discussions
about their care and treatment and able to influence how the service is run.
 Outcome 04: People should get safe and appropriate care that meets their
needs and support their rights.
 Outcome 07: People should be protected from abuse and staff should
respect their human rights.
 Outcome 14: Staff should be properly trained and supervised, and have the
chance to develop and improve their skills.
 Outcome 16: The service should have quality checking systems to manage
risks and assure health, welfare and safety of people who receive care.
Overgate Hospice was ‘compliant’ with all of the above outcomes and no sanctions
or requirements were made by CQC following the inspection.
2e. Data Collection
Overgate Hospice is currently using the electronic patient information system
SystmOne. The system allows, with patient consent, for Overgate Hospice to share
data with other health professionals to support the care of patients in the hospitals
trust and the community.
During the period 2011/12 Overgate Hospice developed a structured system for
Advance Care Planning within the hospice for both Inpatients and Day Hospice
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patients. The new system aimed to incorporate the various models in existence and
improve the quality of information gathered making it standard across the locality.
During the period 2011/12 Overgate Hospice has adopted the use of the Do Not
Attempt Cardio Pulmonary Resuscitation (DNA CPR) document which has been
implemented across the region following discussion and agreement with the
Yorkshire Ambulance Service.
Part 3: Review of quality performance
The National Council for Palliative Care (NCPC): Minimum Data Sets (MDS)
We have chosen to present information from the NCPC MDS which is the only
information collected nationally on hospice activity. The figures below provide
information on the activity and outcomes of care of patients.
Inpatient Unit Services
2010/11
222
Total number of patients
90%
% New patients
7%
% Re-referred patients
70%
% Occupancy
30%
% Patients returning home
12.4 days
Average length of stay - cancer
Average length of stay – non
cancer
8.6 days
2011/12
256
94%
13%
71%
25%
8.2 days
7.2 days
Inpatient Unit
The number of patients accessing the Inpatient Unit during 2011/12 has increased by
13% from the previous year.
This means that more patients have been cared for in what is likely to be one of their
preferred places of care at the end of life.
There has been a significant reduction in the average length of stay for cancer
patients in Overgate Hospice by 34% in 2011/12. This reduction could be due to the
improved partnership work between the hospice and community teams in supporting
patients to remain in their homes for longer periods before they need to access
hospice inpatient services.
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Day Hospice
Due to a change in IT systems we are only able to provide base line information
regarding Day Hospice. The following information relates to the period 2011/12.
204 patients accessed Day Hospice services of which 188 (92%) were new patients
and the remaining 16 (8%) were patients re-referred to the service.
The new Day Hospice building which was completed in June 2011 allows the team to
deliver services in a comfortable, bright and appropriate setting which meets the
needs of the service users and the staff. The feedback regarding the accommodation
is positive from service users and the recent Away Day provided an opportunity for
them to provide such feedback to the organisation.
Quality Markers we have chosen to measure
In addition to the limited number of suitable quality measures in the national data set
for palliative care, we have chosen to measure our performance against the
following:
INDICATOR
2010/11
Patient Safety Incidents
Number of patients admitted to the
Inpatient Unit with pressure damage
52
Number of patients who developed
pressure damage whilst in the Inpatient
Unit
1
Number of patients admitted to the
hospice with Grade 3 or above pressure
damage
11
Number of patients who developed grade
3 or above pressure damage following
admission to the Inpatient Unit
0
2011/12
33
2
11
1
Overgate Hospice asks about pressure damage at the point of referral to the service.
Pressure damage is graded from 1 (minor) to 4 (serious). Overgate Hospice records
and reports all pressure damage at the monthly Clinical Governance meeting. All
patients undergo an individualised holistic assessment with regards to pressure area
care and recommendations are recorded within their notes. Any patient who
develops a grade 3 pressure ulcer whilst in the hospice will be reported to the CQC
as part of Regulation 18 - Notifiable Events.
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The one patient, who developed a grade 4 pressure ulcer whilst a patient on the IPU
was admitted with a grade 3 pressure ulcer. The patient, who did have the mental
capacity to make this informed decision, chose not to comply with some of the
pressure relieving measures recommended by the clinical team.
INDICATOR
2010/11
Infection Prevention and Control
The number of patients admitted to the
Inpatient Unit with MRSA
5
The number of patients infected with
MRSA whilst in the Inpatient Unit
0
The number of patients admitted to the
Inpatient Unit with C, difficile
1
The number of patients infected with C.
difficile whilst in the Inpatient Unit
0
2011/12
2
0
1
0
Overgate Hospice asks about the patient’s infection status at the point of referral to
the service.
Where capacity allows, all patients admitted with an infection will be nursed in a
single room and any treatment relating to the infection will be continued on admission
as appropriate.
Clinical Audit
Clinical audit is a way in which the organisation can learn more about and improve
the delivery of services, the outcomes for patients and the experiences they have.
A patient and relatives’ survey is also performed on the Inpatient Unit using paper
questionnaires and earlier this year we introduced a verbal process of gathering
patients’ and relatives’ experiences of the Inpatient Unit. A volunteer with a nursing
background talks to patients and relatives on the Inpatient Unit about their
experience of the hospice and transfers the information provided to a proforma for
collation and report at a later date. The outcome of this data will be reported later in
2012.
Clinical audits are initiated by the Audit Lead with the support of clinical staff who are
involved in the process. Infection Control audits are performed by the Infection
Control Team with the support of the Housekeeping Team where appropriate.
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Where issues are identified during an audit an action plan is developed to address
the problem. Progress on the action plan is monitored through the Clinical
Governance Group and all Clinical Audits are presented at the Clinical Governance
Meeting. Should audit show remedy is required, further audit will be undertaken,
following an agreed time, to see if the action taken has resolved the issues identified.
Overgate Hospice has become part of a pilot group working with other Yorkshire
Hospices trialling a hand held device to perform audits. The aim of the group is to
develop standardised audit which will allow organisations to ‘benchmark’ findings.
The device allows audits to be undertaken, collated, uploaded and reported in real
time. Overgate Hospice is working in partnership with the company and other
hospices to achieve standards across the region.
Below is a selection of clinical audits undertaken at Overgate Hospice during
2011/12:
Audit
Completed
Emergency
March
Equipment
2012
*Multidisciplinary
Notes relating to
clinical decision
making
Visiting Student
Placements
Complaints
Destruction of
patient records
Disinfection
solutions used
on IPU
Action
Plan
NO
Feb 2012
NO
May 2012
YES
Dec 2011
NO
Jan 2012
NO
March
2011
YES
Liverpool Care
Pathway (LCP)
July 2011
Counselling
Actions to be undertaken
to
Improve practice
YES
N/A
N/A
Full completion of the
placement document
N/A
N/A
Education of clinical staff in
relation to the correct
dilution
Change of product type
Attention to detail – remind
staff of importance
Review areas which are
being missed and update
document accordingly to
minimise omissions
A need to review the
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Action Plan
Completed
N/A
N/A
In process
of review
N/A
N/A
Completed
Completed
questionnaire – simpler to
understand
Completed
A need to include preprinted boxes on the drug
sheet for anticipatory drugs
2011
YES
Completed
Review of current drug
sheet
* As part of this audit it was noted that hospice staff had been the instigators of
service client
satisfaction
Anticipatory
drug prescribing
May 2011
YES
Advanced Care Planning in 74% of the notes studied.
There was little evidence that Advanced Care Planning had taken place prior to
patients being admitted to the Hospice.
Feedback from patients and families on services.
Overgate Hospice values the feedback it receives from patients and families as this
is an important way in which the organisation can identify issues, resolve problems
and improve the quality of the care we provide.
As part of our commitment to listening to service users, we provide separate
questionnaires to patients and families who are discharged from the Inpatient Unit.
Further questionnaires are sent to families of patients who have died on the Inpatient
Unit. All patients who attend Day Hospice are also provided with a questionnaire on
discharge from the service and all Carers who attend the Carers’ Group are also
provided with a questionnaire when their programme is ended.
The questionnaires are anonymous but where concerns are raised, even if no identity
is given, the issues are raised with the team/persons involved in a timely manner and
all efforts are made to resolve the issue and to learn from what has occurred.
The annual Inpatient Questionnaire from March 2011 until February 2012 had a
response rate of 48% (n=) a slight reduction from the previous recorded for 2010/11
which was 50%.
The annual Relatives/Carers Satisfaction Survey from March 2011 to February 2012
had a response rate of 43% (n=) a slight improvement on the rate for 2010 which
was 37%.
The current questionnaires used to obtain feedback from patients and families is due
for review and a more structured approach using the CQC Essential Standards of
Quality and Safety (2009) as our guide will be considered in the future.
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As part of improving how feedback is obtained, Overgate Hospice has been piloting
alternative ways of gathering information from a wider group of Service Users. One
of the ways being piloted at present is the engagement of an experienced volunteer
with a nursing background to speak directly to patients on the IPU about their
experience of Overgate Hospice. Six months data will be reported in August 2012.
A copy of the full surveys and audits are available in Overgate Hospice’s reception
and through contact with info@overgatehospice.nhs.uk
How feedback influences service provision
The issue of individual patient bedrooms continues to be a subject raised regularly as
part of patient and family feedback. The Inpatient Unit currently operates with 2
four-bedded bays and 4 single rooms and the development of more single rooms for
the future requires further discussion. The organisation has secured funding from the
PCT to undertake a review of the IPU facilities. This review is due to commence later
this year and the Board of Directors and members of the SMT will share the findings
with service users and staff.
Comments from Calderdale Primary Care Trust (PCT) Local
Involvement Network (LINK) and Health Scrutiny Committee
for Calderdale
The Quality Account was sent to the appropriate commissioners at the PCT on the 1st
June 2012 for comment and statement as required. Unfortunately there has been no
comment from the PCT received to date.
Attempts to engage with LINK and the Health Scrutiny Committee for Calderdale has
been difficult and to date all efforts on the part of Overgate Hospice to engage with
them have been unsuccessful.
Overgate Hospice will continue to try and engage with the PCT commissioners, LINK
and the Health Scrutiny Committee for Calderdale. All efforts will be made to try and
ensure their comments are included in next years Quality Account.
Conclusion
This is our first Quality Account Overgate Hospice has undertaken so we hope you
enjoy reading it. We continue to put quality at the heart of everything we do and by
explaining about the care we provide in reports like this we can demonstrate the
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effective, safe care and excellent patient experience to the public, staff and our
commissioners. It is not surprising that health and social care colleagues have not
yet made comments on this report given the amount of changes taking place but we
continue to work in collaboration with them and value their continued support.
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