Quality Account 2011-2012
“We cannot thank you enough for the care, compassion and
respect you gave to mum in her final days. It meant so much; we
were honored to have you all in our home. Mum was one very
special lady and you made us feel you all felt that as well”
(Sons and daughter of a patient cared for by Hospice at Home team)
1
CHIEF EXECUTIVE SUMMARY
Rowcroft Hospice is an independent charity providing specialist palliative care services
to patients, their families and friends across the 300 square miles of South Devon.
Rowcroft also provides information, education and raises awareness about palliative and
end of life care to patients, family members, health and social care professionals and
the public.
In this third annual quality account, developed by the Quality and Patient Safety
Committee, we report on the quality of Rowcroft Hospice’s services over the past year.
This report focuses on the main quality indicators: patient safety, clinical effectiveness
and patient and family experiences. We report on the progress made towards achieving
our agreed key priorities in 2011-2012 using direct feedback from patients, their families
and friends who have used our services.
This report provides information about other quality improvements we have made within
the year and sets out our key priorities for 2012-2013 using the ‘Energise for Excellence’1
quality framework. We have engaged our staff, volunteers and users of the service in
developing these priorities. We hope this report provides you with information to
demonstrate our continuing commitment to developing and enhancing the quality of our
services for the benefit of our local population.
Giles Charnaud
Chief Executive
1
Department of Health (2011) Energise for Excellence
2
PART ONE: WHAT OUR ORGANISATION IS DOING WELL
In our previous years Quality Account we set three key priorities for service improvement in each
of the following quality indicators: patient safety, clinical effectiveness and patient and family
experience. The following report provides evidence of our progress on these service
improvements.
Patient safety
We agreed to review oxygen use and supply on the inpatient unit, remove one bed
from Willow ward on the inpatient unit to create appropriate bed space and to
provide suitable additional patient equipment storage.
o In response to a Department of Health Estates and Facilities Alert (Ref:
EFA/2010/008) regarding the safe use of medical gas cylinders, we sited wall
fixtures at every bed space, which allow oxygen cylinders to be attached to the
wall. In addition we changed the size of oxygen cylinder we use to a new smaller
and lighter type to further reduce the potential for injury to both patients and
staff. Revised oxygen guidelines are in development.
o A bed has been removed from Willow ward providing greater space and privacy
for patients and their families.
o A capital business case for provision of new equipment storage has been agreed.
Building is due to commence later this year. In the interim, temporary
accommodation for equipment has been made available.
Patient safety indicators
Indicator
Number of patients newly detected
with MRSA whilst cared for on the
inpatient unit
Number of patients contracting
Clostridium Difficule, ESBL,
Salmonella, pseudomonas and
Klebsiella pneumonia whilst
admitted to IPU.
Number of patient falls per 1,000
occupied bed days
Number of patients who developed
new pressure sores (grade 2 and
above, per 1,000 occupied bed
days) whilst cared for on IPU
Actual number of patient
medication incidents
2011/2012
2010/2011
0
0
0
0
7.9
(South West region
hospices average = 8)2
7.6
(South West region
hospices average = 10.2)
1
(South West region
hospices average = 17.8 )
Not recorded
17
(SW regional hospices
average = 27.7)
12
(South West region
hospices average = 12)
2
Ten hospices from across the South West have been bench-marking patient falls, pressure ulcers and medication
incidents to support best practice.
3
Clinical effectiveness
We agreed to enhance our Hospice at Home service to provide a 24 hour service,
doubling the activity by 2012, review our staff skill mix and develop a workforce
plan and to explore ways of providing our community specialist palliative care
service closer to patients’ homes; piloting appropriate options in local communities.
•
The Board of Trustees agreed a business case in
September 2011 to enhance the Hospice at Home
service to provide a 24 hour, seven day a week
service, which became operational in December
2011 across the whole of South Devon. Based on
the first four months service activity there has
been greater than a 100% increase in referrals to
the team compared to the previous year. This
service
is
partially
funded
through
a
commissioning contract with Torbay Care Trust.
•
A report on the skills mix and workforce review
with recommendations for increasing the number
of registered nurses per patient bed for the
inpatient unit was presented to and agreed by the
Board of Trustees. Recruitment to the five new
posts will be completed by autumn 2012.
•
A clinical nurse specialist has been running a weekly outpatient clinic at
Dartmouth Hospital and in May 2011 one of our nurse specialists seconded as a
service development manager, subsequently was awarded a national grant from
the Burdett Trust/Help the Hospices to conduct an 18 month project to pilot
further satellite clinics in Dartmouth and surrounding areas. These will begin in
2012-2013.
Audits
For the year 2011-2012 Rowcroft Hospice will submit audit data to the National Minimum
Data Set for specialist palliative care. Results will be available publicly in autumn 2012
from the National Council for Palliative Care:
http://www.ncpc.org.uk/publications/index.html.
19 audits were conducted over this reporting period. Topics included: response time for
inpatient hospice admissions and OT referrals, clinical nurse specialist in palliative care
attendance at Gold Standard Framework meetings, use of care of the dying pathway,
medicines management, documentation of patients allergies and sensitivities, hospice at
home response times, record audit and Lymphoedema's 31 day cancer waiting time
referral response audit. In addition, monthly audits were completed for hand hygiene
and inpatient unit patient environment.
Recommendations from all audits were reviewed by the Quality and Patient Safety
Committee and used to improve clinical effectiveness. The audits were conducted in the
inpatient unit, community service and lymphoedema service. Six audits are currently in
progress. We are participating in a Peninsula Cancer Network audit that commenced in
March and will conclude in May, 2012.
4
Research
There have been no national research studies in palliative care to take part in and no
original research studies have been conducted at Rowcroft in this reporting period. Our
Director of Patient Care continues to provide input as a co-applicant on a 2 year national
study by Volunteering UK and the Lancaster University, looking at the role of volunteers
in hospices within the UK. A research paper written by one of our staff is currently in
press in the International Journal of Nursing Studies3.
Patient/family experience
We prioritised the provision of comfortable visitor/relative chairs and appropriate
shelving in toilets for people who have a colostomy/ileostomy.
•
We have increased the number of recliner armchairs at the bedside which visitors
are able to use. We have also replaced the seating in the visitor’s rest area, with
2 sofas which have a recliner action. In 2012/13 we will commence a replacement
programme for the remaining, stackable, visitors seating.
•
In the ward bath and shower rooms we are currently installing shelving for
patients for ease of use in regards for those with colostomies or ileostomies. For
other patients these shelves will provide an area where toiletries are easily
accessible when in the shower.
We committed to providing more forms of communication to patients about our
services and signpost patients to other relevant services using differing media,
including the use of digital media in the outpatient department reception area.
•
In the patient experience survey 100% community patients
(n =34) and 100% outpatients (n =36) reported they received
the right amount of information about their condition and
treatment (inpatients were not asked this question in this
survey). New fact sheets for patients and a new website
will be provided from April 2012 detailing the types of
services we deliver and how to access them. The outpatient
centre reception now has a TV monitor that will have a
rolling programme of information about our services.
3
Horne, G., et al., (2012) Maintaining integrity in the face of death: A grounded theory to explain the perspectives of people affected by lung cancer
about the expression of wishes for end of life care. Int. J. Nurs. Stud. 49 (6), 718-726.
5
We agreed to report on the patient experience project and make recommendations
for future methods of gaining patient and relative feedback on their experiences of
hospice services.
•
We reported last year that we had been awarded a package of support by Picker
Institute Europe and Fr3dom Health to design and run patient and family
experience surveys across our services. 316 people were interviewed. 107 patients
and 26 relatives provided their feedback. The results of the surveys were
extremely positive.
“Listened to our concerns. Provided us with a comfortable mattress.
Liaised with our GP on our behalf concerning pain relief. Helped us with
financial concerns.”
(Patient quote)
6
The key findings reported by Picker Institute Europe were:
Inpatients – All respondents (100%) rated their care as excellent or very good and found
ward staff helpful; 95% of patients were definitely given enough opportunity to discuss
anything with staff.
Outpatients – All respondents (100%) were given the right amount of information about
their condition or treatment, definitely received answers to their questions that they
could understand, and definitely had confidence and trust in their therapist.
Relatives and friends – All respondents (100%) reported they were always made to feel
welcome by ward staff, always given enough privacy, and informed as much as would
like to be regarding decisions. All of those interviewed also rated the care as excellent.
Community service patients – All respondents (100%) were able to discuss worries and
fears with the team, always had confidence and trust in the team, had the right amount
of support for family and friends, and had the right amount of information given to their
family and friends. Comments in the free-text section of this survey also reflect the
positive view of care.
Across the surveys there were a few potential areas to consider for improvement or
further exploration from a small number of patients reports. Each team drafted an
action plan. The following improvements were made: notices asking people to be aware
of the noise levels were posted at inpatient reception, which is the main thoroughfare
through the ward; the community team explored how they assess spiritual needs and
undertook further training. A question about spiritual support will be included in the
survey planned for next year. The hospice kitchen staff provides a varied menu and visit
patients daily to discuss their individual wishes.
“I have been overwhelmed by the support I have received thus far. I am in
the early stages of diagnosis/treatment with a limited time line (which I
am determined to stretch!) and the support I have received has enabled
me to maintain this positive attitude. The care I receive is excellent,
managing mine and my husband's needs when we talk with our nurse and
he immediately formed an excellent rapport with us. We feel very
fortunate to have such care available to us at a time which we never
thought we would need it. Words cannot express out thanks enough.”
(Patient quote)
The report was presented to the Clinical Governance Committee in October 2011 and
also shared with the local NHS End of Life Care Commissioning Manager. The results are
helping to inform future service developments. The full report on the analysis and
recommendations from the patient, family and public surveys conducted in 2011 can be
downloaded from our website www.rowcrofthospice.org.uk
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PART 2: WHERE IMPROVEMENTS IN SERVICE QUALITY ARE REQUIRED
This next section includes statutory statements about how Rowcroft Hospice is regulated
and also describes where we believe we can make further improvements in the quality
of care we provide.
Rowcroft hospice provides the following services:
o
o
o
o
o
o
o
17 bedded inpatient unit
Community specialist palliative care service
24/7 Hospice at Home service
Outpatient services
Chronic Oedema service
Bereavement service
Education and training for health and social care staff, volunteers and carers, in
palliative and end of life care
Rowcroft Hospice is required to register with the Care Quality Commission and is
currently registered (2010) under the following categories: treatment of disease,
disorder or injury; diagnostic and screening procedures; transport services, triage and
medical advice provided remotely. We have also recently registered under the category
‘personal care’ for our enhanced Hospice at Home service.
Rowcroft Hospice has the following conditions on registration:
o The establishment may provide overnight beds for a maximum of 19
patients at any one time.
o The establishment may not treat patients under the age of 18 years.
o The prior written approval of the Care Quality Commission must be
obtained at least one month prior to providing any treatment or service not
detailed in the statement of purpose.
Rowcroft Hospice is subject to periodic review by the Care Quality Commission (CQC).
The last unannounced inspection was on February 13th, 2012. The CQC report can be
accessed at: http://www.cqc.org.uk/directory/1-106245011
The income generated by the contract for service provision to the NHS in 2011/12
represents 26% of the total income generated to enable the provision of these services
by Rowcroft Hospice. The remaining funds were generated through fundraising
activities, legacies and donations by our local community. The total value of services
provided in 2011/12 was £ 5,108,333.
The management of Rowcroft Hospice has reviewed all the data available to them on the
quality of care provided in its services. It is intended to pursue the following key findings
and appropriate quality actions to further enhance the quality of our services:
Patient safety – delivering care
We want to continue to learn from any clinical incidents to continue improving patient
safety. One way of doing this is through the use of methods such as conducting root
cause analyses (National Patient Safety Agency) and reviewing ‘Never Events’ lists to
ensure we examine our systems and practice, learning from mistakes and preventing
8
mistakes happening. In addition we want to take the Department of Health’s ‘Saving
Lives’ further in terms of catheter care.
Other areas for further service improvement are the review of our infection prevention
policies and procedures, and medicines management procedures to ensure these meet
the specific requirements in caring for patients in their own homes.
Clinical effectiveness – measuring impact
Clinical evidence, best practice and increasing
demands on the current lymphoedema service
suggests that to provide a clinically effective
service for all patients with chronic oedema in
south Devon a new service model is required.
Rowcroft’s
lymphoedema
therapists
in
collaboration with their regional lymphoedema
colleagues have subsequently developed a new
integrated pathway of care for people with all
forms
of
chronic
oedema
(including
lymphoedema). In addition, in collaboration with the lymphoedema user group a new
follow-up protocol has been developed that will be implemented in 2012-2013.
As a specialist palliative care service we continually strive to increase our knowledge
and skills in symptom management. We want to be able to demonstrate the clinical
effectiveness of our symptom management through patient reported outcome measures
in addition to the evidence we already collate on patient experience of services.
Getting staffing right & measuring staff experience
Reviewing our community specialist palliative care workforce to ensure that staff
knowledge, skills and competencies will meet the needs of our future patient population
will help assure the quality of future care provision. All hospice staff will require
training in caring for and managing people with dementia, to meet the increased
incidence of people with dementia who will access our services in the future.
There is a need to further develop the palliative and end of life care education and
training programme for our local community health and social care staff, volunteers and
public, to meet the requirements of the national end of life care strategy.
Patient and family experience
Gaining feedback from patients, their families and friends will continue to be important
to support future improvements in the quality of care provided. We need to further
develop our feedback surveys to ensure we gain the detail required to respond to
identified needs.
We also want to further develop services that are responsive to the needs of individual
local communities and look at methods to ensure patients from all settings with all types
of disease groups have access to hospice services when they need them.
“The team works so positively in providing customised care. This is
specialised work that is excellent.”
(Patient quote)
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OUR PRIORITIES FOR 2012 - 2013
We will continue to commit to prioritising patient safety, clinical effectiveness and
enhancing patients’ and their families’ experiences of our hospice services through
getting staffing right, delivering care, measuring impact, monitoring patients, their
family and friends and staff experience4. We will monitor the progress towards these
improvements through the Quality and Patient Safety Committee, Executive Committee,
Clinical Governance Committee and Board of Trustees.
The following section outlines are key priorities for this coming year with outcome
measures for monitoring progress.
Patient safety – delivering care
a. Continue to learn from clinical incidents and near misses by implementing
further governance tools such as root cause analyses
b. Develop mechanisms for enhancing best practice in catheter care.
c. Review infection prevention policies and procedures and medicines
management for use in community settings
d. Continue to bench-mark patient falls, medication errors and pressure ulcers
with our regional hospice colleagues
Quality outcomes: Use of root cause analyses where appropriate, use of Saving Lives
catheter module, reviewed policies for infection prevention in the community, reports
of regional hospices benchmarking data for 2012-2013
Getting staffing right
a. Review community multidisciplinary team workforce to ensure it meets the
needs of our future patient population
b. Develop staff awareness of dementia and plan training for all staff in dementia
care
Quality outcomes: Report with recommendations for further development of
community workforce, future dementia action plan including agreed training programme
for all staff.
Clinical effectiveness – measuring impact
a. Evaluate the effectiveness of the enhanced Hospice at Home service
b. Develop and implement a new clinical model for the management of all
patients with Chronic Oedema
c. Participate in the piloting of a palliative outcome measure to determine the
effectiveness of interventions in symptom management.
d. Participate in an audit of achievement of patients preferred place of care with
other south west regional hospices
Quality outcomes: Evaluation report on Hospice at Home service, implementation of
Chronic Oedema service, completed pilot report of use of outcome measure/s, report of
regional audit results.
4
Department of Health (2011) Energising for Excellence
10
Patient, family, friends and staff experience
a. Develop satellite services for patients
and carers in rural communities to ‘take
care further’
the
feasibility,
potential
b. Explore
opportunities and patient benefits of
remote
working
(for
example
telemedicine); to further enhance access
to hospice care.
c. Gain further detail on patients, their
families and friends experiences of
services including the enhanced hospice at home service.
d. Gain staff views on patients’ and families experiences through appraisal
process, staff survey and engagement in service development.
Quality outcomes: report on satellite services developed, position paper on remote
working, patient, family and friends, and staff experience findings with
recommendations.
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CHAIRMAN OF THE BOARD OF TRUSTEES’ STATEMENT
Rowcroft Hospice Board of Trustees is committed to seeking and supporting ongoing
improvements in the development and quality of our services. This past year has seen
further significant investments in enhancing patient safety, clinical effectiveness
through additional staffing, and ensuring we gain and use feedback from patients,
relatives and visitors about their experiences.
As a Board of Trustees we have identified our strategic direction for the next four years
and this will see us ‘taking care further’ in terms of the quality of care provided, as well
as developing ways of helping people affected by all types of progressive life-limiting
illnesses to access our services.
As Chairman of the Board of Trustees of Rowcroft Hospice I endorse this report and
commit the Board to supporting achievement of the key priorities for 2012-2013 as set
out.
Mrs. Susan Newman
Chair of the Board of Trustees
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ANNEX
End of Life Care Commissioning Manager’s statement
NHS Torbay, as part of South Devon & Torbay Clinical Commissioning Group (SD&TCCG),
is the lead NHS commissioner for End of Life Care / Specialist Palliative care services
across Torbay & South Devon, and has developed a strategic plan to 2014 for the
direction of the provision of end of life care services, with the aim of ensuring the
delivery of high quality patient centered care.
NHS Torbay (SD&TCCG) is committed to continue to work with and support Rowcroft
Hospice in jointly exploring new methods of delivering specialist palliative and end of
life care, concentrating on the needs of patients to ensure the delivery of services
which:
•
•
•
•
•
•
•
Are of good clinical quality and are evidence based;
Are sensitive to patients’ needs;
Meet agreed performance levels;
Are sustainable and affordable;
Are responsive to local priorities; and
Reflect co-commissioning priorities;
Respond positively to service users feedback;
As the lead NHS commissioner for these services I lend my support to this report.
Mrs. Maggi Clough
Commissioning Manager NHS Torbay (SD&TCCG) / EOLC Lead South Devon
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ANNEX CONTINUED
Torbay LINk’s Statement
Torbay LINk welcomes this opportunity to comment on the Rowcroft Hospice third
annual Quality Account.
These Accounts give a clear and concise description of improvements in quality and key
priorities for 2012-13 in specialist palliative care services.
The quality indicators of: patient safety; clinical effectiveness; and patient and family
experience, are identified and explored.
High satisfaction levels are to be welcomed and Rowcroft is to be congratulated
on being awarded the Burdett Trust for the 18 month pilot.
LINk recognises ongoing improvements in areas such as improved data collection,
responsive mechanisms regarding clinical incidents, and increased referrals. These high
standards are evidenced by the included quotes contributed by individual patients.
The example of the siting of wall fixtures and the removal of a bed is a good indication
of how the organisation balances the need for safety and efficiency with patient wellbeing.
The changing and evolving needs of the community have been recognised and a positive
response is to be seen in innovative outreach and increased provision focusing on
patients with dementia.
While LINk has identified no omissions, it would be of value to have more information on
liaisons with other local and national organisations providing end of life care, and the
proposed development of the education and training programme.
Consequently, Torbay LINk is pleased to support this Quality Account. We would further
like to express how much we value and appreciate the excellent work undertaken by
Rowcroft across our three towns.
Mr. Kevin Dixon
Vice Chair Torbay LINk
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ANNEX CONTINUED
Torbay Carers Forum statement
Torbay Carers Forum appreciates this opportunity to comment on the Rowcroft Hospice
Quality Accounts.
The Accounts present the work of Rowcroft clearly. Potential areas for development
have been identified and progress has been made for on-going improvements. For
example, the challenges in the area of managing infection control in patients’ homes
and working with dementia patients have been recognised.
Education and training for volunteers and carers and for health and social care staff in
palliative, end of life care and bereavement is welcomed by carers across the Bay.
We also recognise Rowcroft’s commitment to the comfort of visitors and carers. It is
further evident that the provision of good-quality information for patients and their
families is a priority.
Torbay Carers Forum would, therefore, like to thank Rowcroft for their good work with
carers and those they care for in Torbay.
Torbay Carers Forum
15