St Christopher’s Group
Quality Account 2011-12
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St Christopher’s Group Quality Account 2011-12
Part 1
Statement on quality from Barbara Monroe, Chief Executive
St Christopher’s and Harris HospisCare set out to provide the best possible
care for people with life-limiting illnesses and those close to them, and all
our staff and volunteers participate in this endeavour. Our mission is to
promote and provide skilled and compassionate palliative care of the
highest quality and we have a national and international reputation for
providing care, delivering teaching and engaging in research. We are
committed to finding ways continuously of improving our services to
patients and families and we have a robust clinical governance framework
that enables us to do this.
We have delivered a wide range of courses to increasing numbers of
generalist and specialist health and social care professionals. In particular
we have this year delivered 11 courses for a Department of Health funded
social care pilot, resulting in ongoing contracts to train social care staff in
the boroughs of Southwark, Lewisham and Bromley.
We are in the process of running a ‘Training the Trainers’ course in
partnership with Help the Hospices and the Department of Health to achieve
a national roll out of our successfully evaluated programme for acute trusts,
‘Quality End of Life Care for All’ (QELCA) to improve end of life care in this
setting. Eighteen acute trusts and 21 hospices are involved.
Our care home programme has now supported 160 nursing homes with an
ongoing improvement in care home deaths, and two thirds of these homes
have the Gold Standard Framework accreditation. We are delighted to have
launched an evaluation into the application of Namaste, a scheme of
intensive sensory stimulation for older people with advanced dementia,
which builds on our previous research on dementia.
We are delighted to have been successful in our bid to lead one of the 6
pilot projects set up nationally by the Department of Health to collect
detailed and complex activity data with the ultimate aim of creating a per
patient tariff for end of life care following the Palliative Care Funding
Review that was published in July 2011.
In this, our second Quality Account, we identify our priorities for quality
improvement for 1012-3, and review our performance against the quality
indicators we selected last year. I and my team of senior managers have
been closely involved in this review and in developing these measures,
which have been endorsed by the Board of Trustees. I am able to confirm
that the information in this Quality Account is, to the best of my knowledge,
accurate.
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Part 2
Priorities for improvement
We have identified four areas for improvement in the coming year, under
each of the domains of quality set out in the Department of Health Report
High Quality Care for All: patient safety, clinical effectiveness and patient
experience.
1. Patient safety
i) In response to a National Patient Safety Alert we are in the process of
changing the syringe drivers we use from Graseby to McKinley T34. All
relevant staff on the inpatient unit and in the community teams have
been trained in their use.
What are we aiming to achieve? We will ensure that this transition
takes place smoothly without compromising patient safety.
How will we know what we have achieved? We will monitor medication
incidents and compare the rate of errors relating to the use of syringe
drivers in 2010-11 with that in the current year, and undertake an
analysis of any such errors to ensure that avoidable errors are prevented.
ii) St Christopher’s is an NHS business partner and therefore is required
to meet the NHS Information Governance toolkit requirements. We want
to ensure that all our clinical staff are fully aware of their
responsibilities in relation to information governance.
What are we aiming to achieve? We plan in the course of 2011-2 to
ensure that all clinical staff have completed and passed the NHS
Connecting for Health IG Training Toolkit.
How will we know whether this has been achieved? We will monitor
the number of staff who have completed and passed the module and
compare this figure with the total number of clinical staff.
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2. Clinical effectiveness
We now have data in relation to more than 1000 completed SKIPP
patient- reported outcome measures and are able to show how results
over time have remained broadly constant (see Part 3). We want to
undertake a more detailed analysis of these data.
What are we aiming to achieve? During 2012-13 we will commission a
statistician to help us find out, for example, which symptoms patients
say we improve and what relationship there is, if any, between the
existence of the different symptoms and patients’ assessment of their
quality of life.
How will we know whether we have achieved this? We will report on
the results of the analysis which we expect will enable us to concentrate
our care on the issues that matter most to patients.
3. Patient experience
What are we aiming to achieve? During 2012-13 we will set up an
effective nutrition group that will ensure that:
- nutritional screening takes place on admission
- a wider range of high-calorie meal supplements for suitable patients is
on offer
- we review the timing and process of meal ordering and availability of
food outside set meal times
How will we know whether we have achieved this? We will undertake
an audit of patient notes to ascertain that screening is taking place, and
survey inpatients about the range and acceptability of food on the menu
We will review progress in relation to each of these 3 priority areas at Board
meetings twice a year.
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Review of indicators for 2011-2
Patient safety
Last year we said that we would test out our major incident plan,
purchase ski pads for the evacuation of non-ambulant patients, and train
staff in their use.
What we did:
We undertook a table top exercise of an emergency scenario with
representatives from every Hospice department. This enabled us to see
where we needed to modify our major incident plan. We have written a
fire evacuation policy with advice from the Fire Service and our health
and safety consultant. We have purchased ski pads for non- ambulant
patients and staff have been trained to use them as part of their manual
handling training. We plan to undertake a further drill of the emergency
incident plan during 2012-3.
Clinical effectiveness
Last year we said that we would develop a programme of workshops to
support nurse managers make use of the nursing competency tools that
we had developed in 2009-10.
What we did:
In 2011-12 we ran 4 workshops and assessed the quality of appraisals and
sought feedback from nurses and their managers. As a result we have
developed a targeted approach to the use of the competency document
which we are implementing this year.
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Patient experience
Last year we said we would organise a national conference to
disseminate information about the two new tools we began using in
2010-11 to measure patient experience of care: SKIPP, a patientgenerated outcome measure VOICES-SCH, a validated survey used to
measure the quality of care from the point of view of bereaved carers.
We said we would aim to achieve the same high standards we reached in
the first 6 months of results.
What we did:
We organised a conference that attracted 32 delegates from all over the
country and invited representatives from hospices and palliative care
units using SKIPP to talk about their experiences of implementation. As a
result, several more organisations have started using SKIPP and VOICESSCH- this means that we will soon be in a position to compare the results
we are getting with those of others.
We have maintained the good results we achieved in the first 6 months
of use of SKIPP and VOICES-SCH. Further details are available in Part 3Review of quality performance.
We also said:
We would evaluate our ‘Community Support Volunteers’ pilot which
involves recruiting, training and placing carefully selected volunteers
with patients who have been discharged from our services, or who would
benefit from some additional support. These volunteers are available to
spend up to three hours a week with patients, befriending them, and
offering practical help with straightforward tasks at home or
accompanying them to appointments. They work closely with the
patient’s home care nurse.
What we did:
We obtained feedback from patients and volunteers involved in the pilot.
Several themes emerged from what patients told us. Patients very much
appreciated the time the volunteers spent with them. One said ‘Nobody
else just sits with me’; another commented ‘I have not felt listened to
before’. Some patients who were wary of healthcare professionals felt it
was easier to accept help from a volunteer.
Volunteers were surprised to find that ‘just being’ with patients could be
so rewarding for both parties. They sometimes found it hard to strike a
balance between friendship and contact as volunteers, and many found
it hard to come to terms with the death of a person they had come to
know well.
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We are ensuring that volunteers receive regular supervision and support
and have recruited to a new post of volunteer officer to coordinate this
work.
We are also continuing to recruit volunteers to this project which is
providing added value to a new social care pilot we are delivering in
Croydon Borough to frail elderly people in their last year of life.
Participation in clinical audits
As an independent hospice, St Christopher’s does not participate in the
national NHS clinical audit programme that covers subjects that do not
apply at the hospice. However, we regularly undertake audits which we
select according to network, local or internal priorities. Audits and
evaluations we have carried out in 2011-2:
Subject matter
Implication for practice/outcomes of
audit
Follow-up actions
Review of
admissions –
October 2011March 2012
In this period 79% of admissions met
the target we have set ourselves. We
have made this target more
demanding as we are now admitting
patients categorized as emergency
and urgent admissions 24 hours a
day.
This audit was undertaken in order to
establish the reasons for delays in
discharging patients from the
inpatient unit. It found that
discharges are delayed mainly by
circumstances outside the control of
the Hospice (such as the fluctuating
condition of the patient or delays in
equipment being installed in the
home)
This audit resulted in refresher
teaching sessions being delivered to
home care nurses undertaking out of
hours duties
Routine blood sugar monitoring on
admission of known diabetics and
people on steriods has now been
halted. Where possible urine rather
than blood monitoring of people on
steroids is being undertaken.
Continue to monitor
Delayed
discharges
Out of hours
calls
Blood/urine
monitoring
charts on the
inpatient unit
No action required by the
Hospice
No further action
required
Review guidance and
reaudit practice in 2012-3
Teaching session
delivered to nurses ad
doctors (Feb/May 2012)
Meeting with Diabetologist
planned for June 2012.
St Christopher’s
Consultant is one of
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Audit of anticonvulsant
medication
Asepsis
Audit of
compliance
with
regulations
pertaining to
controlled
drugs
Cleaning audits
Audit of
patient falls
Audit of care
home deaths
Pressure sore
audit
Most prescribing not done by
Hospice. Guidelines written for use
by staff in acute sector
This nursing audit showed that staff
were following good practice
guidelines.
Overall practice was found to be
good although some improvements in
the way in which nurses were making
entries on the Controlled Drug
Register were recommended
A high standard of cleanliness was
found in all clinical areas
Evidenced that falls risk assessments
were taking place and that staff were
using a range of strategies for
preventing falls in patients who were
assessed as being at high risk of doing
so
The project team working in
collaboration with local care homes
is undertaking a long-term
programme to reduce the number of
inappropriate deaths in hospital of
care home residents. To date there
has been a 20% rise in care home
deaths and subsequent reduction in
inappropriate hospital deaths between
2008 and 2011
One hundred and thirty eight patients
had a pressure sore on admission to
the hospice between October 2011
and March 2012. Only 4 pressure
sores deteriorated to levels 3 or
above while under the Hospice’s
care. In each of these cases, the
patient’s skin had been assessed
regularly and treated correctly, and
the exacerbation of the wound was
the result of the deterioration of the
patient’s condition.
palliative care
representatives at
Parliamentary Launch of
the Older People's
Diabetes Network, 18
June 2012 at the House
of Commons
Liaison with Acute Trust.
Audit annually to ensure
good practice is
maintained
Re-audit in 12 months to
ensure good practice is
maintained
New handwash sinks to
be installed in 2012-3 to
meet infection control
requirements; sluice
doors to be installed
Continue to audit
Continue to audit.
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Participation in clinical research
St Christopher’s has been involved in conducting six clinical research
studies, either alone or in partnership with university departments. All
studies received appropriate research ethics approval. Our earlier work
with the Maudsley Hospital is the largest study of depression in palliative
care population and has given rise to seven peer-reviewed publications to
date, with more to follow. This year has seen the publication of two books
that are the first in their field: a textbook on the palliative care of patients
with dementia was edited by two members of our staff, and a textbook on
the use interventional pain techniques in cancer pain was edited by one of
our staff in association with colleagues from King’s College Hospital. Both
books were published by Oxford University Press.
Goals agreed with commissioners
Use of the CQUIN framework
A proportion of St Christopher’s income during 2010-11 was conditional on
achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation payment framework. Each of
these was achieved as follows:
CQUIN1: To improve internal communications at St Christopher’s and
between the Hospice and PCTs in relation to continuing care funding for
patients. Achieved.
CQUIN2: To undertake an audit of pressure sores of grade 3 and above that
develop in patients under the care of the hospice. Achieved. (See audit
section above)
CQUIN3: To record the volume and nature of bereavement support activity
delivered to bereaved carers. Achieved.
What others say about St Christopher’s
St Christopher’s is registered with the Care Quality Commission (CQC) and is
registered to provide the following regulated activities:
o
o
o
o
Treatment of disease, disorder or injury (St Christopher’s and Harris
sites)
Personal care (St Christopher’s site)
Diagnostic and screening procedures (St Christopher’s and Harris
sites)
Transport services, triage and medical advice provided remotely (St
Christopher’s and Harris sites)
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The CQC has not taken enforcement action against St Christopher’s during
2011-12.
St Christopher’s is subject to periodic reviews by the Care Quality
Commission, the last of which was on 14th February 2012. The CQC’s
assessment of St Christopher’s following that review is awaited. (The
previous review in 2009 showed that all the standards inspected had been
met).
St Christopher’s has not participated in any special reviews or investigations
by the CQC during the reporting period.
Data quality
St Christopher’s is not required to submit records to the Secondary Uses
service for inclusion in the Hospital Episode Statistics. In accordance with
the Department of Health, it submits a National Minimum Dataset (MDS) to
the National Council for Palliative Care.
The Hospice undertakes regular quality assurance checks of its data. We
have monthly meetings of representative users of our electronic patient
record system as a result of which any integrity issues are identified and
corrected. In addition we regularly quality assure the data provided to PCTs
(patient demographics, inpatient, day care and home care activity
summaries, place of death etc)
Information Governance Toolkit attainment levels
St Christopher’s is an NHS business partner and therefore is required to
meet 29 of the Information Governance toolkit requirements. We have met
all the IG requirements for 2011-12.
Clinical coding error rate
St Christopher’s was not subject to the Payment by Results clinical coding
audit during 2011-2 by the Audit Commission.
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Part 3
Review of quality performance
We review all our services regularly and our clinical governance scorecard is
one of the ways in which we keep track of trends in relation to quality and
patient safety (See page 12 for the scorecard covering the 6-month period
to March 2012). This is evidence of the way in which we track critical areas
of care. It also highlights that we have low rates of complaints, infection
rates on our inpatient unit, and medication errors. We assess each patient
on admission to the inpatient unit in order to put measures in place to
reduce the likelihood of a fall while allowing them the freedom to move
around as they wish. Our falls rate in the inpatient unit is 0.015 falls per
occupied bed per 6 months, which is very similar to that of other hospices
and palliative care units.
Our audit programme reviews the effectiveness of our clinical care as does
feedback from patients and carers.
The result of the 12 months to October 2011 of the SKIPP patient outcomes
measure shows that of patients surveyed within 3 days of admission to the
inpatient unit 35% (n= 84) said that that in relation to the problem that was
of greatest concern to them ‘things had got much better’; 41% (n=100) said
that ‘things had got a little better’ and 12% (n=30) that there had been ‘no
change’ since their admission.
The hospice had made a ‘great’ or a ‘very great difference to how things
are going at present’ to 55% of those surveyed.
In home care, 30% of patients surveyed within a month or so of initial
contact said that in relation to the problem that was of greatest concern to
them ‘things had got much better’ (n=80) since the nurse started visiting
them; 42% said that ‘things had got a little better’ (n=113) and 16% (n=42)
that there had been ‘no change’. The home care team had made a ‘great’
or a ‘very great difference to how things are going at present’ to 62% of
those surveyed.
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St Christopher’s and Harris HospisCare Summary clinical governance overview ( Oct 2011- March 2012)
Written complaints
Number received: 6
- number upheld: 2
-number partly upheld: 1
- unsubstantiated : 3
Written complaints by 6-month period
April-September
2011
8
Oct 2011-March
2012
6
Oral complaints n= 3 (one upheld)
Wider actions taken by the hospice following
complaints during this period.
- Training for home care staff and night
coordinators on responding to out of hours
situations in the community.
- Written information to be developed for
relatives planning a funeral without a funeral
director.
SKIPP - in relation to their most pressing
concern
IPU: Things have got much better since
admission = 28% (n=167)
HC: Things have got much better since the
nurse started visiting = 37% (n=119)
VOICES-SCH
90% of carers (n= 120) thought that the patient
had received exceptional or excellent care
from the ward nurses
82% of carers (n =196) said that the care the
patient received from the SCH/HH home care
team was exceptional or excellent
Incidents:
Total
Total
Total
Total
Total
Total
Total
Total
Total
clinical incidents:
non-clinical incidents:
medical device incidents:
fire-related incidents:
security incidents:
information security incidents
medicine- related incidents
violence /aggression incidents:
n of RIDDOR reports:
AprilSept
2011
Oct
11Mar
12
127
32
3
2
5
66
3
2
126
47
1
4
4
59
6
6
Completed actions arising from incidents, alerts and risk
assessments, and after event reviews
-
New patient property forms have been printed and
staff reminded to record all valuables and sign
disclaimer forms.
EPR procedures have been changed to ensure home
care teams are advised when a patient is discharged
from IPU
We are using bags to transport oxygen cylinders
securely in our ambulances
Diarrhoeal management and outbreak policies
amended to reflect advice from HPA.
Alerts
Total alerts
from CAS
CAS alerts on
which action
required and
taken
Total MHRA
drug alerts
n. MHRA alerts
on which action
required and
taken
15
0
25
4
Infection control
n patients during period
who developed C Diff/
MRSA while on IPU*:
C Diff
MRSA
bacteraemia
0
0
* = patients admitted with
unknown infection status who
develop symptoms 3 days or more
after admission.
During this period, we had
an outbreak of Norovirus,
with 2 positive samples out
of 11.
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Feedback from patients and carers
Feedback from patients and carers is one of the most important ways in
which St Christopher’s and Harris HospisCare measures the quality of the
care they give. We receive many compliments and positive comments from
patients and families. Here is a selection from the most recent survey of
bereaved carers:
“Coming here helped me to discover
who I am. I am not treated like a
cancer patient but as a person, this
care extends to my home. Although
I’ve got cancer and I know I’m going to
die soon, they are not focusing on the
dying but on what matters to me. St
Christopher’s has the art of helping
you find yourself without realising
you’re doing it.” (Patient)
I can't begin to deserve the
feelings of relief I experienced
when he was transferred from
hospital to the hospice. Just
knowing he was getting
exceptional care in the last
days of his life, made such a
difference to all the family. I
could actually sleep at night.
(Wife of patient)
I have received helpful support from a
bereavement counsellor for which I
am extremely grateful. She is an
enormous help to me at this time and I
appreciate her visits. (Bereaved
husband)
We found the team exceptional. It was reassuring to know that
they were in touch with the hospital and District Nurses and
out GP. If ever we were in need of help they were who we
turned to. And they always came up trumps. Well done. (Family
of patient)
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All the home care team were exceptionally professional and
caring. A credit to care services. The care my husband
received from the home care team and the hospice staff
was always excellent, which is a rare statement today.
Support was/is given not only to the patient but to the family
as a whole. We cannot thank them enough. Always my
husband wanted to die at home; it was not practical
towards the end. I couldn't have given him the same
excellent care the hospice staff gave. He had immediate
care when symptoms were treated as they arose. He
couldn't have had that at home. Therefore his death was
more comfortable and dignified. (Wife of patient)
The home care team were fantastic. As soon as they
became involved I felt a weight of responsibility lift off my
shoulders. To have people to discuss things with, and who
helped my father, who was able to trust the nurses. That
brought him a measure of comfort. To know that his wish
to stay at home would be respected meant that we could
stop worrying about it. Thank you. (Daughter of patient)
The inpatient care that my mother received was amazing.
The Ward Sister, nurses, doctors, auxilliary staff were all
exceptional! They were so caring and nothing was too
much trouble for them. The help and support that I have
received from the social worker has been tremendous.
Thank you! Thank you! Thank you! (Wife of patient)
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Statements from external bodies
Bromley LINks comments on St Christopher’s Group
Quality Account 2011/2012
Bromley LINk welcomes the opportunity to comment on St Christopher’s
Quality Account. We think the Quality Account for 2011/2012 gives a true
representation of the quality of the services offered by St Christopher’s.
We are very fortunate in Bromley to have a hospice group that is at the
forefront of development and provision of high quality end of life services.
Bromley LINk appreciates the willingness of St Christopher’s Hospice to
involve the LINk in the services for end of life care and look forward to
developing a good working relationship over the coming year before the LINk
evolves into HealthWatch.
Bromley PCT comments on St Christopher’s Group
Quality Account 2011/2012
The PCT follows the national Quality and Innovation framework (CQUIN),
which enables commissioners to reward excellence, by linking a proportion of
provider’s income to the achievement of local quality improvement goals. This
allows on-going commissioner and provider discussions to create a culture of
continuous quality improvement, agreed on an annual basis.
For 2010/11 this included improving communication, audit of pressure sores,
and analysis of bereavement support, all key outcomes for both the hospice
and the PCT.
The PCT welcomes the fact that having a world leading organization in close
proximity, has helped improve the awareness of End of Life care issues in
Bromley, particularly amongst health and social care practitioners.
This has led to all GP practices using a nationally accredited care pathway for
their palliative and End of Life patients, and crucially care homes are also
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engaged. In fact, with the help of the hospice, the PCT has been able to
develop care homes to become beacon sites for End of Life Care.
Opportunities to give feedback on this quality account
We welcome feedback on this quality account. If you would like to do this,
please email b.monroe@stchristophers.org.uk or write to:
Dame Barbara Monroe
Chief Executive
St Christopher’s Hospice
51-59 Lawrie Park Road
Sydenham SE26 6DZ
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