Making every day
matter
Quality Account
2011/12
stclarehospice.org.uk
Registered Charity No. 1063631
St Clare Hospice
Quality Account
2011/12
“When I first walked in the door as St Clare I felt as if someone had started to hug
me and taken the fear away. It’s all in a setting which is relaxing and where you’re
valued.You are treated as a person, not your diagnosis.”
Madeleine, Day Therapy patient.
“You matter because you are you.
You matter to the last moment of your life, and we will do all we can, not only
to help you die peacefully, but also to live until you die.”
Dame Cicely Saunders
Contents
Part 1
Statement on Quality from the Chief Executive Officer…………………………………2
Statement on Quality from the Board of Trustees……………………………………….4
Part 2
Priorities for Improvement………………………………………………………………….6
Priorities for Improvement during 2011/12….…………………………………………..14
Participation in Clinical Audits…………………………………………………………....16
Participation in Clinical Research
CQUIN Framework
Registration with the Care Quality Commission
Data Quality, Information Governance Toolkit and Clinical Coding Error Rate
Part 3
Review of Quality Performance…………………………………………………………..18
Complaints, Compliments and Safety Information.…………………………………….24
Local Audits…………………………………………………………………………………25
Statements from External Stakeholders…………………………………………………33
How to Provide Feedback………………………………………………………………...35
Part 1: Statement on Quality
Chief Executive Officer Statement
I am delighted to present this Quality Account for St Clare Hospice. As an
organisation we are continually striving to ensure we provide quality driven and
individualised services to the patients and families of West Essex and the borders of
East Hertfordshire. Quality is integral to all we do here at St Clare. It is at the
forefront of our minds when delivering our services on a daily basis right through to
compiling our future strategy.
As an organisation we constantly monitor, assess, review and evaluate our work.
We actively seek the views from everyone involved with St Clare Hospice and take a
positive approach to learning, developing our services to meet the needs of local
people. Here at St Clare we care for anyone who is affected by a life limiting illness;
support is also given to their families and friends both during the illness and through
the time of bereavement.
We encourage patients and families to be involved in the planning of their care.
As a team we support patients and families through difficult times, providing a
sensitive and caring approach when people need to make decisions and plan for
their future. We do this in a timely and sensitive manner, always remembering the
person at the heart of their journey.
Over the past year we have worked hard as a team to ensure the foundations of our
care are solid and equitable across the organisation. We have developed in-house
training packages, taken a proactive approach to risk management and incident
analysis, and developed our clinical documentation to optimise our approach to
delivering safe, quality driven and individualised care with patients and families
engaged throughout the process.
2
In addition to this we work hard to provide support and care for all our staff, allowing
them to continue to work in what can be a challenging environment. Members of staff
have access to regular support from their managers, an employee assistance
programme and for our clinical staff a comprehensive supervision programme.
We are caring for more patients and families, providing a wider range of services
than ever before. Our Day Therapy and Outpatient services have developed
significantly and are responsive and proactive to individual needs. The team work in
collaboration with other health and social care providers, delivering services in partnership
within the hospice.
In 2011 we were fortunate enough to extend our Hospice care out into the
community. When the community specialist nurses joined the Hospice team
this marked the beginning of future service development, all based on the needs and
wishes of patients and families. This quality account is the product of a team’s hard
work, their commitment in delivering quality care and developing services with the
people they care for.
I am pleased to present this quality account for 2011/12 and to the best of my
knowledge the information contained therein is accurate.
Tanya Curry
Chief Executive
3
Chairman of the Board of Trustees Statement
During the course of this year St Clare has celebrated its first 21 years and we were
pleased to have a visit from the Countess of Wessex celebrating the achievements
of the Hospice and the role that it had played in providing high quality specialist
palliative care for the people of West Essex and part of East Hertfordshire.
The past year has been very challenging with changes in our senior management
team and with the transfer of the community team from NHS West Essex to St Clare
Hospice. This enabled the Hospice to provide a joined-up service for the local
community. We aspire to eventually providing a Hospice at Home service so that we
can live out our original mission of providing top quality specialist palliative care.
Governance has been vital for St Clare Hospice and as Trustees we wish to ensure
that the Hospice operates in a safe and professional manner in all areas of its work.
Despite the difficult financial climate and rapidly changing health economy we are
proud to have delivered more services to more patients and their families than ever
before. We have fostered a culture of continually learning and improving our services
with shortfalls being identified and acted upon quickly.
We have reviewed our governance structure to make it robust and proactive with an
open approach to risk management and learning. To achieve this we have delegated
some of the governance role to sub-committees which can cover every element of
the Hospice and to monitor the performance of each part of Hospice life. This has
meant that the Trustees have attended Hospice meetings and functions to keep in
touch with the day to day work of St Clare.
We actively seek feedback from all people using our services as well as from our
volunteers and our partners in the local community. This enables us to use the
information positively to learn, develop and improve the quality of all that St Clare does.
4
Despite the many challenges throughout the year we have never lost sight of the fact
that the only reason for St Clare’s existence is to provide the specialist palliative care
for our local population and to support, not only the patients but also their relatives
and friends who often need on-going support.
As Chairman of the Board I am pleased to support this quality account.
Michael Chapman D.L
Chairman
5
Part 2 - Priorities for Improvement
Introduction
This Quality Account demonstrates that St Clare is committed to delivering high
quality care that is safe, effective and provides patients and their carers with a
positive experience. It also reflects our vision and mission to continually develop our
specialist services for patients and their carers, whether they are at home or in the Hospice.
The priorities for quality improvement identified for 2012/13 are set out below and
impact directly on each of the three domains of quality, patient safety, clinical
effectiveness and patient experience.
Priorities for improvement - 2012/13
Priority 1: Develop the Hospice at Home service –
Clinical Effectiveness and Patient Experience
Following the transfer of the specialist community palliative care team to
St Clare Hospice in 2011 we are now planning to develop a Hospice at Home
service that will be available throughout Harlow, Uttlesford and Epping.
The service aims to enable patients with advanced illness to be cared for at home,
and to die at home if that is their preference. Care may be provided to prevent
admission to, or facilitate discharge from inpatient care and support families and
carers within their own homes.
The first stage of this development is for the community service to be provided seven
days per week as from the summer of 2012. The longer term aim from 2013 is to
further develop the service to provide an integrated community service that brings
the skills, ethos and practical care associated with the Hospice movement into the
home environment, throughout the day and night and putting the patient and those
who matter to them at the centre of the care.
6
The first stage will be audited to review its impact.
Measures:
•
Audit of response times to referrals by the community team
•
To review weekend admissions and determine what impact the new service
has on admission avoidance.
•
Audit whether the Preferred Priorities of Care documentation is completed for
patients seen by our specialist community team.
•
Review Advice Line calls and use the results to inform service development
and professional / patient education.
•
Questionnaire feedback on our service from patients, their carers and other
health and social care professionals.
Priority 2: Review and Implement further elements of The End of Life Care Strategy
– Clinical Effectiveness; Patient Experience; Patient Safety
In 2012/13 St Clare Hospice is prioritising the implementation of the Department of
Health’s End of Life Care Strategy, promoting high quality care for all adults at the
end of life. This will include commitment to the Gold Standards Framework,
Preferred Priorities of Care and the Liverpool Care Pathway. The drivers for this
priority are based on audit of current practice within the Hospice and a commitment
to continually improving practice.
2a. Gold Standard Framework
The aim of the Gold Standards Framework is to deliver gold standard of care for all
people nearing the end of life. It is a systematic common-sense approach to
formalising best practice, so that quality end of life care becomes standard for every
patient, helping clinicians identify patients in the last years of life, assess their needs,
symptoms and preferences and plan care on that basis, enabling patients to live and
die where they choose. Gold Standards Framework embodies an approach that
centres on the needs of patients and their families and encourages inter-professional
teams to work together. Gold Standards Framework can help coordinate better care
provided by generalists across different settings. (End of Life Care Strategy 2008, DH)
7
At St Clare Hospice the team acknowledge and support the benefits of attending
Gold Standards Framework meetings in our local community.
Our specialist medical and nursing teams already attend meetings held in practices
in our community catchment area. The experience has been positive and by
continued collaboration with our primary healthcare colleagues and listening to
feedback from patients, families and healthcare professionals in 2012/13 we aim to
achieve:
- Consistent high quality care
- Alignment with patients’ preferences
- Advanced Care Planning
- Increased home care and less inpatient based care especially where this is the
patient’s preference.
Measures:
Measurement will be based on the Gold Standards Framework After Death Analysis
(ADA) designed as an improvement tool and is in complete alignment with the
Department of Health draft quality markers. The following information will be
collected:
•
Demographics including diagnosis, gender, Preferred Priorities of Care,
actual place of death
•
Information
on
communication
and
coordination
of
care,
including services used
•
Care planning, symptom control assessment, continuity of care,
out of hours care
•
Carer support and care in the dying phase
•
Number of crisis admissions, hospital bed days, reasons for not achieving
Preferred Priority of Care
8
2b. Liverpool Care Pathway
The Liverpool Care Pathway (LCP) is a care pathway which prompts clinicians to
treat symptoms, promoting comfort and discontinuing invasive treatments that would
not benefit patients in the last days or hours of life, caring also for families and carers
with psychological support during the terminal phase and after death.
Increasingly the Liverpool Care Pathway is being adopted by those providing end
of life services. The Liverpool Care Pathway offers a care pathway approach to
the last days of end of life care. First developed for use with cancer patients, has
now been successfully modified for use for people with other conditions. It can be
used in hospitals, care homes, hospices and in people’s own homes.
(End of Life Care Strategy 2008, DH)
At St Clare the LCP has been used for several years and in 2012/13 we will reflect
on its use in the Hospice and support its implementation and on-going use in other
environments, including hospital, care homes and primary care. St Clare Hospice
aims to ensure the LCP is used, where appropriate, and to raise awareness of its
appropriate use at multi-disciplinary team meetings, Gold Standards Framework
meetings and education sessions.
Measures:
•
Documentation audit of Liverpool Care Pathway use
•
Questionnaire feedback on the use of Liverpool Care Pathway from health
care professionals.
•
Record of education sessions by St Clare Hospice staff on Liverpool Care
Pathway
2c. Preferred Priorities for Care
The Preferred Priorities for Care (PPC) is a person-held document designed to
facilitate individual choice in relation to end of life care. Effective communication and
recording the individual’s preferences and wishes enables both the individual and
their carers to become empowered. It is helpful for information contained within the
PPC (with the individuals permission) to be shared with their key care providers.
9
Several large scale surveys of the public have been undertaken in recent years to
ascertain people’s preferences and priorities in relation to end of life care. These
surveys are complemented by detailed research based on focus groups and
interviews with older people and those who are approaching the end of life.
Although people’s preferences and priorities may change as death approaches,
these changes will be linked on occasion to the concerns regarding the availability of
services for their PPC.
The main findings can be summarised as follows:
•
Most people would prefer to be cared for at home, as long as high quality care
can be assured and as long as they do not place too great a burden on their
families and carers.
•
Some research has shown that some people (particularly older people) who
live alone wish to live at home for as long as possible, although they wish to
die elsewhere where they can be certain not to be on their own;
•
Some people on the other hand would not wish to be cared for at home,
because they do not want family members to have to care for them. Many of
these people would prefer to be cared for in a Hospice;
•
Most, but not all, people would prefer not to die in a hospital – although this is
in fact where most people do die.
•
To ensure that people’s individual needs, priorities and preferences for end of
life care are identified, documented, reviewed, respected and acted upon
wherever possible. (End of Life Care Strategy, DH 2008)
The PPC document provides the opportunity to discuss concerns that may not
otherwise be addressed. The explicit recording of individual wishes can form the
basis of care planning in multi-disciplinary teams and other services, therefore
reducing unplanned admissions and avoiding inappropriate and/or unwanted
interventions.
10
At St Clare Hospice we strive to ensure that people’s PPC are discussed, recorded
and met. However, audit has demonstrated that this is an area that still requires
improvement, which we aim to achieve with:
•
Attendance at Gold Standards Framework meetings to ensure PPC is
addressed at an early stage
•
Education sessions on the use of the PPC
•
Ensure discussion of
PPC at our
Hospice based multi-disciplinary
team meetings
•
Raising awareness with the public about PPC and Advance Care Planning
Measures:
•
Documentation audit of the holistic notes on the completion of individuals PPC
•
Documentation audit of the multi-disciplinary team meetings information sheet
•
Inclusion of Preferred Priorities for Care and Advance Care Planning in public
awareness sessions
•
Outcome audit to determine whether patients that die attained their PPC
•
Record of education sessions attended and delivered by St Clare Hospice
staff on the PPC
11
Priority 3: Development of Management of Breathlessness –
Clinical Effectiveness and Patient Experience
Breathlessness is the distressing awareness of the process of breathing.
Breathlessness is very frightening and occurs in about a third of all patients receiving
palliative care but in up to three-quarters of patients with advanced cancer and in
over a half of patients with chronic obstructive pulmonary disease, heart disease and
renal disease.
As a specialist palliative care provider we recognise that breathlessness is not
limited to those with cancer or respiratory disease and that it is a particularly
distressing and frightening symptom, not only for patients but also for carers.
St Clare Hospice has chosen to address the symptom of breathlessness as a priority
for 2012/13 as this distressing symptom requires skilful management.
Our aim is to improve the assessment and management of breathlessness in both
malignant and non-malignant disease by:
•
Providing a training session for St Clare Hospice staff from Addenbrooke’s
Hospital
Breathlessness
Intervention
Service,
focusing
on
non-
pharmacological management.
•
Extending the scope of the Breathlessness Group to include carers as well as
patients with conditions such as chronic obstructive pulmonary disease,
advanced heart failure, pulmonary fibrosis and cancer.
•
Extending the Breathlessness Group programme to include Advance Care
Planning
•
Joint Physiotherapist and Specialist Nurse Clinic to facilitate collaborative
working with the acute sector, improved pharmacological management and
avoidance of hospital admissions
•
Participation in external education programmes arranged by, or with primary/
secondary care colleagues to share the Hospice knowledge and skill in this
area of care.
12
•
Use of Cancer Dyspnoea Scale for the assessment of breathlessness in
patients with cancer.
•
Develop links with multi-disciplinary community colleagues with attendance at
respiratory multi-disciplinary team meetings
Measures:
•
Documentation audit of attendance at external multi-disciplinary meetings
•
Documentation audit of attendance of staff at training sessions
•
Documentation audit of the use of Cancer Dyspnoea Scale in our assessment
and re-assessment processes
•
Questionnaire feedback of patient experience for those attending the joint
Physiotherapy/ Specialist Nurse Clinic
•
Questionnaire feedback of patient experience for those attending the
Breathlessness Group
•
Survey of number of patients attending Breathlessness Group
•
Survey of number of patients attending joint Physiotherapy/Specialist
Nurse Clinic
•
Survey of number of patients presenting with both malignant and
non-malignant breathlessness
13
Priorities for Improvement from 2011/12
The aim of the Quality Account is to not only set future priority improvements but to
also evidence achievements on priorities for improvement from the previous year.
The quality improvements for 2011/12 were:
Improvement Priority 1: Clinical Mandatory Training – Patient Safety
All substantive members of clinical staff have attended mandatory clinical training.
This was identified as a priority through audit, particularly relating to record keeping,
documentation, safety and the new guidance in 2011 from the East of England
Strategic Health Authority on cardio-pulmonary resuscitation procedures. Training
provided for substantive staff including Nurses, Doctors, Occupational Therapists
and Physiotherapy staff. We will re-audit key record keeping and documentation
areas and for rollout of training to all clinical staff in the coming year.
Improvement Priority 2: Development of Multi-disciplinary Holistic Notes –
Clinical Effectiveness and Patient Safety
This priority was identified through the audits on record keeping and documentation
and from the 2011 Care Quality Commission assessment of services (See audit list).
The holistic notes were revised in 2011, involving consultation with all staff groups.
The review has been comprehensive and has particularly impacted on the area of
care planning and ease of access. We will re-audit the revised holistic notes in the
coming year.
Improvement Priority 3: Proactive Risk Management –
Clinical Effectiveness and Patient Safety
Proactive risk management has been developed and addressed during 2011.
Areas of improvement include:

Comprehensive attendance at quarterly Risk Management meetings, led by
our facilities manager.
14

Active ownership of risk by the senior management team

SWOT analysis of the organisation which fed into the risk management traffic
light system.

Revision of the risk management traffic light system to ensure areas of risk
are regular analysed and acted upon appropriately.

Any serious incidents are investigated using a full Root Cause Analysis
process. The organisation invested in root cause analysis training for another
two members of the management team over the past year.
St Clare Hospice collects information on all areas of risk, including incidents and
accidents, drug errors, compliments and complaints. The Hospice has developed a
culture of learning, providing an environment that supports development and
implementation of action plans to deal with highlighted risk management issues.
Review of services
During 2011/12 St Clare Hospice provided five services for adults partly funded by
the NHS. The services were:
•
Inpatient Unit
•
Day Therapy
•
Outpatients
•
Community
services
–
St
Clare
Community
Specialist
Nurses,
Physiotherapists, Occupational Therapists and Social work / Psychological
services
•
Bereavement support
St Clare Hospice has reviewed all the data available to them on the quality of care in
all of these services. The income received from the NHS in 2011/12 represented
30% of the total cost of running our services.
15
Participation in national clinical audits
During 2011/12
St Clare Hospice was not eligible to participate in any national clinical audits or
national confidential enquiries and therefore there is no information to submit. This is
because none of the 2011/12 audits or enquiries related to specialist palliative care.
Research
The number of patients receiving NHS services provided by St Clare Hospice that
were recruited during that period to participate in research approved by a research
ethics committee was 0. During 2011/12 there were no appropriate national, ethically
approved, research studies in palliative care in which we could participate.
Use of CQUIN payment framework
St Clare Hospice income during 2011/12 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation payment framework.
Statements from Care Quality Commission (CQC)
St Clare has no conditions attached to registration and the Care Quality Commission
has not taken any enforcement action during 2011/12. St Clare Hospice was
inspected by the CQC in May 2011 and areas of minor concern were highlighted and
have been addressed.
Data Quality and your actions to improve Data Quality
St Clare Hospice will be taking the following actions to improve data quality
Standardise reporting structures for complaints and compliments
Standardise authorisation and data collection methods for staff training
Minimum Data set to be compared with historical data to monitor changes in services
Collate and analyse information from informal audits and surveys, using the data to
monitor and improve services.
16
Information Governance Toolkit
St Clare Hospice has registered to use the Information Governance Toolkit but at
this time it has not been used to assess information governance management. This
will be reviewed in 2012/13.
Clinical coding error rate
St Clare Hospice was not subject to the Payment by Results clinical coding audit
during 2011/12 by the Audit Commission.
17
Part 3 - Review of Quality Performance
The figures below provide information on the activity and outcomes of care for
patients in 2011/12 and 2010/11 compared to the median for other Hospices
prepared by the National Council for Palliative Care (NCPC).
The National Council for Palliative Care: Minimum Data Sets for
2010/11and 2011/12
St Clare
Total number of
patients
2011/12
St Clare
Total number of
patients
2010/11
National
median number
of patients
2010/11
National min.
2010/11
National max.
2010/11
586*
426**
417**
175**
963**
*
**
Excluding patients cared for by the newly established community team during 2011/12
Excluding patients cared for in the community in 2010/11
The National Council for Palliative Care: Minimum Data Sets for Inpatient Units
2010/11and 2011/12
St Clare Hospice has been identified as a small unit (fewer than 10 beds); there are
38 units included in this category.
All Service Users
St Clare
2011/12
St Clare
2010/11
National
median
number of
patients
2010/11
Total
patients
203
173
163
42
586
New
patients %
92.1
93.0
89.1
38.2
97.6
Number
re-referred
8
5
10
0
90
National min
2010/11
National max
2010/11
18
Diagnosis
St Clare
2011/12
St Clare
2010/11
National
median
number of
patients
2010/11
3.3%
3.7%
8.5
1.0
38.2
St Clare
2011/12
St Clare
2010/11
National
median
number of
patients
2010/11
National min
2010/11
National max
2010/11
2928
2490
2388
365
3,441
Cancer Avg.
length of
stay
9.4
10.0
12.0
8.4
28.1
Non Cancer
Avg. Length
of stay
10.2
6.4
10.1
0.0
42.0
%
Occupancy
78.3
78.4
78.5
53.4
100
%
Availability
100
85.3
100
80.1
100
% Non
Cancer
National min
2010/11
National max
2010/11
Bed Usage
Available
bed day
19
The National Council for Palliative Care: Minimum Data Sets for Day Therapy
2010/11and 2011/12
Day Therapy service at St Clare Hospice has been identified as a medium unit
(126-179 patients); there are 50 units included in this category.
All Service Users
St Clare
2011/12
St Clare
2010/11
National
median
number of
patients
2010/11
Total
patients
145
128
146
126
179
New
patients %
70.3
78.9
61.0
28.1
78.9
5
4
0
37
St Clare
2011/12
St Clare
2010/11
National
median
2010/11
National min
2010/11
National max
2010/11
24.0
9.9
14.9
1.2
47.1
Number
16
re-referred
National min
2010/11
National max
2010/11
Diagnosis
% Non
Cancer
20
The National Council for Palliative Care: Minimum Data Sets for Outpatients
2010/11and 2011/12
Nationally St Clare Hospice has been compared with units with fewer than 96
patients (52 units).
All Service Users
St Clare
2011/12
St Clare
2010/11
National
median
number of
patients
2010/11
Total
patients
139
72
48
0
94
New
patients %
84.8
86.1
67.5
33.3
100
Number
re-referred
3
5
0
0
22
St Clare
2011/12
St Clare
2010/11
National
median
number of
patients
2010/11
National min
2010/11
National max
2010/11
44.3
16.1
7.6
0
100
St Clare
2011/12
St Clare
2010/11
National
median
2010/11
National min
2010/11
National max
2010/11
238
121
41
3
519
National min
2010/11
National max
2010/11
Diagnosis
% Non
Cancer
Attendances
Number of
Clinics
Held
21
The National Council for Palliative Care: Minimum Data Sets for Community
Team (Home Care) 2010/11and 2011/12
Nationally St Clare Hospice has been compared with fewer than 543 patients
(43 units).
Interactions with all Service Users
St Clare 2011 – 2012*
St Clare 2010 - 2011
1505
89
791
0
Total face to face contacts
Total telephone contacts
*Service was developed significantly with the introduction of four specialist nurses, administrator and
team manager.
Contact Analysis
Professional
Face to face first
Face to face follow up
Telephone
Medical consultant
1
0
0
Doctor
0
0
0
469
1689
6613
0
0
54
Physiotherapist
88
43
165
Occupational
Therapy
73
33
227
Social worker
18
0
801
Spiritual Carer
0
0
0
Psychologist
4
0
0
Complementary
Therapist
0
0
0
Other Health Care
professional
6
0
0
Clinical Nurse
Specialist
Nurse
22
St Clare
2011/12
St Clare
2010/11
National
median
2010/11
National
min
2010/11
National
max
2010/11
101.3
24.4
96.2
1.0
256.5
5.01
9.0
9.5
0.0
63.2
31.83
22.8
28.5
9.0
50.0
Average length of
home care
New non-cancer %
% of patients aged 25
to 64
The National Council for Palliative Care: Minimum Data Sets for Bereavement
Services 2010/11and 2011/12
Nationally St Clare Hospice has been compared with fewer than 105 clients
(47 units).
All Service Users
St Clare
2011/12
St Clare
2010/11
National
median
number of
patients
2010/11
99
53
60
7
104
68.6
66.0
71.4
33.3
100
3
0
0
0
19
Total
patients
New
patients %
Number
re-accessing
National min
2010/11
National max
2010/11
Contact with service users
St Clare 2011/12
St Clare 2010/11
Face to face (by trained
and supervised person)
293
104
Face to face – complex
intervention by mental
health specialist
124
102
23
Other quality Markers we have chosen to measure
In addition to the limited number of suitable quality measures in the national dataset
for palliative care, we have chosen to measure our performance against the following:
• Complaints & Compliments
• Incidents & Accidents
• Local Audit
• Other Quality Initiatives
• Patient and Carer feedback
Complaints and Compliments
Complaints 2011/12
Total number of complaints 2011/12: 42
A total of 42 complaints were received (5 related to patient/family care).
Any complaints received were fully investigated and appropriate action taken.
All complaints were discussed at the Risk Management Group and Root Cause
Analysis carried out on two complex complaints, one of which related to a clinical
matter.
Safety Information
Accidents/Incidents 2011/12
Trips/Falls (of accidents)
Accidents
Drug
Incidents
Patient
Other
52
29
15
35
8
Drug related incidents – There were 29 drug related incidents, all were investigated and
corrective action taken. There were no serious consequences from these incidents.
Accidents – Of the accidents 43 of these were trips, slips and falls and 35 of these related
to patients. No serious injuries incurred.
24
Local Audits
To ensure a high quality of services a variety of audits were undertaken using
nationally agreed formats often specifically developed for Hospice care as well as
locally developed audit tools. This has enabled us to monitor the quality of services
and make improvement where needed. It is planned to develop an annual audit
programme to further improve the effectiveness of audit activity.
During 2011/12 St Clare Hospice’s Clinical Governance Working Group reviewed the
results of 20 audits. The audits related to a cross section of Hospice activity including
the holistic notes (see section on improvement priority 2 for 2011-2012), the inpatient
unit, the day therapy service, advice line calls, and assessments by the community
palliative care team.
Review of holistic notes
Audit
Standard
All pain
assessment
documentation
is completed
on admission
The admission
details should
be legible and
completed for
each patient.
Findings
Action Plan
The importance of involving patients
in completing pain assessment
charts.
Staff education on how to
complete the documents and
the importance for patient
care.
Management of symptoms increased
patient confidence in the Hospice
team.
To increasingly involve
patients in the management
plan.
Meeting the standard gave the patient
confidence in the care they received. To use the validated pain
tools according to patient
Completing the chart improved the
need.
patient experience.
The standard fell short in several
areas such as religion, consent,
mental capacity, and the preferred
place of care document.
Repetition was an issue and staff
could save valuable time not having
to ask the same question twice.
Staff education on the
importance of the completion
of all details and the issues
that arise if this is not done.
Record keeping education
included in mandatory clinical
training.
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Patients will
have the
mental
capacity
documentation
completed
The
abbreviated
mini mental
test score is
completed for
all patients
All patients
have a holistic
assessment
completed by
time of
discharge
Ensure
paperwork is
completed and
filed following
patient
discharge or
death
45 patient’s notes were audited.
17 patients (37%) patients were
lacking in capacity but only 1 patient
had been identified to lack capacity
according to the documentation.
Of the 46 notes reviewed only one
mini mental test score was
completed.
The audit did not reach the standard
of holistic assessments completed.
Patients who are in for short stays
difficult to obtain all information.
An individualised approach may be
preferable not requiring the
completion of all sections for all
patients.
46 notes audited The three relevant
sections from 46 notes were audited
Completion rates ranged from 11 –
40%.
100% were filed correctly
Education sessions provided
on Mental Capacity and the
use of documentation.
Clear procedure on the
completion of the
documentation and when it
should be completed.
Holistic notes reviewed with
staff consultation and
education sessions provided.
Education about the need for
assessment and the need to
complete all sections or
indicate why section not filled
in.
To set time scales for
completion of individual
sections.
Review documentation so
that it is clear that all sections
have been assessed.
Educate all team members to
file notes appropriately to
save time.
Education session to ensure
that there is a good
understanding amongst staff
about.
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Inpatient Unit
Standard
The Inpatient
Unit MDT
meeting will be
attended by
representative
of the Hospice
multiprofessional
team
Findings
Action Plan
Not all Inpatient Unit MDT meetings
are attended by representatives of the
Hospice multi-professional team.
Nurses, doctors, and social worker are
present for more than 50% of all
meetings.
To review findings at clinical
governance working group.
Chaplain, Macmillan nurses, OT and
bereavement counsellor were present
for the minority of meetings. There was
no physiotherapist representation at
any of the meetings.
To ensure facilities continue
to gain access to bedroom
for specialist cleaning.
To monitor
infection
control in the
Inpatient Unit
We are compliant with all long-term
infection control objectives.
Documentation of daily
cleaning regime.
High and Low dusting
regime to continue.
Inpatient Unit Kitchen to be
cleaned daily.
General
practitioners
will be
informed of
the outcome of
all advice line
calls taken by
Hospice staff
Of the 67 call documented through the
advice line over a two month period, 16
calls (24%) made mention of the GP
being sent the outcome and in 14 calls
(21%) a fax sheet to the GP was
included.
Clean laundry room to be
kept for clean laundry only.
Discuss with team whether
the standard is realistic.
Those taking advice line
calls should collect the GP
details during the call.
The outcome section could
include a box to confirm
when sheet faxed to GP.
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Day Therapy
Standard
The Day Therapy
MDT meeting will be
attended by
representative of the
Hospice multiprofessional team
Findings
Not all Day Therapy MDT
meetings are attended by
representatives of the Hospice
multi-professional team nurses,
doctors, physiotherapists and
social workers are present for
more than 50% of all meetings.
Psychological therapist,
chaplain and Macmillan nurses
are present for the minority of
meetings.
Action Plan
To review findings at clinical
governance working group.
There was no occupational
therapy representation at any of
the meetings.
Continue monitoring the
cleaning regime.
To monitor infection
control in Day
Therapy
We are compliant with all longterm infection control objectives.
Daily assessment and
documentation of Day
Therapy cleaning regime.
Day Therapy to be cleaned
daily.
Treatment rooms to be high
dusted regularly.
Monitoring of high and low
dusting.
Three sections of five randomly
selected notes were audited:
All patients rereferred to Day
Section 1: 20% compliance
Therapy will have
new goals set prior to
Section 2: 0% compliance
placement
Section 3: 20% compliance
Day Therapy manager to
revisit the productive ward
guidelines.
Staff education on goal
setting and handover
procedures.
Review documentation in
the revised holistic notes.
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Management goals
at initial assessment
will be documented
in section 2 of the
holistic notes (post
productive ward).
Day Therapy manager to
revisit the productive ward
guidelines.
Section 1: Patient goals were
documented in TEN sets of
notes on the date of assessment
(100%)
Staff education on goal
setting and handover
Section 2: Patients needs were
procedures
identified in SEVEN sets of
notes on the date of assessment Review documentation in
(70%)
the revised holistic notes
Staff education on goal
setting and handover
procedures
Management goals
at initial assessment
will be documented
in section 2 of the
holistic notes (post
productive ward).
Treatment plans for
each patient will be
set during the
handover in the
morning that patients
are expected to
attend.
Management goals
will be documented
at Each Day Therapy
MDT meeting in
section 2 of the
holistic notes (pre
productive ward).
Section 1: Patient goals were
documented in EIGHT sets of
Staff education on
notes on the date of assessment completing Holistic
(80%)
assessments and
documenting needs team to
Section 2: Patients needs were
re-visit PW guidelines
identified in FIVE sets of notes
on the date of assessment
Discuss whether it is
(50%)
necessary to document
needs in section 2 at the
initial assessment
Ten sets of notes were
randomly selected.
Of a total 12 possible
documented meetings, 11 were
documented in 2 patients, 9
meetings in 2 patients, 8
meetings in two patients, 7 in
three patients and 6 in one
patients.
Day Therapy manager to
revisit the productive ward
guidelines.
Staff education on goal
setting and handover
procedures.
Review documentation in
the revised holistic notes.
The audit standard was
achieved in 30% of the 10 notes
audited:
Week 1-3: MDT management
documented in 6
Week 5-7: MDT management
documented in 8
Implementation of the
Productive Ward goal
setting modules.
Week 9-12: MDT management
documented in 9
29
Management goals
will be documented
at each Day Therapy
MDT meeting in
section 2 of the
holistic notes (post
productive ward).
The audit standard was
achieved in 40% of the 10 notes
audited:
Week 1-3: MDT management
documented in 7
Week 5-7: MDT management
documented in 6
Week 9-12: MDT management
documented in10
Day Therapy manager to
revisit the productive ward
guidelines.
Staff education on goal
setting and handover
procedures.
Review documentation in
the revised holistic notes.
24 Hour Advice Line
Standard
Findings
Action Plan
All Advice Line
calls will have a
documented
outcome
Of the 89 calls received in the three
month audit period, all had a
documented outcome.
No change
Community team
Standard
Findings
The community
CNS will deliver
specialist palliative
care through a
quality service in
accordance with
national standards
and guidelines
Ten sets of notes were selected
at random.
Patients were not having a
holistic assessment as
determined using Help the
Hospice Audit Tool.
Action Plan
Address requirement for a
policy and procedure
through the clinical
governance working group.
Specialist Nurses to attend
mandatory training on use of
the holistic notes for
assessment.
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Other Quality Initiatives
Newsletter and website
St Clare News is published three times per year for all stakeholders. Along with our
website it provides information on our services and celebrates the achievements of
all aspects of the Hospice. They also provide an opportunity for patients, carers, staff
and volunteers to comment on the work of the Hospice. Internal communication
cascades are also in place.
What have carers and users said about St Clare Hospice?
National Hospice Care Week
During National Hospice Care Week 2011 the following image was created
summarising all the views of carers and users of St Clare Hospice. The size of the
word relates to how many times it was used to describe carers and users experience
of St Clare Hospice. The organisation is pleased to see Support, Caring and Loving
as being the predominant descriptors used.
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User Feedback Questionnaires
At St Clare Hospice every service user has the opportunity to provide feedback on
their experience of the service. Information is collected using a service questionnaire
and then collated. The feedback is shared with staff on a quarterly basis; key themes
are highlighted, with an action plan completed. An annual summary is produced and
shared with our commissioners. The Hospice team receive all data as well as an
annual agreed action plan detailing priorities for improvement. The action plan is a
live document, reviewed every quarter to ensure as an organisation we are
responsive to feedback and proactive in our work. Displays around the Hospice
building showing a summary of feedback received and the action taken are due to be
implemented by July 2012. These displays will be refreshed and updated quarterly.
Comment Card Feedback
Comment cards are available at St Clare Hospice and in the St Clare Hospice retail
shops. As with the User Feedback Questionnaires, the feedback from the comment
cards is used to help improve services provided by St Clare Hospice. Feedback
relating to compliments and complaints is shared with the management team at the
hospice’s risk management meeting. This is in turn shared with wider team members
and the Board of Trustees through the governance structure.
User Involvement Forum.
The Forum is lead by the Director of Patient Care and is made up of members of the
public who have received care or who are currently receiving care from St Clare
Hospice. Meetings are held every two months with the group being very active and
supportive in all areas of Hospice development. The ultimate aim is to always
improve Hospice services using valuable feedback and the experience of service
users.
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Statement from Local Involvement networks, Overview and Scrutiny
Committees and Primary Care trusts
Essex Health Overview and Scrutiny Committee
Thank you for the opportunity to comment on the Quality Accounts for 2011/12.
The HOSC rarely has dealings with a hospice. However, it is well aware of the
important role they carry out and the long tradition of support of hospices by Essex
residents. The Committee’s chairman is himself, the Chief Executive of a hospice.
The HOSC has also commented on end of life strategies in use in the county, so is
aware of the issues involved.
The HOSC welcomes the role of the hospice in supporting relatives and involving
them in any care arrangements put in place. - It welcomes the development of the
Hospice at Home service. There is much evidence that people prefer to die in their
own homes, however pleasant the surroundings of a Hospice may be. The HOSC
would be pleased to receive an update on this at one of its meetings during 2012/13,
to understand how the service operates in practice and how the benefits and any
disadvantages are being measured and acted upon.
Graham Redgwell Secretary to Essex HOSC
NHS Commissioners/Quality Account leads
A copy of this Quality Account was sent to NHS North Essex Cluster (West Essex
Clinical Commissioning Group) and NHS Hertfordshire.
NHS West Essex Primary Care Trust response to
St Clare Hospice Quality Account for 2011/12
This is the final year that Quality Accounts are being commented on by NHS West
Essex PCT (Primary Care Trust - PCT). The PCT welcomes this Quality Account as
a commitment to an open and honest dialogue with the public regarding the quality
of care in St Clare Hospice.
Assurance from the PCT is required to ensure that the information in this Quality
Account is accurate, fairly interpreted, and representative of the range of services
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delivered. Though the PCT are commenting on a draft version of this Quality
Account, it is pleased to be able to assure the accuracy of the content in general.
The PCT is however unable to assure all data reported, as some is yet to be reported.
You describe processes to monitor your own progress through the year, these
appear robust. You give an outline summary of actions taken in the past twelve
months and your vision for the year to come. You provide information on activities
you have used to involve people in your services including a Newsletter and Carers
week. We are pleased to note the comments made by those who use your service.
Your priorities for improvement in 2011/12 have been supported by the North Essex
PCT Cluster. You have made clear links between all targets and how you have made
progress and how this has been measured. We recognise that you are an
independent charity providing services free of charge part funded by the NHS.
Your work to deliver services which meet the End of Life Strategy 2008 and the Gold
Standard Framework, including the development of the Hospice at Home service is
seen to have made progress and we note your intentions to further develop this. We
note the positive effect that has been recorded by people and their families you have
cared for. You give a comprehensive description of your participation in and learning
from clinical audit, although there were no relevant national audits for you to
participate in.
In your report there is information about your performance in respect of data quality
we note that you are taking action to improve data quality. We also note that you
have registered for the Information Governance Tool Kit and are in the process of
producing actions for 2012/13.
You have provided an overview of your activity giving comprehensive information
which compares your activity to others across the country that provide similar services.
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Your strategic priorities for improvement in 2012/13 are:
1. Developing the Hospice at Home Service
2. Implementation of the elements of The End of Life Strategy
3. Development of symptom management
4. Review of Services
We note you have also described the processes for monitoring and assuring the
progress of your work in these areas.
In conclusion the North Essex PCT Cluster considers St Clare Hospice Quality
Accounts for 2011 to 2012 as providing an accurate and balanced picture of the key
reporting period. The PCT encourages the organisation to continue to implement the
multiple and wide-ranging efforts and initiatives to improve and be innovative in its
delivery of quality in the services delivered.
Denise Hagel, Interim Director of Nursing
LINk Southend and Essex
A copy of this Quality Account was sent to LINk Southend and Essex. A verbal
response was provided which was positive. St Clare Hospice is represented at LINk
meetings and other lay-person lead involvement forums throughout the year.
How to provide feedback to St Clare Hospice on this report
or any of our services
We would like to encourage you to contact us with questions, comments or suggestions
following reading this report or from your experience of St Clare Hospice. Contact details
can be found on the back cover of this report or you can write to:
Tanya Curry
Chief Executive Officer
St Clare Hospice, Hastingwood Road, Hastingwood CM17 9JX
or email:tanya.curry@stclarehospice.org.uk
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