ST ELIZABETH HOSPICE
QUALITY ACCOUNT
2011 - 2012
“I want to thank you so much for all you did last week for my dad –
your calm, caring, reassuring presence helped mum and I cope –
making dad’s last few hours pain-free and peaceful made it all so much
more bearable for us all and allowed him to die at home in his own bed
with his family around. You came into our life at a very dark moment
and you brought light and peace, I shall never forget you – what you do
for people is just amazing .... thank you, our last memories will now be
of dad sleeping peacefully until he slipped away’’
Quote from letter received from family
“All the people that were spoken to during a visit to the hospice
confirmed that the staff are wonderful, caring and considerate. They
behave in a professional way and nothing is ever too much trouble.”
Care Quality Commission Review of Compliance December 2011
565 Foxhall Rd
Ipswich
Suffolk
IP3 8LX
www.stelizabethhospice.co.uk
Registered Charity Number 289154
This Quality Account was endorsed by the St Elizabeth Hospice Board
of Trustees on 8th March 2012
FRAMEWORK FOR QUALITY ACCOUNTS
Quality Accounts aim to improve organisational accountability to the public and engage
boards in the quality improvements agenda for an organisation.
LEADS TO
Public accountability
Leadership engaged with improvement of quality of
services
There is a legal requirement under the Health Act 2009, for St Elizabeth Hospice, as a provider of
NHS services, to produce a Quality Account.
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1
Contents Page
Page
Part 1 – Chief Executive’s Statement about Quality
Information about St Elizabeth Hospice
Our Purpose, Vision and Principles
Front Cover
3
Part 2 – Priorities for improvement and statements of assurance
from the Board
2.1
Priorities for improvement 2012-2013
5
2.2
Priorities for improvement 2011-2012
8
2.3
Overview of Quality Performance
2.3.1
Review of Services
11
2.3.2
Participation in National Clinical Audits
11
2.3.3
Participation in Local Audits
12
2.3.4
Research
13
2.3.5
Goals agreed with commissioners – use of the
CQUIN Payment Framework
13
2.3.6
What others say about St Elizabeth Hospice
13
2.3.7
Data Quality
14
2.3.7
14
NHS Number Code Validity
2.3.7.1 Information Governance Toolkit Attainment
14
2.3.7.2 Clinical Coding Error Rate
14
Part 3 –Review of Quality Performance April 2010-March 2011
3.1
St Elizabeth Hospice Governance policy statement
15
3.2
Who has been involved in Our Review of Quality
19
3.3
Statements from the Suffolk Local Involvement Network
(LINks), NHS Suffolk and the Overview & Scrutiny Committee
19
Further information
19
3.4
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PART 1: STATEMENT ON QUALITY
OUR VISION
“Improving life for people living with a progressive illness”
We will work to achieve this vision by
Striving to
- provide support and care responsive to people’s needs
- influence the provision of care
- work cooperatively with others
- grow our resources and use them effectively and efficiently
And by
- being accountable to the community
Our statement of purpose is
1. Improving life for people living with a progressive illness by providing multi-disciplinary
holistic specialist and dedicated palliative care services to patients and their families and
carers
2. Improving life for people living with a progressive illness by working alongside other
statutory and voluntary agencies to provide specialist and dedicated palliative care in a
timely and effective manner where the patient wishes to be.
3. Improving life for people living with a progressive illness by acting as a resource to the
local community regarding general and specialist palliative care to increase confidence
and competence in improving life for people living with a progressive illness.
4. Improving life for people living with a progressive illness by providing care that respects
the choices made by patients and their families so that patients are treated in their
preferred place and die in their place of choice where possible
5. Improving life for people living with a progressive illness by working towards equitable
provision of all services leading to increased use of services by people with non malignant
progressive disease and those from seldom heard communities.
6. All the above goals will be monitored through quantitative and qualitative data collection
and audit processes
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STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
I am very pleased to present the first Quality Account for St Elizabeth Hospice. Maintaining
the high quality of our services is at the heart of our Hospice. Our quality framework and
quality monitoring systems are actively reviewed and developed each year.
We operate an open culture where staff, volunteers and patients and carers are encouraged
to report concerns. This culture, together with our broader user involvement and feedback
supported by our Partnership Group, provides us with reassurance about the quality of care
we are providing and helps us to identify areas where we can still make improvements.
We have made good progress in achieving our priorities for 2011-2012, through
improvement in the management of blood transfusions, the merging of the Community
Specialist Palliative care team with our Hospice at Home and Community Health Care
Assistants teams under the leadership of our new Nurse Consultant and completing our
inpatient extension and refurbishment project, delivering higher levels of privacy and dignity
for those who use our services.
For 2012 -2013 our priorities for the year focus on improving links with other agencies
involved in the safeguarding of adults to ensure locality-wide standards, reducing the risk of
patients falling, implementing our electronic patient records system and some of the
recommendations of the review of our One Call Palliative care advice line.
The Care Quality Commission conducted a review of the compliance of our services in
November 2011 and we were found to be compliant with all the outcomes. Their
recommendations for future improvements have been included in next year’s priorities. We
continue to work with the Care Quality Commission to ensure we meet the new Essential
Standards of Quality and Safety on an ongoing basis.
This report has been prepared with input from staff, patients and carers and to the best of
my knowledge the information in the document is accurate.
Jane Petit
Chief Executive
June 2012
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Part 2 PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF
ASSURANCE FROM THE BOARD
2.1 PRIORITIES FOR IMPROVEMENT 2012-2013
Areas for improvement for 2012-2013 are set out below. They have been selected because
of the impact they will have on patient safety, clinical effectiveness and patient experience.
2.1.1 PATIENT SAFETY
Priority One
Safeguarding adults
• Staff will receive the level of training appropriate to their role, with respect to safeguarding
adults
• The hospice will link into the PCT Safeguarding Leads Group and with Suffolk County Council.
• The hospice will review its guideline information about safeguarding adults to ensure clarity for
all staff
How this priority was decided
There was an unannounced CQC inspection in November 2011. The hospice demonstrated
high levels of compliance with the Health and Social Care Act, across the services. The only
area where improvement could be made was around the safeguarding of adults.
Vulnerable adults are defined as any person who is aged 18 years or over and who is or
may be in need of community care services because of frailty, learning or physical or
sensory disability or mental health issues and who is or may be unable to take care of him or
herself, or take steps or protect him or herself from significant harm or exploitation (DOH
2000 No secrets)
Safeguarding issues arise when a vulnerable adult has experienced significant harm from
someone they are in a personal/close relationship with and where there is an expectation of
trust or are at risk of experiencing such harm. As an organisation we have a duty to protect
vulnerable people from harm. Possible abusers can include paid carers and other
professionals as well as friends and family. Also vulnerable adults with children can be
targeted by virtue of the fact that they have children. Abuse can also include
abusing/threatening children, in order to abuse the adult.
Currently we have a procedure for safeguarding adults and training is provided. The Family
Support Team supports the clinical teams when a situation arises and ensures correct
procedures are followed to protect vulnerable people. However, at inspection, it was
identified that more could be done to forge local relationships with others who investigate
reports of risks and that more training could be provided for other staff groups who are likely
to come across these issues.
How the priority will be achieved
A new senior nurse link role will be introduced to work alongside the Family Support Team
Leader, to maintain links with the Safeguarding Leads and attend relevant meetings. This
will then better inform our procedures, which will be reviewed.
An extended Safeguarding training programme will be agreed and implemented across all
relevant staff groups.
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How progress will be monitored and reported
The progress will be monitored by the Quality and Improvement Group, which in turn, reports
to the Clinical Governance Committee. The Education Governance group will monitor
training needs, attendance and training satisfaction. This may also be reviewed at the next
CQC inspection.
The Safeguarding link role will monitor compliance on a day-to-day basis.
2.1.2 PATIENT SAFETY
Priority Two
Falls prevention
•
To offer a falls prevention programme to patients at risk of falls and who could benefit from
the programme
How this priority was decided
Patient incidents, such as falls, are all recorded and investigated. Audits of patient incidents
identify trends such as a rise or fall in the number of incidents. In some cases patients can
have several falls during their stay on the Inpatient unit and staff have been trained to
identify the patients who are more likely to fall. In these cases a risk assessment is made to
help to reduce the risk and action taken such as the use of lower beds or moving the patient
to a different area of the inpatient unit to enable them to be monitored more closely.
Research suggests that the Occupational Therapists and Physiotherapists at the hospice
could provide more support to patients and their families to lower the risk of falls through
prevention programmes. This is known to be successful elsewhere.
How the priority will be achieved
The Therapy team will lead this development and pilot a programme in 2012. For the pilot
the patients and families offered this programme will already be known to the hospice.
How progress will be monitored and reported
Monitoring will be by the Patient Services Group, which meets six-weekly, and will include
comparing the numbers of falls reported previously and the patient and family experience of
the programme and what benefits they have received from the programme. Progress will be
recorded in the minutes and in the end-of-year report. This group reports to the Patient
Services Committee, which is a sub-committee of the Board of Trustees.
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2.1.3 CLINICAL EFFECTIVENESS
Priority Three
Patient Electronic records
•
To record all patient activity electronically which will ensure all staff have the most up-to-date
information readily available to them, regardless of where they work or where the
patient/family is receiving the care
How this priority was decided
The hospice operates in both the community and the inpatient units. At present it holds
paper records for patients which are shared between services, e.g. Day unit and Community
teams and inpatient unit teams. There can be a delay viewing records in a timely fashion
which can in turn delay a patient’s treatment. Time can be wasted when making internal
referrals and repeating information that has already been recorded. We also use ICare which
is an IT system for recording patient data and currently this is running alongside paper
records.
It will be more efficient and safer and therefore more effective to patient care to have all
records recorded electronically using ICare so that all appropriate staff can access
information which is up to date and available regardless of where the practitioner is working.
This will save time and promote accuracy and safety.
How the priority will be achieved
All staff will be given IT training, as needed. All staff needing to access ICare will be given
training. Patient documentation will be designed electronically.
Patient records will be transferred over to ICare.
How progress will be monitored and reported
A group has been identified to implement and monitor this change. Its members include
managers, clinicians, directors and administrators.
2.1.4 PATIENT EXPERIENCE AND CLINICAL EFFECTIVENESS
Priority Four
Advice Line
•
To ensure the advice line continues to be available 24/7 to patients, carers and professionals to
give advice about palliative and end of life care.
•
Advice is given in an efficient way which is responsive and effective and meets the needs of
callers in a respectful manner
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How this priority was decided
In July 2010, OneCall was launched. The Board approved the provision of palliative care
advice to patients, families and professionals in East Suffolk. Advice is provided by senior
experienced palliative care nurses, with medical support and is available 24 hours a day, 7
days a week.
A set of standards for the service was agreed and a review planned for the end of year one.
Calls to the service grew over the 12 months reaching up to 1000 calls a month. The
demand for the service has exceeded expectation.
A full service review has been undertaken independently which the Senior Managers are
now considering.
To ensure the service maintains standards and its objectives, an agreement will need to be
reached concerning service delivery, training and resource.
How the priority will be achieved
Managers working with the Community team will look at managing workload, expectations of
role and outcomes, within staffing resources. A revised model of service management, for
OneCall, will be developed.
For 2012-2013 the priority will be to introduce further training in advanced telephone skills
and standardisation in terms of receiving and managing advice.
We will also introduce a different approach to monitoring the advice given to callers and user
satisfaction.
How progress will be monitored and reported
This will be monitored by the teams involved, the senior managers and the Quality
Assurance and Improvement Group. The outcomes will be reported through the
Governance Committee and Senior Management team meetings to the Board of Directors.
2.2 PRIORITIES FOR IMPROVEMENT 2011-2012
Areas for improvement for 2011-2012 are set out below. They were selected because of the
impact they would have on patient safety, clinical effectiveness and patient experience.
2.2.1 PATIENT SAFETY
Blood Transfusions
In the summer of 2010 a medical audit was undertaken of our practice of giving blood
transfusions. Fifty-four blood transfusion episodes were analysed and compared with the
British Committee for Standards in Haematology guidelines.
The findings identified that we could improve the documentation of symptoms prior to
transfusion, as decisions should be focused on the symptoms the patient is experiencing
rather than on the level of haemoglobin in the blood as demonstrated by a blood test result.
The audit also showed that we did not always document that an explanation had been given
and consent gained from the patient receiving the transfusion.
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The recommendation made was for the Hospice to produce a Blood Transfusion
Assessment Sheet which would include;
- the patient’s blood transfusion history
- history of reactions to blood transfusions or any special requirements
- the indications for the transfusion in terms of the severity of symptoms
- what the haemoglobin results were after the transfusion and if the patients
symptoms had improved.
- a decision about whether a repeat transfusion would be appropriate
The re audit of blood transfusions is not yet complete but it does show already that
- documentation of consent was 100%
- indication for transfusion was more often related to symptoms
- 90% of patients had an improvement in their symptoms following the blood
transfusion. However this improvement was only slight in 20% of patients.
2.2.2 CLINICAL EFFECTIVENESS
Management of Community Specialist Palliative Care Service
The Community Specialist Palliative Care service was managed as a separate service from
the hospice but often worked with the same patients and their families. They liaised closely
with hospice staff and gained support from the Hospice Medical Consultant.
The team was a busy one with no extra
resources allocated to expand the
service.
In 2010 as part of the changes in Suffolk
Primary Care Trust (Commissioners) an
options appraisal was undertaken on the
future management of the service. The
Hospice felt that taking on the
management of the service fitted with our
objectives and put forward a case for us
to take over the contract for the service.
The Hospice was successful and the
team was transferred to our management under the TUPE regulations at one minute past
midnight on April 1st 2011.
The improvements achieved by the change are:
- reduction of duplication in services, thereby saving time and reducing the need for
the patient to tell their story to many different professionals.
- earlier access for the patient and their family to the breadth of Hospice services and
continuity of care.
- pooling of resources to ensure timely response to patient and family need.
- Multi-disciplinary assessment of patients and follow-up.
- widening access to the community service for patients with a diagnosis other than
cancer.
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2.2.3 PATIENT EXPERIENCE
Refurbishment Project
Patient surveys were suggesting that the
inpatient unit had become dated and
areas for improvement were identified
which would enhance patient experience.
There is a mixture of four single sex
bedded bays and single rooms. Patients
tell us they like a choice of both as some
patients find it very upsetting to be in a
single room away from others while other
patients prefer the privacy of a side room.
However providing care in a bay did not
give high enough levels of confidentiality
for either staff or patients and their
families because of the openness and the ease of being overheard.
A building project group, which included members of our partnership group, was set up and
the work begun to update the inpatient unit, the Hospice entrances, family rooms, clinical
areas and the viewing rooms. This was a £1.7 million project. Patient services continued, in
alternative spaces within the hospice, and the refurbishment was completed earlier in the
year.
Using the tool Excellence Design Evaluation Toolkit, an evaluation of the patient
environment was recorded pre- and post-refurbishment. The results were very pleasing with
significant improvement in all areas.
In order to achieve the higher levels of privacy and confidentiality, each bed space was
made more self-contained with separate environmental control and division with bespoke
furniture. The result was to reduce the travel of noise and breaking up the space to provide
individual areas within the bay and make it harder for conversations to be overheard.
There was the opportunity for the general public, users and professionals to tour the patient
areas before patients moved back. The feedback from the tours, again was very pleasing
with high praise, some of which is noted
below
•
•
•
“This is a great improvement on
an already excellent facility.
Having spent two weeks living in
the family room with my sister the
idea of making it look like home is
wonderful. You should be very
proud.”
“A lovely transformation everything has been carried out
with great care and consideration for both patients and visitors.”
“Wonderful refurbishment, well planned and executed. Will give great help and care
to patients and visitors. Thanks for tour.”
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2.3. STATEMENT OF ASSURANCE FROM THE BOARD
St Elizabeth Hospice is constantly aiming to improve quality of care and services to patients
and their families. It demonstrates this through its Governance structure. It has a culture of
openness and learning by its mistakes and not apportioning blame.
The following are statements that all providers must include in their Quality Account. Many
of these statements are not directly applicable to specialist palliative care providers.
2.3.1 REVIEW OF SERVICES
During 2011-2012 St Elizabeth Hospice provided and/or subcontracted the following NHS
services:
In-Patient Unit
Day Service Unit
Hospice at Home
Community Clinical Nurse Specialists and Healthcare Assistant
Family Support services, including bereavement service, Art and Music Therapists and
Chaplaincy team
Therapy services, including Lymphoedema, Complementary, Physiotherapy and
Occupational therapy
St Elizabeth Hospice has reviewed all the data available to them on the quality of care of
these NHS services.
The income generated by the NHS services reviewed in April 2011-March 2012 represents
39% of the total income generated from the provision of NHS services by St Elizabeth
Hospice for April 2011–March 2012.
2.3.2 PARTICIPATION IN NATIONAL CLINICAL AUDITS
As a provider of specialist palliative care, St Elizabeth Hospice is not eligible to participate in
any of the national clinical audits or national confidential enquiries as they did not relate to
specialist palliative care. We will also not be participating in them next year for the same
reason. (Mandatory statement).
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2.3.3 PARTICIPATION IN LOCAL AUDITS
Apr 11
May 11
Jun 11
Jul 11
Aug 11
Sep 11
Oct 11
Nov 11
Dec 11
Jan 12
Feb 12
Mar 12
Drug (6 monthly)
OT/Physio
H@H (annual)
Staff Survey (bi annual)
Community Audit
Incidents – Patients
(6 monthly)
Incidents – Non-patients
(6 monthly)
Complaints, Compliments
& SUI’s (quarterly)
Discharge (bi annual)
Documentation (annual)
Education/Training
(annual)
Art/Music (bi annual)
Comp/Lymph (bi annual)
Day Care (on-going)
Controlled Drug Audit
Bereavement Feedback
Infection Control Report
CQC Evidence
Volunteer
The reports of thirty clinical audits have been reviewed and St Elizabeth Hospice has used these results to influence its priorities for improvement
in 2012-2013.
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2.3.4. RESEARCH
There were no patients receiving NHS services provided or subcontracted by St Elizabeth
Hospice in 2011-2012 recruited to participate in research approved by a research ethics
committee. (Mandatory statement).
There have not been any national research projects in palliative care in which our patients
were asked to participate.
One hundred and thirty-five volunteers were recruited to participate in “An analysis of what
motivates individuals in Suffolk to volunteer and an assessment of the benefit of a volunteer
motivation model to Suffolk volunteer organisations”.
2.3.5. GOALS AGREED WITH COMMISSIONERS
St Elizabeth Hospice’s income in 2011-2012 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework because it is a third-sector organisation. It was therefore not eligible to
take part. (Mandatory statement).
2.3.6. WHAT OTHERS SAY ABOUT ST ELIZABETH HOSPICE
2.3.6.1 Care Quality Commission
St Elizabeth Hospice is required to register with the Care Quality Commission (CQC) and its
current registration status is that we are regulated for the following activities with no
conditions:
Personal Care
Diagnostic and screening procedures
Treatment of disease, disorder or injury
The Care Quality Commission has not taken enforcement action against St Elizabeth
Hospice during the period April 2011-March 2012.
In the summer of 2011 the hospice undertook a self-assessment of its compliance with the
Health and Social Care Act 2008. Although we were content that we did comply with all
Outcomes, we identified areas for further improvement which were implemented through the
Quality Assurance and Improvement Group.
On 9th November 2011 the CQC carried out a review as part of their routine schedule of
planned reviews. The inspection included:Outcome 1
Respecting and involving people who use services
Outcome 4
People should get safe and appropriate care that meets their needs
and supports their rights
Outcome 7
People should be protected from abuse and staff should respect their
human rights
Outcome 12 People should be cared for by staff who are properly qualified and
able to do their job
Outcome 16 The service should have quality checking systems to manage risks
and assure the health, welfare and safety of people who receive care.
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St Elizabeth Hospice was found to be compliant with all of the Outcomes; they stated:
“Of the people that were spoken with during the visit to the hospice, they all
confirmed that they felt very safe in the hospice and that staff were approachable to
discuss any of their concerns.”
‘’All the people that were spoken with during a visit to the hospice confirmed that the
staff are wonderful, knowledgeable, caring and considerate. They behave in a
professional way and nothing is ever too much trouble.’’
‘’Of the staff spoken with they all confirmed that training and development at the
hospice is well planned and organised and meets the group’s and individual staff
members’ needs.’’
‘’Confirmation was given that staff complete safeguarding training; however it was
not clear what level of safeguarding training different staff members received and
how often they received this training and annual updates.’’
CQC improvement action from Compliance Review Visit November 2011 – actions denoted
in Priorities for improvement 2012-2013:
‘’... further work is required by the hospice to maintain their ongoing compliance.
People who use the service can expect to be protected from abuse, however
clarification must be made to safeguarding training , what level of training staff
members receive and how often. Also safeguarding contact details must be readily
available for ease of access.’’
2.3.7. DATA QUALITY
St Elizabeth Hospice did not submit records during 2011-2012 to the Secondary Uses
Service for inclusion in the Hospital Episode Statistics which are included in the latest
published data. (Mandatory statement).
This is because we are not required to submit data to this system.
2.3.7.1 Information governance
St Elizabeth Hospice did not hold a formal contract with NHS Suffolk for 2011-2012 for
Information Quality and Records Management, assessed using the Information Governance
Toolkit version. (Mandatory statement). The Hospice is considered level 1 compliant. We
have an action plan in place with a date for achievement of level 2 compliance by March
2012. The Hospice, in improving patient safety, is introducing electronic records in April
2012. To ensure a patient’s information is fully protected we have been required to complete
the Information Governance Statement of Compliance (IGSoC). The Hospice has shared
records in accordance with the Data Protection Act. The IGSoC provides additional
standards which the Hospice is working towards in order to enhance its handling of personal
identifiable data.
2.3.7.2 Clinical coding
St Elizabeth Hospice was not subject to the Payment by Results clinical coding audit during
2010 -2011 by the Audit Commission. (Mandatory statement).
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PART 3 REVIEW OF QUALITY PERFORMANCE
3.1 QUALITY OVERVIEW
3.1.1 St Elizabeth Hospice governance policy statement
The organisation aims to ensure that the overall direction, effectiveness, supervision and
accountability of the organisation by putting in place processes which:
• achieve continuous quality improvements by identifying and instigating best practice,
learning through mistakes, and
• creating an environment in which excellence can flourish.
• ensure compliance with relevant regulations and legislation.
• ensure efficacy and effectiveness
• ensure that the charity meets its objects as outlined in the Memorandum of
Association
Our policies are underpinned by procedures and standards.
The Quality Assurance and Improvement Group has a rolling audit programme as well as
the ability to prioritise new audits if this response is required.
The Partnership Group has been
established for six years and comprises
patients and past carers together with
hospice staff. They have an Action Plan,
which for 2010-2011 included;
- user input in new projects, such as
the refurbishments
- to gain feedback from patients and
families
- networking with other user groups
- promoting the hospice
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15
-
reviewing services in terms of meeting patient need
review opportunities for gaining patient and carers’ experiences
The Accountable Officer is also the Registered Manager and a member of the Locality
Intelligence Network group. She monitors drugs incidents, makes six monthly Drug incident
reports and assesses the storage, destruction and use of controlled drugs formally every six
months.
Each Directorate has a risk register which is updated regularly. Risk assessments and
incidents are raised at the Health and Safety Group.
3.1.2 Quality overview
In 2010-2011 St Elizabeth cared for 1030 patients and their families across the range of
services
The Partnership Group reviewed how the hospice gathered the public/patients’ views.
The chart demonstrates their findings
Events
Intranet
Great Yarmouth
& Waveney
Focus Group
Users &
Carers
FEEDBACK
How ?
Ambassadors
Anecodotal
Snapshots with
Patients
Formal
Complaints
Partnership
Group
Comments
Box
Website
Feedback
Social
Media
Shops
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Instant
Specific
Questions
Newsletter
16
Conclusion
‘’ In general both Tim and I felt the marketing team have the data feed situation well covered
and have developed areas for future development following feedback. The team have not
only captured the traditional ways of doing this but have taken steps to ensure the Hospice is
up and functioning in the 21st Century with the Social Media route. They are planning to
develop inter-active ways to enhance what they have already had in place. It is all very
exciting to see the scope the team are taking to ensure that we can obtain the many ways of
data collection. This meeting concluded knowing that the marketing team have their finger
on the pulse and we look forward to hearing the many different ways they are taking to
achieve the data needed.’’ Partnership Group, August 2011
This is a selection of patient and carer comments on our services.
Help the Hospice Day Unit Survey- 56% response rate
-
-
-
-
-
92.5% had confidence in the staff
caring for them (7.5% had
confidence most of the time)
100% were satisfied/very satisfied
that they were involved in the
planning of their care
62.5% had the opportunity to
discuss wishes for the future
(advance care planning)
92.5% always felt they were
treated with dignity and respect
(7.5% most of the time)
92.5% felt their privacy needs were met (7.5% most of the time)
90% were always/most of the time satisfied with the quality of the food
Patient Quotes
‘’Drivers of hospice transport are always most courteous and caring. Also most
cheerful and willing to chat.’’
‘’All staff excellent.’’
‘’Very caring to me at all times, I now enjoy my days there.’’
‘’I feel the key workers tend to put more time into specific cases of their choosing.’’
‘’The staff are excellent in every way.’’
‘’Despite new building work carried out, the inside cleanliness and general
surroundings are excellent’’
‘’The food is wonderful, cooked to perfection, it couldn’t be better’’
‘’None, as I think day care is excellent in every way, nurses, doctors very caring, kind
and very considerate. I love going there every Thursday. They all so wonderful
people, no complaint at all, no one should complain about St Elizabeth Hospice.’’
‘’This is just a perfect place to end one’s life. Please may I be given this choice
surrounded by my family to end my days.’’
Complaints, Compliments and Sudden Untoward Incidents (SUI)
Oct-Dec 2010 12 complaints (11 non-patient care related) 55 compliments 0 SUI
Jan-Mar 2011 9 complaints (4 non-patient care related) 105 compliments 0 SUI
Apr-Jun 2011 10 complaints (6 non-patient care related)
57 compliments 0 SUI
Jul-Sep 2011 16 complaints (10 non-patient related)
61 compliments 0 SUI
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All complaints received at St Elizabeth Hospice are taken seriously, fully investigated and
processed as laid out in our complaints procedure. Examples of compliments received:-
“For my own part, I can only say thank you from the depths of my heart for your
unfailing kindness and care towards me. It got me through the worst period of my
life.”
“The Hospice is a truly beautiful place, light and airy, a haven of peace and quiet,
peopled by such wonderfully caring, kind and dedicated staff, including the
receptionist whom we understand is a volunteer. Even the garden is a truly beautiful
place, lovingly tended by equally friendly gardeners”.
“You were all marvellous in your understanding at that terrible time. You gave me a
strength I never knew I had...”
Quality Markers we have chosen to measure
In order to inform the governance process St Elizabeth Hospice monitors outcomes across
six different areas of the Hospice work monthly using recognised tools and national
benchmarking data.
This enables the Board to look at areas of development over a period of twelve months to
monitor progress and identify actions for any areas of concern.
Domain
Outcome
Patient experience
Relief of Symptoms
Patient Choice
Tools
-
Achievement of Goals
-
Meeting patient’s needs
-
Achievement of
preferred place for care
-
Patient safety
Maintain a safe
environment
Effective workforce
Employer of choice
Financial sustainability
Financial health
-
Organisational
effectiveness
Widening access
-
Use of resources
-
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pain assessment audit
Edinburgh post natal depression
scale
HOPE Spiritual assessment Tool
Edmonton scale
audit of complaints and
compliments
audit of preferred priorities for
care
audit of delayed discharges
audit of advance care plans
audit of patient accidents
audit of drug incidents
audit of hospital acquired
infections
staff retention
working days lost due to
sickness
investment in training
audited accounts
increase in patients with noncancer diagnosis
uptake of day care places
uptake of nurse-led clinic places
time in service
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3.2 WHO HAS BEEN INVOLVED
Chief Executive Officer
Senior Management Team
- Director of Patient Services
- Medical Director
- Director of Corporate services
- Director of Income Generation and Marketing
Quality and Improvement Group
Partnership group
Governance Committee
Board of Trustees
3.3 STATEMENTS PROVIDED FROM COMMISSIONING PCT, LINKs and OSCS
“I have been asked to thank you for sharing this document. Following reading of the report,
we have no comments to add.”
Lynne Wigens
Director of Patient Safety and Clinical Quality & Director of Infection Prevention and Control,
Suffolk Primary Care Trust
Rushbrook House
Paper Mill Lane
Bramford, Ipswich, IP8 4DE
Email: lynne.wigens@suffolk.gov.uk
“Suffolk LINk thanks St Elizabeth Hospice for the opportunity to comment on the Quality
Accounts for 2011/2012. This is the first year in which the Hospice has been required to
submit a quality account.
The St Elizabeth Hospice Quality report is readable and the language should be accessible
to the general public. The report describes an organisation which is clearly very caring and
determined to provide a high quality of care to their patients.
During the year the Hospice undertook an extension and refurbishment of their facilities
which has been well received by patients and family members; they also took on the
Community Specialist Palliative care team, whilst achieving their quality priorities and
achieved their quality objectives.
The Hospice also underwent a CQC visit which found that they had a high level of
compliance, with a small issue concerning the safety of vulnerable adults.
The priorities set out for the next year follow on from the previous year and take note of the
CQC findings. The Hospices’ priorities for the next year are sound and well founded.
The Suffolk LINk wishes the Hospice well in the next year and looks forward with pleasure to
closer working with St Elizabeth Hospice in the coming year.”
Marion Fairman-Smith, Chairman
Suffolk LINk
Red Gables
Ipswich Road
Stowmarket, IP14 1BE
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19
“The Suffolk Health Scrutiny Committee has decided not to comment individually on the
Suffolk provider’s Quality Accounts this year, and would like to stress that this should in no
way be taken as a negative comment. The Committee has taken the view that it is
appropriate for Suffolk’s Local Involvement Network (LINk) to consider the Quality Accounts
and comment accordingly.”
Theresa Harden
Business Manager,
Democratic Services,
Suffolk County Council, Endeavour House
8 Russell Road, Ipswich, Suffolk, IP1 2BX
Tel: (01473) 260855
Email: theresa.harden@suffolk.gov.uk
Web: http://www.suffolkcc.gov.uk
3.4 Further Information
LINks
Local Involvement Networks (LINks) are made up of individuals and community groups, such
as faith groups and residents' associations, working together to improve health and social
care services.
Suffolk LINk
Tel: 01449 771 246
Related website: www.suffolklink.org
Contact email address: info@suffolk.org
Overview and Scrutiny Committees (OSC)
Every local authority with responsibilities for Social Services, have the power to scrutinise
local health services. The OSC take on the role of scrutiny of the NHS; major changes and
ongoing operation and planning of services
Website; Quality Accounts toolkit :http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidan
ce/DH_112359
If you have any feedback on this document, please email our enquiries line on
enquiries@stelizabethhospice.org.uk or visit our website www.stelizabethhospice.org.uk and
complete our form for comments, compliments or complaints, which is found in the Contact
Us section.
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