St. Gemma’s Hospice, Leeds
Quality Account
2011 / 12
“ Words will never express my feelings for the care
and concern shown to my wife, myself and family
at this incredibly difficult time.”
CONTENTS
PART ONE
Our Mission, Vision and Values....................................................................................................... 1
Statement on Quality from the Chief Executive............................................................................... 2
PART TWO
Priorities for Improvement 2012/2013............................................................................................. 3
Statements Relating to the Quality of the Services Provided........................................................... 6
Review of Services......................................................................................................................... 7
Statements from the Care Quality Commission (CQC).................................................................. 10
PART THREE
Priorities for Improvement 2011 / 2012 ........................................................................................ 11
Review of Quality Performance .................................................................................................... 14
Patient and Family Experience of the Hospice.............................................................................. 16
Staff Experience of Working at the Hospice.................................................................................. 18
PART FOUR
Statements from the NHS Airedale, Bradford and Leeds,............................................................. 19
Leeds LINk and Leeds Overview and Scrutiny Committee
References, Glossary and Further Information ............................................................................. 21
PART ONE
Our Mission
St. Gemma’s provides compassionate and skilled specialist
palliative care of the highest quality, both in the Hospice and in
the community. We recognise each person’s need for respect,
dignity and independence as we care for adult patients, from
all backgrounds, with active, progressive, advanced illnesses,
and provide continuing support for their families.
Our Vision
Support
• patients in making informed choices and decisions about
their care especially at the end of life
• families having their needs assessed
• families including children, to access a high quality
bereavement service
The vision of the Hospice is to promote life and enhance its
quality within a welcoming, caring and safe environment.
We work in co-operation with service users and colleagues
to promote and influence high quality specialist palliative
care locally, nationally and internationally. By contributing to
research, sharing knowledge and good practice our aim is
to improve patient care in all settings.
• patients and their families using a range of services that
are free to patients, through the efficient use of income
Our Values
• continuing education and research
We strive to
• continuing learning and development for employees and
volunteers
Promote
• rehabilitation and independence using multi-professional
team skills and resources
Create
• audit and quality assurance activities
• an ethos and environment which is inclusive, welcoming,
supportive and respectful of all, where hospitality and
compassion are hallmarks of care
• involvement of users at all levels of our service
Respect
• standards of good practice and accountability within
professional codes of conduct, Hospice policies and
external audit • each person’s life, their intrinsic value, privacy, dignity,
culture, autonomy, faith and beliefs
• all colleagues, internal and external as we work together
to enhance the service
Meet
• the physical, emotional, spiritual and social needs of
patients and families by working in partnership with them
• the patient and families need for regular communication
and information
Quality Account 2011 / /12
1
Statement on Quality from the Chief Executive
I am pleased to present St. Gemma’s Quality Account for 2011/12. In this our second Quality Account we report to the public
on the quality improvements we have achieved in 2011/12 and set out what improvements we plan to deliver for 2012/13.
As I have worked with staff and volunteers over the past year it is evident the Hospice has made excellent progress against
the priorities identified in last year’s account. This was endorsed by an unannounced inspection by the Care Quality
Commission in November 2011 ; the Inspector agreed we were meeting all essential standards for quality and safety.
St. Gemma’s works closely with other providers and commissioners across the city and has contributed to the Palliative
and End of Life Care Strategy that was launched earlier this year. Further detail of our progress against last year’s priorities
is outlined in part three of the report. I have provided a brief summary :
Infection prevention and control
We have reviewed and implemented updated training for all our staff, including diploma level training for two of our nurses.
We have updated all our infection control policies and audits of infection control in practice show high levels of compliance.
The Care Quality Commission reported the Hospice as fully compliant with infection control requirements in November 2011.
The St Gemma’s Academic Unit of Palliative Care
This has been established in partnership with the University of Leeds. Led by Professor Mike Bennett, the Academic Unit
brings together clinical research, clinical audit and palliative care learning and teaching. This brings quality of patient care
to the forefront, integrating patient care with expert theoretical knowledge. Professor Bennett has already secured a major
national research grant to develop and implement interventions for improving the management of pain for cancer patients.
The Day Hospice and community teams
These are now merged, with increases in our medical and nursing staffing levels for both teams to allow clearer leadership,
more flexible working across the teams and new models of care for patients, all of which are directly aimed at improving the
quality of care for patients.
The Hospice will continue to build upon and monitor these improvements and we have identified four new priorities for
2012/13 as outlined in more detail in part two of this report. The priorities are to :
•
•
•
•
increase the involvement of patients and their families in planning their care and recording their wishes
improve the ways in which we measure clinical outcomes and obtain effective feedback from patients and their families.
develop and begin the implementation of a new strategy for volunteers, such a vital resource for our Hospice.
improve transport to and from our Day Hospice for patients.
The last of these priorities – improving transport to and from our Day Hospice for patients – was a priority identified by our
patients themselves.
The forthcoming year is likely to be challenging for the Hospice as with all charities in the current economic climate. I am
confident that St. Gemma’s will continue, through astute financial management, to be a leading provider of high quality
palliative and end of life care, with patients and their families being at the heart of our service.
This year’s account has been facilitated by our Clinical Audit Facilitator, working with patients, families and clinical staff
across all of our services. The Hospice Leadership Team has been closely involved in setting our priorities for quality
improvement and in delivering the improvement on the ground. The Board of Trustees has endorsed our Quality Account
and I am able to confirm that the information contained in this document is, to the best of my knowledge, accurate.
Kerry Jackson
Chief Executive
2
Quality Account 2011 / 12
PART TWO
Priorities for Improvement
1st April 2012 - 31st March 2013
At St. Gemma’s we continually review our services and seek
to improve and develop them. The Hospice has a five year
strategy, developed in consultation with patients, public
and staff which is supported by annual business plans. The
strategy and plans outline our future vision and objectives
and set out how we will achieve them. Reviewing service
priorities and ensuring we continue to meet patient and carer
needs at the end of life is a continuous process.
Clinical and support teams are fundamental to the delivery
of the strategy and two way communication between all
teams and the Hospice Leadership Team, Board of Trustees
and the Chief Executive ensures delivery is monitored
through mechanisms such as audit and project reports,
activity data and feedback obtained through patient and
family forums. Engagement with patients and families takes
place through their respective forums which meet three
times a year, in addition to continuous monitoring of levels
of satisfaction via comments, compliments and complaints,
surveys and informal feedback.
Priority 1 – Patient Safety
Enhancing patients’ and families’
involvement in discussions about care at
end of life
It is essential that all patients and, with consent, their family,
have the opportunity to have discussion about their care and
decision making towards the end of life. This is often referred
to as “advance care planning”. This will ensure that patients’
wishes are known, respected and communicated to those
who need to know. Although we have made considerable
progress, the Hospice will continue to review the processes
for achieving effective advance care planning for our patients.
• patient information is updated and communicated to
relevant members of the Hospice team
• communication takes place with members of the wider
health and social care teams that support the patient
• the Hospice remains part of the team developing the
Electronic Palliative Care Co-ordination System
(EPaCCS) which supports this essential communication
• Hospice staff are trained in both communication and
documentation requirements
Demonstrating improvements will be achieved by :
• audit of the assessment pathway to review whether all
appropriate documentation is being completed
◊ Target 2012/13 – 80% of patients will have a record
in their clinical notes referring to an advance care
planning discussion
◊ Target 2012/13 – 100% of patients who have
expressed the wish not to be resuscitated will have a
Yorkshire and Humber Regional Do Not Attempt
Cardiopulmonary Resuscitation (DNACPR) form in place
◊ Target 2012/13 – 80% of patients will have their
preferred place of care and preferred place of death
recorded
◊ Target 2012/13 – Clinical Nurse Specialists will
support 80% of Gold Standards Framework meetings
and utilise EPaCCS data
• review of training records
◊ Target 2012/13 – all registered clinical staff will have
received advance care planning training
We will ensure :
• obtaining patient feedback
• information is available to all patients (verbal and written)
• patients are supported with understanding information
and making decisions
• appropriate documentation is in place, for example the
electronic patient record and discharge letter
Quality Account 2011 / /12
◊ Advance care planning will be considered as part of
the patient feedback processes
• case reviews of patients who have made statements
about their wishes to ascertain to what extent their
wishes are met will be undertaken
3
Priority 2 – Clinical Effectiveness
Measuring clinical outcomes and obtaining patient and carer feedback
The Hospice cares for over 2,500 patients and their families
each year. To ensure the service is of high quality, it is
monitored through clinical audits, staff surveys, internal and
external inspections.
The most influential evaluators of our service are the
patients and their families.
Measuring feedback is essential in order for us to
understand the needs of our users and their families.
In palliative and end of life care this can be difficult as
the patient is in the advanced stages of their illness and
eliciting views can be seen as an additional burden (Hanson
et al 2010, Dy et al 2008, Addington-Hall et al 2007).
Understanding the patient and family experience of their
care and their impressions of the environment help St.
Gemma’s to target areas where improvements can be
made. It will allow us to develop and implement appropriate
patient reported outcome measures (PROMs) for the
patients and families that are cared for by St. Gemma’s.
Our intention in the following year is twofold. We will :
• review the method by which we receive feedback from
patients and families
• fully explore palliative care patient reported outcomes
measures, identifying those which are most useful. We
will introduce an appropriate PROM tool to the In-Patient
Unit (IPU) and and further extend the use of the existing
PROM – St. Christopher’s Hospice Index of Patient
Priorities (SKIPP) in the Day Hospice and community
4
These will be achieved by :
• consultation with patients, families and staff to develop
revised feedback mechanisms which can show validity
and reliability
◊ Target 2012/13 – revised tool in use by March 2013
40% of IPU patients / 70% of Day Hospice patients /
40% of community patients using the tool
• developing ways whereby patients’ and families’ views
can be elicited by those not directly involved in their care
◊ Target 2012/13 – trained non-clinical staff or
e-technology in place
• analysis of the current SKIPP measure in the Day
Hospice
◊ Target 2012/13 – analysis complete and results
presented; action plans developed where required
• extending the use of SKIPP to patients in the community
◊ Target 2012/13 – SKIPP piloted in the community by
December 2012 with 40% usage by end of March
2013
Quality Account 2011 / 12
Priority 3 - Patient Experience
Enhancing the roles of clinical volunteers
We aim to provide care for more patients and their families
within a challenging economic climate. Volunteers already
work in the clinical environment and make an important
contribution in supporting patients and families. Clinical
volunteers currently undertake roles in the In-Patient Unit,
Day Hospice, and complementary therapy team and in
the bereavement and spiritual care services. The Hospice
wishes to explore new roles for volunteers, to optimise the
skills they offer, allowing in the long term, clinical teams to
care for more patients and improve the patient experience.
In order to do this we need to ensure :
• effective recruitment of volunteers, matching their skills
and experience to the roles available
◊ Target 2012/13 – agreement of a volunteer strategy
◊ Target 2012/13 – revised role profile completed in
Day Hospice and therapy teams
• support for the volunteer in his/her specific role
◊ Target 2012/13 – volunteer questionnaire developed
• development of training, both mandatory, such as
confidentiality and infection control, and that required to
support individual roles
◊ Target 2012/13 – clinical volunteers’ training fully
explored
Priority 4 – Patient Experience
Transport to the Day Hospice
Ambulance transport for patients to attend the Day Hospice
is an area of concern for our patients and staff. Most
patients arrive at the Day Hospice using their personal
transport or through the services of a volunteer driver
provided by the Hospice. A small number of patients need
to travel by ambulance. Ambulance transport arrangements
can be unpredictable with delays for patients in getting to
and from the Hospice, along with occasional protracted
journeys, causing patients to be very tired. We intend to
fully explore this issue by :
• gathering further evidence of the current service
provision and obtaining verification of the number of
patients who are affected
◊ Target 2012/13 – audit completed in Day Hospice on
current service provision with action plans developed
where indicated
• obtaining more detailed feedback from patients
◊ Target 2012/13 – obtain patient stories to gain their
experiences of transport
As a result of the above an action plan for a long term
solution will be developed.
Quality Account 2011 / /12
5
Statements Relating to the Quality of the Services Provided
Statement of Assurance from the Board
The Board of Trustees is assured by the progress made in 2011/12 and supports the quality improvements planned for
2012/13. The Board is committed to the provision of high quality care for patients, families and staff across all Hospice
services.
The Trustees have undertaken unannounced quality assurance visits of patient services. Trustees speak to patients and
families with their consent and also with staff. The last visit took place 3rd February 2012 and the results were presented to
the Clinical Governance Committee on 6th March 2012. The service scored 47/48 which was deemed as excellent. This
has assisted Trustees in understanding the core business of the Hospice and has given the Board assurance of the quality
of care provided.
The Board of Trustees will continue to monitor the progress against the priorities for quality improvement, as well as
additional quality monitoring initiatives such as key performance indicators and the clinical risk register through the Clinical
Governance Committee, a joint committee of Trustees and Clinical Directors.
Rosemary MacDonald
Chairman of the Board of Trustees
6
Quality Account 2011 / 12
Review of Services
In the following review there are statements (in italics)
required by regulations which have to be included in the
report. Explanations will be given where applicable.
• Social workers provide specialist support and
counselling
• Bereavement services for adults and children
During 2011/12 St. Gemma’s Hospice
provided the following services
• Spiritual Care service supporting patients and their
families
• In-Patient Unit which provides 24 hour care and support
by a team of specialist staff
• Education and training for both Hospice and external
staff
• Day Hospice which gives patients extra support to
manage symptoms, gain confidence at home and
maximise quality of life
St. Gemma’s Hospice has reviewed all the data available to
us on the quality of care in all of these services.
• Out-Patients Service – an Out-Patient visit can provide a
consultation with a Doctor, Advanced Nurse Practitioner
or Therapist
Financial Considerations
• Community Services – the team consists of a Consultant
in Palliative Medicine and Specialist Nurses providing
support and advice in the home
• Therapies to support independence and promote
comfort including :
◊ Physiotherapy
• The income generated by the NHS services reviewed in
2011/12 represents 31% of the total income generated
from the provision of NHS services by St. Gemma’s
Hospice for 2011/12
• St. Gemma’s receives an annual grant from NHS Leeds ;
this is a fixed sum regardless of Hospice activity or the
level of voluntary income
• 100% of the financial support we receive from the NHS
is spent directly on patient services
◊ Occupational therapy
◊ Dietetics
◊ Complementary therapy
• The running costs of St. Gemma’s are forecast to be
£8.6 million in 2012/13. The majority of this has to be
raised through donations, legacies, fundraising initiatives
and our chain of charity shops
• St. Gemma’s Hospice’s income in 2011/12 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.
Quality Account 2011 / /12
7
• Clinical Effectiveness of the Specialist Palliative Care
Team (Yorkshire Sub-Regional Clinical Effectiveness
Audit Group). This has now been completed.
Participation in Clinical Audits
• The Break Through cancer Pain (BTcP) Registry – a
multi-centre programme to describe patients with
breakthrough cancer pain for whom treatment with
Abstral is started.
National
• During the period 2011/12 there were no national clinical
audits or confidential enquiries relating to the services
that St. Gemma’s provides.
The Clinical Effectiveness Group at the Hospice oversees a
programme of audit which includes the use of national audit
tools and locally designed tools. There is a multidisciplinary
approach to audit with dissemination of reports, monitoring
of action plans and re-audit where necessary.
Local
The Hospice is participating in the following regional audits :
• Yorkshire and Humber Do Not Attempt Cardiopulmonary
Resuscitation Project
Audit
Result 2011 / 12
The reports of 30 local clinical audits have been reviewed
in 2011/12 and the Hospice intends to take a number of
actions as identified below to improve the quality of care.
Result 2010 / 11 Actions
Controlled Drugs
90%
90%
Immediate action was taken to ensure correct procedures
were followed for amending corrections and ensuring
signature sheets were updated
Accountable Officer
90%
84%
Continued development of Standard Operating Procedures
and clarification of information provided to patients about
the safe storage and disposal of controlled drugs
Ensuring Safe Discharge Process (Discharge
Pathway)
88%
52%
Individualised feedback was given to staff where
improvement was required
Infection Control – Hand Hygiene
91%
N/A
Immediate feedback was given to staff where improvement
was required after low risk contact with patients
Management of General Medicines in Day Hospice
80%
N/A
Review of procedure for storage of patients’ own
medicines and updating of Standard Operating Procedures
Positive Patient Identification
80%
100%
Some inconsistencies with writing of personal identifiers
on name bands according to a revised policy. Action taken
to ensure compliance with policies
Documentation
84%
58%
Action plans in place to address shortfalls in use of
abbreviations, provision of specimen signature and
amendments of alterations
Our focus is continually on the quality of life for patients, and
their families, ensuring a positive experience of our care,
and treating and caring for people in a safe environment.
In our future audit programme we are committed to using
the Quality Standards for End of Life Care from the National
Institute for Health and Clinical Effectiveness (NICE) as the
basis for audit criteria in order to assess and improve the
quality of care we provide.
In addition to clinical audit a number of service evaluations
have taken place. These include :
• Benefits of Clinical Supervision – a positive evaluation of
members of the multi-disciplinary team receiving supervision
• Evaluation of the Experience of Clinical Supervisors – this
report showed a positive experience for both supervisors
and supervisees
8
• Secondment to the Community Team – demonstrating
positive results from In-Patient Unit nurses who have had
a range of relevant experiences by working with the
community team
• Moving On and Beyond Programme in Day Hospice
– the outcomes from this programme suggest that it has
had a positive impact on patients up to four weeks after
the end of the programme. A longer period of follow up
may be possible following the next programme
• A Review of Patients attending Day Hospice – twenty
patients were included and their symptoms and
problems reviewed. Their length of attendance, the
involvement of other professionals and the type of
service offered were presented. This review contributes
to understanding the service that is provided in order to
meet the complex needs of patients.
Quality Account 2011 / 12
Participation in Research
The number of patients receiving NHS services provided
or subcontracted by St. Gemma’s in 2011/12 that were
recruited to participate in research approved by a research
ethics committee was nil.
This means that there have not been any national research
projects in palliative care in which our patients were asked
to participate.
The Hospice has provided data for the following ethically
approved research project :
Diagnosis of depression in patients receiving specialist
community palliative care : Does using a single screening
question identify depression otherwise diagnosed by clinical
interview ? This was completed in July 2011.
The launch of the Academic Unit of Palliative Care led by
Professor Mike Bennett will lead to increased involvement in
regional, national and international research programmes.
Quality Account 2011 / /12
9
Statements from the Care Quality Commission (CQC)
St. Gemma’s Hospice is required to register with the Care Quality Commission and its current registration is for the
following regulated activities :
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury
St. Gemma’s Hospice has the following conditions on registration :
• Only treat people over 18 years of age
• Only accommodate a maximum of 34 In-Patients
St Gemma’s Hospice is subject to periodic review by the Care Quality Commission. The last review was 14th November 2011.
The CQC’s assessment of the Hospice following that review was : St. Gemma’s Hospice, Leeds was meeting all
essential standards for quality and safety.
the visit we spoke to four people using the service. They told us they were very happy with the care and
“During
treatment they received at St. Gemma’s. They said they were involved in decisions about their care and treatment.
People told us all the staff were kind and attentive, they said when they called for help staff responded quickly. People
said the food was very good, they said the menu was varied and they were able to have their meals at times that suited
them. They said the environment and facilities were good and it was always clean. CQC inspection November 2011
”
Where the Care Quality Commission has carried out on-site inspections, these are available on our website.
The Care Quality Commission has not taken enforcement action against St. Gemma’s Hospice during 2011/12. St. Gemma’s
Hospice has not participated in any special reviews or investigations by the Care Quality Commission during 2011/12
Data Quality
St. Gemma’s Hospice is not required to submit records during 2011/12 to the Secondary Uses service for inclusion in the
Hospital Episode Statistics.
The Hospice deployed SystmOne in April 2010. This system supports an electronic patient record which can be shared
with other external users of the system, for example, General Practitioners and District Nurses. The Hospice has internal
arrangements to monitor the quality of the data. The system uses the NHS number as the key identifier for patient records.
Information Governance
St. Gemma’s Hospice’s score for 2011/12 for Information Quality and Records Management, assessed using the
Information Governance Toolkit version 9, is 67% which means the Hospice is fully compliant at level 2, the required
national standard.
The Hospice, in improving patient safety, continues to develop electronic records and aims to be “paper lite” by 2013. The
Hospice has shared records in accordance with the Data Protection Act and has in place Data Sharing Agreements. The
Hospice continues to monitor handling of Personal Identifiable Data against the standards in the Information Governance
Statement of Compliance.
St. Gemma’s Hospice was not subject to the Payment by Results clinical coding audit during 2011/12 by the Audit
Commission.
10
Quality Account 2011 / 12
PART THREE
Priorities for Improvement
1st April 2011 – 31st March 2012
Priority 1 – Patient Safety
Infection Control
This priority was identified because a high standard
of infection prevention and control is a fundamental
requirement in palliative and end of life care. Our internal
infection control audit had demonstrated variable standards
of practice and the Hospice has sought to achieve a
consistently high standard across all clinical areas by
implementing an action plan for improvement.
This priority has been achieved as follows :
• Our action plan has remained on schedule
• Training for all staff has been reviewed and updated
• Two Registered Nurses have undertaken diploma level
study in infection control
• All infection control policies have now been reviewed and
ratification is currently taking place
• Infection control re-audits achieved 90%
• The Care Quality Commission at the unannounced
inspection in November 2011 saw the Hospice as fully
compliant with infection control standards
Quality Account 2011 / /12
11
Priority 2 – Clinical Effectiveness
Establishment of a Professorial Post
and Academic Unit
This priority was identified as it was recognised that the key
to making significant improvements in patient treatment is
advancement in medical and other healthcare interventions.
This can only be achieved by undertaking high calibre
research in the field of palliative care and end of life care.
Progress in achieving this priority has been as follows :
• Professor Mike Bennett was appointed in July 2011. In
addition to research and teaching activities, Professor
Bennett is working as a Consultant in Palliative Medicine
at the Hospice for two days a week involved in the direct
care of patients and training of clinical staff
• The St. Gemma’s Academic Unit of Palliative Care
(AUPC) has been launched in collaboration with the
University of Leeds
12
• The National Institute for Health Research (NIHR)
Comprehensive Local Research Network (CLRN) have
agreed to support a research group in palliative care and
chronic pain based at the AUPC to allow patients to take
part in clinical studies. A Research Nurse has been
appointed who will be based at the AUPC in the Hospice
• In addition, a £2 million NIHR programme grant has been
awarded to Professor Bennett to develop and implement
interventions for improving the management of cancer
pain. This five year programme of work will be based at
the AUPC and will lead to better quality of care for
patients at the Hospice and surrounding areas
• Professor Bennett, in collaboration with Hospice staff,
has clearly structured the AUPC into three areas –
research, learning and teaching and clinical
effectiveness. This structure encompasses all functions
integral to the delivery of education both within and
external to the Hospice as well as internal processes to
achieve clinical effectiveness
Quality Account 2011 / 12
Priority 3 - Patient Experience
Integration of Community and Day Services
This priority was identified in order to respond to changing
patient need. In particular, the increase in non-cancer
patient referrals, co-ordination of complex patient pathways
and the need to improve continuity of patient care. There
was also the requirement for a flexible workforce which is
able to meet these changing needs.
Progress has been as follows :
• Clear Leadership
◊ The post of Community and Day Services Manager
has been created to lead the integrated service.
Together with the Consultant in Palliative Medicine for
the service and the Advanced Nurse Practitioner, the
Hospice Leadership Team provides clear vision and
direction to the integrated service.
• Flexible workforce
◊ Knowledge and experience within all aspects of the
service has been enhanced in a variety of ways. The
Registered Nurses now work in both the Day Hospice
and community service. This provides greater
continuity of the service which is important for
patients. Nurses also benefit from understanding the
Quality Account 2011 / /12
patient’s needs at home and the co-ordination of care
required between the service and the Primary Health
Care Team. Nurses from the In-Patient Unit are now
gaining experience in the integrated service. This has
led to enhanced discharge planning and improved
provision of out of hours advice to patients and
professionals, as nurses now have a better
understanding of community services across health
and social care. Further expansion of nurse led
Out-Patient clinics both in the Hospice and as
satellites in community are now under development.
• New Models of Care in the Day Hospice
◊ One model focuses on psychosocial support for
patients. Social Workers and Occupational Therapists
have developed their roles to lead the changes
required. They are supported by the Health Care
Assistants who are also extending their skills. Benefits
reported by patients include more acceptance of their
diagnosis and situation, building more positive
relationships with their families and gaining a sense of
control and purpose.
◊ The second model focuses on problem solving and
setting goals for those with physical and/or complex
psychosocial symptoms. Patients have reported that
the benefits include an increase in motivation and
being more proactive in planning for the future.
13
Review of Quality Performance
The Hospice is committed to continuous quality
improvement with leadership focused on professional
development for the clinical teams, service improvements
for the patients, planning, prioritising and ensuring best use
of resources. The Hospice seeks to support patient choice
and where possible deliver care where the patient wishes to
be ; either in their own home with Specialist Nurse support
or in the In-Patient Unit.
Reporting systems are in place to ensure robust
governance arrangements. A Clinical Effectiveness
Group oversees clinical audit and clinical developments.
This group reports to the Hospice’s Clinical Governance
Committee that in turn reports to the Board of Trustees.
Monitoring Activity – A Review of Hospice
Data
Hospice data is submitted to NHS Airedale, Bradford and
Leeds, on a quarterly basis.
The Hospice also submits annual information to the
National Council for Palliative Care (NCPC) and Help the
Review of Hospice Data
Hospices. This enables comparisons with other specialist
palliative care services locally and nationally.
Out of Hours Service
We offer patients a 24/7 admissions service to the InPatient Unit. Patients, their families, and professionals can
access specialist telephone advice through the In-Patient
Unit out of hours. The nurse assesses each call and either
gives advice or seeks support from the doctor on call.
Monitoring this service continues in order to determine if
there is a need to extend the face to face service to seven
days a week. The community team service provides a face
to face service 08.30 -17.00 Monday to Friday.
An evaluation of the out of hours service from November
2010 to October 2011 concluded that this remains a
valuable service and the continued monitoring has helped
to clarify the different aspects of the service. A number
of recommendations are being addressed which include
additional education for Hospice nurses receiving the calls,
monitoring the quality of nursing and medical advice and
use of the Consultant on call. The team will continue to
explore the case for extending the community service to the
weekend.
2011 / 12
2010 / 2011
Total referrals (new and re-referrals)
2059
N/A
New referrals
956
1009
% cancer diagnosis (new referrals)
85%
89%
% non-cancer diagnosis (new referrals)
15%
11%
Number of admissions
603
566
Average length of stay (days)
14.4
15.7
Attendances
1657
1626
% places used
72%
68%
3269
3140
Adult bereavement attendances
1458
1129
Young People’s Service attendances
683
N/A
Total bereavement attendances
2141
1129
Overall Service – Patient Care
In-Patient Unit
Day Hospice
Community
Community Nurse Specialist and Consultant visits
Bereavement Support
14
Quality Account 2011 / 12
Key Quality Indicators
The Hospice encourages the reporting of drug incidents
which may be near misses, internal incidents or external
incidents, e.g. dispensing incidents or incidents witnessed
in the community.
The majority of incidents in the Hospice are near misses ;
this means there has been no patient harm and a potential
incident has been avoided due to an error being identified
before an incident occurred. Lessons from near misses are
shared and practices modified as a result. Where Controlled
Drugs are involved this is shared with the Local Intelligence
Network – Controlled Drugs through occurrence reporting.
All incidents are discussed by the Pharmacy Group and a
report submitted to the Clinical Governance Committee.
Slip, trips and falls are monitored and each incident is
reviewed to ensure all efforts have been made to minimise
the risk of falls whilst maximising the patient’s level of
independence. Trends have been monitored and steps
taken to improve the patient environment to minimise the
risk of falls. A reduction in falls has been noted in the latter
Key Quality Indicator
half of 2011/12. This may be the result of the introduction of
a falls screening assessment for patients on admission.
The tool has increased staff awareness and led to involving
supportive services – physiotherapy, occupational therapy
and pharmacy advice – sooner in the care pathway.
Predominantly patients admitted to the Hospice are
at end stage disease, and are high risk of developing
pressure ulcers. It is noted that the number of pressure
sores recorded has increased ; this is due to improved
data collection. All patients are now assessed within six
hours of admission, this is audited, and a Watkinson score
calculated, this is demonstrated through a continuous
audit. Recording of pressure sores is done electronically
on SystmOne (electronic patient records system) ; this has
allowed effective monitoring and improved data collection.
Pressure relieving equipment is provided where indicated
and the care management plan reflects the high risk status
and the nursing interventions required to minimise the risk of
development of a sore.
2011 / 12
2010 / 11
83%
78%
Total number of clinical complaints
2
3
Number of complaints upheld
2
2 partial
Number of complaints not upheld
0
1
Drug incidents / near misses (internal)
30
29
Number of slips, trips and falls
110
98
Number of patients developing pressure ulcers Grade 2 and above
37
25
1
(1 unknown if transferred
or acquired)
2
1
1
3 ( unknown if transferred
or acquired)
1
as above)
0
Number of patients on an End of Life Care Pathway
Complaints
Patient Safety
Number of patients admitted with MRSA
Number of patients infected with MRSA during admission
Number of patients admitted with clostridium difficile
Number of in-patients who contracted clostridium difficile
Quality Account 2011 / /12
15
The Patient and Family Experience of the Hospice
During 2011 Patient and Carers’ Satisfaction Questionnaires
showed care to be either “excellent” or “very good”,
however, the response rate was low. Response rates have
been compared across the Yorkshire and Humber region
where they range from less than 10% to 60% with the
mode being less than 10%. The Hospice is keen to gain
more informed feedback using validated and reliable tools.
This will allow us to make a difference to the individual
experience and also inform overall service development.
Reviewing patient feedback processes is a quality
improvement identified for 2012/13.
Carer feedback In-Patient Unit
91% of carers were able to ask questions, raise concerns
and were able to discuss how they were feeling.
91% of carers felt that they were fully included in the final
days / hours of their relative’s life and were given the chance
to discuss their understanding of what was happening.
Comments included :
Feedback received in 2011/12.
“eWords will never a
In-Patient Unit
All patients felt that staff “always” or “most of the time”
listened to them. They also felt that staff “always” made an
effort to meet their individual needs and wishes.
All patients felt that they “always” or “most of the time” had
the opportunity to make decisions about their care.
90% were satisfied with their involvement in the planning of
their care.
90% of patients “always” or “most of the time” understood
the explanations of their treatment.
Comments included :
dequat
xpress
ely
my feeli
ngs for
care sh
the
own to
my wife
family a
and
t this d
ifficult t
ime.
”
“
The friendship and support
provided by St Gemma’s staff was
outstanding. The quality of care was
just amazing and I cannot thank
everyone enough. It is a shame that
every person cannot
access this care in
were
We as a family
their final days.
ay
d
given day to
r
updates on he
care.
d
an
t
treatmen
”
“
”
“sI never expected to
uch wo
receive
nderful
care an
person
d
al atten
tion. Yo
service
u
r
is supe
rb.
”
thought it was somewhere
“Originally
to come and die. Did not realise
that pain management and rest and
relaxation were
considered.
”
orking
ew
“Ehevererygionves 100% at
lent.
all times. Excel
16
”
Quality Account 2011 / 12
Day Hospice Patients
These patients have a regular opportunity to feedback to
staff about their experience. Patients have also had the
opportunity to speak to the Clinical Audit Facilitator who is
independent of the Day Hospice team.
Feedback from community patients is informal through
thank you cards and letters; a structured approach to
gaining community feedback is under development.
Patients enjoy all aspects of their day especially the good
food, companionship, some activities which include Wi-Fit,
quizzes, time spent in the garden and visits from outside
speakers, for example, Leeds Museum. They feel well
supported by all members of the multi-disciplinary team.
Accessing a new prescription in a timely way and the
good communication between the Day Hospice and GPs
provides much reassurance for patients.
However, one area of concern voiced by a number of
patients was the transport provided by the Yorkshire
Ambulance Service. Unfortunately, the timing of journeys
was often problematic causing some patients to be picked
up too early or late. Likewise, for the return home, transport
could be delayed leading to a long and tiring day. This
also had an effect on carers and their ability to benefit
from their respite time. The use of volunteer drivers was
much appreciated. (Please see Priority 4, page 5 for further
information about what the Hospice will do to try to resolve
this problem).
“a wTaakes the worries
y.
”
“ It’s faultless
– has a nice
”
feeling.
“atmosphere
is good. ”
The whole
Bereavement Service Evaluation
An evaluation of the Bereavement Service took place in July 2011. The response rate was 33% and there was useful
feedback :
• 63% felt that the Bereavement Worker had really listened to them
• 75% were able to say what was troubling them
• 63% felt that they were coping better following the period of support
There were also some individual comments – two clients would have preferred their support to have started earlier after
their bereavement and there was some indication of mixed feelings about group sessions versus individual counselling.
Quality Account 2011 / /12
17
The Staff Experience of Working at the Hospice
The Staff Survey took place in November 2011. The
response rate was 54%. Although this is a lower response
than our first staff survey of 2008 it presents a balanced
view, being representative of staff regarding gender, length
of service and area of work profiles. Overall, the results of
the survey are positive
• 99% agree that the Hospice delivers a quality service to
its users
• 94% consider the Hospice to be a good place to work
• 90% agreed they have job satisfaction
• 80% felt they knew “a lot” about Hospice values
The training to support managers to deliver effective
appraisals, identified as a concern by the last survey
which took place in 2008, has resulted in an increase in
staff having annual appraisals from 71% to 82%. 60% of
staff agreed that their appraisal was useful to them and
70% of managers felt competent to carry them out.
Within the current survey there were eighteen areas of
strength identified. Two areas for improvement which
have been identified for action are concerning workload
and communication/staff engagement. The latter had
previously been an area for improvement specifically
18
relating to overall Hospice communication. Concerns about
communication are greater in specific work areas and so
the survey has enabled the Hospice to identify those work
areas / staff groups and plan how to better communicate
with these areas in future. There is also an intention to
review how the Staff Representative Forum operates
and consider whether this is still an effective tool for staff
communication / engagement.
Overall, staff feel satisfied that they work in a committed
and supportive team.
80% of staff are satisfied with their work area and Hospice
based staff benefit from an environment which is well
maintained – a recent refurbishment of the catering facilities
has provided a bright, welcoming and relaxing environment.
Staff turnover in 2011 was 9.6% (7% in 2010) and sickness
absence is 3.2 % (3.9% in 2010).
Staff are supported by access to an Occupational Health
Service, complementary therapy service and clinical
supervision.
An evaluation of the implementation of clinical supervision
conducted in October 2011 demonstrated benefits for
clinical staff and in particular the nurses.
Quality Account 2011 / 12
PART 4
Statement from Jo Coombs
Director of Quality and Nursing
NHS Airedale, Bradford and Leeds
NHS Leeds commissions palliative care services from
St. Gemma’s Hospice and welcomes the opportunity to
comment on this Quality Account.
We believe the account to be a fair reflection of the quality
of services provided by St. Gemma’s Hospice. However,
due to some reporting differences and timescales, we
are unable to confirm the accuracy of the activity data
published in the account.
We are also pleased to note the comparison of data that
shows progress or otherwise with regards to complaints
and aspects of patient safety. We note the increased
number of slips, trips and falls and number of patients
developing pressure ulcers grade 2 and above against last
year’s figures, and recognise that the increased numbers
may indeed be due to improved reporting and data
collection. However, we think that the hospice should seek
to satisfy itself and commissioners via monitoring meetings
that this is the case.
We support the proposal to enhance patients and families
involvement in discussions about care at the end of life, and
we commend the specific standards that the Hospice aims
to achieve.
We commend the inclusion of patient and staff feedback
within the account. Some further examples of remedial
actions taken where there were less positive comments
would have been helpful and demonstrated to readers that
the Hospice actively listens to concerns.
Likewise, we also fully support the intention to introduce
patient reported outcome measures, as increasingly
commissioners will look to commissioning for outcomes
rather than activity. Again, we are pleased to see specific
measures and targets against which the Hospice intends to
measure progress.
The forthcoming year will see changes in the way
that health services are commissioned within the city.
Commissioners look forward to a move towards more
standardised service models, and collaborative working
with other palliative care providers particularly in relation to
equity of service and access.
We are pleased to note the intent to enhance the roles
of clinical volunteers and to support them through the
provision of training and the development of a role profile.
We are also supportive of the proposal to explore issues
relating to ambulance transport.
We look forward to continued progress throughout the
coming year with all priorities highlighted in this account,
and would like to thank the Hospice for providing us with
the opportunity to comment.
With regards to quality performance over the past year,
we are pleased to note the progress made with regards
to infection control; however we believe that inclusion of
the audit action plan and the related outcomes within the
document would help to further inform service users of the
intentions and associated progress, particularly in relation to
the self-identified variable standards of practice mentioned.
We are impressed at the actions implemented and progress
made in establishing a professorial post and academic unit.
We believe that this outcome has major significance for
palliative care services, and look forward to the enhanced
outcomes that this may produce. We were pleased to note
the work that had taken place with regard to the integration
of community and day services.
Quality Account 2011 / /12
Statement from Leeds Local Involvement
Network (LINk)
The Leeds LINk would like to thank St. Gemma’s Hospice
for again submitting its Quality Account for comment
to the Leeds LINk Steering Group. Following last year’s
submission the LINk is pleased to note that St. Gemma’s
Hospice has continued to develop its working relationship
with the LINk through meetings with the Joint Chairs
and regular communication updates via e-bulletins and
newsletters. The Leeds LINk Joint chairs have been very
impressed by the good practice evident in St. Gemma’s
Hospice’s thoughtful way of approaching their work.
19
Statement from the Scrutiny Board
(Health and Wellbeing and Adult Social Care)
Following the production of the previous year’s Quality
Account, the Chair of the Scrutiny Board for 2011 / 12,
Cllr. Lisa Mulherin, was offered the opportunity to visit the
Hospice and see, first hand, the facilities and services on
offer and the care provided. Cllr. Mulherin was pleased to
take this opportunity and felt the facilities and commitment
of staff provided a valuable service for service users and
their families.
However, it should be noted that as part of its work
programme for 2012 / 13, the Scrutiny Board intends to
consider progress against the goals and targets set out in
the quality accounts for a range of service providers.
This may include the work and progress achieved by
St. Gemma’s. As part of this process and to help the
Scrutiny Board provide any future comments, the Scrutiny
Board may also consider input from other stakeholders,
such as service commissioners, the Care Quality
Commission (CQC) and the Local Involvement Network
(LINk).
The Quality Account for 2011 / 12 has been submitted to
the Scrutiny Board for consideration, but due to competing
priorities the Scrutiny Board is unable to provide any
comments at this time.
20
Quality Account 2011 / 12
References, Glossary and Further Information
References
Department of Health (2008) End of Life Care Strategy :
Promoting High Quality Care for all Adults at the End of Life.
The Stationery Office, London.
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/
@dh/@en/documents/digitalasset/dh_086345.pdf
National Institute for Health and Clinical Excellence (2011)
Quality Standard for end of life care for adults
www.nice.org.uk/media/EE7/57/EoLCFinalQS.pdf
Information for patients www.nice.org.uk/media/E9C/A9/EndOfLifeCarePatientInfo.pdf
Hanson, L., Schenck, A. P., Rokoske, F. S., Abernethy,
A. P., Kutner, J. S., Spence, C., et al. (2010). Hospices’
Preparation and Practices for Quality Measurement. Journal
of Pain and Symptom Management, 39 (1), 1-8.
NICE National Institute for Health and Clinical
Excellence
NICE provides guidance which helps health and social care
professionals to deliver the best possible care based on the
best available evidence.
Further information
For further information about this Quality Account or to
request a copy in large print please contact our Clinical
Audit Facilitator, Edwina Gerry :
edwinag@st-gemma.co.uk or 0113 218 5500.
Addington-Hall. (2007). Research Methods in Palliative Care.
(J. M. Addington-Hall, E. Bruera, I. J. Higginson, & S.
Payne, Eds.) Oxford: Oxford University Press.
Dy, S. M., Shugarman, L. R., Lorenz, K. A., Mularski, R. A., &
Lynn, J. (2008). A Systematic Review of Satisfaction with Care
at End of Life. The American Geriatrics Society, 56, 124-129.
Glossary
CQC Care Quality Commission
This is the independent regulator of health and social care
in England. It regulates health and adult social care services
provided by the NHS, local authorities, private companies or
voluntary organisations.
LINk Local Involvement Network
This is a network of local people and community groups
whose aim is to improve health and social care in their
locality. They are able to share their thought, ideas and
concerns with those who plan and run services in order to
improve them.
NCPC National Council for Palliative Care
This is an organisation for all of those involved in providing,
commissioning and using hospice and palliative care
services.
Quality Account 2011 / /12
21
Community
Palliative Care
Day Services
In-Patient Care
Bereavement
Support
Clinical
Teaching
and Research
St. Gemma’s Hospice
329 Harrogate Road
Moortown
Leeds
LS17 6QD
Hospice
0113 218 5500
Fundraising 0113 218 5555
postmaster@st-gemma.co.uk
www.st-gemma.co.uk
Registered Charity No. 1015941
Company Number 2773867