Quality Account
2011 -2012
‘‘Thoughts flow free – words do not come easy. Sitting at home with the loved one’s
empty chair it is so comforting to know they are getting the very best love, care and
attention that it is possible to receive. However it is not only the patient who receives
the care and attention, loved ones feel and enjoy the comforting aura which
surrounds St. Luke’s. Thank you are two little words which carry so much to such a
dedicated team who provide the love and care’’.
St Luke’s Hospice
Nethermayne
Basildon
Essex
SS16 5NJ
Registered Charity No. 289466 and as a Company in England No. 1812104
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Introduction
Chief Executive Statement
St Luke’s Hospice (Basildon and District) places a high emphasis on the quality of its
services which are designed to meet the specific and changing needs of individuals
across the community.
The Hospice’s commitment to quality is evidenced both via its Corporate and
Governance practice which regularly assesses performance across all areas and
which reflects the views of service users emphasising the organisations’ focus on the
delivery of the highest possible standards of care.
Corporate and Clinical Governance processes are well embedded across the
organisation and clinical governance practice and processes have been commended
by the Care Quality Commission.
The Hospice has an excellent reputation for adopting a flexible and innovative
approach to service provision and despite being a relatively small organisation the
breadth and scope of services delivered is comparable to many larger hospices
nationally. A continual review of service delivery across the locality enables the
hospice to identify gaps in the provision to expand and develop services to meet the
diverse and changing needs of the community.
The economic environment within which the charity operates has remained
challenging, yet innovative approaches to income generation, and the greatly valued
on-going support of our community has enabled our work not only to continue, but
has also allowed all our services to reach more people. Establishing new satellite
services and increased home assessments has improved access for service users
across South West Essex.
The collective approach of all of our staff and volunteers and the successful
partnerships which exist with a wide range of health and social care professionals
ensure the best possible levels of care for the benefit of all our service users.
The success of the organisation for the period April 2011 to March 2012 is a
reflection of the commitment and dedication of all our staff and volunteers who strive
to deliver the highest level of service whilst also embedding systems of continuous
improvement across the whole organisation.
I am pleased to present this Quality Account for 2011/12 – to the best of my
knowledge the information reported is a fair and accurate account.
Eileen Marshall
Chief Executive June 2012
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Part 2
2.1 Priorities for Improvement
i) Establishment of a Specialist Physiotherapy Service
There is currently no dedicated Physiotherapy Service within the South West Essex
locality of the Essex Cancer Network and therefore the proposal is to establish a
dedicated Specialist Physiotherapy Service.
The aim of the service will be to:

Establish a new Specialist Physiotherapy Service to provide an expert
resource and person-centred service to meet the varied needs of patients,
carers, families and other health and social care professionals

Respond to assessed need appropriately and quickly, to maintain and
maximise independence, support rapid facilitated discharge and work
collaboratively with patients and professionals to enable effective life-style
management and support individual choice and support programmes.
The team will provide a specialist service to patients with a cancer/palliative care
diagnosis who have complex needs. They will work to implement a structured and
supported rehabilitative model of care available to patients at all stages of their
cancer journey. The team will provide one-to-one assessment and support.Working
collaboratively, the team would also facilitate rapid discharge home and sustainable
care at home.
The development will ensure an equitable and accessible service in line with other
localities within the region and will enable us to develop support in a range of ways
across a wide range of need.
The quality and operation of the service will be monitored and evaluated through a
variety of systems including:

Monitoring of activity levels and referral response targets

Satisfaction surveys. Outcomes and action plans will be reported to and
monitored by the Audit, Research & Quality Assurance Group (ARQ) and will
be part of the Annual Audit Plan

Rehabilitation pathways will be audited and reported

Quality performance will be reported through the Corporate & Clinical
Governance Group, Senior Management Team and Trustees

Recommendations will be implemented as per NICE guidance (2008) on
specific rehabilitation outcome measures.
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As this would be the first dedicated Specialist Physiotherapist Service within South
Essex locality of Essex Cancer Network, full evaluation of the effectiveness of
thesupport provided will be evident in the establishment of supportive care pathways,
these will then be audited.
An annual service review will be conducted and a report disseminated to all major
stakeholders.
ii) Priority 2
Enhancing the Contribution of Services Users to Service Provision
The participation of Service Users and carers in the work of St Lukes Hospice is
seen as an essential component of the overall Hospice strategy, ensuring that the
organisation continues to develop a patient-focused approach tothe delivery of high
quality services. It is a requirement of the National Cancer Peer Review Measures
and has been recognised in the National Cancer Plan (2004), Cancer Reform
Strategy (2010) and Improving Outcomes: A Strategy for Cancer (2011) as an
important component of health care provision.
Specific Objectives will include:

Supporting and encouraging the development of effective relationships
between the service user group and relevant professionals/clinicians

Encouraging the development of the service user groups/individuals,
facilitating relevant training, attendance at seminars/conferences and any
other opportunities to expand their knowledge and experience

Identifying gaps in service user representation, especially ‘hard to reach
groups’, and develop plans to rectify them
The vision of the St Luke’s Service User Group is to value and utilise the knowledge
and experience of service users and to facilitate their involvement in the
development of high quality Hospice services in South West Essex.
The group will aim to ensure user representation on relevant hospice groups as
appropriate e.g. Clinical Development Team and will help develop high-quality,
patient-centred care and improve hospice care services.
The group will meet monthly. Minutes of the meetings will be considered public
documents, circulated to members and made available to the Audit, Research and
Quality Assurance group, Corporate and Clinical Governance group, Clinical
Development Team meeting, Senior Management Team and Board of Trustees in
order to inform and support service development.
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iii) Priority 3
Survivorship and Living with Long Term Conditions
The Hospice has actively extended it services to meet the needs of individuals who
survive and recover from cancer as well as those who continue to live with a long
term condition and their carers.
During 2012/13 the Hospice will deliver the HOPE Programme (Help Overcome
Problems Effectively), designed by Coventry University. The programme seeks to
overcome the challenges involved in living with a long term health condition, or
caring for someone young or old with a long term health condition or disability, or
those who have recovered from cancer and their carers. The approach is
underpinned by the disciplines of health and positive coaching psychology.
The programme, developed by Coventry University has been adopted by Macmillan
Cancer Support. Teams within the Hospice have been trained to provide the
programme; two sessions will be established in October 2012 and January 2013.
The outcomes of the programme will be reported through the organisation’s Clinical
Development Team, Corporate and Clinical Governance, Senior Management Team
and the Board of Trustees.Outcomes from the programme will be fed back to
Macmillan Cancer Support and Coventry University as part of a national evaluation
process and will also inform the development of other specific therapeutic and
support groups.
Part 2.2
Statements of Assurance from the Board
Review of services
During 2011/12 St Luke’s Hospice provided four NHS services.
The services were as follows:




In-Patient Unit
Day Hospice
Out Patients
Hospice at Home
The Hospice has reviewed all the data available to them on the quality of care in all
of these NHS services.
The income generated by the NHS services reviewed in 2011/12 represents 100 per
cent of the total income generated from the provision of NHS services by St Luke’s
Hospice for the reporting period 2011/12.
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Participation in clinical audits
During 2011/12 there were no national clinical audits and no national confidential
enquiries covering NHS services relating to palliative care. St Luke’s Hospice only
provides palliative care, therefore were ineligible to participate.
The Hospice has a robust audit system which has been commended by external
verifiers.
The Hospice Consultant, Dr Piggott, is actively involved in audit, governance and
quality assurance systems throughout the Hospice. She carries out a yearly audit of
Cardio-Pulmonary Resuscitation (CPR) decisions. This year she will be auditing the
implementation of the new East of England Integrated Do Not Attempt Resuscitation
(DNARCPR) Policy & Form. She also ensures a regular programme of medical
audits in conjunction with junior doctors.
Research
Over the last year Dr. Piggott has been the Basildon Principal Investigator on a multicentre research trial investigating a drug treatment for fatigue. This has completed
recruitment and Dr. Piggott is now in the process of starting some new trials in the
Hospice and hospital settings. In addition Dr. Piggott is instrumental in developing
Day Hospice and non-malignant disease services. She has recently started, with
the Community Heart Failure Team - a Heart Failure Palliative Medicine Clinic. The
impact of this on patient’s quality of life and admission avoidance will be monitored.
During 2011/12 the Hospice @ Home Team pre-piloted the Carers Support Needs
Assessment Tool, developed by Cambridge University. The success of the project
was such that the Hospice subsequently received permission to use the evaluation
tool across the organisation.
Quality improvement and Innovation Goals Agreed with our Commissioners
St Luke’s Hospice in 2011/12 was not conditional on achieving quality improvement
and innovation goals through the Commissioning for Quality and Innovation payment
framework because CQUIN goals did not form part of the NHS Standard Contract
agreed for this period.
2.3 What others say about us
St Luke’s Hospice is required to register with the Care Quality Commission and its
current registration status is unconditional. The Hospice has no conditions on
registration.
The Care Quality Commission has not taken any enforcement action against St
Luke’s Hospice during 2011/12.
St Luke’s Hospice has not participated in any special reviews or investigations by the
CQC during the reporting period.
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St Luke’s Hospice is subject to periodic reviews by the Care Quality Commission and
its last review was in April 2011. St Luke’s Hospice has no actions to take as no
points were made in the CQC’s assessment. The Hospice was fully compliant and
rated as low risk.
Data quality
St Luke’s Hospice places a high emphasis on the quality of data, which is regularly
monitored to assess quality and performance. Our new Electronic Patients Records
System will support this process.
NHS Number and General Medical Practice code Validity
St Luke’s Hospice did not submit records during 2011/12 to the Secondary Uses
Service for inclusion in the hospital episode statistics, which are included in the latest
published data.
Information Governance Toolkit attainment levels
This is not applicable for St Luke’s Hospice and palliative care.
Clinical Coding error rate
St Luke’s Hospice was not subject to the Payment by Results clinical coding audit
during 2011/12 by the Audit Commission.
i) Care Quality Commission
The Hospice is required to register with the Care Quality Commission (CQC). The
CQC Compliance Officer undertook an unannounced 1 day inspection in April 2011.
The subsequent report was very positive and reflected the competence and
enthusiasm of all staff and volunteers.
Comments from the Compliance Officer included:“People with whom we spoke were very happy with the services provided by St.
Luke’s … and felt well informed and fully involved their care and treatment … People
told us that privacy and dignity is respected at all times”
“People with whom we spoke told us they feel safe and secure within the Hospice
and that if any concerns were raised that the staff would take them seriously and
would not tolerate any form of abuse”
“People told us they thought the Hospice was very clean and the standards of
hygiene were good”
“People can feel fully confident that their medicines are managed safely and
effectively”
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“People told us that they felt comfortable talking to the staff about any issues that
they had, that they feel confident that any concerns or complaints they raise will be
listened to and acted upon”
“A recent complaint was looked at and we saw that it had been managed
appropriately in an open and transparent way”
“When we visited the service we saw that records were well organised and held
securely. Whatever we needed to see was available.’’
ii) Trustee Provider Visits
Provider visits have been regularly undertaken by the Board of Trustees. The visits
have produced positive and affirming reports in respect of service delivery and staff
and patient satisfaction.
iii) Volunteers
During March 2011 and April 2011 the Volunteer Co-ordinator carried out a survey of
all Volunteers at St Lukes Hospice. 230 surveys were distributed 90 volunteers
returned the questionnaire, representing a 42% return.
The top five areas of satisfaction were noted as:





Induction to the Hospice
A recommendation that St Lukes as a good place to volunteer
Training given in order to carry out the role
Encouragement and support is present throughout volunteering roles
Volunteering is interesting, challenging and rewarding.
Areas for improvement were noted as:


Circulating the newsletter to a wider audience
Improving communication generally
Arising from the survey it was noted that:

44% of volunteers have been volunteering with us for 5 years or less, 26%
between 5 – 10 years, 19% between 10 – 20 years. 9% of those who
responded have 20+ years of service with us

The majority of volunteers (51%) volunteer once a week. 23% come in more
than twice a week

33% say they work between 11 and 20 hours per week

86% feel that they had a sufficient induction to the organisation when they
started
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
34% felt they were sometimes involved in decision making, 45% felt well
involved and only 12% felt they were not well involved

86% felt they receive enough training to carry out their role

92% knew who the person responsible in their team for providing
encouragement and support

73% felt that they received sufficient feedback from the team

59% rated the recruitment and induction programme as very good to great

47% thought the Volunteer Newsletter was excellent and interesting. 54%
found the Staff/Volunteering Quarterly Newsletter helpful and interesting

90% would recommend St Luke’s as a good place to volunteer 7% either
didn’t answer or were unsure
The survey generally indicated that our volunteers were satisfied or very satisfied
and very much enjoyed their Volunteering experience, were very positive about it
and believed it made a real difference to their lives. Given patterns of attendance
communication is an area which could be improved, arising from the survey a new
volunteer notice board has been identified and a volunteer consultation programme
has been established. A formal thank you event was held at the hospice during
national carer’s week and this will be repeated during consecutive years to reinforce
the value and contribution volunteers make across the organisation.
iv) What our patients say
“My stay here has been the most pleasant I have ever spent anywhere! The
staff are second to none, kind, caring and friendly and nothing is ever too much
trouble. I will miss all their smiling faces. The garden is wonderful to sit in and
enjoy – as to the kitchen staff, I want to take them home, the food has been
excellent. I haven’t eaten so much in a long time”
“Thank you! After a very comfortable and pleasant stay, I feel much better now
than when I was admitted. I don’t want to go elsewhere but I have requested to
come back here at a later date. Well done! Every one of you deserves a gold
medal”
“I was devastated when I received my diagnosis in October 2009. I not only felt
really “poorly” but felt as if my time had come. I started to attend St. Luke’s Day
Hospice in November. I was understandably apprehensive at first ......... wary of
the word “Hospice” but I quickly came to realise that making the most of the time
you have left is a large part of what the Unit enables you to do. It’s about living
with diagnosis rather than allowing it to define you”.
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”Thank you does not seem adequate to express how grateful I am to you, for
your patience and tender loving care, not only to my mum but also to myself. I
will especially remember the afternoon you came and gave me your support and
time, when I most desperately needed it. I thank you from my heart.”
“I would not be at home without hospice at home. The weekly phone calls and
the volunteer and staff have become family.”
“A big thank you to everyone at Hospice @ Home for the help and support for
my mum in the last few days of her illness. I was wondering what I was going to
do and you came to my rescue to put things into place to help my lovely mum.
By then she had had enough of that horrible cancer. I can’t thank you and your
colleagues enough. I remember calling Gill in a bit of a tizzy and she said “don’t
worry darling I will have a sitter out tonight to help” and that evening as promised
the lovely Jenny arrived. Thank you all for your help; you are such lovely caring
people.”
Part 3
Review of Quality performance 2011-12
Priority 1
The Diversional Nurse Therapy Programme
The Diversional Therapy Programme has initiated a range of social and therapeutic
activities that have significantly improved quality of life for patients, including craft
activities and demonstrations and development of a wonderful sensory garden for
patients and staff to enjoy. The ‘21st birthday’ mosaic made by patients to celebrate
21 years of the Hospice is displayed at the main entrance to the building. During
2011/12 developments have significantly progressed with many new activities and
projects enjoyed by all.
Priority 2
Extension of Macmillan Dove Community Counselling Service
The Hospice was successful in securing a Macmillan Cancer Support grant to extend
and develop this very busy service. The grant covers the appointment of three new
posts to support the development of Level 2 counselling support. This will help
streamline service provision and manage workload while ensuring clients receive the
most appropriate care and support. The additional staff will be based at a new
satellite venue in Billericay. The extension will include development of counselling
and support interventions for those who are newly diagnosed, struggling with
treatment or are the worried ‘well’ (survivors) as well as continuing to offer pre and
post bereavement support. The new centre is fit for purpose and very conducive to
service delivery in a calm and tranquil setting.
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Priority 3
VERVE (Valuing Local Diversity, Enhancing Patient Experience, Raising Public
Awareness & Visible Equity in End of Life Care)
This Workstream is co-chaired by St Luke’s Head of Care Services and the
Community Services & Development Manager. The group has worked hard and
collaboratively to increase public awareness with regard to choice and planning
around end of life care (in the broadest terms). Outcomes include:

Developing ‘mini’ road shows across the locality including in GP surgeries,
libraries etc

Collating over 400 End of Life ‘Planning & Choice’ questionnaires and
beginning to disseminate outcomes across the locality. Anarticle re
outcomes and findings was published in the Internal Journal of Palliative
Nursing in May 2012

Given talks/workshops at a variety of events including Dying Matters –
Small Actions, Big Difference Conference in February 2012

The two chairs were asked to advise on a play being staged at the Royal
Court Theatre, Sloan Square. ‘In Basildon’ was written by award-winning
local playwright David Eldridge and directed by Dominic Cooke.
The
cast were made up of well-known character actors whose portrayal of life
‘In Basildon’ (also the name of the play) was superb. The play centred on
relationships linked to the death of a character and as well as exploring
family dynamics, focussed on issues associated with death and
bereavement and end of life care
Priority 4
Electronic Patient Records
A new electronic patient record system was introduced in 2011and is now well
established. All staff have attended training and embraced the system, even those
who were not confident using a computer. Staff are now competent and the transfer
to electronic patient notes has been relatively trouble free and now thoroughly
embedded in practice. The system ensures that record keeping and reporting is
accurate and that data can be freely obtained for audit and monitoring purposes.
Priority 5
Improvements to Accommodation and Facilities
In 2011 funding was received to transform patient areas within the In Patient Area
New larger doors were installed to patient’s bedrooms and bright new awnings
situated at the back of bedrooms overlooking the garden have been a huge success.
The patio area has been remodelled and is extremely pleasant and now large
enough to accommodate several families who wish to sit outside when the weather
permits. The wider doors leading from the bedrooms provide easier access to the
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patio and garden for the patients to enjoy. Patient’s beds can be wheeled out and
the new tables and chairs provide a welcoming and relaxing environment for all. It is
clear too that many more people are now using the patio and garden. The whole
area is so pleasant and calm that relatives often use it as a space to sit and be quiet
with their reflections and thoughts. Conversely it can also be seen that families are
interacting more and offer each other support.
Between October – December 2011 the main Hospice reception was refurbished
free of charge by a group of contractors. The extension, refitting and fixtures and
fittings were completed ahead of schedule and included the relocation of IPU nurses
office with an improved Pharmacy room. The work was driven by a leading local
businessman who galvanised a range of contractors to offer their services and
expertise to deliver a fabulous main entrance that now affords a much larger and
welcoming environment, which is clean and bright, well lit and benefits from
improved natural lighting. The new facility greatly enhances the patient experience
especially those patients arriving via ambulance as the area is more conducive to
allowing ease of access for stretchers.
In addition to this major undertaking the upper floor in the old farmhouse has also
been upgraded – resulting in additional office space for staff. This has been another
successful project affording additional accommodation to support service delivery.
Data
The Hospice contributes to and is measured by data from the National Council of
Palliative Care (NCPC) Minimum Data Sets (MDS), which enables hospices to
benchmark activity and performance against other similar organisations.
All Hospice services continued to demonstrate high levels of activity with a 15%
increase on activity from the previous year.
The majority of indicators measured, achieved above national averages and is a
reflection of staff commitment to improving access to services and supporting
individuals with complex needs.
The provision of services for individuals with illnesses other than cancer increased
across the In Patient Unit, Day Hospice and Out Patient services and reflects the
Hospice’s aspiration to increase support to these individuals and or groups.
Beyond the MDS the Hospice regularly monitors activity and performance on a
monthly basis.Data is incorporated into Corporate and Clinical Governance
procedures and reported at Corporate and Clinical Governance Committee, Senior
Management Team meetings and at Board level.
Statements from PCT and Link
This Quality Account had been shared with South West Essex PCT and Link.
The following statements have been submitted.
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QUALITY ACCOUNT 2011/2012
PCT Commentary on St Luke’s Hospice
NHS South Essex welcomes the opportunity to comment on the first annual Quality
Account prepared by St Luke’s Hospice. As a commissioner of services NHS South
Essex has the following statement to make for inclusion in St Luke’s Quality Account.
To the best of NHS South Essex’s knowledge, the information contained in the
Account is accurate and reflects a true and balanced description of the quality of the
provision of services.
The PCT has a strong working relationship with St Luke’s Hospice. The service has
responded effectively and efficiently to the demanding local agenda including
supporting the development of End of Life services to support the QIPP programme.
The provider is able to meet all contractual requirements and flexibly considers any
service developments. St Luke’s is preparing itself to meet the needs of the Clinical
Commissioning Groups as they assume the responsibility for the commissioning of
end of life services. In anticipation, St Luke’s has identified a number of opportunities
to develop local service provision.
The PCT is pleased to note the development priorities for St Luke’s with the
establishment of a specialist physiotherapy service, service users contribution
objectives and plans to continue enhancing and meeting the needs of those who live
with a long term condition and their carers.
The PCT welcomes the topics chosen for local clinical audit and supports St Luke’s
objectives in ensuring through monitoring that the quality of patient lives is
improved. The PCT visited St Luke’s Hospice to look at Infection Prevention and
Control; the outcome of this audit was that we were very impressed with the
standards implemented by the staff there, often under very difficult circumstances.
They were able to evidence compliance with the requirements (relevant to their
service) of the code of practice for Infection Prevention and Control as part of the
social care act 2008.
St Luke’s staff and volunteers should be congratulated on the positive report and
comments received from the Care Quality Commission’s Compliance Officer
following an unannounced one day inspection. The comments cover a wide range of
services and issues and, as identified in the account, rightly reflect the competence
and enthusiasm of staff and volunteers there.
The PCT notes the generally positive volunteers satisfaction survey results and
supports the hospice’s actions to both improve communications to this group and
formally mark the merit with which the organisation holds these valuable people.
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The review of quality performance priorities in this account is testament to St Luke’s
commitment to improvement in a number of areas, all of which will continue to have
positive and far reaching impacts on their patients and carers.
The Quality Account gives a good reflection of achievements for 2011/2012 and St
Luke’s Hospice has been clear where they believe there is room for improvement.
NHS South Essex is fully supportive of all the priorities identified by them in taking
forward the patient safety, effectiveness, experience and involvement agendas and
looks forward to working in partnership with them in the forthcoming year.
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