Quality Account 2011 – 2012
Adding Quality to Life.
“It’s impossible to express the extent of our
gratitude for the difference you all made to the
quality of Mum’s final weeks, the quality of her
death and the quality of the experience of the loss
of our Mother”
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Part 1 – Chief Executives Statement
On behalf of St Luke’s Executive Team and the Board of Trustees, it gives me
great pleasure to present this, the first quality account for St Luke’s Hospice.
Achieving and maintaining the highest quality standards is a key priority for
the Hospice and this is evident through the Boards approach to Corporate and
Healthcare Governance.
Through our Healthcare Governance Committee and operational groups I am
able to give assurance to our Board that the appropriate processes and
procedures are in place to underpin our activities and that these are regularly
monitored and reviewed.
This also gives real assurance to our patients and their families.
I am proud that St Luke’s regularly receives feedback from families stating
that not only was the care exemplary but that their loved ones were cared for
in a loving and dignified manner. Example comments received include “We
are writing to thank you for the outstanding care given to our Mum” ….. “as a
result her quality of life was as good as it could possibly be”..
This can only be achieved with the support and dedication of the team of
employees and volunteers who put the words into action and are able to make
the difference. In all senses it is “our people who are at the heart of St Luke’s”
– our patients, families, volunteers and employees and learning from their
experiences is key to success.
I would like to thank all of our employees and volunteers for their
achievements over the past year and the part they have played in providing
high quality care.
Despite the current economic climate, the Hospice has continued to provide
high quality services to an increased number of patients and remains
financially viable, thanks to generous support from our local community.
During 2011/12 the Hospice succeeded in reaching all its target levels for
activity agreed with the NHS and it is worth noting that the Community
Services in particular exceeded targets. This is of note given the shift in
emphasis and drivers towards care in the community and is an area I
anticipate we will continue to see grow over the coming twelve months.
Achieving and maintaining the highest quality standards is a priority for St
Luke’s.
I am responsible for the preparation of this report and its contents. To the best
of my knowledge, the information reported in this Quality Account is accurate
and a fair representation of the quality of healthcare services provided by St
Luke’s Hospice.
Peter Hartland
Chief Executive
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Part 2 – Priorities for Improvement 2012 -13
2.1
Through self assessments and inspection during the last year St. Lukes
Hospice has satisfied the Care Quality Commission that standards of
care are being met.
As such, the Board did not have any areas of regulatory shortfall to
include in the priorities for improvement for 2012-2013. However, it was
keen to ensure that the environment of care was of the same high
standard as the care provided.
2.2
It also looked at how the hospice could extend and improve its services
to better meet the needs of the local population. The Board then looked
at development opportunities for service improvement.
St. Lukes Hospice confirms the top quality improvement priorities for
2012 to 2013 to be:
2.3
Priority 1- Development of a £5.5 million part new build and part
refurbished In Patient Unit consisting of 14 single rooms with en suite
facilities and two multi bedded rooms.
2.4
Why did we choose this?
The hospice has just celebrated its 40th year, being opened in 1971 as
one of the first specialised palliative care facilities outside London. The
Board of Trustees, the Executive and the Care Quality Commission
(CQC) recognised that the existing unit was of its age. The CQC report
stating that ‘The in-patient unit no longer meets current best practice
guidance in relation to the physical environment but we found that the
unit continues to meet the needs of people who use services in this unit
and potential environmental risks are appropriately managed.’
2.5
Who did we involve in deciding what changes to make?
It is really important that patients and their carers were fully involved in
planning any changes to ensure that their needs continue to be met.
The Service User Coordinator worked with patients and their families to
determine their preferences on issues such as the development of
single bedrooms rather than multi bed rooms. All the views have been
reflected in the final plans
2.6
What will happen to patients during the building work?
It will be very much business as usual with the same number of beds
and services maintained during the development. The hospice team
have developed plans to ensure that disruption to patients is minimised
and quality standards are maintained. There will be active monitoring of
the quality of the environment and services during the refurbishment to
assess whether the plans are effective or if further actions are required.
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2.7
When will the work be completed?
Preparation work is already well underway. The scheme will start on
June 11th 2012 and take about 18 months to complete
2.8
What improvements to quality will the changes make?
The new unit will significantly improve the patient and carer experience
by improving privacy and dignity, greater opportunity to personalise
their own place of care and increased personal space. It will also
improve the work environment for our care teams.
2.9
How will we monitor that these improvements have been realised?
The hospice will actively monitor both formal and informal patient and
carer feedback
2.10
Priority 2 - Redevelopment of the Patient’s / Carer Handbook
2.11
Why did we choose this?
The current handbook is out of date and is not currently being issued to
new patients however; an interim leaflet has been developed. Carers
do not routinely receive written information when their partner or
relative is admitted to one of the hospice services.
2.12
Why is that important
The ethos of the hospice is the provision of care and/or support to all
persons associated with an episode of care in the hospice. Part of this
is people understanding fully what services are available and how to
access them. Whilst the information is provided verbally there is a risk
that it may be inconsistent or forgotten by the service user which may
result in somebody wanting help but not knowing how to access it.
2.13
What improvements to quality will the handbook make?
Patients and carers have a greater knowledge of the hospice and the
services it provides.
2.14
How will we monitor that these improvements have been realised?
The hospice will monitor patient and carer feedback and the uptake of
support services identified in the handbook.
2.15
Priority 3 - Replace all MA16A syringe drivers as part of a city wide
programme
2.16
Why did we choose this?
The National Patient Safety Agency monitors all incidents that happen
in the NHS. Through their analysis a significant patient safety issue
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was identified relating to this particular syringe driver and they issued a
patient safety alert. All the hospitals in Sheffield agreed to a
replacement programme of the drivers to comply with the requirements
of the NPSA alert.
2.17
St Luke’s hospice receives and actions all alerts issued to the NHS via
the Central Alerting System and for the sake of patient safety and
consistency of approach across the whole health community it has
played an active part in the city wide replacement plan.
2.18
What improvements to quality will the changes make?
Improved patient safety and clinical effectiveness
2.19
How will we monitor that these improvements have been realised?
The hospice monitors and reports on any accident, incident or near
miss regularly and routinely
2.20
Priority 4 - Improve support and education to city nursing homes in
relation to specialist palliative care
2.21
Why did we choose this?
A member of the Community Specialist Palliative Care Nursing
(CSPCN) Team has a defined role to provide guidance, advice and
support relating to specialist palliative care to all the care teams
working in the nursing homes in Sheffield.
They produce an annual nursing home report that identified the need
for more focused support and more enhanced skills regarding specialist
palliative and end of life care.
The hospice has committed to a fixed term appointment of a further
person to work with the existing support and through its collaborative
working with NHS Sheffield, two further fixed term appointments to
support an education programme for nursing home staff has been
agreed.
2.22
What improvements to quality will the changes make?
Implementation will improve the patient experience by providing
enhanced skills and support to persons providing specialist palliative
and end of life care in Sheffield Nursing Homes
2.23
How will we monitor that these improvements have been realised?
The hospice in conjunction with NHS Sheffield will develop and agree a
series of performance indicators. Improvements will be monitored by
feedback from the nursing homes regarding the quality of the support
provided. Improvements to the skills relating to palliative care will be
monitored via the CSPCN reports.
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2.24
Priority 5 - Review the current provision of Community Services
2.25
Why did we choose this?
St Luke’s regularly reviews its services to ensure they continue to meet
the needs of service users whilst operating in an effective and efficient
manner.
The review of community services is part of this planned review and
reflects both the changing profile of the population and the national
drive towards more primary care in the community setting.
2.26
What improvements to quality will the review make?
The review and any subsequent actions required will ensure that St
Luke’s community services continue to be fit for purpose to support
patient choice about where they want their care to be provided
2.27
How will we monitor that these improvements have been realised?
We will monitor Service User feedback as part of patient satisfaction
checks
2.28
Priority 6 – Improve learning and development opportunities for staff
2.29
Why did we choose this?
The maintenance and improvement of skills and competencies of our
staff is fundamental to ensuring the highest standards of quality care.
The hospice undertook a major review of its structures and
management systems during 2010/11 and reviewed and revised its
learning and development strategy.
The focus of the strategy is ensure staff get appropriate induction,
mandatory and specific training, the need for such training being
determined by role profile, mandatory requirement and performance
and development review. The individualised training plan will form part
of an Individual Learning Passport.
Once again the hospice seeks not to work in isolation of the wider
health community and other agencies establishing relationships with
the following organisations –
-
South Yorkshire Partnership Forum
Sheffield Teaching Hospitals NHSFT
Sheffield Hallam University
Help the Hospices
Chamber of Commerce
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The hospice will also utilise flexible opportunities of learning and is
participating in the piloting of I - Learning Royal College of Nursing
computer based package.
2.30
What improvements to quality will the review make?
Maintenance and / or improvement of skills via a Clinical Competency
framework.
2.31
How will we monitor that these improvements have been realised?
Improvements will be monitored via the performance and development
review programme
2.32
Statements of assurance from the board
The following are a series of statements that all healthcare providers
must include in their Quality Account. Some of these statements are
not directly applicable to specialist palliative care providers.
2.33
Review of services
During 2011/12 St. Lukes Hospice provided three services to the NHS.
The services were as follows:
– In-Patient Unit
– Therapies and Rehabilitation Day Services
– Community Specialist Palliative Care Nursing
St Luke’s Hospice has reviewed all the data available to them on the
quality of care in all of these services.
2.34
Income generated
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. Lukes Hospice for 2011/12. The
income generated from the NHS represents approximately 33% of the
overall cost of running these services.
2.35
Participation in clinical audits
The Hospice recognises the importance of clinical audits and is
committed to full participation in relevant studies. During 2011/12, no
national clinical audits and no national confidential enquiries covered
NHS services relating to palliative care. St Lukes Hospice only provides
palliative care.
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2.36
Eligibility to participate in national confidential enquiries
During that period St Luke’s Hospice was not eligible to participate in
any national clinical audits and national confidential enquiries.
As St Luke’s was not eligible to participate in national clinical
audits or national confidential enquiries no further information is
listed under these headings
2.37
Local Clinical audits
Whist not involved in national audit the hospice completed or agreed a
number of local audits including the following –
-
Discharge Summary
Infection Control
Management of Controlled Drug Medications
End of Life Care Progress Audit
Management of Diabetes in the Last Week of Life.
Wherever areas requiring attention were identified detailed action
plans, including responsibilities and timescales were agreed and
implemented.
2.38
Research
St Luke’s recognises the importance of research in helping to improve
and develop services and quality care for patients and is fully
committed to participating in appropriate studies. However there was
no appropriate, national, ethically approved research studies in
palliative care in which we could participate.
The number of patients receiving NHS services provided or subcontracted by St Lukes Hospice in 2011/12 that were recruited during
that period to participate in research approved by a research ethics
committee was 0.
Whilst there were no national research studies a number of local
research projects were agreed and given Ethics Committee approval or
were proposed and awaiting approval. These included –
-
-
Sheffield Profile Assessment for Referral and Care (SPARC) a holistic
questionnaire designed to identify supportive or palliative care needs,
regardless of diagnosis or stage of disease
Choice & Decision-Making at End of Life (Awaiting Ethics Committee
approval)
Partnership Working Between Specialist and Generalist Palliative Care
Providers. (Planning and approved within 2011/12. To be undertaken
during 2012/13)
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2.39
Quality improvement and innovation goals agreed with our
commissioners
St Luke’s Hospice income in 2011/12 was not conditional on achieving
quality improvement and innovation goals through the Commissioning
for Quality and Innovation payment framework however, formal quality
monitoring reports are provided to the commissioners each quarter.
2.40
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
Care Quality Commission has not taken any enforcement action
against St. Lukes Hospice during 20010/11.
2.41
Periodic reviews by the CQC
All health and social care providers are subject to regular review by the
Care Quality Commission.
During 2011 they reviewed all the information they hold about St
Luke's, carried out a visit on 24 May 2011, observed how people were
being cared for, talked with people who use services, talked with staff,
checked our records, and looked at records of people who use our
services. As a result they reported that all standards were being met.
The report gives the findings, in summary and in full and is available on
the Care Quality Commission Website
2.42
Reviews and investigations by CQC
St. Luke’s Hospice has not participated in any special reviews or
investigations by the CQC during 2011/12.
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Part 3 - Quality Overview
3.1
During 2011 St Lukes has provided care and support to an increasing
number of patients and their families/ carers, and has met and
exceeded its activity targets agreed with the NHS Commissioners.
3.2
A number of quality improvements were implemented during the period
to improve the patient experience, ensure continuing patient safety and
improve clinical effectiveness. These are summarised below.
3.3
Patient Falls Pathway
The hospice was involved in a city wide approach to the prevention or
effective management of patient falls. Help the Hospices subsequently
produced a hospice specific pathway which St Luke’s has piloted and
implemented.
3.4
Patient Handover Communication
The NHS Institute for Innovation and Improvement developed an
existing communication tool and tailored it for use in a healthcare
environment. This has been implemented to improve consistency and
quality at patient handover to reduce the risk of patient safety related
incidents.
The system has been enhanced within the hospice by the introduction
of a daily safety bulletin which communicates specific and detailed
information relating to risks.
3.5
Hospitality Services
The hospice identified a need to change hospitality services to provide
a better meal service and release nursing time to provide care. The
Registered Nurses remain responsible and accountable for the patients
nutritional status and wellbeing.
Following consultation a hotel style hospitality service has been
implemented which provides a personalised service offering freshly
made food.
The focus of the service is on individual choices. Patient meals are
served when they require them not just at set meal times. All food is
served from the kitchen where it is freshly prepared and not held in hot
food trolleys.
Chefs take requests for any meal service users would like even if it is
not on the menu. Most requests can be met immediately, on the rare
occasion this is not done the hospice commits to providing the meal the
next day.
The introduction of the service has released time to allow nursing staff
to help patients –
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-
prepare for mealtimes with respect to hygiene
consume meals, snacks and drinks
improve and maintain the social and pleasurable aspects of eating and
drinking
monitor and document patients intake
ensure patients are comfortable and settled following meals
Service user surveys have been undertaken post implementation with
very positive results.
3.6
Security Review and Upgrade
A full review of the physical infrastructure and access systems was
undertaken in conjunction with local Crime Reduction Officers. This
resulted in the implementation of a full external and internal door
access system and improvements to alarm systems and CCTV.
3.7
Learning and Development Strategy
The review and revision of the learning and development strategy has
allowed the hospice to plan focused training to ensure personnel have
the appropriate support training.
The full implementation of the strategy and plan is a priority area for
2012/13
3.8
Laundry Upgrade
The on site laundry facilities have been upgraded to ensure quality is
maintained. This upgrade has involved provision of three new washers,
improving the working environment and improving the system of work.
3.9
It is of key importance that the hospice continues to ensure the quality
of care provided and that the service user, relative and/ or carer
experience is as good as is possible. It does this in a number of ways
including but not exclusively –
-
Help the Hospices Survey Reports
National Council for Palliative Care benchmark data
In house audits and inspections
External and independent assessments or reviews (such as the CQC)
Service User involvement and feedback
Internally developed key performance clinical quality standards which
are measured on a quarterly basis
Formal quarterly reporting to NHS Sheffield as the commissioner of
NHS care
Complaints data
Review and analysis of accident, incident and near miss data
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3.10
The following section gives a summary of how the hospice reviews its
quality against some of these headings and whilst it is not intended to
confuse this account with large amounts of statistical data, where
appropriate example indicators are shown.
3.11
Help the Hospices undertake a patient survey, currently every two
years, during which service users have full opportunity to express their
views on the services offered by the hospice. St Luke’s participates in
the survey with the Service User Coordinator analysing the results to
identify any areas for improvement.
3.12
The Hospice is required to provide statistical data to the National
Council for Palliative Care. This data and subsequent benchmarking
allows the hospice to understand how it is performing. St Lukes is
categorised as a large hospice, having more than 16 beds and as such
is compared to like size organisations in England, Wales and Northern
Ireland.
Key figures from the comparison undertaken for 2010/11 include the
following indicators
National
Median
St Lukes
Available Bed Days
7277
8184
Bed Occupancy
77.3%
87.6%
Availability
99.4%
100%
New Patients
89.3%
89.5%
Day Care Sessions
241
253
Day Care Places
3576
5060
Day Care Attendances
2282
3242
Continuing Care
87
123
Total Contacts
2269
2135
Contacts per Service User
3.6
4.2
Phone Calls per Service User
1.6
2
Indicator
In Patient Unit
Therapies and
Rehabilitation Centre
Bereavement Support
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3.13
The hospice agrees target levels for activity with NHS Sheffield as
Commissioners of NHS Care. The table below shows how the hospice
has exceeded the activity targets across the three services provided.
.
3.14
In Patients (Admissions)
Total
Target Admissions
312
Total Admissions
327
Difference
15
Therapies and Rehabilitation
Centre (Attends)
Total
Target attends
2858
Total Attends
3242
Difference
384
Community (Contacts)
Total
Target
St Luke's Community Team
Community Nurse visits
Occupational Therapists
Physiotherapists - home
Psychotherapy
4068
4108
3820
25
255
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Difference
40
The Hospice receives many commendations from patients and families,
a small number of complaints are received each year (4 last year).
Commendations are welcomed and celebrated at Clinical Governance
as well as in the individual teams.
Complaints are taken extremely seriously; they are thoroughly
investigated, reported on (anonymised) via the Healthcare
Improvement and Compliance Groups to the Healthcare Governance
Committee and annually to the CQC.
Immediate action is taken to rectify any shortfalls or concerns
identified.
3.15
-
St Luke’s has developed a range of key performance indicators
including the following –
Percentage of drug errors against the number of admissions
Percentage patient falls against the number of admissions
Clinical complaints
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-
Percentage hospice acquired MRSA rate against admissions
Percentage hospice acquired C Diff rate against admissions.
Number of patients on End of Life Care Pathway versus number of
patient deaths where patients eligible for pathway
Total admissions In Patient Unit
Total attendances Therapies and Rehabilitation Centre
CSPCN team visits
These indicators are routinely monitored via the hospice governance
arrangements
3.16
Comments Regarding the Account – Independent Assurance
NHS Sheffield (Commissioners)
We have reviewed the information provided by St Luke’s Hospice in
this report. Based on the regular quality and contracting reports NHS
Sheffield receives and contract meetings, our view is that the report is
materially accurate and gives a fair picture of the Hospice's
performance.
St Luke’s Hospice provides, overall, high-quality care for patients, with
dedicated, well-trained and specialist staff. The Hospice has a very
good reputation within the Sheffield community and it provides key End
of Life Care services for the population in conjunction with other EOLC
providers in Sheffield.
NHS Sheffield supports the plan to develop a part new build and part
refurbished Inpatient Unit which will significantly improve the
experience of patients and their carers during their time at St Luke’s. It
will also improve the work environment of staff. The other identified
priorities for improvement during 2012/13 are in line with national and
local strategic drivers and will contribute to the planned citywide
improvements in the quality of care for patients in their last year of life
during 2012/13.
Ian Atkinson
Chief Operating Officer
NHS Sheffield
St Luke’s sought guidance from NHS Sheffield regarding a contact for
Sheffield Local Involvement Networks (LINk’s). Unfortunately no
networks have commented on the account. In order to improve
communications and opportunities for input the hospice intends to
actively seek early contact with the Healthwatch network as it emerges
to full implementation in October 2012
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Sheffield City Council - Healthier Communities and Adult Social
Care Scrutiny Committee
On behalf of Sheffield City Council's Healthier Communities and Adult
Social Care Scrutiny Committee we welcome the opportunity to
comment on St Luke's Quality Accounts, and would like to begin by
thanking the staff and volunteers of the hospice for the valuable service
they provide to the city.
We are particularly pleased to see the inclusion of the review of
Community Services as a quality priority for 2012/13 - the Committee
recognises the increasing importance of providing services closer to
home and looks forward to seeing the results over the coming year.
We commend the hospice for exceeding its activity targets in all service
areas during 2011/12; and are pleased to see the progress that has
been made in hospitality services - a great example of improving
patient experience and increasing efficiency.
We look forward to engaging with the Hospice over the coming year in
monitoring improvement on the quality priorities.
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