Quality Account 2011 – 2012
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PART 1 - Chief Executive Statement of Quality
Welcome to our first Quality Account. This report is for our patients, their families and
friends, the general public and the local NHS organisations that give us twenty-seven
per cent of our costs. The remainder of money required to pay for our services is
raised through fundraising, legacies and our 46 shops.
The aim of this report is to give clear information about the quality of our services so
that our patients can feel safe and well cared for, their families and friends are
reassured that all of our services are of a very high standard and that the NHS is
receiving very good value for money.
We could not give such high standards of care without our hardworking staff and our
1500 volunteers, and together with the Board of Trustees, I would like to thank them
all for their support.
Our Director of Patient Care, Medical Director and all clinical managers are responsible
for the preparation of this report and its contents. To the best of my knowledge, the
information in the Quality Account is accurate and a fair representation of the quality
of health care services provided by St Peters Hospice.
The positive safety, experience and outcomes for all of our patients and their carers
are of paramount importance to us. Therefore, we continue to actively seek the views
of all who access our services.
Cathy Taylor MSc MBA FCMI CMgr
Interim Chief Executive
June 2012
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PART 2
2.1 Priorities for improvement 2012-2013
Following the extensive developments in our quality monitoring during 2011/12 St
Peters Hospice (SPH) has agreed a clinical quality action plan for the next 2 years
(Appendix 1).
This action plan has been approved by the SPH Trustees, Executive team and Clinical
Audit group. Key priorities within this action plan have been agreed with these groups
and include the following:
Future planning Priority 1 - Effectiveness
To improve how we respond to personal needs of patients by ensuring that patients
who are at the end of life have their wishes and preferred place of death clearly
recorded.
This will be monitored through quarterly audits and the report and
recommendations will be approved by the Clinical Audit and Clinical Services groups.
Future planning Priority 2 – Patient Experience
To support all of our referred patients and their families/carers to improve where
possible, on how we deliver services. This will be achieved through use of
Patient/Carer Reported Outcome Measurement questionnaires (PROMs and CROMs) in
at least four of our services, and a new User Involvement Forum which will include at
least one patient and one carer as well as relevant senior hospice clinicians and a GP.
The report and recommendations will be approved by the Executive team.
Future planning Priority 3 – Safety
To ensure where possible that patients, families and carers are cared for safely and
according to their wishes and preferences. We will monitor all incidents against our
approved Health and Safety monitoring systems and report to internal groups (Clinical
Governance) as well as external groups (our NHS commissioners, GP’s etc.).
SPH also participates in a quality measurement project across ten South West
hospices. This data is exchanged willingly in order to be as sure as we can that there
is quality and equality for all who use hospice services. Ideas and best practice are
encouraged.
2.2 Statements of assurance from the Board of Trustees
The Board of Trustees’ commitment to quality
The Board of Trustees is fully committed to delivering high quality services to all our
patients whether in the community, in the hospice or at an Outreach setting. Trustees
are involved in monitoring the health and safety of patients, the standards of care
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given to patients, feedback from patients, including complaints, and plans to improve
services further. They do this by receiving regular reports on all these aspects of care
and discussing them at Board meetings. Of equal importance our Trustees visit the
hospice and other settings where services are delivered e.g. patients homes several
times per year. Some of these visits are unannounced and written reports are
discussed by the Board and then sent to the Care Quality Commission. Copies are
available on request to the Chief Executive. During the visit Trustees speak to
patients, carers, staff and volunteers. In this way the Board has first hand knowledge
of what patients, families and carers think about the quality of services provided,
along with feedback from staff and volunteers. This year the Trustees have visited at
least 12 times in different areas of our service.
The Board is confident that the care and treatment provided by St Peters Hospice is of
a high quality and cost effective.
Following a recent unannounced inspection by the Care Quality Commission (CQC) in
May 2012 the Board of Trustees are delighted to be reassured that SPH are compliant
with the quality and safety standards set by CQC.
2.3 Review of services
During 2012/13 SPH will continue to provide eight services- which will exceed service
level specifications agreed with the NHS. The NHS contributes 27% of our overall
funding. SPH has reviewed all the data available to the NHS on quality of care for all
our services.
These services are as follows:
1. In-Patient Unit – 18 beds staffed by 54 IPU nurses and supported by the wider
clinical team. Last year we had 441 admissions to our In-Patient Unit and the
average length of stay was 11.5 days. Approximately 53% of our admissions die
with us the remaining patients were all helped with their symptoms and other
needs before being discharged.
2. 24 hour advice line for our patients and other healthcare professionals in our
area. The advice line took more than 1,300 calls last year and more than 200 of
these did not relate to our registered patients: we were able to support GPs and
District Nurse’s to make complex decisions regarding care.
3. Day Services – up to 20 patients 4 days per week
– up to 30 patients or carers in groups on one day per week
Last year our Day Services referrals increased by 66%.
4. Physiotherapy/Occupational Therapy – to help patients maintain a good quality
of life for as long as possible
5. Hospice at Home – to enable patients to die at home. Last year the number of
patients supported increased by 81%.
6. Community Nurse Specialist Service – providing advice, support and symptom
control to more than 2000 patients per annum
7. Medical Consultants – paid for by St Peter's Hospice cover the hospice, the
community and contribute to the Bristol Hospitals Palliative Care teams.
8. Psychological, Social and Spiritual Care (PSS) services – to provide social,
emotional and spiritual support for patients, families and carers, including the
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bereaved. This service includes music therapy, clinical psychology and other
creative therapies.
SPH also funds, through charitable money and the support of volunteers, a range of
complementary therapies to help patients and families deal with the physical and
emotional aspects of terminal illness.
SPH continually monitors the effectiveness of these services through measuring the
numbers of patients seen and contacts made, clinical audits, patient/carer feedback
and specific service reviews.
Additionally we provide an extensive education programme to support our staff in their
roles, as well as those from other health care providers supporting end of life patients.
2.4 Participation in clinical audits
To ensure provision of a consistently high quality service, SPH has a clear strategy for
clinical audit and an annual plan which contributes to the overall Quality Action Plan
(Appendix 1). Priorities are selected in accordance with what is required by the Care
Quality Commission (who regulate hospice care), requests from individual
departments and any areas where a formal audit would inform the risk management
processes within the hospice. Audit provides a means to monitor the quality of care
being provided so we can review and make improvements where needed. We share
our audits with others in our region to ensure that our practice is used to compare
ourselves with others.
Each quarter, our clinical monitoring committees review the audit schedule.
SPH is currently participating in a national confidential enquiry into the deaths of those
with learning disabilities, in association with the University of Bristol. We also submit
data to the National Council for Palliative Care in order to compare our services with
other hospices across the nation.
At the regular multidisciplinary Clinical Audit group meetings we have many
interesting discussions about how to demonstrate our effectiveness and achieve the
outcomes currently identified in our NHS Community contract. For example one audit
of a clinical procedure led directly to changes in how we practice more safely and
effectively. We also strive to use audit as a tool to evaluate our new service
developments. e.g. the further development of the PSS team will be an area for audit
the forthcoming year. Our multidisciplinary Clinical Forum Group also discusses new
ideas and how we can implement them appropriately to support our patients, families
and carers.
Notes from our quarterly clinical committees keep the Board of Trustees fully informed
about audit results including any identified shortfalls. Through this process, the Board
has received an assurance of the quality of the services provided.
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2.5 Research
SPH has a research policy and a Research Advisory Group in order to monitor and
approve any research activity at the hospice. This includes members of our staff
actively engaged in their own research related to higher education requirements and
staff from other hospices who may want to do some research with our staff or
patients.
2.6 Quality improvement
commissioners
and
innovation
goals
agreed
with
A small proportion of our NHS income in 2012/13 is conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation (CQUIN) payment framework. For the coming year our NHS CQUIN goals
are:
Indicator 1: Develop and report on a collective concept (with 3 other local hospices)
of referral criteria and services for people aged 16-25yrs who are identified as having
specialist palliative care needs.
Indicator 2: To improve access to specialist palliative care support, treatment and
advice for minority and deprived populations and non-malignant conditions. We will
achieve this through increasing our face to face consultation with the general public so
that they become more aware of our services and how they may be relevant to our
entire local population. This will include work with the homeless, local prisons and
minority groups.
Indicator 3: To further improve access for and support to primary care teams by the
community specialist nurses (CNSs). This will be achieved by our CNSs holding regular
meetings with GPs and District Nurses to increase the number of people referred to
our services being supported in the community by consultations with our health and
social care team.
2.7 What others say about St Peters Hospice?
St Peters Hospice is currently registered as an independent health care provider under
the Care Standards Act 2000. SPH is subject to annual self assessment reviews with
the last assessment in March 2011. There were no actions to take following the last
assessment as the hospice was fully compliant. Since that time the hospice has had an
unannounced inspection from CQC. From self assessment and the outcomes of the
inspection SPH is fully compliant with the standards set by CQC.
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The following quote is taken from the inspection report by CQC:
‘We spoke with patients and relatives on the in-patient unit. One person told us that
they could not wish for anywhere better for their relative and the staff were
“fantastic”.’
The report is available on the CQC website. www.cqc.org.uk/
Other health care professionals regularly attend courses at our education department,
and offer positive feedback on our clinical services as well as our education courses.
Recently our medical programme for trainee doctors received high praise with an ‘A’
grade being awarded by the Primary Care School Board for SPH’s educational
provision.
‘This grade is only given to the very few minority of posts that are regarded as
offering a truly outstanding training experience for our trainees.’
We recently held a GP focus group in order to ascertain views about our services and
intend to continue holding these at regular intervals.
‘ We would like to see more services for non cancer patients.’
‘Outreach services would be welcomed as it means reduced transport costs and
hospice input without the stigma of a patient attending the hospice’.
What our patients say about St Peters Hospice
We frequently receive compliments and expressions of gratitude for the care that
patients, their families and carers are given. e.g.
“A big thank you for everything you do in such a caring and compassionate way. We
were truly touched by the service you offer.”
“We would like to thank you so much for the care and support given by staff to both
Mike and his family which I know was invaluable in his final few months. Your hard
work and dedication does not go unnoticed.”
The following comments are taken from questionnaires given to patients:
Day Services
‘Staff were intuitive as well as responding to requests, they listened’
‘Fantastic service, treatment excellent, could not improve’
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Inpatient Unit (IPU)
‘The staff were all exceptionally friendly and co-operative’
‘…I have nothing but praise for doctors, nurses, auxiliary staff and volunteers all who
carried out a service which is superb’
User Involvement
SPH seeks to involve the users of our services in a variety of ways in order to get
feedback on our services and to inform future developments. We have a forum that
meets regularly with a range of staff, patients and carers/families of our patients.
All of the surveys we undertake as well as the minutes of our meetings with patients
and families are documented so that we can learn from our feedback.
2.8 Data Quality
As agreed with the Department of Health, SPH submits a National Minimum Dataset
(MDS) to the National Council for Palliative Care. SPH provides quarterly contract
activity data in the agreed format to the local NHS Commissioners as well as an
annual report.
Data is stored and utilised in accordance with the SPH Information Governance policy,
which is fully compliant with legalisation. An annual audit of Information Governance
is undertaken with a report and recommendations approved by the Clinical
Governance and Information Management Committees.
SPH is not subject to all Department of Health/Government regulations but it is a
registered company in England and Wales and is limited by guarantee. It is also a
charity registered with the Charity Commission. SPH prepare reports and accounts in
compliance with the accounting standard SORP 2005 and these are audited by a firm
of independent auditors. Report and accounts, which are for the year ending 31
March, are filed with both Companies House and the Charity Commission. All reports
are also available on our website www.stpetershospice.org or upon request.
PART 3
Review of Quality Performance
The hospice receives in the region of 1,700 new referrals per year across all services.
A whole hospice approach is utilised to monitor and improve the quality of services
delivered. This is achieved through clear policies and procedures, recognised forums
for discussion and agreement of best practice, a robust recruitment and induction
process, an on-going performance review system supported by excellent training and
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education for staff and volunteers.
Service users are consulted through our
PROMs/CROM’s, other questionnaires and in our User Involvement Forum in relation to
service delivery and future development.
Complaints both informal (verbal) and formal (written) are infrequent but are recorded
and discussed. Formal letters of complaint received are investigated thoroughly and
reported to the Executive Team, Clinical Governance Committee, our Board of
Trustees and NHS organisations. Where shortfalls in services are identified, immediate
action is taken to minimise the risk of recurrence. In 2011/12 there were seven formal
patient complaints and these were resolved satisfactorily. Two of our complaints
related to the closure of our former service known as FLAGS (family liaison and grief
service) but the complainants were reassured that the service is are still being
provided after internal reorganisation .
Board of Trustees Provider visits
The Board of Trustee Provider visits look at 3 key areas to review quality; care, staff
and environment. The following are comments from their written reports:
‘The time and guidance given by Liz to the patients was clearly appreciated both by
the patients and their families’
‘All patients spoken to, spoke highly of care and its effect on pain control and morale’
‘The education staff member was an experienced and knowledgeable facilitator who
knew the course members as individuals, including their professional backgrounds.’
‘Gardens spectacular. Wards clean and tidy’
What our staff say about the organisation
SPH values the opinions of the staff regarding the quality of the service provided.
Regular staff support meetings are held and in October 2011 a Staff Support survey
was undertaken across all business areas. Of the 67 participants who took part 81%
felt sufficiently valued in their role and 75% felt sufficiently supported working at SPH.
Staff Survey
The last employee satisfaction survey was undertaken in 2010 by an external
facilitator which showed positive results with the three statements receiving the
highest level of agreement and scoring an average of 3.2 or more out of 4 are as
follows:
 ‘I know how my job contributes to the success of the Hospice’
 ‘I know what is expected of me in my job’
 ‘I enjoy my job’
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The hospice has a very low turnover of staff and our annualised sickness levels are
also less than 3% for clinical staff (comparing very favourably to many other health
care providers).
What our regulators say about the organisation
SPH has to submit a self assessment to the Care Quality Commission (CQC), formerly
the Healthcare Commission, on an annual basis.
The CQC confirmed that they did not need to carry out a statutory inspection in
2011/12 as from the self assessment submitted they did not identify any serious
issues that warranted inspection. However as our last statutory inspection was carried
out 5 years ago, in May 2012 we received an unannounced visit from CQC. We are
pleased to announce we were found to be compliant in all standards measured by the
CQC inspector.
A further quote from the CQC report:
“The provider had an effective system to regularly assess and monitor the quality of
service that people receive”.
Julia di Castiglione
Director of Patient Care
Carole Dacombe
Medical Director
June 2012
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Appendix 1
Quality Action Plan
Year 1: July 2012  March 2013
ACTION
Review incidence of
 Pressure sores
 Falls
 Drug Errors
Check the standard of record
keeping
Audit of Controlled Drugs
Audit assessment of spiritual
needs of patients on IPU
Review results of Infection
Control
Audit and areas for
improvement
Monitor Staff sickness and
benchmark against NHS figures
Survey staff views
Bereavement client CROM
(Carer Reported Outcome
Measurement)
Further develop our systems
for patient assessment using
validated tool
Assess patient care
environment using PROM’s
(Patient Reported Outcome
Measurement). Pilot system
and review results
Administration of Medicines
Audit
Audit preferred place of death
– documentation of patient
wishes
Audit use of Advanced decision
code and documentation of
patients’ wishes
BY WHEN
EXPECTED OUTCOME
September 2012
September 2012
October 2012
March 2013
ACHIEVED
Measures agreed for the hospice and
standards set
Compare favourably to similar
organisations
Make sure record keeping is in
accordance with our policies and any
changes are identified and put into
action
Evidence that controlled drugs are
managed safely and in compliance
with the law
Evidence that IPU patients spiritual
needs are assessed appropriately
and necessary changes to
assessment process identified and
put into action
Necessary changes identified,
measures agreed for the hospice
and put into action
October 2012
DH benchmarks established and
standards set.
Discuss results with staff, identify
any changes and put into action
Evidence that bereaved client was
satisfied with the service received
from their allocated worker and
necessary changes identified and put
into action
Assessment system is revised to
ensure accuracy of completion and
documentation
October 2012
October 2012
December 2012
December 2012
August 2012
Evidence that SPH provides high
quality care environment and
necessary changes identified and put
into action
March 2013
Evidence that medicines are
administered correctly and
necessary changes identified and put
into action
May 2012
Evidence that patients wishes are
documented
Evidence that patients’ wishes are
correctly documented on electronic
patient record
Sept 2012
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In Progress
ACTION
Review the IPU and the Advice
Line Services
Prepare Quality Account and
update quality action plan
Bid for Dept of Health money
to improve patient areas
Introduce and pilot a new
dependency scoring system
BY WHEN
EXPECTED OUTCOME
ACHIEVED
A full review and action plan to
ensure on-going and dynamic
change with associated quality of
care
Clear plan for SPH quality
improvement linked to key
performance indicators.
November 2012
March 2013
New mattresses and new recliner
chairs
June 2012
Evidence that dependency scoring
system used in all patient areas and
measurable caseloads
November 2012
Year 2: April 2013 March 2014
ACTION
Infection Control Audit and
identification of areas for
improvement
Screen all patients on
admission to In patient Unit
(except those for Terminal
Care) for MRSA
BY WHEN
July 2013
Necessary changes identified and
linked to action plan
June 2013
Patients with positive result for
MRSA to be identified and treated
Audit mouth care for inpatients
Dec 2013
Audit incidence of falls on In
Patient unit and risk
assessment process
Sept 2013
Audit ordering, collection,
transportation, receipt and
storage of Controlled drugs
Sept 2013
Audit of use and validity of
dependency scoring system by
all SPH teams
Apr 2013
Evaluation of Outcome
measurement tools and
changes to patient dependency
Sept 2013
Monitor Staff sickness and
benchmark against NHS figures
Dec 2013
Ongoing monitoring of
previously established
benchmarks for
 Pressure Sores
 Falls
 Drug Errors
Evaluation of unmet needs for
Hospice at Home service
EXPECTED OUTCOME
Evidence that mouth care is
provided for patients in accordance
with agreed guidelines
Establish baseline for falls
incidence and agree falls risk
assessment process
Evidence that controlled drugs are
managed correctly and necessary
changes identified and linked action
plan
Evidence that dependency scoring
system is used correctly against
guidelines and necessary changes
identified and linked to action plan
Evidence that outcome
measurement tools are used in
accordance with guidelines
SPH benchmarks established and
standards set.
March 2013
Evidence of compliance with SPH
standards and necessary changes
identified and linked to action plan
March 2013
Identification of supply versus
demand, necessary changes
identified and shared with relevant
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ACHIEVED
ACTION
BY WHEN
EXPECTED OUTCOME
groups
Monitor clinical staff knowledge
and skills using Skills for
Healthcare End of life
competencies via staff
meetings, organisational
groups and staff training
records
Review and further extend our
patient assessment tools e.g.
Nutritional assessment
Review results of patient,
carers, bereaved clients
satisfaction survey for
Complementary Therapies
Audit of bereaved client
satisfaction
Report on quality of SPH
services and revise Quality
improvement plan
April 2013
Evidence that SPH clinical staff are
meeting required competencies to
provide a high standard of End of
Life care
June 2013
Patient assessment is accurately
completed and documented
Evidence that patients carers,
bereaved are satisfied with
Complementary therapy service
and necessary changes identified
and linked to action plan
Evidence that bereaved client was
satisfied with the service received
from their allocated worker and
necessary changes identified and
linked to action plan
November 2013
Dec 2014
Clear plan for SPH quality
improvement linked to key
performance indicators
March 2013
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ACHIEVED
Year 3: April 2014  March 2015
ACTION
Audit on identified key
areas of Symptom
Management
Review results of Patient
satisfaction surveys and
identify any required
actions
Ongoing monitoring of
previously established
benchmarks
Report on quality of SPH
services and revise action
plan
BY WHEN
EXPECTED OUTCOME
Evidence that symptoms are
managed effectively
July 2014
September 2014
Evidence that patients are
satisfied with SPH services and
necessary changes identified and
linked to action plan
March 2014
Evidence of compliance with SPH
standards and necessary changes
identified and linked to action
plan
March 2014
Clear plan for SPH quality
improvement linked to key
performance indicators
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ACHIEVED