Statement   of   Values
•
St   Teresa’s   Hospice   exists   to   help   people   suffering   from   life ‐ limiting   illness;   we   help   patients   to   keep   their   dignity,   which   is   paramount,   we   preserve   patient   choice,   and   we   provide   care   and   support   for   carers.
•
The   organisation   is   an   independent   charity   and   fiercely   preserves   this   status   in   order   to   be   flexible   to   respond   to   areas   of   greatest   need.
•
Free   care   is   provided,   through   a   range   of   services,   to   patients   and   to   their   primary   carers;   these   services   are   built ‐ up   on   the   basis   of   patient   need   and   choice,   using   a   holistic   approach.
•
Services   are   accessible   to   everyone   in   the   community   (regardless   of   race,   creed/non ‐ creed,   sexual   orientation,   social   standing,   age,   or   financial   status).
•
The   Hospice   team   is   a   dedicated,   skilled,   eclectic   mix   of   employed   and   voluntary   people;   all   personnel   are   valued   and   supported   to   achieve   hospice   and   personal   goals.
•
People   who   work   for   the   Hospice   in   any   capacity   are   expected   to   demonstrate   commitment   to   the   cause,   and   to   the   attainment   of   our   charitable   objectives.
Index:
Part   1
Part   2
Part   3
Quality   Statement
Priorities   for   Improvement   2012/13
Report   on   Priorities   for   Improvement   2010/11
Statement   of   Assurance   from   the   Board
Review   of   Quality   and   Performance
Supporting   Statements
St   Teresa’s   Hospice,   The   Woodlands,   Woodland   Road,   Darlington,   DL3   7UA     |    (01325)   254321   www.darlingtonhospice.org.uk

Quality   Accounts   now   represent   a   critical   part   of   the   overall   quality   improvement   infrastructure   of   the   NHS.
St   Teresa’s   Hospice   operates   within   a   culture   of   continuous   improvement.
We   consider   the   provision   of   high   quality   care   to   be   of   paramount   importance,   and   we   strive   to   ensure   that   quality   assurance   and   control   are   intrinsic   to   all
Hospice   services,   whether   direct   clinical   care,   support   services,   or   fundraising   operations.
We   maintain   a   strong   focus   on   both   corporate   and   clinical   governance,   which   enables   us   to   meet   our   Hospice   Philosophy   and   to   deliver   excellent,   appropriate,   safe   and   effective   clinical   services.
During   the   year,   the   Hospice   has   completed   self   assessment   and   has   successfully   been   audited   in   an   unannounced   Care   Quality   Commission   inspection.
Findings   of   both   of   these   identified   no   shortfalls   in   our   service   or   governance   provision.
This   focus   on   high   quality   care,   with   the   patient   at   the   centre   of   our   services,   has   led   to   significant   developments   and   innovative   practice,   resulting   in   St   Teresa's   Hospice,   a   local   charity,   working   in   partnership   with   a   national   charity   and   the   NHS   to   drive   up   the   quality   of   patient   care   in   our   area.
We   have   led   the   development   of   a   county ‐ wide   bereavement   consortium,   which   gives   equity   of   access   and   choice   to   all   individuals   living   within   Darlington   and   County   Durham   via   a   multi ‐ disciplinary   Family   Support   Team   model,   first   pioneered   by   our   hospice.
The   Hospice   is   working   within   the   second   year   of   its   rolling   five   year   strategy.
This   is   the   first   Quality   Account   produced   by   the   Hospice,   and   covers   all   of   our   services,   whether   funded   by   NHS   contributions,   or   our   own   fundraising,   personal   donations   and   applications   to   grant ‐ making   trusts.
The   Quality   Account   gives   us   the   opportunity   to   comment   on   the   quality   of   our   services,   rather   than   simply   focussing   on   financial   and   statistical   information.
This   account,   written   in   consultation   with   service   users,   is   endorsed   by   our   Board   of
Trustees   which   is   keen   to   support   quality   improvement   within   the   Hospice   and   view   this   reporting   format   as   an   opportunity   to   demonstrate   existing   good   practice   to   stakeholders,   whilst   focusing   on   the   coming   year's   priorities   for   improvement.
Looking   forward,   we   will   continue   to   focus   on   maintaining   quality   of   care   and   driving   up   the   standards   as   necessary,   and   have   identified   key   improvement   areas   across   the   domains   of   Patient   Safety,   Clinical
Effectiveness   and   Patient   Experience.
In   our   25th   Anniversary   Year,   I   am   pleased   to   present   this,   our   first   Quality   Account   which   has   been   prepared   as   a   team   effort   and,   to   the   best   of   my   knowledge,   is   an   accurate   and   fair   representation   of   the   quality   of   services   provided   at   St   Teresa's   Hospice.
Jane   Bradshaw,   CEO
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St   Teresa’s   Hospice   Board   of   Trustees   is   committed   to   continuous   service   improvement   and   has   supported   the   development   and   implementation   of   a   formalised   five   year   strategy   which   focuses   on   safe,   effective   care   which   provides   patients   and   their   carers   with   a   positive   patient   experience.
This
Quality   account   focuses   on   specific   improvement   priorities   for   2012/2013   which   cross   the   domains   of   Patient   Safety ,   Clinical   Effectiveness   and   Patient   Experience .
Service   users   and   staff   have   been   consulted   on   both   the   strategy   and   this   Quality   Account,   and   have   agreed   the   outlined   priorities   for   improvement.
St   Teresa’s   Hospice   is   fully   compliant   with   the   National   Minimum   Standards   (2002)   and   has   satisfied   the   Care   Quality   Commission   (CQC)   that   standards   are   being   met   through   both   self   assessment   and   an   unplanned   CQC   inspection   in   November   2011.
2.1
Improvement   Priority   1   for   2012/2013   (Patient   Safety)
Introduction   of   “ Deciding   Right ”
Priority :   Introduction   of   the   Deciding   Right   document   to   integrate   the   principles   of   advanced   care   decisions   for   all   appropriate   patients   accessing   St   Teresa’s   Hospice   services
Why   choose   this   as   a   priority?
Deciding   Right   is   an   initiative   which   integrates   Advanced   Care   Planning,   the   Mental   Capacity   Act,
Cardiopulmonary   Resuscitation   and   Emergency   Health   Care   Plans.
Patients   are   referred   to   the
Hospice   from   a   variety   of   settings:   GP’s,   care   homes,   acute   trusts,   patients   home,   and   sometimes   as   temporary   residents.
A   plethora   of   documents   is   available   in   the   health   care   economy   which   all   do   similar   things   but   the   paperwork   is   different.
By   adopting   Deciding   Right ,   and   supporting   its   roll ‐ out   in   the   community,   patient   safety   will   be   improved   as   all   patients’   advanced   wishes   will   be   reported   on   recognised,   colour   coded,   patient   held   documentation   which   is   transferrable   along   the   patient   pathway.
The   priority   was   identified   by   the   Clinical   Governance   group   on   recognising   the   many   different   documents   in   patients’   notes,   following   patient   record   audit.
How   will   this   priority   be   achieved?
A   switchover   date   will   be   set   when   the   Hospice   will   move   to   using   Deciding   Right .
Leading   up   to   the   switchover   date,   education   and   key   members   of   the   clinical   teams   will   attend   “train   the   trainers”   sessions,   and   will   then   cascade   training   internally.
Paperwork   will   be   ordered   ahead   of   the   switchover   date.
Progress   will   be   monitored   by   the   Clinical   Governance   Group.
How   will   this   priority   be   measured?
Audit   of   patient   records   will   indicate   the   success   of   the   roll ‐ out   of   Deciding   Right .
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2.2
Improvement   Priority   2   for   2012/2013   (Patient   Safety)
Introduction   of   Patient   Safety   Thermometer
Priority :   Introduction   of   Patient   Safety   Thermometer
What   is   the   Patient   Safety   Thermometer?
The   NHS   Safety   Thermometer   provides   a   quick   and   simple   method   for   surveying   patient   harms   and   analysing   results,   via   the   completion   of   an   electronic   spreadsheet.
Why   choose   this   as   a   priority?
St   Teresa’s   Hospice   views   patient   safety   as   its   top   priority.
The   safety   thermometer   is   a   tool   to   survey   patient   harm   and   harm ‐ free   care,   and   its   use   will   be   a   Commissioning   for   Quality   and
Innovation   (“CQUiN”)   measure   within   the   Hospice   NHS   contract.
How   will   this   priority   be   achieved?
The   Head   of   Nursing   will   oversee   the   implementation   of   the   tool   and   any   training   requirements   for   staff.
Night   staff   will   complete   the   tool   on   a   daily   basis   for   all   in   patients.
How   will   this   priority   be   measured?
The   results   will   be   reported   to   the   PCT   quarterly   from   October   2012   and   to   the   Hospice   Clinical
Governance   Board;   any   improvement   outcomes   will   be   overseen   by   the   Clinical   Governance   Board.
2.3
Improvement   Priority   3   for   2012/2013   (Clinical   Effectiveness)
Introduction   of   SystmOne   to   improve   Clinical   Communication
Priority:   SystmOne   will   be   introduced   to   the   Hospice,   and   will   be   fully   operational   with   all   new   patients   entered   onto   the   electronic   patient   management   system   from   November   2012.
The   introduction   of   the   system   will   improve   clinical   effectiveness   in   the   Hospice   by   improved   communication   between   healthcare   professionals   involved   in   a   patient’s   care,   improved   medicines   management   and   reporting.
Why   choose   this   as   a   priority?
The   priority   has   been   identified   by   staff   recognising   the   benefit   which   such   a   system   can   have   in   improving   communication   with   professional   colleagues   involved   in   a   patient’s   care,   and   by   the   Board   of   Trustees   who   are   keen   to   keep   pace   with   local   developments.
(By   the   autumn   2012   all   GP’s   in
Darlington   will   utilise   SystmOne).
The   system   will   improve   clinical   effectiveness,   as   staff   will   be   able   to   see   a   full   electronic   patient   record,   with   up   to   date   interventions   by   other   colleagues   involved   in   a   patient’s   care.
Medicines   management   will   be   improved   as   the   system   can   be   used   for   drug   calculations,   and   reporting   on   existing   services   will   be   more   efficient   and   will   inform   future   services.
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How   will   this   priority   be   achieved?
A   full   project   implementation   plan   will   be   drawn   up   in   partnership   with   the   PCT   and   CSC   (System
Provider)   with   timescales   aligned   to   the   project   implementation.
The   Hospice   has   identified   project   leads   who   will   be   tasked   with   implementing   the   project   and   they   will   report   back   to   the   Clinical
Governance   group   and   to   the   PCT   project   manager.
How   will   this   priority   be   measured?
Training   log   for   all   clinical   staff,   audit   of   patient   records.
2.4
Improvement   Priority   4   for   2012/2013   (Patient   Experience)
Improved   Engagement   with   Service   Users
Priority:   To   establish   a   formal   integrated   User   Partnership   Group
Why   choose   this   as   a   priority?
St   Teresa’s   Hospice   has   a   Carers’   support   group   which   has   been   involved   and   consulted   with   on   service   developments.
However,   the   Hospice   Board   has   recognised   that   increased   and   more   formalised   user   involvement   would   be   beneficial   as   the   Hospice   moves   forward,   as   service   users   have   the   most   informed   views   on   how   our   services   should   develop.
How   will   this   priority   be   achieved?
A   member   of   staff   will   be   identified   to   provide   support   to   the   group   and   will   write   terms   of   reference.
Service   users   and   their   families   will   be   formally   asked   if   they   wish   to   attend   and,   on   appointment,   a   Chairperson   will   be   invited   to   attend   Board   meetings   and   contribute   to   the   annual   report.
How   will   this   priority   be   measured?
Meeting   attendance   sheets
2.5
Improvement   Priority   5   for   2012/2013   (Patient   Experience)
Development   of   the   Hospice   Day   Therapy   Services
Priority:   To   develop   Hospice   Day   Therapy   adopting   a   rehabilitation   model
Why   choose   this   as   a   priority?
St   Teresa’s   Hospice   constantly   strives   to   follow   evidence   based   practice.
The   NICE   Supportive   and
Palliative   Care   Guidance   recommends   access   to   rehabilitation   services   for   patients   including   at   the   end   of   life.
Senior   clinical   staff   have   identified   a   paucity   of   allied   health   professional   support   for   patients   at   the   Hospice   but   particularly   in   Day   Therapy.
Day   therapy   services   will   be   reviewed   to   offer   a   rehabilitation   model   of   care   for   patients,   within   which   they   will   be   able   to   access   a   range   of
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services,   including   a   wider   range   of   complementary   therapies   and   exercise   and   movement   via
“Tripudio”   (which   is   a   gentle,   seated,   dance ‐ based   exercise   programme,   specifically   designed   for   the
Day   Therapy   setting).
Patients   themselves   have   been   consulted   on   the   Hospice   plans   to   review   services   and   have   tried   a
“taster”   session   of   Tripudio   and   as   a   direct   impact   of   their   positive   feedback   this   will   be   incorporated   into   the   future   model.
The   future   Day   Therapy   model   will   improve   patient   experience   by   helping   patients   to   improve   mobility,   or   live   better   with   their   disability,   and   will   support   them   to   function   in   daily   activities   whilst   overcoming   feelings   of   loss   of   control   and   providing   a   feeling   of   well   being   and   self   worth.
How   will   this   priority   be   achieved?
Allied   health   professional   funding   is   being   sought   from   a   variety   of   sources.
The   Hospice’s   Strategic
Management   Team   will   lead   the   review   and   introduction   of   rehabilitation,   a   wider   complementary   therapy   range   of   services   and   introduction   of   Tripudio,   with   patient   involvement,   and   will   report   back   to   the   Board   of   Trustees   on   a   bi ‐ monthly   basis.
How   will   this   priority   be   measured?
Patient   satisfaction   survey
Staff   observational   reports
2.6
Report   on   Priorities   for   Improvement   from   2010/2011:
St   Teresa’s   Hospice   is   fully   compliant   with   the   National   Minimum   Standards   (2002)   and   has   satisfied   the   Care   Quality   Commission   (CQC)   that   standards   are   being   met   through   both   self   assessment   and   an   unplanned   CQC   inspection   in   September   2011.
This   document   reflects   the   Hospice’s   first   Quality   Account.
However,   the   Hospice   is   in   year   2   of   a   5 ‐  year   rolling   strategy   within   which   areas   of   improvement   were   highlighted.
The   areas   of   improvement   have   taken   account   of   the   economic   constraints.
The   Board   has   been   in   full   support   of   the   improvement   areas   and   carers   have   been   consulted   where   possible.
The   identified   improvement   priorities   for   2010/2011   were   as   follows:
2.6.1
Introduction   of   a   Rapid   Response   and   Rapid   Discharge   Service
St   Teresa’s   Hospice   has   been   pivotal   to   the   design   and   implementation   of   an   innovative   Rapid
Response   and   Rapid   Discharge   service,   where   the   Hospice,   a   local   charity,   has   worked   in   partnership   with   the   NHS   and   a   national   Charity,   Marie   Curie.
The   service   crosses   the   three   domains   of   patient   experience,   clinical   effectiveness   and   patient   safety.
The   Rapid   Response   team   comprises   a   Marie   Curie   registered   nurse   and   a   St   Teresa’s   Hospice   health   care   assistant   who   are   available   24   hours   a   day,   365   days   a   year   to   respond   within   an   hour   to   a   patient   in   their   own   home,   wherever   this   may   be.
The   team   aims   to   prevent   avoidable   hospital   admissions,   and   to   help   a   patient   to   achieve   their   preferred   place   of   care,   either   by   offering   support
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in   the   home,   or   facilitating   a   rapid   discharge.
The   funding   source   is   from   three   key   partners:   St
Teresa’s   Hospice,   Marie   Curie   and   the   NHS   (the   fourth   partner   is   County   Durham   and   Darlington
Foundation   Trust).
The   project,   initially   set   up   as   an   18   month   pilot,   commenced   patient   activity   in   October   2011.
The   interim   report   published   in   March   2012   provides   excellent   outcomes,   with   over   50   new   patients   referred   over   a   6   month   period,   the   majority   of   these   would   otherwise   have   required   a   hospital   admission.
Statistical   evidence   demonstrates   the   project   is   realising   its   aims   and   patient   evaluation   is   extremely   high.
The   partners   are   now   busy   working   to   secure   ongoing   funding   for   the   service.
Extracts   from   Patient   and   Carer   Feedback    about   the   Rapid   Response   Service:
“Dad   had   pain   but   we   didn’t   want   to   call   999   so   we   called   for   the   RR   Team”
“Thank   you   so   much,   this   is   keeping   him   at   home   where   he   wants   to   be”
Patient’s   wife   stated:   “we   couldn’t   have   managed   without   you   –   it’s   been   wonderful   that   you’ve   been   able   to   stay   here   and   support   us.”
“Pt   stated   she   was   going   to   call   an   ambulance,   but   decided   to   try   us   first.
Pt   said   she   wanted   to   remain   at   home   and   was   grateful   we   helped   her   to   do   so.”
2.6.2
Introduction   of   a   Comprehensive   Patient   Pack
The   Board   was   aware   of   the   patient   information   agenda   and   agreed   to   invest   in   the   production   of   a   comprehensive   patient   information   pack.
The   pack   contains   individual   leaflets   on   each   of   the
Hospice   services   and   is   given   to   every   patient.
Specific   information   is   also   provided   for   carers   and   bereaved   individuals.
The   format   is   paper   copy   but   is   also   available   electronically   and   can   be   translated   as   necessary.
Positive   evaluation   has   been   provided   by   service   users.
The   Hospice   is   exploring   ways   of   making   information   available   for   the   visually   impaired.
2.6.3
Refurbishment   of   Day   Hospice   Areas   (Dept   of   Health   Grant)
The   Hospice   was   successful   in   securing   a   Department   of   Health   Capital   Grant   to   upgrade   Day
Hospice   facilities.
The   purpose   of   this   refurbishment   project   was   to   make   changes   to   the   building   and   equipment   in   our   Hospice   Day   areas,   which   would   increase   patient   dignity,   privacy   and   comfort.
The   improvement   work   has   been   completed   and   meets   all   statutory   and   regulatory   requirements.
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Upgraded,   washable   flooring   has   improved   hygiene    and,   importantly,   patient   safety   by   removing   fall   hazards,   the   overall   quality   and   accessibility   of   the   environment   is   much   improved   including   the   creation   of   an   additional   patient   bathroom,   and   improvements   were   also   made   to   kitchen   an   dining   facilities,   all   adding   to   the   quality   and   feeling   of   well ‐ being   for   patients   who   visit   the   Hospice.
Patient   evaluation   has   been   extremely   high.
BEFORE   Refurbishment
AFTER   Refurbishment
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Part   2   cont.
The   following   statements   must   be   provided   within   a   Quality   Account   by   all   providers.
Many   of   these   statements   are   not   directly   applicable   to   St   Teresa’s   Hospice,   therefore   explanations   are   given.
a.
Review   of   Services
During   the   reporting   period   2011/2012   St   Teresa’s   Hospice,   Darlington,   provided   the   following   services   to   the   NHS:
•
6   Bedded   In   patient   Unit
•
Day   Therapy   Service
•
Hospice   at   Home
•
Rapid   Response   service
•
Lymphoedema   services
•
Family   Support   (including   welfare   benefits)
•
Complementary   Therapies
During   the   reporting   period   2011/2012   St   Teresa’s   Hospice,   Darlington,   provided   or   sub   contracted   7
NHS   services   (no   funding   received   for   Complementary   therapies).
The   Hospice   has   reviewed   all   the   data   available   to   them   on   the   quality   of   these   NHS   Services.
The   income   generated   by   the   NHS   services   reviewed   in   2011/2012   represents   100   per   cent   of   the   total   income   generated   from   the   provision   of   NHS   services   by   St   Teresa’s   Hospice   Darlington   for
2010/2011.
The   income   generated   represents   approximately   40   %   of   the   overall   costs   of   running   these   services.
What   this   means :
St   Teresa’s   Hospice   is   funded   by   both   NHS   income   and   by   fundraising   activity.
The   Hospice   receives   funding   from   two   different   PCT   areas   approximately   80:20   for   its   NHS   funding   which   reflects   patient   activity   from   the   two   PCT   areas.
The   grants   allocated   by   the   NHS   contribute   to   approximately   40%   of
Hospice   total   income.
This   means   that   all   services   are   partly   funded   by   the   NHS   and   partly   by   Charitable   Funds.
St   Teresa’s
Hospice   for   the   accounting   period   2012/2013   has   signed   an   NHS   contract   in   place   of   the   traditional   voluntary   sector   grant.
b.
Participation   in   Clinical   Audit
•
During   2011/2012   no   national   clinical   audits   or   confidential   enquiries   covered   NHS   services   provided   by   St   Teresa’s   Hospice.
•
During   2011/2012   St   Teresa’s   Hospice   participated   in   no   national   clinical   audit   and   no   confidential   enquiries   of   the   national     clinical   audits   and   national   confidential   enquiries   it   was   eligible   to   participate   in.
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•
The   national   clinical   audits   and   national   confidential   enquiries   that   St   Teresa’s   Hospice   was   eligible   to   participate   in   during   2011/2012   was   none.
•
The   National   audits   and   national   confidential   enquiries   that   St   Teresa’s   Hospice   participated   in,   for   which   data   collection   was   completed   during   2011/2012,   are   listed   below   alongside   the   number   of   cases   submitted   to   each   audit   or   enquiry   as   a   percentage   of   the   number   of   registered   cases   required   by   the   terms   of   audit   or   enquiry.
o St   Teresa’s   Hospice   was   not   eligible   to   participate;   therefore,   there   is   no   information   to   submit   or   list   here.
What   this   means :
St   Teresa’s   Hospice   as   a   provider   of   palliative   care   is   not   eligible   to   participate   in   any   national   audit   or   confidential   enquires   as   these   have   not   pertained   to   palliative   care   during   the   accounting   period
•
St   Teresa’s   Hospice   has   not   reviewed   any   national   or   local   audits   during   2011/2012   and   therefore   has   no   actions   to   implement    c.
Research
•
The   number   of   patients   receiving   NHS   services   provided   or   sub ‐ contracted   by   St   Teresa’s
Hospice   in   2011/2012   that   were   recruited   during   that   period   to   participate   in   research   approved   by   an   ethics   committee   was   none.
There   was   no   appropriate,   nationally,   ethically   approved   research   studies   in   palliative   care   in   which   St   Teresa’s   Hospice   could   participate.
d.
CQUIN   Payment   Framework
•
St   Teresa’s   Hospice   NHS   income   in   2011/2012   was   not   conditional   on   achieving   quality   improvement   and   innovation   goals   through   the   Commissioning   for   Quality   and   Innovation   payment   framework   because   it   had   a   voluntary   sector   grant   in   place.
In   the   accounting   period   2012/2013,   CQUIN   measures   are   within   the   NHS   contract.
e.
Statement   for   the   Care   Quality   Commission
•
St   Teresa’s   Hospice   is   required   to   register   with   the   Care   Quality   Commission   and   its   current   registration   status   is   for   the   following   regulated   activities:   o Diagnostic   and   screening   procedures   o Treatment   of   Disease,   disorder   or   injury   o Personal   Care
•
St   Teresa’s   Hospice   is   registered   with   the   following   conditions:   o Services   are   provided   for   people   over   18   years   old   o The   maximum   of   6   patients   may   be   accommodated   overnight   o Notification   in   writing   must   be   provided   to   the   Care   Quality   Commission   at   least   one   month   prior   to   providing   treatment   or   services   not   detailed   in   the   Statement   of
Purpose
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•
St   Teresa’s   Hospice   completed   a   self   assessment   for   the   Care   Quality   Commission   in   2010   and   had   an   unplanned   visit   in   November,2011.
St   Teresa’s   Hospice   has   not   participated   in   any   special   reviews   or   investigations   by   the   Care   Quality   Commission   in   2011/2012.
f.
Data   Quality
•
St   Teresa’s   Hospice   did   not   submit   records   during   2010/2012   to   the   Secondary   Users   service   for   inclusion   in   the   Hospital   Episode   Statistics   which   are   included   in   the   latest   published   data.
What   this   means :
St   Teresa’s   Hospice    is   not   eligible   to   participate   in   the   scheme.
g.
Information   Governance   Toolkit   Attainment.
•
ST   Teresa’s   Hospice   did   not   participate   in   the   Information   Governance   Toolkit.
However,   the
Hospice   has   its   own   internal   Information   Governance   Policy.
h.
Clinical   Coding   error   rate
•
St   Teresa’s   Hospice   was   not   subject   to   the   Payment   by   Results   clinical   coding   audit   during
2011/2012   by   the   audit   commission   (as   it   had   a   voluntary   sector   grant   in   place   for   the   reporting   period).
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The   review   of   Quality   at   St   Teresa’s   Hospice   can   be   considered   across   the   three   domains   of   Patient
Safety,   Clinical   Effectiveness   and   Patient   Experience.
The   following   information   provides   information   on   these   areas   during   the   accounting   period   2011/2012.
‐
Clinical   Incident   Reporting ‐  reporting   on   clinical   incidents   was   chosen   as   it   gives   an   insight   for   the
Hospice   and   patients   as   to   how   “safe”   the   service   was   during   the   accounting   period.
Clinical   incidents   are   reported   by   staff   involved   every   time   they   happen   and   investigated   by   the   Clinical
Governance   Board.
Table   1   Demonstrating   Clinical   Incidents   during   Accounting   Period   2011/2012
Clinical   Incident
Slips,   trips   and   falls  ‐  patients
Slips,   trips   and   falls   –   staff   and   volunteers
Drugs
Clinical   issues     7
Detail:
1.
Hospice   did   not   notify   funeral   home   that   deceased   has   Hepatitis   C.
2.
Non   Hospice   syringes   in   sharps   box
Æ
3.
EoLCP   commenced   without   it   being   signed   by
Doctor
4.
On   admission   discovered   that   patient   was   MRSA   positive   but   not   been   informed   about   this   in   advance.
5.
Threatening   and   abusive   behaviour   towards   member   of   staff
6.
Hospital   discharge   letter   arrived   for   patient   we   did   not   know.
Æ
Æ
Æ
Æ
7.
Rapid   Response   member   of   staff   refused   to   verify   death   of   patient.
Æ
Æ
9
2
4
Action   Taken
Patient’s   mobility   evaluated   and   staff   to   supervise
Incidents   discussed   with   staff   and   policies   and   procedures   amended
Nurses   reminded   to   inform   funeral   homes   about   infectious   diseases.
Memo   to   all   staff   re   self   medicating.
No   action   taken
IPU   staff   to   ask   question   prior   to   admission   of   patients.
Head   of   Nursing   spoke   with   individual   involved
Hospital   and   GP   contacted   to   see   if   they   wanted   to   refer   to   Hospice.
No   action   verification   of   death   was   outside   of   Marie
Curie   Policy   for   this   patient
12

‐
Measuring   clinical   effectiveness   is   important   to   the   Hospice   as   it   helps   identify   areas   of   improvement   and   is   important   to   both   the   Hospice   and   the   public   as   it   helps   us   demonstrate   that   our   services   are   achieving   what   we   intended   to   achieve.
The   Hospice   collects   statistical   information   on   every   patient   and   enters   this   into   a   National   Minimum
Dataset   held   by   the   National   Council   for   Palliative   Care   which   allows   collation   of   information   on   demographics,   comparisons   between   services   and   conclusions   to   be   drawn   on   patients'   preferences   and   achievement   of   these   preferences.
The   following   table   provides   a   comparison   of   the   Hospice   performance   against   the   most   recently   published   report   (May   2011)   on   the   National   Council   for
Palliative   Care   National   Minimum   Data   Set   for   2009/2010   where   an   appropriate   comparison   can   be   made.
Table   2   Comparing   St   Teresa’s   Hospice   to   the   National   Minimum   Dataset
Area
In   patient   services
St   Teresa’s   Hospice
2010/2011
(For   info   only)
Total   Number   of   Patients   within   a   year   treated
119
Total   New   Patients    100
St
181
122
14
Teresa’s
2011/2012
Hospice
Re ‐ referred   Patients
Average   Bed   Occupancy   (%)
14
60% 86%
82   % Cancer   Diagnosis   (%)
Non   cancer   diagnosis   (%)
Average   length   of   stay   (days)
76%
24%
6.7
18
7.7
%
Died   in   Hospice   (%)
Discharge   care   home   (%)
Discharge   acute   (%)
Discharged   Home   (%)
Day   Therapy
Total   Number   of   Patients   Treated
Number   of   New   Patients
34
1%
1%
72
137
%
48%
73
3
5
92
80
/
146
/
/2
/
40%
1%
%
49%
Minimum   Dataset
2009/2010
36,701
‐
‐
73%
90%
10%
12.2
50.6%
38.5%
13

Total   Days   available   places
Total   Places   attended
Total   places   booked   DNA
Average   length   of   care   (days)
Cancer   Diagnosis   (%)   76%
Non   cancer   diagnosis   (%)   24%
Access   to   Physiotherapist   (total   number   of   Hospices   in   UK)
No
3920
2014
943
213
Access   to   medical   consultant   (total   number   of   Hospices   in   UK)
Yes
Access   to   occupational   therapist
(total   number   of   Hospices   in   UK)
No
Access   to   spiritual   support   (total   number   of   Hospices   in   UK)
Yes
Access   to   social   worker   (total   number   of   Hospices   in   UK)
Yes
Access   to   complementary   therapist
(total   number   of   Hospices   in   UK)
Yes
Hospice   at   Home
Total   Number   of   Patients   treated
213
New   Patients
Patients   died   in   Hospice   (%)
Patients   died   at   home   (%)
Patients   died   at   Care   home   (%)
164
23%
55%
9%
Patients   died   at   Hospital   (%)   10%
Patients   died   at   Community   hospital
(%)
1%
Cancer   Diagnosis
Non   cancer   diagnosis
Length   of   care   (days)
Average   number   of   deaths   (%)
55
45
103
43%
14
Yes
Yes
Yes
Yes
No
80%
20%
No
3920
3247
794
300
184
132
15%
68%
3%
8%
1%
52
48
127
35%
47/101
51/101
70/101
46%
9%
18%
4%
‐
‐
17%
86
14
4.2
70%
182
84%
16%
51/101
38/101
50/101

3.2.1
In   patient   Unit
During   the   accounting   period   the   Hospice   had   a   total   of   181   patients   on   the   In   patient   Unit,   122   of   which   were   new   referrals.
Bed   occupancy   was   86%,   higher   than   the   MDS   which   was   73%.
The
Hospice   recognised   during   the   previous   accounting   period   occupancy   was   low   and   took   steps   to   promote   the   service   and   make   better   links   with   health   care   professionals   in   the   community.
This   proved   very   useful   as   bed   occupancy   rose   to   86   %   [from   60%   in   the   accounting   period   2010/2011].
The   Hospice   was   successful   at   supporting   non   cancer   patients,   with   82%   of   the   in   patient   population   treated   having   a   cancer   diagnosis   compared   to   the   MDS   of   90   %.
Average   length   of   stay   is   shorter   than   the   national   average   during   the   accounting   period.
The   number   of   patients   dying   in   the
Hospice   is   also   lower   at   40%   compared   to   the   MDS   of   50%.
Considering   these   statistics   alongside   the   place   of   death   for   patients,   one   assumption   is   that   the   Hospice   was   extremely   effective   at   facilitated   discharge,   enabling   a   patient   to   die   in   their   preferred   place   of   care   at   home   with   49   %   of   patients   dying   at   home,   compared   to   a   national   average   of   38%.
3.2.2
Day   Therapy
The   total   number   of   places   was   3920,   with   an   attendance   rate   of   3247,   an   increase   on   the   previous   accounting   period.
Reflecting   on   this   and   the   following   year's   statistics   the   Hospice   is   reviewing   day   therapy   provision   as   outlined   in   the   improvement   aims.
Average   length   of   care   was   above   the   national   average   of   182   days   with   Hospice   average   length   of   care   being   300   days.
In   Day   Therpay,   as   in   the   In   patient   Unit,   the   Hospice   is   again   pro ‐ active   and   effective   in     supporting   non   cancer   patients,   with   80%   of   patients   having   a   diagnosis   of   cancer   compared   to   the   national   average   84%.
St   Teresa’s   is   one   of   few   Hospices   nationally   that   does   not   have   access   to   allied   health   professionals;   again   this   will   be   addressed   within   this   current   accounting   period.
The   Hospice   has   excellent   support   from   complementary   therapy   staff   and   all   patients   had   access   to   a   palliative   care   consultant.
3.2.3
Hospice   at   Home
The   Hospice   at   Home   service   supported   184   patients   during   the   accounting   period.
68%   of   those   patients   were   supported   to   die   at   home,   15%   died   in   the   Hospice   with   3%   in   a   care   home   and   8%   in   hospital.
Again   the   Hospice   was   able   to   support   non   cancer   patients   extremely   well   with   48   %   of   total   patients   having   a   diagnosis   other   than   cancer.
3.2.4
Rapid   Response   Service
The   Rapid   Response   service   was   established   during   the   accounting   period,   and   was   operational   for   6   months.
The   service   was   established   with   the   key   aim   of   supporting   patients   at   home,   avoiding   hospital   admission   at   the   end   of   life   where   possible   and   appropriate.
The   information   provided   is   quantitative,   as   qualitative   research   is   being   carried   out   throughout   the   18   month   pilot   project.
The   following   information   depicts   performance   for   the   service   during   this   time   period.
15

3.2.4
Rapid   Response   cont.
Type   of   referral   to   the   service
ƒ A   total   of   50   patients   incurring   180   visits
ƒ Cancer   patients   x   37
ƒ Non ‐ cancer   patients   x13.
Dementia   (3),   Parkinson’s   disease   (1),   CHD   (1)   renal   failure   (1),
COPD   (5),   EOLC   (2)
1
1 1
5
2
Abbreviations:
CHD:     Coronary   Heart   Disease
COPD:   Chronic   Obstructive
Pulmonary   Disease
EOLC:    End   of   Life   Care
3
Cancer
Dementia
Parkinson's   Disease
CHD
Renal   Failure
COPD
EOLC
37
Key   Performance   Indicators
Key   Performance   Indicators   (KPI)   were   agreed   with   commissioners   prior   to   the   service   commencing.
The   KPI   demonstrate   if   the   service   is   meeting   its   goals.
Table   3   Key   Performance   Indicators   for   Rapid   Response
Key   Performance   Indicator Target
Response   to   patient   within   an   hour   of   referral
95%
Measurement   of   an   advanced   care   plan   in   place
(ACP)
100%
Achievement
100%
100%
Notes
Achievement   of   Preferred
Place   of   Care
50%
Total   Number   of   Never
Events
0%
66%
0%
Measurement   of   the   plan   in   place   was   achieved   at
100%.
Of   the   patients   referred   to   the   service   only
20%   of   Patients   had   it   in   place   (8   out   of   50)
33   patients   were   supported   at   home   avoiding   hospital   admission
These   are   events   that   should   never   happen
16

3.2.4
Rapid   Response   cont.
Invest   to   Save
One   of   the   drivers   for   the   project   was   to   generate   cost   efficiencies.
During   the   initial   6   months   of   the   project:
ƒ From   patients   visited,   33   were   supported   at   home,   saving   the   NHS   £57.750
in   avoidable   hospital   admissions
ƒ From   patients   visited,   33   were   able   to   stay   in   their   own   home   at   a   total   saving   to   NEAS   of
£6,237.
ƒ Total   cost   saving   of   £63,987   (based   upon   cost   per   non ‐ elective   admission   as   advised   by
NHS   Durham   and   Darlington   Commissioning   support).
In   summary,   the   service   within   its   first   6   months   of   being   operational   has   achieved   its   aims,   is   providing   a   quality   service   for   patients   allowing   them   to   achieve   their   preferred   place   of   care   and   is   generating   cost   efficiencies.
Case   studies   have   been   collected   on   every   patient,   and   feedback   includes:
−
“Thank   you   so   much,   this   is   keeping   him   at   home   where   he   wants   to   be’
−
‘You   are   so   kind   and   helpful;   I’m   really   pleased   we   contacted   you’
−
Patient’s   wife   stated   ‘we   couldn’t   have   managed   without   you   –   it’s   been   wonderful   that   you’ve   been   able   to   stay   here   and   support   us.’
−
‘Pt   stated   she   was   going   to   call   an   ambulance   but   decided   to   try   us   first.
Pt   said   she   wanted   to   remain   at   home   and   was   grateful   we   helped   her   to   do   so.’
−
‘Pts   husband   stated   that   we   had   done   “a   lot   of   good   for   him   today”   felt   more   in   control   and   reassured.
−
‘Family   had   commented   to   another   service   provider   that   they   had   found   the   RR   team   to   be
“an   invaluable   service”   felt   very   supported’
−
‘Residential   home   staff   commented   how   they   felt   supported   and   re ‐ assured   by   staff   presence.’
−
‘Care   home   staff   thanked   us   for   our   help   in   settling   the   lady’
−
‘Family   said   how   caring   and   helpful   the   team   had   been’
−
‘Contacted   by   GP   Dr   Nevison   who   thanked   us   for   our   input’
−
‘DN   thanked   us   for   our   input’
17

3.2.5
Clinical   Audit
Audit   is   a   valuable   way   of   examining   everyday   practice.
During   the   reporting   period   the   Hospice   has   introduced   a   12   month   program   of   Clinical   Audit.
The   following   audits   were   undertaken   during   the   accounting   period   2011/2012.
Table   4   Summary   of   Clinical   Audits   2011/2012
Name   of   Audit   Date   completed   Actions   to   be   taken   to   improve   practice
Yes Essential   Steps   in   Infection
Control
January   2012
Action
Yes
plan place
in   Target
June
Date
2012
Completion of
Medicines
Management
Clinical
Supervision
February
March
2012
2012
Yes
Yes
Yes
Yes
July
July
2012
2012
Medical   Records    March   2012   Yes Yes Sept   2012
All   of   the   findings   of   the   audits   are   presented   to   the   Clinical   Governance   Board   and   action   plans   agreed,   and   monitored   by   the   board.
The   full   program   of   audit   will   be   rolled   out   through   the   next   accounting   per iod.
18

‐
3.3.1
Patient   satisfaction   survey
St   Teresa’s   Hospice   carries   out   bi ‐ annual   patient   satisfaction   survey.
This   was   completed   in   the   previous   accounting   year.
The   Hospice   will   move   to   annual   surveying   in   future.
In   addition   the   Hospice   also   receives   many   letters   of   compliment   and   thanks.
Some   of   the   comments   are   included   below:
“...grateful
thanks   for   your   help   and   support   during...illness.
I   found   the   carers   group   meetings   a   great   help,   to   talk   to   people   who   understood...I
know...
enjoyed   his   time   with   you   and   enjoyed   the   chat...and
the   change   from   being   at   home.
Many   thanks   for   all   your   help   and   kindness   during   the   sad   time.”
“We   would   like   to   thank   all   for   you   for   taking   such   care   of...in
her   last...days,   she   couldn’t   have   wished   for   anything   more,   you   were   kind   and   caring   and   we   cannot   thank   you   enough.”
“Many a
I
am
“...life
weeks
became journey thanks transport support.” in   volunteer
most
which involved...A
much marvellous
to during
much the very drivers
the the grateful job.”
big hospice for more
drivers, last for
your easier thank
you making pleasant
for month.
help was
to the
–
the during
all they
and   the
the do
“I   am   writing   to   you   to   praise   and   acknowledge   the   nurses   and   volunteers   that   work   at   St   Teresa’s
Hospice...
The   nurse’s   care   for...was
for   the   highest   standard,   they   were   at   all   times   caring,   compassionate,   professional   and   respectful.
Not   only   was   the   care   for...
outstanding,   but   the   support   they   provided   me   was   what   got   me   through   what   was   possibly   one   of   the   worst   weeks   of   my   life.
Although   the   nurses   were   often   busy,   what   little   time   they   did   have,   they   would   spend   with   the   patients   and   their   families,   and   for   me   during   very   dark   hours,   the   nurses   would   lift   my   spirits   and   bring   a   smile   to   my   face
Those   nurses   are   simply   the   best   of   the   best   and   the   words   “Thank   You”   will   simply   never   be   enough.”
“...I
would   like...to
thank   the   whole   team   a   St.
Teresa’s   Hospice   for   the   very   special   care   given   to...
in...last
months.
Day   Care,   Hospice   at   Home   and   the   in ‐ patient   nurses   were   all   excellent!
...had
...dying
wish   and   died   at   home   and   had   the   very   best   care   possible,   without   your   help   he   would   not   of   had   that   level   of   care.
We   are   especially   grateful   to   the   Hospice   at
Home   team   for   their   care   and   compassion,   each   one   is   an   angel!”
19

3.3.1
Patient   satisfaction   survey   cont.
“I   wish   to   thank   you,   on   behalf   of   myself   and   my
for   all   the   comfort,   care   and   support   given   to   both...and
ourselves   during   his   final   few
in   St.
Teresa’s.
all   made   such   a   difference   to   our   remaining   time   together.”
“To   all   the   staff   that   work   so   hard,   I   cannot   tell
how   much   I   appreciated   the   two   years
I   came   to   you   every   Friday.
Here these   years   on,   and   still   enjoying   life.
I   am,
I’m   sure   all   the   love   and   care   you   gave   me   helped   to   keep   me   going.
I   still   miss   all   the   lovely   girls   we   had   to   encourage   us   and   make   us   so   happy.”
“Thank   you   for   your...bereavement
support.
I   haven’t   forgotten   how   kind   and   amazing   you   all   were   to...Not
forgetting   your   lovely
‘Sitters’.”
“Thank   you,   for   everything you   do”
“Thank   you   very   much   for   your   kindness   and   support   you   gave   to...and
myself.
He   enjoyed   his   days   out   at   St   Teresa’s...”
“What   can   I   say?
...
Only   that   I’ve   been   happy   here   on   Thursdays   at   the   wonderful   Hospice!
Everyone   has   been   so   helpful   towards   my   recovery.
I   have   enjoyed   my   days   here   where   I’ve   met   so   many   lovely   people...Thank
you   and   I   am   so   grateful   that   I   can   walk   out   of   your   door.
You   all   will   be   in   my   thoughts   and   prayers,   thanks   again   for   the   lovely   days   I’ve   spent   with   you!”
20

3.3.2
Awards   and   Complaints
The   Hospice   receives   many   letters   of   thanks   and   recommendations   from   patients   and   families   which   are   celebrated   with   staff   teams.
During   the   accounting   period   the   hospice   was   awarded   a   5*   rating   for   kitchen   hygiene   following   an   unannounced   visit   by   EHO.
The   Hospice   was   also   awarded   a   Special   Enterprise   award   for   the   Hospice   Charity   Shops   by   Evolution
Volunteer   Bureau.
Complaints   are   seen   by   the   Hospice   as   an   integral   part   of   service   improvement   as   they   provide   valuable   feedback   about   the   quality   of   service   we   are   providing.
Having   said   this,   complaints   are   rarely   received.
In   the   reporting   period,   2011/2012   no   complaints   were   received.
Each   complaint   would   be   thoroughly   investigated   at   Clinical   Governance   meetings   and   at   the   board   of   Trustees   meeting.
Although   we   had   no   serious   untoward   incidents,   if   we   did   they   would   be   reported   to   the
Care   Quality   Commission.
Table   5   Complaints   received   During   Accounting   Period   2011/2012
Complaint
Action   Taken   and   Outcome
None   required
None
3.3.3
Future   Performance   Measures
During   the   forthcoming   accounting   period   2012/2013   The   Hospice   will   develop   further   key   performance   indicators   for   its   services   and   will   explore   the   National   Indicators   for   Quality
Improvement   to   determine   if   these   can   be   aligned   to   our   services.
Three   Quality   indicators   for   the   domains   of   Quality,   Patient   experience,   Patient   safety   and   clinical   effectiveness   will   be   chosen   and   reported   against   in   the   next   Quality   Account,   examining   both   quantitative   and   qualitative   evidence.
The   annual   program   of   audit   will   be   fully   implemented,   reported   to   the   Clinical   Governance   Board   and   improvement   actions   put   in   place.
The   way   we   collect   all   of   our   patient   feedback   from   all   sources   including   new   media   sources   such   as
Facebook   and   Twitter   will   be   better   organised   and   collated   for   presentation   in   the   2012/2013
Quality   Account.
21

The   Board   of   Trustees   is   fully   committed   to   the   provision   of   a   high   quality   service   at   the   Hospice.
The   Hospice   has   a   well ‐ established   clinical   and   corporate   governance   structure,   with   members   of   the   Board   playing   an   active   part   in   ensuring   that   the   Hospice   fulfils   its   mission,   according   to   its   charitable   intentions,    and   in   ensuring   that   the   organisation   remains   responsible   and   compliant   in   all   areas   of   CQC   Registration,   Health   and   Safety,   Employment   Law   and   other   relevant   legislation.
This   Quality   Account   was   approved   at   the   Board   Meeting   of   24 th
May,   2012
Signed
Alasdair   MacConachie   OBE,   DL,   FRSA,   Chairman
Board   of   Trustees   of   the   Darlington   &   District   Hospice   Movement
22

23