Martlets Hospice
Quality Accounts 2011-2012
Part 1
CHIEF EXECUTIVE STATEMENT
Statement by Caroline Lower, Chief Executive
Welcome to the Quality Account Report, 2011-12, of the Martlets Hospice.
The Martlets Hospice continues to fulfil its vision for supporting all those in
Brighton & Hove who are facing the end of life, in particular those with complex
needs regardless of their diagnosis. Through its ability to generate significant
income from a variety of sources the Martlets also continues to supplement the
NHS in providing end of life care to the level of over £3m a year.
On behalf of myself and the Board of Trustees, I would like to thank all of our
staff and volunteers for their achievements over the past year. Despite the huge
challenges arising from a shortfall in our charitably raised funding which, is a
direct consequence of the current economic climate, the Hospice has continued
to provide high quality services. Regretfully we were forced to close our Day
Hospice and to make other significant reductions to our salary budget but this
has resulted in financial stability. We are thus able to commence the new
financial year in a stronger position.
Our report provides you with a summary of our performance against selected
quality measures for 2011/12 and our initiatives and priorities for 2012/13.
The Martlets Hospice is highly committed to quality improvements at all levels of
its services. We have developed this approach to quality over many years and
have worked hard to embed a culture of clinical improvement within all our
services. This is achieved in two ways through the Clinical Governance Group,
made up of representatives from all of the services, which meets bi monthly and
undertakes all audits and ensures implementation of desired quality
improvements. Secondly a formal Sub-Committee of the Board, chaired by a
Trustee maintains a watchful overview of all clinical governance and quality
improvement processes.
This report demonstrates our continued commitment to ensuring our patients
receive the best possible care. Within the clinical practice of the Hospice there
is a culture of continuous quality improvement, in which shortfalls or complaints
are identified and acted upon quickly. The Patient Satisfaction Survey is one of
the mechanisms we use to identify those areas of required improvement. We
are also starting to involve patients or carers and in a number of different ways.
Two of our carers participated in a community engagement event when over 50
local healthcare providers and voluntary groups attended the hospice to discuss
issues such as ‘what is a good death’ and what are the barriers locally to good
joined up end of life care.
Also this past year we have achieved notable success in improving the
recording of patient falls which will enable us to reduce the number of
preventable falls in the future. Another initiative is a new service in the form of a
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designated respite bed that has been introduced in response to the expressed
needs of families and carers. The respite bed allows patients to be cared for at
home for longer than may otherwise be possible due to carer exhaustion. This
has been well received.
I am very pleased to have the opportunity to convey all that we are trying to
achieve and to confirm my personal commitment to continuous improvement. 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 our
Hospice.
Caroline Lower
Chief Executive
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Part 2
LOOKING FORWARD: PRIORITIES FOR IMPROVEMENT 2012 – 2013.
2.1 Priorities for improvement
Throughout 2011-2012 we identified many quality improvements that could be
made over the next 12 months. In selecting our priorities we have been mindful
of national and local policy as well as those issues which are of concern to our
service users, our workforce, our partners and our Trustees.
Following our assessment the top priorities for the year 2012-2013 are set out
below:Priority 1: Increasing volunteer involvement.
Priority 2: Becoming more proactive in gaining service users views – both
positive and negative.
Priority 3: To increase the safety and well being of patients by the installation of
an updated nurse call system.
Priority 1:
Increase volunteer involvement.
There has been a change in the needs of the hospice as well as the traditional
volunteer. By increasing volunteering opportunities with a greater variety of
tasks it is hoped that we will attract a wide range of volunteers of different ages,
different walks of life and skills which can only be beneficial to the hospice and
be more fulfilling to the volunteer.
How was this identified as a priority?
The hospice has an excellent team of volunteers who have possibly been
underutilised in many areas. Volunteers have always been an important part of
the hospice and contribute in many ways. Through meetings some volunteers
have expressed that they would like to become more involved with the support
of patients and/or their families.
How will this be achieved?
A team of volunteers will provide art and craft activities to patients and visitors
on the In-Patient Unit.
The development of a team of specifically trained volunteers providing regular
home visits to support a socially isolated person, who is either a patient, or a
close family member of a patient of the Martlets Hospice/Macmillan Community
Team.
Priority 2:
Become more proactive in gaining patient/carer views – both positive and
negative.
The nurse in charge of In-Patient Unit will meet with patients and families within
the first few days after admission. This informal meeting will be a chance for the
nurse in-charge to introduce them self and to discuss with the person using the
service what the hospice is doing right but also what could be improved.
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How was this identified as a priority?
The hospice does already distribute questionnaires to both patients and their
carers to gain feedback about the service. The feedback we get is usually good
however we know that we can always do better but often people are just so
grateful to be in the hospice they do not like to suggest improvements. It is
hoped that by having an informal discussion with a skilled communicator ways
to improve will be identified.
How will this be achieved?
The nurse in charge will arrange to meet with each new patient and their family
within two days of admission – although sometimes this would not be
appropriate. The discussion will be an opportunity for the patient and their family
to ask questions and also for the nurse to find out what is working well and what
needs to be improved. This information will be recorded and discussed at the
Hospice Clinical Governance Meetings.
Priority 3:
To increase the safety and well being of patients by the installation of an
updated nurse call system.
The nurse call system is used by our patients and their families to request
assistance. Our existing nurse call system is 15 years old, certified as obsolete
and needs urgent replacement. We have great difficulty finding replacement
parts for repair and extension.
How was this identified as a priority?
The call points often break and we have had to take some rooms out of action
for weeks while we wait for replacement parts. Our existing system also offers
very limited portability. All nurse call points are either fixed bell cords, such as in
toilets and by beds, or they are on short leads. This restricts the areas in which
a patient can safely sit or move about whilst being able to remain in reach of the
nurse call bell.
The new system will reduce the risk of accidents and incidents. It will offer
better comfort, re-assurance and safety to our patients, whilst supporting their
independence and choice.
How will this be achieved?
We are applying for a grant to fund the replacement. The appropriate nurse call
system that would be best for the needs of the patients has been identified.
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LOOKING BACK: PRIORITIES FOR IMPROVEMENT 2011 – 2012.
Following our assessment the top priorities for the year 2011-2012 were as
follows:
Priority 1: Formation of a volunteer’s involvement group.
Priority 2: Decreasing the number of patient falls.
Priority 3: Improving documentation of health records through the introduction of
an Electronic Patient Records (EPR) system.
Priority 1:
Formation of a Volunteer’s Involvement Group.
The formation of a Volunteer’s Involvement Group was to improve
communication and to promote greater involvement of hospice volunteer
representatives.
It had been hoped that the volunteer forum would have been in place by 2012.
This unfortunately has not happened due to key staff changes within the hospice
and the need to prioritise other events.
The increasing financial pressures and the subsequent closure of the day
hospice has taken priority during the past 12 months. As an outcome of the day
hospice the focus has been on meeting with volunteers to support and maintain
motivation as well as harnessing their skills to support other clinical areas. A
positive outcome includes the planned development of art and craft activities for
hospice In-Patients and carers and a Community Volunteer Visiting Service.
Further discussions have since taken place around the formation of a Volunteer
Involvement Group and alternative suggestions have been raised as possibly
being more suitable. These include open afternoons or drop in sessions to
which all volunteers are invited and discussions can be had or concerns can be
raised either as a group or individually.
Priority 2:
Decreasing the number of patient falls.
The aim of this initiative was to provide practical guidance to managers and staff
in order to minimise the risk of harm and maintain patients and staff safety.
Patient safety has to be balanced with maintaining independence, privacy and
dignity. This is particularly pertinent in hospices where patients are supported to
maintain their independence for as long as possible. However, this does mean
that falls are not uncommon. To decrease the number of falls preventable risks
need to be identified and precautionary action put in place. For example, this
could just mean replacing loose slippers with better fitting slippers.
Patient falls within the In-Patient Unit have been carefully recorded and
monitored over the last 12 months. In addition statistics relating to falls are
reported to a hospice benchmarking group to compare the numbers with other
hospices. However, within this group there have been similar numbers of falls in
all the participating hospices. With the number of falls recorded accurately in the
past 12 months we have been able to set a baseline from which all future
initiatives to reduce the number of patient falls will be able to be accurately
evaluated for effectiveness.
Falls are reviewed regularly at the bi-monthly Clinical Governance Meetings and
hospice guidelines have been produced to support staff in identifying and
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managing the risks that may contribute to falls. There has also been an initiative
to improve the reporting of falls where senior staff are checking the initial
submitted report of a fall to ensure adequate detail is being recorded and staff
are identifying preventative action wherever possible.
Priority 3:
Improving the delivery of patient care through the successful introduction
of an Electronic Patient Records (EPR) system.
An electronic health record is a digital version of an individual’s medical record.
The electronic patient record system has been introduced over the last 12
months and is now in use throughout the hospice.
The key benefits of the system include increased effective and more secure
access to patient information by health professionals involved in the patients
care.
The new system also enables accurate data for statistical reporting to be
collected more efficiently, saving staff time and cost.
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PART 3
STATEMENT OF ASSURANCE
The following are statements that all providers must include in their Quality
Account. Many of these statements are not directly applicable to palliative care
providers however we are still required to include specific statements.
3.1 Review of Services
During 2011-2012 the Martlets Hospice supported the NHS commissioning
priorities with regard to the provision of local specialist palliative care by
providing:
Hospice at Home services which includes end of life care as well as
respite care.
In-Patient Unit which also includes NHS Continuing Healthcare Funded
Beds
In addition the Hospice has provided the following services through charitable
funding:
Day Hospice (Closure in October 2011)
Bereavement Support Services
Outpatient Breathing Clinic
During the reporting period of 2011-2012, the Martlets Hospice provided two
NHS services. The Martlets Hospice has reviewed all the data available to them
on the quality of care in all of these services.
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3.2 Income generated
The income generated by the NHS services reviewed in 2011-2012 represents
less than one third of the total income generated by Martlets Hospice for 20112012.
The NHS provided money through a grant for the partial running costs of InPatient beds. Through contracts funding was also provided for two NHS
continuing healthcare beds and the Hospice at Home services. The remaining
income is through charitable donations and through fundraising events, shops
and lottery.
3.3 Participation in Clinical Audit
During 2011-2012 no national clinical audits or confidential enquiries covered
NHS services provided by the Martlets Hospice. The Martlets Hospice only
provides palliative care.
During the 2011-2012 period the Martlets Hospice participated in no national
clinical audits and no confidential enquiries as it was not eligible to participate in
any.
The national clinical audits and national confidential enquiries that the Martlets
Hospice was eligible to participate in during 2011-2012 are as follows: None
The Martlets Hospice was not eligible in 2011-2012 to participate in any national
clinical audits or national confidential enquiries and therefore there is no
information to submit. As a provider of specialist palliative care the Martlets
Hospice is not eligible to participate in any of the national clinical audits or
national confidential enquiries. This is because none of the 2011-2012 audits or
enquiries related to specialist palliative care.
The Hospice will also not be eligible to take part in any national audit or
confidential enquiry in 2012-2013 for the same reason.
3.4 Hospice Clinical Audits
Clinical audits have taken place within the Martlets Hospice; these form part of
the annual audit cycle programme. The monitoring, reporting and actions
following these audits ensure care delivery that is safe and effective. The clinical
audit cycle includes audits around documentation, medicine management,
pressure ulcer management, infection control and care of the dying audit.
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Audit/review
Date completed
Spiritual care audit focussing on documentation of spiritual needs.
January 2011
Recording of consent.
October 2011
Auditing the appropriate use of antibiotics.
April 2011
Manual handling risk assessment audit looking at the correct
completion of these forms.
October 2011
Monitor the frequency of patients with pressure ulcers on
admission and patients that develop pressure ulcers whilst as the
hospice.
September 2011
Reviewing of all accidents, incidents and near misses recorded.
Infection control audits:
1. Hand Hygiene
2. Environment
3. Kitchen area (General)
4. Disposal of waste
5. Handling and disposal of linen
6. Spillage and/or contamination with blood/body fluids
7. Personal Protective Equipment
8. Safe handling and disposal of sharps
9. Specimen handling
10. Management of patient equipment
11. Uniform
12. Short term urethral catheter management
Identification audit (patient wristbands) to check that all patients
had a wristband to enable correct identification of patients when
dispensing medication.
Reporting every 4
months
September 2011
September 2011
Reviewing of drug errors to ensure that areas of improvement have
been addressed.
Medication – to ensure correct controlled drug use, order, delivery,
receipt and stock to demonstrate best practice.
Medication – that the Accountable Officer for controlled drugs has
met the requirements of the current law and regulations
Reported every 4
months
Feedback from Counselling Service showing the numbers that
access the service and satisfaction.
January 2011
Feedback from Bereavement Support Service showing a high
degree of satisfaction with what is provided.
January 2011
Care of the Dying Pathway Audit looking at documentation
Reviewing of all complaints whether informal or formal and
discussing what lessons could be learned.
November 2011
November 2011
November 2011
Reported every 4
months
Audit on admission documentation & procedures
December 2011
Review of acupuncture to evaluate the current service
November 2011
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3.5 Research
The number of patients receiving NHS services provided or subcontracted by
the Martlets Hospice in 2011-2012 that were recruited during that period to
participate in research approved by a research ethics committee was: None.
3.6 Use of the Commissioning for Quality and Innovation (CQUIN) payment
framework
The Martlets Hospice 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 is a third sector
organisation and as such was not eligible to participate in this scheme during
the reporting period.
3.7 The Care Quality Commission
The Martlets Hospice is required to register with the Care Quality Commission.
The Martlets Hospice is required to undertake only regulated activities at the
following location: Martlets Hospice, Wayfield Avenue, Hove, East Sussex.
BN3 7LW.
The Martlets Hospice is subject
to periodic reviews by the Care
Quality Commission and the
last on-site inspection was
June 2009.
The Martlets Hospice has not
participated in any special
reviews or investigations by the
Care
Quality
Commission
during 2011-2012.
3.8 Data Quality
The Martlets Hospice did not
submit records during 20112012 to the Secondary Users
service for inclusion in the Hospital Episode Statistics which are included in the
latest published data. This is because the Martlets Hospice is not eligible to
participate in this scheme.
However, the Martlets Hospice does submit data to the Minimum Data Set
(MDS) for the Specialist Palliative Care Services collected by National Council
of Palliative Care on an annual basis, with the aim of providing an accurate
picture of hospice and specialist palliative care service activity. The service
activity for the Hospice at Home service is in Part 4.
3.9 Information Governance Toolkit attainment levels
The Martlets Hospice is not required to use the Information Governance Toolkit,
however, as a standard for good practice we are currently working towards
reaching 100% level 2 compliance by the end of March 2013.
3.10 Clinical coding error rate
The Martlets Hospice was not subject to the Payment By Results Clinical
Coding Audit during 2011-2012 by the Audit Commission.
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Part 4
QUALITY OVERVIEW
We have chosen to present an overview of the Hospice at Home service. The
Hospice at Home service offers end of life care and respite care in a patient’s
own home. It is a vital service that is instrumental in helping patients to stay at
home for as long as possible and to die at home if that is what they choose.
Total number of patients cared for in
2011-2012
Age
19-24 years
25-64 years
65-74 years
75-84 years
85 years and over
Patients with a non cancer diagnosis
Total face to face contacts
Total telephone contacts
Patients who died at home
Patients who died in care home
Patients who died in hospice
Patients who died in hospital
Average length of care
382
0
24%
19%
34%
23%
26%
3852 visits
4919 telephone calls
77%
3%
11%
9%
22 days
The hospice asks for feedback from patients and carers who receive care and
support from the hospice. Below are just some of the positive comments we
receive every year from people who have experienced the Hospice at Home
services.
“Just wonderful – every single member of the team who visited were
caring, compassionate and highly professional. I cannot comment highly
enough about the home team.”
“Her wish was to stay in her own home until the end of her life, without
you it would not have been possible.”
“I can’t express how much it meant to us as a family, to have them visit
each day for assistance, advice and comfort. I know that my husband’s
final days were made so much more comfortable and that he was greatly
helped by their calm and gentle presence.”
“Thank you for all your dedicated hard working trying to keep my husband
pain free and comfortable at home. You are a wonderful crowd and I could
not have done it without your support and help.”
“You were all incredibly kind and gentle to mum and us. You never gave
me the impression of being hurried and you never left our house without
making sure we were all ok and our questions had been answered.”
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“Thanks to the help given by yourselves, her doctor and the district
nurses she was able to have the death she wanted and for that I will be
eternally grateful.”
We would also like to highlight one element of community service that has been
a huge success to date.
The Macmillan Volunteer Welfare Benefits Partnership is a four-way partnership
between the Martlets Hospice, Age UK, Macmillan Cancer Support and Sussex
Community Trust. The aim of the project is to support people with life limiting
illnesses with welfare benefits advice and support. The uptake and results have
been fantastic.
From January 2011- March 2012 there were...
315 Referrals
372 Home visits
835 telephone contacts
The results were...
165 Attendance Allowance Claims to the value of
£621,488
126 Disability Living Allowance claims to the value of £819,000
Totalling
£1,440,488
This project shows the value of different organisations working together to
achieve the best for patients and carers, and for this particular project alleviating
financial hardship and deprivation for many patients and families.
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SUPPORTING STATEMENTS
As required by the regulations, this document has been sent to the Brighton and
Hove Local Involvement Network (LINk), Overview and Scrutiny Committee
(OSC) and the Primary Care Trust (PCT) for Brighton and Hove for comment.
Brighton & Hove Clinical Commissioning Group Response to Martlets
Hospice Quality Account 2011/12
Brighton & Hove Clinical Commissioning Group [CCG] welcomes a copy of your
Quality Account for 2011-12 for comment.
The document outlines your
commitment to quality through patient safety, patient experience and measuring
clinical effectiveness. Though quantitative targets are not detailed, your focus
is clear and the document is well set out and readable.
Against your priorities set in 2011-12, the CCG recognises the improvements
the Martlets have made in relation to reducing falls. This has been done
through accurate data collection and benchmarking with similar organisations to
determine your own measurable targets. The production of your guidelines for
staff to reduce the risk of falls is a key quality indicator for inpatient units
nationally and we note your emphasis on balancing independence and privacy
against patient and staff safety.
The introduction of electronic patient records has improved efficiency in access
and security for patient records. This supports patient safety and facilitates
accurate statistical reviews to build on the extensive audit programme you have
undertaken.
We note that the formation of a Volunteer’s Involvement Group was not
achieved last year due to staff changes and other pressures but your Quality
Account recognises the dependence on, and appreciation of the valuable role
played by volunteers in the organisation. We look forward to the development of
the volunteer role in 2012-13 in supporting socially isolated people by regular
home visits.
The Quality Account for 2012-13 reflects the high national priority in eliciting
patient experience to learn from their perceptions and improve the way your
services are delivered. The highly personal approach of a skilled nurse seeking
the views or patients and carers within 2 days of admission we hope will extend
to the clients using the Hospice at Home service, that the CCG commissions for
the residents of the city. Though there is no specific mention of advanced care
planning including the preferred place of care and avoidance of hospital
admission, we trust these will be captured in your conversations and patient
care plans and considered in the development of services.
The CCG supports the national priority for patient safety through the reduction of
accidents and incidents in all providers of healthcare. We share your aspiration
to improve nurse responsiveness, reduce falls and improve patient dignity and
independence through the securing of an updated nurse call system.
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We look forward to closer working with the Martlets in achieving your identified
quality priorities for the coming year.
Marilyn Eveleigh, Head of Clinical Quality & Risk, Brighton & Hove CCG
27th June 2012
The Martlets Hospice would like to thank everyone for their contribution to
this Quality Account. We look forward to working with all stakeholders
over the coming year to deliver the improvements to which we are
committed.
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