The Peace Hospice
Quality Account 2012 - 2013
“I would just like to say a huge thank you to
all the staff at the Peace Hospice for treating
... with respect and making his life more
comfortable” (March 2012)
www.peacehospice.org.uk
Respecting the value of every life
Part 1
Chief Executive’s Statement
Welcome to our first annual Quality Report for 2012/13
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. I am delighted to say that during this time the hospice has
continued to provide high quality services to an increased number of patients.
This report provides you with a summary of our performance against selected quality measures for
2011/12 and our quality initiatives and priorities for 2012/13.
The hospice has a culture of continuous quality monitoring, in which any shortfalls are identified
and acted upon quickly. The safety, experiences and outcomes for patients and their families are of
paramount importance to us all at the Peace Hospice.
We are pleased to report that during 2011 we completed an upgrade of the 1st floor of the hospice with
the help of a Department of Health grant. This means we now have the accommodation for additional
complementary therapy and counselling facilities, overnight accommodation for carers and families,
and a dedicated area where we can work with children and young people.
Patient Satisfaction Surveys are one of the mechanisms we use to identify those areas of required
improvement. Almost all the comments we receive are overwhelmingly positive: this is what a patient
recently discharged from the inpatient unit wrote:
“All the staff from cook to nurses were lovely and made my stay a positive one”
We have a Clinical Governance Implementation Group, made up of representatives from all of the
services, to monitor closely all matters relating to clinical effectiveness, patient safety and patient
experience. Clinical audits and learning outcomes are undertaken and disseminated by this group. In
addition the Clinical Governance Committee, which includes trustees and staff, maintains a watchful
overview to assure itself of the clinical governance and quality improvement processes
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.
Sue Plummer
Chief Executive
June 2012
Part 1.1
Looking Forward:
Priorities for improvement 2012 - 2013
The Peace Hospice is fully compliant with the National Minimum Standards (2002) and has satisfied the
Care Quality Commission that standards are being met within the organisation. As such the Board did
not have any areas of shortfall to include in the priorities for improvements.
Throughout 2011/2012 we identified and developed our priorities for the year 2012/2013. 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: To write a Care Strategy
Priority 2: To review Day Care services
Priority 3: To set up a Volunteer Home visiting service
Priority 1
A Care Strategy
We plan to write a care strategy overarching all of our
clinical services to ensure that quality patient / client
care remains the charity’s top priority and is at the
forefront of the hospice agenda.
The requirement for this was identified following a
review of our services and change in staff personnel
which identified the need to clarify and consolidate our
clinical vision.
Priority 2
Review of Day Care Services
We plan to review our day care services to ensure that we are meeting
the needs of our local population by identifying gaps in current service
provision and then filling the gaps identified.
We secured funding from Macmillan Cancer Support to fund a joint
project with Hospice of St Frances to review both hospices day services.
This involves finding out from the local population what kind of service
they want, exploring best practice by visiting other day care services
and bringing ideas back to us.
We plan to review the findings and implement changes to our current
service.
We aim to provide a broader range of services for a wider section of the
public – for example ethnic and minority groups and a wider age range.
Priority 3
Volunteer Home Visiting
We plan to increase the amount of time the Hospice at Home team are
able to spend with patients in their own homes, giving them support
and company.
Whilst the Hospice at Home team already provide a respite sitting
service, we identified through interviews with patients and carers, that
the amount of time the Hospice at Home team were able to spend doing
respite sits, was, at times, felt to be too short.
Consequently, we will recruit a team of trained volunteers to visit
patients at home to provide respite care, offering friendship to the
patient, their family and carers and attempt to alleviate the social
isolation so often experienced by many caring for a relative or loved one
at home. This will also free up time to allow the Hospice at Home team
to support more patients.
Part 2
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 and therefore explanations of what these
statements mean are also given.
2.1 Review of Services
During 2011/2012 the Peace Hospice provided the following services through its main clinical areas listed
below:
In-Patient Unit
Hospice at Home
Day Care
Family Support Services
Outpatient Services Clinic
The Peace Hospice has reviewed all the data available to them on the quality of care in all of these services.
2.2 Income generated
The income generated by the NHS represents approximately 27% of the overall cost of running these services.
The balance is raised by the Hospice through voluntary donations, its own shops and other fundraising.
2.3 Participation in Clinical Audit
During 2011/2012 no national clinical audits or confidential enquiries covered NHS services provided by the
Peace Hospice. The Peace Hospice only provides palliative care.
During this period the Peace Hospice was not eligible to participate in any national clinical audits and no
confidential enquiries of the national clinical audits and national confidential enquiries.
The national clinical audits and national confidential enquiries that the Peace Hospice was eligible to
participate in during 2011/2012 are as follows: None
The national clinical audits and national confidential enquiries that the Peace Hospice participated in during
2011/2012 are as follows: None
The Peace 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 Peace 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.
2.4 Local Clinical Audits
Clinical audits have taken place within the Peace Hospice; these form part of the annual audit cycle
programme within the Hospice’s overall Quality Action Plan. The monitoring, reporting and actions following
these audits ensure care delivery that is safe and effective. The clinical audit cycle includes audits on
documentation, risk assessments, medicine management, pressure ulcer management and infection control.
Where necessary changes or improvement to practice are identified and are implemented at an individual,
team or service level. Further monitoring is part of the cycle.
The Hospice has also taken part in Mount Vernon Cancer Network audits, for example on holistic assessment
and preferred place of care.
2.5 Research
The number of patients receiving NHS services provided or subcontracted by the Peace Hospice in 2011/12
that were recruited during that period to participate in research approved by a research ethics committee
was: None.
The hospice was part of a jointly funded project with 3 other hospices and a local university. The brief of the
research project was to explore how the local population (including minority groups such as gypsy travellers)
perceived hospice care, with the intention being that this better understanding would be used when
reviewing our services.
2.6 Use of the CQUIN payment framework
The Peace Hospice income in 2011/12 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.
However the hospice successfully achieved their CQUIN targets leading to a small amount of additional
funding
2.7 The Care Quality Commission
The Peace Hospice is required to register with the Care Quality Commission and its
current registration status is unconditional. The Peace Hospice has no conditions on registration.
The Peace Hospice has not participated in any special reviews or investigations by the Care Quality
Commission during 2011/2012.
2.8 Data Quality
The Peace Hospice did not submit records during 2011/2012 to the Secondary Users service for inclusion
in the Hospital Episode Statistics which are included in the latest published data. The Peace Hospice is not
eligible to participate in this scheme.
However the Peace Hospice does submit data to the Minimum Data Set (MDS) for Specialist Palliative Care
Services collected by National Council of Palliative Care on a yearly basis, with the aim of providing an
accurate picture of hospice and specialist palliative care service activity.
2.9 Clinical coding error rate
The Peace Hospice was not subject to the payment by results clinical coding audit during 2011/2012 by the
Audit Commission.
Part 3
Quality Overview
3.1 The National Council for Palliative Care:
Minimum Data Sets for Palliative Care 2010/2011
The Peace Hospice
National median (for
similar sized Hospices)
246
219
70.6%
76.7%
14%
8.1%
45.2%
44.1%
86
94
23.3%
14.5%
7.1
7.9
258
234
17.8%
15.3%
92
49
Inpatient Unit
Total patients
Occupancy
% of new patients – non cancer
% of inpatient stays ending in patient
returning home
Day Care
Total patients
% of new patients – non cancer
Average no of attendances per session
Hospice at Home
Total patients
% of new patients – non cancer
Outpatients
Total patients
% of new patients – non cancer
18.5%
6.7%
Total number of clients
710
545
Total contacts
4243
2301
Bereavement Services
3.2 Quality Markers we have chosen to measure
In addition to the limited number of suitable quality measures in the national data set for palliative
care, we have chosen to measure our performance against the following:
Indicator
April 2011/12
Complaints (clinical)
Total number of complaints
0
The number of complaints upheld in full
0
The number of complaints upheld in part
0
Patient Safety Incidents
The number of serious patient incidents (excluding falls)
0
The number of slips, trips and falls
42
The number of patients who experienced a fracture or other
serious injury as a result of a fall
0
The number of patients admitted to the inpatient unit with
pressure damage
10
The number of patients who developed pressure damage whilst in
the inpatient unit
0
Infection Prevention and Control
The number of patients known to be infected with MRSA on
admission to the inpatient unit
3
The number of patients infected with MRSA whilst in the
Inpatient unit
0
The number of patients admitted to the inpatient unit with
Clostridium difficile
0
The number of patients infected with Clostridium difficile whilst
in the inpatient unit
0
3.3 Clinical Audit
The audits set out in the hospice annual audit plan for 2011/12 were completed. Examples of topics
being: cleaning, patient falls, record keeping. Many of them were small “spot checks” as a result of
previous audits to ensure the recommendations made, were implemented. This was particularly around
the use of risk assessments for inpatient patients. Examples where improvements were made:
•
•
•
50% improvement in use of a bed rails assessment prior to their use
50% increase in a documented wound assessment
All patients now have a falls risk assessment on admission to the unit
Compliance to policies have also been audited, for example the cultural sensitivity policy and the selfadministration of medication policy.
The choice of audit topics is informed by our clinical incidents reporting system which has successfully
encouraged open reporting in a no blame accountability culture. This is also the case for our Quality
Action Plan as a whole.
Plans for 2012/13: To carry out the audits on the annual audit plan
3.4 Other Quality Initiatives & Service Developments
We have reviewed our services to ensure they meet the needs of our users. For example we have
undertaken a large review of our volunteer service and also of our bereavement service. Both reviews
have led to changes which we believe will lead to a better service.
Plans for 2012/13 include:
•
•
To evaluate the work that our Schools and Colleges Co-ordinator and Children and Young People Support worker are doing.
To implement the “Productive Ward” in our Inpatient Unit
3.5 Feedback from Service Users
The Peace Hospice places a high value on feedback from those who use our services. Feedback is
gained from a variety of sources including patients, carers and other professionals.
In 2011/12 the hospice continued to give questionnaires to patients discharged from the inpatient
unit, and also introduced questionnaires for day care, hospice at home and bereavement service users
too. Six monthly analyses of the questionnaires show that in almost all instances, results are very
positive. The results are monitored by the clinical governance group and any areas identified where
improvement can be made are noted and acted upon.
“All the staff were very caring & did everything they could to make your stay
comfortable and happy as far as their job allowed. They also became your
friend & confident.”
(Comment from IPU patient)
“Excellent. Every effort made to assist individual needs”
(Comment from Day Care patient)
“I can talk to any of the nurses if I have any worries”
(Comment from relative of Hospice at Home patient)
“I would recommend it to others ... and have nothing but
gratitude for the service received”
(Comment from client receiving Bereavement Counselling)
The Hospice also took part in Mount Vernon Cancer Network questionnaire where bereaved relatives
were asked to comment on their experiences of different services used throughout their relative’s
illness. Comments relating to the care given by the Peace Hospice were very favourable.
“Our GP managed to get X into the Peace Hospice 48 hours before he died. What a lovely and friendly
place to end his days”
“Mr X’s care at the Peace Hospice was excellent on each occasion that he was admitted. From the lady
on reception, and all the male and female staff were friendly, caring and helpful in every way. The
volunteers who helped in the kitchen were all helpful and fully dedicated to their job. My grateful
thanks to each and everyone.”
During the last 3 years we have also carried out 48 in-depth interviews with patients and their carers
who have used the hospice at home, day care or in-patient services. The interviews provided us with
rich, insightful information that has helped us identify gaps in service provision and areas where the
quality of service could be improved. For example we identified the need to set up the Volunteers
Home Visiting service having listened to carers of Hospice at Home patients.
Plans for 2012/13:
•
•
To review questionnaire content
To survey health professionals who use our service
Complaints:
Complaints are taken extremely seriously and we try and learn from them. Complaints
are thoroughly investigated and reported at the Clinical Governance Group meeting, to the
Board of Trustees and the Care Quality Commission. Immediate action is taken to rectify any shortfalls or
concerns identified. For example we have made improvements to how we plan our discharges from the
inpatient unit following a complaint in 2010.
The Peace Hospice strives to meet the individual needs of patients and families using our services and will
continue to do so.
3.6 Board of Trustee Unannounced visits
These visits take place twice a year, and where appropriate, Trustees talk to patients and their families about
their experiences of hospice services. Comments, in almost all circumstances are very positive and action
plans are adopted to take forward any points arising.
Comment from Trustee
The Hospice has successfully encouraged a culture of continuous improvement of patient care. We do not rest
on our laurels but examine our performance critically as a central part of the way we work. The confidence
with which this is said derives from the firm foundation of knowing how we are performing against the
standard we have set for ourselves and taking methodical, carefully monitored action to make good any gaps
identified. We also continuously assess the adequacy of our “service repertoire” and seek to improve it.
3.7 Supporting Statement NHS Hertfordshire
During 2011/12, The Peace Hospice has continued to provide a high quality and much valued service
to the population covered within Hertfordshire. Their inpatient and community service continues to be
an invaluable resource and the Hospice has contributed positively to the development of end of life and
palliative care services during the past year.
Further investment in end of life care through the Hospice will commence in 2012/13, piloting a 24 hour
Doctor led admission service through a three way partnership between NHS Hertfordshire (and the emerging
clinical commissioning Groups) and the Hospice of St Francis.
The Peace Hospice has remained enthusiastic participants of the wider review and development of palliative
and end of life care services in the County and plays a vital part in contributing to the Countywide developing
strategy for end of life care.
2012/13 presents new demands for all Hospices including The Peace Hospice as well as establishing its
compliance with new NICE guidelines, responding to a more comprehensive review of the service against
agreed performance metrics and responding to the challenges of adapting to the new environment of clinical
commissioning groups. The Hospices’ positive and enthusiastic support for these initiatives and willingness
to be a partner for improvement will benefit those who need the general and specialised care and support
services that the Hospice offers.