The Rotherham Hospice, Broom Road, Rotherham, S60 2SW.
Telephone 01709 308900 Fax 01709 371702
www.rotherhamhospice.org.uk
A Registered Charity No. 700356. A Company Limited by Guarantee Registration No 2234222
Rotherham Hospice
Quality Account
2011/12
“Our mission is to deliver, champion, and
teach, high quality care and choice for those
with a terminal illness.
We will do this through the creation of a
sustainable centre of excellence, improving
quality of life and personal experience.”
“Placing the patient at the centre
of everything we do”
Contents Page
Part 1
Chief Executive’s Statement about Quality
1.1 Overall Statement of Purpose
1.2 Responsibility towards patients, families and friends
1.3 Other responsibilities
Part 2
Priorities for improvement
2.1 Priorities for improvement 2012-2013
2.2 Priorities for improvement 2011-2012
Part 3
Statements of assurance from the Board of Trustees
3.1 Overview of Quality Performance
3.2 Review of Services
3.3 Income Generation
3.4 Participation in Clinical Audits
Participation in National Clinical Audits
Participation in Local Audits
3.5 Research
3.6 CQUIN goals agreed with commissioners
3.7 What others say about Rotherham Hospice
3.8 Reviews and investigations by CQC
3.9 Data Quality
3.10 Information Governance Toolkit Attainment
3.11 Clinical Coding Error Rate
3.12 NMDS figures
Part 4
Supporting Statements
4.1 Statement from NHS Rotherham
4.2 Statement from Rotherham Clinical Commissioning Group
Part 1
Chief Executive’s Statement
On behalf of our Board of Trustees and the Executive Team, I am pleased to present the
Quality Account for Rotherham Hospice for 2011/12. The continued work of our dedicated
members of staff and volunteers enables the Hospice to deliver high quality services. Our
team here continues to strive for excellence in all they achieve.
Our patients, their families, and carers are at the very centre of our care and delivering
quality care to them is our main focus. Indeed, quality is at the heart of our mission,
principally, improving quality of life and personal experience. The Hospice has established a
strong governance framework from ‘board to ward’ that enables us to focus on the quality of
our services. Our Board of Trustees is focussed on good governance and through the
Finance and Resources, and Governance, sub-committees play a key role to ensure the
organisation is both viable and responsible. Our Executive Team delivers the operational
assurances through a framework of clinical and corporate governance groups.
The safety, experiences, and outcomes for patients, their families and carers are of utmost
importance to all of us at Rotherham Hospice. Our Patient and Family Involvement Group
are represented within our governance framework and play a key role in communicating
feedback and offering advice to ensure all our services and activities are responsive and
deliver on quality.
During the last year the completion of the new state of the art 10 bed extension to the
Hospice that takes the Inpatient Unit from 8 to 14 beds, ensures the Hospice continues to be
both ‘fit for purpose and fit for the future’. This development has significantly improved the
quality of all the patient and family environments in the Hospice and is directly improving
patient experience.
Our regulators, the Care Quality Commission, have inspected all our patient areas and
confirmed that they meet their demanding clinical standards. Our services are not simply
about meeting standards and delivering high quality and excellence in all we do. They are
about delivering holistic care and embracing people as individuals, providing care and
improving their personal experience and, ensuring dignity and privacy.
The safety, experience and outcomes for all our patients and their loved ones are of
paramount importance to us. We continue to actively seek the views of our service users.
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 the healthcare services provided by Rotherham Hospice.
Mike Wilkerson
Chief Executive
13th June 2012
1.1
Overall Statement of Purpose
The purpose of the Rotherham Hospice is to enhance, through specialist palliative care and
education, the quality of life of patients and those important to them. The hospice is
committed to achieving this by providing services for patients requiring specialist palliative
care during the changing phases of their illness.
It is also the aim of Rotherham Hospice Trust to ensure that all staff working within the
Hospice and associated services are fully engaged and empowered to provide high quality
care. In addition, that all patients receiving care from the Rotherham Hospice and associated
services, receive a high quality, effective service that is safe, free from unnecessary risk and
promotes personalisation, privacy & dignity.
Our purpose is to care for our patients and to support their families and friends. We aim to
give the most appropriate and efficient treatment and care to our patients; to assist in the
relief of their physical and emotional suffering and to help them to lead an acceptable,
purposeful and fulfilling life in their home or in the hospice.
We will offer a well co-ordinated, multi-professional and ‘seamless’ service, which integrates
hospice specialist palliative care services with primary, secondary and tertiary health care
services; other voluntary/independent agencies; social services and, in the case of children
and young people, education services.
Our approach will be non-judgemental and non-discriminatory. We consider it equally
important to give support to those who care for our patients, whether they are professional
carers, members of the family or friends.
1.2
Responsibility towards patients, families and friends
Patients, families and friends will be treated as individuals; with compassion, humility,
honesty and love. We will listen to them and, whenever possible, involve them in decisions
about patient treatment. Their preferences, beliefs and customs will be respected and their
complete privacy and dignity assured through the use of single rooms, screens, discrete
interview rooms and heightened awareness by staff of these requirements. The needs of
patients at different stages of their illness will always be taken into account. There is no
charge to patients or their families for use of our services.
1.3
Other responsibilities
The community generously contributes a great deal of money, time and effort to sustain our
work. We must use these resources wisely, prudently and effectively.
Part 2 Priorities for Improvement
The Board of Trustees is committed to the delivery of high quality care. That is care which is
safe, effective and provides patients and carers with a positive experience. The priorities for
quality improvement that have been identified for 2012/13 are set out below. They have
been selected because of the impact they will have on patient safety, clinical effectiveness
and patient experience.
2.1.1
Priorities for Improvement 2012/13
Patient safety, Clinical effectiveness and Patient experience
Priority 1 – Review and redesign of Community/hospice/hospital
SPC/EOLC Services
Standard: To lead on a “Whole Systems” review of current SPC and EOLC
service provision across Rotherham and the development of a single
coordinated service with active EOLC register that allows patients to
receive high quality end of life care in their preferred place.
How this priority was identified:
This priority was identified through active involvement with the EOLC
commissioning group where trends of inappropriate service provision,
duplication, lack of service and no coordination have all been identified as
effecting patient and family experience, clinical outcomes and financial
recourses. It was then discussed that an increase in the responsive hospice
service could address some of these issues. However a desire to address the
whole situation was expressed and the hospice is now to lead a pilot project to
map, plan and “test out” future models of practice.
How this priority will be achieved:
This priority will be achieved through the appointment of a project lead to take
forward the entire piece of work from gap analysis to service redesign. An event
will be held to assist with mapping processes with key stakeholders, followed by
action research groups to establish what areas of service need to be changed
and the models that need to be applied. The hospice will then deliver on the
service redesign changes to allow adequate review of the pilot phase.
Monitoring & reporting methods:
The project will be monitored through the project lead, joint EOLC strategy group
and independent University evaluation. These monitoring and reporting
processes will include quantitative measures such as activity data including
demand for service, units of care, and admissions averted. They will also include
qualitative measures, including, preferred place of care and patient experience.
Clinical effectiveness and Patient experience
Priority 2 – Nutrition and hospitality
Standard: All Inpatients and Day Unit patients receiving nutritional support
and hospitality services from the hospice will feel they have had adequate
involvement in their nutritional assessment and that their individual needs
have been met.
U
How this priority was identified:
This priority has been identified through recent feeding audits and through
patient and family feedback. These processes have identified that patients and
families do not always feel that they have the right level of choice regarding
meals and that in some cases presentation and menu suitability do not meet
individual need. How this priority will be achieved:
This priority will be achieved through the development of Nutrition and Hospitality
Steering Group, who will look at the identified problems and work with catering
staff, all types of service users and clinical staff to plan changes to service that,
will give a direct positive impact on people’s perception of the services provided.
This is expected to include changes to how needs are assessed, menu choices,
serving style and presentation.
Monitoring & reporting methods:
The progress and outcomes of this group will be monitored through the clinical
governance group on a monthly basis. Improvement plans will be drawn up and
reported against to this group and any variance will be responded to
appropriately. The outcomes of this piece of work will also help to influence
catering and hospitality staff Learning and Development programmes.
Patient experience
Priority 3 – Bereavement Support Services
Standard: All patients, family members and those close to patients will
receive pre and or post bereavement support appropriate to their individual
needs.
U
How this priority was identified:
Ongoing review of current bereavement support services has demonstrated that
although quality can be assured for the level of volunteer service provided, there
are significant gaps in the levels and structure of service provided overall. There
is also recognition that bereavement services are not standardised across all
parts of the organisation. This priority has also been identified as an area for
improvement through the CQUIN framework. How this priority will be achieved:
A mapping exercise to look at provision of service across areas will take place
during Q1 to help establish current provision and shortfall. An action plan will
then be drawn up to address, structure of service, education, provision and
patient and family feedback. This will then be considered for innovation to ensure
best use of resource and capacity before an implementation plan is drawn up in
Q2. Implementation of some aspects of change such as feedback will
commence in Q1 but others will be phased across the year
Monitoring & reporting methods:
The progress and outcomes of this piece of work will be monitored through the
clinical governance group on a monthly basis. The work will also be reported to
commissioners on a quarterly basis in line with CQUIN reporting measures.
2.1.2
Priorities for Improvement 2010/11
Patient Safety
Priority 1 – Reduction in falls on the inpatient unit
Standard: The number of falls in the hospice inpatient unit will be reduced
by 50% by the end of March 2012
U
How this priority was identified:
This priority was identified by the evaluation of the number of Incident Reporting
Forms being completed by staff following patient falls in the hospice inpatient
unit. This information was supported and expanded on by the yearly falls audit
undertaken by some of the ward staff. Time, place and circumstances around the
falls have all been evaluated. Patients are admitted to the unit for assessment
and management of complex symptoms, disease progression and end of life
care; many are on more than 4 different medications which may include opiates,
sedatives and antidepressants all of which are considered to increase the patient
risk of falls.
How this priority will be achieved:
This priority will be achieved by developing a more robust Fall Risk Assessment
tool and the increased utilisation of sensor alarms where appropriate. Staff are
currently looking at the various sensor equipment available and its suitability for
use in the hospice setting. This process includes examining what other health
care institutions are currently using and their evaluation of its effectiveness.
Monitoring & reporting methods:
Ongoing falls audit and the completion of the hospices Incident Reporting Forms,
when a patient fall occurs, will be used to monitor and evaluate the effectiveness
of the new systems implemented
Outcomes Achieved:
The work of the falls group has allowed the revision of falls assessment tools and
the introduction of daily review of moving and handling assessments for all
patients on the inpatient unit. It has also procured new electronic laser kits which
alarm if the “beam” is broken and therefore inform staff of mobile patients. These
are proving to be a real asset in addition or as an alternative to bed and chair
alarms. Falls continue to be reported and recorded to board and commissioners
on a quarterly basis. This is also included in 2012/13 as part of Safety
Thermometer.
Clinical Effectiveness
Priority 2 – Introduction of a Transfusion Care Pathway
Standard: All inpatients requiring palliative transfusion services will be
able to access them whilst remaining an inpatient at Rotherham Hospice
by September 2011
How this priority was identified:
Hospice inpatients are currently transferred to Rotherham Hospital if they require
a blood transfusion. Patients are very often reluctant to be transferred to the
hospital even for an overnight stay. Many of the patients require complex
symptom management that can best be managed within the Hospice setting and
transfer can hinder this. Feedback received from patients show that the current
situation is not satisfactory they frequently express disappointment that this
procedure cannot be undertaken here.
How this priority will be achieved:
A Blood Transfusion Pathway will be developed and the sourcing of blood
products negotiated with an accredited supplier. A Blood Transfusion policy will
be put in place within the Hospice and staff training to include a competency
package will be undertaken.
Monitoring & reporting methods:
A process for untoward occurrences and transfusion errors to be reported to the
blood bank will be put in place. These incidents will also be reported to the
Hospice Clinical Governance Group through the Incident Reporting process.
Audit processes will be put in place to monitor the number of blood transfusions
undertaken, staff training and updates, and any untoward occurrences.
Outcomes Achieved:
All qualified nursing staff have received training in transfusion practice and
Rotherham transfusion services transfusion processes. A “train the trainers”
model has been adopted to ensure competency for transfusion and is being lead
by the inpatient unit nurse manager. Blood transfusions are now taking place
within the hospice setting. There is still an identified need to increase the number
of staff who are competent to provide pre transfusion cannulation.
Patient experience
Priority 3 – Improved processes for patient/family and staff feedback
Standard: All patients/family members will understand the process for
feeding back their concerns, complaints or compliments about the
services they receive:
How this priority was identified:
Although patients have an information pack in their rooms requesting feedback
about their care and the environment this is not comprehensive. To ensure that
we capture the complete patient and relative experience a full patient/relative
survey needs to be completed.
How this priority will be achieved:
Implementation of Patient Related Outcome Measures (PROMS) and Family
Related Outcome Measures (FROMS). These will be established through the
Patient and Families Involvement group and through feedback from the inpatient
surveys.
Monitoring & reporting methods:
The patient and families survey will be completed on the Inpatient unit annually.
The results will be formulated into a report and fed back to the Hospice
Governance Group, Patient and Families Involvement group and Hospice
website.
Outcomes Achieved:
Ongoing patient and family feedback is received from all patients who attend the
inpatient unit. This is now sent out 6 weeks post discharge or death. Feedback is
also sought via questionnaire form all day unit patients on an annual basis. It has
been decided to increase this in 2012/13 to 6 monthly as part of a patient
experience CQUIN measure. In addition overall complaints procedures have
been reviewed and all investigations and responses are reported through the
appropriate governance groups and on to board.
Part 3
3.1
Statements of assurance from the board
Rotherham Hospice is fully compliant with the National Minimum Standards (2002) and has
satisfied the Care Quality Commission (CQC) that standards are being met through
registration assessment in 2011. In addition to this, all CQC and contractual compliance
standards are continuously monitored through a robust governance framework and as such,
the Board of Trustees did not have any areas of regulatory shortfall to include in the priorities
for improvement for 2012/13.
The following are a series of statements that all providers must include in their Quality
Account. Many of these statements are not directly applicable to specialist palliative care
providers.
3.2
Review of services
During 2011/12 Rotherham Hospice provided and/or subcontracted the following NHS
services:
• In-Patient Unit
• Day Services
• Hospice Community Team including Clinical Nurse Specialist Services
• Family Support services, including bereavement service, Carers support and
Chaplaincy services
• Therapy services, including, Complementary, Physiotherapy and Occupational
therapy
Rotherham Hospice Trust has reviewed all the data available to them on the quality of care
across all of these services.
3.3
Income generation
Rotherham Hospice is commissioned via the National Community Contract, to deliver NHS
End of Life Care and Specialist Palliative care Services on behalf of NHS Rotherham. The
income generated by the NHS services reviewed in 2011/12 represents 100% of the total
income generated from the provision of NHS services by Rotherham Hospice for 2011/12.
The income generated from the NHS represents approximately 50% of the overall cost of
running these services.
3.4
Participation in clinical audits
National clinical audits and national confidential enquiries
During the period 2011/12 Rotherham Hospice was not eligible to participate in any national
clinical audits and national confidential enquiries.
As Rotherham Hospice was ineligible to participate in any national clinical audits and
national confidential enquiries there is no list or number of cases submitted to any audit or
enquiry as a percentage of the number of registered cases required by the terms of the audit
or enquiry.
Local Clinical audits
Rotherham Hospice has conducted and or reviewed 12 local clinical audits during 2011/12 as follows:
Timescales
Audit
Lead
Medicines management Full
Review
CD SOP review
TP/FH/PH/GB
GB/PH
Patient feeding Audit
CT/TP
Catering satisfaction
YJ/JT
IPC – Sharps Audit
TP/HL
IPC – Hand washing Audit
TP/HL
IPC – Cleaning Compliance
YJ/JT
Pressure Sore Audit
TP/PH
Falls Audit
TP/
Electronic record (data
quality)
Community Service
Provision
Compliance evidence
PH/DR
April
11
May
11
June
11
July
11
August
11
Sept
11
Oct
11
Nov
11
Dec
11
Jan
12
Feb
12
March
12
PH/MW
PH/HH
These Audits have then informed local action or service improvements plans and assisted in identifying key priority areas for the coming year.
3.5
Research
The number of patients receiving NHS services provided or sub-contracted by Rotherham
Hospice in 2010/11 that were recruited during that period to participate in formal research
approved by a research ethics committee was 0.
3.6
Quality improvement and innovation goals agreed with our
Commissioners/ CQUIN payment framework
Rotherham Hospice NHS income in 2011/12 was conditional on achieving quality
Improvement and innovation goals through the Commissioning for Quality and
Innovation payment framework. These CQUIN measures were in relation to the following
areas:
•
•
% of patients appropriately placed on LCP prior to death
Reduction in the number of patients in hospice care who had to attend the local
foundation trust for the completion of high impact interventions such as blood
transfusion and ultra sound scanning.
Both of these CQUIN measures were achieved.
3.7
What others say about us
Rotherham Hospice is required to register with the Care Quality Commission and its current
registration status is approved/unconditional. Rotherham Hospice has no conditions on
registration and registration is approved as follows:
Rotherham Hospice Trust is registered in respect of 4 Regulated Activities:
-
Accommodation for persons who require nursing or personal care
Diagnostic and screening procedures
Transport services, triage and medical advice provided remotely
Treatment of disease, disorder or injury
Regulation also states that:
-
3.8
Services can only be provided to people 18 years of age and over
A maximum number of 14 patients can reside in the inpatient unit at any one time
Reviews and investigations by CQC
Although Rotherham Hospice is subject to periodic reviews by the Care Quality Commission
no review was conducted during 2011/12.
Rotherham Hospice has not participated in any special reviews or investigations by the CQC
during 2011/12.
The Care Quality Commission has not taken enforcement action against Rotherham Hospice
during the period April 2011-March 2012.
Through 2011/12 Rotherham Hospice undertook a self-assessment of its compliance against
all 28 CQC domains and in turn the Health and Social Care Act 2008 and Care Quality
Commission Registration Regulations 2009.
Although we were content that we did comply with all outcomes, we identified areas for
further improvement which will be implemented through the governance framework.
3.9
Data Quality
Rotherham Hospice did not submit records during 2011/12 to the Secondary Users Service
for inclusion in the Hospital Episode Statistics which are included in the latest published
data. This is due to ineligibility to take part in the scheme.
However, in the absence of this we have a local system in place for monitoring the quality of
data and the use of the electronic Patient Information system, SystmOne.
This provides monthly information on data quality and ensures accuracy in recording and
reporting mechanisms.
Monthly data quality performance for 2011/12 is as follows:
Apr-11
93.41%
Oct-11
88.07%
May-11
90.46%
Nov-11
91.24%
Jun-11
92.06%
Dec-11
92.04%
Jul-11
88.71%
Jan-12
92.65%
Aug-11
88.56%
Feb-12
91.21%
Sep-11
87.98%
Mar-12
91.71%
Data quality target stands at 90%. Therefore compliance was achieved for the majority of the
year, with a small section of decreased quality being addressed following the introduction of
new staff.
3.10
Information Governance Toolkit attainment levels
Rotherham Hospice Information Governance Compliance has previously been incorporated
with local NHS providers. For the period 2011/13 the Trust is developing an action plan to
independently achieve level 2 over the next two years. A detailed proposal of the steps
required to achieve this have been complied as an IGOS implementation plan and is being
taken forward as part of the broader governance agenda.
3.11 Clinical coding error rate
Rotherham Hospice was not subject to the Payment by results clinical coding audit during
2011/12.
3.12
NMDS figures
The National Council for Palliative Care: Minimum Data Sets 1 April 2011 to 31 March 2012.
The Rotherham Hospice – Inpatient Unit
New patients
Continuing patients
Re-referred patients
Total Number of patients
Completed stays – total discharges and
deaths
Total Inpatient admissions
Available bed days
Occupied bed days
Unoccupied bed days
The Rotherham Hospice – Day Unit
New patients
Continuing patients
Re-referred patients
Total Number of patients
Number of Day Care sessions held in the
year
Number of Day Care places available in the
year
Number of actual day care attendances by
patients in the year
Number of booked attendances where
patient did not attend
Bereavement Support Service
New service users
Continuing service users
Re-accessing service users
Total service users
Telephone contacts (less than 10 mins)
Number of contacts with service users face
to face – individual support (by trained and
supervised person)
Number of discharged service users
Number of continuing service users at end of
year
Average length of support from first contact
to last contact
Specialist Palliative Care Community
Services
New patients
Continuing patients
Re-referred patients
Total number of patients
Multiple referrals
278
4
8
290
334
341
4669
3917 (84%)
752
125
72
0
197
251
3765
3097
1246
46
25
0
71
55
179
44
27
653
319
18
990
28
Total contacts face to face visit
Total contacts telephone
7575
5647
Hospice at Home Service
New patients
Continuing patients
Re-referred patients
Total number of patients
Total contacts face to face visit
Total contacts telephone
114
90
10
214
2419
1329
Part 4
4.1
Supporting statements
NHS Rotherham PCT Commissioners
The Quality Account reflects the innovation and drive evidenced by the Hospice over the last
12 months. Excellent work has been undertaken to improve the quality of care for patients
and their families across clinical and spiritual services. NHS Rotherham supports the future
direction of Hospice services and looks forward to a productive working relationship over the
next 12 months.
Chris Edwards
Chief Operating Officer
NHS Rotherham
4.2
Rotherham Clinical Commissioning Group (Rotherham CCG)
The commitment of the Hospice team to deliver safe effective care with an emphasis on a
positive experience for patients and their families is evidenced in the report. The plans for
the future are welcomed as further evidence of this commitment, and we look forward to
working with the hospice in the development of further high quality services for the people of
Rotherham
Dr Russell Brynes
GP EOLC Commissioning Lead
Rotherham CCG