.
Quality Account
High quality care for all
Reporting period: 1st April 2012 to 31st March 2013
Ashgate Hospice Quality Account May 2013 Anna Baker
1
Patients and Carers’ Feedback
Thank you all so much for caring for C so well. She has had lovely meals served by
staff really eager to please. She has had the kindest of attention by all the nursing
staff, Dr Parnacott and you have been painstaking in organising the blood transfusions
and medications to help us on into the future. On a personal note thank you for
allowing me to stay with C in her room. It meant such a lot to us both
Thank you so much for the respectful and caring treatment you have my husband,
myself and my daughters. Losing your loved one is difficult but your constant
compassion, understanding and support helped me in a way I cannot express. From
the doctors, nurses and volunteers you showed him nothing but respect and he
maintained his dignity thanks to the hospice
(received from the relatives of patients on the hospice ward)
I loved the fact that the team was so closely involved with the day to day workings of
the hospice - it felt like a tangible link to the calm and loving care that mum received
(received by the Family Support and Bereavement Team)
We just want to thank you as a family for the support and care that you gave to us to
keep R, a most wonderful husband and dad at home. It was his wish to be at home for
as long as possible with his wife and belongings around him. The equipment provided
was prompt, and ensured that his dignity and pride was maintained during the most
difficult times, thank you
(received by the Therapy Team)
Ashgate Hospice Quality Account May 2013 Anna Baker
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Chief Executive’s Statement
Ashgate Hospice is an independent charity and company limited by Guarantee.
Governed by a Board of Directors, who also act as Trustees; the charity is now in its
25th year of existence. Above all, Ashgate Hospice is a clinical provider of high
quality services for patients and their families and carers who are facing life limiting
illness and who have Specialist Palliative Care and End of Life Care needs.
The Hospice prides itself on quality and I am confident that quality is of prime
importance in respect of all our governance arrangements. The Hospice has an
open culture of continuous monitoring and improvement in which any shortfalls are
very quickly identified and acted upon as well as learning being shared.
The Hospice provides a genuinely holistic service in which the needs of individual
patients and their families are assessed and met. We are keen to share our
expertise with others in order to promote excellence in care right across the local
health sector. We are also looking forwards in order to ‘seek out’ opportunities for
collaboration with others and for opportunities to work in partnership in order to
ensure that the people of north Derbyshire can receive the best possible Specialist
Palliative and End of Life care.
Despite the very challenging financial climate, we continue to provide a
comprehensive range of high quality, compassionate and cost effective services and
in writing this statement I would like to acknowledge and thank everyone who
supports, volunteers and works at the Hospice. It is the team effort, commitment of
staff and volunteers and the excellent patient feedback that we receive that enables
me to feel confident in giving strong assurance around quality.
Finally, I am certain that to the best of my knowledge, the information reported in
this Quality Account is an accurate and fair representation of the quality of
healthcare services provided by the Hospice.
Lucy Nickson
Chief Executive
May 2013
Ashgate Hospice Quality Account May 2013 Anna Baker
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Section 1
Improvement priorities
Priorities for improvement 2013-2014
The hospice received an unannounced inspection in 2012 following which the Care
Quality Commission confirmed that the hospice was meeting all the essential
standards of quality and safety. The hospice does not therefore have any areas of
shortfall to include in the priorities for improvement for 2103-2014.
In developing the strategic plan for the hospice, particular attention was paid to the
changing commissioning landscape within health and social care organisations, and
the influence that would have on hospice services. We looked at how the hospice
could extend its services to meet the needs of the local population, enabling people
to receive care in the place of their choice.
The top three quality improvement priorities for 2013 to 2014 are as follows:
Future planning Priority 1
Recruit to Quality Audit and Information post
The hospice is keen to develop a more coordinated approach to the management of
audit, quality reporting and other performance metrics. It is recognised that this will enable
us to better understand trends and impact on patient services, and act accordingly.
We recognise that we must be able to effectively and robustly demonstrate our
performance to commissioners, the Care Quality Commission and the public and see the
recruitment of this post as essential to being able to achieve that.
The Board of Directors/Trustees recognises and supports the need for this investment
and as such, recruitment is currently underway.
Ashgate Hospice Quality Account May 2013 Anna Baker
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Future planning Priority 2
Hearing the Patient and Carer Voice and their experience of hospice
care
The hospice is planning a more co-ordinated approach to actively ‘hearing the voice’ of
patients, families and carers in order to be able to assure ourselves and others on the
quality of the services provided; and to be able to work towards any improvements that
may be needed.
The Hospice works hard to identify and assess the holistic needs of patients and carers,
in line with the NICE quality standard for end of care, which states:
“Families and carers of people approaching the end of life are offered comprehensive holistic
assessments in response to their changing needs and preferences, and holistic support
appropriate to their current needs and preferences.”
In doing this we aim to better understand unmet need or areas where there is potential for
development. Ultimately, by hearing people’s voices and engaging with people, we aim to
give patients and carers greater confidence and to help them to deal with the pressures of
caring for someone with a life limiting illness.
Future planning Priority 3
Meeting the Challenges of the new commissioning environment
We have recently had significant changes to our senior management team with the
appointment of a new Chief Executive and Head of Clinical Services. As a result of this,
and in collaboration with Ashgate Board of Directors, the following priorities and
objectives are being developed and will underpin our strategic planning:

Be a leading advocate for hospice care, providing services from within the hospice and into
the community across north Derbyshire.

Promote and support excellence in care.

Expand the capacity and reach of the hospice into the community.

Be a source of expertise and education to the wider health community.
The strategy and objectives will be finalised during this year and will form part of the 3
year strategic plan
Ashgate Hospice Quality Account May 2013 Anna Baker
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Progress against the improvement priorities identified in 2012-2013
Throughout 2012-2013, the hospice had a number of initiatives to enable it to offer a
more comprehensive service to the local community, and progress against the
quality improvement priorities for 2012-2013 was influenced by financial constraints
of the charity. Progress is discussed below.
Progress made against Improvement Priority 1: Equipment for
bariatric (very obese) patients
The inpatient ward and day unit now have access to the following bariatric equipment
which has improved the patient experience and ensured safe practices for our clinical
staff:

rise recline chair,

arm chair

wheelchair

transflo cushion

commode
All staff received moving and handling training with specific reference to managing
bariatric patients during 2012
If a patient requires a bariatric bed, we will arrange for one to be delivered, based on
need. There is usually minimal delay with this arrangement.
Ashgate Hospice Quality Account May 2013 Anna Baker
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Progress made against Improvement Priority 2: Clinical Recording
System
In May 2012 the hospice moved from the HCAS clinical recording system to SystmOne in
all clinical areas. This has enabled the following improvements:

a contemporaneous multi disciplinary patient record,

The ability to share records and patient information, following patient consent, with
other health care professional e.g. GP’s, community service provider staff.

The ability to run reports on outcomes, activity and standards of record keeping
(though this is not a complete years data having commenced during 2012 in a
phased approach)

The appointment of a SystmOne Caldicott Guardian

Review of IT policy and development of SystmOne risk register to ensure there is a
cycle of review and change as necessary
Further work is in progress with this system to ensure best practice and optimum
use for the hospice requirements.
Progress made against Improvement Priority 3: Syringe Drivers
In line with best practice recommendations, Ashgate hospice changed the syringe drivers
used in the ward during 2012 to ensure continuity throughout the health community.
Training and education was provided, and is available as part of the essential clinical
training programme. Progress was monitored through the clinical governance advisory
group and reported to the board of trustees.
All staff now feel confident in the use of the new devises
Ashgate Hospice Quality Account May 2013 Anna Baker
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Section 2 Mandated Statements
Statements of assurance from the board
The following are a series of statements that all providers must include in their
Quality Account.
Review of services
During 1st April 2012 to 31st March 2013, Ashgate Hospice provided the following
services:

In-Patient Unit

Day Unit

Lymphoedema service

Hospice at Home – N Derbyshire Community

Palliative Care Clinical Nurse Specialist – N Derbyshire Community

Palliative Care Clinical Nurse Specialist in-reach service (into local acute
hospital)

Therapy services (inpatient, day unit and community) – occupational therapy
and physiotherapy

Family Support and Bereavement Service

Spiritual care

Specialist Education and Training (health community, local universities)
Ashgate Hospice Clinical Governance Advisory Group receives regular reports,
which enable them to review the quality of care provided by all clinical services.
This group meets quarterly, and is a subcommittee of the Board. A quarterly report
from this group is submitted to the board of trustees
Participation in national clinical audits
During 2012/13, Ashgate Hospice was ineligible to participate in the national clinical
audits and national confidential enquiries.
Ashgate Hospice Quality Account May 2013 Anna Baker
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Research
During 2012/13, Ashgate Hospice did not participate in any national clinical
research.
Quality improvement and innovation goals agreed with our
commissioners
The goals and indicators for the hospice as required by the commissioners were as
follows:
Goal 1
To ensure that all front line staff have all the necessary skills,
knowledge and attitudes related to the care of the dying
Goal 2
To ensure that all individuals approaching the end of life are
offered a care plan
Goal 3
The hospice should have mechanism for auditing and reviewing
quality of end of life care.
Goal 4
Relatives involved in end of life care decisions to the extent that
they and the patient wish
Goal 5
Undertake surveys on how services have benefited users and
carers
Goal 6
Highlight main achievements and successes during the year
Goal 7
Report on the number of complaints and how they were
resolved
Goal 8
Report on activity relating to day unit, ward, community palliative
clinical nurse specialists
Ashgate Hospice Quality Account May 2013 Anna Baker
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What others say about us
Ashgate Hospice is required to register with the Care Quality Commission
The Care Quality Commission has not taken any enforcement action against
Ashgate Hospice during 2012/13. The registered manager for Ashgate Hospice is
the Head of Clinical Services and our regulated activities are: treatment of disease,
disorder and injury, surgical procedures, diagnostic and screening procedures,
nursing care, and personal care.
Ashgate Hospice is subject to periodic reviews by the Care Quality commission. The
last on-site inspection was in 2012
Data quality
In accordance with agreement with the Department of Health, Ashgate Hospice
submits a National Minimum Dataset (MDS) to the National Council for Palliative
Care. Ashgate Hospice provides the MDS report to the local PCT commissioner.
Ashgate Hospice will be taking the following actions to improve data quality:

The IT Manager and the Head of Clinical Services will continue to review
the data outputs in order to improve the quality of patient data reporting.

The appointment of a Quality Audit and Information manager will assist in
reporting essential quality data that is timely and fit for purpose
Ashgate Hospice Quality Account May 2013 Anna Baker
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Section 3 Quality overview
Comparison with national minimum data sets
The most recent National Minimum Dataset covers the period 1st April 2011 to 31st
March 2012. Ashgate Hospice data for 2012-13 have been collated but there are no
comparative data available at the time of writing.
Community: Palliative Care Clinical Nurse Specialist
Community Specialist Palliative Care MDS data
Community Specialist Palliative Care MDS Data 2011-2012
% New Patients
% New Patients Non Cancer
Average Length of Care All Patients(Days)
Average Face to Face Visits (per Patient)
Average Telephone Contacts (per Patient)
69.98
7.46
67.2
3.65
7.8
The hospice sees the community team as providing a significant role in improving
the quality, accessibility, flexibility and integration of palliative and end of life (EOL)
care in our catchment area.
2011/12 face to face contacts = 2310
Non face to face contacts = 9000
2012/13 face to face contacts = 2097 (May to March)
Non face to face contacts = data not yet available
Thank-you for your compassionate care of my wife, she asked to be made as comfortable
as possible when the time came and this you did. She died peacefully and in no pain....so
your work had a very profound effect”
I thank you from the bottom of my heart for making it possible for X to die in his own
surroundings in my arms. I will never forget your kindness, help and amazing support.”
Quotes from patients relatives
Ashgate Hospice Quality Account May 2013 Anna Baker
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HOSPITAL CNS (in reach service to Chesterfield Royal Hospital Foundation
Trust)
2011/12 face to face contacts = 3000
2012/13 face to face contacts = 3262 (May to March)
I just wanted to say thank-you for all the care and understanding you gave to O and myself.
You do a fantastic job and we appreciated it very much.”
Thank-you for the kindness and gentleness you showed to us during dads last difficult days,
i so appreciate all that you did for us and for helping to make that time as peaceful and pain
free as it could be.”
Quotes from patients relatives
Hospice at Home
MDS data
Hospice @ Home MDS Data 2011-2012
% New Patients
% New Patients Non Cancer
Average Length of Care (In Days)
Av. Face To Face Visits Per Patient (All Patients)
Av. Telephone Contacts Per Patient (All Patients)
85.5
8.7
25.4
10.4
1.8
2011/12 face to face contacts = 1103
Non face to face contacts = 583
2012/13 face to face contacts = 1021 (May to March)
Non face to face contacts = 431 (May to March)
The Hospice at Home team provide support to patients and families across north
Derbyshire predominantly in the last 3 months of life. The team will deliver nursing
care and personal care as required, and based on need. The length of intervention
is variable and each contact can last for half a day or more; again depending on
need. The team work in collaboration with other agencies (social care, health and
Ashgate Hospice Quality Account May 2013 Anna Baker
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other third sector) and in partnership with families. Our intention is to work with
commissioners and other providers to develop this concept further.
Thank-you for the genuine love and care you gave to mum, without your help we not have
been able to care for her at home”
Thank-you for coming to care for X, and giving me the space to be able to take a break. It
meant a lot to me to know that I did not have to worry and I could leave him in your capable
and expert hands.”
Quotes from patients carers and relatives
In-Patient Unit
ACTIVITY
LEVELS
2012/2013
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Actual
510
527
510
527
527
510
527
510
527
527
476
527
6205
459
503
486
515
485
474
500
487
505
509
465
514
5902
475
518
498
529
508
487
514
497
513
523
473
525
6060
19
27
28
24
23
22
23
22
21
19
19
22
Apr
IN-PATIENT UNIT
Available Bed
days
Occupied Bed
days
Occ plus Booked
beds
Admissions
347
Re-admissions
CCG
North Derbyshire
Hardwick Health
Not Aligned
Other
Av Length of
stay
Discharges
(Breakdown)
Home
Hospital
Nursing Home
Others
Discharges
Total
Deaths
7
4
6
5
11
8
9
5
4
10
6
3
18
8
0
0
21
9
0
1
29
5
0
0
25
4
0
0
28
6
0
0
21
9
0
0
26
6
0
0
21
6
0
0
24
1
0
0
25
4
0
0
18
7
0
0
16
9
0
0
272
74
0
1
14
17.2
18
19.4
16
21
20.6
17.45
18.4 16.8 15.2 17.2 14.7
7
3
0
0
10
2
0
0
10
5
0
0
10
1
0
0
10
3
2
0
13
1
1
0
8
1
0
0
7
2
0
0
6
4
0
0
9
0
4
9
2
2
0
8
0
0
0
107
24
9
0
10
12
15
11
15
15
9
9
10
13
13
8
140
15
18
17
19
18
18
20
18
16
18
9
17
203
Ashgate Hospice Quality Account May 2013 Anna Baker
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Inpatient MDS data
IPU MDS Data 2011-2012
% New Patients
% Occupancy
% New Patients Non Cancer
% Total Patients Returning Home
Average Length of Stay - Cancer
Average Length of Stay - Non Cancer
88.35
84
4.4
67.32
13.2
15.5
The hospice has a specialist community team, who cover the north Derbyshire area
and include clinical nurse specialists, occupational therapists and physiotherapists,
Hospice at Home team, all of whom are supported by two medical consultants. As a
result, patients are managed in their home environment, or alternative place of care,
for as long as possible. Once the need arises for an in-patient admission, the
hospice is committed to supporting patients to return to their home, or alternative
place of care, as soon as their symptoms have been managed.
This is in accordance with the charity’s aims to offer comprehensive specialist
palliative care to adults in north Derbyshire with progressive, advanced disease and
a limited life expectancy,
The Length of Stay and the effective use of the admission and discharge criteria
enable the timely admission of patients needing specialist in-patient palliative care.
The percentage occupancy remains high for this hospice at 93% for 2012/13, which
is considerably higher than the national median value of 75.5%. The inpatient unit
has an average waiting list of 3-4 patients per day, and with the increase in beds
from 29th April 2103 we estimate that we will meet the current need for specialist
inpatient care.
I can’t tell you how brilliant my experience has been on the ward at Ashgate; I can’t thank
you enough for the excellent nursing, therapy and medical care.
Feedback from one of our patients who came in for symptom control and was
discharged home after a 10 day stay
Ashgate Hospice Quality Account May 2013 Anna Baker
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Day Unit
Activity Levels 2012/2013
Apr
May
Jun
July
14
Aug
Sept
Oct
Nov
22
Referrals
16
21
13
11
13
16
Attendances
171
227
180 200 214
144
158 192
Non53
42
45
50
55
65
33
attenders
IPU
9
7
7
6
8
2
3
attenders
* Day Unit was closed for 5 days due to the weather
**Day Unit closed for 1 day due to the weather
*** Day Unit closed for 4 days due to the weather
Dec
Jan
7
123
Feb
18
March
15
11
116* 135** 104***
177
1609
41
38
50
54
51
577
2
2
0
3
4
53
During 2012 and 2013 the day unit has been through a review of service provision
and now offers two core services. Medically-led day therapy for patients with life
limiting illness; respite places on a 6 week basis to support carers and offer activities
and socialisation. During 2013/14 the service will undergo another review, engaging
with stakeholders, patients and carers to ensure that the service is providing the
appropriate level of care and support for the patients of N Derbyshire. Feedback for
the Patients’ Forum and the Carers’ Forum indicates that this support is highly
valued.
If I was ever unsure and asked about the problem the staff always made the time to answer
my questions
I would be much more unable to cope with my cancer, I would miss the opportunity too-my
carers would feel less confident about “coping” with me and my difficult times.
Patients’ feedback
I don’t have to worry about R during the 6 week period when he is at Ashgate
Carers Feedback on 6 week respite place
Ashgate Hospice Quality Account May 2013 Anna Baker
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Lymphoedema Service
During 2007 and 2008 the team received 208 referrals
During 2012 and 2013 the team received 302 referrals
% New Patients with Cancer
% New Patients Non Cancer
% Places Used
66
34
99
This service is consultant led and supported by a small team (3 staff) who deliver
out patient service and home based care as required across N Derbyshire. The
team work in collaboration with other health and social care providers, and aim to
deliver specialist training (though recent activity has increased making this quite
difficult to deliver with the current resource)
I would like to take this opportunity to comment about Ashgate Hospice’s Lymphoedema
team. Since my referral to the team and following their advice I have seen a wonderful and
vast improvement in my Lymphoedema condition. My overall health, fitness, mobility and
quality of life have improved 100% and I have lost weight too. Family and friends have
commented it’s like ‘having the old me back again’. To say the Ashgate Hospice
Lymphoedema service is invaluable is an understatement. They have made a huge
difference to me and I would like to say a big THANK YOU
Patients’ feedback
Therapy Service
Occupational Therapy has seen a 30% increase in referrals since 2007 with a total
of 652 referrals during last year (2.4 WTE).
Physiotherapy has seen a 49% increase in referrals since 2007 with a total of 423
referrals during last year (1.8 WTE)
All therapy services are provided on the ward, in the day unit and into the
community across North Derbyshire, with the majority of their work carried out in the
community. The service work with cancer and non cancer patients and work
collaboratively with other health and social care providers across north Derbyshire.
Approximately 1600 pieces of specialist equipment were provided to patients from
Ashgate Therapy service during last year
Ashgate Hospice Quality Account May 2013 Anna Baker
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Without the support and assistance from the Physiotherapist, I would not be able to achieve
the progress I am making today
She took the time to go through the plus/minus of the equipment, left me feeling much less
negative than before her visit
Found them to be a fantastic team who attended quickly and assessed appropriately, in a
professional manner and then put the relevant equipment in place. Many thanks, very much
appreciated.
The team were all excellent and better than any I have had previously from other services,
especially as they really listened – I am 97 and many do not!
The Therapy team have been a great help in the care for my mum. Whatever problem we
have encountered in her care, they have listened, advised and have dealt with our problem
professionally, with an extremely caring attitude.
Equipment has been ordered and has arrived promptly and even when we had a problem
with a toileting sling, this was tried and didn’t suit mum’s needs, other alternatives were
found. I would like to say a big thank you for all their help and advise in making life caring
for mum easier, for our family and the carers.
Absolutely delighted with everything, which is helping to make difficult times easier.
Patient and carer views 2012 survey
Family Support and Bereavement Service
One of the Charity’s aims is to offer professional advice and support to families and
carers during the patient’s illness and during the initial stages of bereavement.
Between 1st April 2012 and 31st March 2013 the service received 258 referrals, and
provided telephone advice and support to over 700 patients and carers. Patients
and carers were supported through a variety of interventions such as bereavement
support group (1 session per week for 6 weeks), home visits, and support from an
art therapist (evidenced as particularly useful when working with children).
I would just like to thank you for the support and care I received but most of all for the
extended care which continued after Mum died. I particularly benefitted from the following:
Initial meeting, being given an image to concentrate on at the most difficult times, until I
found other ways of coping in the following weeks.
Ashgate Hospice Quality Account May 2013 Anna Baker
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I now use the strategies that L*** has suggested and even ‘though the loss and anger is
still there, I know that it is a normal grieving process. I also know that I can come back if
I need to which is very reassuring.
Selection of comments from service users
Chaplaincy
Ashgate hospice employs a full time chaplain to provide spiritual care and support to
the patients and carers as an integral part of the holistic care. On average there are
30 – 40 face to face contacts per week. Part of the role is in providing post
bereavement support, leading groups and working with the family support and
bereavement team
Thank you for the understanding and kindness you gave to B A and myself during our vigil
at N’s bedside. I know N took comfort from the prayers and communion you gave him. I
assure you that you are the right man for the job....with gratitude
I wanted to say that it has been such a pleasure to get to know you. Your sensitivity, peace
and gentleness are wonderful and you carry something so precious – God’s presence.
Just a little note to say thank you for all your support over the last 4 months; I can’t tell you
how much I have appreciated it. The work you and your team do at Ashgate is wonderful,
and you are a real asset to the hospice.
Quotes from relatives cards to the Chaplain
Ashgate Hospice Quality Account May 2013 Anna Baker
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Quality indicators:
Prevention and management of pressure ulcers
Between 1st April 2012 and 31st March 2013, 353 patients were admitted to the IPU.
A Waterlow score was determined for all patients.
Of the number admitted 104
(29%) patients had pressure ulcers on admission. All pressure ulcers, and areas at
risk of developing into a pressure ulcer, were given a grading using the EPUAP
classification system. All patients had a documented care plan, which includes
monitoring on an ongoing basis. Preventative measures were put in place for all
patients, such as pressure relieving mattresses and cushions. Collaborative
working with DCHS tissue viability team supports our staff in the latest prevention
and treatment of vulnerable patients
None were reported to the CQC during this time.
Prevention and management of patient falls
Between 1st April 2012 and 31st March 2013 there were 32 patient falls, none of
which were serious and needed minor first aid only. This is an area, as with all
hospice settings, where we expect to see a high level of falls. All patients have a
falls risk assessment on admission, and preventative measures are put in place
following the assessment. Following a fall the risk assessment is reviewed and
further measures are implemented if necessary. Many patients are frail and
confused in the hospice setting and we therefore ensure high staffing levels are in
place.
Mandatory training
100% staff attendance at mandatory training days: topics include:
Fire, infection control, safeguarding, moving and handling and resuscitation as core
elements, with additional specific clinical topics planned following appraisal and
training needs analysis. (For example venepuncture, basic observations male
catheterisation, heart failure and palliative care).
Infection prevention and control
Between 1st April 2012 and 31st March 2013 none of our patients developed MRSA
or C Difficile whilst in the ward. Two patients were admitted with MRSA in surgical
wounds which were treated successfully
Ashgate Hospice Quality Account May 2013 Anna Baker
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Our participation in clinical audits
To ensure that the hospice is providing a consistently high quality service, we
undertake our own clinical audits, using national audit tools developed specifically
for hospices, which have been peer reviewed and quality assessed. This allows us
to monitor the quality of care being provided in a systematic way and creates a
framework by which we can review this information and make improvements where
needed.
Each year, the Clinical Governance Advisory Group approves the audit schedule for
the coming year. Priorities are selected in accordance with what is required by our
regulators and any areas where a formal audit would inform the risk management
processes within the hospice.
Through the Clinical Governance report, the Board of Directors is kept fully informed
about the audit results and any identified shortfalls. Through this process, the Board
has received an assurance of the quality of the services provided.
The following audits were completed between 1st April 2012 and 31st March 2013.
Self-assessment by the Accountable
This audit has to be completed annually.
Officer
The hospice was fully compliant with the legal
requirements.
Management of controlled drugs
This audit has to be completed annually to provide
evidence to support the self assessment by the
Accountable Officer.
Infection control: Code of Practice
The hospice is fully compliant with the code of
Practice.
Patient/Carer experience:
Each service undertakes this survey bi annually

Ward
May 2012

Day unit
May 2012
Ashgate Hospice Quality Account May 2013 Anna Baker
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
Community Clinical Nurse
March 2012
Specialists

Family Support & Bereavement

This audit identified some areas for improvement, but
the overall result was excellent

Therapy Services
March 2012

Lymphoedema service
March 2011
Referral to Treatment Time –
Community clinical nurse
Therapy, Lymphoedema service and community CNS
specialists
Feb 2012
Record Keeping
Community CNS, Ward & Day Unit 2011
This audit was postponed to 2013/14 to enable
SystmOne clinical recording system to be embedded
in practice
What our staff says about the organisation
Ashgate hospice values the opinions of the staff regarding the quality of the service
provided and views are currently captured through a number of methods; staff panel
representatives, newsletters and staff meetings. Plans for 2013 include the
participation in the national Birdsong Survey in June 2013 and a newly planned
series of staff engagement events as part of embedding new Leadership.
The Board of Trustees’ commitment to quality
The Board of Trustees is fully committed to the quality agenda. The hospice has a
well established governance structure, with members of the Board having an active
role in ensuring that the hospice provides a consistently high quality service.
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Annex
Quality Account 2012/2013
Ashgate Hospice
Commissioner Statement
NHS North Derbyshire Clinical Commissioning Group (NDCCG) is happy as
requested, to provide the commissioner statement on the quality account provided
by Ashgate Hospice. It is clear that careful consideration has been given to the
content and accuracy in line with the national guidance. NDCCG can confirm that
Ashgate Hospice has produced a Quality Account that meets the required criteria.
The Quality Account is an annual report to the public that aims to demonstrate that
the Service is assessing quality across the healthcare services provided. The
Quality Account is a clear and well-structured report which will enable public
understanding and outlines the key service areas and achievements and
developments across the year.
NHS North Derbyshire Clinical Commissioning Group look forward to working with
Ashgate Hospice over the coming year to support them to continue to commission
and deliver high quality patient care.
Hayley Wardle
Head of Clinical Quality
On behalf of North Derbyshire Clinical Commissioning Group
31st May 2013
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