Quality Account
2012/13
“The Hospice has a dedicated and stable team of staff who collectively possess considerable
skills, knowledge and experience – they are in turn supported by dedicated volunteers in all
parts of the organisation. The key will be to ensure that they are all fully engaged with the
external challenges, understand the part they can play and receive the learning and support
they require. The management challenge is influenced by the complexity of the organisation, its
range of services areas, the involvement of a large number of volunteers and the need to
operate within the community including shops.”
Investors in People 2012
“The people we talked with, who were using the services of the Eden Valley Hospice, all
expressed satisfaction with the support and services they were receiving. People told us that the
staff looked after them well and their needs were being met,” and “We observed staff engaging
with people in ways that demonstrated that they were trained and experienced to deliver
appropriate and sensitive support.”
Care Quality Commission Inspection Report 2012
Contents
1.
2.
3.
4.
Introduction
Chief Executive Quality Statement
Background Information
Strategy for 2012/15
4.1 Mission Statement
4.2 Purpose and Priorities
4.3 Key aims for the next three years
4.4 Delivering the strategy
5. 2012 Activity Data
5.1 Adult Inpatient Unit
5.2 Day Hospice
5.3 Outpatients
5.4 Eden House Children’s Hospice
5.5 Family Support Team
6. Review of Quality Performance
6.1 External Inspections
6.2 Self Assessment
6.3 Quality Framework
6.4 Incident Reporting
6.5 Slips, Trips and Falls
6.6 Medication Related Incidents
6.7 Infection Control
6.8 Safety Alerts
6.9 Appraisals and Training
6.10 Audit
6.11 Practice Development
6.12 Working with others
6.13 Awareness of external trends and developments
6.14 User Feedback
6.15 Complaints
6.16 Research
6.17 Finance
7. Stakeholders’ Comments
7.1 Cumbria Health Scrutiny Committee
7.2 Healthwatch Cumbria
8. Priorities for 2013/2014
8.1 Improving access to and in the Hospice
8.2 Improving fire safety
8.3 Implementing a planned programme of audit
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1. Introduction
This Quality Account is a report about the quality of palliative care services provided by Eden
Valley Hospice. Most organisations providing healthcare which is commissioned or funded by
the NHS produce a Quality Account, including independent sector and charitable organisations.
This is the first annual Quality Account for Eden Valley Hospice covering 2012/2013.
The original aim behind developing Quality Accounts was to ensure that organisations providing
NHS services focused their attention on quality as well as on financial balance. Although Eden
Valley Hospice does not provide NHS services, the Hospice does receive some funding in the
form of a grant from Cumbria Primary Care Trust, as well as a Section 64 grant from the
Department of Health to support Eden House, Cumbria’s Children’s Hospice.
Eden Valley Hospice is an independent charity which provides palliative care services for both
adults and children. In 2012 the cost of running Eden Valley Hospice was £3,124,985. 26.5% of
our funding came from the NHS.
We welcome this opportunity to reflect on the quality of our services, to share these reflections
with our stakeholders and to present our plans for the future. This is our first Quality Account
and any feedback on the style and format will help us to improve it next year.
2. Chief Executive Quality Statement
I am pleased to present the first Quality Account for Eden Valley Hospice. Maintaining and
further developing high quality care is essential to the work of the Hospice. During 2012 we
started to use the Care Quality Commission (CQC) Essential Standards of Quality and Safety as a
Framework to review and develop the quality of our care. In a small organisation this has
involved staff and volunteers at all levels.
During 2012 the Hospice received a very positive report as part of the Investors in People
revalidation. This was followed by Care Quality Commission unannounced inspection which
found that the Hospice was meeting all the national standards.
This report contains information from different working groups across the Hospice and to the
best of my knowledge the information in the document is accurate.
Janet Ferguson
Chief Executive
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3. Background Information
Eden Valley Hospice is dedicated to providing specialist palliative and end of life care to adults
from the local area and children throughout Cumbria, as well as caring for their families, friends
and carers. We aim to provide the highest standards of nursing and medical care, to sustain
quality of life and dignity and to provide patients with relief from pain. Our aim is to control
symptoms, relieve physical and emotional distress and provide support to both patients and
their family. Eden Valley Hospice services include a 12 bedded adult In-patient unit, adult day
hospice, out-patient clinics, family support team, complementary therapies, training and
education.
We aim to:
 Provide specialist palliative care in a therapeutic environment for people living with a
progressive illness, supporting them to live life comfortably and fully.
 Extend care and comfort to families, supporting them as partners in care and
recognizing their individual needs.
 As well as managing physical symptoms, we offer care for the spiritual, emotional,
psychological and social needs of patients and carers.
 Provide bereavement care and support.
 Provide a local resource, as a centre of knowledge for the management and support of
those requiring palliative care, from which the community can access help.
 Share our knowledge and beliefs to support each other, listening and communicating
effectively.
 Be aware of and respect each individual’s strengths and weaknesses.
Eden House Children's Hospice is an integral part of Eden Valley Hospice providing day to day
palliative care and support to children and young people who are living with a life limiting illness.
Family and sibling support are also important elements of our service. Care is provided in a home
from home setting and each young person who is staying with us has their own bedroom. The
ethos of Eden House is to work in partnership with the child, their family and other
professionals. The aim of the care team is to maintain the child’s normal routine and make their
stay as special and enjoyable as possible.
We aim to:
 Provide a flexible, high quality and child/young person focused service of respite and
palliative care across Cumbria.
 Work in partnership with the children, their families and all agencies involved with their
care.
 Offer support to families as well as children.
All our services are provided by qualified and experienced staff, supported by a large team of
committed volunteers.
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4. Strategy for 2012/15
4.1
Mission Statement
Eden Valley Hospice will provide palliative care services for adults and children with
incurable or life limiting illnesses, enabling them and their carers to live life as fully and
independently as possible.
4.2
Purpose and Priorities
Our purpose is to maintain and extend the availability of high quality palliative care
services for adults and children.
Against a background of significant shifts in health service policy and future funding,
demographic changes and challenges in raising voluntary income, the Trustees and
Management Team worked together to decide our direction and priorities for
2012/2015.
4.3
Key aims for the next three years
Eden House Children’s Hospice aims to:
 Raise the profile and reach of our service.
 Plan transition arrangements for young adults.
 Develop links with paediatric medical services.
Our Adult Hospice Services will:
 Extend the accessibility of our medical, non-medical and support services through
increased outreach arrangements.
 Promote our experience and expertise with professionals in nursing homes,
residential care services and other health care providers.
Working with others we intend to:
 Further develop our collaboration and partnerships with other hospices and
palliative care providers.
 Work with NHS and other providers to develop a local palliative care strategy.
 Play a key role with commissioners in establishing how services are commissioned
across Cumbria.
With stakeholders we will:
 Be alert and responsive to the views of those who use or share an interest in our
services.
 Invest in promoting a significant increase in awareness about the nature, range and
availability of our services.
Eden Valley Hospice – Quality Account 2012/13
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 Maintain our commitment to the training and development of volunteers, staff and
trustees.
 Continue to develop and maintain new and existing volunteer roles and initiatives
within the Hospice and in the wider communities we serve.
Our approach to funding will seek to:
 Ensure financial sustainability.
 Grow our capacity for community based fundraising.
4.4
Delivering the strategy
Each year an operational plan is developed to describe the timescale and means of
implementing the strategy and how progress towards achieving its aims will be
measured.
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5. 2012 Activity Data
5.1
Adult Inpatient Unit
Adult In-patient - 2012
No.beds
12
Total number of patients
239
Average length of stay (days)
12.1
% occupancy
75.8%
% new patients
89.1%
% cancer (new patients)
*83.3%
% non-cancer (new patients)
*12.1%
% patients discharged
*50.7%
% patients deceased
*49.3%
* discrepancy due to dual diagnoses and the
11 patients registered without a recorded
diagnosis
5.2
Day Hospice
Day Hospice - 2012
Total number of patients
109
Average length of stay (days)
140.6
% new patients
64.2%
% cancer (new patients)
*69.7%
% non-cancer (new patients)
*16.5%
* discrepancy due to dual diagnoses and the
15 patients registered without a recorded
diagnosis
5.3
Outpatients
Outpatient - 2012
Total number of outpatient
appointments scheduled
Total number of appointments
attended
New patient appointments
Follow up appointments
Did Not Attend
Blood transfusions administered
as a day treatment
(3 patients had two blood
transfusions and 11 patients had
a single blood transfusion)
Eden Valley Hospice – Quality Account 2012/13
320
284
72
212
19
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5.4
Eden House Children’s Hospice
Care provided for children and their families during 2012:
January
February
March
April
May
June
July
August
September
October
November
December
Total
Day Care
Nights of Care
82
84
82
86
90
90
95
94
82
88
80
86
1039
71
67
67
70
73
77
89
89
57
73
75
81
889
Total
Episodes
51
43
48
42
37
46
46
44
31
41
48
49
527
Support is also offered to the families of children who attend Eden House. During 2012
there were 3 family support days and 4 siblings’ days, including the annual children’s
outing.
5.5
Family Support Team
Eden Valley Hospice Family Support team includes two Palliative Care Social Workers,
Chaplain and Counsellor, supported by chaplaincy and bereavement volunteers. During
the year we have been developing systems for collecting and presenting data about
the activity in these areas which will be included in the Quality Account for 2013.
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6. Review of Quality Performance
The provision of palliative and end of life care is complex, involving a number of different
professionals and organisations. Moreover, the models of care for adults and children are very
different. In health care the main domains of quality are patient experience, safety and
effectiveness. A range of different processes and systems are used to support learning and
development across all these areas of our work in Eden Valley Hospice.
6.1
External Inspections
Both staff and volunteers contributed to the Investors in People accreditation process
in 2012. The Assessor reported it was clear that staff and volunteers remain
committed, energised and enthusiastic “all have successfully maintained the happy and
caring atmosphere at the Hospice and there have been impressive improvements to the
facilities since the last review”. He recognised a collective awareness and appreciation
of the future role of the Hospice within the community it serves, improved
communications and a changing culture.
On 27 April 2012, inspectors from the Care Quality Commission (CQC), the
independent regulator of health and adult social care services in England, paid an
unannounced visit to Eden Valley Hospice to assess our compliance with the CQC
standards that apply to hospices. They found the Hospice to be compliant with all the
outcomes which were included in the inspection. The positive nature of the Care
Quality Commission report suggests that the constructive approach we have taken to
the standards, using them as a tool to bench mark and identify areas for improvement
has been a constructive one which we will build on during 2013. This achievement
reflects the ongoing commitment of staff and volunteers to provide consistently high
quality care to all patients and their families. An Environmental Inspection of the
kitchen took place on 01.03.2013. This was in conjunction with Carlisle City Council and
the Food Standards Agency. The kitchen received a Food Hygiene rating of 5 stars, very
good.
6.2
Self Assessment
Different forms of self assessment have become part of the Hospice annual activity.
During 2012/13 we assessed our information management processes against the NHS
Information Governance Toolkit Version 10 for Voluntary Organisations. This involved
reviewing our policies and procedures against the standards in the toolkit. We then
had to provide evidence to demonstrate our compliance with the standards. This
assessment demonstrated compliance with the different areas of data protection,
confidentiality and information security. We also identified areas where we could
develop and improve our systems.
Eden Valley Hospice – Quality Account 2012/13
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Along with partner organisations we also measured our multidisciplinary approach
against proposed national Cancer Peer Review Standards for palliative and end of life
care and recognised areas where we could work differently and develop together. This
has resulted in a pilot of a new joint multidisciplinary meeting to review complex cases.
6.3
Quality Framework
During 2012 we started using the CQC Essential Standards of Quality and Safety as a
framework for assessing quality and identifying gaps and areas for action. This process
was led by a small steering group and involved staff from across the organisation.
Trustees were linked with specific outcomes. We have now established a process for
reviewing an outcome at each monthly Management Team meeting to ensure our
assessments and evidence remain accurate, relevant and up to date.
The Hospice Clinical Governance Group meets three times a year. This group is chaired
by a Trustee and supported by two other Trustees. The group has an overview of
incidents, clinical developments and patient feedback. The infection Control Group and
Food and Nutrition Group report directly into clinical governance and make sure we
continually improve and develop our approach to these areas of care. Significant
incidents are also reviewed by the Senior Management Team.
6.4
Incident Reporting
There is a robust process for documenting, reviewing and reflecting on incidents. A
summary of all accidents, incidents and near misses is submitted to the Clinical
Governance Committee, chaired by the Vice Chair of Trustees.
6.5
Slips, Trips and Falls
Slip, trips and falls are monitored and each incident is reviewed to ensure all efforts
have been made to minimise the risk of falls whilst maximising the patient’s level of
independence. Trends have been monitored and steps taken to improve the patient
environment to minimise the risk of falls.
In 2012 a total of 56 incidents involving patients were reported as detailed below:
Reason for incident
Patient trying to maintain level of independence (found by
staff following the incident)
Sudden change in patient’s condition
Slip/trip/fall/poor balance
Total
Eden Valley Hospice – Quality Account 2012/13
Total number
37 (66%)
5 (9%)
14 (25%)
56
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6.6
Medication related incidents
The Hospice encourages the reporting of drug incidents. The majority of incidents in
the Hospice are near misses; this means there has been no patient harm and a
potential incident has been avoided due to an error being identified before an incident
occurred. Lessons from near misses are shared and practices modified as a result.
Where Controlled Drugs are involved this is shared with the Local Intelligence Network
for Controlled Drugs through occurrence reporting. All drug incidents are reported to
the Clinical Governance Committee.
In 2012 there were 19 incidents as detailed below:
Reason for incident
Error/omission in recording when medication administered
e.g. incorrect entry in Controlled Drug register
Incorrect dose of medication
Omission of medication
Discarded medication
Error relating to frequency of administration
Error relating to route of administration
Total
Total number
8
3
5
1
1
1
19
A medication error was reported when a Fentanyl patch was not changed on time. The
Head of Nursing reviewed the incident and developed a new monitoring form for this
type of medication.
All incidents were investigated and, where necessary, corrective action was taken.
There were no serious consequences to patients from any of these incidents.
6.7
Infection Control
Eden Valley Hospice asks about the patient’s infection status at the point of referral to
the service, and monitors patients during their in patient stay.
Patient Infection 2012 (Adult in-patient unit)
Number of patients admitted with MRSA
Number of patients infected with MRSA during admission
Number of patients admitted with Clostridium Difficile
Number of in-patients who contracted Clostridium Difficile
Eden Valley Hospice – Quality Account 2012/13
Number of
cases
1
0
2
0
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6.8
Safety Alerts
The Hospice reviewed and actioned relevant alerts received from the Central Alerting
System including drug safety alerts from the Medicines and Healthcare products
Regulatory Agency and Medical Devices Alerts. In 2012, action was taken in relation to
26 alerts which were relevant to the Hospice.
6.9
Appraisals and Training
There is an annual appraisal system in place for all staff. This identifies areas for
development, new skills and training needs. Appraisal training was carried out in 2012,
with the forms and process reviewed. Appraisals are cascaded through the
organisation with the aim of 95% of all staff having an appraisal during 2013.
Mandatory Training is provided internally for all staff and volunteers and reinforced by
a booklet. Following appraisal, particular training is identified to meet the needs of
individual members of staff and this is accessed from local and national sources.






The Head of Nursing is working towards her MSC in Palliative Care.
Clinical Sister for the Adult In Patient Unit completed Palliative Care Nursing
Degree in September 2012
Clinical Sister in Day Hospice and a Staff Nurse from the Adult Unit are working
towards a Palliative Care Nursing Degree
The Support Services Manager is working towards a BA in Voluntary Sector Studies
The Hospitality Manager is working towards a Diploma in Management
We currently have an apprentice working towards an NVQ in Business and
Administration, through the Apprenticeship programme.
6.10 Audit
A number of audits have been undertaken including an audit on the use of the
Liverpool Care Pathway in end of life care and an audit of steroid prescribing. However
the Hospice needs to develop a systematic plan for audits. Help the Hospices have a
number of audits tools which could be used in the future.
During 2012/2013 there were no national clinical audits or confidential enquiries which
covered the services provided by Eden Valley Hospice, therefore we did not participate
in any.
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6.11 Practice Development
A new Team Leader post has been created and filled to support the nursing team in
the Adult Inpatient Unit. The Practice Development Nurse post was vacant in Eden
House, however this has now been filled, and the new post holder is exploring the
training needs of staff and planning education sessions. Training has taken place about
opioid conversions. Training was organised for Eden House staff about spiritual care,
support for families and training about the management of specific disorders.
6.12 Working with others
Eden Valley Hospice has participated in Cumbria wide development work together
with the commissioners and other organisations. This has focused on developing
palliative and end of life care across settings. We also proactively link with Cumbria
and Lancashire Network End of Life Care Network as well as with other hospices in
Cumbria and across the North West.
The Hospice is involved in facilitating the roll out of Deciding Right across Cumbria.
We have participated in the benchmarking against Palliative Care Peer Review
standards together with other organisations and the wider Multi Disciplinary Team
(MDT). This has led to the decision to trial a new format MDT across the north of
Cumbria using the video conferencing equipment installed by the Cumbria and
Lancashire Cancer network.
6.13 Awareness of external trends and developments
During the second half of 2012 we monitored the criticism in the media about the
Liverpool Care Pathway and were aware of the growing anxiety about its use. Staff
carried out a risk assessment and agreed a careful approach, which was later followed
by audit.
6.14 User Feedback
A working group has been established to look at different ways of gaining user
feedback. New questionnaires have been developed as well as simple comment forms.
A volunteer has regularly carried out patient interviews every month. We are now
revisiting this and plan to train a small group of volunteers to talk to patients and
families about their experience of using the Hospice.
Poor attendance at evening meetings for parents of children attending Eden House.
Verbal feedback suggested parents found it difficult to attend because of the need
for childcare. Our approach was redesigned to offer Family Support Days where the
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child who is a patient, siblings and parents are all catered for with different activities
and support. These have been successful and well received so far.
6.15 Complaints
All complaints are recorded, documented and investigated. These are then reviewed
by Complaints and Disciplinary Sub-Committee of Board of Trustees every six months.
Last year we received 2 letters about the transfer of patients from Eden Valley
Hospice to Care Homes. These highlighted that the patients were distressed at
leaving the Hospice. A retrospective audit of notes of patients who were transferred
or where transfer was discussed was undertaken by a member of the medical team.
The results of this were used to modify our practice around nursing homes transfers.
6.16 Research
During the year no patients were recruited to research studies. We have agreed to
participate in an observational research study called Improving Hospice Environments
for Older People.
As a small organisation we have limited opportunities for research. However, we
hosted a research workshop facilitated by End of Life Observatory to encourage
awareness and interest in research in palliative and end of life care. We plan to
establish stronger links with the research network over the coming months.
6.17 Finance
The accounts of Eden Valley Hospice and its subsidiary company Eden Valley Hospice
(Shops) ltd, are audited on an annual basis, in accordance with the Companies Act
2006 and the Charities Act 2011. The auditors have signed off the 2012 accounts, with
nothing to report, confirming that the accounts reflect a fair view of the state of the
charity’s affairs and are prepared correctly. An internal audit will be carried out by
trustees during 2013, by members of the Finance and Audit sub-group of the Board.
The 2012 accounts are available from Paul Cookson, Head of Finance at Support
Services.
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7. Stakeholders’ Comments
Eden Valley Hospice Quality Account was sent to Cumbria Clinical Commissioning Group,
Cumbria County Council Scrutiny Committee and Cumbria Health Watch for comments which
are listed below.
7.1
Cumbria Health Scrutiny Committee
The Cumbria Health Scrutiny Committee welcomes the opportunity to comment on the
Eden Valley Hospice’s Quality Accounts for 2012-13.
In reviewing the draft document, members responded that the document was both
readable and accessible, and the issues were clearly presented and commented upon
in a practical way.
In terms of the layout of the document, members felt that on the whole this was good,
however in order to improve this further for the reader the headings could perhaps be
clearer, helping to signpost the reader to the purpose of each section. There was also
the suggestion that the text could perhaps be broken up more with pictures to
illustrate the issues, and overall, these would make the document more readerfriendly.
With regard to the level of detail contained within the document, Members felt that
information on development of staff and the type of training that is provided in
relation to the appraisal process would be beneficial. In addition, more emphasis
could have been placed on the outcomes of the unannounced inspection.
Other areas considered were whether the higher proportion of people attending the
Hospice have cancer diagnoses, rather than other illnesses, given the percentages
outlined in the document. One member also highlighted the issue of closer
involvement with social workers and wondered whether this might be developed to
the benefit of service users.
Members were very supportive of the projected schemes identified going forward and
are aware that the Eden Valley Hospice has a tremendous reputation for the care and
support they provide. This is a detailed and comprehensive document, and overall we
appreciate the work that has taken place over the recent year and look forward to
continuing to work with the Hospice.
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7.2
Healthwatch Cumbria
We were asked to provide some feedback on the Eden Valley Hospice Quality Account
for 2012-2013. The following document details our comments and recommendations,
although we would like to stress that Healthwatch Cumbria is an organisation still very
much in its infancy and without a full staff team available. We therefore feel that in
future, with greater resources available, we can produce a much more detailed
feedback report.
Overall, we feel that document is very clearly set out; it is easy to follow and is very
understandable. The proportionate use of text and graphs has made it accessible, and
we like the fact it is a concise document.
We have a few questions regarding the content of the document. The strategy section
lays out the key aims for the Hospice over the next three years. In the ‘Delivering the
strategy’ section it says an operational plan will be developed. Will this be an internal
plan, or will it be accessible to everyone? It would be interesting to see what the plan
entails and if it is followed.
In the section entitled slips, trips and falls, it mentions trends have been monitored
and steps towards improvement have been taken. What are the trends and what steps
have been take to ensure improvement? We feel this needs to be explained in a bit
more detail.
Under the medication related incidents section, it states that there have been 19
incidents. Is this number of incidents high or not in comparison to other small
hospices? A percentage would have been good to show the difference and compare to
number of patients.
There is some evidence of patient infections, although it is good to see that nothing
was contracted at the Hospice itself.
There were some other questions we had in response to reading through this account:
 What did the audits show? Is this data available?
 You acknowledge some flaws in Liverpool care pathway. Are you continuing to use
it?
 Could you include more patient feedback?
 How mainly complaints have been received? The exact number does not appear to
be included, or is not in the most obvious place.
 Is the Hospice in profit or deficit? The issue appears to be skirted over, and an
indication would be useful to know.
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
Were staff, patients or family involved in Friends and Family survey about whether
or not they agree that if a friend or relative needed similar treatment, they would
be happy with the standard of care provided?
As mentioned, we feel this is generally a well laid out document that is easy to follow
understand. It gives a good over view of the Hospice’s performance, but some extra
detail with statistics to back it up might be useful.
8. Priorities for 2013/2014
Three priorities have been identified for the coming year.

Patient experience:
Improving access to the Hospice

Safety:
Improve Fire Safety

Effectiveness
Implementing a planned programme of audit
8.1
Improving access to and in the Hospice
Eden Valley Hospice has been providing care since 1991. Over the years new areas
have been added to the Hospice, parts have been redesigned and the levels of activity
and complexity have increased. As a natural consequence of this the number of people
coming to the Hospice by car has also increased.
The specific areas for improvement, particularly the main entrances and car parking
have been identified through incidents, observation and comments made by people
coming to the Hospice.
An application has been submitted to the Department of Health Capital Improvement
Scheme. The Hospice has been notified that 68% of funding has been agreed and the
detailed terms of the grant will be agreed in June.
Improvement will include:
 Rebuilding of main entrance to Hospice to include wider automatic doors
 Replacement of entrance doors to adult inpatient unit
 Replacement of entrance doors to Eden House, so that doors open automatically
 Refurbishment of toilets near reception so they are accessible by wheelchair users
 Replacement of ambulance
 Garage for ambulance and Eden House vehicle and creation of turning circle
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8.2
Improve Fire Safety
The improvement needed to the Fire alarm system has been identified following the
recruitment and training of Fire Wardens and the establishment of regular Fire
Warden meetings and feedback from staff.
The fire warning system has been in place since the Hospice was first built and as new
sections have been added to the building the system has become increasingly complex,
with different fire panels in different areas.
The system will be improved by:
 Replacing the original detectors in older parts of the building with new ones
 Both fire panels will be the same
 Panels will indicate exactly where the alarm is coming from
 Hold fire drills
 Continue weekly system test
8.3
Implementing a planned programme of audit
It has been identified as part of the operational development plan that although audits
are undertaken there is no clear plan for this to ensure different areas are covered and
that areas of work are systematically re audited following changes in practice.




Calendar for clinical audit, with identified leads for each audit
The audit calendar will be monitored
The Clinical Governance Group will maintain the overview of this and agree any
additional work
Recommended changes in practice or areas for improvement will be noted
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