It’s all about you
Quality Account
Reporting Period April 2012 to March 2013
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Farleigh Hospice relies on fundraising, donations and gifts in Wills to
provide vital services for local people affected by life limiting illnesses
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Charity registration no. 284670
Quality Account 2012 - 2013
Contents
Sections
PAGE
Part 1: Introduction by Chief Executive Janet Doghan.................................................3
Part 2: Priorities for Improvement and Statements of Assurance from
the Board (in regulations)
Future priorities for improvement - 2013 – 2014..............................................................4
Priorities for improvement from 2012 – 2013 ...................................................................8
Mandatory Statements of assurance from the board......................................................12
Part 3: Review of quality performance
National Council for Palliative Care: Minimum Data Sets – 2011 – 2012 .......................15
Farleigh Hospice Quality Performance Information 2012 -2013.....................................16
Quality Markers we have chosen to measure .................................................................20
Other quality initiatives.....................................................................................................29
What people say about our organisation.........................................................................34
Statement from Mid Essex Clinical Commissioning Group ........................................40-41
Statement from Mid Essex Locality, Essex & Southend LINk .....................................42-43
Statement from Healthwatch Essex .................................................................................44
Statement from Essex Health Overview & Scrutiny Committee .....................................44
Appendix A – Audits completed April 2012 – March 2013.......................................45-46
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Part 1
Introduction by Chief Executive
Farleigh Hospice has received NHS income from Mid Essex Primary Care Trust under an agreement for the
provision of services for the year 2012-13. One of the obligations connected with the receipt of NHS
funding for the delivery of services is the production of a Quality Account which sets out future priority
improvements and also evidences achievements on priorities for improvement from the previous year.
With the assistance of revenue funding received from Mid Essex PCT, Farleigh Hospice has been able to
deliver considerable services to the local population. We acknowledge the funding with gratitude and aim
to use this account to demonstrate to the PCT the quantity and quality of services delivered. Farleigh
Hospice services have been developed in close collaboration with our health commissioners and in
accordance with the locally developed joint End of Life Care Strategy 2009-14. We are proud of our
relationship with the emerging Clinical Commissioning Group (CCG), previously the PCT and we are keen to
work with them to provide improved End of Life Care services to the local population.
We also owe a debt of gratitude to our many loyal supporters who give generously of their time, skills and
money. As a charity Farleigh Hospice is dependent upon a number of different sources of income including
donations and gifts in wills, fundraising, shops, and a weekly lottery. These voluntary sources of income
are just as vital as the NHS funding.
I chair regular meetings of the Hospice's Governance Group where trustees, senior managers, the Quality
Improvement Lead and the Independent Service User Facilitator rigorously debate, challenge and add value
to the quality programme. Our aim is to ensure on behalf of the Board of Trustees that a framework exists
through which Farleigh Hospice is accountable for continuously improving the quality of services and
safeguarding high standards of care. Our dedicated Quality Improvement Lead facilitates a focused and
co-ordinated approach to quality across the whole charity and ensures that all action plans are completed
and implemented.
This Quality Account follows the model requirement set out in the regulations. To the best of my
knowledge, the information reported in this Quality Account is accurate and a fair representation of the
quality of healthcare provided by Farleigh Hospice.
Janet Doghan MIHM DipHSM
Chief Executive
For any queries, comments or any further information please email us at: comments@farleighhospice.org
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Quality Account 2012 - 2013
Part 2
Priorities for Improvement and Statements of Assurance from the
Board (in regulations)
Introduction
Farleigh Hospice Strategic Plan – ’Your Hospice and the Next Three Years’ – 2011–2014 outlines our vision
moving forward which is, as always, inspired by the needs of people affected by a life limiting illness.
There is still much to do to maintain existing services and to improve them so that they are flexible
enough to respond to people's changing needs.
This quality account only considers quality issues within the provision of clinical care and relevant support
services necessary to provide this care. This does not take into account the fundraising and administrative
functions of the organisation where separate quality initiatives are employed.
Future priorities for improvement - 2013 – 2014
The Board of Trustees is committed to the delivery of high quality care which is safe, effective and meets
the needs of people who use our services and to support the continuous development and improvement of
these services.
These priorities have been developed through consultation with people who use our services including
patients, carers, staff and volunteers.
The priorities we have selected will impact directly on each of the three domains of quality:–
●
●
●
patient safety
clinical effectiveness
patient experience.
Looking forward Farleigh Hospice confirms that the top four quality improvement priorities for 2013- 2014
to be:Future improvement priority 1
Development of a Clinical Volunteers Training Programme
Quality Domain: - Patient Safety and Patient Experience
This will take the form of an Achievement Log which would be adapted for each volunteers role
containing all the information they would need and training they would need to undertake.
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How was this priority identified?
The hospice recognizes it is important to not only recruit the right volunteers but to also support them and
prepare them for their role. The Education and Training Group had developed a matrix of training
requirements for all staff working in clinical areas in the hospice.
It became clear that the training requirements for staff were relatively straightforward but much more
complex for volunteers. It was also not easy to get volunteers in one place to attend training.
How will this be achieved?
It has been decided to introduce an Achievements Log for volunteers in clinical areas This log would be
adapted for each volunteer role and will contain all information they will need and training they will need
to undertake.
How will this be monitored?
Once the volunteer has worked through the log they will be given some questions based on the
information provided and once they demonstrate achieving the required level of competence their
manager will sign off their log. Evaluation of the volunteer training programme will be carried out at the
end of 2013. The Education and Training group will monitor and evaluate the process with the idea of
introducing the process to all volunteers in the hospice.
Future improvement priority 2
Develop and introduce Clinical Key Performance Indicators (KPIs)
Quality Domain: - Patient Experience, Clinical Effectiveness
The KPIs will be based on End of Life Care Quality Markers and be developed for all clinical teams to
monitor and improve the quality of care provided by the hospice. Once established they will be
reviewed and audited annually.
How was this priority identified?
The Department of Health published its The End of life Care Strategy in 2008 and the subsequent Quality
Markers were developed to support delivering improvements in care. Clinical Key Performance Indicators
(KPIs) are to be developed based on these Quality Markers to demonstrate the quality of services and
underpin programmes for improvement.
How will this be achieved?
Each clinical department will develop their own service specific KPIs with targets and information on
evidence to support achievements.
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Quality Account 2012 - 2013
How will this be monitored?
The KPI’s will be monitored on a regular basis through Clinical Heads of Departments meetings and an
annual report to the Governance Group at the end of March 2014.
Future improvement priority 3
Development of the Farleigh Hospice Information service –
Quality Domain: - Patient Experience
Development of an Information ‘Pod’ - within Broomfield Hospital, Mid Essex Hospital Services NHS
Trust. This will be a joint venture with Farleigh Hospice, Mid Essex Hospital Services NHS Trust and
Macmillan Cancer Support.
How was this priority identified?
People concerned about or affected by cancer need information that is timely and relevant, and easy to
understand in order for to them to make informed decisions.
Farleigh Hospice currently has an information centre based at the hospice, the Lantern Suite, in Chelmsford
and provides a community service on the HOP (Hospice Outreach Project) vehicle. To further develop and
improve the availability of information and support Farleigh Hospice is planning a joint venture with Mid
Essex Hospital Services NHS Trust and Macmillan Cancer Support to open an Information ‘Pod’ in the atrium
of Broomfield Hospital.
How will this be achieved?
A proposal has been developed and agreed. Staff and volunteers will be recruited some coming from the
current Farleigh Hospice Information service.
How will this be monitored?
Information will be kept about number of contacts, reason for visits and outcomes. This will form part of
the annual report on the uptake of the Farleigh Hospice Information Service.
Future improvement priority 4
Consultation on future Strategy and Service development for the hospice
Quality Domain: - Patient Experience
This will involve widespread consultation of service users and potential service users on Farleigh
Hospice’s next strategic plan.
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How was this priority identified?
Farleigh Hospice’s Strategic Plan - ’Your Hospice and the Next Three Years’- 2011- 2014 outlines the
hospice’s vision moving forward which is, as always, inspired by the needs of people affected by a life
limiting illness. The strategy will soon be in need of rewriting and updating to reflect the changing needs
of the people we serve. To ensure the best possible services are included it is planned to have a
widespread consultation exercise of service users and potential service users.
How will this be achieved?
Several methods will be used to consult with service users and potential service users using a multi media
approach. A survey will be included with the Annual Report when it is distributed in August as well as
opportunities to comment on the Farleigh Hospice website and Face book and Twitter accounts.
How will this be monitored?
The production of a draft new Farleigh Hospice Strategic Plan for 2014 – 2017 will then go out for
consultation before the final plan is agreed and published.
How will progress be monitored for all future priority improvements – 2013 - 2014?
The Farleigh Hospice Board of Trustees will monitor and report on progress through a variety of
methods including:●
Annual return to the Charity Commission
●
Annual Review and audited Report and Accounts
●
Quality Accounts and Annual Governance report
●
Quality and Audit reports and Patient Surveys
●
Annual General Meetings of the Company
●
Farleigh Hospice News and other periodic communications
●
Updates posted on the Farleigh Hospice Intranet and Farleigh Hospice Website
●
Events such as Open Days, Volunteers Day
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Priorities for improvement from 2012 – 2013
The aim of the Quality Account is to not only set future priority improvements but to also evidence
achievements on priorities for improvement from the previous year.
In last year’s report we set out five priorities for improvements for our services. All the areas identified
were specifically selected as they would impact directly on the care our patients and carers received, either
through improving patient safety, clinical effectiveness or the patient’s experience.
The quality improvements for the previous year. 2012 -13 were:Priority 1
Evaluation of the Hospice @ Home service in Mid Essex
Quality Domain: - Patient Experience
Standard:- The Hospice @ Home service for Mid Essex was introduced in February 2011 and in 2012 –
2013 this service was reviewed and evaluated to establish a clear understanding of activity, patient
outcomes, patient and carers’ views, health professionals’ views and future resource requirements.
●
Several audits were undertaken as part of the evaluation including: ➢
➢
➢
➢
Carers’ survey
End of life Bed Census at Mid Essex Health Trust (MEHT)
Crisis calls audit
Health professionals views of the service.
●
All audits evidenced that the Hospice @ Home service achieved its aims, met expectations and
demonstrated the impact the service had made in the community. Out of hospital deaths were
increased in the Mid Essex area. Patients and carers felt supported with an average of 90% of
patients achieving their Preferred Place of Care (PPC). It had been predicted that 2,400 visits would
be made by the team but the actual total over the year was 6,270.
●
The increase in out of hospital deaths at Mid Essex Health Trust (MEHT) is a direct result of the
introduction of Hospice @ Home service alongside other new services.
●
The evaluation also highlighted areas where services could be improved and based on these
outcomes, reviews of other hospices services and a literature review a report was prepared by the
Manager of Community Service making recommendations to further develop the Hospice @ Home
service and other community services. The proposed developments will further improve care and
provide more opportunities for collaborative working.
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Priority 2
Development of a Staff Training Matrix for Mandatory Training
Quality Domain: - Patient Safety
Standard: - All staff involved in patient care must undergo mandatory training, which is appropriate
to their role, as part of their induction and relevant update training. To ensure that the training
provided is right for the post a training matrix which clarifies training requirements for each
individual post will be developed.
●
The Education and Training group was established with representatives from all areas in the hospice
to ensure that there was consensus on mandatory training required for every post in the hospice.
●
The training matrix was developed and reviewed and an electronic version was made accessible to
all staff.
●
All new post holders have a copy of mandatory training requirements attached to the Job
Description.
●
At appraisal all current staff have their Job Descriptions reviewed and this process will include
signing off the mandatory training requirements for their role. The aim is to complete this process
by January 2014.
●
The training matrix is now part of the Learning and Development plan for the hospice and as such
will be reviewed annually by the Education and Training group.
Priority 3
Provision of efficient and effective service following a review of clinical services using the LEAN
process
Quality Domain: - Clinical Effectiveness
Standard:-. In August 2011 a review was undertaken of the patient pathway using the LEAN
processes (LEAN is a process which involves staff in critically reviewing current work practices to
eliminate wasteful processes or those that do not add value to clinical care). Following this process, a
review was carried out to assess the impact on services and to measure progress.
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●
The introduction of LEAN at Farleigh Hospice goes back almost 2 years with LEAN training for clinical
staff to review and LEAN the patients’ pathway. By assessing three main principles which focus on
identifying areas where there are problems or interruptions to the flow of work, the LEAN, process
enabled the clinical departments to see how they could deliver a more effective service, both
within their working environment and when meeting the needs of patients, families and carers.
Changes in processes were introduced which have now been embedded in practice.
●
An additional Clinical Nurse Specialist was appointed to ease the pressure of 7 day working on the
community team. This post, assisted by the results of the LEAN process on the patient pathway, has
helped increase the workload activity within the community team making 3,547 visits in 2012 –
2013 an increase of 43%.
●
Following this project four LEAN champions (now known as LEAN Advisers) were identified from
different departments to embed the principles of LEAN within all areas of Farleigh Hospice. The
advisers attended 2 days training and have now completed 1 project looking at the Equipment and
Wheelchair loan services. The LEAN Advisers meet weekly and currently have 3 projects underway,
all from different departments.
●
A Project Charter has also been developed to clarify what a project is about, identify who will be
responsible for the project (sponsor), which LEAN Advisers(s) will be supporting and to achieve ‘buy
in’ from management.
●
The 1st LEAN Open Forum was held which showed the timeline for the development of LEAN so far
at Farleigh Hospice, introduced the LEAN Advisors and explained about their role and delivered a
presentation on the first project and lessons learnt. It is planned to hold regular open forums with
the aim to provide feedback from the staff involved in LEAN projects and teach different LEAN tools
and techniques.
●
The LEAN Advisers are working to develop a “LEAN culture” at Farleigh Hospice (it’s not just about
the projects; it’s a “way of life”!).
Priority 4
Connection to NHS ‘N3’ broadband network computer service to improve clinical
communication
Quality Domain: - Clinical Effectiveness
To achieve the ‘N3’ (fast broadband networking service within the NHS) computer connection which
will improve access to diagnostic test results carried out by the NHS.
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●
To enable Farleigh Hospice to progress its N3 application we were required to complete the IG
Toolkit (v10) with an overall baseline of Level Two achievement. The toolkit was submitted in
December 2012, independently reviewed and approved with no requirement to complete an
improvement plan. We were issued with an IG Statement of Compliance – a prerequisite for N3
application.
●
Funding towards the cost to provide the broadband connection in Chelmsford and Maldon was
made available as a Commissioning for Quality and Innovation target (CQIN) by the PCT. The ‘N3’
connection and the main installations for both Chelmsford and Maldon sites were set-up during
March 2013, followed by final testing and user training in April and May.
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Mandatory Statements of Assurance from the Board
The following are statements that all providers must include in their Quality Account. Many of these
statements are not directly applicable to specialist palliative care providers and therefore explanations of
what these statement mean are also given.
Review of services
During 2012 - 2013 Farleigh Hospice provided the following specialist palliative care services:●
●
●
●
●
●
●
●
●
●
●
●
Inpatient Care Unit – 10 beds
Day Hospice – at Chelmsford and Maldon – 90 places per week
Nurse led clinics
Outpatients
Community services – including Hospice @ Home, Farleigh Hospice Clinical Nurse Specialists,
Physiotherapists, Occupational Therapists, Social Workers
Counselling
Carer Support
Well Being Services – creative therapies, chiropody, hairdressing, complementary therapies
Information and ‘drop in’ services at Chelmsford and on the HOP (Hospice Outreach Project) vehicle
in the community
Chaplaincy
Bereavement support for children, young people and adults
Education and Training
What this means
Farleigh Hospice is an independent charity which provides all services free of charge. The income
generated from the NHS in 2012/2013 represented 46% of the overall costs of service delivery with
the remaining income to fund our services coming from voluntary charitable donations, legacies,
hospice shops and lottery, events, corporate and community fundraising.
Participation in clinical audits
Although 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.
●
During 2012 - 2013 no national clinical audits or confidential enquiries covered NHS services
provided by Farleigh Hospice. As Farleigh Hospice only provides palliative care it was not eligible to
participate in any of these above activities.
●
During that period Farleigh Hospice participated in no national clinical audits and no confidential
enquiries of the national clinical audits and national confidential enquiries as it was not eligible to
participate in any.
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●
●
●
●
The national clinical audits and national confidential enquiries that Farleigh Hospice was eligible to
participate in are as follows: NONE.
The national clinical audits and national confidential enquiries that Farleigh Hospice participated in
are as follows: NONE.
The national clinical audits and national confidential enquiries that Farleigh Hospice participated in
and for which data collection was completed are listed below alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered cases required by
the terms of that audit or enquiry. NONE.
Farleigh Hospice was not eligible to participate in any national clinical audits or national confidential
enquiries and therefore there is no information to submit.
What this means
As a provider of specialist palliative care Farleigh Hospice was not eligible to participate in any of the
national clinical audits or national confidential enquiries. This is because none of the 2012 - 2013
audits or enquiries related to specialist palliative care. The hospice will also not be eligible to take
part in any national clinical audit in 2013 – 2014 for the same reasons.
Local audits
To ensure a high quality of services an annual audit programme has been established and a variety of
quality and audit activities were undertaken using nationally agreed formats often specifically developed
for hospice care as well as locally developed audit tools. For all these audits undertaken, where necessary,
local action plans for improvements were developed, and in general they will be re-audited within the
next 12 months to check for improvements. This has enabled us to monitor the quality of services and
make improvements where needed. The reports of 80 local audits were reviewed by the Farleigh Hospice
Governance group of which 64 related to clinical care and relevant support services necessary to provide
this care and evidence compliance.
Details of audits completed in 2012 – 2013, to improve the quality of services, can be seen in Appendix A.
Research
The number of patients receiving NHS services provided by Farleigh Hospice in 2012-13 that were recruited
during that period to participate in research approved by a research ethics committee was NONE. There
were no appropriate national, ethically approved research studies in palliative care in which we could
participate during this period.
Use of CQUIN payment framework
The Service Level Agreement for Farleigh Hospice NHS income in 2012–13 included a Commissioning for
Quality and Innovation (CQUIN) sum in respect of the successful completion of the ‘N3’ connection (fast
broadband networking service within the NHS) to Farleigh Hospice in Chelmsford and Maldon. This has now
been completed.
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Statements from CQC
Farleigh Hospice in Chelmsford and Farleigh Hospice in Maldon are required to register with the Care
Quality Commission and are currently registered to provide the following regulated activity:●
●
Personal care,
Treatment of disease, disorder or injury
Farleigh Hospice is subject to periodic reviews by the Care Quality Commission and the last on-site
inspections were in April 2012 for Farleigh Hospice in Chelmsford and August 2012 for Farleigh Hospice in
Maldon. Farleigh Hospice was fully compliant with all the Essential Standards of Quality and Safety as set
out in Care Quality Commission (Registration) Regulations 2009 and the Health and Social Care Act 2008
(Regulated Activities) Regulations 2010. CQC has not taken any enforcement action during 2012 – 2013.
Farleigh Hospice has not participated in any special reviews or investigations by the CQC in this period.
Data Quality
Farleigh Hospice did not submit records during 2012-13 to the Secondary Users service for inclusion in the
Hospital Episode Statistics which are included in the latest published data.
Why is this?
This is because Farleigh Hospice is not eligible to participate in this scheme. In the absence of this we
have our own system in place to collect and monitor data through the electronic patient information
system iCare. Farleigh Hospice also submits data to the Minimum Data Set (MDS) for Specialist
Palliative Care Services collected by National Council for Palliative Care on an annual basis with the
aim of providing an accurate picture of hospice and specialist palliative care activity.
Information Governance Toolkit
Farleigh Hospice submitted its Information Governance Toolkit assessment version 10 in December 2012 to
Mid Essex PCT and NHS Connecting for Health for review. The outcome from both organisations was
satisfactory with sufficient compliance to support the application for an ‘N3’ connection.
What this means
‘N3’ (fast broadband networking service within the NHS) computer connection will improve access to
diagnostic test results carried out by the NHS. Results will be more easily accessible for medical staff,
leading to quicker decisions regarding treatment of patients. This was a Future Improvement Priority
4 for 2012 – 2013 see page 11 above
Clinical coding error rate
Farleigh Hospice was not subject to the Payment by Results clinical coding audit during 2012 – 2013 by the
Audit Commission.
Why is this?
There is currently no payment tariff for palliative care services.
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Part 3
Review of Quality Performance
The National Council for Palliative Care: Minimum Data Sets – 2011 – 12
The figures below provide information on the activity and outcomes of care for patients in 2011 – 12
compared to the median for other similar hospice services prepared by the National Council for Palliative
Care. (NCPC)
This information is however for the previous year not the reporting year as the NCPC dataset for 2012–
2013 will not be available until September 2013.
2011 - 12
Inpatient Services
Total number of patients
Total number of new patients
% New patients
% New patients – non cancer diagnosis
% Occupancy
% Inpatient stay ending in death 52.5%
Average length of stay ( days )Cancer
Average length of stay ( days )Non Cancer
Farleigh Hospice
Number/%
241
219
90.9%
5.5.0%
72.7%
55.0%
9.2
9.6
NCPC National Median
Number/%
217
193
89.1%
9.9%
75.7%
Day Care
Total number of patients
Total number of new patients
% New patients
% New patients – non cancer diagnosis
Total Day Care Attendances
% Places used
Average length of attendance
227
160
70.5%
15.6%
2507
55.1%
108.1
248
160
66.1%
15.1%
2314
58.0%
163.9
Home Care
Total number of patients
Total Number of new patients
% New patients
% New patients – non cancer diagnosis
% of patients who died at home
Average length of care ( days )
1071
761
71.1%
14.3%
65.0%
58.7
1310
895
68.8%
14.1%
55.5%
98.7
Bereavement
Total Service Users
Total number of new service users
% New referrals
Total number of contacts
Total number discharged
% discharged
1430
715
50.0%
3422
825
57.2%
492
305
67.4%
2379
265
57.5%
Outpatients
Total number of patients
Total number of new patients
% New patients
% New patients – non cancer diagnosis
Average attendance per patient ( days )
Total Outpatient clinic attendances
26
10
38.5%
40.0%
100.5*
2613*
42
28
77.6
9.5%
2.4
104
12.6
11.1
* These figures include Outpatient Group Attendances such as ‘Easibreathe’ groups
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Quality Account 2012 - 2013
Farleigh Hospice Quality Performance Information 2012 - 13
Detailed below is data about services provided by Farleigh Hospice relating to the review period April 2012
to March 2013.
General information
The total number of people i.e. patients, carers and bereaved, cared for by Farleigh Hospice in the last year
was 2,445 an increase on the previous year.
Referrals
The number of referrals and new patients to the hospice was also similar to last year. Hospital referrals
continue to be the highest source of referrals.
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Patient Diagnosis
Farleigh Hospice has always provided end of life care for cancer and non cancer patients and over the last
few years there has been a slow increase in the number of non cancer patients accessing hospice services
– 17% of referrals had a non cancer diagnosis.
Preferred Priorities of Care (PPC)
An increasing number of patients, 65%, have died in their usual place of residence/ home.
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Quality Account 2012 - 2013
Inpatient care
The workload in the Inpatient Unit (IPU) has
been variable over the year with the
admission numbers, 286, being the same as
last year. Bed occupancy was 75% similar to
last year. There is rarely a waiting list for
admissions, the average time from referral to
admission being 2 days. Longer times are
often at the patient’s request/ preference.
20% of all admissions to the IPU are from
hospital which may reflect patient’s or
family’s wishes to die in the hospice rather
than in hospital.
The average length of stay was 9 days showing a small increase from last year of 8.7 days.
It is interesting to note that the number of admissions per bed is 28.6 which is higher than the national
average for hospice beds of 23.5.
Six patients admitted to the IPU were under 40 years of age.
46% of patients were discharged with the majority returning home (40.5%).
IPU admissions were 14.6% of the hospice workload. This is similar to last year and reflects the impact of
the community services including Hospice at Home (H@H).
Community care
Farleigh Hospice Community Specialists Nurses
The Farleigh Hospice Community Specialist
Nursing Team had some staff changes in the
year but continued to cope with high
workloads. The number of new patients
continues to rise and was 637, 7% increase
on the previous year. 79% of referrals go to
the nursing team a big increase from the
previous year – 53.3%.. The nursing team
carried out 3,899 visits, a 10% increase from
the previous year (3,547). Over 50% of
community patients die in their usual place of
residence/ home.
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Hospice @ Home
The Hospice at Home team provided 8,288
care hours in patients homes to 431 patients.
89% of the visits were for 1 hour. 90.3% of
Hospice @ Home patients achieved their
Priorities of Care (PPC).
Day Hospice
The Day Hospices in Chelmsford and Maldon
both saw a reduction in the number of new
patients and attendances – 2,031 attendances
this year compared to 2,335 the previous
year. This may be due to the fact that patients
are more acute/near to death when referred
to the hospice. The number of non
attendances has reduced.
Bereavement Services
The mid Essex adult bereavement service,
Circle, was launched in May 2012. The team
was increased by 0.6wte counsellors and
sessional counsellors have been used to help
meet the increased demand in both adult and
children’s services.
Circle – Adult Bereavement service had 776
new referrals – 707 linked to the hospice and
69 external referrals.
YoYo Project – Lose and bereavement service for children and young people, had 116 new referrals – 31
linked to the hospice and 85 external referrals.
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19
Quality Account 2012 - 2013
Quality Markers we have chosen to measure
Quality is at the heart of everything we do. In addition to the number of suitable quality measures in the
national data set for palliative care, we have chosen to measure our performance against the following:●
●
●
●
●
●
●
Complaints and Compliments
Safety Information
Infections and Pressure Ulcers
Education and Training
Local Audits
Other Quality Initiatives
What others say about our organisation
Complaints and Compliments
20 complaints were received between April 2012 and March 2013, less than the previous year, 8 related to
patient/family care.
Complaints 2012 – 2013
Total number of complaints related to patient/family care
8
Total number of these which were upheld
0
Total number of these which were partially upheld
3
Themes for partially upheld complaints
20
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Communication
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Quality Account 2012 - 2013
All were fully investigated and appropriate actions taken. All complaints were discussed by the Senior
Management Team to facilitate organisational learning. Action plans were developed to address issues
raised. One audit was carried out as a result of a complaint – Volunteer Transport Requests - which resulted
in a new transport information form being introduced. One clinical complaint has been referred for
independent review.
Compliments
Although the number of complaints was small the number of compliments was significantly higher as
evidenced through letters and cards from families and carers, comments in the annual Patient Satisfaction
Surveys and customer feedback in our shops. In a recent review over a one month period 231 compliments
were received which over a year could amount to over 2736 compliments. Of the 231 sample 82 related to
clinical care and relevant support services necessary to provide this care. Of these 30% were offered
verbally in person or by telephone, 52% were cards, letter, emails, and gifts. Of those related to clinical
care and relevant support services 34% were about the Hospice @ Home service, 18% Chaplaincy, 16%
IPU and 12% Day Hospice.
Safety information
Risk Assessment
General risk assessments, which are reviewed at least annually, are in place to address health and safety
hazards in all areas of the organisation. Additionally, COSHH risk assessments have been carried out for
hazardous substances.
Accidents, Incidents, Near Misses –
For the period 1st April 2012 to 31st March 2013 there were 105 health and safety and clinical incidents
reported.
Staff, Volunteers, Visitors and Members of the Public incidents
There were 43 health and safety related incidents reported involving staff, volunteers, visitors and
members of the public. In 22 of these no injury was sustained, of the 21 incidents where injuries were
sustained 19 were minor and 2 were classed as medium. Of these, 3 were reported to the Health and
Safety Executive, 2 involved staff and 1 a member of the public at a fundraising event. As can be seen
from the chart the most common cause of injury was slips, trips and falls.
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21
Quality Account 2012 - 2013
Patients incidents
There were 62 clinical incidents, 59 of which were patient falls. 2 resulted in major injuries which were
reported to the Care Quality Commission and the Health and Safety Executive.
Patient Falls
59 incidents were patient falls which were categorised in line with Health and Safety Executive reporting
requirements as follows:
22
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Quality Account 2012 - 2013
Two incidents were categorised as major and were reported to the Care Quality Commission and the Health
and Safety Executive. A Root Cause Analysis of the incidents was carried out by the hospice.
Medication related incidents –
32 medication related incidents occurred of which 4 were near misses.
All were investigated and, where necessary, corrective action was taken. There were no serious
consequences to patients from any of these incidents. Audits of these medication related incidents are
carried out quarterly.
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 –
31 medical device alerts were reviewed and appropriate action taken when relevant.
Patient Infections and Pressure Ulcers
Infections and pressure ulcers cause pain and distress to patients and families and have cost implications to
organisations. Infections and pressure ulcers are monitored on an on-going basis by the Manager of the
Inpatient Unit and reported to Farleigh Hospice’s Governance Group and the Care Quality Commission.
Infections are also reported to the Infection Control Team on a quarterly basis.
Information relating to the incidence of Patient Infections and Pressure Ulcers is collated into an annual
audit. There continues to be a very low number of infections and pressure ulcers acquired at the hospice.
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23
Quality Account 2012 - 2013
Infections
There were 11 reported infections during the period compared to 12 last year. 10 of the 11 infections were
not acquired in Farleigh Hospice. This was a slight decrease in reported infections overall but one of the
reported infections was a hospice-acquired infection compared to the same period last year when none
were acquired in the hospice.
Patient Infection 2012 - 2013
Unit
No Cases
No on admission
No Acquired At Farleigh Hospice
Inpatient Unit/Day Hospice
11
10
1*
* One patient acquired Clostridium Difficile on the Inpatient Unit as a result of antibiotic therapy.
24
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Quality Account 2012 - 2013
Pressure Ulcers
There were 39 reported pressure ulcers during this period compared to 28 last year. Although there was an
increase in the number of reported pressure ulcers, the actual number acquired in the hospice remains very
low and is the same as the previous year.
Pressure Ulcers 2012 - 2013
Unit
No Cases
No on admission
No Acquired At Farleigh Hospice
Inpatient Unit
23
21
2*
Day Hospice Maldon
6
0
0
Day Hospice Chelmsford
10
0
0
* 2 patients developed ulcers while in the IPU, but refused preventative measures despite being informed
of the risks.
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25
Quality Account 2012 - 2013
Education and Training
Palliative and End of life care
During 2012 – 13 the aim was to continue
and increase this education work to the wider
community. The Education Coordinator
continued to develop and deliver education
and training focused on palliative and end of
life care to staff in residential care homes,
community hospitals, nursing homes,
community nurses and GPs as well as to
hospice staff. There were short sessions and
study days at Farleigh Hospice as well as
outreach sessions in the community as detailed below:●
Palliative Care Essentials – Farleigh Hospice delivered 11 Palliative Care Essential study days. The
targeted audience was community staff, care homes, care agencies and new Farleigh Hospice staff.
The total register for the 11 days was 136 participants. Topics included introduction to e-learning,
Advanced Care Planning, Spirituality, Dementia, Pain Management and Communication.
➢
The evaluations by the participants were very positive valuing discussing work related
scenarios and demonstrating learning outcomes –‘you made it all so accessible’, ‘huge thank
you for a great session’, ‘impressed by content and outstanding delivery’. This positive
outcome prompted more people to book to attend sessions.
●
Micro teaching - Farleigh Hospice Education Department delivered 21 micro teaching sessions (1 to
4 hour), over the year, with a total audience of 195 participants, from, Broomfield Hospital, nearby
local care homes, community health workers and volunteer settings as well as Farleigh Hospice
staff. Topics covered were similar to the Palliative Care Essentials but also included Managing Anger,
Legal Issues and the Patients Journey. Other departments such as quality and audit, bereavement,
allied health care and the medical team have also provided micro teach sessions or study days
although the attendance for these are not included above.
●
Outreach Palliative Education programme – Over the year 18 successful visits were made to
community hospitals, care homes, care agencies and community nurses workplaces with a total
registered audience of 177. Topics delivered in the clinical settings included Use of Syringe Drivers
and Diagnosing Dying. 4 planned meetings had to be cancelled at the last minute / on the day due
to participants experiencing low staffing or work related emergencies.
●
GP teaching - The medical team and Farleigh Hospice Clinical Nurse Specialists with education
support, facilitated 2 palliative care education study days for GP trainers and trainees in October and
November 2012. 110 GPs attended. The medical team also delivered bespoke teaching in GP
surgeries, responding to individual palliative education needs of the community teams.
26
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Quality Account 2012 - 2013
●
Miscellaneous
➢
Mid Essex Buzz group - the purpose of this group is to support senior community nurses with
developments and updates in end of life care issues (for example advance care planning)
and to share good practice, which they would then share with their own team. It is hoped to
include care homes in the Buzz group meetings in 2013.There were 5 meetings averaging
10 participants per meeting.
➢
Other activities included encouraging and supporting individuals to register with e learning
and Athens passwords to access NHS library.
➢
Supporting individuals with resources for projects or assignments, work related queries and
advice for interview preparation.
Education and Training - Palliative and End of Life Care 2012 - 2013
Type of Event
Palliative care
essentials study days
Micro Teaching sessions –
1 - 4 hours sessions
Outreach Palliative
Education programme
Total No
of events
11
21
18*
Staff targeted
Total No
Attended
Community and care home staff
and new Farleigh Hospice staff
136
Broomfield Hospital, nearby local care
homes, community health workers
and volunteer settings as well as
Farleigh Hospice staff
195
Community hospitals, care homes,
care agencies and community nurses
177
Local audits
To ensure a high quality of services a variety of audits are undertaken using nationally agreed formats
often specifically developed for hospice care as well as locally developed audit tools. This has enabled us
to monitor the quality of services and make improvement where needed.
The Quality and Audit Activity programme for the previous year had 52 local reports and in February 2013
the last action plans from these reports were completed.
In 2012 – 13 the reports from 80 local audits were reviewed by the Farleigh Hospice Governance group of
which 64 related to clinical care and relevant support services necessary to provide this care and evidence
compliance. Action plans were developed as a result of these audits to improve the quality of services
provided. The outcomes from the audits were reviewed by the Governance Group on a regular basis and in
their Annual Governance report.
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27
Quality Account 2012 - 2013
Details of audits completed in 2012 – 2013 can be seen in Appendix A
An explanation of those involved in this Quality Account
The Quality Account was discussed and reviewed by Farleigh Hospice Governance group which includes
senior managers from all relevant areas, Trustees, a Service User Facilitator and the Quality Improvement
Lead. The task of writing it was designated to the Quality Improvement lead and Chief Executive.
Discussion then took place within the Senior Management team regarding the key priorities for
improvement for 2012 – 13 following suggestions from Heads of Departments and the Multi Departmental
Quality Assurance group. Six were selected and after consultation with staff, patients, carers, volunteers
and the public four were selected for inclusion in the report.
The Quality Account was then completed and circulated to the Governance Group and Board of Trustees for
discussion and comment and it was distributed externally to the Mid Essex Clinical Commission Group;
Healthwatch Essex and the Essex Health Overview and Scrutiny Committee. Comments received have been
included in the report.
28
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Quality Account 2012 - 2013
Other quality initiatives
30
brating 3
ele
Celebrating 30 years of Caring for life across mid Essex
ring for Li
Ca
ears of
0y
30 years ago Farleigh Hospice or Chelmsford Hospice as it was originally known first
applied to be a registered charity. The hospice has come a long way since then and
this was marked by a special edition of Farleigh Hospice News which depicted a time
line of the significant mile stones in the development of services and facilities for
patients and families over the last thirty years. There was also a ‘get together’ with staff
and patients in the Chelmsford Day Hospice hosted by the Head of Patient Care. ‘Farleigh Hospice in now
30 years old….it has grown from humble beginnings into an organisation that provides care and support to
nearly 3,000 people a year’. The hospice aims to continue to find new ways of extending care and support
for the people of mid Essex. A productive relationship with the new Clinical Commissioning Group (CCG)
will be key to this strategy.
fe
C
Dignity in everything we do!
Dignity Action Day
Farleigh Hospice is passionate and committed
to providing the highest level of dignity in
everything we do and this plays a dual role
across the hospice. In the care and support
we provide to our service users, as well as by
actively promoting dignity within the whole
organisation. Following successful campaigns
in previous years, Farleigh Hospice once again
supported this year’s national initiative
‘Dignity Action Day’ which staff and
volunteers across the whole organisation
were invited to participate in the special day
and remember that dignity is always at the
heart of everything we do.
Farleigh Hospice is always pleased to
celebrate success among staff and volunteers
and we were delighted when a Senior Health
Care Assistant and Farleigh Hospice Dignity
Champion who works on the IPU was
awarded ‘Dignity Champion of the Month’ by
the Social Care Institute for Excellence (SCIE).
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29
Quality Account 2012 - 2013
New Rehabilitation Suite completed
The new rehabilitation suite replicates a self contained flat
which can be used by patients in preparation for their return
home. By containing its own bedroom, lounge, kitchen and
bathroom/wet room, with the facility to easily call for
assistance if required, the suite aims to re-build confidence
by giving patients independence in a completely safe
environment. It also allows their family members to stay
and spend time with them. The IPU Manager, says, “We are
absolutely delighted that the new rehab suite is finished and
now being used by patients…… the room is now called ‘The
Garden Room’ which seems to suit it very well, “it’s great to
see patients’ families spending real quality time with their
loved ones as a family unit in lovely, safe surroundings.”
Bereavement Service Development
This year saw several new developments in the bereavement
service. May saw the opening up of the service to all bereaved
adults from the mid- Essex area, ‘CIRCLE adult bereavement support’
with a subsequent increase in staff and volunteer counsellors.
There were also changes in the children and young people’s service –
the Yo-Yo Project. We continued our 1-1 work with children - in April
we were successful in obtaining a further 3 years funding from BBC
Children in Need -. and introduced a Bereavement Group for 10-16
year olds that ran during the summer holidays. Visits took place to
secondary schools to meet and undertake workshops for 11-12 year
olds onboard the HOP (Hospice Outreach Vehicle) to break down
some of the barriers around death and dying, open up discussions, and share experiences of loss. The first
User Forum was also held where parents and children were invited to give feedback on the service they
had received and suggest any improvements. From this we developed a new range of leaflets for parents,
children and young people facing loss or bereavement.
The first Family Dinner for families facing a loss also took place and was a wonderful evening of food and
entertainment for the families, in the safe environment of the hospice. Family portraits were taken and a
wonderful time was had by all.
An exhibition was held in October with artwork lovingly created by children and young people who
received support, both pre and post bereavement, from our Child Bereavement Service – the Yo-Yo Team.
This will be an annual event.
30
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Quality Account 2012 - 2013
Getting Arty
During the months of May, June and July Farleigh Hospice ran
a series of Storytelling and Art workshops. These unique
sessions were targeted at patients, families and carers as
part of the national ‘Dying Matters Awareness’ campaign
and a wider programme of events which were jointly
organised and with the Essex County Council Arts
Development Team. The aim of the sessions was to combine
therapeutic arts and a time for reflection with the
opportunity to learn something new in a supportive
comfortable group setting.
Feedback from participants included:- ‘It was a chance for
thinking time and to meet new people’, ‘It helped me to
relax’, ‘It was great to hear other people’s stories and
experiences’.
The majority of those who attended also said they would be
really interested in taking part in any similar planned events.
‘Falls Awareness’ Week
Farleigh Hospice supported national
‘Falls Awareness’ week which took
place in June
As part of this initiative our Inpatient
Unit promoted and participated in the
nationwide campaign to address the
issue of falls especially in the elderly.
The campaign which was led by Age UK
encouraged anyone who works or
comes into contact with older people,
to take part and host an event or
activity. The Inpatient Unit used the
campaign as an opportunity for people
to find out more about falling over, and
to learn about ways to prevent it happening. Staff designed a notice board which contained lots of useful
information and statistics for patients and visitors to view. There was also a quiz called ‘Boost your Bones’
and an area which asked ‘are these slippers safe?’ to highlight how unsafe some slippers can be to walk
in. All of the information was displayed for any staff and visitors to the Inpatient Unit.
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31
Quality Account 2012 - 2013
Health and Safety Awareness booklet
In August a new Health and Safety Awareness booklet was
launched. The booklet was developed by our Health and Safety
officer and is intended to be for both staff and volunteers. This
has been distributed to all existing members of staff and
volunteers and now forms part of our induction process. The
booklet contains basic information on a range of common health
and safety issues and includes a questionnaire which is completed
and returned to demonstrate understanding of the topics
contained in the booklet. To date over 202 booklets have been
issued and 123 questionnaires have been returned.
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Farleigh Hospice wins
‘Community Award’
In September Farleigh Hospice had
received the ‘Community Award’ at the
Essex Business Excellence Awards 2012.
To be considered for this award we were
required to demonstrate that we
improve the quality of life of our patients
and their families. The award for best
community organisation in the not for
profit sector, was judged by Essex and Suffolk Water who
recognised Farleigh Hospice for excellence in serving patients and families in mid Essex.
HOPE -New course for carers
Farleigh Hospice invited carers of cancer
patients to attend a specially tailored course
which it ran in November for 6 weeks. The
‘Help Overcoming Problems Efficiently’ course,
or ‘HOPE’, aims to build confidence to help
people to deal with their emotional issues,
anxiety, depression and anger. It also helps
carers to set goals and encourages them to
make changes to their lives to enhance quality,
confidence and happiness. The course finished
just before Christmas and the carers on the
course gave very positive feedback. Another
course is planned for June 2013.
32
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1
Quality Account 2012 - 2013
Gifts of Time
Farleigh Hospice is supported by over 500
volunteers in a variety of areas across the
organisation – patient care to retail.
Volunteers’ Day forms part of the annual
events calendar at the hospice to let the
volunteers know just how much they are
valued. This year there was a new item on the
agenda – gifts of time offered by various
members of staff outside of their normal
working week. ‘Promise it’s worth the wait’
gave volunteers who attended on the day the
chance to win anything from a home-made
cake a month, to half a day of gardening. This innovative idea was very well received and demonstrated
how much staff value the regular contribution of volunteers who work alongside them.
“I was delighted to win a two hour embroidery lesson in the Volunteers’ Day raffle. The whole experience
was thoroughly enjoyable …….. I think the idea of people donating their time and particular expertise to
the Farleigh Hospice cause in this way is something which should be actively encouraged.”
Good governance for hospices – board development programme
In the previous year, the board participated in a development programme facilitated by Help the Hospices
and delivered by a team of consultants from Cass Business School (Centre for Charity Effectiveness).
Following on from the programme it was agreed to evaluate board satisfaction so that this might be
measured annually, the aim being to demonstrate improved levels of satisfaction resulting from the
delivery of the action plan. The survey takes account of seven principles from Good Governance: A Code
for the Voluntary and Community Sector.
Specialist Palliative Care Peer Review
All palliative care services were required to undertake a self assessment of their compliance with the
specialist palliative care measures issued by the National Cancer Action Team (NCAT)
As a provider of specialist palliative care Farleigh Hospice took part in this review with Mid Essex Hospitals
Trust which was a critical review of our procedures and systems compared with the set of nationally
agreed measures which are considered to represent best practice. Completing the review was a
demanding process but the relevant joint documentation was completed ahead of agreed timescales and
submitted to NCAT. The review demonstrated over 90% compliance with national standards. Demonstrating
compliance is a great benefit to the hospice as the exercise was about improving standards of care and
better outcomes for people who use our services.
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33
Quality Account 2012 - 2013
What people say about our organisation
During the year we worked with patients, their families and the wider public to understand what, for
them, is the most important information that will help them to make a decision on the quality of the
services we provide.
What our Patients say
Every year Farleigh Hospice conducts surveys which focus on the quality of care being delivered. The
surveys are carried out by the Independent Service User Facilitator, and are completed throughout the year
by interviewing patients during their stay on the IPU or at the Day Hospices. Independent Practitioner
Audits of the Independent Living Team and the Bereavement Service were also completed to seek
feedback from users of these services. Overall the responses about all these services were positive and
affirming:Comments from Patients in the Inpatient Unit
When asked if they had any suggestions to improve the service most said they could not think of
anything:-
..I’ve never felt
so cared for
I am so pleased
with my stay, I don’t
want for anything
......Farleigh Hospice offers a
wonderful service
All found the cleanliness of the hospice, its outlook and environment excellent
........wonderful
grounds
Home from Home
All felt the quality and choice of food was excellent
...food choice and portions size
enabled me to eat again
Everyone felt their relatives and visitors were well looked after
34
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Quality Account 2012 - 2013
Comments from Patients in Day Hospice
Over 60% of patients had concerns before their first visit to the Day Hospice as they did not know what to
expect, however they all added how relieved they were on attending
I was really scared of racism
.....because of my nationality but my
experience from the word go was the
absolute opposite
I thought it was the
end of the line
but now I love it
When asked about their overall experience attending the Day Hospice everyone felt it was very good or
excellent
..incredible
support .....
Good for me and good
for my family
Meeting people
and having a laugh
... I look forward to
this every week
Comments about the Independent Living Team (ILT)
When asked if they felt satisfied with the advice and support provided
Absolutely
marvellous – more than
I could expect
... Outstanding – can’t
say enough
I can’t believe how
wonderful and how much
you can offer to people
Comments about the Bereavement Service
When asked if they felt satisfied with the advice and support provided
It was so terrific …..
Farleigh Hospice is doing
such a good job
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35
Quality Account 2012 - 2013
What our Carers say –
Farleigh Hospice provides a dedicated service to carers which aims to offer support to carers of hospice
patients across mid Essex and prevent them from feeling alone and isolated. At Farleigh Hospice we
continue to recognise the vital role carers play throughout the year by providing them with their own
support service.
National Carers’ Week took place in June and as part of the campaign Farleigh Hospice held various events.
The aim of this national initiative is to not only recognise the contribution carers make to the community
and the people they care for, but also to provide a platform to raise important issues surrounding their
valuable and often unrecognised work
This year during Carers week Farleigh Hospice carers enjoyed two pamper days, a Strawberry Cream Tea,
and a barge trip. We received lots of positive feedback about the events.
..stress free and
relaxing
much needed time to unwind
Congratulations
for pulling off a
brilliant day!
Carers ‘drop ins’, ‘pamper’ days and candle lit dinners continue to be held throughout the year as part of
ongoing support.
A drumming workshop was also organised for carers using a unique type of instrument referred to as a
‘DJEMBE’, which originates from West Africa. We had excellent feedback and everyone who attended said
they would really like to do it again, so listen out for the sound of drums.
Drumming is known to relieve stress,
give a feel good feeling and be fun
Carers Coordinator
What our staff say
The annual staff survey was run by Birdsong Charity Consulting; on behalf of Help the Hospices. This was a
specialist survey for staff working in hospices and other third sector organizations which allowed
benchmarking of our results with other hospices.
We were delighted to achieve a response rate of 73% (131 staff)
36
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Quality Account 2012 - 2013
Overall high levels of satisfaction were expressed by staff in the survey
General satisfaction can be gauged by the questions
Overall, I am satisfied
with my job
I plan to be working for this
charity in a year’s time
78% agreed
82% agreed
Not only are these high scores, but both these scores were higher percentages than all hospices in the
survey
It was agreed that no other specific actions were required but in conjunction with the Sickness Absence
Working Party proposals it was agreed to introduce an Employee Assistance Programme and Cash Plan. This
was implemented in January 2013 and staff are already expressing appreciation of it benefits.
What our Volunteers say Volunteers are an integral part of Farleigh Hospice and a Volunteers day was organized and run in
recognition of their valued work. The fourth annual Volunteers’ Day took place in October with a higher
level of attendance than previous years. Not only does the event give Farleigh Hospice an opportunity to
show its appreciation of our wonderful team of volunteers, it’s also a great way to update everyone with
what’s been going on, and what’s planned for the future.
I am very impressed with
how the event has been
organised. The team have
been great and really helpful.
Thank you for such an inspiring
volunteer’s day. It was a good top up to
hear of new plans and to meet with other
volunteers who all do such different jobs. I
look forward to next year’s event
I had a lovely time
and learnt lots of
things I didn’t know
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37
Quality Account 2012 - 2013
Volunteer satisfaction surveys were also carried out in the Day Hospices and Information Service and the
Inpatient Unit. In the Day Hospices and Information Service overall the results demonstrated a high level of
satisfaction from the volunteers with their roles, support, information received, facilities and working
environment. The volunteers in the Inpatient Unit showed similar levels of satisfaction and all felt
supported and appreciated by their line manager.
All the staff go out
of their way to say
thank you at the
end of each shift
Staff always thank us for
helping at end of shift
I always feel
respected by the
team I work with
What our Trustees say Two Trustee Provider visits took place in 2012– 13 at roughly six monthly intervals which involved trustees
visiting facilities and interviewing staff, patients and volunteers and checking that services comply with
relevant regulations. The aim is to provide Trustees with an opportunity to inspect and monitor services
and feedback on behalf of the board. The remit of the June visit was to inspect the services we provide to
patients and the November visit to review all aspects of the organisation
A report from each of the visits was discussed at the Governance Group. The comments were positive with
no issues requiring immediate resolution. Action plans were developed to address minor issues which were
followed up and concluded by the Senior Management Team.
As usual with these visits the Trustees were impressed with
the quality of the service delivered, the commitment of the
staff and volunteers who were interviewed and the positive feedback
from patients. In all cases individuals were more than happy to
answer questions helpfully and to participate fully in the process.
38
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Quality Account 2012 - 2013
What the Care Quality Commission say
Onsite inspections were carried out by the Care Quality Commission in April 2012 at Farleigh Hospice in
Chelmsford and in August 2012 at Farleigh Hospice in Maldon
Comments from the review committees:In Chelmsford –
We spoke with two people who use the service. Both said they were made to feel
very comfortable and that they had experienced a good admission process. They
said they were given good information about the hospice before they were
admitted and that they would feel comfortable in raising any issues with staff. Both
people with whom we spoke said they were very happy with the care they were
receiving, with one of the people describing it as 'incredible'. They were very
complimentary about the food and felt that staff were very caring. One person said
that the doctors explained everything well and clearly, whilst the second person
commented that staff attend them very quickly if they called them.
In Maldon –
People we spoke to were very happy with the care and facilities provided at the day
care centre. People told us that they felt informed about their care and treatment
and that the staff team were knowledgeable and caring.
People's comments included
'They treat people here in a dignified way' and 'it’s a pleasure
to come to the day centre'.
…..it can be seen that Farleigh Hospice’s standards are high
and conform to all requirements.
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Quality Account 2012 - 2013
Statement from Mid Essex Clinical Commissioning Group
Mid Essex Clinical Commissioning Group response to Farleigh Hospice Quality Account 2012 - 2013
This is the first year that Quality Accounts are being commented on by Mid Essex Clinical Commissioning
Group (CCG). The CCG welcomes this Quality Account as a commitment to an open and honest dialogue
with the public regarding the quality of care provided by Farleigh Hospice.
Assurance from the CCG is required to ensure that the information in this Quality Account is accurate, fairly
interpreted, and representative of the range of services delivered.
Though the CCG is commenting on a draft version of this Quality Account, it is pleased to be able to assure
the accuracy of the content in general. The CCG is however unable to assure all data reported, as some is
yet to be reported.
You describe processes to monitor your own progress through the year including the involvement of the
Trustees, these appear robust. You give an outline summary of actions taken in the past twelve months
and your vision for year to come. You provide information on a number of quality initiatives undertaken
during the year and we note the opening of your bereavement service “Circle” and activities you have
used to involve people in your services including the Dignity Action Day.
Your priorities for improvement in 2012 - 2013 were supported in part by the shadow CCG through the
agreement of CQUIN schemes which provide a financial incentive to improve quality. In particular support
for developments in information governance and access to data.
In your report there is information about your performance in respect of data quality we note that you are
taking action to improve data quality, and have developed a minimum data set. We also note that you
were involved in the completion of the Information Governance Tool Kit and that you were assessed as
level 2 which is the national requirement. You have provided an overview of your activity giving
comprehensive information which compares your activity to others across the country providing similar
services, although as pointed out this is not timely as subject to national release.
We also note that your measures for patient safety – incidents, accidents and near misses, low infection
rates, and pressure ulcers which have been reported onward as necessary to regulators, but not locally.
Also, patient experience - complaints and compliments and clinical effectiveness – clinical audit of which
you give a comprehensive description of your participation in and learning from clinical audit, although
there were no relevant national audits for you to participate in.
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Your strategic priorities for improvement in 2013 - 2014 are:
1.
Development of a clinical volunteers training programme
2.
End of life care quality markers
3.
Development of information service
4.
Future strategy and service development consultation
In conclusion Mid Essex Clinical Commissioning Group considers Farleigh Hospice Quality Accounts for 2012 2013 as providing an accurate and balanced picture of key issues in the reporting period. The CCG
encourages the organisation to continue to implement the multiple and wide-ranging efforts and
initiatives to improve and be innovative in its delivery of quality in the services delivered.
Carol Anderson
Director of Nursing and Quality
Mid Essex Clinical Commissioning Group
June 2013
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Quality Account 2012 - 2013
Statement from Mid Essex Locality, Essex & Southend LINk
Farleigh Hospice Quality Account 2012-13 submission by Mid Essex Locality, Essex & Southend LINk
“Essex & Southend LINk (E&S LINk), which existed throughout 2012-13 and ceased to exist on 31 March
2013, was divided into five Locality Groups. Its Mid Essex Locality Group covered Chelmsford Borough,
Maldon District and Braintree District and so was the Group which related to Farleigh Hospice and was
responsible for this statement.
During 2012/13 E&S LINk developed a good working relationship with Farleigh Hospice as a ‘critical friend’.
Initially this took the form of correspondence and discussions following its submission to Farleigh Hospice’s
Quality Account for 2011-12 which was the first main contact between us. This led to a greatly improved
mutual understanding of each other’s roles and activities. Farleigh Hospice provided full information in
answer to questions that had been raised and these were confirmed by independent sources.
A presentation about Farleigh Hospice’s services was delivered to the E&S LINk public Mid Essex Locality
meeting on 5 July 2012 and was followed by a full discussion about all relevant issues. This was then a
regular item at all further such meetings until 31 March 2013 and Farleigh Hospice’s Chief Executive
attended some of those meetings. Members expressed their appreciation of Farleigh Hospice’s services and
acknowledged that Farleigh Hospice was regarded by the patients and people in its catchment area as
providing excellent palliative and hospice care services.
Farleigh Hospice’s staff attitudes and clinical practice were of primary concern to patients and were
regarded as being very good. The Dignity and Respect agenda was at the heart of everything that Farleigh
Hospice does.
Turning to the Priorities set for 2012-13:
●
The increase in out of hospital deaths in accord with patients’ wishes was welcomed and the
contribution to this by the Hospice@Home service in Mid Essex was acknowledged; there was hope
that this would continue until everyone in Mid Essex is able to die in their place of choice;
●
The development of a Staff Training Matrix for Mandatory Training and establishment of an
Education and Training Group were welcomed; it was noted that the process of signing off
mandatory training requirements as part of the annual appraisal process is due to be completed by
January 2014; agency, bank and temporary staff must have satisfactory induction and training
as well;
●
The benefits of introducing the LEAN process had improved service efficiency and effectiveness in
the ways reported; this systematic approach was welcomed; patient pathways and experience need
to be constantly assessed, by Executives, Non-Executives and outside monitors; the Board must lead
Farleigh Hospice as a learning organisation and patient stories should be an agenda item at all
Board meetings;
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Quality Account 2012 - 2013
●
The steps taken to connect Farleigh Hospice to the NHS ‘N3’ broadband network computer service
will improve patient care by speeding up diagnostics and decisions about treatment.
Other issues:
●
With the NHS organisational changes on 1 April 2013 it was recognised that new ways would need
to develop to enable patients and public to engage with the hospice movement in Essex and East
of England;
●
This Quality Account describes Farleigh Hospice’s systems for dealing with patient and carer advice
and liaison as an integral part of all its services;
●
This Quality Account gives qualitative and quantitative information about compliments, complaints
and incidents; in future it would be helpful to see incidents reported in line with other health care
providers as to Serious Incidents, Never Events, types of acquired infections and the degrees of
seriousness of ulcers on the 1-4 scale;
●
Before E&S LINk ceased to exist it contributed to consideration of priorities for the future and its
contributions included: because of the extensive use of volunteers attention to their training and
performance was suggested; the introduction of Clinical Key Performance Indicators in line with
other NHS funded providers was suggested; the development of the provision of information and
advice from Farleigh Hospice as an expert provider was suggested; and, the involvement of
stakeholders, patients and public in planning and developing engagement with them generally was
recommended; it was good to see these aspects reflected in priorities for the future.
Janet Doghan, Chief Executive of Farleigh Hospice for a considerable time, announced she would retire in
July 2013. Her great contribution to the development of Farleigh Hospice with best wishes were offered to
her and to all involved with Farleigh Hospice for the future.”
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Quality Account 2012 - 2013
Statement from Healthwatch Essex for Quality Account report 2012-2013
We recognise that Quality Account reports are a useful tool in ensuring that NHS healthcare providers are
accountable to patients and the public about the quality of service they provide. We fully support these
reports as a means for providers to review their services in an open and honest manner, acknowledging
where services are working well and where there is room for improvement.
We welcome the opportunity to provide a patient and public perspective on the Quality Accounts. As a
newly-established organisation (we took on statutory responsibility on 1st April 2013), we are not in a
position to comment retrospectively on the findings of the past year. We will, however, cooperate fully in
the future production of these reports. We are an organisation which intends to provide comment rooted in
evidence – be it ‘soft’ intelligence or more extensive, quantitative data. Following the Francis Report, we
believe there is a significant challenge and opportunity for the whole health and social care system to look
at how evidence relating to patient experience can be set on an equal footing with standard NHS data
about performance and quality.
We share the aspiration of making the NHS more patient-focussed and placing the patient’s experience at
the heart of health and social care. An essential part of this is making sure the collective voice of the
people of Essex is heard and given due regard, particularly when decisions are being made about quality of
care and changes to service delivery and provision.
Our wish is therefore that Healthwatch Essex works with its partners in the health and social care sector to
engage patients and service users effectively and to ensure that their views are listened to and acted upon.
We look forward to working together in the production of Quality Accounts in the coming year and making
sure that the voice and experience of patients and the public form an integral part of these documents. At
a time when the NHS is facing great change and financial challenge, patient experience and quality of care
are more important than ever, and we welcome the opportunity to help shape the NHS of the 21st century.
Statements from Essex Health Overview and Scrutiny Committee
A copy of the Quality Account 2012/13 was forwarded to Essex Health Overview and Scrutiny Committee
but we had not received any comment at the time of publication.
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Appendix A
Audits completed April 2011 – March 2012
DATE
AUDIT
Department
May-12
Audit of Prognostication tool ................................................................................Medical
May-12
Gift Aid....................................................................................................................Fundraising
May-12
Compliance with DNAR..........................................................................................Clinical
May-12
Antibiotic use at Farleigh Hospice ........................................................................Medical
Jun-12
Infection Control - Day Hospice – Farleigh Hospice in Chelmsford ......................Clinical
Apr-12
Food Hygiene Standards Farleigh Hospice in Maldon ..........................................Clinical
Apr-12
Cleaning - Day Hospice Farleigh Hospice in Maldon ............................................Clinical
Jul-12
Patient's Preferred Name ......................................................................................Clinical
Jul-12
Omitted and Delayed Medication April 12 - June 12..........................................Clinical
Jul-12
Patient Falls in the IPU April 2011 - March 2012 .................................................Clinical
Jul-12
Medication Adverse Events April - June 2012 ......................................................Clinical
Aug-12
Communicating with patients and families when a patient has died and
needs transferring..................................................................................................Clinical
Jul-12
Controlled Drugs (CDs) Audits ...............................................................................Clinical
Aug-12
Storytelling and Art Workshops evaluations.........................................................Clinical
Aug-12
Infection Control - Inpatient Unit ..........................................................................Clinical
Aug-12
Gift Aid - Fundraising - April - June 2012 .............................................................Fundraising
Sep-12
Procurement - in progress .....................................................................................Finance
Sep-12
Lantern Suite Room Usage ....................................................................................Clinical
Sep-12
Oxycodone prescribing in IPU ...............................................................................Medical
Sep-12
Santa Fun Runs for Farleigh Hospice 2011 ...........................................................Fundraising
Sep-12
Carers Survey IPU ...................................................................................................Clinical
Aug-12
Audit of Audits .......................................................................................................Quality
Aug-12
Internal Audit .........................................................................................................Quality
Sep-12
Patient Identification Bands IPU............................................................................Clinical
Sep-12
Independent Practitioner Audit - ILT ....................................................................Clinical
Oct-12
Verbal Orders in IPU ...............................................................................................Clinical
Sep-12
Gift Aid - Retail ......................................................................................................Fundraising
Sep-12
Management of Controlled Drugs(CDs) Help the Hospices audit tool ................Clinical
Oct-12
Life Time Value of Donors - Community Fundraising ..........................................Fundraising
Oct-12
Infection Control - Day Hospice Farleigh Hospice in Maldon ..............................Clinical
Oct-12
Omitted and Delayed Medication July - Sept 2012..............................................Clinical
Oct-12
Volunteers Day Evaluation.....................................................................................Fundraising
Aug-12
Farleigh Hospice Occupational Therapy Provision ................................................Clinical
Aug-12
Farleigh Hospice Social Work Provision.................................................................Clinical
Oct-12
Liverpool Care Pathway (LCP) Document Review-...............................................Medical
Oct-12
Compliance with DNAR .........................................................................................Medical
Oct-12
Farleigh Hospice Physiotherapy Provision ............................................................Clinical
Oct-12
Independent Practitioner Audit - Bereavement ..................................................Clinical
Oct-12
Patient Satisfaction Survey IPU 2012 ....................................................................Clinical
Dec-12
Cleaning in Inpatient Unit .....................................................................................Hotel Services
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Quality Account 2012 - 2013
DATE
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Dec-12
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Jan-13
Feb-13
Feb-13
Feb-13
Mar-13
Mar-13
Mar-13
Mar-13
Mar-13
Mar-13
Mar-13
Mar-13
AUDIT
Department
Cleaning in Farleigh Hospice in Chelmsford .........................................................Hotel Services
Cleaning in Lantern Suite ......................................................................................Hotel Services
Respite admissions to IPU ....................................................................................Clinical
NHS Pension Payments ........................................................................................Finance
Planned Preventative Maintenance Farleigh Hospice in Maldon ........................Maintenance
Reactive Maintenance Farleigh Hospice in Maldon..............................................Maintenance
Volunteer Transport Requests................................................................................Clinical
Gift Aid Fundraising................................................................................................Fundraising
Welcome Events – 2012 ........................................................................................HR
Gift Aided Donations by Staff and Volunteers - in progress ................................Fundraising
Regional Oral Care Audit........................................................................................Medical
Planned Preventative Maintenance Retail Shops and Lottery Office ..................Maintenance
Reactive Maintenance Retail Shops and Lottery Office .......................................Maintenance
Information Technology User Survey 2012...........................................................IT
Local Hospice Lottery Life Time Value ..................................................................Fundraising
Staff Survey ............................................................................................................HR
Cleaning all clinical areas, North Court Road........................................................Hotel Services
Planned Preventative Maintenance North Court Road - .....................................Maintenance
Reactive Maintenance North Court Road ............................................................Maintenance
Catering and Menu Survey ...................................................................................Hotel Services
Information Governance Toolkit v 10 ..................................................................IT
Internal Controls Checklist – Finance ....................................................................Finance
Patient Satisfaction Survey – Farleigh Hospice in Maldon ...................................Clinical
Patient Satisfaction Survey – Farleigh Hospice in Chelmsford .............................Clinical
Report on Events targets – compare monthly results .........................................Fundraising
Cleaning in Farleigh Hospice in Maldon................................................................Clinical
Food Hygiene Standards assessment ..................................................................Hotel Services
Omitted and Delayed Medication Oct – Dec 12....................................................Clinical
Open Day including Seeds of Life event 2012 evaluation...................................Fundraising
Walk for Life 2012 evaluation ..............................................................................Fundraising
Mouth Care – in progress .......................................................................................Clinical
Verbal orders 1.10.12 – 31.1.13 ............................................................................Clinical
Clinical Supervision ................................................................................................Clinical
Management of Controlled Drugs (CD) Help the Hospices audit
tool – re-audit of non compliance .........................................................................Clinical
Speed of Response times to Donations 2012 – 2013 – in progress ....................Fundraising
Ambassadors – Role and Support..........................................................................Fundraising
Verbal Orders – 1.2.13 – 28.2.13 ...........................................................................Clinical
Lantern Suite Infection Control .............................................................................Clinical
Volunteer Satisfaction Survey – Day Hospice and Information Service ...............Clinical
Light up a Life (LUPL) survey.................................................................................Fundraising
If you would like further details of the above audits please contact: susan.bridger@farleighhospice.org
46
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Thank you. It is because you care that we can.
www.farleighhospice.org
info@farleighhospice.org
Telephone: 01245 457300
North Court Road, Chelmsford, CM1 7FH
Charity registration no. 284670