Isabel Hospice Quality Account
2012 – 2013
ISABEL HOSPICE MISSION STATEMENT
To deliver a range of high quality, free, specialist palliative and supportive care
services, which meet the physical, psychosocial and spiritual needs of patients,
carers and family members including during bereavement.
To collaborate with other healthcare services in providing co-ordinated services at
an appropriate time and place according to each individual’s needs.
To support and empower healthcare professionals through education and training.
To ensure that service provision is sustainable and continuously improved to match
the evolving needs of the eastern Hertfordshire community
‘All the staff are wonderful, dedicated and caring. They quickly become your friend.’
‘I found staff including volunteers exceptionally caring and I was well looked after. All
my needs were well catered for and I was well cared for. Thank you ALL.’
‘Wonderful care and support. All medical staff were clear in their medical provision
from tablets to Dr’s re my condition and future treatment.’
‘Always feel good when I’m here’ (respite patient)
‘I commend all the staff involved with the group. Paula’s leadership and man
management were the main stay. I would recommend the group to anyone.’
Isabel Hospice
61 Bridge Road East
Hertfordshire
AL7 1JR
Registered charity number: 1046826
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1. Statement from the Chair, Chief Executive and Hospice Director
It gives us great pleasure to present the second Quality Account for Isabel Hospice
for 2012/13. The Hospice is an independent charity (registered number 1046826)
and is constituted as a company limited by guarantee. The charity does not charge
patients, carers or their families for any of the services provided.
Care and support is provided through an integrated team of Community Nurse
Specialists; Hospice at Home nurses and support workers; day services in three
geographically spread locations; a twelve bed in patient unit which also provides
respite care; together with family support team members offering pre- and postbereavement counselling, psychosocial and spiritual care. We also provide benefits
advice, art therapy, complementary therapies and a twenty four hour seven day a
week advice line. In addition, the hospice provides peer support groups such as the
Fatigue and Breathlessness and Living Well with Isabel.
The Allied Health Professionals Team aims to address the physical needs of patients
and their families; assisting them to maintain their dignity and maximise their quality
of life. The physiotherapist, occupational therapist, lymphoedema therapist and
therapy assistant provide treatment programmes across the organisation: in the IPU,
day satellites and in patients’ homes; working as all clinical departments, in close
partnership with the multi disciplinary team.
The clinical teams are led by a Medical Director and Hospice Director. As well the
organisation supports the development of knowledge and skills in the
multidisciplinary workforce by providing education to professionals such as General
Practitioners and staff working in nursing homes; also providing a learning
environment for junior doctors and student nurses.
The hospice is supported by the work of dedicated and hard working corporate teams
such as fundraising, trading, human resources, finance, information management
and volunteers. Volunteers support all aspects of the work of the hospice; with roles
ranging from nurse helpers, drivers, therapists and administration.
The charity is run by a Board of Trustees and has strong corporate and clinical
governance arrangements. These include sub-committees: Assurance and Risk;
Clinical Governance, Finance and Employment and Remuneration. Various
committees/groups report in to these committees such as the Senior Management
Group; Infection Control; Drugs and Therapeutics and Quality Improvement Forum.
Department managers and staff are closely involved in planning and communications
through their own regular meetings with Senior Managers and the Executive.
Hospice management aims to ensure that every member of staff and volunteer feels
valued and then has appropriate access to regular support and/or clinical
supervision. The views of staff are sought through a staff forum and findings form
the ongoing review of the organisation’s corporate and clinical strategies.
Quality is at the heart of the service provided. We evidence this through the Board’s
approach to corporate and clinical governance, and our commitment to staff training
and development. Emphasis is placed on having clear achievable standards which
are audited and regularly monitored.
We develop, implement and maintain systems and processes to ensure that we grow
as a viable and responsible organisation, meeting the needs of the communities we
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serve. We ensure that our services are of the highest quality and deliver the
aspirations set out in our mission statement, philosophy and strategy.
Our philosophy is about recognising the uniqueness of each individual, valuing their
autonomy and promoting choice; it also recognises that each patient is in a continual
state of change – physically, emotionally and spiritually and that staff are sensitive to
these changes, providing care that is competent, sensitive and compassionate.
We put the needs of patients first, treating them as individuals with dignity and
respect and looking ahead to meet their needs in a constantly changing healthcare
climate. Feedback from patients, relatives and carers in the form of forums and
satisfaction surveys is used to develop service provision.
We recognise that the excellent care provided cannot happen without the knowledge,
skills and support of the whole Isabel Hospice team, including the valuable
contribution of volunteers and so our thanks go to all of them at this time.
In the past year the Board and Senior Management have been engaged in a
thorough review of strategy to ensure the Hospice is clear about its priorities and
development plans over the next five years. The headlines of this review are outlined
later in this report.
Many initiatives have been introduced during 2012/13 such as a new performance
review process; improved statutory/mandatory training programme and monitoring;
two hourly ward rounds; Dignity Champions; additionally nurses have been given
responsibilities in their roles including medicines management, clinical audit, diabetes
management, falls prevention and wound care. Nursing assistants have also been
given additional responsibilities such as nutrition; mentoring and advance care
planning.
Isabel Hospice began to implement the Productive Ward in 2011/12; strengthened in
2012/13 (part of the national initiative called Quality, Innovation, Productivity and
Prevention) which is aimed at ensuring organisations maintains the highest levels of
quality whilst promoting efficiency and cost effectiveness. A team of nurses and
nursing assistants lead this initiative and have been delighted at the impact it has had
on improving their ability to provide more timely and efficient care.
We are delighted to present this Quality Account for 2012/13 and, to the best of our
knowledge the information contained therein is accurate.
Signature:
Charles Lewis, Chairman, Board of Trustees
Signature:
Nigel Furlong, Chief Executive
Signature:
Helen Dodd, Deputy Chief Executive and Hospice Director
Date:
31 May 2013
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2. Priorities for improvement and statements of assurance from the
Board 2012/13
Isabel Hospice is committed to continuously reviewing the quality of care delivered to
its patients. Monitoring occurs in clinical and department team meetings; the Board
and sub-committees of the Board such as the Clinical Governance Committee; Audit
and Risk; Trustees annual inspection; Quality Improvement Forum; analysis of
incidents and complaints; undertaking patient and relatives surveys; clinical audits;
self assessment against the Care Quality Commission and the collection of the
minimum dataset required by the NHS, all of which is regularly reported to and
reviewed by the Board. This list is not exhaustive, merely indicative of the amount of
quality monitoring undertaken at the Hospice.
Monitoring is supported by the use of strong information management such as
Crosscare, the Electronic Patient Record.
2.1 Future planning priorities
The key priorities for improvement are highlighted in priorities 1 - 6, however in
addition to these; Isabel Hospice has identified other key areas for development,
many of which are already underway. These include:
 Further enhancement and development of the long term strategy
 Re-launch of the clinical supervision programme
 Implementation of revalidation for doctors
 Roll out of the ACP volunteers
 Recruitment of a specialist Infection Control Lead to undertake a full review of
Isabel Hospice infection control policies and procedures
 Transition from Graseby syringe pumps to McKinley T34 syringe pumps
 E learning roll out
 Implementing the review of the Policy Development Framework
 Strengthen the management of complaints and incidents
 Continue strengthening the uptake of statutory/mandatory training
programmes with an emphasis on bank nurses and doctors and
implementation of a process to inform staff when they are due to repeat
specific statutory/mandatory training
 Increase the delivery of the Fatigue and Breathlessness management
courses to cover the full geographical area, and start to consider other
programmes targeted at empowering patients
Priorities for improvement – Patient Safety
During 2012/13 a clinical audit was undertaken of pressure ulcer prevention and
documentation and it was identified that improvements could be made.
Diabetes management in the inpatient setting is one of the national clinical priorities
for 2013/14. In view of this it seems timely for Isabel Hospice to have a clearer
understanding of the best practice and any improvements required so that it can
report it is learning and progress with improvements in next year’s quality Account,
alongside NHS providers. The organisation recognises that Diabetes management in
the end of life setting can be challenging and has already recognised that a
strengthened training programme for staff would be beneficial.
Priority one - Pressure ulcer prevention and management
By the end of 2013/14, the charity aims for all nurses and nursing assistants across
the inpatient unit and Hospice at Home team to be able to grade all pressure ulcers
on admission and discharge according to the NICE guidelines 2005 (CG29)
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Prevention and Treatment of Pressure Ulcers, to routinely use body maps to
document all pressure ulcers and any other marks on the skin such as bruises, tears,
burns, rashes and so on and ensure pressure ulcer prevention measures match
standards documented in the NICE guidelines 2005 for Pressure Ulcer Prevention
and Management. All pressure ulcers grade 2 or above will be reported using the
incident reporting process and there will be timely reporting of pressure ulcers grade
3 or above to the Care Quality Commission if developed whilst in inpatient care or
admitted to our care from previous care providers.
A clinical audit of practice was undertaken in 2012/13 against NICE 2005 standards
was undertaken and at the time of writing this report a report is under publication with
subsequent action plan to follow.
Documentation on this aspect of care can be complicated on the electronic patient
record as there are several places where assessment and care planning can take
place so the electronic patient record system will be reviewed to ensure that
documentation can be simplified; guidance will be provided to staff on how and
where the document the required information.
A training programme will ensure that all nurses and nursing assistants are trained
on requirements; once fully implemented there will be a re-audit to assess
compliance and to see if practice is embedded.
Progress will be monitored through the Quality Improvement Forum through to the
Clinical Governance Committee.
Priority two - Diabetes management
An audit of clinical practice against national standards will set the direction for
identifying best practice and/or improvements within the inpatient setting. Once an
audit has been undertaken, findings will be reviewed by the Quality Improvement
Forum and a plan developed to disseminate learning and implement changes. Part of
the review will determine how easy it is to document assessment and care planning
on the electronic patient record system.
Two nurses from the inpatient unit will lead on the review, dissemination of learning
and programme to implement improvements, supported by the Quality, Compliance
and Training department.
It is expected that competencies for diabetes care will be developed and
implemented through 2013/14 and in to 2014/15.
The results of audit will be presented at the Clinical Audit presentation sessions.
Progress will be monitored through the Quality Improvement Forum through to the
Clinical Governance Committee.
Priorities for improvement – clinical effectiveness
2013/14 will see the full implementation of a Patient Reported Outcome Measure for
Isabel Hospice. This will be the assessment of pain and symptoms using the
Edmonton Symptom Assessment Scale (ESAS).
Many patients are admitted to Isabel Hospice for symptom control and the ESAS is
used for some patients however Isabel Hospice would like to see ESAS used in a
more robust way.
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Priority three - Full implementation of Edmonton Symptom Assessment Scale
The standards are:
Pain assessment
 All in-patients will have a daily pain score documented on their observation
charts
 A Numerical Rating Scale scoring between 0 and 10 will be used
 A formal standard for assessment and response to pain scores will be jointly
developed and implemented by the inpatient unit medical and nursing teams.
Symptom assessment
 To standardise symptom assessment and review, a new symptom
assessment tool will be introduced
 The tool has previously been used in the Day Hospice and for initial
assessment of medical out-patients and will now be used routinely in the IPU
on admission and to assess response to specific interventions, such as blood
transfusions.
The ESAS will be implemented in January 2014 when staff have had training on its
use, when the implications for recording on the electronic patient record have been
completed and the new doctors to be recruited are settled in to their posts.
The project will be monitored by the Medical Team, with progress documented
against an action plan, reporting to the Quality Improvement Forum. Audits will be
undertaken at regular intervals to ascertain gaps in implementation and take early
remedial action.
Priority four - Strengthening the implementation of NICE quality standards,
technology appraisals and guidelines
During 2012/13 Isabel Hospice began to review its systems and processes to
determine where it met best practice for its implementation and where improvements
could be made. This work will continue in to 2013/14.
A review of Isabel Hospice compliance against the NICE quality standards for End of
Life Care for Adults (2011) using the End of Life Care Quality Assessment (ELCQuA)
tool. A group of clinicians will undertake the review supported by the Quality,
Compliance and Training department.
An action plan will be developed if any gaps are identified and progress will be
monitored by the Quality Improvement Forum through to the Clinical Governance
Committee.
Priorities for improvement – patient experience
Priority five - Agree service strategy with East & North Herts Clinical
Commissioning Group
This priority has been carried forward from last year; significant progress has been
made but more work is required as the new CCG takes over from the PCT as our
commissioners. It is anticipated that 2013/14 will be a transitional year during which
strategy is developed together and in consultation with service users.
The focus of the strategy will be on providing patients with the best possible
experience in the place they call home, commensurate with their safety and their
family’s/carers needs or for those who are more mobile at a place most convenient to
attend. This will entail revising the balance of resources deployed by the Hospice
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with the community nurses and the inpatient unit and improving the quality of service
delivery in the community by all healthcare professionals, in particular developing a
clear service proposition for care:
 at home (or the place the patient calls home i.e. it could be a nursing home)
 at a local centre for day and outpatient services
 at the In Patient Unit for those needing 24/7 residential care
Measures
As a result of the research undertaken in 2012/13 a set of Key Performance
Indicators (KPIs) has been identified via Help the Hospices. These KPIs have been
developed to assist hospices in the process of assessing their impact rather than
simply levels of activity. The working model that we plan to develop is structured as
follows:
Outcomes
Proportion of patients cared for in location of choice
Proportion of patients dying in own home
Reach
Proportion of spc eligible patients cared for
Proportion of spc eligible patients by disease
Quality
Patient reported feedback
Family/carer reported feedback
Efficiency
Unit costs
Value added (up-stream savings)
Sustainability
Cost/income ratio
Reserves ratio
The Senior Management Group will monitor progress, using accurate data collected
from Crosscare and the skills of the auditor. Reports will be received by the Board
from the Clinical Governance Committee
Priority six - Planning for reconfiguration of services at QE2 site in Welwyn
Garden City
Again this is work in progress brought forward from 2012/13 (there have been delays
outside the control of the Hospice) The Hospice’s inpatient unit is currently attached
to the QEII hospital which will be replaced by a new local general hospital on an
adjacent site by the middle of 2015. The Hospice is exploring options for a rebuild
that will put the patient experience at the heart of the design concept and act as a
hub for the community developments envisaged by the strategic plan.
The project team will examine the end to end processes this will entail so that the
needs of patients that are identified earlier in their disease journey can be better
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served and that if and when In Patient Care is required this is provided in the best
possible affordable premises.
This process design work will inform later design briefings given to architects, and will
involve a wider range of stakeholders including GPs and other healthcare
professionals, our catering and cleaning contract partners and patients themselves.
Success criteria
 Ease of access
 Ease of use
 Fit with community services
 Patient satisfaction with services, physical environment and ambiance
 Financial viability
Success will be monitored by the Board of Trustees who will receive regular reports
from the Senior Management Group and Project team.
2.2 Statements of Assurance
The Hospice underwent a series of internal and external reviews throughout the year.
External
1. Contract reviews by the East & North Herts Clinical Commissioning Group
The Hospice meets quarterly with the Contract Manager representing the End of Life
Commissioner for East and North Herts Clinical Commissioning Group (successor
organisation for NHS Hertfordshire) and key finance, performance management and
clinical activity indicators are reviewed and discussed as appropriate.
2. Care Quality Commission (CQC)
In June 2012 Isabel Hospice had an unannounced CQC inspection. This highlighted
compliance in the following outcomes:
 Outcome 01: Treating people with respect and involving people in decisions
about their care
 Outcome 04: People should get safe and appropriate care
 Outcome 07: People should be protected from abuse and respect their
human rights
 Outcome 16: The service should have quality checking systems to manage
risks and assure the health, welfare and safety of people who receive care
Isabel Hospice did not immediately fully meet Outcome 14: Staff should be properly
trained and supervised, and have the chance to develop and improve their skills; an
improvement was required on the number of staff completing appraisals and the
number of staff completing the statutory/mandatory training programme.
However in October 2012 a new appraisal and performance review process was
implemented and by March 2013 all departments completed undertaking these
reviews with all their staff.
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Uptake of appraisals in clinical areas:
Clinical area
Inpatient Unit
% uptake
100
Clinical area
% uptake
100
Community
Family Support
100
Quality, Compliance & Training
100
Medical
100
Allied health professions
100
Uptake of appraisals in non-clinical areas:
Non-clinical area
Trading shops
% uptake
100
Non-clinical area
Trading Head Office
% uptake
100
Volunteers
100
Fundraising
100
HR
100
IT
100
Finance
100
Facilities Management
100
Executive office
100
As a result of the CQC assessment, the statutory/mandatory training programme was
reviewed and additional dates added. Two new providers have been found for
Conflict Resolution/Lone Worker and Child Protection so the uptake for these is
expected to significantly improve in 2013/14.
The table below demonstrates compliance across clinical areas of the main
statutory/mandatory requirements.
Department
FIRE
Moving &
Handling
Equality &
Diversity
Hand
Washing
Moving &
Handling
non-clinical
Allied Health
Professions
100%
100%
100%
75%
N/A
Family Support
89%
N/A
100%
78%
56%
Community
95%
90%
86%
95%
N/A
100%
N/A
100%
N/A
100%
Medical
40%
60%
80%
60%
N/A
Medical Admin
100%
N/A
100%
100%
50%
72%
66%
81%
78%
N/A
IPU Admin
100%
N/A
100%
100%
67%
Education
100%
100%
100%
100%
100%
Community Admin
IPU staff
3. Revalidation of doctors through the General Medical Council
Revalidation is the process, introduced in December 2012, by which the General
Medical Council will confirm the continuation of a doctor’s licences to practice in the
UK. Its purpose is to assure patients and the public, employers and other healthcare
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professionals that licensed doctors are up to date, complying with the relevant
professional standards and fit to practise. Licensed doctors will have to revalidate
every five years.
As part of the revalidation process for Isabel Hospice doctors, the hospice has joined
the East & North Herts NHS Trust medical appraisal programme to ensue robust
annual review of individual doctor’s performance. We are also working jointly with
Garden House Hospice, in North Hertfordshire, to share expertise in implementing
the revalidation process. The current Isabel Hospice doctors are due to revalidate in
2014.
4. Cancer peer review
The East Herts Specialist Palliative Care Multidisciplinary Team (MDT) is part of the
Mount Vernon Cancer Network and is hosted by East & North Herts NHS Trust. The
MDT is comprises two services:
 Queen Elizabeth II Hospital (E&N Herts NHS Trust) Specialist Palliative
Care Team
 Isabel Hospice (in-patient unit, day hospice and community teams)
In 2012-13, the MDT participated in a self assessment as part of the National Cancer
Peer Review Programme. The programme is led by the National Cancer Action
Team and includes expert clinical and patient/carer representation, provides
important information about the quality of clinical teams and a national benchmark of
palliative care services across the country.
The MDT performed well in the self assessment, achieving 88% compliance with the
review measures, demonstrating the high quality care we provide to our patients. The
MDT is now working to improve on this performance for the repeat review in 2013-14.
5. Commissioning for Quality and Innovation Incentive Scheme (CQUIN)
Below is a table showing the agreed CQUIN targets for 2012/13 and the Isabel
Hospice performance against these targets:
CQUIN
Number of requests that were inappropriate for
any reason
Target
<20%
Actual
3.4%
Average length of stay at unit
>80%
81.4%
<13 days
9.72 days
Number of HNA completed on admission to IPU
>85%
100%
Number of end of treatment plans completed for
transfer
>85%
100%
Hospice at Home – Number of deaths at home
target
>50%
68.66%
Community specialist team - number deaths at
home target
>50%
52.52
Number of patients offered ACP with no offer or
ACP at the time of admission
>85%
97.44%
Average length of stay
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Internal
6. Review of terms of reference of the Senior Management Group
Following agreement with the Board of a new strategic direction with its focus on
quality, and community service development, the Senior Management Group
membership was strengthened by the addition of Heads of Department responsible
for Clinical Quality, Community Nursing and strategic planning.
7.Trustees unannounced inspection
The Trustees undertake an annual unannounced inspection. This inspection looks at
the quality of the care environment, quality of care and quality of documentation and
interviews patients, their families, Hospice staff and volunteers to inform their
findings. In 2012/13 the Trustees inspection revealed a requirement to update and
improve the complaints file and review the storage of large equipment. Both actions
have been achieved.
8. Review by University of Hertfordshire of training provision for student
nurses
In October 2012, the University of Hertfordshire jointly undertook a review with the
inpatient unit of the provision of student nurse education. The audit is biannual. The
hospice passed all standards set by the university however it agreed to ensure that
one or two mentors would undergo additional training as sign off mentors; important
for student nurses who are about to become qualified nurses and, to share its
Equality and Diversity policy.
9. Staff attitude survey
The second Staff Attitude Survey was conducted in September with 82 staff
completing it; although the numbers show a decrease since the 2011 survey the
results remain statistically viable.
The survey replicated the 68 questions across 8 categories from the previous survey
and the results can be used as an indication of employee engagement together with
a measure of the effectiveness of the changes introduced over the last 12 months.
Key Findings:
 Significant increase in participation by staff working in the shops which may
be attributed to the appointment of a Retail Operations Manager
 Results show an improvement in internal communication, indicating
employee’s understanding of the strategic direction and values of the
organisation has increased. This could be attributed to the greater
involvement of managers in discussions relating to strategy and planning;
actions for this year include the continuing management involvement with the
strategic planning process and coaching of line managers in supporting staff
in a fair and consistent manner
 The highest positive rating of the survey was for ‘I feel proud of the service
the hospice gives to our patients‘. This together with high scores for Team
Working indicate that staff feel loyal to the organisation and feel they are well
managed with achievable and meaningful objectives
 Training and Development continues to score lower than other areas and
whilst all statutory and mandatory training is provided in line with the
organisations legal obligations, opportunities for staff to develop skills and
expertise is an area that will be focussed on in 2013
 Whilst staff acknowledge the impact of the economic climate on the
availability of funds for pay awards, results indicated concerns over the lack of
a formal appraisal process. A new Performance Review system has now
been introduced linking pay to organisational objectives and completion of
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mandatory training. Scores in this area should significantly improve in this
years survey.
10. Review of education and training strategy
During 2012/13 a Learning and Development Strategy Group was developed. The
remit of this was to review all training provision across the organisation; including the
statutory/mandatory programme; clinical development and professional development.
This led to the commitment of extending the organisation’s statutory/mandatory
programme and decreasing the frequency of some of the statutory/mandatory topics
such as safeguarding vulnerable adults from three years to two years. Training
providers were reviewed in terms of value and cost and the Human Resources
department have worked closely with the provider of the human resources electronic
system to implement during 2013/14 a process where staff are formally notified by
the system when training is due.
11. Review of Quality Improvement procedures and reporting
During 2012/13 the new Head of Clinical Compliance and Training led a review of the
systems for assuring quality improvement within clinical areas. As a result the
Clinical Audit Forum was transformed in to the Quality Improvement Forum. Whilst
clinical audits continued to be reported to the committee, other key aspects of clinical
quality were included such as patient/user satisfaction surveys; progress with NICE
implementation; management of central alerts; specific projects such as ACP
volunteers and Dignity Champions and compliance with the Care Quality
Commission outcomes
12. Clinical audits
Clinical audit is an essential element of assessing and monitoring the quality of care
provided. During 2012/13 a programme of audits was in place across inpatient and
community care; undertaken by doctors and nurses.
Below is a list of some of the audits that took place AND were reported during
2012/13. Note that if an audit took place in February and March 2013 that the
outcomes will be reported and actions taken forward in the following year (i.e.
2013/14):
Use of abbreviations in clinical record Discussion
keeping
DNACPR
and
documentation
of
Implementation of the two hourly ward Opioids in palliative care: Safe and
rounds
effective prescribing
Controlled drug prescribing
Risk of falls & prevention
Liverpool Care Pathway
Oxygen prescribing
Pressure ulcer management
Policy sign off
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3.Review of quality performance
stakeholders in 2012/13
and
engagement
with
other
3.1 Review of Quality performance 2012/13
Services provided
 Community – clinical specialist nurses, palliative care support workers and
Hospice at Home
 Day care from Hall Grove, Welwyn Garden City, Stockwell Lodge in Cheshunt
and Thorley in Bishops Stortford
 In-patient care
 Cross setting i.e. medical input, psychological therapy, art therapy,
lymphoedema therapy, bereavement counselling, complementary therapies
such as massage, and the support of allied health professionals such as
physiotherapy and occupational therapy
 Specialised clinics such as Fatigue and Breathlessness and teenage
bereavement
How funded
37% of charitable costs (33% of the costs of running the Charity) are met from the
NHS contract with the commissioning organisation, which requires the Hospice to
provide a minimum level of care for NHS patients. The rest is received through
fundraising and trading activities.
Key achievements in 2012/13
Appraisal system:
As already highlighted, the implementation of the new appraisal system was a huge
success. This could not have been achieved without the strong leadership from the
human resources department and the managers who implemented it.
Statutory/mandatory training:
The improvements in the uptake of the statutory/mandatory training programme are
also notable. Strengthened monitoring of uptake, targeted invitation to specific staff
and follow up of those who did not attend were important added functions.
Community and day services:
Community and day services underwent significant change during 2012/13. There
was a reconfiguration of workloads for CNS’s to improve the Hospice at Home
(H@H) service developments; establishing a service seven days per week from 9am
to 9pm with the aim of supporting patients with their preferences to die at home.
The CNS and medical teams support the East of England GP End of Life Facilitator
role and actively deliver the training requested by East Herts GPs in the Lower lea
Valley, Upper Lea Valley and Stort Valley and Welwyn and Hatfield.
A dedicated Community Nurse Specialist continues to act as an End of Life
Facilitator programme; working in care homes in partnership with Peace Hospice,
and Hospice of St Francis for a further year; until 31st March 2014.
The Day Services review has entailed sourcing a more conducive venue for larger
groups, again within current constraints of staffing. Stockwell Lodge facilities have
allowed us to join the smaller services offered at Waltham Cross and Hailey View.
We have so far had positive feedback regarding the facilities as well as increased
referrals.
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Day Hospice services has always been recognised as a popular service as a way to
support patients with life limiting illness. The merging of H@H and day services
under one umbrella team has allowed for creative thinking to review the benefits as
well as the gaps in the current delivery of care in our day services.
In 2013, Isabel Hospice implemented a pilot programme called, “Living Well with
Isabel.” This programme is a series of sessions for patients and carers; covering
topics aimed at helping them with the changes and challenges of living with a life
limiting illness.
The sessions are an opportunity to receive and share information. The topics are
chosen that may benefit patients and carers and are based on feedback given by
patients and carers known to our services. Sessions are facilitated by various
members of the Hospice multi professional team.
Incidents management:
The management of incidents was moved to the Quality, Compliance and Training
department. Staff who report incidents are now routinely informed about progress
made with incidents and informed when they are closed, along with being advised of
the outcome. Learning within clinical departments takes place through the clinical or
staff meetings and the Head of Clinical Compliance and Training works with other
departments to ensure any cross-department learning can take place. An audit of
incident management has been undertaken (report due in May 2013). A preliminary
key finding is that the incident report form may need to be re-designed or an
electronic system implemented.
Patient Experience Surveys:
The Quality, Compliance and Training department supports clinical departments with
the management and reporting of Patient Experience surveys. During 2012/13 the
format and reporting of all surveys was reviewed, along with plans to make
improvements that are highlighted. The Friends and Family Test was introduced, for
implementation in all surveys from April 2013 and a recommendation from the Picker
Institute (2012) was introduced to surveys in 2012. Surveys take place across almost
all areas of clinical practice including bereavement care, inpatient, day services and
children’s services. During 2013/14 the focus will be on improving the response rate
from surveys distributed.
Infection Prevention and Control:
There were no infection control outbreaks within Isabel Hospice, including norovirus,
despite there being norovirus in local partners and having such unwell patients. This
is a commendation to the staff who understand the importance of good hand hygiene
procedures. The Infection Control Committee reviewed its terms of reference and a
draft reviewed Infection Control Strategy is pending approval. The sluice room in IPU
has been replaced with all new and up to date equipment; further reducing the risk of
infection to staff and patients.
Clinical risk registers:
A thorough review was undertaken of all clinical risk registers which resulted in one
agreed format and enhanced documentation of risks with a regular process for
review. Managers were given basic level instruction on completion, review and
robust version control. During 2013/14 further training will be provided. Risk
registers are reviewed by the Trustee lead for Clinical Governance, Hospice Director
and Head of Clinical Compliance and Training. Risks rated above 12 are placed on
the Strategic Risk Register and discussed at the Assurance & Risk Committee.
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Achievement against Quality Account targets for 2012/13:
The following are significant achievements against the 2012/13 targets reported in
last year’s Quality Account:
Falls prevention:
A detailed audit was undertaken which highlighted improvements could be made to
prevent falls. As a result of this audit, all staff in the inpatient unit are undergoing
training on the newly designed falls risk assessment and care plan windows on
Crosscare and the re-designed moving and handling risk assessment. From April
2013 all patients will be assessed for the risk of falls within six hours of admission.
The two hourly ward round template has been revamped to ensure that risks of falls
are routinely considered at each encounter with patients. We have identified that
patients with a high risk of falls are more prone to falls in one particular corridor of the
inpatient unit. With this information we can now implement strengthened risk
management to help prevent falls in this area. Other falls prevention methods are
under review including a review of the use of safety sides (bedrails) and electronic
equipment to detect movement at the earliest opportunity that may result in a fall. It is
expected that the changes will take a while to effect a reduction in the number of falls
especially as confidence in incident reporting increases and patients are naturally
very unwell when entering a hospice setting. A re-audit will take place towards the
end of 2013 to assess the success of the new procedures.
Drug errors:
During 2012/13 a new drug incident report form was introduced. This was to enable
improved reporting and improved documentation of the management of incidents. A
programme of competencies assurance has been introduced in relation to various
aspects of drug administration including controlled drugs, oxygen therapy, syringe
pumps, blood transfusions, intravenous medications and PEG and NG tube. A
Practice Development Nurse was recruited to manage this process. She is
supported by a Lecturer/Practitioner. There was an increase of five drugs incidents
on the previous year; however this is attributed to increased confidence in reporting
and management.
Sharps in juries:
There were four reported sharps injuries in 2012/13 compared to one in 2011/12. A
review of practice has taken place and new equipment is now in use so a reduction is
expected during 2013/14.
Infection rates:
Four patients were admitted with MRSA and two with C Diff from other care
providers; however none of these were transmitted to other inpatients; a reflection on
the sound use of universal precautions.
Crosscare (electronic patient record system):
The Crosscare Enhancement Group continues to strengthen the documentation of
clinical care through the review of Crosscare windows. The group has a work plan
with priorities identified through to March 2014. Outcomes of clinical audits that
require changes to be made to Crosscare are taken through to the group. One audit
highlighted the need for change but the changes were outside of the remit of Isabel
Hospice so have been fed up to the manufacturer in the hope that the changes
recommended will benefit all other care providers who use the system.
E learning:
With so many quality improvement initiatives underway during 2012/13 this was
delayed for implementation until 2013/14. A pilot module; data protection, has
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however been designed and will be rolled out in May 2013. Further modules will be
developed.
Medium term strategy:
Our strategic review process this year has shown that:
• There is inequality of Specialist Palliative Care delivery across eastern
Hertfordshire
• The Hospice is not achieving all its impact measure targets
• Circumstances are forcing change (e.g. closure of QE2 Hospital in Welwyn
Garden City)
• The Hospice spends more money each year than it receives from regular
income sources and is over-reliant of irregular receipts and reserves.
• In client terms coping with this change requires:
– An improved service delivery model to manage demand which
outstrips our ability to supply the needs of all our community
• In financial terms coping with this change requires:
– Improved cost: income performance
– A capital injection of up to £10m over the plan period
• Addressing these issues in the short term will facilitate wider changes in the
medium term by enabling:
– Investment to improve the In patient Unit when the old QE11 is
demolished
– Investment in care in the community throughout eastern Hertfordshire
• Over a planning horizon of 5 to 10 years this should enable Isabel Hospice to:
– Continue to deliver the existing/improved range of services
– Deliver services from fit-for-purpose buildings in clients’ localities
– Achieve all our impact measure targets and our mission.
3.2 Stakeholder engagement
Isabel hospice has worked closely in the following ways with a range of
stakeholders including:
 Patients, carers and their families
 GP’s in their role as providers of care as well commissioners
 PCT - regular review meetings and mapping exercises
 Mount Vernon Cancer Network; often providing training for them to other
health care professionals across the sector
 University of Hertfordshire – to provide training to pre-registration student
nurses
 Carers - a forum to ascertain their views and experience
 Care providers across the country where a patient may wish to relocate in
order to meet their preferred priorities of care
 One Clinical Nurse Specialist works closely with nursing home providers;
supporting nursing staff with delivery of care. The Hospice also works closely
with schools, helping to create an understanding of the work of the Hospice
 The East And North Herts Acute Trust – clinical supervision for CNS’s
provided by a psychologist
 Specialist equipment providers to meet the specific care needs the patients
and community we serve.
 Work in partnership with Citizens Advice Bureau on provision of Hospice
Benefits Advisor
 Hertfordshire Local CD Intelligence Network
 Hertfordshire Urgent Care and pharmacies
 Continuing Healthcare
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Statement from End of Life Commissioner for 2012/13
Isabel Hospice has continued in 2012/13 to maintain the high standards of care and
intervention expected by its Hertfordshire Commissioner.
Offering a range of services for those with palliative care needs and particularly
those within the last year of life, the Hospice remains a valued and valuable resource
to its patients as well as relatives and carers.
Of particular note is the willingness of the Hospice to support a range of initiatives
which has included supporting the education of health and social care students,
supporting Dying Matters week and the Hospices involvement in the local
community.
Under new CCG arrangements, the Hospice remains a keen and willing partner to
continue to develop best quality practice in supporting those who are at the end of
life or need a Hospice environment.
The Hospice will in 2013/14, be further developing it’s services through
implementation of the Friends and Family Test, as well as monitoring those it cares
for through use of the NHS Safety Thermometer.
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