Quality Account
April 2012 – March 2013
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Keech Hospice Quality Accounts 2012 - 2013
Table of Contents
Table of Contents............................................................................................................................................................................................................................. 2
Report from the Chief Executive Officer ....................................................................................................................................................................................... 4
Our vision ......................................................................................................................................................................................................................................... 5
Report from the Clinical director .................................................................................................................................................................................................... 5
Priorities for improvement and statements of assurance from the board ....................................................................................................................................... 8
1. Improvement ............................................................................................................................................................................................................................. 8
Priorities for improvement in 2013 – 2014 .................................................................................................................................................................................... 8
2. Review of services .................................................................................................................................................................................................................. 11
3. Participation in Clinical Audit ............................................................................................................................................................................................... 12
4. Research .................................................................................................................................................................................................................................. 12
5. Use of CQUIN payment framework ...................................................................................................................................................................................... 13
6. Statement on the Care Quality Commission ......................................................................................................................................................................... 13
7. Data Quality ............................................................................................................................................................................................................................ 13
8. Information Governance Toolkit ............................................................................................................................................................................................ 14
9. Clinical coding error rate ........................................................................................................................................................................................................ 14
10. Organisational Structure ..................................................................................................................................................................................................... 15
ADULT SERVICES .............................................................................................................................................................................................................................. 16
11. Adult Service Statistics ....................................................................................................................................................................................................... 16
Breakdown of patients using the service ...................................................................................................................................................................................... 17
Patients who have accessed more than one service ..................................................................................................................................................................... 18
Adult Inpatient Unit Activity ......................................................................................................................................................................................................... 19
Comparison of bed nights.............................................................................................................................................................................................................. 20
Breakdown showing reasons for overnight stays ......................................................................................................................................................................... 21
Keech Palliative Care Centre Patient numbers ............................................................................................................................................................................. 22
Care Centre services patients have accessed: .............................................................................................................................................................................. 22
Carer Activity ................................................................................................................................................................................................................................. 23
Services accessed by relatives and carers..................................................................................................................................................................................... 23
Other activity undertaken by Adult Services ................................................................................................................................................................................ 24
12. Accidents, Incidents, Complaints and Compliments.......................................................................................................................................................... 25
13. Infection Control ................................................................................................................................................................................................................. 28
14. Safeguarding ....................................................................................................................................................................................................................... 28
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Keech Hospice Quality Accounts 2012 - 2013
CHILDREN’S SERVICES ................................................................................................................................................................................................................... 29
15. Children’s Service Statistics ................................................................................................................................................................................................ 29
Breakdown of patients using the services year to date................................................................................................................................................................ 30
Patients who have accessed more than one service ..................................................................................................................................................................... 31
Children’s In-house Activity .......................................................................................................................................................................................................... 32
Occupancy 2012/13 ....................................................................................................................................................................................................................... 32
Bed nights 2012/13
......................................................................................................................................................................................................... 32
Children’s Community Activity .................................................................................................................................................................................................... 33
16. Accidents, Incidents, Complaints and Compliments (Children’s Service) Accidents .................................................................................................... 34
Compliments received about the children’s service ..................................................................................................................................................................... 35
17. Infection Control ................................................................................................................................................................................................................. 36
18. Safeguarding ....................................................................................................................................................................................................................... 36
19. Quality and Compliance...................................................................................................................................................................................................... 37
20. Surveys ................................................................................................................................................................................................................................ 43
21. Systmone ............................................................................................................................................................................................................................. 44
22. Research .............................................................................................................................................................................................................................. 44
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Keech Hospice Quality Accounts 2012 - 2013
Report from the Chief Executive Officer
Together with the Board of Trustees, I would like to thank all our staff and volunteers for their achievements over the past
year. Despite the current economic climate, the Hospice has continued to increase the number of people it supports,
providing a wide range of services whilst remaining financially sound.
At Keech Hospice we strive to continually deliver safe and innovative services, whilst giving reassurance that the
organisation as a whole has patient care and quality at its core. The safety, experience and outcomes for all our patients
and those close to them are of paramount importance to us. We continue to actively seek the views of everyone who
comes into contact with our services to enable us to gain insight into the care people want and the quality they expect.
Once again our regulators have assessed the treatment and care provided by the Hospice as being of high quality.
Following our unannounced CQC inspection in May 2012, the Care Quality Commission found that there were no shortfalls in the services
provided by the Hospice. This is a tribute to the hard work of staff and volunteers who work so tirelessly for Keech Hospice and to our culture
of continuous quality monitoring in which any shortfalls are identified and acted upon quickly.
I am responsible for the preparation of this report and its contents. To the best of my knowledge, the information reported in this Quality
Account is accurate and a fair representation of the quality of healthcare services provided by our Hospice.
Mike Keel
Chief Executive officer
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Keech Hospice Quality Accounts 2012 - 2013
Our vision
Our Vision is that High quality Palliative care is available to all who need it in our community.
Our Mission statement:
We will be the patients champion,
We will seek out all the people that need palliative care, ensure their needs are assessed and ensure that they are
addressed in the way they choose.
We will be the voice of palliative care in our community
By doing this the charity will be supporting the health, social and educational services to meet their obligations
Report from the Clinical Director
This has been another successful year in delivering services for our patients, children and families. This year has
been particularly marked by the launch of our new Care Strategy. The strategy has been shared with a range of
stakeholders and partners.
Our new strategic objectives are:
1. Providing Excellent Care – to ensure that patient’s children and families receive outstanding care from all they come into contact with.
2. Wider Reach – To lead the provision of Community services in order to ensure that excellent care is delivered to patients in their own
home (or care home)
3. Right Choices – To ensure that the preferred place of care for all patients and families is recorded and communicated across the whole
health system.
4. Value for money – To ensure better value for money across our hospice services
5. Working together – To build on and develop further partnerships with health and social care professionals in our area
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Keech Hospice Quality Accounts 2012 - 2013
Adult Services
We continue to support a large number of patients and carers through our day therapy services in Keech Palliative Care Centre. This model of
programmes of therapies devised against patient outcomes is proving to be a great success as well as attracting interest from other Hospices.
In addition to this work we have been piloting pathways for End of Life care patients with non-malignant diseases. We now host the Multi
Disciplinary Team meetings (MDT) for Cardiac Failure patients, Respiratory patients and patients with chronic Neurological conditions. We are
working closely with professional from the community and the hospital on this work. One of the goals of this work is to improve standards of
care whilst reducing Hospital admissions.
This year the Adult Inpatient Service has seen an increase in patients from a younger age range and increased number of patients dying with
us; this has resulted in an increase in the complexity of the work load. We continue to offer support though our telephone advice line and Outof-Hours service.
Occupancy numbers have dropped slightly this year and a shortage of Macmillan Nurses has had an impact on referrals to us because
Macmillan Nurses are a frequent point of referral. We are monitoring the situation closely.
Last year the hospital conducted an audit of cancer patients admitted for emergency reasons to the hospital via A&E. Whilst they expected to
find that the primary reason for admission was due to crisis episodes it in fact showed that many of these patients were admitted for palliative
reasons (73%), and 50% were not known to the community service and therefore the hospice. The main reason for this is thought to be that
they were still early in their disease process but needed interventions to help them. This presents a challenge for the wider Palliative Care
Partnership, including ourselves, in identifying those patients. It is up to the Partnership to work closely with specialist units to ensure these
patients are not ‘lost’ to the local system. These results could suggest that the increased attention on end of life care ma y be distracting
awareness from people with a cancer diagnosis who need palliative care early in their journey.
The Voices survey published in early 2012 did not show Luton in the best light and in response to this and the survey above, the Acting CEO of
Luton Clinical Commissioning Group, the CEO of the L&D Hospital and representatives from Cambr idge Community Services and Keech
Hospice Care began a Task and Finish Group to see how the whole system could respond. We are delighted that as a result of this work three
new work streams have been commissioned, A locality Register, A coordination Service and an Out of Hours Care Response Team. We look
forward to these projects starting and making a difference to the people of Luton.
We continue to support patients on the Liverpool Care Pathway and to ensure that they have Advanced Care Plans.
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Keech Hospice Quality Accounts 2012 - 2013
Children’s Services
This year with a focus on the new strategy we have spent time refreshing our children’s service with an enhanced direction on Palliative Care
for children with a health need. We have redefined our admission criteria and have worked closely with our commissioners to ensure any
changes to family expectations is supported and managed.
We have developed a number of new protocols, pathways guidelines and care plans. This is supported by a clear competency fram ework for
nurses. After a time struggling to recruit nurses we have now succeeded in reaching our establishment numbers.
The year ahead will focus on taking our rightful place as a leader and influencer in children’s palliative care locally.
Our community team continues to deliver excellent care and an enhanced approach to the Rapid Response Service will take us from strength
to strength.
Medical Services
The medical team have faced some vacancies this year with challenges to recruit. However the successful appointment of a Spec ialty Dr with
a Paediatric focus will be a great asset.
All medical staff had an appraisal this year under the format and guidance of the GMC Revalidation process. This meant we wer e compliant
with recommendations and ORSA Green RAG rated. The agreement we have with the L&D Hospital to support us is working out very well with
medical staff having access to 360 degree feedback surveys.
Inspection and Accreditation
We were inspected by CQC on the 16 th March 2012 and were complaint with all standards inspected. We were also re-inspected by HACQ
and are currently completing an action plan.
Patient Safety
Following the launch of the Frances Report we have decided to take a more evidence based view of patient safety. This is not because we
have any concerns but because we wanted to offer a more systematic evidence base to our work. In response we have developed a Patient
Safety Strategy which outlines our intentions; this strategy is monitored by a random monthly safety thermometer inspection.
I would like to thank the Care Team for an amazing job this year and the Clinical Governance team for all their support.
Liz Searle
Clinical Director
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Keech Hospice Quality Accounts 2012 - 2013
Priorities for improvement and statements of assurance from the board
1. Improvement
The Council of Management is committed to the delivery of high quality care that is safe, effective and provides patients and carers with a
positive experience.
The priorities that we have identified for 2013/14 are set out below. We have selected these to impact on patient safety, clinical
effectiveness and patient experience.
Priorities for improvement in 2013 – 2014
Patient Experience
Priority 1:
To increase the number of referrals and total beneficiaries to our service
Target:
It is planned that by end 2013/14 the number of referrals to our service has increased in
total by 10%.
To develop at least two new community-based services by the end of the financial year that
are fully funded.
How was this identified as a priority? This was identified as a priority through the Charity’s Care Strategy
How will this priority be achieved?
How will progress be monitored?
This will be achieved raising our profile and communicating our services through meetings
held with the Primary Care Commissioning Groups, communicating our services
throughout the community we serve and through working with acute hospitals
Progress will be monitored through reporting at management meetings, including Clinical
Governance Committee by reviewing statistics on the number of referrals/beneficiaries
recorded and regular progress reports on new services developed.
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Keech Hospice Quality Accounts 2012 - 2013
Patient Safety, Patient Experience and Clinical Effectiveness
Priority 2:
To assure the quality of the services we provide.
Target:
To develop 3 outcomes measure for Children's Services and successfully achieve adult
outcome measures.
To continue to produce a Quality Report which shows an improvement in trends.
Annual user satisfaction survey has better response and higher levels of satisfaction.
All targets are met and full CQUIN payment is received for NHS contracts.
How was this identified as a priority? This was identified as a priority through the Charity’s Care Strategy
How will this priority be achieved?
To continue to work with and develop the use of the Care Quality Commission Outcome
Measures
Through successfully maintaining our status of Accredited Hospice with CHKS (part of the
Capita Group)
To monitor the nature and number of incidents, accidents, complaints and near misses that
occur while implementing safeguards to reduce the risk of repetition and by identifying
trends.
Ensure that satisfaction surveys are made available to all patients, carers and relatives.
Explore various options of obtaining user feedback.
How will progress be monitored?
Achievement of service targets within contracts.
Progress will be monitored through reporting at management meetings, including Clinical
Governance Committee of all incidents, accidents, complaints and near misses and to our
commissioning colleagues through contractual meetings.
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Keech Hospice Quality Accounts 2012 - 2013
Clinical Effectiveness
Priority 3:
Increasing our presence within the community
Target:
To provide care for patients closer to home
How was this identified as a priority?
This was identified as a priority through the Charity’s Care Strategy
How will this priority be achieved?
W e will achieve this priority through close working partnerships with Community care providers,
the local CCG, GP’s and acute care and the development of joint care pathways which place
high quality care at the heart of those plans
Progress will be monitored through reporting at internal management meetings, joint contract
performance meetings with the local CCG and collaborative working meetings with other
stakeholders.
How will progress be monitored?
Patient Safety, Patient Experience and Clinical Effectiveness
Priority 4:
To work within our new 5 year care strategy
Target:
To further develop and achieve identified targets within our 5 year care strategy
How was this identified as a priority?
This was identified as a priority through the Charity’s Care Strategy
How will this priority be achieved?
Though consultation with all stakeholder groups and staff.
How will progress be monitored?
Progress will be monitored through reporting at management meetings, including Clinical
Governance Committee of progress made against strategy.
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Keech Hospice Quality Accounts 2012 - 2013
2. Review of services
During 2012/13 Keech Hospice Care provided the following specialist palliative care services to the NHS:
Adult Service
• Inpatient unit
• Palliative Care Centre
Children’s Service
• Inpatient unit
• Day Care
• Community Nursing Team
In addition we have also provided the following services through charitable funding:
• Hospice at Home
• Complementary Therapy
• Music Therapy
• Family and Carer support
• Bereavement Care
• Spiritual Care
• Hydrotherapy pool
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Keech Hospice Quality Accounts 2012 - 2013
3. Participation in Clinical Audit
•
During 2012/13 no national clinical audits or confidential enquiries covered NHS services that Keech Hospice Care provides
•
During that period Keech Hospice Care 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. However we ensured that key audits were
completed using nationally recognised excellence audit tools for hospices developed by Help the Hospices.
•
The national clinical audits and national confidential enquiries that Keech Hospice Care participated in during 2012/3 are as
follows: N/A
•
The national clinical audits and national confidential enquiries that Keech Hospice Care participated in and for which data collection
was completed during 2012/3 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: N/A
•
The reports of 0 national clinical audits were reviewed by the provider in 2012/3. This is because there were no national clinical
audits relevant to the work of Keech Hospice Care.
•
Keech Hospice Care was not eligible in 2012/3 to participate in any national clinical audits or national confidential enquiries
and therefore there is no information to submit.
•
The local clinical audits that were reviewed in 2012/3 are listed in section below along with proposed actions required to improve
the quality of healthcare provided.
•
Keech Hospice Care submits an annual National Minimum Data Set to the National Council of Palliative Care and uses
nationally approved audit tools (Help the Hospices) to audit Infection Control, General Medication and Controlled Drugs. Sinc e
2009 we have achieved the status of accredited Hospice with CHKS. This is a quality assurance accreditation which is tailored
to Hospice services.
4. Research
The number of patients receiving NHS services provided or sub-contracted by Keech Hospice Care in 2012/3 that were recruited
during that period to participate in research approved by a research ethics committee was NONE.
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Keech Hospice Quality Accounts 2012 - 2013
5. Use of CQUIN payment framework
A proportion of Keech Hospice Care income in 2012/3 was conditional on achieving quality improvement and innovation goals as
specified by our Commissioning Partners and the agreed CQUIN’s where achieved in 2012/13.
6. Statement on the Care Quality Commission
Keech Hospice Care is required to register with the Care Quality Commission and is currently registered to carry out the
regulated activities:




Treatment of disease, disorder or injury
Accommodation for persons who require nursing or personal care
Nursing Care
Personal Care
There are no restrictions on our registration.
The Care Quality Commission has not taken any enforcement action against Keech Hospice Care in 2012/3.
Keech Hospice Care has not participated in any special reviews or investigations by the Care Quality Commission in 2012/13.
7. Data Quality
Keech Hospice Care did not submit records during 2012/3 to the Secondary Users Services for inclusion in the Hospital Episodes
Statistics which are included in the latest published date because it is not eligible to participate in this scheme. W e do however have
our own system for monitoring the quality of data.
At the end of February the children’s and adults service ‘went live’ with a new patient administration system.
SystmOne is an electronic patient record system which is also used by many healthcare professionals in the community meaning
that we can share information from and with other services (with given consent from the patient). Systmone is also linked wit h the
NHS spine which makes for an easier registration process when a patient is referred into the service, it also means that our doctors
are able to access test results online.
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Keech Hospice Quality Accounts 2012 - 2013
8. Information Governance Toolkit
Keech Hospice achieved 66% Using version 10 of the Information Governance Assessment Report for 2012/3: This represents a
“satisfactory” result
9. Clinical coding error rate
Keech Hospice was not subject to the Payment By Results clinical coding Audit during 2012/3 by the undertaken by the audit
commission.
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Keech Hospice Quality Accounts 2012 - 2013
10.
Organisational Structure
Council of Management
Clinical Governance
committee
Finance
committee
Income and Marketing
Committee
People
committee
Clinical management
team
Senior Management Group
Education group
Widening access
team
Clinical Information
group
Notes audit group
Drugs and
therapeutics group
Operational management team
Risk Management and health & Safety
Quality Improvement
Medical gases committee
Governance
Operational
Management
Infection Control
Group
Moving & Handling
group
Estates and
facilities
improvement
group
Health and safety
Representatives
meetings
Clinical Audit group
User Groups
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Keech Hospice Quality Accounts 2012 - 2013
ADULT SERVICES
11.
Adult Service Statistics
Patient Numbers
LY/Target
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Total referrals received
LY = 361
19
24
23
38
54
40
29
24
27
30
34
33
375
Total Referrals
accepted
Total patients who have
used the adult service
LY = 359
19
23
23
38
54
40
29
24
27
30
34
33
374
LY = 360
145
145
138
134
137
151
146
141
128
132
133
160*
445
*The number of patients seen in March has increased considerably; this could be due to the switch to systmone where it is not yet
clear how we differentiate patients from carers. The number of carers supported in March has decreased by a similar amount to the
increase.
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Keech Hospice Quality Accounts 2012 - 2013
Breakdown of patients using the service in 2012/3
Out of the 445 patients who have accessed our service year to date the graph below gives a breakdown of the services they used:
Total BME 2012/3 = 19.3%
Total BME this time last year =15 %
Local BME = 35%
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Keech Hospice Quality Accounts 2012 - 2013
This diagram below shows patients who have accessed more than one service
PCC
199
28
1
2
6
138
3
42
70
Therapy
Services
376
38
Inpatient
Unit
153
Therapy services include; music and complimentary
therapy, social work and Hospice at home
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Keech Hospice Quality Accounts 2012 - 2013
Adult Inpatient Unit Activity
Patients
Bed night Activity
LY/target
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
-
6
5
4
5
5
6
4
6
8
5
3
5
LY = 153
14
13
16
11
16
16
16
18
11
9
9
13
162
Total patients
LY = 140
20
18
20
16
20
22
17
23
19
14
12
18
153
Days in month
-
30
31
30
31
31
30
31
30
31
31
28
31
365
Total Beds open
-
8
7.5
8
8
7.6
8
8
8
7.3
5.4
6.7
7.1
7.8
240
235
240
248
235
240
248
240
226
170
188
222
2732
LY = 2198
148
172
157
177
159
127
131
171
193
141
158
175
1909
61%
73%
65%
71%
67%
53%
53%
71%
85%
83%
84%
78%
70%
Died on unit
Target
80%
LY = 86
10
7
13
6
11
12
10
10
9
6
2
10
106
Discharged Home
LY = 49
5
6
2
2
3
6
4
6
3
5
4
0
46
Discharged to
Hospital
Discharged to Care
Home
Patients on unit at
end of month
% patients with an
ACP
Number of RIP
patients on LCP
% of RIP patients on
LCP
LY = 4
0
0
0
0
0
0
0
0
0
0
0
0
0
LY = 11
0
1
0
3
1
0
0
0
2
0
1
0
8
-
5
4
5
5
6
4
6
8
5
3
5
8
8
Target/LY
80%/76%
LY= 77
80%
72%
60%
56%
55%
59%
59%
52%
68%
57%
67%
72%
54%
8
6
12
5
10
12
9
9
9
3
1
8
92
Target
100%
80%
86%
92%
83%
91%
100%
90%
90%
100%
50%
50%
80%
87%
Patients at
beginning of month
Admissions in
month
Bed nights available
Total Bed nights
used
% occupancy
Outcome
Advance Care
Planning (ACP)
Liverpool Care
Pathway (LCP)
YTD
In January, February and March we were operating on 5.4, 6.7 and 7.1 beds per night respectively. This was due to staff sickness and intensive training for Systmone (the new patient
database). % Occupancy is calculations are based on the number of bed nights available per month
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Keech Hospice Quality Accounts 2012 - 2013
Comparison of bed nights used in the same period for 2011/2 Vs 2012/3
Bed nights 2011 = 2198
Bed nights 2012 = 1909
Occupancy 2011 = 77%
Occupancy 2012 = 70%
Ave LoS year to date = 14 nights
LoS 2011/12 = 11.7 nights
Page 20
Keech Hospice Quality Accounts 2012 - 2013
Breakdown showing reasons for overnight stays
Out of 153 patients who had an overnight
stay:
137(90%) had a cancer diagnosis
11 (7%) had a non cancer diagnosis
5 (3%) had no diagnosis recorded
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Keech Hospice Quality Accounts 2012 - 2013
Keech Palliative Care Centre Patient numbers
LY/target
Patients
Activity
Outcome
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Total patients using
PCC in Month
Attendance at
Palliative Care Centre
Patient died
LY = 206
71
62
56
52
56
62
58
62
45
54
61
63
199
LY = 2055
221
196
150
152
179
161
182
188
90
124
159
183
1985
LY = 34
2
7
8
2
2
3
4
3
2
1
4
0
38
Patient discharged
LY = 20
3
2
4
1
1
1
2
1
0
0
0
0
15
Ave length of time reg
with service (months)
LY = 7
7
4
5
3
1
2
2
10
9
10
5
0
5
The graph below shows which Palliative Care Centre services patients have accessed:
Page 22
Keech Hospice Quality Accounts 2012 - 2013
nfidential)
Carer Activity
LY/target
Patients
Activity
Outcome
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Total patients using
PCC in Month
Attendance at
Palliative Care Centre
Patient died
LY = 206
71
62
56
52
56
62
58
62
45
54
61
63
199
LY = 2055
221
196
150
152
179
161
182
188
90
124
159
183
1985
LY = 34
2
7
8
2
2
3
4
3
2
1
4
0
38
Patient discharged
LY = 20
3
2
4
1
1
1
2
1
0
0
0
0
15
Ave length of time reg
with service (months)
LY = 7
7
4
5
3
1
2
2
10
9
10
5
0
5
The graph below shows the services accessed by relatives and carers.
Page 23
Keech Hospice Quality Accounts 2012 - 2013
nfidential)
Other activity undertaken by Adult Services
LY/Target
Out of Hours visits
Advice Line
Out of hours nursing
visits carried out
Number of call
received on advice line
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
LY = 164
9
6
10
5
9
8
11
13
21
8
10
13
123
LY = 453
50
30
35
31
28
30
23
21
34
19
18
36
355
The graph below shows the outcomes recorded from
the out of hours nursing visits:
The graph shows the categories of advice given from
the out of hours advice line:
Page 24
Keech Hospice Quality Accounts 2012 - 2013
nfidential)
12.
Accidents, Incidents, Complaints and Compliments
Accidents
Last year
Patient accidents
Staff accidents
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Adult In-patient Unit
22
3
3
1
2
0
0
2
2
1
0
1
1
16
Palliative Care Centre
1
0
0
0
1
0
0
1
0
0
0
0
1
3
Reported to RIDDOR
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Number of care staff
accidents
Reported to RIDOOR
11
0
0
2
0
0
1
2
1
1
0
1
0
8
1
0
0
0
0
0
1
0
0
0
0
0
0
1
Last year
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
7
0
0
0
0
0
0
1
0
0
0
0
0
1
10
1
0
0
0
1
0
1
1
2
0
0
1
7
5
0
2
2
1
2
2
2
0
0
0
0
0
11
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
Incidents
Incidents
Medication Incidents
Incidents involving
patients
Incidents involving
adult IPU (not patients)
Number of Medication
Incidents Reported
Complaints
Last year
complaints
Verbal complaints made
by family
Written complaints
made by family
0
Page 25
Keech Hospice Quality Accounts 2012 - 2013
nfidential)
Compliments received about the adult service
Listed below is a selection of compliments received about the adult service:

Thank you so much for the inspirational care you provided for our dad. He was very comfortable in the hospice and we cannot b e
thankful for that

Thank you for helping my dad in what was the most difficult battle of his life. I thank you for all the support that you gave him and
kindness

You couldn’t do enough for us ….. you made a sad time more bearable than I would have thought possible

Mum could not have spent her last days anywhere better, the team are fantastic and we can’t thank them enough for all the care th ey
gave to us all.

Thank you for all you did for our granddad you helped and allowed us to enjoy our last weekend

Thank you so much for looking after our Dad. You gave him the best care and attention to make him as comfortable as possible as he
fought to the very end
.
Page 26
Keech Hospice Quality Accounts 2012 - 2013
nfidential)
Page 27
Keech Hospice Quality Accounts 2012 - 2013
nfidential)
13.
Infection Control
Last
year
0
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
0
0
0
0
1
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
The number of patients admitted to the unit with Cdifficile
The number of patients infected with C-difficile while
on the in-patient unit
0
0
0
0
0
1
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
The number of patients known to be infected with an
alert on admission *
The number of patients who contracted an alert
organism infection whilst on the unit (if known)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Last year
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
No. of CQC reportable
safeguarding issues
0
0
0
0
0
0
0
0
0
0
0
0
0
0
No. of non CQC
reportable
safeguarding issues
2
0
1
0
0
0
0
0
0
0
0
0
0
1
The number of patients known to be infected with
MRSA on admission to the unit
The number of patients known to be infected with
MRSA whilst on the in-patient unit
14.
Safeguarding
Safeguarding
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Keech Hospice Quality Accounts 2012 - 2013
nfidential)
CHILDREN’S SERVICES
15.
Children’s Service Statistics
Patient Numbers
LY/Target
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Total referrals received
in month
Total referrals accepted
in month
Total referrals declined
in month
Discharges
LY = 69
8
4
11
10
4
3
5
7
7
6
5
1
71
LY = 65
6
3
10
8
4
3
5
7
6
6
4
1
63
LY = 4
2
1
1
2
0
0
0
0
1
0
1
0
8
LY = 31
2
0
3
1
0
0
3
7
3
4
0
9
32
Deaths
LY = 27
1
4
1
6
6
3
3
4
5
3
3
0
39
Total Families
supported in month
LY = 284
123
129
124
104
122
106
86
130
112
107
105
64
268
Page 29
Keech Hospice Quality Accounts 2012 - 2013
nfidential)
Breakdown of patients using the services year to date
Total BME 2011/12 = 29%
Total BME 2012/13 = 30%
Local BME 2012/13 = 35%
Page 30
Keech Hospice Quality Accounts 2012 - 2013
nfidential)
This diagram shows patients who have accessed more than one service
In-House
115
5
25
169
76
69
Community
215
45
39
Therapies
169
Therapies includes: music, complimentary and Hydrotherapy
Page 31
Keech Hospice Quality Accounts 2012 - 13
Children’s In-house Activity
Patients
Bed night activity
Total Patients inhouse and day care
Total bed nights used
% Occupancy
Deaths
Average length of
stay (nights)
Deaths in-house
Day care
Day care attendances
LY/target
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
LY = 135
59
51
48
47
48
39
8
20
32
29
33
30
115
LY = 1299
108
97
87
82
70
51
0
46
63
52
60
86
802
Target
80%
LY = 2.4
90%
78%
73%
66%
56%
43%
0
38%
51%
42%
54%
69%
60%
3
2.3
2.4
2.6
1.5
2.7
0
2.3
1.9
1.8
2.7
3.5
5
LY = 5
0
2
1
2
1
0
0
0
1
1
0
0
8
LY = 866
70
78
79
76
38
61
8
25
31
33
40
24
563
The graph below shows a breakdown for overnight stays:
Occupancy 2012/13 = 60%
Occupancy 2011/12 = 71%
Bed nights 2012/13 = 802 Bed
nights 2011/12 = 1299
Out of the 97 patients who had an overnight
stay:
10% had a cancer diagnosis
90% had a non cancer diagnosis
Page 32
Keech Hospice Quality Accounts 2012 - 13
Children’s Community Activity
Patients
Activity
Deaths
LY/target
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Total families
supported
Number of visits
LY = 244
83
95
80
58
78
73
67
97
76
88
76
25
215
LY = 2034
140
154
105
102
122
160
77
179
113
98
73
39
1362
Number of phone calls
LY = 2931
274
224
179
193
145
95
56
89
67
73
62
66
1523
LY = 22
1
2
0
4
5
3
2
4
3
2
3
0
29
Deaths supported in
the community
The graph shows the type of community visit
undertaken.
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Keech Hospice Quality Accounts 2012 - 13
16.Accidents, Incidents, Complaints and Compliments (Children’s Service )
Accidents
Patient accidents
Staff accidents
Last year
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Number of patient
accidents (in-house)
Number of patient
accidents (community)
Reported to RIDDOR
9
2
0
1
0
0
0
0
0
0
0
0
0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Number of care staff
accidents
Reported to RIDDOR
4
0
0
0
0
0
0
1
1
0
0
2
0
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Last year
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
7
0
0
1
0
0
1
0
0
1
1
0
0
4
2
0
3
0
0
2
0
0
0
0
0
0
2
7
16
0
1
0
1
1
0
0
2
1
0
1
0
7
Last year
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
5
0
0
0
0
0
1
0
0
0
1
0
0
2
0
0
0
0
2
0
0
0
0
0
1
0
0
3
Incidents
Incidents
Medication Incidents
Incidents involving
patients
Incidents involving
children’s IPU (not
patients)
Number of Medication
Incidents Reported
Complaints
Complaints
Number of verbal
complaints made by a
family
Number of written
complaints made by a
family
All patient accidents, incidents and complaints are reviewed in detail by the Clinical Governance Committee.
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Keech Hospice Quality Accounts 2012 - 13
Compliments received about the children’s service
Listed below is a selection of compliments received about the children’s service:

The loving care and dedication is fantastic

I will treasure the artwork and the diaries that came home with my daughter after each stay

Thank you for all the help, support and care you have shown us, you made us feel very relaxed and like one of the family

Words are not enough to thank you for all your kindness, support and caring over the past very difficult weeks. I will never forget
how wonderful you have been

Keech gave us the chance to stay together as a family, without the worries of day to day life. It gave me in particular the opportunity of
being with and spending some very happy times with my son and wife, memories we shall treasure forever

Thank you for all you did with XX, you helped us create memories we will cherish forever
Page 35
Keech Hospice Quality Accounts 2012 - 13
17.
Infection Control
Last
year
0
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
The number of patients admitted to the unit with Cdifficile
The number of patients infected with C-difficile while
on the in-patient unit
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
The number of patients known to be infected with an
alert on admission *
The number of patients who contracted an alert
organism infection whilst on the unit (if known)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
YTD
No. of CQC reportable
safeguarding issues
0
0
0
0
0
0
0
0
0
0
0
0
0
No. of non CQC
reportable
safeguarding issues
3
1
1
1
2
0
1
2
0
2
1
1
15
The number of patients known to be infected with
MRSA on admission to the unit
The number of patients known to be infected with
MRSA whilst on the in-patient unit
18.
Safeguarding
Last year
Safeguarding
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Keech Hospice Quality Accounts 2012 - 13
19.
Quality and Compliance
CQC
Between January and March we have been preparing for our unannounced inspection from the Care Quality Commission. It is
expected that as a minimum we will receive 1 unannounced inspection per year. Our last inspection was in May 2012.
Accreditation Report (CHKS/HAQU)
Since our external survey in November 2012 we have been working on our action plans for the areas where we scored partial or
non compliance. The deadline for submitting our additional evidence is September 2013. Once submitted our evidence will be
considered by the Accreditation Awards Panel who will then make the final decision as to whether or not we have maintained our
accredited standards.
Clinical Audit
The Clinical Audit Group meet quarterly, they last met on 13th May 2013. There were 2 new audits presented (Patient Accident
Audit and Complaints Audit), plus the General Medicines Audit for Children’s service was presented to the Drugs and
Therapeutics Committee. The Clinical Audit Group also reviewed the progress made against the action plans from previous
audits.
The following table contains a summary of audits that have been either carried over from last year because they still have an
active action plan, have been presented to the Clinical Audit Group/Drugs and Therapeutics Committee or have been completed
and are awaiting presentation. Members of Clinical Governance Committee receive a copy of the Clinical Audit Group minutes
which give more detail as to the content and recommendations of the audit. At any time any member of Clinical Governance
Committee can request to see the audit report.
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Keech Hospice Quality Accounts 2012 - 13
The table below details audits conducted throughout 2012/13:
Audit
Infection Control Audit
2012 (annual audit)
Adult or children’s
Service
Adult Service
Audit in progress or
completed
Has an action
plan been
developed
from this audit
Infection Control
Completed
Yes
Presented to Clinical
Audit Group (CAG)
November 2012
Infection Control Audit
2012 (annual audit)
Children’s Service
Completed
Both
Controlled Drug Audit 2012
Adult IPU
Completed
Presented to CAG in
February 2012
Medication
Completed
Presented to Drugs and
Therapeutics Committee
in October 2012
Action Plan
Completed or in
progress
Issues around
maintenance of rooms
and equipment.
In progress
Ongoing efforts
to train all staff
and to log bed
equipment
movements and
maintenance.
In progress
Estimated
completion by
end of June
2013.
Action plan
complete
Yes
Issues around work
garments and
temperature of fridges
and Meadow Suite.
Yes
Issues around policies
and personnel/training.
Yes
Issues around signature
lists and recording of
expired drugs.
Presented to CAG
February 2013
Infection Control Audit
2012 (Health & Social Care
Act pilot)
Summary of Actions to
be undertaken to
improve practice
In progress
Final action point
estimated to be
complete by May
2013.
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Keech Hospice Quality Accounts 2012 - 13
Audit
Admissions to the inpatient unit (re-audit)
Infection Control Audit
(annual audit)
Adult or children’s
Service
Completed
Action Plan
Actions to be
undertaken to improve
practice
effective record keeping.
Action Plan
Completed/To
be Completed
Adult Service
Yes
Not required
n/a
n/a
Children’s service
Infection Control
Yes
Yes
New, washable sofa
beds to be purchased.
In progress
Requirement for
refurbishment
highlighted
Fabric tea towels
removed from kitchen
area
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Keech Hospice Quality Accounts 2012 - 13
Audit
Infection Control Audit
(annual audit)
Adult or children’s
Service
Completed
Action Plan
Adult Service
Yes
Yes
Actions to be
undertaken to improve
practice
Minor maintenance
required including fixing
a faulty recliner and
cleaning of extractor fan.
Action Plan
Completed/To
be Completed
Complete
New colour coding
system implemented for
housekeeping
equipment.
Staff reminded to use
the protective eye and
face masks when there
is a risk of any body
fluids splashing in eyes.
Tea towels removed
from unit kitchen
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Keech Hospice Quality Accounts 2012 - 13
Audit
General Medicines Audit
Adult or children’s
Service
Both adult and
children’s service
Completed
Action Plan
Management of Medicines
Yes
Yes
Actions to be
undertaken to improve
practice
Action Plan
Completed/To
be Completed
Policy and Procedure
requires review to reflect
recommendations made
in audit including:
• Covert administration
• Storage of medicines
• Review of
appendices
Completed
Various forms to be
updated
Anaphylaxis box to be
mounted on wall
Controlled Drugs Audit
Both adult and
children’s service
Yes
Yes
Signature list updated
Complete
Reminder to staff of
quality of documentation
Parental Drug Chart Audit
(re-audit)
Children’s service
Yes
Yes
Nurses to be reminded
of checking parental
drug chart on each
admission
Completed
In addition to the audits listed above we conduct a regular audit of patient records to ensure that each patient has an accurate and legible
clinical record. The clinical record content enables the patient to receive effective continuing care and to be identified without risk of error.The
record enables the healthcare team to communicate effectively, facilitates the collection of data for research, education and audit and can be
used in legal proceedings
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Keech Hospice Quality Accounts 2012 - 13
The graph showing the number of records audited over the last year:
Page 42
Keech Hospice Quality Accounts 2012 - 13
20.
Surveys
The table below details patient, carer and family surveys conducted throughout 2012/13. We value the feedback we receive from patients and
families as this is a way we can identify issues, resolve problems and improve the quality of care we provide. The results of our surveys are
collated into an annual report a copy of which can be found on our website. The Hospice has recently introduced the friends and family test.
Survey
Family and patient
satisfaction survey
conducted 2012/13
Adult or children’s
Service
Children’s service
Survey in
progress or
completed
Completed
Has an action
plan been
developed from
this audit
Summary of Actions
to be undertaken to
improve practice
Yes
Implementation of, and
training around,
new computer system.
Introduction of improved
handover sheets
Action Plan
Completed or in
progress
In progress.
Estimated
completion end of
March 2013
Revision of guidelines for
bed booking to reflect the
need
for
emergency
palliative care beds and
short
term
bookable
respite.
Formulation of an events
team within the care team
to help co-ordinate trips
and fun activities.
Bereavement Care
Satisfaction Survey
compiled throughout
2011
Adult Service
Completed
Yes
Appropriate training for
all Silver Lining
(bereavement group)
facilitators in enhanced
group facilitation skills to be
developed
Initial planned
delivery was
October 2012 this
has been moved
to June 2013 as
new module
being written
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Keech Hospice Quality Accounts 2012 - 13
21.
Systmone
At the end of February and after month’s of preparation the children’s and adults service ‘went live’ with Systmone.
Systmone is an electronic patient record system which is also used by many healthcare professionals in the community meaning that
we can share information from and with other services (with given consent from the patient). Systmone is also linked with the NHS
spine which makes for an easier registration process when a patient is referred into the service, it also means that our doctors are able
to access test results online.
There is still a lot of development required on the system but initial feedback from the teams has been positive.
22.
Research
Keech Hospice Care is not currently taking part in any research
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Keech Hospice Quality Accounts 2012 - 13
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Keech Hospice Quality Accounts 2012 - 13