Quality Account 2013
Our care places the patient at the centre of everything we do. Contents
Part 1 - Introduction
1.1
1.2 1.3 1.4 1.5 1.6 1.7 1.8 “Our mission is to deliver,
champion, and teach, high
quality care and choice for
those with a terminal illness.
We will do this through the
creation of a sustainable centre
of excellence, improving quality
of life and personal experience.”
Chief Executive Statement
Introduction Overall Statement of Purpose
Responsibility towards Patients, Families,
Carers and Friends
Other Responsibilities
Specific Aims
Our History
Our Hospice today
2
3
3
4
4
4
5
5
Part 2 - Priorities for Improvement
7
2.1 Priorities for Improvement 2012­2013
2.2 Priorities for Improvement 2013­2014
7
10
Part 3 - Statements of Assurance from the
Board of Trustees
14
3.1 Review of Services 3.2 Income Generation
3.3 Participation in Clinical Audits
Participation in National Clinical Audits Participation in Local Audits 3.4 Research 3.5 CQUIN goals agreed with Commissioners
3.6 What others say about Rotherham Hospice
3.7 Reviews and Investigations by CQC
3.8 Data Quality 3.9 Information Governance Toolkit Attainment
3.10 Clinical Coding Error Rate 14
14
14
14
15
17
17
19 20
21
21 21
Part 4 - Supporting Statements
22
4.1 Statement from Rotherham Clinical
Commissioning Group (Rotherham CCG)
22
4.2 Statement from Rotherham Health and
Wellbeing Board
22
Part 1 - Introduction
1.1
Chief Executive Statement
On behalf of our Board of Trustees and the
Executive Team, I am very pleased to be able to
present the Quality Account for Rotherham
Hospice for 2012/13.
Our patients, their families, and carers are at the
very centre of our care and delivering quality
services to them is our priority. Quality is at the
heart of our mission to place the patient and not
the illness at the centre of everything we do to
improve quality of life and personal experience.
The commitment of the Board to ensure the
Hospice delivers excellence in care across all of its
service is evident through its strong governance
framework. I am able to give the Board the
assurance they need that the appropriate
processes and procedures are in place to underpin
all our activities and services; through the
operational Clinical and Corporate governance
groups and the Board committees of Clinical
Strategy, Finance and Resources and Marketing
and Communications.
I am also grateful to the Rotherham Clinical
Commissioning Group (previously Rotherham PCT)
for their continued commissioning of our services
and the financial support through this contract. I am proud of our relationship with RCCG and their
support for the Hospice and commitment to
developing services that deliver end of life care of
the highest quality to a wide range of patients in
Rotherham.
Consistently achieving our high standards of care
is only possible through the continued hard work
of our dedicated members of staff and volunteers.
Our team here continues to strive for excellence in
all they achieve and the Board and Executive Team
would like to thank each and every one for their
commitment to providing the highest quality care
to our patients and their families and carers.
The safety, experiences, and outcomes for patients,
their families and carers are of utmost importance
to all of us at Rotherham Hospice. Hearing the
voice of patients, families and carers is important to us and we seek feedback, comments,
suggestions and advice wherever we can to help
inform our service developments and governance
framework. We receive many positive comments
about the quality of our care across all our services
from patients and professionals alike.
Learning lessons to continually improve care is a
key priority for the Hospice. I am committed to
developing and nurturing an environment of
openness, honesty and transparency to ensure that we fulfil our duty of candour. The Hospice is
committed to addressing any concerns and
complaints effectively and efficiently and to ensure
we learn lessons to continuously improve our care
and services.
The hospice is a very dignified place, the care and support for patients plus relatives is exceptional.” – Inpatient Unit
“I am made to feel special in every way. Fridays are eagerly anticipated!” – Day Hospice “Very good, professional service, very good support for patients, family, carers and GP’s too”.
“Carers report feeling confident and supported in caring for their loved ones at home with the help of the Hospice at Home service”. ­ GP who has used Hospice at Home services
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 the healthcare services provided by Rotherham
Hospice.
Mike Wilkerson
Chief Executive
2
1.2 Introduction Rotherham Hospice presents this Quality Account
as an annual report to the public, as a provider of
NHS commissioned healthcare services. In line with
national requirements it exercises our
accountability to service users, stakeholders and
the broader public and demonstrates how all areas
of the organisation have engaged in our quality
improvement agenda, reflecting the three domains
of quality: patient safety, clinical effectiveness and
patient experience.
This Quality Account is both retrospective and
forward looking, providing a review of services
delivered throughout 2012/13, explaining what is
being delivered well and where service
improvement can be made. It also looks forward,
describing key priorities for improvement
throughout 2013/14.
Finally this Quality Account demonstrates the
engagement of service users, key stakeholders, staff
and others with an interest in the organisation in
determining the quality of our services and the
priorities for improvement in the future.
For further information on the content of Quality
Accounts or to view an account for a specific
organisation, please see the NHS Choices website:
http://www.nhs.uk/aboutNHSChoices/professional
s/healthandcareprofessionals/
qualityaccounts/Pages/about­quality­
accounts.aspx
1.3 Overall Statement of Purpose
The purpose of Rotherham Hospice is to enhance,
through specialist palliative care and education, the quality of life of patients and those important to
them. The Hospice is committed to achieving this by providing services for patients requiring specialist palliative care during the changing phases of their illness. It is also the aim of Rotherham Hospice to ensure
that all staff working within the Hospice and
associated services are fully engaged and
empowered to provide high quality care. In addition,
that all patients receiving care from the Hospice and
associated services, receive a high quality, effective
service that is safe, free from unnecessary risk and
promotes personalisation, privacy and dignity.
Our purpose is to care for our patients and to
support their families, carers and friends. We aim to
give the most appropriate and efficient treatment
and care to our patients; to assist in the relief of their
physical and emotional suffering and to help them
to lead an acceptable, purposeful and fulfilling life in
their place of residence or in the Hospice. We will offer a well co­ordinated, multi­professional
and ‘seamless’ service, which integrates Hospice
specialist palliative care services with primary,
secondary and tertiary health care services; other
voluntary and independent agencies; social services
and, in the case of children and young people,
education services. Our approach will be non­judgemental and non­
discriminatory. We consider it equally important to
give support to those who care for our patients,
whether they are professional carers, members of
the family or friends. Our care places the patient at the centre of everything we do. 3
1.4 Responsibility towards Patients, Families, Carers and
Friends
Patients, families, carers and friends will be treated
as individuals; with compassion, humility, honesty
and love. We will listen to them and, whenever
possible, involve them in decisions about patient
treatment. Their preferences, beliefs and customs
will be respected and their complete privacy and
dignity assured through the use of single rooms,
screens, discrete interview rooms and heightened
awareness of staff to these requirements. The
needs of patients at different stages of their illness
will always be taken into account. There is no
charge to patients or their families for use of our
services. 1.5 Other Responsibilities
The local community generously contributes a
great deal of money, time and effort to sustain our
work. We must use these resources wisely,
prudently and effectively. 1.6 Specific Aims
Our aims are to:
• Provide supportive and palliative care for adults with a terminal illness regardless of age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, gender, sexual orientation or civil partnerships.
• Encourage patients to maintain their identity, dignity and independence.
• Provide a welcoming and homely environment to all.
• Facilitate effective, meaningful communication between patients, staff and significant others through a multidisciplinary team approach.
• See the patient as a unique individual and plan with them their care management, whilst promoting their independence.
• Nurture the patient’s feelings of self­worth and promote a sense of still being able to actively live life.
• Support patients and their families in decision making and adapting to changes throughout their illness.
• Offer a continuation of care and support through the initial stages of loss and bereavement.
• Maintain standards of the highest quality, supporting staff and volunteers’ personal and professional development.
• Work together in developing an environment based on support and mutual respect.
• Provide education and information to Rotherham healthcare professionals and the general public regarding palliative care issues.
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1.7 Our History
The Rotherham Hospice Appeal was formed in
1988, with the purpose of raising £1 million to
provide Hospice care for the people of Rotherham.
By 1993 over £550,000 had been raised, and the
search for a suitable site began. Rotherham
Metropolitan Borough Council offered the site of
its old council horticultural nurseries towards the
end of that year. The site fulfilled all the criteria
required, and was accepted on a 99 year lease for a
peppercorn rent. The building of Rotherham
Hospice was completed in May 1996, and the
Hospice opened its doors to Day Hospice patients
in mid­1996. A year later in September 1997 the
Inpatient Unit was opened providing 4 single en­
suite rooms and a 4­bed ward.
In 2009, the Board of Trustees approved plans for a
ten­bed extension to the Hospice Inpatient Unit. In
late 2010 the original Hospice was also refurbished
to create a modern Hospice suitable for quality
care provision into the future. The 10­bed
extension was opened in April 2011 and the
Hospice now has an Inpatient Unit with 14 single
en­suite rooms.
1.8 Our Hospice Today
Rotherham Hospice offers a range of services that
respond to local need. We strive to provide a
homely, welcoming environment, placing
significant emphasis on an individual’s dignity,
privacy and comfort.
The Hospice delivers this care through the
following services:
• Inpatient Unit – consisting of 14 single inpatient bedrooms all with en­suite facilities including capacity for bariatric care.
• Day Hospice – providing 15 places a day 5 days a week (excluding bank holidays). Transport for patients to and from the Hospice is also provided.
• Community Care – through the Hospice Community Team which provides Clinical Nurse Specialists covering all of the Rotherham Borough, a 24/7 Advice Line and a Hospice at Home team delivering hospice care in a patients
place of residence.
• Family Services – including Occupational Therapists, Physiotherapists, bereavement support which includes a child bereavement support group and complementary therapies.
Patients and carers can find out more about the
services the Hospice offers and how the charity
operates by reading the Patient and Visitor
Information Booklet provided on admission and
leaflets available in the Hospice and on our
website. Our members of staff will also discuss
topics during the patient’s admission or
attendance and on a daily basis as the need arises.
Our website www.rotherhamhospice.org.uk also
provides further information for patients and
families.
Our care places the patient at the centre of everything we do. 5
We believe interaction with families and carers
is very important to those in our care, and we
actively encourage an open visiting policy. Family
members and carers are also more than welcome
to use the reclining chairs and beverage and snack
facilities on offer, should they wish to stay. They
can also make use of family overnight
accommodation on site should this be required.
We ensure that patients can stay in touch with
loved ones through the use of telephones and
wireless internet facilities in the patient areas.
The views and opinions of those using our service
are very important to the Hospice. Members of
staff seek comments and suggestions through
‘Patient and Carer Experience’ surveys that are
provided on admission and discharge. Patients and
families are also encouraged to share their views
verbally or in writing to staff. A leaflet with further
information is available from reception, and the
complaints procedure will be discussed with
patients and families on admission to the Hospice.
In the first instance, those wishing to raise a
concern are requested to contact either our Senior
Sister on the Inpatient Unit, our Day Sister on the
Day Hospice or the Clinical Services Director, who
is the Registered Manager.
Rotherham Hospice is regulated by the Care
Quality Commission and they can be contacted at:
Finsbury Tower, 103 – 105, Bunhill Row, London,
EC1Y 8TG. The Commission’s telephone number is
03000 616161. The Commission has a website at
www.cqc.org.uk
6
Part 2 - Priorities for Improvement 2.1 Priorities for Improvement 2012/13
Looking Back 2012/13
Priority One – Review and redesign of Community/Hospice/Hospital
Specialist Palliative Care/End of Life Care Services
(Addressing clinical effectiveness, patient safety and patient experience)
Standard
To lead on a “Whole Systems” review of current
Specialist Palliative Care and End of Life Care (EOLC)
service provision across Rotherham and the
development of a single coordinated service with
active EOLC register that allows patients to receive
high quality end of life care in their preferred place.
How was this priority identified?
This priority was identified through active involvement
with the EOLC commissioning group where trends of
inappropriate service provision, duplication, lack of
service and no coordination have all been identified as
affecting patient and family experience, clinical
outcomes and financial recourses. It was then
discussed that an increase in the responsive Hospice
service could address some of these issues. However a
desire to address the whole situation was expressed
and the Hospice is now to lead a pilot project to map,
plan and “test out” future models of practice.
Performance against this priority
Maintaining stakeholder engagement for a whole
systems review has been difficult in some instances,
due to some stakeholders having to change focus to
address independent organisational issues. This has
resulted in a single focus on the pilot as a driver for
change as opposed to a significant part of a systems
wide change process.
The pilot has been received very positively across
commissioners, partner health care and domiciliary
organisations and the local authority. This has allowed
growth in terms of joint processes, increased
collaboration and less duplication. Responding to
service trends in capacity and demand, patient and
family needs and stakeholder feedback and revised
methodology has seen the service evolve from
planned provision to “responsive” crisis management,
enabling fewer people (at higher risk) to be managed
at a greater intensity.
This has resulted in positive outcomes for patients,
families and key stakeholders by reducing hospital
and Hospice admissions, reducing GP call out and
preventing unnecessary social care interventions
whilst increasing carer confidence to provide care at
home. This has increased the number of people being
able to receive care in their preferred place and
improved collaboration in relation to community care
at the end of life, regardless of the person’s residence.
Statistics on preferred place of care have increased
from 4.3% to 74.6% across community patients.
There has also been a dramatic increase in the uptake
of formal and non formal education programs across
joint health and social care provider organisations
including nursing homes, residential homes,
domiciliary services, local authority and GP practices.
What people told us about these
improvements
Feedback about the changes made to services have
been received from patients, relatives, carers, GP’s,
district nurses and partner organisations. Some of
these are summarised below.
“Without this service many of my patients would certainly not have been able to die in their preferred place (at
home) and I am sure that more if not all of them would have been admitted to hospital”. ­ GP “The service provided the care the patient needed quickly and efficiently” – . District Nurse
“I feel we were completely involved in the decisions made regarding care and treatment” – . Patients relative
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Priority Two – Nutrition and Hospitality
(Addressing clinical effectiveness and patient experience)
Standard
All inpatients and Day Hospice patients receiving
nutritional support and hospitality services from the
Hospice will feel they have had adequate involvement
in their nutritional assessment and that their individual
needs have been met.
The group has also been instrumental in making
changes in relation to the presentation of food
including the use of pictures to ensure all meals
are presented in the same way and demonstrate
appropriate portion sizes.
How was this priority identified?
Further work is still required in the area of workforce
review and this will be taken forward in the
coming year.
This priority has been identified through recent
feeding audits and through patient and family
feedback. These processes have identified that patients
and families do not always feel that they have the
right level of choice regarding meals and that in some
cases presentation and menu suitability do not meet
individual need.
Performance against this priority
The Hospice Nutrition and Catering Forum is now a
well­established group that considers all aspects of
both patient and family needs in relation to nutritional
screening, understanding and responding to special
requirements and individual choice, standards of food
preparation and presentation. It also allows
continuous access to the Dietician who is now an
active member of the group.
This work has seen the introduction of new systems to
record personal choices and specific requirements and
changed practice to encourage catering staff to have
more direct contact with the people for whom they
provide services. It has also seen the introduction of
improved systems to allow catering staff to have “on
hand” information about the needs of each patient
and improved menu choice and better utilisation of
resources.
The Nutrition and Catering Forum will be responsible
for conducting future audits and implementing any
agreed changes.
What people told us about these
improvements
Inpatient Unit staff have told us that changes to assessment of
nutritional status has led to more meaningful discussions and
appropriate care planning. One comment made by an inpatient who actually attended a
Catering Forum was, “I was extremely happy with the food.”
“Really loved the all day breakfast, really nice when others do
the cooking” – Day Hospice patient.
8
Priority Three – Bereavement Support Services
(Addressing patient experience)
Standard
All patients, family members and those close to
patients will receive pre and or post bereavement
support appropriate to their individual needs.
How was this priority identified?
On­going review of current bereavement support
services has demonstrated that although quality can
be assured for the level of volunteer service provided,
there are significant gaps in the levels and structure of
service provided overall. There is also recognition that
bereavement services are not standardised across all
parts of the organisation. This priority has also been
identified as an area for improvement through the
CQUIN framework.
Performance against this priority
Mapping of patient records identified gaps in
understanding of some patient’s cultural needs, beliefs
and preferred wishes at the end of life. This in some
instances led to a shortfall in the quality of recording
of any pre­bereavement work that took place
between staff, patients, families and carers. The
introduction of a new holistic record has increased the
engagement of patients and families in joint care
planning processes, including discussions in relation to
advance care planning, preferred place of care and any
other specific direct wishes. This has increased the
performance against pre­bereavement support in a
very positive way both from a compliance perspective
and more importantly for patient and family
outcomes. services has increased as a result of raised awareness
and expectation and service experience surveys show
very positive results from those people who access
services.
Bereavement support is predominantly delivered via
volunteer befrienders, with escalation to level 2, 3 and
4 counselling support where required. This has helped us to identify where further changes
to the service, including growth and service redesign,
could provide increased capacity and improved
outcomes. This will be taken forward next year as an
integral part of the development of Patient and Family
Support Services.
2012/13 has also seen the growth of bereavement
support services for children and young people.
Structured pre­bereavement work with patients and
families has helped to increase relationships and
therefore enable access for children’s bereavement
support for children and families who otherwise
would not seek support. What people told us about these
improvements
Early identification of any areas of concern can
facilitate early support for bereaved relatives and
friends and this has resulted in all relevant people
being offered bereavement support services 6 weeks
following a death. The uptake of bereavement support
Our care places the patient at the centre of everything we do. 9
“The support was helpful as it had been 7 months since my
bereavement, it made me realise what I felt was normal”
“My support volunteer was friendly but not intrusive”
“Extremely helpful, let me talk about matters I could not
discuss with the family. Also helped me to stop feeling
guilty about the past”
2.2 Priorities for Improvement
2013/14
Rotherham Hospice Board of Trustees is
committed to the delivery of high quality care. That
is care which is safe, effective and provides patients
and carers with a positive experience. Throughout 2012/13 we identified many quality
improvements that could be made over the next
12 months. In selecting our priorities we have been
mindful of national and local policy as well as
those issues which are of concern to our service
users, our workforce, our partners and our Trustees. The priorities for quality improvement that have
been identified for 2013/14 are set out below. They
have been selected because of the impact they
will have on patient safety, clinical effectiveness
and patient experience. Priority 1: Phase 2: Redesign of Hospice Community Team
Priority 2: The development of Patient and Family Support Services, including
the introduction of Hospice based social work facilities
Priority 3: The introduction of structured Complementary Therapies for Hospice patients and their families.
10
Priority One – Phase 2: Redesign of Hospice Community Team (Addressing clinical effectiveness, patient safety and patient experience)
Standard
How will this priority be achieved?
Phase 2: To ensure that the Hospice implements the
findings of the “Whole Systems” review of Specialist
Palliative Care and End of Life Care (EOLC) service
provision across Rotherham, creating sustainability
and increased quality and effectiveness.
This priority will be achieved through formal
evaluation processes which include the collection,
collation and analysis of quantitative measures such
as activity data including demand for service, units
of care, and hospital admissions averted. It will also
consider qualitative measures, including, preferred
place of care and patient experience.
Final validation will be supported by Sheffield Hallam
University. Findings of this evaluation will then be
used to determine future working models and
service configuration.
How was this priority identified?
This priority was identified as an integral part of the
evaluation and validation stages of the redesign of
Specialist Palliative Care Services and End of Life
Care Services across the borough. The overall review was considered as a two year work
stream with pilot phase testing out future models for
validation and commissioning consideration.
Monitoring and reporting methods
The project will be monitored through the project
lead, joint EOLC strategy group and independent
University evaluation. On­going performance and option appraisals will
be decided through the joint commissioner and
provider stakeholder group and final evaluation
findings will be reported to the local Rotherham
Clinical Commissioning Group for
commissioning consideration.
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Priority Two – The development of Patient and Family Support Services,
including the introduction of Hospice based social work facilities
(Addressing clinical effectiveness and patient experience)
Standard
How will this priority be achieved?
All patients, carers and family members will have
access to holistic services that address their physical,
social, spiritual, cultural and diverse individual needs.
This priority will be achieved through the
appointment of a qualified social worker into the
holistic role of Patient and Family Support Services
Manager. This will allow dedicated time and focus to
enable all of the services under this umbrella to be
driven forward in a symbiotic manner. It will be this
integration of services that achieves improved
outcomes for patients and families by ensuring
timely assessment, reduced duplication and
increased understanding of need.
Patient flow throughout Hospice services will be
seamless, coordinated and be delivered in an efficient
timely manner, improving patient experience and
maximising use of organisational recourses.
How was this priority identified?
Although bereavement support and carer support
services have been delivered by hospice staff and
volunteers for some time, these services have been
predominantly volunteer led and therefore sporadic
on occasions.
In addition, dedicated Social Worker time at the
Hospice has only been possible thorough local
authority funding therefore this has created delays
in assessment and care planning processes,
particularly for patients requiring local authority
or Continuing Health Care funding to support
their discharge package.
Monitoring and reporting methods
Service activity data, service user feedback surveys,
and the measurement of carer outcomes such as:
reduced calls to advice line, admissions for carer crisis,
will be collected and presented on a monthly basis to
the Clinical Governance Group to allow the service to
be developed in a way that continues to meet the
needs of its users. This information will then be reported to the
Executive Team and Clinical Strategy Committee
as part of a broader quality matrix.
12
Priority Three – The introduction of structured Complementary
Therapies for Hospice patients and their families
(Addressing clinical effectiveness and patient experience)
Standard
Patients, carers and family members will benefit from
the holistic care provided by Hospice services,
including the provision of complementary therapies
to enhance personal experience.
All complementary therapies to Hospice patients
will be free at the point of delivery.
How was this priority identified?
Complementary therapies have been provided at
Rotherham Hospice since its inception but have never
been funded as a core service provision. This has led to
sporadic care on occasions as volunteer therapists
have not been able to commit to providing services
on a regular basis. This was identified as an area for improvement as with
little investment a tiered approach to complimentary
therapy and therapeutic touch could be established
which would enhance patient experience across a
number of services.
How will this priority be achieved?
This priority will be achieved through the
appointment of a qualified Complementary Therapist.
This will allow dedicated time and focus to enable this
area to be driven forward across all services.
13
All complementary therapy treatments provided
by the Hospice will be overseen by the qualified
Complementary Therapist and all volunteer
complementary therapists will be supervised
and monitored by the above person.
This will allow a tiered approach and increased
capacity.
Monitoring and reporting methods
Service activity data, service user feedback surveys,
and the measurement of carer outcomes such as:
reduced pain, agitation, insomnia etc. will be collected
and presented on a monthly basis to the Clinical
Governance Group to allow the service to be
developed in a way the continues to meet the
needs of its users. This information will then be reported to the
Executive Team and Clinical Strategy Committee
as part of a broader quality matrix.
Part 3 - Statement of Assurance form
the Board of Trustees
The following are a series of statements that all providers must include in their
Quality Account. Many of these statements are not directly applicable to specialist
palliative care providers. 3.1 Review of Services
During 2012/13 the Rotherham Hospice provided
the following NHS services: • Inpatient Unit ­ consisting of 14 single inpatient bedrooms all with en­suite facilities including capacity for bariatric care.
• Day Hospice ­ providing 15 places a day 5 days a week (excluding bank holidays). Transport for patients to and from the Hospice is also provided.
• Hospice Community Team including Clinical Nurse Specialist Services, 24/7 Advice Line and Hospice at Home
• Bereavement services, Carers support and Chaplaincy services Therapy services, including, Complementary, Physiotherapy and Occupational therapy and Psychology services.
Rotherham Hospice has reviewed all the data
available to them on the quality of care and
efficiency across all of these services and used this
information to facilitate service improvements and
or demonstrate commissioner and regulatory
compliance.
3.2 Income Generation
Rotherham Hospice is commissioned via the
National Community Contract, to deliver NHS
End of Life Care and Specialist Palliative Care
Services on behalf of NHS Rotherham
(retrospectively) and in future the Rotherham
Clinical Commissioning Group. The income generated by the NHS services
reviewed in 2012/13 represents 100% of the total
income generated from the provision of NHS
services by Rotherham Hospice for 2012/13. The overall income generated from the NHS
contract represents 50% of the overall cost of
running all Hospice services.
3.3 Participation in Clinical
Audits
National Clinical Audits and
National Confidential Enquiries
During the period 2012/13 Rotherham Hospice
was not eligible to participate in any national
clinical audits or national confidential enquiries.
As Rotherham Hospice was ineligible to participate
in any national clinical audits and national
confidential enquiries there is no list or number
of cases submitted to any audit or enquiry as a
percentage of the number of registered cases.
This is because none of the 2012/13 audits or
enquiries related to EOLC or specialist palliative
care. The Hospice will also not be eligible to take
part in any national audit or confidential enquiry
in 2013/14 for the same reason.
Although the Hospice did not have the
opportunity to participate in national clinical
audits throughout 2012/13, internally the
following local clinical audits were conducted.
14
Local Clinical audits Rotherham Hospice has conducted and/or reviewed 14 local clinical audits during 2012/13 as follows:
Standard
Phase 2: To ensure that the Hospice implements the
Audit
Lead
Medicines Management
Full Review
Medical Director/Clinical
Lead/IPU Sister/Pharmacy
Lead
Controlled Drugs
Standard Operating
Procedures Review
Clinical Lead/Pharmacy
Lead
April May June July Aug Sept Oct Nov Dec Jan Feb March 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013 2013 2013
NHS Safety Thermometer Clinical Lead/IPU Sister
Additional Safety
Thermometer markers
Clinical Lead/IPU Sister
Compliance Evidence
Clinical Lead/Governance
Facilitator
Patient Experience Audit
IPU Sister/Clinical
Governance/Facilitator/
Trustee of Board
External Records Audit
External Assessor
Revised Records Audit
IPU Sister
Patient Falls Audit
IPU Sister/Focus Group
Infection Prevention and IPU Sister & IPC Lead
Control Sharps and Hand
Washing Audit
Data Quality
Clinical Lead/Data
Analyst
Data Collection,
recording and reporting
CEO/Clinical Services
Lead/IG Group
Audit on High Impact
Interventions(inc safety,
processes, impact and
experience)
Clinical Services Lead
Patient Feeding /
Nutrition Audit
IPU staff and Support
Services Manager
Our care places the patient at the centre of everything we do. 15
Our care places the patient at the centre of everything we do. We are committed to providing the highest standard of specialist palliative care for patients suffering from life limiting illness over the age of 18.
16
3.4 Research
The number of patients receiving NHS
commissioned services provided by Rotherham
Hospice in 2012/13 that were recruited during
that period to participate in formal research
approved by a research ethics committee was 0. One formal research programme has been
approved by the Sheffield Hallam University Ethics
Committee but to date no patients have been
recruited due to the criteria for inclusion.
This has been reconsidered and resubmitted for
revised approval. With this in mind the research
will now be conducted in 2013/14.
3.5 Quality Improvement and
Innovation Goals agreed with
our Commissioners/ CQUIN
payment framework
A proportion of Rotherham Hospice income from
the NHS in 2012/13 was conditional on achieving
Quality Improvement and Innovation goals agreed
between Rotherham Hospice and Rotherham PCT
and any person or body they entered into a
contract, agreement or arrangement with for the
provision of NHS services, through the
Commissioning for Quality and Innovation
payment framework. The CQUIN measures were in relation to the
following areas:
All of these CQUIN measures were achieved in full.
Further details of the agreed CQUIN goals for 2013/14 and
for the following 12 month period are as follows:
1. 2. 3.
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Carer Support (Local CQUIN)
Safety Thermometer (National CQUIN)
Joint Care Planning (Local CQUIN)
CQUIN Measure 1 Spirituality and Bereavement Service user Experience
This indicator focuses on the delivery of spirituality
and bereavement support for patients, carers and
family members during all phases of terminal
illness including • Pre­bereavement, at the end of life and family members who are closely affected by a death.
To ensure that patients and family members are
offered, when and where appropriate, ongoing
bereavement, emotional and spiritual support
according to their needs.
CQUIN Measure 1 Performance Summary
2012/13 saw 100% of all bereaved relatives or
significant partners being offered the opportunity
to access structured bereavement support. 73 new
adults joined the bereavement support program
throughout the year ensuring that service was
delivered to 467 people in total. In addition 16 new
children joined the children’s bereavement program
extending this service to 39 children in total.
This has been extended to include two group
sessions to allow quality and demand to be met.
Adults: Of those leaving bereavement services
100% of people were offered the opportunity to
participate in the bereavement support surveys.
Of these people 55% responded and of these
responses 89% demonstrated a positive experience.
Children’s bereavement support surveys were
completed in Q4 by 100% of children, parents
and guardians who attended the groups.
These showed an overall positive experience. (Lichert scaling system used as measurement tool)
CQUIN Measure 2 NHS Patient Safety Thermometer
CQUIN Measure 3 Patient Carer and Stakeholder Experience
Collection and submission of data on patient harms
using the National Patient Safety Thermometer. To measure, monitor and improve patient, carer
and stakeholder experience via near time
experience surveys across all Hospice services.
From July 2012, survey all relevant in­patients
on a monthly basis focusing on patient harm:
­ falls;
­ pressure ulcers;
­ catheter associated urinary tract infections.
Submit data on a monthly basis to the NHS
Information Centre.
www.hscic.gov.uk/thermometer
CQUIN Measure 2 Performance Summary The Clinical Services Director (CQUIN lead) and the
Data Analyst (Data Lead for Safety Thermometer)
continue to drive forward the principles of Harm
Free Care to ensure the Hospice has a
comprehensive understanding of the safety
thermometer tool and the CQUIN requirements.
All staff have been fully briefed and a nominated
lead for each clinical area has been identified.
The nominated lead is responsible for co­ordinating
data collection and submission (via the data
analyst) each month. Although no national minimum is set for %
achievement of Harm Free Care it is important
to note that although measured across small
numbers, the Hospice continues to achieve a
very high standard. With 92% Harm Free Care
recorded across the year.
Progression on data collection and collation has
been extremely positive and in turn has led to
additional measurements being added locally to
the tool to allow a broader understanding and
assurance of how Harm Free Care is achieved.
Achievement against this additional data was
recorded in Quarters 3 and 4 at 83%. This
demonstrates positive attitudes to individual
patient risk assessment and re­assessment in
relation to pressure sores, falls, moving and
handling and nutritional screening.
The information is also being collected weekly
to allow consistency and continuity in audit
processes.
The provider will evidence that they have offered
all patients, carers and family members the
opportunity to participate in service experience
surveys (target 100% offered) This will be offered
to all patients following discharge and to family
members following bereavement.
The survey response rate will be a minimum
of 40%.
Improvement trajectories to be agreed with
the commissioner.
CQUIN Measure 3 Performance Summary Patient experience surveys have been carried out
across the Inpatient Unit in quarters 1 and 2.
Quarter 3 was the first time the survey was rolled
out to include the Hospice Community Team. Throughout the year data has been collated
and analysed as follows:
Of those leaving services 100% of people were
offered the opportunity to participate in the
experience survey. Of these people 76%
responded and of these responses 97%
demonstrated a positive experience. (Response
rates have fluctuated across the three months in
quarter 4, with some forms still expected to be
returned in Q1 of the new year).
Feedback has been used to inform the need for
service changes and review and to demonstrate
compliance and provide information to other
service users on our quality of service provision.
The Day Hospice survey was completed in
quarter 4 with 57 forms given out to Day Hospice
attendees. 84% of patients and carers returned
their forms and 96% demonstrated a strong
positive experience.
(Lichert scaling system used as
measurement tool)
Hospice information can be accessed via the
NHS Information Centre website.
www.hscic.gov.uk/thermometer
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3.6
What others say about us
As a learning organisation, Rotherham Hospice is
keen to engage all service users and key
stakeholders in feedback to support service
improvement and increase quality and experience.
With this in mind the organisation has robust
networking systems in place with local strategic
partners to ensure we receive feedback which can
facilitate service improvement by strengthening
what we do well and learning from situations
where we did not meet expectation.
The Hospice also has a number of working groups
which include representation from external
organisations. These include our Equality and
Diversity Group, PLACE assessment Group and
our Nutrition and Catering Forum.
Finally, feedback is sought in the form of service
user satisfaction surveys and stakeholder surveys
(community pilot only). These surveys have helped us to understand how
our services are perceived by the people who use
them. Learning form the comments made has
enabled us to acknowledge where shortfalls in
service provision exist and make positive service
changes to address these.
This year Rotherham Hospice also participated in
the “Postcard Campaign” led by the Commission
for Hospice Care. This asked people who had
experienced Hospice services to say “What was
different about hospice care”? and “What if anything
was special about the care and support received”? All of the respondents gave very poignant
comments which reinforce the culture of the
Hospice. Some of these comments express not only
care and compassion at times of sadness, but also
praise the overall uplifting feel of the Hospice
environment.
A selection of these comments are listed below:
C
“Good hospitality. Gives back confidence. Builds moral. Friendly”.
“They take the time, to listen and speak to me. My needs were
met 100%”.
“My needs are met without me having to ask for help.”
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3.7 Care Quality Commission (CQC)
Rotherham Hospice is required to register with
the Care Quality Commission and its current
registration status is approved and unconditional.
Rotherham Hospice has no conditions on
registration and registration is approved as follows:
Rotherham Hospice has not participated in any
special reviews or investigations by the CQC
during 2012/13. The Care Quality Commission has
not taken enforcement action against Rotherham
Hospice during the period April 2012­March 2013.
Rotherham Hospice Trust is registered in respect
of 4 Regulated Activities: Throughout 2012/13 Rotherham Hospice
undertook a self­assessment of its compliance
against all 28 CQC domains and in turn the
Health and Social Care Act 2008 and Care Quality
Commission Registration Regulations 2009. This
enabled the organisation to understand its level
of compliance and identify any areas for further
improvement which will be implemented
through the governance framework. • Accommodation for persons who require nursing or personal care
• Diagnostic and screening procedures
• Transport services, triage and medical advice provided remotely
• Treatment of disease, disorder or injury
Regulation also states that:
• Services can only be provided to people 18 years of age and over
• A maximum number of 14 patients can reside in the Inpatient Unit at any one time
As part of an unannounced CQC compliance
inspection on Monday 13th May 2013, the
following standards were considered and
outcomes achieved:
Consent to care and treatment (Outcome 2) √ Met this standard with very positive feedback
Meeting nutritional needs (Outcome 5)
√ Met this standard with very positive feedback
Infection prevention and control (Outcome 8)
√ Met this standard with very positive feedback
Requirements relating to workers (Outcome 12) √ Met this standard with very positive feedback
Complaints (Outcome 17)
√ Met this standard with very positive feedback
Records (Outcome 21)
√ Met this standard with very positive feedback
20
3.8 Data Quality
Rotherham Hospice did not submit records during
2012/13 to the Secondary Users Service for inclusion
in the Hospital Episode Statistics which are included
in the latest published data. This is due to
ineligibility to take part in the scheme.
However, in the absence of this we have a local
system in place for monitoring the quality of data
and the use of the electronic Patient Information
system, SystmOne. This provides monthly
information on data quality and ensures accuracy
in recording and reporting mechanisms.
Monthly data quality performance for 2012/13 is as follows:
Rotherham Hospice score for 2012/13 for
Information Quality and Records Management
assessed using the Information Governance
Toolkit was 66% (Satisfactory at level ll).
Throughout 2012/13 the Hospice has put in place
the relevant framework documentation, polices,
training, and security infrastructure to be able to
demonstrate an attainment of level 2 compliance
with NHS Connecting for Health’s, Information
Governance standards. This ensures we provide
service users, key stakeholders, staff and others
with an interest in the organisation, with the
confidence that their information is dealt with
efficiently, safely and securely. Apr­12
May­12
Jun­12
Jul­12
Aug­12
Sep­12
92.5%
94.4%
94.8%
94.64%
93.22%
93.34%
Oct­12
Nov­12
Dec­12
Jan­13
Feb­13 Mar­13
96.12%
95.74%
95.88%
95.41%
93.28%
94.93%
Commissioning data quality targets stand at 90%. Therefore compliance has been consistently
achieved throughout the year.
3.10 Clinical Coding Error Rate
Rotherham Hospice was not subject to the Audit
Commissions, Payment by results clinical coding
audit during 2012/13
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3.9 Information Governance
Toolkit attainment levels
Part 4
Supporting Statements
4.2 Rotherham Clinical Commissioning
Group (Rotherham CCG)
“The hospice report is an encouraging read. It records the success
the hospice has had in the past year in its continual drive to
improve services for Rotherham residents as they enter the last
days of their lives. It is gratifying to see how many positive
comments the hospice receives in questionnaires, and yet does
not become complacent.The response to the patients opinions
of the catering services are testament to this.The partnership
working between the hospice and the CCG is proving fruitful and
rewarding.The pilot is already delivering an improved level of
service in difficult times.This is only possible with staff who are
committed and professional, and the encouragement they receive from the organisation is evident.
We look forward to a continuation of this work in the coming year.”
Dr Russell Brynes
GP EOLC Commissioning Lead
Rotherham CCG
4.3 Rotherham Health and Wellbeing Board
“On behalf of the Health & Wellbeing Board, I strongly support
the work of the Hospice in caring for the people of Rotherham.
We strongly endorse and support the high quality of care
provided by the Hospice and believe this report fairly represents
the achievements of the Hospice.”
Dr John Radford
Director of Public Health
On behalf of the H&WBB
www.rotherhamhospice.org.uk
22
Rotherham Hospice, Broom Road
Rotherham, South Yorkshire S60 2SW
Tel: 01709 308900
www.rotherhamhospice.org.uk
A Registered Charity.
A Company Limited by Guarantee.
Registered Address: Broom Road, Rotherham, S60 2SW
Company Registration No: 2234222
Registered Charity No: 700356
Our care places the patient at the centre of everything we do.