St Christopher’s Group Quality Account 2012-3 1 St Christopher’s Group Quality Account 2012-13 Part 1 Statement on quality from Barbara Monroe, Chief Executive St Christopher’s and Harris HospisCare set out to provide the best possible care for people with life-limiting illnesses and those close to them, and all our staff and volunteers participate in this endeavour. Our mission is to promote and provide skilled and compassionate palliative care of the highest quality and we have a national and international reputation for providing care, delivering teaching and engaging in research. We are committed to finding ways continuously of improving our services to patients and families and we have a robust clinical governance framework that enables us to do this. We recognise the importance of training generalist and social care professionals in addition to specialist colleagues. We have continued to work with adult social care staff in Southwark to improve their understanding of end of life care and equip them with the skills to initiate conversations about planning end of life care. We are also exploring the possibility of becoming an accredited training centre for Qualifications Credit Framework (QCF) courses and will be running a summer school for 16-18 year olds which will provide participants with 14 credits towards a full Diploma. The aim is to create a pool of prospective carers for the future workforce. We continue to support seventeen acute trusts and their local hospices through our ‘Quality End of Life Care for All’ (QELCA) ‘Training the Trainers’ course, in partnership with Help the Hospices and the Department of Health to improve end of life care in the acute setting. The evaluation of the programme is almost complete. With funding from the LB Croydon we have been running a pilot social care project in the borough, delivering personal care to people in their last year of life. The aim of this responsive and flexible service is to reduce unnecessary hospital admissions and enable people to die at home, if that is what they wish. We hope to extend this work into other areas through collaboration with reablement teams in other areas. Our Care Home Project Team (see dedicated pages on the St Christopher’s Hospice website: www.stchristophers.org.uk/care-homes ) has been working with local care homes across five local PCTs. Seventy one per cent of the nursing homes (n=73) have received GSFCH accreditation. The number of frail older residents dying in their place of choice (i.e. the nursing home) continues to increase and has now reached 78% (n=1351). The Steps to Success programme for residential care homes (adapted from the DH’s Route to Success) is currently being used in 19 residential care homes. 2 We have introduced end of life care medications ‘as stock’ into three GSFCH accredited nursing homes in Croydon. This has reduced drug wastage and at simultaneously provided a more effective service for residents dying in these nursing homes. We were selected as one of the 7 pilot projects set up nationally by the Department of Health to collect detailed and complex activity data with the aim of creating a per patient tariff for end of life care, and are pleased to report that we reached our target ahead of schedule.(See Research section) In this, our third Quality Account, we identify our priorities for quality improvement for 2013-4, and review our performance against the quality indicators we selected last year. I and my team of senior managers have been closely involved in this review and in developing these measures, which have been endorsed by the Board of Trustees. I am able to confirm that the information in this Quality Account is, to the best of my knowledge, accurate. 3 Part 2 Priorities for improvement We have identified three areas for improvement in the coming year, under each of the domains of quality set out in the Department of Health Report High Quality Care for All: patient safety, clinical effectiveness and patient experience. 1. Patient safety During 2012-3 we have had to close our inpatient unit for some months in order for large-scale refurbishment of the wards. What are we aiming to achieve? We are improving our inpatient environment through replacement of pipes and electrical cabling and windows, installation of doors to the sluices and of more hand wash sinks. We plan also to create better storage space for patient equipment. Each of these measures will also contribute to infection prevention and control on the unit. How will we know what we have achieved? We hope to be able to reopen the inpatient unit by the autumn of 2013. On reopening, we will review the responses in our bereaved carer survey that relate to the inpatient unit. We will continue to carry out regular infection control audits and monitor outcomes. 4 2. Clinical effectiveness During 2012-3, thanks to funding from the LB Croydon Social Services, we have recruited and trained carers to deliver personal care in the LB Croydon to people in their last year of life. What are we aiming to achieve? The aim of this project is to enable people to die at home, if this is what they wish, by reducing avoidable hospital admissions and ensuring close liaison with primary and secondary care teams. We want to give people experience of excellent personal care by providing a sensitive and responsive service. How will we know whether we have achieved this? We will carry out an evaluation of this project, including feedback from clients and their families, in order to enable us to extend this work into other geographical areas. 3. Patient experience During the period of closure of our inpatient wards at the hospice, we have opened a 14- bed ward in an NHS acute trust and have developed an intensive nursing service for patients at home who might otherwise have been admitted to the inpatient unit. What are we aiming to achieve? We aim to offer patients and families excellent care, regardless of the environment, whether on NHS premises or at home. We want to know how well we are achieving this. How will we know whether we have achieved this? We will assess patients’ experience of these new arrangements by analysing separately the results of our SKIPP patient- reported outcome measures and our bereaved carer survey. We will review progress in relation to each of these 3 priority areas at Board meetings twice a year. 5 Review of indicators for 2012-3 Patient safety i) Last year, in response to a National Patient Safety Alert we said we would ensure a smooth transition from Graseby to McKinley T34 syringe drivers without compromising patient safety. ii) We also said that we would ensure that all clinical staff had completed and passed the NHS Connecting for Health IG Training Toolkit. What we did: i) All relevant staff were trained in the use of McKinley T34 syringe drivers prior to implementation. We analysed our medication errors in the first year of use of McKinley T34 and compared it to the previous year’s errors. This showed a small increase in the number of syringe driver- related errors in 2012-3. These were technical errors which did not result in any patient harm. Hospice staff have received further training and updates about the types of errors that are at risk of occurring with the McKinley T34 syringe drivers. ii) Ninety six percent of staff completed and passed the introductory or refresher modules of the NHS Connecting for Health IG Training Toolkit. We will continue to ensure that staff complete the required modules annually. Clinical effectiveness Last year we said that we would commission a statistician to help us undertake a more sophisticated analysis of the results from our completed SKIPP patient- reported outcome measures. For example, which symptoms patients say we improve and what relationship there is, if any, between the existence of the different symptoms and patients’ assessment of their quality of life. What we found: The analysis confirmed what our SKIPP results were telling us. Against a generally positive picture, some concerns nominated by patients (difficulty moving around, breathlessness, and generally feeling ill) are more resistent to relief than others. (Breathlessness in particular has been found to be an indicator not only of the degree of lung damage but of shortness of prognosis whatever the underlying diagnosis). Inpatients, who are admitted because they have a higher symptom burden, and whose symptoms are therefore likely to present challenges, have worse quality of life, are more depressed and are more difficult to help than patients at home. However most respondents, irrespective of their 6 original concern, feel that contact withe the hospice had made a positive difference to their quality of life. Patient experience Last year we said we would set up an effective nutrition group that would ensure that: - nutritional screening takes place on admission - a wider range of high-calorie meal supplements for suitable patients is on offer - we review the timing and process of meal ordering and availability of food outside set meal times What we did: We have added a nutrition screening tool to our electronic patient record for completion by staff on admission. An audit of the records of patients admitted before the closure of the inpatient unit showed that these assessments were being carried out. We plan to re-audit when the inpatient unit opens again in the autumn. Training of volunteers has taken place to support patients with eating and drinking. We have instituted a ‘smoothie of the day’ which aims to provide a nutritious drink for patients who need it. Our new chef has tested out meals with modified consistencies with patients attending the Anniversary Centre, and our Speech and Language therapist will be producing a texture descriptor for use in the hospice. The puréed meals will be available to patients in the inpatient unit on reopening. We have plans to offer an à la carte menu to patients, and for meal times to take place over longer periods, so that patients have greater choice about when to eat. 7 Participation in clinical audits As an independent hospice, St Christopher’s does not participate in the national NHS clinical audit programme that covers subjects that do not apply at the hospice. However, we regularly undertake audits which we select according to network, local or internal priorities. Audits and evaluations we have carried out in 2012-3: Subject matter Implication for practice/outcomes of audit Follow-up actions Review of admissions –July – September 2012 In this period 86% of admissions met the target we have set ourselves. We have made this target more demanding as we have moved the target from ‘working days’ to ‘days.’ Staff were found to be complying with hospice policy. Improvements have been made to signage for non -clinical staff entering the wards. Recording of relevant information on the patient record has been identified as an area for improvement. Mattresses have been asset numbered and are serviced annually. Monthly audits identify any actions that may be required between services. For example any stained mattresses are cleaned and sent for decontamination. Practice was observed in relation to venepuncture and care of central venous access devices. Guidance has been revised and annual clinical staff update training now includes this area of practice. Two audits have taken place this year. Recommendations have been better to secure clinical waste bins in the hospice grounds and to include information about colour-coding and labeling of sharps bins in the annual update training for clinical nurse specialists. Our inpatient unit at the hospice has been closed for refurbishment and essential works. We will continue to monitor admissions once the unit reopens in 2013. Audit documentation on patient record in 2013-4 Barrier nursing Mattress audit Asepsis Waste/sharps audit Continue to audit Audit annually to ensure good practice is maintained Reaudit annually 8 Cleaning and infection control audits High standards of cleanliness were found in all clinical areas. Cleaning of fabric upholstery was recognised as an area for improvement and some sinks need to be replaced. Sluice doors to be installed in wards. New cleaning regime documentation is in draft. Hand hygiene These audits occur monthly and have highlighted the need for non- clinical staff to be reminded about hand hygiene. Additional annual training has been provided for volunteers, orderlies and stewards Evidenced that falls risk assessments were taking place and that staff were using a range of strategies for preventing falls in patients who were assessed as being at high risk of doing so Audit of patient falls Refurbishment of wards in 2013-4 will include installation of new hand wash sinks to meet infection control requirements; sluice doors to be installed; replacement of upholstered chairs. Storage arrangements for patient equipment to be factored into ward refurbishment programme. Continue to audit Length of hospice stay Identified a small group of patients whose stay length significantly exceeded the average and demonstrated that there is no repeated, correctable cause underlying this. Reinforced the importance of actively planning discharge from the moment of a patient’s admission. Audit of care home deaths The project team working in collaboration with local care homes is undertaking a longterm programme to reduce the number of inappropriate deaths in hospital of care home residents. Rates of death in care homes continues to increase, as does the use of end of life care tools such as advance care planning. Continue to audit Pressure sore audit One hundred and one pressure sores were identified on patients’ admission to the hospice between October 2012 and March 2013. Twenty eight of these (27.7%) developed or deteriorated while under the hospice’s care. Of these, only 3 were assessed as being grade 3 Continue to audit. 9 (European Pressure Sore grading). In each case the patient’s skin had been assessed regularly and treated correctly, and the exacerbation of the wound was the result of the deterioration of the patient’s condition. Discharge from Identified specific failures of service clarity in the letters sent to summary the Primary Healthcare Team letters when a Home Care patient is discharged from the hospice’s service. Blood Glucose Completion of the audit cycle monitoring following earlier audit of hospice inpatient diabetic management. Showed that monitoring had become more consistent with guidance in respect of diabetic patients but not for patients on steroids. Medical 100% medical discharge Discharge summaries done. 96% sent summaries within the standard of 3 working days. London Cancer Alliance Baseline Audit of Palliative Care services The hospice participated fully in this audit which aimed to provide evidence of the adequacy of specialist palliative care provision across a London population of 5.0 million, the first time this has been done. An improved template has been designed. Introduction into practice facilitated by a CNS training and mentorship programme. Renewed emphasis to staff on the importance of monitoring blood glucose in non-diabetic patients who have been prescribed steroids. This is a regular annual audit to monitor the consistency and timeliness of medical team communication with GPs and District Nurses. The audit provided benchmarking information to the hospice but is of regional importance in raising standards of palliative care. It will be repeated on a regular basis. Participation in clinical research St Christopher’s has been involved in conducting four clinical research studies, either alone or in partnership with others. The hospice led a group of 5 NHS palliative care providers in a successful bid to provide data to a major Department of Health research project intended to inform and support the design of a funding tariff for palliative care. The study commenced in August 2012 and involves a major collection of cost- 10 related information. We have completed our quota of data submissions, while data collection is continuing at partner sites with a target completion date of Spring 2014. Our care home project team has completed two research projects: a cluster randomised control trial (CRCT) looking at facilitation of the GSFCH programme in 38 Nursing Homes, and implementation of the Namaste Care programme into five nursing homes. A qualitative piece of research on advance care planning that was completed last year is now ready for publication. The care homes research has yielded an unprecedented dataset of nearly 2,550 patients. Publications are in preparation. St Christopher’s has worked in partnership with Marie Curie in a project researching the views of professionals involved in the care of people with dementia. This is complemented by the hospice’s own on-going research on the Namaste technique for assisting those with advanced dementia (see above) and the work of one of the unit’s medical team to assess the knowledge of palliative medicine speciality trainees regarding the assessment of pain in patients with dementia. Goals agreed with commissioners Use of the CQUIN framework A proportion of St Christopher’s income during 2012-3 was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework. Each of these was achieved as follows: CQUIN1: To set up a database of all health funded (CC1) patients, including date when NHS Health Care Funding was agreed and date of review (where relevant). To report quarterly on number and % of patients where review was undertaken. To ensure health funded patients are re-assessed prior to discharge from the community team. Achieved. CQUIN2: To undertake a Quality Audit of applications for health funded care. In the inpatient unit to include an analysis of the communication both internally and with the PCT continuing care teams. Achieved. (See audit section above) CQUIN3: To redesign and streamline the section of the hospice electronic patient records system relating to discharge in order to improve communication in relation to applications for continuing health funding. In progress. 11 What others say about St Christopher’s Group St Christopher’s is registered with the Care Quality Commission (CQC) and is registered to provide the following regulated activities: o o o o Treatment of disease, disorder or injury (St Christopher’s and Harris sites) Personal care (St Christopher’s site) Diagnostic and screening procedures (St Christopher’s and Harris sites) Transport services, triage and medical advice provided remotely (St Christopher’s and Harris sites) The CQC has not taken enforcement action against St Christopher’s during 2012-3. St Christopher’s is subject to periodic reviews by the Care Quality Commission, the last of which was on 6th March 2013. The CQC’s assessed the hospice as being compliant with all the outcomes inspected. St Christopher’s has not participated in any special reviews or investigations by the CQC during the reporting period. Data quality St Christopher’s is not required to submit records to the Secondary Uses service for inclusion in the Hospital Episode Statistics. In accordance with the Department of Health, it submits a National Minimum Dataset (MDS) to the National Council for Palliative Care. The Hospice undertakes regular quality assurance checks of its data. We have bi-monthly meetings of representative users of our electronic patient record system as a result of which any integrity issues are identified and corrected. In addition we regularly quality assure the data provided to PCTs (patient demographics, inpatient, day care and home care activity summaries, place of death etc.). Information Governance Toolkit attainment levels St Christopher’s is an NHS business partner and therefore is required to meet 29 of the Information Governance toolkit requirements. We have completed the IG requirements to level 2. Clinical coding error rate St Christopher’s was not subject to the Payment by Results clinical coding audit during 2012-3 by the Audit Commission. 12 Part 3 Review of quality performance We review all our services regularly and our clinical governance scorecard is one of the ways in which we keep track of trends in relation to quality and patient safety (See page 13 for the scorecard covering the 6-month period to March 2013). This is evidence of the way in which we track critical areas of care. It also highlights that we have low rates of complaints, infection rates on our inpatient unit, and medication errors. We assess each patient on admission to the inpatient unit in order to put measures in place to reduce the likelihood of a fall while allowing them the freedom to move around as they wish. Our falls rate in the inpatient unit is 0.016 falls per occupied bed per 6 months, which is very similar to that of other hospices and palliative care units. Our audit programme reviews the effectiveness of our clinical care as does feedback from patients and carers. The result of the last 6 months to March 2013 of the SKIPP patient outcomes measure shows that of patients surveyed within 3 days of admission to the inpatient unit 35% (n= 84) said that that in relation to the problem that was of greatest concern to them ‘things had got much better’; 41% (n=100) said that ‘things had got a little better’ and 12% (n=30) that there had been ‘no change’ since their admission. The hospice had made a ‘great’ or a ‘very great difference to how things are going at present’ to 55% of those surveyed. In home care, 30% of patients surveyed within a month or so of initial contact said that in relation to the problem that was of greatest concern to them ‘things had got much better’ (n=80) since the nurse started visiting them; 42% said that ‘things had got a little better’ (n=113) and 16% (n=42) that there had been ‘no change’. The home care team had made a ‘great’ or a ‘very great difference to how things are going at present’ to 62% of those surveyed. 13 St Christopher’s and Harris HospisCare summary clinical governance overview (Oct2012-March 2013) Incidents Written complaints Number received: 4 (1 upheld; 3 partly upheld) Written complaints by 6-month period April-Sept 2012 Oct 2012-March 2013 1 4 Oral complaints n= 1 (upheld) Wider actions taken by the hospice following complaints during this period: CNSs – history [WHAT DOES THIS MEAN?] Service User Experience Total Total Total Total Total Total clinical incidents: health and safety incidents medical device incidents: information security incidents medicine- related incidents n of RIDDOR reports: Oct 11Mar 12 AprilSept 2012 Oct 12 -Mar 13 126 47 1 4 59 6 111 22 0 8 56 1 81 17 0 9 44 3 Notification to Care Quality Commission Grade 3+ pressure sores n=1 Fracture n=1 SKIPP - in relation to their most pressing Completed actions arising from incidents, alerts and risk concern assessments, and after event reviews: IPU: Things have got a little/much better since admission = 82% (n=69) - Closure of inpatient unit for essential pipe works and HC: Things have got a little/much better refurbishment since the nurse started visiting =66% (n=77) - Community nurses out of hours advised to undertake faceVOICES-SCH to-face assessment of patients and full history wherever 96% of carers (n=107 ) thought that the possible patient had received exceptional or - Revised staff guidelines about arrangements for consultant excellent care from the ward nurses cover out of hours re advice to hospital trusts 84% of carers (n =151) said that the care the - Revised procedures for gritting paths in snowy weather patient received from the SCH/HH home - Plans developed for transition to ‘safe’ sharps care team was exceptional or excellent Alerts Total alerts from CAS CAS alerts on which action required and taken Total MHRA drug alerts n. MHRA alerts on which action required and taken 36 3 15 0 Infection control n patients during period who developed C Diff/ MRSA while on IPU/Linden*: C Diff MRSA bacteraemia 0 0 *= patients admitted with unknown infection status who develop symptoms 3 days or more after admission. 14 Feedback from patients and carers Feedback from patients and carers is one of the most important ways in which St Christopher’s and Harris HospisCare measures the quality of the care they give. We receive many compliments and positive comments from patients and families. Here is a selection from the most recent surveys of patients and bereaved carers: “My mother felt like there were people who cared and made her feel like a person again, helped her deal with her illness and they helped me through a very difficult time and the support I got from everyone and I am still getting full support after my mother’s death” (Home care patient’s daughter) “Home would have been ideal [place to die] but his condition meant hospice care was not only necessary but absolutely perfect and probably better than home” (Family member) “I was made so welcome, especially so as I also had our newborn baby with me too” (Inpatient’s wife) The care he received from St Christopher's Hospice was loving care - that and the nurses' whole attitude was wonderful and made things much easier for the patient, and all of us. He was reluctant to come to the hospice and wanted to stay at home, but after two days he said "Why didn't you bring me here sooner!" (Inpatient’s wife) 15 “I love the food- the chef is coming home with me. I haven’t lost my sense of humour!” (Inpatient) Home Care team from the hospice were exceptional, very supportive emotionally and practically. Could not have asked for more helpful, caring people (Family member) “ I really look forward to coming to St Christopher’s, making new friends and also getting out if the house” (Day care patient) “Coming here really gives me a focus and someone to talk to about my problems. I enjoy the activities like physiotherapy and relaxation. Meeting others here is really great” (Patient in Anniversary Centre) “I really appreciated the atmosphere here. In .. hospital it is all fear and trepidation, here it’s strength and calm... I felt you were on our side. [In hospital I wondered] is this really in the patient’s interest? There was no arena to discuss this. Here I felt we were talking about the same thing. Communication [here] is straight and honest.” (Bereaved carer) 16 Statements from external bodies CCG comments on St Christopher’s Group Quality Account 2012-2013 "Commissioners have recognised again this year that St Christopher’s has continued to provide a quality palliative care service to service users in their preferred place of care, especially in patients’ own homes. The St Christopher’s Care Home Project Team provide vital training and support to Care Homes as they are being accredited for the Gold Standard Framework End of Life Care Pathway. A similar programme is now being adapted to residential homes to enable people to remain in their preferred place of care. In addition St Christopher’s continue their commitment to pro-actively review ways in which their service can be developed and to spread their knowledge and expertise to others who come into contact with those families and patients facing the end of their life. In particular Commissioners have noted how effective their clinical nurse specialists are in case managing patients and their families to ensure good, positive outcomes. These specialists are highly skilled at communicating to ensure commissioners are fully appraised of patient needs and how they can be best met. CQUINs continue to be an important part of improving quality and innovation and in 2013/13 schemes included ensuring that patients were re-assessed prior to discharge from the community team, carrying out quality audits and redesigning and streamlining the electronic patient record system to improve discharge. All CQUINs were met." Healthwatch Bromley is a new independent organisation and is in the process of establishing its membership. For this reason it did not feel able to comment on St Christopher’s Quality Account this year. Opportunities to give feedback on this quality account We welcome feedback on this quality account. If you would like to do this, please email b.monroe@stchristophers.org.uk or write to: Dame Barbara Monroe Chief Executive St Christopher’s Hospice 51-59 Lawrie Park Road Sydenham SE26 6DZ 17