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