QUALITY
ACCOUNT
2012/13
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Our Vision
Putting local patients and families at the heart of everything we do, we will
ensure that on the journey towards the end of life, we provide the right care,
in the right place, at the right time
Our Values:
Care – We will provide 1st class care, delivered by competent people who
put the patient at the heart of all we do
Compassion – We will treat everyone with respect, dignity and empathy
Collaboration – We will work with others to ensure that patients and
families receive the best end of life care possible
Charity – We will provide care free of charge to patients and families and
will connect with our local communities so that they continue to finance
our present and our future
St John’s Hospice
Built by the people, for the people
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Part 1
Chief Executive’s Statement
It gives me great pleasure to present this, the first Quality Account for St John’s Hospice,
Lancaster. In this account our aim is to show how the Hospice measures quality, involves
patients, carers and staff and strives to always look for areas where we can improve our
care.
A Quality Account is an annual report to the public from providers of NHS healthcare about
the quality of services they deliver. It is important to note that St John’s Hospice only
receives around 30% of its funding from the NHS, the rest (around £2.5million) is donated by
the local community. The majority of services described in this document are funded by
charitable donation rather than by the NHS.
Quality sits at the centre of all that the Hospice does. Our vision is that everyone in our
catchment area of South Lakeland, parts of North Yorkshire and all of North Lancashire with
any life-limiting condition will have high quality care and support at the end of their life in
the right place, at the right time.
We asked patients, families, volunteers and staff to sum up in one word what St John’s
means to them. Their key words can be seen here:
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Our Corporate and Clinical Governance structures ensure that we have both the systems and
processes in place to maintain a viable and responsible business, whilst ensuring that our
services are of the highest quality and meet the aspirations of our vision. Our services are
subject to unannounced inspections at any time. In order to prepare for this, during the
2012/13 period we instigated a “peer review” mock inspection by colleagues. It is important
to us that we are viewed as part of a wider healthcare community and are not seen to work
in isolation. The findings from our peer review were welcomed and used to ensure
continuous improvement for patients and families.
On the 2nd February 2013, the CQC conducted an unannounced inspection of the Hospice.
The Hospice was fully compliant in all areas inspected.
This year we are proud to have achieved:
An increase in the number of patients accessing our care following the refurbishment
of the ward
The development of a day hospice group specifically for patients with Chronic
Obstructive Pulmonary Disease (COPD)
Introduction of McKinley Syringe Drivers following NPSA alert
Extension of the hours to the Hospice at Home service in North Lancashire
Pilot “Reminiscence” programme in day hospice
Purchase of scanning equipment to prevent patients being transferred to hospital
unnecessarily
Developed a three year hospice strategy linked to commissioning priorities
Our goals for future improvement include:
To become the palliative care “hub” for North Lancashire
To move from paper to electronic records, using an IT system that our GP colleagues
also use
To complete a review of food and nutrition throughout the Hospice
To gather accurate data and information in order to demonstrate our value to
commissioners
I am responsible for the preparation of this report and its contents. To the best of my
knowledge, the information contained in this Quality Account is accurate and a fair
representation of the quality of healthcare services provided by our Hospice.
Sue McGraw
Chief Executive
11th April 2013.
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Part 2
Priorities for Improvement 2013/14
The priorities for improvement we have identified for 2013/14 are set out below. These
have been developed in conjunction with patients, carers, staff and stakeholders. We have
expressed our priorities in terms of the three domains of quality:
Patient safety
Clinical effectiveness
Patient experience
Priority 1 – Patient Safety & Patient Experience
Review and Improve the patient experience on the Ward
This will include looking at the physical aspects of the building, equipment and resources in
the rooms and the communal areas
How was this priority identified?
Feedback from patients, families, carers, visitors and staff is crucial to the on-going
development of our care. Whilst there is no doubt that the hospice environment is safe and
well maintained, we wanted to give our stakeholders the opportunity to highlight areas
where we could make simple changes to improve the patient experience.
Over a 3 week period, we asked everyone who visited to tell us what one small thing would
make a big difference. We will continue to do this over the next twelve months to ensure
that the patient and public voice is at the centre of our plans.
How will progress be monitored and reported?
Further consultation sessions will be arranged
Our patient and family User Group will be consulted
Suggestions will be reported to the Care and Quality Sub-Committee who in turn will
report to the full Board
Priority 2 – Clinical Effectiveness
Become the Palliative Care “Hub” for North Lancashire and share our learning with
neighbouring commissioning groups
Provide a telephone “hub” and a 24/7 rapid response service in the community for end of
life patients in North Lancashire
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How was this priority identified?
Almost half of complaints to the NHS relate to bereavement or the way in which someone
has died. Since the End of Life Care Strategy was produced in 2008, Commissioners have
been keen to understand ways to deliver end of life and palliative care more effectively.
The End of Life Care Commissioning Lead in North Lancashire, guided by key national drivers
such as the NHS Mandate, end of life care profiles for the area, predictive modelling tools
and experience from having worked in the hospice and as a local GP over a number of years,
recognised that the current model was not sustainable. Most people, given a choice, would
prefer to die in their own home, and yet statistics show that only around 35% achieve this.
The development of the Hub came as an initiative to address this issue whilst ensuring that
the most cost effective model was provided.
How will progress be monitored and reported?
A multi-agency project group will monitor progress
Satisfaction surveys with bereaved relatives
Monitoring of performance using the National Council for Palliative Care’s Minimum
Data Set, alongside locally developed CCG KPIs (to be advised)
Progress will be reported to the Care and Quality Sub-Committee, who in turn will
report progress to the full Board
Priority 3 – Safety
Adoption of an electronic patient record system to ensure patients receive safe, effective
and consistent care
We will adopt the system used by GPs in both our Commissioning areas
How was this priority identified
As the hospice is a charity and not part of the NHS, we do not have access to the IT
infrastructure that many of our colleagues in the wider healthcare community are currently
using. When patients are transferred to us, we have to access paper documentation which is
not always available in a timely manner. Equally, on discharge, our colleagues in the
community have little or no information immediately. Clearly this has the potential for delay
and mistakes in communicating key information which may affect patient safety.
How will progress be monitored and reported?
A cross healthcare community project group will monitor and report on the
effectiveness of the new system
Regular audits will be undertaken
Staff will be consulted to ensure they are involved in the development of the project
Surveys of partners will be undertaken to ensure that the project is effective
Progress will be reported to the Care and Quality Sub-Committee who, in turn will
report progress to the full Board
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Priorities for Improvement 2012/13
As this is the first Quality Account produced by St John’s Hospice, there was no formal
statement of priorities for improvement in 2012/13. However, we constantly strive to make
improvements for patients and families. Below are just three examples, expressed in terms
of the three domains of quality, where we made improvements in 2012/13.
Patient Experience
Ward Improvements
Following a complete refurbishment of the Ward, we have gradually increased bed
occupancy to put us in the upper quartile for bed occupancy as guided by the National
Council for Palliative Care Minimum Data Set
On completion of the ward refurbishment, the facilities within the Hospice were vastly
improved. Facilities for families to stay over-night and a family day room with a comfortable
and welcoming atmosphere were introduced enhancing the patient and family/carer
experience.
Our reception area was improved to enable disabled access in an inviting and calming
environment.
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Patient Safety
Safer Ambulatory Syringe Drivers
We worked with colleagues across Cumbria and North Lancashire to choose a syringe driver
to meet the requirements of the NHS patient safety alert, December 2010.
Ambulatory syringe drivers are widely used for palliative care and long term therapy in all
clinical settings and at home. Some ambulatory syringe drivers have rate settings in
millimetres (mm) of syringe plunger travel and require manual calculation to set the correct
dose, which introduces the risk of errors. On the 10th December 2010, the NPSA
recommended that these syringe drivers should be phased out within five years.
In line with community partners across North Lancashire and South Cumbria, the Hospice
adopted the McKinley Ambulatory Syringe Drivers and following training and education to all
staff these were implemented across the organisation, three years before the NPSA
deadline, therefore reducing the risk of medication errors.
Clinical Effectiveness
Extension of Hospice at Home Hours
To meet unmet community demand, the Hospice at Home Service hours were extended to
cover the hours of 7am-10pm
Traditionally, our hours of working for the Hospice at Home team were 8.30am-4.30pm. This
limited service did not link with the working hours of other colleagues in the community. In
addition, patients’ needs were not being met at crucial times during the day/evening.
Clinical Effectiveness/Patient Safety
The Appointment of a Quality & Development Co-Ordinator
To ensure that the increasing demand to meet regulatory requirements is met, the Hospice
invested in a new post, Quality & Development Co-Ordinator. This senior post will be
managed by the Head of Care and will ensure the Hospice meets its duty to ensure clinical
effectiveness, patient safety and patient experience are at the forefront of care.
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Part 2 (Continued)
Statements of Assurance from the Board
Quality Accounts have a series of statements that MUST be included. Many of these
statements do not apply to St John’s Hospice. Explanations of these statements are given
where appropriate and are prefaced by the words: “MANDATORY STATEMENT”.
During 2012/13, St John’s Hospice provided the following services:
In Patient Unit – 17 beds (registered for up to 20.)
Hospice at Home Service
Day Hospice
Family Support and Bereavement Service
Education and Training – Community including 6 Steps to Success programme with
Care Home
Education and Training – Students including Lancaster University GP trainees,
GPSTRs from the Liverpool University Deanery, Nurses and Occupational Therapists
from UCLAN and University of Cumbria
Out Patient Clinics – Including malignant and non-malignant Lymphoedema
Charitable donations support 70% of this work, the remaining 30% comes from the NHS.
During 2012/13, we made the transition from receiving funding via 3 PCTs (North Lancashire
Cumbria and North Yorkshire,) to receiving funding from two Clinical Commissioning Groups
(CCGs) Lancashire North and South Lakes Locality.
MANDATORY STATEMENT – St John’s Hospice has reviewed all the data available to them
on the quality of care in all these NHS services.
Participation in Clinical Audits
The Hospice Audit calendar is led by the Head of Care, co-ordinated by the Education
department and overseen by the clinical team. Audits are a standing item on the Clinical
Governance Committee agenda and are discussed monthly at the clinical management
meeting.
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The following are examples of audits conducted within the Hospice in 2012/13:
End of Life Documentation checklist
Management of oral Candidasis
Bedrails Decision Record
Hoist Battery Charging Regime
Day Hospice of Patient HAD Scores
Recognition of Depression and Use of Anti-Depressants
Notification of Death Letter
Drug Allergies
Fire Recommendations
St John’s Hospice took part in the North West Audit Group regional heart failure audit during
2012/13
Research
MANDATORY STATEMENT - The number of patients receiving NHS services provided or subcontracted by St John’s Hospice in 2012/13 that were recruited during that period to
participate in research approved by a research ethics committee was NONE
Use of the CQUIN Payment Frame
MANDATORY STATEMENT - St John’s Hospice NHS income in 2012/13 was not conditional
on achieving quality improvement and innovation goals through the Commissioning for
Quality and Innovation payment framework because it is a third sector organisation and as
such was not eligible to participate in this scheme during the reporting period.
Statement from the Care Quality Commission (CQC)
St John’s Hospice is required to register with the CQC; we are registered to carry out the
regulated activities:
Treatment of disease, disorder or injury
Diagnostic and screening processes
Transport services, triage and medical advice provided remotely
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St John’s Hospice has the following conditions on registration:
Only treat people over 18 years old
Only accommodate a maximum of 20 in-patients
The CQC has not taken any enforcement action against St John’s Hospice during 2012/13.
An unannounced CQC inspection took place on the 2nd February 2013. The following
standards were inspected:
Respecting and involving people who use services
Care and Welfare of people who use services
Safety and Suitability of Premises
Requirements relating to workers
Complaints Handling
All areas inspected fully met CQC standards.
Data Quality
MANDATORY STATEMENT - St John’s 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.
However, St John’s Hospice does submit data to the Minimum Data Set (MDS) for Specialist
Palliative Care services collected by the National Council for Palliative Care on an annual
basis, with the aim of providing an accurate picture of Hospice and Specialist Palliative Care
service activity.
Information Governance Toolkit
St John’s Hospice Information Governance Assessment Report overall score for 2012/13 was
39% and progress was considered satisfactory by the Information Governance Delivery
Service.
Clinical Coding Error
MANDATORY STATEMENT – St John’s Hospice was not subject to the payment by results
clinical coding audit during 2012/13.
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Part 3
Review of Quality Performance
In this section, we have chosen to provide data benchmarking St John’s Hospice with figures
from the National Council For Palliative Care Minimum Data Set, (MDS.) The MDS is the only
national benchmarking tool for Hospices.
In Patient Unit
2012/13
2011/12
Total number of patients
293
286
Number of new patients
259
248
% Occupancy
74%
67%
Location after end of stay
161 – Deaths
160 – Deaths
(NB Figures do not total
because some patients were
admitted more than once.)
169 – Home
172 – Home
7 – Care Home
14 – Care Home
4 – Acute Hospital
12 – Acute Hospital
9 - Other
7 - Other
15.4
11.6
2012/13
2011/12
Total number of patients
315
250
Total number of visits face to
face
4902
4155
Total number of telephone
calls
4722
3858
% of people who died at
home
92%
93%
Average length of care
25.9 days
38.4
Average length of stay
Hospice at Home
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Day Hospice
2012/13
2011/12
Total number of patients
140
144
% new patients
69%
74%
Average period of
attendance
85 days
91.4 days
2012/13
2011/12
Total service users
456
444
Number for whom formal
support ended
391
379
Average length of support
47 days
88 days
Family Support and
Bereavement Service
Feedback from Staff
St John’s Hospice is a significant local employer with low rates of staff turnover and high
levels of applicants when vacancies are advertised.
An annual staff satisfaction survey is conducted, the top three statements that staff agreed
with were:
I enjoy the work I do – 97%
I am proud to work for St John’s Hospice – 96%
I feel like I am making a difference – 92%
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Feedback from Patients, Families and Carers
Feedback from patients, families and carers is one of the most important ways for us to
understand and improve the services we provide. Here are some examples of comments and
compliments in our service users’ own words:
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Surveys
We conduct regular patient and family surveys on the ward, here are some recent
comments:
“I feel like I’m in Heaven”
“We think it’s great”
“I’d prefer plainer food. Some days I don’t know what’s available and at what times”
As a result, a Board member will lead a review of food and nutrition in the Hospice over the
next 12 months.
Complaints 2012/13
Complaints are all monitored by the relevant member of Senior Management Team, clinical
complaints are discussed at the Clinical Governance Committee and are reported to the full
Board.
Complaints
Number
Total number received
4
Total number of complaints upheld in full
1
Total number of complaints upheld in part
2
Total number of complaints not upheld
1
Opportunities to give Feedback on this Quality Account
We welcome feedback on our first Quality Account. If you have any comments, please email:
Sue.mcgraw@sjhospice.org.uk
Or write to:
Sue McGraw
Chief Executive
St John’s Hospice
Slyne Rd
Lancaster LA2 6ST
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Annex
Quality Account Consultation with Key Stakeholders
St John’s Hospice, Lancaster Quality Accounts Feedback
Cumbria County Council
The Cumbria Health Scrutiny Committee welcomes the opportunity to
comment on the St John’s Hospice Quality Accounts for 2012-13.
Councillors sitting on the Health Scrutiny Committee have provided their
individual feedback on the document and have highlighted firstly how readerfriendly the document is, with photos nicely breaking up the text and providing
the reader with a well laid-out document that is informative, interesting and
progressive.
Further, councillors have found the document to be concise and both
accessible and clear in the language it uses. The account provides a clear
picture of what is happening across the hospice and the comparisons
provided on the previous year is very helpful too. The overall picture is of a
well run and caring establishment.
At the same time, there was a suggestion that perhaps more information
could have be drawn from the unannounced inspection of 2 February 2013,
with more detail provided upon the inspection successes. In addition,
councillors feel that readers would be interested to hear what St John’s were
pleased about, following the inspection, and whether there were any points
that it wished to develop and incorporate in future priorities going forward. It
is an important element of quality accounts documents to have a strong
element of reflection.
Health Scrutiny members appreciate the work that has taken place over the
recent year and look forward to continuing to work with the Hospice.
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Healthwatch Cumbria
Best Life Building
4-8 Oxford Street
Workington
Cumbria
CA14 2AH
Tel: 03003 038 567
www.healthwatchcumbria.co.
uk
Re: Feedback on St John’s Hospice Quality Account
To Whom It May Concern:
We were asked to provide some feedback on St John’s Hospice Quality
Account for 2012-2013. The following document details our comments and
suggestions, although we would like to stress that Healthwatch Cumbria is
an organisation still very much in its infancy and without a full staff team
available to carry its public engagement function. We therefore feel that in
future, with greater resources available, we can produce a much more
detailed feedback report.
Feedback
Upon reading the Quality Accounts for St John’s Hospice, the Healthwatch
Cumbria team feel that they are very well laid out, giving clear precise
information. They have clearly set out their priorities using the various
tools at their disposal, such as “peer review mock inspections”, regular
patient surveys, consultations etc. It is good to see that they have an active
patient and family user group who are able to inform decisions, services
delivered etc.
There was a general consensus that the idea of a cross healthcare
community project around patient’s records is excellent, as it is vital that
patient records are available to hospice staff. We feel this is very positive.
One of our team was impressed with the feedback from the staff, which
clearly show a very happy staff team work at the hospice. She said “I like
the feedback from patients, families and carers, in their own words, which
show how much they valued the care and services received from the hospice
and staff team.”
Overall, we feel it is a very accessible document, highlighting the good work
of the Hospice over the past year.
Yours sincerely,
Healthwatch Cumbria
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Lancashire Overview and Scrutiny Committee, Lancashire County Council
had no comments to make this year.
No response was received from Healthwatch Lancashire.
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