Quality Account 2012/13
“Improving the quality
of living and dying”
1
Chief Executive Statement of Quality
This Quality Account is for our patients, their families and friends, the general public
as well as the local NHS organisations.
It is of note that twenty-two per cent of our costs are provided by the NHS and the
remainder of our funding is from charitable donations.
The aim of this report is to give clear information about the quality of our services to
demonstrate that our patients can feel safe and well cared for, that all of our services
are of a very high standard and that the NHS is receiving very good value for money.
We could not give such high standards of care without our hardworking staff and our
1500 volunteers, and together with the Board of Trustees, I would like to thank them
all for their support.
Our Director of Patient Care, Medical Director and all clinical managers are responsible
for the preparation of this report and its content. To the best of my knowledge, the
information in the Quality Account is accurate and a fair representation of the quality
of health care services provided by St Peters Hospice.
Our focus is, and always will be, our patients, their families and carers and therefore
we actively continue to seek the views of all who access our services in order to
ensure we maintain the highest standards of quality.
Simon Caraffi
Chief Executive
May 2013
2
Contents
Chief Executive Statement of Quality .............................................. 2
Who we are and what we do .......................................................... 4
Our purpose (Mission statement).................................................... 4
Our aim (Vision) .......................................................................... 4
Map of our area ........................................................................... 5
Priorities for improvement ............................................................. 6
Our progress against our priorities for improvement 2012/13 ............. 6
Priorities for improvement 2013/14 ............................................... 11
Review of services ...................................................................... 13
Participation in clinical audits ........................................................ 14
Research ................................................................................... 15
Quality improvement and innovation goals agreed with commissioners 15
Our progress against our CQUINs 2011/12 ..................................... 15
Our CQUINs for 2013/14 .............................................................. 17
Data Quality............................................................................... 17
Review of Quality Performance ...................................................... 18
What others say about St Peters Hospice ........................................ 19
What our patients say about St Peters Hospice ................................ 19
User Involvement ....................................................................... 20
What our staff say about St Peter's Hospice .................................... 22
Staff training and appraisals ......................................................... 22
Statements of assurance from the Board of Trustees ........................ 23
Board of Trustees Provider visits ................................................... 23
What our regulators say about St Peter's Hospice ............................ 24
What our NHS Commissioners say about St Peter's Hospice ............... 25
Quality Action Plan ...................................................................... 27
3
Who we are and what we do
St Peter’s Hospice (SPH) is Bristol’s only adult hospice. We have been looking after
people in our area for 35 years. Our commitment is to contribute to improving the
quality of life of patients while extending care and support to their families and loved
ones.
Our purpose (Mission statement)
To provide care and support for adult patients, families and carers in our community
living with life limiting illnesses in order to improve the quality of their living and
dying. We do this working closely with other health and social care providers.
Our aim (Vision)
St Peter’s Hospice will play a leading role in the development and delivery of the best
possible care and support services for adult patients, families, and carers living with
life limiting illness in our community.
4
Map of our area
St Peter's Hospice covers 4 primary care team (PCT) areas: the whole of Bristol, parts
of Bath and North East Somerset, South Gloucestershire and North Somerset. Our
Community Nurse Specialist team have bases in Staple Hill, Bedminster, Brentry and
Yate making it easier for us to provide accessible care and support across this large
geographical area (Please note that the 4 PCTs have become 6 Clinical Commissioning
Groups since 1st April 2013).
5
Priorities for improvement
Our progress against our priorities for improvement 2012/13
Priorities for 2012/13
Priority 1
Effectiveness
To ensure patients who are at the end of their
life have their wishes and preferred place of
death clearly recorded
Priority 2
Patient Experience
To support all of our referred patients and
their families/carers to improve where
possible on how we deliver services
Priority 3
Safety
To ensure patients, families and carers are
cared for safely and according to their wishes
and preferences
Priority 1
We said we would monitor this through quarterly audits
We continuously monitor the recording of patient’s wishes for care and preferred place
of death. Through a quality measurement project in May 2012 across ten South West
hospices we took part in an audit of preferred place of death (PPD) and whether
patients died in their preferred location.


94% of patients who wanted to be cared for at home died in their preferred place
of death or preferred place of care. This is 16% higher than the survey average and
higher than the national average1
17% of patients didn’t have a recorded preferred place of death. A variety of
reasons prohibited this such as a sudden deterioration in a patient’s conditions or
emergency transfer to a hospital.
1
In 2010 only 39.3% of people in England died in their usual place of residence
End of Life Care Strategy, Third Annual Report, Department of Health, 2011
6
Actual Place of Death vs. Preferred Place of Death/ Preferred Place of Care
(PPD/PPC)
Priority 2
We said we would implement Patient/Carer Reported Outcome
Measurement questionnaires (PROMs and CROMs) and set up a User
Involvement Forum.
Patient and Carer Reported Outcome Measures (PROMs and CROMs) were
implemented across all service areas in August 2012 to provide a universal system for
obtaining feedback from those who use our services and to replace any existing
surveys.
A total of 280 Patient and Carer Outcome Measure questionnaires were received
between August 2012 and March 2013. There were 5 core questions (the same across
all services) and a sixth question was a service specific question. The 5 core questions
for services and groups used a rating system of:
“I really felt like
•
Always
Royalty.
Hospice
in
•
MostThe
of the
time
general has a wonderful
atmosphere not at all as
I imagined it may be
•
•
Sometimes
Never
7
Highlights include:

100% of carers and families felt the facilities on the IPU were adequate for families
and carers.
Did you feel you had confidence in those
caring for you? (All teams)
Most of the
time
12%
Sometimes
1%
Always
87%

94.4% of respondents felt that Community Nurse Specialists (CNS) always
responded to their concerns and questions.

100% of respondents felt the Hospice at Home (H@H) nursing and supportive care
was about right for their family or relative.
Did you feel you were treated with
dignity and respect? (All teams)
Most of the
time
5%
Blank
1%
Always
94%
8
“The support from the
nursing and medical staff
has been of the highest
quality and everything that
has been done for my
husband has been with the
greatest care”
Comment from
PROMs
We have listened to feedback received via PROMs and CROMs surveys, letters and
verbal requests and as a result several improvements have been made. These include:
You said… The mattresses on the in-patient unit can sometimes feel too hard.
We did… We have replaced all our mattresses with pressure relieving mattresses so
we can make patients’ stay with us more comfortable as the pressure can be adjusted.
You said… More craft and well-being sessions as part of the Day Hospice programme.
We did… We recently had a visit from the Bodyshop team at Cabot Circus who
provided a pampering and make up session for Day Hospice patients.
Last year we re-developed our User Involvement Forum which provides an opportunity
to gather feedback from patients, carers and families who have experienced our
services (see page 20 for further information).
Priority 3
We said we would monitor care through Health and Safety monitoring
systems and participate in a quality measurement project across ten South
West hospices
We have worked hard to reduce patient falls by 30% compared to last year. This has
been achieved through a new Falls Policy where we assume that all patients are at
risk. We have also used risk scoring to help determine if 1 to 1 nursing is appropriate.
Since October 2012 we have been using the National Patient Safety Agency grading
system to assess levels of harm when incidences occur. This has shown that there has
only been 1 fall that has resulted in injury greater than level 1 (Level 1 is a minor
graze or bruising).
We participate in a quality measurement project across ten (twelve since January
2013) South West hospices enabling us to benchmark against our peers. We submit
data every quarter on patient falls, pressure ulcers acquired during a patient’s stay at
the hospice and medicines incidents. 9 hospices took part in benchmarking last year.
9
“I like the new furniture.
It’s smart and brightens up
the place and very
comfortable".
Comment from patient
regarding the new furniture
in the Day Hospice
Hospice
Average
Number
of beds
C
10
Occupied Bed
days (OBD)
on in-patient
unit
2514
E
12
D
Falls per
1000 OBDs
Pressure
ulcers per
1000 OBDs
Medicine
incidents per
1000 OBDs
10.3
4.8
1.6
3135
13.4
1.3
5.1
7
1878
17.6
3.7
3.7
K
17
4984
7.4
1.4
5.8
B
20
5607
5.7
3.0
2.1
F
H-St Peter's
Hospice
J
25
8130
7.4
5.8
3.8
18
4450
9.7
1.8
4.0
14
4102
7.3
3.4
7.8
A
11
2716
12.2
1.5
1.8
10.1
3.0
4.0
Hospice Average
OBD= Occupied bed days
In addition to the actions completed on our action plan (Appendix 1) we have
completed the following:

The development of the psychological, spiritual and social (PSS) team to
encompass creative therapies including art therapy, psychological and spiritual
support.

Refurbishment of the Day Hospice, which has received positive responses,
improving space for use for patients and carers.

Refurbishments of treatment rooms on the in-patient unit which have helped to
reduce the number of drug errors significantly over the last year. Patient Own
Drug (POD) dispensing units have also been fitted to all rooms on the in-patient
unit.
10
Priorities for improvement 2013/14
Our priorities for improvement for 2013/14 are:
Future planning Priority 1 - Effectiveness
Standard: Forming effective partnerships to support end of life co-ordination
in our local area
Measure: This will be monitored through collaboration with other healthcare providers
and the creation of a report and model for effective working to provide high quality
end of life care. Partner and User Involvement comments will also be sought.
Future planning Priority 2 – Effectiveness
Standard: To actively seek to procure a new patient record system. Through
this process our aim is to review clinical systems to improve data collection
across all patient areas
Measure: This will be monitored through our Clinical Records Steering group and ICT
Management Forum. We will also consult the external ICT support service we use,
Solsoft, to ensure that any new systems will run effectively and efficiently with our ICT
infrastructure.
Future planning Priority 3 – Patient Experience
Standard: Extend the Hospice at Home service so that more carers/ families
feel able to look after patients in their own homes
Measure: Correct staffing levels will allow more patients to be cared for in their own
homes and their families to be supported by the SPH Hospice at Home team.
11
“By having a separate space, slightly
away from the main building, means
we can work with people
confidentially to explore the
sensitive issues that arise from
coping with life limiting illness.”
Julie Francis
Psychological, Social,
Spiritual (PSS) Team
Manager
Future planning Priority 4 – Patient Experience
Standard: To implement a Hospice Volunteer Neighbour programme to
provide practical and social support to benefit patients and their carers.
Measure: Recruitment of Volunteer Neighbours will allow more patients to feel able to
cope with daily life in their own home. This initiative will be managed by the Volunteer
Resources team who will recruit and train volunteers to carry out tasks such as
providing company, light household tasks, collecting prescriptions and walking the
dog.
Future planning Priority 5 – Safety and Facilities
Standard: To review our Brentry site and any potential developments
ensuring sustainability for future patient and carer needs
Measure 1: During the next year SPH will focus on increasing on-site recycling and
develop good practice in recycling and waste management.
Measure 2: A review of the in-patient unit bed levels will be undertaken to determine
how best to utilise the space to meet future demands. This will feed into Clinical
Strategy planning.
Measure 3: SPH has been awarded £460,000 from the Department of Health to
improve the hospice buildings as part of a £60 million grant programme to hospices
across the nation. The money awarded to SPH will be used to build the PSS garden
rooms equipped to deliver creative therapies such as art, music and dance (Artist
impression above).
The building will help us reach more people earlier on in their journey, before they
need more clinical/medical support. The building will act as a ‘stepping-stone’ for
patients, families and their carers who will be in contact with the Hospice.
12
Review of services
During 2013/14 SPH will continue to provide the following services with service level
specifications agreed with the NHS. The NHS contributes 22% of our overall funding.
SPH has reviewed all the data available to the NHS on quality of care for all our
services.
1. In-Patient Unit – 18 beds staffed by 54 IPU nurses and supported by the wider
clinical team.
2. 24 hour advice line offering specialist palliative care advice to healthcare
professionals and carers (This is not commissioned by the NHS)
3. Day Services – up to 20 patients 4 days per week
– Fatigue and Breathlessness programme
4. Physiotherapy/Occupational Therapy – to help patients maintain a good quality
of life for as long as possible
5. Hospice at Home – to enable patients to die at home.
6. Community Nurse Specialist Service – providing advice, support and symptom
control to more than 1600 patients per annum
7. Medical Consultants – cover the hospice, the community and work with the
Bristol Hospitals Palliative Care teams.
8. Psychological, Social and Spiritual Care (PSS) services – to provide social,
emotional and spiritual support for patients, families and carers, including
bereavement care. This service includes music therapy, psychological support,
carers groups and other creative therapies.
St Peter's Hospice monitors all services on a monthly basis through collating of data
on number of patients seen, face to face contacts and telephone contacts.
13
Participation in clinical audits
An annual clinical audit plan is drawn up and reviewed by our clinical monitoring
committees. This also contributes to our overall Quality Action Plan (Appendix 1).
Highlights from completed audits include:
Completed Audits 2012/13
Advice Line
Documentation
audit
Referrals to Day
Hospice
Several recommendations on how to
improve the service were identified
Improvements in recording of spirituality
information identified
98% of patients were contacted within 5
days of a referral being received
This year our audits will include discharge planning, infection control, controlled drugs
and general medicines.
We are also participating in a multicentre and multisite audit to determine how many
patients do not wish to receive life prolonging measures (resuscitation).
Our multidisciplinary Clinical Forum Group also discusses new ideas and how we can
implement them appropriately to support our patients, families and carers.
Notes from our quarterly clinical committees keep the Board of Trustees fully informed
about audit results including any identified shortfalls. Through this process, the Board
is assured of the quality of the services provided.
14
Research
Any involvement in research is carefully monitored by our Research Advisory Group
and clear guidelines are set under our Research Policy.
Last year SPH participated in a national confidential enquiry into the deaths of those
with learning disabilities, in association with the University of Bristol.
We encourage the sharing and discussion of published clinical research across clinical
teams through our Journal Club which meets every quarter. This helps to support
continuous learning and best clinical practice.
Quality improvement and innovation goals agreed with
commissioners
A small proportion of our NHS income in 2012/13 is conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation (CQUIN) payment framework.
Our progress against our CQUINs 2012/13
CQUINS for 2012/13
Indicator 1
Indicator 2
Indicator 3
Develop and report on a collective concept (with 3
other local hospices) of appropriate services for
people aged 16-25yrs who are identified as having
specialist palliative care needs.
To improve access to specialist palliative care support,
treatment and advice for minority and deprived
populations and non-malignant conditions.
To further improve access for and support to primary
care teams by the community specialist nurses
(CNSs).
15
“They faithfully attend
and are very helpful”
Comment from partner survey
regarding community team
attendance at palliative care
meetings
Indicator 1
We have worked closely with Weston Hospicecare, St Margaret’s Hospice, Children’s
Hospice South West and Dorothy House Hospice Care to clarify the parts played by
children and adult hospice services in the ‘transition pathway’, outlining how to
support children/young adults with life limiting diseases as they move from childhood
to adulthood. Any requests for hospice care for young adults outside our referral
criteria age of 18 are carefully reviewed by our medical teams to ensure that
appropriate measures are put in place.
Indicator 2
Our community teams have helped to strengthen our connections with ethnic minority
and deprived populations through work with the homeless and local prisons. We have
also raised awareness of our services through multi-faith forums and will continue to
do so this year.
We have cared for more patients with non-cancer diagnoses in the Bristol area this
year with a 2.3% increase on last year’s results. This equates to 17.1% of our total
number of patients for Bristol (n= 906).
Indicator 3
We have increased our attendance at Palliative care meetings at GP practices and in
primary care settings, sharing knowledge and expertise in end of life care with these
teams.
The SPH 24 hour advice line, providing specialist palliative advice to healthcare
professionals and carers continues to be well used with a 40% increase in calls
compared to last year. We have recently conducted an Advice Line review and hope to
implement some of these recommendations this year.
16
Our CQUINs for 2013/14
For the coming year our NHS CQUIN goals are:
CQUINS for 2013/14
Indicator 1
Indicator 2
BNSSG (Bristol, North Somerset South
Gloucestershire) cluster Whole System
End of Life Care co-ordination
Prospective audit and review of the quality
of discharges to nursing homes following a
complaint
Indicator 1 will be monitored through working in partnership(s) with other healthcare
providers in our geographical area. The partnerships will create written reports and a
model to improve sharing and recording of preferred place of death and care
discussions and preferences, which will also be implemented.
Indicator 2 will be monitored through an audit of patients discharged from our inpatient unit to nursing homes which will be discussed at Clinical Audit Group and
Clinical Governance.
Data Quality
SPH provides six monthly patient activity data in the agreed format to the local NHS
Commissioners as well as an annual report as agreed in our NHS Community contract.
Data is stored and utilised in accordance with the SPH Information Governance Policy,
which is fully compliant with legalisation. We have improved our information
governance training to ensure clinical and administrative staff have completed online
training via the NHS Information Governance toolkit. As a result we now have access
to the NHS secure email system which we hope will speed up the transfer of patient
information with healthcare partners in the community.
17
We are, however going to review and update our electronic patient record system. As
a result clinical processes will be examined to improve the quality of data collection to
ensure a more streamlined approach.
SPH is not subject to all Department of Health/Government regulations but it is a
registered company in England and Wales and is limited by guarantee. It is also a
charity registered with the Charity Commission. SPH prepare reports and accounts in
compliance with the accounting standard Statement of Recommended Practice (SORP
2005) and these are audited by a firm of independent auditors. Report and accounts,
which are for the year ending 31 March, are filed with both Companies House and the
Charity Commission. All reports are also available on our website
www.stpetershospice.org or upon request.
Review of Quality Performance
The hospice receives in the region of 1,700 referrals per year across all services. The
quality of services are maintained, monitored and improved through clear policies and
procedures, a robust recruitment and induction programme and excellent training and
education for staff and volunteers. Service users are consulted through our
PROMs/CROM’s (see page 7 and 20) and our User Involvement Forum in relation to
service delivery and future development.
All complaints are investigated. Complaints both informal (verbal) and formal (written)
are infrequent but are recorded and discussed. Formal letters of complaint received
are investigated thoroughly and reported to the Executive Team, Clinical Governance
Committee, our Board of Trustees and NHS organisations.
In 2012/13 there were 8 informal complaints and 3 formal complaints, but none in the
last quarter. 2 of the informal complaints related to anxiety over the use of the
Liverpool Care Pathway and the complainants were reassured that we do not use it at
St Peter's Hospice.
A further 3 related to the behaviour of volunteers and these individuals have been
addressed, provided with extra training and relatives reassured.
18
“I refer many patients to
all areas of the service St
Peter's provides and am
always comfortable with
service provision
outcomes”
Comment from partner
survey-Hospital
team nurse
Another informal complaint (July 2012) was about the hospice discharging a patient to
a nursing home and this later became the subject of a formal complaint. A full root
cause analysis investigation was conducted. The Care Quality Commission and Bristol
Social Services became involved in case of a safeguarding issue and all parties were
reassured that this was not the case. To date we have not received any
correspondence from the family in response to the investigation. As a result of this
complaint a full set of learning actions were presented to our Clinical Governance and
Clinical Services (Trustees’) Committees. These have been completed in full including
retrospective audit of patients discharged to nursing homes. A prospective audit will
be the next stage of this learning (and is also one of our CQUINs for this year) so that
we as a hospice may discover if we are, in fact, discharging the correct patients from
our services and facilities.
What others say about St Peters Hospice
In February 2013 we conducted an electronic survey with healthcare professionals in
our local area to obtain feedback on several key service areas to help improve these
services for the future. Using a rating scale of 1 to 10 the average satisfaction level
from respondents was 8.1 out of 10. Comments received from this survey will feed
into clinical strategy planning.
What our patients say about St Peters Hospice
We frequently receive comments and expressions of gratitude for the care patients,
their families and carers are given. For example:
“Everyone worked together to provide the best care- everything was discussed fully
and clearly. My brother and I felt that we were part of a team caring for our mother.”
“I found it the most relaxing place there is. I enjoyed meeting the other patients and
the nurses and volunteers were most helpful. Nothing was too much trouble.”
19
This year we introduced a new style Patient and Carer Outcome Measure (PROMs and
CROMs) questionnaire making it easier to gain feedback from service users particularly
if they have used several of our services.
User Involvement
St Peter's Hospice runs a User Involvement Forum periodically which is made up of
patients, carers and families who have experienced our services. Last year we
redeveloped our User Involvement Forum under the leadership of a volunteer chair
person who was also a former service user. The aims of this forum are to:





Contribute to the development of our services
Provide a supportive environment for all to share ideas.
Encourage participation of all service users during the meeting.
Respect and listen to all contributions.
Limit the meetings to 1 hour so that users and patients can concentrate and
participate throughout the meeting.
20
“It’s a bringing together
from right across the
hospice … there’s a lot of
laughter”
“It’s uplifting!”
Comments about the
hospice choir
Sadly our volunteer chair person died unexpectedly and we will re-evaluate the format
of the forum in this year.
We have also created User Involvement boards on the in-patient unit and in the
reception area at Brentry to help promote activities for patients and carers, including
St Peter's Hospice choir.
We have signed up to take part in the NHS initiative Patient Led Assessments of the
Care Environment (PLACE). This assessment is an equal collaboration between
Hospice staff and patients, family and carers, focusing on:
 Cleanliness
• Food and hydration
•
•
Building condition and appearance
Privacy, dignity and well being
The PLACE team will walk around the hospice and rate each of the key areas against
set criteria. We are beginning to actively recruit patient/carer assessors to assist us.
A St Peter’s Hospice choir has been set up, led by the Music Therapist for staff,
patients, carers and volunteers. The choir has proved to be very popular with high
attendance levels. The choir will perform at SPH 35th anniversary event in June.
In March 2013 Day Hospice patients were asked to participate in a survey into
whether alcohol should be served with lunches for patients attending the 12 week Day
Services programme. The results indicate that most respondents (96%) do not drink
during their time at the hospice and 61.5% said it made no difference to their
experience, but 39% did say it made a difference so a choice is provided.
Patients have also been involved in choosing the colours of the curtains on the inpatient unit.
21
“Clinical supervision provides
me with a place to stop, reflect
and consider different angles
on the issues I deal with
regarding staff and clients in
my care. I feel supported and
refreshed by the process”
Comment about clinical
supervision
What our staff say about St Peter's Hospice
SPH values the opinions of staff regarding the quality of service provided. In mid 2013
our biennial staff survey will be conducted using the same questions employed in the
2010 survey to allow direct comparisons.
Previous surveys had asked for greater support for staff. As a result a clinical
supervision programme for all staff directly involved in patient care has been
implemented with group and individual sessions.
Our PSS team also hold regular mindfulness and meditation sessions for staff, patients
and carers.
As part of our five year strategic plan a clinical staff plan has been produced which will
identify the necessary skills, qualifications and experience needed to enhance our
clinical team’s capability.
Staff training and appraisals
All paid staff receive mid-year and end of year appraisals in which objectives for the
coming year are set and a personal development plan drawn up. The SPH Education
department has implemented several e-learning modules for mandatory training
including food hygiene, back care and fire safety awareness. New software has
improved the recording of training for paid staff and volunteers, informing line
managers when mandatory training is due.
22
Statements of assurance from the Board of Trustees
The Board of Trustees’ commitment to quality
The Board of Trustees is fully committed to delivering high quality services to all our
patients whether in the community or at the hospice site. Our trustees are involved in
monitoring the health and safety of patients, the standards of care, feedback from
patients, including complaints, and plans to future service development. They do this
by receiving regular reports on all these aspects of care and discussing them at Board
meetings.
In January 2013 our Board of Trustees agreed a 5 year strategy with nine strategic
goals identified. The SPH vision and mission have been revised (see page 4) and the
way ahead of the services we provide has been mapped with growth and development
targets identified where appropriate. This report is available on request.
The Board is confident that the care and treatment provided by St Peters Hospice is of
a high quality and cost effective.
Board of Trustees Provider visits
Our trustees visit the hospice and our community teams on a regular basis as part of
their duties. The Board of Trustee Provider visits look at 3 key areas to review
quality; patient care, staff and the environment. A new policy has been introduced to
formalise reports.
23
“We spoke with patients and
relatives on the in-patient unit.
One person told us that they
could not wish for anywhere
better for their relative and
that staff were "fantastic".
Taken from CQC
inspection report
June 2012
What our regulators say about St Peter's Hospice
St Peter's Hospice is currently registered as an independent health care provider under
the Care Standards Act 2000.
SPH is subject to periodic reviews by the Care Quality Commission. In 2012/13 St
Peter's Hospice is registered under the following categories: nursing care, transport
services, triage and medical advice provided remotely, treatment of disease, disorder
or injury and diagnostic and screening procedures regulated activities with the Care
Quality Commission (CQC) under the Health and Social Care Act 2008.
Since our CQC inspection in May 2012 we have not had another visit or been asked to
fill in a self assessment form. We continuously review quality of care against the CQC
standards through ‘spot checks’ on the in-patient unit and collating of relevant and up
to date documentation.
During our last inspection we were found to be compliant against the standards
measured and SPH has no actions to take as a result. The CQC report can be accessed
via www.cqc.org.uk/
24
What our NHS Commissioners say about St Peter's
Hospice
Statement from NHS Bristol Clinical Commissioning Group
“Bristol Clinical Commissioning Group welcomes the opportunity to comment on St
Peters Hospice Quality Account for 2012/13. This reflects the open and collaborative
approach of St Peter’s in working with patients, carers and the general public
regarding the quality and ethos of care provided by St Peters. The report details the
range of work that St Peter’s undertakes locally and considers all the relevant
mandatory elements. The information presented within the report has been reviewed
and the CCG is satisfied that the position reflects an accurate account of the quality of
the services provided. The report is consistent with the contract and performance
management information that we receive from St Peters and feedback from patients,
carers and clinicians. St Peter’s commitment to securing patient views and then taking
active steps to respond to this feedback comes across strongly in the work that the
hospice does and is reflected in this quality account.
The account identifies significant progress in relation to:

Ensuring that patients were able to die in their preferred place of death.

Recording and responding to patient and carer views on the quality and nature of
the services provided

Overall patient safety and quality of care including the monitoring of falls, pressure
ulcers and medicine incidents

Taking practical steps to improve psychological, social and spiritual support to
patients

Making changes to the physical environment and provision of equipment that
support improvement s to patient quality and experience.
Bristol CCG will be pleased to continue our work with St Peters over the coming
year. This will include ensuring that appropriate patient safety, clinical quality, data
and information governance mechanisms are in place, used and routinely reviewed
and improved on an ongoing basis.
25
We will continue to work closely with St Peters in order to:

Undertake further work on falls prevention and risk minimisation

Develop collaborative arrangements with other local services to ensure robust end
of life care coordination within Bristol

Extending the responsiveness of community hospice services so that more people
can be supported within their own homes

Continuing to prioritise preventing pressure ulcers, infection control, controlled
drug and general medicines management

Retaining the focus on patient feedback, experience and outcomes
The continued collaborative work between St Peters and the CCG will remain essential
in 2013/14 and should be strengthened and developed by new collaborative working
arrangements and the increased involvement of CCG clinicians.”
Judith Brown
Operations Director
NHS Bristol Clinical Commissioning Group
South Plaza
Marlborough St
Bristol
BS1 3NZ
Julia di Castiglione
Carole Dacombe
Director of Patient Care
Medical Director
June 2013
26
Appendix 1
Quality Action Plan
Last year’s actions were completed in full. Most of Year 2 actions were also completed.
Last year (Formerly Year 1): July 2012  March 2013
ACTION
Review incidence of
 Pressure sores
 Falls
 Drug Errors
Check the standard of record
keeping
Audit of Controlled Drugs
Audit assessment of spiritual
needs of patients on IPU
Review results of Infection
Control
Audit and areas for
improvement
Monitor Staff sickness and
benchmark against NHS figures
Survey staff views
BY WHEN
September
2012
September
2012
October 2012
March 2013
October 2012
October 2012
October 2012
Bereavement client CROM
(Carer Reported Outcome
Measurement)
December 2012
Further develop our systems for
patient assessment using
validated tool
Assess patient care environment
using PROM’s (Patient Reported
Outcome Measurement). Pilot
system and review results
December 2012
August 2012
EXPECTED OUTCOME
Measures agreed for the hospice and
standards set
Compare favourably to similar
organisations
Make sure record keeping is in
accordance with our policies and any
changes are identified and put into
action
Evidence that controlled drugs are
managed safely and in compliance with
the law
Evidence that IPU patients spiritual
needs are assessed appropriately and
necessary changes to assessment
process identified and put into action
Necessary changes identified, measures
agreed for the hospice and put into
action
Review of all policies and procedure
DH benchmarks established and
standards set.
Discuss results with staff, identify any
changes and put into action
Evidence that bereaved client was
satisfied with the service received from
their allocated worker and necessary
changes identified and put into action
Assessment system is revised to ensure
accuracy of completion and
documentation
Evidence that SPH provides high quality
care environment and necessary
changes identified and put into action
27
ACHIEVED
Sept 2012
Feb 2013
Sept 2012
Audit &
Action Plan
3 monthly
CD
reconciliation
audits
In progress
Oct 2012
March 2013
On-going
June 2012
completed
clinical
supervision
Completed &
being
repeated
On-going
On-going
Signed for
PLACE Feb
2013
ACTION
BY WHEN
Administration of Medicines
Audit
March 2013
Audit preferred place of death –
documentation of patient wishes
May 2012
Audit use of Advance decision
code and documentation of
patients’ wishes
Review the IPU and the Advice
Line Services
Sept 2012
Prepare Quality Account and
update quality action plan
March 2013
Bid for Dept of Health money to
improve patient areas
June 2012
Introduce and pilot a new
dependency scoring system
November 2012
November 2012
EXPECTED OUTCOME
ACHIEVED
Evidence that medicines are
administered correctly and necessary
changes identified and put into action
Evidence that patients’ wishes are
documented
Many
complete
and on-going
Dec 2012
Evidence that patients’ wishes are
correctly documented on electronic
patient record
A full review and action plan to ensure
on-going and dynamic change with
associated quality of care
Clear plan for SPH quality improvement
linked to key performance indicators.
Dec 2012
New mattresses and new recliner chairs
New building
Vehicle for those with disability
Evidence that dependency scoring
system used in all patient areas and
measurable caseloads
Achieved
28
March 2013
Achieved
In progress
This year (formerly Year 2): April 2013 March 2014
ACTION
BY WHEN
EXPECTED OUTCOME
ACHIEVED
Jan 2013 and
on-going
Infection Control Audit and
identification of areas for
improvement
Audit mouth care for inpatients
July 2013
Necessary changes identified and linked
to action plan
Dec 2013
Audit incidence of falls on In
Patient unit and risk
assessment process
Sept 2013
Evidence that mouth care is provided
for patients in accordance with agreed
guidelines
Establish baseline for falls incidence
and agree falls risk assessment process
Audit ordering, collection,
transportation, receipt and
storage of Controlled drugs
Sept 2013
Audit of use and validity of
dependency scoring system by
all SPH teams (Superseded by
whole systems review of inpatient unit)
Evaluation of Outcome
measurement tools and
changes to patient dependency
Monitor Staff sickness and
benchmark against NHS figures
Apr 2013
Ongoing monitoring of
previously established
benchmarks for
 Pressure Sores
 Falls
 Drug Errors
Evaluation of unmet needs for
Hospice at Home service
March 2013
Evidence of compliance with SPH
standards and necessary changes
identified and linked to action plan
Sept 2013
Monitor clinical staff knowledge
and skills using Skills for
Healthcare End of life
competencies via staff
meetings, organisational groups
and staff training records
Review and further extend our
patient assessment tools e.g.
Nutritional assessment
Review results of patient,
carers, bereaved clients
satisfaction survey for
Complementary Therapies
Audit of bereaved client
satisfaction
April 2013
Identification of supply versus demand,
necessary changes identified and
shared with relevant groups
Evidence that SPH clinical staff are
meeting required competencies to
provide a high standard of End of Life
care
Sept 2013
Dec 2013
Evidence that controlled drugs are
managed correctly and necessary
changes identified and linked action
plan
Evidence that dependency scoring
system is used correctly against
guidelines and necessary changes
identified and linked to action plan
Evidence that outcome measurement
tools are used in accordance with
guidelines
SPH benchmarks established and
standards set.
June 2013
Patient assessment is accurately
completed and documented
November 2013
Evidence that patients carers, bereaved
are satisfied with Complementary
therapy service and necessary changes
identified and linked to action plan
Evidence that bereaved client was
satisfied with the service received from
their allocated worker and necessary
changes identified and linked to action
plan
Dec 2014
29
Completed
and on-going
through
benchmarking
initiative
Feb 2013 and
on-going
New system
being piloted
Pilot study
Mar/April
2013
On-going
On-going
ACTION
BY WHEN
EXPECTED OUTCOME
March 2013
Clear plan for SPH quality improvement
linked to key performance indicators
Mid 2013
Revised referral criteria to fit changing
palliative care demographics
Review of triage and advice line
to work towards a 7 day per
week service
June 2013
Merged triage, advice line and referral
system
Implement in-patient review
recommendations following
review conducted in Feb 2013
by independent reviewers
Log unmet needs in in-patient
unit , PSS team and art
therapies team
Dec 2013
Full list available on request
Oct 2013
To measure team demand and capacity
Consolidate plans for full
creative use of new garden
room with optimal flexibility for
PSS team
Develop a medical team model
to support the future
Early 2013
New building to be built and funded by
Department of Health grant
Dec 2013
Review medical staffing alongside other
disciplines review
Report on quality of SPH
services and revise Quality
improvement plan
Review of referral criteria and
capacity for all our services
30
ACHIEVED
Next Year (Formerly Year 3): April 2014  March 2015
ACTION
Audit on identified key areas
of Symptom Management
BY WHEN
EXPECTED OUTCOME
July 2014
Evidence that symptoms are managed
effectively
Review results of Patient
satisfaction surveys and
identify any required actions
September 2014
On-going monitoring of
previously established
benchmarks
Report on quality of SPH
services and revise action
plan
Consider priorities for
expansion in Hospice at
Home and other community
based services
March 2014
Evidence that patients are satisfied
with SPH services and necessary
changes identified and linked to action
plan
Evidence of compliance with SPH
standards and necessary changes
identified and linked to action plan
Clear plan for SPH quality
improvement linked to key
performance indicators
To scope expansion of day services in
the community, volunteer services
and PSS support
March 2014
31
ACHIEVED
32
33
34
35
St Peter's Hospice
Charlton Road
Brentry
Bristol
BS10 6NL
Switchboard: 0117 9159400
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