St Teresa’s Hospice
The Darlington & District Hospice Movement
Quality Account for the Year 2012 - 2013
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TABLE OF CONTENTS:
PART 1
CHIEF EXECUTIVE’S STATEMENT
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PART 2 LOOKING AHEAD: IMPROVEMENT PRIORITIES FOR 2013/14
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2.1 INTRODUCTION:
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2.2 IMPROVEMENT ASPIRATIONS FOR THE CURRENT YEAR
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PART 3 REVIEW OF QUALITY PERFORMANCE
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3.1 REPORT ON PRIORITIES FOR IMPROVEMENT 2012/13
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2012/13 - IMPROVEMENT PRIORITY 1 (PATIENT SAFETY)
2012/13 - IMPROVEMENT PRIORITY 2 (PATIENT SAFETY)
2012/13 - IMPROVEMENT PRIORITY 3 (CLINICAL EFFECTIVENESS)
2012/2013 - IMPROVEMENT PRIORITY 4 (PATIENT EXPERIENCE)
2012/2013 - IMPROVEMENT PRIORITY 5 (PATIENT EXPERIENCE)
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3.2 STATEMENT OF ASSURANCE FROM THE BOARD
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3.3 REVIEW OF QUALITY PERFORMANCE DURING 2012/13
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2012/13 PERFORMANCE - PATIENT SAFETY
2012/13 PERFORMANCE - CLINICAL EFFECTIVENESS
2012/13 PERFORMANCE - PATIENT AND STAFF EXPERIENCE
THE BOARD OF TRUSTEES STATEMENT
SUPPORTING STATEMENTS: ST TERESA’S HOSPICE QUALITY ACCOUNT 2012/13
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APPENDICES
(i)
Audit Table
(ii)
Patient & Carer Feedback Action Plan
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Part 1
Chief Executive’s Statement
This report on the quality of services provided by St Teresa’s Hospice (The Darlington & District
Hospice movement) is an important part of our information strategy to communicate openly with all
stakeholders. Since the production of our last Quality Account, both corporate and clinical
governance at the Hospice have been further strengthened. The Board of Trustees has commenced
a development programme and reviewed its membership. A new Chair will be appointed from July
2013.
St Teresa’s Hospice Board of Trustees is committed to continuous service improvement and has
supported the implementation of a formalised five year strategy (2010-2015) focussing on safe,
effective, high quality care which provides patients and their carers with a positive patient
experience. Significant progress has been made with the implementation of the Strategy, so much
so that, following a review, a new strategic plan will be produced during the forthcoming year, which
is relevant to the new commissioning and healthcare landscape.
The new strategy will further develop a model of working where the Hospice is a dynamic “hub” of
the community which combines the highest quality patient care that is evaluated and cost effective
with social experiences and activities alongside continuous service improvement and innovation.
In July 2012, a Clinical Governance sub strategy was written and implementation commenced across
all disciplines. The sub strategy is designed to provide a systematic framework for improving and
maintaining quality of patient care in the Hospice. It embodies high standards of care, transparent
responsibility and accountability for those standards and a constant dynamic of improvement.
Key improvement areas across the domains of Patient Safety, Clinical Effectiveness and Patient
Experience are outlined in this Quality Account and are supported by action plans; we aim to ensure
a “one hospice” approach, across all teams, to achieve these goals.
The Quality Account is written in consultation with service users, and is endorsed by our Board of
Trustees, The Board enthusiastically supports quality improvement and views this reporting format
as an opportunity to demonstrate existing good practice to stakeholders, whilst focusing on the
coming year's priorities for improvement.
Jane Bradshaw
Chief Executive
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Part 2
Looking Ahead: Improvement Priorities for 2013/14
2.1 Introduction:
This Quality account focuses on specific improvement priorities for the coming year which cross the
domains of Patient Safety, Clinical Effectiveness and Patient Experience.
Service users and staff have been consulted on both the strategy and this Quality Account, and have
agreed the outlined priorities for improvement.
St Teresa’s Hospice is fully compliant with the National Minimum Standards (2002) and has satisfied
the Care Quality Commission (CQC) that standards are being met through both self assessment and
an unplanned CQC inspection in January 2013. The CQC inspection was extremely successful and St
Teresa’s Hospice was deemed fully compliant.
Since writing the last quality account, significant re-configurations in the NHS have taken place with
the advent of the Clinical Commissioning Groups (CCG) and GP Commissioning. The Hospice’s
catchment area crosses at least two CCG areas: Darlington CCG and Hambleton, Richmondshire and
Whitby CCG. The majority of patient flows are from within Darlington CCG.
2.2 Improvement Aspirations for the Current Year
Improvement Aspiration 1 (Patient Safety, Patient Experience, Clinical
Effectiveness)
To Improve End of Life Care for Darlington Care Homes Residents
Why choose this as an Aspiration?
St Teresa’s Hospice provides the best possible palliative care to the people of Darlington and North
Yorkshire and through provision, collaboration, innovation and education supports the wider
delivery of supportive and palliative care.
In 2012, Darlington Borough Council offered all of its registered care homes the opportunity to
register on the GSF for Care Home Framework (GSF) which gives quality assurance, improvement
and recognition. The GSF improves the quality, coordination and organisation of care facilitating
individuals to remain in their preferred place of care as they approach the end of life and has been
developed from its original use in Primary Care so that it is transferrable to the Care Home setting. It
is hoped that the program will both improve quality of care for residents of care homes and prevent
avoidable hospital admissions, through better organisation and proactive planning.
14 out of a possible 16 Homes registered on the program. Unfortunately, none of the homes made
progress with the enormity of the program, which was initially underestimated. Therefore,
Darlington Borough Council approached the Hospice in spring 2012 to seek support for the program
and funding was sought from Darlington CCG to contribute towards the Hospice’ costs for a
facilitator. The project began last year and will continue during 2013/14.
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By supporting the Care homes to implement the GSF framework including providing training on
specific topics relating to end of life such as recognising when a patient is actually approaching the
end of life, proactive planning using a standardised approach to care planning including discussion
with families about DNACPR (Do Not attempt to resuscitate), and other care planning tools such as
advanced care plans it is hoped quality of care will improve and patients will be able to die in their
preferred place of choice. Targeted education delivery and shadowing of Hospice staff will develop
the workforce within care homes enabling them to deliver higher quality care.
How will this Aspiration be achieved and measured?
Objective
Measure of performance
All registered care homes will both hold
Audit of care homes registers.
a GSF register and code patients on their
Target: 100% of registered care homes
register, at least once per month
are coding at least once per month
In 2013/14 at least 4 homes will apply
for accreditation
To reduce avoidable Hospital admissions
for patients nearing the End of Life
Where care homes are part of a national
group and therefore must use corporate
advanced care plans, their paperwork
will be audited to ensure it meets the
basic principles of Deciding Right. In all
other care homes Deciding Right will be
promoted
All patients for whom it is appropriate
will have an advanced care plan
Advance care plan practical training
session
Ad hoc training provided to specific
homes on gaps in knowledge (for
example
symptom
management,
advanced care planning etc)
To provide care homes with an
opportunity to shadow staff at the
hospice
Care homes feel supported by the
facilitator so that they can themselves
implement the GSF program
Audit of care home admissions to A and
E pre and post intervention
Evidence of accreditation or application
for accreditation for 4 identified homes
Evidence of individual case studies
demonstrating the impact of the
changes implemented through GSF
program
Audit of care homes documentation.
Target: 100% of care homes are using
advanced
care
planning
and
documentation that meets best practice
Audit of care plan use in homes,
Target: 100% of all patients who are
coded as “B” or above have an ACP in
place
Training logs/registers
Register of training and training packs
Letter to all care homes inviting them to
shadow staff at the Hospice, Register of
shadow shifts. Target: Each care home
to send at least one member of staff to
the hospice
Survey of homes; Target 100%
satisfaction with support received by the
Hospice
Dependent upon CDDFT
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Improvement Aspiration 2 (Patient Safety)
To Introduce Core Competencies for Health Care Assistants
Why choose this as an Aspiration?
At St Teresa’s Hospice we aim to ensure that all care focuses on the safety, needs, wishes and
priorities of the patient, their carer and family. In order to do this, the workforce must be
appropriately skilled to recognise the changing needs of patients and patterns of care must be
planned and delivered to meet these needs, and those of the family.
To fully meet patients and carers needs, several factors must be in place, a flexible, co-ordinated
multi disciplinary team, correct staff to patient ratios, appropriate leadership, the correct skill mix
within teams and appropriate workforce development, training and education and support of the
development of new and enhanced posts and roles.
Over the past 12 months significant time and effort has been spent reviewing internal structures,
examining the components and skill mix of the multi-disciplinary teams and to make sure the teams
are able to deliver the strategic plan whilst working within the auspices of the clinical governance
sub strategy. Gaps in the teams have been identified and significant changes have been made
including the appointment of a Nurse Consultant, a Macmillan Physiotherapist, 2 senior nurses and
additional counsellors. Several further appointments to support the delivery of safe and effective
patient care will be made over the coming months in line with budgetary constraints.
The above is all very important and is a component part of high quality care delivery. It is also
important that staff are supported to develop their skills through continuous professional
development and clinical supervision, which is available to all clinical staff. One way of supporting
continuous workforce development is through core competences, to ensure that all staff are
confident to work with patients as they approach the end of life, and ensures a basic minimum
standard that all staff are working to. The hospice clinical governance strategy highlights the
intention to develop core role competences across all staff grades, however during 2013/14, priority
will be given to developing competences for health care assistance roles, base lining existing staff
against these competences and implementing the corresponding education program.
The findings of the Francis report add further endorsement to this Quality Aspiration. The report
talks about Fundamental Standards of Behaviour, introducing Core competencies will help to
achieve this and further enhance our culture of “putting the patient first”.
How will this Aspiration be achieved and measured?
Objective
Target/ Measure of performance
To establish a task and finish group to review
Agreed competency framework for
the St Christopher’s Hospice accredited End
Hospice Health care assistants Band
of Life Competency Framework (2012) and
2 and Band 3
determine any additional competency areas
required for Health care assistants within St
Teresa’s Hospice
To launch the competency framework to all
100% of Hospice contracted Health
Hospice contracted Health care assistants
care assistants to receive the core
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To Support Hospice Health Care assistants to
baseline themselves against the framework,
and managers to authorise competency level
To develop training matrix and education
program for identified gaps in knowledge
within staff group
competency framework. Measure:
distribution list.
100% of Hospice Health care
assistants
to
baseline
themselves/authorised competence
by line managers
Training matrix and timetable for
education in place by 31st March
2014
Improvement Aspiration 3 (Clinical Effectiveness)
To introduce improvements to the Hospice at Home Service - to enhance the
patient experience, improve access to the service, improve assessment and
care planning
Why choose this as an Aspiration?
There continues to be a significant difference between patients preferred place of care (PPC) and
actual place of care (or death). A survey carried out in 20101 identified Preferred Place of Care, this
can be seen in the table below compared with actual place of death Table 1 Comparison of
Preferred Place of Care to Actual Place of Care 2010
Home
Hospice
Hospital
Care Home
National Preferred Place
of Care
63
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3
1.5
National Actual place Actual Place of Care
of Care
Darlington 2011
21
20.4%
5
3.9%
53
50.1%
18
17.8%
Other
3.5
3
7.8%
The table clearly demonstrates the national picture of disparity between preferred place of care and
the actual place of death. Locally, similar to the national average, many more people are dying in
hospital rather than in their own homes or in the hospice. The national mortality rate is set to
increase dramatically, the hospice recently carried out a needs assessment which indicated that by
2020 over 40% of the Darlington population will be over 50 years and 10% will be over 75. The
number of people aged 65 and over is projected to rise from 17,400 in 2008 to 23,800 in 2023 and
29,100 in 2033.The number of people aged 85 and over is projected to increase from 2,400 in 2008
to 3,800 in 2023 and 6,000 in 2033. This will have a significant impact on the need for Hospice care.
The Hospice recognises the importance of supporting patients to achieve their PPC, and has been
supporting patients in their own homes with its Hospice at Home service for over 25 years. Since
2011 with the inception of the joint partnership project between the Hospice, NHS and Marie Curie
the Rapid Response Service has been available.
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PRISMA telephone survey,2010, Source: National End of Life Intelligence Network
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During the last year service review of the Hospice at Home service has been undertaken alongside
participation in a national survey of Hospice at Home services co-ordinated by Help the Hospices.
Findings of the National Survey reinforce the extreme value provided by Hospice at Home services
across England and that these services continue to be core Hospice services. The 76 Participating
Hospices delivered 4843 episodes of care over 3 months (1 episode is referral to discharge), 83.5%
cancer diagnosis, 16.5% no cancer diagnosis and where services where involved 87% of patients
involved achieved their PPC.
Locally, the Hospice at Home service continues to be popular however, average annual provision of
services has decreased recently. Several reasons can be attributed to this including change over in
district nursing staff who have historically been the biggest referral source, increase in social and
domiciliary care provision, changes in demographics and increases in patients admitted to care
homes rather than being cared for at home possibly due to family members work commitments,
complexity of patient conditions and lack of knowledge of the existence of the service. The Hospice
has also been poor at promoting the service and several staffing changes have not helped.
Also, our statistics have demonstrated significant changes in patient profiles over the past few years,
many more non cancer patients are supported by the service and patients are presenting with more
complex needs there has also been an increase in patients with Dementia.
In order to support patients to achieve their PPC ,high quality services must be available to support
a patient and carer at home. Supporting the Care Closer to Home agenda is important to the
Hospice and therefore over the forthcoming year we will make improvements to the existing
Hospice at Home service. The intention is to improve assessment and care planning for patients
which will improve patient experience and improve accessibility to the service.
How will this Aspiration be achieved and measured?
Objective
Target/ Measure of performance
Recruitment of Hospice at Home Team
Successful recruitment
leader
Establishment
of
comprehensive
Evidence of documentation, patient
assessment, care planning and risk
audit will demonstrate 100% of
assessment process
patients will receive assessment
Development Hospice at Home team by
Competency framework
supporting core competency for Health care
assistants and specialist training in
Dementia
Improvements in service in response to
Service user questionnaires pre and
service user feedback
post intervention
Increase in service provision
Increase in provision by at least 10%
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Improvement Aspiration 4 (Clinical Effectiveness, Patient Experience)
To improve services offered to patients with Dementia
Why choose this as an Aspiration?
The number of people with Dementia is increasing and presents an urgent challenge to all health
and social care providers both in terms of the number of people affected, cost and availability of
skilled workforce to support patients. There are approximately 670,000 people in England with
Dementia and in Darlington in 2012 there was 1368 diagnosed Dementia cases2 and according to the
Alzheimer’s society in 2021 this will rise to 1771 cases for Darlington alone. Dementia is commonly
associated with older age, and as such the incidence of other diseases increase, it can therefore be
expected that many of the Darlington Dementia population will also have co-morbidities. The
National Dementia strategy (2009), highlights that end of life care for people with Dementia is often
poorer than those who are cognitively intact, with poorer care planning, decreased access to
services, in particular hospice care and poor symptom and pain control.
The Hospice aims to improve the services it offers to patients with Dementia. It will do this by
ensuring it has a skilled workforce to recognise and identify those who may be undiagnosed with
dementia and to support people with Dementia with their unique needs. The Hospice will also
ensure that the [premises is fit for purpose and is both safe and accessible for patients with
dementia and begin to configure services to support patients in their own homes.
How will this Aspiration be achieved and measured?
Objective
Target/ Measure of performance
To identify patient population accessing
Undertake baseline of population
the Hospice with dementia pre and
accessing services Jan-Mar 2013 & Janpost intervention
Mar 2014
To educate the workforce in dementia
100% of clinical & non clinical paid staff to
awareness
undertake dementia awareness training
A core group of staff to undertake
Core staff group of 8 to undertake
enhanced
Alzheimer’s
Society
training, 100% of these staff to receive
accredited training
accreditation
Undertake Dementia friendly premises
Audit plan and physical improvements
audit
To gain service user feedback
100% of Dementia patients or their carers
to be offered the opportunity to comment
on services
2
End of Life Intelligence network, April 2013
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Improvement Aspiration 5 (Clinical Effectiveness, Patient Experience)
To fully integrate nutritional screening into Hospice assessments, to ensure
all patients’ nutritional requirements are met and to provide a catering menu
that will meet both patients and their guests’ requirements.
Why choose this as an Aspiration?
Many chronically unwell people experience dietary difficulties and deficiencies related to or resulting
from their illnesses. Comprehensive Nutritional screening aims to identify those who are at risk or
who are already malnourished. On identification of those at risk from malnutrition, the Hospice
needs to be able to provide appropriate advice and care plans to patients to prevent further weight
loss and to ensure that its catering facility can meet basic nutritional requirements for in patients,
and can modify diets to provide additional nutritional support including for those with special
dietary requirements (Coeliac, diabetic, staged diet). Staff need to be appropriately skilled to provide
advice on diet and nutritional supplementation and to recognise when specialist dietetic referral is
necessary; they must also be able to monitor and review nutritional intake of food and fluids.
Nutrition should be seen as part of treatment for all patient populations and specific groups of
patients will benefit from nutritional advice, which should therefore be readily available.
There are no restrictions on visiting patients in the inpatient unit, but currently , the Hospice can
only offer hot drinks and a limited selection of snacks to visitors. To improve patient and carer
experience the Hospice will expand its catering provision to give visitors choice and availability.
How will this Aspiration be achieved and measured?
Objective
Target/ Measure of performance
Introduction of Nutritional screening for
100% of patients will be offered nutritional
patients as appropriate (Identification of
screening (caveat: given the nature of the
Tool, staff training, System One
patient population, nutritional screening
Templates)
will not always be appropriate, this will be
documented in patient notes).
Nutritional advice for those requiring it
Identify a mechanism for provision of high
quality
nutritional
advice
by
an
appropriately skilled dietician and in-house
training for staff
Introduction of food and fluid intake
Audit of patient records; 100% of patients
charts
commencing nutritional support will have
intake monitored
Review menus to ensure that they
User satisfaction survey
provide sufficient patient choice and
Comparison of menus to Estimated
meet nutritional requirements of all
Average requirements (EAR)
groups.
Review Food presentation and service
Survey of mealtimes to ensure appropriate
giving consideration to roles and
support is given by staff to enable patients
responsibilities of staff; support given to
to eat and drink
patients to eat, review of crockery and
cutlery
Review of procurement to ensure best
Service user survey to determine
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value for money, without compromising
quality.
Scoping new Bistro area
requirements; Business plans
Improvement Aspiration 6 (Patient Experience)
To improve access to Complementary Therapies and extend the range of
complementary therapies available at the Hospice
Why choose this as an Aspiration?
Complementary therapies can be used to treat specific symptoms in addition to orthodox medicine
and can help people to cope with the stresses caused by their disease, improve sleep and improve
quality of life. Many therapies also provide a sense of well being and can offer a patient some
control as a positive choice they can make about their health. Carers can benefit for similar reasons
and by supporting carers we are enabling them to care for a loved one for longer and without
reaching a crisis point.
Aromatherapy massage is available to patients in their own home and at the Hospice, and on a
limited basis to carers; acupuncture is available to all patients at the Hospice. Recognising the
valuable contribution to a patient’s treatment and coping mechanisms of both patients and carers,
the Hospice intends to increase the range of provision available and accessibility for patients in their
own homes.
How will this Aspiration be achieved and measured?
Objective
Target/ Measure of performance
To recruit a Complementary therapy
Successful recruitment
lead to develop the service
To recruit at least 3 additional volunteer
Minimum of 3 additional complementary
therapists to increase the range and
therapists, statistics to demonstrate an
provision of therapy services
increase in therapy sessions provided
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Part 3
Review of Quality Performance
3.1 Report on Priorities for Improvement 2012/13
The Quality improvements outlined in our first Quality account 2011/2012 have all been
satisfactorily achieved, however, in all areas continuous improvement is planned. The Board of
Trustees have been in full support of the improvement areas over the past year and have received
regular reports on progress. Services users have been consulted with where appropriate.
The identified improvement priorities for 2010/2011 were as follows:
2012/13 - Improvement Priority 1 (Patient Safety)
Introduction of the Deciding Right document to integrate the principles of advance care
decisions for all appropriate patients accessing St Teresa’s Hospice services
Quality Improvement Achieved
How did we achieve this?
Deciding Right is an initiative which integrates Advanced Care Planning, the Mental Capacity Act,
Cardiopulmonary Resuscitation and Emergency Health Care Plans. The Hospice chose this as a
quality improvement to improve patient safety. Patients are referred to the Hospice from a variety
of settings: GP’s, care homes, acute trusts, patients home, and sometimes as temporary residents,
and from two different PCT/SHA (now different CCG) areas. A plethora of documents prior to
switching to Deciding Right documentation was available in the health care economy which all do
similar things but the paperwork is different.
The Hospice education manager undertook training on Deciding Right in April 2012.
Following this, she educated all internal staff during May and June to ensure that they were
all conversant and trained appropriately to utilise the documentation. A switchover date
was set and from the 1st of June all patients entering the Hospice as part of admission where
transferred or initiated as appropriate on the Deciding Right DNACPR, all patients discharged
into the community with this nationally recognised and validated paperwork.
Education was made available to GP practice end of life care leads in Darlington and North
Yorkshire, who were then responsible for cascading information within their own practice
Education sessions were scheduled and District Nurses, clinical nurse specialists and care
homes invited
Targeted education to care homes was delivered as part of the GSF in Care Homes project
Both CDDFT and Darlington CCG choose not to use the Deciding Right Advanced Care plan
(ACP), therefore the Hospice facilitated the development of a suitable ACP for use within
CDDFT and Darlington CCG.
The Hospice gained service user feedback on the
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documentation and ensured its ratification by CDDFT Clinical effectiveness board prior to its
launch in March 2013
Successful achievement of this measure can be demonstrated through audit results of
patient records evidence the successful transition to Deciding Right documentation in 100%
of patients requiring DNACPR documentation. Training logs are available and minutes of GP
lead meetings demonstrating those accessing education sessions.
How do we plan to continually improve?
The Hospice will continue to improve uptake of Deciding Right documentation through the GSF in
Care Homes project in Darlington. Care home staff will be educated on the use of Deciding Right
documentation. All newly appointed staff will receive training as part of induction.
2012/13 - Improvement Priority 2 (Patient Safety)
Introduction of Patient Safety Thermometer
Quality Improvement Achieved
How did we achieve this?
St Teresa’s Hospice views patient safety as its top Priority. The safety thermometer is a tool to
survey patient harm and harm-free care and was included as a CQuIn measure for the Darlington
PCT annual contract 2011/2012. The safety thermometer assesses against the domains of pressure
ulcers, falls, catheters, urinary tract infections and venous- thrombo-embolism (VTE)
Senior clinical staff in the Hospice were trained and a process established whereby the
“snapshot” measure would be undertaken for all patients on the In patient Unit and
accessing Hospice at Home services on the 4th of each month with the exception of VTE
(following prior agreement with the PCT due to its inappropriateness of use in the palliative
care setting)
The safety thermometer was reported to County Durham PCT without exception on the 4th
of each month and no adverse variances recorded
The CQuIn target was considered met with full payment received.
How will we continue to improve?
The hospice will continue to use the safety thermometer and during the forthcoming year will be
discussed at each clinical governance meeting, and any specific issues discussed. The Hospice will
report findings nationally in 2013/14.
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2012/13 - Improvement Priority 3 (Clinical Effectiveness)
SystmOne will be introduced to the Hospice, and will be fully operational with all new
patients entered onto the electronic patient management system from November 2012.
The introduction of the system will improve clinical effectiveness in the Hospice by
improved communication between healthcare professionals involved in a patient’s care,
improved medicines management and reporting.
Quality Improvement Achieved
How did we achieve this?
The Hospice CEO and Deputy CEO/clinical Service Manager were identified as the internal project
leads for implementation of the project and worked with the PCT representative to form the project
team who ensured that:
All staff were fully appraised of the business change prior to commencing the project
Each department had a SystmOne Champion as an information conduit
Staff of all grades were chosen to work on departmental project teams
All staff undertook Information Governance training prior to receiving smartcards
The schedule was carefully planned, training schedules agreed in advance and additional
resources sought where necessary to release staff for training
IT infrastructure was planned and installed in advance
All NHS stakeholders were communicated with and benefits shared
The Go Live date was delayed from November 2012 until the 28th of January 2013 as a result
of delays within the PCT
Following Go Live it was recognised there was insufficient IT infrastructure, this has been
rectified
The Hospice is currently running a paper based system and SystmOne which will continue
until satisfactory audit of patient records and comprehensive reporting mechanisms are in
place.
Alongside the role out of SystmOne Summary Care Record was also deployed
How will we continue to improve?
Audit of patient records will begin from June 2013, following successful audit any remedial action
required will be taken, the Hospice intends to become completely paperless. Reporting systems
need to be established so that essential quantitative data can be extracted and reported upon. The
Hospice has contributed to the early work on the enhanced summary care record and will continue
to influence this piece of work. The Hospice intends to set up a North East User Group. Staff users
have all undertaken the information governance module, and the hospice has satisfied CQC
requirements in relation to information governance however, hospice Information governance will
be examined more closely to identify any areas of improvement during the forthcoming year.
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2012/2013 - Improvement Priority 4 (Patient Experience)
Priority: To establish a formal integrated User Partnership Group
Quality Improvement Achieved
How did we achieve this?
On writing the Quality Account 2011/2012 the intention had been to establish a formal User group.
However, on discussion with service users it was quickly understood that due to the nature of the
user group, palliative patients and their carers that this formalised user involvement was not an
acceptable option. This was because users themselves did not feel well enough to regularly commit
to involvement in a group nor did their carers wish to leave them. The Hospice Strategic
management team therefore decided to set up a variety of mechanisms to capture user feedback
and involvement. This then became a CQuIn measure for the Darlington 20122/2012 contract.
Therefore, although a service user group has not been established with a formal remit the Hospice is
now engaging with service users in a more formalised way, the quality improvement has still been
achieved.
The following was put in place in 2012/2013:
Semi structured interviews with randomly selected service users from Hospice at Home, Day
therapy and Inpatient services
Use of Patient questionnaires, report published by University of Kent (Linked to Help the
Hospices)
Use of Carer questionnaires
Service user focus groups- specific focus groups set up to look at topics as they arise, for
example feedback on the new Advanced Care Plan Documentation, Taster session of
Tripudio exercise program before introduced into Day Hospice
Review of suggestion boxes and collation of all complaints, comments and compliments.
How will we continue to improve?
Whilst the hospice understood the value of service user engagement and feedback, the time taken
to elicit this information was underestimated. Therefore, the information gathered through the
processes described above needs to be evaluated and shared across all departments and relevant
improvements planned for. In 2013/14, service user engagement will become part of an individual’s
role within the hospice to oversee, plan and co-ordinate.
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2012/2013 - Improvement Priority 5 (Patient Experience)
Priority: To develop Hospice Day Therapy adopting a Rehabilitation model
Quality Improvement Achieved
How did we progress this?
St Teresa’s Hospice constantly strives to follow evidence based practice. The NICE Supportive and
Palliative Care Guidance and End of Life Care Strategy (2008) recommend access to rehabilitation
services for patients including at the end of life. The day hospice historically operated a social
model. The new day therapy model Day Therapy model will improve patient experience by helping
patients to improve mobility, or live better with their disability, and will support them to function in
daily activities whilst overcoming feelings of loss of control and providing a feeling of well being and
self worth. The transition to a new day therapy model is partially achieved. Progress has been slower
than expected due to budgetary constraints for appointing the physiotherapist, despite this many
successful improvements have been made.
Following consultation with staff and patients the following changes have successfully been
implemented:
Partnership working with Macmillan has enabled the Hospice to employ a full time
Physiotherapist, commencing in March 2013. The post holder will support patients
throughout all Hospice departments, but will have a strong presence in Day Hospice. The
Physiotherapist will use holistic assessment to plan packages of care for patients and follow
them up in the community to ensure a seamless patient journey.
Following a “taster” session with service users, following which excellent feedback was
achieved 10 staff have been trained in Tripudio, a form of fitness for rehabilitation and
health. The program is easily tailored to the ability and needs of the patient group.
Formal evaluation of the program has shown very positive patient experience. All guests
have indicated that they have enjoyed it, even those who could not take part reported
enjoying watching it. Some guests reported that they do the exercises at home themselves
on the mornings that they do not visit the Hospice.
Some comments include:
“...feel the benefits after I have finished and I enjoy that I can sit down and
still take part”
“...that it helps with my breathing”
“..Some said that they didn’t think they would be able to do any type of
exercise”
“...enjoy it because I feel part of a group that are doing the same thing”
Blood transfusions are now available at the Hospice for all palliative anaemic patients at the
time of writing 7 patients had received a transfusion, all reported excellent patient
experience and GP feedback has also been extremely positive
16
A Breathlessness management clinic has been set up as part of day therapy. The target
group of respiratory patients are often socially isolated and have little access to social or
emotional support, good quality advice or peer support. The clinic is run as a 6 week
program supported by the multi-disciplinary covering breathlessness management, anxiety,
depression, Preferred Place of Care, DNACPR and ACP. Prior to the clinic patients are given
information packs by the Respiratory Specialist Nurse, which informs them of the hospice
and services available. This is also discussed in more details during the clinic. Pre clinic and
post clinic questionnaires are included so the service can continue to improve.
Feedback has been excellent so far, some comments include:
“Impression of hospice has changed immeasurably, the help and caring
available is outstanding.”
“The session on advance care planning and DNAR opened up a subject which
wasn’t easy to talk about, but was handled so well with kindness and tact.”
“I always thought the hospice would be a gloomy place, filled with whispers
and connected only with death and dying. I now see this was a completely
wrong impression.”
“All my questions and fears were answered with great knowledge, humour
and friendliness.”
“It has been the best step I have taken in years.”
How will we continue to improve?
As the introduction of the physiotherapist was delayed until March 2013, the service has yet to be
evaluated. Formal evaluation of the service is being set up nationally validated evaluation tools
(Therapy Outcome Measures and Palliative Care Assessment Score) and a range of key performance
indicators will be identified. The post holder will also identify areas where care has been
compromised or could be enhanced by an occupational therapist as part of the multi-disciplinary
team. Following evaluation recommendations will be made to the board.
Lymphoedema services at the hospice are currently extremely vulnerable owing to contractual
issues and the Hospice is currently negotiating with the CCG regarding ongoing service levels and
commissioning. Depending upon the outcome, Lymphoedema services will move under the
umbrella of day hospice and this service could be further enhanced and developed by involvement
of the Physiotherapist and a dedicated Lymphoedema Tripudio clinic which will support patients
with maintenance and prevent exacerbation of symptoms.
The national model of Health and Well Being clinics has been launched and the hospice is very keen
to explore further as more people are now surviving cancer and its treatments but living with
debilitating side effects. The Health and well being clinics aim to support patients with rehabilitation
and live a fulfilling life beyond their disease. The Hospice would be an ideal base for such a clinic, we
could effectively make use of existing expertise and often patients accessing current services would
benefit from this approach.
17
The Hospice is keen to support patients closer to home and prevent avoidable Hospital admissions.
Building on the success of introduction of blood transfusions over the forthcoming year we will
explore the introduction of IV antibiotics. Again building upon the success of the breathlessness
clinic, a heart failure clinic is planned.
The Hospice supports both Darlington and North Yorkshire, however, on recognition that the rurality
of areas of North Yorkshire prevents patients accessing the Hospice, the possibility of Satellite Day
therapy for these patients will be explored.
18
3.2 Statement of Assurance from the Board
The following statements must be provided within a Quality Account by all providers. Many of these
statements are not directly applicable to St Teresa’s Hospice, therefore explanations are given.
a.
Review of Services
During the reporting period 2012/2013 St Teresa’s Hospice, Darlington, provided the following
services to the NHS:
6 Bedded In patient Unit
Day Therapy Service
Hospice at Home
Rapid Response service
Lymphoedema services
Family Support (including welfare benefits)
Complementary Therapies
During the reporting period 2012/2013 St Teresa’s Hospice, provided or sub contracted 7 NHS
services (no funding received for Complementary therapies). The Hospice has reviewed all the data
available to them on the quality of these NHS Services.
The income generated by the NHS services reviewed in 2012/2013 represents 100 per cent of the
total income generated from the provision of NHS services by St Teresa’s Hospice Darlington for
2010/2011. The income generated represents approximately 40 % of the overall costs of running
these services.
What this means:
St Teresa’s Hospice is funded by both NHS income and by fundraising activity. The Hospice receives
funding from two different PCT areas approximately 80:20 for its NHS funding which reflects patient
activity from the two PCT areas. The grants allocated by the NHS contribute to approximately 40%
of Hospice total income.
This means that all services are partly funded by the NHS and partly by Charitable Funds. St Teresa’s
Hospice for the accounting period 2013/14 has signed an NHS contract in place of the traditional
voluntary sector grant with Darlington CCG and Hambleton, Richmond and Whitby PCT. Contracts
for Rapid response have rolled over as part of a pilot project and are due to expire in September
2013.
b.
Participation in Clinical Audit
During 2012/2013 no national clinical audits or confidential enquiries covered NHS services
provided by St Teresa’s Hospice.
During 2012/2013 St Teresa’s Hospice participated in no national clinical audit and no
confidential enquiries of the national clinical audits and national confidential enquiries it
was eligible to participate in.
19
The national clinical audits and national confidential enquiries that St Teresa’s Hospice was
eligible to participate in during 2012/2013 was none.
The National audits and national confidential enquiries that St Teresa’s Hospice participated
in, for which data collection was completed during 2012/2013, are listed below alongside
the number of cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of audit or enquiry.
St Teresa’s Hospice was not eligible to participate; therefore, there is no information to
submit or list here.
What this means:
St Teresa’s Hospice as a provider of palliative care is not eligible to participate in any
national audit or confidential enquires as these have not pertained to palliative care during
the accounting period
St Teresa’s Hospice has not reviewed any national or local audits during 2012/2013 and
therefore has no actions to implement
c.
Research
The number of patients receiving NHS services provided or sub-contracted by St Teresa’s
Hospice in 2012/2013 that were recruited during that period to participate in research
approved by an ethics committee was none. There was no appropriate, nationally, ethically
approved research studies in palliative care in which St Teresa’s Hospice could participate.
d.
CQUIN Payment Framework
St Teresa’s Hospice NHS income in 2012/2013 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework because it had a voluntary sector grant in place for the North Yorkshire
element of contracts.
St Teresa’s Hospice NHS income in 2012/2013 was conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework for 2 elements within the County Durham contract. The 2 CQuINS
represented 2% of the overall contract value and successful achievement of both has been
achieved with full payment.
In the accounting period 2013/14 CQUIN measures are within the NHS contract with
Darlington CCG for a continuation of the Safety Thermometer, service users and in relation
to Dementia. At the time of writing no CQuIn had been agreed with Hambleton, Richmond
and Whitby CCG.
e.
Statement for the Care Quality Commission
St Teresa’s Hospice is required to register with the Care Quality Commission and its current
registration status is for the following regulated activities:
 Diagnostic and screening procedures
 Treatment of Disease, disorder or injury
20
 Personal Care
St Teresa’s Hospice is registered with the following conditions:
 Services are provided for people over 18 years old
 The maximum of 6 patients may be accommodated overnight
 Notification in writing must be provided to the Care Quality Commission at least one
month prior to providing treatment or services not detailed in the Statement of
Purpose
St Teresa’s Hospice was subject to an unplanned inspection by the Care Quality Commission
in January 2013 and was deemed fully compliant.
St Teresa’s Hospice has not participated in any special reviews or investigations by the Care
Quality Commission in 2012/2013.
f.
Data Quality
St Teresa’s Hospice did not submit records during 2012/2013 to the Secondary Users service
for inclusion in the Hospital Episode Statistics which are included in the latest published
data.
What this means:
St Teresa’s Hospice is not eligible to participate in the scheme.
g.
Information Governance Toolkit Attainment.
St Teresa’s Hospice did not participate in completion of the Information Governance Toolkit
in 2012/2013. However, the Hospice has its own internal Information Governance Policy. All
clinical staff have completed the Connecting for Health Information Governance module as
condition of receiving NHS smartcards, and this will be added to mandatory training
programs.
h.
Clinical Coding error rate
St Teresa’s Hospice was not subject to the Payment by Results clinical coding audit during
2012/2013 by the audit commission (as it had a voluntary sector grant in place for the
reporting period).
21
3.3 Review of Quality Performance during 2012/13
The review of Quality at St Teresa’s Hospice can be considered across the three domains of Patient
Safety, Clinical Effectiveness and Patient Experience. The following information provides
information on these areas during the accounting period 2012/2013.
2012/13 Performance - Patient Safety
Clinical Incident Reporting
Clinical Incident Reporting- reporting on clinical incidents was chosen as one measure as it gives an
insight for the Hospice and patients as to how “safe” the service was during the accounting period.
Clinical incidents are reported by staff involved every time they happen and investigated by the
Clinical Governance Board with appropriate action plans put in place.
Table 2 Demonstrating Clinical Incidents during Accounting Period 2012/2013
Clinical Incident
Slips, trips, falls and accidents - patients
1
Slips, trips, falls and accidents – staff and 6
volunteers
Drug errors
0
Other
1
Clinical issues
16
Safety Thermometer
St Teresa’s Hospice has completed the patient safety thermometer for the past 12 months as part of
the CQuIn for the Inpatient services and Hospice at Home services. The Safety thermometer is a
“snapshot” measure taken across pre determined domains on the same day each month. During the
April 2012-March 2013 time period, there were no harms recorded in any of the domains measured.
Table 3 Demonstrating Safety Thermometer Performance April 2012-March 2013
Month
IPU
H@H
IPU
H@H
IPU
H@H
IPU
H@H
IPU
H@H
IPU
H@H
IPU
H@H
22
PU
Catheter Catheter & VTE *
UTI
2
0
-
Falls
July/Aug/Sept 0
0
2012 **
July/Aug/Sept 0
0
0
0
2012 **
Oct 2012
0
2
0
0
Oct 2012
0
0
0
0
Nov 2012
0
0
0
0
Nov 2012
No patients recorded
Dec 2012
0
0
0
0
Dec 2012
0
1
0
0
Jan 2013
0
0
0
0
Jan 2013
0
0
0
0
Feb 2013
0
0
0
0
Feb 2013
No patients recorded
March 2013
0
2
2
0
March 2013
0
0
0
0
*VTE not recorded for Hospice patients
** Test period no accurate recording
2012/13 Performance - Clinical Effectiveness
Measuring clinical effectiveness is important to the Hospice as it helps identify areas of
improvement and is important to both the Hospice and the public as it helps us demonstrate that
our services are achieving what we intended to achieve. There is no single way of demonstrating
clinical effectiveness; the following will provide a picture of activity.
Hospice Performance against the National Minimum Dataset
The Hospice collects statistical information on every patient and enters this into a National Minimum
Dataset held by the National Council for Palliative Care which allows collation of information on
demographics, comparisons between services and conclusions to be drawn on patients' preferences
and achievement of these preferences. The following table provides a comparison of the Hospice
performance against the most recently published report (May 2012) on the National Council for
Palliative Care National Minimum Data Set for 2010/2011 where an appropriate comparison can be
made.
Table 4 Comparing St Teresa’s Hospice to the National Minimum Dataset
Area
In patient services
Total Number of Patients
within a year treated
Total New Patients
Re-referred Patients
Average Bed Occupancy
(%)
Cancer Diagnosis (%)
Non cancer diagnosis (%)
Average length of stay
(days)
Died in Hospice (%)
Discharge care home (%)
Discharge acute (%)
Discharged Home (%)
Other
Day Therapy
Total Number of Patients
Treated
Number of New Patients
Total Days available
places
Total Places attended
Total places booked DNA
Average length of care
(days)
Cancer Diagnosis (%)
Non cancer diagnosis (%)
St Teresa’s
Hospice
2010/2011
(For info only)
St Teresa’s
Hospice
2011/2012
(For info only)
Minimum
Dataset
2010/2011
St Teresa’s
Hospice
2012/2013
119
181
100
14
60%
122
14
86%
73%
131
6
64%
76%
14%
6.7
82 %
18 %
7.7
87%
13%
13.5
84%
16%
8.1 days
34 %
1%
1%
48%
40%
1%
2%
49%
55%
4%
2%
38.%
1%
46%
5%
2.5%
33%
13.5%
137
146
-
121
72
3920
80
3920
-
54
3840
213
1947
794
300
127
1852
847
326
76%
24%
80%
20%
85%
17%
65%
35%
141
23
Area
Hospice at Home
Total Number of Patients
treated
New Patients
Patients died in Hospice
(%)
Patients died at home
(%)
Patients died at Care
home (%)
Patients died at Hospital
(%)
Patients
died
at
Community hospital (%)
Cancer Diagnosis
Non cancer diagnosis
Length of care (days)
St Teresa’s
Hospice
2010/2011
(For info only)
St Teresa’s
Hospice
2011/2012
(For info only)
Minimum
Dataset
2010/2011
St Teresa’s
Hospice
2012/2013
213
184
-
182
164
23%
132
15%
9.8%
132
12%
55%
68%
73.3%
68%
9%
3%
4.9%
7%
10%
8%
8.5%
13%
1%
1%
2%
0
55
45
103
52
48
127
83%
17%
123
55%
45%
120
In patient Unit
During the accounting period the Hospice had a total of 141 patients on the In-patient Unit, 131 of
which were new referrals. Bed occupancy was 64%, lower than the MDS which was 73%. The
number of patients is down on last year which can be partly explained by a change in referral criteria
when compared to the last reporting period as the hospice no longer accepts planned respite and
partly due to medical cover, prior to appointment of the nurse consultant, complex patients could
not be accepted.
Furthermore, the Hospice needs to review the way in which it records occupancy, currently a bed is
available if it does not have a patient in however, cleaning and reserving a bed make it unavailable
and this is not currently recorded. The Hospice has 6 inpatient beds, and the national average is
14.75.
The Hospice was successful at supporting non cancer patients, with 84% of the in patient population
treated having a cancer diagnosis compared to the MDS of 87 %. Average length of stay is shorter
than the national average during the accounting period. The number of patients dying in the
Hospice is also lower at 46% compared to the MDS of 55%. Considering these statistics alongside the
place of death for patients, one assumption is that the Hospice was extremely effective at facilitated
discharge, enabling a patient to die in their preferred place of care at home with 33 % of patients
dying at home. Nationally, 55% of all admissions result in death and over a half of all patients
admitted to inpatient units did not die on their first admission which dispels the myth that people
only go to a hospice to die.
Day Therapy
The total number of places was 3840, with an attendance rate 1827 a slight decrease on the
previous accounting period. However, the rate of DNA was increased and the numbers of patients
24
attending from the inpatient unit was significantly reduced when compared to last year which is a
reflection of the increased complexity in the patient population.
Day therapy will be promoted more broadly as the changes over the accounting period are
embedded. Average length of care was above the national average of 127 days with Hospice
average length of care being 326 days, this is partly explained by the patient caseload. St Teresa’s
Day Therapy has a cancer population of 65% and non cancer population of 35% predominantly
neurological patients, who have longer and increasingly, progressively debilitating disease
trajectories (and therefore require longer access to day therapy services). Similarly to the national
picture, St Teresa’s Hospice had no Dementia patients where Dementia was their primary diagnosis.
Hospice at Home
The Hospice at Home service supported 182 patients during the accounting period. 68% of those
patients were supported to die at home, 12% died in the Hospice with 7% in a care home and 13% in
hospital. Again the Hospice was able to support non cancer patients extremely well with 55 % of
total patient population having a diagnosis other than cancer.
Rapid Response Service
The Rapid Response service was established in September 2011 as an initial 18 month pilot project,
as a Partnership between NHS county Durham, Marie Curie and St Teresa’s Hospice for Darlington
based patients. The project was extended for a further 6 months and the pilot will finish in
September 2013. The service was established with the key aim of supporting patients at home,
avoiding hospital admission at the end of life where possible and appropriate. The information
provided is quantitative for the accounting period 2012/2013, and qualitative research is being
carried out by Marie Curie as part of the full pilot project evaluation.
Table 6 Rapid Response Performance 2012/2013
Parameter
Total Number of Patients
Total no. of referrals (total no. of patients) 242
Total No. Of Visits
Facilitated Discharge to die at Home from
Hospital
Total No. OF Patients Supported to Die in PPC
(usually home)
Total Number of Avoidable admissions (usually
from a patient’s own Home)
Cancer Diagnosis
COPD
Heart Failure
Neurological
Elderly Frail
1633
31
184
136
131 (54%)
40 (16.5%)
29 (11.9%)
14 (5.7%)
28 (11.5%)
Key Performance Indicators
Key Performance Indicators (KPI) were agreed with commissioners prior to the service commencing.
The KPI demonstrate if the service is meeting its goals.
25
Table 7 Key Performance Indicators for Rapid Response 2012/2013
Key
Performance Target
Indicator
Response to patient 95%
within an hour of
referral
Measurement of an 100%
advanced care plan in
place (ACP)
Achievement Notes
Achievement
of 50%
Preferred Place of Care
Total Number of Never 0%
Events
76%
100%
100%
0%
Measurement of the plan in place was achieved
at 100%. Of the patients referred to the service
only 57% of Patients had it in place (138 out of
242)
184 patients were supported at home avoiding
hospital admission out of a possible 242
These are events that should never happen
Clinical Audit
Audit is a valuable way of examining everyday practice. During the reporting period the Hospice has
introduced a 12 month program of Clinical Audit, which is reported on at each clinical governance
meeting. The program can be seen in Appendix 1.
2012/13 Performance - Patient and Staff Experience
Patient satisfaction
St Teresa’s Hospice has invested significant time in exploring patient and service user experience
over the past year. User feedback has been sought is a variety of ways including the following:
Patient Questionnaires
Carer Questionnaires
Semi Structured Interviews
Focus Groups
Suggestion Boxes
Additional volunteered information is also recorded from comments, thank you cards and letters
and feedback on the Hospice website.
Patient Questionnaires- the Hospice subscribed to the annual Help the Hospices Patient Survey,
report to be produced June 2013
Carer Questionnaires- Drop in group, analysis of the questionnaires indicated very positive carer
experience but that carers were continuing to use the group often in excess of 3 years. The group
will be re-focused to provide support to carers up to 3 years post bereavement and development of
a “Friendship” group for longer term social needs.
Bereavement Care Questionnaire- most people provided extremely positive feedback, no negative
feedback was received at all
26
Semi structured Interviews – twice a year a series of semi structured interviews took place conducted
by a trained Hospice trustee and non clinical team member
Focus Groups- Focus groups were set up to address specific pieces of work, e.g. the development of
an Advanced Care Plan
The benefit of this formalised user feedback is recognised and the Hospice intends to build upon this
for the forthcoming year. The action plan for Service User engagement can be seen in Appendix (ii)
Staff Experience
An annual staff experience survey was carried out, this year it focused on Staff satisfaction and had a
75% response rate. Overall, Staff satisfaction is high, which is backed up by a high staff retention
rate and extremely low staff and volunteer turnover rates, several staff commented that they had
not received training in year, when the response rate for the mandatory training workbook was
100%.
During the year, we have introduced a new reporting system for staff sickness in all departments.
Recognising that these statistics are important indicators, a report is given at the quarterly HR subcommittee meeting and monthly updates are given to all departmental heads.
The Hospice has updated its capability procedures and sickness monitoring systems, so that any
worrying trends would be flagged up early, and managers have access to good guidance; however,
there are no current sickness trend alerts.
Staff Training
There is an annual Mandatory Training program for all staff. During 2012/2013 all staff who were
entitled to access System One also undertook mandatory information Governance training and this
will be added to the annual mandatory training matrix. Annual appraisal is in place for all staff and
continuous professional development needs are identified normally at this point and fed into
individual CPD programs.
Awards and Complaints
The Hospice receives many letters of thanks and recommendations from patients and families which
are celebrated with staff teams. Complaints are seen by the Hospice as an integral part of service
improvement as they provide valuable feedback. In the reporting period 2012/13 no complaints
were received. Although complaints are very rare, the Hospice does have a complaints process in
place. Serious untoward incidents would be reported to both the Care Quality Commission and CCG.
Corporate Governance Measures
The Hospice has a Board of Trustees which delegates operational responsibility to the CEO and also
has the following Officers in place:
Anti fraud policy officer (Hospice Trustee)
Caldicott Guardian, (CEO) who is responsible for Safeguarding Patient Information
2 Privacy Officers (CEO & Deputy CEO/Head of Clinical Services)
Accountable Emergency Officer (CEO)
Prevent lead (Hospice Trustee)
Accountable Officer, Drugs (Hospice Education Manger)
27
The Board of Trustees Statement
The Board of Trustees is fully committed to the provision of a high quality service at the Hospice.
The Hospice has a well-established clinical and corporate governance structure, with members of
the Board playing an active part in ensuring that the Hospice fulfils its mission, according to its
charitable intentions, and in ensuring that the organisation remains responsible and compliant in all
areas of CQC Registration, Health and Safety, Employment Law and other relevant legislation.
Signed
Alasdair MacConachie OBE, DL, FRSA,
Chairman
Board of Trustees of the Darlington & District Hospice Movement
28
Supporting Statements: St Teresa’s Hospice Quality Account 2012/13
Statement from Health and Partnerships Scrutiny Committee of Darlington Borough
Council:3
Members have met with Chief Executive and Clinical Services Manager from St Teresa’s
Hospice and undertaken a visit of the facilities and are extremely impressed by the enormity
of services offered by the Hospice.
Members welcome how the services over the years have developed to include Hospice at
Home, Day Care (now Day Therapy), In Patient Unit, Family Support and Bereavement
Services.
The Hospice has also strengthened its Management Team to include a new Finance Director,
Head of Clinical Services and Nurse Consultant. This enables the Hospice to remain current
and ensures that the services provided are relevant for those who need them.
Members are pleased that following a review of Clinical Services, services have evolved in
response to the level of need for example, improvements to Day Therapy Services. The
focus of the Day Therapy Model is based around palliative rehabilitation ... This builds on the
ethos of care closer to home and what the Council, Darlington Clinical Commissioning Group
and County Durham and Darlington NHS Foundation Trust are aiming for.
The Hospice is also able to care for patients with complex needs and staff are trained to
administer intravenous drips, antibiotics and blood transfusions at the hospice instead of
transferring patients to hospital. The Blood Transfusion Service at the Hospice has been
extremely well received by both local GP's and patients. GP's are able to refer directly to the
Hospice, preventing a hospital admission ...... allows the patient to receive their treatment in
an appropriate, comfortable and calm environment.
Members are delighted that GPs have established a positive relationship with the Hospice
and that GP Palliative Care Leads Group meetings are convened at the Hospice. The Hospice
plays an important role in facilitating good links with all GP Practices, disseminating topical
information and developing action plans and GPs have welcomed the support.
Members acknowledge that benefits of St Teresa’s remaining an independent charity as the
Hospice is able to be responsive to need and adaptable. The aim is to ensure all of the
services are integrated with any state provision to avoid duplication and ensure what is best
for the patient.
3
[Extract from the Final Report of the Older People and End of Life Care Task and Finish
Review Group to consider the Older People and End of Life Care workstreams of County
Durham and Darlington NHS Foundation Clinical Strategy, Chaired by Cllr Jan Taylor. Yr
ended March 2013]
29
Statement from Darlington Clinical Commissioning Group
30
Appendix (i)
Summary of Clinical Audits 2012/13
Month of
Audit
April
2012
Audit Title
Audit Purpose
Audit of Paper
patient records

May
2012
Drop in
review

May
2012
End of life care
pathway audit`
group




July
2012
Audit
bereavement
Questionnaires
of



October
2012
Darlington
Bereavement
forum evaluation



December
Audit of Hospice

To audit recording of patient
information in accordance with
Hospice Policy
To audit the End of Life Care
Pathway in accordance with
guidance
Audit of attendance at group and
experience of service users
To identify if this group is meeting
its agreed objectives
To identify levels of satisfaction
with FST’s service
To
identify
any
service
improvements which may be made
Outcome / Actions Plan to improve practice


Attendance remains high but repeat attendance by new members remains low.
The responses affirm that the current format, with its emphasis on peer support and social contact, continues
to be appropriate and that the volunteers are affective in facilitating this group.

There is evidence that after 2 or 3 years members are generally in a position to move on from support at the
hospice. We will undertake further consultation with service users to explore the possibility of longer term
members setting up their own friendship group.

Most of the referrals are via the hospice so it may be helpful to continue raising awareness of the service with
GPs and other health professionals.
Audit of service users’ comments
and evaluation about the ongoing
bereavement support provided by
FST
To identify levels of satisfaction
with FST’s service to all families of
people who have died under the
care of the hospice
To
identify
any
service
improvements which may be made
Analysis of real-time and /or
written feedback from participants
of the DBF
To identify if this group is meeting
its agreed objectives
To
identify
any
service
improvements which may be made




As part of ongoing commitment to






Overall the comments received were positive and levels of satisfaction remain high.
Comments made regarding other hospice services have been passed on to the relevant departments.
Suggests for service improvements included evening drop-in (x1)and follow-up visits (x1).
In the past we have provided evening drop-in groups but these are generally not used, however we now offer drop-in
support in both Darlington and Richmond providing alternative times and days, giving a wider range of choice than
previously available.
We do not routinely undertake follow-up telephone calls or visits. The decision to provide follow-up in addition to
postal support is made at the weekly clinical team meeting based upon information provided on the handover form.
Generally, the Forum has met its aims. The three presentations this year were all well attended and received positive
feedback, however, our goal of setting up a website has not been achieved. A website for the Forum will be explored in
2013.
The Hospice is to continue hosting regular events in line with the groups’ suggestions.
There will be time at each event for sharing news/issues and networking.
The hospice will liaise with members about Dying Matters Week in Darlington and explore the feasibility of staging a
multi-agency event.
Audit completed and action plan put in place. Inspection January 2013 deemed Hospice fully compliant.
31
Month of
Audit
2012
December
2012
December
2012
January
2013
January
2013
January
2013
Audit Title
Audit Purpose
compliance to CQC
Essential standards
Christmas tree of
memories
evaluation
Essential Steps in
Infection Control




Audit
of
Staff
receiving Clinical
Supervision

Audit
of
Experience:

Staff
1.
Annual
Questionnaire
Audit
of
Staff
Experience:
2. Audit of Staff
Sickness Levels




January
2013
Audit of Clinical
staffing levels

January
2013
January –
monthly
January
2013
January
32
Patient
Safety
Thermometer

Audit of Opiod
prescribing

Audit of Hospice
compliance to CQC
Essential standards
Audit of Patients


quality and to ensure compliance in
readiness for inspection
Evaluate questionnaires completed
by staff and volunteers on the day
To identify if this event is meeting
its agreed objectives
To
identify
any
service
improvements which may be made
To ensure Hospice Compliance
across all domains of Infection
Control
Identify staff accessing clinical
supervision
Identify quality of supervision and
determine if meeting staff and
organisational needs
To assess staff satisfaction and
identify improvements where
necessary
To assess whether levels are within
acceptable parameters
To assess whether appropriate
action is taken in case of long-term
absences
To check for any tell-tale trends –
e.g. overload in one department
resulting in burn-out, etc
Audit of staffing ratios and skill mix
against national recommendations
To identify Hospice performance
across domains of VTE, Falls,
pressure sores, catheter care
To identify effectiveness of the
Morphine/Diamorphine
switchover training program and
subsequent practice
As part of ongoing commitment to
quality and to ensure compliance in
readiness for inspection
To identify current service use and
Outcome / Actions Plan to improve practice



Review completed.

Audit completed- 100% c
Event worked well.
Next year we will follow up on recommendation to check the Book of Remembrance against the attendance list to
ensure names have not been missed.


Audit demonstrated supervision was infrequent, often unorganised and set up with counter-productive staff groups
Complete re-design of supervision provision. Comprehensive program of supervision overseen by external supervisor
agreed and in budget to commence April 2013

The annual Staff Questionnaire demonstrated that staff are under-valuing online training and workbooks (i.e. not
counting as a training course) in some cases. Action was taken to ensure all courses are evaluated and recorded, and
that information is cascaded as appropriate, via team meetings.











No other trends were identified
During the year, a new reporting system for staff sickness in all departments was introduced.
A report is now given at the quarterly HR sub-committee meeting and monthly updates are given to all departmental
heads.
The Hospice has updated its capability procedures and sickness monitoring systems, so that any worrying trends
would be flagged up early, and managers have access to good guidance; however, there are no current sickness trend
alerts.
One member of staff was successfully rehabilitated into a new post, following a capability assessment.
Audit indicated shortage of HCA for both IPU and RRT
Appropriate organisational policy followed for requesting additional posts, ratified and in budget April 2013 for 2 new
wte HCA
No adverse variances recorded to date, will be monitored on a month basis and deviations reported on at Clinical
Governance meeting
100 % compliance with prescribing of opioid of choice. Audit to be repeated in July
Action plan created and gaps identified and immediately rectified. Annual CQC inspection in January 2013, Hospice
was fully compliant. Audit against standards will be completed again in December 2013
Provision is dramatically reduced in comparison to previous years, which is not consistent with national push to move
Month of
Audit
2013
January
2013
Audit Title
accessing Hospice
at home
Patient Satisfaction
Audit Purpose

compare to historical statistics
Audit
to
evidence
patient
satisfaction and identify areas of
improvement
Outcome / Actions Plan to improve practice





February
2013
February
– monthly
2013
Audit
of
Complementary
therapy
service
against
network
criteria
Audit of SystmOne
Post Go Live

To identify compliance with NECN
criteria
for
Complementary
therapists





Volumetric report completed to
audit numbers of staff trained who
are utilising the system


February
2013
March
2013
March
2013
Audit of Discharges
from CDDFT to
Hospice
Audit of Patient
Flows
Review of Carers’
Group






Weekly audit of tasks, waiting lists
and caseloads to identify issues
with use of the system
To identify problematic discharges
from CDDFT to the hospice
To identify patient flows to services
from Darlington and North
Yorkshire
Audit of attendance at group and
experience of service users via real
time and/or written feedback
To identify if this group is meeting
its agreed objectives
To identify levels of satisfaction
with FST’s service
To
identify
any
service
improvements which may be made



care closer to home.
Recognition of lack of leadership for the service, planned Hospice at Home lead role, in budget to commence Q2
Two groups of Semi-structured interviews were carried out by a non-clinical member of staff and a Hospice Trustee,
with 6 randomly selected carers, to assess patient satisfaction with services.
Excellent feedback was received and a full confidential report has been forwarded to clinical governance group for
start of new hospice year (April).
There were no problems/complaints to act upon following the interviews (it was recognised that this should be
escalated immediately should any issue be raised).
One comment was received regarding patients “keeping quiet” about being in pain, which has been forwarded to staff,
as part of their learning.
Register of therapists now in place
All therapists now have appropriate indemnity insurance
Planned development of patient information leaflet
Recognition of development needs of the service and agreement by Education and personnel committee to develop a
Complementary Therapy lead, in budget to recruit Q2.
Report showed 61 users trained and only 44 logged onto the system. Each one explained through long term sickness,
holiday, managers issued with smartcards for reports only
Weekly audit of tasks has identified
gaps in staff knowledge where training has been put in place
Problems with allocating DTU patients- new system put in place
Caseload management issues
Delays in were analysed and delayed discharges were associated to equipment (Oxygen concentrators purchased) and
to lack of ward knowledge on Hospice accepting 24/7 referrals. SPC team now all aware can refer 24/7
Identification of large numbers of day therapy patient from N. Yorks, discussions to begin with North Yorkshire staff to
identify better ways of serving patient population in April 2013
Delayed until May 2013
33
Appendix (ii)
Patient & Carer Feedback: OUTLINE ACTION PLAN FOR 2013-14
Abbreviations: GMT – General Management Team (Heads of Depts); SMT – Strategic Management Team (CEO, Deputy, and 4 Senior Managers)
Over-all Objectives for the Year:
Have a co-ordinated approach, which allows for additional feedback to be solicited if necessary (e.g. in the case of focus groups on specific topics) and to ensure
appropriate and timely feedback, following any suggestions by patients or carers.
REGULAR REPORTS AND “REAL TIME” OUTCOMES will be a feature (i.e. “real time” feedback and action wherever possible, rather than delayed reporting and lengthy
plans).
Buy-in from all departments to ensure feedback is captured whether it be soft or formal intelligence-gathering
Ensure stakeholders, whether patients, carers, staff or volunteers, hear how this makes a difference
No
Item
Objective / Improvement areas from last year
1.
Share last year’s findings
-
Bring forward recommendations from annual report, and
formalise the structure.
2.
Provide
resource
additional
-
Following the recommendations in the annual report, we will
identify Patient & Carer Satisfaction as a key part of a named
individual’s role.
3.
Use
of
Questionnaires
Patient
-
To elicit feedback direct from patients who are currently using
the Hospice’s services.
To ensure that staff are (sensitively) promoting the
questionnaires.
To ensure that there’s a robust system for collating and
evaluation.
To ensure that issues are escalated and action plans are speedily
implemented
To share results effectively.
-
34
DETAIL
-
Share Annual Report with Managers &
Teams
Hold evaluation and forward planning
session
Budget has been approved
Formalise role description for additional
(hospice) resource
Approval by HR sub-committee
Appointment of additional resource (New
Lead)
- Receive and share report from University
of Kent regarding participation in the Help
the Hospices patient Survey
- Task group to forward-plan, to improve
patient questionnaire distribution and the
numbers returned if possible
- Share outcomes with patient, carer and
staff groups
Ensure Service User experience is
reported on in the annual Quality Account
Produce Annual Report
Share at Board of Trustees
Evaluation and Forward planning at GMT
Lead
By When
Jane
Bradshaw
GMT
Meeting
25.04.13
JB/Victoria
Ashley
Diane Farrell
New Lead
(see above)
JB
VA
April - June
2013
June 2013
June 2013
and ongoing
No
Item
Objective / Improvement areas from last year
4.
Use
of
questionnaires:
Carer
-
Improve distribution across all services
5.
Conduct Carer Interviews:
-
Building on the new structure created last year, continue to elicit
feedback from Carers, in a 1:1 semi-structured conversational
style, regarding the experiences of their loved ones who used the
Hospice’s services.
-
Ensure appropriate and timely feedback, following any
suggestions by carers ; REGULAR REPORTS AND “REAL TIME”
outcomes will be a feature (i.e. “real time” feedback ,rather than
delayed reporting)
DETAIL
-
-
-
6.
7.
Service
Groups:
User
Focus
Review suggestion boxes:
-
-
Proposed groups:
a. Hospice now and future (Involvement in writing the new
strategic plan)
b. Improving patient comfort (in light of 68% from Dept of
Health Application)
Others topics tba
Continue to monitor, report and action plan
Aim to improve on frequency of servicing and passing on info
from the boxes
Aim to improve feedback to initiators, where known
Aim to improve general feedback via meetings, newsletters, etc
-
meeting
- Share report and action plan at Clinical
Governance Meeting
Review the process now in place
Forward-plan with Dept Heads
Monitor progress
Produce Annual Report
Share report and action plan at Clinical
Governance Meeting
Share at Board of Trustees
Obtain written feedback about the
process from those responsible, in order
to ensure they are well-supported and to
inform future plans
Continue ongoing planned programme
with Trustee and Staff Rep, holding two
sessions (of six 1:1’s) to be held
September and March
Implement a tracking system through
clinical governance
Ensure any issues are speedily escalated
and resolved, and outcomes shared with
the initiator.
These groups will be coordinated and
facilitated by the new lead.
Aim to have had at least 2 by end of year
As the Hospice is producing a new
strategic plan, the focus groups will be
involved as stakeholders.
Produce annual report
Ensure all staff are aware of boxes
Ensure boxes are maintained in a
presentable condition with writing
materials and forms easily accessible
Make agenda item at team meetings to
ensure escalation process is known and
information is shared.
Lead
By When
JB
GMT
Meeting
April 2013
JB
April 2013
Ann Foster,
Lynne Wright
Sept. 2013
&
March
2014
JB & VA
May 2013
New
Lead
(see above)
From June
2013
ongoing
New Lead
(see above)
From June
2013
ongoing
35
No
Item
8.
Produce Report
letters received:
9.
36
Objective / Improvement areas from last year
from
Ensure
Service User
Representation at Key
Hospice Meetings:
-
Collate comments from thank you letters and check for actions
necessary
Produce update to Clinical Governance Meetings
Produce annual report
To ensure the “User Voice” is appropriately represented at key
Hospice meetings such as AGM, Board of Trustees, CQC
inspections.
DETAIL
Lead
By When
-
Weekly trawl of correspondence
Timely action planning as necessary
Produce annual report
New Lead
(see above)
From June
2013
ongoing
-
Ensure that User rep’s and/or the staff
lead (New Lead above) are invited to key
meetings in the Hospice calendar.
JB, VA and
Senior Admin.
All year