Reaching out to transform
end of life care
Quality Accounts 2012/13
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Table of Contents
Part 1..................................................................................................................................................................... 3
Chief Executive summary ......................................................................................................................... 3
Part 2..................................................................................................................................................................... 4
2.1 Priorities for improvement .............................................................................................................. 4
2.2 Feedback on priorities for improvement 2012/13 ................................................................ 6
2.3 Statement of assurance from the board relating to the quality of NHS services ....... 6
2.2 Summary of published audit, research or academic studies during 2012/13..........13
Part 3.................................................................................................................................................................. 16
3.1 Review of quality performance.....................................................................................................16
3.2 Patient experience..............................................................................................................................19
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Part 1
Chief Executive’s summary
At the heart of everything we do is a commitment to
providing care of the highest quality to people living with an
illness that is no longer curable. We are working towards a
vision of a community where people talk openly about
dying, live well until the end of their life and where nobody
dies alone afraid or in pain. The team of skilled and
compassionate clinical specialists, working at St Wilfrid’s
Hospice Eastbourne, is motivated by a shared commitment
to excellence and continuous improvement.
This set of Quality Accounts has been prepared by clinicians
working in the patient safety, clinical effectiveness and
patient experience work streams that are sub committees of the Clinical
Governance Committee. The Board of Trustees and external scrutinizers sitting on
the Clinical Governance Committee have approved this set of quality accounts. To
the best of my knowledge, the information presented in this set of Quality
Accounts is a fair and accurate representation of the care provided by St Wilfrid’s
Hospice Eastbourne.
Kara Bishop
Chief Executive
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Part 2
St Wilfrid’s Hospice has declared itself compliant as part of the registration process
with the Care Quality Commission (CQC) to comply with the Health and Social Care
Act 2008 (Regulations 2010). As part of the routine schedule of planned reviews St
Wilfrid’s Hospice was visited on 23 November 2012 and an unannounced inspection
undertaken. The CQC found the hospice to be compliant with all outcomes.
2.1 Priorities for improvement 2013/2014
1. To improve all aspects of communication with patients and carers,
health and social care partners to achieve a better patient experience
Communication was a common theme in complaints received by St Wilfrid’s
Hospice during 2012/13. We received nine complaints in total of which
were related to communication
During 2012/13, through the hospice’s Accident, Incident and Near Miss
Reporting procedure, sixteen clinical incidents were categorized as being
due to communication issues
St Wilfrid’s Hospice will be moving to a new purpose built hospice during
the autumn of 2013 and there will be an increase in clinical activity by the
end of this reporting year. This poses a potential risk of increased
opportunities for incidents or complaints relating to communication
Communication is a core component of care across our hospice services,
which is of a good standard, but we want to strive to do better.
Implementation and measurement:
As part of our key objective to formally report on the quality and impact of
our service, we will obtain patient feedback through patient questionnaires
to identify themes around communication which can be addressed. Thirty
three patient questionnaires were returned in 2012/13 and we will increase
this by 40 per cent
We do not currently survey carers on aspects of our communication. We
will implement this during 2013/14
We will continue to monitor incident reporting and complaints and identify
those which relate to communication. We will aim to demonstrate at a
minimum no increase in the number of incidents and complaints related to
communication
Reflective sessions for staff and volunteers around aspects of
communication to promote learning and development
During 2012/13 St Wilfrid’s Hospice did not formally deliver training on
communicating with those who use our services. We will deliver at least
one focused training session around aspects of customer care and evaluate
this to inform further training plans
We will survey our key health and social care partners by the end of quarter
four of the current reporting year on their experience of communication
with St Wilfrid’s Hospice
At least one audit in the hospice’s annual audit plan will be related to
aspects of communication.
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2. To improve our standards of health record keeping to ensure patient
safety through risk management
Identified through investigation of complaints that documentation was not
always of an acceptable standard
St Wilfrid’s Hospice underwent a significant change in practice to using an
electronic health record at the end of March 2013
One of the key priorities for the hospice is to protect patient confidentiality
as demonstrated through its clinical governance structure and relevant
policies and procedures.
Implementation and measurement:
During the first quarter of this reporting year we will survey staff to
ascertain a baseline of skills and confidence in using an electronic health
record. We will develop action plans including training from the findings
and re-survey staff during the final quarter of the reporting year
We will produce and implement a new Health Record Keeping policy and
procedure to guide practice
As part of the hospice’s annual audit plan at least one audit will focus on
health record documentation standards
We will develop and implement a set of competencies for staff who use our
electronic health record
We will continue to monitor incident reporting and complaints to identify
any which relate to health record documentation and report on learning and
action plans. We will aim, as a minimum, to not see any increase in these
incidents in relation to 2012/13.
3. To maintain and build on standards of patient safety and care in the new
hospice environment to deliver safe effective care.
During 2013-14 St Wilfrid’s Hospice will move to its new hospice facility and
there may be potential risks involved in the process
The set up at the new hospice will also necessitate new ways of working
To deliver patient care in our new hospice we will require Care Quality
Commission (CQC) registration
St Wilfrid’s Hospice received a highly positive report following its inspection
by the CQC in November 2012. We will protect and continue to deliver the
outstanding levels of care for which the hospice is valued.
Implementation and measurement:
By the end of the first quarter of this reporting year we will review all
clinical policies and procedures to ensure they are appropriate for the new
hospice
We will successfully register the new hospice with the CQC
We will ensure mandatory training and induction is delivered and attended
as part of a planned change management process
We will continue to monitor and report on medication incidents, falls and
pressure ulcers with aim for no proportional increase on 2012/13
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At least one audit in St Wilfrid’s Hospice annual audit plan will focus on one
of the key areas of patient safety: medicines management, falls, pressure
ulcers
We will develop learning and action plans from incidents to inform
improvement initiatives
We will be ready for an unannounced CQC inspection and achieve a
successful inspection
We will review the guidance from the Department of Health for all NHS
providers to have implemented ‘friends and family’ test and develop a
process to demonstrate we are asking our patients and their families and
friends for feedback on their experience of the hospice
We will link patient and carer feedback to identify any concerns or themes
developing during the reporting period developing action plans in response
which will be presented to the clinical governance board.
2.2 Feedback on priorities for improvement 2012/13
This set of accounts is the first produced by St Wilfrid’s Hospice; therefore,
priorities for improvement were not set in April 2012. As part of its commitment
to on-going quality assurance, St Wilfrid’s Hospice has demonstrated improvement
in patient care during the year 2012/13 including:
A review of its clinical governance structure to provide the most effective
approach
The development of a medicines management group
The move to an electronic health record to improve patient care.
2.3 Statements of assurance from the board relating to the quality of NHS
services provided
The following are a series of statements that all providers must include in their
Quality Accounts. Not all of these statements are directly applicable to specialist
palliative care, including hospice providers.
Review of services
During 2012-13 St Wilfrid’s Hospice provided the following services:
In patient care within our ten bed In Patient Unit (IPU). During this
reporting period there were 263 admissions to our IPU
Care to patients within their own home and usual place of residence,
including care homes, through our Hospice at Home team and Specialist
Nurse Practitioner. During the reporting period 495 patients were visited by
St Wilfrid’s Hospice at Home team
Day care to patients in our Day Therapy Unit (DTU). St Wilfrid’s Hospice
cared for 186 patients in its DTU during the reporting period.
St Wilfrid’s Hospice has reviewed all the data available to it on the quality of care
across these services. The income generated by the NHS services reviewed in
2012/13 represents 15 per cent of the total income generated from the provision of
services by the hospice for 2012/13.
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Participation in clinical audits
National audits and confidential enquiries
During 2012/13 there were no national clinical audits and no national confidential
enquiries covering NHS-related services that St Wilfrid’s Hospice provides. St
Wilfrid’s Hospice was not eligible to participate in any national clinical audits or
national confidential enquiries during 2012/13.
Local clinical audits
The reports of 16 local clinical audits were reviewed by the hospice in 2012/13 and
St Wilfrid’s Hospice intends to take actions to improve the quality of health care as
a result of these audits as demonstrated in the following tables:
Audit Title
Ambulance
Transfer Patient
Audit
Method
Participation
Recommendations
Evidence had been
collected which
proved that on some
occasions there could
be a delay in patient
transfers.
Medical,
nursing and
administrative
teams
The data collection
highlighted that four
different numbers could
be used when booking
patient transport; it was
considered to be
important to identify
which number should be
used. Communication
with the ambulance
service indicated that
there should be a process
to use when trying to
transport palliative care
patients.
This impacted on the
patient, family,
hospice and
community staff.
Further work
commenced to
examine the booking
of patient transport.
Further work; To have a
target of 80 per cent of
patients who require
transport should happen
within 4 hours.
Work with other hospices
in the area to provide
guidelines for the
transportation of
patients.
A flow chart to be
produced which would
detail which number is to
be used.
A questionnaire was
produced and over a
six month period
when transport was
booked data was
collected.
Information
Recorded on
Referral
Documentation
Audit
It was identified that
when referrals were
being transferred to
Cross care that some
information was being
missed.
The aim of the audit
was to highlight which
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Clinical
Administrator
To work towards
developing an electronic
referral system.
To put in place robust
training.
To identify who of the
current referrers are
information was
missing.
using an NHS account
when referring.
100 sets of notes and
referral forms were
looked at and data
was collected.
Discharge Process This audit is the
Audit
second piece of work
looking at the
discharge process in
the IPU. The audit
considered the length
of time it took from
the completion of
funding
documentation for
fast track, continuing
healthcare or social
care funding, to the
allocation of an
assessment date and
the arrangement of a
care package or
noosing home
placement.
Nursing team
The Fast Track procedure
was put in place on
average 4 days from the
receipt of forms to POC
being put in place.
CHC funding took on
average 10 days from the
receipt of forms for a POC
to be put in place.
Social care took on
average 14 days.
Further work to refine the
process of faxing the
documentation to the
PCT.
Thirteen sets of notes
were picked at
random from patients
who had been on the
IPU over the last six
months and had been
discharged with a
package of care or to
a nursing home
Capillary Blood
Glucose Testing
Audit
To ensure that the
hospice has uniform
standards of blood
glucose monitoring in
each department.
Training to be given to all
staff who complete this
documentation.
For a named member of
the PCT to attend the
weekly MDT meeting on
the IPU.
Nursing team
20 episodes of blood
sugar testing were
observed in either the
IPU or DTU.
On average once started
documentation is
completed within two
days.
The HCA'S have devised a
checklist for this
procedure.
To ensure all staff
members throughout the
hospice are aware of the
recommended process for
testing blood sugar.
For the process to be
displayed in all clinical
areas.
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Religion Audit
It was highlighted
that there was a
limited recording of
information such as
religion and
spirituality both in
patient notes and
cross care.
Chaplain
There is a training need
indicated and for staff to
be given clarity on what
religious information
should be recorded, and
how they can explore
other areas of spirituality.
20 sets of notes were
picked at random
from all departments
and comparisons were
made with cross care
records.
Discharge
following an
In-patient
Admission Audit
To evaluate the
quality and accuracy
of discharge
summaries.
A spiritual assessment
tool is being reviewed in
DTU with the aim of it
being implemented across
all departments.
Medical and
nursing teams
Current discharge
documentation shows
that there is a lot of
repetition between
the doctor and nurse
discharge summaries.
To review the
effectiveness of the
moving and handling
assessment
documentation.
The way forward; to set
up a working party with
the aim of devising a
template for a combined
discharge summary.
Nursing team
20 sets of notes
randomly chosen,
questions were asked
including date
documentation
completed, who
A proforma checklist was
used which included
questions such as record
of diagnosis, advanced
care planning,
medications, allergies and
follow up plans.
The audit highlighted that
some information such as
allergies was routinely
left out and there was
repetition of some
information in both
summaries.
20 sets of notes were
randomly examined
and the discharge
letters were
crosschecked with the
patients’ notes for
accuracy and
repetition.
Moving and
Handling
Documentation
Audit
The results showed that
although some
information is being
recorded, there are some
inconsistencies.
In over 80 per cent of the
questions the information
had been documented,
but the area for
improvement was the
weekly reassessment, the
documentation was not
being updated.
Further work; to review
the incidence of falls and
to see if there has been a
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completed it, was a
management plan
completed, were
patients reassessed
during their
admission.
Information
Governance
Audit
reduction since the
implementation of this
documentation.
To assess the
effectiveness of the
information
governance training.
Nursing team
Questionnaires were
produced and were
given to 20 members
of the hospice team.
This included clinical
and non-clinical staff.
The results highlighted
that the clinical staff who
had participated in the IG
training were aware of
the majority of the
principles.
Non-clinical staff had a
good knowledge of the IG
principles but had some
concerns about the
changes to technology
within the hospice.
Further work; for IG
training to feature in the
new staff induction
program.
For a volunteer to be an
IG lead and cascade
information to the
volunteers.
Hospice at Home
Notes Tracking
Audit
There has been
Nursing team
evidence to show that
the note tracking
procedure is not being
followed on some
occasions. Therefore
resulting in time
wasting as staff have
to find the notes.
122 sets of notes
were checked
The results showed that
the majority of the notes
had been tracked to the
correct place.
Further work; staff to be
reminded of the
importance of tracking
notes to enable the
hospice to become 100
per cent compliant.
The changeover to
electronic notes should
elevate this problem
further.
Infection Control
Equipment
Decontamination
Yearly audit of
equipment
decontamination on
the IPU.
Nursing team
A range of clinical
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The results showed 88 per
cent compliance, however
the audit highlighted that
certain pieces of
equipment such as
commodes were not being
equipment was
examined and staff
were questioned on
their knowledge of
the Decontamination
Policy and Procedure.
cleaned effectively or
regularly.
Further work; The
development of a
cleaning rota.
Handling and
Disposal of Linen
To ensure that the
correct process is in
place when we store,
use and dispose of
linen on the IPU, and
that staff are aware
of this process
Estates and
facilities
Staff who were
questioned were using the
correct process and were
wearing the correct
uniform, and we were
proved to be 100 per cent
compliant within this
area.
Environmental
Audit
This audit is carried
out on a monthly
basis to ensure that
all areas in the
hospice contain
equipment that is
effective within a
clean environment.
Nursing team
Findings have resulted in;
the introduction of new
cleaning wipes, sourcing
of a new bedpan washer
and an increase of the
amount of spare curtains
on the IPU.
Re-audit of
Out of Hours
Documentation
There was evidence
to show that out of
hours documentation
was not being fully
completed.
Nursing team
Out of hours hand over
forms were not being
faxed to the appropriate
health care professionals.
Whilst the notes recorded
requests for JIC
medication and DNACPR,
it was not being
documented that these
items were in the care
setting.
20 sets of notes were
checked for the
recording of preferred
place of care, do not
attempt
cardiopulmonary
resuscitation
(DNACPR) forms, out
of hours hand over
forms and just in case
(JIC) boxes.
Nutritional
Assessment
Spot audit carried out
to monitor the
effectiveness of the
nutritional assessment
which was
implemented in 2011.
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Further work; for staff to
be made aware of the
importance of accurate
documentation, and for
the documentation to be
checked on a more
regular basis (process to
be devised).
Nursing team
90 per cent of the
nutritional assessments
had been effectively
completed.
The reassessment of
patients after 7 days
To ensure
documentation is
being effectively
completed and
specialist referral is
being sought.
needs to be implemented.
Patients and other
members of the MDT are
to encourage reviewing
the paperwork.
10 sets of notes were
examined.
Oral Assessment
The oral assessment
chart was introduced
to the IPU in 2010.
This is regularly
audited to ensure its
effectiveness. There
was also evidence to
show that a patient
had a mouth problem
but that it had not
been documented.
Nursing team
This audit has highlighted
that there needs to be a
more robust structure in
place to ensure that there
is a weekly reassessment.
When a treatment is
commenced it must have
a corresponding
management plan, the
prescriber must ensure
that this is in place.
7 sets of notes were
examined for
evidence of
documentation,
management plans,
referral and
reassessment.
Drug Chart
Prescribing
To ensure that the
drug charts are
correctly written to
ensure patient safety.
Seven medication
charts were examined
and a spread sheet
with a list of 21
questions was devised
by the Foundation
Year (FY) 2 doctor.
Medical team
Areas for concern;
abbreviations were used
on the drug charts that
have not been approved
for use in the Medicine
Management Policy and
Procedure.
Steroid prescriptions need
to be more robust.
The Medicine Management
Procedure has been
amended with the correct
abbreviations and this has
been cascaded to the
prescribers.
Guidelines to be added to
the Medicines
Management Policy for
the correct way to
prescribe and monitor a
steroid history.
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FY2 doctor to repeat this
audit on a quarterly basis.
Accountable officer for controlled drugs
The Accountable Officer role at St Wilfrid’s Hospice is fulfilled the Specialist Nurse
Practitioner. She has undertaken an audit of controlled drugs audited during
2012/13 using the tool developed by Help the Hospices. The Accountable Officer
found the hospice to be compliant with the tool in all respects to standard
operating procedures. The number of controlled drug incidents during the
reporting period demonstrated a slight reduction compared to the previous year.
The hospice benchmarks practice against other hospices in the South East and is
mid table with respects to incidents involving controlled drugs.
Research
There were no patients receiving NHS services provided or sub-contracted by St
Wilfrid’s Hospice in 2012-13 that were recruited during that period to participate
in research approved by a research ethics committee.
St Wilfrid’s Hospice is committed to evidence based care and during the reporting
period has reviewed and strengthened its approach to ensuring evidenced based
care is embedded within the hospice, through the clinical governance structure.
2.4 Summary of published audit, research or academic studies during 2012/13
Research
St Wilfrid’s Hospice has not recruited patients to National Portfolio Research
studies between March 2012 and March 2013.
St Wilfrid’s Hospice staff members involved in research:
Karen Clarke, Deputy Chief Executive, undertaking a Doctorate in Palliative
Care, End of Life Observatory, Lancaster University
Ruth Nunn, Registered Nurse (RN), Trina Perry, RN, and Eirian Levell,
Hospice at Home Nurse Manager are studying for BSc (Hons) in Professional
Practice at the University of Brighton
Dr Luci Cook, Specialty doctor at St Wilfrid’s Hospice is in the final year of
her Diploma in Palliative Medicine, University of Cardiff
Lara Cowley, Specialist Physiotherapist, is studying for an MSc
Physiotherapy and BSc Psychology
Dr Farida Malik, Consultant in Palliative Medicine, is co-chair of the Sussex
Palliative Care Research Specialty Group whose aims are to promote
research in palliative care within the Sussex region. The group is affiliated
with the Sussex Cancer Network and the Surrey & Sussex Comprehensive
Local Research Network (S&S CLRN).
St Wilfrid’s Hospice staff members providing external teaching on research
degrees:
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Dr Farida Malik, Consultant in Palliative Medicine, regularly teaches on the
MSc in Palliative Care based at Kings College London. In the year 2012/13,
she has taught both on the needs of caregivers and sleep in palliative care
Felicity Hearn, Head of Psychological, Spiritual and Social Care, has also
taught on the MSc in Palliative Care at Kings College London in 2012/13.
Statements from the CQC
St Wilfrid’s Hospice is required to register with the Care Quality Commission and its
current status is that it is registered to provide treatment of disease, disorder or
injury and diagnostic and screening procedures. The CQC has not taken
enforcement action against St Wilfrid’s Hospice during 2012/13. St Wilfrid’s
Hospice underwent an unannounced inspection on 23 November 2012 and was
found to be compliant with all outcomes.
Registered Provider visits
During 2012/13 two Trustees undertook visits to the hospice to review the services
provided. They provided feedback to their visits, which is summarised below:
From Alan Breeze, Trustee:
I have always witnessed a professional and caring approach by all involved with the
hospice – both clinical and non-clinical. As a recently appointed trustee, I was
pleased to be invited to a hospice visit in December 2012. This entailed attendance
at the morning admissions meeting, visiting three patients at their homes with the
Registered Nurse, having lunch at the day therapy unit with the patients and
attending the in-patient unit at the hospice. Throughout the day, I was struck with
the care and professionalism being offered by all clinical staff and the warmth and
friendship shown to the staff by all patients. It was evident that there was a strong
bond between the hospice and its patients.
From Neil Elphick, Trustee:
I had a very interesting, enlightening and uplifting day. I sat in on the admissions
meeting - a fascinating discussion to listen to! I joined the Day Therapy Group,
which had a very nice atmosphere. I visited the In Patient Unit with the very
professional Jenny Ashdown (Registered Nurse) who impressed me greatly. I was
only able to visit one patient who was being visited by her son. As expected they
were both very complimentary and grateful about (the patient’s) treatment from
every member of the staff and could find no fault whatsoever.
Data quality
Good data quality underpins the effective delivery of patient care and is essential
if improvements in quality of care are to be made. Improving data quality, which
includes the quality of ethnicity and other equality data, will thus improve patient
care and improve value for money. During 2012/13 St Wilfrid’s demonstrated an
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improvement in recording patient’s ethnicity. For those admitted to the In Patient
Unit 93 per cent had their ethnicity recorded.
St Wilfrid’s Hospice, in accordance with agreement with the Department of Health,
submits a National Minimum Data Set (MDS) to the National Council for Palliative
Care. The hospice has been accredited to access and has maintained an N3
community of interest network (COIN) connection which required the satisfaction
of 29 requirements as specified in the NHS Information Governance toolkit for third
party business partners which includes hospices.
Use of the Quality, Innovation, Improvement and Prevention (QIPP) payment
framework
A proportion of St Wilfrid’s Hospice’s income in 2012/13 was conditional on
achieving quality improvement and innovation goals agreed between St Wilfrid’s
Hospice and East Sussex Downs and Weald Primary Care Trust (PCT) for the
provision of NHS services through the QIPP framework.
This involved engagement with the PCT End of Life Care board to work with care
homes locally to achieve the specific outcomes of:
Reducing inappropriate admission to the acute hospital
Increasing the use of advance care planning
Increasing the use of the Liverpool Care Pathway
Increasing the use of the ‘do not attempt cardiopulmonary resuscitation’
document agreed with the Sussex Cancer Network
The St Wilfrid’s Care Homes project was able to demonstrate improvement in all
the above areas through working with selected care homes locally to improve the
quality of end of life care.
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Part 3
3.1 Review of Quality Performance
A new clinical governance structure
The clinical governance board at St Wilfrid’s Hospice reviewed its structure during
2012-13 to improve quality assurance and increase staff engagement. This resulted
in the decision to formalize a clearer structure based on the three pillars described
in the clinical governance toolkit. These pillars are patient safety, clinical
effectiveness and patient experience. Three groups have been formed to lead on
these areas with broad staff membership, reporting in to the clinical governance
board, chaired by the Chief Executive, on a quarterly basis. This change in
structure was agreed during the reporting year and will be fully implemented from
April 2013.
The clinical governance framework in the hospice covers all areas focusing on
patient care, described in the following section.
Clinical risk
St Wilfrid’s Hospice has a strong process of managing accidents, incidents and near
misses (AINM). During 2012/13 there was a reduction in the number of incidents
involving medications, and a reduced number of falls. Reporting of pressure ulcers
commenced during 2012/13. All AINMs are reported to the Patient Safety Group,
chaired by the Head of Nursing, for further analysis and actions as well as lessons
learned. Reporting is also made to the clinical governance group.
Clinical effectiveness
During the reporting period the hospice reviewed its clinical audit group to ensure
that audit activity was congruent with the organisation’s objectives and to improve
the feedback cycle for learning and improvement in practice. The audit group will
now be incorporated within the Clinical Effectiveness group, chaired by the
Medical Director, which will report to the clinical governance board.
Patient engagement
St Wilfrid’s Patients Forum is an active and well-established group of current
patients, facilitated by the Deputy Chief Executive, who, during 2012/13, met on a
monthly basis and influenced patient service developments. During 2012/13 the
Patient’s Forum produced a Patient’s Promise which has influenced the
development of the quality improvement priorities for 2013/14.
Infection control
The hospice has an infection control group chaired by the In Patient Unit Nurse
Manager, which meets every six weeks and has staff membership from across the
hospice. During the reporting year a key priority was to ensure the hospice meets
the requirements of incoming EU legislation on safer needles to manage the risk of
needlestick injury. This is a sub group of the Patient Safety Group.
Medicines management
In an aim to improve safety in medicines management the hospice developed a
medicines management group. This is chaired by the In Patient Unit Nurse Manager
and has multi-professional membership, including external membership of a
Pharmacist. Achievements by the group include a reviewed and updated medicines
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management policy and procedure and a pilot of single nurse administration of
controlled drugs. This is a sub group of the Patient Safety Group.
Complaints
The hospice has continued to address any concerns or complaints. The Patient
Experience Group, chaired by the Deputy Chief Executive, oversees the
management of complaints and reports to the Clinical Governance Board.
Responses to complaints during 2012/13 include the review and change to the
policy and procedure governing management of syringe drivers to set a standard
that any patient admitted to the hospice for whom a syringe driver is indicated will
have this set up within one hour of that decision.
Health and safety
The hospice has a well-established Health and Safety group chaired by the Chief
Executive. In addition to an external health and safety expert, the group’s
membership comprises of clinicians, senior managers, estates and facilities,
information technology and learning and development. The group meets on a
quarterly basis.
Information governance
During 2012/13 the hospice has implemented mandatory training using the
information governance toolkit on line resource, for all staff and volunteers with
access to information. The uptake of training has not been acceptable and all line
managers are engaging with the Learning and Development Manager to improve
this and aim for 100 per cent of staff having completed the mandatory modules.
The hospice has migrated to use an electronic patient health record during 2012/13
which has been a significant achievement and will improve effectiveness,
communication and safety in patient record keeping.
Psychosocial care
The hospice has a Psychosocial Champions group under the facilitation of the Head
of Psychological, Social and Spiritual Care. This group aims to address any
identified gaps in the delivery of psychosocial care as well as improving the support
for all staff across the organisation. During 2012/13 the group has implemented
reflective review sessions open to staff and volunteers to provide peer support,
reflection and learning, as well as identifying areas for development or change.
Staff support
St Wilfrid’s Hospice recognises the value of staff support and development in order
to provide safe, effective care. The hospice has a learning and development
department, which has delivered a programme of training for staff within the
hospice as well as to external groups and individuals.
During 2013/13 a new competency framework was implemented for Registered
Nurses, which will provide clear evidence of the level of competence for differing
levels of staff. A competency framework for Health Care Assistants will be
launched in May 2013.
Learning and development
For 2012 /13 the mandatory training for clinical staff was reviewed and refreshed
to ensure staff were fully trained to offer safe and effective patient care.
Clinical staff took part in mandatory refresher update training on health & safety
and risk assessment, information governance, and safeguarding. A blended learning
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approach was taken involving face to face sessions and on line learning. These
changes will be fully evaluated during 2013/14.
All clinical staff attended a yearly Clinical Update training day which included
moving and handling, fire safety, Infection control, medicines management,
resuscitation, anaphylaxis and defibrillation. A database is being developed to
monitor attendance and capture feedback. Several staff are completing modules
and degrees with Universities in professional practice, end of life care and
dementia in line with their current job roles. Education sessions have been
delivered throughout the year which promote patient care have included
tracheostomy training, venepuncture training , managing palliative care
emergencies and registration of several staff onto the e-ELCA (electronic learning
for end of life care for all) training modules.
Patient safety
St Wilfrid’s Hospice monitors its safety of patient care through the AINM process. A
summary of the key areas for patient safety are presented in the following tables:
Reported Falls Comparison
8
6
4
2012/13
2
0
2011/12
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2012/13
6
3
5.5
2
6
5
5
2
3
6
1
3
2011/12
2
7
5
6
6
2
4
0
4
7
2
4
Reported Drug Incident Comparison
8
6
4
2
0
2012/13
2011/12
Apr
4
2
May
1
1
Jun
2
5
Jul
2
0
Aug
1
2
Sep
2
5
Oct
1
2
Nov
3
1.5
Dec
2
2
Jan
2
5.5
Feb
2
7
Mar
5
6
Infection Control Comparision
2
1
0
Apr May
2012/13
1
2011/12
0
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
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Injuries Comparision
2.5
2
1.5
1
0.5
0
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2012/13
Apr May
0
0
1
1
0
0
0
2
1
0
1
0
2011/12
0
1.5
1
2
1
1
0
0
1
2
0
0
During 2012/13 there has been one episode of clostridium difficile infection
acquired during an in-patient stay within the hospice. Infection control measures
prevented any cross infection to other patients. There are no incidents of MRSA or
E coli bacteraemia being acquired within the hospice.
Patient activity
The national minimum data set is submitted annually to the National Council for
Palliative Care and allows comparison with other hospice providers. A copy of the
report can be found at
http://www.ncpc.org.uk/sites/default/files/MDS%20Report%201011%20A4_1.pdf
3.2 Patient experience
During 2012/13 St Wilfrid’s Hospice implemented patient satisfaction
questionnaires for those having an in-patient stay, and subsequently to those cared
for by the Hospice at Home team and DTU. The number of patients completing the
questionnaires has been disappointingly low and there are efforts to improve this.
Feedback has been largely very positive, however, some areas for improvement
have been identified, including addressing spiritual needs.
CQC comments
Feedback from the CQC following their unannounced inspection identified a
number of positive comments including the following:
We were told by the patients that used the service, "I feel that they actually listen
to me and not just look at my illness." Another said "Wonderful place and the staff
are so kind," and, "They put a flower on my food tray, it's lovely to feel so cared
for."
Staff told us that they worked closely as team, and that all decisions made about
care were fully discussed with the patient, family and multi-agency team. One
staff member said "It's a really great place to work." Another said "We have a really
good team of staff and the volunteers are a valuable support to our patients."
The full report is available through the CQC website at:
http://www.cqc.org.uk/directory/1-128576488
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Feedback from those who experience care provided by St Wilfrid’s Hospice
‘My mother died in the hospice seventeen years ago….we still remember your
fantastic treatment…both the care and the kindness stay with us.’
from the daughter of a patient who died in St Wilfrid’s Hospice
‘Thank you for coming out to help us so promptly when we needed you, and for
being so patient and sensitive. You made a big difference to our lives at that
difficult time’
from the family of a patient who was supported to die at home by the Hospice at
Home team
For further information about our services and support at St
Wilfrid’s Hospice please visit our website at
www.stwhospice.org
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