The Butterwick Hospice
at
Bishop Auckland
Quality Account
2012 - 2013
The Butterwick Hospice at Bishop Auckland
Woodhouse Lane
Bishop Auckland
Co Durham DL14 6JZ
Registered Charity 1044816
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Our Mission Statement and Philosophy
Why we are here
We aim to improve the quality of life for those who have a progressive life limiting illness
and those close to them and to offer positive support for every challenge they may
encounter during their illness and to see death as part of life’s journey.
In particular we will:
Provide supportive and specialist palliative care for adults with progressive life limiting
conditions
Ensure each person receives care in a homely environment whilst maintaining privacy,
dignity and choice.
Provide holistic centred care by responding to and respecting the patient and those close to
them by meeting their individual, physical, social, cultural, educational, spiritual and
emotional needs throughout the illness and bereavement.
Acknowledge and respect the way those close to the patient care for them and endeavour
to continue their chosen pattern of care.
Work together in developing an environment based on support and mutual respect.
Maintain the high quality of the service through ongoing reflection, evaluation and
education.
Communicate effectively and efficiently both within the Hospice and with external
agencies, to ensure continuity of care and promote service development.
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Part 1:
Chief Executive’s Statement
It gives me great pleasure to present the Quality Account for the Butterwick Hospice at
Bishop Auckland in respect of the year ended 31st March 2013.
The Hospice is an integral part of Butterwick Hospice Care (registered charity 1044816)
which provides services from three separate Hospices in the North East of England. The
entire Hospices’ services are provided totally without charge to our patients and their
carers.
The day to day operational management of the Butterwick Hospice at Bishop Auckland’s
clinical services are under the leadership of Mrs Paula Wood who is designated the
Registered Manager in the Hospice’s registration with the Care Quality Commission.
The Butterwick Hospice at Bishop Auckland endeavours to provide an excellence in
evidence based palliative care for all patients regardless of age or diagnosis; to be a centre
of expertise and a specialist resource within the community as a whole.
The needs of patients and their carers are paramount to the Charity’s existence and are
the root and focus of all we do.
Quality is at the core of the Charity’s strategic and operational priorities.
An independent impartial assessment of the quality of care provided was
obtained when the Care Quality Commission performed a routine unannounced
inspection of the Hospice in August 2012. Their Report showed that the Hospice
was meeting all of the required standards. A copy of their full Report is available
at : www.cqc.org.uk/directory/1-113000544.
During the last year we have worked effectively in partnership with NHS County Durham
and Darlington and we look forward to working in future with the Durham Dales,
Sedgefield & Easington Clinical Commissioning Group for the benefit of the community we
freely serve.
In the year the Hospice has achieved the Commissioning for Quality and Innovation
(CQUIN) outcomes detailed in the 2012/13 Contract with NHS County Durham and
Darlington.
The Charity only achieves its key objectives because of the professional skills, commitment
and enthusiasm of our staff and volunteers.
I am responsible for the preparation of this report and its contents. To the best of my
knowledge, the information reported within this Quality Account is accurate and a fair
representation of the quality of healthcare provided by our Hospice.
Graham Leggatt-Chidgey
Chief Executive
May 2013
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Part 2:
1.
Priorities for improvement and statements of assurance
from the board (in regulations)
IMPROVEMENT
Within the Organisation quality is fundamental to improvement and accountability. The
Board of Trustee’s continue to support and promote the ongoing development and
improvement of services to ensure that the care and support provided evolves to meet
patient and carer needs.
The priorities for quality improvement for 2013/14 are set out below.
These priorities have been identified in conjunction with patients, carers, staff and
stakeholders. The priorities we have selected will impact directly on each of the three
priority domains:
2a.

Patient safety

Clinical effectiveness

Patient experience
Priorities for improvement 2013-2014
Patient Safety
 Priority One
The introduction of a patient reference group
within the Butterwick Hospice
How was this identified as a priority?
The Francis report published in Feb 2013 highlighted the serious issues from Mid
Staffordshire NHS Foundation Trust. One of the themes to come from the report was to
recommend:
Openness –enabling concerns and complaints to be raised freely without fear and
questions asked to be answered.
Transparency- allowing information about the truth about performance and outcomes to
be shared with staff, patients, the public and regulators.
Candour-any patient harmed by the provision of a healthcare service is informed of the
fact and an appropriate remedy offered, regardless of whether a complaint has been made
or a question asked about it.
The Butterwick Hospice promotes openness and honesty with the public and regulators by
producing an annual Quality Account and inspection reports from the Care Quality
Commission are available for all to access. However recommendation.62 from the Francis
Report emphasises improved patient focus which should incorporate greater public and
patient involvement into its own structures.
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Introducing a patient reference group within the Hospice will allow open discussions
regarding service developments/evaluation of audit reports/Review of Hospice literature
and review of how complaints / incidents are handled.
How will this priority be achieved?
Letters will be distributed to all patients to identify who would be interested in being
involved in a patient reference group.
Once the group is identified, terms of reference will be formulated to clarify the purpose of
the group, how regularly the group will meet and the membership of the group.
Meeting dates will be arranged and circulated to the group.
A regular agenda will be set and minutes of meetings will be recorded and then circulated
to the group.
How will progress be monitored and reported?
Minutes of meetings will be produced and circulated. Any action points will be set and
recorded in the minutes.
An Action plan will be produced in accordance with audit feedback, reviews and outcomes
of the patient reference group meetings.
The minutes of these meetings will form part of the agenda in the Clinical Strategy and
Governance Committee which has Trustee and management representation.
Clinical Effectiveness
 Priority Two
To obtain the Children’s Charter status
How was this identified as a priority?
The number of children accessing the Hospice family support service has increased over
the past 12 months. The Hospice is also working in partnership with the Bridge Young
carers. This group supports children who are in a carer capacity where a parent is
diagnosed with a progressive life limiting illness. The Bridge Young Carers informed the
Hospice that we could obtain the Children’s Charter status which is a quality marker stating
that you meet the holistic needs of children in your organisation. The Children’s Charter is
a recognised accreditation with the Care Quality Commission.
How will this priority be achieved?
County Durham and Darlington NHS and Durham County Council have jointly endorsed the
use of a self assessment tool for the Children’s Charter.
This self assessment will be performed to identify the Hospices current position in meeting
the requirements of the charter.
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Working with the Bridge young carers an action plan will be devised to meet the areas not
currently achieved within a set time frame.
How will progress be monitored and reported?
A member of the Hospice family support team will be allocated to work with the Bridge
young carers. The self assessment will be performed by the Hospice family support worker.
Any areas that the Hospice does not currently achieve will be formulated into an action
plan. This action plan will be reviewed regularly by the Hospice family support worker and
the Bridge young carers until all pledges are met.
The self assessment will then be forwarded for accreditation.
Once accreditation of the Children’s Charter is given the Hospice will inform the Care
Quality Commission and we will be able to promote the Childrens Charter within the
Hospice documentation and information packs.
To introduce a tool for the identification of patients
with dementia, alongside their known medical
conditions.
How was this identified as a priority?
Dementia is a significant challenge to the NHS. Currently only 42% of people with
dementia in England have a formal diagnosis despite the fact that a diagnosis can greatly
improve the quality of life of the person with dementia. In order to increase the number of
people diagnosed with dementia, the Department of Health have introduced a dementia
CQUIN. The Hospice continuously strives to deliver high quality care, therefore working
within the dementia CQUIN will allow the Hospice to identify patients who may have
dementia alongside their known medical condition and refer to appropriate services for a
further in depth assessment, as well as supporting their carers.
How will this priority be achieved?
All clinical staff to be trained in dementia awareness.
A dementia diagnostic assessment tool will be performed on admission if the patient meets
the stipulated trigger.
(See overleaf)
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A baseline assessment of the Hospice building will be performed to identify any reasonable
adjustments required to improve the experience of dementia patients and their carers who
access the Hospice services.
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A Carer questionnaire will be performed on any carer whose loved one was diagnosed with
dementia following the initial Hospice assessment to ensure they are feeling supported.
How will progress be monitored and reported?
Staff training records will be updated when staff access dementia Awareness training.
In order to identify the number of patients referred for further in depth dementia
assessment will be recorded on the Hospice database.
An environmental audit and action plan will be produced to identify areas and action
required to improve the environment of people with dementia.
A Carer’s questionnaire will be sent to all carers of patients who have been formally
diagnosed with dementia to identify whether they feel supported. An action plan will be
produced with the outcomes of the questionnaire and any actions required.
Patient experience

Priority Three
Questionnaire to capture patient and carer
experience of Hospice services and
experience at time of death
How was this identified as a priority?
This was identified as a priority in the Hospice Quality Account for 2012/13.The results of
the carer questionnaires was extremely positive; however the Hospice only received a 31%
response rate. During 2013/ 14 the Hospice wants to improve the response rate and will
identify ways in which this can be achieved.
How will this priority be achieved?
Patients will be identified on the Hospice database. Following the death of the patient a
questionnaire will be posted to the patient’s next of kin three months post bereavement,
rather than previously being posted 6 months post bereavement. The number of
questionnaires distributed will be monitored against the number of responses received.
The Butterwick Hospice will liaise with other Hospices in order to share ideas and look at
different methods in order to increase the response rate.
How will progress be monitored and reported?
The results of the questionnaires will be collated and a report will then be produced
quarterly highlighting the results. An action plan will be formed following each quarterly
report to highlight any action required from the questionnaires. The results will be
forwarded to stakeholders and staff.
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2.2
Review of services
During 2012/13 the Butterwick Hospice at Bishop Auckland provided five key services:
 Hospice at Home
 Family support and bereavement service
 Neurological service
 Day Hospices across 4 sites
 Outpatients
We have reviewed all the data available on the quality of care in all of the above services.
To all the staff of the Butterwick Hospice Bishop Auckland
I can’t tell you how much you’ve helped me
over the past months. Everyone has been so
kind, cheerful and understanding. Each of
you is unique in your own way. I think of
you as lifelong friends.
A Thank You letter
from a Day Care Patient
You always go the extra mile to ensure that
each one of us is treated with sensitivity and
care. (The fridge magnets are so you
remember me every time you go past)
I look forward to popping in for visits in the
future. Once again thank you all so much.
Love,
xxx
The income generated by the NHS services reviewed in 2012/13 represents 100% of the
total income generated from the provision of the NHS services by the Butterwick Hospice
for 2012/2013. The income generated from the NHS represents approximately 45% of the
overall patient care costs incurred by the Hospice.
2.3
Participation in Clinical Audits, National Confidential Enquiries
During 2012/13 there were no clinical audits or national confidential enquiries covering
NHS services relating to palliative care. The Butterwick Hospice at Bishop Auckland only
provides palliative care therefore were ineligible to participate.
Local Clinical Audit and Service Improvement
During 2012/2013 the Hospice performed several audits using Help the Hospices (the
national umbrella membership Organisation for independent charitable Hospices) audit
tools which are nationally recognised and which set a benchmark to monitor the quality
and efficiency of Hospice services across the country.
Audits performed during 2012/2013
 Record Keeping
 Day care admission and initial assessment
 Preferred place of care
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






Support Team Assessment schedule
Medication documentation
Safety Thermometer
Patient questionnaires
Carer questionnaires
Bereavement evaluation tool Response times to referrals and assessment
Infection control audits.
Below are completed infection control audits performed during 2012/2013.
Hospice Hand Hygiene Audit
Hospice: Bishop Auckland Day Unit
Calculation:
yes x 100%
yes + no (do not include N/A responses)
Adult / Children
Auditors: J O, accompanied by
LM&PW
Audit score
Audit date: 13.6.12
100%
Yes

2
Staff comply with Uniform Policy and bare below the elbows guidance.
There are posters displayed at clinical wash hand sinks showing correct method
of hand decontamination.
3
Liquid soap is available at all hand wash sinks.

4
Alcohol handrub is available at the entrance/exits to depts and patient areas.

5
Dispensers are clean and filled and drip trays are clean.

6
Dispensers are labelled correctly.

7
Clinical staff carry personal dispensers of alcohol handrub.
An approved wall mounted hand cream dispenser is available in each clinical
dept.
Staff decontaminate their hands before serving meals to the patients
(observe/question two staff).
A poster is displayed to make visitors aware of the importance of hand hygiene
before entering and leaving the dept.
1
8
9
10





13
14
Elbow operated or sensor taps are available at all clinical hand wash sinks.

15
Staff are aware of the Hand Hygiene Policy and its location (question two staff).
Staff are aware when it is not appropriate to use alcohol handrub (question two
staff).
Patients are offered the opportunity for hand hygiene after going to the toilet
and before meals (question two patients)

12
16
17
Action plan required?
YES
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N/A

Up-to-date hand hygiene promotion posters are on display.
Hand wash sinks are accessible, clean, free from plugs, overflows, equipment,
and patient’s property.
Hand towel dispensers are filled and staff are aware of where supplies are kept
(question two staff)
11
No




Nominated
Date for
Date for
Problem/issue
Actions
responsibility
completion
review
Hand hygiene posters should be
To obtain hand hygiene poster
standardised in line with the
in line with Stockton site
LM
July 2012
12
Stockton site
To display hand hygiene
months
A hand hygiene reminder poster
poster in new wing entrance
LM
should be displayed adjacent to the
July 2012
gel dispenser at the entrance to the
new wing.
COMMENTS
The day room washing up sink continues to be allocated as the hand wash sink. When the area is re-furbished this
sink should be replaced with a hand wash sink.
Hospice Sharps Safety Audit
Hospice: Bishop Auckland Day Unit
Calculation:
yes x 100%
yes + no (do not include N/A responses)
Adult / Children
Auditors: J Ol, accompanied
by L M & PW
Audit score
Audit date: 13.6.12
100%
Yes
1
Staff are aware of the waste disposal and accidental exposure to bodily fluids
policies and where they are located (question two staff).

2
Sharps bins are correctly assembled and an assembly poster is displayed.

3
Sharps bins are signed and dated.

4
Sharps bins are less than two thirds full and free of non sharp items.

5
Sharps bins are closed when not in use.

6
Appropriately sized sharps bins are available.

7
Sharps bins are positioned safely.

8
Sharps are disposed of at the point of use (observe/question two staff)

9
Locked sharps bins are stored in a designated secure room prior to collection.

10
Blood glucose meter storage boxes are free of used sharps.
11
An ‘accidental exposure to bodily fluid’ poster is on display.
Staff know what actions to take in the event of a needlestick injury (question two
staff).
Staff understand what post exposure prophylaxis (PEP) is, and how to access it
(question two staff).
12
13
Action plan required?
No
N/A




YES
Problem/issue
Actions
Update to date ‘accidental
exposure to bodily fluid poster’
should be displayed, in line with
Stockton site.
Exposure to bodily fluids
poster to be updated in line
with Stockton site
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Nominated
responsibility
Date for
completion
Date for
review
LM
July 2012
12
months
COMMENTS
It is excellent that full compliance was achieved with all applicable standards.
Treatment room in use therefore unable to access blood glucose meter storage box.
Temporary closure mechanism on sharps bin difficult to open due to tight fit.
Hospice Personal Protective Equipment (PPE) Audit
Hospice: Bishop Auckland Day Unit
Calculation:
yes x 100%
yes + no (do not include N/A responses)
Adult / Children
Auditors: J O, accompanied by
LM&PW
Audit score
Audit date: 13.6.12
100%
Yes
No
N/A
1
Staff are aware of the standard precautions policy and its location (question two
staff).

2
There is an adequate supply of gloves available.

3
There is an adequate supply of aprons available.

4
Glove/apron dispensers are available in patient areas.

5
Gloves are worn as single use items

6
Face masks are available (surgical and FFP3).

7
Face visors are available.

8
Staff are observed using PPE appropriately

9
PPE is disposed of appropriately.

Staff are observed decontaminating their hands after removing PPE.
Visitors are given guidance on PPE when appropriate for their use (question two
11 staff)
Staff are aware of correct procedure to follow when dealing with blood spillages
12 (question two staff).
Action plan required?
NO

10
Problem/issue
Nominated
responsibility
Actions


Date for
completion
COMMENTS
No clinical activity at the time of the audit, therefore standards 8-10 not applicable. It is excellent that full
compliance was achieved with all applicable standards.
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Date for
review
Part 3
3.1
Review of quality performance 2012- 2013
Development 1: Patient Safety
The Palliative Home Care Team Care Assistants to be
able to assist with administration of medications
within patients own homes.
State how development was identified
The Care Quality Commission performed an unannounced inspection in October 2011. One
area reviewed was patient and staff information.
The Inspectors recommended that we review the Palliative Home Care Team staff
handbook as the guidance relating to assisting with medication was unclear and could be
misinterpreted.
In response to this feedback the Palliative Home Care Team Leader and the Registered
Manager reviewed the Hospice’s procedure relating to the administration of medication by
Health Care Assistants within patients’ homes.
Previously the Health Care Assistants did not assist with any administration of medications
but relied on the patient’s relatives or contact an out of hours (NHS) Registered Nurse to
visit the patient to give any medication required. The Hospice reviewed guidelines on
administration of medications within domiciliary care and made the decision to train
Hospice Health Care Assistants to enable them to assist with the administration of
appropriate medication.
How was it achieved?
Staff were identified to access administration of medication training.
Training was then arranged for staff to access a place on the course.
Training was also delivered relative to palliative care and end of life drugs.
A risk assessment tool was identified which will be utilised with each patient prior to staff
assisting with medication within a patients home.
Training was accessed by staff relating to the implementation of the risk assessment tool.
All staff will undergo a competency review in relation to assisting with
patients homes. This will be performed by the Palliative Home Care
Competencies will be completed in June 2013. There was a delay due to
When able to demonstrate competency, staff will be authorised to
administration of appropriate medications.
medication in
Team Leader.
staff sickness.
assist in the
Review and evaluation of success of development
All completed training was recorded in Individual Training records.
Individual Competency records will also be completed and kept in staff files. The new
procedure for assisting with medication within patients’ homes will be reviewed on a 2
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yearly basis or before if subject to change in relative legislation or guidance. Procedures
are reviewed by the Senior Clinical Team who meet on a monthly basis. Procedures and
education/ training are part of the agenda.
Development 2 Clinical Effectiveness
1. To make contact with patient within 5 working
days of receiving referral
2. To assess the patient within 10 working days of
receiving referral
3. For patient to attend Hospice within 15 working
days of receipt of referral
State how development was identified
This was identified by the Commissioners for County Durham and Darlington NHS Trust as
a Key Performance Indicator within the Hospice Contract. The Contract specifies that a
95% target was to be achieved in relation to first contact within 5 days of receipt of
referral.
How was it achieved?
Information was inputted into the Hospice database with patient’s date of referral, date of
first contact and date of first attendance. These results were then collated into a report
indicating if the Hospice has achieved its targets.
Review and evaluation of success of development
Results were collated into a quarterly report and sent to stakeholders. An action plan was
formulated in order to address any areas that did not achieve target, with an explanation
of what had prevented objectives being achieved.
28 sets of notes from Bishop Auckland and Outreach Day Care Services were audited.
These were notes of all new referrals received from October to December 2012.
Results
Please see table attached.
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28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
7 Day Target
10 Day Target
15 Day Target
Day Care Referrals
Conclusion
Overall all Day Hospices met targets as stated above.

The results highlighted that 96% of the patients were first contacted within 5
working days. 71% of patients were assessed within 10 working days and 54% of
the patients attended for their first day care session within 15 working days.

Where target hasn’t been met, this is usually in a circumstance where the patient
has been unable to attend or contact sooner. In these circumstances 3 patients had
been admitted to hospital, 5 patients requested a later date after the Christmas and
New Year break, 2 patients were too poorly to attend, 2 patients decided against
attending and 1 patient passed away before accessing.
Action Plan
The next audit will be completed in 3 months
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Development 3 Patient Experience
Questionnaire to capture patient and carer experience of Hospice services and experience
at time of death
State how development was identified
One of the 7 key principles of the Calman-Hine report (1995) which was re emphasised in
the NHS Cancer Plan (2000) was that services should be patient focused and take into
account the views of patients, families and carers.
The Butterwick Hospice previously distributed and collated patient satisfaction
questionnaires; however we did not capture the carers experiences when death occurs.
The Department of Health had implemented the national VOICES (DOH
questionnaire in order to monitor the effectiveness of the End of Life Strategy.
2011)
Based on the VOICES (Department of Health 2011) questionnaire the Butterwick Hospice
would distribute questionnaires to deceased patients’ carers’ six months post bereavement.
How was it achieved?
Patients were identified on the Hospice database. Following the death of the patient a
questionnaire was posted to the patient’s next of kin six months post bereavement. The
number of questionnaires distributed was monitored against the number of responses
received.
Review and evaluation of success of development
The results of the questionnaires were collated and a report was then produced quarterly
highlighting the results. An action plan was formed following each quarterly report to
highlight any action required from the questionnaires. The results were then forwarded to
stakeholders and staff.
CARER’S QUESTIONNAIRE EVALUATION
July- September 2012
During the period from July to September 2012 the Butterwick Hospice at Bishop Auckland
cared for patients and their families accessing through Day Hospice, Home Care,
Complementary Therapy and Family Support Services.
We sent questionnaires to 29 relatives and carers six months after the death of the
patient, in which we asked whether we had met all of their needs and also to try to find
out if there were any changes we needed to make to the service.
There were 9 questionnaires returned and these are the results and comments from them.
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QUESTION 1
Please indicate which Hospice Service was accessed
6
Day Hospice
Home Care
4
Complementary
Therapy
2
Family Support
Other
0
Jul - Sept 2012
QUESTION 2
Before or during your time accessing the Hospice Service did
you receive an information pack/leaflet?
6
4
Yes
No
Can't Remember
2
0
Jul - Sept 2012
QUESTION 3
If you received an information pack/leaflet:
a) Was the information pack leaflet easy to understand?
Yes
No
Can’t Remember
No Answer
6
0
1
2
Comment – “Details discussed by phone and with Macmillan Nurse.”
b) Was the information pack/leaflet helpful?
Yes
No
Can’t Remember
No Answer
6
0
1
2
c) Was there anything in the information pack/leaflet that you found incorrect?
Yes
No
Can’t Remember
No Answer
0
4
3
2
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QUESTION 4
When you accessed the Hospice Service did the staff caring for
your loved one introduce themselves?
10
8
Always
6
Most of the Time
4
Some of the
Time
Never
2
0
Jul - Sept 2012
QUESTION 5
In your opinion did the Hospice staff know enough about your
loved ones condition and treatment?
8
Always
6
Most of the Time
4
Some of the
Time
Never
2
0
Jul - Sept 2012
QUESTION 6
Did you have confidence and trust in the staff who were caring
for your loved one?
8
6
Always
Most of the Time
4
Some of the Time
Never
2
0
Jul - Sept 2012
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QUESTION 7
Did the Staff provide explanations about the treatment and care
provided to your loved one?
8
6
Always
Most of the Time
4
Some of the Time
Never
2
No Answer
0
Jul - Sept 2012
QUESTION 8
Did you have the opportunity to ask questions when you wanted
to?
8
Always
6
Most of the Time
4
Some of the
Time
Never
2
0
Jul - Sept 2012
QUESTION 9
Did you feel staff made an effort to meet your loved ones
individual needs and wishes?
8
Always
6
Most of the Time
4
Some of the
Time
Never
2
0
Jul - Sept 2012
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QUESTION 10
During their access to the Hospice service did your loved one get
enough help to meet their personal care needs? We’re thinking of
things like bathing, dressing, and help with eating and going to
the bathroom.
6
Yes definitely
Yes to some
extent
No
4
They didn’t need
any help
Don’t know
2
Not Applicable
0
Jul - Sept 2012
QUESTION 11
How much of the time was your loved one treated with respect
and dignity by the Hospice Staff?
8
Always
6
Most of the Time
4
Some of the Time
Never
2
0
Jul - Sept 2012
QUESTION 12
Did you feel you were treated with courtesy?
8
Always
6
Most of the Time
4
Some of the
Time
Never
2
0
Jul - Sept 2012
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QUESTION 13
Did you feel that your privacy was respected e.g. during
discussions with staff?
10
8
Always
6
Most of the Time
Some of the
Time
Never
4
2
0
Jul - Sept 2012
QUESTION 14
If you visited the Hospice please rate the following by circling
your response (1= Poor and 5= Excellent or N/A for not
applicable)
a) The cleanliness of the premises
5
1
4
2
3
3
2
4
5
1
N/A
0
Jul - Sept 2012
No Answer
b) The quality of the catering
5
1
4
2
3
3
4
2
5
1
N/A
0
Jul - Sept 2012
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No Answer
c) Access to food other than set meal times
6
1
2
4
3
4
2
5
N/A
0
Jul - Sept 2012
No Answer
d) The general environment/surroundings
6
1
2
4
3
4
2
5
N/A
0
Jul - Sept 2012
QUESTION 15
No Answer
If your loved one needed to call for assistance were you
satisfied with the response?
4
Always
Most of the Time
Some of the
Time
Never
2
Not Applicable
No Answer
0
Jul - Sept 2012
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QUESTION 16
Overall, how satisfied were you with the care provided to your
loved one?
8
Vary Satisfied
6
Satisfied
Dissatisfied
4
Very dissatisfied
2
No Answer
0
Jul - Sept 2012
QUESTION 17
Do you feel the involvement with the Hospice had a positive
impact on your loved ones quality of life?
6
Yes Definitely
Yes to some extent
4
No
2
Don't Know
No Answer
0
Jul - Sept 2012
Please could you comment further?




“More on my Quality of Life as a full time carer – Gave me opportunity to care
for others”
“I can’t thank them enough through ……… illness. I am most grateful”
“Butterwick Hospice provided us with some wonderful people who provided care
overnight. This service is essential when trying to care for someone in their last
weeks of life in their own home. Thank You.”
“I was always deeply satisfied with the quality of care received”
QUESTION 18
Were you aware of what to do if you wanted to make a
complaint?
Yes
No
No Answer
QUESTION 19

5
2
2
Do you have any further comments or suggestions to help us
in the further development of our service?
“This service was there when I needed it; I was in a very bad place before your
help and support. I was struggling trying to care for 3 people, 1 of which was
bed bound in our home. Thank You.”
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

“All of the staff were really angels. Most caring to me while also there for ………. I
can’t praise them enough. I hope they will be there for me when my time is
near. God Bless you all.”
“I would not wish to make a complaint as the sitters and the other carers were
excellent.” *
QUESTION 20
-
Do you have any comments on the content or style of this
questionnaire?
No Comments
The National Council for Palliative Care: Minimum Data sets
We have chosen to present information from the NCPC minimum data set which is the only
information collected nationally on Hospice activity. The figures below provide information
on the activity and outcomes of care for patients accessing the Butterwick Hospice in
Bishop Auckland and outreach services.
Day Hospices
Number of patients who attended Bishop
Auckland Day Hospice
Number of attendances to Bishop
Auckland Day Hospice
Number of patients who attended
Barnard Castle Day Hospice
Number of attendances to Barnard
Castle Day Hospice
Number of patients who attended
Weardale Day Hospice
Number of attendances to Weardale Day
Hospice
Number of patients who attended
Sedgefield Day Hospice
Number of attendances to Sedgefield
Day Hospice
Palliative Home Care Team (PHCT)
Number of patients who received care
from PHCT
Number of Contacts from PHCT
Total Number of hours of care given
Physiotherapy
Number of patients who were seen by
the Physio’ at Bishop Auckland Hospice
Total number of physiotherapy contacts
at Bishop Auckland Hospice
Number of patients who were seen by
the Physio’ at Barnard Castle Hospice
Total number of physiotherapy contacts
at Barnard Castle Day Hospice
Number of patients who were seen by
the Physio’ at Weardale Day Hospice
Total number of physiotherapy contacts
at Weardale Day Hospice
Number of patients seen by Physio’ at
Sedgefield Day Hospice
Total number of physiotherapy contacts
at Sedgefield Day Hospice
Apr07
–
Mar08
102
Apr08
–
Mar09
89
Apr09
–
Mar10
147
Apr10
–
Mar11
106
Apr11
–
Mar12
91
Apr12
–
Mar13
116
1407
1229
1250
1049
1317
1305
20
21
38
29
15
37
307
349
342
264
208
237
28
28
30
35
17
34
308
346
300
266
264
284
29
20
33
30
22
28
416
473
482
374
479
425
119
100
182
136
117
137
1264
9855
1110
8964
987
7546
997
7703
1088
8063
1016
7458
37
252
52
145
42
191
61
319
50
342
46
330
17
21
14
9
7
4
153
141
45
23
21
11
17
19
10
16
12
16
103
81
39
81
66
56
23
17
0
7
12
2
181
129
0
36
81
5
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Bereavement Services/Family
Support
Number of Patients accessing the Service
Number of Contacts
Number of Home Visits
Number of ‘Drop Ins’
Number of Telephone contacts
Complementary Therapies
No. of patients who received
Complimentary Therapy – Bishop
Auckland Hospice
Number of Treatments
No. of patients who received
Complimentary Therapy – Barnard
Castle Day Hospice
Number of Treatments
No. of out patients who received
Complimentary Therapy – Barnard Castle
Number of Treatments
No. of patients who received
complementary Therapy – Barnard Castle
Home Visits
Number of Treatments
No. of patients who received
Complimentary Therapy – Weardale Day
Hospice
Number of Treatments
Number of out patients who received
Complimentary Therapy – Weardale
Number of Treatments
No. of patients who received
Complimentary Therapy – Weardale
Home Visits
Number of Treatments
No. of patients who received
Complimentary Therapy – Sedgefield Day
Hospice
No. of treatments
No. of out patients who received
Complimentary Therapy. – Sedgefield
No. of treatments
No. of patients who received
Complimentary Therapy – Sedgefield
Home Visits
No. of treatments
Number of Oil Replenishments
MS Aromatherapy
Number of Drop In patients received for
Complimentary Therapies. – Barnard Castle
Number of Treatments
Number of Drop In patients who received
Complimentary Therapy – Bishop Auckland
Number of Treatments
Number of Drop In patients who
received
Complimentary
Therapy
–
Weardale
Number of Treatments
Heart Failure Support Group
Number of patients attending the Group
Number of attendances to the Group
199
202
376
67
170
240
278
40
211
233
103
297
103
188
575
319
359
322
235
934
416
520
108
261
794
494
869
230
84
114
124
78
84
87
923
925
876
777
882
992
25
20
29
19
15
30
194
12
233
7
241
11
176
5
154
4
200
3
48
52
30
26
15
5
11
10
13
12
5
9
90
107
138
59
49
26
22
33
30
26
22
27
216
14
210
15
198
4
226
0
247
2
261
4
21
27
4
0
11
4
39
25
48
29
26
27
326
219
295
248
209
193
32
29
54
26
23
18
236
1
210
4
263
7
267
7
210
4
179
4
1
5
11
15
6
17
15
27
38
22
45
56
174
60
133
38
139
65
99
43
200
50
308
28
9
11
14
9
12
12
62
6
56
8
49
10
34
7
45
9
44
13
43
48
49
33
48
45
10
18
10
10
21
13
67
83
59
33
69
68
30
355
32
263
28
164
33
307
39
330
35
322
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Number of patients who received Tai Chi
24
Number of Tai Chi attendances
120
Number of patients who received
Complimentary
Therapy
(at
Group 24
sessions)
Number
of
received
Complimentary
Therapy
146
(at the Group sessions)
Number of patients receiving
7
Counselling sessions
Number of Counselling contacts
42
Neurological Day Care
Number of patients attending
17
Neurological Day Care
Number of attendances to Neurological
115
Day Care
Number of patients who
15
received Complimentary Therapy
Number of received Complimentary
98
Therapy
Number of patients who
15
received Physiotherapy
Number of received Physiotherapy
64
Number of patients receiving
7
Counselling sessions
Number of Counselling contacts
16
Total Number of patients/clients
who have accessed Hospice Services
471
27
175
8
10
22
157
34
222
26
174
26
11
24
30
28
201
93
131
155
131
5
6
2
5
6
35
18
17
45
48
36
56
56
76
92
231
578
665
712
641
24
53
46
67
85
302
365
318
395
475
22
47
47
69
86
219
14
522
19
591
51
666
56
607
42
75
53
139
278
61
486
522
544
601
670
3.2 An explanation of those involved in this quality account
The Quality Account was discussed at the Hospices Management Team meeting which is
chaired by the Chief Executive and includes clinical and non clinical managers, the Director
of Clinical Services and the Director of Finance.
The task of writing it was delegated to the Registered Manager and Chief Executive.
The Quality Account was also discussed at the senior Clinical Meeting where the quality
priorities were agreed.
It has also formed part of an Agenda item of the Clinical Strategy and Governance
Committee which is a key element of the Charity’s governance structure: the Minutes of
which are distributed to the Board of Trustees as will a copy of this Quality Account.
Once completed the Quality Account was distributed to Clinical and non clinical Managers
for comment and approval. The completed Quality Account was then forwarded to the
Durham Dales, Easington and Sedgefield Clinical Commissioning Group and the Health and
Wellbeing board to approve and comment on the quality priorities mentioned in the report.
Research
The number of patients receiving NHS services provided by or sub contracted by the
Butterwick Hospice at Bishop Auckland in 2012-2013 that were recruited during that period
to participate in research approved by a research ethics committee was: none. There were
no appropriate national, ethically approved studies in palliative care that the Butterwick
Hospice could participate in.
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What others say about us
The Butterwick Hospice is required to register with the Care Quality Commission and its
current status is unconditional. The Butterwick Hospice has no conditions on registration.
The Care Quality Commission has not taken any enforcement action against the Butterwick
Hospice at Bishop Auckland during 2012/13
The Butterwick Hospice is subject to periodic reviews by the Care Quality Commission and
its last review was 29th August 2012.
The Butterwick Hospice was fully compliant and rated as low risk following assessment by
the Care Quality Commission.
Below are some of their findings.
People told us, “There is a
lovely friendly atmosphere
here. The staff are very
kind and caring.”
People told
us they were
happy with
the service
and knew
how to raise
issues.
People told us they treated
respectfully by staff and the
support the Hospice could
provide was clearly
explained to them before
they chose to attend the day
Hospice.
Everyone we spoke to
felt safe. One person
said,”I always feel safe
with the staff and
volunteers.”
During our inspection we
looked at the quality
monitoring system the
provider had in place. One
tool was used to measure
people’s physical,
psychological and spiritual
wellbeing.
The Butterwick Hospice at Bishop Auckland has not participated in any special reviews or
investigations by the Care Quality Commission during 2012/1213
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Statements
Hospice Quality Account
Thank you for asking me to comment on your quality account. Durham Dales, Easington and
Sedgefield Clinical Commissioning Group has responsibility for monitoring the quality of
service provided in all services that we commission. The quality accounts offer an insight into
the care provided at Butterwick Hospice. The Clinical Commissioning Group also receives
information about patient experience, incidents and any safeguarding issues. These contribute
to an overall picture of a provider.
Having reviewed the quality account Durham Dales, Easington and Sedgefield Clinical
Commissioning Group is happy to agree that the content of the document represents an
accurate reflection of the service provided. We are pleased to note the introduction of a patient
reference group and the focus on dementia.
The section on patient feedback and the questionnaire that have been completed indicates a
very high level of patient satisfaction which we are pleased to see.
Overall the clinical commissioning group is happy to endorse the report.
Yours sincerely
Gill Findley
Director of Nursing
Stewart Findlay – Chief Clinical Officer
Annie Dolphin – Chair

As Healthwatch are still establishing their board, the Hospice has been
informed that they will be unable to comment on this year’s Quality Account.
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