The Peace Hospice
Quality Account 2012 - 2013
The Peace Hospice is a centre of excellence dedicated to
improving the quality of life for patients and families
facing a life-limiting illness by providing care and support
in the setting of their choice
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
Part 1
Chief Executive’s Statement
Welcome to our second annual Quality Report for 2013/14. This report is for our
patients, their families and friends, the general public and the local NHS organisations
that contribute to our costs. We raise the additional money to pay for our services
through fundraising, legacies, donations and Peace Hospice shops. The aim of this
report is to give clear information about the quality of our services so that patients feel
safe and well cared for, their families and friends are supported and reassured that all
of our services are of the highest standard. The report provides you with a summary
of our performance against selected quality measures for 2012/13 and our quality
initiatives and priorities for 2013/14.
The Hospice has a culture of continuous quality monitoring, in which any concerns are
identified and acted upon quickly. As ever the safety, experiences and outcomes for
patients and their families are of paramount importance to us all at the Peace Hospice.
The Care Quality Commissions unannounced visits in August 2012 and May 2013
identified no shortfalls in the services provided by the Hospice and this is a real tribute
to the commitment and hard work of every member of staff and all the volunteers who
give their time, skill and expertise to enable our patients and their families to be cared
for. I would like to thank all of our staff and volunteers for their role in delivering this
care on behalf of the Board of Trustees and myself.
I am responsible for the preparation of this report and its contents. To the best of my
knowledge, the information reported in this Quality Account is accurate and a fair
representation of the quality of healthcare services provided by our hospice.
Sue Plummer
Chief Executive
June 2013
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
Part 1.1
Looking Forward:
Priorities for improvement 2013 – 2014
The Peace Hospice is fully compliant with the Essential Standards of Quality and Safety
as set out in Care Quality Commission (Registration) Regulations 2009 and the Health &
Social Care Act 2008 (Regulated Activities) Regulations 2010.
The Care Quality Commission carried out unannounced inspections in August 2012 and
May 2013, and assessed the following standards:
Respecting and involving people who use services
Care and welfare of people who use services
Safeguarding people who use services from abuse
Staffing
Complaints
Management of Medicines
All of these standards were found to be met, and as such, the Board did not have any
areas of regulatory shortfall to include in the priorities for improvement for 2013-2014.
Following our assessment we have identified the top priorities to further improve the
services delivered to our patients and their relatives for the year 2013/2014. We have
selected priorities that will impact directly on each of the three domains of quality;
patient safety, clinical effectiveness and patient experience and they are:-
Priority 1: Patient Experience – Releasing time to care
How this was identified?
During a review of how staff spent their time in a typical week, it was identified that a
proportion of their time was spent on non-direct patient contact activities, for example,
internal meetings, administration and updating of patient records. We want to change
this so that more time can be spent with patients and their families.
How we plan to achieve this
We have recruited to a new role of community liaison coordinator. One of their main
tasks will be to improve the referrals process, such that less administration effort will
be needed by individual services.
We will review the patient record system and look for ways to simplify input in
order that less time is spent at the computer whilst maintaining a high standard of
information capture.
We will advertise more roles for volunteers who have specific experience/qualifications
so that they can take on some aspects of patient care and administration thus releasing
time for other staff.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
We will implement aspects of the productive ward used by the NHS to streamline aspects
of our services – for example in the inpatient and day care units we will introduce:
• E ffective handover – which will reduce the amount of time communicating
information about patients from one shift to another
• A
“Patient status at a glance” board – which will give key information about each
patient for staff to see “at a glance”, reducing the interruptions to other staff
caring for patients, with requests for information.
Priority 2: Patient safety/clinical effectiveness –
To strengthen the role of education in delivery of services
How this was identified
Whilst the Hospice has always aimed to meet training requirements and support
updating professional practice, it is recognised that we are now in a position to improve
on current systems. In previous years we have run mandatory training sessions
during the year and staff were invited to attend. We found however, that it was at
times, difficult for people to attend these courses due to other work pressures and
part time working.
How we plan to achieve this
We have recruited to a new post of Practice Development Nurse. Part of her role is to
ensure that the nurses are competent to carry out their required roles in all the hospice
clinical settings.
We have 2 palliative care nurses who, as part of a project, will be going in to teach
general nurses working in care homes, the community and hospitals about end of
life care.
We have decided to implement a new IT system to deliver some aspects of mandatory
training. This system is internet based and will mean that staff can, within certain
parameters choose when they take a course. The training system will prompt staff
when they need to update mandatory training and will allow the training and human
resources staff to monitor progress of all employees and ensure they are up-to-date
with the necessary training for their role.
riority 3: Patient experience/clinical effectiveness –
P
Increase the number of patients referred to our services
We would like to reach more members of the community who need our services.
This is an ongoing objective and we believe it helps us focus our attention on our
services, volunteering, trading, and fundraising.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
How we plan to achieve this
During the year 2013-2014 we plan to:
1.Increase the number of referrals to the clinical core services – the appointment to
the new role of referrals co-ordinator and their planned close working with local
health care professionals in the community will help achieve this.
2.Agree with the local Clinical Commissioning Group that emergency out of hours
admissions (which are currently being run as a pilot project), will be funded
beyond 2013.
3.Appoint to identified clinical service gaps to ensure a patient services multidisciplinary team is available to all our patients, carers and families:
• A social worker (community liaison role) – to take some of our services out of the
hospice to the patient/client in their homes enabling more people to be reached
• A creative therapy coordinator
• Increase medical hours to support our out of hours service
4.As an NHS Any Qualified Provider of accredited bereavement service, increase
referrals to the bereavement service
5.As an NHS Any Qualified Provider of accredited bereavement service, increase
referrals to the bereavement service
Looking Back
Priorities for Improvement 2012-2013
In our last Quality Account we identified the following priorities for 2012-2013 and
below we report on progress made against these.
Priority 1: To write a care strategy
Priority 2: To review day services
Priority 3: To set up a volunteer home visiting service
Priority 1
A Care Strategy
We planned to write a care strategy overarching all of our clinical services to ensure
that quality patient/client care remains the charity’s top priority and is at the forefront
of the hospice agenda.
Progress against this objective
To meet this objective, we decided to write a number of objectives and service related
goals and actions rather than having just one overarching care strategy.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
Our clinical objectives are to:
• Reach more people by increasing the number of patients and users accessing
services by 3% by the end of 2013 .
• Release more time to care by promoting innovation within the patient services
and increasing the time clinical staff time spend directly on patient care by 3%
by the end of 2013.
• Ensure the Peace Hospice continues to provide safe and effective services.
Delivery of the high standards of care evidenced through national standards and
agreed key performance indicators
Priority 2
Review of day services
We planned to review our day services to ensure that we were meeting the needs of our
local population. We secured funding from Macmillan Cancer Support to fund a joint
project with Hospice of St Frances to review both hospices day services. We aimed to
provide a broader range of services for a wider section of the public – for example more
ethnic and minority groups and groups for people of different ages.
Progress against this objective
Following the recommendations the Starlight Centre at the Peace Hospice is now the
home of our day services. We have a range of workshops, groups, individual treatment
sessions and programmes to provide skills and strategies to improve quality of life and
independence, support to patients and their carers and advice and information. We
know that this support needs to be available throughout the journey of the illness and
must be timely and flexible to suit the needs of our community.
We have secured further funding from Macmillan Cancer Support to fund a joint one
year co-ordinator post with The Hospice of St Francis to consolidate the work already
started and strategically promote the services. We are also appointing Physiotherapy
and Rehabilitation Assistant posts to be able to provide a rehabilitative approach
to maximise independent function. These posts add to our multi professional team
providing a wide range of clinical skills enabling us to increase our services on offer
over the next year.
We plan to continue to develop the range of services over the coming year. We are
particularly looking to increase the support for carers and develop a pathway for those
with a brain tumour. We also hope to secure funding for a Creative Therapy post to
explore the use of the creative arts with our patients and those who care for them.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
Priority 3
Volunteer Home visiting
We planned to increase the amount of time the Hospice at Home team were able to
spend with patients in their own homes, giving them support and company.
Whilst the Hospice at Home team already provide a respite sitting service, we identified
through interviews with patients and carers, that the amount of time the Hospice at
Home team were able to spend doing respite sits, was, at times, felt to be too short.
Consequently, we planned to recruit a team of trained volunteers to visit patients at
home to provide respite care, offering friendship to the patient, their family and carers
and attempt to alleviate the social isolation so often experienced by many caring for a
relative or loved one at home. This will also free up time to allow the Hospice at Home
team to support more patients.
Progress against this objective
Over the year we have recruited and trained a team of 4 volunteers who visit people
in their own homes. The nursing team identify carers who would benefit from having
a couple of hours break from caring/being with their loved one and the volunteers
provide respite care to these patients and their families/carers. We currently have
approximately 3 - 4 visits per week provided by the volunteers and this subsequently
releases 6 - 8 hours of clinical time. This extra time increases the overall capacity of
the nursing team to enable it to support more people to remain at home if this is their
choice.
Part 2
Statement of assurance
The following are statements that all providers must include in their Quality Account.
Many of these statements are not directly applicable to palliative care providers and
therefore explanations of what these statements mean are also given.
2.1 Review of Services
During 2012/2013 the Peace Hospice provided the following services through its main
clinical areas listed below:
Inpatient Unit
Hospice at Home
Day Care
Supportive Care Services
Outpatient Services Clinic
The Peace Hospice has reviewed all the data available to them on the quality of care in
all of these services.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
2.2 Income generated
The income generated by the NHS represents approximately 21% of the overall cost
of running these services. The balance is raised by the Hospice through voluntary
donations, its own shops and other fundraising.
2.3 Participation in Clinical Audit
During 2012/2013 no national clinical audits or confidential enquiries covered
NHS services provided by the Peace Hospice. The Peace Hospice only provides
palliative care.
During this period the Peace Hospice was not eligible to participate in any national
clinical audits and no confidential enquiries of the national clinical audits and national
confidential enquiries.
The national clinical audits and national confidential enquiries that the Peace Hospice
was eligible to participate in during 2012/2013 are as follows: None
The national clinical audits and national confidential enquiries that the Peace Hospice
participated in during 2012/2013 are as follows: None
The Peace Hospice was not eligible in 2012/2013 to participate in any national
clinical audits or national confidential enquiries and therefore there is no information
to submit.
As a provider of specialist palliative care the Peace Hospice is not eligible to participate
in any of the national clinical audits or national confidential enquiries. This is because
none of the 2012/2013 audits or enquiries related to specialist palliative care.
The Hospice will also not be eligible to take part in any national audit or confidential
enquiry in 2013/2014 for the same reason.
2.4 Local Clinical Audits
Clinical audits have taken place within the Peace Hospice; these form part of the
annual audit cycle programme within the Hospice’s overall Quality Implementation
Plan. The monitoring, reporting and actions following these audits ensure care delivery
that is safe and effective. The clinical audit cycle includes audits on documentation,
risk assessments, medicine management, and infection prevention and control.
Any changes or improvement to practice identified, are implemented at an individual,
team or service level. Further monitoring is part of the cycle.
2.5 Research
The number of patients receiving NHS services provided or subcontracted by
the Peace Hospice in 2012/2013 that were recruited during that period to participate
in research approved by a research ethics committee was: None.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
2.6 Use of the CQUIN payment framework
The Peace Hospice income in 2012/13 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation payment framework because it is a third sector organisation and as such
was not eligible to participate in this scheme during the reporting period.
However the hospice successfully achieved their CQUIN targets leading to a small
amount of additional funding
2.7 The Care Quality Commission
The Peace Hospice is required to register with the Care Quality Commission and its
current registration status is unconditional. The Peace Hospice has no conditions
on registration.
The Peace Hospice has not participated in any special reviews or investigations by
the Care Quality Commission during 2012/2013. However, the Hospice was successful
in meeting all required standards when inspected by the Care Quality Commission in
August 2012 and May 2013.
2.8 Data Quality
The Peace 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. The Peace Hospice is not eligible to participate in this scheme.
However the Peace Hospice does submit data to the Minimum Data Set (MDS) for
Specialist Palliative Care Services collected by National Council of Palliative Care on
a yearly basis, with the aim of providing an accurate picture of hospice and specialist
palliative care service activity.
2.9 Clinical coding error rate
The Peace Hospice was not subject to the payment by results clinical coding audit
during 2012/2013 by the Audit Commission.
Part 3
Quality overview
3.1 The National Council for Palliative Care:
Minimum Data Sets for Palliative Care 2011/2012 and 2010/2011
The Peace Hospice provides data to the National Council for Pallative care on an annual
basis and the table on the following page is a subset of that data.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
The Peace
Hospice
The Peace
Hospice
The Peace
Hospice
2010/2011
2011/2012
2012/2013
Inpatients
Total patients
Occupancy
% of new patients –
non cancer
Day Care
Total patients
% of new patients –
non cancer
Average no of
attendances per session
Hospice at Home
Total patients
% of new patients –
non cancer
Outpatients
Total patients
% of new patients –
non cancer
Bereavement Services
Total number of clients
Total contacts
246
240
299
70.6%
74%
74.6%
14%
14%
18%
86
83
89
23.3%
48%
42%
7.1
9
7.6
258
282
234
17.8%
21%
16.4%
92
78
49
18.5%
46%
29.7%
710
606
545
4243
4713
4116
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
3.2 Quality Markers we have chosen to measure
In addition to the limited number of suitable quality measures in the national data set
for palliative care, we have chosen to measure our performance against the following:
April
2011/12
April
2012/13
Total number of complaints
0
3
The number of complaints upheld in full
0
0
The number of complaints upheld in part
0
1
The number of serious patient incidents
(excluding falls)
0
0
The number of slips, trips and falls
42
60
Indicator
Complaints (clinical)
Patient Safety Incidents
(46 falls were in the 1st 6
months.
We recognized this number
was too high and – following
an in-depth analysis of falls
in the Hospice over the past
6 months, and subsequent
implementation of an action
plan, have considerably reduced
the number of falls –
14 falls were in the 2nd 6
months)
The number of patients who experienced a
fracture or other serious injury as a result of
a fall
0
0
The number of patients admitted to the
inpatient unit with pressure damage
10
4
The number of patients who developed
pressure damage whilst in the Inpatient Unit
0
0
The number of patients known to be infected
with MRSA on admission to the inpatient unit
3
1
The number of patients infected with MRSA
whilst in the Inpatient Unit
0
0
The number of patients admitted to the
inpatient unit with Clostridium difficile
0
0
The number of patients infected with
Clostridium difficile whilst in the
Inpatient Unit
0
0
Infection Prevention and Control
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
3.3 Clinical Audit
The audits set out in the hospice annual audit plan for 2012/13 were completed.
Examples of topics being: patient falls, management of breakthrough pain and use of
the distress thermometer. Many of them were small “spot checks” as a result of previous
audits to ensure the recommendations made, were implemented, for example the use of
bed rails, and the nutrition risk assessment.
Examples where improvements were made:
• Reduction in patient falls
• An increase in the use of the distress thermometer as a way of screening to
assess the emotional and well being of our patients and families.
Compliance to policies has also been audited, for example to the patient
valuables policy.
The choice of audit topics is informed by our clinical incidents reporting system which
has successfully encouraged open reporting in a no blame accountability culture.
This is also the case for our Quality Implementation Plan as a whole.
Plans for 2013/14: To carry out the audits on the annual audit plan and implement any
recommendations.
3.4 Other Quality Initiatives & Service Developments
We have reviewed our services to ensure they meet the needs of our users. For example
we have undertaken a review of our Supportive Care Services and have since employed
an additional social worker, and improved our governance systems in our bereavement
service.
We have reviewed the roles of our Schools and Colleges Co-ordinator, and Children and
Young People Support worker, and they now work more closely together to form our
children’s service. The team is actively seeking to work with schools and colleges in
areas where we have not previously been involved to provide a more equitable service.
In June 2012 we introduced a new post – that of Practice Development Nurse. Her role
is to work with clinical staff as a role model to ensure safe working and help with the
implementation of quality initiatives based on best practice.
We have set up a group of other local Hospices and we benchmark ourselves against key
quality data.
Plans for 2013/14 include:
• A review of the Hospice at Home service
• A review of how we record our clinical incidences to streamline the process
• To take part in the national Patient Led Assessments
• To review our education
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
3.5 Feedback from Service Users
The Peace Hospice places a high value on feedback from those who use our services.
Feedback is gained from a variety of sources including patients, carers and other
professionals.
In 2012/13 the hospice continued to give questionnaires to patients discharged
from all clinical services. Six monthly analyses of the questionnaires show that in
almost all instances, results are very positive. The results are monitored by the clinical
governance group and any areas identified where improvement can be made are noted
and acted upon.
• “It has changed my life for the better. I’m so grateful” (Bereavement Service)
• “truly grateful – a privilege to come” (Day Care)
• “without the support... I would have ended up needing hospital care myself
(hospice at home)
• “thank you for your kindness and care” (Inpatient Unit)
Plans for 2013/14:
• To review questionnaire content
• To survey health professionals who use our service
Complaints:
Complaints are taken extremely seriously and we try and learn from them. Complaints
are thoroughly investigated and reported at the Clinical Governance Group meeting
and to the Board of Trustees. Immediate action is taken to rectify any shortfalls or
concerns identified. For example the introduction of Care Rounding in our in-patient
unit. This is where we record our checks on our patients to see if they need a drink, to
use the toilet, to help get comfortable and so on. The Peace Hospice strives to meet the
individual needs of patients and families using our services and will continue to do so.
3.6 Board of Trustee visits
These visits take place twice a year, and where appropriate, Trustees talk to patients
and their families about their experiences of hospice services. Comments, in almost all
circumstances are very positive and action plans are adopted to take forward any
points arising.
The Hospice has successfully encouraged a culture of continuous improvement of
patient care. We do not rest on our laurels but examine our performance critically as a
central part of the way we work. The confidence with which this is said derives from the
firm foundation of knowing how we are performing against the standard we have set
for ourselves and taking methodical, carefully monitored action to make good any gaps
identified. We also continuously assess the adequacy of our “service repertoire” and
seek to improve it.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
3.7 Supporting Statements
Statement from Lead for End of Life and Palliative Care – Gordon Pownall
During 2012/13, The Peace Hospice in partnership with the NHS and other end of life
and palliative care services, has continued to provide a high quality and much valued
service to the population covered within Hertfordshire. The services they provide
are an invaluable resource and the Hospice continues to positively contribute to the
development of end of life and palliative care services during the past year.
Quality targets for the year 2013-2014 have been agreed with the Peace Hospice and
they include:
·
T o use the NHS safety thermometer to monitor falls, pressure ulcers and urinary
tract infections and to reduce incidences of these wherever possible
·
T o monitor patient experience by asking whether the patient would recommend
the service to friends and family
·
T o increase the percentage of patients with a non-cancer diagnosis who are referred
to the Hospice.
Further investment in end of life care through the Hospice was made in 2012/13,
piloting a 24 hour Doctor led admission service through a three way partnership
between NHS Hertfordshire and the emerging clinical commissioning Groups,
the Peace Hospice and the Hospice of St Francis. This pilot was very successful and the
clinical commissioning Group is now planning to extend the pilot until the end of 2013.
The Peace Hospice has remained enthusiastic participants of the wider review and
development of palliative and end of life care services in the County and plays a vital
part in contributing to the Countywide developing strategy for end of life care.
2013/14 presents new demands for all Hospices including the Peace Hospice,
including establishing its compliance with new NICE guidelines, responding to a
more comprehensive review of the service against agreed performance measures
and responding to the challenges of adapting to the new environment of clinical
commissioning. A true strength of the Hospice is that of its positive and enthusiastic
support for these initiatives and its willingness to remain an active partner for
improvement in services. By adopting this approach and taking responsibility not
only for its own development but that of end of life and palliative care services in the
wider community, the Hospice will continue to benefit those who need the general and
specialised care and support services at what is a crucial time for patients and families.
Respecting the value of every life
The Peace Hospice • Quality Account 2012 - 2013
Statement from Healthwatch Hertfordshire
Healthwatch Hertfordshire thanks the Peace Hospice for the opportunity to read
and comment on their draft Quality Account. However we do not feel that we are in a
position to make comments about the quality of service provided this year but note
the following:
·
Priorities are set out clearly with plans to show how they will be achieved.
·
I t is good to see the ambition of the Hospice’s palliative nurses to work with nurses
in care homes, the community and hospitals to teach them about end of life care.
·
T he appointment of a community liaison coordinator and offering additional roles
for volunteers to enable staff to spend more time with patients is welcome.
·
T he progress made against last year’s priorities demonstrates the commitment of
both staff and volunteers to quality improvement.
We look forward to seeing the results from your chosen priorities and would value
increased engagement with the Hospice through our Stakeholder Panel.
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