Quality Account
2012/13
‘All people spoken with were complimentary about the staff. A visitor told us "The
staff always make me feel welcome as a visitor at any time of day or night."
One person commented "It feels like they have plenty of staff as they are always
there when you need them’’
CQC inspection December 2012
The Prince of Wales Hospice
Halfpenny Lane
Pontefract, WF8 4BG
01977 708868
www.pwh.org.uk
Registered Charity Number 514999
1
PART 1
Statement from the Chief Executive
I am pleased to present this Quality Account for The Prince of Wales Hospice, and in
so doing would like to thank all our staff and volunteers for their hard work and
commitment over the past year and for their continuing efforts. Moreover, I should
like to record that, despite the ongoing difficult economic climate in which we
operate, the Hospice has continued – and continues – to provide high quality
services to our patients, to their families and to their carers.
Indeed, the provision of high quality services is the central tenet of our operations:
the safety, experiences and outcomes for our patients and their families and carers
are of the utmost importance to us all. It is through our continuous efforts to improve
our standards of care that we are now a leader locally in the provision of specialist
palliative care. Furthermore, we have developed, and continue to develop, a robust
system of clinical governance at both Board and managerial levels that underpins
and guides our clinical services and their development.
Our regulators, the Care Quality Commission, conducted unannounced inspections
of the Hospice in 2011 and 2012 and, on both occasions, confirmed that we met their
exacting standards. However, our service provision is not just about meeting
standards, it is predicated on delivering the best holistic care that embraces people
as individuals, improves their wellbeing and ensures dignity and privacy.
I am ultimately responsible for the preparation of this report and its contents,
although I am indebted to Dr. Bill Hulme and Julie Ferry, Clinical Services Manager,
for their hard work in pulling it together. To the best of my knowledge, the
information reported in this Quality Account is accurate and gives a fair
representation of the quality of the healthcare services provided by The Prince of
Wales Hospice
David Stewart,
Chief Executive
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Statement of Purpose
The Prince of Wales Hospice provides specialist palliative care. Specialist palliative
care is the active total care offered to a patient with a progressive illness and to
those close to them, when it is recognised that the illness is no longer curable.
Specialist palliative care concentrates on quality of life and the alleviation of
distressing psychological, spiritual, physical and social symptoms within the
framework of a co-ordinated, inter-disciplinary service. In addition, specialist
palliative care offers support in bereavement.
Its objectives are:
•
to provide personalised specialist palliative care in a multidisciplinary and noninstitutional environment that meets patient needs;
•
to provide specialist palliative care to patients irrespective of diagnosis, age, sex,
sexual orientation, religion and/or ethnicity;
•
to provide an extensive and flexible range of holistic services that respond to the
needs of the patient and to those close to them;
•
to provide comprehensive information and support to enable patients and those
close to them to make informed decisions;
•
to provide specialist palliative care by staff who have undertaken specialist
training and who are supported in their work by a comprehensive educational and
training programme;
•
to disseminate palliative care expertise, through education and training initiatives
and to provide comprehensive advice and signposting to patients, families, carers
and other health care professionals; and
•
to work closely and effectively with the primary and acute health and the social
care sectors to ensure seamless and integrated care.
The following services are provided by The Prince of Wales Hospice to patients in
residential care (Incare) and day therapy units:
•
pain and symptom control;
•
rehabilitation, including occupational therapy;
3
•
therapies, including physiotherapy and complementary therapies;
•
spiritual support;
•
supported self-help*;
•
practical and financial advice;
•
pre-bereavement and bereavement support.
•
consultant led 24 hour telephone advice to families patients and professionals.
*Day therapy unit only.
The Prince of Wales Hospice also provides the following services to the families,
carers and loved ones of patients:
•
complementary therapy
•
spiritual support;
•
practical and financial advice; and
•
pre -bereavement and bereavement support.
The Prince of Wales Hospice will arrange for patients to be transported to and from
the Hospice in ways that best meet the needs of the patient, comfortably and safely.
As part of its range of services, The Prince of Wales Hospice runs clinics at the
Hospice, Wakefield Hospice and The Rosewood Centre Dewsbury to provide the
specialist management of patients with primary and secondary lymphoedema. The
nurses who run these clinics have undertaken specialist training and are supported
in their work by a comprehensive educational and training programme. They will
provide lymphoedema patients, including their family and carers, with
comprehensive information and support to enable them to make informed decisions
about their treatment.
The Prince of Wales Hospice is a limited company registered by guarantee under the
name The Five Towns Plus Hospice Fund Limited (company number 1797810) and
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is a registered charity (number 514999). It is situated at Halfpenny Lane, Pontefract
WF8 4BG. The registered manager of The Prince of Wales Hospice is Mrs Julie
Ferry, who can be contacted at The Prince of Wales Hospice, Halfpenny Lane,
Pontefract WF8 4BG. Her telephone number is (01977) 781468 and e-mail address
is jferry@pwh.org.
PART 2
Priorities for improvement
At The Prince of Wales Hospice, we constantly review our services and seek to
improve and develop them year on year. The Hospice has a business plan for
2013/14 which outlines our future vision and how we will achieve this.
The Hospice’s strategy is one of continuous improvement in the quality and scope of
the care for patients with life limiting illness, closer collaboration with partner
organisations, including the NHS in the provision of palliative care, and the education
of those professionals who require an understanding or knowledge of specialist
palliative care.
Priority 1: Patient Safety – Paper-light clinical services
The Prince of Wales hospice is using a computer based patient record (SystmOne)
and it is envisaged that over the course of the next 12 months, clinical work becomes
paper light to save time and resources and to aid better communication with other
clinical services. The Hospice has shared records in accordance with the Data
Protection Act and has data sharing agreements in place.
SystmOne is designed to make end of life care as smooth and hassle-free as
possible. Created to provide easy and efficient sharing between voluntary
organisations and the NHS, SystmOne palliative is the one tool hospices need
to take the stress out of necessary administrative tasks.
It is essential that patients and their families, with consent, share their clinical details
with other professionals in order for the care delivered to be consistent and safe.
As part of the National End of Life Care Programme the identification of a coordinated approach to care though the use of information technology (IT) is
recommended. By supporting and recording patients preferred care preferences,
improved communication across all setting will be improved.
To make more robust use of IT within the hospice
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To have greater and better communication and integration of systems
To have improved audit trails of clinical activity
Priority 2: Clinical Effectiveness – Research
This priority has been identified as part of the national Cancer Peer Review process.
A centrally co-ordinated research group has been formed so that small hospices
such as The Prince of Wales Hospice, can feed into larger research projects at
regional and national level.
With this in mind, the Hospice will be lead by Dr Bill Hulme to support work at a
regional level and participate in collaborative research within the region. This work
will then in turn be cascaded to the Hospice teams as a means of demonstrating and
achieving good practice.
Priority 3: Patient Experience- To improve Day therapy services
This priority responds to the ever changing needs of our patients. The Hospice has
seen an increase in patients being referred with a non-cancer diagnosis, an increase
in complex patient needs and the need to improve the continuity of patient care.
Our day therapy services have seen many changes to its model of care over the past
few years, and to be able to meet these ever changing needs there needs to be
clear leadership;
new models of care to be introduced;
a flexible and skilled workforce to meet the needs of the ever-changing
patient caseload; and
training and development of staff
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Picture: The new Day Therapy suite, opened in 2012.
The advanced nurse practitioner who leads and manages Day Therapy service has
developed a day therapy service framework which outlines the aims of the service
for the future
PART 3
Review of Services
During 2012/13, Prince of Wales Hospice provided the following services:
Inpatient Unit;
Day Therapy Services; and
Lymphoedema outpatient service
The Prince of Wales Hospice has reviewed all the available data on the ‘quality
of care’ for the above services.
The annual running cost of the Hospice was £2.2 million in 2011-2012, most of which
was raised through voluntary donations, legacies, fundraising initiatives and a chain
of charity shops. The NHS’s contribution to the running costs of the Hospice would
represent approximately 34% of the total.
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Participation in Clinical audits
National
During 2012/13 there were no clinical audits or national confidential enquiries
covering NHS services relating to palliative care. The Prince of Wales Hospice
provides specialist palliative care and therefore was ineligible to participate.
(Mandatory statement)
This means that the Hospice has not been eligible to participate in any national
audits because they are not about our particular service
Local
The Hospice is not participating in any regional audits but does have a robust
internal audit programme. This programme is led by the Clinical services manager
and the results are reported to the Clinical Governance Board on a quarterly basis.
Our focus is on the quality of life for patient and their families and our audit ensures
that we are caring for patients in a safe environment.
Participation in Research
The number of patients receiving NHS services recruited to participate in research
approved by a research committee was nil. (Mandatory statement)
This means that there have not been any national or local research projects in
palliative medicine in which our patients have been asked to participate.
5. Goals agreed with commissioners
The Prince of Wales Hospice income in 2012/13 was not conditional on achieving
quality improvement and innovation goals through the Commissioning for Quality
and Innovation payment framework (CQuINS). However, this will be something that
the Hospice clinical team will use for the forthcoming year as a means of achieving
and demonstrating a quality service and commissioning of services. Various tools
will be adopted including the NHS safety thermometer and CQuINS measures.
Statement from the Care Quality Commission (CQC)
The Prince of Wales hospice is required to register with the Care Quality
Commission (CQC). Its current registration is for:
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diagnostic and screening procedures;
treatment of disease, disorder or injury; and
transport services, triage and medical advice provided remotely
The Prince of Wales Hospice has the following conditions on its registration to:
only treat people over 18 years of age
only accommodate a maximum of 14 patients
The CQC did not take enforcement action against The Prince of Wales Hospice
during 2012/13
The Hospice is subject to periodic reviews by the CQC and the last review was in
December 2012 in the form of an on-site visit. The CQC’s assessment of the
Hospice following the visit was:
“The Hospice was assessed as being fully compliant in the areas assessed which
were:
Outcome 3- Consent to care and treatment
Outcome 4 - Care and welfare of people who use services
Outcome 9 - Management of medicines
Outcome 13 - Staffing
Outcome 14 – Complaints”
The inspectors spoke to patients, carers and staff members and reported
‘We spoke with four people who were using the service and two of their
visitors. They all spoke positively about how the staff involved them in
decisions about their treatment and care and how they acted in accordance
with their wishes.’
For example, one person said
"The staff here have kept me fully informed and involved and have supported
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me to make choices about my treatment and care."
Another person said "They talk to me about everything. It is really good."
7. Data Quality and Information Governance
The Hospice deployed SystmOne in March 2010. This system supports an electronic
patient record which can be shared with other healthcare organisations such as GPs
and district nurses.
The Hospice has internal mechanisms to monitor the quality of data.
The system uses NHS numbers as key identifiers for patient records.
The Hospice has recently begun additional training for all staff in the use of
SystmOne whereby over the forthcoming year, the Hospice aims to become a paperlight organisation.
In addition, the Hospice has recently appointed an IT manager who will be
responsible for the administrative support. This will ensure there is ongoing PC and
system maintenance to support the hospice infrastructure, and through the creation
of a single business unit for IT systems across the hospice further enable users to
focus on their core activity whilst feeling confident that a sound IT infrastructure is in
place to help support them in doing this.
PART 4
Quality Overview
Priorities for improvement form 1st April 2011 – 31st March 2012
Priority 1 – Infection control
This priority was identified because good infection control is paramount in all
healthcare settings, including end of life and specialist palliative care. The hospice
policy and procedures ensure that health related infections are kept to a minimum.
Measures achieved:
10
The Hospice has an infection control group which meets regularly and has a
rolling audit programme based on the Help the Hospices audit tool.
Recommendations from action plans are implemented;
The Hospice has adopted the Mid Yorkshire infection control policy as good
practice;
All staff have had mandatory training on infection control; and
Rates of health related infections have remained low, in fact there were 7
reported in 2011-12, of which 6 were identified through screening when
admitted to the Hospice.
Priority 2 – Bereavement services
This priority was identified in order to allow us to review the data inputting for the
National Council for Palliative Care minimum data set (MDS) and further develop the
service
Measures achieved:
better quality data is now being captured, but work is ongoing to implement
data collection from the volunteers in the service;
work is ongoing with other providers and closer collaboration with Mid
Yorkshire Trust is underway.
further improvements in the inputting of data through SystmOne are expected
for 2013/14.
Priority 3 – Out of hours admissions
This priority was identified as patient choice at the end of life is important. Since
March 2012, the Hospice has worked with Marie Curie, Wakefield Hospice and
Wakefield District NHS to develop a 24 hours a day, 7 day a week service. Out of
hours admissions have been recorded since October 2012 when the project formally
commenced with monthly data collection being analysed and a quarterly reports
being submitted to Wakefield District. Further funding for the project was allocated
and the project will now run for a further 6 months
Measures achieved a 24 hour/ 7 day a week responsive service is now in place at the Hospice;
patients have been transferred from A and E department where the preferred
place of care is the hospice to prevent an unnecessary hospital admission;
there is an increase in the number of recorded preferred place of care/death
discussions having taken place;
11
there is an increase in the use of the hospice telephone advice line for both
health professionals and patients/carers; and
collaborative working with other voluntary providers with monthly meetings to
ensure that the service is meeting Key Performance Indicators
For the period of October 2012 to March 2013 the Hospice has had 11 out of hours
admissions which and has had 110 advice line calls recorded. These numbers are
significantly higher than those recorded last year when the hospice did not offer 24/7
admissions. This progress will be monitored closely over the forthcoming year.
Review of quality performance
The hospice is committed to continuous quality improvement with leadership focused
on professional development for the clinical teams, service improvement for patients,
planning, prioritising and ensuring the best use of resources. Reporting systems are
in place to ensure robust clinical governance arrangements. All aspects of clinical
governance report to and are discussed at the Hospice’s Professional Operations
Group, and report to the Board of Trustees through its Clinical Governance
Committee.
8.1 Monitoring activity
Hospice data is submitted annually to the National Council for Palliative Care
‘Minimum Data Set’ to allow comparison with similarly sized specialist palliative care
units both regionally and nationally.
In Patient Data
2012/13
2011-2012
New patients
181
193
Total patients
224
243
admitted
No aged 19-24
0
0
No aged 25-64
16 female / 26 male
28 female / 24 male
No aged 65-74
25 female / 35 male
32 female / 28 male
No aged 75-84
31 female /27 male
25 female / 29 male
No aged over 85
9 female / 12 male
18 female / 9 male
Age not recorded
0
0
Total - cancer
161
158
diagnosis
Total - non-cancer
18
25
diagnosis
Patients diagnosis
2
10
not recorded
12
Average length of
stay
Average occupancy
10.3 days
11 days
51%
78%
These statistics highlight the progress made in recent years to improve the number
of patients accessing hospice in-patient care, and for a broader range of conditions.
The higher than average level of patients with a non-cancer diagnosis is due in part
to closer collaboration with other services (e.g. the Hospice’s COPD programme,
heart failure multi-disciplinary meetings and joint clinics with motor neurone disease
services). It is recognised that both locally and nationally there is a long way to go
before the palliative care needs of patients with non-cancer conditions are met, and
the hospice will try to continue to improve in this area.
The Hospice increased its beds from 10 to 12 in October 2012. The average
occupancy reflects this by way of figures for the year based upon 10 beds being
available, whereas the latter part of the year was based upon 12 beds, which has
lowered average occupancy.
DAY THERAPY DATA
New patient referrals
Total patients
aged 19 -24
aged 25-64
aged 65-74
Aged 75-84
Aged over 85
Total - cancer
diagnosis
Total - non-cancer
diagnosis
Patients diagnosis not
recorded
% occupancy
2012/13
68
90
0
12 female / 9 male
8 female / 14 male
13 female / 8 male
2 female / 2 male
50
2011-2012
97
125
0
15 female / 13 male
20 female / 18 male
15 female / 9 male
5 female / 2 male
77
13
15
5
5
74.4 days
73.6 days
Despite Day Therapy services delivering high quality care to its users, it is
recognised that it has lower than average levels of occupancy. The Hospice team is
currently evaluating the Day Therapy programme to see how this can be improved.
High levels of non-attendance in part reflect the ill health of some of its users, but it is
thought that more patients should be able to access the new facilities the service has
to offer. The service currently only runs two days per week, and it is envisaged that
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this will be increased over the forthcoming year. As can be seen as one of this
year’s priorities the aim is to increase attendance, offer services to more patients
with a non cancer diagnosis and also to support more carers.
Bereavement services
Total service users
New service users
Number of telephone calls
to users
Number of face-to-face
sessions
Average (mean) length of
period of support
2012-13
92
68
818
2011-2012
94
57
413
421
260
85.2 days
215 days
As stated in our priorities for 2011-12 the hospice wishes to capture data more
accurately on the work carried out by the hospice bereavement service. This will
enable comparison with other bereavement services and ensure our users receive
adequate support from the Hospice.
As the service relies heavily on volunteers to make telephone calls, and on
occasions undertake 1-1 sessions with the bereaved, we have devised a more
robust data collection sheet to allow all activity to be captured and entered onto
SystmOne.
There have been many changes to the service through the use of audit and updating
policies over the past year which is captured in the average length of support as we
now have a policy of being able to support the bereaved for up to a year, which
includes face to face contact and through telephone contact.
Lymphoedema Clinic
Total new referrals
Average waiting time from
referral to first
appointment
Total number of
appointments
2012-2013
119
3-4 weeks
2011-2012
127
3-4 weeks
1328
1199
The lymphoedema clinic provides treatment and advice for patients suffering with
limb and body swelling caused as a result of an underlying illness or treatment, and
those born with inherited conditions as a cause. The daily out-patient clinic sees
patients both in Prince of Wales Hospice and on two days a week in Wakefield
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Hospice. We now offer 2 days per month at the Rosewood Centre in Dewsbury for
patients from the North Kirklees area to enable them to be cared for closer to home.
Referrals have increased from North Kirklees and there are plans to increase the
service to 4 days per month to accommodate the new referrals and ensure that the
waiting time is reduced for first face-to-face assessment to take place.
8.2 Quality Markers
As part of the Hospice’s continuous drive to improve the quality of the care provided
to patients and relatives, it has devised a series of ‘quality markers’ that are
monitored quarterly. This then informs the Hospice senior management team and
Board on areas that require closer scrutiny or intervention to deliver a high quality
service. Below is the template of quality markers that will be used to measure the
Hospice’s performance in 2013/14
GROUP
Metric
Comments/ improvement strategies
Patient safety
Drug errors
Hospice
acquired
infections
Pressure
ulcers
Total number of
errors.
Number of controlled
drug errors.
MRSA and C difficile
rates (not acquired in
hospital)
Means of assessing overall workload
Difficult to benchmark with other
hospices due to reporting rates
Incidence on in-care
on arrival and
reported upon during
the patient stay
Total number of falls
on in-care
Reportable to CQC (Grade 3 or 4
ulcers only)
In addition to annual hand hygiene
audit
To benchmark against national figures
Slips/trips and
falls
Number of patients
having falls in day
therapy
Hospice environment
Records of cleaning
undertaken.
Cleanliness
Removal of contaminated waste
promptly and safely
15
Waste
management
Visual inspections of
all waste streams to
identify segregation
Means of assessing that correct
segregation procedures are being
adhered to and waste is dealt with
promptly to provide an uncluttered
working environment
INCARE
Number of In-care
referrals
To use SystmOne as measure
Patient care
Patient flow
activity
Referral waiting times
Number of
admissions
Average patient stay
(days)
Overall bed
occupancy.
DAY THERAPY
Total number of
referrals
Total number DT
attendances
Total number
assessed in DT
Discharges
Average Occupancy
Total number of
discharges.
Audit of discharges to be undertaken
% deaths on in-care
Integrated Care on ICP
Pathway for
(Annual ICP audit)
the Dying
(ICP)
Audit notes of deaths not on ICP for
reasons why
% notes with
Preferred place documented
of death/care discussions.
(PPOD/PPOC)
% achieved PPOD.
Number of written
compliments/thank
Compliments/ you cards
Annual audit of ICP re % achieved
PPOD.
Audit all deaths of patients known to
hospice re PPOD
Respond to specific comments and
emerging themes
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complaints
Number of recorded
complaints.
User satisfaction
survey results.
Day therapy feedback
8.3 Clinical Audit
The Hospice’s Professional Operations Group oversees the clinical audit programme
which includes the use of national audit tools (from Help the Hospices) and locally
designed tools. Several clinical audits are currently being piloted using a handheld
computer that provides immediate analysis, and comparison with other hospices in
the region. All clinical staff are encouraged to participate in the audit programme,
including the writing and dissemination of reports, formation of action plans and reauditing where necessary.
Below is a selection of the some of the audits completed in 2011/12
Audits
undertaken
Completed
Results
Actions
Falls
Annually
This audit
demonstrated
that the
hospice
statistics for
falls was
below
average
To maintain good practice , to
continue to monitor falls, through
regular falls assessment, use of
preventative measures and the
addition of a new policy
Infection
control – hand
hygiene
Annually
This
demonstrated
that good
hand hygiene
was
maintained.
Feedback was given to all staff
through presentation of results
More frequent audits are to take
place to ensure this practice is
maintained. The use of hand gels
17
and hand washing is indicated and is
reiterated in mandatory training.
Accountable
officer
Annually
Documentation Annually
This audit
indicated a
90%
achievement
The standard operating framework
was revisited and amendments
made to practice and continued
improvement in maintaining good
practice.
The hospice is to look into using
patients own controlled drugss next
year.
This audit
indicated that
here are still
improvements
to be made
The inpatient documentation has
been reviewed is now in use.
The use of a hand held audit tool is
to be used in the future to allow
benchmarking of local hospices.
8.4 The Patient and Family Experience of the Hospice
The Hospice has always placed a high value in feedback from its patients and
families who use the facilities, and this assists with the aim of continual improvement
in services available to the public.
Feedback for the in-patient unit is formally collected through a patient and carer
questionnaire, which is provided to every patient admitted to the in-care unit.
Between June 2011 and January 2012, 21 questionnaires were completed.
Feedback from letters and cards and a comments book are also used to evaluate the
care provided.
The patient and family satisfaction questionnaire generally showed a high level of
satisfaction with the hospice services, with nearly every respondent rating the
hospice environment and care provided as either ‘very good’ or ‘excellent’. Where
there are negative comments made, these are addressed in an action plan and
discussed with the head of the appropriate department.
All the results from the patient questionnaires are displayed in the hospice tea bar
with action plans attached.
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Comments included:
‘I have been highly impressed by the kindness and empathy of all the staff who
have taken time to help me in very difficult circumstances’.
‘It is brilliant that you can stay overnight and be there whenever you need to
be.’
‘You are not restricted to set times when people are terminally ill you need to
have flexible times’
‘I cannot put into words the thanks I feel for all the excellent help and care
from everyone’
Some areas of concern have been identified through the questionnaire, mainly
around lighting in the patient rooms and noise from the corridors.
One comment was:
“The lighting could be better on days with poor daylight the room was dull and
depressing”
A further suggestion to improve noise was:
“A carpet the corridor would lessen the noise from footwear”
These comments have been fed back to the hospice facilities manager and an
architect has been asked to review the room lighting. Staff are also reminded not to
wear noisy footwear and night staff being more considerate when opening and
closing doors
Day Therapy services feedback
There have been many changes to day therapy over the past year, and
questionnaires were completed by users, and the feedback has been used to adjust
the service there needed. Overall satisfaction with the service was high with all
respondents either rating the service as ‘good’ or ‘excellent’. The rolling education
programme for users to live well with their illness was also well evaluated, with all
respondents stating that they found the information both relevant and useful. In the
forthcoming year, the service will offer a social model of care following feedback from
some of the service users. This model will allow carers of the patients to attend too
which has been seen as an unmet need.
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8.5 The Staff Experience
The Hospice has conducted anonymous staff surveys over the past 2 years. These
were completed either electronically or on paper and can be used to compare
findings with hospices and other charities around the country.
The survey was completed by a combination of paid staff and volunteers. Highlights
included 76% of paid staff and 100% of volunteers stating that they were ‘proud to
work for the charity’ and 86% or paid staff and 100% of volunteers stating they ‘enjoy
work at the hospice’
Areas of concern have been discussed and addressed where possible. Of note only
29% agreed that “Communication between different teams/departments is effective”
and only 24% agreed that “Senior management are well informed about what other
staff think and do”.
There were also high levels of concern regarding job security and the resultant
impact on staff morale.
Following this feedback the hospice chief executive set up a staff consultative
committee which meet on a three monthly basis to discuss the running of the
organisation. The group consists of a representative from each department of the
organisation. Various areas of discussion which have taken place include new
policies, information about budgets and in-patient care.
Minutes of other staff meetings are also distributed electronically and on a notice
board.
Another method of improving communication is the Hospice internal newsletter
which is to be revisited for 2013.
PART 4
9. Statement from the Board of Trustees
As Chair of The Prince of Wales Hospice’s Board of Trustees’ clinical governance
committee, I am delighted to endorse the Hospice’s Quality Account for 2013/14.
Clinical governance is the cornerstone on which the provision of excellent medical
and clinical healthcare depends. The rigorous and systematic oversight of all
medical and clinical policies, procedures and practices by the Hospice’s clinical
governance committee ensures that the services provided by the Hospice are of the
20
highest quality, are audited regularly and are developed in line with recognised and
emerging best practice. The support my committee receives from the practitionerled professional operational group also helps ensure that our views are reflected in
day-to-day activities, as well as at a more strategic level.
The clinical governance committee reports regularly to the Board of Trustees which,
in turn, scrutinises its performance to ensure that its decisions are sound and are
consistent with the Hospice’s charitable objectives. The Board also receives and
considers detailed key clinical performance indicators so that it can monitor clinical
activities.
The Board of Trustees has a number of other committees (e.g. finance, fundraising
and human resources) that individually and collectively ensure that its corporate
governance responsibilities are managed in ways that are wholly for the betterment
of the Hospice’s services for patients, their families and their carers.
To the best of my knowledge the information contained in this Quality Account is
accurate.
Ian Dransfield
Trustee and Chair of the Clinical Governance Committee
11. Statement from OSC
The Prince of Wales Quality Account was presented to the Overview and Scrutiny
Committee at Wakefield County Hall on the 11th April 2013.
This was well received and had positive feedback.
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12. Statement from Healthwatch Wakefield
Quality Account 2012/2013
The Prince of Wales Hospice, Pontefract
Comments by Healthwatch Wakefield.
1) Healthwatch Wakefield thanks the Prince of Wales Hospice, Pontefract (the Hospice) for the
opportunity to comment on the Hospice’s Quality Accounts for the year 2012/2013.
The commentary is prepared with the help of the legacy and knowledge left by our predecessors
Wakefield Local Involvement Network (LINk). The LINk left the following legacy comment in relation
to the Hospice.
“Any progress in the availability of Psychological support “
2) To prepare the comments this year we created a Task and finish group.
Finally we had a meeting with the Hospice representatives consisting of :
1. The Chief Executive of the Hospice
2. The Medical Director
3. The Clinical Services Manager
We found that the Quality Accounts are easily readable and engaging.
It is clear beyond any doubt that the hospice provides a very comprehensive and personalised
specialist palliative care service in a multidisciplinary fashion, 24hours a day, 7 days a week. It has 14
beds to provide inpatient care but also provides care on an outpatient and day care basis. It has also
developed a service for specialist management of patients with primary and secondary
lymphoedema which is not available in many hospices around the country.
They also provide Consultant led 24 hour telephone advice to families, patients and professionals.
Psychological advice and support to patients, families and staff are provided by the counsellors in
the pre-bereavement and bereavement support teams. We hope that they are successful in getting
the specialist psychological help soon.
The staff are well trained to deal with patients with dementia and patients with acute confusion and
or delirium.
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We were disappointed that the hospice had not been informed of a patient diagnosis, on two
occasions, prior to admission, although there is a very significant improvement from the last year
(2011-2012) when there were 10 such patients.
We have noted the hospices priorities as determined by the hospice for the year 2013/2014 and we
wish them good luck in achieving their targets.
To the best of my knowledge the information provided in the Quality Account is accurate.
N K Mathur, LINk lead for Quality Accounts and on behalf of
Healthwatch Wakefield
Statement on the behalf of the Wakefield Clinical Commissioning Group (CCG)
The Prince of Wales hospice provides specialist palliative care for the
population of Pontefract and its surrounding area
It provides excellent inpatient care for people nearing the end of their life,
offering support both for the patient and their friends and families.
It also offers holistic support for people and their families in a day-care
setting in the form of the day therapy. In addition it provides extensive
learning opportunities for local health care providers who aren't specialists
in palliative care and offers clinical advice when needed through their advice
line.
I personally recently spent a week at the hospice as part of a course and was
struck by the supportive and caring environment provided.
Dr Lynda Wright
GP lead for palliative care, Wakefield CCG
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