QUALITY ACCOUNT 2012 – 2013
“Your care of mum was outstanding, nothing was too much trouble and
she mentioned this everyday while she was able to. We also felt cared for
too and this will never be forgotten by any of us”
“Thank you for every extra day and every extra moment that you gave to
us”
Quotes from Service Users March 2013
PART 1
Chief Executive’s Statement
Together with the Board of Trustees I have great pleasure in presenting Wakefield Hospice’s
first Quality Account for the year 2012 - 13.
Quality Accounts are prepared to report on the quality of the services and care provided by
Wakefield Hospice in compliance with the Health Act 2009.
Wakefield Hospice is an independent charity (registered number 518392) and is run by a
voluntary Board of Trustees. The charity makes no charge to the people who access its care
services. We fundraise to generate 70% of our required income from our local community,
making the people of Wakefield our major stakeholders and as such, to whom our major
responsibility to deliver evidence based, high quality end of life care is directed.
The Hospice is registered with the Care Quality Commission and was last inspected on 7
December 2012 when the Hospice was found to be fully compliant in meeting all of the
essential standards of quality and safety. The inspectors routinely talked to patients and
relatives during the inspection process and were told that people felt they were involved in
decisions about their care and treatment, and that:
“Staff always explained things to check out if it’s acceptable. I never feel coerced”
This is a testimony to the dedication and cohesiveness of the whole Hospice team as well as to
a work culture that is entrenched in the continuous monitoring of quality outcomes.
In striving to provide the best in End of Life Care across our district, the Hospice cannot
operate in isolation. We communicate and work in collaboration with local NHS and Social
Care Services at strategic and operational levels to ensure and support the need for best
palliative care practice to be available not just in the Hospice but in all care settings across the
locality. As such we are working collegiately across organisations to develop new high quality
services which we hope will provide patients and their families to achieve more autonomy and
independence at the end of their life.
Robust governance procedures are essential elements of the management of Wakefield
Hospice. Corporate governance has ensured that we have continued to provide a financially
sound and responsive service for our local community in the midst of a period of successive
economic recession and austerity measures.
Clinical governance essentially involves our staff, volunteers and importantly service users. It
enables us to monitor our services by examining the three priority areas that underpin all that
we do; these areas are quality, patient safety and patient experience of the service.
We consistently receive positive feedback from patients and carers who report on their whole
Hospice experience and I would like to thank our staff and volunteers for the part that they
have played in this achievement.
2
I am responsible for the production of this report and to the best of my knowledge the
information contained in this Quality Account for 2012 - 13 is an accurate and a fair
representation of the healthcare services provided by Wakefield Hospice.
Karen Crawshaw
Chief Executive Officer
17 April 2013
“Everything was excellent and I feel that at anytime I would be welcomed
and treated in a professional manner”
Service User September 2012
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PART 2
1. Priorities for Improvement 2013 – 2014
Wakefield Hospice is fully compliant with the National Minimum Standards (2002) and during
a scheduled regulatory inspection held in December 2012 provided evidence to the Care
Quality Commission that the regulatory standards had been met. The Hospice has been
categorised as a low risk organisation and as such, the Board do not have any areas of shortfall
to include in the priorities for improvement for 2013 - 2014.
Following consultation with staff, patients and the Wakefield District Palliative and End of
Life Care Locality Group, we have sought within the confines of the existing budget
constraints and a rapidly changing health and social care environment to establish how services
could be improved to better serve our patient and carer population.
Wakefield Hospice confirms that the top three quality improvement priorities for 2013 - 2014
to be:
Future Planning Priority 1
1.1 Clinical Effectiveness
24/7 Rapid Response Team and Out of Hours Hospice Admissions Project
To continue to develop 24/7 admissions to the in-patient unit, collating the information
required within the scope of the project outline;
to work collegiately to support the
development of the Marie Curie Out of Hours Rapid Response Nurse Team within the
district; to meet the outcomes of the project with the aim of securing on-going substantive
funding for the service.
In February 2012 Wakefield Hospice, Marie Curie Cancer Care and The Prince of Wales
Hospice were given the exciting opportunity by NHS Wakefield District PCT to work in
partnership to deliver a new 24/7 integrated service to support more people at the end of life, to
be cared for and die in the place of their choice, and to prevent inappropriate out of hours
emergency admissions to hospital.
This is a pilot project which has been funded for 18 months and became operational in October
2012. The project will function within existing integrated models of working in Wakefield and
will link with other developments to enhance end of life care across the locality.
In October 2012 Wakefield Hospice extended the scope of the in-patient admission policy to
enable 24/7 admissions into the unit. Since then, we have worked collegiately with The Prince
of Wales Hospice and Marie Curie Cancer Care to develop an Out of Hours Rapid Response
Team of palliative care nurses who aim to meet patients immediate short-term need for
intervention whilst at home during the end stage of their lives. This element of the service is
still developing and hopes to support multiple patients during a shift through visits in person
4
and via telephone support. This integrated service approach has been designed to respond to
the changing clinical condition of a patient through requests for urgent care at short notice.
How was this identified as a priority?
This development was identified as a priority by the joint work that had previously been
undertaken by Wakefield Hospice staff and all of the stakeholders within the Wakefield
District Palliative and End of Life Care Locality Group. The work stream identified gaps in
current service provision for which 24/7 access to a palliative care nurse for short term
intervention, or 24/7 access to a hospice bed would prevent inappropriate emergency
admissions to hospital for end of life care in acute crisis situations.
How will this priority be achieved?
This extension of existing service provision has been crucially dependant upon funding from
the Primary Care Trust. Non recurrent funding has been made available for an 18 month
period to allow the three third sector organisations to jointly pilot this new service initiative
against set key performance indicators and outcome measures.
Measures
The project will aim to provide a better experience for patients at the end of life and their
carers. It will seek to demonstrate:
• An increase in people being cared for and dying in the place of their choice
• Improved patient and carer satisfaction
• A reduction in palliative care patient bed days and deaths that occur in the acute sector
Demographic and clinical information will be collected in respect of patient characteristics.
Service activity and quality outcomes will be measured as well as to assess the comparative
costs of care between home, hospital and hospice.
The pilot project will aim to provide evidence of the benefits and cost effectiveness of this
service to secure mainstream long term funding. A dedicated project manager has been
engaged to ensure that that the project has the necessary governance structures, as well as to
maintain momentum and to ensure that key milestones are achieved. The project manager will
also ensure that a robust evaluation is undertaken (both quantitative and qualitative) to inform
the future of the services. In addition the Hospice clinical governance group and Board of
Trustees will receive reports and audit results from the project management team.
“I have heard a lot of comments during my stays!!! And never once a
negative one”
Service User March 2013
5
Future Planning Priority 2
1.2 Clinical Effectiveness
Education Post
To develop and recruit a dedicated Hospice Palliative Care Educator to provide end of life
care education and training programmes for hospice staff and volunteers and the wider
health and social care community;
to income generate from the programmes as is
appropriate.
There are increasing opportunities to tender to provide training in EOLC for statutory health
and social care staff, as Commissioning bodies seek to meet their mandatory obligations in
providing their staff with the skills required to deliver on the requirements of the national End
of Life Care Strategy.
How was this identified as a priority?
In the previous 12 months we have received grants with which to provide much needed and
appreciated communication skills training and a palliative care course for nurses, general
practitioners and health care assistants. These grants were the result of work undertaken by the
Hospice’s Consultant and the Director of Clinical Services. Managing the projects has been
time consuming for both members of staff and work pressures do not allow time to expand
upon this success and prospect for the potential income that might be generated by having a
core calendar of curricular activities. The Hospice also has a first class education facility
which is currently under utilised; appropriate marketing of the facility could additionally
generate revenue to support the Hospice.
How will this priority be achieved?
A robust business case to recruit a dedicated Hospice Educator in Palliative Care was presented
to the Board of Trustees, who has agreed to the recruitment of an Educator to develop this
initiative.
• A job description has been prepared
• A person spec has been developed
• The Hospice Board of Trustees have agreed to fund the post
• A suitable candidate will be recruited
• An education / training diary of events and courses will be developed
• A modest budget will be given for appropriate marketing of the courses and education
facility
Measures
The senior management team will work with the successful candidate to agree and develop a
new education strategy for the Hospice using MOST techniques (Mission, Objectives, Strategy
and Tactics). A time line for implementing and evaluating the strategy will be agreed and key
milestone dates will be set by which to performance manage the initiative. An education
programme will be developed and marketed. Annual audit will provide demographic and
qualitative data to support continuous improvement and service development to the Board of
Trustees.
6
Future Planning Priority 3
1.3 Patient Experience
Extend Mechanisms of Patient Feedback
The Hospice will develop a more robust Patient / Carer Service User Group and widen the
scope of available mechanisms of achieving patient feedback.
The Hospice has historically elicited patient satisfaction with services through the distribution
of questionnaires and via commendation in received Thank You letters. We intend to explore
and trial wider means of gathering feedback from users of our services. We understand that it
is important for the people receiving care at Wakefield Hospice to have their say, whether they
are a patient, carer or family member.
How was this identified as a priority?
The Hospice recognises that by listening to Service Users and representing their views the
Hospice can continue to deliver the highest standards of care possible, to make their users feel
comfortable, safe and valued.
The Hospice has recently formed a fledgling Patient and Carer Service User Group. We would
like to work with Service Users in a cohesive and mutually beneficial partnership to develop
new and existing initiatives.
How will this priority be achieved?
The Service User Group will be assisted to develop clear terms of reference and be supported
by the Hospice Social Worker to establish the functioning of the group. Administrative
support will also be provided.
Additional means of capturing patient and carer satisfaction will be explored using Information
Technology and nationally available audit tools. Where possible, this work will be
benchmarked alongside other Hospices.
Measures
There will be a wider choice of tools available for users of the Hospice service to give
feedback on their experience. The Service User Group will become fully functional and will
feed into the Hospice governance, reporting and strategic planning mechanisms.
“The care, the attention, the dignity shown to my husband (and myself)
was exceptional. Every single member of the team, everyone showed
their expertise in their role and their associated duties and that combined
with regard and compassion was so very evident and very much
appreciated by us both”
Service Users 2012
7
Future Planning Priority 4
1.4 Patient Safety
Infection Control
Good infection control is an essential requirement in terms of providing good palliative
care, maintaining registration with the Care Quality Commission and patient confidence.
The Hospice has an excellent record for infection control, with minimal hospital acquired
infection rates. The Hospice complies with the Mid Yorkshire Hospitals Trust Infection
Control Policy and under the guidance of the Hospital Infection Control Clinical Nurse
Specialist. The Hospice has three Infection Control Link Nurses who are members of the local
Hospital and regional Hospice Infection Control forums.
How was this priority identified?
Recent in-house infection control audits have demonstrated variable standards of practice
amongst both clinical and ancillary staff. A need was identified to achieve consistently high
standards of practice across all staff disciplines who work on the in-patient unit.
How will this priority be achieved?
The Infection Control Link Nurses will review in-house training on infection control and will
target staff groups to make training specific to their individual or collective needs.
Monthly spot audits will be undertaken using the Kairos Electronic Audit System which
contains pre loaded cleaning and infection control audits that are uploaded to a central source
that enables benchmarking against a number of other Yorkshire Hospices.
Measures
Audit action plans from the audits will be acted upon and the results fed into both Clinical
Governance and Service Governance meetings.
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Future Planning Priority 5
1.5 Clinical Effectiveness / Patient Experience
Refurbishment and small building extension for the Day Therapy Unit
Funding from a non recurrent capital grant has been made by the Department of Health to
enable the existing facility to be completely reconfigured by removing dividing walls and
building a small extension.
This will provide a new relaxation room and create
physiotherapy and complementary suites. The reconfiguration of the area will enable a
quiet communal space as well as a dedicated arts and craft area.
How was this priority identified?
The existing day unit was designed in1988 to cater for predominantly an elderly patient group.
Patients attended for respite care and therapy services were limited. Over time the client
profile has changed considerably and additionally carers now account for 45% of attendees.
The scope of therapies offered has increased to encourage and meet the needs of a younger,
more autonomous and focused client base. Our day therapy services now appeal to all age
groups and operate exclusively on a drop in basis. Day and evening services offer support,
therapies and rehabilitation in addition to structured programmes for the bereaved and those
surviving their illnesses. The day unit environment has not kept pace with the rate of service
change and was never conceived to provide the range of services currently on offer. Hence,
space is poorly arranged. Some services are delivered from a converted bathroom which
remains tiled and is ergonomically unsuitable. A second therapy room was created by erecting
a partition wall in the corner of the physiotherapy room; this room struggles to function due to
noise transference which reduces the benefit of the therapy offered. Quiet communal areas and
complementary therapies are sited adjacent to the busy and noisier arts and craft area. The unit
is wholly not conducive to the healing, restorative, creative care we aim to provide. We hope
to increase available space and maximise cohesive delivery of the wide range of therapy
services that support and improve quality of life for patients, carers and the bereaved.
How will this priority be achieved?
The project is wholly dependant upon the capital grant it has received from the Department of
Health to fund this project. The project will be executed as per the plan that was submitted
with the grant application. This will involve relocating the day therapy service to another part
of the Hospice for the duration of the work (16 weeks). Day services will continue to operate
but on a limited scale during this time. Additionally, one in-patient single bedroom will be
taken out of operation for the duration of the project in order to provide a base for
physiotherapy services to be maintained.
How will this be monitored?
The timetable for the project will be confirmed with the contractors once the contracts are let.
The time line from start to finish will be monitored at formal weekly site meetings held with
the Hospice project managers, the contractors and the day therapy unit manager. It is expected
that the architect will attend specific site meetings at pre determined milestone stages of the
project to ensure that design specifications and costs are as per the project design brief.
9
Minutes of all meetings will be recorded as true by the attendees. Informal discussions
between hospice project managers and contractors will take place on a daily basis in order that
any issues arising can be dealt with immediately.
Financially the project will be monitored by creating identified income and expenditure
nominal codes within the hospice accounts and budgets will be set within codes. These
budgets will be monitored on a regular basis, discussed with the Hospice Management Team
on a weekly basis (Chairman of Board of Trustees in regular attendance) and reported to the
Board of Trustees on a bi-monthly basis.
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2. Priorities for Improvement 2011 - 12
As 2012 - 13 is the first year that Wakefield Hospice has been required to produce a Quality
Account, we have chosen to review areas that had been identified for improvement in our
Business Plan for 2011 - 2012 as well as ongoing initiatives that enable the Hospice to be
flexible in the services that are offered to our local community. These plans had been
identified through needs assessments and / or joint working with colleagues in the Primary
Care Trust (PCT); when possible with direct patient involvement; at all times within the
limitations of financial constraints.
As the Hospice was fully compliant with the National Minimum Standards (2002), the Board
did not have any areas of shortfall to include for improvement in this period.
The Quality Improvement priorities for 2011- 2012 were as follows:
2.1 Chronic Obstructive Pulmonary Disease (COPD) Rehabilitation Programme Pilot
Project
Clinical Effectiveness
Following a robust and positive evaluation of 2010 – 2011’s first year pilot of the COPD
Rehabilitation Programme, the Hospice was successful in securing funding from the PCT to
extend the pilot project for a second year. The aim of the programme was to evidence a
reduction in the number of admissions into acute hospital services that people with end
stage COPD account for. We hoped to achieve this by providing a structured programme
that included education and anxiety management techniques as well as by supporting
patients to make Advance Care Plans that gave consideration where their preferred place
of death would be. The second year of the programme evaluated equally well and has
raised awareness amongst the community Matrons, General Practitioners and COPD
Clinical Nurse Specialist of the need and benefits of Advance Care Planning for this cohort
of patients. The Hospice declined to continue with the project for a third year as
recruitment of patients who met the appropriate criteria for the programme was difficult.
However, since the programme ceased we can demonstrate the benefit of the awareness
raising of palliative care amongst the referring clinicians within this speciality as this has
been evidenced by a significant increase of patients with end stage COPD who are
accessing Wakefield Hospice’s Day Therapy Unit and in-patient services.
“Excellent help and support programme. I would recommend the course,
it’s the most suitable programme I have ever done”
COPD Rehabilitation Programme Attendee 2012
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2.2 Education Clinical Effectiveness
To maximise the expertise of Hospice staff and education facilities and staff by providing a
palliative care course for hospital and community health care professionals.
Achieved:- The Hospice is successfully working in conjunction with Teesside University to
deliver a 9 month accredited Practical Palliative Care Course for General Practitioners.
The course was fully subscribed by doctors from practices in the Wakefield District and has
evaluated highly. As such it has attracted charitable funding to offer placements for a
second cohort of GP students in 2012 – 2013.
“I have found the whole course really useful, and the information and the
tasks have all been appropriate and really useful and applicable to
practice. The Hospice week was really useful, in particular seeing how
everything works, but also through spending time with the different team
members in addition to seeing what the community team also do”
General Practitioner Course attendee 2013
2.3 Extend the remit of the in-patient unit to accept Out of Hours Admissions
Clinical Effectiveness / Patient Experience
Achieving: - Funding was secured from the PCT in 2011 - 12 to enable 24/7 admissions to
the hospice in-patient unit for an 18 month pilot project period. Admission out of normal
working hours had previously been restricted due to the prohibitive additional staff costs
that would have been required to provide 24/7 admissions. The aim of the project is to
reduce the number of patients who inappropriately access acute hospital beds in the last 48
hours of life. This will reduce costs for the Hospital Trust, reduce the pressure on available
hospital beds and support the PCT commitment to deliver its responsibilities within the
National End of life Care Strategy. Work is in progress to capture the data that is required
to evidence the need for on-going substantive funding.
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2.4 Improvement to the Hospice grounds and gardens
Patient Experience
The Hospice physical environment was improved through a comprehensive programme of
refurbishment and groundwork projects which were made possible by our success in
securing successive grants. The creation of a labyrinth in the garden has provided a
tangible tool which the chaplains and the bereavement support team use to support patients
and families who are in spiritual distress to make some sense of their situation. The success
of the landscaping project has captured the hearts and imagination of all visitors to the
Hospice, so much so, that we have been given many donations in terms of money and gifts
in kind to extend and maintain the project. Additionally the fundraising team have secured
grants to support the environmental biodiversity within the grounds. The grounds are now
accessible and extensively used and appreciated by patients and families who are accessing
both in-care and day services. The kitchen garden area is becoming more established and
during the summer months we were able to harvest our own fruit and herbs to prepare
meals for patients and staff.
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3. Mandated Statements
Statements of Assurance from the Board
The following are a series of mandatory statements that all providers must include in their
Quality Account. Many of these mandatory statements are not directly applicable to Hospices.
Explanations (in italics) of what the mandatory statements mean are given as appropriate.
3.1 Review of Services
During 1st April 2012 to 31st March 2013, Wakefield Hospice provided the following service:
• In –Patient Service
• Day Therapy Service
• Bereavement Services
• Education and Training
• Therapies
• Occupational Therapy
• Physiotherapy
• Complementary Therapies
Wakefield Hospice continually monitors internal quality standards relating to the care
delivered to patients and families in all of the above services.
The income generated by the NHS services reviewed in 2011 – 2012 represents 30% of the
total income generated from the provision of NHS services by Wakefield Hospice for 2011 –
2012. (Mandatory Statement)
Wakefield Hospice has received an annual grant from NHS Wakefield District PCT; this is a
fixed sum regardless of the Hospice’s activity or the level of voluntary income. This means
that 100% of the financial support that we receive from the NHS is spent directly on patient
services. The remaining 70% of income required is generated through generous donations and
support from our local community, legacies, fundraising initiatives, and our chain of charity
shops.
3.2 Participation in Clinical Audits, National Confidential Enquiries
During 2012 - 13 there were no national clinical audits and national confidential enquiries
covered by the NHS services provided by Wakefield Hospice (Mandatory Statement). This
means that As a provider of specialist palliative care Wakefield Hospice was 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.
However, Wakefield Hospice carries out a rolling plan of internal clinical audits through out
the year as a means of measuring the quality of the services it provides.
3.3 Research
The number of patients receiving NHS services provided by or subcontracted by Wakefield
Hospice in 2012 – 2013 that were recruited during that period to participate in research
approved by a research and ethics committee was 0 (Mandatory Statement). This means that
In 2012 – 2013 there were not any local or national ethically approved research projects that
patients at Wakefield Hospice were eligible to participate in. However, the Hospice has
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registrars on placement from the Leeds Deanery who are undertaking local research as part of
their studies. During the year this included research into Corneal Donation and management
of Dry Mouths.
3.4 Goals Agreed with Commissioners
Wakefield Hospice’s statutory income in 2012 – 2013 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework. This is because Wakefield Hospice as a third sector provider of services
does not use any of the NHS National Standard Contracts and therefore is not eligible to
negotiate a CQUIN Scheme. (Mandatory Statement)
3.5 What Others Say About the Hospice
Statement from the Care Quality Commission:
“People told us they were involved in decisions about their care and
treatment. They said all the staff listened to them, took notice of what they
said and respected their privacy and dignity”
(CQC, December 2012)
Wakefield Hospice is required to register with the Care Quality Commission and is registered
as an Independent Hospital, Hospice for Adults. Wakefield Hospice’s current registration
service is for the following activities:
• Diagnostic and Screening Procedures
• Transport Services, triage and medical advice provided remotely
• Treatment of disease, disorder or injury
Wakefield Hospice may only provide services for persons aged 18 years or over and a
maximum of 16 patients may be accommodated overnight. Notification in writing must be
provided to the Care Quality Commission at least one month prior to providing treatment or
services not detailed in our Statement of Purpose.
Wakefield Hospice was subject to an unannounced inspection on 7 December 2012 and was
found to be fully compliant with the standards by which it was measured. The Care Quality
Commission has not taken any enforcement action against Wakefield Hospice as of 31 March
2013. (Mandatory Statement)
3.6 Data Quality
Wakefield Hospice did not submit records during 2012 - 2013 to the Secondary Uses service
for inclusion in the Hospital Episode Statistics which are included in the latest publication data.
This is because Wakefield Hospice is not eligible to participate in the scheme. However, in the
absence of this and with our patients consent, the Hospice utilises the electronic patient
information system SystmOne to share information on patient records with our colleagues in
primary and secondary care settings to support seamless patient care. The system uses the
NHS number as the key identifier for patient records. In accordance with the Department of
Health, additionally, Wakefield Hospice submits a National Minimum Data Set to the National
Council for Palliative Care. (Mandatory Statement)
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3.7 Information Governance
Wakefield Hospice Information Governance Assessment Report overall score for 2012 – 2013
was 0% and was not graded. This is because Wakefield Hospice has not been required to
complete the Information Governance Toolkit. However, as a point of good practice the
Hospice is actively working towards improving its organisational Information Governance to
an attainment of Level 2 Compliance with a view towards publishing its first independent
submission for the Information Governance Toolkit in March 2014. (Mandatory Statement)
3.8 Clinical Coding Error Rate
Wakefield Hospice was not subject to the Payment by Results clinical coding audit during
2012 - 2013 by the Audit Commission. (Mandatory Statement)
In-patient en suite single bedroom
In-patient four bedded bay
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PART 3
Quality Overview
Hospice Data is submitted to NHS Wakefield on a quarterly basis. The Hospice also submits
annual minimum data set information to the National Council for Palliative Care (NCPC),
which make it possible to make some comparison with collegiate Hospice services within
England, Northern Ireland and Wales. Wakefield Hospice data for 2012 – 2013 will be
submitted to NCPC in May 2013. A comparison of services for this reporting period is
therefore not available until the NCPC publish their final report in the summer. The last
available comparison for 2010 – 11 is shown:National Council for Palliative Care Minimum Data Set: In Patient Unit
In patient Unit
Wakefield
Hospice
2012 - 2013
Wakefield
Hospice
2011 - 2012
National
Median
2010 - 2011
Total no of admissions
294
262
245
New patients
243
213
198
% bed occupancy
73.7%
*79%
76.7%
Patient Discharges &( Deaths)
112 - (180)
92 - (170)
(134)
Cancer diagnosis
250 = 85%
250 = 95.5%
182
Non Cancer diagnosis
44 = 15%
12 = 4.5%
8.1%
Average length of stay
12.5 days
13.6 days
12.3 days cancer
13.6 days non
cancer
Patients age 16-24
0
0
0
Patients age 25-64
77 = 26%
72 = 27.4%
31.4%
Patients age 65-84
181 = 61.5%
124 = 47.3%
57%
Patients age 85 +
36 = 12.5%
17 = 6.4%
10.8%
* Reduced bed availability during refurbishment of single bedrooms in 2011 -12 increased
available bed occupancy level.
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Day Therapy Unit
1 April 2012 – 31 March 2013
a) New patients
128
b) Continuing patients
221
c) Total number of patients
349
d) Cancer / malignant diagnosis given in b) above
93
e) Other diagnosis given in b) above
12
f) Not recorded given in b) above
36
g) Number of Day Care sessions available in the year
195
h) Number of actual Day Care attendances in the year
2732
Bereavement Services
1 April 2012 – 31 March 2013
New service users
138
Continuing service users
82
Re-accessing service users
5
Total service users
235
Telephone contacts lasting more than 10 minutes
1375
Face to face – group work (facilitated)
23
Face to face – individual counselling by professional accredited person
257
Other forms of contact
351
Number of discharged service users
20
Number of continuing service users at the end of the year
215
Our Participation in Clinical Audits
To ensure that the Hospice is providing a consistently high quality of service, we undertake our
own clinical audits, using national tools developed specifically for Hospices, which have been
peer reviewed and quality assessed. This allows us to monitor the quality of care being
provided to people in a systematic way that creates a framework by which we can review the
information and make improvements where needed. The Hospice Clinical Governance report
provides a means to keep the Board of Trustees fully informed about audit results and any
identified shortfalls or risk management issues.
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The following audits were completed during 1 April 2012 and 31 March 2013
Audit
Completed Action
Plan
Yes
Yes
Actions undertaken or to be undertaken
to improve practice
Continue to audit 3 monthly.
Yes
Yes
Patient Satisfaction
Survey
December 2012
Accountable Officer Self
Assessment
January 2013
Syringe Drivers
March 2013
Wound and Pressure Area
Care
November 2012
Hand washing
March 2013
Bare below the Elbow
March 2013
Essential Steps Infection
Control Audit
March 2013
Yes
Yes
Remind staff to ensure chart number
recorded. Ensuring all documentation is
complete. Repeat audit in 3 months.
Copy of audit to be circulated to all
departments. Copy to be placed on display
in reception.
Continue to audit 6 monthly.
Controlled Drug audit
Feb 2013
Medicines Chart Audit
March 2013
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Ensure start time of initial prescription
recorded.
Ensure consent for equipment documented.
Ensure MRSA screening results
documented.
100% compliance. To repeat in one month.
Yes
Yes
100% compliance. To repeat in one month.
Yes
Yes
Specialist
Mattress Audit
November 2012
Yes
Yes
Blood Transfusion
April 2013
Yes
Yes
Nutrition
Jan 2013
Yes
Yes
Wristband Audit
March 2013
Yes
Yes
Re-write Infection Control Policy.
Continue liaising with MYTH Infection
Control Team. Continue attending
Yorkshire Hospices Infection Control
Forum group. Continue using Kairos PDA
audit tool and involvement in Inter-Hospice
Audit development. Infection Control for
mandatory training implemented. Flow
chart for room cleaning developed
2 Static mattresses destroyed and replaced.
1 Air mattress top cover destroyed and
replaced.
2 Dynamic mattress motors PAT tested.
Reminder to medical staff to complete
indication for transfusion. Nursing staff
reminded to ensure respiratory rate is
recorded within observations. Nursing
reminded to complete end time of each unit.
Education and information to be delivered
to staff to implement use of ‘measurement
underarm circumference’ within the MUST
assessment.
Reminder to staff to ensure wristbands are
checked during patient cares to ensure
remain legible after bathing.
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Audit
Patient Record
Documentation
Audit
March 2013
Completed Action
Plan
Yes
Yes
Environment Audit
March 2013
Yes
Yes
Physiotherapy
December 2012
Patient and Carer
satisfaction Day Therapy
Unit
March 2013
MDT attendance
February 2013
Preferred place of care
December 2012
Complementary Therapy
records
October 2012
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Actions undertaken or to be undertaken
to improve practice
Staff to be reminded to ensure NHS number
documented on all sheets. To ensure
consent to share information is obtained on
admission and documented. Education
session on psychosocial assessment to be
provided by hospice social worker.
House Keeper to shadow House Keeper in
nearby hospice. Caretaking staff to add
cleaning of light fittings to maintenance
schedule.
To ensure discharge date is documented on
patient’s notes.
To ensure patients and carers are aware of
how to make a complaint.
Core team members reminded of attendance
requirements.
To promote advance care planning across
all hospice services.
To review treatment plan structure.
Quality Markers that we have chosen to measure
INDICATOR
2012 - 2013
COMPLAINTS
Total number of complaints
0
Total number of complaints upheld in full
0
Total number of complaints upheld in part
0
PATIENT SAFETY INCIDENTS
Number of patient accidents excluding falls
12
Number of slips, trips and falls
33
Number of accidents reportable under RIDDOR
0
SAFEGUARDING
Number of patients, clients, and families referred to Social Worker because of
safeguarding issues
0
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The Board of Trustees Commitment to Quality
The Board of Trustees is fully committed and supportive of the Hospice Quality Agenda. The
Hospice has a well established governance structure, with members of the Board having active
roles in ensuring that the Hospice provides a high quality service in accordance with its
Statement of Purpose.
Members of the Board regularly undertake visits and inspections of the Hospice, when they
speak to patients, family members, staff and volunteers. This provides the Board with a first
hand knowledge of what the patients and staff think about the quality of the services that are
provided.
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APPENDIX
Supporting Statements
Healthwatch Wakefield thanks Wakefield Hospice (the hospice) for the opportunity to
comment on the Hospice’s Quality Accounts for the year 2012/2013.
The commentary is prepared with the knowledge gained by being a member of the Wakefield
Local Involvement Network (LINk) council.
To prepare the comments we created a Task and finish group and finally we had a meeting
with the hospice representatives consisting of Chief Executive of the Hospice and Director of
Clinical Services. We also had the opportunity to have a tour around the premises and the
gardens, which provide a very suitable surrounding for patients requiring palliative care.
The 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, 24 hours day 7 days a week. It
has 16 beds to provide inpatient care but also provides care on an outpatient and day care basis.
They have drop in facilities where patients or carers can come in for advice and any help
needed. It shares specialist management of patients with primary and secondary
lymphoedema, with The Prince of Wales Hospice, Pontefract.
Psychological advice and support to patients, families and staff are provided by the counsellors
in the pre-bereavement and bereavement support teams and other members of staff.
The staff are well trained to deal with patients with dementia, and patients with acute
confusion, and or delirium.
We have noted the hospice’s 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
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