Willow Burn Hospice
Quality Accounts 2012-2013
www.willow-burn.co.uk
~ Treasuring Life ~
Chief Executive Statement
On behalf of myself and the Board of Trustees, I would like to thank all of our staff and
volunteers for their achievements over the past year. Despite the continued turbulent
economic climate, the hospice has been able to provide high quality services to an
increased number of patients and remains financially sound, thanks to generous
support from our local community of individual and corporate donors as well as grant
giving organisations.
Quality is high on the hospice agenda and
ever since Willow Burn Hospice’s inception
it has always had an excellent reputation
for delivering high quality services. As proof
CHKS accreditation was confirmed for the
first time in September 2011 and Willow Burn
Hospice is currently undertaking a review of
its services against new CHKS standards.
This quality assurance system ensures that
staff are patient centred and listening and
responding to the experiences and concerns
of patients, carers and family members
is at the heart of everything that we do.
Our activities are informed by the views and
experiences of patients, carers and their
families. The collection and use of their
feedback has become firmly embedded into
the day to day organisation of the care and
support delivered by the hospice.
The CHKS Accreditation process helps to bring
a much needed focus on quality within the
organisation and ensures that staff are aware
of how to raise concerns about quality and
safety and systems exist to ensure that they
are acted upon. Staff experience is monitored
and other indicators of staff engagement have
been developed. It is clear that the staff that
work for Willow Burn Hospice want to work
for an organisation that treat patients as they
would want family members of their own family
to be treated and that good relationships with
patients positively influences job satisfaction
which when surveyed staff indicated
satisfaction levels were at 88%.
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Regulators have assessed the treatment and
care provided by the hospice as being of
high quality. Following a CQC inspection in
November 2012 where direct interviews with
patients, carers and staff / volunteers were
held Inspectors identified no shortfalls in the
services provided by Willow Burn Hospice.
Comments received included:
•‘the hospice provides an excellent range
of services’
•‘the care here is superb’
•‘the staff are wonderful’
This is a tribute to the hard work of every
member of staff working for Willow Burn
Hospice. The hospice has a culture of
continuous quality monitoring, in which any
shortfalls are identified and acted upon quickly.
The safety, experiences and outcomes for
patients and their families are of paramount
importance to us all at Willow Burn Hospice.
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.
Helen Mills | Chief Executive
24th May 2013
Looking forward: Priorities for improvement 2013-2014
Priority 1 - Patient reported experience and outcome measures
Patient Reported Outcomes (PRO) is an
umbrella term that covers a whole range
of potential types of measurement but is
used specifically to refer to self-reports by
the patient. PRO data may be collected via
self-administered questionnaires completed
by the patient themselves or via interviews.
The latter will only qualify as a PRO where the
interviewer is gaining the patient’s views, not
where the interviewer uses patient responses to
make a professional assessment or judgement
of the impact of the patient’s condition. Thus,
PROs are a means of gathering patient rather
than clinical or other views on outcomes. This
patients’ perspective can play an important role
in service development.
The Francis Report (2013) advocated the
development of patient reported experience
measures being used routinely alongside
other data such as patient reported outcome
measures as they provide opportunities for
clinicians to understand the impact of their care
on patients. He went onto say that the results
be published in a manner allowing fair and
informed comparison between organisations.
Using patient feedback, results and analysis
of patient feedback, including qualitative
information, need to be made available to all
stakeholders in as near “real time” as possible,
even if later adjustments have to be made.
Willow Burn acknowledges that patients’ views
on their care are an essential component in
assessing its quality. We are keen to ensure that
the services we provide meet the needs of both
patients and carers. One of the methods used
to measure the standards of care provided is
to ask patients and carers if they could spare
the time to complete a short anonymous
questionnaire about their experience of our
services. We ask that they be open with their
responses, as this will give us vital information
to help us plan personalised care.
As Lord Darzi stated “you can only do
personalised care if you can measure the
experience of the patient.”
The motivational factor in choosing this as a
priority is the recognition that this is currently
the only routine method used to gather
information. Although feedback is good, given
the low number of responses and lack of
constructive comments it is difficult to identify
areas for development. For some groups the
filling in of traditional paper forms is a barrier
which they find impossible to overcome.
Therefore, we need to explore alternative
methods of engaging with patients and carers.
A working group is to be set up to look at the
current procedure and explore other means of
obtaining patient feedback.
One suggestion advocated by Francis (2013)
is to have a proactive system for following up
patients shortly after discharge. This would
not only be good “customer service”, it would
probably provide a wider range of responses
and feedback on their care.
As the clinical team do not work in isolation,
in addition to obtaining feedback from
patients and carers, it is proposed to also
obtain feedback from other stakeholders
in relation to other elements of the service
e.g fundraising activities.
Measures:
• Set up a working group and minute progress
• Audit current methods used
• Explore alternative tools/methods
• Implement a range of methods
• Produce written report and include in Quality Accounts
• Report to be available to all stakeholders in hard copy and on our website
www.willow-burn.co.uk
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Priority 2 - Clinical Audit - Organisational priorities for clinical audit are identified
and documented in an annual clinical audit plan
In line with the requirements of the CQC and as
demonstrated in our previous Quality Accounts
Willow Burn Hospice already has a clinical audit
programme in place. However, in response to
the Francis Report (2013) it is felt that this could
be further developed. The report sets out that
clinicians should be allocated specified time in
the working month in which they are required to
engage in audit related activities. Compliance
with the requirements to engage in audit should
be monitored by the Board of Trustees on a
regular basis and the extent of participation
reported to the public in the Quality Accounts.
The hospice demonstrates its commitment
to ensuring high quality patient care through
the undertaking of the CHKS accreditation
programme. Standard 5 of this programme
relates to Clinical Governance and includes
the use and review of evidence of clinical
effectiveness, clinical quality and audit.
In order to develop a more robust programme
Willow Burn intends to utilise the National
Institute for Health and Clinical Excellence’s
publication, Principles for Best Practice in
Clinical Audit (2008). The guidance defines
clinical audit as a quality improvement
process that seeks to improve patient care
and outcomes through systematic review
of care against explicit criteria and the
implementation of change. Aspects of the
structure, processes, and outcomes of care are
selected and systematically evaluated against
explicit criteria. Where indicated, changes are
implemented at an individual, team, or service
level and further monitoring is used to confirm
improvement in healthcare delivery.
In order to prepare staff the hospice is to
introduce an ongoing programme of audit
training to ensure auditors have the relevant
skills to undertake audit.
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www.willow-burn.co.uk
The clinical audit programme will be supported
and co-ordinated across the organisation with
responsibility for co-ordinating audits being
supervised by the Deputy CEO. This will be
undertaken by the multiprofessional team
and will involve all clinical staff employed by
the hospice.
The review of audit findings will be undertaken
at clinical staff meetings before being put
forward to the Leadership Team, Clinical
Governance Group and Board of Trustees.
Once the review has been carried out clear
objectives and targets for improvement in
relation to outcome indicators will be set so
that measurable progress can be assessed
over time.
Measures:
• Undertaking of the audits as set out in the programme
• Monitoring of compliance through Clinical
Governance and The Board of Trustees
• Records of training
• Changes implemented as a result of audit
• Participation reported to the public in the Quality Accounts
Priority 3 - To build a world class hospice facility - Phase 2
The current hospice building is a detached old
hospital ward which was part of an old (circa
1930’s) isolation hospital situated on land that
was purchased by Willow Burn Hospice in
March 2011. The facility is based on a 10 acre
site with various hospital and other buildings
occupying the land, all of which are derelict
and have remained empty for many years.
The current hospice resource is not a purpose
built facility and lacks some of the basics
that patients have come to know and expect
from services.
Day Hospice services would include the scope
for services to be accessible 7 days per week
and will provide a wide range of activities based
upon healthcare outcomes. Delivering clinical
effectiveness has been built into the design of
the new facility, so too has spatial efficiency.
Adding value to the innovative service redesign will be the development of a well-being
centre offering a range of complementary
therapies that will enhance the patient and
carer experience.
Recent investments ensure that the facility
meets Care Quality Commission accessibility
and food preparation standards however;
longer term it is recognised that the hospice will
need to relocate its services to a purpose built
resource on the basis that the existing facility
is not in good physical condition and no longer
meets operational requirements. Handling
increased demand for services is extremely
challenging with little flexibility in the way the
building can be used. Security has been an
issue in recent months, car parking is currently
provided on land owned by another stakeholder
on the site. Inpatient privacy and dignity
is compromised by the building in that the
inpatient rooms do not have en-suite facilities.
This means that female patients have to leave
their room to access the toilet that is located in
a nearby but busy public area of the hospice.
Willow Burn Hospice is passionate about
treasuring ‘life’ in all its guises, including the
planet and every attempt will be made to use
green technologies and building methods and
natural materials are proposed for the new
resource. The new resource will be four times
the size of the existing facility, but with just
25% increased utility costs as a consequence
of using green technologies, the methods
and usage of efficient building materials.
Timber Panel construction methods will be
used and by doing so will substantially lessen
the construction time needed to build the
facility. The style of the resource will help it
to blend in with the local countryside and all
building materials will come from sustainable
sources and be sourced locally wherever
feasible. Restorative gardens and allotment
spaces will be created to ensure that both the
indoor and outdoor spaces have a therapeutic
and energising value.
The hospice running costs have increased
substantially in recent years. This in part is
due to the requirement of a temporary boiler
solution being installed as a consequence of a
shared boiler having been decommissioned.
A new hospice facility would see the
continuation of inpatient care and respite
service but with an increased capacity of six
beds, all of which would be accessible twenty
four hours per day, seven days per week.
Service re-design is currently underway within
the existing hospice and will become fully
operational within the new build.
The building of Phase 1 is to commence by the
end of July 2013 and will take approximately
30 weeks for completion. Once built this will
enable the hospice to deliver Day Hospice
services from the purpose built facility.
Phase 1 will house two temporary inpatient
bedrooms to enable the continuation of
inpatient care, including respite care, symptom
control, pain management and end of life care
whilst the existing facility is demolished to
make way for the new inpatient unit.
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The existing building will continue to operate
until the funding is secured to build Phase 2.
At a cost of circa £2.2m, the hospice has a
range of campaigns that it intends to attract
donations large and small. One of these
campaigns includes the creation of a woodland
in Allensford where over 10,000 native trees
have been planted. Individual and Corporate
sponsorship of trees will help to attract over
£500,000 towards the new hospice build. It
is recognised that the full scheme will take a
number of years to be fully completed and it is
Willow Burn Hospice’s vision to have the new
hospice fully operational by 2016.
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www.willow-burn.co.uk
Measures:
• To build phase 2
Priority 3 2011-2012
Progress Update We have now secured funding to build
the first phase of the new hospice and
this should be completed by spring 2014.
Therefore, we now have a new priority,
which is to raise sufficient funding in order
to start Phase 2 of the 3-phase development.
Statements of assurance relating to the quality of
NHS services provided
The following are a series of statements that all
providers are required to include in their Quality
Accounts. However, some of these statements
are not directly applicable to specialist palliative
care providers.
Aim
Willow Burn Hospice aims to treasure life by
improving the quality of life for those who
have a life limiting illness and the families of
these patients. We also offer positive support
for every challenge that they may encounter
during the illness and to see death as part of
life’s journey.
Review of Services
During 2012-2013, Willow Burn Hospice
provided the following services through its main
clinical areas listed below:
1
2
3
4
5
Inpatient Unit
Day Hospice programme
Hospice at Home
Family Support Service
Specialist Lymphoedema Service
1 Inpatient Unit
This unit has 4 beds and provides end of life
care, pain and symptom management and
emotional and psychological support. There
is 1 bed designated for respite care, allowing
patients to be admitted for a week and allowing
carers to have a well-earned break from the
pressures of caring for someone with a life
limiting illness. The staff in the unit care for the
patient and embrace the whole family, giving
them emotional support and confidence that
their loved one is being well cared for.
As one relative commented: “The love at
Willow Burn Hospice meets you at the door”
In 2012-2013 the unit cared for 128 patients.
79% of these had a cancer diagnosis, while the
remainder had other life limiting conditions such
as Chronic Respiratory Disease, neurological
conditions and heart failure. Average
occupancy levels were 75%.
Patient Testimonial
“Thank you all for being so kind, giving
my husband such care and devotion and
giving to me piece of mind. Your loyal
dedication is second to none; there is no
one better to depend upon. It is good to
know we can turn to steadfast and caring
Willow Burn”
2 Day Hospice programme
The rehabilitation model developed 18 months
ago continues to provide flexibility and choice
for patients whilst maintaining a high quality
of physical, psychological and spiritual wellbeing for them. The aim of the model is to
enable patients with a life limiting condition to
maximise their full potential. In 2012-2013, 115
patients accessed the service, with 880 overall
attendances and an occupancy rate of 57%.
Unfortunately this figure does not accurately
reflect the actual occupancy with Day Hospice.
It indicates an average attendance length of
7.6 days (880 divided by 115), in fact the vast
majority of our patients attend for 12 sessions,
or slightly longer in some cases.
The discrepency in the figures may be due to a
change in the way our data is recorded within
this time period. Additionally we did not record
those patients who were allocated a place but
were unable to attend, due to illness, medical
appointments and bad weather.
This has now been addressed and will hopefully
result in a more accurate record of Day Hospice
activity next year.
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The Day Hospice, led by the Therapy Team,
is run on a sessional basis (morning and
afternoon), 3 days a week. Patients can choose
to attend from an hour up to a day, depending
upon how they feel that the programme can
most effectively meet their needs. The LeBed
Method (a therapeutic movement programme
for people with any type of chronic illness)
forms the first hour of every session, with the
aim of promoting wellbeing. Patients then have
access to a varied programme of activities
throughout the rest of the day.
A dedicated team of professionals, support
staff and volunteers provide a range of
interventions including Reiki, Tai Chi,
therapeutic horticulture, creative writing, art,
emotional support, aromatherapy massage,
social interaction and therapeutic games.
Patients also have access to other multidisciplinary professionals, such as staff nurse,
counsellors and a GP with Specialist Interest in
Palliative Care.
A 12 week period of attendance is usually
offered, although support and sign posting to
other services is undertaken in preparation for
discharge. Individual goal-setting is done with
every patient and the effectiveness of input
and attendance is measured using the Adapted
Mycaw Outcome Measure. Some excellent
outcomes have been achieved in terms of
increasing confidence, physical function and
wellbeing for many patients.
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In addition to this, the therapists run a 6 week
active steps programme, which is focused
on those living with cancer who are trying to
actively get on with their lives. In 2012-2013,
6 programmes were run, with 21 patients and
114 attendances. 1 advanced programme was
also delivered, over 6 sessions, with 6 patients
and 30 attendances.
The rehabilitation model of care used at Willow
Burn Hospice is unique within County Durham
and amongst other hospices within the North
East region. This has resulted in widespread
interest from other providers, who have visited
Willow Burn to observe and learn from what
has been achieved.
Patient testimonials
“The positive effects that I get from
the treatments and the company last
all week”
“I have enjoyed attending and feel more
confident that I can manage at home with
my illness”
“You certainly go out feeling better than
you do when you come in”
“I can now get straight into bed without
needing to sit on the side first to get my
breath back. The exercises have increased
my fitness”
3 Hospice at Home
Hospice at Home is an integral component of
palliative care, bringing the ethos and practical
care associated with ‘hospice’ into the home
environment. It also puts the patient, and those
who matter to them, at the centre of the care.
In 2012-2013, the Hospice at Home service
cared for 23 patients and 42% of these had
a non-cancer diagnosis. In total, the service
undertook 152 visits and provided a total of
1,082 hours of care.
Of the 15 deaths, 73.9% remained at home
in their perferred place of care. 8.7% died in
the hospice; 13% in hospital and 4.3% in a
care home.
Patient Testimonial
“We have found the carers very
dependable, reliable and helpful with a
friendly and caring manner for which we
feel very grateful”
4 Family Support Service
This service offers free, confidential, practical
and emotional support/counselling to those
who have been diagnosed, or affected by
a diagnosis or death of someone with a life
limiting illness. The service is based at the
hospice and available at both the hospice and
in the community.
In 2012-2013, the service supported 115
people. There were 331 ‘one to one’ sessions,
13 family and 9 other sessions, plus 67
telephone support contacts.
The service is based on the chosen Family
Support Model, an evidence-based model
offering a range of support that includes advice,
information, education, sign posting and
emotional support.
It is a psychosocial approach that can draw on
many different interventions and approaches in
order to provide holistic care for the client.
Willow Burn’s Family Support Service was set
up in March 2010 and is part of a consortium
established with 3 other hospices in the county,
delivering a family support model advocated
by the National Institute of Clinical Excellence.
The service is accessible at various locations
within Derwentside. For example, clients can
be seen at the hospice, GP surgery, or at
home. It is available to people of all ages and is
tailored to their individual needs. There is also a
bereavement service each month, to remember
those people known to Willow Burn Hospice
who have died.
Patient testimonial
“Everything that was done to help me and
my family was outstanding and will never be
forgotten. I couldn’t ask for anything better.
I will always be grateful for what you have
done for us.”
5 Specialist Lymphoedema Service
This service provides treatment, advice
and support to enable patients to manage
swelling of limbs, trunk, breast, neck, face or
genitalia. Simple and complex lymphoedema
can be treated using the four cornerstones
of treatment, as well as manual lymphatic
drainage and bandaging. In 2012-2013, the
service supported 56 patients through the
delivery of 202 appointments.
Willow Burn Hospice has reviewed all the data
available to it on the ‘quality of care’ in all of the
above services.
Patient testimonials
“My legs are markedly better and the
LeBed exercise is working wonders”
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Income generated
The income generated from the NHS represents
approximately 38% of the overall running costs
of the hospice.
Participation in Clinical Audits, National
Confidential Enquiries
During 2012-2013, there were no national
clinical audits or national confidential enquiries
covering NHS services relating to palliative
care. Willow Burn Hospice only provides
palliative care, therefore were ineligible
to participate.
Local Clinical Audit
Clinical audits have taken place within Willow
Burn Hospice; these form part of the annual
audit cycle programme. The monitoring,
reporting and actions following these audits
ensure the delivery of safe effective practice,
enhancing the patient experience. All audit
reports are discussed; action plans shared at
clinical staff meetings and clinical governance
meetings and are then shared with the
Leadership Team and Board of Trustees.
The programme includes the following
4 audits:
• Infection control
• Patient records
• Medicines Management
• Clinical Indicators
a) Infection Control Audit
The audit tool used focuses on the ‘Code of Practice’ for health and adult social care on the prevention and control of infections under The Health and Social Care Act 2008. This sets out the ten criteria against which a registered provider will be judged on how it complies with the registration requirement for cleanliness and infection control.
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This audit was carried out by County Durham & Darlington NHS Trust Infection Prevention Control Team. It is designed
to enable hospice staff to monitor
their compliance with infection control standards and policies, thereby reducing the risks of healthcare associated infections and ensuring patients are cared for in a safe, clean environment thus enhancing their care experience.
Overall the results were excellent, the unit and staff being fully compliant in all areas. Clarity was sort in relation to the following:
• Induction booklet given to staff - an infection control workbook has been developed and now forms part of the induction process.
• Are mattress audits carried out? -
Although there were no records of audit there is a signed sheet to say the mattress is cleaned after each patient.
• Mattresses are discarded if body fluids have penetrated into the mattress fabric - all beds are fitted with low air loss mattresses, should these become soiled they are sent for decontamination.
b) Patient Records Audit
A monthly audit of nursing records is carried out on five sets of notes of discharged patients utilising the CHKS Standard 22, Health Records - Hospice Services Audit Tool. This examines patient and carer details, clinical information and record entry with the aim of determining compliance with the NMC guidance for record keeping.
The positive results reflect the clinical team’s understanding that they are subject to increasing scrutiny regarding their record-keeping and fully appreciate that comprehensive records are an essential requirement of their role. The majority of the measures were fully compliant with the following exceptions:
• On one occasion there was no discharge leaflet in the patients record - on investigation a copy of the leaflet had been supplied to the patient and GP but a copy had not been retained for our records.
• Signed consent for audit - in the early part of the year this was not achieved on a number of occasions. However, now compliance is at 90%. It is acknowledged that when patients are admitted for end of life care or without relatives it is not possible to obtain signed consent.
c) Medicines Management Audit
To ensure patient safety and clinical effectiveness, Willow Burn Hospice utilises the medicines management audit tools developed by Help the Hospices which includes:
• Management of controlled drugs
• Management of general medicines
• Self administration of medicines
• Medical gases
Overall there was an increase in compliance since the last audit was undertaken. The following actions have been completed:
• A sign has been displayed which includes details of emergency action procedures in relation to oxygen therapy.
• The relatively new staff on duty at the time of the audit were not aware of the risk assessment relating to self medication. Training was cascaded.
• Stock Controlled Drugs were kept in sequence of strength but not segregated due to lack of space. Individual patient medicine cabinets have been fitted in the bedrooms allowing increased space to store stock CDs.
• HCAs have received medicines management training and are now authorised to witness and sign the destruction of excess CD into the pharmy-box.
d) Clinical Indicators Audit
As part of the hospice’s continual development, the Inpatient Unit carries out a clinical indicator audit on all patients, monitoring all infection and pressure damage both on admission and on discharge. This enables us to critically analyse the pressure relieving equipment and care delivery within the hospice.
The results indicated the effectiveness of the care delivered. Although disappointing, the following three exceptions were found to have a valid explanation.
1 incident of grade 1 pressure damage This occurred in a patient who was nutritionally compromised, immobile and with poor skin integrity. The patient was nursed on a low air loss mattress.
2 patients developed oral thrush In both cases the oral intake of the patient was poor or nonexistent.
1 patient developed a chest infection - They had a compromised immune system.
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Research
The number of patients receiving NHS services
provided or subcontracted by Willow Burn
Hospice in 2012-2013 that were recruited
during that period to participate in research
approved by a research ethics committee
was: None. The hospice does however
have a research policy in place should the
opportunity arise.
Use of the CQUIN payment framework
Willow Burn Hospice income for 20122013 was conditional on achieving quality
improvement and innovation goals through
the Commissioning for Quality and Innovation
payment framework as follows:
Indicator 1
This related to submission of the NHS Safety
Thermometer Data to enable measuring of
patient harm, with a view to analysing the
results and monitoring local improvement over
time. This measured harm in 3 key areas - falls,
pressure ulcers and urine infection in patients
with catheters.
Indicator 2
This related to patient experience and required
an increase in the number of patients who
achieved good care/death. This was measured
by the completion of carer questionnaires
identifying the percentage of principle carers
who agree that their relative/friend achieved
good care/death. The regular collection and
actioning of experience data is an established
means of identifying service areas where
potential improvement/further evaluation is
required and enabling an understanding of what
is important to carers to be achieved.
The hospice satisfied the Quality Incentive
Scheme Indicators set out above and has
successfully achieved the Quality Incentive
Payment from the Commissioners.
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Periodic Reviews by the
Care Quality Commission
Willow Burn Hospice is required to register with
the Care Quality Commission and its current
registration status is ‘unconditional’ which
means there are no conditions attached to
its registration. The Care Quality Commission
has not taken any enforcement action
against Willow Burn Hospice during the
2012-2013 period.
Willow Burn Hospice is subject to a periodic
review by the CQC and the last unannounced
inspection took place on 16th October 2012.
The following standards were inspected as part
of the routine inspection.
• Respecting and involving people who use services
• Care and welfare of people who use services
• Safeguarding people who use services from abuse
• Supporting workers
• Assessing and monitoring the quality of service provision
• Records
All standards were fully met.
The inspector looked at the personal care
and treatment records of people who use the
service, observed how people were being
cared for and checked how people were cared
for at each stage of their treatment and care.
They talked with people who use the service
and talked with staff.
The report states what people told them and
what they found:
“Care at the hospice is based around each
individual’s needs. The aim is to control
symptoms, relieve physical and emotional
distress, embrace and support both patient and
their carers, whilst maintaining their
independence. When we spoke to people using
the service they said the hospice provided an
excellent range of services.”
One patient said “The care here is superb.”
Another said “The staff are wonderful.”
“Suitable arrangements were in place for
people to take part in appropriate therapies and
activities in line with their needs and
preferences.”
Data Quality
Willow Burn 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. Willow Burn Hospice is not
eligible to participate in this scheme.
However, Willow Burn Hospice does submit
data to the Minimum Data Set (MDS) for
Specialist Palliative Care Services collated
by the 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.
Clinical Coding Error Rate
Willow Burn Hospice was not subject to the
Payment by Results clinical coding audit during
2012-2013 by the Audit Commission.
The relationships between staff and the people
who used the hospice were good and
personal support and treatment was provided
in a way that promoted and protected their
privacy and dignity.
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Priority 1 2011-2012 Progress Update - The introduction of a staff and
volunteer engagement programme
Significant time and resource has been invested
in the human resources and volunteer service
over the last 12 months. These services have
now been combined into a single department
called HR & Volunteer Service. The department
is headed by a lead who takes overall
ownership of strategy. A coordinator and an
assistant help with the day to day management.
This is the first of many steps that we are taking
towards an overall ‘people’ strategy.
A key priority last year was to embed the
treasuring life ethos into the induction
programme. This is, of course, an ongoing process and while amendments and
improvements have been made, it has been
agreed to completely revamp the programme
to include a group session that focuses on
services, aims and the foundations behind our
core value of treasuring life. This induction will
be rolled out to staff and volunteers once it has
been approved by the Leadership Team and
Board of Trustees.
We have also reviewed the annual appraisal
system and developed a Key Performance
Indicator monitoring system covering every
function within the organisation. These KPIs
will be updated by each department and
provide a focus at the monthly Leadership
Team meetings. Every 6 months, the overall
departmental KPIs will be reviewed by the
department lead and their line manager
and these reviews will then form part of the
appraisal process.
Every member of staff has been given in depth
appraisal training and has been offered the
opportunity to influence the appraisal system
moving forward, specifically on how we gather
and interpret feedback for the appraisals.
It was agreed that a Leadership Development
Programme would be progressed to focus on
business objectives and help to drive quality,
improve team dynamics and leadership skills.
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Much work has been done on this, including
the formation of core competencies, linked to
core values that will provide the framework for
the leadership programme in the future.
Two surveys were introduced in 2012-2013: a
staff survey and a volunteer survey. The staff
survey was completed by 83% of employees
and provided extremely positive results.
100% of respondents felt that they work very
much as part of a team; 91% agreed that
they had an effective working relationship
with their line manager and 100% felt that the
organisation works hard to deliver patient/carer
satisfaction. Overall, staff satisfaction is 88%,
a fantastic achievement.
The completion rate for the volunteer survey
was lower, with only 47 out of 170 volunteers
returning a survey. Therefore, focus groups
were also held to gather data. The volunteers
were particularly complementary about the
improvement in communications, noting the
regular newsletter that they receive, along with
more informal ‘huddle’ style meetings.
A key activity that took place in 2012-2013
was an evaluation of our volunteer service.
This was conducted following the completion of
the Willow Burn Active Volunteer Engagement
Service (WAVES), supported from a successful
bid to the Big Lottery Fund. The WAVES project
had been set up to provide effective support for
Willow Burn volunteers. Although the project
had achieved all its mandated outcomes and
milestones, we were interested in exploring its
outcomes and impacts even further. In order
to do this, we secured £10,000 of additional
funding from the Supporting Change and
Impact Programme, also run by the Big
Lottery Fund, to undertake a comprehensive
evaluation programme.
The main findings from the evaluation were
that, whilst WAVES had achieved its outcomes,
it had also raised some interesting issues
around how the volunteer service operates
and how it should function in the future.
This included:
• It was acknowledged that it was a positive move for the organisation to have a full-time, dedicated Voluntary Service Manager. However, to do both the strategic management and coordination was a huge task, so the role should be divided into a management and a coordinator role.
• WAVES had enabled more structure to be introduced through process and support systems offered to volunteers and the evaluation revealed that a correct balance had been achieved between formal and informal approaches.
• Some work still needs to be done around communication with staff, as not all staff knew about the processes involved in volunteer recruitment. Work also needed to be done to speed up the application process for volunteers.
• In relation to training and personal development plans, training was important. Moving forward, it is recommended that we develop new ways for volunteers to achieve personal/professional goals. Training will be continued for all volunteers, focusing on both specific and flexible opportunities.
• During the WAVES project, 2 events a year had been introduced to celebrate and recognise the contribution of volunteers. These were extremely popular, offering a welcome opportunity for social interaction, aided communication and training elements.
• The evaluation clearly highlighted the variety, importance and surprising benefits that volunteering has, not just to the volunteer, but to the staff, the patients, the services and the organisation as a whole.
Some useful initiatives have been made as a
result of the evaluation. Volunteer profiles are
being developed, along with more specific
volunteer tasks within the Day Hospice. A
volunteer debriefing session is now done at
the end of every day at the hospice and a
support group has been set up for volunteer
complementary therapists. Volunteers have
been learning massage techniques and passing
these skills onto clinical staff. We are also
going to introduce training for volunteers so
that they can assist with the bereavement drop
in service.
Family Support Service Information Board at a
Valuing Volunteers Day.
www.willow-burn.co.uk
15
Priority 2 2011-2012 Progress Update - Data collection - a recording system
to be put into place for the management of patient care data
The driver for this priority was to ensure
that the hospice managed, stored and used
information in such a way that data was secure,
confidentiality was respected and information
technology was used to improve the efficiency
and effectiveness of hospice administration.
In recognising the significance of data
collection and the consequence of not having a
robust system in place the hospice appointed
a Data and Information Governance Lead.
His first step in this process was to undertake
an audit of the data collection methods in use
all of which were paper based. The review
highlighted how time consuming it was to
extract purposeful data and raised questions
relating to the accuracy of the data collected.
A gap analysis was carried out to identify what
additional information was needed to meet
the requirements of the National Minimum
Data Set (NMDS), the NHS commissioners
and data relating to CQUIN measures.
This resulted in the development of a bespoke
clinical data capture system specifically
relevant to the needs of the hospice and has
greatly improved the quality of all clinical data
captured electronically.
Members of the multi-professional clinical team
and administrative staff are responsible for
inputting the data. Therefore, in order to ensure
the effective use and accuracy of the system a
training programme was developed supported
by an operational manual. In the transition
period spread sheets were introduced to record
the data allowing this to be imported once the
system was fully operational.
Willow Burn has successfully completed its
first full year of quarterly dataset submissions
to our NHS Commissioners, as a required
part of our standard contract. In addition we
have also submitted our NMDS well within the
required timeframe to the National Council for
Palliative Care.
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All of this data capture is vital for ultimately
shaping the range and quality of commissioned
care services in our area as well as maintaining
a data warehouse which Willow Burn can
interrogate in order to support its key business
decisions and further improve the quality of
service delivery.
Regular monthly data audits are carried out
to ensure that all of Willow Burn’s electronic
data capture systems contain accurate and up
to date information in compliance with Data
Protection principles.
In line with our Information Governance
Strategy Willow Burn is currently working
towards meeting full compliance with the
NHS Information Governance Toolkit (IGT)
and have already met all required Information
Governance Standards as set out by CHKS.
The hospice is implementing a number of
measures including regular internal audits to
ensure that each requirement of the IGT is
adhered to and that Willow Burn complies with
the current statutory requirements.
We strive for continual improvement and one
example of this has been to address the way
in which Day Hospice occupancy is recorded.
In 2012-2013, we recorded a Day Hospice
occupancy rate of 57%. Unfortunately, this
figure does not accurately reflect the actual
occupancy. It indicates an average attendance
length of 7.6 days (880 divided by 115), when
in fact the majority of our patients attend for
12 sessions or slightly longer in some cases.
The discrepancy in the figures may be due to a
change in the way our data was recorded and
additionally, we did not record those patients
who were allocated a place but were unable
to attend due to illness, medical appointments
and bad weather. We acknowledge this
and will hopefully provide a more accurate
measurement of Day Hospice activity next year.
Who has been involved?
Chief Executive Officer
Deputy Chief Executive Officer
Leadership Team
Income Generation Compaign Lead
HR and Volunteering Lead
Board of Trustees
Statement provided from commissioning PCT
North Durham Clinical Commissioning Group
(CCG) is pleased to have had the opportunity to
review and comment on the Quality Account of
Willow Burn Hospice for 2012/2013.
The CCG would like to commend the Hospice
on its structure and measured approach to
quality improvements and the positive impacts
made for patients, families and staff.
Overall the CCG felt that the report was concise
and written in a meaningful way for both
stakeholders and users. We would also like to
offer the following commentary:
Willow Burn has had a high degree of
engagement with commissioners over the last
12 months, demonstrating a willingness to
strengthen the commissioning and contractual
relationship between parties. In this year,
the CCG has had the opportunity to visit the
hospice, meet the staff and directly observe
the service and care to patients. Therefore,
the CCG can confirm that this document is
an accurate representation of the services
provided and improvements made during
2012/13 within Willow Burn.
We recognise that improvements are being
made to patient experience, using the learning
from the Mid Staffordshire Inquiry to strengthen
how they measure and improve patient
care and experience. The structured approach
to clinical audit is reflective of their desire to
further improve the quality of care and service
innovation, not only through their internal
quality systems but also through making best
use of the commissioning for quality and
innovation (CQUIN) scheme agreed ourselves.
Obviously, the development of the facilities
planned for 2013/14 will make a significant
difference for Hospice and the services and
care they deliver to patients.
It is recognised, that although developed
directly for hospices, Willow Burn has
embraced use of the Safety Thermometer and
has been able to identify areas of potential
harm to patients, which are integrated as
improvement priorities for next year and we
look forward to seeing the improvements being
taken forward.
The CCG agrees with the priorities outlined in
this quality account for the coming year and
will continue to work in partnership to achieve
the common goals of improving patient,
family and staff experience and safety for
all patients.
www.willow-burn.co.uk
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Volunteering
Willow Burn Hospice recruited 38 new
volunteers in 2012-2013. Each new volunteer
brings knowledge and experience and makes
a unique contribution to the organisation.
During the last twelve months, there has been
an influx of volunteers to organise collection
boxes, contribute to the administration of the
Day Hospice and provide some resource for the
retail operation. Their contribution is critical to
the success of Willow Burn Hospice.
Retaining existing volunteers is just as
important as attracting new people to the
organisation. There are currently 162 volunteers
on the Willow Burn Hospice roster. These are
treasured individuals who selflessly donate
their time and energy to the charity, whatever
the weather. We are proactively recruiting and
started a significant recruitment drive at the end
of 2012. Our aim is to add 50 more volunteers
each year for the next 3 years.
Staff and volunteers gather for the start of a sponsored walk.
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Using the volunteer timesheets introduced in
January 2012, we can quantify the impact of
the support that they provide. In 2012-2013,
we calculate that volunteers donated 9,332
hours to the hospice. When this is compared
to the industry-standard hourly rates for
their individual skills, it equates to
approximately £80,000.
We promote National Volunteer Week every
year and use it as one way to say thank you
to our existing volunteer team and to generate
interest from new volunteers. We have a
programme of events during Volunteer Week
and distribute marketing materials including
posters and flyers. Some of our volunteers
have been with the hospice for many years
and we hope that this reflects the very positive
volunteering experience that we strive to offer.
We also capture their feedback in volunteer
surveys, which help us to understand what they
enjoy about the role and suggest how we can
make continual improvements to it.
Income Generation /Fundraising: 2012-2013
A restructure in 2012 brought about the
emergence of a new Income Generation
Department. A new lead was appointed with
responsibility to co-ordinate fundraising activity
and to aid in developing the various income
streams. Alongside these changes, a new
Income Generation Strategy is being developed
to help provide guidance and a focus on those
areas that are thought to be underdeveloped or
that have stagnated due to lack of resources.
The Board and Leadership Team are also
reviewing those strands that require much effort
but see little return to ensure that resources are
focused effectively.
Fundraisers accept the massive challenge they
face in trying to ‘grow’ new donors to develop
relationships that benefit both sides, whilst
also striving to maintain the loyalty and trust
of existing supporters. However, the rewards
gleaned through being involved with people
who want to give to such a deserving local
cause, create a motivated and hardworking
team wanting only the best for the hospice.
Built on heavy industry, the demise of which
was seen in the 70’s and 80’s, the northwest Durham area is not a rich community.
There are few affluent areas within its
boundaries and a much larger proportion
of deprivation, evidenced by low home/car
ownership, higher than average unemployment
figures, large numbers of individuals suffering
from acute conditions, and an older populous.
It is from this community that Willow Burn
takes many of its patients and from this
same community that it receives fantastic
financial support.
“The friendship of others and the
feeling that I am doing something
worthwhile. I enjoy the fun
and laughter”
Fundraising testimonials
“The idea that you’re helping others,
meeting new people, helping old
friends and making new ones”
“I feel useful. I know more about
the local community. I understand
Willow Burn better. I enjoy working
with the people with whom I come
into contact”
Fundraising amongst local organisations,
including schools, churches and other formally
structured establishments, in conjunction with
more socially oriented individuals and groups,
pull together across the year, to ensure the
financial stability of the hospice, allowing it to
continue to offer its vital services. As an NHS
contribution of only 38% was forthcoming
during the 2012/13 year, a slight decrease on
2011/12, the importance of this support has
again been acknowledged by trustees and staff
to be imperative in keeping the ‘doors open’.
www.willow-burn.co.uk
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Community Events
2012/13 saw the conquering of more than a
few formidable challenges for some of our
community fundraisers. Lesser, but equally
respected sums of money from new and young
supporters are also acknowledged within
the text.
• Nine local men raised over £7.5k having undertaken the Three Peaks Challenge.
• Consett SAFC Supporters Association raised over £10k for the hospice, the proceeds of a number of fundraisers including cycling from Consett to Sunderland for their team’s last match of the season.
• Great North Run 2012: This popular event brought in over £15k in sponsorship.
• Willow Burn Trustee, and local fundraiser, Paul Jackson, raised over £5k by way of a Christmas Party Night and Restaurant Evening.
• As one of the chosen charities of the Durham Shopping Extravaganza, the hospice was the beneficiary of a split in the proceeds amounting to £6k. The hospice also received matched funding from the County Durham Foundation of £500.
• Shotley Bridge CC raised £5k and received matched funding from the Prison Service Charity Fund bringing the total to £6k.
• Aaron’s Aim was a project initiated by a local lad, who is ten years of age and who’s granddad had been diagnosed with cancer. This young man organised a cake stall at his school and with the help of some ‘grown-
ups’ promoted a Fun Day at the Grove Club in Consett. The sum total of his efforts was £1,320, all donated to Willow Burn.
One of our yougest “Willow Burn warriors”, at the
ripe old age of 12, collecting on Red Nose Day.
Special guest Baroness Tanni Grey-Thompson
presenting a cheque for £6,000 on behalf of the
Durham Shopping Extravaganza.
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IMO’s/Tree of Remembrance/LUAL: The
hospice continues to be the recipient of funeral
collections, donations from bereaved relatives
and associated fundraisers. 2012/13 has seen
this income increase by 25%, although there
has a been a decrease in General Donations, a
situation which is thought to have arisen as a
consequence of changes to financial coding.
Included within the upturn is the Tree of
Remembrance income, which sits under the
IMO umbrella. This saw a dramatic increase
in its second year - the tree raised over
£4k as opposed to just over £2k in 2011.
Although plans for 2012 had included looking
for a new site, which will now happen in 2013,
the Co-operative Funeral Service added to the
funds raised by their own tree and boosted
the sum by £700. Talks to site a second tree
at the Stanley side of the district are currently
taking place.
Income in respect of the hospice’s LUAL
service reached almost £11k. The event was
enhanced by seasonal decorations made
by inmates from Frankland Prison and the
introduction of a merchandise table which
made over £300 on the afternoon, highlighted
a demand for relevant saleables. Both of
these new developments will be embedded
into plans for the 2013 service. Talks are
already underway in consideration of using the
Empire Theatre in Consett as a future venue, if the event continues to grow.
Legacies: Legacy income was minimal
throughout 2012 and as the budget cycle was
ongoing it was deemed to have been pretty
unproductive and in much need of marketing
and promotion. However, over the winter
period, the hospice learnt that it was to be the
recipient of four legacies amounting to £175k
and that there was a possibility of income
from an estate which is now being managed
by trustees. Unfortunately, none of these
monies were transferred into Willow Burn’s
accounts during the same financial year and
the cumulative sum has been carried over
into 2013/14.
Collection Boxes: There are currently over
250 collection boxes sited across the local
area. These brought in almost £15k during
2012/13, on a par with the previous year, but
not reaching the projected target aspired to for
the current period. It is hoped, however, that an
operational overhaul will engender increased
revenue for 2013/14. The geographical area
is now covered by nine volunteers, each
responsible for their own patch and for the
development of this ‘steady earner’.
Gift Aid: Much work has been done during
the year, on bringing Gift Aid claims up to date
culminating in income being up on target.
The hospice welcomed the HMRC news of
the additional Small Claims Scheme which will
enhance the 2013/14 total by £1250.
Grants: Willow Burn was successful in
obtaining funding to the value of £212,304
during 2012/13. This was down on a target
of over £250,000, but as the financial year
was drawing to a close, the hospice received
the exciting news that it had been successful
in being awarded over £350k from the
Department of Health. At the close of the year
the offer letter had still not been sent.
www.willow-burn.co.uk
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Capital Fundraising Campaign
During the budget cycle it was identified that
funds to the value of £200k were needed to
enable us to progress the Phase 1 build of the
new hospice. This was our intended marketing
message in 2013/14. However, the much
welcomed awarding of the Department of
Health’s grant, now gives us great pleasure in
aspiring to project reporting of the completion
of the build in next year’s Quality Accounts.
Any residual monies will be transferred into the
Phase 2 pot.
During the early part of the calendar year, a
request was received from the Will Charitable
Trust, enquiring into further details about
the new build project. Although there is no
guarantee that we will receive anything, this
presents an unexpected opportunity to acquire
funds between £10k and £100k in 2013/14,
especially as the Trust has recently requested a
visit to the hospice.
Willow Burn Events
Recognising the contribution an additional
post might make to this income stream, the
board agreed investment into a new Events &
Community Fundraiser, who was recruited and
came into post in March. This new member of
staff is responsible for the planning and delivery
of all Willow Burn events and also in liaising
with the community and corporate partners in
organising successful fundraising activities.
Make A Will Month: This event is dependent
upon the co-operation of five local solicitors.
In 2013, a sixth solicitor from Chester Le
Street joined the team. Although, at the time
of compiling this report, the income for this
event has not been confirmed or received,
it is thought it will achieve a similar income to
previous years.
Lambton Challenge: This event was made
possible through the Sir Tom Cowie Fund
and was run in June, in partnership with the
Foundation of Light and Lord Durham, using
the beautiful grounds of Lambton Castle in
Chester Le Street. Over 400 participants joined
in the day’s activities and income amounted
to £6k.
Volunteering: The income Generation Team
relies heavily on support from volunteers and
has used them throughout the year. Working
closely with Volunteer Services, it is a great
pleasure for the department to engage with
such a diverse and committed ‘workforce’ and
to know that both paid and unpaid ‘staff’ are
learning and growing as individuals through the
interaction with people from inside/outside the
organisation, all of whom have great respect for
its work.
Corporate Fundraising
A new Income Generation Campaigns Assistant
post was made available in March 2013, the
incumbent of which is responsible for setting
up a system that will enable the hospice to
keep track of corporate relationships and so
build increased confidence in the partnerships
we forge. Together with the IG and Marketing
Leads, she will also help devise new corporate
campaigns and deliver these to new and
existing supporters.
At the end of 2012, Elddis Transport announced
the ‘retirement’ of its Willow Burn Truck
(www.trucking4willowburn.co.uk) which has
brought in almost £80k to the hospice over the
last eight years. The company has pledged
its continued support of Willow Burn and
is looking forward to liaising over new and
exciting projects that will have mutual benefits.
Nicholson’s Sealing Technologies together
with matched funding from the company are
continuing to use Payroll Giving as a means
of ensuring regular donations to the hospice.
The company was also very generous in
donating the sum of £5k from 2011/12 profits.
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Capital Fundraising
The Capital Campaign is progressing well.
Willow Burn Wood: Although plans for the
planting of 10,000 trees – a mix of sessile oak
and other species, including cherry and rowan
– were delayed because of inclement weather
and a long drawn out winter, the woodland
was finally planted in March 2013. Publicity
material targeting both individual and corporate
sponsors had been disseminated from as early
as October 2012 and by the financial year end,
thirty-two individual trees had been sponsored.
A new website was developed and launched
in 2012 too, and by the time planting had
taken place, one each of the Gold (£10k) and
Silver (6k) corporate packages had already
been bought.
Plans to organise a launch day to aid in
promoting the new wood and to seek support
from an increased number of corporates were
also drawn up during the 2012/13 financial year.
The wood has the potential to generate £500K
overall with £90K targeted in 2013/14. It will
also offer the opportunity of engagement with a
large number of potential new donors.
A Corporate ‘Friends’ Scheme: The
framework for a new Friends scheme was
agreed in early 2013. This will be rolled out
during 2013/14.
The planting begins at Willow Burn Wood
In Summary
With the continued support of our local
community, corporate partners, staff and
volunteers, Willow Burn Hospice was able to
raise a significant amount during 2012/13.
Although we have seen a downturn in some
income areas, in the main, if slightly down,
monies generated are on a par with the
previous financial year.
In terms of a financial overview, and short
to mid-term development, the management
team accepts that little or no economic growth
nationally, together with the personal weight
carried on the shoulders of the public in trying
to find stability and to secure individual futures,
will continue to have a bearing on the level
of generosity donors can afford to give to
charities. Despite this, there have been some
shining examples of giving, outlined in the
previous information – all of which Willow Burn
Hospice is more than grateful for and thanks
are constantly being said.
www.willow-burn.co.uk
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Comparative Health Knowledge Systems (CHKS)
In September 2011, Willow Burn Hospice
successfully gained CHKS Accreditation,
awarded by the Independent Accreditation
Awards Panel, thereby receiving national
recognition of its commitment to providing
a quality service to patients, staff and
external organisations.
The Healthcare Accreditation and Quality Unit
(HAQU) Accreditation Standards for Hospice
Services are designed to provide a framework
for quality assurance and quality improvement
for health care providers. The programme
provides a quality assurance tool for hospice
services by setting out the framework of
standards which need to be in place to ensure
the capacity to provide high quality service and
to ensure that this is consistently reproducible.
The hospice worked through several
assessment stages to measure compliance with
the standards, beginning with self assessment
within all hospice departments, followed by
a review of progress and an internal survey.
There was then an external peer review
carried out by HAQU trained senior healthcare
professionals from the hospice and palliative
care sector. A report of the survey findings
was produced to provide the hospice
with an ongoing agenda for service and
team development.
At the time of going to print, the hospice has
completed its latest self-assessment and is
scheduled for a three day review by CHKS
Assessors. This will be the first assessment
since the award was made in 2011.
Willow Burn Hospice, Derwentside Hospice Care Foundation,
Maiden Law Hospital, Lanchester, Co Durham, DH7 0QS
Switch Board: 01207 529224
Fax: 01207 529303
Registered Charity Number 519659
Website: www.willow-burn.co.uk
Companies House Number 2263960