Woodlands Hospice
2012 - 2013
Woodlands Hospice
Charitable Trust
UHA Campus,
Longmoor Lane,
Liverpool L9 7LA
Tel: 0151 529 2299
Charity No. 1048934
Quality Account
“The work you do is truly
amazing but not so amazing
as the inspirational individuals
that make Woodlands a rather
special place, a true oasis in
the desert.”
(Quote from relative 2013)
www.woodlandshospice.org
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Welcome to Woodlands Hospice
Quality Account 2012/13
Contents
Chief Executive’s
Statement
4-5
Section 1
Priorities for
Improvement
6 - 12
Section 2
Statutory Information and
Statement of Assurances
from the Board
13 - 16
Section 3
What others
say about us
17 - 29
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CHIEF EXECUTIVE’S STATEMENT
Woodlands Hospice Charitable Trust is an independent charity committed to delivering
the best possible practice and development of Specialist Palliative Care for people with
cancer and other life limiting illnesses. It honours people’s right to dignity and respect at
whatever stage of their illness, by its aim to improve the quality of life for patients and
their carers.
Woodlands is based in North Liverpool and covers a population of 330,000 in North
Liverpool, South Sefton and Kirkby in Knowsley.
For all of us who work at Woodlands, staff and volunteers, we pride ourselves on
providing a high quality service for all our patients and we strive to continually improve
any areas which we feel would further enhance our patients’ experience.
In 2011/12 we set three main priorities to further improve our quality standards and from
the summaries provided within this report it is clear that we have made excellent
progress in all three areas.
Our achievements in Infection Control reflect the continuous monitoring and training
within the team to ensure our patients remain free from harm. The external review from
the Infection Control Lead Nurse at University Hospital Aintree NHS Foundation Trust
confirmed our high standards in this area.
The redesign of our Day Therapy and Outpatient services has progressed well during the
year to ensure we are able to offer improved flexibility and accessibility in these services
and also to encourage attendance from the younger generation. We are looking forward
to delivering our day services in the newly designed centre next year and are confident
the flexibility will further improve our patients’ experience and open the services up to
those who currently do not use them.
Advanced Care Planning is a national priority to ensure we are all able to state our
preferred place and priorities of care as we approach the end of our lives and for our
patients this is what can bring a ‘good death’ and help families in bereavement. We have
made progress with Advance Care Planning within the Hospice but will be working hard
in 2013/14 with others locally to ensure patients journeys follow their wishes whatever
the setting.
I am always delighted to receive the many positive compliments, letters and cards of
thanks we receive on a daily basis for the care we have provided to patients and their
families and our patients surveys overwhelmingly reflect quality service. We do however,
from time to time, not always meet the expectations of patients or families and we are
always very disappointed to receive any letter of complaint or negative comments but we
ensure we always undertake a full investigation into all issues raised and follow these up
with robust action plans to address any identified issues and to ensure our high
standards of quality and safety are consistently applied to all patients in all services.
Our governance framework is very robust and ensures quality is monitored in a variety of
ways including sub committees of the Board addressing quality of service and standards
of performance. Trustees have continued this year with their ongoing programme of
unannounced visits to the Hospice to regularly review the Care Quality Commission
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essential standards of quality and safety and evidence from these visits shows a high
standard of care across all services.
Of particular note last year was the visit from the Care Quality Commission Inspectors in
November 2012 resulting in their report advising that of the five areas they reviewed
Woodlands had met all the required standards and their observations of the care given
was very positive. What was particularly pleasing was the achievement of the Medicines
Management standard which was acknowledged fully by the Care Quality Commission
following the introduction of the new pharmacy contract with Liverpool Heart and Chest
NHS Foundation Trust and the significant amount of work put into this area by the
Inpatient Services Manager and the staff on the ward. The improved framework is now in
place and monitored on a regular basis to ensure these very high standards are
maintained.
During 2011/12 we further developed the Hospice at Home service for South Sefton and
we are delighted with the independent evaluation that was undertaken of this new
service, 12 months into operation. The comments we received from the patients, families
and the health care professionals referring to our service and working with those using
our service was excellent and it is a service we are very proud of.
Our three main priorities for improvement this year include the work we are proactively
doing with tissue viability and the avoidance of pressure ulcers wherever possible and
setting up the staff group with a team lead will help with this process.
With the national changes to the Local Involvement Networks we were unable to
progress our desire to involve these external organisations on a proactive basis to review
our services but with the development of the Local Healthwatch teams we will ensure we
will work with them to establish a programme of review as appropriate during 2013/14.
However one of our main priorities is to set up and develop a patient and family forum as
we are very keen to gain external views of our service on an ongoing basis and wish for
patients to be able to influence our service moving forward. We look forward to reporting
feedback from this forum in next year’s Quality Account.
Our third main priority relates to the introduction of outcome measures which is really
important for us to find ways of knowing that the care we
provide is achieving the outcome our patients need and
wish for.
Woodlands is absolutely committed to a high quality and
safe service for all our patients and we have a strong
ethos to ensure dignity and privacy at all times. We will
always strive for continuous quality improvement whilst
maintaining the very high standards we are proud of.
I confirm that to the best of my knowledge, the
information contained within this Quality Account is a true
and accurate account of quality at Woodlands Hospice
Charitable Trust.
Mrs Rose H Milnes
Chief Executive
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Mrs Rose H Milnes
Chief Executive
Section 1: Priorities for Improvement
The priorities for quality improvements identified for 2013/2014 are set out below and
have been identified by the Senior Management Team following feedback from
patients, carers and staff.
1a. Priorities for Improvement 2013-2014
Patient Safety
Priority 1: Tissue Viability – The Hospice will maintain high standards of skin
care for patients and minimise the risk of pressure ulcer development
How was this identified as a priority?
The Hospice recognises that the effective management and prevention of pressure
ulcers can improve the quality of life for patients living with a life limiting condition. In
support of this the Senior Management team and Board of Trustees have identified
the incidence of pressure ulcer development as a key performance indicator and
therefore believe this to be a priority for patient safety.
How will this be achieved?
There are currently senior nurses within the Hospice who provide support and
expertise in relation to skin care and pressure ulcer prevention; in addition data is
collected to identify the incidence of pressure ulcer development. In order for this
priority to be achieved the senior nurses plan to:
• Establish a tissue viability working group to manage this priority
• Continually review and revise the current data collection and audit tools to identify
areas for improvement
• Arrange an independent assessment of tissue viability care within the Hospice
• Complete a comprehensive review of tissue viability policy and procedures to
ensure best practice
• Develop an annual training programme for staff in relation to tissue viability
• Review and revise patient information leaflets relating to tissue viability
How will progress be monitored and reported?
Progress will be monitored through evidence of audits and action plans developed by
the tissues viability link nurses. Reports of achievement against the above plan,
including audit results, staff training and policy revision will be submitted to the
Clinical Governance Committee and Board of Trustees bi monthly for approval and/or
ratification.
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Clinical Effectiveness
Priority 2: To introduce the use of Clinical Outcome Measures – the hospice
will incorporate the use of outcome measures into clinical practice to aid multidisciplinary team working, clinical decision making and help assess quality of care.
How was this identified as a priority?
It was acknowledged within the hospice, that other than patient satisfaction surveys,
we had a lack of evidence helping us assess whether we were meeting patients
needs. It was identified amongst the senior clinical team that we required a more
robust way of assessing quality of care. It was envisaged that through the
development and recording of outcome measures we could demonstrate the impact
of the hospice service on the patient’s symptoms and quality of life.
How will this be achieved?
From April to November 2012 we conducted a pilot to help identify potential outcome
measures that could be used within the hospice. Four different outcome measures
were assessed in a preliminary pilot and three of these were then further evaluated in
an extended pilot. The results of this pilot were presented to the Senior Management
Team and the Board of Trustees. As a result of this it was recommended that we
introduce Palliative care Outcome Scale version 2 (POS-2) and the Palliative
Performance Scale (PPS) to the in-patient unit and the hospice day therapy.
The use of these tools has commenced within the hospice day therapy setting and
due to be implemented in the in-patient unit in the near future.
It is also hoped that the outcome measures will be used in multi professional team
meetings to aid clinical decision making.
How will progress be monitored and reported?
The progress will be evaluated through audits of the outcome measures and the
results reported back to the Senior Management Team, Clinical Governance
Committee and Board of Trustees. Through the Senior Management Team the results
will also be reported to the Clinical Commissioning Groups. If additional support can
be secured in the form of information technology and administrative staff it may be
that wider dissemination of these measures would be possible, for example in
outpatient and community settings.
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Patient Experience
Priority 3: Development of a Patient and Family Forum to ensure that people
who are using our services have a more active role in the planning,
development and evaluation of services.
How was this identified as a priority?
Services at Woodlands have always been planned with the involvement of people
who are using the services, the patient and their family. We have actively sought the
opinions of patients and families who have used our services and encouraged them
to tell us about what we do well and where there is room for improvement.
Patient surveys are a recognised tool for ascertaining opinions on services and apart
from annually surveying service users we also request comments and opinions
following every patient discharge.
The most beneficial kind of user involvement is where people can have some real
involvement in decision making around any proposed changes to services, enabling
service users to be part of the process of development and change
The Hospice wants to work with service users to ensure that:
• Current high standards of care are maintained
• Service developments continue to focus on the needs and priorities of patients and
families.
• Service users are better informed of services
• There is shared responsibility and partnership
How will this be achieved?
• The Hospice will initially ask for patient participation in a Patient and family Forum
from patients already known to Woodlands Hospice.
• Family members and bereaved carers attending the Bereavement group will be
asked whether they wish to be a part of the new forum
• Membership will be sought from the local community
• Terms of reference, a strategic plan and operational procedures will be agreed and
implemented.
• The forum will meet regularly at the Hospice.
How will progress be monitored and reported?
The forum will be monitored and reviewed by the Senior Management Team and will
report regularly to the Clinical Governance committee.
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1b. Priorities for 2012-13 Review of progress
Patient Safety:
Priority 1: Infection Control- The Hospice will continually strive to maintain
high standards of Infection Control and minimise the incidence of healthcare
acquired infections.
• We have reviewed our annual audit programme for infection control to reflect new
developments and areas for improvement identified through monthly audits.
• We have had an independent review of the Hospice environment in relation to
infection control and prevention which concluded that ‘with very minor
considerations, the Hospice environment is clean and fit for purpose’. An action
plan has been developed and implemented to address the minor concerns.
• Infection prevention and control training and information packs have been
implemented for non clinical staff and volunteers to complement the clinical staff
training.
• We have commenced a review of infection control policies
• Only one link nurse is yet to attend the infection control degree module planned for
September 2013
• All audits , action plans and the decontamination policy have been
reviewed/approved by the Clinical Governance Committee and Board of Trustees
• It is envisaged that all policy documents will be reviewed and patient information
leaflets standardised by the end of July 2013
Clinical Effectiveness:
Priority 2. Day Therapy and Out-patient services. To improve access to the
multi-professional team within the Day hospice offering Day Therapy/Outpatients/Outreach in a variety of ways to facilitate greater choice and flexibility.
• A comprehensive review of Day therapy and Out-patient services has been carried
out.
• The new service, a combination of Day Therapy, Out-patient clinics, an extensive
programme of groups and community outreach therapies will be available Monday
to Friday at the newly established Woodlands Hospice Well-being and Support
centre from May 2013.
• Services will be available from 9.30am - 4.30pm Monday to Friday on a more
flexible/accessible basis.
• The group programme will initially offer Breathlessness Management, Coping with
Stress and Anxiety, ”Keep Moving” exercise group, Creative arts, and Supportive
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Living education programme, and lymphoedema support encouraging patients to
attend sessions appropriate to their needs.
• Patients will attend a multi-professional assessment day where they can access
the multi-professional team
• Following team assessment, a programme of therapeutic interventions will be
agreed and patients may attend for individual and/or group therapies throughout
the week.
• New roles for Volunteers within the hospice are being developed to assist the
clinical staff in the newly defined services
• Ongoing review of the newly developed services will continue throughout the year..
Patient experience:
Priority 3: Advance Care Planning- all patients will be offered the opportunity to
discuss and formulate an advance care plan stating their wishes and preferences
at the end of life.
• We have developed and commenced a programme of multi-professional education
for all hospice staff including volunteers.
• On the in-patient unit we have revised our weekly Multi –disciplinary team meeting
documentation record to capture whether patients have made an advance care
plan or have particular issues relating to this and whether they have a documented
Preferred Place of Care. This is due to be audited in the near future.
• We had identified that we were looking to develop the hospice’s own patient held
documentation to support and record any advance care planning decisions.
However Aintree ICN (Integrated Clinical Network) of which the hospice is a
member, have recently received an allocation of MPET (Multi-professional
Education and Training) money and it has been decided as an ICN to use this
money to employ an Advance Care Planning facilitator. Their role will be to
develop consistent, unified documentation across the ICN to encompass the
hospital, hospice and community settings. This integrated approach to developing
appropriate unified documentation has therefore superseded our previous plans to
develop our own paperwork within the hospice
• Work to promote the sharing of this information with the development of EPaCCS
(Electronic Palliative Care Coordination System) will also be a key responsibility
for this new post.
• We have joined an Advance Care Planning Working Group to further support an
integrated approach to Advance Planning.
• Work will be ongoing to ensure full delivery of this priority in due course.
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Other Quality improvements 2012-13
Monitoring of Quality
• Clinical audit plan and non-clinical audit plan established and regularly reviewed
by members of the Senior Management Team.
• CQC Provider Compliance assessment (PCAs) tools completed, but will
continually be reviewed in the light of changes and developments in services.
• Ongoing programme of monthly Trustee Visits to review compliance with CQC
Essential Standards of Quality and Safety.
• All audit results and quality reports and any resulting action plans submitted to
Governance and Clinical Governance committees.
• Risk Register established and regularly reviewed by Governance and Clinical
Governance committees and the Board of Trustees.
Working groups
A number of multi-professional Working groups have also been established which
report regularly to the Clinical Governance, Governance and Health and Safety
committees. These include:Dignity
• Multi-professional working group meeting schedule established to consider
Dignity issues.
• Dignity Charter developed.
• Ongoing development of comfort charts.
Infection Control
• Multi-professional group, with membership from across all services.
• Comprehensive audit programme established and implemented in clinical areas.
• Ongoing review of audit results and action plans reviewed by Clinical Governance
and Health and Safety Committees.
• Infection Control now established component of all staff induction programmes.
Nutrition
• Multi-professional group meeting monthly to consider all nutritional issues.
• Hospice Nutrition Policy in development.
• Nutritional Assessment Tool developed.
• Patient Information leaflet re. Nutrition in development.
Falls
• Multi-professional falls group meeting regularly to review management of falls
across the Hospice.
• Falls system in situ- being regularly audited.
• Updated falls system being considered.
• New patient safety slippers introduced to reduce the risk of falls.
• Falls risk assessment implemented in day therapy.
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Medicines Management
• Multi-professional group meeting monthly to review medicines management
across the Hospice.
• Medicines policy reviewed, Standard operating procedures developed.
• Self medication policy developed and implemented to provide patients with greater
independence.
• Information leaflets for General Practitioners prescribing ketamine and methadone
for pain relief created.
• Audit programme established and regularly reviewed.
• Ongoing Training programme implemented.
Documentation
• Group established to review all nursing documentation.
• Introduction of new core care plans.
• Introduction of revised initial assessment process and documentation.
• Training programme in development.
• Development of ongoing audit programme.
Patient Information
• Development of information leaflets for new Woodlands Hospice Well-being and
Support Centre services.
Education
• Woodlands hospice staff have contributed to a wide range of education run by
Aintree Integrated Clinical Network ( ICN) over the past 12 months. This includes:
• Collaborative programme of GP education in Specialist Palliative Care over a
six month period with Willowbrook and Marie Curie Hospices.
• Six Steps to Success programme of education for Care Home staff in South
Sefton.
• Social Worker education programme.
• Core communication skills training.
• There is also an ongoing programme of in house education for hospice staff.
Community Engagement
• Community Engagement Lead for locality, based at the Hospice.
• Active Hospice participation in Dying Matters week, May 2012, to promote a
greater awareness of issues around death and dying.
• Active promotion of Hospice Care in Hospice Care Week (October 2012).
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Section 2: Statutory Information and
Statement of Assurances from the Board
The following are statements that all providers must include in their Quality Account.
(Not all of these statements are directly applicable to specialist palliative care
providers.)
2.1 Review of Services
During 2012/13, Woodlands Hospice Charitable Trust provided the following services
• In-patients
• Day Therapy
• Community Outreach
• Out-patients
• Lymphoedema
• Bereavement and Family support.
• Hospice at Home (In South Sefton only)
Woodlands Hospice has reviewed all the data available to them on the quality of care
in all of these services.
The income generated by the NHS services reviewed in 2012/13 represents 78 per
cent of the total income required to provide the services which were delivered by
Woodlands Hospice Charitable Trust in the reporting period.
What this means: Overall, 78% of our total costs are currently funded by the
NHS. The majority of NHS funding is related to the In-patient Unit which
transferred over from the NHS in 2009 with a three year funding arrangement
which has been rolled over annually since. We rely on Fundraising activities
to generate the remainder of our income.
2.2 Participation in clinical audits
During 2012/13, Woodlands Hospice was not eligible to participate in any of the
national clinical audits or national confidential enquiries. This is because none of the
audits or enquiries related to palliative care.
The Hospice clinical audit programme for 2012/13 consisted of audits for Medicine
Management, Controlled Drugs, Infection Control, Care Plans. For some of these
audits we have used the Help the Hospices Audit Tools which are particularly
relevant to the requirements of Hospices and enables performance to be benchmarked against other hospices. In addition Woodlands Hospice also participates in a
number of Regional and Supra-regional audits as part of the Merseyside and
Cheshire Palliative Care Network Audit Group.
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2.3. Research
The number of patients receiving NHS service provided by Woodlands Hospice in
2012/13 that were recruited during that period to participate in research approved by
a research ethics committee was 0. There was no appropriate national, ethically
approved research studies in palliative care in which we could participate.
2.4 Quality improvement and Innovation goals
agreed with our commissioners.
Woodlands Hospice’s income in 2012-2013 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation payment framework because it is a third sector organisation; it was
therefore not eligible to take part (Mandatory statement)
2.5 What others say about us
Woodlands Hospice is required to register with the Care Quality Commission and its
current registration is for the following regulated activities:
• Diagnostic and Screening procedures
• Treatment of disease, disorder or injury
Woodlands Hospice is subject to periodic reviews by the Care Quality Commission.
During November 2012, the Care Quality Commission carried out an
unannounced inspection and found that the Hospice was fully compliant with the
following Standards:Outcome 1 Respecting and Involving people who use
the services- People should be treated with respect,
involved in discussions about their care and treatment
and able to influence how the service is run.
“People’s privacy, dignity and independence were
respected. Staff showed they had a clear
understanding of the need to respect and value the
people they supported. Staff gave responses that
they knew people well and had provided support
based on people’s individual needs and choices.
We observed staff interacting with relatives with
sensitivity and compassion.”
Outcome 4 Care and Welfare of people who use the
services- People should get safe and appropriate care
that meets their needs and supports their rights
“Records showed that people’s healthcare needs
had been closely monitored and appropriate
referrals made to other health professionals. Risk
assessments were part of people’s care plans and
covered areas of risk such as falls, nutrition,
pressure areas and the use of equipment.”
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Outcome 9 Management of Medicines – People
should be given the medicines they need when they
need them and in a safe way.
“We found appropriate procedures for medicines
prescribing, administering and recording which
helped make sure they were handled safely. The
Hospice had developed a policy and procedure to
support people to look after some of their own
medicines. Safely supporting people to manage
their own medicines helps promote their
independence and helps them to retain their
dignity.”
Outcome 14 Staff should be properly trained and supervised and have the chance
to develop and improve their skills
“Staff we spoke with said they had all completed induction, and received
support with supervision and mentoring. All staff had an annual appraisal and
regular supervision.”
Outcome 16 The service should have quality checking systems to manage risks
and assure the health, welfare and safety of people who receive care.
“The provider had effective systems to regularly assess and monitor the
quality of services that people receive. The trustees carried out regular spot
checks during which they reviewed essential standards of care. We saw
reports from these checks with robust action plans and timescales for
improvements. We were shown a comprehensive clinical audit programme and
associated action plans. This showed that the service had been pro-active in
reviewing and maintaining the standard of clinical care.”
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We were very pleased to receive such positive feedback from The Care Quality
Commission following their visit and we will continue to monitor our compliance with
all of the Essential Standards of Quality and Safety
Environmental
Health
An environmental health
inspection at the
beginning of the year
confirmed that high
catering standards were
being achieved and that
the Hospice had
maintained its 5 star
rating.
Fire Safety
Following an audit of the hospice’s fire safety arrangements by the Fire Authority in
January 2013 a number of new processes and some new equipment have been put
in place.A revised model for fire training has been developed and is being rolled out
to all staff and volunteers.New door closers have been fitted to the first floor offices
and an ongoing programme of non-urgent maintenance has been planned
2.6 Data Quality
Woodlands Hospice did not submit records during 2012/13 to the Secondary Uses Service for
inclusion in the Hospital Episode Statistics which are included in the latest published data.
Why is this? This is because Woodlands Hospice is not eligible to participate
in this scheme. However, in the absence of this we audit our clinical records
regularly and submit annually National Minimum Dataset reports to ensure
our data is as accurate as possible.
Woodlands Hospice score for Information Quality and records management was not assessed using
the Information Governance Toolkit. This toolkit is not applicable to palliative care.
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SECTION 3 – Quality overview
Review of quality performance
Woodlands Hospice is committed to continuous quality improvement.
This section provides:
• Data and information about the number of patients who use our services
• How we monitor the quality of care we provide
• What patients and families say about us
• What our regulators say about us
Monitoring activity
The Hospice submits information annually to the The National Council for Palliative
Care (NCPC) Minimum Data Sets which is the only information collected nationally
on hospice activity.
In-patient unit
In the In-patient unit, where there are 15 beds, the average length of stay for 2012/13
was 13.3 days although there is wide variation according to need. The unit has a
consistently high level of occupancy of 85.9 % during this period.
Woodlands Hospice
2011-2012
2012-2013
Total number of patients
276
284
83.5%
85.9%
12.2 days
13.3 days
In-Patient Unit (15 beds)
%New patients
88.3%
% Patients returning home
55.9%*
% occupancy
Average length of stay
87.7%
55%
* Corrected after publication
Day Therapy
The total number of patients attending for Day Therapy was 329. The Day Hospice
has 100 places per week and the average attendance for 2012/13 was 50.3% with
the average episode of care being 158 days. (NB. Although the attendance figure is
50.3% the total percentage of patients attending plus places booked and patients not
attending is 86%) This reduction in actual attendance over the past couple of years
prompted us to review our non-in-patient services and identify it as a priority for
2011-12.The revised services will offer more flexibility and choice for our patients and
families.
Woodlands Hospice
2011-2012
2012-2013
Total number of patients
336
329
% Places used (patient attendances)
51.6%
50.3%
Day Therapy(100 places week)
% New patients
Average length of stay
74%
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140.2 days
70.2%
158 days
Our community services consist of:
Community Outreach Service
This is a Therapy Outreach service providing Occupational Therapy, Physiotherapy
and Complementary Therapy interventions in the patient’s home, for those patients
who are unable to travel to the Hospice.
Woodlands Hospice
2011-12
2012-13
Total number of patients
200
227
58.6%
53.6%
Community Outreach Services
% New patients
82%
% patients with non-cancer
16.5%
% patients who died at home
86.3%
13.2%
Bereavement Services
Individual support is offered to the bereaved by members of the clinical team who
have been key workers to the families. In addition a Bereavement Group is held
monthly at the Hospice and a ‘celebration of Life’ service is held annually.
Woodlands Hospice
2011-12
2012-13
Total number of users supported
95
101
Total contacts
475
565
Bereavement services
% new service users
72.6%
62.3%
Hospice at Home
The Hospice at Home service is currently provided only in South Sefton, offering
escorted discharge home from hospital or hospice, a 24 hour sitting service and
Consultant led Crisis Intervention/prevention.
Woodlands Hospice
2012-2013
Total Number of patients
138
Accompanied Transfer Home (from Hospice or Hospital)
15
Hospice at Home
Crisis Intervention home visits
Sitting Service
% Home Deaths (place of residence)
% Hospital Deaths
53
85 patients (650 sits)
76.1%
18
7.5%
Woodlands Hospice at Home has been commissioned by NHS Sefton until March
2014 with the aim of enabling patients to achieve their Preferred Priorities for Care
and reduce unnecessary hospital admissions. The service is currently for South
Sefton residents with a South Sefton GP and has three elements:-
• Crisis intervention – at the request of the GP, the Consultant in Palliative Medicine
visits the patient at home to review and advise, preventing any unnecessary
hospital admission
• Accompanied transfer home from hospital or hospice – where, on discharge, a
Health Care Assistant accompanies the patient home and stays with the family
ensuring everything is in place and handing over to the District Nurse or care
agency.
• Sitting service – Day or Night sits by Hospice at Home Health Care Assistant,
enabling the family to stay at home by giving practical and emotional support to the
patient and family.
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Quality Markers we have chosen to measure
In addition to the limited number of suitable quality metrics in the national palliative
care dataset, we have chosen to measure our performance against the following:
Patient Safety Incidents
INDICATOR
2011-12
2012-13
Number of slips, trips and falls
35
43
Number of serious patient safety incidents
1
2
The Falls Multi Professional Group meets regularly to review all incidents of slips,
trips and falls across all services and looks for local solutions to minimise the
incidence of falls.
Our patients are generally quite frail and we have a robust falls monitoring system in
place which helped us to reduce our falls by 58% in 2011/12 and whilst this system is
still in place we have identified that the bed pads attached to the current alarm
system cannot be used for patients who are at risk of pressure ulcer development.
The bed pad is placed directly under the patient, on top of the mattress, and provides
no pressure relief.
A clip and cord attached to the patient has been used as an alternative but
increasingly patients try and remove this and start to mobilise which puts them at
risk.
There has been a slight increase in falls this year but we have recently sourced a
falls bed pad that can be placed beneath the mattress which would not compromise
the patient’s skin integrity and where finances allow we will start to invest in this
system to hopefully once again see a further reduction in falls.
The Group are very proactive in managing falls prevention and there are no other
new actions to be considered at this time although regular audit will ensure we
continue to work with our patients to prevent falls wherever possible.
Infection Prevention and Control
INDICATOR
2011-12
2012-13
Number of patients infected with MRSA bacteraemia
during admission
0
0
Number of patients admitted with MRSA bacteraemia
Number of patients admitted with clostridium diffocile
Number of in patients who contracted
clostridium diffocile
0
1
1*
0
1
0
*unknown if transferred or acquired
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Once again this year we have maintained our excellent standards of infection
prevention and control with no incidents of key infections as detailed above. The
multi professional team together with the Housekeeping team work hard throughout
the year to keep us free from these infections and patients and families regularly
comment how clean the environment is at all times.
The Nurse led Infection Control team have a robust audit programme and respond
quickly to any areas identified as needing improvement to ensure our standards
remain high.
Needlestick injuries are a potential source of infection for health care workers and a
new Needlesafe European Directive comes into force in May 2013. During 2012/13
the team have been trialling new products with retractable needles ensuring that we
will be compliant with this directive within the appropriate timescales.
Clinical Audit
Clinical audit is used to monitor quality, enabling us to learn from the findings and
continually improve the delivery of our services. A Clinical audit plan is developed for
the year and includes a mix of local and regional audits.
Multi-professional audit meetings are held every two months in partnership with the
Hospital and Community Palliative Care teams. All staff are given the opportunity of
presenting the results of any audits they have taken a lead on at these meetings.
Following an audit, any issues are highlighted and an action plan is developed.
Patient feedback is also used to monitor quality of services .In addition to an annual
patient survey, Comment forms issued to all patients admitted to the In-patient unit
and those patients discharged from the Day Hospice are reviewed regularly and a
report compiled every six months.
The hospice has a regular programme of unannounced Trustee Visits which are
based around the Care Quality Commission’s essential standards. During these
visits, Trustees talk to both staff and patients asking for their views on topics relating
to the particular outcome being reviewed and check supporting documentation.
Following each visit a report is produced and any actions identified. Action plans are
reviewed by the Clinical Governance/ Governance Committees.
Through the Governance committees the Board of Trustees is kept informed about
audit results and any identified shortfalls.
Through these processes the Board receives an assurance of the quality of the
services provided.
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The following table shows a sample of the audits completed during 2012/13
Patient Safety
Audits
Infection Control
Safe Disposal of
Sharps
Findings and Actions to be taken
to improve compliance/practice
The audit identified that staff are aware of the policy
following sharps injury.
The temporary closure mechanism on sharps boxes was
in use as per policy at the time of the audit.
Staff were re-issued with the Procedure for safe disposal
of sharps as a number of sharps bins were overfilled.
Infection Control
Correct
Management of
Spillage and/or
Contamination
with Blood/Body
Fluids
Medicines
Management
Pharmacist
Controlled Drug
Audit
Medicines
Management
Quality of
Prescribing
Action plan
completed
January
2013
The audit identified that staff who come into contact with
body fluid spillages have been successfully immunised
against Hepatitis B
April 2012
As per policy the auditor found that dedicated Spillage
kits are available for decontaminating and cleaning
body fluids
Not all nursing staff asked knew how to use a Spillage
kit therefore this has been incorporated in to the
infection control update training sessions.
The audit identified that the Hospice has good
compliance with policies and procedures for the safe
management of controlled drugs.
April 2012
The auditor recommended that an approved list of stock
controlled drugs is included in the Controlled Drug
Policy.
The audit identified that there is good compliance with
the standards of prescribing set out in the Hospice
Medicines Policy
The audit highlighted that not all medical staff
interviewed had attended ‘Prescribing training’ on
induction therefore prescribing training was initiated for
all medical staff on induction.
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May 2012
Patient Safety
Audits
Findings and Actions to be taken
to improve compliance/practice
Administration of
Medicines
The audit identified that 0.4% of drug administrations
were not signed by a Registered Nurse.
Medicines
Management
Documentation
Care Plans
To address this issue all Nursing staff attended training
in relation to the administration of medicines and this
session is now part of the annual training programme
for all trained nurses.
The audit identified that all patients have evidence of a
plan of care that reflects problems identified through a
holistic assessment
Action plan
completed
August
2012
December
2012
Core care plans require more individualised information
in relation to patients preferences
Re-audit 6 monthly
Documentation
Nursing
Documentation
The documentation group reviewed the monthly
documentation audits and the nursing assessment
documentation in use. A revised nursing assessment
document was developed to improve the collection and
recording of information required to plan individualised
care.
Staff training in the use of the new documentation was
completed prior to implementation on the inpatient unit.
The documentation group aim to develop an audit tool
to audit the new documentation by July 2013
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January
2013
In progress
Regional Audits
The use of
Ketamine and
Methadone in
Palliative Care
Patients
The management
of renal failure in
palliative care
patients
Trustee Visits
Findings and Actions to be taken
to improve compliance/practice
The audit demonstrated a wide variation in
prescribing practice particularly for Ketamine and
new regional guidelines were developed to help
improve practice. This included recognition of the
need to do baseline observations and monitoring of
pulse and blood pressure.
March 2013
We have also developed Ketamine and Methadone
information leaflets for GPs and Community
Pharmacies
The audit reviewed our knowledge and confidence
about prescribing for patients with renal impairment.
Generally, we were more confident about the need
for medication dose adjustment in those with
conservatively managed renal failure; but less so for
those patients who were still under-going dialysis.
The revised guidelines provided additional
information and resources on both these clinical
situations. The audit included a review of commonly
prescribed analgesia and those which were safer to
use in patients with renal impairment.
Outcome 12,13,14
Requirements related
to workers. Staffing and
Supporting Workers
Outcome 17
Complaints
Action plan
completed
Findings and Actions to be taken
to improve compliance/practice
The audit identified the need for
development of a Central Learning and
Development Plan for all staff across the
Hospice.
The audit identified the need for notices in
all patient rooms re. How to make a
complaint.
It also identified the need to review
Complaints Policy and introduce staff
training in handling complaints in line with
revised policy.
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In progress
Progress to date
In progress
Completed
Complaints
Policy being
reviewed
followed by
staff training
Complaints
Whilst the Hospice receives an overwhelming number of compliments and positive
comments, we are not always able to meet every patient or families expectations
which may result in them expressing their concerns, either formally or informally. In
addition we proactively encourage comments and input from all patients and carers.
Where we do receive complaints, we take each and every one very seriously as we
would not wish for any patient or family member to feel dissatisfied with our service
as we pride ourselves on high quality care for all.
Written Complaints
2011-12
Verbal Complaints
2011-12
Total number
Total number
2012-13
Outcome
2012-13
Outcome
2
4
11
11
See trends/themes below
See trends/themes below
Trends/themes of complaints.
Any increase in the number of complaints is always a concern for us and during the
year we closely analysed the comments within each of the complaints and felt that
there were 5 emerging themes. (Complaints may have contained more than one
issue)
Theme/trend
Outcome
Experience did not match the
expectations of the patient/family
set prior to admission
Formal discussion commenced with other health
care professionals external to the Hospice to ensure
they understand our services fully and patients
expectations are set up correctly prior to admission.
Staff communication and attitude
The environment
Communication specifically about
the Liverpool Care Pathway
Bereavement support service
inconsistent across Inpatient
service and Day services
More rigorous handover processes being developed.
Advanced communication skills training for Senior
RGNs completed and communication skills training
introduced for Health Care Assistants. More latterly
in the year introduction of weekly ward rounds by the
Hospice Lead Nurse to ensure patient satisfaction
In particular the size of the bedrooms which will be
addressed in capital works as finances allow
Intense press coverage of the Liverpool Care
Pathway has prompted many enquiries and we have
improved our education and communication around
this high quality end of life tool.
Bereavement service being fully reviewed.
Every written complaint was responded to formally within policy timescales and an
action plan developed to address any shortcomings. The action plans are monitored
by the Senior Management Team and the Governance committees.
For all verbal complaints a member of the Senior Management Team speaks
personally with the patient and/or family and again appropriate action taken.
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3.1 What our patients and families say about the
organisation
The Hospice encourages patients and their families to let us know what they think of
our services. Information on how to tell us is displayed throughout the Hospice and is
given to patients and families on admission or first attendance. Comments forms are
routinely distributed to all patients admitted to the In-patient Unit and are displayed in
all areas of the hospice. Comment boxes are displayed in all reception areas.
Regular patient forums are held in the Day Hospice with Day Therapy patients being
asked for their views on a variety of subjects. In 2013/14 one of our priorities is to
establish a Patient and Family Forum.
The results of our surveys are shared with patients, families, staff and volunteers.
The surveys and comment forms are anonymous but if there are concerns people
are asked to identify themselves so that we can follow up to resolve any issues and
learn from them.
The following are some of the comments received from our most recent Day
Therapy and Community Outreach surveys:
“Care and
consideration to each
individual’s needs is
exceptional”
“Woodlands
has helped me
immensely, both
mentally and
physically”
“Privacy is given
at all times. Always treated
with respect and helpfulnesscan’t fault the staff”
“Glad I was told about WoodlandsI had been afraid when I was first diagnosedI felt alone like I was the only one with a
terminal illness, until I came to Woodlands.
Best thing that could have been
introduced to me”
“Woodlands has
been a life-line to me
and I cannot express my
gratitude strongly
enough”
“When I had
questions to ask they were all
explained to me so I could
understand easily”
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“The treatment
I have received from
every member of staff
has been excellent and
so professional”
A formal evaluation of our Woodlands Hospice at Home service in October 2012
gave us some excellent feedback both from service users and healthcare
professionals referring to the service.
“By allowing my
husband to stay in his own home
with expert help, it gave both him
“Having my husband
at home with his family, that is what and the family peace of mind in
horrendous circumstances”
he wished and I was so pleased we
could do that for him”
“Accompanied
transfer home
provided both patient
and family support and
re-assurance at their
time of anxiety of
having their Dad home
who was in the dying
phase”
“They talked
us through things on
a day to day basis
and we would not
have got through this
difficult time without
their care and
support”
(Discharge
Planner)
“I think
the crisis
intervention visits
have been the key
element in making
that specialist
assessment in the
patient’s home and
preventing
inappropriate
admission”
“We have found
(Doctor)
WoodlandsHospice at Home
service an excellent resource.
It is of great benefit to the palliative patients within the
community, supporting and enabling them to remain at
home, working closely with other disciplines”
(District Nurse)
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The following extract is from a letter we received from the relative of a patient
following a recent admission to the In-patient Unit:
“I cannot begin to tell you
how much of a difference you made to our
family and we all appreciated the warm welcome and
constant support during her brief stay. I was truly impressed by
the knowledge and expertise of staff but most of all the atmosphere,
actions and behaviour of staff and volunteers all of which contributed
to a feeling of trust and safety, so essential in such stressful circumstances.
The work you do is truly amazing but not so amazing as the inspirational
individuals that make Woodlands a rather special place, a true oasis in
the desert. I just wanted you to know how impressed I was with the
service you provide and let you know that I thought the service
was of an exceptionally high standard
and worthy of the highest praise”
The following are other comments received from relatives
of patients on the In-patient Unit:
“Thank you
to all the nursing
staff for looking after our lovely
neice. You are all amazing
people and we cannot thank you
enough for the care you gave
to her.”
“We would
just like to thank
you all for the wonderful
support and care you gave to
our dad in his final days. You
were all a great comfort and
support to us which we will
never forget.”
“Words cannot
convey how grateful
we are for the loving
care and attention
given to our dear
mum.”
“Thank you
so much for all
your care and love, you
all made him so content
and happy with your caring
ways and lovely smiles,
popping in to see him all the
time. We can never thank
you enough.”
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3.2 What our regulators say
Woodlands Hospice is registered with the Care Quality Commission and as such is
subject to regular review in the form of unannounced inspections. Please see Section
2.5 for details of our most recent review (November 2012)
3.3 The Board of Trustees’ commitment to quality
The Board of Trustees of Woodlands Hospice Charitable Trust is fully committed to
prioritising quality. All Trustees participate in the programme of unannounced Trustee
Visits giving them an opportunity to familiarise themselves first hand with the
workings of the Hospice and an opportunity to hear the views of patients, families,
staff and volunteers. The organisation has a robust Governance structure with
Trustees taking an active role in ensuring that the Hospice provides a high quality
service and fulfils its Statement of Purpose.
3.4 Supporting Statements
Healthwatch Sefton
As a new company, Healthwatch Sefton is in the throes
of setting itself up. Healthwatch Sefton welcomes the
opportunity to work with the Hospice over the coming
years as a critical friend to ensure that local people
receive quality services. We have received a copy of
the draft Quality Account from the Trust and will use the
information within the account to help us in our work
over the coming 12 months.
Clinical Commissioning Groups
This Quality Account has been sent to South Sefton CCG for comment, and we are
waiting to hear back.
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Woodlands Hospice Charitable Trust
UHA Campus, Longmoor Lane, Liverpool L9 7LA
Tel: 0151 529 2299
Charity No. 1048934
www.woodlandshospice.org