.
Quality Account
High quality care for all
Reporting period: 1st April 2013 to 31st March 2014
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Ashgate Hospice Quality Account May 2014 Anna Baker
Patients and Carers’ Feedback
‘’My friend was here in December and I could not believe the dedication and care
shown to her. My mum is now here and the same care and compassion is shown. I
have a broken heart but I can go home each night with the knowledge my mum has the
best care as possible’’
‘’You exceeded all expectations. The level of care received by all of you was second to
none, not only for X but for us too. X was treated with the upmost dignity and respect at
all times. All of his needs were met and nothing was too much trouble. You gave X his
wish by helping him stay pain free and pass away peacefully. You are all amazing!’’
‘’Excellent patient care and services, overwhelmed at the way all staff excel in their
professionalism and superb team work’’
(received from the relatives of patients on the hospice ward)
(received from FAMCARE (Healthwatch) comments on the holistic package Ashgate
provides)
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Ashgate Hospice Quality Account May 2014 Anna Baker
Chief Executive’s Statement
Ashgate Hospice continues as an independent charity and company limited by Guarantee
and is governed by a Board of Trustees. Now in its 26th year of operation, Ashgate is the
leading provider of Specialist Palliative and End of Life Care in North Derbyshire.
The Hospice prides itself on delivering the highest quality and I am confident that quality is
integral to all of our internal governance arrangements, as well as to the assurance that we
offer externally.
The Hospice has an open culture of continuous monitoring, benchmarking and
improvement. Any shortfalls in quality are very quickly identified and acted upon, and
learning used and shared in order to improve the quality of care and services provide by us.
The Hospice provides a genuinely holistic service in which the needs of individual patients
and their families are assessed and met. We are keen to share our expertise with others in
order to promote excellence in care right across the local health and social care sector. We
strongly believe that the hospice has a significant role to play locally and nationally in terms
of influencing around quality in care, in particular in terms of advanced communication skills,
compassion, dignity and respect.
We continue be forward looking, ‘seeking out’ opportunities for collaboration and for
opportunities to work in partnership, in order to influence delivery of Palliative and End of
Life care in all settings.
Despite the continued challenging financial climate, we continue to provide a
comprehensive range of high quality, cost effective services, and offer significant social
return on investment and benefit to the local community.
I would like to acknowledge and thank everyone who supports volunteers and works at the
Hospice. It is the team effort, commitment and expertise of our staff and volunteers, and the
excellent patient feedback that we receive that enables me to feel confident in giving strong
assurance to North Derbyshire and Hardwick CCG’s on quality. I am confident that to the
best of my knowledge, the information reported in this Quality Account is an accurate and
fair representation of the quality of healthcare services provided by Ashgate Hospice.
Lucy Nickson
Chief Executive May 2014
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Ashgate Hospice Quality Account May 2014 Anna Baker
Section 1
Improvement priorities
Priorities for improvement 2014-2015
The hospice received an unannounced inspection in 2013 following which the Care
Quality Commission confirmed that the hospice was meeting all the essential
standards of quality and safety. The hospice does not therefore have any areas of
shortfall to include in the priorities for improvement for 2014-2015.
In developing the strategic plan for the hospice, particular attention was paid to the
changing commissioning landscape within health and social care organisations, and
the influence that would have on hospice services. We looked at how the hospice
could extend its services to meet the needs of the local population, enabling people
to receive care in the place of their choice.
The top three quality improvement priorities for 2014 to 2015 are as follows:
Future planning - Priority 1
“Using national comparisons of our care in preventing falls, pressure
ulcers and in medicines management”
Ashgate Hospice is now part of a national hospice benchmarking scheme looking at the
number of patients who fall, the number of patients who develop a pressure ulcer in our
care that could have been avoided, and how we manage medication. This benchmarking
started in April 2014 and will tell us how we are doing compared with other similar
hospices across the country (over 100 hospices have joined this scheme). Although we
are very good at managing all of these things already, we plan to analyse this information
very carefully to find out ways of improving, where we can, so that we give the best care
we can.
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Ashgate Hospice Quality Account May 2014 Anna Baker
Future planning - Priority 2
“Staff development for the future”
In order to continue to provide the highest quality care we plan to develop further the
clinical skills and competencies in our staff groups. This will include some practical skills
on the ward such as venepuncture (taking blood), male catheterisation, dementia care
awareness, information governance and general computer skills.
In the Palliative Care specialist nursing teams, based at Chesterfield Royal Hospital and
those working in the community, we plan to increase those able to prescribe medicines
and undertake advanced clinical skills assessment.
In the hospice at home team we plan to implement some training on taking basic
observations (blood pressure, pulse, urine testing)
These changes will ensure we continue to deliver high quality services across all clinical
areas, and ensure that patient’s experience of care is improved.
Future planning - Priority 3
“Extending our reach into the community to see more patients”
One of the hospices most important aspirations is to be able to provide more care to a
greater number of people. We believe that we can do this by expanding our services in
the community and in patient own homes. We have begun to do this by expanding our
small hospice at home team with the help of some additional short term funding from
North Derbyshire Clinical Commissioning group but it is our aim to be able to continue
with these developments beyond 2014.
It is also our aim to work with the commissioners to extend the service further towards
being able to provide full 7 day cover, including support to patients and their in the
overnight period.
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Ashgate Hospice Quality Account May 2014 Anna Baker
Progress against the improvement priorities identified in 2013-2014
Throughout 2013-2014, the hospice had a number of initiatives to enable it to offer a
more comprehensive service to the local community, and progress against the
quality improvement priorities for 2013-2014 was influenced by financial constraints
of the charity. Progress is discussed below.
Progress made from Improvement Priority 1:
‘’Recruit to Quality, Audit and Information Manager post’’
This post was recruited to in July 2013, and has added value to the organisation in terms
of developing, supporting and reporting on clinical audit, more information on which is
available on page 21 and 22. The post holder also has responsibility for gathering
information on the quality of the care we deliver. Some aspects of this are reported to
the clinical governance committee at Ashgate Hospice, some is reported to the Clinical
Commissioning Group, some to HealthWatch and to the Care Quality Commission.
By carrying out these audits we see where we can improve the standards of care, which
is very important to us
Progress made against Improvement Priority 2:
‘’Hearing the Patient and Carer Voice and their experience of hospice
care’’
The Hospice works hard to identify and assess the holistic needs of patients and carers,
in line with the NICE quality standard for end of care, which states:
“Families and carers of people approaching the end of life are offered comprehensive
holistic assessments in response to their changing needs and preferences, and holistic
support appropriate to their current needs and preferences. We have worked hard to
capture the voice of our patients and their loved ones this year. We have developed a
simple three question comment card, and these are located across the hospice areas,
and the anonymous comments are placed in an adjacent box. We take all these
comments seriously and discuss the key themes as part of our strategy for the future. We
also have developed a patient’s forum, and the first group meeting is planned for this
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Ashgate Hospice Quality Account May 2014 Anna Baker
month.
All the clinical teams ask the patient and their loved ones about the care they have
received and whether they have any suggestions for improvement. Comments and
quotes from these are threaded throughout this report.
The hospice is also working with national company Quality Health to design a robust
patient experience survey that can be used year on year to build evidence around
experience and to help us to monitor trends and were improvements may be needed.
Progress made against Improvement Priority 3:
‘’Meeting the Challenges of the new commissioning environment’’
Funding
We have worked successfully with the Clinical Commissioning Group (CCG) this year and
have submitted four bids for additional funding, all of which were approved

Third consultant in palliative medicine: recruitment underway.

Continuation of additional funding for the Hospice at Home team until March 2015

Continuation of funding for additional beds for two more years (at 50% funding)

Part funding for Welfare Benefits Advisor

Agreement that the hospices core grant will remain at the same level for 3 years
Relationships and influence
We have been involved in the Derbyshire End of Life Strategy development with the CCG,
alongside other partner agencies, we are also now part of both the Urgent Care Board
work stream and the 21st Century Integrated Healthcare Steering group.
Help the Hospices Commission Report on the Future of Hospices
Following the publication of this report in the autumn of 2013, the hospice Senior team
and Board of trustees are using some of the recommendations about hospices being fit
for the future to shape our emerging 3 – 5 year strategy.
This strategy will be ready in draft form during the summer of 2014 and we intend to share
it and consult on it with commissioners, other providers and members of the public at this
stage.
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Ashgate Hospice Quality Account May 2014 Anna Baker
Section 2 - Mandated Statements
Statements of assurance from the board
The following are a series of statements that all providers must include in their
Quality Account.
Review of services
During 1st April 2013 to 31st March 2014, Ashgate Hospice provided the following
services:

In-Patient Unit

Day Unit

Lymphoedema service

Hospice at Home – N Derbyshire Community

Palliative Care Clinical Nurse Specialist – N Derbyshire Community

Palliative Care Clinical Nurse Specialist in-reach service (into local acute
hospital)

Therapy services (inpatient, day unit and community) – occupational therapy,
physiotherapy and Complementary Therapy

Patient and Family Support (Bereavement) Service

Spiritual care

Specialist Education and Training (health community, local universities)
Ashgate Hospice Healthcare Governance Advisory Group receives regular reports,
which enable them to review the quality of care provided by all clinical services.
This group meets quarterly, and is a subcommittee of the Board. A quarterly report
from this group is submitted to the board of trustees
Participation in national clinical audits
During 2013/14, Ashgate Hospice participated in a national audit FAMCARE which
looked at feedback from carers regarding their opinion on care received from our
services
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Ashgate Hospice Quality Account May 2014 Anna Baker
Research
During 2012/13, Ashgate Hospice did not participate in any national clinical
research; however one of the Palliative Care Clinical Nurse Specialists presented a
published paper to the European School of Oncology (ESO): Advanced Breast
Cancer Conference (ABC2) Lisbon November 2013.
Quality improvement and innovation goals agreed with our
commissioners
The goals and indicators for the hospice as required by the commissioners were as
follows:
Goal 1
To ensure that all front line staff has all the necessary skills,
knowledge and attitudes related to the care of the dying
Goal 2
To ensure that all individuals approaching the end of life are
offered a care plan
Goal 3
The hospice should have mechanism for auditing and reviewing
quality of end of life care.
Goal 4
Relatives involved in end of life care decisions to the extent that
they and the patient wish
Goal 5
Undertake surveys on how services have benefited users and
carers
Goal 6
Highlight main achievements and successes during the year
Goal 7
Report on the number of complaints and how they were
resolved
Goal 8
Report on activity relating to day unit, ward, community palliative
clinical nurse specialists
What others say about us
Ashgate Hospice is required to register with the Care Quality Commission
The Care Quality Commission has not taken any enforcement action against
Ashgate Hospice during 2013/14. The registered manager for Ashgate Hospice is
the Director of Clinical Services and our regulated activities are: treatment of
disease, disorder and injury, surgical procedures, diagnostic and screening
procedures, nursing care, and personal care.
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Ashgate Hospice Quality Account May 2014 Anna Baker
Ashgate Hospice is subject to periodic reviews by the Care Quality commission. The
last on-site inspection was in July 2013
Data quality
In accordance with agreement with the Department of Health, Ashgate Hospice
submits a National Minimum Dataset (MDS) to the National Council for Palliative
Care. Ashgate Hospice provides the MDS report to the local CCG commissioner.
Ashgate Hospice will be taking the following actions to improve data quality:

The IT Manager and the Director of Clinical Services will continue to
review the data outputs in order to improve the quality of patient data
reporting.

The Quality, Audit and Information Manager will assist in reporting
essential quality data that is timely and fit for purpose
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Ashgate Hospice Quality Account May 2014 Anna Baker
Section 3 Quality overview
Comparison with national minimum data sets
The most recent National Minimum Dataset covers the period 1st April 2012 to 31st
March 2013. Ashgate Hospice data for 2013-14 have been collated but there are no
comparative data available at the time of writing.
Community: Palliative Care Clinical Nurse Specialist
Community Specialist Palliative Care MDS data
Community Specialist Palliative Care MDS Data 2012-2013
% New Patients
% New Patients Non Cancer
Average Length of Care All Patients(Days)
Average Face to Face Visits (per Patient)
Average Telephone Contacts (per Patient)
69.98
7.46
67.2
3.65
7.8
The hospice sees the community team as providing a significant role in improving
the quality, accessibility, flexibility and integration of palliative and end of life (EOL)
care in our catchment area.
2012/13 face to face contacts = 2300 (11 months data)
Non face to face contacts = 4000 (11 months data)
2013/14 face to face contacts = 1867
Non face to face contacts = 4338
Thank-you for your compassionate care of my wife, she asked to be made as comfortable
as possible when the time came and this you did. She died peacefully and in no pain....so
your work had a very profound effect”
I thank you from the bottom of my heart for making it possible for X to die in his own
surroundings in my arms. I will never forget your kindness, help and amazing support.”
Quotes from patients relatives
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Ashgate Hospice Quality Account May 2014 Anna Baker
HOSPITAL CNS (in reach service to Chesterfield Royal Hospital Foundation
Trust)
2012/13 face to face contacts = 3262 (11 months data)
2013/14 face to face contacts = 4321
This small team based at Chesterfield Royal work across all wards and settings where
patients may be at the end of their life, or who are in the palliative stage of their illness.
They are provided by Ashgate Hospice and work very closely with the consultant and other
medical staff as part of a team delivering specialist palliative care to the acute hospital
I just wanted to say thank-you for all the care and understanding you gave to O and myself.
You do a fantastic job and we appreciated it very much.”
Thank-you for the kindness and gentleness you showed to us during dads last difficult days,
i so appreciate all that you did for us and for helping to make that time as peaceful and pain
free as it could be.”
Quotes from patients relatives
Hospice at Home
MDS data
Hospice @ Home MDS Data 2012-2013
% New Patients
% New Patients Non Cancer
Average Length of Care (In Days)
Av. Face To Face Visits Per Patient (All Patients)
Av. Telephone Contacts Per Patient (All Patients)
85.5
8.7
25.4
10.4
1.8
2012/13 face to face contacts = 1000 (11 months data)
Non face to face contacts = 300 (11 months data)
2013/14 face to face contacts = 1930
Non face to face contacts = 411
The Hospice at Home team provide support to patients and families across north
Derbyshire predominantly in the last 3 months of life. The team will deliver
supportive care and personal care as required, and based on need. The length of
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Ashgate Hospice Quality Account May 2014 Anna Baker
intervention is variable and each contact can last for half a day or more; again
depending on need. The team work in collaboration with other agencies (social care,
health and other third sector) and in partnership with families. Having received some
additional funding for two extra posts during the year, our intention is to work with
commissioners and other providers to develop this concept further.
Thank-you for the genuine love and care you gave to mum, without your help we not have
been able to care for her at home”
Thank-you for coming to care for X, and giving me the space to be able to take a break. It
meant a lot to me to know that I did not have to worry and I could leave him in your capable
and expert hands.”
Quotes from patients carers and relatives
In-Patient Unit
ACTIVITY LEVELS - 2013/2014
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
ACT
510
651
438
451
533
630
651
630
651
637
588
651
7021
489
595
438
451
533
536
623
583
559
586
526
589
6508
Occ plus
Booked beds
511
621
446
466
542
558
641
594
573
591
526
596
6665
Admissions
28
25
15
24
20
30
41
34
43
38
35
36
Re-admissions
7
6
4
6
7
3
1
1
3
5
1
1
28
27
15
25
21
26
36
29
30
33
26
27
323
7
2
4
5
6
7
6
6
16
8
10
10
87
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
3
0
14
19.2
16.2
17.4
21.3
18.5
14.8
16.7
12.7
7
0
2
1
11
1
1
0
12
0
1
0
11
1
0
0
10
1
0
0
7
4
2
0
15
0
1
0
5
2
1
0
14
3
1
0
Apr
IN-PATIENT UNIT
Available Bed
days
Occupied Bed
days
414
CCG
North
Derbyshire
Hardwick
Health
Others
Not Aligned
Av Length of
stay
Discharges
(Breakdown)
Home
Hospital
Nursing Home
Others
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Ashgate Hospice Quality Account May 2014 Anna Baker
13.6 14.6
19
4
0
1
12
2
0
0
16.4 16.28
15
1
1
0
138
19
10
2
Discharges
Total
10
13
13
12
11
13
16
8
18
24
14
17
169
Deaths
25
18
14
14
14
16
26
28
26
19
22
19
241
Inpatient MDS data
IPU MDS Data 2012-2013
% New Patients
% Occupancy
% New Patients Non Cancer
% Total Patients Returning Home
Average Length of Stay - Cancer
Average Length of Stay - Non Cancer
88.35
84
4.4
67.32
13.2
15.5
The hospice has a specialist community team, who cover the North Derbyshire area
and include clinical nurse specialists, occupational therapists and physiotherapists,
Hospice at Home team, all of whom are supported by two medical consultants. As a
result, patients are managed in their home environment, or alternative place of care,
for as long as possible. Once the need arises for an in-patient admission, the
hospice is committed to supporting patients to return to their home, or alternative
place of care, as soon as their symptoms have been managed.
This is in accordance with the charity’s aims to offer comprehensive specialist
palliative care to adults in north Derbyshire with progressive, advanced disease and
a limited life expectancy,
The Length of Stay and the effective use of the admission and discharge criteria
enable the timely admission of patients needing specialist in-patient palliative care.
The percentage occupancy remains high for this hospice at 93% for 2013/14, which
is considerably higher than the national median value of 80%. The inpatient unit has
an average waiting list of 1-2 patients per day with the increased bed numbers. The
majority of patients are admitted in the same day of referral or one day after.
I can’t tell you how brilliant my experience has been on the ward at Ashgate; I can’t thank
you enough for the excellent nursing, therapy and medical care.
Feedback from one of our patients who came in for symptom control and was
discharged home after a 10 day stay
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Ashgate Hospice Quality Account May 2014 Anna Baker
Day Unit
Activity Levels 2012/2013
DAY UNIT
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
ACT
Referrals
19
12
28
21
18
16
24
19
21
22
23
16
239
Attendances
158
180
170
190
199
163
225
188
150
220
227
200
2270
Non-attendees
65
74
65
95
54
59
61
74
63
45
20
27
702
8%
12%
24%
10
6
107
% DNA
29% 29% 28% 33% 21% 27% 21% 28% 30% 17%
IPU attendees
5
5
9
5
15
16
10
4
14
8
During 2013 and 2014 the day unit has been through a review of service provision
and now offers two core services. Medically-led day therapy for patients with life
limiting illness; respite places on a 6 week basis to support carers and offer activities
and socialisation. During 2013/14 the service underwent another review, engaging
with stakeholders, patients and carers to ensure that the service is providing the
appropriate level of care and support for the patients of N Derbyshire. Feedback for
the Patients’ Forum and the Carers’ Forum indicates that this support is highly
valued.
If I was ever unsure and asked about the problem the staff always made the time to answer
my questions
I would be much more unable to cope with my cancer, I would miss the opportunity too-my
carers would feel less confident about “coping” with me and my difficult times.
Patients’ feedback
I don’t have to worry about R during the 6 week period when he is at Ashgate
Carers Feedback on 6 week respite place
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Ashgate Hospice Quality Account May 2014 Anna Baker
Lymphoedema Service
During 2012 and 2013 the team received 253 referrals
During 2013 and 2014 the team received 307 referrals
% New Patients with Cancer
% New Patients Non Cancer
% Places Used
66
34
99
This service is consultant led and supported by a small team (3 staff) who deliver
out patient service and occasionally, home based care, across N Derbyshire. The
team work in collaboration with other health and social care providers, and aim to
deliver specialist training.
I would like to take this opportunity to comment about Ashgate Hospice’s Lymphoedema
team. Since my referral to the team and following their advice I have seen a wonderful and
vast improvement in my Lymphoedema condition. My overall health, fitness, mobility and
quality of life have improved 100% and I have lost weight too. Family and friends have
commented it’s like ‘having the old me back again’. To say the Ashgate Hospice
Lymphoedema service is invaluable is an understatement. They have made a huge
difference to me and I would like to say a big THANK YOU
Patients’ feedback
Therapy Service
Occupational Therapy has seen a 30% increase in referrals since 2007 with a total
of 652 referrals during last year (2.4 WTE).
Physiotherapy has seen a 49% increase in referrals since 2007 with a total of 423
referrals during last year (1.8 WTE)
All therapy services are provided on the ward, in the day unit and into the
community across North Derbyshire, with the majority of their work carried out in the
community. The service work with cancer and non cancer patients and work
collaboratively with other health and social care providers across north Derbyshire.
Approximately 1600 pieces of specialist equipment were provided to patients from
Ashgate Therapy service during last year
Part way through the year we recruited to a complementary therapist and from July
2013 to March 2014 there were 116 referrals
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Ashgate Hospice Quality Account May 2014 Anna Baker
Without the support and assistance from the Physiotherapist, I would not be able to achieve
the progress I am making today
She took the time to go through the plus/minus of the equipment, left me feeling much less
negative than before her visit
Found them to be a fantastic team who attended quickly and assessed appropriately, in a
professional manner and then put the relevant equipment in place. Many thanks, very much
appreciated.
The team were all excellent and better than any I have had previously from other services,
especially as they really listened – I am 97 and many do not!
The Therapy team have been a great help in the care for my mum. Whatever problem we
have encountered in her care, they have listened, advised and have dealt with our problem
professionally, with an extremely caring attitude.
Equipment has been ordered and has arrived promptly and even when we had a problem
with a toileting sling, this was tried and didn’t suit mum’s needs, other alternatives were
found. I would like to say a big thank you for all their help and advise in making life caring
for mum easier, for our family and the carers.
Absolutely delighted with everything, which is helping to make difficult times easier.
Patient and carer views 2012 survey
Patient and Family Support (Bereavement) Service
One of the Charity’s aims is to offer professional advice and support to families and
carers during the patient’s illness and during the initial stages of bereavement.
Between 1st April 2012 and 31st March 2013 the service received 258 referrals, and
provided telephone advice and support to over 700 patients and carers. Patients
and carers were supported through a variety of interventions such as bereavement
support group (1 session per week for 6 weeks), home visits, and support from an
art therapist (evidenced as particularly useful when working with children).
I would just like to thank you for the support and care I received but most of all for the
extended care which continued after Mum died. I particularly benefitted from the following:
Initial meeting, being given an image to concentrate on at the most difficult times until I
found other ways of coping in the following weeks.
I now use the strategies that L*** has suggested and even ‘though the loss and anger is
still there, I know that it is a normal grieving process. I also know that I can come back if
I need to which is very reassuring.
Selection of comments from service users
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Ashgate Hospice Quality Account May 2014 Anna Baker
Chaplaincy
Ashgate hospice employs a full time chaplain to provide spiritual care and support to
the patients and carers as an integral part of the holistic care. On average there are
30 – 40 face to face contacts per week. Part of the role is in providing post
bereavement support, leading groups and working with the family support and
bereavement team
Thank you for the understanding and kindness you gave to B A and myself during our vigil
at N’s bedside. I know N took comfort from the prayers and communion you gave him. I
assure you that you are the right man for the job....with gratitude
I wanted to say that it has been such a pleasure to get to know you. Your sensitivity, peace
and gentleness are wonderful and you carry something so precious – God’s presence.
Just a little note to say thank you for all your support over the last 4 months; I can’t tell you
how much I have appreciated it. The work you and your team do at Ashgate is wonderful,
and you are a real asset to the hospice.
Quotes from relatives cards to the Chaplain
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Ashgate Hospice Quality Account May 2014 Anna Baker
Quality indicators:
Prevention and management of pressure ulcers
Between 1st April 2012 and 31st March 2013, 353 patients were admitted to the IPU.
A Waterlow score was determined for all patients. Of the number admitted 104
(29%) patients had pressure ulcers on admission. All pressure ulcers, and areas at
risk of developing into a pressure ulcer, were given a grading using the EPUAP
classification system. All patients had a documented care plan, which includes
monitoring on an ongoing basis. Preventative measures were put in place for all
patients, such as pressure relieving mattresses and cushions. Collaborative working
with DCHS tissue viability team supports our staff in the latest prevention and
treatment of vulnerable patients
One case was reported to the CQC during this time, and developed because a
patient refused the recommended treatment and advice.
Prevention and management of patient falls
Between 1st April 2012 and 31st March 2013 there were 32 patient falls, none of
which were serious and needed no treatment or minor first aid only. This is an area,
as with all hospice settings, where we expect to see a high level of falls. All patients
have a falls risk assessment on admission, and preventative measures are put in
place following the assessment. Following a fall the risk assessment is reviewed
and further measures are implemented if necessary. Many patients are frail and
confused in the hospice setting and we therefore ensure high staffing levels are in
place.
Mandatory training
100% staff attendance at mandatory training days: topics include:
Fire, infection control, safeguarding, moving and handling, information governance
and resuscitation as core elements, with additional specific clinical topics planned
following appraisal and training needs analysis. (For example: intravenous
antibiotics, dementia awareness, and medicines management).
Infection prevention and control
Between 1st April 2012 and 31st March 2013 none of our patients developed MRSA
or C Difficile whilst in the ward. Two patients were admitted with MRSA in surgical
wounds which were treated successfully
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Ashgate Hospice Quality Account May 2014 Anna Baker
Our participation in clinical audits
To ensure that the hospice is providing a consistently high quality service, we
undertake our own clinical audits, using national audit tools developed specifically
for hospices, which have been peer reviewed and quality assessed. This allows us
to monitor the quality of care being provided in a systematic way and creates a
framework by which we can review this information and make improvements where
needed.
Each year, the Clinical Governance Committee approves the audit schedule for the
coming year. Priorities are selected in accordance with what is required by our
regulators and any areas where a formal audit would inform the risk management
processes within the hospice.
Through the Clinical Governance report, which is shared with the Health Care
Governance Committee, the Board of Directors is kept fully informed about the audit
results and any identified shortfalls. Through this process, the Board has received
an assurance of the quality of the services provided.
The following audits were completed between 1st April 2013 and 31st March 2014.
Self-assessment by the Accountable
This audit has to be completed annually.
Officer
The hospice was fully compliant with the legal
requirements.
Management of controlled drugs
This audit has to be completed annually to provide
evidence to support the self assessment by the
Accountable Officer.
The hospice was fully compliant with the legal
requirements
Infection control: Code of Practice
The hospice is fully compliant with the code of
Practice.

Patient/Carer experience:
Each service undertakes this survey bi annually
Ward
Last large audit May 2012. Informal audit and

feedback captured since and next audit due now
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Ashgate Hospice Quality Account May 2014 Anna Baker

Day unit
August 2013 demonstrated excellent results

Community Clinical Nurse
Due in Summer 2014
Specialists

Family Support & Bereavement


This audit is carried out continuously as part of
service governance and has given excellent results
Therapy Services
This audit is carried out continuously as part of
service governance and has given excellent results



Lymphoedema service
February 2014 and demonstrated excellent results
Referral to Treatment Time –
Community clinical nurse
Hospice at Home achieved 98% response time
specialists
Community CNS achieved 96% response time
Occupational Therapy achieved 95% response time
Patient and Family Support Team achieved 100%
response time
Lymphoedema team achieved 100% response time
Record Keeping
Initial audit on the use of clinical records on the
electronic records system completed in December
2014 for all teams.
Further audit planned for the autumn of 2014
What our staff says about the organisation
Ashgate hospice values the opinions of the staff regarding the quality of the service
provided and views are currently captured through a number of methods; staff panel
representatives, newsletters, informal drop in sessions with staff and members of
the Senior Management Team, and staff meetings. During 2013 the hospice
participated in the national Birdsong Survey, and the survey is due to be repeated
each year. Each directorate has looked at the results in detail, developed an action
plan and worked with the staff to improve areas that had been identified. The key
themes were shared with the board of trustees.
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Ashgate Hospice Quality Account May 2014 Anna Baker
The Board of Trustees’ commitment to quality
The Board of Trustees is fully committed to the quality agenda. The hospice has a
well established governance structure, with members of the Board having an active
role in ensuring that the hospice provides a consistently high quality service. There
are two recent additions to the Board of Trustees, both with a clinical and NHS
background. These additions also ensure a greater level of internal ‘check and
balance’ and enquiry into the quality of services that we provide.
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Ashgate Hospice Quality Account May 2014 Anna Baker
Annex A
Quality Account 2013//2014
Ashgate Hospice
Commissioner Statement
General Comments
NHS North Derbyshire Clinical Commissioning Group (NDCCG) as a commissioner
of services from Ashgate Hospice is providing the commissioner statement on the
quality account and in doing so has provided NHS Hardwick Clinical Commissioning
Group with the opportunity to make comments and contribute to the commissioner
statement. NDCCG can confirm that Ashgate Hospice has produced a Quality
Account that appears to be accurate and representative of the information available
to NDCCG through contract monitoring and quality assurance processes during the
year.
Measuring and Improving Performance
Last year Ashgate Hospice detailed 3 improvement priorities, these were the
recruitment of a Quality Audit and information manager, hearing the patient and
carer voice and meeting the challenges of the new commissioning environment, it is
clear from the Quality account that significant progress has been made in all of
these areas. There is evidence of a strong focus on quality, patient and carer
feedback throughout the account which should be commended and the
development of the new patient’s forum should enhance this further.
The hospice received an unannounced Care Quality Commission inspection in 2013
where it was confirmed that the hospice was meeting all essential standards of
quality and safety. The improvement priorities for 2014/15 focus on extension of
services to enable people to receive care in the place of their choice and briefly
comprise of –
 Participation in a national hospice benchmarking scheme, focusing on falls,
pressure ulcers and the management of medication
 Staff development to ensure clinical skills and competencies and maximise
care quality as a result
 Extension of community services specifically looking at 7 day service
provision and night time cover
It is clear from the data presented that the expansion of the Hospice at Home team
has led to a significant increase in both face to face and non face to face contacts,
which has increased the quality of care and support to the patients of North
Derbyshire and their families.
It is recognised that staff satisfaction and a feeling of being valued positively affects
patient care, Ashgate Hospice participated in the national Birdsong survey and the
results and themes have led to action plans and improvements which have been
shared with the board of trustees.
The Hospice has demonstrated good results in relation to infection control and there
have been no incidences of patients developing C Difficile or MRSA while on the
ward.
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Ashgate Hospice Quality Account May 2014 Anna Baker
All falls data is examined closely by the Hospice and there have been no serious
falls; the Hospice attributes this to ensuring high staffing levels are in place to assist
patients.
Additional comments
The Quality Account is an annual report to the public that aims to demonstrate that
the Hospice is assessing quality across the healthcare services provided. The
Quality Account is patient friendly and is enhanced by the patient comments and
feedback which are throughout and clearly demonstrate that the Hospice is
providing a comprehensive range of palliative and end of life care in a variety of
settings.
The Hospice has worked collaboratively with commissioners and all key
stakeholders to ensure patients receive high quality care in the right care setting.
NHS North Derbyshire Clinical Commissioning Group and associate commissioners
look forward to continuing to work with the Hospice to commission and deliver this
high quality patient care.
Jayne Stringfellow
Chief Nurse & Quality Officer
On behalf of NHS North Derbyshire Clinical Commissioning Group
9th June 2014
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Ashgate Hospice Quality Account May 2014 Anna Baker
Annex B
Quality Account 2013//2014
Ashgate Hospice
Healthwatch Statement
Healthwatch Derbyshire came into operation on the 1st April 2013 and was very
much in its infancy when asked to submit a response to last year’s Quality
Account.
As the result of a service evaluation conducted over 4 days in March/April 2014,
Healthwatch Derbyshire is now in a much better position to respond to this Quality
Account from an evidence based perspective. The intelligence gathered from
these visits has enabled us to reflect on the views and experiences of people
accessing the services provided by Ashgate Hospice.
The service evaluation found that the Ward and the Day Centre to be
immaculately clean, the gardens and meadows were beautiful and maintained to
high standard.
The Hospice was warm and welcoming with modern and up-to-date facilities.
There was a huge emphasis on quality of care, treatment and medication.
Patient satisfaction levels were extremely high; nothing remotely negative was
noted from a patient’s perspective, or from a carers’ view. Patients were made
to feel very comfortable and every patient received a high standard of care.
Carers were accommodated and supported by staff and volunteers.
Doctors were very attentive and all had a very good bedside manner with
medication changes and treatment results being chased up. Volunteers felt
supported to take on their numerous roles.
The full report can be found on the Healthwatch Derbyshire website.
Furthermore, Healthwatch Derbyshire is pleased to read about the previous
priority for 2013-14 of ‘Hearing the Patient and Carer Voice and their Experience
of Hospice Care’ and the organisation has clearly taken a proactive approach to
collating and using such feedback.
The independent feedback collected by Healthwatch Derbyshire as part of our
recent service visit, and the overwhelmingly positive findings gives another
valuable source of independent feedback and presents the opportunity for
triangulation with other sources.
Healthwatch Derbyshire is providing, and will continue to provide, a valuable
source of independent patient feedback to be used by the organisation as
appropriate. All feedback received about Ashgate Hospice and the services it
provides will continue to be shared throughout 2014-15.
We look forward to continuing to work Ashgate Hospice now and in the future.
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Ashgate Hospice Quality Account May 2014 Anna Baker