The Butterwick Hospice
at
Bishop Auckland
Quality Account
2013 - 2014
The Butterwick Hospice at Bishop Auckland
Woodhouse Lane
Bishop Auckland
Co Durham DL14 6JZ
Registered Charity 1044816
Our Mission Statement and Philosophy
Why we are here
We aim to improve the quality of life for those who have a progressive life limiting illness and those
close to them and to offer positive support for every challenge they may encounter during their illness
and to see death as part of life’s journey.
In particular we will:
Provide supportive and specialist palliative care for adults with progressive life limiting conditions
Ensure each person receives care in a homely environment whilst maintaining privacy, dignity and
choice.
Provide holistic centred care by responding to and respecting the patient and those close to them by
meeting their individual, physical, social, cultural, educational, spiritual and emotional needs
throughout the illness and bereavement.
Acknowledge and respect the way those close to the patient care for them and endeavour to continue
their chosen pattern of care.
Work together in developing an environment based on support and mutual respect.
Maintain the high quality of the service through ongoing reflection, evaluation and education.
Communicate effectively and efficiently both within the Hospice and with external agencies, to ensure
continuity of care and promote service development.
Part 1: Chief Executive’s Statement
It gives me great pleasure to present the Quality Account for the Butterwick Hospice at Bishop
Auckland in respect of the year ended 31st March 2014.
The Hospice is an integral part of Butterwick Hospice Care (registered charity 1044816) which provides
services from three separate Hospices in the North East of England. All the Hospices’ services are
provided totally without charge to our patients and their carers.
The day to day operational management of the Butterwick Hospice at Bishop Auckland’s clinical
services are under the leadership of Mrs Paula Wood who is designated the Registered Manager in the
Hospice’s registration with the Care Quality Commission.
The Butterwick Hospice at Bishop Auckland endeavours to provide an excellence in evidence based
palliative care for all patients regardless of age or diagnosis; to be a centre of expertise and a specialist
resource within the community as a whole.
The needs of patients and their carers are paramount to the Charity’s existence and are the root and
focus of all we do.
Quality is at the core of the Charity’s strategic and operational priorities.
An independent impartial assessment of the quality of care provided was obtained when the
Care Quality Commission performed a routine unannounced inspection of the Hospice on
17th May 2013. Their Report showed that the Hospice was meeting all of the required
standards. A copy of their full Report is available at: www.cqc.org.uk/directory/1113000544.
During the last year we have worked effectively in partnership with NHS Durham Dales, Sedgefield &
Easington Clinical Commissioning Group and other partners for the benefit of the community we freely
serve.
In the year the Hospice has achieved the Commissioning for Quality and Innovation (CQUIN) outcomes
detailed in the 2013/14 Contract with the NHS Durham Dales, Sedgefield & Easington Clinical
Commissioning Group.
The Charity only achieves its key objectives because of the professional skills, commitment and
enthusiasm of our staff and volunteers.
I am responsible for the preparation of this report and its contents. To the best of my knowledge, the
information reported within this Quality Account is accurate and a fair representation of the quality of
healthcare provided by our Hospice.
Graham Leggatt-Chidgey
Chief Executive
May 2014
Part 2:
1.
Priorities for improvement and statements of assurance
from the board (in regulations)
IMPROVEMENT
Within the Organisation quality is fundamental to improvement and accountability. The Board of
Trustee’s continue to support and promote the ongoing development and improvement of services to
ensure that the care and support provided evolves to meet patient and carer needs.
The priorities for quality improvement for 2014/15 are set out below.
These priorities have been identified in conjunction with patients, carers, staff and stakeholders. The
priorities we have selected will impact directly on each of the three priority domains:
a.

Patient safety

Clinical effectiveness

Patient experience
Priorities for improvement 2014-2015
Patient Safety
 Priority One
To introduce a clinical champion for
oxygen and HOOF management
How was this identified as a priority?
An estimated 3 million people have Chronic Obstructive Airway Disease in the UK. The NICE Guidance
for COPD 2010 identifies that people with end stage COPD should be given care from a Multidisciplinary
Palliative Care Team.
The number of people referred to the Hospice with a non cancer diagnosis has increased significantly.
The Hospice now provides care to 45% patients with a non cancer diagnosis.
There is also an increase in the number of patients attending the Hospice who require long term
oxygen therapy. Following an incident when a staff member accidentally dropped a transportable
oxygen bottle causing some oxygen to escape it highlighted the importance of training regarding
transportation, storage and management of oxygen. In order to ensure patient safety a Registered
Nurse will be identified as a Clinical Champion to take the lead in the management of patients who
require oxygen therapy and to implement training to the rest of the clinical team.
How will this priority be achieved?
A clinical staff meeting will discuss the introduction of a Clinical Champion in relation to oxygen and
HOOF management and will identify a Registered Nurse who has an interest in Chronic Obstructive
Pulmonary Disease.
External training will be sought in order to train the Clinical Champion with regards to Oxygen and
HOOF management.
The Clinical Champion will arrange training sessions with all the clinical staff.
The Clinical Champion will formulate a competency framework for the management / administration
/transportation and storage of oxygen.
The Clinical Champion will review the competencies of all clinical staff using the competency framework
for the management/administration / transportation and storage of oxygen.
How will progress be monitored and reported?
Staff training records will be updated when staff have completed training in transportation/ storage
and management of oxygen therapy.
Individual competency records will be completed and kept in staff files.
An evaluation of patient records and completed HOOF forms will be performed to ensure information is
fully completed and accurate.
An audit will performed into the correct storage of oxygen on the Hospice premises.
Clinical Effectiveness
 Priority Two
The implementation of the Carers
support Needs Assessment Tool
How was this identified as a priority?
End of Life Care policy and guidance recognises the important contribution of family carers to patient
support and recommends that their needs should be assessed in order to support them in their caring
role.
Although the Hospice mission statement identifies the needs of carers as well as the patient the
Hospice does not use a specific evidence based tool directly for carers. Currently carers needs are
assessed within the patient assessment process.
The Hospice wanted to assess carers needs independently and therefore reviewed the literature to
identify if there was an identified validated tool available.
The National Forum for Hospice at Home endorsed by Help the Hospices had been involved in a
programme of research commencing in 2008 with Dr Gunne Grande in order to develop an evidence
based assessment tool. This work led to the development of the Carers Support Needs Assessment
Tool (CSNAT).
The CSNAT approach is a process which provides carers the opportunity to consider, express and
prioritise any further support needs they have. The assessment conversation forms the basis for
subsequent action planning. The process of assessment is facilitated by the practitioner and led by the
carer.
This validated assessment tool appeared easy to use for the carer and straight forward for the Hospice
to implement.
How will this priority be achieved?
The Hospice Registered Manager and Palliative Home Care Leader to attend training workshop on the
implementation of the Carers Support Needs Assessment Tool.
Training sessions will then be delivered to the nursing team on the background to using the tool and
how to implement the assessment tool in practice.
The assessment documents will be given to the nursing team in order to introduce the assessment
process to carers during their first visit.
Letters will be sent to the District Nursing Teams informing them that the Hospice will be introducing
the Carers Support needs assessment tool within patient’s homes.
How will progress be monitored and reported?
Monthly data will be collated onto the Hospice database in relation to:

The number of new patients referred to the service

The number of Carers Support Needs Assessments distributed.

The number of CSNATS completed.

The number of CSNAT`s actioned.
A questionnaire will be completed by the nursing team prior to the implementation of the tool and then
6 months after the tool has been implemented.
Patient experience

Priority Three
Implementation of the NHS Friends and
family test within the Hospice.
How was this identified as a priority?
Improving patient experience is a key priority for the Hospice and also incorporated in the
Governments vision and is set out in the White Paper ‘Equity and Excellence’. The 2012/13 Operating
Framework made clear the priority for the NHS was to put the patient centre stage and to have a focus
on improving patient experience.
The NHS Outcomes Framework Domain 4 focuses on ‘ensuring that people have a positive experience
of care’.
The Francis Inquiry report into Mid Staffordshire NHS Foundation Trust highlighted the importance of ‘a
timely, effective mechanism to draw attention to failings to provide adequate level of care’ and in
addition it was important that feedback is gathered from a full range of patients.
The Friends and Family Test is a simple, comparable test which provides a mechanism to identify poor
performance and encourage improvements where services do not live up to the expectation of
patients. It is a quick, consistent, standardised patient experience indicator and will provide a simple,
easily understandable metric based on near time experience, which is comparable from a patient’s
point of view and can act as a benchmark for organisations.
The friends and family Test enables the public to compare healthcare services, identify those who are
performing well and allow other organisations to improve their services.
How will this priority be achieved?
The Friends and Family Test will be produced on a postcard. Information will be displayed in the
Hospice informing patients about the Friends and Family Test. In order to ensure confidentiality and
anonymity for patients’ postcards will be posted on completion into a box in the Hospice reception.
The results from the Friends and Family Test will be inputted onto the Hospice database. Results will be
displayed in the Hospice on a monthly basis and the results will also be forwarded to the Clinical
Commissioning Group.
How will progress be monitored and reported?
The results of the Family and Friends Test will be collated into a report with a completed action plan.
This report will then be discussed as part of the Integrated Governance meeting which has
representation from all Hospice departments.
The results will form part of the minutes for the Clinical Governance and Strategy Committee which has
trustee representation.
2.2
Review of services
During 2013/14 the Butterwick Hospice at Bishop Auckland provided five key services:
 Hospice at Home
 Family support and bereavement service
 Neurological service
 Day Hospices across 4 sites
 Outpatients
We have reviewed all the data available on the quality of care in all of the above services.
Below are some comments from a patient evaluation based on the impact the Hospice has to quality of
life.
‘Do you feel the involvement with the Hospice has had an impact on your quality of life?’







“A huge impact. It feels good to go out on my own (from family always helping me) to
socialise being around so many people who are genuine, compassionate and caring both
staff and patients alike. I now look forward to going out on my one day a week”
“Definitely – aided my recovery”
“It certainly does. I do rotation but I’m all ready to go because I look forward to going
because it’s a day I know my family don’t have to worry”
“I actually look forward to going to the Hospice. I have made a lot of friends and really
admire the staff and volunteers who go out of their way to make my life comfortable”
“Meeting other people every week”
“It gets me out of the house and into company which I enjoy”
“It has given me a reason to look forward to going, mixing with people in similar
circumstances”
The income generated by the NHS services reviewed in 2013/14 represents 100% of the total income
generated from the provision of the NHS services by the Butterwick Hospice for 2013/2014. The
income generated from the NHS represents approximately 45% of the overall patient care costs
incurred by the Hospice.
2.3
Participation in Clinical Audits, National Confidential Enquiries
During 2013/14 there were no clinical audits or national confidential enquiries covering NHS services
relating to palliative care. The Butterwick Hospice at Bishop Auckland only provides palliative care
therefore were ineligible to participate.
Local Clinical Audit and Service Improvement
During 2013/2014 the Hospice performed several audits using Help the Hospices (the national umbrella
membership Organisation for independent charitable Hospices) audit tools which are nationally
recognised and which set a benchmark to monitor the quality and efficiency of Hospice services across
the country.
Audits performed during 2013/2014










Record Keeping
Day care admission and initial assessment
Preferred place of care
Support Team Assessment schedule
Medication documentation
Safety Thermometer
Patient questionnaires
Carer questionnaires
Bereavement evaluation tool Response times to referrals and assessment
Infection control audits.
BUTTERWICK HOSPICE CARE
PALLIATIVE HOME CARE SERVICE
Preferred Place of Care
April 2014
PREFERRED PLACE OF CARE
January – March 2014
INTRODUCTION
Following publication of the preferred place of care document evidence suggested that whilst more
than 50% of patients wish to die at home fewer than 20% actually do so.
The hospice was approached by the End Of Life Project Co-ordinator from Cancer Care Alliance to audit
the preferred place of care for patients within the Palliative Hone Care Services.
CRITERIA
The sample used was looking at 30 sets of notes of patients who died between January – March 2014.
CONCLUSION
The results showed that the preferred place of care was recorded in all cases.
2 patients did not die in the preferred place of care while the remaining 28 died at home, as they
wished. This highlighted that within the Palliative Home Care Service 93% of patients died in their
preferred place of care.
RECOMMENDATIONS

Continue to audit a sample of patients who have died in a 3 month period. This is in order to
identify any underlying trends also to improve recording of information and to identify any areas
for improvement in the service.

Ensure the information regarding PPC is recorded for each patient to provide accurate audit
results.
RESULTS
The results are as follows:
Patient
PPC
Place of Death
Yes
130361
Home
Home

130377
Home
Home

140001
Home
Home

130409
Home
Home

130312
Home
Home

140002
Home
Home

130295
Home
Home

140019
Home
Home

130399
Home
Home

140024
Home
Home

130282
Home
Home

140031
Home
Home

140038
Home
Home

140042
Home
Home

140009
Home
Home

No
Patient
PPC
Place of Death
Yes
140052
Home
Home

140044
Home
Home

130400
Home
Nursing Home
130252
Home
Home

140057
Home
Home

140049
Home
Home

130134
Home
Home

140063
Home
Home

140007
Home
Home

140066
Home
Hospice
140012
Home
Home

140036
Home
Home

140090
Home
Home

140014
Home
Home

70122
Home
Home

No


30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
Died in Preferred Place
of Care
Did not die in Preferred
Place of Care
Not Recorded
No. of Patients
Overall Percentage Summary
100%
90%
Died in
Preferred
Place
80%
70%
60%
Died
Elsewhere
50%
40%
30%
Not
Recorded
20%
10%
0%
Oct
06 Jan
07
Jan - Apr Mar Sept
09
09
Oct May - Nov May - Oct - Jan - Apr - Jan - Jul- Oct - Jan 09Oct 10 - Oct
Dec Mar Dec
Jun Sept Dec Mar
Mar
10
Apr
11
11
12
12
13
13
13
14
10
11
Hospice Environmental Audit
Hospice: Bishop Auckland Day Unit
Calculation:
yes x 100%
yes + no (do not include N/A responses)
Adult / Children
Auditor: Julie Olsen accompanied
by L Blakemore
1
Audit date: 25.6.13
Yes
Staff know where infection prevention and control policies are located (question two
staff).
√
2
The environment is uncluttered, dust free and visibly clean.
√
3
√
5
Bins are foot operated and in working order.
Waste is segregated correctly, labelled and stored safely in a designated secure room
prior to collection.
Linen skips are used appropriately, not overfilled and stored safely in a designated
secure room prior to collection.
6
Detergent wipes are stored in wipe dispensers and are readily available.
√
7
Storage areas are uncluttered, clean and equipment is stored off the floor.
√
8
Communal facilities eg toilets and bathrooms are clean.
√
9
There is no evidence of inappropriate use of communal toiletries.
√
10
Multi patient equipment is dust free, visibly clean and cleaned after each use.
11
There is evidence of a weekly cleaning programme for patient equipment.
The linen cupboard is designated for the storage of clean linen and clean items only.
4
Audit score: 92%
√
√
√
√
13
A cleaning programme is in place for toys.
√
14
Toys are visibly clean.
√
15
Wheelchairs are clean and serviceable.
√
16
Furniture is intact, covered in impermeable material, able to be cleaned easily.
Patient wash bowls are washed, dried and stored appropriately, inverted after each use.
√
√
17
18
Telephones and computer keyboards are clean.
√
19
The kitchen is clean and tidy.
√
20
Single patient use slings are available for use with hoists.
√
21
Bed area curtains and blinds are visibly clean.
√
22
Disposable suction liners are in use and changed between patients.
Mattress covers are intact with no evidence of staining or contamination to the foam
interior (inspect two mattresses-remove cover, inspect outside and inside surface and
foam interior).
√
There is an up to date record of mattress inspection available.
Pillow covers are fully sealed and intact with no evidence of contamination to the foam
interior (inspect pillows from two beds).
There is planned programme of maintenance and water testing for the hydrotherapy
pool.
√
24
25
26
N/A
√
12
23
No
√
√
√
Environmental Audit Action Plan
Action plan required?
YES
Problem/issue
Hairdressers room –
 Water damage to the
ceiling which require
repair.
Hospice: Bishop Auckland Day Unit
Actions
Update Dec
2013
Roof
damage
awaiting
repair
Maintenance team
to investigate cause
of damage and
arrange repair
Fiona Wagner
/ Lesley
Blakemore
Housekeeping team
to be informed
Fiona Wagner
Staff are aware that the flat
roof above this area needs
inspecting for damage.

The low shelf and hair
dressers chairs were noted
to be dusty (chair legs) and
covered in hair.

Although equipment is
cleaned weekly, a record
should be held for evidence
of this.

Treatment room –
 Torn chair requires repair.
Date for
review



Nominated
responsibility
Date
completed
July 2013

Hairdresser to be
informed of the
need to record
cleaning schedule
Maintenance team
to assess damage
and arrange repair.
Paula Wood
August
2013
July 2013
August
2013
Fiona Wagner
Aug 2013


Underside of treatment
couch dusty.


Fabric notice board,
replace with wipe cleanable
when funding allows,
although recognised as low
risk.
Laundry Room –
 The bucket sink can be
removed when funding
allows.


Patient toilets –
 Small wooden shelves
below soap dispensers are
worn and unable to be
cleaned effectively, replace
with wipe cleanable
shelves or remove if not
required.
Notice board to be
replaced when
funding allows.
Sink to be removed
when funding
allows.
Discussion
required to decide
replacement or
removal
Fiona Wagner
Fiona Wagner
/ Lesley
Blakemore
August
2013
Chair
disposed of.
July 2013
August
2013
Fiona Wagner
September
2013
Paula Wood /
Lesley
Blakemore
September
2013
Removed
Aug 2013

Bathroom –
 Wooden cupboard on floor
– not able to be cleaned
easily, chipboard exposed,
Housekeeping team
to be informed
Discussion
required to decide
replacement or
removal
Paula Wood /
Lesley
Blakemore
September
2013
Awaiting
funds to
replace
replace with wipe cleanable
wall cupboard if still
required.

Banana board to be
replaced when
funding allows.
Wooden banana slide board
– replace with wipe
cleanable board when
funding allows.
Dirty utility in new wing –


Paula Wood /
Lesley
Blakemore
September
2013

Stacked wash bowls on top
of bed pan washer. Move
to a clean room and store
inverted.
Bowls to be moved
to a clean room and
staff to be
reminded to store
bowls individually
inverted.
Paula Wood /
Lesley
Blakemore
September
2013
July 2013

Old shower room –


Work in progress to
convert to a store
room. Old drain
under new shelving
needs to be
covered/sealed.
Ensure measures are
being taken to
prevent dust
contamination of
corridor/patient
areas.

Ensure the drain
has been
covered/sealed
effectively.
Ensure areas are
sealed effectively
when any work is
in progress.
Fiona Wagner
/ Lesley
Blakemore
September
2013
Aug 2013
Paula Wood /
Lesley
Blakemore
September
2013
Aug 2013
September
2013
Copies to: Infection Prevention & Control Link Worker and Head of Hospice Inpatient Services
Hospice Hand Hygiene Audit
Hospice: Bishop Auckland Day Unit
Calculation:
yes x 100%
yes + no (do not include N/A responses)
Adult / Children
Auditor: Julie Olsen accompanied by
L Blakemore
Audit score: 94%
Audit date: 25.6.13
Yes
√
2
Wall mounted handrub is available at the entrance/exit to the ward/dept.
A poster is displayed to make visitors aware of the importance of hand hygiene before entering and
leaving the dept.
3
Up-to-date hand hygiene awareness posters are on display in the ward/dept.
√
4
A hand cleaning techniques poster is displayed at all clinical hand wash sinks.
√
5
All staff comply with the uniform policy and bare below the elbows guidance.
Clinical hand wash sinks are designated for handwashing only and are accessible, clean, free from
plugs, overflows, equipment, and patient’s property.
√
Elbow operated or sensor taps are available at all clinical hand wash sinks.
Liquid soap, paper hand towels and a foot operated waste bin are available at all hand wash sinks.
√
1
6
7
√
√
9
Handrub is available in all patient rooms (via wall dispensers and/or personal handrub dispensers
carried by HCW).
√
10
A wall mounted hand cream dispenser is available on the ward/dept.
√
11
All hand hygiene product dispensers are clean and filled, and drip trays are clean.
√
12
All dispensers are correctly labelled (soap/handrub/handcream).
√
13
Staff know where extra supplies of hand hygiene products are kept (question 2 staff).
Staff are aware of the Hand Hygiene Policy and know how to access it.
(question 2 staff).
Staff are aware of when it is not appropriate to use handrub
(question 2 staff).
Staff decontaminate their hands before serving meals to the patients (question/observe two staff).
√
15
√
√
√
16
17
N/A
√
8
14
No
Patients are offered opportunities for hand hygiene including after going to the toilet and before
meals (question two patients).
Action plan required?
√
YES
Problem/issue
Actions
Nominated
responsibility
Date for
review
Date
completed
Remove plug from handwash sink in
domestic cupboard
Maintenance form to be
completed to have plug
removed.
Paula Wood /
Lesley
Blakemore
September
2013
July 2013
Copies to: Infection Prevention & Control Link Worker and Head of Hospice Inpatient Services
Hospice Sharps Safety Audit
Hospice: Bishop Auckland Day Unit
Calculation:
yes x 100%
yes + no (do not include N/A responses)
Adult / Children
Auditor: Julie Olsen accompanied
by L Blakemore
Audit score: 100%
Audit date: 25.6.13
Yes
1
Staff are aware of the waste disposal and accidental exposure to bodily fluids policies
and where they are located (question two staff).
√
2
Sharps bins are correctly assembled and an assembly poster is displayed.
√
3
Sharps bins are signed and dated.
√
4
Sharps bins are less than two thirds full and free of non sharp items.
√
5
Sharps bins are closed when not in use.
√
6
Appropriately sized sharps bins are available.
√
7
Sharps bins are positioned safely.
√
8
Sharps are disposed of at the point of use (observe/question two staff)
√
9
Locked sharps bins are stored in a designated secure room prior to collection.
√
10
Blood glucose meter storage boxes are free of used sharps.
√
11
An ‘accidental exposure to bodily fluid’ poster is on display.
Staff know what actions to take in the event of a needlestick injury (question two staff).
√
N/A
√
12
13
No
Staff understand what post exposure prophylaxis (PEP) is, and how to access it
(question two staff).
Action plan required?
Problem/issue
√
NO
Actions
Nominated
responsibility
COMMENTS
It is excellent that full compliance was achieved with all applicable standards.
Copies to: Infection Prevention & Control Link Worker, Head of Hospice Inpatient Services
Date for
completion
Date for
review
Hospice Personal Protective Equipment (PPE) Audit
Hospice: Bishop Auckland Day Unit
Calculation:
yes x 100%
yes + no (do not include N/A responses)
Adult / Children
Auditor: Julie Olsen
accompanied by L Blakemore
Audit score: 100%
Audit date: 25.6.13
Yes
No
N/A
1
Staff are aware of the standard precautions policy and its location (question two
staff).
√
2
There is an adequate supply of gloves available.
√
3
There is an adequate supply of aprons available.
√
4
Glove/apron dispensers are available in patient areas.
√
5
Gloves are worn as single use items
√
6
Face masks are available (surgical and FFP3).
√
7
Face visors are available.
√
8
Staff are observed using PPE appropriately
√
9
PPE is disposed of appropriately.
√
10
Staff are observed decontaminating their hands after removing PPE.
Visitors are given guidance on PPE when appropriate for their use (question two
staff)
Staff are aware of correct procedure to follow when dealing with blood spillages
(question two staff).
√
11
12
Action plan required?
Problem/issue
√
√
NO
Actions
Nominated
responsibility
Date for
completion
COMMENTS
No clinical activity at the time of the audit, therefore some standards not applicable. It is excellent that full
compliance was achieved with all applicable standards.
Date for
review
Part 3
3.1
Review of quality performance 2013- 2014
Development 1: Patient Safety
The Introduction of a patient
reference group within Butterwick
Hospice at Bishop Auckland
State how development was identified
The Francis report published in Feb 2013 highlighted the serious issues from Mid Staffordshire NHS
Foundation Trust. One of the themes to come from the report was to recommend:
Openness –enabling concerns and complaints to be raised freely without fear and questions asked to
be answered.
Transparency- allowing information about the truth about performance and outcomes to be shared
with staff, patients, the public and regulators.
Candour-any patient harmed by the provision of a healthcare service is informed of the fact and an
appropriate remedy offered, regardless of whether a complaint has been made or a question asked
about it.
The Butterwick Hospice promotes openness and honesty with the public and regulators by producing
an annual Quality Account and inspection reports from the Care Quality Commission are available for
all to access. However recommendation.62 from the Francis Report emphasises improved patient focus
which should incorporate greater public and patient involvement into its own structures.
Introducing a patient reference group within the Hospice would allow open discussions regarding
service developments/evaluation of audit reports/Review of Hospice literature and review of how
complaints / incidents are handled.
How was it achieved?
Letters were distributed to all patients/clients to identify who would be interested in being involved in a
patient reference group.
Once the group was identified, terms of reference were formulated to clarify the purpose of the group,
how regularly the group would meet and the membership of the group.
Meeting dates were arranged and circulated to the group.
A regular agenda was set and minutes of meetings were recorded and then circulated to the group.
Review and evaluation of success of development
The initial response to the request for members to a reference group from patients was poor; however
the Hospice had a bereavement group called the Look Ahead Group who met weekly. An explanation
was given to the group regarding the purpose of introducing a reference group within the Hospice and
3 clients agreed to take part.
A meeting was arranged with the 3 clients, the Registered Manager, Head of Family support and a
Hospice volunteer. Terms of reference were agreed and the reference group agreed to meet quarterly.
Minutes of meetings were produced and circulated. Any action points were set and recorded in the
minutes.
The patient/ client reference group have successfully reviewed the family support literature and have
also been involved in producing an information booklet in relation to `What to do following
bereavement.
Development 2 Clinical Effectiveness
To obtain the children’s charter
status
State how development was identified
The number of children accessing the Hospice family support service had increased over the past 12
months. The Hospice was also working in partnership with the Bridge Young carers. This group support
children who are in a carer capacity where a parent is diagnosed with a progressive life limiting illness.
The Bridge Young Carers informed the Hospice that we could obtain the Children’s Charter status which
is a quality marker stating that you meet the holistic needs of children in your organisation. The
Children’s Charter is a recognised accreditation with the Care Quality Commission.
How was it achieved?
County Durham and Darlington NHS and Durham County Council have jointly endorsed the use of a
self assessment tool for the Children’s Charter.
This self assessment was completed to identify the Hospices current position in meeting the
requirements of the charter.
A member of the Hospice family support team was allocated to work with the Bridge young carers. The
self assessment was completed by the Hospice family support worker.
Any areas that the Hospice did not currently achieve were formulated into an action plan. This action
plan was reviewed regularly by the Hospice family support worker and the Bridge young carers until all
pledges were met within a set time frame.
The Hospice produced a policy for working with a child or young person which incorporated a flow chart
for referral to other agencies.
A philosophy of care towards young carers was also produced.
An information board was displayed in the Hospice waiting area which highlighted information
regarding how to identify a young carer and common signs that children or young people might be
young carers.
Review and evaluation of success of development
The self-assessment was then forwarded for accreditation.
Once accreditation of the Children’s Charter was given, the Hospice informed the Care Quality
Commission and we are now able to promote the Children’s Charter within the Hospice documentation
and information packs.
To introduce a tool for the
identification of patients with
dementia, alongside their known
medical conditions.
State how development was identified
Dementia is a significant challenge to the NHS. Currently only 42% of people with dementia in England
have a formal diagnosis despite the fact that a diagnosis can greatly improve the quality of life of the
person with dementia. In order to increase the number of people diagnosed with dementia, the
Department of Health have introduced a dementia CQUIN. The Hospice continuously strives to deliver
high quality care, therefore working within the dementia CQUIN would allow the Hospice to identify
patients who may have dementia alongside their known medical condition and refer to appropriate
services for a further in depth assessment, as well as supporting their carers.
How was it achieved?
100% clinical staff completed training in dementia awareness.
A dementia diagnostic assessment tool was performed on admission if the patient met the stipulated
trigger.
Below is a table identifying the number of assessments performed.
July 1st 2013- 31st March 2014
Number of patients who underwent a nursing assessment
Number of patients with a known dementia
Number of patients who underwent a dementia assessment
Number of patients referred to GP following a dementia assessment
104
4
2
1
As part of the CQUIN proposal the Hospice was asked to perform an environmental audit to ensure the
building was dementia friendly. The Hospice reviewed different environmental assessment tools and
identified the Kings Fund EHE environmental assessment tool to implement as this was built on the
work performed by NHS Trusts to support the implementation of the National Dementia Strategy in
England. This assessment tool contained 7 overarching criteria and sets of questions to prompt
discussions.
A baseline assessment of the Hospice building was performed to identify any reasonable adjustments
required to improve the experience of dementia patients and their carers who accessed the Hospice
services.
BUTTERWICK HOSPICE CARE
COMMENTS AND ACTION PLAN FOLLOWING A COMPLETED AUDIT
This form is to be completed following an audit. Please give comments where appropriate where criteria are not fully met and complete action section
to show how your department aims to increase the level of achievement for the specific criteria (where criteria numbers exist) or areas for
improvement.
Please send a copy of your results to the Quality and Development Nurse for monitoring purposes and collation into the organisation’s
audit log.
Title of audit
Dept/Site to which audit relates
Action Plan completed by:
Signature
Criteria
No.
Dementia Environmental Assessment Tool
Audit undertaken by:Bishop Auckland Hospice
Paula Wood
Comments
1.f
Limited space for wheelchairs in waiting
area if seating area is full.
4.h
No small seating areas along main
corridor.
Toilet signs are not visible from all areas.
5.a
Name and
Designation
Action Plan
To remove 1 chair from waiting area to
make space for a wheelchair.
To identify an area to make available a
seating area for people to rest along main
corridor.
To purchase toilet signs and erect in all
areas for people to see.
Anneliese Whitehead
2nd July 2013
Registered Manager
By whom
By when
Date Achieved
Paula Wood
31st August
2013
31st Aug
2013
Paula Wood
31st August
2013
31st Aug
2013
Fiona
Wagner
31st October
2013
31st March
2014
Update Dec
Signs now
ordered
5.c
Toilet signs have small pictures and
signage however they may be difficult to
see.
To purchase more appropriate signage for
toilet doors.
Fiona
Wagner
31st October
2013
Update Dec
Signs now
ordered
31st March
2014
Criteria
No.
5.h
Comments
Small markings of red and blue on taps
however may be difficult to see.
Action Plan
To have more noticeable markings
indicating hot and cold taps.
By whom
Fiona
Wagner
Please see criteria number 5c
6.b
6.c
Please see criteria number 5c
6.g
No signage to new outpatient wing.
Signage chosen. To purchase when
funding allows.
Jackie Firth
7.c
Main reception area occasionally
cluttered with information and goods.
To ensure only relevant information and
goods are displayed.
Paula Wood
7.d
Corridor floor noisy.
To look for alternative flooring when
current flooring requires replacing.
Fiona
Wagner
By when
Date Achieved
31st 0ctober
2013
31st March
2014
Update Dec
Signs now
ordered
31st March
2014
Update Dec
Signs now
ordered
31st March
2014
Update Dec
Signage now
ordered.
31st March
2014
31st August
2013
31st Aug
2013
Flooring does
not need
replacing at
present. To
look at
alternative
flooring when
needed.
Another part of the CQUIN proposal was to introduce a Carer questionnaire to be distributed to any
carer whose loved one was diagnosed with dementia following the initial Hospice assessment to ensure
they were being fully supported.
BUTTERWICK HOSPICE QUESTIONNAIRE
This questionnaire is designed to help us gather information to ensure that the
Hospice is providing adequate care and support to patients with dementia and their
relatives.
For each item identified below, circle the number
to the right that best fits your judgment of its quality.
Use the rating scale to select the quality number.
Very helpful
Quite Helpful
A Little Help
No Help
Not Sure
No Reply
Scale
1.
Recognising and supporting carer’s emotional need?
1
2
3
4
5
6
2.
Recognising and supporting the person with Dementia’s
emotional needs?
1
2
3
4
5
6
3.
Recognising and supporting the carer’s physical needs
1
2
3
4
5
6
4.
Recognising and supporting the person with Dementia’s
physical needs?
1
2
3
4
5
6
5.
Recognising and supporting carer’s social needs?
1
2
3
4
5
6
6.
Recognising and supporting the person with Dementia’s social
needs?
1
2
3
4
5
6
7.
Building trust and establishing a good rapport?
1
2
3
4
5
6
8.
Showing compassion, respect and understanding?
1
2
3
4
5
6
9.
In being a good listener?
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
How helpful was the hospice in…
10. In advising on understanding the impact for caring for
someone with dementia?
11. In advising on relevant services and support agencies?
12. In offering advice, guidance and support with caring for
someone with Dementia?
13. In offering strategies to help the carer cope with caring?
14. In exploring the impact of dementia on the family as a
whole?
15. In working with other professionals to provide coordinated
care?
Review and evaluation of success of development
Staff training records were updated when staff accessed dementia Awareness training.
In order to identify the number of patients referred for further in depth dementia assessment was
recorded on the Hospice database.
An environmental audit and action plan was produced to identify areas and action required to improve
the environment of people with dementia.
A Carer’s questionnaire was sent to all carers of patients who had been formally diagnosed with
dementia to identify whether they felt supported. An action plan was then produced with the outcomes
of the questionnaire and any actions required.
Patient experience

Priority Three
Questionnaire to capture patient and
carer experience of Hospice services
and experiences at time of death
State how development was identified
This was identified as a priority in the Hospice Quality Account for 2012/13.The results of the carer
questionnaires was extremely positive; however the Hospice only received a 31% response rate.
During 2013/ 14 the Hospice wants to improve the response rate and will identify ways in which this
can be achieved.
How was it achieved?
Patients were identified on the Hospice database. Following the death of the patient a questionnaire
was posted to the patient’s next of kin three months post bereavement, rather than previously being
posted 6 months post bereavement. The number of questionnaires distributed were monitored against
the number of responses received.
The Butterwick Hospice liaised with other Hospices in order to share ideas and look at different
methods in order to increase the response rate.
Review and evaluation of success of development
The results of the questionnaires were collated and a report was then produced quarterly highlighting
the results. An action plan was formed following each quarterly report to highlight any action required
from the questionnaires. The results were then forwarded to stakeholders and staff.
The Hospice then looked at the overall response rate in comparison to the previous year’s results. This
showed an increase of 25%.
April 1st 2012-March 31st 2013
April 1st 2013- March 31st 2014
Response rate – 26%
Response rate – 51%
Below are some comments from Carers.

“No comment to make – Everything was perfect, my wife loved having the carers around”

“The nurses at the Hospice knew my mam personally over the years. My mam counted them
as friends rather than staff. We are grateful for the empathy, love, care and support shown
to my mam.”

“Throughout my husband’s illness the care was a lifeline to me to have time for myself, a 24
hour carer. Very much appreciated.”

“Your care for our Dad meant that as a family we could get two or three nights sleep a week
and as we cared for Dad at home that was invaluable. Our Dad liked and trusted your
nurses, as we all did.”

“We found that the assistance and care was excellent and the girls were a great support to
the whole family as well as our mum. Thank you so much, we really appreciated all the help
you gave.”
The National Council for Palliative Care: Minimum Data sets
We have chosen to present information from the NCPC minimum data set which is the only information
collected nationally on Hospice activity. The figures below provide information on the activity and
outcomes of care for patients accessing the Butterwick Hospice in Bishop Auckland and outreach
services.
April 07 March 08
April 08 March 09
April 09 March 10
April 10 March 11
April 11 March 12
April 12 March 13
April 13 March 14
102
89
147
106
91
116
108
1407
1229
1250
1049
1317
1317
1208
No' of Patients who attended Richardson
Day Hospice
20
21
38
29
15
37
25
No' of attendances to Richardson Day
Hospice
307
349
342
264
208
237
300
No' of Patients who attended Weardale
Day Hospice
28
28
30
35
17
34
24
No' of attendances to Weardale Day
Hospice
308
346
300
266
264
284
277
No' of Patients who attended Sedgefield
Day Hospice
29
20
33
30
22
28
23
No' of attendances to Sedgefield Day
Hospice
416
473
482
374
479
425
257
119
100
182
136
117
137
128
1264
1110
987
997
1088
1016
973
9855
8964
7546
7703
8063
7458
7218
Day Hospices
No' of Patients who attended Bishop
Auckland Day Hospice
No' of attendances to Bishop Auckland Day
Hospice
Palliative Home Care Team (PHCT)
No' of Patients who received care from the
PHCT
No' of Contacts from PHCT
Total No' of Hours of Care given
April 07 March 08
April 08 March 09
April 09 March 10
April 10 March 11
April 11 March 12
April 12 March 13
April 13 March 14
37
52
42
61
50
46
46
Total no' of Physiotherapy contacts at
Bishop Auckland Hospice
252
145
191
319
342
330
245
No' of Patients who were seen by the
Physiotherapist at Richardson Hospice
17
21
14
9
7
4
4
Total no' of Physiotherapy contacts at
Richardson Hospice
153
141
45
23
21
11
4
No' of Patients who were seen by the
Physio at Weardale Day Hospice
17
19
10
16
12
16
9
Total no' of Physiotherapy contacts at
Weardale Day Hospice
103
81
39
81
66
56
39
No' of Patients who were seen by the
Physio at Sedgefield Day Hospice
23
17
0
7
12
2
0
Total no' of Physiotherapy contacts at
Sedgefield Day Hospice
181
129
0
36
81
5
0
No' of Outpatients who were seen by the
Physiotherapist
-
-
-
-
-
18
25
Total no' of Outpatient Physiotherapy
treatments
-
-
-
-
-
40
57
No' of Clients accessing the service
199
170
211
188
235
261
215
No' of '1 to 1' Contacts
202
240
233
575
934
794
781
-
-
103
319
416
464
466
No' of 'Drop In's'
376
278
297
359
520
869
784
No' of Telephone Contacts
67
40
103
322
108
230
68
No' of Patients who received Comp'
Therapy at Bishop Auckland Hospice
84
114
124
78
84
87
87
No' of Treatments at Bishop Auckland
Hospice
923
925
876
777
882
992
1017
No' of Patients who received Comp'
Therapy at Richardson Day Hospice
25
20
29
19
15
30
22
No' of Treatments at Richardson Day
Hospice
194
233
241
176
154
200
290
No' of Patients who received Comp'
Therapy at Weardale Day Hospice
22
33
30
26
22
27
20
No' of Treatments at Weardale Day
Hospice
216
210
198
226
247
261
255
No' of Patients who received Comp'
Therapy at Sedgefield Day Hospice
32
29
54
26
23
18
19
No' of Treatments at Sedgefield Day
Hospice
236
210
263
267
210
179
199
Physiotherapy
No' of Patients who were seen by the
Physio at Bishop Auckland Hospice
Berevement/Family Support
No' of Home Visits
Complementary Therapies
Comp' Therapies - Outpatient
No' of Outpatients who received Comp'
Therapy - Barnard Castle
No' of Outpatient Treatments - Barnard
Castle
No' of Outpatients who received Comp'
Therapy - Weardale
No' of Outpatient Treatments - Weardale
No' of Outpatients who received Comp'
Therapy - Sedgefield
No' of Outpatient Treatments - Sedgefield
Comp' Therapies - Homevisits
No' of Patients who received Comp'
Therapy - Barnard Castle Homevisits
No' of Homevisits Treatments - Barnard
Castle
No' of Patients who received Comp'
Therapy - Weardale Homevisits
No' of Homevisit Treatments - Weardale
No' of Patients who received Comp'
Therapy - Sedgefield Homevisits
No' of Homevisit Treatments - Sedgefield
April 07 March 08
April 08 March 09
April 09 March 10
April 10 March 11
April 11 March 12
April 12 March 13
April 13 March 14
12
7
11
5
4
3
2
48
52
30
26
15
5
2
14
15
4
0
2
4
3
21
27
4
0
11
4
11
1
4
7
7
4
4
4
1
5
11
15
6
17
8
11
10
13
12
5
9
11
90
107
138
59
49
26
55
39
25
48
29
26
27
37
326
219
295
248
209
193
142
15
27
38
22
45
56
38
174
133
139
99
200
308
205
9
11
14
9
12
12
11
62
56
49
34
45
44
39
6
8
10
7
9
13
11
43
10
67
48
18
83
49
10
59
33
10
33
48
21
69
45
13
68
38
7
36
17
36
56
56
76
92
106
115
231
578
665
712
641
688
15
24
53
46
67
85
97
98
302
365
318
395
475
528
15
22
47
47
69
86
101
64
219
522
591
666
607
623
7
14
19
51
56
42
13
16
75
53
139
278
61
16
471
486
522
544
601
670
639
MS Aromatherapy
No' of Drop In Patients - Barnard Castle
No' of Drop In Treatments
No' of Drop In Patients - Bishop Auckland
No' of Drop In Treatments
No' of Drop In Patients - Weardale
No' of Drop In Treatments
Neurological Day Care
No' of Patients attending Neurological
Day Care
No' of attendances to Neurological Day
Care
No' of Patients receiving Comp' Therapy
in Day Care
No' of Comp' Therapy Treatments given in
Day Care
No' of Patients receiving Physiotherapy in
Day Care
No' of Physiotherapy Treatments given in
Day Care
No' of Patients receiving Counselling in
Day Care
No' of Counselling contacts in Day Care
Total No' of patients/clients who have
accessed Hospice Services
3.2 An explanation of those involved in this quality account
The Quality Account was discussed at the Hospices Management Team meeting which is chaired by the
Chief Executive and includes clinical and non clinical managers, the Director of Clinical Services and the
Director of Finance.
The task of writing it was delegated to the Registered Manager and Chief Executive.
The Quality Account was also discussed at the senior Clinical Meeting where the quality priorities were
agreed.
It has also formed part of an Agenda item of the Clinical Strategy and Governance Committee which is
a key element of the Charity’s governance structure: the Minutes of which are distributed to the Board
of Trustees as will a copy of this Quality Account.
Once completed the Quality Account was distributed to Clinical and non clinical Managers for comment
and approval. The completed Quality Account was then forwarded to the Durham Dales, Easington and
Sedgefield Clinical Commissioning Group and the Health and Wellbeing board to approve and comment
on the quality priorities mentioned in the report.
Research
The number of patients receiving NHS services provided by or sub contracted by the Butterwick
Hospice at Bishop Auckland in 2013-2014 that were recruited during that period to participate in
research approved by a research ethics committee was: none. There were no appropriate national,
ethically approved studies in palliative care that the Butterwick Hospice could participate in.
What others say about us
The Butterwick Hospice is required to register with the Care Quality Commission and its current status
is unconditional. The Butterwick Hospice has no conditions on registration.
The Care Quality Commission has not taken any enforcement action against the Butterwick Hospice at
Bishop Auckland during 2013/14
The Butterwick Hospice is subject to periodic reviews by the Care Quality Commission and its last
review was 17th May 2013.
The Butterwick Hospice was fully compliant
and rated as low risk following assessment
by the Care Quality Commission.
Below are some of their findings.
Consent to treatment and care.
We saw the checklist used by staff
recorded if consent to the assessment
process had been gained in line with local
procedures. This meant people could
make an informed choice about using the
Hospice.
We saw the Hospice provided people with
appropriate information and support to
their care. Comments on the patient
satisfaction survey to the question `Did
you receive a clear explanation of the
service available included.
“They were very informative” and
“Just the right amount of information.”
Care and Welfare of people who uses services.
We reviewed three care records in detail and saw
documentary evidence of how peoples needs were
assessed when they began to use the service and
regularly thereafter.
We saw people had access to a wide range of support
services, which included physiotherapy, chiropody,
family support counsellors and Lymphoedema clinic.
There was documentary evidence of formal, weekly
reviews of care and we found these reviews were up to
date for everyone who used the service.
We spoke to three people who used the service. They
were all very positive about the care and support they
received.
Comments included:
“I really enjoy meeting the other patients and staffthey give me lots of support”
“The staff are so friendly”
The Butterwick Hospice at Bishop Auckland has not participated in any special reviews or investigations
by the Care Quality Commission during 2013/1214
Statements