QUALITY ACCOUNT
2013/2014

Part 1
Chief Executive Statement of Quality
Statement from the Director of Nursing,
Cornwall and Isles of Scilly NHS
Statement from Kernow Clinical Commissioning Group
Statements of Assurance from the Board
Who we are and what we do
Part 2
Report of previous year’s quality performance
Priorities for Improvement 2014/15
־ Clinical Effectiveness
־ Patient Experience
־ Patient Safety
Part 3
Review of Quality Performance
־ Statistical Data
־ Audits
־ Provider Visit Report
־ What our Regulators, Care Quality Commission say about us
־ What our patients and families say about us
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Page No:
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5-8
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10 -15
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17-25
26
26-27
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Welcome to the second Quality Account produced by Cornwall Hospice Care. This document is produced as a statutory requirement because Cornwall Hospice Care receives a small amount of funding from the NHS. It is also a means of helping the users of our services and other stakeholders to see how we work and how we intend to develop our services for the people of Cornwall and the Isles of Scilly.
Quality continues to be at the heart of all that we do. We provide the highest possible quality of specialist palliative care at out two hospices, Mount Edgcumbe, St Austell and
St Julia’s, Hayle. We provide consultant led medical care to the Royal Cornwall
Hospitals Trust, Cornwall Partnership Trust and the Peninsula Community Health as well as to nursing homes in the County. We are the main employer of medical staff qualified in specialist palliative care in the County.
We operate a 24 hour specialist palliative care advice line which is relied on by the healthcare community including the doctors out of hours service.
We provide a well established and well used Lymphoedema service
We continue to have capacity to provide a good number of out-patients appointments in excellent facilities but as yet these facilities remain un-commissioned by the NHS.
Medical education is provided to the Peninsula Medical School (University of Exeter) under a separate funded contract which has been very successful for both parties.
Our commitment to quality is underpinned by a clinical governance structure that includes a Board of Trustees which includes 4 highly experienced clinicians, a Clinical services sub- committee and a working Clinical Governance Committee.
Cornwall Hospice Care is a charity and raises 85% of funds from voluntary sources and only 15% is funded by the NHS; significantly less than neighbouring hospices in Devon receive and well below the national average of 30%.
We are grateful to the people of Cornwall who continue to support us and to ensure that our Board of Trustees is able to commission high quality services on their behalf. I am proud of the staff and volunteers who have delivered these achievements.
Our theme this year is collaboration. We are keen to work with our partners to deliver more joined up care for patients in Cornwall.
I am pleased to be able to present the Quality Account for 2013/14 and hope that you find it interesting and demonstrative of the high quality of our services.
Paul C Brinsley
Chief Executive Officer
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“Cornwall Hospice Care is a key provider in delivering specialist palliative care to the population of Cornwall and Isles of Scilly. From the perspective of commissioners of health care, Cornwall Hospice Care can be relied upon to deliver high quality services in an area of health care where there is a need to provide care compassionately and sensitively responding to the fluctuating needs of the patients and their carers and families. The Hospice management have demonstrated their willingness to work collaboratively across care settings in this constantly changing and challenging climate.
”
Carol Williams
Director of Nursing
NHS England
“Cornwall Hospice Care has continued to provide, and support the delivery of high quality palliative care services across Cornwall. NHS Kernow Clinical Commissioning
Group (CCG) would particularly like to highlight the work Cornwall Hospice Care has been involved with in 2013/14 with regard to collaborative working with our partner organisations; such as input into Multi-Disciplinary Teams and the Palliative Care Advice
Line. NHS Kernow is looking forward to working with Cornwall Hospice Care in order to further develop the palliative care pathway to ensure services are provided seamlessly for those needing care.” Matthew Scott
Commissioner
The Board of Trustees is fully committed to delivering high quality services to all our patients. All Trustees are involved in monitoring the clinical activities, by receiving written reports as well as undertaking provider visits on a quarterly basis (two Trustees for each visit). These visits are unannounced and their written report discussed by the
Board. A Provider Visit Template ensures rigor and relates to The Care Quality
Commission Outcomes.
Four Clinical Truste e’s are active members of the Clinical Services Committee as well as two members of the Executive Team and two members of the Senior Management team, which represents 50% Clinical staff and 50% Trustee’s.
The Board is confident that the care and treatment provided by Cornwall Hospice Care is of high quality and cost effective and can be sustained in the foreseeable future.
In a time of austerity, the Charity continues to improve and develop services to meet the needs of the patients and their families. We depend on the generosity and continued commitment and support to the people of Cornwall.
Mrs Elizabeth Anderson
Chair of the Board of Trustees
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The Aims
Cornwall Hospice Care is a registered charity committed to providing Specialist
Palliative Care (SPC) and End of Life Care (EoLC) for complex patients (irrespective of diagnosis) over the age of 18 years.
The service is driven by patient need, is completely flexible and includes in-patient beds, out-patient care, outreach into the community and in-reach to Acute Hospitals,
Community Hospitals and Nursing Homes by the Multidisciplinary professional team.
It is free of charge at the point of delivery.
The services include:

Symptom control assessment and management

Emotional/psychological support assessment and management

Social support assessment and management

Spiritual support assessment and management
The Objectives
The service provides advice and support for adult patients and their carers, who have specialist palliative and end of life care needs due to life limiting illnesses. This can be across a range of facets including pain management, symptom control and social, emotional and spiritual issues. In addition to the patient and carer focus the hospice also acts as a lead in education programmes and end of life care across the county.
We provide:

The best quality of life to patients and carers

To work in collaboration with other healthcare providers

To work in collaboration with other Specialist Palliative Care and End of Life Care providers.

To deliver and support education and training across Cornwall Health Community
Expected Outcomes

To provide high quality SPC and EoLC services

To act as a specialist resource to healthcare professionals

To be recognised as a centre of excellence for SPC & EoLC services
Geographic Coverage/Boundaries
Cornwall Hospice Care is a countywide service.
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Location(s) of Service Delivery
The two In-Patient units are:
Mount Edgcumbe Hospice St Julia's Hospice
Porthpean Road Foundry Hill
St Austell Hayle
PL26 6AB TR27 4HW
Tel : 01726 65711 Tel : 01736 759070
Mount Edgcumbe Hospice is currently operating 12 beds.
St. Julia ’s is currently operating 10 beds.
Days/Hours of operation
24 hours per day 7 days per week. On-call to patients and families 24/ 7.
Referral criteria and sources
Patients who have a complex specialist palliative care needs; physical, psychological, social, and spiritual needs.
Cornwall Hospice Care and other agencies provide Specialist Palliative Care, agreed to working together to meet collaborative working.
Referral route
Direct contact by either the General Practitioner (GP) or Consultant by phone / fax / email or letter. This can be mediated by other professional practitioners on behalf of the
GP’s, Consultants or out-of-hours clinicians.
In-patient activity
Provision of in-patient Specialist Palliative Care and End of Life Care for patients with complex needs including symptom control, psychological, social and spiritual support.
The multi-professional team include: Medical Staffing, Consultants in Palliative
Medicine, Specialist Grade Doctors, Nursing Teams in both units, Physiotherapists,
Occupational Therapists, as well as a range of support and administration staff.
Outpatient appointments
Outpatient appointments are offered to review the needs of the patients, and see the appropriate professional/professionals as appropriate. These include Palliative Care
Consultants, Specialist Nurses, Physiotherapist, Occupational Therapist, Lymphoedema
Clinical Nurse Specialist, and Bereavement Counsellor within each hospice.
Day Case Treatments
Both Hospices have four treatment couches in each of the out-patient facilities. There are a range of treatment options available, for example, Blood Transfusions, Non
Chemotherapy Infusions which include Bisphosphonates, Antibiotics, Magnesium, Iron, as well as procedures such as paracentesis and pleural taps.
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Specialist Palliative Care Advice Line
Exists to provide healthcare professionals, patients and carers, access to 24 hour, 7 day a week, specialist palliative care advice for support and symptom control.
Integrated Lymphoedema Services
Within each hospice we have well established clinics, supporting patients with cancer- related Lymphoedema.
Combined Pain and Palliative Care Clinic
Operates on a weekly basis since 2000, where patients with complex pain is reviewed by the Anaesthetists and the Palliative Care Consultants. The development of this service has enabled 24 hour on-call cover and spinal (intrathecal) management of severe and iritractable pain. Referrals are from General Practitioners and other
Consultants, and patients are normally seen within a few days.
Joint Oncology Clinics at the Acute Trust
All the Hospice Palliative Care Consultants work within the Acute Trust and Oncology
Clinics to ensure a seamless service across all settings.
Bereavement Services
Cornwall Hospice Care have bereavement service supporting the needs of the patients and their carers who have accessed hospice facilities.
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The Specialist Palliative Care teams within Cornwall (Cornwall Hospice Care, Specialist
Community Palliative Care Nurses [CSPCN - previously known as macmillan nurses] and the
Hospital Specialist Palliative Care team at RCHT are working in a new integrated way to try and help all healthcare professionals provide good palliative care. Our vision is to help provide the right care in the right setting at the time for patients with malignant and non-malignant disease via the services represented in the table below:
What service?
Inpatient admissions to hospices
24 hour telephone advice access to consultants)
Email advice for non-urgent enquires
(with
When?
24/7
24/7
24/7; response within 24 hours
How to access?
Mount Edgcumbe (MEH) - 01726 65711
St Julia’s (SJH)- 01736 759070
01736 757707
PCadvice@cornwall.nhs.uk
Review by SPCN in community
Domiciliary visits
Inpatient review of patients in
RCHT
Weekdays and weekends 9-4.30pm; response within 48 hours of referral
Weekdays 9-5pm; aim to visit within 48 hours of request if urgent, otherwise as appropriate for patient and referrer
Weekdays 9-5pm; urgent (same day ) and non-urgent
Phone - Bodmin switch 01208 251300
Email - Communitypalliative.Referral@pch-cic.nhs.uk
Fax - 01872 24 6948
Mount Edgcumbe - 01726 65711
St Julia’s - 01736 759070
Palliative Care secretaries – 01872 258305
Urgent – RCHT switchboard – bleep 3055
Inpatient review of patients within community hospitals
Weekdays 9-5pm; on same basis as domiciliary visits
Mount Edgcumbe - 01726 65711
St Julia’s - 01736 759070
Outpatient reviews within the hospice
Weekdays 9-5pm; on same basis as domiciliary visits
Mount Edgcumbe - 01726 65711
St Julia’s - 01736 759070
Joint pain & palliative care clinics at RCHT
Monday afternoon
Joint oncology & palliative care clinics at RCHT
Day case procedures; blood transfusions & bisphosphonates at MEH
Monday am (R Newman & M Collinson and T
Talbot) Lung
Tuesday am (D Stevens & D Wheatley) Breast
& Urology
Tuesday pm (C Campbell & T Talbot) Brain
Thursday am (J Gibbins & R Ellis) Upper &
Lower GI & Urology
Wednesdays 9-5pm
Respective oncology secretaries via RCHT switchboard
Mount Edgcumbe 01726 65711
Lymphoedema team at SJH and
MEH
Lymphoedema at RCHT
Specialist Palliative Care
Physiotherapy team
Education sessions
Weekdays 9-5pm
Weekdays 9-5pm
Will try and accommodate to needs
Email – hospice.lymphoedema@Cornwall,NHS.UK
Mount Edgcumbe - 01726 65711
St Julia’s - 01736 759070
RCHT - 01872252714
North - Bodmin.CRT@pch-cic.nhs.uk
East - 01579 335310, Liskeard.CRT@pch-cic.nhs.uk
North Kerrier & Carrick - 01326 434728,
Falmouth.CRT@pch-cic.nhs.uk
South - 01326 435825, Helston.CRT@pch-cic.nhs.uk
Restormel - 01637 893658 Newquay.CRT@pchcic.nhs.uk
Mount Edgcumbe 01726 65711 (Sue Bowman)
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In last years Quality Account, we identified developments relating to Clinical
Effectiveness; Patient Experience and Patient Safety.

Improving Out of Hours services across Cornwall
Increased awareness of Advice Line
Improved monitoring of activity
Development of electronic templates of records and advice given
Improved access to data across all settings
Development and initiation of email advice line to compliment telephone access
-

We have successfully completed the refurbishments
Which has enhanced the Patients and Carers experience and increase capacity.
Ensuring compliance with infection control standards and regulations

Implementation of the Productive Ward Series and Traffic Light System
In order to maximise care delivery, demonstrating effectiveness of interventions. The
Traffic Light System of prioritising patient need was initiated in St. Julia’s Hospice, and due to its development and great success and now been rolled out within both units.

The two Units work as closely as possible together to ensure there is coherence across the organisation, sharing innovative practice to enhance both units.
 We have explored various methods of gaining patient’s and carers views as well as exploring community engagement with Stakeholders and Fundraising Support
Groups to listen to the local areas on how we can be more involved in the issues within the communities of Cornwall and their future needs.
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With the increase of Consultants within Cornwall Hospice Care there has been a drive to increase collaborative working, starting with the Community Specialist
Palliative Care Nurse Specialists in the west of the county. This has supported joint working on documentation and patient outcome measures. The aim is to roll this way of working to the central and east of the county.
Cornwall Hospice Care (CHC) provides specialist support to the Community
Specialist Palliative Care Nursing Team (CSPCNT), previously known as the macmillan team. For the CSPCNT to function as a specialist palliative care team
(and meet peer review criteria/standards for specialist care), regular input from the palliative care consultants is essential. Historically this has been done in various guises due to numerous reasons. CSPCNT have tended to seek advice from CHC when their input into patient care has reached their level of expertise, rather than discussing all patients under the care of the team. Many community teams in the country are integral to a hospice service with routine input from the palliative care consultants. There are suggestions in the literature about how such services can be organised and developed to achieve best care for patients.
Since January 2013, CHC have worked collaboratively with the CSPCNT to try and develop a consistent approach for patients to enable consistent and equitable care to patients across the area. The overall aim has been to improve the quality of decision making and enhance the delivery of care given to patients in the community setting.
In the West of the county, we have piloted a model (based on the literature available) of discussing all new patients referred to the CSPCNT in a community
Multi-Disciplinary Team (MDT) meeting (with consultant input from CHC) together with patients who have complex symptoms which may need medical input (these were the only cases that were previously discussed at the MDT). The discussion of all new patients enables open conversations about the suitability of the referral to specialist services and what this service is hoping to achieve for individual patients and their families. It enables clear and focused identification (and documentation) of patients’ (and family and the referrer/healthcare professional) problems, concerns and goals to enable an individualized care plan for each patient. Within this discussion the complexity of needs, phase of illness, dependency, estimated prognosis, suitability for discussions about advance care planning and placement onto the Gold Standards Framework (GSF) are determined for each patient. During the MDT streamlining of care and signposting to appropriate services (pain clinic, oncology clinic, hospice stay, and domiciliary visit) are discussed.
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CHC have provided daily advice to the CSPCNT about patients with complex symptoms and perform domiciliary visits or arrange inpatient stays in the hospices as need and appropriate. This service is available around the clock, advice is given to specialist palliative care nurses via the advice line to enable quick answers to their enquiries.
As this model has been highly evaluated by the West team, CHC and the
CSPCNT aim to mirror this practice in each team and MDT, to enable the care to be equitable to all patients in Cornwall. Future work with this team would include review of caseloads of individual nurses to assess ongoing management of patients and on-the-job training for the CSPCNT by carrying out visits to patients with them. We hope to consider the routine use of patient and/or carer rated outcome measures to ensure patients are receiving optimal care. We also hope to improve the referral of patients with non-malignant disease to the community team.
Steering the collaboration of services between hospice, community and acute hospital.
We also worked collaboratively with the acute hospital team, and have agreed common referral and discharge criteria to the service as a whole. Furthermore, we have agreed a common symptom assessment chart (based on validated models) to enable uniform assessment across service, and in that future, to provide patient reported outcome measures (PROMs).
The improved working relationships across services has led to open and honest discussions about duplication across services and identified confusion of healthcare professional referrers. We have therefore agreed that a single point of access would be fundamental to overcoming this. We envisage this as a pivotal step in Cornwall to enable specialist services to support generalists in providing palliative and end of life care to their patients.
Support to General Practice trainee (ST4)
We have supported a GP trainee to carry out an important piece of work around the current challenges of delivering end of life care to all patients in the community. This included a survey to GPs and nursing staff and a needs analysis. As a result, it was identified that anticipatory medications would be helpful to improve symptom control in the community and enable patients to stay in their own homes as they approach the end of their life. Through extensive collaboration, we have supported the roll out of JICB in the Penwith area. If this pilot is successful it is envisaged that it will be rolled out across Cornwall.
With consultant expertise and financially, the initiative and implementation in
West Penwith of a trial of anticipatory prescribing and site ing of “Just in Case
B oxes” in patients homes. This will ensure timely control of distressing symptoms. Evidence from other services evaluated in other areas of the country are that “Just in Case Boxes” (JICB) also prevent admissions to acute services and help ensure death in the preferred place of care for the patient.
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Cornwall Hospice Care provides an advice line which is now the sole 24/7 provider of specialist advice and support for healthcare professionals in Cornwall.
The service has been running for over four years and calls have nearly doubled over that time. Calls are initially answered by nursing staff who are able to deal with a quarter to a third of calls; calls requiring medical advice are passed to a senior member of medical staff. The principal is “one call in; one call out” so that callers do not have to make repeated calls to access the help they need. The message is passed to the most appropriate clinician who calls back directly so that advice and help can be given promptly.
Calls come from a wide range of sources (fig 1) and relate mainly to symptom control (fig 2)
Fig 1 – callers to advice line
Fig 2 – content of calls
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Key Achievements

The advice line has been set up, developed and run with no additional funding and provides a high quality service 24/7 with access to specialist medical and nursing staff.

There is now an email advice service for less urgent queries running alongside the phone line with consultant response to enquiries within 24 hours.

Targeted awareness programs increased the appropriate use of the service by junior doctors in the acute hospital ‘out of hours’ and by the GP ‘out of hours’ service over weekends and bank holidays to improve palliative care for patients being cared for by teams who do not know them.

From July 2014, the advice line will be the single provider of out of hours palliative care advice in Cornwall, simplifying access for users.
Aspirations

Work is in process to improve and develop the IT systems supporting the advice line so that information about advice given can be rapidly shared with key clinicians involved in the patients’ care. We are working to integrate IT systems with other care providers where possible.

Plans are being developed to extend the role of the advice line to a single point of access service for palliative care referrals in Cornwall to ensure simple direct access for patients and clinicians to the right support, in the right place, at the right time.
Cornwall Hospice Care is working with other healthcare providers in Cornwall to improve integrated services so that patients receive the optimal treatment and care in the most appropriate setting for their individual wishes and needs. As part of this process we are reviewing our own IT systems and the processes of information sharing so that all those involved in patients’ care have access to full, accurate and up to date information when they need it.
In 2012/3 we invested in the IT system CROSSCARE to improve and capture clinical data. The system has not met need, as the aim was to improve data quality, recording and reporting in addition to standardisation of patient notes and care plans across both hospices,
Crosscare was used initially to record information from the out of hours advice line, Lymphoedema clinics, out
–patient clinics, bereavement service and provide
MDS reports annually. In improving the clinical notes, both units capture the patients treatment and care in a timely and detailed record that can be accessed immediately, rather than needing access to tablets, ipads and desk top computers.
Cornwall Hospice Care has appointed an IT manager, with a remit of improving the interfaces across both the clinical and income generation aspects of the charity, ensuring we have a cost effective and efficient infrastructure.
The introduction of WIFI in both units has enhanced patients and their families access to the internet
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There are a range of options for gathering patients and carers views. We are working with other hospices in the South West of England to implement a new format of patient and carer feedback, with the aim of accessing appropriate and meaningful data. The aim is to enhance patient and carer feedback, therefore identifying areas of best practice in addition to highlighting opportunities for improvement where necessary. This enables us to be able to benchmark across similar services.
As part of the Clinical Governance agenda, we wish to establish a system for gaining more patient and carer’s views, in order to ensure these are given adequate consideration in planning and providing services.
We aim to have a more robust evaluation of user and carer responses and the use of this information to inform our strategic plan.
The Volunteer Coordinator within Cornwall Hospice Care is developing a programme to set up a Volunteer Council within our organisation and build on existing best practice, promoting excellence in the future and exploring new approaches to volunteering, in line with the Help the Hospices Commission working paper, published in November 2012.
Cornwall Hospice Care are currently in an enviable situation of having a full compliment of Consultants, Nursing Staff and Allied Healthcare Professionals enabling us to drive forward Service Development, utilising these resources within and external to our organisation.
Cornwall Hospice Care is one of the main providers supporting the Peninsula
Medical School curriculum and is planning to increase our involvement in the coming year.
Advanced Communication Skills Training
We lead the National Advanced Communications Skills Training programme across the Peninsula throughout 2013/14 and continue to deliver training to nursing homes in Cornwall.
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With the dissolution of the local Cancer Networks and the National Cancer Action
Team in April 2013, the highly successful Advanced Communication Skills training program for senior cancer clinicians was placed in jeopardy. CHC took on the management and stewardship of the remaining resources and provided the training at a 20% cost saving and with exceptionally high satisfaction and learning outcome results over 2013-14. We are now developing a flexible and innovative range of communication skills training which can be tailored to the needs of different groups of clinicians
The hospice offers education, internally and externally and supports the development of an integrated education and training strategy across all providers within Cornwall. We have the additional capacity to provide bespoke education and training in response to the challenges experienced by colleagues in other healthcare settings which we provide formally and informally as requested.
.
We continue to establish collaborative links with other healthcare providers and hospices across the Southwest to respond effectively to local and national directives.
Revalidation
In line with revalidation of medical staff and closely followed by the nursing staff, we are going to strengthen our appraisal processes to inform our Education
Strategy
We are undertaking a Review of our Education Strategy to ensure it is fit purpose in line with the changes and challenges within the Healthcare environment.
Research
CHC are going to be actively involved in developing research later in the year.
We have an exciting opportunity to collaborate with Gloucester in a study
“ An exploration of what bereaved relatives think about intrathecal pain relief devices for the treatment of cancer pain”.
Cornwall is an important centre for this type of pain relief. The study will take six months and we will publish the paper in the next Quality Account.
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Cornwall Hospice Care receives over 1,000 referrals per year across all services. The quality of the services are maintained, monitored and improved through a clear governance structure.
The hospice undertakes regular quality assurance checks of its data.
MEH SJH Combined
Admissions
Discharges
Deaths
Bed Days
Av. Length of Stay
Occupancy
Lymphoedema
Sessions
Day Cases
253
125
124
3003
8.51
84.97%
1092
90
173
68
97
2775
6.84
87.73%
648
15
426
193
221
5778
1740
105
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
MEH
SJH
18-24 Years 25-64 Years
16
65-84 Years 85 Over Years

Age breakdown by actual numbers for MEH and SJH
Male
Female
Breakdown of gender by actual numbers for MEH and SJH
MEH
129
SJH
87
Combined
216
210
124 86
2013/14
(We are pleased with this response of formal compliments as well as the thanks we receive)
Cornwall Hospice Care undertake Clinical Audits and Quality Monitoring to ensure compliance with the Care Quality Commission. The Clinical Governance meetings prioritise the audits across the Clinical Services.
We are presenting significant audits that inform the basis of our aspirations in our
Quality Account.
Background
This is a re-audit of admissions to both units over a sample period of 3 months (July –
September 2013). Previous audits had shown

Between 24% (2010) and 33% (2013) of admissions were out of hours

All urgent admissions were admitted the same day

90% of planned admissions were admitted within 48 hours

On call admissions were frequently by a doctor from the other site team and there was some inequity between sites in terms of consultant and middle grade admitting.
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Changes in practice
To provide a more equitable service with maximal continuity of care the following changes to medical working practices were made:

a balanced on call rota was introduced to ensure doctors from both site teams were on call the majority of the time

a staggered shift system was trialled to extend the working day at Mount
Edgcumbe, enabling more patients to be admitted by the day medical team.
Methods
All admissions over a 3 month period were reviewed by clinicians using a standardised form.
Results
Key points:

Out of hours admissions remain at 30% (fig 1)

All urgent admissions are admitted same day and over 80% of planned admissions within 48 hours (fig 2)

75% of admissions are from the community, thus avoiding acute hospital admissions (fig 3)

95% of all admissions are now admitted by a doctor who will be part of their ongoing care team, providing excellent continuity of care. There is equity of practice across both sites
Recommendations

consideration of “roll out” of staggered shift system to both sites

audit of patients not admitted, to explore unmet need

Periodic re-audit to ensure maintenance of these standards.
Figure 1. Out of hours admissions
Weekends/BH
16%
Weekdays OOH
14%
Weekdays 9-5
70%
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Figure 2. Time from referral to admission
80
70
40
30
20
10
60
50
0 planned admissions urgent admissions
Figure 3. Source of referrals for admission referrals for admission within 4 days within 48 hours within 24 hours same day
GP
SERCO
Macmillan other community
Hospital team oncology other hospital
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Background
St Julia’s Hospice provides 8 beds for the delivery of specialist palliative care and end of life care to patients’ in the west of Cornwall. The unit admits patients 24 hours a day, 7 days a week. Whilst there has always been quantitative evidence about the volume of activity undertaken within the unit it has been much more difficult to assess the quality of care delivered.
Over the last few years there have been attempts to measure the quality of hospice care and various tools have been developed nationally. St Julia’s has been using several of these tools and this audit looked at 100 consecutive admissions to the hospice, beginning with the inpatients on January 1 st 2013, to see whether we had been successful in documenting the quality of care delivered.
Method
100 admissions were taken chronologically from the admissions book which records all admissions to the hospice.
The notes were scrutinised and information taken from:
The clinical section of the notes
The administrative section which contains details of admission, discharge and death
The summative record of the ward board
The SKIPP (St Christopher’s index of patient priorities) form
The Distress Thermometer Record
The weekly scoring sheet from the MDT
To determine whether the patients had received effective intervention and how quickly this was achieved, the length of stay of each patient was also documented.
20

21

22

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Discussion
This audit demonstrates that the patients admitted to St Julia’s were all appropriate in that they all needed either symptom control or terminal care. 99% of the admissions had specialist needs and 97% were either in an unstable, deteriorating or terminal phase of their illness.
The clinical notes demonstrated that 59% of the distresses documented on admission were treated effectively within 48 hours. 85% were relieved within 1 week. The intervention that took 16 days to be effective was treatment of a massive lymphoedema resulting in improved pain control
There were 11 admissions where there was no documentation of an effective intervention.
8 of these admissions resulted in the death of the patient. The patients were all scored as being complex, unstable, deteriorating or terminal and 6 of these admissions were in the hospice for less than 2 days.
In the case of the effective interventions the STAS scoring did demonstrate an improvement in the scoring from complex specialist need to specialist need that could be delivered in other care settings. The documentation of the phase in the illness was consistent with the documentation in the clinical notes at the time of the MDT discussion each week and would perhaps be a helpful indicator to document daily on the ward board and summary sheet in the clinical notes, as often patients were originally admitted for symptom control, this was achieved but the patient was then deteriorating and so stayed longer as an inpatient.
The SKIPP tool was completed too few times to provide a helpful and reliable indicator of effective care and therefore consideration needs to be paid as to whether it needs to be implemented more rigorously or whether adaptation of already effective clinical records would provide that information in a more time effective and less onerous way for the patients.
The Distress Thermometer was only filled in for 18% of admissions and was inconsistent with the clinical documentation. Patients often ticked multiple boxes with no indication of prioritisation of the distress and the score did not correlate with the number of distresses identified.
The audit demonstrated that the patients admitted to the inpatient unit were appropriate.
The STAS scoring tool and Phase of Illness tool we have used in St. Julia’s are effective and we should consider using this scoring mechanism daily. Although the clinical documentation does record the effect of interventions and care, it would perhaps be constructive to consider adapting the notes so that this information is more readily apparent.
November 2013
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Over the past five years CHC has developed close working with the specialist dementia team at Cornwall Foundation Trust to provide high quality care for dementia patients at the end of life and support those caring for them. Joint working led to the development of specific symptom control guidance for this patient group, training for staff and rapid access to the Palliative Care Advice Line and face to face consultant reviews so that complex patients with severe dementia could continue to be cared for safely and effectively in their current place of care at the end of life. This initiative hugely reduced the inappropriate transfer of dementia patients at the end of life from the specialist units to the acute hospital and has been presented at local and national conferences and cited by the British Geriatric Society as an example of good practice.
In the light of the Neuberger report on the LCP, the policy and symptom control guidance have been reviewed and revised to emphasise the importance of individualised multidisciplinary assessment, management of and prescribing for this very complex group of patients.
Goal: To continue to support dementia services with training and clinical advice and review and to reaudit the effectiveness of collaboration.
Working jointly with the medicines management team at Royal Cornwall Hospitals Trust
(RCHT), who have been developing a new electronic, shared local formulary for use across settings, we have identified high quality guidelines to make available to clinicians. This ensures that information is of high quality, regularly updated and reviewed is in line with and used in multiple settings across the UK. We work closely with the formulary committee to assess how new drugs should be used in palliative care in Cornwall in order to support safe, cost effective and consistent prescribing across settings.
Goal: To roll out and publicise these resources and to continue to work closely with pharmacy services in Cornwall
CHC has worked closely for several years with the Motor Neurone Disease coordinator and other clinicians involved in the care of patients with MND to run a regular MND multidisciplinary team meeting to review patients’ care needs and ensure key information is shared. The situation is especially complex in the east of the county.
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The Board of Trustees have an annual programme of Provider Visits. Two Trustees visit a unit every three months (each unit will be inspected every six months). All of the trustees participate in the programme.
Unannounced Trustee Provider Visits are conducted in line with the Care Quality
Commission regulations. Recent visits were undertaken on 27
Edgcumbe Hospice and the 2 nd th March 2014 at Mount
Jun e 2014 at St Julia’s Hospice.
Trustees visiting the hospices interview staff, volunteers and patients, tour both sites and write a written report to the Board of Trustees regarding the standards of care provided within each unit.
Cornwall Hospice Care (Mount Edgcumbe Hospice & St. Julia’s Hospice) are registered with the Care Quality Commission (CQC) under ‘Other Independent Healthcare’ provider in line with the Care Standards Act 2000.
Registered to provide the following regulated activities under The Health and Social
Care Act 2008:

Treatment of disease, disorder or injury

Nursing Care
Cornwall Hospice Care is subject to periodic reviews by the Care Quality Commission, the last of which was on the 2
14 th nd December 2013 at Mount Edgcumbe Hospice, and the
December 2013 at St. Julia’s Hospice.
The Care Quality Commission has assessed the hospices as being compliant with all the outcomes inspected.
Cornwall Hospice Care has not participated in any special reviews or investigations by the CQC during the reporting period.
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“People we spoke with who used the service, or were visiting relatives at Mount
Edgcumbe told us "the staff are phenomenal, they are excellent at what they do", "It's an amazing service, the staff are kind, caring and helpful" and "every one of the staff treat people with kindness and ensure people keep their pride".
“We spoke with a visitor to the hospice who had come to see their relative. They told us they were extremely pleased with the care their relative received and said the staff always discussed their relatives care and treatment with them and that this had been agreed with their relative”.
“During our inspection we spent time observing the staff interacting and providing care to people. We saw staff were consistently respectful and helpful towards people who used the service. People were consistently given the time they required for a chat. One person who used the service told us "I can always talk to any of the staff if something is bothering me, they are all very helpful and make time to answer any questions I have".
“During our inspection, we spoke with the registered manager and with three members of staff. They all showed a good knowledge of the care needs and choices and preferences of the people who used the service and spoke in a caring way about each person”.
“People we spoke with considered the staff treated them as an individual and were aware of all aspects of their care and treatment.”
Comments made by people we spoke with included; "I have complete trust in the staff", and "I am looked after very well, I have no complaints and nothing is too much trouble for any of the m [the staff] “.
We also spoke with people who were visiting friends and / or family who all provided
Positive feedback. We were told; "I felt at peace within an hour of us arriving here", "the staff feel like part of an extended family and they look after all of our family and make sure we are OK" and "nothing is too much trouble, X tells me they feel safe here and that means I don't worry when I go home".
“We found the nutritional needs of people were met and we observed and people told us that there was a wide choice of food provided, which was of a high quality”.
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”
Words seem very inadequate to express how we feel, so please read between the lines and know how highly you and your caring and skills are appreciated
From the minute we walked through the door, we knew he was in the very best place. The hospice is a place I will never forget!
“Keep up the fantastic work that you do, with the dignity and compassion that our relatives deserve. Heartfelt
Thanks”.
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Mount Edgcumbe Hospice
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 01726 65711
St Julia’s Hospice
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 01736 759070
Income Generation
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 01726 66868 /66869
Cornwall Hospice Care is a Limited Company
Registered in England and Wales
Company No: 5660401
Registered Office:
Porthpean Road
St Austell
PL26 6AB
Registered Charity No: 1113140
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