Quality Account Reporting period April 2013 to March 2014 Farleigh Hospice exists to meet the needs of local people affected by life limiting illnesses and to support those who have been bereaved. Through the ongoing generosity of the mid Essex community we provide a range of high quality services totally free of charge. By giving people choice and involvement in the care they receive we make a real difference when and where it matters most. www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013 - 2014 CONTENTS Sections Page Part 1: Introduction by Chief Executive - Alison Stevens 1 Part 2: Priorities for Improvement & Statements of Assurance From the Board (in regulations) 2 Future priorities for improvement - 2014 – 2015 4 Priorities for improvement from 2013 – 2014 7 Mandatory Statements of Assurance from the Board 12 The Francis Report & Farleigh Hospice 15 Part 3: Review of quality performance National Council for Palliative Care: Minimum Data Sets – 2011/12 & 2012/13 16 Farleigh Hospice Quality Performance Information 2013 -2014 17 Quality Markers we have chosen to measure 24 Other quality initiatives 33 What people say about our organisation 39 Statement from mid Essex Clinical Commissioning Group 43 Statement from Healthwatch, Essex 45 Appendix A – Audits completed April 2013 – March 2014 46 Quality Account 2013-2014 Part 1 Introduction by Chief Executive Welcome to our third Quality Account. This report is for our patients, their families and friends, our supporters, the general public and mid Essex Clinical Commissioning Group, who part fund our services. The aim of this report is to give clear information about the quality of our services so that patients feel safe and well cared for and their carers and families are supported and reassured that all of our services are of a very high standard and well governed at all levels throughout the organisation. This is particularly important since the recent publication of the Francis Report detailing how organisations must demonstrate the safety and quality of their services. Our Head of Patient Care, Ann Smits, has undertaken a comprehensive review of how Farleigh Hospice complies with the Francis Report recommendations and I am proud that we already meet many of the requirements and the Hospice Board have approved an action plan to meet full compliance. We strive to ensure the highest quality of care through ongoing training of our staff and volunteers, satisfaction surveys, policy reviews and a comprehensive audit programme. A number of our Board members undertake observational visits to review all aspects of our work, talking to staff, volunteers and users of our service to ensure we maintain the standards agreed. We have worked hard in the past year to consult with as many people as possible to identify the needs of our patients, carers and bereaved clients for the next four years and have now published our strategic plan for 2014-2018, ‘Your Hospice and the Next Four Years’. I am grateful to all who contributed and believe this plan will build on the existing excellent work of Farleigh Hospice and enable others to benefit from our support when they need us most. I wish to thank all of our staff and volunteers for their ongoing hard work and commitment to Farleigh Hospice and to our local community and NHS funders for their continuing support. This Quality Account follows the model requirement set out in the regulations by the Department of Health. To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality of healthcare provided by Farleigh Hospice. Alison Stevens RN, DipHSM, MA Chief Executive For any queries, comments or any further information please email us at: comments@farleighhospice.org www.farleighhospice.org info@farleighhospice.org 01245 457300 1 Quality Account 2013-2014 Part 2 Priorities for Improvement and Statements of Assurance from the Board (in regulations) Introduction Farleigh Hospice Strategic Plan - ’Your Hospice and the Next Four Years- 2014- 2018’ outlines our vision moving forward which is of a community in which anyone affected by life limiting illness or bereavement has access to skilled compassionate care and support at the right time for them and in a place of their choice. There is still much to do to maintain existing services and to improve them so that they are flexible enough to respond to people’s changing needs. This quality account mainly considers quality issues within the provision of clinical care and relevant support services necessary to provide this care. It does not fully take into account the fundraising and administrative functions of the organisation. Future priorities for improvement - 2014 – 2015 The Board of Trustees is committed to the delivery of high quality care which is safe, effective and meets the needs of people who use our services and to support the continuous development and improvement of these services. These priorities have been developed through consultation with people who use our services including patients, carers, staff and volunteers. The priorities we have selected will impact directly on each of the three domains of quality:●● Patient safety ●● Clinical effectiveness ●● Patient experience. Looking forward Farleigh Hospice confirms that the top four quality improvement priorities for 2014- 2015 are to be:- Future improvement priority 1 Widening access to services Quality Domain: - Patient experience, Clinical effectiveness To widen access to our services through a review of our referral criteria and process to be able to reach out to those who may have issues and concerns at an early stage in their illness. 2 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 How was this priority identified? Following the consultation process and development of the new Farleigh Hospice Strategy ‘Your Hospice and the Next Four Years 2014 - 2018’ one of the objectives in the strategy was ‘To widen access to Farleigh Hospice services’. How will this be achieved? The Clinical Heads of Departments will lead a steering group to review criteria and process by which people access services. They will develop recommendations to be considered by the Senior Management Team and implement. How will this be monitored? Development will initially be proposed by the Clinical Heads of Departments who will develop a strategy, for review by the Senior Management Team and the Board of Trustees. Future improvement priority 2 Review of ‘Our Vision’, ‘Our Mission’ and ‘Our Core Values’ Quality Domain: Patient experience To develop a consistent and clear message about our current and future services by reviewing our vision, mission and core values and how we communicate with service users and other stakeholders. How was this priority identified? Following the consultation process and development of the new Farleigh Hospice Strategy ‘Your Hospice and the Next Four Years 2014 - 2018’ one of the objectives in the strategy was ‘To be clear about our message’. Agreeing what our Vision, Mission and Core Values are is important because it helps us clarify who we are and what we do. It provides a focus to create a place where everyone can achieve their best. How will this be achieved? To ensure we are clear about our message as an organisation the Heads of Departments will review and update the current ‘Mission’ statement and develop a new ‘Vision’ statement for the hospice. Key to this will also be agreeing the core values for the hospice which are shared and owned by all staff. Following a consultation process with staff the final Vision, Mission and Core Values will be discussed and agreed by the Senior Management Team and the Board of Trustees. This discussion will include agreeing how to promote the agreed Vision, Mission and Core Values with all stakeholders. How will this be monitored? Heads of Department meetings will be set up as workshops to discuss and agree outcomes which will be recorded in the meeting minutes. The Senior Management Team and the Board of Trustees will monitor progress and feedback will be given to staff through Farleigh Focus and notice boards around the organisation. www.farleighhospice.org info@farleighhospice.org 01245 457300 3 Quality Account 2013-2014 Future improvement priority 3 Introduction and rollout of ‘‘SystmOne’’ Quality Domain: - Clinical effectiveness, Patient safety The introduction and rollout of ‘‘SystmOne’’ which will be our new electronic patient record system to improve communication and information sharing between the hospice and NHS services e.g. District Nurses, GPs and hospitals. How was this priority identified? During 2013 – 14 Farleigh Hospice achieved connection to the ‘N3’ NHS broadband and the Information Technology and Clinical Teams carried out the preparatory work for the introduction of a new electronic care records management system called ‘‘SystmOne’’ replacing iCare and providing a range of additional benefits for patients and staff at Farleigh Hospice. The new system is designed to make the work of clinical staff much easier, with patient notes being stored electronically in one place for all the healthcare professionals caring for that patient to access. It is also designed to improve the sharing of information and enhance the quality and consistency of patient records. As well as providing secure access to up-todate information about patients under our care, the new system is designed to ensure all key healthcare professionals involved in a person’s care have the same up-to-date information about a patient’s progress and treatment. This enables a more joined up approach to providing care across health and social care organisations with GPs, NHS teams and associated healthcare organisations all working securely with a single set of patient records. ‘SystmOne’ is also linked to the NHS ‘national spine’- meaning any administrative patient details, such as changes of address, are immediately highlighted for correction, and the system is specially designed to protect the confidentiality of clinical information. The development of the new system will enable ongoing monitoring of the patient services provided by Farleigh Hospice and will aid future planning to meet local needs. How will this be achieved? Prior to the ‘go live’ for ‘SystmOne’ in April 2014 a programme of staff training was undertaken to ensure clinical and administrative staff understood the new system and were able to access and use the new electronic patient record. As part of the development plan, ‘Champions ‘ and ‘Super Users’ were identified and they will be available on an ongoing basis to support staff using the system. Additional functions will be rolled out to support the use of ‘SystmOne’ in the community and as a management tool to provide clinical reports on the service we provide. How will this be monitored? A ‘User forum’ will be established to review, problem solve and develop the system. This group will feedback to the Heads of Departments and the Senior Management Team A dedicated Helpdesk will also be created to resolve technical issues. The ‘Future State Mapping’ will be reviewed and updated to reflect changes to systems and processes post ’go live’ and identify any areas for future improvement. 4 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Future improvement priority 4 Development of a Rehabilitation Model Quality Domain: - Clinical effectiveness, Patient safety & Patient experience To further develop the Independent Living Team using a rehabilitation model. This will include the opening of a new Rehabilitation space at North Court Road in Chelmsford and also patient and carers workshops in both Chelmsford and Maldon. How was this priority identified? It is being recognised nationally that as treatment and management of many diseases has improved, patients and their carers are living with symptoms and side effects that are a lasting legacy of their survival. This situation requires a supportive approach to care, to enable people who are living with a life limiting illness to do as well as they can for as long as they can, and thus optimise their physical and mental wellbeing. The Independent Living Team have been utilising a rehabilitation model in their practice which they plan to develop further in Chelmsford and the newly refurbished day hospice in Maldon. How will this be achieved? The opening of the new Rehabilitation space in Chelmsford will offer more opportunities for regular physical exercise, education, and other activities to improve physical and mental wellbeing. A programme of events for patients and carers will be developed to offer a variety of opportunities in the Chelmsford and Maldon facilities as well as the community. How will this be monitored? Key Performance Indicators for the Independent Living Team will be used to monitor progress. Service user feedback will also help review and monitor views of the programme. All activities will be recorded in the electronic patient record – ‘SystmOne’. The programme will be discussed at the Clinical Heads of Departments and feedback on events given through Farleigh Focus, Farleigh news, Farleigh Intranet and Website. www.farleighhospice.org info@farleighhospice.org 01245 457300 5 Quality Account 2013-2014 How will progress be monitored for all future priority improvements – 2014 - 2015? The Farleigh Hospice Board of Trustees will monitor and report on progress through a variety of methods including:●● Annual General Meetings of the Company ●● Annual return to the Charity Commission ●● Annual Review and audited Report and Accounts ●● Events such as Open Days, Volunteers Day ●● Farleigh Hospice News, Farleigh Focus and other periodic communications ●● Quality Accounts and Annual Governance report ●● Quality and Audit Activity reports and Patient Surveys ●● Updates posted on the Farleigh Intranet and Farleigh Web site 6 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Priorities for improvement from 2013 – 2014 The aim of the Quality Account is to not only look forward by setting future priorities for improvements but to also look back and evidence achievements on priorities for improvement from the previous year. In last year’s report we set out four priorities for improvements for our services. All the areas identified were specifically selected as they would impact directly on the care our patients and carers received, either through improving patient safety, clinical effectiveness or the patient’s experience. The quality improvements for the previous year, 2013 -14 were:- Priority 1 Development of a Clinical Volunteers Training Programme Quality Domain: - Patient safety & Patient experience This will take the form of an Achievement Log which would be adapted for each volunteers role containing all the information they would need and training they would need to undertake. ●● The hospice recognised that it was important to not only recruit the right volunteers but to also support them and prepare them for their role. The Education and Training Group had developed a matrix of training requirements for all staff working in clinical areas in the hospice. It became clear that the training requirements for clinical staff were relatively straightforward to achieve, however, it was recognised that it was much more difficult delivering training for volunteers, for example getting them in one place to attend training. ●● The Volunteer Handbook and Achievement Record was developed for volunteers in clinical areas and adapted for each volunteer role, containing all the information they would require to carry out their role safely. It is a self learning tool designed to allow the individual to complete the required induction and training within a 12 month period. ●● The Volunteer Handbook and Achievement Record was developed in April 2013 and piloted between April and July 2013. The feedback was positive from the volunteers involved and following some minor adjustments based on the comments received it was decided to roll it out to all volunteers working in clinical areas. ●● The aims of the Volunteer Handbook and Achievement Record are to provide: ●● An overview of aims and objectives of the organisation and how it’s funded, staffed and managed. ●● Highlight the benefits of volunteering and the difference that volunteers make to Farleigh Hospice. ●● Have an awareness of the policies, procedures and processes that are in place. ●● Gain an understanding of the needs of our patients. ●● Complete the induction and training that is required for specific roles. www.farleighhospice.org info@farleighhospice.org 01245 457300 7 Quality Account 2013-2014 ●● Each volunteer is allocated a link staff member to help with the process and once the volunteer has worked through each section they are given some questions to test their understanding based on the information provided. Once they are able to demonstrate the required level of competence their staff member signs off their achievement record. Once completed volunteers received a certificate of achievement. ●● It is planned to evaluate the introduction of the Volunteer Handbook and Achievement Record later in 2014. Informal feedback to date has been good with most volunteers finding it a positive experience and supportive to them in their roles. New volunteers commented on how useful it was as part of their induction to their role. ●● If it is found to be a successful way of delivering information and training the Education & Training Group will be recommending the introduction of a similar system for volunteers in non clinical areas such as Support Services and Fundraising. Priority 2 Develop and introduce Clinical Key Performance Indicators (KPIs) Quality Domain: - Patient experience, Clinical effectiveness The KPIs will be based on End of Life Care Quality Markers and be developed for all clinical teams to monitor and improve the quality of care provided by the hospice. Once established they will be reviewed and audited annually. The Department of Health published its The End of life Care Strategy in 2008 and the subsequent Quality Markers were developed to support delivering improvements in care. Clinical Key Performance Indicators (KPIs) were developed based on these Quality Markers to demonstrate and evidence the quality of services provided by the hospice and underpins programmes for improvement. The following Clinical Key Performance Indicators were developed:●● General Clinical standards that applied to all clinical departments ●● Community Team standards for Community Clinical Nurse Specialists ●● Hospice @ Home standards for staff working in patients homes ●● Triage standards for access to our services ●● Information Service standards for the HOP (Hospice Outreach Project vehicle), Lantern Suite and information ‘Pod’ in the atrium at Broomfield Hospital ●● Day Hospice standards for nursing staff working in Day Hospice in Chelmsford & Maldon ●● Circle standards for Adult Bereavement services ●● Yo-Yo standards for Children’s Bereavement and Pre-bereavement services 8 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 ●● Therapy & Wellbeing standards for occupational therapy, physiotherapy, complementary therapy ●● Psychosocial Team standards for social work / welfare benefits, counsellors and carer services ●● Inpatient Unit standards for services provided in the IPU ●● Chaplaincy standards for the chaplain and spiritual care ●● Service user involvement standards for involving and informing service users ●● Education & Training standards for education coordinator providing internal and external End of Life Care education & training ●● Medical team standards for medical staff Each set of KPIs detailed the following:- ●● Standards/Quality Markers ●● Outcomes to be achieved ●● Key Performance Indicators to be measured ●● Compliance level/ acceptable performance level ●● Data source for compliance The KPIs were monitored on a regular basis through Clinical Heads of Departments meetings and some minor amendments were made over the year. They will also be reviewed annually with a report of outcomes going to the Governance Group. It had been planned to complete the annual evaluation for April 2014 but this has been delayed now until June 2014 due to the pressure on the Clinical Heads of Departments workloads with the development of templates and deployment of an electronic patient record system - ‘SystmOne’. The introduction of these KPIs has proved useful and will continue to be used to demonstrate and evidence the quality of services provided by the hospice and underpin programmes for improvement. Future KPIs will be developed. Priority 3 Development of the Farleigh Hospice Information Service Quality Domain: - Patient experience Development of an Information ‘Pod’ - within Broomfield Hospital, Mid Essex Hospital Services NHS Trust. This will be a joint venture with Farleigh Hospice, Mid Essex Hospital Services NHS Trust and Macmillan Cancer Support. ●● The hospice recognized that people concerned about or affected by cancer and other life limiting illnesses needed information that was accessible, timely and relevant, and easy to understand in order for to them to make informed decisions. www.farleighhospice.org info@farleighhospice.org 01245 457300 9 Quality Account 2013-2014 ●● Farleigh Hospice already offered advice and support through their information service based at the hospice in the Lantern Suite, in Chelmsford and also through the community service on the HOP (Hospice Outreach Project) vehicle which visits a variety of venues across mid Essex throughout the year. ●● To further develop and improve the availability of information and support, Farleigh Hospice worked in partnership with Mid Essex Hospital Services NHS Trust and Macmillan Cancer Support to develop and open an Information ‘Pod’ in the atrium of Broomfield Hospital. ●● The Information ‘Pod’ opened in September 2013 and is open Monday to Friday, 9.00am to 5.00pm. ●● The Information Service has a bank of trained volunteers who can work at the ‘Pod’, inside the Lantern Suite or onboard the HOP. This flexibility gives variety for the team themselves and means that visitors to the ‘Pod’, who might then prefer to come to the HOP or Lantern Suite next time, have consistency and the benefit of seeing members of the same team. The option of service rotation gives added flexibility for the whole Information Service and means that volunteers can move between bases as needed during busy periods. ●● Not only does the ‘Pod’ extend the Farleigh Hospice Information Service to a wider audience it also allows more people to access the services of the hospice, which will further raise the hospice profile out in the wider community.” ●● As part of the original proposal to develop the ‘Pod’ it was anticipated that the team would have 1500 contacts a year. In the first 2 weeks of operation they saw 250 individuals; far exceeding expectations, with projected first year contacts now standing at 3500. ●● Information will be kept about the number of contacts, reason for visits and outcomes throughout the year as this will form part of an annual report on the uptake of the Farleigh Hospice Information service. ●● The analysis of data collected to date indicates that the Information ‘Pod’ is providing a service to different groups of people than those who have previously accessed the other Farleigh Hospice Information services. The visitors are younger, many are patients currently receiving treatment, on curative pathways or undergoing reconstructive surgery with the team focusing on supportive and emotional care and issues relating to survivorship and living with and beyond illnesses. Visitors who may have been apprehensive approaching a hospice have felt confident being signposted by the team to Farleigh Hospice Services for further support and advice when it’s relevant. ●● A short satisfaction survey was carried out after 5 month on all visitors to the ‘Pod’ in one day. All visitors were happy to complete the survey with 94% feeling the environment gave them the opportunity to browse, talk about concerns and talk in confidence. Visitor comments:- “Nice calming environment” “Warm welcome – made me feel at ease” “No one has explained things in the way you have, thank you” “Would be good to be open at weekends” Future plans for the service are to consider 7 day opening and outreach work onto the wards and clinics. 10 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Priority 4 Consultation on future Strategy and Service development for the hospice Quality Domain: - Patient experience This will involve widespread consultation of service users and potential service users on Farleigh Hospice’s next strategic plan. ●● Farleigh Hospice’s Strategic Plan - ’Your Hospice and the Next Three Years’- 2011- 2014 which outlined the hospice’s vision moving forward which was, as always, inspired by the needs of people affected by a life limiting illness. A new strategy was required with updating to reflect the changing needs of the people we serve. To ensure preparation of the best possible plan a widespread consultation exercise of service users and potential service users was undertaken. ●● A multi media approach was employed in the consultation exercise. A survey was included with the Annual Report when it was distributed in August 13 which resulted in over 2000 responses. There were also opportunities to comment on the Farleigh Hospice website, Face book and Twitter. ●● The consultation on the strategy led to some very useful comments from staff, volunteers, service users and supporters. All comments were then collated and fedback to the Board of Trustees who agreed the final version of the new strategy at their Board meeting in March 2014. Farleigh Hospice’s Strategic Plan –‘Your Hospice and the Next Four Years - 2014-2018’ The strategic plan has 6 key objectives:- ●● To widen access to Farleigh Hospice services ●● To Coordinate care ●● To be clear about our message ●● To use resources effectively and efficiently ●● To maximize income ●● To engage with our local community ●● A Strategic Prioritisation Matrix was developed identifying activity to achieve each objective spread over the four years of the strategy. The annual operational plan was also developed giving more detail for 2014/15 as to what we will aim to achieve, by when, who will take responsibility and any resource implications of carrying out the plan. ●● There will be a full launch of the Strategic Plan in April with a series of ‘road shows’ to share thoughts and ideas as to how the plan might be achieved over the four year period. It is planned that these will take place across mid Essex encouraging staff, volunteers, supporters and general public to attend. www.farleighhospice.org info@farleighhospice.org 01245 457300 11 Quality Account 2013-2014 Mandatory Statements of Assurance from the Board The following are statements that all providers must include in their Quality Account. Many of these statements are not directly applicable to specialist palliative care providers and therefore explanations of what these statement mean are also given. Review of services During 2013 - 2014 Farleigh Hospice provided the following specialist palliative care services:●● In-Patient Unit – 10 beds ●● Day Hospice – at Chelmsford & Maldon – 90 places per week. (Maldon was closed in August 2013 due to flood damage and it reopened in April 2014) ●● Medical and Nursing Outpatients ●● Community services – including Hospice @ Home, Farleigh Clinical Nurse Specialists, physiotherapists, occupational therapists, social workers ●● Counselling ●● Carer Support ●● Well Being Services – creative therapies, chiropody, hairdressing, complementary therapies ●● Information and ‘drop in’ services at the Lantern Suite in Chelmsford, on the HOP (Hospice Outreach Project) vehicle in the community and the Information ‘Pod’ at Broomfield Hospital run in partnership with Broomfield Hospital and Macmillan Cancer Support ●● Chaplaincy ●● Bereavement support for children, young people and adults ●● Education and Training What this means Farleigh Hospice is an independent charity which provides all services free of charge. The income generated from the NHS in 2013/2014 represented 44% of the overall costs of service delivery with the remaining income to fund our services coming from voluntary charitable donations, legacies, events, corporate and community fundraising, hospice shops and lottery. Participation in clinical audits Although the following are a series of statements that all providers must include in their Quality Account many of these statements are not directly applicable to specialist palliative care providers. ●● During 2013 – 2014 no national clinical audits or confidential enquiries covered NHS services provided by Farleigh Hospice. As Farleigh Hospice only provides palliative care it was not eligible to participate in any of these above activities. 12 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 ●● During this period Farleigh Hospice participated in no national clinical audits and no confidential enquiries of the national clinical audits and national confidential enquiries as it was not eligible to participate in any. ●● The national clinical audits and national confidential enquiries that Farleigh Hospice was eligible to participate in are as follows: NONE. ●● The national clinical audits and national confidential enquiries that Farleigh Hospice participated in are as follows: NONE. ●● The national clinical audits and national confidential enquiries that Farleigh Hospice participated in and for which data collection was completed are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. NONE. ●● Farleigh Hospice was not eligible to participate in any national clinical audits or national confidential enquiries and therefore there is no information to submit. What this means As a provider of specialist palliative care Farleigh Hospice was not eligible to participate in any of the national clinical audits or national confidential enquiries. This is because none of the 2013 - 2014 audits or enquiries related to specialist palliative care. The hospice will also not be eligible to take part in any national clinical audit in 2014 – 2015 for the same reasons. Local audits To ensure a high quality of services an annual audit programme has been established and a variety of quality and audit activities were undertaken using nationally agreed formats often specifically developed for hospice care as well as locally developed audit tools. For all these audits undertaken, where necessary, local action plans for improvements were developed, and in general they will be re-audited within the next 12 months to check for improvements. This has enabled us to monitor the quality of services and make improvements where needed. The reports of 74 local audits were reviewed by the Farleigh Hospice Governance group of which 62 related to clinical care and relevant support services necessary to provide this care and evidence compliance. Details of audits completed in 2013 – 2014, to improve the quality of services, can be seen in Appendix A. Research The number of patients receiving NHS services provided by Farleigh Hospice in 2013-14 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 research studies in palliative care in which we could participate during this period. www.farleighhospice.org info@farleighhospice.org 01245 457300 13 Quality Account 2013-2014 Use of CQUIN payment framework The Service Level Agreement for Farleigh Hospice NHS income in 2013–14 included a Commissioning for Quality and Innovation (CQUIN) sum in respect of the successful completion training in Non medical prescribing for Clinical Nurse Specialist. This training has now been completed and discussion are now taking place as to how this extended role will be introduced in 2014 – 2015. Statements from Care Quality Commission (CQC) Farleigh Hospice in Chelmsford and Farleigh Hospice in Maldon are required to register with the Care Quality Commission and are currently registered to provide the following regulated activity:●● Personal care, ●● Treatment of disease, disorder or injury Farleigh Hospice is subject to periodic reviews by the Care Quality Commission and the last on-site inspections were in April 2013 at Farleigh Hospice in Chelmsford. Farleigh Hospice in Maldon was not subject to a review as the facility was closed from August 2013 as a result of flooding. Farleigh Hospice was fully compliant with all the Essential Standards of Quality and Safety as set out in Care Quality Commission (Registration) Regulations 2009 and the Health & Social Care Act 2008 (Regulated Activities) Regulations 2010. The CQC has not taken any enforcement action during 2013 – 2014. Farleigh Hospice has not participated in any special reviews or investigations by the CQC in this period. Data Quality Farleigh Hospice did not submit records during 2013-14 to the Secondary Users service for inclusion in the Hospital Episode Statistics which are included in the latest published data. Why is this? This is because Farleigh Hospice is not eligible to participate in this scheme. In the absence of this we have our own system in place to collect and monitor data through the electronic patient information system iCare. Farleigh Hospice also submits data to the Minimum Data Set (MDS) for Specialist Palliative Care Services collected by National Council for Palliative Care on an annual basis with the aim of providing an accurate picture of hospice and specialist palliative care activity. Information Governance Toolkit Farleigh Hospice submitted its Information Governance Toolkit assessment version 11 in March 2014 to Mid Essex Clinical Commissioning Group and the Health & Social Care Centre (HSCIC) The outcome from both organisations was satisfactory for this year’s IG Toolkit and we again passed the required standard; with Farleigh scoring 67% overall, with Level Two attainment being achieved in the areas of Confidentiality and Data Protection Assurance, Information Security Assurance and Clinical Information Assurance – and a slightly higher score recorded for Information Governance Management at 73%. This demonstrated sufficient compliance to maintain the ‘N3’ connection. 14 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 The report also highlights some key considerations for the next IG Toolkit compliance period (i.e. 20142015) – these being clinical procedures relating to the adoption of ‘SystmOne’ and the associated smartcard/RA activities. What this means ‘N3’ (fast broadband networking service within the NHS) computer connection improves access to diagnostic test results carried out by the NHS. Results will be more easily accessible for medical staff, leading to quicker decisions regarding treatment of patients. This is also a requirement for connection and use of ‘SystmOne’ the electronic patient record system which goes live on 1st April 2014 Clinical coding error rate Farleigh Hospice was not subject to the Payment by Results clinical coding audit during 2013– 2014 by the Audit Commission. Why is this? There is currently no payment tariff for palliative care services. The Francis Report & Farleigh Hospice The Francis Report (2013) is the result of the public inquiry, chaired by Robert Francis QC, under the Inquiries Act 2005, into serious failings at the Mid Staffordshire NHS Foundation Trust. This report made 290 recommendations and a review of these demonstrated 102 related to the care provided by Farleigh Hospice. A review of these recommendations by Farleigh Hospice Head of Patient Care indicated that FH is already meeting many of the recommendations. For the 102 recommendations that apply to Farleigh Hospice a detailed report and action plan was written and presented to the Board of Trustees in February 2014 to demonstrate full compliance or areas for further improvement. A lead person and timeframe was agreed for each action and the action plans will be reviewed by the board on a regular basis. If you would like further information about this report please email us at: comments@farleighhospice.org www.farleighhospice.org info@farleighhospice.org 01245 457300 15 Quality Account 2013-2014 Part 3 - Review of Quality Performance The National Council for Palliative Care: Minimum Data Sets 2011 – 2012 & 2012 – 2013 The figures below provide information on the activity and outcomes of care for patients in 2011 – 2012 and 2012 – 2013 compared to the median for other similar hospice services prepared by the National Council for Palliative Care. (NCPC) This information is not the reporting year as the NCPC dataset for 2013– 2014 will not be available until September 2014 Total number of patients % New patients % New patients – non cancer diagnosis % New patients with ethnicity recorded % Occupancy First admission Repeat admission Total number of patients Total number of new patients % New patients % New patients – non cancer diagnosis Total Day Care Attendances % Non attendance Average length of attendance Total number of patients Total Number of new patients % New patients % New patients – non cancer diagnosis % of patients who died at home Total Service Users Total number of new service users % New referrals Total number of contacts Total number discharged % discharged Total number of patients Total number of new patients % New patients % New patients – non cancer diagnosis 16 Farleigh Farleigh Hospice Hospice 2011 - 2012 2012 - 2013 In Patient Number/% Number/% 241 234 90.9% 91.9% 5.5.% 8.8% 82.2% 72.6% 72.7% 73.6% 212 228 72 58 Day Care 227 179 160 114 70.5% 63.7% 15.6% 19.3% 2507 2032 28.6% 29.7% 108.1 91.8 Home Care/ Hospice @ Home 1071 1158 761 787 71.1% 68% 14.3% 17.5% 65.0% 80.5% Bereavement 1430 2843 715 1305 50.0% 45.9% 3422 7342 825 1306 57.2% 45.6% Out Patients 26 59 10 42 38.5% 71.2% 40.0% 19.0% www.farleighhospice.org National Median 2011 - 2012 National Median 2012 - 2013 Number/% 217 89.1% 9.9% 92.8% 75.7% 192 58 Number/% 166 89% 8.6% 92.4% 76.2% 144 48 248 160 66.1% 15.1% 2314 26.6% 163.9 137 86 64.3% 23.5% 1632 27.1% 148.7 1310 895 68.8% 14.1% 55.5% 1369 898 68% 14.5% 52% 492 305 67.4% 2379 265 57.5% 486 313 69.4% 2408 283 54.7% 42 28 77.6 9.5% 51 37 73.8% 13.5% info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Farleigh Hospice Quality Performance Information 2013 – 14 Detailed below is data about services provided by Farleigh Hospice relating to the review period April 2013 to March 2014. General information The total number of people i.e. patients, carers and bereaved, cared for by Farleigh Hospice in the last year was 2,728 an increase on the previous year of 11.6%. The increase in people cared for is primarily carers and the bereaved. Total People Cared for by Farleigh Hospice 1857 2135 2225 2445 2728 April 2009 April 2010 April 2011 April 2012 April 2013 - March - March -M arch - March - March 2010 2011 2012 2013 2014 The increase in the Information Service and its accessibility (see above Priorities for Improvement 3, 2012 – 2013) has increased the number of people cared for by the hospice. Although currently the Information Service contacts have not been included in the total number of people cared for by the hospice, as shown in the chart above, had they been included the total number of people cared for by Farleigh Hospice would be 7,742. www.farleighhospice.org info@farleighhospice.org 01245 457300 17 Quality Account 2013-2014 Patient Referrals The number of patient referrals and new patients to the hospice was similar to last year. Hospital referrals continue to be the highest source of referrals. Source of referral % GP 70% 60% Community Nurse 50% MEHT 40% 30% Social Services 20% Family/self 10% 0% April 2009 March 2010 April 2010 March 2011 April 2011 March 2012 April 2012 March 2013 April 2013 March 2014 Other hospice/hospital Pal Care Team Other Total Number of Patients Cared for by Farleigh Hospice 1194 April 2009 March 2010 18 1287 April 2010 March 2011 www.farleighhospice.org 1382 April 2011 March 2012 1387 April 2012 March 2013 1453 April 2013 March 2014 info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Patient Diagnosis Farleigh Hospice has always provided end of life care for cancer and non cancer patients and over the last few years there has been a slight increase in the number of non cancer patients accessing hospice services – in the review period 17.5% of referrals had a non cancer diagnosis. Diagnosis of all patients % 89.5 88.5 85 82.5 17.5 17 15 11.5 10.5 83 April 2009- April 2010- April 2011- April 2012- April 2013March 2010 March 2011 March 2012 March 2013 March 2014 Cancer Non cancer Preferred Priorities of Care (PPC) PPC’s for all services are recorded below. 35% of patients did not have a recorded PPC. The average PPC’s achieved for patients under the care of the Hospice at Home Team was 89%. Preferred Priorities of Care (PPC) 64 63 59 0.39 30 6 8 10 April 2012 - March 2013 April 2013 - March 2014 11 April 2011 - March 2012 Usual Place of Residence/ Home www.farleighhospice.org 30.86 28 Care Home info@farleighhospice.org Hospital Hospice 01245 457300 19 Quality Account 2013-2014 Place of Death as % of all Patient Deaths An increasing number of patients died in the hospice primarily because patients are now being referred at a later stage of their illness to the hospice. In 2009/2010 referral to the service to death was 40 days in 2013/2014 it was 24 days. This has an impact on services and workload and is the most significant issue facing the hospice at the present time. Place of Death as % of all Patient Deaths 49 44 39 35 28 34 26 27 21 21 21 12 13 14 April 2009 March 2010 April 2010 March 2011 April 2011 March 2012 Usual Place of Residence/ Home 16 18 18 April 2012 March 2013 Care Home 18 21 26 April 2013 March 2014 Hospital Hospice Inpatient care (IPU) The workload in the Inpatient Unit has been variable over the year with the total admissions being 320 which are higher than the previous year which was 286. Of these 233 were ‘first’ admissions to the inpatient unit. There were 35 unavailable bed days on the Inpatient Unit due to redecoration and building works. Bed occupancy was 68.7% slightly lower than the previous year. There is rarely a waiting list for admissions, the average time from referral to admission being 2 days. Longer times are often at the patient’s request/ preference. It is interesting to note that admissions per bed are 32 which is higher than the national average of 23.5 and demonstrates the busyness of the unit which keeps the occupancy down. 18.7% of all admissions to the Inpatient Unit were from hospital which probably reflects patient/family wishes to die in the hospice rather than the hospital if dying at home is not appropriate or cannot be arranged. This is less than the previous year which was 20% of admissions. 20 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Four patients under the age of 40 were admitted to the inpatient unit during the year. The average length of stay was 7.8 days showing a decrease from last year of 9 days. 56% of patients were discharged with the majority returning home (52%) an increase from the previous year. IPU admissions were 11.7% of the hospice workload. This is less than last year and reflects the greater use of the community services including Hospice at Home. Community care Farleigh Hospice Community Specialist Nurses The Farleigh Hospice Community Specialist Nursing Team continued to face high workloads. The number of new patients continued to rise and was 662, a 3.9% increase on the previous year. The Triage nurses ensure patients are seen by the most appropriate member of staff with 76.6% of referrals going to community nurses similar to the previous year – 79%. The nursing team carried out 3,376 visits which was less than the previous year (3,899) but this was due in part to four nurses taking time out to undertake the Nurse Prescribing Course. Hospice @ Home The Hospice at Home team provided 7,977 care hours in patients homes to 367 patients. 85% of the visits were for 1 hour however there has been an increase in the number of 2 hour visits reflecting the increasing needs of some patients. www.farleighhospice.org info@farleighhospice.org 01245 457300 21 Quality Account 2013-2014 Day Hospice Farleigh Hospice’s Maldon Day Hospice was flooded in August resulting in services being relocated to the Kingswood centre in Southminster and by an extra day a week at the Chelmsford Day Hospice. Some patients could not or chose not to attend the reprovided services. The number of attendances for the year was 632 with 35 new patients referred compared to 38 the previous year. The Day Hospice reopened in April 2014. The Day Hospice in Chelmsford saw an increase in attendances from 1,216 in the previous year to 1,557 and also in the number of new patients attending. Independent Living Team The work of the Allied Health Professionals Team has increased due to reallocation of staffing creating a Team Leader post and two part time Therapy assistant posts. This has allowed an increase in group work e.g. arts, crafts, creating writing, outdoor group, providing patients and carers with choice and access to activities. This has resulted in a significant increase in the number of people accessing groups from 197 the previous year to 533 this year. The social work role was also reviewed enabling more focused social work support, increased counselling and welfare rights advice. The Wellbeing service underwent changes over the year with a new coordinator who recruited additional therapists and volunteers to increase the capacity of the services offered which include, massage, hairdressing and chiropody. 87% of this work is with patients and the remainder with carers with 666 treatments being delivered in Chelmsford and Maldon and 125 treatments in the community. 22 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Information Service The information service saw an increase in the number of people to whom we were able to provide advice and support through the opening of the Information ‘Pod’ in the atrium at Broomfield Hospital, Chelmsford. Since opening in September 2013 an average of 15 individuals a day were seen. The Lantern Suite team, in Chelmsford, had 1,660 people visit over the year and the Hospice Outreach Project (HOP) vehicle visited a variety of locations across mid Essex on 133 days and staff met with 1,324 individuals. Bereavement Services The mid Essex adult bereavement service ‘Circle’, was not only available to provide support for the bereaved families and carers of hospice patients but also to other bereaved adults in mid Essex who were appropriate for the service. The service had 659 new referrals in the year with – 559 linked to the hospice and 100 external referrals. The service provided 417 one to one support sessions, 992 Bereavement Counselling sessions, 255 group attendances and provided telephone support. The Yo-Yo Project which is a pre and post bereavement service for children and young people had 132 new referrals – 25 linked to the hospice and 107 external referrals. They provided individual, group and telephone support over the year with approximately 27% of the one to one work taking place in the hospice. Sessional counsellors have been used to support counsellors, student counsellors and volunteers to help meet the increased demand in both adult and children’s services. www.farleighhospice.org info@farleighhospice.org 01245 457300 23 Quality Account 2013-2014 Quality Markers we have chosen to measure Quality is at the heart of everything we do. In addition to the number of suitable quality measures in the national data set for palliative care, we have chosen to measure our performance against the following:●● Complaints & Compliments ●● Safety Information ●● Infections & Pressure Ulcers ●● Education & Training ●● Local Audits ●● Other Quality Initiatives ●● What others say about our organisation Complaints & Concerns During the reporting year the Complaint Procedure was reviewed and updated following a clinical complaint, received last year, which had been referred for independent review. The updated procedure was reviewed and approved by the mid-Essex Clinical Commissioning Group and the complainant and now includes accessing, when necessary, external support and advise from PALS. (Patient Advice and Liaison Services) It also now includes the logging of ‘Concerns’ which would be dealt with in an informal manner and ‘Complaints’ which follow a more formal process. The aim was to gain a better understanding of issues raised about the organisation as it may be important to follow up on those issues even if the individual may not wish to make a formal complaint. 12 complaints were received between April 2013 and March 2014, 7 less than the previous year, and of those 6 related to clinical care. Complaints comparison 2009 - 2014 Total No. Complaints No. Complaints Patient/family care 31 25 18 14 6 20092010 24 20102011 www.farleighhospice.org 19 10 20112012 8 20122013 12 6 2013 2014 info@farleighhospice.org 01245 457300 Quality Account 2013-2014 All complaints are categorised following completion of an investigation as green, amber or red based on the seriousness and likelihood of the issue to recur. The outcome of the complaint is agreed – Not Upheld, Partially Upheld, Upheld and the theme of the complaint e.g. – clinical care, communication, attitudes, fundraising issues are also recorded to monitor trends. Complaints 2013– 2014 Total number of complaints related to patient/family care Total number of these which were upheld Total number of these which were partially upheld Main theme from complaints 6 2 3 Communication All were fully investigated and appropriate actions taken. All complaints were discussed by the Senior Management Team to ensure correctly dealt with and to facilitate organisational learning Compliments Although the number of complaints was small the number of compliments was significantly higher as evidenced through letters and cards from families and carers, comments in the annual Patient Satisfaction Surveys and customer feedback in our shops. Information Security Incidents In the period there were only two incidents reported through the Information Security Incidents process and in both cases there were no actual data losses and therefore not formally reported, but both were seen as potential breaches and treated as such in the associated Senior Information Risk Owner reports. Safety information Risk Assessment General risk assessments are in place to address health & safety hazards in all areas of the organisation. Additionally, COSHH risk assessments have been carried out for hazardous substances. All risk assessments are reviewed at least annually or sooner if circumstances change. Accidents / Incidents For the period 1st April 2013 to 31st March 2014 there were 47 health & safety related incidents reported involving staff, volunteers, visitors and members of the public. In 21 of the reported incidents no injury was sustained, of the 26 incidents where injuries were sustained 24 were classed as minor and 2 were classed as medium. Of the injuries, 3 were reported to the Health & Safety Executive, 2 involved staff and 1 a volunteer. As can be seen from the chart below, manual handling was the most common cause of injury. www.farleighhospice.org info@farleighhospice.org 01245 457300 25 Quality Account 2013-2014 Cause of Injury 4% 4% 4% 4% 8% 31% 7% 19% 19% Number of incidents Contact with hot object Manual Handling Slip, Trip or fall from level Struck object5 Contact with hazardous substance Struck by moving/falling object Equipment failure 1 Needlestick Other 1 8 5 2 1 1 2 Patient Incidents For the period 1st April 2013 to 31st March 2014 there were 55 clinical incidents, 50 of which were patient falls. Patient Falls Of the 50 patient falls, 2 resulted in injuries which were reported to the Health & Safety Executive, 1 of which was also reported to the Care Quality Commission. All were fully investigated by the hospice. The patient falls were categorised, as follows. Patient Falls - Injuries 6% 2% 2% No injury sustained 90% 26 www.farleighhospice.org - 45 Minor injury requiring a single intervention -3 Moderate injury (e.g. requiring suturing) -1 Major injury (e.g. requiring surgery) -1 info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Medication related incidents – 49 medication related incidents occurred of which 4 were near misses. Medication Adverse Events 35 30 25 20 15 10 5 0 32 29 31 27 14 8 4 2 April 09March 10 5 0 April 10March 11 Patient related 4 7 April 11March 12 5 44 April 12March 13 Non patient related April 13March 14 Near misses All were investigated and, where necessary, corrective action was taken. There were no serious consequences to patients from any of these incidents. Audits of these medication related incidents are carried out quarterly. Safety Alerts The hospice reviewed and actioned relevant alerts received from the Central Alerting System including drug safety alerts from the Medicines and Healthcare products Regulatory Agency and Medical Devices Alerts – 67 medical device alerts were reviewed and appropriate action taken when relevant. Patient Infections and Pressure Ulcers Infections and pressure ulcers cause pain and distress to patients and families and have cost implications to organisations. Infections and pressure ulcers are monitored on an on-going basis by the Manager of the Inpatient Unit and reported to Farleigh Hospice’s Governance Group and the Care Quality Commission. Infections are also reported to the Infection Control Team on a quarterly basis. Information relating to the incidence of Patient Infections and Pressure Ulcers is collated into an annual audit. There continues to be a very low number of infections and pressure ulcers acquired at the hospice. Infections There were 18 reported infections during the period compared to 11 the previous year. 2 patients were identified with 2 separate organisms. None of the 18 reported infections were acquired at Farleigh Hospice and all were from patients admitted to the Inpatient Unit. Patient Infection 2013 - 2014 Unit No Cases Inpatient Unit/Day 18 Hospice www.farleighhospice.org No on admission No Acquired At Farleigh 18 0 info@farleighhospice.org 01245 457300 27 Quality Account 2013-2014 Infections Inpatient Unit 18 12 11 0 Total No. Cases 2011 2012 Total No. Cases 2012 2013 Total No. Cases 2013 2014 Total No. Acquired At Farleigh 2011 2012 1 Total No. Acquired At Farleigh 2012 2013 0 Total No. Acquired At Farleigh 2013 2014 Pressure Ulcers There were 45 reported pressure ulcers during this period compared to 39 the previous year. All were from patients admitted to the Inpatient Unit. Although there was an increase in the number of reported pressure ulcers, the number acquired in the hospice was 4, 12 were present on transfer from hospital and 29 on transfer from the community. Pressure Ulcers 2013 - 2014 Unit No Cases Inpatient Unit 45 Day Hospice Maldon 0 Day Hospice Chelmsford 0 No on admission 41 0 0 No Acquired At Farleigh 4* 0 0 * 2 patients developed ulcers while in the IPU, but refused preventative measures despite being informed of the risks. The other 2 patients had appropriate preventative measures but developed ulcers at the end of life related to their poor physical health 28 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Pressure Ulcers 45 39 28 4 22 Total No. Total No. Total No. Total No. Total No. Total No. Cases 2011 Cases 2012 Cases 2013 Acquired Acquired Acquired -2 012 -2 013 -2 014 At Farleigh At Farleigh At Farleigh 2011 - 2012 2012 - 2013 2013 - 2014 Safeguarding Vulnerable Individuals The hospice has a safeguarding lead who advises and supports staff with any concerns they have regarding safeguarding issues. Some issues were raised by staff but no safeguarding alerts were raised by Farleigh Hospice staff in the review period. A system was established to anonymously record safeguarding issues to ensure relevant training was provided on common issues faced by hospice staff Education & Training - Palliative and End of life care During 2013 – 14 the aim was to continue and increase this education work to the wider community. The Education Coordinator continued to develop and deliver education and training focused on palliative and end of life care There were short sessions and study days at Farleigh Hospice as well as outreach sessions in the community as detailed below:● Palliative Care Essentials – Farleigh Hospice delivered 11 monthly 2 day “Palliative Care Essential study days – An introduction to palliative care for the generalists”. The total register for the 11 study days was 172 participants who attended from acute hospital sector (Broomfield), dementia unit (Crystal centre), care homes and Farleigh Hospice. Discussion and teaching focused on communication, advance care planning, holistic assessment, recognising dying and symptom control, pain assessment and management and the importance of self awareness and self care. www.farleighhospice.org info@farleighhospice.org 01245 457300 29 Quality Account 2013-2014 ●● The evaluations by the participants were very positive valuing discussing work related scenarios and demonstrating learning outcomes – “We have learned lots and found the days informative and helpful”, “We got lots out of it”, “Extremely interesting and of clinical benefit”, “…furthered my knowledge of palliative care” • Micro teaching - Farleigh Hospice Education Department delivered 16 micro teaching sessions (1 to 4 hour), over the year, with a total audience of 242 participants, from, Broomfield Hospital, nearby local care homes, community health workers and volunteer settings as well as Farleigh Hospice staff. Topics covered were similar to the Palliative Care Essentials but also included presentations from the Coroner’s office, Funeral Directors and about benefits and budgets. • Outreach Palliative Education programme – Over the year 10 requests were received for palliative care education outside the hospice from the acute hospital sector (Broomfield), dementia unit (Crystal centre) and care homes with a total registered audience of 95. Topics delivered in the clinical settings included Use of Syringe Drivers and Advanced Care Planning (ACP). • Advanced Clinical Teaching - The medical team and Farleigh Community Nurse Specialists, Independent Living Team with education support, facilitated advanced clinical teaching sessions aimed at experienced clinicians both internal and external to Farleigh Hospice. 28 sessions were organised with 116 participants. Topics covered included Prognostication, Neuropathic pain and Management of Nausea and vomiting. Education & Training - Palliative and End of Life Care 2013 - 2014 Type of Event Palliative care essentials study days Micro Teaching sessions – 1 - 4 hours sessions Outreach Palliative Education programme Advanced Clinical Teaching 30 Total No Staff targeted of events 11x 2 days Community and care home staff and new Farleigh Hospice staff 16 Broomfield Hospital, nearby local care homes, community health workers and volunteer settings as well as Farleigh Hospice staff 10 Community hospitals, care homes, care agencies and community nurses 28 Farleigh Medical team, Community Nurse specialist, Independent Living team www.farleighhospice.org info@farleighhospice.org Total No Attended 173 x 2 days 242 95 116 01245 457300 Quality Account 2013-2014 Local audits To ensure a high quality of services a variety of audits were undertaken using nationally agreed formats often specifically developed for hospice care as well as locally developed audit tools. This has enabled us to monitor the quality of services and make improvement where needed. The Quality & Audit Activity Programme for the previous year had 80 local reports and all action plans form these reports have all been completed. In 2013 – 14 the reports from 74 local audits were reviewed by the Farleigh Hospice Governance group of which 62 related to clinical care and relevant support services necessary to provide this care and evidence compliance. The number of audits from clinical departments was less this year due to the closures of the Day Hospice in Maldon from August 2013 due to flooding. Action plans were developed as a result of these audits to improve the quality of services provided. The outcomes from the audits were reviewed by the Governance Group on a regular basis and in their Annual Governance report. Quality & Audit Activity April 2013 - March 2014 25 12 10 7 3 2 5 6 2 11 Total by Department Details of audits completed in 2013 – 2014 can be seen in Appendix A An explanation of those involved in this Quality Account The Quality Account was discussed and reviewed by Farleigh Hospice Governance group which includes senior managers from all relevant areas, Trustees, a Service User Facilitator and the Quality Improvement Lead. The task of writing it was designated to the Quality Improvement Lead and Chief Executive. Discussion then took place within the Senior Management team regarding the key priorities for improvement for 2013 – 2014 following suggestions from Heads of Departments and the Multi www.farleighhospice.org info@farleighhospice.org 01245 457300 31 Quality Account 2013-2014 Departmental Quality Assurance group. Four were selected and after consultation with staff, patients, carers, volunteers and the public, it was agreed to include all four in the report. The Quality Account was then completed and circulated to the Governance Group and Board of Trustees for discussion and comment and it was distributed externally to the mid Essex Clinical Commission Group; Healthwatch Essex and the Health Overview & Scrutiny Committee, Essex. Comments received have been included in this report. 32 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Other quality initiatives Farewell and Welcome In July 2013 Janet Doghan retired as Chief Executive at Farleigh Hospice after almost 15 years in post. Janet said “Working here has been a massive privilege. I have never forgotten the responsibility which has been entrusted upon me, and others to ensure that all of our income is spent wisely for the most cost effective provision of patient and family care. Representing Farleigh Hospice and hearing the fantastically positive comments about our care has made me proud to be a member of the hospice team.” Alison Stevens, the new Chief Executive was officially welcomed, to Farleigh Hospice in August, at a reception held at the main hospice site in Chelmsford. Around 100 guests joined to celebrate Alison’s arrival including local Clinical Commissioning Groups (CCGs), members of various Trusts, local businesses, MP’s from across the Chelmsford, Maldon and Braintree areas, members of the clergy, VIP’s and other valued supporters of the Hospice. Alison said, “What a wonderful welcome reception! This I believe is a true reflection of the way in which Farleigh Hospice works – a truly committed and dedicated team who put their heart and soul into everything they do. Thank you. It is an honour and privilege to have been appointed to lead Farleigh Hospice forward from the really strong foundation already in place”. On her first day Alison had to deal with a Care Quality Commission inspection which went well. Over the past months Alison has been out and about meeting staff, volunteers, service users and supporters across mid Essex and is now finalizing the details of the new strategy ‘Your hospice and the next four years’ Helping our patients get ‘Out & About ‘ The Independent Living Team at Farleigh hospice is comprised of various staff, with a range of expertise, all with a passion for supporting people to live their lives to the full despite the challenges they may be facing. They took the concept of independent living that bit further in August 2013, with the introduction of a new group for patients and their carers:- the ‘Out & About ‘Group! Just as the name suggests, the aim of the group is to support Farleigh Hospice patients and their carers to get out and about and access their local community. The inaugural outing the group visited www.farleighhospice.org info@farleighhospice.org 01245 457300 33 Quality Account 2013-2014 a local county park in Chelmsford, walking (and wheeling) around the wonderful gardens, enjoying being outdoors in beautiful surroundings and finishing with a picnic. Further visits have taken place over the year including a trip to the promenade in Maldon “It was nice that everything had been thought of; chairs, walkers, food, drinks...” “The driver was wonderful; he even thought to bring our coats that we had left on the minibus” “Thought it was excellent, really looking forward to the next one in Maldon” “Lovely afternoon, glad I came” The Independent Living Team also ran many different groups and workshops for our patients and their carers over the year. These included:‘What’s your Story’ Workshop – a programme for patients, carers, friends and visitors to take part in writing and sound workshops - ‘To give your story a voice’. Barge Trip –This was a beautiful trip, taking in the stunning Essex countryside views in a Victorian barge. This offered the chance for both carers and the cared for to relax and meet new friends. Art and Craft Group - A fun social group for patients to find the artist inside! Easibreathe Group - A weekly fun and easy way to manage and improve breathing techniques It is planned to increase the number of groups and workshops in 2014 – 2015 (see Future Priorities for Improvement page??? Yo-Yo Project Art Gallery Grand opening! In September 13 some very special and emotive artwork was unveiled in Farleigh Hospice’s Art Gallery in Chelmsford. The artwork was created by children and young people who have been receiving support, both pre and post bereavement, from Farleigh Hospice’s Children’s Bereavement Service, ‘The Yo-Yo Project’. The children worked on their artwork during individual and group sessions from mid August and after it’s unveiling, the gallery was on display until the end of October to all visitors, staff and volunteers to the hospice. The children and young people who utilise Farleigh Hospice’s Yo-Yo Project and contributed their work to the gallery had been dealing with difficult and emotional circumstances which resulted in them creating some emotional and very personal work. Each piece of work had an association to someone significant in their lives who is either seriously ill, or deceased. The age of children accessing Farleigh Hospice’s Yo-Yo Project service spans from 4, to 18. The service is tailored to meet individual needs and children and young people can either receive one-to-one support through the service, or take part in group sessions. Counselling is provided at the hospice, in schools, or at their home. A special children and families room located within the hospice offers a homely and 34 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 dedicated area for the work of the Yo-Yo Project to take place and is also where the majority of the artwork was produced. The team leader for the bereavement service concluded:- “It’s great to have this opportunity for the children, and members of their families, to get together to share and discuss their work, along with everyone else’s.” Seeing red – Farleigh Hospice celebrates Dignity Action Day 2014 Farleigh Hospice once again supported the national initiative ‘Dignity Action Day’. Although the day is traditionally celebrated annually on 1st February, Farleigh Hospice celebrated the special occasion a day early, on Friday 31st January, so that more people from across the organisation could take part. This special day is celebrated nationally in different ways, but all staff working at Farleigh Hospice were invited to wear something red for the day. People showed their support by donning their red tops, necklaces, badges and hair bands The IPU Nurse who organized the day concluded, “We think it is important to mark Dignity Action Day and highlight the importance of dignity in care delivery. Marking the day in this simple way helps to highlight an important aspect of what we do and also brings the different departments at Farleigh Hospice together.” New ‘Schwartz Round’ group established for Farleigh Hospice staff and volunteers Working and volunteering at Farleigh Hospice is extremely rewarding, but it can also be emotionally challenging. To give staff and volunteers a chance to share their experiences and feelings about their work at Farleigh Hospice, a new group was established using the ‘Schwartz Round’ concept “Schwartz Rounds” is a concept initially started in United States by a patient who felt that the team looking after him (and by that he included the whole team from porters, to consultants to the kitchen staff preparing his meals) would benefit from an opportunity to respond to him and his illness as human beings. Healthcare organisations across the US and the UK have adopted “Schwartz Rounds by providing a forum to explore together some of the challenging psychosocial and emotional issues that arise when working in a health care organisation. The first “Schwartz Round “at Farleigh Hospice was held in February 2014 with other regular sessions planned in the future. The interest and impact on the introduction of this staff support concept will be evaluated later in the year. www.farleighhospice.org info@farleighhospice.org 01245 457300 35 Quality Account 2013-2014 Equality & Diversity Group The Farleigh Hospice Equality and Diversity Group formed in January 2013 with the overarching remit of developing and embedding equality and diversity throughout the organisation. It also aimed to develop an action plan to meet the requirements of the Equality Act 2010 and the equality duty. Membership of the group was drawn from all departments and at the inaugural meeting the Terms of Reference were set along with an action plan for the group identifying work streams to focus on over the year. ●● To have a diverse workforce representative of the local population ●● To ensure Farleigh Hospice services are accessible and inclusive for all who meet the criteria for service provision ●● To be proactive in demonstrating our commitment to being an inclusive organization that welcomes diversity ●● To embed equality and diversity values throughout the organisation and ensure staff are equipped to competently manage equality and diversity issues they are responsible for ●● Widen access to Farleigh Services The group achieved a significant amount in line with the Public Sector Duties, however a bias towards the clinical services at the hospice can be seen in the areas currently represented at the group and therefore in the work plan. It is planned to emphasise the importance of organisation wide representation at the group and provide time / incentive for those areas as yet not represented to attend. Diversity Climate Survey 2013 The Equality & Diversity group were interested in information about staff‘s views and perceptions of equality and diversity in the hospice. “Diversity” refers to all significant differences between individuals including sex, age, race, ethnicity, religion, physical & mental ability, educational achievement and occupation. A standardised survey developed by Professor Robert Bean, an Australian Business Consultant was used with some questions slightly modified to reflect ethnicity and religion relevant to the UK. The Diversity Climate Survey is intended for use across an entire workforce and provides data on individual, work group and organisational factors relating to the ways individuals perceive and feel about the presence and management of diversity in their workplaces and the influences that aspects of diversity and diversity management may have on their career development. The results of the survey can evidence themes around values and belief providing a baseline to target future training and policy in relation to issues of equality & diversity. 63 staff completed the survey this is about 30% of current staff. The results are scored Level 1 – Poor, Level 2 - Below Average, Level 3 - Average to good and Level 4 – Excellent. Farleigh Hospice results were positive achieving Level 4 with a score of 60.97 out of 69. To improve scores the aim would be to target questions which scored the lowest and these would identify also if the areas needing attention related to Individual, Department or Organisational issues. Overall the results were positive and demonstrated that respondents felt Farleigh Hospice was managing 36 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 diversity well and they felt positive about workforce diversity. The response rate was however 30% and it would be good to increase participation in future questionnaires. An action plan was developed following the survey which will be repeated again in 2015. Help the Hospice Benchmarking tool Farleigh Hospice took part in the pilot of the Help the Hospices National Hospice Inpatient Safety Benchmarking tool. The tool records information on Patient Falls, Pressure Ulcers and Medication Incidents. The information is submitted monthly to Help the Hospices who collate the information and benchmark you against similar size hospices. The information can also be used to evidence patient safety and compliance for the Care Quality Commission – ‘Is it safe?’ – the provider learns from any safety incidents that have occurred and changes practice in response (2013). The hospice will be continuing to record information on this tool and it is anticipated that there will be a web based version available in 2015. New Cleaning Standards The High Cleaning Standards that are required for Farleigh Hospice are now set out and detailed within the new “Cleaning Standards for Farleigh Hospice”. Information contained within the standards shows, the areas/items to be cleaned, the standard to be met, frequency of cleaning and the staff groups responsible – Nursing, Maintenance or the Cleaning department. The standards were developed to meet national regulations within healthcare as well as being tailored to the needs of a hospice environment. A tablet computer was then used to record the results during audits of different areas giving instant results and enabling action plans to be quickly developed and implemented. These standards will be audited on a yearly basis to ensure Farleigh Hospice remains a clean, safe working environment and to ensure a reduced risk of infection. New Year, New Website After many months of designing and developing, the new-look Farleigh Hospice website was up and running in January 2014. As with the old Farleigh Hospice website, the new one contains plenty of information about all the different services Farleigh Hospice provides and how to access them, how people can get involved and raise funds, along with lots of other things like forthcoming events, upcoming training sessions for healthcare professionals, job and volunteering vacancies, latest news and publications, an online shop and much, much more! We are extremely grateful to Coast Digital, award winning Digital Marketing Agency based in Stanway, Essex, who developed this new site for Farleigh Hospice completely free of charge. The site looks fresh and modern, with the inner pages looking clean and un-cluttered and repetition of information is kept to a minimum with the information across the site being clear, concise and easy for people to find and refer to. www.farleighhospice.org info@farleighhospice.org 01245 457300 37 Quality Account 2013-2014 Get Farleigh Hospice ’SNUG’ The Farleigh Hospice ’Snug’ is a social network user group space that has been set up with assistance from Essex County Council. It is a safe place where all users of the hospice can use social media to chat, discuss and share creative and other areas of interest on line as well as finding out what is happening at Farleigh Hospice. There were concerns that some Farleigh Hospice users might not be attracted to a social media space but the initial take up of the idea was very positive. LEAN at Farleigh Hospice The introduction of Lean at Farleigh Hospice goes back almost 3 years and the hospice currently has three Lean advisers who have taken on additional responsibilities to support and empower staff to use LEAN techniques and principles. LEAN is about change – getting people together to identify and discuss issues and come up with solutions. The aim is to have more efficient, effective and cost effective processes and importantly then sustaining the change The LEAN advisers have worked on several projects over the year -reviewing handover in IPU to make better use of time, staff training application process to reduce reworking and errors, room bookings for meetings and sessions to ensure best use of facilities, payroll processing to reduce duplication and save time and reviewing energy usage - Go Green in 2014!. No problem is as simple as it seems. The LEAN advisers also presented a poster at Help the Hospices’ conference in October 2013 - ‘LEAN – looking with fresh eyes’ which detailed their journey from training to projects. They have received additional training days and ongoing support from Kevin Clayton, LEAN Consultant who has volunteered his time to continue this support for the hospice. The LEAN advisers are working to develop a ‘LEAN culture’ at the hospice. The hospice plans to ‘recruit’ more LEAN Advisers to continue this work. 38 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 What people say about our organisation During the year we worked with patients, their families and the wider public to understand what, for them, is the most important information that will help them to make a decision on the quality of the services we provide. What our Patients say Every year Farleigh Hospice conducts surveys which focus on the quality of care being delivered. The surveys are carried out by the Independent Service User Facilitator, and are completed throughout the year by interviewing patients during their stay on the IPU or at the Day Hospices. Overall the responses about all these services were positive and affirming:- Comments from Patients in the Inpatient Unit When asked if they had any suggestions to help us develop our services all felt there was nothing they could suggest that we could do to develop our services as we already do more than they could expect. “ ...could not think of anything to improve the service” “ ..grateful to be pain free”... All found the cleanliness of the hospice, its outlook and environment “Very good or Excellent” “Excellent” “Spotless” “ Very hygienic” “Decor is natural & calm” “Wonderful outlook” “Good to be able to go out for walks” “Great for young children” All felt the quality and choice of food was excellent “So lovely, shame I can’t eat much but so good” “ Choice & portion size just right” Everyone felt their relatives and visitors were well looked after “My daughter and grandchildren think it’s wonderful, they are so well looked after” “Brilliant!” All rated their overall experience of being on the Inpatient unit as “Excellent” Comments from Patients in Day Hospice 40% of patients had concerns before their first visit to the Day Hospice as they did not know what to expect, however they all added how relieved they were on attending “I was anxious but hoped I would like and I do” “I am of Indian origin and was worried if |I would be accepted, I couldn’t be more wrong, I feel so cared for” “ ..thought it would be doom and gloom and could not be re-assured until I saw it for myself – now it’s the highlight of my week” www.farleighhospice.org info@farleighhospice.org 01245 457300 39 Quality Account 2013-2014 “I had been to a day centre before and did not like it so I was worried that this would be the same but it is so different – just wonderful” When asked about their overall experience attending the Day Hospice everyone felt it was “Very good or excellent” “..I cannot speak highly enough about Farleigh”” “Look forward to it every week” “Very important to me” Comments about the Hospice @ Home care ‘The care, compassion and most of all the respect given to my husband in his last needful days is beyond compassion’ ‘They did everything to help keep my husband’s dignity and were so kind and caring to all of us’ ‘..they brought sunshine here when it was dark ..’ What our Carers say – Farleigh Hospice provides a dedicated service to carers which aims to offer support to carers of hospice patients across mid Essex and prevent them from feeling alone and isolated. At Farleigh Hospice we continue to recognise the vital role carers play throughout the year by providing them with their own support service. ●● National Carers’ Week took place in June and as part of the campaign Farleigh Hospice held various events. The aim of this national initiative is to not only recognise the contribution carers make to the community and the people they care for, but also to provide a platform to raise important issues surrounding their valuable and often unrecognised work This year during Carers week Farleigh Hospice carers enjoyed two pamper days, a Strawberry Cream Tea, and two barge trip. We received lots of positive feedback about the events. “It has been a beautiful day. To be able to spend time outside with a very friendly bunch of people has been a real treat, thank you so much.” “The trip was very enjoyable and the company good, cup cakes were delicious!” “Brilliant afternoon, thank you to all Farleigh Hospice staff once again and staff on board.” “A thoroughly enjoyable day, thanks for inviting me.” Carers ‘drop ins’, ‘pamper’ days and candle lit dinners continue to be held throughout the year as part of ongoing support. What our staff say In 2013 Farleigh Hospice decided to take part again in an annual staff satisfaction survey for Hospices, delivered by Birdsong Charity Consulting in conjunction with Help the Hospices. Each hospice receives a benchmarked report that compares its results with the other hospices, other third sector responses and previous survey results. We were delighted to achieve a response rate of 73% (131 staff) 40 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Overall high levels of satisfaction were expressed by staff in the survey General satisfaction can be gauged by these questions ●● Overall, I am satisfied with my job - 88% agreed ●● I plan to be working for this charity in a year’s time - 82% agreed ●● I would recommend this charity as an employer – 81% agreed Not only are these high scores, but these scores were higher percentages than all other hospices in the survey In 2013 an additional statement was added asking “ If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation” the response was that 97% agreed. In 2012 in the NHS the overall score from all organisations in response to the same question was 63% so this is a very good result. What our Volunteers say – Volunteers are an integral part of Farleigh Hospice and a Volunteers day was organized and run in recognition of their valued work. The fifth annual Volunteers’ Day took place in September at Anglia Ruskin University. Not only does the event give Farleigh Hospice an opportunity to show its appreciation of our wonderful team of volunteers, it’s also a great way to update everyone with what’s been going on, and what’s planned for the future. This year volunteers were invited to bring a guest, the idea being to encourage more people to become volunteers. The event was well attended with volunteers from all areas of the hospice. The feedback was very positive about the day “I had a great time thank you” “I was a guest and enjoyed the day very much” “A very informative day” A full Volunteer Survey also took place in October 2013 which was open to all volunteers across the organisation. 262 completed the survey which is about 45% of volunteers. The aim of the survey was to get up to date information e.g. how long people had been a volunteer, seek views on a variety issues e.g. training and working environment and gauge levels of satisfaction. Overall most respondents were very satisfied with their role and support they received and there was an increase in the number of new volunteers as well as those who had been volunteering for 6 to 10 years. 17% had been with Farleigh for over 11 years “Working in the shop is a pleasure. All the volunteers are friendly and our manageress seems to have hit the right balance as we get many customers popping in on a regular basis for a browse and a chat” “I volunteer 3 days and have met a lovely bunch of people. It’s given me my confidence back.” “I am very proud to be a small part of the ‘Farleigh Hospice’ family in the amazing work that we do for people with life-limiting illnesses and their families/carers.” “Working at Farleigh is an important part of my life – I would not want to be without it; it feels like my family.” www.farleighhospice.org info@farleighhospice.org 01245 457300 41 Quality Account 2013-2014 What our Trustees say – Two Trustee Provider visits took place in 2013– 14 at roughly six monthly intervals which involved trustees visiting facilities and interviewing staff, patients and volunteers and checking that services comply with relevant regulations. The aim is to provide Trustees with an opportunity to inspect and monitor services and feedback on behalf of the board. The remit of the June visit was to inspect the services we provide to patients and the November visit to review all aspects of the organisation A report from each of the visits was discussed at the Governance Group. The comments were positive with no issues requiring immediate resolution. Action plans were developed to address minor issues which were followed up and concluded by the Senior Management Team. “The team was once again impressed by the favourable comments by patients on the quality of the care provided. The members of staff and volunteers interviewed came across as committed and professional and were a pleasure to interview” What the Care Quality Commission say An onsite inspection was carried out by the Care Quality Commission in July 2013 at Farleigh Hospice in Chelmsford. This was a routine unannounced inspection to check that essential standards of quality and safety were being met. All standards assessed were fully met. Comments from the CQC inspection During our visit we were able to talk with two people who were using the service, one relative, three members of the staff team and two volunteers. This enabled us to gain an insight into the services offered at Farleigh Hospice and to find out what people thought of the care and support they received. People told us that they had been given the opportunity to visit the service before deciding whether they wanted to attend and their consent had been obtained before any care or treatment had been given. One person told us: “I have always felt in control of my decisions and supported in my choice of care I want to be provided.” We were told that the staff and volunteers were very supportive and nothing was too much trouble. One person explained: “They can’t do enough for you.” There was a very relaxed atmosphere throughout our visit and staff and volunteers went about their duties in a happy and cheerful manner. Everyone spoken with was very satisfied with the support provided at Farleigh Hospice. One person told us: “I find it very therapeutic and supportive.” “It couldn’t be more different than my experiences in the hospital I feel like I am being treated as an individual. The staff and the volunteers are all marvellous; it has been a positive experience.” Another person explained: No inspection was carried out at Farleigh Hospice in Maldon as the Day Hospice was closed in August 2013 due to flooding and did not reopen until April 2014. 42 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Statement from mid Essex Clinical Commissioning Group Mid Essex Clinical Commissioning Group response to Farleigh Hospice Quality Account 2013 - 2014 This is the second year that Quality Accounts are being commented on by Mid Essex Clinical Commissioning Group (CCG). The CCG welcomes this Quality Account as a commitment to an open dialogue with the public regarding the quality of care provided by Farleigh Hospice. Assurance from the CCG is required to ensure that the information in this Quality Account is accurate, fairly interpreted, and representative of the range of services delivered. Though the CCG is commenting on a final draft version of this Quality Account, it is pleased to be able to assure the accuracy of the content in general. You provide information on a number of quality initiatives undertaken during the year and we note the opening of the Pod at Broomfield and patient and public engagement on your 2014 – 2018 Strategy. Your priorities for improvement in 2013 - 2014 were supported in part by the CCG through the agreement of CQUIN schemes which provide a financial incentive to improve quality. In particular support for training in non-medical prescribing for your Clinical Nurse Specialist. You have responded to the recommendations from the Francis report and have an action plan in place where there is a need for further improvement. In your report there is information about your performance in respect of data quality we note your intention to migrate to SystmOne. We also note that that you were involved in the completion of the Information Governance Tool Kit and were assessed as satisfactory which is the national requirement. We also note that your measures for patient safety – incidents, accidents and near misses, low infection rates, and pressure ulcers which have been reported onward as necessary to regulators and locally as required. Also, patient experience - complaints and compliments and clinical effectiveness – clinical audit of which you give a comprehensive description of your participation in and learning from clinical audit, although there were no relevant national audits for you to participate in. Your strategic priorities for improvement in 2014 - 2015 are: 1. Widening access to services – review of referral criteria and process 2. Review of our vision, mission and core values - communication 3. Introduction and rollout of SystmOne 4. Development of a Rehabilitation Model – Independent Living Team www.farleighhospice.org info@farleighhospice.org 01245 457300 43 Quality Account 2013-2014 In conclusion Mid Essex Clinical Commissioning Group considers Farleigh Hospice Quality Accounts for 2013 - 2014 as providing an accurate and balanced picture of key issues in the reporting period. The CCG encourages the organisation to continue to implement the multiple and wide-ranging efforts and initiatives to improve and be innovative in its delivery of quality in the services delivered. Carol Anderson Director of Nursing and Quality Mid Essex Clinical Commissioning Group June 2014 44 www.farleighhospice.org info@farleighhospice.org 01245 457300 Quality Account 2013-2014 Statement from Healthwatch Essex Statement from Healthwatch Essex for Farleigh Hospice Quality Account 2013-2014 Healthwatch Essex is an independent organisation with a vision to be a voice for the people of Essex, helping to shape and improve local health and social care services. We recognise that Quality Account reports are an important way for local NHS services to report on what services are working well, as well as where there may be scope for improvements. We welcome the opportunity to provide a critical, but constructive, perspective on the Quality Accounts for Farleigh Hospice, and we will comment where we believe we have evidence – grounded in people’s voice and lived experience – that is relevant to the quality of services delivered by Farleigh Hospice. In this light, it is therefore necessary to say services provided by Farleigh Hospice have not featured significantly either in our programme of research in 2013-14, or the evidence of people’s voice and lived experience gathered through our outreach or engagement work. As Healthwatch Essex develops these programmes over the coming year, we would expect Farleigh Hospice to feature more prominently in the future. However, from our reading of the Farleigh Hospice Account, we are pleased to see the Hospice has actively engaged service users in designing a new strategy, which was updated to reflect the changing needs of service users. During 2013/14 Farleigh Hospice also reviewed and updated their complaints procedure following a complaint which required independent review. The process now allows for external support and advice, for a more transparent process. The hospice received 12 complaints over the past year, which was a reduction from the previous year. The 2013 Farleigh Hospice Patient Survey, asked 12 people about their experiences on the Inpatient Unit. Overall, feedback was positive- people were given choice about their care, felt listened to, and treated with dignity and respect. People rated their overall experience on the inpatient unit as excellent. Healthwatch Essex shares the aspiration of putting patient experience at the centre of services, and believes that listening to the voice and lived experience of patients, service users, carers, and the wider population, is a vital component of providing good quality care. We hope to work collaboratively with Farleigh Hospice over the coming year, to engage service users effectively and ensure that their views are listened to and acted upon. We look forward to working together in the production of Quality Accounts in the coming year and making sure that the voice and experience of patients and the public form an integral part of these. Statement from Health Overview & Scrutiny Committee, Essex A copy of the Farleigh Hospice Quality Account 2013 – 2014 was forwarded to the Health Overview and Scrutiny Committee, Essex but we did not receive any comments at the time of publication www.farleighhospice.org info@farleighhospice.org 01245 457300 45 Quality Account 2013-2014 Appendix A Audits completed April 2013 – March 2014 Date Apr-13 Apr-13 Apr-13 Apr-13 Apr-13 Apr-13 Apr-13 Apr-13 Apr-13 May-13 May-13 May-13 May-13 Jun-13 Jun-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Jul-13 Aug-13 Aug-13 Aug-13 Aug-13 Aug-13 Aug-13 46 Report Gift Aid improving income from donor conversion in retail Retail Gift Aid Donor Satisfaction Survey 2013 Patient Satisfaction Survey 2013 Inpatient Unit Triage - Re Referrals Infections & Pressure Ulcers 2012 - 2013 Omitted & Delayed Medication Jan - March 2013 Volunteer Satisfaction Survey Inpatient Unit Cycle for Life 2012 - evaluation Motor Neurone Disease (MND) installation and use of Stair Lifts Fundraising gift aid declarations Medication Adverse Events July 2012 - March 2013 Verbal Orders Audits April 2013 - June 2014 (4 reports) Cleaning in Inpatient Unit Compliments Falls in the Inpatient Unit - in progress Safety Awareness Book: Introduction and use Health, Safety & Environmental Annual Report 2012/13 Patient Satisfaction Survey 2013 Farleigh in Maldon Patient Satisfaction Survey 2013 Farleigh in Chelmsford Cleaning in Day Care Farleigh in Chelmsford Cleaning in Lantern Suite Reactive Maintenance response times Farleigh in Chelmsford Planned preventative maintenance response times Farleigh in Chelmsford Reactive Maintenance response times Retail & Lottery office Planned preventative maintenance response times Retail & Lottery office Reactive Maintenance response times Farleigh in Maldon Planned preventative maintenance response times Farleigh in Maldon Complaints Report 2012 - 2013 Triage response times to received referrals Infection Control – Inpatient Unit Medication Adverse Events April - June 2013 Audit of Audits 2013 Internal Audit 2013 PR & Marketing audit - Success rate of press releases Omitted & Delayed Medication April - June 2013 Health & Social Care Act (2008) Infection Control Compliance Controlled Drugs, Accountable Officer audit www.farleighhospice.org info@farleighhospice.org Department Fundraising Fundraising Clinical Clinical Clinical Clinical Clinical Fundraising Clinical Finance Clinical Clinical Hotel Services Quality Clinical Health & Safety Health & Safety Clinical Clinical Hotel Services Hotel Services Maintenance Maintenance Maintenance Maintenance Maintenance Maintenance Quality Clinical Clinical Clinical Quality Quality Fundraising Clinical Clinical Clinical 01245 457300 Quality Account 2013-2014 Audits completed April 2013 – March 2014 Date Sept-13 Oct-13 Oct-13 Oct-13 Oct-13 Oct-13 Oct-13 Oct-13 Oct-13 Nov-13 Nov-13 Nov-13 Nov-13 Nov-13 Nov-13 Nov-13 Dec-13 Dec-13 Dec-13 Dec-13 Dec-13 Jan-14 Jan-14 Jan-14 Feb-14 Feb-14 Feb-14 Feb-14 Feb-14 Feb-14 Feb-14 Feb-14 Feb-14 Mar-14 Mar-14 Mar-14 Mar 14 Report Record of events targets, monthly reports comparison Omitted & Delayed Medication July- September 2013 Legacy Pledger Audit Diversity Climate Survey Internal Clinical Supervision Evaluation Incoming donations audit Medication Adverse Events July - September 2013 Money Laundering Retail - shops’ selling area by commodity Santa Fun Run 2012 Open Day (Seeds of Life) 2013 Board Review 2013 Executive Summary Internal Control Checklist CC8 - Finance Fundraising Gift Aid Declarations Infection Control Inpatient Unit re audit areas of non compliance Welcome Nurse Checklist Welcome to Farleigh Hospice Events 2013 Staff Survey 2013 Volunteers Survey 2013 Verbal Orders July - September 2013 Patient Identification Bands Inpatient Unit Use of Oxycodone compared to Morphine in IPU Medication Adverse Events Oct - Dec 2013 Walk for Life evaluation 2013 Cleaning in Day Care Farleigh in Chelmsford Cleaning in Lantern Suite Cleaning in the Inpatient Unit Planned Preventative Maintenance Farleigh in Chelmsford July Dec2013 Reactive Maintenance Farleigh in Chelmsford July -December 2013 Infection Control Farleigh in Chelmsford Cycle for Life evaluation 2013 Volunteers Day Evaluation 2013 Food Hygiene Standards North Court Road Report of the internal medical outpatient referrals during 2013 Planned Preventative Maintenance Retail & Lottery July -December 2013 Reactive Maintenance Retail & Lottery July -December 2013 Information Governance Toolkit: Statement of Compliance www.farleighhospice.org info@farleighhospice.org Department Fundraising Clinical Fundraising Quality Quality Finance Clinical Finance Fundraising Fundraising Fundraising Board/SMT Finance Finance Clinical Clinical HR HR HR Clinical Clinical Clinical Clinical Fundraising Hotel services Hotel services Hotel services Maintenance Maintenance Clinical Fundraising Fundraising Hotel Services Medical Maintenance Maintenance IT 01245 457300 47 Quality Account 2013-2014 If you would like further details of the above reports please contact: susan.bridger@farleighhospice.org ________________________________________________________ Thank you. It is because you care that we can Farleigh Hospice, North Court Road, Chelmsford, Essex, CM1 7FH Charity Registration No 284670 48 www.farleighhospice.org info@farleighhospice.org 01245 457300