Quality Account
2013-2014
LOROS Sites:
LOROS Hospice
Groby Road
Leicester
LE3 9QE
Tel: 0116 231 3771
Fax: 0116 232 0312
Website:
www.loros.co.uk
Registered Charity No:
506120
Registered company in England and Wales: 1298456
CQC Provider ID:
1-101728486
This Quality Account was endorsed by the LOROS Board of Trustees
VISION
(Our long term aspiration for our society)
Everyone with an incurable illness has the right to excellent care. This should value
and respect their uniqueness and their own choices. People should be enabled to
live and die with dignity and with appropriate and compassionate support for them
and their loved ones.
MISSION
(Our goals and activities in working towards our Vision)
LOROS is a charity whose aim is to enhance the quality of life of adult patients with
cancer, progressive neurological conditions and end-stage organ failure for whom
curative treatment is no longer possible. Patients are treated at the hospice and in
the community based upon clinical need, regardless of background and the ability to
pay.
LOROS specialises in holistic, multidisciplinary care, focused on the whole person
and including family and carers. The care given takes into account the patients’
physical, psychological, social and spiritual needs as well as their own choices.
Family members are supported in adjusting to loss and bereavement.
LOROS contributes to the education and training of its own and other health and
social care professionals and of volunteers. The charity is also committed to
research in order to improve the understanding and practice of palliative care.
VALUES & BEHAVIOURS
(How we will strive to be)
PROFESSIONA
L
OCUSED
F
COLLABO
RATIVE
OMPASSIONATE
C
STED
TRU
in our attitude and everything we do
on patients, families and carers whilst listening,
learning and adapting to their diverse needs
in working together and with others
in providing care and responding sensitively to
requests for support
within our organisation and by our community
“ Many thanks for your kind and loving support which has enriched our life”
June 2013
“I sit here in a daze contemplating all that has happened to me and my family over the
last two months and all that I can think of is how on earth would we have coped
without all of your consistent kindness, hard work, empathy, smiles, understanding,
patience and support"
July 2013
“Being there was like a little piece of heaven”
September 2013
“ Everyone from the primary care staff right the way down to the cleaners, were so
friendly and helpful and always seemed to go that extra mile. We can’t praise you
enough”
December 2013
“ I want to thank you wonderful people for all you did. This journey was not easy but
everyone did their best to make it as comfortable as possible”
February 2014
Contents
Part 1
Statement on Quality from Chief Executive
1
Part 2
Priorities for Improvement 2014/15 – Future Planning
2-4
Statements of Assurance from the Board
5
Review of Services (Mandatory Statement)
5
Participation in Clinical Audits (Mandatory Statement)
6-7
Research (Mandatory Statement)
8
Goals Agreed with Commissioners (Mandatory Statement)
9
What Others Say About Us (the Provider) (Mandatory Statement)
9-11
Data Quality (Mandatory Statement)
11
Information Governance Toolkit (Mandatory Statement)
11
Clinical Coding Error Rate
11
Part 3
Report on Review of Quality Performance 2013/14
12-21
Quality Overview - Review of Quality Performance
22-25
Clinical Dashboard
26-28
Clinical Data
29-32
Demonstrating Patient Outcomes
33
Feedback from Patients/Families
34-46
What Our Staff Say About the Organisation
47-48
The Board of Trustees Commitment to Quality
Glossary of Terms
Written statements by other bodies
49
50-51
52
Part 1
Statement on Quality from the Chief Executive
LOROS is an independent local charity providing palliative care and support to around
2,500 people each year across Leicester, Leicestershire and Rutland. Patients are
offered our care services based upon clinical need and independent of gender, race,
colour, creed or the ability to pay. In fact all of the care services are provided free of
charge as a consequence of about 1/3 of the cost being funded by NHS and 2/3 from
the generosity of the local community.
LOROS has an excellent track record of delivering outstanding care over the last 29
years and a reputation as an extremely worthwhile and valued local charity. This is
based upon a clear purpose and focus and an enduring commitment to quality. LOROS
staff and volunteers are passionate about their roles and the organisation and seek
constantly to capture and act on feedback to improve further.
There are specific examples of commitment to such improvements in quality in this
document particularly in terms of patient safety, outcome measures and enhancing
outreach services.
LOROS is actively engaged with the NHS and other stakeholders in determining how the
quality of End of Life Care can be developed in the future.
A large number of people have contributed to the creation of this Quality Account, most
notably the Director of Care Services and Clinical Governance/Patient Experience Lead.
The LOROS Board of Trustees reviewed and approved this Quality Account in June
2014.
To the best of my knowledge, the information contained in this document is accurate.
Simon Proffitt
Chief Executive
June 2014
1
Part 2
Priorities for Improvement 2014/15 – Future Planning
The hospice has a number of on-going initiatives to enable us to offer a more
comprehensive service to the local community, whilst working within the limitations of
the current financial constraints. All plans for improvement have been influenced by
patient and carer feedback.
The key priorities we have selected have been discussed with the Senior Management
Team and Board of Trustees. These will impact directly on the following domains of
quality: clinical effectiveness, patient experience and patient safety.
Quality Account – Priorities for 2014/15
Patient Safety
Priority 1 – Patient Safety Metrics
Three key aspects of patient safety are falls, medication errors and pressure ulcers.
There is a drive nationally to make improvements in all of these areas. LOROS is
committed to ensuring this happens to provide re-assurance to our patients, the Care
Quality Commission (CQC) and the local commissioners (CCGs.)
We have implemented a number of initiatives in the last few years to help improve care
in these areas including the appointment of a Tissue Viability Lead Nurse and the
introduction of non-interrupted medication rounds. This year we are planning to revise
our nursing care plan which incorporates a falls assessment to ensure a robust MultiDisciplinary Team (MDT) approach, which will help minimise the risk of falls.
To support us in on-going improvement in these areas, LOROS will participate in a
national benchmarking patient safety metrics project coordinated by Help the Hospices,
sharing data on falls, pressure ulcers and medication errors. Approximately 100
hospices are taking part, helping to build national intelligence in relation to patient
safety issues and enabling the sharing of good practice and service improvement
initiatives. This will be invaluable for LOROS enabling us to review our practices against
other units, identifying where we are performing well and also where further
improvements are possible.
Outcomes should include a reduction in the number of incidents and on-going
improvements in service delivery.
Clinical Effectiveness
Priority 2 – Introducing robust patient outcome measurement
Being able to demonstrate tangible outcomes for patients in relation to the impact
LOROS services has on their care, continues to be a challenge. It is important that
2
whatever tool is used it can be easily integrated into clinical practice and that health
professionals use the data to improve patient care. It therefore needs to be part of the
assessment and on-going care planning process.
The Integrated Palliative Outcome Scale (IPOS) is a validated tool that has been used in
a number of palliative care services to capture the outcomes for patients. LOROS is
implementing the tool initially in the Day Therapy service with a view to rolling it out to
other care services following an evaluation after three months.
This information will be used alongside activity and patient experience data to give a
comprehensive overview of the standard of care provided at the hospice and again
identify areas that need development or investment.
Priority 3 - Care during the last days of life – moving on from the LCP
Following the recent national independent review of the Liverpool Care Pathway, the
LCP is being phased out in all care settings across the country by July 2014. In line with
the recommendations LOROS is no longer using the LCP. When it is recognised that a
patient is dying this is now being referred to as ‘the Dying Phase’ which is in line with
the four phases of end of life care identified during the palliative care funding review –
stable, unstable, deteriorating and dying.
The Leadership Alliance for the Care of Dying People, who have the responsibility for
taking forward the recommendations from the review, stated in January 2014 that there
would not be a replacement for the LCP but that there will be some guiding principles
that all care providers should follow. This will support consistency in approach and
ensure that the way in which a dying person is cared for, including the goals and key
aspects of their care, is focussed around the individual, in line with their needs and
preferences and developed and delivered in consultation with them, wherever possible,
and/or their family.
LOROS will provide care during the dying phase in line with these guiding principles (as
is current best practice) and will not have a separate end of life plan or pathway.
LOROS is working closely with other key providers, predominately University Hospitals
of Leicester (UHL) and Leicestershire Partnership Trust (LPT) to try and develop as
consistent approach as possible during this transition. Once the final guiding principles
are published it is envisaged that providers will continue to work collaboratively to
ensure patients receive consistent, high quality end of life care irrespective of the care
setting. Nationally the CQC will focus more on end of life care during 2014/15 and NICE
(National Institute for Health and Care Excellence) are planning on developing new
guidelines on the care of dying adults which are expected to be published in 2016. This
should result in greater clarity for care providers in the future and a mechanism for
demonstrating clear outcomes in relation to end of life.
During the interim LOROS will liaise closely with the Clinical Commissioning Groups to
ensure that the hospice is able to provide appropriate data to demonstrate the provision
of high quality end of life care.
3
Patient Experience
Priority 4 – Developing more outward facing service to meet the needs of
more patients, families and carers
LOROS currently cares for approximately 2,500 patients per year. A great deal of care
provision is delivered at the hospice itself and to increase our reach in the coming year
there is a drive to increase the breadth and scope of service provision.
We have recently reviewed our Family Support Service and to enable it to grow and
develop over the coming years the service has been reconfigured to separate home
visiting and bereavement services. The home visiting service will be supported by an
increased number of volunteers to enable us to deliver services to a much greater
number of patients.
Initial ideas for service development within home visiting include helping to support
patients in the last few days of life within their own homes, by providing reassurance
and support to family members and providing practical support for carers such as
shopping or walking the dog as these are often things that make a big difference to
families but that other agencies no longer offer.
Within bereavement services we are planning to establish bereavement support groups,
both at the hospice and out in local communities. These will provide much needed
support for a greater number of people including the relatives of patients who have
died at home or in another health care setting such as UHL.
There are a number of out-reach services that LOROS would like to offer to patients
who may not wish to come to the hospice and/or who would prefer to access services
in their local community. These may include complementary therapy, lymphoedema and
patient information and/or welfare advice. To help deliver these services we are trying
to secure funding to establish a mobile bus which can be taken to a number of different
venues.
We are also hoping to again work in partnership with Macmillan Cancer Support in the
coming year to develop a project to help improve the access and care of patients who
may not traditionally receive palliative care services such as prisoners, travellers and the
homeless. We would also like to continue increasing the support we provide to local
BME communities.
If we are successful in establishing some of these services, the positive impact for
patients would include greater and easier access to our services and improved care,
particularly for the under-represented patients from these groups.
4
Statements of Assurance from the Board
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 palliative care
providers. Please note that the wording of these statements is prescribed.
Review of Services (Mandatory Statement)
During 2013/14, LOROS has provided for the NHS and the local community:
 In-patient Unit
 Day Therapy Service
 Outpatients and domiciliary palliative medicine consultant visits
 Community palliative care nurse specialist service
 Home visiting
 Counselling
 Lymphoedema Clinic service (cancer and non-cancer)
 Complementary therapy
 Education service
NB – the hospice at home service is not provided by LOROS
LOROS has reviewed all of the data available to them on the quality of care in all of
these services (NHS services). The income generated by the NHS services reviewed in
2013/14 represents one third of the total expenditure incurred in the provision of
services by LOROS for the reporting period 2013/14.
5
Participation in Clinical Audits (Mandatory Statement)
During the period 2013/14 there have been no national clinical audits and no
confidential enquiries relating to the services that LOROS provides. During this period
LOROS did not participate in any national clinical audits and national confidential
enquiries.
Medication related audit results are reported to the Therapeutic Committee and all
others are reported to the Clinical Governance Steering Group. The Board of Trustees
receive regular audit reports identifying areas for improvement, the number of audits
showing full compliance and examples of care delivery which has been improved as a
consequence of undertaking clinical audits. In addition, an annual clinical audit report
is produced in March of each year outlining all activity for the twelve month period.
132 standard clinical audits were undertaken in the period 2013 – 2014, 74 of these
showed full compliance. 3 clinical interest audits were completed, these did not show
full compliance, however identified recommendations were made and acted upon by the
appropriate hospice teams to improve care delivery.
Audit examples of good practice identified:
Help the Hospices medicines management – controlled
drugs: A self-assessment tool for the Accountable Officer
100% compliance achieved in the following areas:
04/07/2013
Subtopic 1 – The appointment of the Accountable Officer
Subtopic 2 – Role and responsibilities of the Accountable Officer
Subtopic 3 – Annual review by the Accountable Officer to ensure compliance with the
relevant legislation, regulations, guidelines and policies
Subtopic 4 – Continuous quality monitoring: Ongoing review to ensure compliance with
the relevant legislation, regulations, guidelines and policies
12/11/2013
Consent to Acupuncture Treatment (Physiotherapy Team)
Results: 15 patients’ computerised records examined retrospectively for satisfactory
completion of consent form for acupuncture.
100% compliance.
6
Respect and dignity patient questionnaire (Main Ward)
- Attitudes and behaviour
- Personal world and personal identity
Results: 15 patients’ computerised records examined retrospectively for satisfactory
completion of consent form for acupuncture.
02/12/2014
100% compliance.
Examples of improvement made as a result of audit processes:
Catheter insertion – Department of Health urinary
catheter care bundle
100% compliance achieved.
13/05/2013
-
April 2013 – 86% compliance achieved.
Training has been introduced and poster presentations organised for display in the ward
area as a consequence of audit results.
27/05/2014
5 moments of hand hygiene (Main Ward)
90.4% compliance achieved.
Previous compliance results:
 April 2013 – 82%
 March 2013 – 78%
 February 2013 – 74%
 January 2013 – 72%
There has been a steady improvement in compliance due to actions taken as a
consequence of audit results. Staff were challenged regarding poor practice as the time
of the audit.
7
Research (Mandatory Statement)
LOROS is actively developing opportunities to question and challenge the provision of
palliative care from its broadest perspective. Research in 2013/14 has included:





IMPACT (Improving Palliative Care for Tomorrow) – Researching the impact of a
Foundation Degree in palliative and supportive care.
Withdrawal of non-invasive ventilation in people with Motor Neurone Disease
(MND) – from the doctors’ perspective.
How nurses working within an inpatient adult palliative care unit identify children,
aged 18 years and under, in need of additional support when they have a parent
who is expected to die.
Decision making by surgeons and anaesthetists in the care of the frail elderly.
Developing a protocol for video based research around doctor-patient
interactions
Research has been disseminated through presentations at both National and
International Conferences; including the October 2013 Help the Hospices conference, in
Bournemouth; March 2014 Palliative Care Congress, in Harrogate; and the Motor
Neurone Disease Association’s International Symposium on ALS (Amyotrophic lateral
sclerosis)/MND in December 2013, which was held in Milan.
LOROS has adopted the Research Governance Framework for the NHS and this is
overseen by the Hospice Education and Research Committee.
Future research continues to be focussed on the following areas:
1. Innovative services in palliative care
2. Diversity and disadvantage
3. Education including communication skills
4. Lymphoedema
5. End of life decision making and advance care planning
Research participant figures:

Non-Invasive Ventilation (NIV) Study: Phase II = 46 (All of whom were a mix of

How do nurses working within an inpatient adult palliative care unit identify children,
aged 18 years and under, in need of additional support when they have a parent
who is expected to die? = 14 (Healthcare professionals)
VerDIs (Phase I): Video analysis of patient doctor consultations = 14
patients/carers, 16 staff
Excellence in Practice: a comparison of hospice nurses' perspectives of care of the
dying patient in the UK and North America = 3 LOROS staff



healthcare professionals and bereaved carers, most of whom were staff or
participants not related to LOROS)
Patient/carer participants = 30
8

Healthcare Professionals = 63
Professor Christina Faull, Consultant in Palliative Medicine and lead for Research at
LOROS, was awarded an honorary Professorship by De Montfort University in
September 2013. Professor Faull also Co-Chairs the DMU and LOROS Centre for the
Promotion of Excellence in Palliative Care (CPEP).
Goals Agreed with Commissioners (Mandatory Statement)
LOROS’ NHS income in 2013/14 was not conditional on achieving quality improvement
and innovation goals through the Commissioning for Quality and Innovation (CQUIN)
Payment Framework, because LOROS is not contractually part of the CQUIN scheme.
We are awaiting revision of our quality schedule and key performance indicators for the
period 2014/15 to be agreed by the West Leicester Clinical Commissioning Group.
What Others Say About Us (the Provider) (Mandatory Statement)
LOROS is required to register with the Care Quality Commission (CQC) and its current
registration is as a provider of the following regulated activities:
The Leicestershire & Rutland Organisation for the Relief of Suffering has the following
conditions of registration that apply:
1. Diagnostic screening procedures
The Registered Provider must ensure that the regulated activity, diagnostic and
screening procedures is managed by an individual who is registered as a manager in
respect of the activity, as carried on at or from the locations LOROS The
Leicestershire and Rutland Hospice.
2. Treatment of disease, disorder or injury
The Registered Provider must ensure that the regulated activity treatment of
disease, disorder or injury is managed by an individual who is registered as a
manager in respect of the activity, as carried on at or from the locations LOROS The
Leicestershire & Rutland Hospice.
Additional conditions that apply at LOROS Hospice:
1. The Registered Provider must only accommodate a maximum of 32 service users
at LOROS The Leicestershire & Rutland Hospice.
The Care Quality Commission has not taken enforcement action against LOROS during
the period 2013/14.
9
The CQC are currently making radical changes to the way they inspect health and social
care services (including hospices) to make sure they provide people with safe, effective,
compassionate and high quality care. LOROS is fully engaged with these change
processes and welcomes emerging opportunities for further development and
improvement of services.
The Care Quality Commission has undertaken an unannounced visit/inspection on
August 2013.
The following standards were inspected and found to be fully compliant
- Meeting nutritional needs
- Safeguarding people who use services from abuse
- Supporting workers
- Assessing and monitoring the quality of service provision
CQC visit August 2013 – LOROS
What people told us and what we found
We spoke with three people who use the service and asked them for their views about
the care, treatment and support they receive. People's comments included: "Brilliant
care, I am fully aware of my care package." "My wife is an absolutely wonderful woman
but it would have been difficult without the help of these people they're absolutely
wonderful." "They tell the family everything about my treatment." (The person told us
this information had been shared with their consent). "The care is excellent; they
explain everything that's going on." "Amazed with the care at LOROS." (Leicestershire
and Rutland Organisation for the Relief of Suffering).
People we spoke with were happy with the meals provided and told us they received
the support they needed, which included support where they were unable to eat or
drink and received nutrition in a different way. People's comments included: "There's a
good choice and it's always really tasty." "The food is excellent, you get asked what you
like and the choices are excellent. The drinks trolley regularly comes round and there's
always a jug of water by your bed."
Staff we spoke with told us they receive the support they need from within their
individual teams and through the provider. Staff told us that support came in many
forms which included clinical supervision and annual appraisals. The provider
encouraged staff to access services to support them which included attending
reflexology sessions as well as being given information about external counselling
services. Staff we spoke with told us they have good access to training and
developmental sessions.
10
People who use the service are asked for their views about the service they receive
within days of their admission to the hospice. In addition, annual surveys are also
complete as part of the annual quality assurance process in place at the service. Groups
involving people who use the service had been set up and met regularly to talk about
their views and experiences and we saw that the outcome of these meetings was used
to develop the services provided by LOROS. The provider had a robust quality
assurance system in place which produced an annual report which is available on the
LOROS website.
Data Quality (Mandatory Statement)
LOROS 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.
Information Governance (IG) Toolkit (Mandatory Statement)
LOROS has developed all relevant documentation and undertaken the appropriate staff
training to achieve level 2 compliance of the Connecting for Health’s IG Toolkit
assessment. This compliance provides assurance to our patients and the general public
that personal data is being dealt with safely and securely.
The Hospices Information Governance Assessment Report Version 11 overall score for
1st April 2013 – 31st March 2014 was 66% and was graded Satisfactory – Green colour.
An Information Governance group has been established to continually monitor and
review IG arrangements across the organisation and is accountable to the Senior
Management Team.
Clinical Coding Error Rate
LOROS was not subject to the Payment by Results clinical coding audit during the
period 2013/14 by the Audit Commission.
11
Part 3
Report on Review of Quality Performance 2013/14
Clinical Effectiveness
Priority 1 – Day Therapy
The pilot Day Therapy service is now running successfully at the Hospice and
Loughborough Hospital. The pilot will run for an initial period of 12 months. A formal
evaluation will then take place to agree the longer term service model. Our plans for
the forthcoming year are to continually monitor, evaluate and adapt provision as
appropriate to meet the needs of patients referred to the service. This will be achieved
by analysing activity data and from patient, staff and volunteer feedback. There are a
number of different services that patients can access including assessments by an
occupational therapist and/or physiotherapist, complementary therapy and creative
therapy in addition to assessments and support from medical and nursing staff. We are
planning to expand our partnership working with UHL and Macmillan Cancer Support in
the establishment of a breathlessness self-management programme for patients. During
this period we will also explore further opportunities of partnership working with other
charities such as Coping with Cancer.
Plans for possible future purpose built day therapy facilities at the hospice site will be
developed based upon the evaluation of the pilot service and the needs of patients
attending day therapy. The possibility of locating a satellite unit in another area of LLR
will also be investigated.
Update
Throughout the year we have continued to evaluate services and adapted what we are
offering in response to feedback from patients. Providing a Day Therapy service at the
‘spoke’ in Loughborough proved challenging as the facilities at Loughborough did not
lend themselves to providing an equitable service. Following a review of the pilot
service in October 2013 the decision was made to cease the service at the spoke.
Day Therapy at Loughborough ceased on 6th December 2013. All patients from
Loughborough have transferred to Day Therapy at LOROS which commenced from
Friday 13th December. Feedback from patients regarding the service continues to be
positive.
To meet patient demand, the number of days the service is available at the hospice
increased from 3 days to 4 days in January 2014. Transport continues to be provided
for those patients who require it. We have found that we are receiving more referrals
to Day Therapy for people who are very dependant with increasingly complex needs.
This has led to challenges in the current facilities to provide high quality care for these
patients so in some cases we have had to discharge these patients.
12
The needs of these patients have been considered in planning the possible future site
developments in the Day therapy area. These plans are progressing with the input of
staff and patients and a decision as to whether the developments will go ahead is
expected later this year.
The breathlessness self-management programme which was piloted in partnership with
Macmillan and UHL was very well evaluated by the patients who attended but
unfortunately due to insufficient numbers of patients attending, it was not viable to
continue. A different model of providing support to breathless patients is currently
being piloted in an outpatient clinic at LOROS where patients can see a Consultant
and/or a Physiotherapist or Occupational therapist.
We are committed to the idea of providing ‘care closer to home’ and following the
lessons learnt at Loughborough we hope to pursue our partnership working with
Macmillan and community services to pilot some ‘outreach’ services in the community.
We will be investigating possible models for this over the coming months. We have
continued to maintain links with Coping with Cancer and still hope to work in
partnership with them in the future.
We are currently seeking the views of patients and referrers on planning different
models of Day Therapy for a 5th day for younger and/or less dependent patients such
as self-management programmes, support groups, well-being sessions. We are
furthering links with Rainbows Hospice to see how we can help to support the young
adults who will be discharged from their service.
Key outcomes achieved:





The number of days the service is available at LOROS has increased to 4.
Fortnightly MDT meetings involving Day Therapy nurses, coordinator, Doctors,
Physiotherapists, Occupational therapists, and Chaplaincy are now embedded
into practice to review and plan the patients’ care.
In patients are able to attend Day therapy if appropriate while they are staying
on the ward to introduce Day therapy services to them.
As the Day therapy service is now on site at the hospice, there is better
integration with other hospice services for example a representative from the
Day therapy team attends the Motor neurone disease MDT meetings and the
Physiotherapists/Occupational therapists are able to take part in the daily care
planning meetings in Day Therapy.
The introduction of ‘Wellbeing’ sessions supported by Clinique when volunteers
run sessions to help patients with skin care and make up.
13
Priority 2 – Education Provision
LOROS continues to develop a reputation for innovative and high quality education in
palliative and end of life care, across the region and also nationally, with provision
ranging from half day workshops to masters programmes. A palliative care foundation
degree has also been running for a number of years. The programmes are both taught
and practice development within the workplace and the range and scope of provision
has expanded into a number of health and social care settings. During 2012/2013 over
3000 individuals accessed the LOROS education programme, in part supported by End
of Life Care Funding.
The LOROS education strategy has been in place for one year and a recent review
identifies success in achieving a number of the first year milestones. The focus for the
next year will be to diversify income streams, extend and enhance provision further and
refine our marketing approaches. The recently appointed Education Business Manager
is an integral role in driving forward the strategy in relation to key business processes.
The LOROS education department is now responsible for internal training and
development of 300 staff and 1,000 regular volunteers. A recent review of training has
been carried out with a refined approach to mandatory and essential for role training.
This year will focus on developing e-learning materials to support internal training and
also more effectively monitor engagement levels and the impact on clinical practice.
We will also be working with key colleagues who manage volunteers across the
organisation to ensure training and development for that essential part of the workforce
is fit for purpose.
CPEP (Centre for the Promotion of Excellence in Palliative Care) a collaboration between
LOROS and De Montfort University, has just celebrated its first birthday. There have
been a number of very successful outcomes which have just been detailed in the first
annual report and include:
-
Public awareness raising, including the launch event, Care and Compassion
event, and specialist palliative care practitioner open door lunch
-
Research activities, including securing funding to support a PhD studentship,
medical education fellow and Macmillan clinical academic nurse researcher
A programme commissioned by Leicester City Clinical Commissioning Group to
improve end of life care for their patients which led to the recruitment of three
GPs to be mentors to practices in their locality and they are being supported by
Dr Christina Faull, a Consultant in Palliative Medicine, and staff at LOROS
A number of exciting research projects which are progressing, and evaluations
will be reported on shortly for those that are concluding soon
14
Update
LOROS continues to develop a reputation for innovative and high quality education in
palliative and end of life care, across the region and also nationally, with provision
ranging from half day workshops to masters programmes. The programmes are both
taught and practice development within the workplace and the range and scope of
provision has expanded into a number of health and social care settings. The changing
context of the external environment has had a significant impact on the provision
during 2013/14, the majority of End of Life Care funding was withdrawn and we have
had to re-assess our approach to the provision of the education across the locality. We
continue to be committed to developing the wider workforce across LLR in terms of
their end of life care practices but we are reviewing the offer and delivery methods.
Key outcomes achieved:

The LOROS education strategy has been reviewed to take into account the above
points and also wider strategic changes, with a re-focus on the goals and clear
implementation plans developed with key milestone points.

We continue to look to diversify income as well as build new partnership
arrangements with stakeholders locally, regionally and nationally. We have been
working on the marketing and promotion of our programmes and contributing
the development of the website as a key tool.

The LOROS education department have been implementing new mandatory
training frameworks across the hospice with the introduction of an e-learning
platform and e-learning modules. We are also working with the different
departmental teams to identify, plan and deliver essential for role training and
also supporting individual and team development.
Patient Experience
Priority 3 – Deciding Right
In 2013 LOROS will be utilising a new guide called ‘Deciding Right – Planning your care
in advance’. This has been developed to help patients consider what care and
treatment they might like to receive if they should become seriously ill, disabled or
unable to make decisions for themselves in the future.
Health professionals and partners from across Leicestershire have come together on the
Deciding Right programme to help provide patients with more choice about their care.
Planning your care in advance is a completely voluntary process and involves
discussions between patients and the people who provide care for them, for example
nurses, doctors, social workers, family or friends. The guide offers advice on how to
have these discussions and also explains how to record their decisions.
15
Taking part in this process gives people the opportunity to express some views,
preferences and wishes about their future care so that these can be taken into account
if they were unable to make their own decisions at some point in the future. It will not
only help them make informed choices but also enable them to communicate their
wishes to all involved in their care.
Thinking about the future and making plans can be difficult and it’s not always easy to
have these discussions. Nobody is obliged to plan their care in advance however this
guide will be a valuable tool to help people through the process and ensure their views
are heard.
Update
We continue to work on changing the culture to ensure we offer patients the
opportunities to discuss their future end of life care wises.
Key outcomes achieved:
-
Training has been delivered to LOROS staff and the Macmillan Nursing Team
-
Emergency health care plans have been completed where patients have shared
their wishes for future care
-
Working with other organisations in LLR to develop an electronic way of sharing
communication about patients
Priority 4 – Enhancing our Communication Processes
LOROS continues to involve patients and carers who have accessed our services
proactively in the planning, developing, monitoring and evaluation of all care services.
You will read later in the Quality Account the progress made in this area over the last
12 months. However as an organisation we recognise this priority is not only
important, but also has many different elements, hence the decision to highlight this
again as a key priority for the coming year.
Since the appointment of the new Marketing & Communications Manager, the LOROS
website project has been further developed. Phase 1 of the website design and build
will begin in May, and will be live by September 2013. Patients and carers will be
involved in the testing phase of the website design to ensure the site is ‘user friendly’,
easy to navigate and has the right content for all service users. The new website will
also ensure that the referral process and important information is easy to access for
GPs and other health and social care staff.
Good communication and information is key at all stages in the patient’s journey and is
vital in helping patient make informed decisions.
16
Our aim is:
 Ensure patient information is current, clinically accurate, relevant to the patient
and presented in a clear, understandable way.
 Ensure there is written information available to patients/carers on a wide range
of areas, covering general information about LOROS and the clinical services
provided and specific clinical information about procedures.
 Comply with Care Quality Commission Essential Standards of Quality and Safety.
This reinforces that people who use health care services need to be given
information which enables them to make informed decisions about their care and
treatment.
 Comply with The National Cancer Peer Review programme – provision of written
patient information.
 Present LOROS as a professional organisation which prides itself in having high
quality patient information which follows a clear format and which conforms to
LOROS style guidelines.
 Help patients make informed decisions.
Over the next year, The Patient Information Group which is made up of key LOROS
staff and patients and carers will review LOROS internally produced information to
ensure it meets the above aims.
A subgroup of the patient information group - The readers’ panel will assist in this
process.
The current Patient and Carer Participation Group will continue to meet quarterly. Our
plan is to consolidate and build on the existing work. The work of the group will be
highlighted internally with all clinical departments and externally in our LOROS
newsletter with the aim of increasing membership to this group.
The election of chair and vice chair will be discussed shortly with group members. It is
hoped that within the next year patients and carers will express interest in these roles
and be elected.
Key outcomes achieved:
 Implementation and embedding of the LOROS Style Guide
 Approval and roll out of the new look LOROS patient information leaflets – in line
with the roll out of corporate brand.
 Build and launch the new LOROS website (Phase 1) by September 2013
 Development of a portfolio of photographs to convey the range and "essence" of
LOROS' services to incorporate into both the website and patient information leaflets
 Development of LOROS social media and key messages on service
 Review LOROS non-patient information and consider how this can be rationalised
and improved to showcase LOROS and its services
Update
17
Good communication and information is key at all stages in the patient’s journey and is
vital in helping patient make informed decisions.
The new LOROS website is now live and we recognise the importance of information
accessibility and are committed to making sure the website is accessible to the widest
possible audience, regardless of technology or ability. It has been built to be ‘user
friendly’, easy to navigate and has the right content for all service users.
The new website ensures that GPs and other health and social care staff can easily
access the referral process and other important information. Patients and carers were
involved in the testing phase of the website design.
Key outcomes achieved:
 Implementation and embedding of the LOROS Style Guide
 Roll out of the new look LOROS patient information leaflets and LOROS factsheets –
in line with the roll out of corporate brand.
 Development of a portfolio of photographs to convey the range and "essence" of
LOROS' services to incorporate into both the website and patient information leaflets
 Development of LOROS social media and key messages on service
We will continue to present LOROS as a professional organisation which prides itself in
having high quality patient information, helping them make informed decisions.
LOROS continues to benefit from the involvement of our patients and carers who have
accessed our services. Our patient and carer participation group and patient
information group provide a forum to gain the views of those people who mean the
most of us.
Our patient and carer participation group and patient information group has continued
to meet quarterly and membership numbers have grown to 9 patients and carers.
Unfortunately the opportunity of one of our patients / carers taking on the role of chair
or vice chair to date has not been taken up. This is something we will continue to make
available and encourage.
Likewise our patient information group has continued to meet every 4-6 weeks. We
have been fortunate to have maintained at least two patients / carer representatives at
each meeting.
Key outcomes achieved:
 Agreed index of both externally and internally produced patient information
which will be used either as a resource by individual departments or on display
for patients/carers to access.
 The review and streamlining of all externally produced patient information /
factsheets
18






Patient information pathway to guide staff in the review / rewriting of patient
information
Establishment of a readers panel which consists of users of our services to
review all revised / reviewed LOROS patient information to ensure they are
relevant and easy to read.
Working plan to prioritise the rewriting of leaflets / factsheets
Design, location and installation of two information points within LOROS to
display the agreed patient information
The agreement of which LOROS patient information leaflets should be displayed
externally and a process to facilitate this
The appointment of a volunteer to replenish leaflets within the two information
points and monitor their usage and uptake
Our plan for the next year is to continue consulting with these groups and in addition
give the group members the opportunity to have a more active involvement within
LOROS. Group members have already volunteered to assist us with the 5 senses
survey – this is a discreet observation of the clinical environment using the 5 senses.
Furthermore we are asking for patients and carers to volunteer to join our newly
formed day care, community and outpatient services steering group.
Patient Safety
Priority 5 – Learning from the Francis Report
LOROS has taken the outcomes of the Francis Report very seriously. The 290
recommendations have been reviewed and those that have potential consequences for
the organisation have been identified. An action plan has been developed identifying
leads to take relevant areas of work forward, and highlighting those recommendations
requiring immediate action and those that will be dependent on national or regional
developments prior to local implementation.
Short term actions include reviewing relevant guidelines and policies to ensure they
comply with Being Open, the guidance published by the National Patient Safety Agency,
ensuring nurses can demonstrate in their annual performance appraisal an up-to-date
knowledge of nursing practice and its implementation and the development of a set of
competences that a leader within LOROS would be expected to possess and
demonstrate. The LOROS ‘Whistleblowing’ Policy has also been reviewed, revised and
reiterated to all staff.
By actioning the relevant recommendations LOROS will also be able to achieve
compliance with a number of external quality measures including demonstrating a ‘duty
of candour’ and ensuring appropriate staffing levels and skill mix in clinical areas.
19
A related initiative to support the patient safety agenda is the appointment of a Tissue
Viability Lead Nurse to ensure delivery of the best level of pressure area care to all
patients through training, education and expert practice. The intended outcomes will be
enhanced care planning and management of pressure areas leading to fewer incidences
of pressure ulcers developing, consistent and accurate grading of pressure ulcers with
the implementation of management plans based upon up to date practices and
research, and fewer incidents of grade 3&4 pressure ulcers developing on the inpatient
unit.
Update
Of the 290 recommendations outlined by Francis, 69 were identified as being relevant
to LOROS and 42 of these required action by the organisation. A recent review has
identified good progress in all areas with all of the short and medium term actions (24)
being addressed by June 2014. Some medium actions have been changed to long term
as are awaiting national or local (CCG) guidance/direction. The long term actions not
requiring external input will be completed by the end of 2014. The Board of Trustees
receive regular update reports on progress against the 42 actions.
Key outcomes achieved:

Participation in a national workforce study to enable LOROS to benchmark
against other comparable hospices in relation to staffing levels and skill mix and
identify potential future staffing models to incorporate into our workforce plan

Revision of clinical competences, which include leadership competences at all
levels

Provision of personal development folders in which all relevant information can
be kept relating to competences, appraisals, evidence of patient/carer feedback,
HCA code of conduct etc.

Revision of key policies to support good practice in relation to patient safety and
duty of candour

Robust and clear mechanisms in place to obtain patient and carer feedback in
relation to compliments and concerns and or complaints

Inclusion of key topics such as Whistleblowing within the staff induction
programme
Since the appointment of the tissue viability lead nurse the following initiatives have
taken place:
20

Revision of care plans and supporting documentation relating to pressure area
care and pressure ulcer management

Robust internal process developed to internally investigate grade 3&4 pressure
ulcers and ensure any required improvements in practice are implemented

Introduction of a pressure area assessment in our Day Therapy Unit to support
the 'every contact counts' initiative.
21
Quality Overview - Review of Quality Performance
LOROS is a specialist palliative care provider which also provides a portfolio of
educational events that can be accessed by external service providers across Leicester,
Leicestershire and Rutland and beyond, enabling the specialist knowledge and expertise
to be shared to improve the care of other patients with palliative and end of life care
needs.
The quality and performance of the services delivered at LOROS are reviewed in several
ways. Each year the Lead Clinical Commissioning Group (CCG) undertakes a quality visit
to measure compliance against a number of quality measures. The Care Quality
Commission undertakes at least one unannounced visit each year, measuring
compliance against 16 different quality outcomes.
Outcomes from a number of Key Performance Indicators (KPIs) are reported regularly
in a clinical dashboard internally to the Board of Trustees and externally to the lead
CCG. In addition, in accordance with the Department of Health (DH) LOROS submits a
National Minimum Dataset to the National Council for Palliative Care.
For the purpose of this quality account, LOROS had 2 quality visits within the last year.
April 2013 Quality Visit
Commissioners observed the day therapy unit and had discussions with a number of
patients.
Key themes from the quality visit in April 2013:
Toilet Facilities
- Signage not appropriate – issue re same sex accommodation requirements
- Privacy curtain in place and nurse call system to be fitted soon
- The lock can be operated from outside
The unit does not display any signage/symbols which would be readily recognised by
patients with dementia or brain injury. Staff advised that such patients are
accompanies by a member of staff.
General signage is small – not friendly for poorly sighted patients.
Patients gave very good feedback about their experiences
- Patients feel very supported and look forward to attending the therapy sessions
- Patients feel the facilities are good and they receive good care
- There is a good choice of food and drink with all dietary requirements catered for
- Patients feel that there is good communication between staff, medical staff and
themselves with any concerns being dealt with effectively
22
Immediate actions
Toilet signage within day therapy amended. Discussion around patients eligibility and
criteria to attend day therapy was discussed with the commissioners. Reassurance was
given that patients with a primary diagnosis of dementia / brain injury do not access
day therapy. For those patients with a secondary diagnosis of dementia or brain injury
are risk assessed.
QUALITY VISIT FEEBACK AND OBSERVATIONS
19th March 2014
Introduction
The Quality visit was arranged as part of the annual arrangements with LOROS so that
Commissioners can be assured of the quality of care, patient safety and experience at
LOROS in line with the requirements of the 13/14 Quality Schedule. Discussion took
place with the Director of Clinical Services and additional assurances and evidence was
sought where necessary. It was agreed that with regard of the Quality Schedule for
2014-15 LOROS could send the evidence at any point to the Quality Commissioners for
their review. Following this, Commissioners visited the In-Patient ward. Quality
Commissioners were shown around the ward by the in-patient sister. Also in attendance
was the IP&C Lead for the CCG’s and the IP&C Lead for LOROS.
Environment
All public and patient areas appeared clean and well maintained with no evidence of
dust, dirt or debris seen on the day of the visit. Surfaces in toilets and bathrooms
appeared clean and intact with no evidence of staining or mould seen on surfaces. The
whole environment promoted a positive caring atmosphere.
The following positive points were noted:
 Equipment (including cleaning) was free of dust and debris
 Alcohol gel and other hand hygiene facilities were available for staff and visitors.
All dispensers were noted to be cleaned and free of product build-up
 All staff on duty demonstrated compliance with the Department of Health
recommendations of bare below the elbows
 Staff were witnessed cleaning their hands prior to patient contact
The whole hospital was remarkably clean and housekeeper staff feel like they are an
integral part of the team.
Infection prevention and control (IP&C)
The Lead Infection Prevention and Control Nurse confirmed with the CCG Head of
Infection Prevention and Control the following was in place:
 An assurance framework in line with the Hygiene Code as it related to the
organisation
23




A programme of audit demonstrating staff compliance with organisational IP&C
policies
A programme of update and review of all policies relating to IP&C
A training and education programme that included IP&C
Staff access to Occupational Health services
Privacy and Dignity
Clinical notes are stored away from public areas and screens are available on all
computers to prevent others from seeing confidential information.
Same sex accommodation is available with physical barriers between male and female
areas. Two or the three bays remain in a single sex state all of the time ( one female
and one male) a third bay is interchangeable from male to female of the same sex but
never with mixed sex. There is clearly identifiable toilets and washing areas.
Staff place a notice on the door of an individual to whom they are attended to notify
others that private care may be taking place. No patients were observed in an
embarrassing circumstance and where screens were used these were used
appropriately.
A patient told us that when they use the call bell it is answered promptly all of the time
irrespective of it being day or night.
There is a quiet room for patients and relatives to use. Visitor’s numbers are managed
via use of a relative’s specific area where there are 3 bedrooms for 3 families at a time
to stay overnight.
Themes from staff
 The patient is at the centre of everything and this is instilled throughout the
organisation - It’s a lovely place of work, they have their priorities rights
 Training is available and you are given enough time until you feel confident
before you are left alone.
 A full induction programme is in place where all policies are gone through
 If there are any issues such as concerns regarding safeguarding or breaches in
infection control we discuss them with our line manger
 If there is an untoward event or distressing event we have a debrief afterwards
and if need staff are referred to the in-house counselling service
 There is break out room for staff if a situation is disturbing and/or distressing
 If not sure about a policy or procedure don’t feel afraid to ask
Quotes from patients and relatives
 You feel that the patient is at the centre of everything and this is instilled
throughout the organisation
 Everything is to our timetable not a timetable set by others
 When you call someone comes
24
They allow my husband to participate in my care
Everyone is so cheerful and they all know your name even volunteers who I’ve
never met ask after me.
 I didn’t want to come here at first but once id been here a day I knew it was
right for me they allow me to have more control over my life as my symptoms
become under control. I am now making plans for my end of life for it to be
here.


Next Steps
It was agreed that LOROS will start to work toward the 14/15 quality schedule and will
send the evidence to quality commissioners as when they generate it. Commissioners
will also work with LOROS to ensure that they feel fully integrated into the whole health
economy in respects of end of life and palliative care.
In Conclusion,
Quality commissioners were extremely assured and impressed with the level of care
that is given at LOROS. We recognised that it is a priority for the organisation to put the
patient at the centre of all they do and this resonates throughout the organisation and
throughout all levels and grades of staff. We would like to thank all those individuals
who took time to speak with us and made us feel welcome.
25
26
27
28
Clinical Data
Indicator
2013/14
2012/13
2011/12
2010/11
2009/10
Total number of new referrals
1888
1847
1616
1697
1574
Total number of admissions to Inpatient Unit (IPU)
819
769
797
730
659
% of admissions ending in discharge
61%
56%
55%
54%
45%
75(M)/83
79(M)/86
83(M)/90
73(M)/80
76(M)/82
11
12
14
13
12
806
552
509
528
649
1809
2071
2316
2623
2197
318
144
99
117
151
996
582
780
937
690
1631
1448
1829
1830
2010
3417
3287
3578
3394
3044
Total number of written clinical complaints
3
3
4
10
8
The number of clinical complaints that were founded
2
1
1
9
5
The number of clinical complaints which were unfounded
1
2
3
1
3
419
404
346
N/A
N/A
% occupancy
Average Length of stay on the IPU (days) midnight figure
Total number of medical outpatient attendances including
Manor Croft and Domiciliary
Total number of Lymphoedema outpatient attendances inc.
Consultant Lymphoedema clinics
Total number of Enablement Team Therapy Clinic
attendances including Acupuncture sessions
Total number of Complementary Therapy Outpatient
sessions not including Ward activity
Total number of attendances by patients at Day Therapy
Unit
Total number of contacts with patients by the CNS Team
The number of written compliments
29
Indicator
2013/14
2012/13
The number of drug incidents
63
36
41
44
36
The number of near miss drug incidents
52
90
50
25
16
Slips, trips and falls (patients only)
The number of patients who experience a fracture or other serious injury as a
result of a fall
116
109
115
109
82
2
0
1
2
2
The number of patients known to be infected with MRSA on admission to the
IPU
9
1
4
5
14
Patients infected with MRSA whilst on the IPU
0
1
0
1
1
8
4
2
2
3
1
5
2
0
1
Number of Patients admitted to the IPU with pressure ulcers
117
55
-
81
66
Number which were Grade 3 or 4
35
15
10
25
15
Number of Patients who developed pressure ulcers whilst on the IPU
39
21
-
25
22
Number which were Grade 3 or 4
4
6
2
2
4
(inc. pressure ulcers of grade 3 and 4 developed at LOROS and fractures)
8
6
0
0
Number of (NHS) Never Events
0
-
-
-
(from 2011 onwards all fractures are classified as Serious Incidents)
The number of patients known to be infected with Clostridium difficile,
Pseudomonas, Salmonella, ESBL or Klebsiella pneumonia on admission
Patients who contracted these infections whilst on the IPU
The total number of serious patient safety incidents or serious incidents
30
2011/12 2010/11 2009/10
3
-
Supporting data:
The hospice cares for over 2,500 patients and relatives each year.
There has been an increase in the number of admissions to the IPU during 2013/14 plus an increase in the % of patients being
discharged to a different care setting, predominately home/care home. The overall bed occupancy has fallen slightly as has Length
of Stay on the IPU.
The increase in attendance in medical outpatient sessions is due to the clinics running alongside the Day therapy Service, 4 days a
week. The input to Day therapy Services has also increased the number of attendees at Enablement clinics.
Smarter ways of working in the Lymphoedema Service including telephone follow up calls and discharging patients if appropriate
account for the reduction in attendances. Unfortunately there is also a high DNA rate in this area. We hope to introduce text
reminders in 2014 via SystmOne to help reduce the DNA rate.
The introduction of volunteer complementary therapists providing sessions in Day Therapy accounts for the increase in
complementary therapy sessions.
We received 3 written complaints during the period April 2013 – March 2014 the same number as in the previous year. One
complaint was regarding the Lymphoedema service and was unfounded. The other two complaints were regarding the IPU, one of
which was not directly related to the care at LOROS. A relative had asked for comments on a patient’s medical condition and care on
admission to LOROS following what they perceived as inappropriate care and treatment at another provider organisation.
All complaints are taken seriously, thoroughly investigated and acknowledged to the person making the complaint. They are also
reported to the Clinical Governance Steering Group. Once the investigation has been completed the findings are shared with the
complainant and the appropriate actions taken with the relevant staff. A register of complaints is kept along with a register of
compliments.
During the past 12 months, the number of incidents reported has increased. However, there has been no harm as a result of these
incidents. A proactive reporting culture supports staff to report all incidents including near misses. All incident forms are initially
reviewed by the relevant head of department and learning points noted and fed back to the appropriate teams to action. The forms
are also seen by the Facilities & Operations Manager who is responsible for Health and Safety at LOROS, the Head of In-Patients
Services and the Director of Care Services. All incidents are logged and reported on a quarterly basis to the Clinical Governance
Steering Group and any further actions identified.
31
Drug incidents are also discussed at the Therapeutics Committee and areas for improvement identified and subsequently actioned.
In addition, incidents relating to controlled drugs are reported quarterly to the Local Intelligence Network. Accountable Officers from
all relevant healthcare providers across LLR are members of this group which provides an external governance process regarding the
management of controlled drugs.
There has been an increase in the number of patients admitted to the IPU with infections during 2012/14 however; infection rates
remain low as LOROS continues to proactively address infection prevention (IP) across the organisation
All grade 3 & 4 pressure ulcers are recorded and reported to the CCG immediately, either on admission or if they develop following
admission to the IPU. Whilst there has been a significant increase in the number of patients admitted to the IPU with a pressure
ulcers including grade 3 or 4, there has also been an increase in patients who have developed pressure ulcers during their admission
although fewer developing into a grade 3 or 4. Following the recruitment of a Tissue Viability Lead Nurse there has been more
education and training to support staff in reducing pressure ulcers. The gaps in data in 2011/12 were due to an internal data
collection issue.
Any Serious Incidents are investigated by LOROS and also reported immediately to the CCG. A total of eight incidents were reported
in 2013/2014; five being pressure ulcers, which developed into grade 3 ulcers whilst the patients were on the IPU, two were
fractures following falls on the IPU. One incident, an unexplained death, is still under review by the CCG. The patient’s death was
expected and the coroner and patient’s relatives were fully aware of the incidents leading up to the death. The coroner did not
request an inquest and agreed for the death certificate to be issued.
In the last year LOROS has started to report on the occurrence of any relevant (NHS) Never Events. There have been none reported
in 2013/14.
32
Demonstrating Patient Outcomes
Outcome measurement continues to have a major role to play in improving the quality,
efficiency and availability of the services provided by LOROS.
We are aware that the NHS reforms place greater emphasis on demonstrating outcomes.
As an organisation we are keen to develop this aspect. This why we have identified this as
a key priority for LOROS in 2014/15, under the heading of clinical effectiveness. Moving
forward we should then be able to demonstrate clear benefits in relation to the services
we provide.
As outlined in Part 2 of this document we will be implementing the Integrated Palliative
Outcome Scale as a Patient Reported Outcome Measure across services in the next year.
This will provide more patient derived data about current concerns, as well as enabling a
clearer idea about how things are changing for patients over time, and what difference
hospice services are making, and indeed need to focus on for the future.
33
Feedback from Patients/Families
What Our Patients Say about the Organisation
LOROS values the views of our patients and carers and actively engages with users of our
services in a number of ways. Patients are encouraged to give on-going feedback through
a variety of approaches such as Patient Satisfaction Questionnaires, “Tell Us What You
Think” forms or joining one of our groups such as the patient and carer participation
group, patient information group or reader’s panel.. The ‘Tell Us What You Think’ feedback
is collated at the end of each month and displayed at the hospice for patients, carers, staff
and visitors to see. This includes positive comments plus any actions that have been put in
place to address suggested improvements to our services.
Patient Satisfaction Questionnaires
A comprehensive Patient Satisfaction Questionnaire is distributed annually across all
departments. A total of 268 questionnaires were handed out to patients/carers during
August 2013 and 135 were returned giving a response rate of 50%. You will see from the
PSQ data, LOROS added in a new question which reported on the family/friend test
element.
Patient and Carer Participation Group
This group has patients and carers as members. Their valuable feedback helps us to
shape our current and future services to meet the needs of patient we care for.
A current member of the group reflects
“When my husband was transferred to LOROS for pain management it was a very
frightening prospect in addition to the emotional stress caused by his illness. However,
the reality was completely different and the experience of being in LOROS was so
comforting for my husband and our family, and therefore for this reason I joined the
Patient and Carer Participation Group , to draw on experiences and hopefully ease people’s
fears and perceptions.”
Patient Information Group / Readers’ Panel
The readers’ panel reviews new and revised LOROS information leaflets. The panel
reviews the language used, the layout and presentation and assesses its appropriateness
for the targeted audience. The readers’ panel works alongside the patient information
group, which meets bi-monthly at the hospice to review patient literature, ensuring it is
available to, and meets the needs, of all groups, including those hard to reach. The group
also works to ensure appropriate literature is distributed externally.
A current member of the group shares her thoughts:
“Being a member has enabled me to continue a personal link with LOROS. At our
meetings the views and experience of all are welcomed and discussed in order to continue
34
to provide the standard and quality of care to patients and families to which the hospice is
committed. Staff and volunteers work together in a spirit of mutual respect. It really is
most impressive and rewarding.”
FAMCARE 2013 - Action Plan
A service evaluation of bereaved relatives’ satisfaction with end of life care. Project lead:
Dr Luke Feathers.
Methodology
Duration of service evaluation: 1st June – 31st July.
Covers deaths on the inpatient unit April 2013 – June 2013.
The FAMCARE2 tool was sent with a generic covering letter and a return / freepost
envelope to Association of Palliative Medicine (APM).
Data analysis was analysed by the Association of Palliative Medicine and fed back to
individual services. Services had access to their own data and also comparable
(anonymous) data from other services.
83 bereaved carers were sent questionnaires. 39 were returned.
Results
In general terms our results were good and comparable or slightly better than the national
benchmark data. Bereaved carers had the opportunity to write free text comments, the
positive comments received far outweigh the negative.
Examples:
“The support and care shown to the patient and family were excellent.”
“We couldn’t have been more impressed with the way in which the staff responded to both
mum and the rest of the family. You have our wholehearted thanks – we cannot praise
enough!”
“The care my husband received on the last day of his life was outstanding. He was
treated with such compassion, dignity and care. The staff supported the whole family
magnificently and it comforted us so much as the end of his life was so peaceful and
dignified. The hospice offered support during the last few months of his life but my
husband did not want to take them up on some of the offers. The sense of calm and
peace in the hospice and the welcome given by all the staff and volunteers is incredible
and it helps the families so much in such difficult circumstances.”
35
The FAMCARE results were returned by the APM mid-November 2013.
17 positive verbatim comments were received alongside four negative verbatim comments. Please note that three out of
the four negative comments were given with positive comments also.
Individual Comments
“Response to patients needs
were often not met and slow”
“The only criticism is that I
repeatedly had to ask the nurses
to ensure he wore his boxer
shorts over his incontinence
pads in order to protect his
dignity as he was prone to
throwing off his bed sheets
which left him exposed”
Action
Progress –
Timeline/
Responsible person
Results discussed at Clinical Consultants and Heads of Department
meeting on 7th January 2014.
07/01/2014
Results subsequently fed back to Team leaders by Ward Manager to
cascade and discuss in team meeting.
Immediate
Ward Manager /
Team Leaders
Detailed feedback of audit by Dr Feathers to Ward Manager and Team
Leaders via ward sisters’ meeting to agree any outstanding actions for
consideration
22/05/2014
Ward Manager /
Team Leaders
Results discussed at Clinical Consultants and Heads of Department
meeting on 7th January 2014.
07/01/2014
Results subsequently fed back to ward staff by Ward Manager and Team
Leaders to cascade and discuss in team meeting.
Immediate
Ward Manager /
Team Leaders
Detailed feedback of audit by Dr Feathers to Ward Manager and Team
Leaders via ward sisters’ meeting to agree any outstanding actions for
consideration
22/05/2014
Ward Manager /
Team Leaders
Dignity awareness now included as part of annual essential for role
training
Ongoing
36
“One particular nurse in red
team offended me when
discussing my husband’s need
for a catheter. She showed no
empathy to our situation”
“A duvet at night would be nice
for when my auntie slept in the
recliner chair”
Team Leaders to review current communication strategies when
discussing elements of care with a patient and their family to ensure that
where possible conversations are held in a quiet area of the ward to
maintain privacy. Red team leader aware and discussed with team via
team meetings.
Duvets can be made available for carers upon request along with pillows.
Housekeeper aware and will offer duvets to families when staying
overnight.
“The system of trying to get into
LOROS was very hard and
upsetting due to NHS especially
when there were vacant beds”
Vacant beds – there are sometime issues around the capacity of medical
and nursing staff to admit to empty beds at times if 4 or 5 patients have
already been admitted that day.
Immediate
Ward Manager /
Team Leader
Immediate
Ward Manager /
Team Leaders
Occupancy runs at around 75% which does allow urgent admissions
(including out of hours which constitute 15% of all admissions) to come
in. It can be very frustrating for patients and families if they feel there has
been resistance to them being admitted and if the patients meet the
referral criteria then LOROS is keen to admit them within the constraints
highlighted above.
Introduction of a Daily Planning meeting to optimise the admission
procedure.
Ward Manager /
Head of Inpatient
Services - actioned
Results have been shared with clinical governance group. The above comments relate to the inpatient unit and the plan
is to discuss the result to the Patient & Carer Participation Group to address any further potential areas for improvement.
37
38
39
Patient Satisfaction Questionnaire (PSQ) - 2013
Action Plan
Question
Results
2.1
Did
you
receive
any
LOROS leaflets?
Yes – 47%
Action
Progress – Timeline/
Responsible person
One of our key priorities for 2013/14 is to enhance our patient
information. This is a key objective for patient experience lead. A
patient information group has been set up.
External patient information index completed. All of the internally
produced LOROS info will have been reviewed at the patient
information group by the end of November 2013. Pathways will be
developing for each clinical department in January 2014 to highlight
at what point info is give.
January 2014 –
Clinical Governance
and Patient
Experience Lead
May 2014 – Pathways
completed and on
intranet
Work has begun on rewriting the agreed internally produced info. A
pathway has been developed to support this and is currently being
tested. We envisage each leaflet from writing to production will take
12 weeks +
February 2014 –
Clinical Governance
and Patient
Experience Lead
May 2014 – 35
factsheets rewritten
and sent to design
agency. 17 leaflets
to be prioritised and
issued to staff by
end of May 2014.
We aim for all internally produced leaflets to be completed in the
new look and feel within 12-18 months.
40
Patient information units have been authorised by SMC and will be
in situ by December 2013.
Looking at the individual department data, the following areas
demonstrate a high percentage of not receiving any leaflets:
Medical outpatients – 83%
No leaflets are currently given out in Medical Outpatients. Head of
Day Care and Community Services to consider whether this should
continue or whether a leaflet should be developed.
Currently an appointment letter with details of what to expect at the
outpatient clinic is sent to patients. A map is also included.
The letter includes a cut off slip for people to complete if they wish
to receive copies of their outpatient letters.
This was discussed at the patient information group on 26th
November and the decision was made to keep the letter and add to
it rather than developing a new leaflet about the clinics.
If different treatments are discussed with people in clinic they are
given information sheets about specific treatments.
Lymphoedema – 40%
Lymphoedema – patients are given a general Lymphoedema
information leaflet on their first appointment and then may be given
specific information sheets about any treatment that will be carried
out as appropriate. Therefore they may not always get information
at each appointment.
Ward – 74%
A patient information booklet has been introduced and is available
on each patient’s bedside locker. The housekeeper or admitting
nurse makes the patient and their family aware of the information
on admission to the ward.
41
January 2014 –
Clinical Governance
and Patient
Experience Lead
January 2014 –
Clinical Governance
and Patient
Experience Lead
Counselling – 56%
The Counselling Team are in the process of reviewing their
information booklet that describes their service. The first draft has
been reviewed and further work is underway to benchmark what
other hospices provide.
This question was also discussed with the Patient information
Group in November. The group felt this question should be
replaced with “Did you receive enough information?”
3.4
You,
your
family and friends
were involved as
much
as
you
wanted
in
decisions
about
you
care
and
treatment?
3.7 Did staff tell
you who to contact
if you were worried
about
your
condition after you
left the hospice?
Always – 78%
4.1
Were
you
offered a copy of
the letter sent to
your GP following
your
outpatient
appointment?
4.2 If no, would
you have liked to
receive a copy?
Yes – 67%
N/A – 9%
Always – 66%
Although the percentage for ‘always’ has decreased from 83% last
year,
9% of respondents felt this wasn’t applicable to them. Both of these
added together = 87%.
Initially 66% seems a low figure, however 26% felt this question
wasn’t applicable to them. Both of these added together = 92%.
N/A – 26%
No – 33%
Yes – 100%
(Head of Day Care and Community Services) to review current
processes of offering copies of letters to patients following medical
outpatients and outline a plan of action.
Currently the outpatient letter which gives details of the appointment
also has a cut off slip which people give to the nurse if they wish to
receive copies of outpatient letters. This is then scanned onto
February 2014 –
SystmOne and a reminder is put onto their notes to action.
Head of Day Care
The consultants are happy to ask patients as well if they wish to
and Community
42
receive letters so that no one slips through the net. I will also ask
the out patients nurse if they can check if a patient wants a copy of
their letter at each appointment even if they have forgotten to bring
the slip back. I will discuss with Clinical Compliance Lead and
Complementary Therapy Manager the best way to audit this. It was
decided not to send all patients copies automatically as some might
not want them. Sometimes it is appropriate to edit the letter sent to
the patient.
5.1 How did you
find…
a) The
hospitality
of the
catering
staff?
b) The variety
of food
offered?
c) The quality
of food?
5.2 If you had any
cultural/special
dietary needs do
you feel these
were met?
6.1 If you were
unhappy with any
aspect of our
services, would
Timeline: November 2013
Having looked at the departmental data, the fall in compliance
relates mainly to Loughborough Day Therapy.
Response from Head of Day Care and Community Services:
Yes – 81%
No – 19%
Yes – 59%
No – 16%
Unfortunately the catering at Loughborough is not under our control
although we have fed back concerns to the Loughborough Hospital
housekeeping as they have been raised and patients report that
improvements have been made. We have tried alternatives such
as taking tins of soup to heat through at Loughborough if patients
prefer. We will be ceasing the day therapy service at
Loughborough from the 6th December and moving the service to
LOROS so hopefully this issue will be resolved.
As mentioned previously, patient information is a key priority for the
organisation. All of our new information will contain a section on
how to complain.
Patients admitted to the inpatient unit are seen by a senior member
43
Services
you know how to
complain?
Unsure - 25%
of staff within 72 hours of admission. This is known as a quality
assurance visit and involves informing the patient and family how to
raise issues/complaints if needed.
This practice will be extended to our day therapy patients.
Day Therapy Manager or Deputy will ask patients on their 3rd visit to
DT if they were unhappy with any services would they know how to
complain.
Quality assurance question – the question will need adapting
slightly from the one asked of in patients so I have asked to meet
with S1 Lead to see about changing the drop down list on S1 and
putting the questions on the DT template. I will then have to go
through the process with Day Therapy Manager and Deputy so we
will aim to start this from the new year if that’s ok (providing S1
Lead can make the changes by then) I will ask if these results can
be reported to clinical governance.
Yes – 57%
No – 23%
10.1 Do/did you
have a keyworker?
Unsure – 20%
Looking at the feedback it would appear that patients and carers
are ticking multiple boxes and not identifying one person as their
keyworker. Furthermore, it would appear that our patients and
carers are not familiar with this term and lack understanding of the
meaning.
Action: Clinical Governance and Patient Experience Lead to
discuss continuing this question next year with patient and carer
participation group.
44
Clinical Governance
and Patient
Experience Lead –
February 2014
12.1 Do you have any additional comments on improving the services you accessed?
“A bus that called at the hospice would be helpful”
“Bigger sandwiches”
Operations Manager:
This is out of our control as it would be the responsibility of the
Bus providers, Arriva, Central Bus etc., and they have no plans
to provide a service on to our estate.
Operations Manager:
Baguettes are also available to order from the snack bar, so
please ask the Volunteers.
Complementary Therapy Manager:
Six sessions of complementary therapy are offered to each
individual that is referred to complementary therapy. We do
accept re-referrals to complementary therapy if appropriate
these are always reviewed on an individual basis. Following the
“[complementary therapy] to be more than 6 sessions it helps
feedback from the survey we will assess the relative’s needs
me relax after the loss of my husband at my young age”
after the bereavement and may offer a further course of 6
treatments. However, we are mindful that we do not want to
make the relative dependent on the service so at the same time
we would also sign post the relative to other services like, for
example, counselling if the relative agrees
Day Therapy Manager:
We are sorry that you felt uncomfortable at being the youngest
patient when you attended day therapy. Our aim is to make all of
“…I feel a bit uncomfortable as I was youngest there but I know
our patients comfortable and to meet their needs of all our
that’s just because of my health reason”
patients regardless of their age. We have taken on board your
comments and we are planning to ‘Trial’ a young person’s day in
the future
Day Therapy Manager:
“Food could be improved” *Loughborough Day Therapy*
This has been addressed above.
45
“Could be a bit quieter at night”
Ward Manager:
At times the level of noise on the ward at night can be variable
which can be caused by a variety of activities relating to our
delivery of patient care. We recognise the importance of
promoting a good night’s sleep and have reminded staff to be
mindful of the noise levels at night.
46
What Our Staff Say about the Organisation
Staff feedback is obtained through team meetings, our Heads of Department (HoDs)
forum, and through staff surveys. In 2013 LOROS participated in the anonymous Birdsong
Survey through Help the Hospices. 73% of staff completed the survey compared to 80% in
2011 and 75% in 2010. Several actions were identified from the 2013 results and the
organisation is keen to see if there had been improvements in these areas:
Birdsong Survey 2013
Section
Organisation and Communication:
Actions/Outcome
This area received
comments.
very
positive
Significant pieces of work have been
undertaken in the areas of, the impact
on the environment and diversity being
valued.
Favourable responses have
reflected this.
An overview of the role of the Board of
Trustees was delivered at the October
2013 HoDs meeting. This also provided
staff with an understanding of the
current major areas of focus.
Morale and work/life balance:
Further improvements will include: the introduction of a change
management process and,
 the development of the LOROS
intranet.
Responses were generally positive.
However, concerns in relation to
contracted hours, stress and work life
balance has been focussed upon.
Concerns were also received that
referred to complexity of patients,
increased pressures on clinical staff and
movement towards a more NHS
environment.
Resourcing levels have been reassessed
to include stronger links to budget
setting and a greater emphasis placed
on agreeing realistic objectives as part
47
of the Personal Development Review
(PDR) process.
There are plans to review the current
service model to ensure it is fit for
purpose.
Chief Executive forums have been set
up as a response from the Heads of
Departments to improve internal
communication generally.
Support for staff to try to minimise
feelings of stress continues as has a
focus on wellbeing. A number of staff
wellbeing initiatives took place during
2013.
Development and Reward:
A remuneration review has commenced
which was identified as a Key Priority
for 2013/14.
LOROS again participated in the 2013
Hospices salary survey. The results of
which will be used along with other
information received to try and ensure
we are paying staff appropriately. This
information will form part of the
remuneration review.
Greater emphasis has now been placed
on the PDR process with the
introduction of the improved initiative
to
support
staff
personal
and
professional development.
People Management:
In order to address the concerns raised
as to whether sickness absence is dealt
with effectively, a review of the
sickness absence management policy,
including gathering benchmarking data
has
been
carried
out.
Recommendations have been put
forward for consideration.
48
The Board of Trustees Commitment to Quality
The Board is fully committed to ensuring the provision of the highest quality of care to
patients and their families, to ensure the organisation achieve its mission. The hospice has
an established governance structure, with members of the Board having an active role in a
number of groups, committees and service development initiatives to ensure LOROS
provides all of its services in accordance to its Statement of Purpose. This has recently
been updated and is publically displayed within the hospice.
The Board of Trustees receive regular written and verbal updates at each Board meeting in
relation to care services including feedback from patients and carers and outcomes from
clinical audits, incorporating those which have led to improvements in service provision.
They also receive the outcomes of any unannounced visits by the Care Quality Commission
(CQC) and the Quality Visits undertaken by the Clinical Commissioning Groups (CCG).
Trustees attend a number of events at the hospice, which gives them the opportunity to
meet staff, volunteers, families and carers and personally receive feedback regarding the
quality of the services provided.
The Board is confident that the care and treatment provided by LOROS is of a high
standard and is cost effective.
49
Glossary of Terms:
ALS - Amyotrophic lateral sclerosis
APM – Association of Palliative Medicine
CCG – Clinical Commissioning Groups
CNS – Clinical Nurse Specialist
CPEP – Centre for Promotion of Excellence in Palliative Care
CQC – Care Quality Commission
CQUIN – Commissioning for Quality and Innovation
DH – Department of Health
DMU – De Montfort University
GP – General Practitioner
HoDs – Heads of Department
IG – Information Governance
IP&C – Infection Prevention and Control
IPU – In-Patient Unit
IPOS – Integrated Palliative Outcome Scale
KPI – Key Performance Indicator
LCP – Liverpool Care Pathway
LLR – Leicester, Leicestershire and Rutland
LPT – Leicestershire Partnership Trust
MDS – Minimum Data Set
MDT – Multi-Disciplinary Team
50
MND – Motor Neurone Disease
NHS – National Health Service
NICE – National Institute for Health and Care Excellence
NIV – Non-Invasive Ventilation
PDR – Personal Development Review
PPD – Preferred Place of Death
PSQ – Patient Satisfaction Questionnaire
UHL – University Hospitals of Leicester
51
Written statements by other bodies.
The LOROS Quality Account 2013 -2014 was sent to the following organisations
for comment:
West Leicestershire Clinical Commissioning Group on behalf of
West, East and City CCGs
No comments received
Leicestershire, Leicester and Rutland Health Overview & Scrutiny Committee
“Appropriate officers are not in a position to provide a sufficient response to the LOROS
Quality Account by the deadline”
Healthwatch Leicester
No comments received
Healthwatch Leicestershire
No comments received
Healthwatch Rutland
Unable to contact the relevant officer by the final date for comment
52