Quality Account 2014
Our care places the patient at the centre of everything we do.
Contents
Part 1 - Introduction
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
“Our mission is to deliver,
champion, and teach, high
quality care and choice for
those with a terminal illness.
We will do this through the
creation of a sustainable centre
of excellence, improving quality
of life and personal experience.”
Chief Executive Statement
Introduction to this Quality Account
Overall Statement of Purpose
Responsibility towards Patients, Families,
Carers and Friends
Other Responsibilities
Specific Aims
Our History
Our Hospice today
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3
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4
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5
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Part 2 - Priorities for Improvement
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2.1
2.2
7
13
Priorities for Improvement 2013-2014
Priorities for Improvement 2014-2015
Part 3 - Statements of Assurance from the
Board of Trustees
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3.1
3.2
3.3
3.4
Overview of Quality Performance
Review of Services
Income Generation
Participation in Clinical Audits
Participation in National Clinical Audits
Participation in Local Audits
3.5 Research
3.6 CQUIN goals agreed with Commissioners
3.7 What others say about Rotherham Hospice
3.8 Reviews and Investigations by CQC
3.9 Data Quality
3.10 Information Governance Toolkit Attainment
3.11 Clinical Coding Error Rate
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25
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Part 4 - Supporting Statements
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4.1
Statement from Rotherham Clinical
Commissioning Group (Rotherham CCG)
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4.2
Statement from Rotherham Health and
Wellbeing Board
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Part 1 - Introduction
1.1 Chief Executive Statement
On behalf of our Board of Trustees and the Executive Team,
I am very pleased to be able to present the Quality Account
for Rotherham Hospice for 2013/14.
Our patients, their families, and carers are at the very centre
of our care and delivering quality services to them is our
priority. Quality is at the heart of our mission to place the
patient and not the illness at the centre of everything we
do to improve quality of life and personal experience.
The commitment of the Board to ensure the Hospice delivers
excellence in care across all of its services is evident through
its strong governance framework. I am able to give the Board
the assurance they need that the appropriate processes and
procedures are in place to underpin all our activities and
services through the internal Clinical and Corporate
Governance Groups and Framework and the Board
committees of Clinical Strategy, Finance and Resources,
Marketing and Communications and Human Resources.
This year we have developed our internal clinical governance
to ensure it is efficient, transparent and encourages staff
engagement. We have achieved this through the addition
of three new groups, which are Best Practice Group, Patient
Safety and Clinical Risk Management Group and Quality
and Clinical Effectiveness Group.
I am also grateful to the Rotherham Clinical Commissioning
Group for their continued commissioning of our services and
the financial support through this contract. I am proud of our
relationship with RCCG and their support for the Hospice and
commitment to developing services that deliver end of life
care of the highest quality to a wide range of patients in
Rotherham. As part of our contractual requirements the
Hospice has achieved the required level for the Information
Statement of Compliance toolkit and has completed the
work required around NHS Protect and Prevent.
Consistently achieving our high standards of care is only
possible through the continued hard work of our dedicated
members of staff and volunteers. Our team here continues to
strive for excellence in all they achieve and the Board and
Executive Team would like to thank each and every one of
them for their commitment to providing the highest quality
care to our patients and their families and carers.
The safety, experiences, and outcomes for patients, their
families and carers are of utmost importance to all of us at
Rotherham Hospice. Hearing the voice of patients, families
and carers is important to us and we seek feedback,
comments, suggestions and advice wherever we can to
help inform our service developments and governance
framework. We receive many positive comments about the
quality of our care across all our services from patients and
professionals alike.
Learning lessons to continually improve care is a key priority
for the Hospice. I am committed to developing and
nurturing an environment of openness, honesty and
transparency to ensure that we fulfil our duty of candour.
The Hospice is committed to addressing any concerns and
complaints effectively and efficiently and to ensure we learn
lessons to continuously improve our care and services.
Patient Quote – Inpatient Unit
“Thank you .... we saw an insight into what goes on in the Hospice
and cannot praise you enough for what you do to make the remaining
time of patient’s lives as comfortable, painless and serene as can
possibly be.”
Patient Quote – Day Hospice
“As you can see by my comments, I'm sure you can't improve anything
that is perfect. All the staff work hard to make things comfortable and the
volunteers are very dedicated. Would like to help them! Thank you all.”
Patient Quote – Meals/Environment
“Lovely tender meat, good choice of vegetables, lovely crusty pie.
Lovely roly poly pudding.”
Patient Quote – Meals/Environment
“Very good professional service. Very good support for patients family
and carers and for GPs too. Carers report feeling confident and supported
in caring for patients/ loved ones at home with H at H service.”
I am responsible for the preparation of this report and
its contents. To the best of my knowledge, the information
reported in this Quality Account is accurate and a fair
representation of the quality of the healthcare services
provided by Rotherham Hospice.
Mike Wilkerson
Chief Executive
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1.2 Introduction
Since April 2010, all providers of NHS
commissioned healthcare services have been
required to produce an annual Quality Account.
Rotherham Hospice presents this Quality Account
as an annual report to the public, as a provider of
NHS commissioned healthcare services. In line with
national requirements it exercises our
accountability to service users, stakeholders and
the broader public and demonstrates how all
aspects of the organisation have engaged in our
quality improvement agenda, reflecting the three
domains of quality: patient safety, clinical
effectiveness and patient experience.
This quality account is both retrospective and
forward looking, providing a review of services
delivered throughout 2013/14, explaining what is
being delivered well and where service
improvement can be made. It also looks forward,
describing key priorities for improvement
throughout 2014/15.
Finally this quality account demonstrates the
engagement of service users, key stakeholders, staff
and others with an interest in the organisation in
determining the quality of our services and the
priorities for improvement in the future.
For further information on the content of this or
another Quality Account or to view an account for
a specific organisation, please see the NHS Choices
website:
http://www.nhs.uk/aboutNHSChoices/professional
s/healthandcareprofessionals/qualityaccounts/Pages/about-quality-accounts.aspx
1.3 Overall Statement
of Purpose
The purpose of Rotherham Hospice is to enhance
the quality of life of patients and those important to
them through specialist palliative care services and
education. The Hospice is committed to achieving
this by providing services for patients during the
changing phases of their illness.
Our purpose is to care for our patients and to
support their families, carers and friends. We aim to
give the most appropriate and efficient treatment
and care to our patients through a holistic
approach, to assist in the relief of their physical and
emotional suffering and to help them lead an
acceptable, purposeful and fulfilling life in their
home or in the Hospice.
We will offer a well co-ordinated, multi-professional
and ‘seamless’ service, which integrates the Hospice
specialist palliative care services with primary,
secondary and tertiary health care services, other
voluntary and independent agencies, social services
and, in the case of children and young people,
education services.
Our approach will be non-judgemental and nondiscriminatory. We consider it equally important to
give support to those who care for our patients,
whether they are professional carers, members of
the family or friends.
Our Vision and Mission statements are:
“Our vision is excellence in care for all those throughout
Rotherham affected by a terminal illness.”
“Our mission is to deliver, champion, and teach, high quality
care and choice for those with a terminal illness. We will do
this through the creation of a sustainable centre of excellence,
improving quality of life and personal experience.”
Our care places the patient at the centre of everything we do.
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1.4 Responsibility towards
Patients, Families, Carers and
Friends
Patients, families and friends will be treated as
individuals with compassion, humility, honesty and
love. We will listen to them and, whenever possible,
involve them in decisions about patient treatment.
Their preferences, beliefs and customs will be
respected and their complete privacy and dignity
assured through the use of single rooms, screens,
discrete interview rooms and heightened
awareness by staff of these requirements.
The needs of patients at different stages of their
illness will always be taken into account. There is
no charge to patients or their families for use of
our services.
1.5 Other Responsibilities
The community generously contributes a great
deal of money, time and effort to sustain our work.
We must use these resources wisely, prudently
and effectively.
1.6 Specific Aims
Our aims are to:
• Provide supportive and palliative care for adults
with a terminal illness regardless of age,
disability, gender reassignment, pregnancy and
maternity, race, religion or belief, gender, sexual
orientation or civil partnerships.
• Encourage patients to maintain their identity,
dignity and independence.
• Provide a welcoming and homely environment
to all.
• Facilitate effective, meaningful communication
between patients, staff and significant others
through a multidisciplinary team approach.
• See the patient as a unique individual and plan
with them their care management, whilst
promoting their independence.
• Nurture the patient’s feelings of self worth and
promote a sense of still being able to actively
live life.
• Support patients and their families in decision
making and adapting to changes throughout
their illness.
• Offer a continuation of care and support
through the initial stages of loss and
bereavement.
• Maintain standards of the highest quality,
supporting staff and volunteers’ personal and
professional development.
• Work together in developing an environment
based on support and mutual respect.
• Provide education and information to
Rotherham healthcare professionals and the
general public regarding palliative care issues.
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1.7 Our History
The Rotherham Hospice Appeal was formed in
1988, with the purpose of raising £1 million to
provide Hospice care for the people of Rotherham.
By 1993 over £550,000 had been raised, and the
search for a suitable site began. Rotherham
Metropolitan Borough Council offered the site of
its old council horticultural nurseries towards the
end of that year. The site fulfilled all the criteria
required, and was accepted on a 99 year lease for a
peppercorn rent. The building of Rotherham
Hospice was completed in May 1996, and the
Hospice opened its doors to Day Hospice patients
in mid-1996. A year later in September 1997 the
Inpatient Unit was opened providing 4 single ensuite rooms and a 4-bed ward.
In 2009, the Board of Trustees approved plans for a
ten-bed extension to the Hospice Inpatient Unit. In
late 2010 the original Hospice was also refurbished
to create a modern Hospice suitable for quality
care provision into the future. The 10-bed
extension was opened in April 2011 and the
Hospice now has an Inpatient Unit with 14 single
en-suite rooms. In 2013 the original Day Hospice
and dining area were developed and refurbished
to create a Garden Room and open plan area with
a new Cafe facility for all our patients, visitors and
members of staff and volunteers.
1.8 Our Hospice Today
Rotherham Hospice offers a range of services that
respond to local need. We strive to provide a
homely, welcoming environment, placing
significant emphasis on an individual’s dignity,
privacy and comfort.
The Hospice delivers this care through the
following services:
• Inpatient Unit – consisting of 14 single inpatient
bedrooms all with en-suite facilities including
capacity for bariatric care.
• Day Hospice – providing 15 places a day 5
days a week (excluding bank holidays).
Transport for patients to and from the Hospice
is also provided.
• Community Care – through the Hospice
Community Team which provides Clinical Nurse
Specialists covering all of the Rotherham
Borough, a 24/7 Advice Line and a Hospice at
Home team delivering hospice care in a patients
place of residence.
• Patient and Family Support Services – including
occupational therapy, physiotherapy,
complementary therapy, counselling and
bereavement support and a child bereavement
support group.
Patients and carers can find out more about the
services the Hospice offers and how the charity
operates by reading the Patient and Visitor
Information Booklet provided on admission and
leaflets available in the Hospice and on our
website. Our members of staff will also discuss
topics during the patient’s admission or
attendance and on a daily basis as the need arises.
Our website www.rotherhamhospice.org.uk
also provides further information for patients
and families.
Our care places the patient at the centre of everything we do.
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We believe interaction with families and carers
is very important to those in our care, and we
actively encourage an open visiting policy. Family
members and carers are also more than welcome
to use the family overnight accommodation,
reclining chairs in patient rooms and beverage and
snack facilities on offer, should they wish to stay.
We ensure that patients can stay in touch with
loved ones through the use of telephones and
wireless internet facilities in the patient areas.
The views and opinions of those using our service
are very important to the Hospice. Members of
staff seek comments and suggestions through
patient and carer experience surveys that are
provided during a patients stay on our Inpatient
Unit or on discharge. Patients and families are also
encouraged to share their views verbally or in
writing to staff. A leaflet with further information is
available from reception, and the complaints
procedure will be discussed with patients and
families on admission to the Hospice. In the first
instance, those wishing to raise a concern are
requested to contact either our Senior Sister on
the Inpatient Unit, our Day Sister on the Day
Hospice or the Clinical Services Director, who is
the Registered Manager.
Rotherham Hospice is regulated by the Care
Quality Commission and they can be contacted at:
Finsbury Tower, 103 – 105, Bunhill Row, London,
EC1Y 8TG. The Commission’s telephone number is
03000 616161. The Commission has a website at
www.cqc.org.uk.
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Part 2 - Priorities for Improvement
2.1 Looking Back at Priorities for Improvement during 2013/14
Priority One – Phase 2: Redesign of Hospice Community Team
(Addressing clinical effectiveness, patient safety and patient experience)
Rotherham Hospice Board of Trustees is committed to
the delivery of high quality care. That is care which is
safe, effective and provides patients and carers with a
positive experience.
Throughout 2012/13 we identified many quality
improvements that could be made. In selecting our 3
key priorities for improvement we were mindful of
national and local policy as well as those issues which
were of concern to our service users, our workforce,
our partners and our Trustees.
The priorities for quality improvement that were
identified for 2013/14 were selected for their impact
on patient safety, clinical effectiveness and patient
experience.
Summary of Implementation and Outcomes.
Standard
Phase 2: To ensure that the Hospice implements the
findings of the “Whole Systems” review of Specialist
Palliative Care and End of Life Care (EOLC) service
provision across Rotherham, creating sustainability
and increased quality and effectiveness.
How was this priority identified?
This priority was identified as an integral part of the
evaluation and validation stages of the redesign of
Specialist Palliative Care Services and End of Life Care
Services across the borough.
The overall review was considered as a two year work
stream with pilot phase testing out future models for
validation and commissioning consideration.
Performance against this priority
Although maintaining stakeholder engagement for a
whole systems review has been difficult in some
instances, continued momentum from the Hospice,
commissioners and key providers has enabled us to
achieve sustainable outcomes for the Hospice at
Home Service.
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The pilot continues to be received very positively
across commissioners, partner health care and
domiciliary organisations and the local authority.
By demonstrating our achievement against clear
project objectives the Hospice has been able to
secure further continuation of the project during
2014/15. These achievements have been evidenced in
terms of both clinical efficiency and clinical
effectiveness, demonstrating an annual saving of
£984,270 from unavoidable hospital admissions.
Providing collaborative care in a responsive manner
has helped to gain patient, family, and professional
confidence in the service, reducing GP and ambulance
call out and preventing unnecessary social care
interventions whilst increasing carer’s confidence to
provide care at home. This has increased the number
of people being enabled to receive care in their
preferred place and improved collaboration in relation
to community care at the end of life, regardless of the
person’s residence. The project has also significantly
supported patients to receive quality end of life care in
nursing and residential homes across the borough.
2013/14 has also seen a continued increase in the
uptake of formal and non formal education programs
across joint health and social care provider
organisations including nursing homes, residential
homes, domiciliary services, local authority and GP
practices.
The Hospice at Home service has supported patients
and families by delivering high quality bespoke
personalised care in partnership with the patient and
carers’ wishes. Person-centred care has been central to
maintaining patient and family independence and
ensuring they feel in control even as the end of their
life approaches.
What people told us about these
improvements
Families in the Community
Care Homes, GPs and DNs
“A big thank you to all the team involved in getting our Father
home and caring for him during his last few days at home. This
meant so much to our Father and his family.”
In addition to patient and family feedback in September
GPs and Community nursing staff were asked to comment
on the service;
“Our family would like to express our heartfelt thanks to all
carers and staff who have visited and cared for our Mother
during the last few weeks of her life. You enabled her to
die in her own home.”
“Very good professional service. Very good support for
patients family and carers and for GPs too. Carers report feeling
confident and supported in caring for patients and loved ones
at home with the Hospice at Home service.”
“With grateful thanks for the wonderful care you gave my
husband in his final weeks of his life and also for the great
support you gave me.”
“The Hospice at Home team offer patients, families and health
professionals access to good end of life care and allows patients
to stay at home. Improves confidence and support to families.
Something to keep!”
“It is difficult to express my sincere gratitude for all the
help and support you gave me while my wife was ill.
I knew that I would never have managed without it and
for that I will always be grateful”.
“Crucial to be able to rapidly access suitable care/ nursing
to patients who are dying.”
“With grateful thanks for the wonderful care you gave my
husband in his final weeks of his life and also for the great
support you gave me.”
“It is difficult to express my sincere gratitude for all the help
and support you gave me while my wife was ill. I knew that
I would never managed without it and for that I will
always be grateful”.
“Fast response and provided high level of care.”
Education
“The training I have provided has empowered staff to explore
all aspects of End of Life Care and enabled them to provide
effective palliative care and End of Life Care for people in any
setting. It has also helped by dispelling myths about death
and dying”.
“Those who were initially unsure about the training
commented on its relevance and how valuable it had been.
They also stated that they would encourage others to attend”.
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Priority Two – The development of patient and families support
services, including the introduction of hospice based social work
facilities
(Addressing clinical effectiveness and patient experience)
Standard
All patients, carers and family members will have
access to holistic services that address their physical,
social, spiritual, cultural and diverse individual needs.
Patient flow throughout Hospice services will be
seamless, coordinated and be delivered in an efficient
timely manner, improving patient experience and
maximising use of organisational resources.
How was this priority identified?
Although bereavement support and carer support
services have been delivered by Hospice staff for some
time, these services have been predominantly
volunteer led and therefore sporadic on occasions.
This service has not been able to have a great impact
on the community service due to capacity. It therefore
has not significantly reduced calls to the Hospice
advice line. It has however, provided education,
guidance and support to the broader community
team in matters relating to social care overall.
Adult Bereavement Support
The adult bereavement support service continues to
be delivered by volunteers but now has increased
support and supervision. This is provided through
specific training and introductory mentorship and
through the revision of reporting and recording
systems.
In addition, prior to 2013/14 dedicated Social Worker
time at the Hospice has not been possible through
local authority funding therefore this has created
delays in assessment and care planning processes,
particularly for patients requiring local authority or
Continuing Health Care funding to support their
discharge or increased care package.
The service has grown in strength with 26 volunteers
providing support to 116 clients throughout the year.
Performance against this priority
Children’s Bereavement Support
Children’s bereavement support services have been
delivered but still in small numbers. The support
provided through this pilot service has proven to be
extremely beneficial to both the children who attend
group sessions and their parents or guardians.
The children’s support group meet once a month at
the Hospice where support is offered to children of
school age who are experiencing the serious illness or
loss of a loved one.The group offers activities that will
provide an environment for young people to have fun
and support them through the mixed emotions they
may be experiencing. It also provides a forum for
shared experience and discussion in a protected, safe
environment.
The Hospice appointed a whole time social worker for
the first time in 2013/14. As part of a work force
development review, it was decided that this role
would not only hold a clinical social work caseload but
drive forward the wider social care agenda within the
Hospice including, bereavement services, carer
support, social inclusion and psychological support.
Through the implementation of this service we have
been able to achieve an increased social work
presence on the Inpatient Unit to allow both support
and education for the nurses. This involved care
planning, discharge assessment and direct
involvement with more patients and families to
support individual decision making that influenced
care assessment, planning and delivery. This has also
allowed better collaboration across services and
disciplines and allows a greater focus on broader
issues at daily MDT meetings.
In line with broader service redesign, there is also
further work planned to see the introduction of new
venues and programs which support our transition in
care planning “from dependence to independence”.
Our care places the patient at the centre of everything we do.
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What people told us about
these improvements
The impact of Social Work Support
Quote from families
“Thank you for your exemplary care of Mum during her
stay in Rotherham Hospice”.
Quote from staff
“The introduction of the Social Worker has greatly improved
the support and advice given to patients, families and
members of staff”.
“Our social worker is a valuable resource in assisting in
the discharge of patients to their preferred place of care”.
Children’s Bereavement Support
Quotes from children
“Fun, kind, welcoming and helpful”.
Adult Bereavement Support
Quotes from feedback questionnaires
“This service is an absolutely wonderful idea and service
for bereaved families and continues the wonderful efforts of
those who have cared for individuals at the end of their life.”
“Fun and cheerful atmosphere”.
“Friends are kind and helpful that’s why I love coming here”.
“Caring, reassuring and helpful”.
“Before my sessions with you it really felt like my problems
were in-built and incurable, but with the benefit of your clarity
and approach, penetrating insight and personal warmth,
I feel I no longer fear those problems. Instead I feel and
recognise that you have given me powerful and effective ways
to overcome my grief. Your patience and understanding and
true kindness. You are an Absolute Star.”
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Priority Three – The introduction of structured Complementary
Therapies for Hospice patients and their families
(Addressing clinical effectiveness and patient experience)
Standard
Performance against this priority
Patients, carers and family members will benefit from
the holistic care provided by Hospice services,
including the provision of complementary therapies
to enhance personal experience.
The introduction of a whole time Complementary
Therapist has allowed the Hospice to provide
complementary therapy treatments across the
Inpatient Unit and Day Hospice services.
All complementary therapies to Hospice patients will
be free at the point of delivery.
The role has focussed on the introduction of robust
governance systems to support the delivery
of treatments and the support, supervision and
mentorship of volunteers who support this service.
How was this priority identified?
Complementary therapies have been provided at
Rotherham Hospice since its inception but have never
been funded as a core service provision. This has led to
ad hoc care on occasions as volunteer therapists have
been unable to commit to providing services on a
regular basis.
This was identified as an area for improvement as with
little investment a tiered approach to complementary
therapy and therapeutic touch could be established
which would enhance patient experience across a
number of services.
The Hospice now has 4 qualified volunteer therapists
and many support volunteers who provide basic hand
and foot massage and therapeutic touch.
The service provides all types of complementary
therapy treatments and also adds to the ambience
of the environment through the provision of
dehumidifiers, aromatherapy diffusers, therapeutic
lighting systems and relaxing music.
The treatments provided are; partial and full body
aromatherapy massages, aromatherapy baths,
inhalation via the aromatherapy diffuser system,
reflexology, reiki and therapeutic touch.
Throughout 2013/14 more than 110 patients have
received 584 treatments helping them to manage
their personal symptoms and receive an overall
positive experience of Hospice care.
An audit has been conducted throughout the year
that shows the benefits achieved for individual
patients and where improvements in service provision
can be made. These improvements will be taken
forward during 2014/15.
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What people told us about
these improvements
Feedback from a patient
“I have never experienced such a wonderful sense of
comfort and calm the experience has been indescribable”
(Day Hospice Reiki patient)
“ had never thought of trying relaxation treatments
before but it was lovely helped me to sleep”
(Inpatient Unit Reiki patient)
“I feel so chilled out after it the calm feeling stays with
me for a good couple of days. Thank you for making me
feel more ‘me’” (Day Hospice reflexology patient)
Quote from staff
“The introduction of structured complementary therapy
enables us to provide a truly holistic service. Patients have
been able to build a relationship with the therapist over a
course of treatment, and we now often find that in this
more relaxed environment they are able to open up,
paving the way for further discussions in relation to
end of life care issues”.
“As staff we can visibly see the positive effects of treatments
with patients appearing more comfortable and relaxed
when the therapy is finished”.
“Having our own therapist to oversee our volunteer therapists
has also led to an expansion of the service”.
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2.2 Looking Forward at Priorities for Improvement during 2014/15
Priority One – The redesign of Day Hospice to create a Day Therapies
and Treatment Service
(Addressing clinical effectiveness and patient/carer experience)
Throughout 2013/14 we have identified 3 key quality
improvements that need to be made throughout
2014/15. In selecting these priorities we have been
mindful of national and local policy as well as those
issues which were of concern to our service users, our
workforce, our partners and our Trustees.
The priorities for quality improvement that have been
identified for 2014/15 have been selected for their
impact on patient safety, clinical effectiveness and
patient experience.
Summary of proposed implementation and
expected outcomes
Standard
Through the introduction of Day Therapy and
Treatment Services, all patients and families attending
Day Hospice Services will be able to access a full range
of holistic care and support treatments to prevent
unnecessary duplication in community practitioner
interventions and unavoidable hospital admissions.
Where appropriate patients, families and carers will be
able to access wellbeing services to optimise their
ability to maintain independence and enable them to
make informed choices about their care.
How was this priority identified?
This priority was identified through feedback from
patients, family members and carers who expressed
their concerns that duplicate appointments were
needed for patients to see additional palliative care
staff as well as attend Day Hospice.
It was also identified in conjunction with
commissioners and other key stakeholders in order to
reduce unavoidable hospital admissions for simple day
therapies and treatments.
This information has been explored through broader
staff discussions to inform an overall redesign of Day
Hospice Services.
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How will this priority be achieved?
This priority will be achieved through the introduction
of Day Therapy and Treatment Services (3 days per
week) and the retention of Traditional Day Hospice (3
days per week). This service will also provide access to
Clinical Nurse Specialist Clinics, and Complementary
Therapy Services.
Day Therapy and Treatment service will also include
the introduction of “Wellbeing Groups” facilitated
weekly for a period of 12 weeks. In addition to patient
attendance, carers would also be included in some of
these sessions improving carer involvement and
support.
In total this newly designed service would allow
facilitated care to be provided for a maximum of 135
patients each week.
Monitoring and reporting methods
This priority will be measured as part of a structured
change management evaluation in line with the
Hospice redesign proposals. This will require the
review of service activity data, referral and access
trends, service user feedback surveys, and the
measurement of patient and family outcomes and
experience.
A multidisciplinary service implementation group will
be initiated to take forward the new service elements
and these staff will also form part of the evaluation
and review team.
Monitoring reviews will be collected and presented
on a monthly basis to the Quality and Clinical
Effectiveness Group to allow the service to be
developed in a way that continues to meet the needs
of its users. This information will then be reported to
the Clinical Strategy Group on a quarterly basis as part
of a broader quality matrix.
Priority Two – The Introduction of a menu of bespoke carer
support packages to enable increased engagement by carers
and improved carer experience.
(Addressing clinical effectiveness and patient experience)
Standard
How will this priority be achieved?
All patients, families and carers will receive the
support and advice they require to maintain family
carer responsibilities and understand the services
and support networks that are available locally.
All patients will be assessed to ascertain if they
have formal or informal carers who support them
at home.
All carers will be provided with a carer support
pack identifying other networks and support
agencies and a menu of carer support services
that will be implemented by the Hospice.
All carers will be offered support services that
meet their requirements and involve their loved
ones in services.
How was this priority identified?
Through the delivery of CQUIN 1 during 2013/14,
it was identified that almost 100% of our Hospice
patients have either an informal or formal carer
who supports them at home. The CQUIN data also
demonstrated that although carers want to receive
advice and support, the support they require is
very varied.
Carers have also provided some information on
the specific types of service they would like to
receive. This has led to the staged development of
a menu of carer support packages that will be
implemented throughout 2014/15 as part of a
broader clinical services redesign.
These will include:
• Drop in sessions for both carer and
patient support.
• The inclusion of caring and carer support
in our new Wellbeing Groups.
• The introduction of “Expert Carers” course in
line with the previously nationally recognised
“Expert Patient Program”
• The provision of an emergency carer contact
card system
Monitoring and reporting methods
Service activity data, service user feedback surveys,
and the measurement of carer outcomes such as:
reduced calls to advice line, admissions for carer
crisis, will be collected and presented on a monthly
basis to the Quality and Clinical Effectiveness
Group to allow the service to be developed in a
way that continues to meet the needs of its users.
This information will then be reported to the
Clinical Strategy Group on a quarterly basis as part
of a broader quality matrix
14
Priority Three – The introduction of a four tier counselling
and support service
(Addressing patient experience)
Standard
How will this priority be achieved?
All patients and families accessing Hospice services
will receive care and support that is mindful of their
holistic health, including their emotional and
psychological wellbeing.
Through service redesign to allow our contracted
clinical psychologist to provide education, supervision
and support to staff at levels 2 and 3.
This will see the formal introduction of a tiered
Psychology and Counselling Service, providing
appropriate support to patients and their families
across levels 1-4.
This will also provide an up skilled workforce with
increased ability to engage in complex
communication with patients and families. This service
redesign also allows for robust governance in this area,
providing supervision and reflection in line with
national requirements.
By introducing allocated counselling and carer
support time, improved outcomes for carers and
families will also be achieved.
How was this priority identified?
This priority was identified through patient, family and
staff feedback and overall service redesign
benchmarking data form 2013/14 demonstrating
where activity and demand within the service were
not being met.
Staff training needs analysis also demonstrated where
core level two staff did not always have the
confidence and competence to provide structured
support using nationally recognised tools.
This was also influenced by the requirements of the
cancer peer review.
15
Structured education will be provided to increase staff
confidence and competence and all staff trained at
level 2 and 3 will receive structured supervision to
strengthen their ongoing practice.
All staff working within the Hospice will receive
training in relation to “Compassion in Practice” to
increase awareness of the emotional needs of
patients, their families and carers.
Monitoring and reporting methods
This priority will be measured as part of a structured
change management evaluation in line with the
Hospice redesign proposals. This will require the
review of service activity data, referral and access
trends, service user feedback surveys, the
measurement of patient and family outcomes and
experience and the monitoring of attendance at
training, reflection and supervision sessions
throughout the year.
Monitoring reviews will be collected and presented
on a monthly basis to the Quality and Clinical
Effectiveness Group to allow the service to be
developed in a way that continues to meet the needs
of its users. This information will then be reported to
the Clinical Strategy Group on a quarterly basis as part
of a broader quality matrix.
Part 3
3.1 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 specialist palliative care or End of Life
Care providers.
3.2 Review of services
National clinical audits and national
confidential enquiries
During 2013/14 Rotherham Hospice provided the
following services:
• Inpatient Unit - consisting of 14 single inpatient
bedrooms all with en-suite facilities including
capacity for bariatric care.
• Day Hospice - providing 15 places a day 5
days a week (excluding bank holidays).
Transport for patients to and from the
Hospice is also provided.
• Hospice Community Team including Clinical
Nurse Specialist Services and Hospice at Home
(Rapid response) services
• Bereavement services, Carers support and
Chaplaincy services
• Therapy services, including, Complementary,
Physiotherapy and Occupational therapy and
Psychological support services.
Rotherham Hospice has reviewed all the data
available to them on the quality of care and
efficiency across all of these services and used this
information to facilitate service improvements and
or demonstrate commissioner and regulatory
compliance.
3.3 Income generation
Rotherham Hospice is commissioned via the NHS
Standard Contract, to deliver NHS End of Life Care
and Specialist Palliative Care Services on behalf of
Rotherham Clinical Commissioning Group.
The income generated by the NHS services
reviewed in 2013/14 represents 100% of the total
income generated from the provision of NHS
services by Rotherham Hospice for 2013/14.
The overall income generated from the NHS
contract represents 56% income for the Hospice
for 2013/14.
3.4 Participation in clinical
audits
National clinical audits and national
confidential enquiries
During the period 2013/14 Rotherham Hospice
was not eligible to participate in any national
clinical audits or national confidential enquiries.
As Rotherham Hospice was ineligible to participate
in any national clinical audits and national
confidential enquiries there is no list or number
of cases submitted to any audit or enquiry as a
percentage of the number of registered cases.
This is because none of the 2013/14 audits or
enquiries related to EOLC or specialist palliative
care. The Hospice will also not be eligible to take
part in any national audit or confidential enquiry
in 2014/15 for the same reason.
Although the Hospice did not have the
opportunity to participate in national clinical
audits throughout 2013/14, internally the
following local clinical audits were conducted.
16
Local Clinical audits
Rotherham Hospice has conducted and/or reviewed 14 local clinical audits during 2013/14 as follows:
Audit
Lead
Medicines Management
Full Review
Medical Director/Clinical
Lead/IPU Sister/Pharmacy
Lead
Controlled Drugs
Standard Operating
Procedures Review
Clinical Lead/Pharmacy
Lead
April
2013
Feb March
May June July Aug Sept Oct
Nov Dec Jan
2013 2013 2013 2013 2013 2013 2013 2013 2014 2014 2014
NHS Safety Thermometer Clinical Lead/IPU Sister
Additional Safety
Thermometer markers
Clinical Lead/IPU Sister
Internal Records Audit
Clinical Lead/Clinical
Governance Facilitator
Patient Experience Audit
Clinical Lead/Clinical
Governance Facilitator
Infection, Prevention &
Control: General
inspection, Sharps audit,
Hand Washing audit,
(ESSENTIAL STEPS)
IPU Sister & IPC Lead/Day
Hospice
PLACE Assessment
(This audit replaces the
PEAT Assessment)
CSD/SS Manager and
Clinical Governance
Group
Audit of Community
Community
Team Advice Line inc Out CNS/Community Team
of Hours
Manager
Audit of Hospice At
Home provision
Data Quality
Clinical Lead/Data
Analyst
Audit of Complementary Clinical Services Lead/DU
Therapy Services
Sister/ Comp Therapist
Our care places the patient at the centre of everything we do.
17
Our care places the patient at the centre of everything we do.
We are committed to providing the highest standard of
specialist palliative care for patients and families affected
by a terminal illness over the age of 18.
18
3.5 Research
The number of patients receiving NHS services
provided or sub-contracted by Rotherham Hospice
in 2013/14 that were recruited during that period
to participate in formal research approved by a
research ethics committee was 9.
Rotherham Hospice has participated in two
research projects during 2013/14.
These are as follows:
University of West Scotland, Lead Researcher
Stevens E. (NHS ethics approval)
Title: The Impact of Specialist Palliative Day
Services on the quality of life, wellbeing and
mood of attendees.
Purpose: To discover if attending Day Hospice
is beneficial to those living at home with
serious illness.
Aim: To produce evidence on whether Day
Hospice Services have affected attendee’s
quality of life and feelings of wellbeing.
5 patients have been recruited to this study
during 2013/14.
What Participation Entails: Completion of
monthly questionnaires in conjunction with
weekly brief discussions.
Cancer Experience Research, Dunham M. (SHU
ethics approval)
Title: Older People’s Cancer Experience
Purpose: To explore older people’s experiences
of the discomfort of living with Cancer.
Aim: To provide a voice for older people’s
cancer experiences, as this area of research
has previously been neglected.
4 patients have been recruited to this study
during 2013/14.
What Participation Entails: Completion of a diary
(where possible) about discomfort and pain in
conjunction with recorded interviews.
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3.6 Quality improvement and
innovation goals agreed with our
Commissioners/ CQUIN payment
framework
A proportion of Rotherham Hospice income from
the NHS in 2012/13 was conditional on achieving
Quality Improvement and Innovation goals agreed
between Rotherham Hospice and Rotherham PCT
and any person or body they entered into a
contract, agreement or arrangement with for the
provision of NHS services, through the
Commissioning for Quality and Innovation payment
framework.
The CQUIN measures were in relation to the
following areas:
CQUIN Measure 1
Carer Assessment and Support
Evidence suggests that most carers will benefit if
the person they look after gets help and support.
However in some cases the carer themselves would
benefit from some support especially if their loved
one chooses to die at home.
This indicator focuses on assessing the needs of
carers. The Hospice will conduct an agreed
assessment and provide appropriate support to
carers, in order that they can continue to care for the
patient. Particular emphasis will be placed on those
carers where the patient has expressed a wish to be
cared for at home. Carers will complete an
experience survey to ensure that the support being
provided is appropriate. The assessment and
experience survey will be repeated at appropriate
intervals to ensure that any changes in carer needs
are identified and supported.
CQUIN Measure 1
Annual Requirement
All patients and carers now receive information
and advice on accessing local carer support
services.
The Hospice will:1. Collect the following information to establish
a baseline:
• Total number of patients who have a carer.
• Carers who had an assessment of their needs.
• Number of carers who care for patients at home
• Carers who care for patients at home and who
had an assessment of their needs
• Carers who were assessed as needing support
and received that support.
• Carers who completed an experience survey.
Further work is underway as part of the overall
service redesign to allow more capacity and
variety in supporting carers. This will allow greater
support through the development of carer
support groups and links to existing community
caring services. Building on the achievements of
this CQUIN is important to the Hospice, to ensure
patient, family and carer engagement in care
planning and delivery. Therefore further work will
be taken forward as a priority for 2014/15.
2. In addition develop both an Assessment Tool and
Experience Survey to be able to identify what
support should be provided to carers.
CQUIN Measure 2
Involvement in decisions about care
*NB -this CQUIN is purely to establish the number
of carers involved with EOLC patients and the
services they would like.
CQUIN Measure 1
Progress Summary
Baseline data has continued to be collected in
relation to overall numbers of carers and the
support that they feel they would benefit from.
All patients receiving Hospice inpatient and
community services were asked if they had a formal
or informal carer. Recording of this has sometimes
not been as robust as we would like. Therefore a
new reporting and recording mechanism will be
used to take this forward during 2014/15.
100% of community patients had carers of some
kind and most were receiving care informally from a
relative or friend solely. 100 % of carers said they
would like practical support, including care from
Hospice at Home or a review of their care package.
It has therefore been difficult to discuss some carer
support as the remedies are beyond the control of
the Hospice.
The 2012 VOICES survey highlights South
Yorkshire as performing poorly with regard to
involvement of patients in decisions about their
end of life care. Personalised care plans are an
important aspect of care particularly at the end of
life as they help patients and carers retain some
control over care decisions. An agreed plan also
provides professionals with written,
documentation outlining the patients care needs
and wishes.
The Hospice will develop a mechanism for
ensuring patients are involved in decisions about
their end of life care.
CQUIN Measure 2
Annual Requirement
The Hospice will develop a mechanism for
ensuring patients are involved in decisions about
all aspects of their care, with particular focus on
decisions relating to end of life care.
The Hospice will devise tools for assessment and
recording that demonstrate the engagement of
patients and families in care decisions.
100 % of carers completing the assessment form
said that they did not want support from outside
agencies or referral to social services for formal
carer’s assessment.
20
CQUIN Measure 2
Progress Summary
CQUIN Measure 3
Annual Requirement
During 2013/14 the Hospice saw the introduction
of new care assessments and care planning
records for all patients and families. Although all
changes take time to fully embed and become
integral to working operations, this move has seen
extremely positive outcomes. The Hospice now
uses this tool for assessment of all patients to the
Inpatient Unit and Community Services.
From July 2012, survey all relevant Inpatients on a
monthly basis focusing on patient harm:
• falls;
• pressure ulcers;
• catheter associated urinary tract infections.
Submit data on a monthly basis to the NHS
Information Centre.
Monthly records audits continue to demonstrate
that all patients are involved in decisions about
their care where possible. In cases where patients
do not have families or carers and therefore need
external support to advocate their needs this is
considered using the Hospice social worker or
independent advocacy services.
CQUIN Measure 3
Progress Summary
Further work to embed this practice into all
services is being considered as part of the overall
service redesign.
An average of monthly records audits across
2013/14 show that more than 98% of patients
had signed joint care plans in place.
CQUIN Measure 3
NHS Patient Safety Thermometer
To reduce harm, the power of the NHS Safety
Thermometer lies in allowing frontline teams to
measure how safe their services are and to deliver
improvement locally
Collection and submission of data on patient
harms using the National Patient Safety
Thermometer.
Although all of these CQUIN measures were
achieved in full, further work is still needed to
take forward identified service improvements.
The Clinical Services Director (CQUIN lead) and the
Data Analyst (Data Lead for Safety thermometer)
continue to drive forward the principles of Harm
Free Care to ensure the Hospice has a
comprehensive understanding of the safety
thermometer tool and the CQUIN requirements.
All staff have been fully briefed and a nominated
lead for each clinical area has been identified.
The nominated lead is responsible for co-ordinating
data collection and submission (via the data analyst)
each month.
Although 2013/14 has had no national minimum
set for % achievement of “Harm Free Care” it is
important to note that although measured across
small numbers, the Hospice continues to achieve
a very high standard.
Progression on data collection and collation has
been extremely positive and in turn has led to
additional measurements being added locally to
the tool to allow a broader understanding and
assurance of how “Harm Free Care” is achieved. The
information is also being collected weekly to allow
consistency and continuity in audit processes.
This continues to demonstrate positive attitudes
to individual patient risk assessment and re
assessment in relation to pressure sores, falls,
moving and handling and nutritional screening.
Commissioners can access the national data
submitted by the Hospice via the NHS Information
Centre website.
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3.7 What others say about us
As a learning organisation, Rotherham Hospice is
keen to engage all service users and key
stakeholders in feedback to support service
improvement and increase quality and experience.
With this in mind the organisation has robust
networking systems in place with local strategic
partners to ensure we receive feedback which can
facilitate service improvement by strengthening
what we do well and learning from situations
where we did not meet expectation.
The Hospice also has a number of working groups
which include representation from external
organisations these include our Equality and
Diversity group, PLACE assessment group and our
Nutrition and Catering Forum.
Finally feedback is sought in the form of service
user satisfaction surveys helping us to gain
information from patient, family members and
carers about the care that they received and their
experience overall. These surveys have helped us to
understand how our services are perceived by the
people who use them. Learning from the
comments made has enabled us to acknowledge
where shortfalls in service provision exist and make
positive service changes for the future.
Selections of these comments are listed below:
From Hospice at Home;
“I feel it is an absolute Godsend and I can honestly say I really
don't know how we would be managing without this wonderful
team of people. Thank you so, so much.”
“We as a family cannot say enough good about this service.
They make a terrible situation a bearable one and made my
mum very happy right to the end. We feel we can't think how
we would have managed without it. There is no other service as
needed as this one is. If we couldn't have had this service our
memories would have been very different.”
“They provided invaluable support for all family members and
the highest standard of medical care for our mum. They became
part of our family and helped us all to cope with every stage of
our family's personal tragedy.”
From Day Hospice;
“Day care is absolutely invaluable as meeting others is helpful,
and makes it easier to access medical care.”
“Fantastic place to attend and very beneficial”
“Only thing missing, access to internet”
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3.8 Care Quality
Commission (CQC)
Rotherham Hospice is required to register with the
Care Quality Commission and its current
registration status is approved and unconditional.
Rotherham Hospice has no conditions on
registration and registration is approved as follows:
Rotherham Hospice Trust is registered in respect
of 4 Regulated Activities:
• Accommodation for persons who require
nursing or personal care
• Diagnostic and screening procedures
• Transport services, triage and medical advice
provided remotely
• Treatment of disease, disorder or injury
Regulation also states that:
• Services can only be provided to people
18 years of age and over
• A maximum number of 14 patients can
reside in the Inpatient Unit at any one time
Rotherham Hospice has not participated in any
special reviews or investigations by the CQC
during 2013/14.
The Care Quality Commission has not taken
enforcement action against Rotherham Hospice
during the period April 2013-March 2014.
Throughout 2013/14 Rotherham Hospice undertook
an ongoing self-assessment of its compliance
against all 28 CQC domains and in turn the
Health and Social Care Act 2008 and Care Quality
Commission Registration Regulations 2009. This
enabled the organisation to understand its level
of compliance and identify any areas for further
improvement which will be implemented through
the governance framework.
As part of an unannounced CQC compliance
inspection on 13th May 2013, the following
standards were considered and outcomes achieved:
Overall Comments:
Verbal feedback on the inspection visit was very positive overall, across all of the domains considered.
The Inspector felt that many areas demonstrated “Best Practice” particularly in encouraging
feedback through surveys, comments, compliments and complaints.
The ability to respond to and learn from complaints was also recognised. The majority of the
inspection was carried out through direct observation of patients and staff and through direct
discussions with staff, patients and families. These findings or questions were then supported by
evidence logs and compliance assessments documentation.
All staff could explain their roles and what was expected of them under each of the domains
including work undertaken by domestics, catering staff, care staff, volunteers and administrators.
All operational management staff were able to provide accurate up to date records on their
elements of service and all of them could portray the governance responsibilities of their roles
and how this feeds into supporting patient care and the broader governance agenda.
23
Standard
Consent to care and treatment (Outcome 2)
Where they are able, people who use services receive
the examination, care, treatment and support they
agree to. This is because clear procedures to get valid
consent are followed in practice, monitored and
reviewed.
Meeting nutritional needs (Outcome 5)
Where the service provides food and drink, people
who use services have their care, treatment and
support needs met because the organisation can
ensure personalised care by providing adequate
nutrition, hydration and support.
Infection prevention and control (Outcome 8)
Providers of services comply with the requirements of
regulation 12, with regard to the Code of Practice for
health and adult social care on the prevention and
control of infections and related guidance.
Requirements relating to workers (Outcome 12)
Manage quality by employing the right people
People who use services benefit from the robust
screening of all staff (Including volunteers, students,
temporary and ancillary staff and practitioners
working under practicing privileges)
Complaints (Outcome 17)
People who use services and those acting on their
behalf can be confident that their comments and
complaints are listened to and dealt with effectively
because appropriate systems and processes are in
place to receive and respond to concerns and
complaints.
Records (Outcome 21)
People who use services can be confident that their
personal records for their care, treatment and support
are properly managed because the service has clear
procedures that are followed in practice, monitored
and reviewed, to ensure personalised records and
medical records are kept and maintained for each
person who uses the service.
Compliance
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
√ Met this standard with
very positive feedback
24
3.9 Data Quality
Rotherham 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. This is due to
ineligibility to take part in the scheme.
However, in the absence of this we have a local
system in place for monitoring the quality of data
and the use of the electronic Patient Information
System, SystmOne. This provides monthly
information on data quality and ensures accuracy
in recording and reporting mechanisms.
Throughout 2013/14 the Hospice has maintained
the relevant framework documentation, polices,
training, and security infrastructure to be able to
demonstrate an attainment of 67% at level 2
compliance with NHS Connecting for Health’s
Information Governance standards, ensuring we
provide service users, key stakeholders, staff and
others with an interest in the organisation with
the confidence that their information is dealt
with efficiently, safely and securely.
The Hospice has completed and submitted its
annual Information Governance Statement of
Compliance in accordance with National
Information Standards and CQC requirements
Monthly data quality performance
for 2013/14 is as follows:
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
95.11%
97.37%
95.88%
95.35%
97.23%
96.68%
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
96.24%
96.76%
97.83%
95.30%
96.07%
94.94%
Commissioning data quality targets stand at 90%.
Therefore compliance has been consistently
achieved throughout the year.
3.11 Clinical Coding Error Rate
Rotherham Hospice was not subject to the Audit
Commissions, Payment by Results clinical coding
audit during 2013/14.
25
3.10 Information Governance
Toolkit attainment levels
Part 4
Supporting Statements
4.1 Rotherham Clinical Commissioning
Group (Rotherham CCG)
“The hospice report is an encouraging read. The hospice strives
to improve the care of Rotherham patients as they enter the last
days of their lives by standardising end of life care delivered by
all healthcare professionals across the patch. Continued positive
feedback from patients and their families are testament to this
effort. There is on-going work to develop a Rotherham wide
palliative care register and improve co-ordination of services for
patients in their preferred place of care. The successful hospice
at home pilot is helping patients receive optimal care at home
while saving money for the local health economy. The
committed staff at the hospice strive to deliver a high quality
service which is constantly developing. The hospice re-design
project demonstrates their drive to continue improving this
service while always maintaining patient care at its core. The
partnership between the hospice and CCG is proving to be
fruitful and rewarding; we look forward to continuing our
working together in the coming year.”
Dr Avanthi Gunasekera
GP EOLC Commissioning Lead
Rotherham CCG
4.2 Rotherham Health and
Wellbeing Board
On behalf of the Health & Wellbeing Board, I strongly support
the work of the Hospice in caring for the people of Rotherham.
We endorse and support the high quality of care provided by
the Hospice and believe this report fairly represents the
achievements of the Hospice.
Councillor Ken Wyatt JP,
Chair of Rotherham Health
& Wellbeing Board.
www.rotherhamhospice.org.uk
26
Rotherham Hospice, Broom Road
Rotherham, South Yorkshire S60 2SW
Tel: 01709 308900
www.rotherhamhospice.org.uk
A Registered Charity.
A Company Limited by Guarantee.
Registered Address: Broom Road, Rotherham, S60 2SW
Company Registration No: 2234222
Registered Charity No: 700356
Our care places the patient at the centre of everything we do.