1
Part 1:
Trust Board Chairman’s Statement
St Barnabas Lincolnshire Hospice is a Lincolnshire charity committed to ensuring
that local people have access to excellent palliative and end of life care. Our focus
is to deliver outstanding services and work with partners to ensure that, regardless
of location or diagnosis, patients and their families receive the care and support
they require.
In our quality accounts we have included a number of initiatives where we have
worked with our colleagues. These include developing arrangements to ensure
that pressure relieving equipment is prescribed proactively, this not only reduces
the risk of pressure damage but minimises the disruption to patients when they are
most poorly. In the coming year we will be working with colleagues to arrange for
equipment to be collected promptly as we know from families that delays cause
them both practical problems and emotional distress.
We have worked very closely with colleagues in the mental health trust, prison
authority and homeless charities to develop the support for people approaching the
end of their life in these settings. Each of these projects combines, not only
provision of care but also support for staff working in these areas so that they may
develop the skills and confidence to provide palliative care to patients in their
keeping.
As Trustees of St Barnabas Hospice we are the guardians of the Hospice for the
people of Lincolnshire. With this we are committed to ensuring that we listen to the
feedback from our patients, their families and the local community so as to promote
the development of our services and extend our reach to more people. Over the
last few years we have refreshed our day therapy services. The new model
designed around the individuals’ priorities, is extremely successful and in the last
two years we have seen a 177% increase in the number of people accessing this
service, which is funded wholly through charitable donations.
With our partners, United Lincolnshire Hospitals Trust, we are developing the
range and support for patients in acute hospitals. In the last year our Consultants,
working with the Specialist nursing team, saw over 300 patients and facilitated an
increase in the number of patients being transferred from hospital to the Hospice
in-patient unit. We have also commenced the development of the first ever
Hospice in a hospital, which is due to open in 2014 and will not only create a six
bedded in-patient unit in Grantham Hospital, but support the wider provision of
palliative and end of life care on the hospital site and in the wider community.
2
On behalf of the Trust Board I am pleased to present this Quality Account for
2013/14 and, to the best of my knowledge, the information contained therein is
accurate.
Mr Robert Neilans
Chairman of the Board of Trustees
3
Trust Board Endorsement of the Quality Account
We, the Trust Board of St Barnabas Lincolnshire Hospice, are pleased to endorse
the content of the Quality Account and, to the best of our knowledge, the
information contained therein is accurate.
Trustee
Signature
Mr Tom Murray
Mrs Jacky Smith
Mr Graham Hale
Mrs Sue Glaister
Mr Peter Jordan
Mrs Ann Daulton
Mr Tony Maltby
Mr Keith Darwin
Mr David Libiszewski
4
Auditors Statement
We have audited the information included in the Quality Account of St Barnabas
Hospice Lincolnshire for 2013/14 by obtaining, reviewing and verifying the
information included in the Quality Account to source documentation held by St
Barnabas Hospice Lincolnshire and are satisfied that the information included in
the Quality Account is correctly and accurately reported.
5
Part 2: Priorities for Improvement and Statements of
Assurance from the Board (in regulations)
1. IMPROVEMENT
The Board of Trustees continues to support the continuous development and
improvement of its services to ensure that the care and support it provides evolve
to meet patient and carer needs.
The priorities for quality improvement we have identified for 2014/15 are set out
below. These priorities have been identified in conjunction with patients and
carers, staff and stakeholders. The priorities we have selected will impact directly
on each of the three priority areas; patient safety, clinical effectiveness and patient
experience.
1a. Priorities for Improvement 2014 – 2015
 Priority One
Patient Safety, Clinical Effectiveness and Patient Experience
Priority One: Working with other health and social care organisations to
lead the development of a palliative care specific pressure damage
prevention pathway for the county.
1.

The prevention of pressure damage is a national ambition 1 for all patients
receiving care because it has a significant impact on the safety and
experience of patients.

End of life patients are particularly vulnerable to pressure damage
because the skin, as an organ, also fails during the dying process and
patients may experience other symptoms that preclude some pressure
damage prevention activities, for example turning a patient to relieve
pressure.

Patients at home may not wish to accept pressure relieving equipment in
their homes when they are very unwell.
NHS and Midlands Strategic Health Authority. http://nhs.stopthepressure.co.uk/
6
How was the priority identified?
This priority was identified at a pressure damage summit held in December 2013
and led by the Deputy Chief Nurse of LCHS as part of the national ambitions work
to reduce and eliminate avoidable pressure damage. There is recognition that
patients at the end of life are at significant risk of pressure damage.
How will priority one be achieved?
This priority will be achieved by working together with other organisations, in health
and social care to develop a proactive prevention pathway that will acknowledge
the specific issues identified in end of life care. The pathway will be based on the
revised National Institute of Health and Care Excellence (NICE) guidance on
prevention of pressure damage to be published in May 2014.
How will progress be monitored and reported?
Progress will be monitored through quarterly reports to the Patient Care Executive.
 Priority Two
Clinical Effectiveness and Patient Experience
Priority Two: The Palliative Care Co-ordination Centre (PCCC) will be used
to recall of equipment from patients’ homes when it is no longer required.

Patients require equipment to support care when they are at home,
examples include mattresses to prevent pressure damage, commodes and
hospital type beds.

When the patient dies this equipment is no longer required and families
want the equipment removed as soon as possible; particularly when the
equipment is in the main living areas.

It is currently the community nurse responsibility to initiate the collection of
equipment.

The Palliative Care Co-ordination Centre is already notified of the death of
a patient and has mechanisms for ensuring a variety of agencies are
notified in a timely manner.
7
How was the priority identified?
This priority was identified by community nursing staff as a way of reducing their
work load. In addition as a health community we had received feed back from
carers’ representatives that there were delays in collecting equipment and that this
caused distress to family. Our Hospice at Home staff, who are not able to recall
equipment, had also received calls and observed equipment being dismantled and
stored in garages.
How will priority two be achieved?
This priority will be achieved by working with Lincolnshire Community Health
Services Trust (LCHST) and Nottinghamshire Rehab Services (NRS) and from
Lincolnshire Community Services. Agreement has already been gained from
commissioners with regard to this priority.
How will progress be monitored and reported?
Progress will be monitored through quarterly reports to the Patient Care Executive.
 Priority Three
Patient Experience
Priority Three: St Barnabas will support the Lincolnshire West CCG in
developing a mechanism for gaining feed back from patients and carers
who may find it hard to have their voices heard.

The importance of volunteer input in gaining feedback from patients and
carers was identified during the Real Time Reporting project undertaken in
Lincolnshire in 2012 /13 and led by Help the Hospices, the National End of
Life Care Programme and Marie Curie.

Training will be provided to volunteers before they interview patients and
carers in their own homes, in hospital and in other care settings.

The focus of the volunteers’ work will be on those patients and carers who
may find it hard to have their voice heard in other circumstances, for
example they may have a sensory deficit that makes attending focus
groups or completing paper based or electronic surveys difficult.

The informal, semi-structured interviews will be based on the 11 themes
within the National VOICES survey to elicit key information that will be
used to develop services across the health and social care community that
improve clinical effectiveness and patient and carer experience.
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How was the priority identified?
This priority was identified by a carer working with the Palliative Care Strategy
Group.
How will priority three be achieved?
This priority will be achieved by St Barnabas recruiting, training and mentoring
volunteers to undertake this work. The volunteers will be co-ordinated by a
member of staff from the CCG to maintain patient confidentiality. Volunteers will
be asked to visit the patient or carer and complete an informal, semi-structured
interview and record the responses. Volunteers will be involved in the design
process.
How will progress be monitored and reported?
Progress will be monitored through quarterly reports to the Patient Care Executive.
1b. Priorities for Improvement 2013 – 2014
 Priority One
Patient Safety, Clinical Effectiveness and Patient Experience

Priority
One: The development of robust operational polices to support the

care
of
patients in secure/locked settings, including prisons and mental

health
units by Hospice at Home staff. To ensure the delivery of safe and

effective
care for patients and support to staff within these settings that will

reduce
inappropriate admission to hospital for the patient.


An ageing prison population means that more people with palliative and
end of life needs will need to be cared for within the criminal justice
system.

Patients with mental health care needs who require care within a secure
setting may also have physical health needs that require palliative and end
of life care. These patients may be required to, or may choose to, remain
in a ward where they have lived for some time and where they know staff
and staff know them.

In both settings end of life care is not common and therefore staff have
little experience and limited opportunities to develop their skills and
competence in palliative and end of life care.
9

During the year the Trust has received referrals from both Lincolnshire
Partnership Foundation Trust (LPfT) and the criminal justice system.
Although the number of referrals has been small they have enabled us to
ensure that a robust mechanism has been put in place to ensure patients
receive appropriate care and LPfT and prison staff have access to advice
and support whilst maintaining safety.

A meeting with staff from HM North Sea Camp enabled us develop an
effective system for referral and ongoing support for any person identified as
requiring palliative care.

Gold Standards Framework (GSF) meetings were instigated to support the
identification and care of those with palliative care needs.

A mechanism for referral to the Hospice at Home team has been agreed
including appropriate risk assessments..

As can be anticipated referrals from these services are sporadic. Nursing
staff from LPfT have attended training delivered by St Barnabas education
facilitator supported by a variety of medical and nursing staff from the
organisation. These have evaluated extremely well.

In addition we have been working to support homeless people at the end of
life, working with staff from LPfT, the YMCA and NOMAD Trust to identify
and provide monthly in reach support to patients with palliative and end of
life care needs.

Five “easy read” leaflets have been created, collaboratively, to advise nonclinical staff and the homeless community, in simple language, the nature of
and how they might try to manage the most common illnesses, these
included:- Heart failure, Respiratory Diseases, Liver failure, Diabetes and
Korsakoff’s Syndrome.

Referrals to day therapy and hospice at home services have been received
as a result. The first patient who attended day therapy said:
“I was in a very bad place and needed XXX to get everything set up. I
wanted to do it but it made me very nervous and I was scared of
mixing with “normal” people and what the nurses might think of me. I
was worried about letting people down because mornings are always
bad for me. Everyone has been so nice to me and I like coming for the
sessions. I have a flat now but I do get lonely so talking is good for me,
even when I don’t think I feel like it. It has meant a lot to me, I feel like
fundraising for them myself”
10
Priority Two
Clinical Effectiveness and Patient Experience

Priority
Two: Identify, and embed into practice, a small range of patient

reported
outcome measures that assess, from the patient’s perspective, the

effectiveness
of medical and nursing interventions and the outcomes of

care
 for the patient.

  The effective measurement of the outcomes of care and treatment are vital
for the continuous improvement of services and the delivery of care.


  The patient is the only person who can measure the difference that care
has made to their symptoms, be that physical or emotional.


 Effective measurement of outcomes enables staff to review care, be that

programmes of care in the Day Therapy service, or individual symptom

management within the Inpatient Unit.

  Effective outcome measures facilitate communication between patients
 The
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andappointment
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has
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their care.
clinical work is focused on the day therapy service where they

The Specialist Nurse Practitioners (SNPs) have initially developed a preassessment questionnaire that is completed by the patient prior to an
holistic assessment being undertaken by a nurse. This document facilitates
communication between the patients and the staff, enables staff to focus on
the issues that are of greatest importance to the patient and also supports
the patient to be in control of, and a partner in, their care.

The pre-assessment questionnaire uses a range of outcome measures to
quantify the patient’s needs. These outcome measures will then be used to
monitor the effectiveness of the programme of treatment at review meetings.

As an adjunct to this work, discussions have also taken place with noncancer nurse specialists to support these developments. It was recognised
that referrals to palliative care services might be improved if tools used to
make it easier to identify frail patients was included within the referral
process. The Responsive Need Tool (RNT), a tool that facilitates
communication of both level of need and urgency, and commonly used
within the county, has been revised with the aim of reflecting the agreed
frailty score. This work continues and is to be piloted in May before being
11
ratified and incorporated with other work including the electronic patient
register.

Looking to the future, St Barnabas hopes to participate in the pilot of an
outcome measure developed by Help the Hospices and St Christopher’s .
Priority Three
Patient Experience and Clinical Effectiveness
Priority
Three: The development of a fully refurbished six-bedded unit at

Grantham
District Hospital to provide a ‘Hospice within a Hospital’. This

development
will be provided in partnership with United Lincolnshire

Hospitals
Trust
(ULHT).


  The need for six local palliative care beds covering Grantham and the
surrounding area was identified as long ago as 2009. NHS Lincolnshire

were unable to procure the beds through a tendering process.


 The aim of this service is to provide local palliative care inpatient facilities

for patients who, whilst requiring an inpatient stay, do not require the

consultant led, specialist palliative care available in Lincoln.

  This means that patients will be able to receive inpatient care whilst

remaining closer to home.

  The beds will be provided in a separate, fully refurbished, ward within

Grantham and District hospital. There are two reasons for developing the

service in this way:

o A stand alone unit of six beds is not cost effective and is not financially
viable.
o The service has been designed to enable staff to in-reach into the
hospital to better support the palliative care needs of patients on other
wards, so improving palliative care throughout the hospital.

The beds will serve as a catalyst for the wider review of palliative care
pathways across the locality to ensure that more patients achieve their
preferred place of care and death.
12
The extension and refurbishment of the ward at Grantham Hospital to develop
the new unit started at the beginning of January 2014 following a period of
remediation on the original building. The work continues and can be viewed on
the St Barnabas website:
http://www.stbarnabashospice.co.uk/Page/92/hospice-within-a-hospital

An artist’s impression of the unit can be seen below.

The interior design of the building, led by the project manager, has included
input from patients and their families, hospice volunteers, staff and the
general public, using the principles of the King’s Fund Enhancing the
Healing Environment.

One of the key aims is to create an independent clinical facility, that is warm,
welcoming and provides a homely feel whilst at the same time being
compliant with infection control requirements.

Access to the unit will be through its own front door off the main hospital
corridor and this will have a distinctively different external appearance to
other wards in the Hospital. We want people to feel the difference as soon
as they approach the unit and walk through the door.

The bedrooms will be extended to create a personal space along the lines of
a sun room that can be used by patients all year round. The design of this
garden area will create the opportunity for patients who are unable to get out
of bed to be able to enjoy the garden space and will have the effect of
"bringing the outside in".
13

There will be a number of communal areas which have been designed to be
used flexibly to meet the needs of patients, carers and the clinical team.
There will also be treatment rooms and facilities for the clinical team.

There will be a relatives’ room with en-suite facilities so that families/carers
can take a break without being too far away from their loved one. The
provision of private space will also mean that when patients are dying,
families and carers are not exposed to having to contain their emotions due
to being in more public areas.

Our ambition is to provide a unit that as suggested by one of our patients is
"welcoming and smart -- but not too posh!" and we are confident that we will
meet this ambition.

Through careful design with the provision of individual rooms, we will be
able to provide a more inclusive service and support patients whose
illnesses are complicated by other factors such as dementia, the needs of
young adults and children etc. and for whom the current service provision is
far from ideal.

The building work is due to be finished in the late summer and once
commissioning and deep cleaning have been completed the first patients
will be admitted.

Prior to the admission of the first patient there will be open days to enable
staff and the general public an opportunity to see the building without
adversely impacting on patients.

In parallel work is ongoing to develop the clinical policies and procedures for
the unit. The aim is to ensure that we capitalise on the skills of partner
organisations to ensure that we are able to provide the widest range of
interventions and avoid moving patients into acute care wherever possible.

The policies will also support the delivery of the quality objectives of the unit:
Patient Experience
Patients, and their families, who are approaching the end of life or requiring
palliative care will:


feel confident that professionals will offer opportunities for end of life
care discussions in a timely, informed and sensitive manner in order to
decrease fear of the unknown and to enable people to retain a sense of
control over their last days and weeks and months of life.
have equitable access to services that can effectively meet their needs
and improve quality of life.
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




be treated with dignity and respect and to feel supported by well
coordinated and responsive services that provide an excellent standard
of care.
have access to information and professionals with expertise to support
difficult decision-making.
have access to services that provide spiritual, psychological, social and
physical support irrespective of ethnicity, religion, culture or sexuality.
experience a peaceful, dignified death.
be able to access information and support in bereavement.
Clinical Effectiveness

Integrated service providing palliative care and care at the end of life
incorporating NICE guidance and with the full involvement of patients
and carers, use of end of life tools, the Gold Standard Framework and
the preferred priorities of care.
Patient Safety

Patient safety will be maintained throughout their admission through:
o the establishment of a service with safe staffing levels and
patients being admitted to the right bed in a timely manner
o the development of a robust process incorporating NICE guidance
and using end of life tools, such as the Gold Standard Framework
and the preferred priorities of care will be employed throughout the
patient’s stay.
o the development of a model of care which identifies the patient
pathway and the actions required should their condition change, and
the roles and responsibilities of members of the clinical team
o the development of a training programme to address the identified
training needs of the nursing team
o regular patient/carer questionnaires and surveys and the
development of plans to address concerns
o the provision of clinical advice from the St Barnabas In-patient unit
and community based palliative care nursing service
o the provision of emergency medical support from ULHT medical
teams
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2.
STATEMENT OF ASSURANCE FROM THE BOARD
The following are statements that all providers must include in their Quality
Account. Many of these statements are not directly applicable to specialist
palliative care providers, and therefore explanations of what these statements
mean are also given.
2a.
Review of Services
During 2013/14 St Barnabas Lincolnshire Hospice supported the Lincolnshire’s
four NHS Clinical Commissioning Group priorities with regard to the provision of
local specialist palliative care by providing the following services:
o
o
o
o
Hospice at Home
Inpatient Unit
Welfare Benefits
Palliative Care Co-ordination Centre
In addition the Trust has provided the following services through charitable funding:
o
o
o
o
o
Day Hospice
Occupational Therapy
Physiotherapy
Lymphoedema
Family Support Services, including bereavement support services
During the reporting period 2013/14 St Barnabas Lincolnshire Hospice provided
three NHS services. St Barnabas Lincolnshire Hospice has reviewed all the data
available to them on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in 2013/14 represents
63 percent of the total income generated from the provision of NHS services by
St Barnabas Lincolnshire Hospice for 2013/14.
What this means:
St Barnabas Lincolnshire Hospice receives NHS funding, through the National
Community Contract, for the Hospice at Home service and Palliative Care Coordination Centre and partial funding for the Inpatient unit and Welfare
services. The Trust also has a small contract with Lincolnshire County Council
for the provision of community Occupational Therapy services. The remaining
income, to support the delivery of Day Therapy, Occupational and
Physiotherapy and the Lymphoedema service, Family Support Services,
including bereavement, is generated through fundraising, shops and lottery
activity and investment income.
16
2b.
Participation in Clinical Audit
 During 2013/14 no national clinical audits or confidential enquiries
covered NHS services provided by St Barnabas Lincolnshire Hospice.
 During that period St Barnabas Lincolnshire Hospice participated in no
national clinical audits and no confidential enquiries as it was not eligible
to participate in any.
 The national clinical audits and national confidential enquiries that
St Barnabas Lincolnshire Hospice was eligible to participate in during
2013/14 are as follows: NONE
 The national clinical audits and national confidential enquiries that
St Barnabas Lincolnshire Hospice participated in during 2013/14 are as
follows: Not applicable
 The national clinical audits and national confidential enquiries that
St Barnabas Lincolnshire Hospice participated in and for which data
collection was completed during 2013/14 are listed below alongside the
number of cases submitted to each audit or enquiry as a percentage of
the number of registered cases required by the terms of that audit or
enquiry. Not applicable
 The reports of no national clinical audits were reviewed by the provider in
2012/13. This is because there were no national clinical audits relevant
to the work of St Barnabas Lincolnshire Hospice.
 St Barnabas Lincolnshire Hospice was not eligible in 2012/13 to
participate in any national clinical audits or national confidential enquiries
and therefore there is no information to submit.
17
2c.
Research
The number of patients receiving NHS services provided or sub-contracted by
St Barnabas Lincolnshire Hospice in 2013/14 that were recruited during that period
to participate in research approved by a research ethics committee was NONE.
What this means:
As a provider of specialist palliative care St Barnabas Lincolnshire Hospice is not
eligible to participate in any of the national clinical audits or national confidential
enquiries. This is because none of the 2013/14 audits or enquiries related to
specialist palliative care in settings other than acute care and were therefore not
relevant.
Despite not being eligible we do monitor the work we do, undertaking audits and
patient and carer surveys. The results of our audits and patient and carer
surveys can be found further on in this report.
The Hospice will also not be eligible to take part in any national audit or
confidential enquiry in 2014/15 for the same reason.
What the Hospice has done.
In the last year the organisation has developed and implemented a new research
policy and undertaken a staff survey on the topic of research. The results of this
survey are being fed back to staff through governance roadshows across the
county.
Our consultant research lead, working with United Lincolnshire Hospitals Trust,
has gained agreement from both organisations to take part in the IMPACCT
multicentre trial (led by the University of Leeds). Recruitment to this trial has
commenced and will continue until the end of June. Patients accessing the day
therapy service in Lincoln, who meet the criteria for the study, will be offered the
opportunity to participate. In addition the consultant continues to link into the
Trent cancer local research network priority group for palliative care.
2d.
Use of the CQUIN Payment Framework
A proportion of St Barnabas Lincolnshire Hospice income in 2013/14 was
conditional on achieving quality improvement and innovation goals agreed between
St Barnabas Lincolnshire Hospice 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.
18
Further details of the agreed goals for 2013/14 CQUIN payments and for the
following 12 month period 2014/15 are available electronically at
www.stbarnabashospice.co.uk .
2e.
Statement from the Care Quality Commission (CQC)
St Barnabas Lincolnshire Hospice is required to register with the Care Quality
Commission and is currently registered to carry out the regulated activity:
Treatment of disease, disorder or injury.
“St Barnabas Lincolnshire Hospice has the following conditions on registration:

The registered provider must ensure that the regulated activity, ‘treatment for
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 a Specialist Palliative Care
Unit.”
Statement of reasons
The registration of the provider of this regulated activity is subject to a registered
manager condition under Regulation 5 of the Care Quality Commission
(Registration) Regulations 200.

The Registered Provider must only accommodate a maximum of 11 patients at
Specialist Palliative Care Unit.
Statement of reasons
We are imposing this condition because your service is set up to accommodate 11
persons. The premises, management or staffing provided at this location are
suitable only for a maximum of 11persons.

The Registered Provider must not treat persons under 18 years in respect of
the regulated activity 'Treatment for disorder or injury' at or from Specialist
Palliative Care Unit.
Statement of reasons
We are imposing this condition because your service is set up to accommodate
persons aged 18 years or over. The premises, management or staffing provided at
this location are suitable only for persons aged 18 years or over.
This Regulated Activity may only be carried on at the following locations:
Specialist Palliative Care Unit, 36 Nettleham Road, Lincoln, LN2 1RE
The Care Quality Commission has not taken any enforcement action against St
Barnabas Lincolnshire Hospice during 2013/14.
19
St Barnabas Lincolnshire Hospice has not participated in any special reviews or
investigations by the Care Quality Commission during 2013/14.
The Care Quality Commission made an unannounced inspection on 10th January
2014. The report is available on the CQC website www.cqc.org.uk/directory/1140658893
and
also
on
the
St
Barnabas
Hospice
website
www.stbarnabashospice.co.uk.
2f.
Data Quality
Statement of relevance of Data Quality and your actions to improve your Data
Quality.
St Barnabas Lincolnshire Hospice did not submit records during 2013/14 to the
Secondary Users service for inclusion in the Hospital Episode Statistics which are
included in the latest published data.
Why is this?
This is because St Barnabas Lincolnshire Hospice is not eligible to participate in
this scheme. However, in the absence of this we have our own system in place
for monitoring the quality of data and the use of the electronic patient information
system, SystmOne. This is important because, with the patients’ consent, we
share data with other health professionals to support the care of patients in the
community.
What have we done?
This year the Trust data analyst has reviewed the inputting of specific
information required for the Minimum Data Set (MDS) to ensure accuracy of
information. To support this we are developing an action plan and audit
process.
2g.
Information Governance Toolkit Attainment Levels
St Barnabas Lincolnshire Hospice Information Governance Assessment Report
score for 2013/14 was:





Level 0 - 0%;
Level 1 - 0%;
Level 2 - 87%;
Level 3 - 10%;
Not Relevant – 3%
20
This means that we have attained 100% Level 2 or above compliance, which is the
requirement for any organisation to access the NHS’s network. Organisations are
graded either satisfactory or unsatisfactory.
St Barnabas Lincolnshire Hospice
Prepared on 08/04/2014
Assessment
Level
0
Level
1
Level
2
Level
3
Not
Relevant
Total
Req'ts
Overall
Score
Grade
Version 11
(2013-2014)
0
0
25
3
1
29
70%
Satisfactory
Fig 4.Table IG Toolkit Assessment Summary Report
Fig 5. Breakdown of Attainment Level for IG Toolkit Version 11
What this means.
Organisations are graded either satisfactory or unsatisfactory.
St Barnabas Trust was graded as ‘satisfactory’ and meets all of the Connecting
for Health standards. This provides patients with the confidence that their
information is being dealt with safely.
21
2h.
Clinical Coding Error Rate
St Barnabas Lincolnshire Hospice was not subject to the Payment by Results
clinical coding audit during 2013/14 by the Audit Commission. This is because
St Barnabas Hospice receives payment under a block contract and not through
tariff and therefore clinical coding is not relevant.
22
Part 3: Review of Quality Performance
The National Council for Palliative Care (NCPC): Minimum Data Sets (MDS)
We have chosen to present information from the NCPC minimum data set which is
the only information collected nationally on hospice activity. The figures below
provide information on the activity and outcomes of care for patients.
Hospice Inpatient Unit
St Barnabas Lincolnshire Hospice
Specialist Inpatient Unit Services
2011/12
Total number of patients
183
% New patients
92%
% Re-referred patients
3%
% Admissions from
69%
patient’s own home
% Admission from acute
30%
hospital
% Occupancy
83%
% Patients discharged to
45%
their home
Average length of stay –
17 days
cancer
Average length of stay –
13 days
non-cancer
2012/13
190
93%
5%
2013/14
183
93%
4%
60%
56%
36%
44%
74%
81%
41%
30%
15 days
17 days
24 days
12 days
There has been a significant increase in the number of patients transferred from
acute hospital.
‘Thank you from the bottom of our hearts for giving xxx the
dearest, kindest farewell’
‘The cooks go out of their way to source and cook excellent
quality food’.
‘After half a day with you, my husband said that he felt he
never wanted to leave’.
23
Specialist Outpatient Service
Specialist Palliative Care Outpatients
2011/12
Total number of patients
239
% New patients
90%
% Re-referred patients
0
% Continuing patients
10%
2012/13
348
91%
1%
9%
2013/14
314
90%
0.3%
10%
The Outpatients data is non comparable with previous years where ‘Hospital
Contact/Support’ was more informal and therefore included with the Outpatient
(Advice/Consultation) data.
In 2013/14 the hospital support increased with the three consultants and the data
now sits within the Hospital Support section below.
Specialist Palliative Care Hospital Support
2011/12
Total number of patients
% New patients
% Re-referred patients
% Continuing patients
2012/13
2013/14
317
100%
0%
0%
2011/12
625
67%
2.5%
2012/13
944
63%
5%
2013/14
1736
60%
4%
36%
30%
8%
11%
218 days
131 days
132 days
Day Therapy
Day Hospice
Total number of patients
% New patients
% Re-referred patients
% continuing patients
% of places booked but not
used
Average length of care
24
There has been an increase of 83% in the number of patients accessing the Day
Therapy service during the year. Over the last two years there has been a 177%
increase in patients accessing the service. The change to the model of care, from
day care to day therapy has provided a more attractive service for younger people
without reducing access for older patients.
“Came to see occupational therapist-very good.
Nurses nice and welcoming too.”
“The day centre is a positive part of being ill.”
Complementary Therapy - “Great shame it’s ended. It’s the highlight of my
week.”
Hospice at Home
Hospice at Home
2011/12
2012/13
2013/14
Total number of patients
1545
1640
1851
% New patients
85%
85%
85%
% Re-referred patients
% of patients who died at
home
% of patients who died in
acute hospital
5.5%
5.2%
7%
79%
79%
86%
9%
9%
7%
40 days
43 days
44 days
Average length of care
The Hospice at Home service has seen an increase of 13% on the number of
patients accessing the service. The number of patients achieving their preferred
place of care is 92% with 86% dying at home. This represents an increase of 6%
and 7% respectively on the previous year.
“The care and support that your team gave us made a dreadful
situation a lot easier.”
“I cannot praise the staff enough; they made the whole experience
a good one.”
“Sincere thanks for the excellent care and compassion you
showed to dad in his last days.”
25
Welfare Benefits Service
Welfare Benefits Service
2011/12
2012/13
2013/14
Total Clients
2837
3212
3667
New Clients
1979
1842
1960
Re-referred Clients
588
1370
1707
£5,426,965.68
£6,483,581.68
£6,956,128
Total money claimed on
behalf of clients
There has been an increase of 14% in the number of people accessing the Welfare
benefits service. The monetary gains have also increased but, due to changes in
the welfare benefits system, are not as great as would be expected from the
increased activity. The table below shows the reduction in the average monetary
gain per person for 2013/14 compared to the previous year.
‘They are absolutely excellent’
Monetary Gain
April 2012 - March 2013
April 2013 - March 2014
Total Number Of
Patient Referrals
Total Annual Cash
Gained
Average Per
Patient
3212
3667
£6,483,581
£6,956,128
£2,018.55
£1,896.95
The average reduction is £121.60 or 6% of the patients’ benefits. This service has
become even more vital as the changes in the welfare benefits have impacted on
palliative care patients. This is reflected in the increase in the number of
re-referrals to the service.
Quality Markers We Have Chosen To Measure
In addition to the limited number of suitable quality measures in the national data
set for palliative care, we have chosen to measure our performance against the
following:
INDICATOR
2011/12
Complaints
Total number of complaints (clinical)
6
2012/13
2013/14
7
9
The number of complaints upheld in full
1
2
3
The number of complaints upheld in part
2
5
1
26
The number of complaints not upheld
3
0
5
Three upheld clinical complaints related to:



Verbal complaint regarding having to wait for help back into bed
Complaint regarding attitude of a member of staff
Patient unhappy with service provided by Family Support Services for
herself and her husband. Failed contacts as planned
One partially upheld complaint related to:

Constructive criticism regarding a variety of aspects of care from a patient’s
relative following admission to the Inpatient Unit.
INDICATOR
2011/12
Patient Safety Incidents
The number of serious patient safety incidents
1
(excluding falls)
2012/13
2013/14
0
0
The number of slips, trips and falls
37
35
32
The number of patients who experienced a
fracture or other serious injury as a result of a
fall.
0
0
0
36
42
55
39
43
41
Number of patients admitted to the Inpatient Unit
with pressure damage
Number of patients who developed pressure
damage whilst in the Inpatient Unit
Pressure damage that developed on the unit was grade 1 and 2. Documentation
indicated all measures to minimise damage were undertaken. The Trust is currently
leading the development of a palliative care pressure damage prevention pathway
across both health and social care.
INDICATOR
Patient Safety
Number of patients, clients and families referred
to Family Support Services because of
safeguarding issues
The number of patients know to be infected with
MRSA on admission to the Inpatient Unit
The number of patients infected with MRSA
whilst on the Inpatient Unit
The number of patients with MRSA bacteraemia
2011/12
2012/13
2013/14
11
16
38
1
0
1
1
0
0
0
0
0
27
The number of patients admitted to the Inpatient
Unit with C. difficile
The number of patients infected with C. difficile
whilst in the Inpatient Unit
1
0
0
0
0
0
The number of patients known to be infected with
an alert organism for example, Staph aureus,
Pseudomonas aeruginosa, ESBL, Klebsiella,
and Streptococcus pneumoniae on admission
10
6
3
The number of patients who contracted any of
these infections whilst in the Inpatient Unit
1
4
3
28
Clinical Audit
Clinical audit is a way in which the organisation can learn and improve the delivery
of its services, the outcomes for patients and the experience they have. The Audit
group has undertaken a programme of audits using national audit tools designed
specifically for hospices.
Patient and relative surveys are also administered to all patients/relatives (as
appropriate) admitted to the Inpatient Unit. The survey reflects the Care Quality
Commission outcomes from the Essential Standards. Clinical staff continue to be
involved in the audit work with a number of staff participating in infection control
and syringe driver audits. The table on the following pages shows the work
undertaken in 2013/14.
Where issues are identified during an audit, an action plan is developed to put the
problems right. Progress on the action plans is monitored through the Clinical
Governance Group to ensure that they are completed. We will then undertake a
further audit to see if the actions we have taken have resolved the issues identified.
Medicines Managements Audits
(including controlled drugs which are now completed quarterly as a requirement by the Local Intelligent
Network Group)
Completed
Audit
Action
Actions to be taken
Action Plan
Plan
to improve practice
Status
Controlled
May
Yes
Working issues regarding some elements of Completed.
Drugs Re-audit
2013
recording within Controlled Drug documentation to
be addressed via briefing sessions for the nursing Regular
staff.
monitoring of
Increased monitoring of the Controlled Drug Register
Register.
implemented.
Medical staff signature list to be updated.
Discharge TTO
Audit
(medicines to
take home)
May
2013
Yes
Expenditure on
opioids
Q3 2011
Q42012
May
2013
No
formal
action
plan
Medical
Gases(Oxygen)
re-audit
May
2013
Yes
Consolidation and plan for electronic format for Nearing
discharge medication.
completion
The importance of accurate discharge
documentation to be reinforced to the Team.
Recommendation to review costs of opioids 6
monthly and to report any exceptional excess N/A
expenditure to the Trust at various levels as
appropriate.
Training in the use of oxygen therapy and non Completed
rebreathing masks for nursing and medical staff to
be implemented.
Reminder to use oxygen indicator cylinder labels
and change to colour of oxygen cylinders.
29
Audit
Completed
Electronic
remote direction
to administer
June
2013
Anticoagulation
June
2013
Controlled
Drugs
(selected
elements)
The
Management of
Blood
Transfusions
within the
Inpatient Unit
August
2013
Sept
2013
Action
Plan
Yes
Yes
Yes
Completed
Key elements
completed.
Remainder of
actions are in
progress.
Re-audit of
forms 2014
Completed
Completed
Nov
2013
No
formal
action
plan
The use of
Fentanyl PRN
products for
breakthrough
cancer pain
Nov
2013
Yes
Nov
2013
Action Plan
Status
Yes
Management of
Controlled
Drugs &
Accountable
Officer
Medical
Gases(Oxygen)
Re-audit
Actions to be taken
to improve practice
Remind staff that identification labels must be
attached to the remote prescriptions, and training
regarding printing of prescriptions.
Medical staff to be reminded to add date and time
when transcribing.
Instruction sheet to be displayed in a more
prominent position.
Convene a meeting of medical staff to consider
barriers to completion of the forms and improve
compliance with their completion.
Revise layout of forms; review and revise
anticoagulation guidelines.
Establish cost benefit of the purchase of a hoist
weighing attachment.
Controlled Drugs register to include a specific
column to document the form of the drug.
Yes
Revise blood transfusion care plan to include
patient consent and confirmation of administration
line change if required.
Further training re: completion of fluid balance
charts.
Team to be reminded of the correct procedure for Regular
managing corrections within the Controlled Drug monitoring of
Register.
the Register
ensures that
issues are
addressed in a
timely manner.
Training sessions re: titration and pain evaluations
Training
for nursing staff.
sessions in
Prompts for patients to be provided to avoid delay
process of
of a second breakthrough dose of medication if
being
required.
arranged.
Display titration information prominently.
Information
displayed.
Ensure oxygen cylinder status labels are available
and that they are used.
Amend ‘Fridge & Oxygen’ Check list.
Display instruction for use of non-rebreathe masks
next to the emergency oxygen cylinder
Update staff on the use of the Oxygen Patient
Group Direction (PGD).
Completed.
Laminated
information for
staff regarding
PGD on
display in ward.
30
Audit
Completed
Medication
Incidents within
the Inpatient
Unit
Nov
2013
General
Medicines
Dec
2013
Controlled
Drugs
(Selected
elements)
Feb
2014
Action
Plan
Yes
No
formal
action
plan
Yes
Actions to be taken
to improve practice
Improve the accuracy of reporting and managing
incidents and ensuring feedback to relatives as
appropriate.
Update mentorship skills of Trust staff to support
new employees.
Medicines management to be closely monitored by
Ward Manager and Deputies.
Patient drug requisition forms to be adapted to
strengthen the receipt documentation process.
Reminder to medical team to include form of
medication.
Remind staff of the correct procedure for amending
documentation.
Remind staff to adhere to their recognised
signature.
Action Plan
Status
Planning to
deliver training
by December
2014.
N/A
Completed
Additional Audits
Audit
Hazard Alerts
Palliative Care
Co-ordination
Centre; Audit of
telephone
contact with 6
identified care
homes.
Welfare;
Customer
satisfaction and
accuracy of
documentation
Complementary
Therapy
Documentation
Hospice at
Home “Unable
to Gain Access
Visits”
evaluation
Completed
Action
Plan
Jan-June
2013
N/A
No specific issues identified.
N/A
May
2013
N/A
No significant issues identified.
N/A
May-July
2013
No
formal
action
plan
Feedback to team via newsletter
N/A
July
2013
Yes
Actions to be taken
to improve practice
Action Plan
Status
Provide a consistent treatment sheet format for all
bases and update staff regarding corrections to
documentation.
Completed
Adjust forms to reflect whether after care advice has
been given to patients.
Process map daily structure of visits within teams
August
2013
Yes
Completed
Re-audit
February
2014
31
Completed
Action
Plan
Nutrition and
Hydration
Service
Evaluation
(including
documentation
review and
questioning of
staff)
August
2013
Yes
Hygiene Code
August
2013
Yes
Strengthen risk assessment format and reinforce to
staff to implement appropriate care plan.
Review key policies to reflect effective
communication between all teams.
Clinical on Call
Manager
Procedure
August
2013
Yes
Hazard Alerts
July to
Dec
2013
Yes
Day Therapy;
Assessment of
the
documentation
check list for
SystmOne
January
2014
Yes
Develop an electronic system for recording calls and
responses.
Review policy and disseminate new processes to
staff.
Review system for receiving and managing alerts at
the weekends
Review the system for responding to Estate &
Facilities Notification Alerts to strengthen the audit
trail.
Training on an individual basis regarding
documentation standards to be delivered to team
members by the Specialist nurse practitioners.
Day Therapy;
Documentation
regarding
Advance Care
Planning and
Advance
Decision to
Refuse
Treatment
Mattress Audit
including Static
and Specialist
Pressure
Relieving
Mattresses
(Dynamic)
January
2014
Yes
Ensure that staff set a date to review individual
advance care plans.
Training to be delivered on an individual basis to
staff on the completion of Advance Direction to
Refuse Treatment documentation.
Training
being
delivered as
part of
individual
reviews
February
2014
Yes
Action required regarding mattresses and covers not
attaining the accepted standard.
Completed.
Audit
Actions to be taken
to improve practice
Action Plan
Status
Develop a Trust Wide Nutrition & Hydration Policy.
Deferred.
Re-establish the Nutrition Group and develop the
Nutrition Link Nurse Role.
Review and simplify nutritional documentation.
Completed
Completed.
Completed
Completed
Training
being
delivered as
part of
individual
reviews
32
Audit
Completed
Infection Prevention and Control Audits
Action
Actions to be taken to improve practice
Plan
Action
Plan
Status
Isolation
precautions
within the
Inpatient Unit
Sept
2013
Yes
Management of
Waste within
the Inpatient
Unit
Oct
2013
Yes
Sluice
Mgt of sharps
within the
Inpatient Unit
Inpatient Unit &
Day Therapy
Lincoln;
External
Infection Prev
Audit
Jan 2014
February
2014
N/A
N/A
March
2014
Yes;
for
both
bases
Reminder to staff the importance of cleaning
Completed
equipment and it’s subsequent labelling.
Update bin labels
Review management of hoist slings.
Improve documentation regarding visual infusion
phlebitis forms.
Hand hygiene
Ongoing
Trust wide
Ongoing
Trust wide
No
Issues addressed as appropriate.
N/A
Yes
Issues addressed as appropriate
N/A
Audit
Completed
Action
Plan
Patient
Nutritional
SurveysInpatient Unit
Complementary
Therapy
Service Patient
Evaluation
Survey
Patient Survey
(Inpatient Unit)
April 2013 to
March 2014
Relatives
Survey
(Inpatient Unit)
April 2013 to
March 2014
June to
December
2013
N/A
Minor issues addressed during survey period.
Surveys to be reviewed and questions updated by the
Nutrition Group- May2014
December
2013
No
formal
action
plan
Feedback results to staff.
Evaluation forms reviewed and updated.
N/A
April 2014 Yes
Responses and actions compiled by the IPU Ward
Manager and added to survey reports.
April 2014
Responses and actions compiled by the IPU Ward
Manager and added to survey reports.
Issues
addressed
as they
arise
Issues
addressed
as they
arise
Cleanliness
Implement a check list for volunteers to remind them of
their responsibilities regarding care of patients who are
Completed
isolated.
Remind staff to supply patients, who are to be isolated,
with an information leaflet in addition to verbal
information.
Clarify legislative guidance regarding waste storage
Completed
compounds.
Provide guidance for management of paper waste.
Provide a receptacle for volunteers to dispose of
handover slips.
Replace first aid kits and order plastic covers for
disposal of contaminated mattresses.
Minor working issues only
N/A
Practice confirmed as safe and compliant with policy.
N/A
Patient and Relative Surveys
Yes
Actions to be taken to improve practice
Action
Plan
Status
N/A
33
Feedback from Patients and Families on Services
We value the feedback we receive from patients and families as this is an
important way in which staff can identify and resolve problems and improve the
quality of the care we provide. We are always looking for new ways to receive
feedback.
This year, in addition to the survey we give to all patients discharged from the
Inpatient Unit or send a survey to the family of patients who die on the unit, we
have used new methods of collecting feedback.
Friends and Family Test
As part of a national programme acute hospitals and some hospice inpatient units
have asked patients if they would recommend the service they provide to their
friends and family.
All of the patients we asked said they would recommend our service to their
friends and family.
The table below shows the results we achieved each month throughout the year.
Inpatient Unit
Data
Inpatient
Discharges
Responses <48hrs
Promoters
Passive
Detractors
NP Score
Sample Size
Apr 13
May 13
June 13
July 13
Aug 13
Sept 13
8
4
1
7
4
5
8
8
0
0
100
100%
4
4
0
0
100
100%
1
1
0
0
100
100%
7
7
0
0
100
100%
4
4
0
0
100
100%
5
5
0
0
100
100%
Data
Inpatient
Discharges
Responses <48hrs
Promoters
Passive
Detractors
NP Score
Sample Size
Oct 13
Nov 13
Dec 13
3
5
5
Jan 14
3
Feb 14
5
Mar 14
5
3
3
0
0
100
100%
5
5
0
0
100
100%
5
5
0
0
100
100%
2
2
0
0
100.00
66.67%
5
5
0
0
100.00
100%
4
4
0
0
100.00
80.00%
34
Day Therapy
Data
Inpatient
Discharges
Responses
<48hrs
Promoters
Passive
Detractors
NP Score
Sample Size
Apr13
Data
Inpatient
Discharges
Responses
<48hrs
Promoters
Passive
Detractors
NP Score
Sample Size
Oct 13
6
May13
Nov 13
5
June13
Dec13
11
July13
8
Aug13
3
Sept13
3
7
2
0
6
1
0
86%
88%
2
0
0
100%
67%
0
0
0
0%
0%
Jan 14
Feb 14
Mar 14
32
24
50
14
11
1
0
0
11
0
0
100%
58%
100%
22%
3
4
4
10
3
0
0
100%
50%
4
0
0
100%
80%
4
0
0
100%
36%
10
0
0
100%
31%
35
It’s the small things …
We continue to receive comments through the “It’s the small things that make a
difference” postcards. We provide them with a postcard which they can send
back to us, identifying the small things that have made a difference to them. This
is another means by which patients, clients, carers and families can feedback to
us.
Below is a selection of comments about the ‘small things’ that made a difference to
our patients during the last year.
Having a contact number
for St Barnabas-was a
lifeline! Caring, sharingnothing too much
trouble-a wonderful
organisation
‘You listened when
no one else would.
And then made
everyone listen to
us. Thank you’
‘Respect, caring
& honest.
Supported all the
family’
‘Gave me
interests and
enjoyment, and
meeting people’
‘Just being there
for me & my
husband. Taking
charge when
needed. Fabulous
care. Thank you’
‘The home care
team contributed
immensely to my
husband comfort &
peacefulness in his
death’
‘Friendship &
understanding’
‘They were kind,
helpful and made it
possible to give
XXX his last wish
to be at home’
36
The Patient Survey
The Patient survey from April 2013 to September 2013 and from October 2013 to
March 2014 had a response rate of 50%.
We asked patients about their care and treatment. We asked the following
questions based on the Care Quality Commission Essential Standards of Quality
and Safety1. In October the format of the survey changed following feedback.
Questions with an * were not asked when the survey was changed – so the results
reflect the answers given to the survey between April and September 2013.
Was your privacy and dignity respected?

95% of patients said ‘yes always’
Was your right to independence respected?

100% of patients said ‘yes always’
Did you feel that the care, treatment and support you were given met your
needs?*

93% of patients said ‘yes always’
Did you feel that the care, treatment and support were delivered in a safe and
effective manner by members of the healthcare team?

100% of patients who responded said ‘yes always’
Did you have confidence and trust and feel safe in the care of the staff
treating you?*

100% of patients said ‘yes always’
How would you rate the Hospice food and drink?*

1
93% of patients rated the food and drink as ‘very good’ or ‘good’
Care Quality Commission (2009) Essential Standards of Quality and Safety
37
Did you feel that the hospice room or ward that you were in was clean?

100% of patients who responded said ‘yes always’
Did you feel safe and comfortable with the equipment used by the staff?*

93% of patients who responded said ‘yes’ (not answered 7%)
We also asked what could be done to develop our services patients said:
(Comments are direct quotes as they appear in the surveys)

‘I think the Hospice is an amazing place. I felt really cared for and very
privileged to be able to stay there’

‘Quite frankly I can’t think how you would improve on St Barnabas. It was
my ‘home from home’. All staff were so caring – wonderful team – would be
difficult to improve. Thank you so much’

‘I was very happy at the Hospice the staff looked after me and supported me
and family members. I would like to say a big thank you to all the staff for
there care’

‘Food absolutely wonderful’
The Relatives’ Survey
The annual Relatives’ Survey from April 2013 to March 2014 had a response rate
of 64%.
When asked what could be done to develop our services, relatives said:
(Comments are direct quotes as they appear in the surveys)

‘I was very pleased how the staff looked after my wife in the short time she
was there.

If, God forbid, I am ever in need of the same care as my dear wife needed I
would wish to go in the same Hospice’

‘Long may you keep up the excellent work!’

‘Unfortunately my husband was gravely ill when transferred to the Hospice
and was only there for three days before he died. The nurses and staff
couldn’t have been more caring and helpful to him, me and my family. It
was a comfort to us all that he was in such a good, caring environment’
38

‘No I could not fault the Hospice at all!’

‘My suggestion is ‘keep up the good work’. Our son and myself were so
grateful for the kindness shown to my husband, and ourselves during the
relevant days. After half a day with you, my husband said that he felt he
never wanted to leave.

You are welcome to use those answers if it is helpful’

‘Every aspect of the service the Hospice offered was superb. My wife felt
calm, comfortable and part of the family of staff who make up your teams.
As did all of us, her family’

‘Every member of staff was so lovely, I can’t think of any complaints. They
are all miracles doing miraculous work’

‘I could not see how it could be improved, the care given to my Mum and
myself and my family was second to none both during her treatment and
after her passing.

I have no problem with my name being put to my comments and would like
to thank everyone again for their wonderful care’

‘My family and I found the care and support both my husband and ourselves
received was excellent’

‘My dear Mum had a dignified and peaceful ending thanks to all. She was
with you for 20 days and sadly passed away Christmas day. The staff
looked after me just as much as my mum. Thank you’

‘The staff at Lincoln could not have been more helpful and understanding to
me and my family. Bless em’

‘I wish you had many more beds to help others through these painful times’

‘The respect shown by staff when my partner passed away was excellent
which I told the Sister the following day excellent work!’
Copies of the full surveys are available on the Trust website
www.stbarnabashospice.co.uk
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Real Time Reporting
The final phase of the Real Time Reporting project was completed this year and
the final report published. The full report of the project is available at:
http://www.stbarnabashospice.co.uk/Files/Resources/Real%20Time%20Reporting
%20-%20Listening%20Differently_73254448.pdf
Below are some of the comments about hospice services taken from the
completed survey:
“Coming to [the hospice] has made my life worth living. I never
wanted to live the way I am but the hospice –its staff and
volunteers have helped me so much. My OT and physio have
helped me so much.”
In addition to the learning developed about the use of the electronic tablet devices
another important aspect identified was the role of the volunteers. It is based on
this learning that we have identified one of our priorities this year and why we are
working with the Lincolnshire West CCG to develop methodology to increase
Public and Patient Engagement. Below is an extract from the report:
“One of the unexpected findings of the project was that of the invaluable role of
volunteers trained to support the process. Their value was multi-faceted, including:

Instilling confidence in individuals who were reticent about the value of
contributing their views and particularly those without family or friends.

Reporting any concerns that individuals had voiced to them with their
permission, in order that they could be resolved. For example, one patient
surveyed was anxious about going home and being a burden on the family.
The volunteer, with the patient’s permission, raised this with the staff nurse
who responded immediately by offering reassurance to the patient that his
concerns were indeed understood and would be addressed.

Providing social support as part of the process.

Working collaboratively with staff to identify individuals for whom the survey
might be appropriate.”
Listening Differently to Users (2014) page 10
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Statement of Directors’ Responsibilities in Respect of the Quality
Account
The directors are required under the Health Act 2009 to prepare a Quality Account
for each financial year. The Department of Health has issued guidance on the
form and content of annual Quality Accounts (which incorporates the legal
requirements in the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations 2010 (as amended by the National Health Service (Quality
Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy
themselves that:

the Quality Account presents a balanced picture of the Trust’s performance
over the period covered;

the performance information reported in the Quality Account is reliable and
accurate;

there are proper internal controls over the collection and reporting of the
measures of performance included in the Quality Account, and these controls
are subject to review to confirm that they are working effectively in practice:

the data underpinning the measures of performance reported in the Quality
Account is robust and reliable, conforms to specified data quality standards
and prescribed definitions, and is subject to appropriate scrutiny and review;
and

the Quality Account has been prepared in accordance with Department of
Health guidance.
The directors confirm to the best of their knowledge and belief they have complied
with the above requirements in preparing the Quality Account.
By order of the Board
…………………………..Date………………………………………..Chair
…………………………..Date………………………………………..Chief Executive
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Statement on St Barnabas's
Quality Account for 2013/14
HEALTH SCRUTINY COMMITTEE
FOR LINCOLNSHIRE
This statement has been prepared by the Health Scrutiny Committee for
Lincolnshire.
Priorities for 2013-14
The Committee welcomes the Trust's progress with its three priorities for 2013/14.
In particular, the Committee is pleased with the development of a six bed Hospice
within a Hospital at Grantham and District Hospital, which we believe will be
essential for the people in the surrounding area. We look forward to the Hospice
within a Hospital opening in the coming year.
Priorities for 2014-15
We support St Barnabas's three priorities for improvement in 2014-15. We would
like to emphasise our support for the development of specific measures to reduce
pressure damage for palliative care patients. Achievement of this priority will
clearly benefit patients and reflects one of the key themes for health care.
Engagement with the Health Scrutiny Committee for Lincolnshire
On 21 March 2014, four members of the Health Scrutiny Committee visited the
St Barnabas Hospice In-patient Unit in Lincoln. The members of the Committee
concluded that the visit was a very positive and encouraging experience, reinforced
by open and honest conversations with staff, patients and relatives.
Here is the report of the visit:
"The St. Barnabas In-Patient unit is located in Lincoln and offers the
following services:





Palliative Care Inpatient Unit
Welfare Benefit Support and Advisory service
Physiotherapy
Occupational Therapy
Lymphoedema Clinic
Bereavement Support
42
"The Mission Statement is “St Barnabas provides specialist palliative and
end of life care so that everyone can access and receive the support they
need to live well and ease the process of dying.”
"The unit is an 11 bed unit with two rooms of four beds (one for male
patients and one for female patients) and three separate one bed rooms.
The unit has a conservatory which includes a children's play area and has a
television. There is a separate lounge from the main ward area. There is
also a large balcony area overlooking the gardens.
"Admission to the unit is normally for a relatively short period of time,
typically ten or eleven days during which time the patient is ‘stabilised’
before returning home. Care is integrated with an outreach team when the
patient is at home, called ‘Hospice at Home’, which embraces physical
needs, emotional needs, social support and spiritual support. This is
supported by the Palliative Care Co-ordination Centre (PCCC), which is
open 365 days a year at the Nettleham Road unit, 9am to 6pm Monday to
Friday and 9am to 5pm Saturday and Sunday and Bank Holidays.
"Food is prepared from scratch in a kitchen on the premises. The range of
choices is very wide, with the patient being served nutritious and tasty food.
"The hospice was very clean and staff were obviously happy in their work.
Each shift has a nursing sister in charge wearing a navy blue uniform. It was
said sight of this uniform was reassuring for patients and visitors.
"Visiting times are open with a recommended ‘quiet time’ of 14.20-15.30, as
much to give visitors respite as patients.
"In terms of quality and governance St Barnabas are inspected by the Care
Quality Commission (CQC) and as a charity is regulated by the Charity
Commission. The most recent CQC report states that St Barnabas met all of
the required criteria with many very positive comments from patients,
relatives, staff and volunteers."
A representative from St Barnabas also attended the Health Scrutiny Committee in
October 2013, as part of an item on palliative and end of life care.
We look forward to continuing engagement with the Committee in the coming year.
Presentation and Accessibility of Information to the Public
We believe that the Quality Account is well-presented and accessible to members
of the public and provides a clear guide on the activities of the St Barnabas.
43
Care Quality Commission
We note that St Barnabas received an unannounced inspection from the Care
Quality Commission on 10 January 2014 and we are pleased that St Barnabas was
compliant with all the standards inspected. We congratulate St Barnabas on this
achievement.
Conclusion
We would like to congratulate St Barnabas Hospice on its achievements over the
last year, in particular the developments at Grantham and District Hospital and we
look forwards to further achievements in the coming year.
44
NHS Lincolnshire Commentary for St Barnabas Hospice Quality Account
Commissioning high quality, safe patient services is Lincolnshire West’s Clinical
Commissioning Groups (LWCCG) highest priority.
Lincolnshire West CCG acknowledges a well written Quality Account from St
Barnabas that incorporates all the elements required through the National Health
Service Quality Accounts guidance. This includes negative responses when a
section is not applicable ensuring that all required information is provided. The use
of clarification boxes at the end of sections to recap and confirm the detail of the
response and provide further information is useful and good practice.
It is anticipated that the areas identified for focus in 2014/15 will continue to
enhance the patient experience and improve patient safety and clinical outcomes.
Lincolnshire West CCG therefore welcomes the focus that the St Barnabas places
on the following 2014/15 quality priorities:
 Working with other health and social care organisations to lead the development
of a palliative care specific pressure damage prevention pathway for the county;
 Utilising the Palliative Care Co-ordination Centre (PCCC) to recall equipment
from patients’ homes when it is no longer required;
 Supporting the Lincolnshire West CCG in developing a mechanism for gaining
feedback from patients and carers who may find it hard to have their voices
heard.
In terms of performance against the 2013/14 Commissioning for Quality and
Innovation (CQUIN) indicators, the following indicators were achieved:




Friends and Family Test
NHS Safety Thermometer - Improvement
Improvement in processes/procedures supporting end of life care
Community Macmillan Nurse Consultant Multi- Disciplinary Team Meetings
It is also recognised that during 2013/14 St Barnabas Lincolnshire Hospice
supported NHS Lincolnshire’s commissioning priorities with regard to the provision
of local specialist palliative care by providing the following services:




Hospice at Home
Inpatient Unit
Welfare Benefits
Palliative Care Co-ordination Centre
St Barnabas was subject to an unannounced visit from the CQC in January 2014
and judged to have met the required standard. Links to the published report were
provided in the Account.
45
Areas for improvement 2014-15
Lincolnshire West CCGs endorse the areas identified as Priorities for Improvement
for 2014-15 and the associated initiatives as detailed within the St Barnabas
Lincolnshire Hospice Quality Account, as well as the CQUIN goals to be achieved
as below:




Friends and Family Test – Increased or Maintained Response
Safety Thermometer - Improvement
Equipment Recall from patients homes when no longer required
Hospice at Home Real Time Reporting - to survey patients in the community and
provide almost real time feedback / reporting
 Patient and Public Engagement - To work with the Lincolnshire West to support
the public and patient engagement agenda for End of Life Care
Lincolnshire West CCG strongly supports the work underway to improve the
patient experience and to capture real time feedback from patients and carers
across the service regarding whether they would recommend the quality of the
service to family and friends.
Lincolnshire West CCG endorses the accuracy of the information presented within
the St Barnabas Quality Account. Overall quality programme performance will
continue to be reviewed by the CCG on an ongoing basis through the formal
contract quality review process.
Wendy Martin
Executive Lead: Nurse/Midwife & Quality
Lincolnshire West CCG
June 2014
46