Quality Account
2013/14
Today. Tomorrow. Together
stclarehospice.org.uk
Registered Charity No. 1063631
St Clare Hospice
Quality Account
2013/14
“I was given time to relax; I was less anxious.
I felt my relative was in very capable hands and that made me at ease.
I felt I could relax for the first time in ages.”
“I feel strongly that I have been introduced to [more] pampering and feeling of
extreme tenderness and care than I have ever encountered. I am so deeply
indebted to you all. Thank you all for everything you have done for me.”
“Day Therapy has made me feel happy and more confident.”
“The counselling I received was invaluable to me.”
“I always felt lighter and brighter after a Day Therapy group.
I enjoyed meeting the other members and appreciated
the efforts of the staff during the groups.”
“After ten days I felt completely safe and ensconced in comfort.”
St Clare Hospice patients and families 2013/14
“You matter because you are you.
You matter to the last moment of your life,
And we will do all we can,
Not only to help you die peacefully,
But also to live until you die.”
Dame Cicely Saunders
Contents
Part 1: Statement of Quality
Statement on Quality from the Chief Executive Officer..................................
1
Statement on Quality from the Board of Trustees.........................................
3
Part 2: Priorities for Improvement
Priorities for Improvement 2014/15................................................................
5
Priorities for Improvement during 2013/14.....................................................
9
Review of Services........................................................................................
13
Financial Considerations...............................................................................
13
Participation in Clinical Audits........................................................................
14
Participation in Clinical Research..................................................................
14
CQUIN Framework........................................................................................
14
Registration with the Care Quality Commission............................................
14
Data Quality, Information Governance Toolkit...............................................
14
Part 3: Review of Quality Performance
Minimum Data Set Activity.............................................................................
16
Complaints, Compliments and Safety Information.........................................
21
Local Audits...................................................................................................
23
Other Quality Initiatives.................................................................................. 24
Care Quality Commission Inspection Report.................................................
25
Statements from External Stakeholders........................................................
26
How to Provide Feedback..............................................................................
27
PART 1: STATEMENT ON QUALITY
Chief Executive Officer Statement
I am delighted to present this Quality Account for St Clare Hospice. As an
organisation we are continually striving to ensure we provide quality driven and
individualised services to the community of West Essex and the borders of East
Hertfordshire. Quality is at the forefront of all we do here, in every aspect of our
operational and strategic work.
We continue to build upon our solid foundations and have an approach that is
forward thinking, responsive and flexible to the ever changing national and local
health care landscape, and most importantly meets the needs of patients and
families. The landscape for Hospices is changing dramatically and following on from
the work of the Commission into the Future of Hospice Care (Help the Hospices,
October 2013) we are challenged to ensure we have a flexible approach to service
development allowing us to be fit and ready for the future changes we know health
care and indeed palliative care will bring.
We have continued to work collaboratively with a wide range of stakeholders in order
to deliver the best quality services, sharing knowledge, experience and resources for
the benefit of local people. Most importantly we actively engage the users of our
services, gaining an enormous amount of positive and constructive feedback on how
we can shape our services for the future.
It has been inspiring to see the growth and development of our services over the
past 12 months. Our new Hospice at Home service was launched in January 2014
and is already starting to see more and more patients and families who require
dedicated, individualised care within their own homes. Care not only for the patient,
but for the family as well. It was always the vision of the team who established
St Clare more than 20 years ago to see this service develop and evolve and we are
so proud that finally it has come to fruition.
Page 1
This Quality Account is a product of a team’s hard work, their commitment in
delivering quality care and developing services with the people they care for. I am
pleased to present this Quality Account for 2013/14 and to the best of my knowledge
the information contained therein is accurate.
Tanya Curry
Chief Executive
Page 2
Chairman of the Board of Trustees Statement
During the course of this year, I’m delighted to report that St Clare has continued to
gather momentum and pace in developing services for people living in West Essex
and East Hertfordshire.
The growth of the Hospice is wonderful to see. Since implementing our 5 year
strategy, we have seen the development of our Community services and our long
awaited Hospice at Home service, which launched in January 2014 and was a
monumental day for St Clare.
Supporting patients and families during one of the most critical times of their lives will
always be our focus; ensuring excellent patient experience and providing a choice
for patients of where they wish to be cared for – be it here at the Hospice or in their
own homes. It is wonderful that through the Hospice at Home service, we now have
a team of nurses and nursing assistants who can care for patients in their own
homes with dignity and compassion, truly what Hospice care is all about.
Along with providing quality driven and individualised care, one of the key
achievements during the year has been the completion of a large refurbishment
project that we were able to undertake following a grant from the Department of
Health. Every clinical department across the Hospice has been transformed into a
light, bright, airy and uplifting space, where patients and families can be comfortably
cared for and enjoy these exceptional facilities.
Day Therapy and Outpatient services now have purpose built rooms so care can be
delivered in an appropriate environment. The feedback from the patients, staff and
volunteers who use these spaces on a daily basis has been wonderful to hear.
As Trustees we wish to ensure that the Hospice operates in a safe and professional
manner in all areas of its work. We have continued to develop our data collection,
reporting and governance structures throughout the year, which I believe is
demonstrated throughout the course of this Quality Account. This enables us to use
the information positively to learn, develop and improve, striving for excellence in all
that St Clare does.
With contracting rounds and the fundraising environment becoming more and more
challenging, the team continue to work hard to engage a wide range of stakeholders
Page 3
and to share the valuable work of St Clare with all of our partners in the local
community.
As Chairman of the Board I am pleased to support this Quality Account.
Patrick Foster
Chairman
Page 4
PART 2 - PRIORITIES FOR IMPROVEMENT
Introduction
This Quality Account demonstrates St Clare’s on-going commitment to delivering
skilled and compassionate specialist palliative care for our local community. It also
reflects our vision to ensure that people with life limiting illnesses have timely access
to skilled, compassionate and sensitive care. We will support patients and their
families to maintain dignity and quality of life by providing exceptional care in a place
of their choice. As a centre of excellence we will continue to lead in the development
of specialist palliative care services for the population of West Essex and East
Hertfordshire.
Our values are fundamental to the delivery of specialist palliative care and underpin
everything we do:
Care:
We treat patients and families the way we want to be treated – with
kindness, compassion and respect
Teamwork:
We value the unique contribution that all our staff and volunteers make
in the delivery of excellent care for our local community
Quality:
We are passionate in our pursuit of excellence and dedicate ourselves
to achieving the highest standard in all aspects of our work
Integrity:
We are honest and ethical in everything we do and accept the
responsibility for the trust placed in us
The priorities for quality improvement identified for 2014/15 are set out below and
impact directly on each of the three domains of quality; patient safety, clinical
effectiveness and patient and family experience.
Page 5
Priorities for improvement – 2014/15
At St Clare Hospice we continually review our services and seek to improve and
develop them. Clinical and support teams are fundamental to the delivery of our
strategy and business plans. This is achieved through effective communication
between front line teams, the Hospice Directors Team and Board of Trustees.
The Hospice will monitor our achievements in respect of the following priorities by
reporting progress through our Clinical Governance Working Group, Risk
Management Group, Clinical Governance Committee, Governance Committee and
ultimately through the Board of Trustees.
Patient Safety
Priority
Hold meetings to
discuss patient care
and propose plans
for improvement
How Identified
CQUIN
How Achieved
In collaboration with
hospital and
community trusts
Monitoring
Quarterly CCG meetings
Participate in a West
Essex End of Life
electronic register
CQUIN
Work in collaboration
with SEPT
Clinical Governance
Working Group
Quarterly CCG meetings
Meet Care Quality
Commission
Outcomes for quality
and safety
CQC registration
requirement
Audit programme
Patient Feedback
Carer Feedback
Clinical Governance
Working Group
CQC Inspection
Develop a Workforce
Strategy
Hospice Strategy
Organisational gap
analysis
Management Team
Directors Team
Board of Trustees
Repeat medication
competences in
nursing staff
Medication errors
In-house training
Risk Management Group
Clinical Governance
Working Group
SOVA training to be
undertaken by all
Hospice staff and
volunteers
CCG KPI
In-house training
Education Group
Clinical Governance
Working Group
Quarterly CCG meetings
Page 6
Clinical Effectiveness
Priority
Introduction of ESAS
as a clinical outcome
tool
How Identified
Priority 2013/14
Staff reflection
Usability survey
How Achieved
Staff Training
Monitoring
Clinical Governance
Working Group
Expand Hospice at
Home provision
Hospice at Home
business plan to CCG
Hospice Strategy
Monitor KPI
Clinical Governance
Working Group
Quarterly CCG meetings
Directors Team
Provide robust data
for our Clinical
Commissioning
Groups
Hospice Strategy
Data audits
Training
Regular meetings with
administrative staff
Regular KPI auditing
Information Governance
meetings
Clinical Governance
Working Group
Quarterly CCG meetings
All staff to have
access to Education
and Training
Hospice Strategy
Appraisal
Review education
strategy
Education lead post
Review e-learning and
collaboration with
Hospices and other
providers
Clinical Governance
Working Group
Management Group
Directors Team
Board of Trustees
Review Day Therapy
Model
Hospice Strategy
Review current model
and compare with
neighbouring providers
Clinical Governance
Working Group
Directors Team
Board of Trustees
Develop IT links to
NHS to share patient
information
Hospice Strategy
Using N3 connection
Information Governance
meetings
Page 7
Patient and Family Experience
Priority
Increase the use of
the Friends and
Family Test
How Identified
CQUIN
How Achieved
Anonymised
questionnaires for all
patients discharged
from inpatient unit
Monitoring
Quarterly CCG meetings
Involve service users
in all aspects of
organisational
development
Hospice Strategy
User Involvement
Forum
Clinical Governance
Working Group
Directors Team
Governance Committee
Develop a
Community Friends
Volunteer Service
Hospice at Home
business plan to CCG
Hospice Strategy
Volunteers Service
Governance Committee
Clinical Managers
Directors Team
Participate and
support CCG
initiatives and
strategic priorities in
End of Life Care in
West Essex
Hospice Strategy
Attendance at Frailty
Board and associated
work streams
Clinical Governance
Working Group
Directors Team
Page 8
Priorities for improvement – 2013/14
The aim of the Quality Account is to not only set future priority improvements but to
also evidence achievements on priorities for improvement from the previous year.
In last year’s report, we set out 4 priorities for improvements for our services. All
areas identified were specifically selected as they would impact directly on the care
our patients and families received, either through improvement in patient safety,
clinical effectiveness or the patient’s experience.
Priority 1: To improve and develop our existing clinical services, maximising
their reach and quality
a. Community Development
i.
We recruited two specialist palliative care nurses enabling us to operate a
seven-day week service from January 2014.
ii.
We recruited a Hospice at Home Coordinator, six Nursing Assistants and
an administrator enabling us to operate a seven-day a week Hospice at
Home service from January 2014.
iii.
A steering group was set up to develop St Clare Hospice Community
Friends, a seven-day week befriending service delivered by volunteers.
This will be developed as a priority in 2014/15
b. Development of a Patient and Family Support Service
i.
We successfully recruited a Social Worker to the Patient and Family
Support Service
ii.
We employed a locum consultant two days per week, who specialises in
social work and bereavement and is supporting with recruiting a Patient
and Family Support Manager.
Page 9
Priority 2: To implement further elements of The End of Life Care Strategy
a. Advance Care Planning (CQUIN)
i.
We have achieved collaborative adoption of ACP document with South
Essex Partnership, University NHS Foundation Trust and Princess
Alexandra Hospital.
ii.
Training of all staff in the Hospice on ACP has been completed in line with
the CQUIN target and we have supported with training of other staff within
other provider organisations.
iii.
We implemented the ACP in our Day Therapy and set up a data collection
process in line with the requirement set out by the local clinical
commissioning group.
b. Improve referral rates of Non Cancer Patients (CQUIN)
i.
Meetings were held with end of life leads to highlight non-cancer patients.
ii.
Letters were sent out to GPs reminding them of our service to patients with
non-cancer life limiting illnesses.
iii.
An article on non-cancer support was published on our website.
iv.
Non-cancer palliative care was highlighted at the end of life steering group.
v.
Although the percentage of patients admitted to our inpatient unit has
remained largely unchanged there has been an increase in each of the
other service areas.
c. Friends and Family Test (CQUIN)
i.
This question has been added to our satisfaction surveys for each of
the service areas.
ii.
In 2013/14, 154 patient questionnaires were returned to us of which
150 (97.5%) documented that it was extremely likely they would
recommend the Hospice to friends and family if they needed similar
care or treatment, 3 (2%) stated it was likely and one questionnaire
was not completed.
Page 10
d. Safety Thermometer
i.
The safety thermometer is a monthly survey that includes falls, pressure
ulcers and catheter-associated infections.
ii.
During 2013/14 we found that some patients are admitted with pressure
ulcers.
iii.
Our highest area of concern was falls and all patients have risk
assessments in place and, as a result, the harm sustained is very low.
This is reviewed regularly by our Clinical Governance Working Group and
with our commissioners
Priority 3: Adoption of a symptom assessment scale
i.
In 2013/14 we reviewed possible symptom assessment tools and decided
to conduct a user-friendliness survey for Support Team Assessment
Schedule (STAS) and Edmonton Symptom Assessment System (ESAS).
ii.
The STAS assesses quality of care in palliative care patients with nine
core or up to 20 optional items covering physical, psychosocial, spiritual,
communication, planning, family concerns and service aspects.
iii.
The ESAS is a tool that was developed to assist in the assessment of nine
symptoms that are common in palliative care patients: pain, tiredness,
drowsiness, nausea, lack of appetite, depression, anxiety, shortness of
breath, and wellbeing. There is also a blank scale for patient-specific
symptoms.
iv.
We tested user-friendliness by asking patients and staff to complete a
Usability form for both tools that assess learnability, efficiency,
memorability, errors and satisfaction of the user.
v.
Patients using STAS reported a number of problems whereas patients
using ESAS found it easy to use and were satisfied with the form; staff
experience reflected that of patients.
vi.
In light of that, St Clare Hospice has decided to use ESAS on patients’
assessments as a priority in 2014/15.
Page 11
Priority 4: Data Quality Improvement
Quality and safety measures have been reviewed and the following parameters have
been agreed with our commissioners:
I.
Complaints
Total number of clinical complaints received
Number of complaints upheld in full
Number of complaints upheld in part
Number of pressure ulcers (attributable to St Clare)
II.
Patient Safety Incidents
Number of pressure ulcers (not attributable to St Clare)
Number of patient safety incidents (excluding falls)
Number of slips/ trips / falls
Number of Serious Incidents
III.
Infection Control
Number of patients known to be infected with MRSA on admission to
inpatient unit
Number of patients infected with MRSA whilst on inpatient unit
Number of patients admitted to the inpatient unit with Cl. Difficile
Number of patients infected with Cl. Difficile whilst in the inpatient unit
IV.
Safeguarding
Number of SETSAF1's raised by St Clare
Number of SETSAF1's raised against St Clare
% of staff who have received Safeguarding Adults in the past 2 years
(including MCA and DOLS)
Page 12
Review of Services
During 2013/14 St Clare Hospice provided the following services
Inpatient Unit, which provides 24 hour care and support by a team of specialist
staff.
Day Therapy, which gives patients extra support to manage symptoms, gain
confidence at home and maximise quality of life.
Outpatient Service, which provides specialist support and advice in Hospice
clinics.
Community Service, which provides specialist support and advice in a patient’s
home.
Therapies to support independence and promote comfort, including:
o Physiotherapy
o Occupational therapy
o Complementary therapy
Social workers provide specialist support and counselling.
Bereavement services for adults and children.
Spiritual Care service supporting patients and their families.
Financial Considerations
The NHS income from our Clinical Commissioning Groups in 2013/14 represented
approximately 30% of our total expenditure.
The running costs of St Clare are expected to be £3.8 million in 2014/15. The
majority of this has to be raised through donations, Gifts in Wills, fundraising
initiatives and our chain of charity shops.
We review all our services on an on-going basis to ensure we are delivering them as
efficiently as we can. Expert care for our patients and their families remains our
priority.
Page 13
Participation in Clinical Audits
During 2013/14 St Clare Hospice was not eligible to participate in any national
clinical audits or national confidential enquiries and therefore there is no information
to submit. This is because none of the 2012/13 audits or enquiries related to
specialist palliative care.
Participation in Clinical Research
The number of patients receiving NHS services provided by St Clare Hospice that
were recruited during that period to participate in research approved by a research
ethics committee was 0. During 2013/14 there were no appropriate national, ethically
approved, research studies in palliative care in which we could participate.
Use of CQUIN payment framework
St Clare Hospice income during 2013/14 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation payment framework because it is a third sector organisation and as such
was not eligible to participate in this scheme during the reporting period. However
the Hospice successfully achieved CQUIN targets leading to a small amount of
additional funding.
The Care Quality Commission (CQC)
St Clare Hospice is required to register with the Care Quality Commission and its
current registration has no conditions attached to it. The Hospice has not participated
in any special reviews or investigations by the Care Quality Commission during
2013/14.
Data Quality
St Clare Hospice submits data to the Minimum Data Set (MDS) for Specialist
Palliative Care Services collected by National Council of Palliative Care on a yearly
Page 14
basis, with the aim of providing an accurate picture of hospice and specialist
palliative care service activity.
All clinical data, performance and quality, are collated, analysed and verified with
clinical managers and the clinical governance committee.
Information Governance ensures the appropriate use of information and the IG
Toolkit is an online system which allows NHS organisations and partners to assess
themselves against Department of Health Information Governance policies and
standards. The Hospice IG Toolkit submission has been audited and deemed
satisfactory and, as a result, staff with access to NHS patient information will now
undertake the appropriate information governance training.
Clinical coding error rate
St Clare Hospice was not subject to the Payment by Results clinical coding audit
during 2013/14 by the Audit Commission.
Page 15
PART 3 - REVIEW OF QUALITY PERFORMANCE
The figures below provide information on the activity and outcomes of care for
patients in 2012/13 and 2013/14 compared to the median for other Hospices
prepared by the National Council for Palliative Care in 2012/13, which at the time of
writing were the latest available.
The National Council for Palliative Care: Minimum Data Sets for Inpatient Units
2012/13 and 2013/14.
St Clare Hospice has been identified as a small unit (fewer than 11 beds); 47 were
units included in this category.
All Service Users
St Clare
2013/14
2012/13
median
National
min
Max
Total patients
209
205
166
39
283
New patients
193
193
147
36
216
8
5
13
0
63
median
National
min
Max
Re-referred patients
Diagnosis
St Clare
2013/14
2012/13
Cancer (% new referrals)
Non-Cancer (% new referrals)
173 (90)
168 (87)
127
28
205
20 (10)
21 (11)
13
1
32
median
National
min
Max
Bed Usage
St Clare
2013/14
2012/13
Available Bed Days
2,920
2,920
3,630
1,095
3,670
Cancer Average stay
10.2
11.2
11.9
4.7
23.5
Non-cancer average stay
10.3
9.9
10.2
1.6
173
% occupancy
86
85
77.2
62.3
100
% availability
100
100
100
87.6
100
Page 16
The National Council for Palliative Care: Minimum Data Sets for Day Therapy
2012/13 and 2013/14.
Day Therapy service at St Clare Hospice has been identified as a medium unit (112180 patients); 49 units were included in this category.
All Service Users
St Clare
2013/14
2012/13
median
National
min
Max
Total patients
157
150
140
112
180
New patients
101
108
91
55
137
18
9
4
0
16
median
National
min
Max
Re-referred patients
Diagnosis
St Clare
2013/14
2012/13
Cancer (% new referrals)
68 (67)
75(69)
66
28
115
Non-Cancer (% new referrals)
33 (33)
33 (31)
21
2
44
Page 17
The National Council for Palliative Care: Minimum Data Sets for Outpatients
2012/13 and 2013/14.
Nationally St Clare Hospice has been identified as a medium unit (between 97 and
316 patients); 50 units were included in this category.
All Service Users
St Clare
2013/14
2012/13
median
National
min
Max
Total patients
170
156
171
98
313
New patients
124
108
102
35
262
11
8
5
0
80
Re-referred patients
Diagnosis
St Clare
2013/14
2012/13
median
National
min
Max
Cancer (% new referrals)
43 (35)
41 (38)
69
13
193
Non-Cancer (% new referrals)
81 (65)
66 (61)
13
0
102
St Clare
2013/14
2012/13
median
National
min
Max
Clinic Attendances
Number of patients
392
132
486
51
1,870
Number of clinics
256
93
170
42
416
Attendances per clinic
1.5
1.4
2.1
0.7
12.6
Page 18
The National Council for Palliative Care: Minimum Data Sets for Community
Team (Home Care) 2012/13 and 2013/14.
Nationally St Clare Hospice has identified as a medium unit (between 633 and 1227
patients); 13 units were included in this category.
All Service Users
St Clare
2013/14
2012/13
median
National
min
Max
Total patients
757
719
838
633
1227
New patients
573
527
588
397
764
80
83
48
7
93
501
479
480
235
642
69
40
85
22
162
Deaths and discharges
776
769
755
421
957
Deaths
293
306
433
155
708
Average length of care (days)
47.5
48.8
130.1
48.8
652.8
Patient visits
1,816
1,430
4,079
0
7,597
Patient telephone calls
1,898
703
3,059
0
10,581
Carer visits
23
23
128
0
1,117
Visits with other professionals
69
35
142
0
5,218
Re-referred patients
Cancer diagnoses (new)
Non-cancer diagnoses (new)
Page 19
The National Council for Palliative Care: Minimum Data Sets for Bereavement
Services 2012/13 and 2013/14.
Nationally St Clare Hospice has been identified as a medium unit (114-262 service
users); 41 units were included in this category.
All Service Users
St Clare
2013/14
2012/13
median
National
min
Max
Total service users
144
129
184
115
259
New service users
83
84
138
69
217
0
0
0
0
25
2012/13
median
National
min
Max
Re-referred service users
Contact with service users
St Clare
2013/14
Total contacts
518
563
928
78
2,833
Contacts per service user
3.6
4.4
5.9
0.3
15.9
Phone calls per service user
0.3
0.5
1.5
0.0
10.8
225.4
150.2
137.0
37.9
479.3
Average support (days)
Page 20
Other Quality Markers
In addition to the limited number of suitable quality measures in the national dataset
for palliative care, we have chosen to measure our performance against the following
indicators that will be measured and reported on during 2013/14.
Complaints
A total of 36 complaints were received 2013/14 (22 related to patient/family care, 13
of which were upheld). Any complaints received were fully investigated, appropriate
action taken and shared at the Risk Management Group and with the Governance
and Clinical Governance Committees.
Quarter ending
Quality Marker
Jun 13
Sep 13
Dec 13
Mar 14
Written complaints
2
5
4
3
Verbal complaints
2
9
6
5
Serious untoward incidents
0
0
0
0
Medication errors - patient harm
0
2
1
1
N/A
3
4
0
13
4
7
3
Pressure ulcers-attributable/non-attributable
N/A
0/7
0/3
1/4
MRSA - attributable/non-attributable
N/A
0/0
0/0
0/0
C. Diff - attributable/non-attributable
N/A
0/0
0/0
0/0
Safeguarding Incidents - attributable/non
N/A
0
0/1
0/3
Other clinical incidents
9
2
2
7
Other non clinical incidents
6
3
6
8
Medication errors - all other including near miss
Slips, trips and falls
Page 21
Safety Information
The clinical team reported a total of 69 incidents and accidents in 2013/14. The
commonest cause of which were slips, trips and falls, which improved during the
course of the year.
Eleven medication errors were reported, four of which were assessed as causing or
likely to cause patient harm. All controlled drug incidents are reported to our
Accountable Officer.
Compliments 2013/14
Compliments are received in a variety of ways at St Clare, including from feedback
surveys in the Inpatient Unit, Day Therapy, Bereavement and Community teams, as
well as letters.
A selection received in 2013/14:
Day Therapy
“Despite “all”, a sense of tranquillity. I looked forward to all our
meetings. A sense of goodness and calm; respect to each
other – the wonder of being human”
Community team
“We think you are doing a grand job and would like to thank all
of you for your help. Thank you again; it’s nice to know there is
someone at the end of a phone when things need sorting.”
Bereavement
“Having never had counselling or such close bereavement
service
before; all I can say is the level of care and understanding was
much greater than I could have expected and I am very grateful
to St Clare and H for this support during the first year; thank
you.”
Page 22
Inpatient unit
“We were encouraged to ask questions and made well aware
that the staff were very happy to answer and would spend time
to make sure we understood.”
Local Audits
Clinical audits have taken place within the Hospice as part of our overall Quality
Action Plan. The monitoring, reporting and actions following these audits ensure care
delivery that is safe and effective and are recorded in our Quality Audit Tracker and
reviewed on a regular basis. In order to ensure a high quality of services a variety of
audits were undertaken using nationally agreed formats often specifically developed
for Hospice care as well as locally developed audit tools. This has enabled us to
monitor the quality of services and make improvements where needed.
During 2013/14 St Clare Hospice’s Clinical Governance Working Group reviewed the
results of 48 audits. The audits related to a cross section of Hospice activity including
the holistic notes (see section on improvement priority 2 for 2013/14), the inpatient
unit, the day therapy service, advice line calls, and assessments by the community
palliative care team.
Examples of audit standards in 2013/14 included:
1. Patient handling care plan is completed for all inpatients within 24 hours of
admission.
2. Day Therapy patients are allocated a Key Worker after their first attendance at
Day Therapy.
3. Discharge letters for patients who have completed Complementary therapies
outpatient placement will be sent within 5 working days of their discharge.
4. For all admitted to the inpatient unit at St Clare Hospice who lack mental
capacity to have the mental capacity documentation completed.
5. To ensure that the mouth care assessments are completed for all patients.
6. DNA CPR forms are fully completed, including documented evidence of
discussion with patient/family.
7. The community palliative care team will prioritise referral according to very
urgent (where possible contact made on day of receipt or next working day),
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urgent (within two to three working days) and routine (within a week of
receipt).
8. Patients assessed by St Clare Hospice clinical team will have their distress
assessed by the use of Distress Thermometer recorded in patients’ notes.
Where necessary changes or improvement to practice are identified and are
implemented at an individual, team or service level.
Other Quality Initiatives
Newsletter and website
St Clare News is published three times per year for all stakeholders. Along with our
website, it provides information on our services and celebrates the achievements of
all aspects of the Hospice. They also provide an opportunity for patients, carers, staff
and volunteers to comment on the work of the Hospice. Internal communication
cascades are also in place.
What have carers and users said about St Clare Hospice?
User Feedback Questionnaires
At St Clare Hospice every service user has the opportunity to provide feedback on
their experience of the service. Information is collected using a service questionnaire
and then collated. The feedback is shared with staff on a quarterly basis; key themes
are highlighted, with an action plan completed. An annual summary is produced and
shared with our commissioners. The Hospice team receive all data as well as an
annual agreed action plan detailing priorities for improvement. The action plan is a
live document, reviewed every quarter to ensure as an organisation we are
responsive to feedback and proactive in our work. Displays around the Hospice
building showing a summary of feedback received and the action taken were
implemented in 2013. These displays are refreshed and updated quarterly.
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Comment Card Feedback
Comment cards are available at St Clare Hospice and in the St Clare Hospice retail
shops. As with the User Feedback Questionnaires, the feedback from the comment
cards is used to help improve services provided by St Clare Hospice. Feedback
relating to compliments and complaints is shared with the management team at the
hospice’s risk management meeting. This is in turn shared with wider team members
and the Board of Trustees through the governance structure.
User Involvement Forum
The Forum is lead by the Chief Executive Officer and is made up of members of the
public who have received care or who are currently receiving care from St Clare
Hospice. Meetings are held every two months with the group being very active and
supportive in all areas of Hospice development. The ultimate aim is to always
improve Hospice services using valuable feedback and the experience of service
users.
Care Quality Commission Inspection Report
Following the unannounced inspection by the Care Quality Commission on
November 25th 2013, St Clare Hospice received a positive report for meeting
essential standards of quality and safety across all five key areas scrutinised:
Care and welfare of people who use the service
Meeting nutritional needs
Cleanliness and infection control
Management of medicines; and
Safety, availability and suitability of equipment.
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Statements from External Stakeholders
NHS West Essex CCG
West Essex CCG (WECCG) has reviewed the information provided by St Clare’s
Hospice and believes this is a true reflection of the organisation’s performance
during 2013/14, based on discussions during the year as part of the on-going quality
monitoring process.
The CCG also acknowledges the strong patient engagement, and focus on patient
experience within St Clare Hospice. Overall a number of improvements have been
made during 2013/14; however WECCG would like to work with St Clare’s Hospice
to see significant focus and drive to ensure on-going improvement in the quality of
services delivered to patients.
WECCG looks forward to working with and supporting St Clare Hospice in further
developing and monitoring the quality of services it provides for patients.
NHS East and North Hertfordshire CCG
East and North Hertfordshire CCG have reviewed the information contained in the
Quality Account.
During 2013-14, St Clare Hospice continued to deliver high quality care to the
population covered in Hertfordshire. The Quality Account clearly sets out
achievement against the priorities set for 2013-14 and demonstrates continued
quality improvement and greater access for service users.
During the year the
Hospice also received a positive CQC inspection where they were found to be
compliant with all the outcomes assessed.
The Hospice continues to have a strong emphasis on user involvement and regularly
seeks feedback from patients and their families on all services through their patient
satisfaction surveys and involvement forum. The Hospice is also looking to engage
the community and voluntary sector through the development of a group of
community friends.
The Hospice’s commitment to patient focused quality
improvement is evident by the high number of service users who said they would
recommend the service to their friends and family.
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The Hospice is also committed to long term strategic planning and has made
fundamental changes to their premises during the year, with every clinical
department being transformed to improve space and create an environment where
patients and their families can be comfortable and cared for.
The priorities set out for 2014-15 build upon the successes of 2013-14 and
demonstrate a commitment to all round quality improvement.
The priorities are
supported and embedded into the CQUIN framework and the Hospice’s 5 year
strategy.
During 2014-15 the CCG looks forward to building on the relationship already
developed with the Hospice to ensure open dialogue and continued quality
improvement for the population covered in Hertfordshire.
How to provide feedback to St Clare Hospice on this report or any of our
services
We would like to encourage you to contact us with questions, comments or
suggestions following reading this report or from your experience of St Clare
Hospice. Contact details can be found on the back cover of this report or you can
write to:
Tanya Curry
Chief Executive Officer
St Clare Hospice
Hastingwood Road
Hastingwood
CM17 9JX
Email:tanya.curry@stclarehospice.org.uk
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