ST ELIZABETH HOSPICE
QUALITY ACCOUNT
2013 - 2014
‘I would like to thank everyone connected with the Hospice … having teenage children, they
made sure that they felt comfortable on visiting their dad … he had a room on his own which
enabled us to spend a lot more quality time with him. His illness progressed rapidly in the
last two weeks of life … we had fantastic help from the Hospice nurses and carers when he
was at home … having a direct telephone number really helped. As his health deteriorated he
wanted to come to the Hospice. We had fantastic help from the nurses who kept us totally
informed. The male nurse gave the kids the hospitality suite and me a bed beside him,
explaining what was happening … and dealt with everything when he passed away.”
Our last Care Quality Commission visit was in January 2014
They found that the service was „cherished by all who used it‟, the „environment....well maintained
and ensured the safety of people who used it.‟ and there is „ a staff group that was well trained and
very well supported to complete their role at the hospice‟.
We met the standards for:
-Respecting and involving people who use services
-Care and welfare of people who use services
-Safety and suitability of premises
-Supporting workers
They also found „there was a potential through incomplete records that care may be unsafely
delivered‟. This was judged to have minor impact on people using our services. We have put in
place an action plan to ensure that we address this area for improvement. We expect this to be
achieved through communication, training and monitoring with immediate effect.
Full copy can be found on the hospice website www.stelizabethhospice.org.uk
565 Foxhall Rd
Ipswich
St Elizabeth
Hospice report to follow soon
Suffolk
IP3 8LX
www.stelizabethhospice.co.uk
Registered Charity Number 289154
This Quality Account was endorsed by the St Elizabeth Hospice Board of
Trustees on 2nd June 2014.
1
FRAMEWORK FOR QUALITY ACCOUNTS
Quality Accounts aim to improve organisational accountability to the public and engage
boards in the quality improvements agenda for an organisation.
LEADS TO
Public accountability
Leadership engaged with improvement of quality of
services
There is a legal requirement under the Health Act 2009, for St Elizabeth Hospice, as a provider of
NHS services, to produce a Quality Account.
2
Contents Page
Page
Part 1 – Chief Executive’s Statement about Quality
Information about St Elizabeth Hospice
Our Purpose, Vision and Principles
Front Cover
4
Part 2 – Priorities for improvement and statements of assurance
from the Board
2.1
Priorities for improvement 2014-2015
7
2.2
Priorities for improvement 2013-2014
10
2.3
Overview of Quality Performance
2.3.1
Review of Services
13
2.3.2
Participation in National Clinical Audits
14
2.3.3
Participation in Local Audits
14
2.3.4
Research
16
2.3.5
Goals agreed with commissioners – use of the
CQUIN Payment Framework
16
2.3.6
What others say about St Elizabeth Hospice
16
2.3.7
Data Quality
2.3.7
NHS Number Code Validity
16
2.3.7.1 Information Governance Toolkit Attainment
16
2.3.7.2 Clinical Coding Error Rate
17
Part 3 – Review of Quality Performance April 2013 - March 2014
3.1
St Elizabeth Hospice Governance policy statement
17
3.2
Who has been involved in Our Review of Quality
21
3.3
Statements from Healthwatch - NHS Suffolk and the Overview & Scrutiny
Committee
21
3
PART 1: STATEMENT ON QUALITY
OUR VISION
“Improving life for people living with a progressive illness”
Objectives and Activities
To further develop the high quality specialist and palliative care we provide for the people of
Suffolk, Great Yarmouth, Waveney and surrounding areas.
Our statement of purpose is
1. Improving life for people living with a progressive illness by providing multi-disciplinary
holistic specialist and dedicated palliative care services to patients and their families and
carers.
2. Improving life for people living with a progressive illness by working alongside other
statutory and voluntary agencies to provide specialist and dedicated palliative care in a
timely and effective manner where the patient wishes to be.
3. Improving life for people living with a progressive illness by acting as a resource to the
local community regarding general and specialist palliative care to increase confidence
and competence in improving life for people living with a progressive illness.
4. Improving life for people living with a progressive illness by providing care that respects
the choices made by patients and their families so that patients are treated in their
preferred place and die in their place of choice where possible.
5. Improving life for people living with a progressive illness by working towards equitable
provision of all services leading to increased use of services by people with non malignant
progressive disease and those from seldom heard communities.
6. All the above goals will be monitored through quantitative and qualitative data collection
and audit processes.
4
STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
It gives me great pleasure to present the Quality Account for the year April 2013 – March
2014. Although we are a charity separate from the NHS, we welcome the opportunity to
prepare this report in recognition of the financial support we receive from the NHS and the
contribution we in turn make to local NHS services. This is the third year that we have
produced such a document and we hope that this, along with previous years’ Quality
Accounts, provides a summary of what we have been doing over the last year to improve
our services. We are always delighted to have any feedback on the document itself, or
indeed, our services more generally, so please do feel free to get in touch.
Our care is based on an active collaboration with patients, their families and carers to
establish their wishes and needs, underpinned by expert holistic assessment by our multiprofessional team. We are continuously striving to maintain and improve the quality of our
services for patients and their families. As such, we have developed a governance structure
that marries clinical, operational and financial governance into an integrated function. This
has enabled the Hospice to focus on the quality of the services provided whilst having the
reassurance that the organisation as a whole has quality at its core. We also seek to gather
patient and carer feedback so that we can improve our services further.
The Hospice is registered with the Care Quality Commission who carried out an
unannounced inspection in January 2014 and we were delighted that the Hospice once
again received a very positive assessment. The inspectors raised a concern on our record
keeping which they felt could have a minor impact on our patients and we have put an
action plan in place to address this.
We continue to work hard to ensure that Hospice premises reflect the quality care we
provide, and we are pleased that we were successful in a recent application to the
Department of Health for a grant towards more improvements in our buildings that are
detailed further on in our Account.
Together with the Board of Trustees, our thanks must go to not only our staff and
volunteers who work tirelessly to provide high quality services but also to our faithful and
committed supporters who enable us to raise the necessary funds to provide our services
free of charge to patients and their families.
I can confirm that I am responsible for overseeing the preparation of this report and its
contents. To the best of my knowledge, the information reported in this Quality Account is
accurate and a fair representation of the quality of healthcare services provided by our
Hospice.
Thank you for your interest in the work of St Elizabeth Hospice.
Jane Petit
Chief Executive
5
6
Part 2 PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF ASSURANCE FROM
THE BOARD
2.1 PRIORITIES FOR IMPROVEMENT 2014-2015
Areas for improvement for 2014-15 are set out below. They have been selected because of
the impact they will have on patient safety, clinical effectiveness and patient experience.
2.1.1 PATIENT SAFETY
Priority One
Falls prevention Programme
The Hospice is participating in the Ipswich and East Suffolk Clinical Commissioning Group
strategy and Nice Guidelines and standards in falls prevention. Also in the Help the Hospices
benchmarking project.
Hospice patients are all to be assessed on their risk of falls and offered advice and care when
they are found at risk of falling and we will ensure staff and volunteers are knowledgeable in
the prevention of falls and actively support people to prevent falls and injury
How this priority was decided
Patient safety and wellbeing is always the highest priority. The Governance Committee
monitors incidents, including falls, and need to make certain all possible is being done to
prevent patient injury.
New NICE guidance - Falls, Assessment and prevention of falls in older people, June 2013,
states people aged 65 and older have the highest risk of falling, causing distress, pain,
injury, loss of independence and mortality. The guideline is aimed at people mainly 65 plus
but also people aged 50-64 who are admitted to hospital judged to be at a higher risk of
falling because of an underlying condition.
In September 2013, the Integrated Falls Pathway Development Group arose as a Task and
Finish group. Its objectives are to:
To reduce admissions
To reduce fragility fractures
To increase the percentage of falls assessments
To increase the speed at which they are undertaken
To reduce mortality and morbidity
To reduce the associated costs (financial and human)
The lead is the Clinical Commissioning Group and the other stakeholders include
Geriatricians, Therapists, ambulance service, implementation managers, Social care,
commissioners, health and voluntary sector; the Hospice and Suffolk Family Carers.
The group will propose a service spanning across many different providers, which agree a
process of assessment and implementation of care and documentation.
We believe the principles of risk assessment and care for those at risk will apply to most of
our patients, regardless of age, because of the complexity of their illness and frailty.
Risk assessments are routine for patients who have fallen on the In-patient units in the
Hospice. We now plan to introduce an improved method of assessment for all patients
whether in the Community, Day units and In-patient units.
7
How the priority will be achieved
The Integrated Falls Pathway Development Group will offer training to the Hospice therapy
team, supporting us to work to an agreed standard across our services following the
publication of its proposal on documentation, it will also provide information on how and
when to make referrals for those patients needing a higher level of intervention.
The Hospice Therapy team will lead on the use of the assessment tools and standardisation
of the advice given to patients and their follow-up care, in conjunction with all members of
the multi-professional team as well as providing in-house training.
The Hospice is a member of the national and regional Executive Clinical Lead in Hospice
and Palliative Care, and has a regular agenda item on falls and benchmarking.
The Hospice will continue to report all patient falls through our incident reporting procedures.
All incidents are investigated and acted upon where necessary and are included in our twice
yearly audit cycle.
In addition we have agreed to participate in the National Hospice Inpatient Safety
Benchmarking project being managed by Help the Hospices which is looking at falls,
incidence of pressure sores and medication incidents. This will enable us to compare our
incidences with Hospices from across the country.
How progress will be monitored and reported
Progress will be reported to the Patient Services Committee Quality Assurance and
Improvement Group which will feed into the Governance Committee and then to the Board of
Trustees.
The benchmarking data will also be reported through to the Board of Trustees as one of the
monthly key performance indicators of patient safety.
2.1.2 PATIENT EXPERIENCE
Priority Two
Development of Transitional Care
To work with young people, their families and other providers to ensure each patient feels
supported when moving from children services to St Elizabeth Hospice services.
How this priority was decided
The Hospice is registered for patients from the age of 14 and above in recognition of the
difficulties which can be faced by young people moving from children‟s to adult services.
There is a need for specific support at this time as the focus of adult and children‟s services
can be very different and this can cause worry and concern for the young people and their
families.
The Hospice therefore wishes to work more closely with other providers to offer support
during what can be a stressful period in their lives.
8
How the priority will be achieved
The Day unit managers will lead this development in partnership with other Hospice and
external multi-professional staff. A training programme for staff will be identified. The patient
and their families will have top priority and the direction for change and service development
will come from them.
The design of the additional spaces and resources in the day unit redevelopment in Ipswich
will allow us to better meet the needs of these younger people and their families. We plan to
work more closely with other providers and offer things, such as events and other
opportunities for patients and families to get the know us and ascertain their individual needs
for our services for when the time comes that they need us.
There will be discussions and plans made around the provision of care we will be able to
offer, during this transition period, which will include how the new and refurbished rooms will
be used in the Day unit at Ipswich.
How progress will be monitored and reported
Progress will be reported to the Patient Services Committee, Quality Assurance and
Improvement Group which will feed into the Governance Committee and then to the Board of
Trustees. The views and ideas of young people, their families and other providers will be
sought and play an important role in the development of services
9
2.1.3 PATIENT EFFECTIVENESS AND PATIENT EXPERIENCE
Priority Three
families and other providers, will be asked for their views and ideas, throughout the
Skill mix review and role development in the Community team
development of this service
To review the roles and skills of those providing care to patients in the community. In
particular, look at developing new volunteer roles and the roles of the Community
Healthcare Assistants. Consider the option of having registered nurses based in the
community who are not working to Clinical Specialist level
How this priority was decided
The community nursing team comprises of 3 teams; Clinical Nurse Specialists, Hospice at
Home Clinical Nurse Specialists and Community Healthcare Assistants. There is also a
volunteer role which supports people at home, often providing company and support to
people enabling family carers to leave the home for short periods of time.
The Community Healthcare Assistants are trained to a minimum level of NVQ II. The carers
often have to manage unplanned events when they make a visit, as the patients they are
caring for are usually very ill and near the end of their lives.
The Clinical Nurse Specialist team are registered nurses who are trained to degree and
masters level and work at a specialist level. They have identified elements of their role which
is not classed as specialist, and therefore could be undertaken by other skilled staff.
The review will look at the skills and experience of those attending patients in their own
homes and how volunteers can further enhance the service provision
How the priority will be achieved
The community manager will lead the review. Good examples and practice from other
organisations will be considered. There will consultation with the staff involved and service
users views and experiences will be sought and listened to. The Medical team will be
involved in the review
How progress will be monitored and reported
Progress will be reported to the Patient Services Committee, Quality Assurance and
Improvement Group which will feed into the Governance Committee.
2.2 ACHIEVEMENT OF PRIORITIES FOR IMPROVEMENT 2013-2014
2.2.1 PATIENT SAFETY
Priority One
Patient transport
The Hospice will provide safe and appropriate transport to patients, and their families,
where it is needed, to enable them to attend hospice services or return home
The hospice will be able to identify and provide transport to those patients and families, who
have no other means of transport, to ensure they can access services and that resources
Areas
for improvement
identified
forneeded.
2013-2014 were set out below.
are deployed
where they
are most
10
The Hospice currently provides transport to patients and families through 4 sources:
1. Volunteers use either their own cars or Hospice vehicles to provide transport.
Expenses are claimed from the Hospice.
2. The Hospice pays a taxi company/or independent provider to provide transport
3. The Hospice arranges an NHS ambulance to provide transport supported by
Department of Health circular for the provision of transport to Hospice patients
4. The Hospice pays for ambulance transport when there is an urgent need, e.g.
same day discharge at patient/families request and when there is no other option
Many patients attending Hospice services have mobility difficulties and due to the rural
nature of our locality many have a fair distance to travel. While some patients and families
attend weekly for day care or a group, others only attend occasionally for an out-patients
appointment.
Patients and their families are generally asked if they are able to provide their own transport
or need it provided. Currently if they ask for transport, we will arrange it free of charge to
them. We are not always able to arrange a volunteer driver so will use taxi services and for
the more infirm patients, we will arrange private ambulance transport.
Due to the rising number of patients attending our Day Units and multiple sites we are
experiencing a greater demand for our transport services. This, together with the increased
cost linked to higher fuel prices and some difficulty in recruiting volunteer drivers, is putting
pressure on our costs.
In order to ensure that we can continue to provide transport to those patients with the
greatest need we have agreed a thorough review of patient transport and to develop a
system for identifying patients for whom Hospice transport is essential. Resources and the
type of vehicle can then be allocated most appropriately. The options will need to include
assessing whether more Hospice owned vehicles and paid drivers are a good provision.
2013-14 We:
reviewed patient journeys from April 2012-2013, analysing the journey, cost, and
efficiency. We were providing close to 4,000 journeys a year, most were single
occupancy and not always using the most efficient provision.
confirmed that patients were accessing Hospice transport, predominantly when
attending the Day unit.
gathered information around the best provision, the options and use of volunteer
drivers and taxis to formulate a proposal of change.
made a plan and discussed the options with staff and volunteers and monitored
patient comments and reactions to the changes bought in. We were more pro-active
in asking whether patients actually needed us to arrange their transport or if they had
their own means of attending the Hospice. Many more patients than expected were
able to do so with no complaints
explained the proposed changes to patients, volunteers and staff and implemented a
change to reduce the number of journeys, ensuring the service is available to those
who need it, and that it is provided in an efficient way that is acceptable to the
patient.
Did we achieve these improvements? 
We now provide transport to patients only where there is a need
We have reduced the amount of journeys and use resources more efficiently to
ensure the people who need our support, is able to receive it. We forecast a 22%
reduction for the next year.
11
We are monitoring user satisfaction and our initial findings are positive with no
obvious effect on the uptake of our services and patient choice
2.2.2 PATIENT EXPERIENCE AND CLINICAL EFFECTIVENESS
Priority Two
Bed and mattresses
The Hospice is committed to providing adequate and appropriate equipment to
patients with identified needs to promote their quality of life, comfort, dignity and,
where appropriate, enable those patients to maintain and promote their
independence.
In 2011-12
through
the Quality,
Improvement
group
(QAIG) care
we identified
It has been
proposed
that theAssurance,
effectiveness
and efficiency
of patient
could be that the
Hospice
may by
be replacing
able to reduce
theKings
risk of
fallsbeds
through
introduction
enhanced
current
Fund
withthe
Volker
beds of a falls prevention
programme for at risk patients.
As part of our consultation on areas of improvement which we could include in our DH
Capital Grant Programme submission, the IPU staff raised the possibility of changing our
current provision of beds and mattresses to improve patient experience and improve staff
workload.
They noted that as our occupancy figures and the complexity of the needs of our patients
increase allocating appropriate equipment promptly and resourcefully is becoming
increasingly challenging for a number of reasons;
availability of high grade pressure relief due to increased needs and increasingly
complex patient care,
changing needs of the patients e.g. increased focus on rehabilitation.
Increased staff time used to change beds, mattress and bedrails and additional cleaning
of equipment
2013-14
We:
Trialled 2 leading company‟s beds and pressure relieving mattresses on the In-patient
Unit. Staff were instructed by the companies on their use and staff and patient‟s views
were sought during the trial.
made decisions based on patient and staff feedback, comfort, research, ease of use,
range of facilities, e.g. bed positioning and best buy.
decided on the beds and mattress‟ we needed and a paper was presented to the senior
management team
Did we achieve these improvements? 
We plan to purchase around 6-8 beds and mattresses initially this year, and replace all
within the next 2 years.
2.2.3 PATIENT EXPERIENCE
Priority Three
Day Services Redevelopment
The project is designed to enable the planned expansion of our Day Services by
providing a flexible, accessible space fit for the changing needs of our community
for the next ten years.
12
The Day Unit in Ipswich opens 5 days a week providing day care, out-patient appointments,
nurse led clinics and groups. Patients and carers are able to see doctors, nurses, therapists,
family support workers and chaplains. There is a lounge and smaller lounge/multi purpose
room overlooking the garden, a small rehab gym, rooms used for Complimentary Therapy,
Lymphoedema treatments, counselling and consultations. There is also a hairdressing room
and kitchen.
The unit is a busy place with around 280 monthly attendances to day care and 50 medical
out-patient appointments alone. The patient lounge can feel quite crowded. The Rehab gym
is functional but needs to be bigger to be able to hold groups in such as Healthy Moves
along with individual patient work. The Hospice intends to expand its palliative rehabilitation
service but will need to expand its environment first. It is also felt that, by moving offices
upstairs and away from the patient area, the patient area will not be disturbed by through
staff traffic and noisy offices as well as freeing more space for service provision.
2013-14 We:
set up a working party of staff, patient/family and architects to look at the needs of
patients and families within an extended Day Unit.
maximised the area available to provide more patient service space by moving staff
offices onto a second floor. By increasing the lounge and therapy space we will be able to
provide more services to more people in a space better equipped for the range of need,
i.e. younger patients, more wheelchair users, more rehabilitation, kitchen space that
enables more independence and more drop in areas. The design will also give us
additional 1:1 rooms so that patients have increased privacy, when needed.
Did we achieve these improvements? 
The build is underway with minimal disruption to patients as we have been able to
accommodate the building work without reducing any of our patient services. The plans
were approved and the extended Day Unit will be ready in the summer of this year.
2.3. STATEMENT OF ASSURANCE FROM THE BOARD
St Elizabeth Hospice is constantly aiming to improve quality of care and services to patients
and their families. It demonstrates this through its Governance structure. It has a culture of
openness and learning by its mistakes and not apportioning blame.
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.
2.3.1 REVIEW OF SERVICES
During 2013-2014 St Elizabeth Hospice provided and/or subcontracted the following NHS
services:
In-Patient Unit
Day Service Unit
Hospice at Home
Community Clinical Nurse Specialists and Healthcare Assistant
Family Support services, including bereavement service, Art and Music Therapists and
Chaplaincy team
Therapy services, including Lymphoedema, Complementary, Physiotherapy and
Occupational therapy
13
St Elizabeth Hospice has reviewed all the data available to it on the quality of care of these
NHS Services.
The income generated from the NHS in relation to services reviewed in April 2013 - March
2014 represents 34% of the total income generated for the provision of these NHS services
by St Elizabeth Hospice for that period.
2.3.2 PARTICIPATION IN NATIONAL CLINICAL AUDITS
As a provider of specialist palliative care, St Elizabeth Hospice is not eligible to participate in
any of the national clinical audits or national confidential enquiries as they did not relate to
specialist palliative care. We will also not be participating in them next year for the same
reason. (Mandatory statement).
2.3.3 PARTICIPATION IN LOCAL AUDITS
The schedule overleaf shows the local audits that St Elizabeth Hospice will carry out in
2014/15.
14
Audit Diary Chart 2014/15
In-Patient Unit
(rolling)
Drug (6 monthly)
Medical (bi
annual)
- Insomnia
- Pain
April
14
AO
Diet & Nutrition
Help the Hospice
– Quality Metrics
Jun
Jul
Aug
sep
AO
Oct
Nov
Dec
AO
VJ
Jan
15
AO
Feb
Mar
VJ
Spec
R
Spec
R
- Paracentesis
H@H (rolling)
Staff Survey
(annual)
Community Audit
(rolling)
SLA Stats (6
monthly)
Incidents –
Patients
(6 monthly)
Incidents – Nonpatients (6
monthly)
Complaints,
Compliments &
SUI‟s (quarterly)
Income Gen.
Discharge (bi
annual)
Documentation
(6 monthly main
and monthly
mini))
Education/Trainin
g (annual)
Day Care
(rolling)
Controlled Drug
Audit
Bereavement
Feedback
Infection Control
Report
CQC Evidence
Quality Account
May
Spe
cR
AO
AO
AO
AO
AO
AO
AO
AO
ST
LL
ST
LL
AO
AO
ST
ST
ST
ST
LL
VJ
VJ
VJ
CN
S
VJ
VJ
VJ
VJ
VJ
FSW
VJ
VJ
SA
AO
AO
AO
VJ
AO
VJ
AO
IPU/
DC
IPU/
DC
IPU/
DC
AO
VJ
AO
AO
ZJ
AO
Abbreviation Table
H@H – Hospice at Home
SLA – Service Level Agreement
SUI‟s – Sudden Untoward Incidents
CQC –Care Quality Commission
IPU- In-Patient Unit
DC – Day Care
FSW – Family Support Workers
Spec R – Specialty Registrar
Coloured boxes with initials represent those members of staff in charge of audit
The reports of 12 clinical audits have been reviewed and St Elizabeth Hospice has used
these results to influence its priorities for improvement in 2014-2015.
15
2.3.4. RESEARCH
There were no patients receiving NHS services provided or subcontracted by St Elizabeth
Hospice in 2013-2014 recruited to participate in research approved by a research ethics
committee. (Mandatory statement).
There have not been any national research projects in palliative care in which our patients
were asked to participate.
2.3.5. GOALS AGREED WITH COMMISSIONERS
St Elizabeth Hospice‟s income in 2014-2015 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. It was therefore not eligible to
take part. (Mandatory statement).
2.3.6. WHAT OTHERS SAY ABOUT ST ELIZABETH HOSPICE
2.3.6.1 Summary feedback from unannounced CQC inspection January 2014
We found a service that was cherished by all who used it. People were enthusiastic about
their praise for the service and the kindness and compassion shown by all who worked and
volunteered at this service. We spoke with 10 people who had recently or were currently
receiving a service. One person typically said, "I was overwhelmed with their kindness and
help. All the staff were lovely. They were skilled and well trained. They made such a
difference. They explained everything. They were able to read the situation and provide the
needed answers".
We found that the care and support people needed was appropriately provided and what
people wanted, but we also found that there was a potential through incomplete records that
care may be unsafely delivered. Care records seen did not always support the care that was
delivered.
We found an environment that was suitable and well maintained and ensured the safety of
people who used it. We found a staff group that was well trained and very well supported to
complete their role at the Hospice.
2.3.7. DATA QUALITY
St Elizabeth Hospice did not submit records during 2013-2014 to the Secondary Uses
Service for inclusion in the Hospital Episode Statistics which are included in the latest
published data. (Mandatory statement).
This is because we are not required to submit data to this system.
2.3.7.1 Information governance
St Elizabeth Hospice did not hold a formal contract with NHS Suffolk for 2013-2014 for
Information Quality and Records Management, assessed using the Information Governance
Toolkit version. (Mandatory statement). The Hospice is considered level 1 compliant. We
have an action plan in place for reaching level 2 compliance which is nearly completed.
16
2.3.7.2 Clinical coding
St Elizabeth Hospice was not subject to the Payment by Results clinical coding audit during
2013 -2014 by the Audit Commission. (Mandatory statement).
PART 3 REVIEW OF QUALITY PERFORMANCE
3.1 QUALITY OVERVIEW
3.1.1 St Elizabeth Hospice governance policy statement;
The organisation aims to ensure the overall direction, effectiveness, supervision and
accountability of the organisation by putting in place a system and processes which:
Achieves continuous quality improvements by identifying and instigating best
practice, learning through mistakes, and creating an environment in which
excellence can flourish.
Ensures compliance with relevant regulations and legislation.
Ensures efficacy and effectiveness.
Ensures that the charity meets its objects as outlined in the Memorandum of
Association.
St Elizabeth Governance Structure
Board of Trustees
Governance
Committee
Quality
assurance
and
Improvement
Group
Finance
Committee
Risk
Management
Group
Health
and
Safety
Group
Patient
Services
Committee
Partnership
Group
Income
Generation
Committee
Nominations
Committee
Remuneration
Committee
The Quality Assurance and Improvement Group has a rolling audit programme as well as
the ability to prioritise new audits if this response is required.
The Partnership Group
The group has been established for over 8 years and is comprised of Patients past and present and
Carers together with Hospice staff members assigned to the group. The group’s ethos is to ensure
that the views and opinions of Patients, Carers and family members using the Hospice are adapted
for improving the care and shaping Hospice services.
17
The Partnership Group in January 2014
Achievements
During 2013 the group had been very busy with conducting Patient Audits on behalf of the
Hospice on the IPU. We have also formally registered as members of Healthwatch Suffolk
and have become a VIP resource for their “Hubs” they are setting up in Suffolk. The Group
has grown this year with the addition of 4 new members two patients and two carers this has
made the group have a more debatable platform and a more constructive point of view with
discussions. We have been actively involved in the planning meetings of the New Day-care
centre and this will remain a focal point for the group with a number of patients on the group
who already attend the centre and others who may start using once the new centre is built.
There have also been other tasks achieved by the group during the year.
Action plan 2014
Reviewing Complementary Therapy available at the Hospice for Patients (This was
not achieved in 2013).
Working closely with the Teams in the Hospice at looking into suitable seating for
Patients in Day-Care and IPU.
Orchestrate communication with outside support groups of the “Non Cancer Patient
Group” in the Hospice to introduce this element into the Partnership Group from this
the group will feed the support group information out to patients and Hospice in a
newsletter.
Continuously review the action plan.
The Partnership Group is striving to ensure that it continues to promote a proactive
Partnership with Hospice departments and Management. To work closely with the
departments that needs our input but to have a listening ear in overcoming issues that we
feel effect Patients and carers which leads to a clear understanding of the needs of the
Hospice users.
Ian Ewers-Larose, Chair of Partnership Group, 17th January 2014
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The Accountable Officer is also the Registered Manager and a member of the Locality
Intelligence Network group. She monitors drugs incidents, makes six monthly Drug incident
reports and assesses the storage, destruction and use of controlled drugs formally every six
months.
Each Directorate has a risk register which is updated regularly. Risk assessments and
incidents are raised at the Health and Safety Group.
The Hospice has its own Responsible Officer, Dr Kelvin Bengtson. All doctors are now
expected to be appraised on a regular annual basis and then revalidated every 5 years. All
systems and processes are in place to ensure that this happens.
3.1.2 Quality overview
In 2013-2014 St Elizabeth cared for 2439 patients and their families across the range of
services.
This is a selection of patient and carer comments on our services
In-Patient Unit Survey
“....completely new to Hospice environment very surprised very happy with service and care”
Hospice at Home audit
“We would just like to say thank you to them all from us and our mum. She died with us in
her home with dignity, we could ask for no more”.
Community Nurse Specialist Feedback Audit
“Fantastic support in all aspects of our journey, could not wished for better. Thank you so
much.”
Complaints and compliments
All complaints received at St Elizabeth Hospice are taken seriously, fully investigated and
processed as laid out in our complaints procedure. Examples of compliments received:Community
“Although mum never needed to spend time in the actual hospice, we are indebted to the Hospice
at Home service, OneCall and the Community Nurses who lovingly looked after mum, and especially
so at her end. Her wish to remain at home during her illness and your team gave her and us the
courage and ability to “make the most” of her last months and indeed pass away at home with the
dignity she greatly deserved. You are all truly wonderful and dedicated people and we couldn’t have
got through such difficult times without you.”
“I am writing to express our gratitude for the care, help and expertise which has been so readily
given by your staff for my wife who sadly died on Saturday …within a very short time I began to
appreciate just how accessible were your staff who had answers to my questions, they were the
ones who picked up the phone. … We were so grateful that Alison Blaken was willing to come to see
my wife in Aldeburgh and was generous with the time she gave us. ….I telephoned OneCall and
Mandy answered, she listened to what I had to say and suggested she come to visit. She was so
good, she saw things needed taking in hand and within two hours a hospital bed was delivered and
arranged and the syringe driver fitted….We became used to seeing the CHCA team ….and were so
pleased when Angie, Cathy and Becky arrived to carry out the final tidying up of my wife.”
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IPU
“I would like to thank everyone connected with the hospice … having teenage children, they made
sure that they felt comfortable on visiting their dad … he had a room on his own which enabled us to
spend a lot more equality time with him. His illness progressed rapidly in the last two weeks of life …
we had fantastic help from the hospice nurses and carers when he was at home … having a direct
telephone number really helped. As his health deteriorated he wanted to come to the hospice. We
had fantastic help from the nurses who kept us totally informed. The male nurse gave the kids the
hospitality suite and me a bed beside him, explaining what was happening … and dealt with
everything when he passed away.”
To the nurses, doctors and staff. We would like to thank you all for everything you did for our son in
law and daughter and grandson, providing them with a lovely room for their wedding and for making
it so special for them and us and also for the love and care you all gave him that allowed him to pass
away in peace.
…We all loved him so much, it was unbelievably difficult to lose him but you all cared for him, and
us, so well we will never be able to thank you enough for treating him so kindly, giving him support
and reassurance and for seeing him as the lovely person he was rather than just a terribly ill man.
You gave us the chance to spend so much time with him, in the caring and supportive atmosphere of
the hospice, time and memories that we will now cherish forever.
Day care
“My purpose in writing this letter is to say a big thank you to everyone at the Hospice … for looking
after my husband and myself so well. You helped make his last year not only bearable but a special
time of acceptance and dignity and I shall always be grateful to you. The Hospice is an extraordinary
and unique place and the people who work there are truly amazing. He enjoyed the “making
memories” group, enjoying the company of the ladies and gentleman … on Fridays he enjoyed his
respite day, meeting Maida, enjoying lunch. On the morning he passed away a pretty nurse from the
hospice was assisting me to give him a bed bath. He faded away from this earthly life with the nurse
holding one of his hands and me holding the other and stroking his brow and talking to him. I
couldn’t have wished for better. At his funeral the Reverend Joanna Perry officiated and helped to
make the occasion very special for all who attended.
Quality Markers we have chosen to measure
In order to inform the governance process St Elizabeth Hospice monitors outcomes across
six different areas of the Hospice work monthly using recognised tools and national
benchmarking data.
This enables the Board to look at areas of development over a period of twelve months to
monitor progress and identify actions for any areas of concern.
Domain
Outcome
Patient experience
Relief of Symptoms
Meeting patient‟s needs
Patient Choice
Achievement of
preferred place for care
Tools
-
pain assessment audit
Edinburgh post natal depression
scale
HOPE Spiritual assessment Tool
audit of complaints and
compliments
audit of preferred priorities for care
audit of delayed discharges
audit of advance care plans
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Financial health
-
audit of patient accidents
audit of drug incidents
audit of hospital acquired infections
staff retention
working days lost due to sickness
investment in training
audited accounts
Widening access
-
Use of resources
-
increase in patients with non-cancer
diagnosis
uptake of day care places
uptake of nurse-led clinic places
time in service
Patient safety
Maintain a safe
environment
Effective workforce
Employer of choice
Financial sustainability
Organisational
effectiveness
3.2 WHO HAS BEEN INVOLVED
Chief Executive Officer
Senior Management Team
-
Director of Patient Services
Medical Director
Director of Corporate services
Director of Income Generation and Marketing
Quality and Improvement Group
Partnership group
Governance Committee
Board of Trustees
3.3 STATEMENTS PROVIDED FROM COMMISSIONING CCG, HealthWatch and OSCS
The following statements were made in response to receiving this Quality Account.
Ipswich and East Suffolk Clinical Commissioning Group
“Ipswich and East Suffolk Clinical Commissioning Group, as the commissioning organisation
for St. Elizabeth Hospice, confirm that the Trust has consulted and invited comment
regarding the Quality Account for 2013/2014. This has occurred within the agreed timeframe
and the CCG is satisfied that the Quality Account incorporates all the mandated elements
required.
The CCG has reviewed the Quality Account data to assess reliability and validity and to the
best of our knowledge consider that the data is accurate. The information contained within
the Quality Account is reflective of both the challenges and achievements within the Trust
over the previous 12 month period.
The priorities identified within the account for the year ahead reflect and support local
priorities.
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Ipswich and East Suffolk Clinical Commissioning Group is currently working with clinicians
and manager from the Trust and with local service users to continue to improve services to
ensure quality, safety, clinical effectiveness and good patient/care experience is delivered
across the organisation.
This Quality Account demonstrates the commitment of the Trust to improve services. The
Clinical Commissioning Group endorses the publication of this account”.
Barbara McLean
Chief Nursing Officer
Overview and Scrutiny Committees (OSC)
The Suffolk Health Scrutiny Committee appreciates the opportunity to comment on this
year‟s Quality Accounts.
This year, the Suffolk Health and Wellbeing Board has agreed that Quality Accounts should
be referred to the Health Scrutiny Committee for discussion and oversight.
In light of the Francis Report, the Committee is clear that accountability in the NHS is not just
about publishing data. This needs to be linked to mechanisms that bring a reality check to
make sure that patients‟ experiences are properly reflected. The Committee believes that
quality improvement should be an ongoing cycle.
The Health Scrutiny Committee has, in the main, been content with the engagement of local
healthcare providers in the work of the Committee over the past year, and is keen that
relationships with local providers should continue to be built upon, with a view to ensuring
the best possible health services for the people of Suffolk.
County Councillor Michael Ladd, Chairman
On behalf of the Suffolk Health Scrutiny Committee
HealthWatch
Thank you for sending us the St Elizabeth‟s QA document. Healthwatch Suffolk will not be
responding this year, but will of course be keen to see the final version and will communicate
any feedback we have about the hospice with you.
Many thanks and kind regards
Jenny Ward
Information Services Officer
If you have any feedback on this document, please email our enquiries line on
enquiries@stelizabethHospice.org.uk or visit our website www.stelizabethHospice.org.uk
and complete our form for comments, compliments or complaints, which is found in the
Contact Us section.
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