Quality Accounts Report
2013-2014
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Part 1: Chief Executive’s Statement
I am pleased to provide our Quality Account for the work of St Joseph’s Hospice,
Hackney. We are a charity, separate from the NHS, but we have prepared the report
in recognition of the financial support we have from the NHS and the contribution
we make to local NHS services.
St Joseph’s Hospice delivers specialist palliative care, end of life care, and respite
care for people with a progressive and life-threatening illness, their families and
carers. Our priority is to look after people with complex or multiple needs and to
provide specialist support and expertise in end of life care to generalist services in
hospitals and the community. In addition we provide expert advice and support to
other professionals on specialist palliative and end of life care, offer specialised
education and training and undertake targeted research in aspects of this care.
Underpinning all our work, as part of our founding mission, is a particular
responsibility to support the poor – whatever the form of their poverty – health,
economic, social, emotional, spiritual etc.
We are committed to providing our services in partnership with other like-minded
organisations.
Our Mission is central to the quality of everything we do at St Joseph’s and in
2013/14 we achieved many quality improvements. These include:
•
Continuing to improve physical spaces at the Hospice, including the
refurbishment of space to enable better coordination of teams and their
interdependencies and opening of the ground floor Community Hub made
possible by a grant from the Department of Health. This has enabled our
Reception and public areas to be more welcoming and accessible to our local
community
•
Continued working with other care providers including Marie Curie to take a
proactive lead across inner East London to make the case for better
coordination of care and for rapid response mechanisms to support people who
are in their last years of life/end of life in the community and their carers
•
Continued work in embedding our compassionate communities initiative – with
pilot projects in Hackney and new initiatives within Newham to ensure easier
access to our services
•
Supporting our staff and teams:
− Initiatives such as the monthly multidisciplinary Schwartz rounds supporting
our staff in their emotional and demanding work with patients and families.
− taking forward actions following our annual staff survey
•
Continued engagement with local ethnically diverse communities
•
Continued expansion of the way we care for people in the community
•
Fully operationalising our First Contact team to create a simpler and revised
pathway for referrals to hospice services and introduce a Nurse led 24/7 advice
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& support telephone line service. This is reflected with our current level of
activity – Appendix 1
•
The hospice has accommodated the inpatient service of Richard House
Children’s Hospice, during the refurbishment of their wards. This has provided
an opportunity to enhance further joint working in supporting young adults
making the transition between children’s and adult hospice services. We have
now established a joint transition team between the two hospices to support this
work
•
Continued joint clinics with local NHS providers which support patients with lifelimiting conditions other than cancer.
Our services are available free to the people who need them. Just over 55% of the
Hospice costs are met by local NHS commissioners. The remainder of our funding
comes from charitable legacies, donations and other fundraising. Our fundraising
represents an additional input of some £6.2 million in 2014-15 into local palliative
care services.
Delivery of consistent, high quality services continues to be at the heart of everything we
do, and our goal is to achieve the best quality of life for our patients and their families all
the time. We do this by providing an active, high quality holistic approach to managing
any distressing problems patients may encounter as a result of their illness. This may
involve management of pain and other symptoms, and the provision of psychological,
social and spiritual support are paramount – based on detailed assessment of the needs
of the patient and discussion regarding their preferences by a multi professional team.
We aim to work in active collaboration with our patients, their families and carers and
are keen to enable patients and their families to be actively involved in the development
of plans for care of their loved one if this is what they wish. These plans, in which quality
is embedded, are reviewed on a regular basis – both formally and informally by staff
involved in their implementation. Formal review is undertaken by a multi-disciplinary
team. In addition we seek to communicate regularly with other healthcare professionals
involved in our patients’ care to ensure seamless support wherever possible.
The Hospice is also keen to work in partnership with other organisations; we fully realise
that we cannot meet our patients’ many needs by ourselves. We work closely with local
NHS providers, CCGs and with Marie Curie, Richard House, Age UK East, Macmillan and
with other voluntary sector care providers to deliver better integrated services. We want
to develop closer links with social services and other relevant local authority services.
We have been an active participant of ‘One Hackney’, a CCG initiative to promote
integrated working to ensure Hackney’s most frail and vulnerable people receive
integrated care to enable them to receive care in the community wherever possible.
Our Finding Space area at the hospice provides a welcoming and comfortable place for a
growing number of user groups to meet and/or deliver care and support. Our Education
Centre is used by more groups for meetings and conferences, which enhances our
presence and visibility within the health and care sector.
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St Joseph’s Hospice is set within an ethnically diverse area. We aim to meet the varying
needs and expectations of all our patients, their families and carers, whatever their
cultural, spiritual or ethnic background. We offer culturally sensitive diets and other
services; we are supported by a comprehensive bilingual and advocacy service and
multi-faith chaplaincy services. We actively reach out to different communities so that
they are aware of our existence and so that we can learn more about their particular
needs.
The standards of high quality care to which we aspire could not be achieved without the
commitment and dedication of our staff and our volunteers all of whom contribute so
actively to help us achieve our mission to serve the people of East London.
St Joseph’s is accountable for safety and quality to the Care Quality Commission
(CQC). For registration and compliance purposes, I am the Responsible Individual
and the Registered Manager is Ruth Bradley, Director of Care Services. We received
a very positive report about our services from the CQC in October 2013 following
inspection of our main hospice site services; all standards were met in relation to the
following:
•
•
•
•
•
Consent to care and treatment
Care and welfare of people who use services
Cleanliness and infection control
Assessing and monitoring the quality of service provision
Complaints
We also had a further inspection of the specialist palliative care service that we
provide to the East Ham Care centre in Newham in March 2014 this was also a
positive report. The following standards were reviewed and all were met:
•
•
•
•
•
Respecting and involving people who use our service
Safety and suitability of premises
Safety and suitability of equipment
Supporting workers
Records
However, we do not rely on CQC reports to validate the quality of our services. We
undertake regular internal inspections. The quality of care generally is overseen by
the Hospice Senior Management Team. Regular reports on quality safety and service
improvement are considered by our multi-professional Clinical Governance
Committee.
This report follows the standard format. We provide a comprehensive range of
palliative care services for the people of City and Hackney, Newham and Tower
Hamlets, as well as specific services in other areas. Although the report will be
reviewed by the Hackney Scrutiny Committee, it picks up work from other areas
where relevant.
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I am responsible for the preparation of this report and its contents. It has been
developed by the Director of Care and Clinical Governance Lead in conjunction with
senior clinical and non-clinical staff and shared with the Chair of the Board of
Trustees before being distributed to local scrutinisers of the Hackney Health and
Wellbeing Board, and commissioning primary care trusts. 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.
Michael Kerin
Chief Executive
11/06/14
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Contents
Priorities for improvement 2014 -2015
Future planning Priority 1- Continue to build on Community
Engagement - to improve service users experience
Future planning Priority 2 – Improving Choices at the End of Life –
to enhance experience Increased Engagement with Service Users –
to inform Improvements to Patients experiences and Clinical
Effectiveness
Future planning Priority 3- To strengthen patient safety and clinical
effectiveness by developing better Information systems and
processes to measure quality and enhance Information Governance
Future planning Priority 4- Continue to Lead in embracing
Partnership working with Health & Social care - to improve Service
users experiences in End of Life care
Priorities for Improvement 2013 -14
Page
7
9
10
11
11
12
Future planning Priority 1- Building on Community Engagement - to
improve service users experience
12
Future planning Priority 2 – Improving Choices at the End of Life –
to enhance experience
18
Future planning Priority 3- Strengthening Information Governance –
to strengthen patient safety and clinical effectiveness
18
Future planning Priority 4- Leading on Partnership working
19
Statement of Assurance from the Board
21
Review of Quality Performance
27
Glossary of terms
29
Appendix 1 – MDS data
30
Appendix 2 – Audit schedule
31
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Part 2: Priorities for Improvement 2014-2015
St Joseph’s Hospice remains compliant with the National Minimum Standards (2002)
and has satisfied the Care Quality Commission that standards are being met through
self-assessment and via a visit from CQC in October 2013 and March 2014. As such,
the Board did not have any areas of regulatory shortfall to include in the priorities
for improvement for 2014-2015.
The work of the Hospice in recent years has been underpinned by our Strategic Plan
(2007-12) which was developed after consultation with local stakeholders. Following
consultation, we have identified strategic priorities for 2012-2015 which reaffirm and
build upon these existing priorities. We have shared our proposals with external
stakeholders (including the Hackney Cabinet Member for Health, Social Care and
Culture).
These take forward our existing priorities, building on the progress we have made in
the last five years.
1. A local leadership role in end of life care
2. Better coordination of care:
a. Key partner in developing the case for an integrated East London palliative
and end of life care coordination service
b. Community developments.
3. Proactive partnerships with NHS and others:
a. to avoid unnecessary hospital admissions and provide 24/7 availability of
key services
b. to meet people’s choice in place of care and death
4. Promoting social justice:
a. “compassionate communities” especially in communities which are
disadvantaged
b. working with other groups who share our goals, to advocate for the needs
of the poor and vulnerable, and to improve information services (eg
working with Macmillan to develop an information service linked into the
Macmillan initiative with Hackney libraries.
5. Greater visibility of the hospice:
a. As a provider of care, education and expertise
b. At the “heart of the community” - encouraging other groups working for
the common good to use hospice facilities where this does not detract
from delivery of our core services.
c. In delivering a range of new services in the community
d. In the image we present on Mare Street through our site strategy.
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6. Ensuring St Joseph’s Hospice’s sustainability:
Remaining sustainable by ensuring the Hospice is financially responsible and
maintains strong governance, management and organisational health.
The priorities in this year’s Quality Account are to build on the work following last
year’s priorities for improvements. This has set the foundations for future planning
and developments and incorporates strategic plans becoming embedded in the
organisational changes taking place.
The Hospice continues to consider how it can extend and improve its services to
better meet the needs of our local population, in line with the six key priorities in the
Strategic Plan and drawing on local NHS plans. We have continued to look at
development opportunities for service improvement from a wide variety of specific
funding sources including Government grants for Hospices, Third Sector grants and
from trusts.
We welcome your comments and ideas on this Quality Account which you can do via
email, letter or telephone to Ruth Bradley, Director of Care Services. If you know of
someone that may need a translation we will make arrangements for this to be
provided via our Advocacy and Interpreter services.
St Joseph’s Hospice confirms that the quality improvement priorities for 2014 to
2015 will be:
Strengthen existing service provision: service improvements to meet changing needs
of local communities, and good practice, for example:
•
St Joseph’s First Contact Team: this multi professional referrals and triage team was
established in September 2013 and already demonstrates that the goal of improving
access to the range of hospice services is being achieved.
−
−
−
Early indications are that internal referrals within the organisation have increased as
well as referrals from GPs, offering a wider range of hospice services to people.
The team aims to allow individuals to be seen at an earlier stage of their life limiting
illness
When patients and clients and their families have been assessed and do not require
Hospice services, we are signposting them to a range of appropriate, local services
that will meet their needs.
•
Development programme of the clinical pharmacist service: to develop the use
of the most appropriate and cost-effective drugs and to improve the quality of medicines
management.
•
Expanding community based support: notably through the development of ‘St
Joseph’s At Home’ community model and taking more services into community settings.
•
Extending care beyond cancer: development of joint outpatient clinics and services
with relevant specialists, respite provision and Finding Space
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•
A source of advice, support and expertise: through education provision, research
and articles, formal and informal engagement with professionals and opinion-formers in
other local organisations and through the information service in Finding Space.
•
Reaching out to local communities and building community capacity: On-going
engagement with different ethnic communities to raise awareness of the work of the
Hospice. We also aim to promote the work of the hospice via fundraising and
volunteering activities.
We are building community capacity in “compassionate communities”, working with
local groups, to help them acquire skills and confidence to support to people in their
community who are dying or who are carers. During 2013 and 2014 the hospice
initiated a Compassionate Communities project in Hackney. A project manager was
appointed to take this work forward and we are already working with local faith groups
to identify what information and support they need to be better able to support
members of their communities who are dying or recently bereaved. The scheme is
being formally launched at an event at the Hospice on 25 June.
•
Additional support to carers: especially through respite provision and activities in
Finding Space and our Compassionate Communities work.
Future planning Priority 1- Continue to build on Community Engagement to improve service users experience
We will continue to seek the views of our service users and other members of the local
communities that we serve about how we can improve our services in relation to their scale,
scope and quality.
This work helps to inform us about how we meet service user needs and build on the work
already achieved to support our current patient needs and expectations and we have used
several approaches to help us achieve this aim:a.
Finding Space, a facility which opened in 2009, is a hub for activities focused on
−
−
−
Community engagement – through which local people find out more about
Hospice and end of life care, and engage with St Joseph’s Hospice to work
together to improve end of life provision in East London
Community empowerment – through which individuals are empowered to
change their experience of end of life care as individuals directly affected by a life
threatening illness, as carers of someone with a serious condition or as family
members facing loss. It is anticipated that their experience could be improved
through increased knowledge of their choices and care available (via the
information service) and through assistance to communicate their preferences and
needs at the end of life. In addition they will be able to receive services and
support in Finding Space that helps them live well despite the challenges of an
advancing illness – for example welfare benefits advice, complementary therapies,
stress management and similar. Carers will receive help and guidance to care
effectively for others and themselves
Community participation – compassionate communities pilot in Hackney
through which individuals and communities are trained and supported to help
provide aspects of end of life care to others in their families, communities or local
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area. Such care could include practical and social support for the patient, their
family or carer.
b.
Newham Satellite Services: A vital part of developing the model for a satellite
service in Newham – which we would aim to replicate in all such community
developments - was to seek the views and ideas of local residents about what type of
service(s) would make a positive impact to their quality of life. Feedback has informed
the development of this service; the satellite service will initially deliver predominantly
supportive care services in Chargeable Lane which is conveniently located to the local
hospital and is a centre where other providers of social care are based offering good
networking opportunities across services. Plans for 2014 – 2015 will be to establish
these services and explore future needs.
c.
Public Health messages to the local community - a work stream with Tower
Hamlets CCG - is to develop a series of articles for publication in local newspapers that
promote public health messages that relate to the last years of life. The hospice has
formed links with public health leads and ‘Faith in Health’ based at the London Muslim
Centre, to ascertain the best means of community engagement on issues such as
Advance Care Planning, Rehabilitative Care, emotional support. Dr Libby Sallnow –
who has been leading on the compassionate communities developments, will be an
advisor to this work.
Future planning Priority 2 – Improving Choices at the End of Life – to
enhance experience Increased Engagement with Service Users – to inform
Improvements to Patients experiences and Clinical Effectiveness
We are keen to take more of our services into the local community. It is acknowledged that
the will be operational challenges of working at satellite bases – the first base in Newham
will serve as a test bed for future developments and a project team has already been
established to consider the issues and options.
Work has been completed on updating our full range of patient and visitor information
leaflets and further work is in progress on the Hospice website which will enable
communities and potential service users to make informed decisions and choices about
accessing the range of services offered by St Joseph’s. We have already introduced a new
‘generic’ information booklet and a specific leaflet for visitors. This revised information will
also be available on the website.
In 2013-14, we started Care Compass, an initiative to extend our hospice services to reach
more people in our local communities, providing a website-based personalised advice and
support service, developing a number of community based services, and using new
technology. The Department of Health awarded St Joseph’s a Small Business Research
Initiative (SBRI) grant to support the website development. Although the development was
not commercial enough for continued SBRI support, the plan is to continue to develop the
website both for local people, to encourage hospices in other areas to establish linked
website-based developments and to seek to secure funding from elsewhere.
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Future planning Priority 3- To strengthen patient safety and clinical
effectiveness by developing better Clinical Information systems and
processes to measure quality and enhance Information Governance
In order to support ongoing development across the wide range of services that the hospice
offers and those that are planned, it is recognized that our current provision of clinical
information systems needs to be strengthened. The priority for 2013 to 2014 was to
improve the current information systems and ensure that we meet all expectations in
respect of information governance. Whilst we have achieved a significant part of this work, it
will continue to be a high priority for 2014 – 2015.
We will be replacing our current Clinical Information system to ensure that is ‘fit for purpose’
and meets the complex and changing needs of the Hospice. The focus for 2014 -2015 will
be on ensuring our IT strategy ensures support for any new system and that the
infrastructure supports effective controls and efficient access to information in order that
new and innovative ways of working can be implemented. Here will be a need to undertake
training and on-going support for staff in any new system that is implemented.
We will ensure the appropriate use of information and avoid unnecessary capture,
processing, sharing and storage and promote integrity and accuracy of information.
One of the key requirements of any new system will be to ensure that we are able to report
accurately on all activity and on all quality indicators for commissioners and to enable the
hospice to review performance measures for individual services by developing quality
dashboards incorporating measures of clinical outcome, patient experience and service
effectiveness and efficiency.
The hospice participated in a national bench-marking project facilitated by Help the Hospices
of the ‘Inpatient Unit Patient Safety Metrics’. This commenced in April 2014, data is
submitted quarterly on falls, pressure ulcers and medication errors and results will enable
the hospice to compare our prevalence with similar sized hospices.
Quality Management data measures such as mandatory training, appraisal and sickness &
absence are now available in a dashboard format. This information will also enable us to
benchmark internally across service areas and also is readily available to compare across
other similar organisations.
Future planning Priority 4 - Continue to Lead in embracing Partnership
working with Health & Social care - to improve Service users experiences
in End of Life care
Borough based working
As noted above, the hospice is an active member of the One Hackney initiative to bring
providers together to meet the needs of the most vulnerable residents in the Borough.
We have established good links with City and Hackney Clinical Commissioning Group to work
together on planning services and are members of a stakeholder group to review clinical
ambitions for end of life care for City and Hackney. Michael Kerin continues as the voluntary
sector member of the Hackney Health and Wellbeing Board.
The hospice Strategic Planning Group; brings together a wide range of senior hospice
leaders and managers to exchange information on and coordinate the strategic
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developments from all areas across the hospice. This will also provide a platform for
reviewing the impacts of schemes in individual Boroughs in our area, and whether they can
be rolled out in other areas. The Borough based working in other East London Boroughs
includes the initiatives in Newham (already noted) and engaging with Bart’s Health NHS
Trust and the relevant commissioners around services in Tower Hamlets, Newham and
Waltham Forest.
Working within our Community
The commitment and input of volunteers will be vital in supporting us in terms of community
engagement. We recently surveyed volunteers working at St Joseph’s Hospice and asked
them “What did you hope to gain from volunteering when you first started?” The
overwhelming majority felt they were making a valuable contribution to the community. This
is encouraging for future recruitment alongside the fact that most prospective volunteers
request to work closely with patients.
Alongside our Compassionate Communities work, we will continue to seek news ways in
which we can work with our partners in health and social care to support people who wish
to die at home or who need additional support from our services in the community. The
hospice will continue to seek opportunities to enable patients and carers to receive flexible,
sensitive accessible and timely care services either in their home or in a location of their
choice. To achieve this we have formed various partnerships to explore suitable models of
home care.
An example of this is the planned work is the Hope for Home initiative. Hope for Home was
formed in response to a perceived lack of support for families and friends who were carers
to people with dementia. St Joseph's Hospice has been commissioned by Hope for Home to
deliver Namaste Care therapy from April 2014, to people with Dementia in their own homes.
Namaste Care will be delivered by trained volunteers managed by a development manager
who is professionally led and supervised by a senior nurse.
Part 3: Priorities for improvement 2013-14
This section reports on the progress on the priorities for improvement last year, and what
was achieved over this period. The quality improvement priorities for 2013-2014 were as
follows:
Improvement Priority 1: Building on Community Engagement - to improve
service user’s experience
Feedback
St Joseph’s Hospice values the views of all its service users. This is especially the case given
the very culturally diverse and ever-changing nature of the population that we serve. We
continue to gather views, and acting upon them is a clear and permanent priority for the
Hospice. The Hospice has sought the views and feedback from taken an explicit decision to
work proactively and engage with local organisations to facilitate access to views of minority
or hard to reach groups around aspects of our care, in order to help us achieve our
objective of “engaging effectively with our local communities”. Our overall aim in this work
has been to increase the sense that St. Joseph’s is there for all, and is “owned” by local
people from all the different communities in East London.
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Compassionate Communities: Hackney
The Compassionate Communities development and implementation of a project plan was to
establish compassionate communities in Hackney and was started formally in mid-2013.
The project aims to build a network of confident lay carers “Community Neighbours” who
support people affected by end of life issues so as to augment the care provided by
professionals. The principles of the project include recognising the unique contribution of
individuals who give time and attention to others in their community who face advancing
illness or bereavement.
The Project Manager identified key community groups to target (because of the limited
capacity and resources of the project, and to ensure the project reached some of the more
vulnerable groups) which include the Turkish/Kurdish communities, the older White
population and the Black Caribbean community. The project is being undertaken in
partnership with Social Action for Health who are specialists amongst those communities.
Some of the project money has been invested further in Social Action for Health workers to
ensure that the training and outreach of the project gathers pace (as there is a limit to the
pace a two-day a week post holder can manage).
The project provides culturally sensitive training, support and supervision for people who are
interested in learning more about how to support others in their communities facing end of
life. It aims to make a difference to the social isolation, practical challenges and gaps in
care and advocacy that people who are unwell or bereaved must cope with. It is also an
opportunity to signpost to all STJH services and break down the barriers to understanding
what a hospice does and what is available locally.
Key challenges for the project include:
• how to ‘fit’ with other community work happening in Hackney (for example, other work
reaching out to religious leaders in Hackney) in order to efficiently share resources and
contacts.
• thinking about how it might inform or shape other community work happening in other
boroughs, such as the Newham community outreach work.
• finding long-term external funding to pay for the project. The Fundraising Team is
working on identifying possible funders.
Care Compass Project
This initiative was established to extend our hospice services to reach more people in our
local communities, providing an onsite personalised advice and support service, developing a
number of community based services, and using new technology.
The Department of Health awarded St Joseph’s a Small Business Research Initiative (SBRI)
grant to support a website development. Our vision was to create a website which is for
everyone who has been diagnosed with, or experienced, a life limiting illness or condition,
including families, carers, and friends. Our work with people indicate that there’s a need for
sharing stories and gaining support, which is not expert or professional, but given by others
experiencing similar situations.
We believe that people would like to engage, help and support others in their community,
understand the services and attend events in their area, and find useful and relevant
information. Our work in listening to people so far shows that an interactive space is
required to share experience, both happy and sad, and that getting help in this way can
really make a difference.
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Although the development was not commercial enough for future SBRI support the plan is
to continue with the website and seek to secure funding from elsewhere.
Events
During 2013-2014 the hospice has continued to hold a series of regular open events, which
engage and inform people in our local communities. In addition, there has also been a
significant amount of engagement as part of the community hospice development
programme ‘St Joseph's at Home’. This programme aims to ensure accessibility to and
acceptability of current and future hospice services. The introduction of new services has
provided an opportunity to introduce volunteer befrienders from local communities to
become part of hospice services.
Events included the following:
Dying Matters Awareness week 13th to 17th May 2013
St Joseph’s team undertook a wide variety of activities to support National Dying Matters
Awareness Week. Five major events were planned during the week:
• ‘Make a Will Week’ Local solicitor helped participants to write a will or to change their
will in return for a donation to the hospice
• ‘Make a Will Workshop’ This session, run by local solicitor Emma Rowe provided
information and advice on writing wills, and why wills matter
• ‘Affordable, Meaningful Funerals’ this was an interactive workshop hosted by Down
to Earth
• ‘The Future of Deaths Parts I and IV’ - Two short films by Anton Mirto documenting a
performance on the interrelationship between living and dying and letting go
(www.a2company.org).
• ‘Hospice Information for Muslims’ – Launch of a new information service for Muslims.
Hosted by Hospice Chaplain Imam Muhammad Karin.
•
‘Living & Dying Well Road show’ – this event included over 18 exhibitors, free
complementary therapy taster sessions, music by the London Sinfonia, mini
workshops and refreshments
Carers Week 10th to 16th June 2013
St Joseph’s ran one event per day across Carers Week:
• Carers’ Pamper Day – with Music, lunch and complementary therapies available
• Hackney Annual Carers Conference – all day event
• Prepared to Care – St Joseph’s and Marie Curie Cancer Care event
• Welfare and Benefits Advice for Carers – drop in service
• Social Work Advice Service for Carers – drop in service
Jewish community
Last year it was noted as key objective for the hospice to re-engage with the Jewish
community. In 2013 we re-engaged with Jewish Care and organised a series of workshops
of 4 workshops between October and November 2013. These workshops were run by our
Advancing Practice Nurse and sessions included:
• Advanced Planning in End of Life Care
• Essential Communications Skills in End of Life Care
• Providing Care towards and at the end of life
• Loss, Grief and Bereavement
An additional session was held in order for the Jewish Care team to meet the Community
Teams at the hospice (City and Hackney Nursing Team, Day Hospice Social work and
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bereavement teams and Finding space team), to gain an overview of multi-disciplinary team
working and find out about our services.
Newham
We have continued to engage local communities in our service developments which
included: This bereavement service, which delivers component Level 2 befriending for adults
living in Newham for people who are suffering from loss and grief due to bereavement. The
service is delivered by trained volunteers who are largely, although not exclusively, drawn
from Newham. The service engages with the local communities by recruiting volunteer
befrienders from Newham and engaging with a wide range of other service providers,
community based groups, and faith groups in Newham to raise awareness and distribute
publicity about the service.
We received external funding for a small six month project to start a new horticultural
project working with people suffering loss and grief, which will be based at West Ham
Cemetery. A Horticultural Therapist has been recruited and will start this innovative work in
early 2014. This project will give an additional option for people who are bereaved to
become involved in a community gardening project.
Carers
In partnership with Marie Curie Cancer Care the hospice has formed a working group to map
existing provision for carers across East London, identifying gaps and developing ideas for
new and innovative ways to support families and carers. The activities during Carers week
provided an opportunity to link with Tower Hamlets CCG service improvement lead to share
some of this early work and provide further information to enhance this. The work that is
developed with Tower Hamlets will be shared with the other 2 inner London boroughs that
we serve
User feedback
Internally, we have introduced a number of different methods for obtaining user feedback,
in order to engage with our users, these include the following:
Service User feedback on Ground Floor Refurbishment - In the summer we surveyed staff,
volunteers, patients, patient families, healthcare professionals and members of the public
about our plans for the refurbishment of the ground floor reception and café. In September
we completed a service user feedback review of the plans to refurbish the ground floor As a
result of feedback received, we have re-shaped the plans, the feedback and results
summary are available on the website, twitter and Facebook. We have:
• Relocated what will be the future main entrance to where the current staff entrance
is. This will mean the main entrance is more visible for visitors and that the
Reception Team can see all the exits to the rest of the building
• Improved the location of the quiet rooms for distressed relatives and patients
• Decided not to create a general internet café but instead provide a wireless network
and computers at the Information Service area
• Put the Information Service near to the main entrance and Reception to make the
service accessible for visitors.
Other survey feedback we are taking into account includes:
• We have provided a volunteer team based at Reception who will accompany visitors
to where they need to go and fetch visitors to take them to their appointments. We
will not have an appointments screen announcing names
• We have made plans for the shop and café to provide a wider range of items for sale
15
•
We will brief the interior design team to provide a warm and welcome environment
with a mix of seating to suit all needs and abilities.
A timescale of the schedule of work was made available to the public.
Help The Hospice’s Annual Survey
The hospice participated in an annual survey conducted by Help the Hospices and Centre for
Health Services Studies (CHSS), University of Kent. 19 hospices participated and the results
were distributed in December 2013. The next step will be to meet with service leads and to
review the findings and make recommendations where there were areas for potential
improvement.
Specific areas for service improvements identified were as followed (and these were very
similar nationally)
• Agreeing more specific goals/outcomes for service users
• Improvements in discussion on advanced care planning
• Improvements in patient user information
• Ensuring more viability on how to give feedback.
Patient-Led Assessment of the Care Environment (PLACE) assessments
The hospice participated in new PLACE assessments during April 2013 and results were
published in September 2013. The assessment involved using service users to assess how
the environment supports patient’s privacy and dignity, food, cleanliness and general
building maintenance.
We recruited volunteers who participated in this year’s assessments. The outcome from the
assessments was very positive and gave a user perspective of the environment – areas for
improvement such as signposting will be a focus for the next year, following the recent
building developments on site. The results were as follows:
• Cleanliness
98%
• Food
94%
• Privacy, Dignity & Wellbeing
93%
• Condition, Appearance & Maintenance
93%
Satisfaction/Feedback Cards
We introduced a new system using feedback cards during 2013–14 asking for response to a
standardised question on the card: ‘How was your experience at St Joseph’s today’ inviting
individuals to respond to the question by choosing one of three options, using a smiling
face, plain and sad face. They are asked to give the opportunity to explain why they have
given their answer, so a second question invites a free text to respond by asking ‘Could you
tell us the main reason for your answer’
The overal % of patients and service users who when asked stated their experience was
positive is as follows:
•
•
•
•
•
•
July
August
September
October
November
December
82%
83%
86%
98%
94%
96%
16
A
sample
below:
of
the
reasons
given
for
their
responses
are
17
Day Hospice survey
Our Day hospice patients completed a survey in August 2013, in partnership with London
Youth. London Youth came in over two days and completed one simple form with the
patients. A further document was also created to be completed if they were able to respond
in more detail. It was felt that it was important to keep this exercise brief initially as many of
the patients become tired and we are considering how we optimize their feedback over the
12 week programme for attending the Day Hospice.
22 people completed the simple form; 10 people did the longer one. The full results are
being used to consider future plans for the Day Hospice.
Improvement Priority 2 – Improving Choices at the End of Life – to
enhance experience
In addition to the activities listed in the previous section, we have developed an
“Empowered Living Team” in Newham with funding from the SEBBA Trust (TBC), supported
by regular training and supervision. What has been developed in the early days of the
project is plans for complementary therapy support groups modeled on the success of the
Neurological Support Group, currently meeting fortnightly in Finding Space, at St Joseph’s
which offers social and therapeutic support to people with neurological conditions such as
motor neurone disease, multiple sclerosis, Parkinson’s disease and their carers. This group
would provide a stepping stone for other hospice services to join in due course expanding
the provision of hospice services beyond the hospice walls. Interest from the therapies,
bereavement, psychosocial, CNS and outpatient team has been expressed to date. There
may also be the opportunity to work more closely with our partners in Newham such as GPs,
community nursing teams, hospital departments, volunteer organisations, schools, colleges,
universities, the police etc.
There is ongoing consultation with both the Newham Bereavement Service, and Marie Curie
Helper Service to explore joint working opportunities with their volunteer cohort in massage
training and regular case study supervision. This is to include the training of volunteers in
simple and effective hand and foot massage techniques which can be used widely with
clients, when judged appropriate, in the home setting.
Improvement Priority 3- Strengthening Information Governance – to
strengthen patient safety and clinical effectiveness
We have actively improved our overall compliance with the Information security regulations
and have implemented actions which have been reviewed by the Information Governance
committee on a monthly basis. Policy and procedures are in place with on-going audit and
review using a structured framework. All staff receive mandatory training relating to
information security. It is expected that all information being used efficiently, effectively and
in accordance with all legal and ethical requirements.
As noted above, during 2014 we have updated our current clinical information system.
There has also been investment in our current communication systems ensuring that they
are up to date and have increased resiliency as well as making sure that our network
infrastructure is able to cope with increasing demands. We have now achieved full
connection to the NHS N3 network, which will enable easier transfer of patient information
in a secure environment.
18
Our current telephone system had a number of shortcomings and is in the final stages of
being replaced by an integrated system. This will address a number of important issues,
including our main telephone does not have a call queuing facility and no automated voice
attendant which results in callers hearing constant ringing when switchboard are dealing
with a single call.
The proposed new system benefits are as follows:
• Web based system – this allows users to log on remotely and will support off-site
connectivity which will support satellite offices and/or home working.
• Windows based - it connects to Windows operating systems and allows individuals
(with permission) and work groups to configure call routing to support their working
practices.
• Can be linked to Outlook and a central telephone directory so reception team and
other staff can see staff availability for improved level of customer service
• the system will be able to handle multiple incoming lines through the main switch
• Voice recording for audit, training and customer service quality control
• Automated attendant – multiple voicemail (unavailable or service announcements)
messages can be set up to support individual department services.
• Ability to send multiple SMS messages
All providers are able to provide a maintenance service including Out of Hours support – a
key requirement given that we are providing services over extended hours
This will greatly improve the efficiency of our teams and enhance communication across the
different disciplines who may be involved in and individuals care or treatment.
Improvement Priority 4- Leading on Partnership working
Coordinate My Care
We have been working with our partners during 2013-14 to continue with the introduction
of Coordinate My Care (CMC) – which is an electronic record to enable health and social care
professionals to access information relating to preferences at the end of life for patients with
life limiting illnesses. This system has been developed following the 2008 End of Life Care
Strategy which recommended ‘creation of locality wide registers for people approach end of
life so that they can receive priority care.’ CMC has continued to be developed by NHS
clinicians to improve coordination across acute and community providers 24/7. The Hospice
hosted an East London Multi-professional meeting in May 2014, with representatives from
palliative care team around East London and member of the CMC facilitation team to review
the issues around some concerns about its use. This was a positive meeting and the benefits
were re iterated. The hospice continues to use this tool as required.
CMC represents a new way of working, which is designed to benefit patients by:
• empowering patient choice
• not needing to repeat information when seeing a new nurse/doctor
• enabling 24/7 access to live information which will improve communication and
coordination of care across all sectors
• ensuring a more appropriate response to crisis calls with the potential to reduce
inappropriate hospital admissions and LAS transfers
End of Life Care Facilitation Service
The Newham End of Life Care Facilitation service will complete the 3 year contract at the
end of November 2014.This service has involved engaging with stakeholders across
19
primary, secondary, community and the third sector, including care homes, to improve
choices and opportunities for people in Newham at the end of life. The service has
promoted high visibility of hospice staff in leading improvement to outcomes of care for
people at the end of life. This service is led and managed by St Joseph’s in partnership with
NUHT and works closely with the St Joseph’s Community Palliative Care Team.
Drawing on this experience, a review of the hospice community palliative care service
recommended in 2013 a greater proportion of dedicated time is spent in all three of our
Borough-based teams to build external relationships with partners across health and social
care which will promote shared understanding, increase opportunities for joint working and
encourage informal learning.
In 2013, the Hospice had access to a 1 year funding opportunity coordinated by Health
Education North Central and East London, the Local Education and Training Board (LETB).
We received funding to extend the End of Life Facilitation model in Newham to Tower
Hamlets and City and Hackney and the Newham Facilitators have taken a lead role to extend
their service model into the LETB funded posts in the other boroughs combined with a
longer term exit strategy for education and facilitation within East London. Our plans are
that one of the Clinical Nurse Specialist within each borough team would take a lead for end
of life care education and facilitation for the local health and social care community with the
aim of sustaining and widening some of the aims and principles of the Newham service
Supportive Care Services in Newham
From 2014, the Hospice social work team have formed a partnership with the London
Borough of Newham team to enable a social worker from each team to be seconded across
health and social care; this will enable the social worker to experience social care for people
and their families with life limiting illness and end of life within another sector, provide
professional development and form professional links
Age UK East London and St Joseph’s Hospice – Last Years of Life Service
Both organisations were successful in a joint bid submission to deliver personal care,
emotional and practical support to people of Tower Hamlets in their Last Years of Life. Age
UK have previously provided this service over 2 years and are now collaborating with us to
introduce other elements of this service. Namaste Care a sensory therapy for people with
cognitive impairment which will be provided by St Joseph’s Hospice. This partnership
continues our positive engagement with Age UK.
Jewish Care Domiciliary Care Team
The hospice has provided a series of workshops for social care workers of the domiciliary
team, Jewish Care. This has provided an excellent opportunity to see how we can best
support and develop skills for generalist teams who are caring for people at end of life. This
opportunity has furthered our ongoing engagement and visibility within the Jewish
community.
Marie Curie Cancer Care and carers
We have continued to partner with Marie Curie Cancer Care over the past 2 years to explore
how we can jointly improve end of life care across East London and to ensure the voluntary
sector contribution is visible within the new commissioning arrangements. We have focused
on 2 key areas of work: coordination of care for east London and support for carers.
The pace of progress has been determined by the engagement of the CCG leads and how
our proposals align with the emerging models of integrated care. There has been renewed
interest by City and Hackney in care coordination and rapid response models of care as part
20
of the ‘One Hackney’ initiative to strengthen integrated care and ensure more people are
cared for in the community and reduce the number of avoidable acute hospital bed days.
Work on supporting carers continues with a lead by Tower Hamlets CCG who are engaging
stakeholders across statutory and voluntary sector to plan a multi sector carers event to
develop service improvements.
Engaging with other Hospices
Richard House Children’s Hospice Inpatient unit has been at St Joseph's hospice since
December 2013 whilst their hospice is being redeveloped, and work continues on our joint
transitional care programme. The hospices are considering further opportunities for
collaborative working. An alliance has been proposed between both organisations to explore
our common focus and purpose in palliative care, and to review a number of areas where
we could work more closely together.
Statements of Assurance from the Board
The following are a series of statements that all providers must include in their Quality
Account. Many of these statements are not directly applicable to specialist palliative care
providers.
1.1
Review of services
During 2013/14 St Joseph’s Hospice provided seven key service areas for the NHS. The
services were as follows:
•
•
•
•
•
•
•
In-Patient
Day Hospice
Community Palliative Care Team Intervention
Finding Space- community engagement and information service (the latter in partnership
with Macmillan)
Bereavement and Psychological Therapies
Social work
End of life care facilitation
St Joseph’s Hospice has reviewed all the data available to them on the quality of care in all
its services.
1.2
Income Generated
The income generated by the NHS services reviewed in 2013/14 represents 100 per cent of
the total income generated from the provision of NHS services by St Joseph’s Hospice for
2013/14. The income generated from the NHS represents approximately 55% of the overall
cost of running these services.
2
Participation in Clinical Audits
During 2013/14, we did not take part in any national clinical audits and national confidential
enquiries covered NHS services relating to palliative care. St Joseph’s Hospice only provides
palliative care.
21
2.1
Eligibility to Participate in National Confidential Enquiries
During that period St Joseph’s Hospice was not eligible to participate in any national
confidential enquiries.
2.2 /2.3/ 2.4/2.5 National
Enquiries.
Clinical
Audits
and
National
Confidential
The national clinical audits and national confidential enquiries that St Joseph’s Hospice was
eligible to participate in during 2013/14 are as follows:
None.
As St Joseph’s Hospice was ineligible to participate in any national clinical audits and
national confidential enquiries there is no list or number of cases submitted to any audit or
enquiry as a percentage of the number of registered cases required by the terms of the
audit or enquiry.
2.6/2.7/2.8
Local Clinical Audits
The reports of 11 local clinical audits were reviewed by St Joseph’s Hospice during 2013/14
and in addition we carried out infection control audits every month (See Appendix 2).
St Joseph’s Hospice intends to take the following actions to as a result:
•
•
•
•
•
•
•
•
•
•
Develop standards re data recording /communication with staff
Develop hospice policy for use of unlicensed medication
Approve and implement new Standard Operating Procedure on prescribing and
administering injectable medication
Improve pharmacy IT access
Produce ‘staff guide’ for staff on use of diamorphine & morphine injectables ensure easy
access to information
Continue development of operational procedure to strengthen the work of multidisciplinary first contact team to improving ease of access to the range of hospice
service.
Improve documentation, through regular documentation audit in annual programme for
2014-2015 to ensure standards for record keeping are maintained.
Continue staff mandatory training in Information Governance for all staff
Continued audit of Nursing Compliance with Monitoring of Blood Transfusions
Encourage pro-active MDT discussion to identify patients who are nearing the end of life.
3. Research
The number of patients receiving NHS services provided or sub-contracted by St Joseph’s
Hospice in 2013/14 that were recruited during that period to participate in research
approved by a research ethics committee was 0.
There were 0 appropriate national research studies and 8 local ethically approved research
studies in palliative care in which we have participated.
These include:
22
Studies completed by external researchers
• (Developing a measure of psychological resilience City University)
• Carers perception of sedation at the end of life -(UCL)
• Employee engagement and self-determination in charity sector employees -(City
University)
• Volunteer Management in palliative care phase 1 - (Lancaster)
• Photographic exploration of a hospice palliative care setting with reference to themes of
environment and absence (London Metropolitan)
• Interviews with palliative care social workers - (Middlesex university)
Current studies being undertaken by external researchers
• Qualitative study of the outcomes of Acupuncture - (Warwick University)
• Exploring the concept of work engagement in a hospice setting - (City of London
University
.
We currently have 8 studies that are awaiting ethical approval.
4/4.1/4.2 Quality Improvement and Innovation Goals Agreed with our
Commissioners
St Joseph’s Hospice income in 2013/14 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework.
5/ 5.1
What Others Say About Us
St Joseph’s Hospice is required to register with the Care Quality Commission and its current
registration status is unconditional. The Care Quality Commission has not taken any
enforcement action against St Joseph’s Hospice during 2013/14.
On-going feedback is received and analysed regularly by the Clinical Governance Lead and
the Hospice Director of Care Services.
The following feedback has been received for this quarterly report, from the Hackney Health
and Scrutiny Committee and Newham Clinical Commissioning Group, our Lead
Commissioners:
23
24
25
6/6.1
Periodic reviews by the CQC
St Joseph’s Hospice is subject to periodic reviews by the Care Quality Commission and the
last formal review was a visit in October 2013 and March 2014 with a subsequent written
report. The CQC’s assessment of St Joseph’s Hospice was that the establishment met all the
standards reviewed, which included:
Standards
Consent to care and treatment
Care and welfare of people who use services
Cleanliness and infection control
Assessing and monitoring the quality of service provision
Complaints
Respecting and involving people who use our service
Safety and suitability of premises
Safety and suitability of equipment
Supporting workers
Records
Outcome
2
4
8
16
17
1*
10*
11*
14*
21*
*East Ham Care centre
7. Reviews and investigations by CQC
St Joseph’s Hospice has not participated in any special reviews or investigations by the
CQC during 2013/2014.
8
Data Quality
St Joseph’s Hospice will be taking the following actions to improve data quality:
•
•
•
•
Continue to work to improve our technology links with the NHS
Review our information technology system with a view to further refining our collection,
analysis and application of data, moving our entire information platform to deliver at a
higher level of complexity and sophistication
Working to further embed the culture of data capture, its use and application across the
organization
The hospice has shared records in accordance with the Data Protection Act.
9. NHS Number and General Medical Practice Code Validity
St Joseph’s Hospice did not submit records to the Secondary Uses service for inclusion in
Hospital Episode Statistics which are included in the latest published data.
10. Information Governance Toolkit Attainment Levels
A self-assessment was undertaken by Clinmed consulting, February 2014 as part of our
organisation’s information governance arrangements for N3 connection to NHS information
systems.
The hospice has undertaken a self-assessment and has compiled an improvement plan in
line with the IT service developments that have taken place during 2013/14
26
11. Clinical Coding Error Rate
St Joseph’s Hospice was not subject to payment by results clinical coding audit during
2013/2014 by the Audit Commission
Part 3: Review of Quality Performance
In terms of quality of care for our patients, once the initial referral has been received each
individual receives a holistic assessment, comprising physical, psychological and spiritual
dimensions from our multi-disciplinary team. Each assessment is carried out in accordance
with each patient’s expressed needs wherever possible, and includes their family and carers.
Following this process, options are outlined to each patient and their family and explanations
are given about which of the Hospice services best might meet the needs of the individual.
If the offer of care is accepted then on-going review of patients by qualified clinicians takes
place in all service areas. Care plans are agreed in conjunction with patients and their
families and these are reviewed regularly and routinely, with active patient engagement
wherever possible.
St Joseph’s receives many commendations from patients and families, and only a very small
number of complaints are received each year (three in 2013/14).
Commendations are welcomed and celebrated at Senior Management and Board level, and
with individual teams.
All complaints are taken extremely seriously. They are all thoroughly investigated, reported
on at Senior Management level and to the Board and reported to the CQC annually.
Immediate action is taken to rectify any shortfalls or concerns identified, and appropriate
training is given out as necessary. Policies and procedures related to clinical governance
may be altered as a result of complaints and any lessons learnt are shared across the teams.
The Hospice is committed to reaching and engaging with the many diverse local
communities that we serve. We collect, analyse and monitor our performance in this area to
inform both practice and service development. The chart below shows the total proportion
of patients from different ethnicities in 2013/14 and that 28% of our patients were from
BME communities. We recognise that we are not necessarily capturing all information
regarding ethnicity of our services users and this is being addressed through our Equality
and Diversity Group.
27
The Hospice is committed to producing high quality and reliable information on which to
base its decisions about service delivery and continuous service improvement .We have
made significant progress in the last two years in terms of improved scope and quality of
data. We continue to consider this as a priority for the coming year.
28
GLOSSARY
Care Quality Commission
The Care Quality Commission (CQC) replaced the Healthcare Commission, Mental Health Act
Commission and the Commission for Social Care Inspection in April 2009. The CQC is the
independent regulator of health and social care in England. It regulates health and adult
social care services, whether provided by the NHS, local authorities, private companies or
voluntary organisations. Visit: www.cqc.org.uk
Clinical audit
Clinical audit measures the quality of care and services against agreed standards and
suggests or makes improvements where necessary.
Commissioners
Commissioners are responsible for ensuring adequate services are available for their local
population by assessing needs and purchasing services. Primary care trusts are the key
organisations responsible for commissioning healthcare services for their area. They
commission services (including acute care, primary care and mental healthcare) for the
whole of their population, with a view to improving their population’s health.
Local Involvement Networks
Local Involvement Networks (LINks) are made up of individuals and community groups
which work together to improve local services. Their job is to find out what the public like
and dislike about local health and social care. They will then work with the people who plan
and run these services to improve them. This may involve talking directly to healthcare
professionals about a service that is not being offered or suggesting ways in which an
existing service could be made better. LINks also have powers to help with the tasks and to
make sure changes happen.
Overview and scrutiny committees
Since January 2003, every local authority with responsibilities for social services (150 in all)
have had the power to scrutinise local health services. Overview and scrutiny committees
take on the role of scrutiny of the NHS – not just major changes but the ongoing operation
and planning of services. They bring democratic accountability into healthcare decisions and
make the NHS more publicly accountable and responsive to local communities.
Registration
From April 2009, every NHS trust that provides healthcare directly to patients must be
registered with the Care Quality Commission (CQC).
Regulations
Regulations are a type of secondary legislation made by an executive authority under
powers given to them by primary legislation in order to implement and administer the
requirements of that primary legislation
Schwartz rounds
Schwatz rounds offer healthcare providers a regularly scheduled time to openly and honestly
discuss social and emotional issues that arise in caring for patients. The focus is on the
human dimension of caring. Caregivers have an opportunity to share their experiences,
thoughts and feelings on thought-provoking topics drawn from actual patient cases. The
premise is that caregivers are better able to make personal connections with patients and
colleagues when they have greater insight into their own responses and feelings.
29
Appendix 1 – MDS Data
The below data has been extracted from the St Joseph’s Hospice, Hackney National
Minimum Dataset (MDS) submission to the National Council for Palliative Care (NCPC). This
data is also shared with our three local CCGs (Newham, Tower Hamlets and City & Hackney)
on a quarterly basis. The most recently published MDS dataset report from the NCPC was
released in June 2014, for the period 1st April 2012 to 31st March 2013. This is the most
recent data available so we have provided these national figures as a comparison to our
data, along with our data for the previous year which is a direct comparison to the MDS
national dataset.
In Patient Unit - IPU
% New patients
% Occupancy
% Diagnosis – non cancer
% Ethnicity – non-white
% Patients returning
home from an IP stay
Average length of stay
STJH 13/14
STJH 12/13
93%
80%
22%
33%*
84%
77%
21%
33%
MDS – National
Mean (12/13)
82%
75% (London 76%)
13%
23%
48%
48%
37.8%
16.3 days
15.7 days
14.4 days
Community Palliative care team - CPCT
STJH 13/14
STJH 12/13
71%
22%
42%
69%
20%
38%
MDS – National
Mean (12/13)
69%
16%
28%
69%
69%
67%
134 days
136 days
111 days
STJH 13/14
STJH 12/13
MDS – National
Mean (12/13)
% New patients
64%
62%
61%
% Diagnosis – non cancer
% Ethnicity - nonwhite
Caseload
25%
38%
40.68
27%
42%
62.05
23%
21%
54.80
% New patients
% Non-cancer patients
% Ethnicity – non white
% Homecare patients who
died at home/hospice
Length of care
Day hospice
30
Appendix 2 - Completed Audits since April 2013 with
actions completed
Title
Infection Control
& prevention
Audits using the
Help the Hospices
toolkit
Audit of Nursing
Compliance with
Monitoring of
Blood
Transfusions
Audit of CPCT
documentation
Multi professional
framework- End
of Life Care needs
and
documentation of
care after death.
Implementation
and use
Aims
Aspect of
service
delivery being
audited
To ensure compliance Improving
with best practice
patient safety
Actions completed
Goods compliance –
continue with monthly
Hand washing audits
To ensure all aspects
of blood transfusion
are managed
effectively and safely
within St Joseph’s and
comply with ‘Better
Blood Transfusion Safe and Appropriate
Use of Blood’
guidance
Improving
patient safety
6 monthly audits scheduled
into annual plan
To ensure
compliance with
standards for record
keeping &
interdisciplinary
working
Re-audit to confirm
continued improved
compliance with good
standard in relation
to end of life care
Improving
patient safety
Develop standards re data
recording /communication
Improving
patient/family/c
arers outcomes
Revised documentation
only just been introduced
There is room for
improvement in our
completion of the care
after death paperwork
The bereavement team
have asked for a prompt
for referral to them.
Re- Assessment must be
undertaken for any patient
re admitted or when
changes occur during their
stay scores to be
reassessed
Plan to re-audit Oct 2014
Develop hospice policy for
use of unlicensed
medication (A medicinal
product that does not hold
a UK marketing
Mandatory Training in
place
Audit best
practice for
Patients who
have acquired
pressure ulcers
whilst in Hospice
Monitor
compliance Improving
with
the patient
recommendations
outcomes
from RCN & NICE
regarding
best
practice
NPSA safety alert
20: Promoting
safer use of
injectable
medicines
To assess compliance
with the
recommendations
listed in the NPSA
Improving
patient safety
31
Patient Safety Alert
20
NPSA patient
safety alert 12:
Ensuring safer
practice with high
dose ampoules of
diamorphine and
morphine
NPSA patient safety
alert 12: Ensuring
safer practice with
high dose ampoules
of diamorphine and
morphine
Are we
prescribing and
monitoring
steroids
appropriately?
Audit
of
VTE
prophylaxis
and
prescribing
on
the in-patient unit
No national guideline Improving
on standards within patient
hospice care
outcomes
Information
governance audit
Audit of oxygen
use in the hospice
inpatient unit
Improving
patient safety
Are we considering
VTE prophylaxis and
prescribing it
appropriately
Improving
patient
outcomes
Assessing compliance
with national
guidance on
information
governance?
Are we prescribing
oxygen in line with
national guidance
Improving
patient safety
Improving
patient safety
authorisation).
Revise SOP on prescribing
and administering
injectable medication
Improve pharmacy IT
access
Regular relevant
mandatory training
Plan to re-audit
Produce ‘staff guide’ for
staff on use of diamorphine
& morphine injectables to
ensure easy access to
information Develop &
disseminate Pharmacy led
training bulletin reporting
on outcomes of audit,
relevant incidents etc
Develop guidelines on
Opioid switching based on
up to date guidance
Teaching delivered to CNSs
on prescribing and
monitoring steroids.
Guidelines to be developed
Presentation to teams,
existing guidance
highlighted.
Change prompt on drug
chart
Regular review of need for
VTE prophylaxis
Detailed action plan
reviewed at monthly IG
Committee meeting to
ensure continued
compliance & monitoring
Good compliance – results
disseminated
through
Medical Gases Committee.
Continue education around
prescription and use of
oxygen
Drug prescription chart
redesigned to facilitate
safer
prescribing
and
monitoring of oxygen use
32