Quality Account 2013/14
“It is the quality that will count
and not the quantity”
Mahatma Ghandi
Chief Executive
Statement of Quality
This Quality Account is for our patients, their families and friends, the general public
as well as the local NHS organisations.
It is of note that twenty-two per cent of our care costs are provided by the NHS and
the remainder of our funding is from charitable donations.
The aim of this report is to give clear information about the quality of our services to
demonstrate that our patients can feel safe and well cared for, that all of our services
are of a very high standard and that the NHS is receiving very good value for money.
We could not give such high standards of care without our hardworking staff and our
1500 volunteers, and together with the Board of Trustees, I would like to thank them
all for their support.
Our Director of Patient Care, Medical Director and all clinical managers are responsible
for the preparation of this report and its content. To the best of my knowledge, the
information in the Quality Account is accurate and a fair representation of the quality
of health care services provided by St Peter’s Hospice.
Our focus is, and always will be, our patients, their families and carers and therefore
we actively continue to seek the views of all who access our services in order to
ensure we maintain the highest standards of quality.
Simon Caraffi
Chief Executive
June 2014
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Contents
Chief Executive Statement of Quality…………………………………………………………………………………….. 2
Who we are and what we do………………………………………………………………………………………………….. 4
Map of our area………………………………………………………………………………………………………………………. 4
Our purpose (Mission Statement)………………………………………………………………………………………….. 5
Our Aim (Vision)…………………………………………………………………………………………………………………….. 5
Priorities for improvement……………………………………………………………………………………………………… 6
Our Progress against our priorities for improvement 2013/14……………………………………………. 6
Priorities for improvement 2014/15………………………………………………………………………………………. 8
Review of services………………………………………………………………………………………………………………….. 9
Participation in clinical audits…………………………………………………………………………………………………. 10
Research…………………………………………………………………………………………………………………………………. 11
Quality improvement and innovation goals agreed with commissioners…………………………….. 12
Our progress against our CQUINs 2013/14…………………………………………………………………………… 12
Our CQUINs for 2014/15……………………………………………………………………………………………………….. 16
Data Quality……………………………………………………………………………………………………………………………. 16
Review of Quality Performance……………………………………………………………………………………………... 17
What our patients say about St Peter’s Hospice……………………………………………………..……………. 18
User involvement……………………………………………………………………………………………………………………. 21
Staff training and appraisals………………………………………………………………………………………………….. 23
Statements of assurance from the Board of Trustees………………………………………………………….. 24
Board of Trustees Provider visits………………………………………………………….………………………………… 24
What our regulators say about St Peter’s Hospice……………………………………………………………….. 24
What our NHS Commissioners say about St Peter’s Hospice……………………………………………….. 25
Quality Action Plan………………………………………………………………………………………………………………….. 26
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Who we are and what we do
St Peter’s Hospice (SPH) is Bristol’s only adult hospice. We have been looking after
people in our area (greater Bristol, South Gloucestershire, part of North Somerset and
the Chew Valley area of Bath and North East Somerset) for 36 years. Our commitment
is to contribute to improving the quality of life of patients while extending care and
support to their families and loved ones.
Our main building is at Brentry but our Community Nurse Specialist team have bases
in Staple Hill, Long Ashton, Brentry and Yate making it easier for us to provide
accessible care and support across this large geographical area.
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I wanted to raise money for
your charity as I shall never
forget how fantastic you were
with my mother two years
ago. I shall never forget you
all, you all were Angels!
Our purpose (Mission statement)
To provide care and support for adult patients, families and carers in our community
living with life limiting illnesses in order to improve the quality of their living and
dying. We do this working closely with other health and social care providers.
Our aim (Vision)
St Peter’s Hospice will play a leading role in the development and delivery of the best
possible care and support services for adult patients, families, and carers living with
life limiting illness in our community.
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Words cannot express the
gratitude felt for all the loving
care given to our beloved
daughter--law. What a fabulous
place to be – the devotion was
so palpable. You’re all
wonderful. Keep up your
wonderful work.
Priorities for improvement - Our progress during 2013/14
Forming effective partnerships to support end of life coordination in our local area.
Priority 1
Effectiveness
We have been working over the last 12 months to form an End of
Life Coordination Service in partnership with Bristol Community
Health. The planning and consultation for this is nearing completion
and the service should go live in the early Autumn of 2014.
To actively seek to procure a new patient record system.
Through this process our aim is to review clinical systems to
improve data collection across all patient areas.
Priority 2
Effectiveness
This has been and is a priority for the coming year. We have an
internal project team to further this work.
We are presently consulting with staff to ensure we have the right
requirements for any future system.
We are also looking at the systems our GP’s use and discussing
various programmes with other hospices that use Electronic Patient
Record systems.
Extend the Hospice at Home service so that more carers/
families feel able to look after patients in their own homes.
Priority 3
Patient
Experience
The number of patients who have received Hospice at Home Care
has increased by 13% in 2013/14 with an increase in care hours of
22%.
End of Life Care continues to be our priority in allocation of care
hours, with respite care being offered when able.
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To implement a Hospice Volunteer neighbour programme to
provide practical & social support to benefit patients & their
carers.
This has been implemented in January 2014 by our volunteer
coordination team across all of our areas.
Priority 4
Patient
Experience
The services provided have supported 17 people with 47 volunteers in
3 months.
Requests for help have varied from
- one off transport requests to a hospital appointment and to the
rubbish dump;
- on going tasks such as walking the dog, keeping the patient/or carer
company; going on outings; making lunch for patient and spouse;
doing the laundry/ironing; taking, the patient/carer shopping or doing
necessary shopping.
Priority 5
Safety & Facilities
To review our Brentry site & any potential developments
ensuring sustainability for future patients & carers needs.
We said we would increase the on site recycling: each department now
has its own clearly labelled recycling bags/boxes identifying what can
be recycled in them.
We said we would review the in patient unit bed levels to determine
how we can best utilise the space. This year we have consulted
patients, carers families and staff to decide what should be our
priorities for the In-Patient Unit. Our aim is to maintain our present
level of 18 beds, but increase the number of single rooms available for
our patients.
This work and planning will progress into 2014/15
We received a £460,000 grant from the Department of Health to build a
working space for our Psycho-Social Spiritual Team. The newly named
‘Garden Rooms’ will enable our art and music therapist to work in a
conducive environment, and also has space for our developing number
of groups for both carers and bereaved family members.
Use of The Garden Rooms commenced in May 2014.
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Priorities for improvement 2014/15
There are other things that we shall be doing but the priorities for
improvement 2014/15 are:
Planning Priority 1 – Patient Experience
We will extend our range of activities to work with families using our newly created
therapeutic spaces.
Planning Priority 2 – Effectiveness
We will grow our community staffing in new models as well as existing ones, to ensure
that our care can be effective and even more accessible.
Planning Priority 3 – Effectiveness
We will reconfigure our Access Services (referrals, triage and advice line) so that our
care is always timely and appropriate for each and every individual who is being cared
for by us.
Planning Priority 4 – Safety and Facilities
We will consult, extensively, with our local health care community to ensure we are
providing the correct care in the correct facilities.
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Thank you for looking after my
beautiful daughter. You all
were wonderful.
My family thank you all.
Review of services
During 2014/15 SPH will continue to provide the following services with service level
specifications agreed with the NHS. The NHS contributes 22% of our overall funding.
SPH has reviewed all the data available to the NHS on quality of care for all our
services.
1. In-Patient Unit – 18 beds staffed by 54 IPU nurses and supported by the wider
clinical team.
2. 24 hour advice line offering specialist palliative care advice to healthcare
professionals and carers (This is not commissioned by the NHS)
3. Day Services
– up to 20 patients 4 days per week
– Fatigue and Breathlessness programme
4. Physiotherapy/Occupational Therapy – to help patients maintain a good quality
of life for as long as possible
5. Hospice at Home – to enable patients to die at home.
6. Community Nurse Specialist Service – providing advice, support and symptom
control to more than 2000 patients per annum
7. Medical Consultants – cover the hospice, the community and work with the
Bristol Hospitals Palliative Care teams.
8. Psychological, Social and Spiritual Care (PSS) services – to provide social,
emotional and spiritual support for patients, families and carers, including
bereavement care. This service includes music therapy, social work
psychological support, carers groups and art therapy.
St Peter’s Hospice monitors all services on a monthly basis through collating of data
on number of patients seen, face to face contacts and telephone contacts. Quality
issues are dealt with immediately, as they arise.
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Participation in Clinical Audits
This year we have further developed our Clinical Audit group to become a Practice
Improvement and Clinical Audit Group. This will enable staff to be supported in the
whole audit cycle in a more comprehensive manner; supporting surveys to be
undertaken to allow clinical standards to be set, as well as auditing set standards. The
regularity of these meetings has increased to 6 weekly to increase activity and
engagement.
We have developed our annual plan for the next year’s audits and surveys, with each
clinical department having a set quarterly plan.
Highlights from completed audits include:
Bereavement Support
Management of
hypoglycaemia
Documented consent
to Complementary
Therapy Treatments
Whilst 100% of bereaved family members
received letters offering support, it
demonstrated where clarification of processes
could be improved.
Demonstrated very high compliance (100%) in
2 out of 3 standards, but highlighted the need
to set individual needs re regularity of blood
sugar monitoring.
49 out of a sample group of 50 had their
consent documented.
This year’s audits will include the assessment and documentation of our patients
potential risk of developing pressure ulcers, timings of medical assessment within the
Day Service, and audit of our new nutritional care plan. Planned surveys include
documentation of initial assessment of a new patient, and of care plans of patients
being cared for by Hospice at Home.
We participated in a regional survey with 9 other hospices looking at the workload and
practice of our Clinical Nurse Specialist Team. The findings from this survey will feed
into our Clinical Action Plan for 2014/15. Further benchmarking surveys will continue.
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Research
Any involvement in research is carefully monitored by our Research Advisory Group.
After detailed discussion with the research team from United Hospital Bristol (UHB)
the Research and Advisory Group agreed that we would participate in research led by
UHB, focussed on the use of a scoring tool of physical symptoms.
This research commenced in May 2014, and will be completed by the end of
December 2014.
We encourage the sharing and discussion of published clinical research across clinical
teams through our existing Journal Club which meets every quarter.
In 2013 the St. Peter’s nursing teams (Registered Nurses, Health Care Assistants and
Student Nurses) have also developed the ‘The Thursday Group’ which looks at
palliative care nursing research articles, encouraging wider confidence in engaging
with research and evidence based practice.
Board of Trustees Provider visits.
Our trustees are appointed to ensure good governance of the hospice. In order to
ensure they review the quality of treatment and care offered they visit the hospice at
least every 6 months on an unannounced visit. The visits are conducted by 2 trustees,
who base their visit on the care patients receive, interviewing staff members, and
looking at the care environment, and inspecting the records of any complaints. The
outcomes of the visit are recorded in a report which is sent to the other Trustees,
Chief Executive, and Director of Patient Care. The report is also discussed in the next
Board meeting.
We have had 3 visits this year, in June and November 2013, and February 2014.
The three reports have given us some very valuable feedback, and all three have
reported very high patient and carer satisfaction with care.
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Student Nurse Placements
In 2013 we accepted student nurses on their Nursing Placement 5 (N5) for the first
time. We had previously taken nursing students for their chosen ‘elective’ placement
of 4 to 6 weeks with very good feedback. We still take these students with a particular
interest in palliative care, but now take 2 cohorts per academic year for a 12 week
experience.
The feedback from both student nurses, our staff who mentor them, and the tutors
from the University of the West of England (UWE) has been very positive. Our
Education Department organises the placements with UWE, and several of our staff
are trained as assessors to support them in meeting their competencies.
The majority of the time is spent in the In-patient Unit and Day services, but the
students have the opportunity to spend time with the wider multi-disciplinary team to
understand the full range of services offered to our patients and carers.
Quality improvement and innovation goals agreed with
commissioners
A small proportion of our NHS income in 2013/14 is conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation (CQUIN) payment framework.
Our progress against our CQUINs 2013/14
CQUINS for 2013/14
Indicator 1
Indicator 2
BNSSG (Bristol, North Somerset, South Gloucestershire,)
cluster Whole System End of Life care Co-ordination.
Prospective Audit & Review of the quality of discharges to
nursing homes following a complaint.
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“They faithfully attend
and are very helpful”
Comment from partner survey
regarding community team
attendance at palliative care
meetings
Indicator 1 – BNSSG End of Life Care Coordination
There has been a full years work on end of life care coordination. A new referral
form has been devised to cover ALL services and not just St Peters Hospice. A new
system of care coordination will begin in early autumn as a result of the project work.
Full details will be given to the public who have already been consulted on many
aspects. It is likely that St Peters Hospice will be entering a formal partnership with
another care provider in order to ensure that this is effective.
Indicator 2 – See summary report below which demonstrates that we are
achieving high standards. Re-audit will take place in 2015.
Summary Report of the Audit of Transfer of Patients to Nursing Homes from
the Hospice In-patient unit.
Background:
This prospective audit was originally planned in September 2012 as 1 of the agreed
actions following completion of an investigation into a complaint relating to the
discharge of a patient from the hospice to a nursing home. It follows on from a
retrospective audit.
The audit proposal was written in the autumn of 2012 and then revised in July 2013,
following the delayed completion of a new discharge planning checklist to support
discharge planning (and this audit in particular) on the IPU.
The audit commenced in September 2013 and the agreed total of 12 discharges was
reached in March 2013.
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Standards agreed in the audit proposal:
1. Discussions will take place with both the patient and relevant family members
regarding the need to plan a transfer to a nursing home – and these discussions
will be clearly documented.
2. A member of staff from the relevant nursing home will assess the patient on the
hospice IPU, speak to a member of the hospice IPU nursing team and be offered
access to all relevant care plans.
3. A comprehensive transfer letter will be written and faxed to the GP who will be
assuming medical responsibility for the patient at the nursing home at least 1
working day before the day of the transfer.
4. As assessment of the patient will be carried out by an experienced doctor (SpR
or above) with a senior nurse to ensure that the patient remains fit for transfer
within 24 hours of the planned transfer.
Transfer to NH audit - results based on discharge
planners
15
10
5
11
6
6
5
1
0
one a)
6
5
0
1
0
one b)
two
YES
n/r
7
8
7
4
0
three a)
4
1
three b)
0
four
Variance
Results: The numbering on the horizontal axis represents answers to the standards
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Transfer to NH audit results including review of
iCare/paper records
15
12
12
11
12
11
10
6
5
0
0
0
one a)
0
0
one b)
two
YES
Standard
Number
1a)
1b)
2
3a)
3b)
4
1
0
1
0
three a)
NO
5
1
three b)
0
0
four
Variance
Proven achievement as
recorded on discharge checklist
50%
50%
91.6%
41.6%
33.3%
66.6%
Proven achievement as recorded
in all available patient records
100%
100%
91.6%
91.6%
50%
100%
Overall findings:

It was largely reassuring in demonstrating the achievement of good levels of
communication with patients, families, NH staff and GPs.

There was some poor recording of activities on the discharge planning checklist
that was designed for this purpose. As a result it became necessary to review
both electronic and paper records in order to complete the final data collection.
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Our CQUINs for 2014/15
For the coming year our NHS CQUIN goals are:
CQUINS for 2014/15
Indicator 1
Indicator 2
Indicator 3
Indicator 4
Friends & Family Test – maintaining 20% return on
our Patient/Carer feedback forms using
‘I Want Great Care’.
NHS Safety Thermometer – to maintain the number
and degradation of grade 2-4 pressure ulcers
recorded on admission.
BNSSG End of Life Care whole system – to increase
our effectiveness in helping people with poor
prognosis to achieve their preferences regarding
care & treatment.
GP Advice & Guidance –
Data Quality
SPH provides a six monthly patient activity report in the agreed format to the local
NHS Commissioners as well as an annual report as agreed in our NHS Community
contract.
Data is stored and utilised in accordance with the SPH Information Governance Policy,
which is fully compliant with legalisation. We have improved our information
governance policies and training to ensure clinical and administrative staff have
completed online training via the NHS Information Governance toolkit. As a result we
now have access to the NHS secure email system which we hope will speed up the
transfer of patient information with healthcare partners in the community.
We are reviewing our electronic patient record system. As a result clinical processes
will be examined to improve the quality of data collection to ensure a more
streamlined approach.
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SPH is not subject to all Department of Health/Government regulations but it is a
registered company in England and Wales and is limited by guarantee. It is also a
charity registered with the Charity Commission. SPH prepare reports and accounts in
compliance with the accounting standard Statement of Recommended Practice (SORP
2005) and these are audited by a firm of independent auditors. Report and accounts,
which are for the year ending 31 March, are filed with both Companies House and the
Charity
Commission.
All
reports
are
also
available
on
our
website
www.stpetershospice.org or upon request.
Review of Quality Performance
The hospice receives in the region of 1,850 referrals per year across all services. The
quality of services are maintained, monitored and improved through clear policies and
procedures, a robust recruitment and induction programme and excellent training and
education for staff and volunteers. Service users are consulted through our PROMs &
CROM’s (see page 7 and 20) in relation to service delivery and future development.
All complaints are investigated. Complaints both informal (verbal) and formal
(written) are infrequent but are recorded and discussed. Formal letters of complaint
received are investigated thoroughly and reported to the Executive Team, Clinical
Governance Committee, our Board of Trustees and NHS organisations.
Our total complaints for 2013/14 = 21 which is 1% of all referrals.
(Total 2012/13 = 11)
Over the year we have received: 2 written complaints, 3 complaints via our monitored
Social Media pages and 16 verbal complaints. All complaints are examined in detail
and an investigation is undertaken. Our verbal complaints have all been resolved to
the satisfaction of the complainant: they have tended to be about our facilities, other
visitors, noise etc. The complainants via social media have been encouraged to get in
touch with us but have not done so.
The written complaints were more complex: The first related to the daughter of a
patient. She complained that her father did not receive adequate care at the end of
his life. A root cause analysis investigation revealed multiple issues, some not relating
to St Peter’s services. The issue that did relate to our services revealed that we did
not allocate care when we had the capacity to do so. We subsequently informed CQC
and safeguarding of our neglect and apologised to the family.
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The second written complaint related to a relationship with an individual member of
staff that they did not perceive to be satisfactory. The investigation revealed a
complex set of circumstances. Again we apologised to the family and further staff
training and peer review of Clinical Practice has been instigated.
The learning from all of our complaints has been examined through management,
governance and with our Trustees. As a result of these coupled with new initiatives we
have improved management and leadership training for managers, we have improved
access to clinical supervision (which is available to all but accessed voluntarily) and we
have engaged in peer review of clinical practice in new ways.
In summary our complaints have gone up but we have also improved our reporting
culture. Total complaints remain at less than 1% of our total patient and client
workload.
What our patients say about St Peter’s Hospice
We have received over 250 compliments in the forms of cards and letters, covering all
areas of St Peter’s Hospice. (NB This number excludes all the positive feedback we
receive from our on-going PROMS Surveys & also that received in our fundraising
department).
A small sample is below:
“I visited your Hospice yesterday afternoon (19th May) to see my aunt. I was very
impressed with every aspect of the facility that I saw. The site was quiet, peaceful and nicely laid
out. My parents and I all agreed that the profusion of well attended planting throughout made the
place more pleasant and colourful, the interior was light and airy and the general feel of the place
was serene and restful. I found the staff to be helpful and friendly. Nursing staff arrived
immediately when we needed someone, and were helpful and chatty. The volunteer who served us
tea and sandwiches at the cafe was similarly friendly and pleasant. I can't immediately think of
anything more I could have expected from you. Needless to say the visit was not a happy one, but
the place and people made it as agreeable as possible and I left feeling at least that my aunt was
in the right place and in good hands.”
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‘Just wanted to share with you, I did a visit on Friday and the patient’s GP Dr …… from
Kingswood was present. He wanted to pass on his thanks for all of SPH efforts with the patient.
She had been seen in the community, attended FAB group, and was dying with Hospice at Home
input at home. He said how on many occasions he has needed to call upon us and accessed the
advice line, and appreciated all the support we gave him and his colleagues. He spoke very highly
of us as a team, and wished for me to share this. So thank you.’
This year we introduced a new style Patient and Carer Outcome Measure (PROMs &
CROMs) questionnaire making it easier to gain feedback from service users
particularly if they have used several of our services.
Carer and Family Satisfaction
Measuring satisfaction as a quality outcome in specialist services, and particularly in
hospice services is reported by many, as notoriously difficult. By using a range of
approaches it is now embedded in the St Peters Hospice working culture. We use the
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same questionnaires for all services and groups and so maintain a standardised
approach that is comparable to the work of others. However, we approach patients
and other service users in several ways in order to meet a wide range of needs: for
example volunteers ask patients who are too ill to write things down, some are sent
by post and others are given out in group settings but they are always available
around our buildings.
We move to a benchmarked system (from 1st April) using “I want great care” and
fortunately the new questionnaires are virtually identical to our existing ones so we
will still be able to show trending data in the future.
PROMS (Patient Reported Outcome Measures) are the subject of a full report which
goes through our governance systems, including our trustees and this report will be
available upon request.
A total of 323 Patient and Carer Outcome Measure questionnaires were
received. This is 81% of the target of 400.
PROMs Analysis (collated results for all of the first 5 questions)
350
300
299
277
254
250
277
243
Number of 200
replies
150
Always
Most of the time
9 22
20
10 0 11
30
Sometimes
3 10
Blank
Question 5
5 10
Question 4
1 10
46
Question 2
0
51
Question 1
50
32
Question 3
100
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•
•
Q1- Did you feel you have confidence in those caring for you?
Q2- Did you feel that you were able to talk to the right person(s) about
your needs?
Q3- Did you feel involved about decisions relating to your care?
Q4-Did you feel you were treated with dignity and respect?
Q5- Did you feel that the hospice support you were receiving was
beneficial at this time?
•
•
•
Rate Our Services (collated results from all services recorded)
120
100
80
105
76
60
38
40
20
0
113
2 5
19
7
2
123
46
36
2
15
22
27
2 6
13
1
14
16
2
1 = Very Low
2
3
4
5 = Very High
User Involvement
We have also created User Involvement boards on the in-patient unit and in the
reception area at Brentry to help promote activities for patients and carers, including
St Peter's Hospice choir.
We have completed our first PLACE Assessment (NHS initiative Patient Led
Assessments of the Care Environment). This assessment is an equal collaboration
between Hospice staff and patients, family and carers, focusing on:
 Cleanliness
• Nutrition
•
•
Building condition and appearance
Privacy, dignity and well being
The PLACE team consisted of volunteers, carers and staff. They walked around the
hospice rating each of the key areas against the set criteria. The results are shown
below:
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Blue percentages = SPH mark
Green percentages = Average across the UK
Our St Peter’s Hospice choir continues to flourish, led by the Music Therapist for staff,
patients, carers and volunteers. The choir has proved to be very popular with high
attendance levels. The choir performed at SPH 35th anniversary event in June.
Our new building in the garden for the PSS team has been under development and
due to be completed in May 2014. Our patient’s, carers and staff were involved in
selecting an appropriate name for the building. Ballots were sent out and the building
was named ‘The Garden Rooms’. The grand opening is to be held at the end of June
2014.
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Staff training and appraisals
All paid staff receive mid-year and end of year appraisals in which objectives for the
coming year are set and a personal development plan drawn up. The SPH Education
department has implemented several e-learning modules for mandatory training
including food hygiene, back care and fire safety awareness. New software has
improved the recording of training for paid staff and volunteers, informing line
managers when mandatory training is due.
Statements of assurance from the Board of Trustees
The Board of Trustees’ commitment to quality
The Board of Trustees is fully committed to delivering high quality services to all our
patients whether in the community or at the hospice site. Our trustees are actively
involved in monitoring the health and safety of patients, the standards of care,
feedback from patients, including complaints, and plans to future service
development. They do this by carrying out regular unannounced visits, receiving
regular reports on all these aspects of care and discussing them at Board meetings.
In January 2014 our Board of Trustees validated our 5 year strategy, and in addition
authorised significant additional expenditure to fund extra clinical posts in the
community and in-patient unit to cope with increased demand. They also gave
strategic direction to review the in-patient unit infrastructure to ensure its fitness for
purpose for the next 20 years.
The Board is confident that the care and treatment provided by St Peter’s Hospice is
of a high quality and cost effective.
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“Clinical supervision provides me
with a place to stop, reflect and
consider different angles on the
issues I deal with regarding staff and
clients in my care. I feel
supported and refreshed by the
process”
What our regulators say about St Peter's Hospice
St Peter's Hospice is currently registered as an independent health care provider
under the Care Standards Act 2000.
SPH is subject to periodic reviews by the Care Quality Commission. In 2012/13 St
Peter's Hospice is registered under the following categories: nursing care, transport
services, triage and medical advice provided remotely, treatment of disease, disorder
or injury and diagnostic and screening procedures regulated activities with the Care
Quality Commission (CQC) under the Health and Social Care Act 2008.
We had an unannounced visit from CQC in September 2013. We continuously review
quality of care against the CQC standards through ‘spot checks’ on the in-patient unit
and collating of relevant and up to date documentation. Below is quote from the
report which is available on line:
“Inspection carried out on 8 September 2013
During a routine inspection we spoke with four people who were using the in patient
service and five relatives of people who used services. People consented to their care
and treatment and staff informed them of the effects and benefits of their treatment.
One person said “staff tell me what every tablet they give me is and explains what the
medication does”. Where people did not have the capacity to consent, the provider
acted in accordance with legal requirements.
People told us that they were pleased with the care and treatment they received. One
person said “you can’t fault the place, the staff are excellent and can’t do enough for
you”.
People’s needs were assessed and care plans developed to meet these needs were up
to date.
People told us that the food at the hospice was very good and they were able to have
their choice of food when they required it.
Systems were in place to ensure cleanliness and infection control was monitored
effectively. People and visitors told us that the service was always very clean and tidy.
We observed staff using personal protective equipment appropriately.
24
Attachment L
“We spoke with patients and relatives
on the n-patient unit. One person told us
that they
could not wish for anywhere better
for their relative and that staff
were "fantastic".
Staff told us they received regular training and support which allowed them to carry
out their roles effectively.
The service had effective systems in place to monitor the quality of the service
provided. This included gaining feedback from people who used the service and their
relatives. We found that this feedback was monitored and acted on to improve the
service.”
The results of this inspection found us to be compliant against the standards
measured and SPH has no actions to take as a result. The CQC report can be accessed
via www.cqc.org.uk/
What our NHS Commissioners say about St Peter's Hospice
Bristol Clinical Commissioning Group (the CCG) welcomes the opportunity to comment on the
draft St Peter’s Hospice Quality Account for 2013/14. The Quality Account reflects St Peter’s
Hospice’s continued commitment to collaborative working and the engagement of patients and
public in its work. The CCG has reviewed the report and is happy to confirm, that to our best
knowledge, the information contained within is an accurate reflection of the
performance and quality for 2013/14.
The CCG is pleased to note the progress made on the priority areas in 2013/14 including:
• The significant commitment that St Peter’s Hospice have made to partnership
working, particularly through their work on End of Life Care Coordination in Bristol
• The continual developments and innovations in service user engagement and patient
experience measures
• The expansion of their volunteer services
We are pleased to confirm that St Peter’s Hospice achieved its Clinical Quality Improvement
and Innovation goals (CQUINS) for 2013/14. The CCG notes the increase in complaints in
2013/14, and while this remains below 1% of the total activity at the hospice, we are pleased
to see that the learning identified and implemented by the hospice has been incorporated
within Quality Account. The CCG is glad to see the continued emphasis on user involvement
and patient experience throughout the quality account and in practice through St Peter’s
Hospices’ work. We support the inclusion of improved patient and family experiences,
25
Attachment L
increased efficiency for access and service delivery in the priorities for improvement in
2014/15.
The CCG will continue to work closely with St Peters on ensuring that the appropriate patient
safety, clinical quality, data and information governance mechanisms are in place, used and
routinely reviewed and improved on an on-going basis. The CCG looks forward to working
with St Peter’s Hospice to:
• Continue to develop collaborative arrangements with other local services, particularly end of
life care coordination
• to continue to support and build a health community approach to End of Life Care
• Extending the responsiveness of community hospice services so that more people can
be supported within their own homes
• Retaining the focus on patient feedback, experience and outcomes
The continued collaborative work between St Peters and the CCG will remain essential in
2014/15.
Dr Martin Jones
Chair
Bristol Clinical Commissioning Group
Julia di Castiglione
Director of Patient Care
Carole Dacombe
Medical Director
26
June 2014
Attachment L
Appendix 1
Quality Action Plan- Summary
This year: April 2013 March 2014
ACTION
Infection Control Audit and
identification of areas for
improvement
Audit ordering, collection,
transportation, receipt and
storage of Controlled drugs
Audit of use and validity of
dependency scoring system by
all SPH teams (Superseded by
whole systems review of inpatient unit)
Evaluation of Outcome
measurement tools and
changes to patient dependency
Monitor Staff sickness and
benchmark against NHS figures
Ongoing monitoring of
previously established
benchmarks for
 Pressure Sores
 Falls
 Drug Errors
Evaluation of unmet needs for
Hospice at Home service
Monitor clinical staff knowledge
and skills using Skills for Health
End of Life Care competencies
via staff meetings,
organisational groups and staff
training records
Review and further extend our
patient assessment tools e.g.
Nutritional assessment
BY WHEN
EXPECTED OUTCOME
ACHIEVED
Necessary changes identified and linked
to action plan
Jan 2013 and
on-going
Sept 2013
Evidence that controlled drugs are
managed correctly and necessary
changes identified and linked action
plan
Feb 2013 and
on-going
Apr 2013
Evidence that dependency scoring
system is used correctly against
guidelines and necessary changes
identified and linked to action plan
New system
being piloted
Sept 2013
Evidence that outcome measurement
tools are used in accordance with
guidelines
Dec 2013
SPH benchmarks established and
standards set.
On-going
Evidence of compliance with SPH
standards and necessary changes
identified and linked to action plan
On-going
July 2013
March 2013
Pilot study
Mar/April
2013
Sept 2013
Identification of supply versus demand,
necessary changes identified and
shared with relevant groups
April 2013
Evidence that SPH clinical staff are
meeting required competencies to
provide a high standard of End of Life
care
On-going
June 2013
Patient assessment is accurately
completed and documented
On-going
27
Completed
Attachment L
ACTION
Review results of patient,
carers, bereaved clients
satisfaction survey for
Complementary Therapies
Audit of bereaved client
satisfaction
Report on quality of SPH
services and revise Quality
improvement plan
Review of referral criteria and
capacity for all our services
Review of triage and advice line
to work towards a 7 day per
week service
Implement in-patient review
recommendations following
review conducted in Feb 2013
by independent reviewers
Log unmet needs in in-patient
unit , PSS team and art
therapies team
Consolidate plans for full
creative use of new garden
room with optimal flexibility for
PSS team
Develop a medical team model
to support the future
BY WHEN
EXPECTED OUTCOME
ACHIEVED
November 2013
Evidence that patients carers, bereaved
are satisfied with Complementary
therapy service and necessary changes
identified and linked to action plan
Several
audits
surveys and
PROMS
presented
Dec 2014
Evidence that bereaved client was
satisfied with the service received from
their allocated worker and necessary
changes identified and linked to action
plan
completed
March 2013
Clear plan for SPH quality improvement
linked to key performance indicators
Completed
Mid 2013
Revised referral criteria to fit changing
palliative care demographics
Completed
June 2013
Merged triage, advice line and referral
system
Completed
Dec 2013
Full list available on request
Oct 2013
To measure team demand and capacity
On-going
Early 2013
New building to be built and funded by
Department of Health grant
Completed
Dec 2013
Review medical staffing alongside other
disciplines review
Completed
Completed
and on-going
Next Year: April 2014  March 2015
ACTION
Audit on identified key areas of
Symptom Management
Review results of Patient
satisfaction surveys and
identify any required actions
BY WHEN
July 2014
September 2014
On-going monitoring of
previously established
benchmarks
March 2014
Report on quality of SPH
services and revise action plan
March 2014
Consider priorities for
expansion in Hospice at Home
and other community based
services
EXPECTED OUTCOME
Evidence that symptoms are managed
effectively
Evidence that patients are satisfied
with SPH services and necessary
changes identified and linked to action
plan
Evidence of compliance with SPH
standards and necessary changes
identified and linked to action plan
Clear plan for SPH quality
improvement linked to key
performance indicators
To scope expansion of day services in
the community, volunteer services
and PSS support
26
ACHIEVED
Completed
Completed
On-going
Completed
and on-going
Completed
and on-going
St Peter's Hospice
Charlton Road
Brentry
Bristol
BS10 6NL
Switchboard: 0117 915 9400