St Teresa’s Hospice
The Darlington & District Hospice Movement
Quality Account for the Year 2013/2014
Our staff team...
Many, caring hands
St Teresa’s Hospice, The Woodlands, Woodland Road, Darlington, DL3 7UA | (01325) 254321
www.darlingtonhospice.org.uk
PART 1
CHIEF EXECUTIVE’S STATEMENT
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PART 2 PRIORITIES FOR IMPROVEMENT 2014/15 AND MANDATORY STATEMENT OF ASSURANCE
FROM THE BOARD
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2.1
2.2
2.3
2.4
PART 3
3.1
3.2
3.3
3.4
INTRODUCTION
FUTURE IMPROVEMENT ASPIRATIONS FOR 2014/2015
PROGRESS ON IMPROVEMENT ASPIRATIONS FOR 2013/2014
MANDATORY STATEMENT OF ASSURANCE FROM THE BOARD
REVIEW OF QUALITY PERFORMANCE 2013/14
PATIENT SAFETY
CLINICAL EFFECTIVENESS
2013/14 PATIENT, CARER, STAFF AND VOLUNTEER EXPERIENCE
OTHER COMMENTS FROM PARTNERS & STAKEHOLDERS
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SUPPORTING STATEMENTS
ST TERESA’S HOSPICE QUALITY ACCOUNT 2013-14
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THE BOARD OF TRUSTEES STATEMENT
ENDORSEMENT BY SENIOR DIRECTORS
DARLINGTON CLINICAL COMMISSIONING GROUP STATEMENT
HAMBLETON, RICHMONDSHIRE & WHITBY CLINICAL COMMISSIONING GROUP STATEMENT
COMMENT FROM HEALTHWATCH, DARLINGTON
COMMENT FROM HEALTH & PARTNERSHIPS SCRUTINY COMMITTEE, DARLINGTON
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2
Part 1
Chief Executive’s Statement
The Darlington & District Hospice Movement, also known as St Teresa’s Hospice is an independent
charity (registered number 518394) and Company limited by guarantee (registered number
2080756).
The Board of Trustees is responsible over all for Governance of the Charity.
The Strategic Management Team of 6, led by the Chief Executive, is comprised of CEO, Director of
Clinical Services, Finance Director, Head of Nursing, Education Manager and Operations Manager,
and our high quality care is only possible thanks to the expertise and commitment of our dedicated
staff and volunteer team.
Through this Quality Account, we have the opportunity to show all stakeholders our commitment to
quality as intrinsic to everything we do. The findings in the Francis Report (investigation into the Mid
Staffordshire Foundation Trust) have highlighted quality of service nationally this year, making this
subject more important than ever; whereas we did not have any serious concerns, we are never
complacent about standards, and have conducted a detailed review against all of the
recommendations therein, which has been used to inform our progressive action plans in all areas.
Our culture of continuous review and improvement through Clinical Governance ensures continuous
quality monitoring, so that any shortfalls are speedily identified, reported, rectified and learned
from, to improve future practice.
At the time of writing, we have reviewed our Strategic Plan and, having achieved all of the key
milestones, have begun the process of renewing our strategy, as we approach our 30th anniversary in
2016. As will be seen from the aspirations set out in this document, we are constantly striving to be
patient-led and to keep updating and improving our services for the people of Darlington & District
without whom, this important charity would not exist.
This Quality Account is written in consultation with service users, and the Hospice team, and is
endorsed by our Board of Trustees, whose members enthusiastically support quality improvement;
to the best of my knowledge, I confirm it as a true and accurate assessment.
Jane Bradshaw
Chief Executive
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Part 2
Priorities for Improvement 2014/15 and
Mandatory Statement of Assurance from the Board
2.1
Introduction
All of the work that St Teresa’s Hospice does is inspired by needs of people affected by a palliative or
life limiting illnesses. This includes patients themselves, their loved ones referred to throughout the
remainder of the document as carers and the general public who may look to us for support around
Public Health issues associated with palliative care and death and dying. The Hospice is busy
embedding a culture of continuous improvement, and much is to be done not only to maintain our
exceptionally high standards today but to keep moving forwards, being innovative and developing
our services so that we can meet needs in the future of an ever changing population demographic
but also to keep apace of the changes in the commissioning landscape.
The following quality improvements you are about to read, and reports on quality performance,
pertain only to clinical care and relevant support services necessary to provide care. The report does
not take into account fundraising and administrative functions of the organisation where separate
quality initiatives are employed.
The Board of Trustees and Senior Management of St Teresa’s Hospice are committed to the delivery
of high quality care which is safe, clinically effective and provides the best possible patient
experience.
2.2
Future Improvement Aspirations for 2014/2015
The following improvement aspirations have been developed with people who use our services
including patients, carers and volunteers and are detailed across the domains of Patient safety,
Patient experience and Clinical effectiveness.
Improvement Aspiration 1:
To build a purpose built, 10 bedded Inpatient unit
Quality Domain- Patient Safety, Patient experience, Clinical Effectiveness
How was this aspiration identified?
The population is growing alongside changing demographics with an expected increase in life
expectancy. By 2020 over 40% of the Darlington population will be over 50 years and 10% will be
over 75 years. With a rise in life expectancy it is also expected that more people will have comorbidities and will suffer with complex illnesses related to older age, such as Dementia, nationally
it is widely recognised that a third of over 85 year olds will suffer from Dementia. The annual death
rate is growing and is expected to rise steeply from 2016; this will have a corresponding rise in the
numbers of people requiring palliative and end of life care.
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The Hospice carried out a local Needs assessment in July 2013, identifying the need for more
inpatient beds for Darlington and District catchment area. The Cancer Care Alliance in 2005 carried
out a needs assessment identifying the need for additional beds and the current (draft) North
Eastern Cancer network wide Needs Assessment indicates that based on epidemiology,
demographics and socio economic factors, considering a population of Darlington alone of 105,584
(St Teresa’s Hospice serves Darlington and District including patients from Durham Dales Clinical
Commissioning Group and Hambleton, Richmondshire and Whitby Clinical Commissioning Group)
there should be between 8.6-10.6 inpatient beds.
Furthermore, the current 6 bedded inpatient unit although offering consistently high quality services
also poses some barriers to care due to accessibility and limitations of the Grade 2 listed building.
The inpatient unit is on the first floor, with a split level landing giving stretcher access to only 3
bedrooms. There is frequently a waiting list in operation as patients can only be admitted to the
upper floor either if they are mobile or in a wheelchair.
The Care Quality Commission on every visit has raised concerns regarding the open landing,
comments that were also flagged in an independent audit of the Hospice for a Dementia Friendly
environment. Patients who are confused, agitated or wandering cannot be admitted to the upper
floor, again limiting the number of referrals that can be accepted and taking into account expected
rise in incidence of dementia, this will be exacerbated in coming years. In addition, the very high
ceilings potentially pose an infection control risk due to difficulties in cleaning.
Fire risk assessments support the need for a purpose built unit. Currently in the event of a fire,
palliative or end of life patients would need to exit the building in a “toboggan”, down 2 flights of
stairs.
Patients have also commented on the heat and ventilation in the rooms and although all bedrooms
have en suites, only patients on the upper floor can access the bathroom (unless mobile). Carers
and relatives, who may be struggling to deal with what is happening to a loved one, have access only
to a very small room which doubles up as a staff room. Staff have very little space to work away from
patients, or to discuss patient care and access to computers can be difficult which together can at
times compromise patient care.
Patients who have sadly died whilst at the Hospice currently exit the building via the stretcher lift
and through a link corridor, which does not offer the optimum dignity and privacy.
How will it be achieved?
St Teresa’s Hospice plans to develop a purpose designed 10 bedded inpatient unit on the Woodlands
site. Each of the ground floor bedrooms will have an en suite and access to the gardens. All rooms
will be uniform in size and shape, with more natural light and proper ventilation, with improved
access for patients using mobility aids. The whole unit will offer privacy and dignity to all patients
during their entire stay with us and have a separate area for relatives and carers to use if they wish.
Overall the aim is to achieve a superior facility that will provide significant improvements in the
physical environment for patients, carers and staff, with enable improved patient safety and patient
experience and delivery of high quality clinical effective care.
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Architects plans have been devised and submitted to Darlington Borough Council Planning
Department in May 2014. Should award of planning permission be granted, consultation for a design
and build project will begin. Earmarked legacy funds will enable building work to commence
alongside a Capital Campaign to raise the funds for the interior outfitting of the building.
How will it be monitored and measured?
A planning subcommittee will be established, overseeing and monitoring milestones, reporting back
to the Board of Trustees.
Dependent upon planning permission, milestones will include:
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Resubmission of architects drawings and planning application
Decision on planning application
Identify and engage company for Design and Build Scheme
Commence Capital Campaign for interior outfitting
Commence building within 2014/2015 Financial year
End of May 2014
June 2014
July 2014
July 2014
March 2015
Improvement Aspiration 2:
To develop leadership on the inpatient unit and to have a named nurse
responsible for each patient on the inpatient unit and day hospice
Quality Domain- Patient Safety, Clinical Effectiveness
How was this aspiration identified?
Following a review of the model of care delivery and careful consideration of the Francis Review and
the vision for nursing set out by the Chief nursing officer for England in the Nursing strategy, two key
areas of improvement have been identified: development of Nurse Leadership at ward level and a
named nurse responsible for the care of every patient in Day Hospice and Inpatient unit. These
improvements are intended to further improve and enhance high quality, individualised care which
is already evident in these clinical areas by the low number of complaints received, excellent patient
feedback and excellent feedback from the Care Quality Commission, however, the Hospice is always
keen to improve.
How will it be achieved?
Leadership is key across the multidisciplinary teams, and the Hospice Senior Management recognises
that high quality leadership will enable delivery of high quality care. The current structure on the
inpatient unit has two Band 6 nurses with shared responsibilities, reporting into the Head of Nursing.
Changes in responsibilities will be introduced which will ensure that one Band 6 will have a
responsibility for shifts on a daily basis and will be responsible for general supervision of staff, coordination of workload within the IPU, be responsible for improving and maintaining standards and
reporting on key performance indicators. The other Band 6 will have greater responsibility for
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clinical leadership and practice development, ensuring audit activity and representation at the multi
disciplinary team meetings.
The Hospice is keen to encourage and develop leadership across all staff grades, and not simply
endorse leadership within a hierarchy. Staff will be encouraged to motivate others and make
improvements to patient care, all registered nurses will be encouraged to take responsibility to
become a link nurse for a disease specific area, and thus provide leadership to colleagues. They will
be encouraged to develop networks within and external to the Hospice in a specific disease area.
This will enable a rich knowledge base at the Hospice and develop improved inter-organisational
links supporting seamless patient care delivery
Getting to know patients and managing their care through the system effectively will improve
patient safety, and remove the possibility of care delivery being a matter of checklists and processes.
A model of a “Named Nurse” will be introduced where individual named nurses will have
responsibility for overseeing total patient care, managing any concerns a patient has and ensuring
that a patient’s care is planned and delivered around a patients need. This is a move away from the
existing team model where staff deliver care on a need basis. A review of current nursing shift
patterns will also be undertaken then an informed decision taken regarding length of shift.
How will it be monitored and measured?
Weekly update meetings and monthly contact meetings with the Head of Nursing and Band 6 staff
will enable monitoring of change in working practice. Link Nurses will be requested to report
regularly to the Journal Club and provide an update at bi-monthly staff meetings.
Regular audit of patient records will identify implementation of the named nurse model. The Head
of Nursing will report progress back to the clinical governance subcommittee on a quarterly basis.
Improvement Aspiration 3:
To Transform Day Hospice services to offer a range of services to meet
patient needs and ensure we reach as many patients as possible
Quality Domain- Patient Experience, Clinical Effectiveness
How was this aspiration identified?
Several circumstances identified the need to review the traditional Day Therapy model. These
included a concern that the service was not being fully utilised evidenced in decreasing attendances.
Identification by senior clinical staff that some of the patient group who were accessing the service
were often too poorly to attend their 12 week programme, and that it would have been beneficial
for attendance earlier in their disease trajectory. Equally a cohort of patients reported that they
struggled with being discharged from the programme as, although no longer clinically dependent,
they had become dependent on the social aspect or care delivered.
Discussions with Clinical Nurse Specialists for Respiratory and Heart failure identified a gap in
services for palliative patients with these diseases. Finally, it was evident from statistical analysis and
feedback from surveying non malignant patient groups that access to the service was too limited,
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and neurological patients in particular did not know they could access the existing services and that
services on offer were not necessarily what they wanted.
How will it be achieved?
In April 2014, the first away day was held with staff to identify the issues and to decide on a way
forward. It was agreed that a flexible model that offered a range of options to patients and their
carers was needed. The model will incorporate the traditional Day Therapy Day which will be renamed and offer a structured programme with clear referral and discharge criteria. This will be
reduced from 4 to 3 days a week to enable introduction of disease specific “clinic programmes”
including Neurology, Heart failure and Respiratory Disease to improve the reach and accessibility to
the Hospice. Patients and carers will be able to access more and different complementary therapies
as outpatients.
A further away day is scheduled for May 2014 following which task and finish groups including in
their membership service users, will support the development of both the clinics and the revised
model of Day therapy and all will sit under the umbrella of Day Hospice Services. Respiratory and
Heart Failure CNS have already agreed in principle to support the clinics and agreement will be
reached on specific days for service delivery.
Service promotion will be key to advertising the change in services to health care professionals and
service users.
How will it be monitored and measured?
Effective leadership will be essential throughout the Day Hospice Transformation; this will be
achieved by appointing a team leader who will meet monthly with senior management to monitor
progress against a detailed action plan which will be reported on bi-monthly to the Board of
Trustees. Both quantitative and qualitative data will be used to inform effectiveness of the Day
Hospice Transformation. A minimum of 10% increase in non cancer patients is aspired to, alongside
an overall increase of 10% in service users. A Patient and staff satisfaction survey pre and post
transformation will be carried out and service user evaluation will be vitally important to identify
and measure the impact of change to patients themselves.
The true measurement of success will be full implementation of the New Model for Day Hospice
however milestones will include:
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Away Day
Appointment of Team Leader
Staff and patient Evaluation pre service transformation
Commence Neurological MDT at Hospice for Darlington Patients’
Agree new programme for Day Hospice internally & with external CNS
Commence Clinics and New Day Programme
Service Promotional activity, GP’s District Nurses, Macmillan Nurses,
Respiratory CNS, Heart Failure CNS and Support Groups
May 2014
June 2014
June 2014
June 2014
June 2014
July 2014
July 2014
Improvement Aspiration 4:
To develop a Clinical Risk Management Framework
Quality Domain- Patient Safety
How was this aspiration identified?
The Hospice as an independent organisation has always had clinical risk management processes in
place which are fit for purpose, however, review of existing processes has identified room for
improvement in our constant strive to improve patient safety and to comply with contractual patient
safety requirements.
How will it be achieved?
The Hospice will develop a Clinical risk management framework that incorporates the following:
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Incident reporting in line with Clinical Commissioning Group Requirements
Falls management
Medicines management
Pressure ulcer management
Sharps Management
Lone worker
Negotiation and agreement with County Durham and Darlington Foundation Trust (CDDFT)
regarding incident reporting needs to be reached, as currently CDDFT NHS employed staff report
incidents via Safeguard system and hospice staff via internal processes.
Key to the success of the framework is staff awareness of fundamental standards of clinical risk
management, and this education will be provided to all areas.
How will it be monitored?
Monitoring of clinical risk management is via the Clinical Governance Group which meets quarterly.
Milestones will include:
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Development of Risk Management Framework
Review and improved Pressure ulcer Management
Full compliance with CCG reporting requirements (One system)
Review and improved falls management programme
Review and improved medicines management
Review and improved pressure ulcer management
Quarter1- July 2014
Quarter 1
Quarter 2
Quarter 2
Quarter 2
Quarter 2
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How will Progress be monitored and reported on for all future improvement aspirations
2014/2015?
St Teresa’s Hospice Board of Trustees will monitor and report on progress through a variety of
methods including:
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Annual return to the Charity Commission
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Annual review and audited reports and accounts
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Quality Account and reports to Clinical Governance Sub Committee
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Annual General Meeting
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Hospice Newsletter and other publications
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Events, such as open days
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Hospice newsletter
2.3
Progress on Improvement Aspirations for 2013/2014
The purpose of the Quality Account is to not only set out future improvement aspirations but to also
evidence achievements on aspirations for improvement for the previous year.
In last year’s report we set out six aspirations for improvements for our services. All aspirations
were specifically selected as they would directly impact on the care our patients and carers received,
through improving patient safety, clinical effectiveness or the patient’s experience.
The quality improvement aspirations for the previous year were:
2012/13 - Aspiration 1:
To improve End of Life Care in Darlington Care Homes
Quality Domain- Patient Safety, Patient experience, Clinical Effectiveness
The Gold Standards Framework (GSF) is a tool to improve End of Life Care, the aspiration was to
support care homes to implement the GSF. The education manager was seconded to the role of GSF
Facilitator; unfortunately the funding for the pilot was not maintained, with the pilot finishing in
August 2013. Despite this, good progress was made with implementing GSF and improvements in
care delivery were demonstrated. Of the 16 participating care homes in the GSF scheme, one
dropped out, four homes were extremely committed and keen to engage, a further cohort of four
homes whilst committed to the programme, progress was slower and the remaining 6 homes due to
internal issues such as staffing had varying degrees of commitment and engagement to the
programme.
What we have achieved:
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Of the 16 participating care homes 8 hold a register for palliative patients and are coding
patients with palliative care needs a further 2 were almost ready to begin coding at the end
of the pilot, 1 officially dropped out
4 Homes made significant progress and are ready to apply for GSF accreditation
Training was delivered to care homes on advanced care planning
Opportunities offered to all care homes for staff to shadow hospice care
Case studies available that demonstrate improvements have been made by preventing
avoidable admissions to hospital, in homes that have implemented change
Excellent feedback from participating homes regarding the value of the facilitator
Feedback from GP’s who are now aligned to specific care homes on improved organisation
within the homes participating in the GSF programme
Increased awareness in all participating homes of the importance of recognition that a
patient is approaching the end of life and appropriate planning to support the patient
Recognition by the Hospice that the GSF alone will not improve patient care, full
engagement and willingness to change is required by individual homes to take responsibility
for the care they deliver
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How we will continue to improve:
The Hospice has maintained good links with the care homes, and has continued to offer advice and
deliver ad hoc training. The Hospice is now represented on the Clinical commissioning Group
Education and Workforce subcommittee and will continue to influence education and care provision
in care homes at a strategic level.
2012/13 - Aspiration 2:
To Introduce Core Competencies for Health Care Assistants
Quality Domain- Patient Safety,
What we have achieved:
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The Competency Framework has been successfully developed and is seen as an important
measure for competence of health care staff to deliver the same, high quality standard of
care.
The Hospice established a task and finish group which successfully developed St Teresa’s
Hospice End of Life Competency Framework for Health Care Assistants
The Hospice established a structure for mentorship for Health care Assistants during the 3
month completion period
15 Staff were issued with the framework. 1 has not yet completed due to long term
sickness, 11 have successfully completed and there have been staff changes but new staff
have been issued with document.
Gaps in competency were identified and training arranged, this will be an ongoing process
How we will continue to improve:
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It is now mandatory for all new contracted health care assistant staff to complete the
Competency Framework
Work will begin during 2014/2015 to develop a competency framework for registered nurses
2012/13 - Aspiration 3:
To introduce improvements to the Hospice at Home Service
Quality Domain- Clinical Effectiveness
Significant improvements have been made to the Hospice at Home service in improving access,
improving assessment and care planning, and patient experience.
What we have achieved:
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A registered nurse has been employed to lead the service and take responsibility for
assessment and care planning, new health care assistant staff have been recruited and
trained
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Development of strong professional links with District Nursing and other health care
professionals
Introduction of a holistic patient assessment, 100% of referred patients have received an
assessment by a registered nurse, review process in place
100% of patients on the caseload have been offered opportunity to partake in Advanced
Care Planning either with Hospice staff or referral onto District Nursing
Improved access to other Hospice services where appropriate (3 patients admitted to
inpatient unit, patients reviewed by physiotherapist and Nurse consultant in their own
homes)
Increased activity; 547 hours of care delivered in Quarter 1, increased to 1001 hours of care
delivered in Quarter 4
Increase in the number of patients dying in their preferred place of care on the caseload; 1
in Quarter 1, increased to 23 in Quarter 4
Improved access for non cancer patients, although percentage of population of cancer, non
cancer patients remains static, more patients overall are accessing the service
All contracted Hospice at Home staff have undertaken the core competency framework
establishing a baseline for quality of care provided
How we will continue to improve:
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Continue to establish strong networks and publish referral criteria to the healthcare
community further promoting the service
Identify gaps in service delivery including the need for personal care and address how these
gaps can be overcome
Carry our formal patient evaluation of the service
2012/13 - Aspiration 4:
To Improve services offered to patients with Dementia
Quality Domain- Patient Experience, Clinical effectiveness
What we have achieved:
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Improved access to services for patients with dementia, in 2012/2013 0 patients with
confirmed diagnosis of dementia patients accessed our services; in 2013/2014 11 patients
with a confirmed diagnosis of Dementia accessed our services.
Dementia case finding question is incorporated into all patient assessments, as a direct
result 3 patients were referred onto their GP for full dementia assessment
Dementia environment audit and significant physical improvements to the building to
enable a dementia friendly environment
65 members of staff have undertaken dementia awareness training and 8 members of staff
have undertaken the enhanced Alzheimer’s society accredited training
Every Dementia patient or carer was offered the opportunity to comment upon the services
they received, by taking part in a semi structured interview with a Hospice Trustee
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Consultant-led education for GPs in Dementia at the end of life delivered at the GP leads
meeting
Participation in Help the Hospice Dementia Project
How we will continue to improve:
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Further staff will be encouraged to undertake the enhanced Alzheimer’s society accredited
training across all departments, and all Hospice at Home staff will be trained
Service user feedback identified a common theme in that patients and carers would have
benefitted from the opportunity of advanced care planning earlier in their disease trajectory.
The hospice will explore its role in supporting patients at diagnosis for a short period of time
Further explore how we can support dementia patients with Hospice at Home services
2012/13 - Aspiration 5:
To fully integrate nutritional screening into Hospice assessments, to ensure
all patients’ nutritional requirements are met and to provide a catering menu
that will meet both patients and their guests’ requirements
Quality Domain- Clinical Effectiveness, Patient Experience
What we have achieved:
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Nutritional screening is now part of the patient assessment document and is carried out for
every patient where appropriate (Not end of life referrals)
Food and fluid intake charts are used on all patients who are identified as medium and high
risk in assessment
Successful recruitment to Head of Catering vacancy, who since in post has lead on
development of patient menu, ensuring it meets the nutritional requirements of all patient
groups including those requiring special diets. Improved communication between ward level
and kitchen to ensure effective transfer of information regarding patient specific dietary
requirements
A review of meal times has led to volunteers and housekeeping staff now assisting in serving
food to Day Hospice patients and Inpatient staff now support feeding and monitoring
patient intake and this is recorded on SystmOne. Volunteers have received training on the
importance of actual nutritional intake and the need to record.
Replacement crockery and cutlery has been purchased including modified cutlery to
promote independence where possible
Service user feedback on choice, menu content, portion sizes regarding the 12 week menu
cycle has been sought
There is now a list of snacks and drinks available 24/7 in all patient bedrooms.
The plans for the Bistro for use by patients, carers, staff and the public has been delayed due
to delay in planning consent associated with the Grade II listed building, work is scheduled to
commence in July 2014
How we will continue to improve:
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The Head of Catering following the Day Hospice transformation will give talks to patients on
the importance of nutrition
Demonstrations on how to make “Smoothies” of the day and presentations on how to follow
a healthy diet, or a High Calorie diet, will be programmed into activities.
2012/13 - Aspiration 6:
To improve access to Complementary Therapies and extend the range of
Complementary Therapies available at the Hospice
Quality Domain- Patient Experience, Clinical Effectiveness
What we have achieved:
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Successfully appointed a Complementary therapy lead to develop the service for patients
and carers
Patients now benefit from access to therapeutic Complementary Therapies including
acupuncture, hand acupuncture, auricular acupuncture, massage, aromatherapy massage,
hot stone massage and Reflexology
Patients now benefit from broader access to diversion Complementary Therapies including
art therapy
Introduction of MYCOR, nationally recognised service evaluation tool
192 outpatient acupuncture patients, 24 patients were seen for massage, 6 patients were
seen as outpatients for reflexology. (NB Day Hospice patients were seen in addition for
massage)
How we will continue to improve:
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Recruit further paid and volunteer therapies
Open up Complementary Therapies to staff (income generation) to promote a healthy
workforce
Support day hospice transformation with increased access to complementary therapies.
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2.4
Mandatory Statement of Assurance from the Board
The following statements must be provided within the Quality Account by all providers. Many of
these statements are not directly applicable to specialist palliative care providers including St
Teresa’s Hospice, therefore explanations of what these mean are given.
2.4.1 Review of Services
During the reporting period 2013/2014 St Teresa’s Hospice, Darlington, provided the following
services to the NHS:
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6 Bedded Inpatient Unit
Day Therapy Service
Hospice at Home
Rapid Response service
Lymphoedema services
Family Support (including welfare benefits)
Complementary Therapies
During the reporting period 2013/2014 St Teresa’s Hospice, provided or sub contracted 7 NHS
services (no funding received for Complementary therapies). The Hospice has reviewed all the data
available to them on the quality of these NHS Services.
The income generated by the NHS services reviewed in 2013/2014 represents 100 per cent of the
total income generated from the provision of NHS services by St Teresa’s Hospice Darlington for
2013/2014. The income generated represents approximately 30 % of the overall costs of running
these services.
What this means:
St Teresa’s Hospice is an independent Charity which provides all services free of charge. The income
generated from the NHS (Darlington Clinical Commissioning Group and Hambleton, Richmondshire
and Whitby Clinical Commissioning Group) in 2013/2014 represents approximately 30% of the
overall costs of service delivery, with the remaining income to fund our services from voluntary
charitable donations, legacies, hospice shops, the One Wish Lottery, events and community
fundraising.
St Teresa’s Hospice for the accounting period 2013/2014 signed an NHS contract with Darlington
CCG, and a voluntary sector grant with Hambleton, Richmondshire and Whitby CCG, similar
arrangements are in place for 2014/2015. Contracts for Rapid Response (partnership service St
Teresa’s Hospice and Marie Curie) have rolled over as part of a pilot project and are due to expire in
March 2015.
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2.4.2 Participation in Clinical Audit
During 2013/2014 no national clinical audits or confidential enquiries covered NHS services provided
by St Teresa’s Hospice.
During 2013/2014 St Teresa’s Hospice participated in no national clinical audit and no confidential
enquiries of the national clinical audits and national confidential enquiries as it was not eligible to do
so.
The national clinical audits and national confidential enquiries that St Teresa’s Hospice was eligible
to participate in during 2013/2014 was none.
The National audits and national confidential enquiries that St Teresa’s Hospice participated in, for
which data collection was completed during 2013/2014, are listed below alongside the number of
cases submitted to each audit or enquiry as a percentage of the number of registered cases required
by the terms of audit or enquiry.
St Teresa’s Hospice was not eligible to participate; therefore, there is no information to submit or list
here
What this means:
St Teresa’s Hospice as a provider of palliative care was not eligible to participate in any national
audit or confidential enquires as these have not pertained to palliative care during the accounting
period
St Teresa’s Hospice has not reviewed any national or local audits during 2013/2014 and therefore
has no actions to implement
2.4.3 Research
The number of patients receiving NHS services provided or sub-contracted by St Teresa’s Hospice in
2013/2014 that were recruited during that period to participate in research approved by an ethics
committee was none. There was no appropriate, nationally, ethically approved research studies in
palliative care in which St Teresa’s Hospice could participate.
2.4.4 CQUIN Payment Framework
Darlington CCG Income- St Teresa’s Hospice NHS income in 2013/2014 was conditional on achieving
quality improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework for 3 elements within the contract. The 3 CQuINS represented 2.5% of the
overall contract value. (CQuIn Measures included dementia, service user feedback, Safety
Thermometer). The Hospice has qualified for full payment of all 3 CQuIns.
Hambleton, Richmondshire and Whitby Income - St Teresa’s Hospice NHS income in 2013/2014 was
not conditional on achieving quality improvement and innovation goals through the Commissioning
for Quality and Innovation payment framework because it had a voluntary sector grant in place.
17
2.4.5 Statement for the Care Quality Commission
St Teresa’s Hospice is required to register with the Care Quality Commission and its current
registration status is for the following regulated activities:



Diagnostic and screening procedures
Treatment of Disease, disorder or injury
Personal Care
St Teresa’s Hospice is registered with the following conditions:



Services are provided for people over 18 years old
The maximum of 6 patients may be accommodated overnight
Notification in writing must be provided to the Care Quality Commission at least one month
prior to providing treatment or services not detailed in the Statement of Purpose
St Teresa’s Hospice is subject to periodic and unplanned reviews by the Care Quality Commission
(CQC), the last on-site inspection was in December 2013. St Teresa’s Hospice was fully compliant
with all the essential standards of Quality and Safety as set out in the Care Quality Commission
Registration and the Health and Social Care act. The CQC has not taken any enforcement action
during 2013-2014 and St Teresa’s Hospice has not participated in any special reviews or
investigations by the CQC in this time period.
2.4.6 Data Quality
St Teresa’s Hospice did not submit records during 2013/2014 to the Secondary Users service for
inclusion in the Hospital Episode Statistics.
What this means:
St Teresa’s Hospice is not eligible to participate in the scheme. In the absence of this we have our
own system in place to collect and monitor data through the electronic patient information system,
SystmOne. St Teresa’s Hospice also submits data to the National Minimum dataset for Specialist
Palliative Care Services collected by the National Council for Palliative Care on an annual basis.
2.4.7 Information Governance Toolkit Attainment
St Teresa’s Hospice participated in completion of the Information Governance Toolkit in 2013/2014,
the outcome was satisfactory and an appropriate action plan for improvements has been developed
which is timetabled for review on an annual basis. All clinical staff have completed annual top ups
for information governance as part of mandatory training.
2.4.8 Clinical Coding error rate
St Teresa’s Hospice was not subject to the Payment by Results clinical coding audit during 2013/2014
by the audit commission.
18
Part 3
Review of Quality Performance 2013/14
The review of Quality at St Teresa’s Hospice can be considered across the three domains of Patient
Safety, Clinical Effectiveness and Patient, Staff and Volunteer Experience. The following information
provides information on these areas during the accounting period 2013/2014.
3.1
Patient Safety
Risk Assessments
Risk assessments are carried out as part of everyday practice, are reviewed at least annually, and are
in place to address health and safety hazards in all areas of the organisation. Additionally COSHH
risk assessments have been carried out for hazardous substances.
Incident Reporting
For the period 1st April 2013-31st March 2014 there were 26 health and safety and clinical incidents
reported. All In-patient unit incidents are reported via Safeguard System (incidents involving NHS
Staff on the inpatient unit) and also reported via internal governance processes and reviewed and
monitored by the Clinical Governance sub group. One of the improvement aspirations for 2014/2015
will focus on improving incident reporting within the Hospice (see section 2). However, overall the
hospice is delighted that we have had no Never Events or Serious Incidents during the accounting
period.
Table 1 Demonstrating Clinical Incidents during Accounting Period 2013/2014
Clinical Incident
Number
Slips, trips, falls and accidents - patients
10
Slips, trips, falls and accidents – staff and 3
volunteers, and visitors
Pressure ulcers
2
Infections
0
Drug errors and adverse effects
2
Incidents relating to medication
4
Other clinical incidents
3
Other non clinical incidents
2
19
Slips, trips, falls and accidents- Patients
There were 10 incidents involving patients, none of which resulted in major injury requiring
reporting to the Care Quality Commission health and safety executive or North east Commissioning
Support Unit. 9 were patient falls, (4 patient falls in the inpatient unit, 1 fall during transfer into car,
1 fall on front steps of the Hospice, 1 fall from a rise and recline chair outside, 1 inpatients own
home) the remaining incident was when a patient trapped a finger.
Slips, trips, falls and accidents- Staff, Volunteers and Visitors
There were 3 health and safety incidents reported involving staff, volunteers and members of the
public. 2 incidents involved trapped fingers and one a minor burn, no serious injury was sustained
during any accident.
Pressure Ulcers
Infections and pressure ulcers cause pain and distress to patients and families. Improvement work
has taken place over the past 12 months on identification of pressure ulcers and it is acknowledged
that this is an ongoing training requirement for the Hospice. 2 pressure ulcers were recorded, on
both occasions patients were admitted to inpatient unit with pre-existing pressure ulcers.
Infections
There were no hospital acquired infections during the accounting period.
Incidents relating to Medication
There were 4 incidents relating to medication, (1 where a GP altered medication resulting in agitated
patient, one patient self medicating took an additional tablet, 1 incident were a drug went missing,
one when medication was left in drug cupboard from previous patient.)
Drug errors
There were 2 drug errors; both were still within safe prescribing limits of administered medications.
Safety Thermometer
St Teresa’s Hospice has completed the patient safety thermometer for the past 12 months as part of
the CQuIn for the Inpatient services and Hospice at Home services. The Safety thermometer is a
“snapshot” measure taken across pre determined domains on the same day each month. During the
April 2013-March 2014 time period, the following harms were recorded in any of the domains
measured.
Table of recorded harms in accordance with Patient Safety Thermometer during
Accounting Period 2013/2014
Clinical
Area
IPU
H@H
20
Pressure
Ulcer
0
0
Catheter
&UTI
2
1
VTE
Falls
0
0
0
0
3.2
Clinical Effectiveness
Many components contribute to demonstrating clinical effectiveness including quantitative data,
Key performance indicators, audit and an overarching, strong clinical governance steer.
Data collection at St Teresa’s Hospice has developed significantly during the accounting period
due to the installation of SystmOne patient information system. However, reporting continues to
be a challenge due to the design of original data inputting templates, this has been acknowledged
and addressed and as a consequence over coming months confidence in data will grow so that
dual recording mechanisms can stop and the Hospice can rely on a “paper-light” system.
Hospice Performance against National Council for Palliative Care Minimum Dataset
The Hospice collects statistical information on activity and submits this to the National Council for
Palliative Care for inclusion in a National Minimum Dataset (MDS). This allows comparison of
local data to the national average. The following table displays performance of St Teresa’s
Hospice to the National MDS from the previous reporting year as the actual data for this
accounting period will not be available until September 2014.
Comparing St Teresa’s Hospice to the National Minimum Dataset
Area
Inpatient
Services
Total number
of Patients
Total
New
Patients
Re-referred
Patients
Average Bed
Occupancy
Cancer
Diagnosis (%)
Non Cancer
Diagnosis (%)
Average
length of stay
(days)
Died
in
Hospice (%)
Discharge
care home(%)
Discharge
acute (%)
Discharged
home (%)
St Teresa's
Hospice
2010/2011
St Teresa's
Hospice
2011/2012
St Teresa's
Hospice
2012/2013
St Teresa's
Hospice
2013/2014
Nat’l Min.
Data Set
2012/13
119
181
141
134
-
100
122
131
128
-
14
14
6
6
-
60%
86%
64%
69%
75%
76%
82%
84%
83%
87%
14%
18%
13%
11%
11%
6.7
7.7
8.1
8.6
13.4
34%
40%
46%
51%
55%
1%
1%
5%
4%
4%
1%
2%
2.5%
5.50%
2%
48%
49%
33%
35%
38%
21
Area
Other
Day Therapy
Total number
of
Patients
treated
Number
of
New Patients
Total
Days
available
places
Total Places
attended
Total Places
booked DNA
Average
length of care
(days)
Cancer
Diagnosis (%)
St Teresa's
Hospice
2010/2011
0%
St Teresa's
Hospice
2011/2012
0%
St Teresa's
Hospice
2012/2013
13.5%
St Teresa's
Hospice
2013/2014
5%
Nat’l Min.
Data Set
2012/13
1%
137
146
121
129
-
72
80
54
70
-
3920
3920
3840
3900
-
1947
1852
1794
-
794
847
873
-
213
300
326
287.5
183
76%
80%
65%
62%
78.%
20%
17%
36%
18%
184
132
182
132
196
137
-
15%
12%
22.50%
-
68%
68%
65%
49.8%
1%
0
0
24%
52%
55%
53.50%
80%
48%
45%
40%
16%
127
120
88
115
Non Cancer
Diagnosis (%) 24%
Hospice
at
Home
Total Number
of
Patients
treated
213
New Patients 164
Patients died
in Hospice %
23%
Patients died
at Home (%)
55%
Patients died
acute
or
community
Hospital (%)
1%
Cancer
Diagnosis (%) 55%
Non Cancer
Diagnosis (%) 45%
Length
of
Care (days)
103
22
Inpatient Unit
During the accounting period the Hospice had a total of 134 patients on the Inpatient Unit, 128 of
which were new referrals. Bed occupancy was 69%, which was lower higher than the MDS which
was 75% (possibly attributable to refurbishment and corresponding reduction in referrals as all
referrers where informed of closure). The Hospice was successful at supporting non cancer
patients, with 83% of the inpatient population treated having a cancer diagnosis compared to the
MDS of 87 %, this figure has remained stable for several years. Average length of stay 8.6 % is
shorter than the national average of 13.6% during the accounting period, this is possibly
attributable to referral criteria, patients are referred to St Teresa’s Hospice for End of life care,
symptom management or crisis respite; we are unable to offer planned respite due to limited
numbers of beds. The number of patients dying in the Hospice is also lower at 51% compared to
the MDS of 55%. However, the majority of referrals were for symptom management. Considering
these statistics alongside the place of death for patients, one assumption is that the Hospice was
effective at facilitated discharge, enabling a patient to die in their preferred place of care, every
inpatient is assessed for Hospice at Home care prior to discharge and the percentage of Hospice
at Home patients dying at home is significantly higher than the national average.
Bar Chart demonstrating Reason for Referral to Inpatient Unit during 2013-2014
120
100
80
Qtr4
60
Qtr3
Qtr2
40
Qtr1
20
0
End of Life
Sympton
Management
Advice and Emotional & Crisis Respite
Support
Carer
Day Therapy
The total number of places was 3900, with an attendance rate of 1794, a decrease on the
previous accounting period. Average length of care was longer than the national average of 183
days with Hospice average length of care being 287 days. In Day Therapy, as in the Inpatient
Unit, the Hospice is again pro-active and effective in supporting non cancer patients, with 62% of
patients having a diagnosis of cancer compared to the national average 78%. St Teresa’s now has
access to physiotherapy services and has excellent support from complementary therapy staff
and all patients had access to a palliative care nurse and medical consultant.
23
Hospice at Home
The Hospice at Home service supported 196 patients during the accounting period, and increase
on previous year. 65% of those patients were supported to die at home compared to a national
average of 50%, Again the Hospice was able to support non cancer patients extremely well with
40 % of total patients having a non cancer diagnosis compared to a national average of 16%. The
Hospice is extremely pleased with the qualitative statistics regarding Hospice at Home, during the
last year the service has been re-structured and is now led by a registered nurse, activity has
increased accompanied by improved quality of service delivery. Informal qualitative evaluation
has also demonstrated a significant improvement in service delivery. Formal qualitative
evaluation will be undertaken in the coming months.
Bar Chart showing total Hospice at Home Hours of Care provided 2013/2014
1200
1000
800
600
Hours of Care Provided
400
200
0
Qtr 1
24
Qtr 2
Qtr 3
Qtr 4
General Information
The total number of patients accessing all of our services has remained static for the past 2 years,
as can be seen in the bar chart below.
Bar Chart of Total number of people accessing our services (Patients, Carers and
Bereaved)
900
800
700
600
Total number of people
accessing our services,
patients, carers and
bereaved
500
400
300
200
100
0
2010/2011 2011/2012 2012/2013 2013/2014
The activity within each service also continues to be constant as can be seen in the bar chart
below.
Total number of people accessing each service 2010-2014
250
200
150
2010/2011
2011/2012
100
2012/2013
2013/2014
50
0
IPU
Day
Therapy
Hospice at
Home
Family
Support
Out Patient
The Hospice has significantly improved access to those patients with a non cancer diagnosis over
the past 3 years as demonstrated in the Bar Chart below.
25
Total number of people accessing each service by diagnosis 2011-2014
600
500
400
Cancer
300
Non Cancer
200
100
0
2011/2012
2013/14
2012/2013
2013/2014
Key Performance Indicators
The Hospice reports quarterly on Key Performance Indicators to meet contractual requirements.
A summary of the Performance for the accounting period can be seen below.
Measure
Time for inpatient referral to decision to admit/not
to admit
Number of Inpatients who have been offered an
Advance Care Plan
Number of inpatients who are on Liverpool Care
Pathway or equivalent at time of death
Inpatient bed availability (i.e. are all beds available
for use- not vacant beds)
Inpatient bed occupancy
% Of Day Hospice / Outpatients receiving a care
plan
Time from Day Hospice/outpatient referral to
assessment
Hospice at Home- record made as to whether
patient has an Advanced Care Plan
Hospice at Home- referral for assessment made to
key worker within 24 hours for those patients who
don’t need an Advance Care Plan
Hospice at home- number of patients who the
service are facilitating nursing care at their time of
death whose referred place of care is achieved
Family Support team and Bereavement – client to
be contacted within 7 working days of receipt of
referral
Family Support team and Bereavement- client
assessment to commence within 15 working days
26
Threshold
Q1
90% within 2 93%
hrs
90%
10%
Q2
85%
Q3
97%
Q4
97%
5%
25%
6%
90%
80%
100% 41%
47%
95%
95%
95%
95%
75%
85%
100%
61%
98%
60%
99%
73%
99%
69%
100%
>90% within 100% 100% 100% 100%
7 days
100%
100% 100% 100% 100%
>95%
71%
53%
75%
100%
>85% by 31st 64%
March 2014
85%
52%
88%
>95%
100% 100% 60%
95%
>95%
100% 74%
90%
31%
Measure
of receipt of referral
Family support team and Bereavement- written
assessment of needs and action plan agreed with
client
Family support team and Bereavement- family and
friends of deceased to be supplied with
information/card about the bereavement service
within 7 days of the service being notified
Family support team and Bereavement- Hospice to
have an individual service action plan with clear
objectives and delivery dates
Threshold
Q1
Q2
Q3
Q4
100%
100% 74%
100%
100% 100% 100% 93%
100%
100% 100% 100% 100%
100% 100%
Local Audit
To ensure a high quality of services and annual audit programme has been established and
variety of quality and audit activities were undertaken during 2013/2014 using nationally agreed
formats such as Help the Hospice audit tools and locally developed audit tools. For audits
undertaken, where necessary action plans for improvement have been developed, which are
monitored by the clinical governance sub group. This enables us to monitor quality and make
improvements where needed. St Teresa’s Hospice has taken steps to ensure all staff understand
and participate in audit where appropriate, by providing a teaching session at the annual staff
workshop on “Audit in your workplace”.
Clinical Governance
There is a strong culture of continuous improvement at the Hospice. Clinical Governance systems
and processes have dramatically improved and the Hospice has a Clinical Governance Sub
strategy with a dedicated annual work plan, performance managed by the Clinical governance
subcommittee of the Board of Trustees. The work plan, updated annually focuses on key areas of
improvement, this year key achievements include introduction of core competencies for all
Health care assistants, training in Advance Care Planning and roll out of Deciding Right and Drug
calculation tests for all registered staff.
Other Quality Initiatives
The Hospice successfully applied for a Capital Grant from the Department of Health (now NHS
England) which was drawn down during 2013/14. Despite receiving only 68% of the original bid
amount, the Hospice has been able to make significant improvements to the premises to improve
both patient safety and patient and carer experience. The recommendations from the Dementia
Audit have been followed and the premises are now Dementia friendly (within the limitations of
the Grade 2 listed building status). Improvements include a dedicated Physiotherapy Gym, New
Equipment for Day Hospice and significant improvements to the inpatient unit including new
doors, fixed hoists, general refurbishment, new beds and furniture for patients’ and relatives’
comfort.
27
3.3
2013/14
Patient, Carer, Staff and Volunteer Experience
Staff Experience
Staff experience is measured in three ways:



Accurate monitoring, reporting and review of sickness levels
Confidential annual staff experience survey
Line management support including 1:1 contact meetings and annual Appraisal process.
Hospice Staff Sickness levels
The reporting system for staff sickness in all departments is now firmly established and a report
produced quarterly for the HR Sub Committee of the Board of Trustees and monthly updates
provided to department heads. Capability procedures and sickness monitoring systems enable
any worrying trends to be identified; however, there are no current trend alerts. The average
sickness rate was 3.61% per wte, when compared to the national average of 3.3% this is slightly
higher which can be explained by 4 long term absences during the reporting period which skew
the figures. However, when compared to public healthcare statistics our sickness absences rates
are favourable, even when including 4 long term absences’.
2013 CIPD Survey Group
Av days lost to absence % of working time lost to
per employee per annum
absence
Overall
7.6
3.3%
All North East England
6.0
2.6%
All with 50-249 employees
6.6
2.9%
All not for profits
8.1
3.6%
All public healthcare
11.1
4.8%
St T’s (our records) 2013-14
9.4
3.6%
Confidential Annual Staff Experience Survey
An annual staff experience survey was carried out with a 78% response rate. Overall, Staff
morale displays no worrying trends.
Line Management and Appraisal
The Hospice ensures all staff regularly meet with their line manager for contact meetings and
have an annual appraisal, 98% of Staff received an annual appraisal during 2013/2014. The
Hospice Management also operates a vital open door policy.
28
Clinical Supervision
All clinical staff are offered the opportunity to partake in clinical supervision and this is a firmly
established practice. During the accounting period, this has also been extended to
administrative staff, recognising that they can also have potentially distressing conversations
with patients and their families.
Board Development
The Hospice Board of Trustees is currently going through a Board Development programme and new
members have been elected onto the Board. During the accounting period the Hospice now has a
new Chairman and President and the Trustee Handbook has been updated.
The Hospice has a strong management structure in place with a Chief Executive Officer with
delegated responsibility from the Board who is supported by a Deputy CEO/Director of Clinical
Services and Finance Director, additional members of the Strategic Management team include the
Operations Manager, Head of Nursing and Education Manager.
The following officers are also in place:
 Anti fraud officer (Hospice Trustee)
 Caldicott Guardian, (CEO) responsible for safeguarding patient information
 2 Privacy officers (CEO & Deputy CEO/Director of clinical Services)
 Accountable Emergency Officer (CEO)
 Prevent Lead (Hospice Trustee)
 Accountable Officer for medications, (Hospice Education Manager)
Volunteer Experience
There are approximately 300 volunteers involved in supporting the Hospice services, with 80 of
these involved inpatient facing roles in clinical services including inpatient unit, Day hospice, family
support, and complementary therapies. Volunteers also support the Hospice in gardening, in the
warehouse including refurbishment of furniture, shops, fundraising, driving patients to and from
appointments, kitchen, reception, administration-the list is almost endless!
All volunteers must attend the Hospice 2 day Induction to ensure as far as possible they understand
the demands that may be placed on them in what at times can be difficult or emotive situations, and
that they understand they volunteer within the scope of Hospice Policies and Procedures.
Volunteers are also given specific training relating to their chosen volunteering area.
Volunteers range from Duke of Edinburgh students, sixth for students wishing to pursue medical
careers and more mature volunteers. We have excellent feedback from the majority of our
volunteers, one such quotes:
"I have thoroughly enjoyed my time at the Hospice and it has reassured me
every week that medicine is the career for me. I have had brilliant
experience……I am positive that it is the caring experience I have gained at the
Hospice which contributed to this”
29
Another young volunteer thought he could raise a few hundred pounds and decided to undertake an
ambitious head shave, he raised £3,000. He was awarded young volunteer of the year by Darlington
Borough Council.
We recognise the valuable contribution volunteers make by giving a BBQ each year, have long
service badges at 10 years and certificates after 25 years of service both presented at our AGM.
Education and Training
Education and Training is high on the Hospice priorities, and we are keen to increase education for
both Hospice staff and Volunteers but also in the wider community. Education opportunities are
detailed below:











GP leads Forum- Each GP practice End of Life lead is invited to attend a bi-monthly meeting
offering both networking and educational opportunities. Guest speakers, normally specialist
Consultants attend to provide education, including during this year Dementia at the End of
Life, Liver Disease and Palliative Care, Lymphoedema, Palliative Care Symptom Management
and Advanced Care planning.
GP Placements- the Hospice offers teaching placements as part of the Palliative Care
Diploma
Students- A variety of students are supported at the Hospice including nursing and social
work students.
Induction- the Hospice runs a standard induction programme for all Staff and Volunteers.
During the accounting period we have improved the way we recruit both contracted and
bank health care assistants by holding an assessment centre. Successful candidates then
undertake a bespoke induction and mandatory training programme.
Mandatory Training- There is a programme of Mandatory training in place and identified
mandatory training mapped to specific roles. All staff now undertake Dementia awareness
training as part of mandatory training.
Core competencies- Core competencies were introduced for all healthcare assistant staff
and developments for registered nursing staff are planned.
Education in Schools- Education in schools, both bespoke and the “Seasons for Growth
Programme”
Dementia Training- 8 members of clinical staff successfully completed an enhanced
Dementia qualification, with further cohorts planned.
Clinical Skills Training- specific bespoke training for clinical staff led by our Nurse Consultant
Journal Club- A monthly journal club runs with different departments taking a lead on
hosting
Management Training Programme- A six month management training course has been held
to enable and develop management and leadership skills for department heads
Awards and Complaints
The Hospice receives many letters of thanks and recommendations from patients and families which
are celebrated with staff teams. One of our Hospice Trustees was awarded “Trustee of the year” for
30
her invaluable support in obtaining service user feedback. Another Hospice volunteer was awarded
“Young Volunteer of the year” by Darlington Borough Council.
Complaints are seen by the Hospice as an integral part of service improvement as they provide
valuable feedback about the quality of service we are providing. Complaints are rarely received. In
the reporting period, 2013/2014 no patient complaints were received. However, the Hospice does
have a complaints process in place. Serious untoward incidents would be reported to both the Care
Quality Commission and Clinical Commissioning Groups.
Patient and Service User satisfaction
St Teresa’s Hospice continues to invest significant time in exploring patient and service user
experience over the past year. User feedback has been sought is a variety of ways including the
following:
 Patient Questionnaires
 Carer Questionnaires
 Semi Structured Interviews
 Focus Groups
 Suggestion Boxes
Additional, volunteered information is also recorded from comments, thank you cards and letters
and feedback on the Hospice website. All of the methods of seeking patient and carer feedback
have been valuable, but one of the most valuable has been semi-structured interviews, conducted
by a Hospice Trustee; feedback has enabled us to improve patient care almost instantaneously- for
example:
Patient indicated
were too warm.
bedrooms
What we did - Invested in Fans
and air conditioning units
Carer was very happy with the Hospice at Home
service but wished she could attend the Carers
Monday afternoon group.
What we did - informed Hospice at Home
Co-ordinator to provide an additional Monday
afternoon visit
Comments from the Inpatient Unit:
“I am still eternally grateful for the kindness and comfort you gave my
grandma. She loved the choice of food and peace she had in her own space.
Jean was happy being in the hospice after being in the hospital for so long.
You could tell how much more relaxed and calm Jean was, being in the
hospice. So I just want to say thank you so much for helping my grandma
achieve peace.”
“My dear wife was only in your care for a few hours, but in those few hours
you tended her with care and consideration. Your condolence card was
gracious and thoughtful”.
31
Comments from the Day Hospice:
“I would just like to say a big thank you to everyone involved in the day care
unit, my Mam was referred about 6 weeks ago, she was extremely
apprehensive and wasn’t sure that it was for her. I went on the first visit with
her everyone made us feel very welcome and she was put at ease. Since
attending St Teresa’s she has looked radiant getting her hair and nails done
made her feel good and she told me the people in your unit made her feel like
she was somebody again! Thank you so much”
Comments from Hospice at Home:
“.. extremely grateful for everything we are doing .. He said all the girls who
are going in to do the overnights are wonderful. He said they are all well
‘genned up’ and very supportive. He can’t praise them enough.”
“My sister and I would like to thank all who not only played a large part in
mum’s ability to enjoy and live to the full her later years, but also always
treated her with respect, compassion and dignity. This is particularly true in
mums last week and although there are too many people to thank by name
we are so grateful for all your efforts. Whilst the medical profession is of late
coming in for criticism from some quarters, we in fact feel the opposite and
would hold up the treatment and care that mother received as an exemplar to
all.”
Comments from Family Support:
“I would like to thank you all most sincerely for your card on the first
anniversary of my husband’s death. It brought me a sense of calm knowing
me and my family weren’t alone. In this modern world it warms my heart to
know that there are still many people who care.”
Patient Questionnaires and Evaluations
The Hospice subscribed to the annual Help the Hospice Patient Survey for Day Hospice and Inpatient
service users, report received April 2014. Only 11 responses were received for Inpatient service and
8 for Day Hospice service. All comments were extremely positive, all respondents indicated they
were allowed privacy and treated with dignity and respect and that cleanliness and hand washing at
the Hospice was good. Some patients commented that they were not generally aware of how to
make a complaint; this will be rectified during the next financial year.
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3.4
Other Comments from Partners & Stakeholders
Bev Riley, Director of Nursing and Quality for Durham, Darlington and Teesside Area
Team. NHS England:
Please see below from our Twitter page:
“bevreilly22: Thankyou to Sheila Dawson & staff @StTeresas Hospice for
taking time out to meet me and show me around! Fantastic work! #nursing”
Partnership-working with Macmillan:
“Macmillan Cancer Support has worked in partnership with St Teresa’s
Hospice in Darlington for around 18 months and have co-created therapy
posts to support people affected by cancer. The approach to this partnership is
within the true spirit of partnership, namely we have worked together to
develop key patient outcomes that can be measured in terms of impact. The
posts are joint funded and post holders have the benefit of a bespoke support
package from St Teresa’s and Macmillan.
The rehabilitation model or emphasis to the work is designed to retain
people’s dignity and self control even in palliative stages of their lives.
Furthermore, the post holders are now well integrated with other service
providers ensuring that added value is achieved by all concerned, including
patients.
The investment Macmillan have made in this service is certainly well made
and it is very pleasing to observe the progress made so far.”
Stephen Guy, Service Development Manager, Macmillan
Partnership-working with Marie Curie:
“The development of the Darlington Community Rapid Response Service is
testament to the effective partnership working between St Teresa’s Hospice
and Marie Curie. This is an innovative project which has influenced other
provision and demonstrates the efficacy of local and national charity
partnership work.”
Karen Torley, Divisional General Manager, North East
St Teresa’s Hospice Comment (extract from our Quality Assurance Policy)
All feedback is invaluable. We encourage positive comments and we ensure that service users are
aware of how to make complaints. We see these feedback mechanisms as providing vital intelligence
to help us to learn and to continuously improve our services at St Teresa’s Hospice.
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Supporting Statements
St Teresa’s Hospice Quality Account 2013-14
The Board of Trustees Statement
The Board of Trustees of St Teresa's Hospice is fully committed to ensuring the hospice fulfils its
primary aim; the delivery to the population we serve of safe, effective, patient-centred end of life
and palliative care, that is timely, efficient and equitable.
We are confident that the organisational framework that has been developed by our Chief Executive
and Senior Management Team will ensure that we are successful in achieving our aims. Board
members are further assured by actively participating in corporate and clinical governance.
This year's Quality Account once again details recent challenges and achievements and also, having
reflected on and identified areas for further improvement, it outlines our aims and aspirations for
the future. These aspirations underline our pledge to provide services of the highest standard that
will meet the needs of our locality now and for many years to come.
Dr Harry Byrne, Chairman
Endorsement by Senior Directors
We the undersigned confirm this Quality Account as a true and accurate assessment of the
standards at St Teresa’s Hospice:
Dr Harry Byrne
Jane Bradshaw
Chairman, Board of Trustees
Chief Executive
Victoria Ashley
Nicola Myers
Director of Clinical Services
Finance Director
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Darlington Clinical Commissioning Group Statement
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Hambleton, Richmondshire & Whitby Clinical Commissioning Group
Statement
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Comment from Healthwatch, Darlington
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Comment from Health & Partnerships Scrutiny Committee, Darlington
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St Teresa’s Hospice | The Woodlands | Woodland Road | Darlington | DL3 7UA
01325 254321 | enquiries@darlingtonhospice.org.uk
www.darlingtonhospice.org.uk
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