The Shakespeare Hospice
Quality Account 2013 - 2014
Address: Church Lane, Shottery, Stratford upon Avon, CV37 9UL
Website: www.theshakespearehospice.org.uk
Registered charity number: 1064091
The Shakespeare Hospice
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Quality Account 2013-2014
Contents
Page
Part 1
Chief Executive’s Statement
3
Our mission statement
4
Strategic vision
4
Key Strategic Aims
5
Values and Principles
6
Part 2
Priorities for improvement and Statements of Assurance
Priorities for improvement 2013-2014
7
Priorities for improvement 2014-2015
9
Statements of Assurance

Audits
11

Services Data
12

Care Quality Commission Inspection
13

Research
13

What others say about us
14
Patient Quotations
14
Part 3
Quality overview

Governance, Board Structure
15

Policies and Procedures
16

Education and Training
16

Accidents, complaints and incidents
16

Internal Unannounced visits
16

Volunteers, Patient Partnership Forum
17
The Shakespeare Hospice
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Quality Account 2013-2014
Part 1
Chief Executive Statement
I am pleased to present the Quality Account for The Shakespeare Hospice.
Maintaining the highest quality of services for our patients and their families, is our
highest priority and I am pleased to report our service user feedback during this
period has been very positive.
Our well established services continue to grow and we have commenced our
Hospice at Home service in new areas during this period. With the support of a
Department of Health capital grant, we have refurbished the Hospice building to now
provide bespoke facilities to support our new young people’s services.
The Care Quality Commission undertook an unannounced visit on 21 st January 2014
and the Hospice was compliant in all areas. Our own clinical governance team also
undertake unannounced visits four times a year.
To the best of my knowledge the information reported in this Quality Account is
accurate and a correct representation of the quality of services provided by The
Shakespeare Hospice.
Angie Arnold
Chief Executive
June 2014
The Shakespeare Hospice
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Quality Account 2013-2014
Our Mission Statement
We will provide specialist palliative care of the highest standard within the Day
Hospice and through Hospice at Home for patients and their carers living with life
limiting illness.
We will enhance the quality of support to patients and carers through a Family
Support Service.
We will reach out and provide support for potentially isolated groups such as Cancer
Survivors, Teenagers and Young People
We will work collaboratively with other health and social care professionals and
explore partnership working to ensure seamless care for our patients and those who
matter to them.
Strategic Vision
Our vision is to provide specialist palliative care for all adults over the age of 18 with
a life limiting illness and to continue to develop a much needed Young People’s
service. Future developments include the extension of support services for children
and young people.
The Shakespeare Hospice
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Quality Account 2013-2014
Key Strategic Aims 2014-2019

Help more people
By improving access to all our services.
We will seek to ensure that all patients and carers who could benefit from our
services are made aware of them and able to access them easily. For
example- the growing number of patients with diseases other than cancer
indicates that the Hospice will need to develop better links with other
specialist services.

Ensure services are responsive to individual needs and choices
We will proactively seek the views of the community to ensure that our care is
responsive to their needs and choice.

Day Hospice
The development of the Day Hospice as a more flexible resource which offers
patients and carers a range of services including day care, drop in,
counselling, therapies and access to members of the clinical team for specific
consultations or support.

Hospice at Home
The Hospice at Home Team will need to respond to the varied needs of
patients and carers in their own homes, in greater numbers than at present.
Extended care within the home to prevent admission to hospital and facilitate
discharge from hospital will need to be explored further in partnership with
other statutory and voluntary providers.

Family Support Services
The range of services provided for families, carers and young people will
continue to expand. Developing support services for Young People (16-24
years) and Bereaved Children will continue to be a priority.

Develop the Workforce
We will continue to value our staff and volunteers by investing in their training
and development to support the provision of high quality palliative care
The Shakespeare Hospice
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Quality Account 2013-2014
services for patients and their carers. We will ensure that staff undertake
continuing professional development, and that skill mix of the teams are
reviewed in line with service development
Values and Principles
Our principles
The Hospice will:

Provide care which is free at the point of delivery

Not discriminate against any person of whatever race, religion, culture

Acknowledge people as individuals and their right to make decisions about
their lives, and in doing so, seek to understand people’s needs, hopes and
fears in a non-judgemental way.

Be a caring employer, recognising the talents of all the staff and volunteers,
and provide supportive and nurturing working environment

Always be conscious that this charity is dependent on voluntary contributions
for the provision of its services which must be cost effective and provide the
best value for charitable monies and care for its contributors
Our values

Respect- everyone involved in the Hospice will at all times respect the views
and feelings of all those with whom they are dealing

Compassion- Compassionate care is at the heart of our relationship with
patient’s, their families and carers, and will also inform all working
relationships within the wider Hospice community

Partnership working- The value of partnerships and working in collaboration
will be acknowledged and fostered in order to complement and supplement
the care available for our patients and carers

Accountability- The hospice will never forget that its purpose is to meet the
needs of the local community and that it is accountable to that community at
all times. The hospice will strive to keep the community informed of its
services and its plans and will proactively seek feedback on all hospice
activities.
The Shakespeare Hospice
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Quality Account 2013-2014
Part 2
Priorities for Improvement and Statements of Assurance from the
Board
The Hospice identified four priorities for improvement during 2013 –
2014. The following progress has been made.
Priority One
To provide more clinical space.
This has been achieved with the help of the DOH grant. The administrative staff has
been relocated upstairs into more suitable purpose built offices and a dedicated
space for young people has been provided downstairs. Furnishings need to be
sourced for the area in order to complete the facilities. An additional new room
upstairs has provided the facility for meetings and clinical educational sessions.
Priority Two
Developing and extending Young People’s Services.
The development of the new Young People’s Services has progressed significantly
over the last 12 months in line with the project plans. Referrals are now being
received for all strands of the Young Person’s service.
A Youth and Community Coordinator was appointed in February 2014. She is
working with local schools. Training given by our CEO and Family Support
Practitioner to teaching staff has been very well received. We continue to liaise with
other appropriate agencies.
Pre and Post bereavement support for children and young people. This service has
received 46 referrals over the past year compared to 31 last year. There are plans to
develop activities with young people outside of the hospice
Support for Young Carers- we are working collaboratively with Warwickshire Young
Carers.
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Quality Account 2013-2014
The Transitional Care strand for 16 – 24 year olds is progressing slowly and there is
continued liaison with Acorns.
Work Experience and Volunteering opportunities for young people - There has been
a dramatic increase in the number of young people wishing obtain work experience
placements within the Hospice and gain volunteering opportunities not only within the
Hospice but also in our retail outlets.
Priority Three
Extending Hospice at Home
The geographical area covered was successfully extended in July 2013. Grant
monies have been obtained to develop a Twilight Service. The team continues to
work closely with the District Nursing teams
Priority Four
Introducing Day Hospice into the Community
This continues to be a priority. The Volunteer Services Manager has taken on a
number of volunteers who have received induction training with a view to helping to
extend services into the community.
The Shakespeare Hospice
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Quality Account 2013-2014
Priorities that have been identified for Improvement 2014 – 2015
Priority One
To develop a social group for those patients/carers who are discharged from
Day Hospice Services.
This will be achieved by a member of the Day Hospice team working with a number
of volunteers to take this forward so that eventually the group becomes selfsupporting.
Priority Two
To continue developing the Young Person’s Services in the Hospice. To
increase the number of referrals of bereaved young people and young carers.
To develop the Transitional Care service by appointing a nurse to the post.
This will be achieved by preparing action plans and with the appointment of a
Transitional Care Nurse to the service who will lead on taking the service forward.
Priority Three
With the extension of the Hospice at Home Service to two other localities the
priority will be to increase the number of patients accessing the service in
these localities. To introduce a twilight service to the population of the area
that we serve.
This will be achieved by working collaboratively with local District Nurses and GPs
and promoting the services wherever possible. The number of referrals from these
areas will be closely monitored.
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Quality Account 2013-2014
How progress will be monitored and reported
Progress will be monitored by the teams involved and the Senior Management team.
The outcomes will be reported through the Clinical Governance Committee, Senior
Management meetings and to the Board of Trustees.
The Shakespeare Hospice
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Quality Account 2013-2014
Statements of Assurance
Audits
Audits conducted over this period include:
1. Patient questionnaire for all services- All of the feedback was positive with small
areas of adjustment. In particular some patients and carers did not know how to
complain. A suggestion box is now in reception and all of our leaflets advise how to
make a complaint. Other very positive feedback came from those users of our
volunteer driver services. The comments were very complimentary and safety was
rated as 100%
2. Carer / bereaved carer questionnaire for all services- Carers also gave positive
feedback. Some of our carers have joined the Patient Participation group that is held
twice yearly. Just over 89% of our carers accessed Complementary therapy when
attending Day Hospice. This is an increase of 10% from the previous year.
3. Record keeping audit –the three team leads undertook this audit. They each
audited a different team to the one they lead. This continues to highlight areas of
good practice but also how we can change the paperwork and processes that we are
using
4. Re-audit of note keeping re pain – in June 2012 an audit of note keeping relating
to pain control management was completed in the Day Hospice. Following
educational intervention a re-audit was completed in July 2013. The results showed
an improvement both in note keeping and resulting action following identification of
pain as a symptom. The results were presented to the Clinical Team and further
monitoring of note keeping / symptom assessment will be undertaken.
5. Infection Control Audit- the link nurse for infection control undertook an audit during
March this year. Areas such as hand hygiene, environment, disposal of waste, etc
were reviewed. Out of 10 categories there were 6 compliant scoring between 87100%, Two categories were not considered as one will be audited externally and the
other not applicable. Within the report recommendations were made and feedback
given to relevant parties.
The Shakespeare Hospice
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Quality Account 2013-2014
Services Data 2014
All the services within the hospice collect data on a monthly basis. This data includes
number of patients seen, number of carers seen, patient contacts and patient visits,
night sits, out of hour’s contacts (specific to Hospice at Home). The annual number
of new referrals for Day Hospice, Hospice at Home and Family Support Services
together with total attendances are shown below.
Hospice at Home - New
Referrals
Day Hospice - New Referrals
250
200
200
150
150
100
100
50
50
0
0
Apr 12 - Mar 13
Apr 12 - Mar 13
Apr 13 - Mar 14
Apr 13 - Mar 14
Hospice at Home - Visits
Day Hospice - Attendances
3000
2500
2000
1500
1000
500
0
2500
2000
1500
1000
500
0
Apr12 - Mar 13
Apr 13 - Mar 14
Apr 12 - Mar 13
Family Support Services
120
100
80
60
40
20
0
YP Pre & Post
Adult
Bereavement Counselling
Apr 12 - Mar 13
The Shakespeare Hospice
Social Work
Apr 13 - Mar 14
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Quality Account 2013-2014
Apr 13 - Mar 14
Care Quality Commission
In January 2014 the Care Quality Commission paid an unannounced visit. This was a
routine inspection to check that essential standards of quality and safety were being
met. The standards inspected were:

Care and Welfare of people who use services

Requirements relating to workers

Supporting workers

Assessing and monitoring the quality of service provision

Complaints
This was a very successful visit and we met the standards for all of the above.
At the time of the inspection the CQC were able to speak to two people who use the
services. They also spoke to the Head of Clinical Services, HR Consultant, two
nurses, diversional therapist, health care assistant and the Hospice at Home Team
Leader.
People were complimentary about the services that they received. One person told
the CQC inspector ‘I love it and I look forward to coming here every week’. Another
said ‘I give it 11 out of 10 and ‘they really care’.
Further information can be found on www.cqc.org.uk
Research
There were no appropriate local or national, ethically approved research studies into
palliative care that the Hospice could participate in.
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Quality Account 2013-2014
What others say about us
‘It’s good talking to someone outside the family who understands what it’s like for me
right now.’ Bereaved young person
‘I like coming here because I can talk about happy times with my Daddy and don’t
feel sad.’ Bereaved young person
‘Visits made a difference because a neutral, trained person with the right skills and
empathy helped my daughter feel secure enough to talk.’ -Parent of Young person
accessing services
Comments below from bereaved carers:
“The Hospice has been a surprise and a totally relaxing experience”
“Background support and Therapies have been excellent”
“Everyone has been thoughtful and caring”
“Could not wish for anything better. Everything is excellent & it really does help you in
all ways”
“Thank you to all staff in making this sad journey more bearable”
“Without the help I have received I do not know how I would have managed”
Commissioners
This Account has been submitted to local Commissioners for their comments
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Quality Account 2013-2014
Part 3
Quality Overview
Governance - The Board
The Shakespeare Hospice has a well-established governance structure ensuring the
provision of a high quality, effective and accountable service. It is governed by a
Board of 14 Trustees one of whom is the Chairman. All Trustees provide their time
and services on a voluntary basis. After a term of three years Trustees may be reelected for a further term of three years before standing down. During the past year 4
new Trustees have been appointed to replace Trustees who have retired from the
Board.
The Chief Executive is responsible for the management of the Hospice. The Board
meets regularly alternate months with the senior management team and more often if
required. In addition an annual Away Day is held to provide an opportunity to develop
ideas and strategic planning. A number of sub-committees chaired by nominated
Trustees have been formed to cover various aspects of governance.

Chairman’s Committee
Purpose - to focus on key areas of Hospice governance, constitutional
matters, strategic business development and major initiatives.

Clinical Governance Committee
Purpose - to ensure that all clinical services are compliant with statutory
requirements and that the quality and delivery of clinical services meet best
practice.

Audit & Finance Committee
Purpose – to review the financial performance of the Hospice, both actual and
forecast, in greater detail than the Board of Trustees, and carry out certain
tasks, such as liaison with the external auditors, on behalf of the Board.

Income Strategy Committee
Purpose – to ensure the sustainable growth of fundraising and retail activity in
line with agreed strategic objectives.
The Shakespeare Hospice
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Quality Account 2013-2014
Policies and Procedures
Clinical and management policies are in place to ensure safe and effective running of
the Hospice and compliance with relevant regulations and legislation. All policies are
reviewed regularly by the appropriate sub-committees and circulated to staff.
Adherence to clinical policies provides an important contribution to the reduction of
clinical risk and enhances patient safety.
Education and Training
We continue to offer relevant training to staff. Training is identified via the annual
appraisal process.
Statutory training such as Moving and Handling, CPR and Fire Drill are delivered on
site. If required external training courses are accessed to meet individual
requirements.
Accidents, complaints and incidents
All complaints and incidents are recorded promptly together with the actions taken
and final outcomes. They are presented regularly to the Clinical Governance
Committee and if necessary procedures are modified to minimize any future risk.
Significant event meetings are held as part of the Hospice’s commitment to
maintaining high quality services and supporting staff.
Internal Unannounced visits
These informal visits to the Hospice are performed several times a year by Clinical
Governance Trustees. Non-clinical Trustees have also taken part in these visits
during the year. They provide an opportunity for Trustees to see the workings of the
Hospice and to meet with patients, carers, staff and volunteers and to hear their
views and comments on current services. This valuable feedback can influence
changes and developments in the services provided by the Hospice.
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Quality Account 2013-2014
Volunteers
Volunteers provide an invaluable contribution to many aspects of the Hospice
services. All volunteers undergo a vetting process including interview, references and
CRB check followed by a training programme. Two day induction courses have been
organised for new volunteers giving them a wide range of information about all
aspects of the Hospice’s services and enabling them to work in a professional and
informed manner.
Patient Participation Forum
Two meetings of the informal Patient / Service User Forum have been held during
the year. These meetings were attended by service users, clinical staff and a
Trustee. Feedback was very positive and a number of valuable suggestions were
made. This group will continue to meet at six monthly intervals and enable the
Hospice to become more responsive to patient need.
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Quality Account 2013-2014