25TH ANNIV
E R S A RY
Quality Account 2013-2014
www.willow-burn.co.uk
~ Treasuring Life ~
Chief Executive Statement
In our 25th anniversary year, I would like to thank all of our staff and volunteers for their
achievements over the past year. Despite the continued turbulent economic climate,
the hospice has been able to provide high quality services to an increased number
of patients and remains financially sound, thanks to generous support from our local
community of individual and corporate donors as well as grant giving organisations.
I am delighted that we will be moving into new premises shortly and hope that both the
Day Hospice patient and staff benefit from the improved environment.
The CHKs Accreditation process helps to bring
a much needed focus on quality within the
organisation and ensures that staff are aware
of how to raise concerns about quality and
safety and systems exist to ensure that they
are acted upon. Staff experience is monitored
and other indicators of staff engagement have
been developed through our HR Working
Group. It is clear the staff that work for
Willow Burn Hospice want to work for an
organisation that treats patients as they would
want members of their own family to be treated
and that good relationships with patients
positively influences job satisfaction which
when surveyed staff indicated satisfaction
levels were at 72%.
Following the CQC unannounced inspection in
August 2013, the inspection confirmed that all
standards inspected were met and inspectors
concluded that the hospice care and treatment
was planned and delivered in a way that was
intended to ensure people’s safety and welfare.
Patients were actively asked their views on the
care provided and their comments included:
“The staff are wonderful. They make
it [the service]. They always ask if you
need a particular thing, even if you
have said you don’t need it in the past.
They understand your needs might
have changed.”
“The therapies are wonderful. I really
enjoy getting my feet massaged and
I have tried the reiki therapy. I felt that it
helped me.”
This is a tribute to the hard work of every
member of staff who works for Willow Burn
Hospice and the volunteers who provide
dedicated support. The hospice has a culture
of continuous quality monitoring, in which any
shortfalls are identified and acted upon quickly.
The safety, experiences and outcomes for
patients and their families are of paramount
importance to us all at Willow Burn Hospice.
I am responsible for the preparation of this
report and its contents. To the best of my
knowledge, the information reported in
this Quality Account is accurate and a fair
representation of the quality of healthcare
services provided by our hospice.
Helen Mills | Chief Executive
24th May 2014
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Looking forward: Priorities for improvement 2014-2015
Priority 1 - Clinical Audit Development
Having developed a robust clinical audit
programme, Willow Burn Hospice needs to find
methods of sustaining improvements through a
systematic approach to changing professional
practice. Audit results help to highlight where
changes are necessary to improve the patient
care experience, which is the organisation’s
primary motivation for all improvements.
Collecting data for a second time helps to
identify if the organisation has been effective
in systemising change. It is noted that during
the past 12 months, the re-audit in some
areas has found practice has not changed.
Willow Burn Hospice intends to develop a
small working group of individuals who will
champion audit and they will be responsible
to the Clinical Governance Working Group for
making suggestions and introducing proposals
for sustainable change with clinical staff and
then to monitor its effectiveness over the next
12 months.
Once a User Engagement Forum has been
established, which is the aim of the Family
Support Service during 2014/2015, it is
intended to seek representation from this forum
to work with the Clinical Audit Working Group,
and that way the clinicians will remain focussed
on audit being a tool to support the patient
care experience.
Measures:• Continued participation in the
audit programme
• Clinical Audit objectives identified
and included in the new Clinical
Services Strategy
• Development of a Clinical Audit
Working Group
• Re-audit results confirm
improvements in practice through
organisational systemisation
• User involvement in the Clinical Audit
Working Group
Sustainable Clinical Audit will be included in
the development of the new clinical services
strategy with clear objectives to engender a
systemised approach and one that is embraced
by everyone in the Willow Burn Hospice
clinical team.
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Priority 2 - Improving care for patients with Dementia
There are around 800,000 people with
Dementia in the UK and by 2040 the number
of people affected is expected to double.
The National Dementia Strategy Living Well with
Dementia was published in February 2009 with
an aim to ensure that significant improvements
are made to dementia services across three key
areas: improved awareness, earlier diagnosis
and intervention, and a higher quality of care.
The strategy identifies 17 key objectives should
result in significant improvements in the quality
of services provided to people with dementia
and should promote a greater understanding
of the causes and consequences of dementia.
Since then, the Prime Minister launched the
Dementia Challenge in March 2012 which sets
out plans to go further and faster in improving
dementia care, focusing on raising diagnosis
rates and improving skills and awareness
needed to support people with dementia and
their carers.
Whilst the hospice will not see patients with a
sole diagnosis of dementia, as part of referral
criteria, we do see palliative patients who have
a co-morbidity of dementia and therefore it is
paramount that we are in a position to meet
these patients’ needs.
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We will aim to create a dementia-friendly
community at Willow Burn Hospice and to
identify patients with dementia and other
causes of cognitive impairment alongside their
medical conditions and ensure that the hospice
delivers high quality care to people with
dementia and provide support for their carers.
We will also undertake a baseline assessment
of the environment and make any reasonable
adjustments required to improve the experience
of dementia patients and their carers.
Measures:• Undertake a monthly audit of patients and
identify the number of those with dementia
referring to GP if appropriate
• Undertake a monthly audit of carers of
people with dementia to test whether they
feel supported
• Provide dementia awareness training for all
clinical staff
• Action achieved against reasonable
adjustments from environmental audit
Priority 3 - New hospice build development
With the completion date set for 30th May
2014, Phase One will open to Day Hospice
patients in June 2014. The phased approach
to the building development enables the
hospice to sustain services throughout the
build programme.
Every effort is being made to generate the
funds needed to build Phase Two and this will
remain a priority until the funds are available
and the build is underway. £100,000 has been
generated so far, against a projected capital
budget of £2.2M.
Phase 1 new build
Willow Burn Hospice phase 2 building
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Statements of assurance relating to the quality of healthcare
services provided
The following are a series of statements that all
providers are required to include in the Quality
Accounts. However, some of these statements
are not directly applicable to specialist palliative
care providers.
Aim
Willow Burn Hospice aims to treasure life by
improving the quality of life for those who
have life limiting illness and the families of
these patients. We also offer positive support
for every challenge that they may encounter
during their illness and see death as part of
life’s journey.
Review of Services
During 2013-2014, Willow Burn Hospice
provided the following services through its main
clinical areas list below:1
2
3
4
5
Inpatient Care
Day Hospice
Family Support
Community Services
Specialist Lymphoedema
1 Inpatient Unit
This unit has 4 beds and provides end of life
care, pain and symptom management and
emotional and psychological support.
One of these beds is designated for respite
care, allowing patients to be admitted for a
week and allowing carers to have a break from
the pressures of caring for someone with a life
limiting illness. The staff care for the patient
and embrace the whole family to provide the
emotional support that they need.
In 2013-2014 the unit cared for 82 patients.
73% of these had a cancer diagnosis, while the
remainder had other life limiting conditions such
as Chronic Respiratory Disease, Neurological
Conditions and Heart Failure. Average
occupancy levels were 70%.
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Carer Testimonials
“The nursing staff at Willow Burn
Hospice were the very best I’ve ever
encountered, full of compassion and
professional always. They eased our
suffering just through showing us they
cared. A shoulder to cry on.”
“Absolute confidence in their knowledge,
capability and their loving care for Dad”
“Unbelievably reassuring and such a
comfort for the family. A superb place
for people in our situation.”
“His wishes and needs were always their
priority. All the people who work there
restored his faith in human kindness.
He always came back with a positive
comment and in a positive frame
of mind.”
“We were made to feel like you were at
home, I really appreciate the help and
guidance we received.”
“Would like to thank staff for their
sensitive approach whilst supporting
my uncle and his partner during his
last days”.
“It was calm and peaceful for the three
days he was cared for before he died.
The only comment I would make is that I
wish there were more beds available.”
“My Mam was only with you for 9 hours
before she passed away. I felt she was
given more attention at Willow Burn
Hospice than the previous 9 days in
hospital, for which my self and my family
will be eternally grateful.”
2 Day Hospice Programme
During 2013-2014 the Day Hospice has
continued to provide a flexible service to a wide
range of patients with both a cancer and a non
cancer diagnosis.
A 12 week programme offers patients the
opportunity to identify their main problems and
concerns and to work towards jointly agreed
goals in the management of their illness.
The programme is holistic in its approach,
maintaining a high quality of physical,
psychological and spiritual well being ensuring
patients are enabled and supported during their
disease journey.
In 2013-2014, 109 patients accessed the
service with 1685 overall attendances and an
occupancy rate of 77%.
The Day Hospice led by the Therapy Team
is run on a sessional basis (morning and
afternoon) 3 days per week. Patients can
choose to attend from an hour up to a full
day depending upon how they feel that the
programme can best meet their needs.
The LeBed Method (a therapeutic movement
programme for people with any type of chronic
illness) forms the first hour of every session,
with the aim of promoting wellbeing. Patients
then have access to a varied programme of
activities throughout the rest of the day.
A dedicated team of professionals, support
staff and volunteers provide a range of
interventions including Reiki, Tai Chi,
hypnotherapy, acupuncture, breathlessness
management, therapeutic horticulture,
creative writing, crafts, emotional support,
aromatherapy massage, social interaction and
therapeutic games. Patients also have access
to other multi disciplinary professionals such as
Nurses, a Counsellor, Family Support Worker
and a GP with Specialist Interest in Palliative
Care as well as a community based Palliative
Care Consultant.
As detailed above, a 12 week period of
attendance is usually offered, although
support and sign posting to other services
is undertaken in preparation for discharge.
Individual goal setting is done with every
patient and the effectiveness of input and
attendance is measured using the Adapted
Mycaw Outcome Measure. Some excellent
outcomes have been achieved in terms of
increasing confidence, physical function and
well being for many patients.
The service continues to evolve and in 2013
a system to enable a “rolling access” to Day
Hospice was developed in response to the
realisation that some individuals with a chronic
life limiting illness were being re-referred
back to the service shortly after discharge.
These patients, many with advanced respiratory
disease, had benefited greatly from Day
Hospice, e.g. reduced anxiety, improved mood,
however found that these symptoms returned
when they were no longer attending.
Regular, time limited access is now provided
through the allocation of 3 places across the
3 Day Hospice days for a 6 week period for
patients who meet the criteria. This appears to
have been effective to date as the re-referral
rate has dropped significantly.
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The rehabilitation model of care used at
Willow Burn Hospice continues to be unique
within County Durham and amongst other
hospices within the North East region. There
is continued interest from other providers who
have visited Willow Burn Hospice to observe
and learn from what has been achieved.
Patient testimonials
“The sense of well being whilst attending
and the immeasurable benefit of being
with others.”
“I feel like a different person. You have
done wonders for me. I would advise
anyone to do this programme.”
“Accessing all the activities and knowing
that I have a purpose in life and
something to look forward to. It has been
fantastic.”
“I am now looking forward to Active
Steps and becoming a volunteer in the
organisation.”
3 Family Support Service
The Family Support Service offers free,
confidential, practical and emotional support/
counselling for people of any age, who have
been diagnosed or affected by the diagnosis or
the death of someone with a life-limiting illness.
This service is available both in the hospice and
in the community, for example a client’s home
or GP Surgery. Staff can also go into schools
and offer support to staff. Family Support
make contact with every patient admitted to
the hospice and their friends and family to offer
both pre and post bereavement support.
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There is a bereavement service at the end
of every month to remember those people
known to the hospice who have died. This is
facilitated by the team and is another way to
offer continued support to friends and family
post-bereavement.
In 2013-2014, the Family Support Service
supported 227 people. There were 722 one
to one sessions, 4 family sessions, 6 group
sessions, 12 Bereavement Support Group
sessions and 147 telephone support contacts.
Willow Burn Hospice Family Support Service
was set up in March 2010 as part of a
consortium established with three other
hospices in County Durham delivering a family
support model advocated by the National
Institute of Clinical Excellence.
This is an evidence based model offering a
range of support to individuals or families
including emotional support, advice,
information, education and sign posting.
This psychosocial approach draws on a wide
range of interventions/approaches to provide
holistic and flexible care to meet the client’s
individual needs. Counselling skills and person
centred principles are evident throughout.
The Team consists of a Macmillan Family
Support Worker and Macmillan Counsellor.
In August 2013, the service integrated with the
Therapy Team, becoming Willow Burn Therapy
Services Team and relocated to the hospice
from a community base. The Lead Counsellor
is responsible for service management and
development. Line management support
is provided by the Macmillan Therapy
Service Leads.
In October 2013, in response to client
feedback, a bereavement support group was
set up. This is a client led group facilitated by
the Family Support Worker and Counsellor.
The sessions were held in the evening at the
hospice on a 2 weekly basis for a period of
12 weeks. The first group was attended by
3 individuals.
Further groups are planned for 2014/15
including a bereavement support group and a
“Moving on from Cancer” group. The “Moving
On” group is proposed to be run jointly with
St Cuthbert’s Hospice, Durham.
Patient testimonials
“I was made to feel relaxed as
though there was plenty of time
to talk about everything I wanted.
I was given very good support and
excellent information.”
“Wonderful service. Kind and caring.
Warm homely atmosphere.”
“Great support when needed without
being intrusive.”
“I shared some very intense thoughts and
feelings. This resulted in me becoming
physically and mentally stronger.
Thank you.”
4 Community Services
The Therapy Team offer a palliative care service
to Derwentside patients in their own home or
care home providing specialist Occupational
Therapy and Physiotherapy.
Input includes functional and mobility
assessments, provision of equipment and
the delivery of specialist treatments such as
neurological rehabilitation and management,
CBT and acupuncture. CBT and acupuncture
are offered as outpatient treatments in the
hospice but, as with lymphoedema, can
easily be delivered in the community if this is
more appropriate.
Our aims are to deliver the service in the most
appropriate place for the patient, prevent
hospital admission and support a timely,
safe discharge.
Support is also given to families and carers
whilst there is close liaison and joint working
with other community health care professionals
and external agencies.
In 2013-2014 there were 218 community
visits by the Occupational Therapist and
Physiotherapist. In addition there were 172
visits by the Therapy Assistants who supported
the OT and PT with equipment fitting and other
treatment interventions.
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Active Steps
Active Steps is a 6 week programme with
one session per week lasting 2 hours.
The programme is led by two Therapy
Assistants, one of whom is a qualified Le Bed
Instructor, supported by other therapy team
members and a volunteer.
The first hour consists of Le Bed exercises
specially designed to improve range of
movement, lymphatic flow, fatigue, stamina and
mood. These exercises are carried out to music
involving the use of props and can be done
seated or standing. They are suitable for all
levels of fitness and ability so are very inclusive
to a wide range of patients.
The second hour is different each week and
can include Tai Chi and relaxation, massage,
benefits of exercise and breathlessness
management, nutrition and healthy eating and
welfare rights. The final session is led by our
volunteer poet who uses reflection and words
to pull all the elements of the programme
together and support the patients with their
emotions and feelings.
During 2013-2014 four programmes have
been delivered in the hospice and three in
the community.
Two programmes were run as a pilot with
support from the Well Being and Health Group
who funded the hire of rooms at The Louisa
Centre in Stanley and Citizen’s House in
Consett. Whilst the uptake of places was good
with 9 attending in Stanley and 5 in Consett,
the majority of patients already had links to
the hospice.
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One programme took place in the Methodist
Church in Witton Gilbert in collaboration with
Breathing Space, a local charity. Over 20
people attended these sessions and this is
to be repeated on a twice yearly basis using
different venues in the area.
In total, the number of patients attending in
the community was 38 with 164 attendances.
The total number of patients attending
the hospice programmes was 18 with
94 attendances.
In December 2013, the Active Steps
Programme was evaluated using the outcome
measure MYCAW, a self assessment tool, and
patient satisfaction questionnaires:• 83% reported an improvement in symptoms and well being
• 100% were satisfied with the programme
Patient testimonials
“I thoroughly enjoyed the exercises
and meeting people. It has made a big
difference to my life.”
“It is very easy to feel on your own with
lymphoedema. The group sessions have
been very helpful.”
5 Specialist Lymphoedema Service
The Lymphoedema Clinic operates one day
a week and provides specialist assessment,
treatment and management of complex and
non complex limb, trunk, breast, neck, facial
and genital swelling.
The service is run by a Specialist
Lymphoedema Practitioner, who is also
the hospice Physiotherapist and a Therapy
Assistant with lymphoedema key worker skills.
Non complex swelling is managed using the
4 cornerstones of treatment focusing on skin
care, exercise, simple lymphatic drainage and
compression garment provision.
Complex lymphoedema has been managed
with specialist interventions such as
kinesiotaping, manual lymphatic drainage and
compression bandaging, which are in addition
to the 4 cornerstones.
Patients who attend the lymphoedema clinic
can be signposted to other hospice therapy
services including Day Hospice, Active Steps,
Family Support Service and complementary
therapies. The Le Bed exercise programme
which is delivered in Day Hospice and the
Active Steps programme is particularly
beneficial in the management of lymphoedema.
In 2013-2014, 69 patients were assessed and
reviewed with a total of 209 attendances.
There were 49 new patients referred into the
service of which 32 were cancer patients.
The Lymphoedema Service is evaluated
annually using patient satisfaction
questionnaires and outcome measures which
record skin condition and levels of swelling.
The most recent evaluation was carried out in
November 2013 and some of the results are
listed below:• The highest number of referrals came from GPs
• Most patients were aged between 25
and 65
• The largest cancer group was breast cancer
• Over 80% of referrals were female
• 90% saw a reduction in the amount of swelling
• 85% received an appointment within 6 weeks of referral
• 100% were satisfied with the service
Income Generated
The income generated from the NHS via
the North Durham and Durham Dales
Clinical Commissioning Group represents
approximately 36% of the overall running costs
of the hospice.
Participation in Clinical audits,
National Confidential Enquiries
During 2013-2014, there were no national
audits or confidential enquiries covering NHS
services relating to palliative care as Willow
Burn is ineligible from participating.
Local Clinical Audit
Clinical audits have been undertaken within
Willow Burn Hospice; these form part of the
annual audit cycle programme. The monitoring,
reporting and actions following these audits
ensure the delivery of safe effective practice,
enhancing the patient experience. All audit
reports are discussed; action plans shared at
clinical staff meetings and clinical governance
meetings are then shared with the Leadership
Team and Board of Trustees.
The programme includes the following
3 audits:•Infection control
•Patient records
•Medicines Management
A) Infection Control Audit
An infection control audit was undertaken on
18th February 2014. It has been designed to
facilitate the monitoring of compliance with
infection prevention and control, standards,
policies and procedures, thereby reducing
the risks of healthcare associated infections
and ensuring patients are cared for in a safe,
clean environment.
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The Head of Clinical services received the report and immediately took all necessary action required which included:• Reminding staff that multiple /stone rings
and wrist watches are not to be worn
on duty
• The cleaning of the janitorial unit in the
sluice and a stool in the bathroom and an
advisory note given to all clinical staff that
the janitorial unit should only be used for
hand washing
• The sluice was also found to be cluttered
on the day but all excess clutter has
since been removed and notes placed on
bins advising not to block access to the
foot pedal
• Internal checking for staining or damage
of mattresses is required and documented
after each patient use. A mattress that
was found to be stained was replaced
immediately and a mattress audit implemented
B) Patient Records Audit
Four audits of nursing records were
conducted during the reporting period using
five sets of notes of discharged patients.
The CHKS standard 22 – Health Records
Hospice Services Audit Tool was used.
The audit examines patient and carer details,
clinical information and record entry with the
aim of determining compliance with the NMC
(Nursing and Midwifery Council) guidance for
record keeping.
The results were positive overall and the
majority of the measures were fully compliant.
However, there were exceptions:• The audits noted missing NHS numbers,
• Consent and audit forms not signed
• Times not recorded
• Codes not entered for omitted drugs
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All omissions have been raised with the staff
team and the GP Specialist Interest has agreed
to undertake random checks of drug charts to
ensure that policies are being followed.
C) Medicines Management Audit
To ensure patient safety and clinical
effectiveness, Willow Burn Hospice utilises the
medicines management audit tools developed
by Help the Hospices which include:• The management of Controlled Drugs
• The management of general medicines
• Self administration of medicines
• Medical Gases
• The Self assessment of the Controlled
Drugs Accountable Officer
Compliance stands at 63.9% against controlled
drugs audit following the decision by the local
pharmacy not to destroy or accept returned
stock. The hospice is currently putting together
an action plan for the planned destruction of all
future unused stock.
The medical gases audit has highlighted
the need to update the standard operating
procedure as it does not include sections that
indicate where the gases should be stored or
how the cylinders should be decontaminated.
The self assessment of the Controlled Drugs
Accountable Officer was 100% complaint
but continuous quality monitoring could be
improved and action plans are being developed
to ensure that all medicines management
practices are routinely monitored.
Research
The number of patients receiving NHS services
provided or subcontracted by Willow Burn
Hospice in 2013-2014 that were recruited
during that period to participate in research
approved by a research ethics committee was:
None.
The hospice does however have a research
policy in place should the opportunity arise.
Clinical Indicators
As part of the hospice’s continual development,
the IPU carries out a clinical indicator audit on
all patients and mirrors the CQUIN framework.
Progress against CQUIN Measures 2013-2014
For the 2013-2014 financial year, Willow Burn
Hospice agreed to the setting of three goals,
contractually known as indicators, as part of
the CQUIN measures linked to funding the
hospice receives from the North Durham and
Durham Dales Clinical Commissioning Groups.
The Commissioning for Quality and Innovation
(CQUIN) framework enables Commissioners
to reward excellence by linking a proportion
of healthcare provider’s income to the
achievement of local quality improvement
goals, whilst also maintaining strong
financial management.
Outcomes:• 100% of patients have a Waterlow Risk
Assessment completed on admission to
establish a baseline of pressure damage
present and identify those at risk of
further harm
• All patients identified as at risk to be
nursed on a low air loss mattress
• Zero patients with deteriorating pressure
ulcers linked to the numbers of patients
with old pressure ulcers – A patient was
admitted from hospital with a grade 2
pressure sore which progressed to a
grade 3. The patient had numerous
risk factors which included spinal cord
compression, diabetes, poor dietary intake
and deteriorating general health. Advice
was sort from the Tissue Viability Nurse and
a care plan implemented.
• 100% of patients admitted to have a
falls screening carried out by the therapy
team and if indicated have a full falls risk
assessment completed
• 100% of patients at risk of falls to be
nursed in low level beds with a crash mat
in position
• 25% reduction in the number of new falls
Indicator 1 - Completion of the NHS
Safety Thermometer
The NHS Safety Thermometer provides a quick
and simple method for surveying patient harm
and analysing results so that we can measure
and monitor local improvement and harm free
care over time.
A survey was undertaken on one day per
month of all in-patients in relation to pressure
ulcers, falls and urinary tract infections.
The data was submitted using the NHS
Information Centre website.
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Indicator 2 – Carer experience, to ensure
patient and carer/family experience of end of
life care is measured and acted upon
This related to patient experience and
required an increase in the number of
patients who achieved good care/death.
This was measured by the completion of carer
questionnaires identifying the percentage
of principal carers who agree that their
relative/friend achieved good care/death.
The regular collection and actioning of
experience data is an established means
of identifying service areas where potential
improvement/further evaluation is required and
enabling an understanding of what is important
to carers to be achieved.
The hospice satisfied the Quality Incentive
Scheme Indicators set out above and has
successfully achieved the Quality Incentive
Payment from the Commissioners.
Indicator 3 – To increase independent
nurse prescribing
Prescribing of medicines by nurses has proved
itself in England to be an important part of the
solution to improving access to medicines and
cutting waiting time for patients.
A Band 6 RGN who is already a community
prescriber is currently undertaking the
nurse prescribing module at New College
Durham with a view to becoming qualified by
July 2014. Mentorship is being provided by
Willow Burn Hospice’s GP Dr D Petterson
(Specialist Interest).
Willow Burn has submitted an application
to access this Health Education North East
funded training and following identification at
appraisal, a further two RGN’s have submitted
an expression of interest to undertake the
Independent Nurse prescribing Module at
Teesside University in 2014.
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Care Quality Commission Periodic Review
In October 2013, the hospice received the
published report relating to the CQC inspection
which took place in August. The report
demonstrated full compliance with the following
assessed standards:• Consent to care and treatment
• Care and welfare of people who
use services
• Cooperating with other providers
• Requirements relating to workers
• Complaints
The assessor spoke with two people who
used the service about the care and treatment
delivered at Willow Burn Hospice. They were
both very happy with the care and treatment
they received.
One person said, “I wish more people knew
about this place. If they came in and saw
what it is really like, they would see how
good it is. I have already planned my
next period of respite care.”
Another person said, “I really look forward
to my time here. It really lifts my mood.”
The full report can be found on the CQC
website, the hospice website and in hard copy
on display in the hospice.
Hazelbrook Specialist Care at Home
Hazelbrook Specialist Care at Home is a wholly
owned trading subsidiary of Derwentside
Hospice Care Foundation (Willow Burn).
The hospice has built its reputation on
delivering the very highest quality palliative care
and the development of these services aims to
bring the ethos and practical care associated
with “hospice” into the home environment.
This is a chargeable service, however
profits made will go to funding the future of
Willow Burn Hospice.
Hazelbrook Specialist Care at Home had its
first Care Quality Commission inspection on
Tuesday 21st January 2014. The service is fully
compliant and received very positive feedback
in relation to the high standard of patient
centered care planning and delivery.
The inspector recognised the uniqueness and
substantial benefits of the partnership working
which exists between the hospice and the
agency resulting in enhanced care delivery.
Data Quality
Willow Burn Hospice did not submit records
during 2013-2014 to the Secondary Users
Service for inclusion in the Hospital Episode
Statistics which are included in the latest
published data. Willow Burn Hospice is not
eligible to participate in this scheme.
However, Willow Burn Hospice does submit
data to the Minimum Data Set (MDS) for
Specialist Palliative Care Services collated
by the National Council for Palliative Care on
a yearly basis, with the aim of providing an
accurate picture of hospice and specialist
palliative care service activity.
Clinical Coding Error Rate
Willow Burn Hospice was not subject to the
Payment by Results clinical coding audit during
2013-2014 by the Audit Commission.
Carer testimonial
“My sister and I would just like to thank
you and your staff so much for all for the
care you are providing for our Mam. It
has taken a weight off our minds
knowing that our Mam is in good hands
receiving excellent care from the loveliest
of people. The last three months have
been very difficult for us all and it was
you who acknowledged that we have had
a very difficult few months and no one
else has shown any empathy towards us
and that was very touching.” www.willow-burn.co.uk
15
Priority 1 Progress Update - Patient reported experience and outcome measures
Willow Burn Hospice recognises that patient’s
views about their care are an essential
component in measuring its quality. Patient
reported experience and outcomes was
identified as Priority 1 in the priorities for
improvement in 2013-2014.
A working group was set up with representation
from different areas of the clinical team
(Nursing, Therapy and Family Support) with
the aim of reviewing existing methods used to
gather feedback from patients and carers, and
to explore alternatives.
The Patient, Carer and Public Engagement
Policy and the CHKS Document “What Makes
a Top Hospital” were used to guide and inform
the group.
Following a review of all of the existing patient
and carer evaluations used, several actions
were agreed as detailed below:• To change the wording of some of the
questions on the IPU evaluation to
ensure they are easy to understand and
only relevant and purposeful questions
are asked. Examples of evaluations
used in other hospices, for example the
St Christopher’s Index of Patient Priorities
(SKIPP) were obtained and used to assist in
this process
• It is also recognised that all of our
evaluations should be available in both
paper and electronic format, to enable
individuals to choose their preferred
method of completion. This in turn may
have a positive effect on return rate. Some
service users may be reluctant to give
negative feedback, even though this can
be essential in informing service review and
development, a statement is to be added to
all evaluations encouraging any comments
or concerns to be recorded
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www.willow-burn.co.uk
• The group identified that a gap currently
exists in obtaining feedback from inpatients
that are nearing the end of life. As
previously stated, evaluation tools used by
other organisations are being considered,
but as a structured questionnaire is often
not appropriate for use with very ill patients,
the Family Support Service are to assist
in the development of prompts/questions
to enable staff to gather feedback in “real
time”. Volunteer support with this is also
being discussed as a future development
• “Comments books” to capture patient/
carer testimonies are now in use throughout
clinical services. See examples below:“After visits when family are back home,
they can rest assured that their loved
one is in the best possible hands”
“I feel loads better, like I’ve had a release.
I’ve held things in for so long. I feel lighter”
“You are all fantastic and for once people
are doing what they say they will do. I trust
you all”
• Other actions resulting from the working
group are to use the existing white boards
in the inpatient rooms as a communication
tool between staff, patients and their
families and volunteers. The CHKS paper
previously referenced cites an example of
best practice where whiteboards are being
used as a planning tool by patients to write
up their own needs and goals
• Due to current under use of the suggestions
box, a new more prominent box is to be
positioned in the hospice reception signing
in area. This will be emptied on a monthly
basis and a report produced from the
comments for circulation to all staff
Two group members are representing
Willow Burn within the Patient, Public
and Carer Membership Scheme (North
Durham Community Engagement Project),
a joint venture between Durham Community
Action and North Durham Clinical
Commissioning Group.
Future Plans
The working group will continue to meet on
a monthly basis to implement the actions
identified, evaluate their effectiveness and share
information gathered with our stakeholders.
As System W (the hospice database) is
now able to capture all data received from
evaluations, the ease of obtaining accurate
information for reporting purposes is
significantly improved.
Priority 3 Progress Update - to
build a world class hospice facility Phase 2
The new hospice phase one is almost at
the point of completion. After a 42 week
build programme the new facility will house
Day Hospices Services following the highly
regarded rehabilitation model.
Planned future developments include
setting up of a Service User Forum at
Willow Burn Hospice.
Priority 2 Progress Update Clinical Audit - organisational
priorities for clinical audit are
identified and documented in a
annual clinical audit plan
Audits were undertaken throughout the year
as per the audit cycle programme but the
programme was further developed during the
year which gives a much more robust approach
to the review of care. This includes the audit
of all clinical practices against policies and
procedures. Audit reports were reviewed by the
Clinical Governance working group and where
changes were required, they were brought to
the attention of the clinical team via the clinical
staff meeting and KPI’s developed.
The new hospice nearing completion
So far, we have raised £100,000 towards the costs
of phase two and have some way to go before we
will be building the next stage of our visionary new
hospice facility.
In addition, the existing hospice has undergone
planned refurbishment which has included: the
redecoration of patient bedrooms and a makeover to
the lounge (thanks to a team of volunteers from the
NHS as part of NHS Change Day), the dining area
and conservatory (thanks to a team of supporters
from B&Q and funding from Cash4Kids).
Hospice conservatory make over
www.willow-burn.co.uk
17
Who has been involved?
Chief Executive
Leadership Team
Board of Trustees
Statement provided from Clinical Commissioning Group
NHS North Durham Clinical Commissioning
Group (CCG) is pleased to have had the
opportunity to review and comment on the
Quality Account of Willow Burn Hospice
for 2013/14.
The CCG would like to commend the Hospice
on the developments taken forward last
year and in their commitment to strengthen
engagement with the CCG on an ongoing
basis, ensuring that quality improvements
and positive impacts are benefitting patients,
families and staff. This includes the progress
made to be able to open a new facility in
July 2014.
Overall the CCG felt that the report was
concise, accessible and written in a meaningful
way for both stakeholders and users. We would
also like to offer the following commentary:
Willow Burn has continued to increase its
engagement with commissioners over the last
12 months, demonstrating a willingness to
strengthen the commissioning and contractual
relationship between parties. In this year, the
CCG has had the opportunity to spend time
with the Hospice and patients, seeing the direct
impact of their efforts.
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www.willow-burn.co.uk
The Hospice has embraced the challenges set
by 2013/14 CQUIN (commissioning for
quality and innovation) improvements, moving
towards systematic approaches to reduce
the risk of harm to patients and improve patient
and carer experience.
The integration of extended quality
requirements into the Hospice 2014/15
contract, post learning from Mid-Staffordshire,
has been welcomed and we will work together
with the Hospice in order to gather and share
meaningful information with stakeholders over
the forthcoming year.
The planned opening of the new facilities in
July 2014 will make an enormous difference
for those patients and staff transferring to the
unit – which is a significant aspect of the
quality account for 2014/15. The continuation
of the clinical audit work for next year is
welcomed, as is the focus on dementia in last
years of life, although the quality account
does not clearly explain the expected benefits
for patient and carers, we will work with the
Hospice so the learning from these
development is understood and shared.
The CCG is committed to work with
Willow Burn over the coming year in order
to achieve the common goals of improving
patient, family and staff experience and safety
for all patients.
Volunteering
Willow Burn Hospice recruited 31 new
volunteers in 2013/2014 and are actively
processing a further 18 applications:Day Hospice - 15
Income Generation - 4
Administration - 2
Stanley Shop - 4
Weekend IPU Volunteers - 2
Events - 2
Warehouse - 2
Each volunteer selected to support the charity’s
activity brings something different into the skill
mix. We are indebted to them for the generosity
of their time and commitment to our cause.
This group of people were allocated roles
across the various departments.
We currently have 66 active volunteers and
many more who we keep in touch with as they
are still as passionate about our cause but are
not able to provide support at this current time.
Volunteers on the Willow Burn Hospice stall at the Durham Regatta
www.willow-burn.co.uk
19
Income Generation/Fundraising: 2013-2014
The overriding good news story in 2013 was
the awarding of a capital grant of £356,480
to Willow Burn Hospice by the Department
of Health. This was instrumental in enabling
building work in relation to Phase one of the
new hospice to commence, and it is against
this backdrop that income generation activity in
2013/14 has taken place. Willow Burn Hospice
has also been able to draw down various
pots of money that have been pledged over
recent years.
This includes monies from:• The Wolfson Foundation £100,000
• The Sir Tom Cowie Charitable Trust
£500,000 (total over the past 5 years)
• The Genesis Foundation £25,000
Following on from the appointment of an
Income Generation Campaigns Lead, earlier in
the year, 2013 saw additional investment being
made into the Income Generation Department,
with the formulation of two new posts: an
Income Generation Campaigns Assistant and a
Community and Events Fundraiser.
Although it would be true to comment that the
community at large has continued to support its
local hospice, we have seen fewer funding pots
come on to the table; more giving groups in the
community folding; companies as lean as they
have ever been. These factors have impacted
on the hospice’s income over the past year.
To add to this, although the hospice’s NHS
contribution has remained stable at 36%, a
large contribution from Macmillan Cancer
Support which has supported the development
and activities of the hospice’s Therapy and
Family Support Teams over the past 3 years ran
out at the end 2013/14.
20
www.willow-burn.co.uk
Given that the Clinical Commissioning Group
recently declined a formal application made
by the hospice for additional funding, we are
now looking to the Big Lottery to cover these
salaries for the next 5 years.
This means that alongside the Phase one build
reaching completion, the Income Generation
Team going into 2014/15 faces an even tougher
challenge in trying to achieve the £850,000
to maintain current services; the potential of
having to cover increased costs associated
with the running of two buildings; looking to
obtain salaries for the MDT; as well as pushing
forward with the capital campaign in support of
the Phase 2 build – a new In Patient Unit.
The recruitment of the Income Generation
Campaigns Assistant has enabled the cleansing
of the corporate element of the Raiser’s Edge
database and has concluded in a Corporate
Work Plan being drawn up which identifies a
steady approach to building relationships with
local companies.
Existing relationships with our committed
corporates continue to be strengthened
and new ones are being built. These include
partnerships with bigger nationals such
as Matalan (Consett), Northumbrian Water
and Newcastle Building Society as well as
with local companies such as Perspective
Business Solutions.
The ways in which community groups and
individuals continue to raise money for
Willow Burn inspires and motivates the
Income Generation Team. Examples include:• A local thirteen year old school girl,
Kay McKinnell shaving her head for
Willow Burn - agreed through her school
and by her family who supported her and
helped raise over £7K for the hospice
• A local business man, Paul Jackson
established the Great North Duck Race in
2013 by launching 2000 plastic ducks into
a small burn in Lanchester and declaring
the lead duck the winner half a mile
downstream
• Two local lads, Philip Marshal and Ross
Terrington broke the non-stop snooker
record by playing continuous snooker for
sixty-five hours and raising nearly £1500
Malcolm Kay and his 14 year old daughter,
Billie, with support from South Moor Golf Club
raised over £6000 during 2013
In the style of the box office hit, Calendar Girls, a group of ladies from Castleside bared all for the hospice,
raising over £11K in the sale of one thousand calendars which was split between three charities: the local
village hall, Cancer UK and Willow Burn
www.willow-burn.co.uk
21
Everlasting Leaves: This beautiful creation
now stands in the hospice garden and is home
to hundreds of stainless steel leaves which
can be purchased by bereaved relatives and
inscribed with a message in memory of their
loved ones.
The marketing of the woodland focuses
upon the sponsorship of trees by individuals
and families to mark life’s milestones
including: weddings, births, anniversaries
and celebrations, not just the death of a
loved one. Corporate support is also being
sought in the form of Bronze, Silver and Gold
packages. To date, two gold, one silver and
two bronze packages have been sponsored by
local companies.
Legacies: It is evident that the hospice’s good
reputation and the exemplary service delivered
to patients is being recognised and financial
support written into an increasing amount of
wills. A legacy development plan has been
implemented for 2014/15 which involves
a review of Willow Burn’s Legacy Strategy
and promotional materials; and seeking out
increased opportunities to publicise legacy
giving to the right groups.
Everlasting Leaves at Willow Burn Hospice
Willow Burn Wood: In May 2013, the hospice
launched its own woodland which evolved
through the gifting of a 14 acre bare field site
to Willow Burn Hospice from local entrepreneur
and philanthropist, Sir Tom Cowie. With support
from Butterwick Trees and the Woodland Trust,
over 10,000 trees were planted, with English
and sessile oaks making up the Willow Burn
logo and the balance of the trees, consisting of
cherry, rowan and crab apple, filling the spaces
in between.
22
www.willow-burn.co.uk
Events: Willow Burn’s own Events Diary is
compiled by the Income Generation Team
and features a mix of quality events that align
themselves with the hospice’s core remit.
The year started with the introduction of a
new sponsored ‘Reflections Walk’ aimed at
bereaved relatives. The activity attracted a
small group of participants, all passionate
about the hospice who together raised a
substantial amount of money for Willow Burn.
This has led to the walk being featured twice on
the 2014/15 calendar.
Our Tree of Remembrance ran for the third time
throughout December 2013 in Matalan Consett.
In conjunction with ASDA in Stanley, a second
successful tree was launched which proved to
be very lucrative and which will be developed
further in December 2014.
The Income Generation team also arranged
Willow Burn’s first ever Spring Fair and raised
over £5K. This fair heralds a format of three
fairs annually, in different locations across
the district.
2013/14 ended with the Income Generation
team reporting upon the best Make a Will
Month ever, with increased income by
over 30%.
As Willow Burn embarks upon its 25th
Anniversary Year, our Book Shop Chat &
Craft Group volunteers have made a fabulous
home-made quilt which they are justly proud
of but in selfless fashion are raffling for the
hospice. This is just one example of how loyal
and inspirational our volunteers are and how
motivational they can be to fundraising staff.
25TH ANNIV
E R S A RY
Retail: Willow Burn Hospice generates some
of its income through retail trading and has
a bookshop in Consett, a traditional Charity
Shop in Stanley and a tea bar at the Consett
Magistrates court. The Shop in Stanley
celebrated 15 years of trading in early 2014
which was marked with a prominent and eye
catching window display and held a tombola
and raffle in store.
Celebrating 15 years at Stanley
The home-made quilt currently being raffled
Approximately £73,500 gross income was
generated during this reporting period and with
plans to open two new stores per year for the
next three years, this is part of Willow Burn
Hospice’s growth plan to diversify its funding
streams and ensure that sustainable sources of
income are achieved in the longer term in order
to sustain hospices services.
www.willow-burn.co.uk
23
Comparative Health Knowledge Systems (CHKS)
In July 2013, the hospice received its second CHKS three day review. The outcome of this visit was that
the hospice continues to be CHKS accredited.
• The transformation of the Day Care service
to a therapeutic rehabilitation model which
is well managed by the Macmillan team
• The involvement of the volunteers in pre
and post session meetings with staff
• The volunteers find this extremely helpful
and really feel part of the team
• The continued patience of staff whilst
working in the current environment both in
the hospice and offices offsite
• The comprehensive procedure on what to
do in the case of a missing patient
• The quality improvement objectives for the
inpatient service and good work undertaken
to meet these
• The way the hospice has recognised the
needs of patients with dementia and has
begun to train staff and think ahead about a
suitable environment
Commendations during the visit:• The board development and leadership
programme, ensuring each area of business
is represented at board level by an
individual trustee
• Maintaining quality at the top of the agenda,
despite all the challenges that Willow Burn
Hospice has been facing
• Engaging the Trustees and the setting up of
dedicated working groups
• The commitment by the GP with a special
interest in palliative care
• The establishment of the
volunteer academy
• Establishing links with the CCGs and
keeping the profile of Willow Burn Hospice
at the forefront of their agenda
• The initiative to carry out a review of internal
communications and the action taken as a
result of this
• The enthusiasm and innovation of the
fundraising team. Despite being in an
economically deprived area, the team have
been very successful in generating funds for
the new build and plans are in place for this
to continue
Willow Burn Hospice, Derwentside Hospice Care Foundation,
Maiden Law Hospital, Lanchester, Co Durham, DH7 0QS
Switch Board: 01207 529224
Fax: 01207 529303
Registered Charity Number 519659
Website: www.willow-burn.co.uk
Companies House Number 2263960