Quality Account Woodlands Hospice 2013 - 2014 Incorporating Priority Areas for 2014/15 “Thank you for the wonderful care, kindness, attention and time you gave us. Woodlands is in a league of its own. Please let all your staff and volunteers know how very much we valued their hard work, friendliness and dedication”. (Letter from a relative, March 2014) www.woodlandshospice.org 1 Woodlands Hospice Charitable Trust UHA Campus, Longmoor Lane, Liverpool L9 7LA Tel: 0151 529 2299 Charity No. 1048934 2 Welcome to Woodlands Hospice Quality Account 2013/14 Contents Chief Executive’s Statement 4-5 Section 1 Priorities for Improvement 6 - 16 Section 2 Statutory Information and Statement of Assurances from the Board 17 - 20 Section 3 Quality Overview and What others say about us 21 - 34 3 CHIEF EXECUTIVE’S STATEMENT Woodlands Hospice Charitable Trust is an independent charity committed to delivering the best possible practice and development of Specialist Palliative Care for people with cancer and other life limiting illnesses. It honours people’s right to dignity and respect at whatever stage of their illness, by its aim to improve the quality of life for patients and their carers. Woodlands is based in North Liverpool and covers a population of over 330,000 in North Liverpool, South Sefton and Kirkby in Knowsley. Our key priority here at the Hospice is to ensure high quality care for all patients and their families and we pride ourselves on the excellent standards achieved on a consistent basis. We are always looking for ways to develop and further enhance every patient experience and have progressed well with the three priorities we set ourselves in the Quality Account for last year. The progress we have made through the Tissue Viability working group to minimise the risk of pressure ulcer development has been very pleasing with results indicating improvement with reduced incidents. Staff training in this area has been heightened and all nursing staff are now even more proactive in the identification and management of developing ulcers. Measuring the difference we make to patients’ outcomes has always been difficult to achieve and there is much discussion locally and nationally about the best tools to do this. Our second priority last year to introduce the use of the Patient Outcome Scale version 2 (POS2) and the Palliative Performance Scale (PPS) helped us to make good strides to measure the difference we make and using them has assisted with ongoing clinical decisions, The professional team are keen to keep abreast of developments within the tools and will be adopting the updated version of the POS tool throughout this year, keeping us at the forefront of this important quality measure. It has always been our intention to develop a Patient and Family Forum and our third priority last year ensured we worked towards this in a structured way. Getting such a group off the ground takes good preparation to ensure the membership is open to a varied representation and we were delighted to have hosted our first meeting of the Forum in March 2014 with excellent feedback. It is really important to Woodlands that we listen to those who use, or have used, our services and encourage them to influence our future services and developments. The Forum has got off to a great start and we look forward to working with the members over the coming years. One of our key areas of quality and safety is our continuing focus around infection prevention and I am delighted once again to report that we have had no Hospice acquired infection at all during the year. This is reflective of all the hard work the team put in to ensuring these highest standards are maintained. Every day we receive positive comments regarding the high quality, personalised service we provide, whether this be through talking with patients and/or families, cards and letters and even now via social media for all to see. It makes me extremely proud to be leading an organisation which shows such care and compassion and which treats all 4 patients with great dignity and respect. It humbles me that patients say they feel ‘lucky’ to be with us here at Woodlands and that families repeatedly talk of the warmth, comfort and support they feel in such a safe environment. From time to time we are not able to fully meet individual’s expectations and any negative comment or complaint is taken extremely seriously and looked into thoroughly. We did have a small increase in the number of written complaints during the year but we openly encourage all concerns to be raised so that we can continually learn from feedback to ensure our high standards of quality and safety are consistently applied to all patients in all services. Our quality assurance framework is very robust and with the appointment of our new Quality and Improvement Manager in year whose role it is to continually drive and monitor the Quality agenda, we are confident that despite regular development to keep pace with the ever changing healthcare provision and expectations we will retain our focus on ensuring high quality care for all our patients and their families. Every year brings new quality priorities to concentrate on and this coming year we have decided on the three priorities which are also of national importance. Our first priority is to extend the good work we progressed last year on the Inpatient Unit with nutrition and hydration into all our services. Linking nutrition to tissue viability ensures we follow on from our pressure ulcer work of last year. There has been much publicity and debate over the last 12 months regarding the Liverpool Care of the Dying Pathway (LCP) and its ultimate withdrawal from use in July 2014 and we, like all health care providers, will be developing more individualised care plans for patients at end of life and working in the coming year on other aspects of the recommendations which were published last year. This will be our second priority for the Quality Account. Finally our third priority centres round the sharing of clinical information across all our services to ensure we minimise the number of times a patient has to tell their story when accessing any of our services. Over the last year our non-Inpatient services have moved to a new computer system to integrate more fully with the Inpatient Unit and this year we will be working on developing the information systems further. Woodlands Hospice is absolutely committed to delivering the highest standards of quality and safety for all our patients and we have a strong ethos to ensure dignity and privacy at all times. We continue to strive for continuous quality improvement whilst maintaining the high standards we are very proud of. I confirm that to the best of my knowledge, the information contained within this Quality Account is a true and accurate account of quality at Woodlands Hospice Charitable Trust. Mrs Rose H Milnes Chief Executive 5 Mrs Rose H Milnes Chief Executive Section 1: Priorities for Improvement The priorities for quality improvements identified for 2014/2015 are set out below and have been identified by the Senior Clinical Team in agreement with the Senior Management Team following feedback from patients, carers and staff. 1a. Priorities for Improvement 2014-2015 Patient Safety Priority 1: Nutrition & Hydration – the Hospice will extend improved practice in nutritional care to the Well-being & Support Centre How was this identified as a priority? The Hospice clinical team acknowledges the importance of appropriately assessing the nutrition and hydration requirements of patients using the service and providing nutrition and hydration appropriate to the patient’s needs whilst maintaining dignity and promoting independence and choice. In order to achieve this, a multi professional steering group was established and a baseline audit of nutritional care on the Inpatient Unit was completed highlighting areas for improvement. This included the completion of an evidence based nutrition policy and procedure and the publication of a patient information leaflet providing nutritional advice. The policy provides guidance for staff in relation to clinically assisted nutrition and hydration and consideration of benefits, burdens and risks of this treatment for patients in the last days of life. Staff training in relation to assessment of a patient’s nutritional needs and implementation of care in accordance with the nutritional policy has been completed on the Inpatient Unit. Following evaluation of these improvements on the Inpatient Unit, the hospice clinical team recognises the need to extend improved practice in nutritional care to the Wellbeing and Support Centre (incorporating day therapy and outpatients). This will ensure best practice for patients across all services. How will this be achieved? • Completion of staff training in relation to the nutritional assessment tool, care plan and nutritional policy and procedure • Introduction of the nutritional assessment tool and care plan to the assessment of patients attending the Well-being and Support Centre • Establishing a regular audit of nutritional care within the Well-Being and Support Centre 6 How will progress be monitored and reported? Progress will be monitored through evidence of audits including patient feedback and achievement of actions following audit. Reports of progress against the above plan including staff training and audit results will be submitted to the Clinical Governance Committee and Board of Trustees bimonthly. Clinical Effectiveness Priority 2: Care of the Patient who is Dying – the Hospice will further integrate its revised end of life care documentation into all relevant domains of clinical care. How was this identified as a priority? The Neuberger Report about the Liverpool Care of the Dying Pathway (LCP) suggested that the LCP should be phased out in July 2014. The report makes a number of recommendations that all organisations involved in end of life care should address. Woodlands Hospice developed and implemented an action plan based on this report and its recommendations. An End of Life (EoL) care communication record was created and implemented on the Inpatient Unit and has been in use from March 2014. This document highlights areas that are important for discussion with patients and families in the dying phase, for example agreeing a plan of care, explanation why the team feels that the patient is dying, comfort measures to be put in place, hydration and nutrition needs and spiritual care. The document is mainly completed by the medical staff at the hospice. However the delivery and documentation of the communication record needs to be implemented further to include all end of life care delivered by the care team at the hospice. This is particularly important for any care received after initial discussions about the dying phase have taken place and the plan of care has been completed, and also for care given after the patient has died. This needs to also be accompanied by revised written information for carers. In addition to the Hospice plans for managing EoL communications, further guidance on EoL care is expected from the Leadership Alliance in the coming months. Depending on the recommendations they make, a further action plan may need to be developed to improve end of life care documentation at Woodlands Hospice. How will this be achieved? • Sustained implementation of the EOL care record. • Integration of EoL care into existing nursing care plans and documentation including immediate bereavement care. This will be done jointly with the Aintree Palliative Care Team to guarantee consistency of approach in this area. • Development of a relevant information leaflet around coping with dying for carers. • Implementation of an action plan depending on further guidance from the Leadership Alliance. 7 How will progress be monitored and reported? Progress will be monitored through audit of the use of the EoL communication record and the revised nursing care plans once implemented. Trustee visits (by medical and lay representatives) will be introduced to review EOL care on the Inpatient Unit on a regular basis. Reports of progress against the above plan and audit results will be reviewed by the Clinical Effectiveness group and submitted to the Clinical Governance Committee and Board of Trustees bimonthly. The Clinical Effectiveness group will also develop and oversee implementation of the relevant action plan for new recommendations by the Leadership Alliance. Patient Experience Priority 3: The Hospice will ensure Integrated Sharing of Clinical Information (including Advance Care Planning) between hospice services to ensure we minimise the number of times a patient has to tell their story. How was this identified as a priority? A significant amount of work has been done over the past 12 months to align computer systems across Woodlands Hospice clinical services and as a result all services with the exception of our Hospice at Home Service now use SIGMA. This was chosen as this is the system used within University Hospital Aintree with which the Hospice has very close working relationships and it was already established on the Inpatient Unit. This has enabled much better collation of data and activity but it has also highlighted that there remains a disparity in how clinical information from patient assessments is documented and shared across hospice services. For example if a patient is well known to Outpatient services through the Well-being and Support Centre and is then admitted to the Inpatient Unit the relevant information from Outpatient assessments doesn’t always follow the patient for that transition in their care. This can result in patients having to repeatedly go over details about their illness including discussions that may be distressing when they are already known to other Hospice services and in addition potentially important information which could impact on their care may not be handed over. We therefore feel this is a priority area to focus on to enhance the patient experience and minimise the number of times a patient is asked to repeat personal details when they are already known to our services. It is important that patients feel there is a seamless integration when they are moving between services and better sharing of clinical records is a key component of this. Integral to this is also the sharing of any documented wishes and preferences made as part of an Advance Care Plan (ACP). Not every patient will wish to formulate an 8 ACP but where this is done it is essential that this is shared with all relevant healthcare professionals and hence how any ACP information is shared between services within and external to the hospice will also form part of this patient experience priority. How will this be achieved? • Consideration of the introduction of standardised multi-professional initial assessment documentation which could follow the patient across hospice services. • Explore the possibility and challenges of electronically scanning clinical records from the Well-being and Support Centre through the Electronic Document Management System currently used by the Inpatient Unit. • Consider introducing an electronic pro forma for Outpatient initial assessment which would allow the sharing of this information via SIGMA which would make it readily accessible to all services across the hospice. • Collaborate where possible with other health care providers to produce consistent documentation to support ACP and effective sharing of that information. • The Hospice is looking to appoint an ACP Facilitator who will predominately have a community focus but will also be able to support the structure and process of ACP within the Hospice. How will progress be monitored and reported? • Patient Experience Surveys will include questions to ascertain patients’ perceptions as to how well their personal information is shared across hospice services • A baseline audit of the existing arrangements for ACP will be carried out • Improvements to initiating, recording, documenting and sharing End of Life and Advance Care Plans will be guided by the Clinical Effectiveness Group and supported by the Documentation Group • Regular ongoing audit of progress against the above plans to be carried out • Reports of achievements against the above plans, including audit results and any policy or procedure revision, will be reported to the Clinical Governance Committee and Board of Trustees for approval and ratification. 9 1b. Priorities for 2013-14 Review of progress Patient Safety: Priority 1: Tissue Viability – The Hospice will maintain high standards of skin care for patients and minimise the risk of pressure ulcer development • A tissue viability working group was established to manage this priority. • Following review of data collection and audit tools relating to patient risk and incidence of pressure ulcers, a more comprehensive system has been implemented. • We have had an independent review of tissue viability in the hospice and addressed the recommendations which included: integration of tissue viability with a nutritional link role, clarity of responsibilities for nursing staff roles in the prevention and management of pressure ulcers and improved data collection. • Facilities for photographing pressure sores and reporting through University Hospital Aintree’s DATIX incident reporting system have been implemented. • We have commenced a review of the policy for prevention and management of pressure ulcers. It is envisaged that this will be completed and implemented by the end of June 2014. • All relevant nursing staff have completed prevention and management of pressure ulcer training. • A patient and carer information leaflet in relation to preventing pressure ulcers has been developed. • Progress against this priority, including audit of pressure ulcer incidence, has been reviewed. Results indicated improvement with reduced incidence of pressure ulcers. • Tissue viability will remain a key and ongoing priority for the Hospice with regular audit and review. Clinical Effectiveness: Priority 2: To introduce the use of Clinical Outcome Measures – the hospice will incorporate the use of outcome measures into clinical practice to aid multidisciplinary team working, clinical decision making and help assess quality of care. • Patient Outcome Scale version 2 (POS2) and Palliative Performance Scale (PPS) have now been implemented for multi-professional day therapy patients in the Wellbeing & Support Centre, and for Inpatients. 10 • The scores are collated weekly for these patients and are presented as part of weekly clinical meetings to assist with clinical decision making. • A summary sheet is used to identify trends and also help focus where particular interventions may be required • By keeping abreast of national developments on outcome measures for palliative care we are now looking to adopt an updated version of the Patient Outcome Scale (IPOS) • Education around the use of outcome measures is ongoing and additional methods to support learning including the possibility of e-learning are being explored Patient experience: Priority 3: Development of a Patient and Family Forum to ensure that people who are using our services have a more active role in the planning, development and evaluation of services. • Different ways of delivering patient involvement forums were investigated and planning meetings were held to agree the format and recruitment process for the first meeting. • The first meeting of the Woodlands Patient & Family Forum was held at the Hospice on 26th March 2014. • As well as patients and carers, there was also representation from local Healthwatch organisations, Person Shaped Support, a local Carer’s Association and a local student social worker. • The Aintree Hospital Patient & Carer Representative joined the group as a guest speaker to talk about the achievements of patient and carer groups she has been involved in. • The aim of the group was agreed as: “To engage with patients, carers and the public who are interested in the ongoing development and quality of services delivered at Woodlands Hospice”, …and to provide “Information from the community, for the community”. • To support achievement of the aim, the group agreed Objectives, Terms of Reference and Ground Rules. • Members of the group reviewed and commented on draft Hospice leaflets including ‘Care of the Dying’ and ‘Advice on Hand Washing for Visitors’. 11 • Comments from attendees at the meeting included: “Excellent meeting; great information and presentation; look forward to the next one” “Sharing of ideas; Friendliness; Open & honest approach” “Excellent – glad to be here” • Feedback from the first meeting was shared with all attendees, staff, the Senior Management Team and the Clinical Governance Committee. • The group agreed to meet bi-monthly for the first six months to enable it to develop and establish membership, develop its strategic plan, and start to influence change and improvement. Meeting dates for the first six months of 2014/15 were agreed. • Work will continue to support the group to become an active and essential part of service development at Woodlands. • Consideration will be given to sharing the planning of future Quality Account priorities with the group. Other Quality improvements 2013-14 Monitoring of Quality • The annual clinical audit plan and non-clinical audit plan continued to be developed (and supported by relevant working groups where appropriate). • All audit results and resulting action plans were reviewed by the Governance and Clinical Governance committees (as relevant). • The review of Care Quality Commission (CQC) Provider Compliance Assessments continued as services developed. • Monthly Trustee visits continued throughout the year to review compliance with CQC Essential Standards of Quality and Safety. • The Risk Register was maintained and regularly reviewed by Governance and Clinical Governance committees and the Board of Trustees, highlighting areas of concern and identifying actions to be taken. • A Clinical Effectiveness Group was established, consisting of Senior Clinical Team members, to monitor and advance Hospice clinical priorities. • The Chief Executive Officer carried out interviews with patients, and the Patient Services Manager carried out regular patient ‘ward rounds’, to ensure that patient experience of services was included in the monitoring of quality. • Incident report monitoring continued throughout the year. No Serious Untoward Incidents were reported. • A Quality and Improvement Manager role was identified, and recruited to, to lead the quality agenda. 12 Working groups Multi-professional working groups continued to meet regularly to support quality and improvement across all services. Outputs during 2013/14 included: Dignity • The multi-professional Dignity Working Group met four times during the year to support the prioritisation of dignity throughout the hospice; both in the care given to patients and their families, and in the workplace. • The Group reviewed and revised the Dignity Policy. • The Group developed and agreed a Dignity Charter. This is now displayed in all Inpatient bedrooms and in clinical areas of the Well-being & Support Centre. • The Group is currently reviewing patient satisfaction surveys across the organisation with a view to developing one cross organisational survey that can be used to survey patients from all our services annually and replace the individual surveys that are currently completed for each service. • The Group produces quarterly reports in relation to dignity in care performance for the Clinical Governance Committee. Infection Control • The Infection Prevention group met regularly with membership from all services. • The comprehensive annual audit programme was reviewed and implemented. Monthly audit results were generally good with most achieving at least the required 95% pass rate. Where opportunities to improve were identified, an action plan was developed and monitored to completion. (Some examples of improvement are included in the table of patient safety audits included in Section 3). • A staff training programme was initiated and is currently ongoing. • Ongoing review of audit results and action plans by this group and the Clinical Governance Committee continued throughout the year. • The Hospice group linked in to Aintree University Hospital Infection Control group for advice and support. Nutrition • A multi-professional steering group met regularly to support the maintenance of adequate nutrition and hydration to patients. • A training package was developed and implemented for clinical staff. • A nutritional care audit was carried out, using the Help the Hospice audit tool, which identified the need for a co-ordinated approach to nutritional care. • As a result of the audit, a new policy and procedure for Nutritional Care was developed and implemented and a patient information leaflet was approved. Printed versions of leaflets are now available on the ward. 13 • Re-audits using the same tool identified an improvement in nutritional care. . • The steering group is currently developing our own audit tool, to be used for future audits, to demonstrate compliance with the Hospice policy and procedure for nutritional care. Falls • A Multi-professional Falls Group met quarterly to review the management of falls across all services. • All patients have falls risk assessment completed, and their ongoing care planned accordingly. • Falls system equipment was reviewed and replaced in accordance with warranty requirements. . • The Falls Link Nurse has delivered staff training on the use of new falls equipment on the Inpatient Unit. Falls training continues to be a part of induction training for all clinical staff (including bank staff). Medicines Management • A multi-professional group continued to meet monthly to review medicines management across the hospice with good attendance across all disciplines. • The group continued to review policies such as the Self Administration of Medicines policy, which was updated to ensure the safe storage of medicines when patients are participating in the scheme. • An improved medicines chart was developed and safely introduced to the Inpatient Unit. The chart now includes a colour-coordinated section specifically for syringe driver medicines to mitigate errors. • The Hospice Pharmacist provides medicines management training for nursing staff, and a comprehensive medicines audit programme continues. Documentation • Following recommendations from the CQC on the need to have more individualised Care Plans in place for patients, Care Plans on the Inpatient Unit were reviewed and updated. A regular audit was established and has demonstrated improvement in this area. • The audit tool for the review of nursing documentation on the Inpatient Unit was reviewed and improved to correlate with the documentation sheets in use. This enabled audits to be completed easily, and problems to be resolved faster. • An audit tool for Hospice at Home documentation was developed and will be implemented in 2014/15. 14 • The group recognised the need to audit Well-being & Support Centre documentation. An audit tool will be developed and incorporated into the 2014/15 clinical audit plan. • A multiprofessional group continues to meet regularly to review clinical documentation across the organisation. Patient Information Woodlands continued to develop information for patients on a wide range of clinical and non-clinical topics; this includes leaflets on Nutritional Advice, Bereavement Support, and a range of leaflets about the support groups available to patients such as the Creative Group and the Supportive Living Programme. A selection of those leaflets can be seen here. Education Over the past 12 months, Woodlands Hospice staff have contributed to a wide range of education, both in house and also to that provided by Aintree Specialist Palliative Care Services Group on a wider footprint. The education sub group of the Palliative Care Services Group is chaired by Clinical Lead for Woodlands Hospice, Dr Graham Whyte and is hosted at Woodlands. Education provided includes: • A collaborative programme of GP education, working in conjunction with Willowbrook and Marie Curie Hospices, to produce a series of evening sessions on Palliative Care for non-malignant conditions. • The delivery of the ‘Six Steps to Success’ programme of education for care home staff in South Sefton. • ‘Opening the Spiritual Gate’ – a series of 1 day workshops, (plus an e-learning option provided by Queenscourt Hospice), exploring spirituality at the end of life. • End of Life Workshop for Social Workers. • Core and Intermediate Communication Skills Training. • Education to support the implementation of the new regional unified ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNA CPR) policy. There is also an ongoing programme of in house education for hospice staff which has included Consent to Care & Treatment, the Mental Capacity Act and Deprivation of Liberty Safeguards (key features of the CQC’s strengthened focus for 2013-16). 15 Community Engagement • The Hospice actively participated in Dying Matters Week, May 2013, to raise awareness of issues around death and dying and promote Advance Care Planning. • The hospice actively promoted Hospice Care Week in October 2013, involving all staff and volunteers. • The Hospice continued to promote Hospice at Home in locality meetings. • The recently appointed Well-being and Support Centre Manager is actively engaged, along with her team, with external referrers to continue to raise awareness of the redesigned service within the community. 16 Section 2: Statutory Information and Statement of Assurances from the Board The following are statements that all providers must include in their Quality Account. (Not all of these statements are directly applicable to specialist palliative care providers.) 2.1 Review of Services During 2013/14, Woodlands Hospice Charitable Trust provided the following services • In-patients • Well-being and Support Centre (incorporating day therapy, outreach, outpatients and group sessions) • Lymphoedema • Bereavement, family support and counselling • Hospice at Home (In South Sefton only) Woodlands Hospice has reviewed the data available to them on the quality of care in each of these services. The income generated by the NHS services reviewed in 2013/14 represents 73% of the total income required to provide services which were delivered by Woodlands Hospice Charitable Trust in the reporting period. What this means: Overall, 73% of our total costs are currently funded by the NHS. The majority of NHS funding is related to the In-patient Unit which transferred over from the NHS in 2009 with a three year funding arrangement which has been rolled over annually since. We rely on Fundraising activities to generate the remainder of our income. 2.2 Participation in clinical audits During 2013/14, Woodlands Hospice was not eligible to participate in any of the national clinical audits or national confidential enquiries. This is because none of the audits or enquiries related to palliative care. The Hospice clinical audit programme for 2013/14 included audits of Medicines Management, Controlled Drugs, Infection Control, and Care Plans. A retrospective audit of Hospice inpatient ‘length of stay’ was also carried out. We have continued to use the Help the Hospices Audit Tools where possible; these are particularly relevant to the requirements of hospices and enables performance to be benchmarked against other hospices. In addition to its own clinical audit programme, Woodlands Hospice also participates in a number of Regional and Supra-regional audits as part of the Merseyside and 17 Cheshire Palliative Care Network Audit Group. Results of some of the audits undertaken and/or presented in 2013/14 can be seen under ‘Clinical Audit’ in Section 3. 2.3. Research During 2013/14, no patients receiving NHS services provided by Woodlands Hospice were recruited to participate in research approved by a research ethics committee. The Hospice has a policy to cover inclusion in research but, during this period, there was no appropriate national, ethically approved research study in palliative care in which we could participate. However, Woodlands senior medical staff are involved in research into decision making for patients with advanced head and neck cancer jointly with University Hospital Aintree, and into the benefits of interventional pain management for cancer pain. Senior medical staff are also leading on general development of research opportunities in palliative care in the region on behalf of the Cheshire & Mersey EOL care network. Staff from the Woodlands therapy team are conducting research into the rehabilitation of lung cancer patients jointly with University Hospital Aintree and the Liverpool Heart and Chest Hospital. In addition, staff have contributed to a number of publications in peer reviewed scientific journals and participate in a regular weekly joint journal club. We have also hosted an academic clinical fellow from the Merseyside palliative care rotation. 2.4 Quality Improvement and Innovation goals agreed with our commissioners. Woodlands Hospice’s income in 2013-14 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework because it is a third sector organisation; it was therefore not eligible to take part (Mandatory statement). 2.5 What others say about us Woodlands Hospice is required to register with the Care Quality Commission and its current registration is for the following regulated activities: • Diagnostic and Screening procedures • Treatment of disease, disorder or injury Woodlands Hospice is subject to periodic reviews by the Care Quality Commission. During August 2013, the Care Quality Commission carried out an unannounced inspection and found that the Hospice was fully compliant with the following Standards:18 Outcome 2: Consent to care and treatment Before people received care or treatment they were asked for their consent and the provider acted in accordance with their wishes. “The people we spoke with told us that they were fully informed about the care they received and that everything had been fully discussed before any procedure had been carried out.” Outcome 4: Care and welfare of people who use services - People should get safe and appropriate care that meets their needs and supports their rights. “Care and treatment was delivered in a way that intended to ensure people’s safety and welfare. Staff demonstrated a strong understanding of people’s needs and how to support them. We found that each person using the service had a care file which contained a set of care plans appropriate to their care and support needs.” Outcome 8: Cleanliness and infection control People should be cared for in a clean environment and protected from the risk of infection. “During our visit we undertook a tour of the unit and inspected a number of bedrooms, bathrooms and communal areas. We found them to be clean and tidy. People we spoke with gave us very positive feedback about the cleanliness of Woodlands. Staff told us that they received regular training in infection prevention and control including training in hand hygiene. Outcome 12: Requirements relating to workers People should be cared for by staff who are properly qualified and able to do their job “Appropriate checks were undertaken before staff began work. People told us that they felt safe and confident in the care they received from the provider. Staff we spoke with understood the care and treatment people needed and were passionate about the support they offered people at Woodlands. 19 Outcome 21: Records People’s personal records, including medical records, should be accurate and kept safe and confidential “People’s personal records including medical records were fit for purpose. Staff were aware of the need to ensure clear records were maintained and stored safely and securely. We saw a leaflet that was provided for people who used the service to explain what information was kept on a person and how it was used. Environmental Health Once again, the high standards of kitchen hygiene and catering have been maintained and an Environmental Health inspection undertaken in January 2014 awarded the Hospice a 5 star rating. Fire Safety The Hospice Fire Safety policy and training model was revised, approved and implemented during 2013/14, taking into account recommendations following a Fire Safety Inspection carried out in January 2013. A routine review of Fire Safety in February 2014 (undertaken by the Fire Brigade) identified no areas of concern. 2.6 Data Quality Woodlands Hospice did not submit records during 2013/14 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are used to provide nonclinical and administrative data for analysis by a range of organisations including local commissioners. Why is this? This is because Woodlands Hospice is not eligible to participate in this scheme. However, in the absence of this we audit our clinical records regularly and submit annually National Minimum Dataset reports to ensure our data is as accurate as possible. Woodlands Hospice score for Information Quality and Records Management was not assessed in 2013/14 using the Information Governance Toolkit but work commenced on compliance with the toolkit in preparation for signing-up to an NHS Standard Contract for all Hospice at Home services commencing in April 2014. Our aim is to achieve level 2 for 2014/15. 20 SECTION 3 – Quality overview Review of quality performance Woodlands Hospice is committed to continuous quality improvement. This section provides: • Data and information about the number of patients who use our services • How we monitor the quality of care we provide • What patients and families say about us • What our regulators say about us Monitoring activity The Hospice submits information annually to the The National Council for Palliative Care (NCPC) Minimum Data Sets which is the only information collected nationally on hospice activity. Inpatient Unit In the Inpatient Unit, where there are 15 beds, the average length of stay in 2013/14 was 14.3 days which is slightly higher than last year. The multi professional team are proactive with discharge planning and supporting patients to achieve their preferred place of care. A retrospective audit of patients with prolonged length of stay identified that these patients have complex symptom control issues at the end of life and require ongoing specialist palliative inpatient care. The unit admits patients 7 days per week and has a consistently high occupancy level of 86%. During the seven months from September 2013 to March 2014, 198 bed days were lost whilst building work was undertaken. This affected the total number of patients that could be admitted. Inpatient Unit (15 beds) 2012-2013 2013-2014 %New patients 87.7% 86.3% Total number of patients 284 % occupancy 85.9% % Patients returning home 55% Average length of stay 13.3 days 21 220 86% 63% 14.3 days Well-being & Support Centre (incorporating Day Therapy, Outreach, and Outpatients) A redesign of services within the Well-being and Support Centre has been undertaken. A combination of multi-professional assessment days, outreach therapies, group programmes and nurse/therapy led clinics are now available which enables more focus on individualised care planning. Feedback from the recent patient survey has been very positive about these services. Day Therapy Following the reconfiguration of services, the data indicates a reduction in day therapy activity from 2012/13 to 2013/14. This is due to day therapy services (now referred to as multi-professional assessment days) being reduced to two days a week with just 15 places on each day (was previously 100 places per week spread across four days). New services have since been introduced to provide attendance for patients on the remaining days. The activity from these services is described by the outpatient services data, where an increase is seen. Day Therapy (30 places week from May 2013) 2012-2013 2013-2014 % New patients 70.2% 79.6% Total number of patients % Places used (patient attendances) 329 50.3% Average length of stay 158 days 22 142 60.3% 158.5 days Community Outreach Service There is a Community Outreach service providing Occupational Therapy, Physiotherapy and Complementary Therapy interventions in the patient’s home, for those patients who are unable to travel to the Hospice. The data from these services demonstrates an increase of 9.6% in the number of patients enabled to die at home (bringing the total percentage closer to the findings of the British Social Attitudes survey, published May 2013, which identified that 67% of patients would prefer to die at home). The percentage of non-cancer patients receiving services has also increased. Community Outreach Services 2012-2013 2013-2014 % New patients 86.3% 92% % patients with non-cancer 13.2% Total number of patients 227 % patients who died at home 53.6% Outpatient Services 200 63.2% 14.5% The increase in activity from 2012/13 to 2013/14 is due to the introduction of new outpatient services (identified from a review of all day therapy services) which include individual Outpatient Clinics and therapy groups such as the Breathlessness Group and the Supportive Living Programme. These new services replace two of the previous day therapy days and are being actively promoted to increase attendance. Outpatient services 2012-2013 2013-2014 % new patients 28.9% 58.2% Number of patients 415 Number of clinics 148 % non-cancer patients 6.1% Number of outpatient attendances 1082 Bereavement Services 502 748 2066 5.6% Individual support is offered to bereaved people by members of the clinical team who have been key workers to the families. In addition a Bereavement Group is held monthly at the Hospice and a ‘Celebration of Life’ service is held annually. Bereavement services saw a 50% increase in the total number of users supported in 2013/14, compared to the previous year. The percentage of new users of the service increased by 18.5% and the total number of contacts increased by 74. Bereavement services 2012-2013 2013-2014 % new service users 62.3% 80.8% Total number of users supported 101 Total contacts 565 23 151 639 Hospice at Home The Hospice at Home service is currently provided only in South Sefton, offering escorted discharge home from hospital or hospice, a 24 hour sitting service and consultant led crisis intervention/prevention. The number of ‘sits’ provided to patients by the Hospice at Home service increased by almost a third in 2013/14, taking the total number from 650 to 863. The percentage of patients enabled to die in their own home (or place of residence) increased from 76.1% to 84.6% and the number of patients needing to be transferred to hospital to die reduced from 7.5% in 2012/13 to just 2.1% in 2013/14. Hospice at Home 2012-2013 2013-2014 Crisis intervention home visits 53 52 Total number of patients 138 Accompanied transfer home (from Hospice or Hospital) 15 139 10 Sitting service 85 patients 91 patients % Home deaths (place of residence) 76.1% 84.6% (650 sits) % Hospital deaths 7.5% 24 (863 sits) 2.1% Quality Markers we have chosen to measure In addition to the quality measures used to provide information to the national palliative care minimum dataset, we have chosen to measure our performance against the following: Patient Safety Incidents INDICATOR 2012-2013 Number of slips, trips and falls 43 Number of serious patient safety incidents Number of patients who experienced a fracture or other serious injury as a result of a fall 2013-2014 2 0 1 0 43 The Multi-professional Falls Group continues to meet on a regular basis to review the incidence of slips, trips and falls across all services and further develop local strategies to reduce the incidence of falls. Whilst the number of falls in this period is the same as the previous year, the number of serious patient safety incidents or injury as a result of a fall reduced to zero. A falls risk assessment is completed for all in-patients, those attending the Well-being and Support Centre and Hospice at Home patients. Where risk of falls is identified, action is taken to minimise that risk. A falls prevention system in use on the Inpatient Unit identified that the bed pads attached to the alarm had to be placed on top of the mattress and were not suitable for patients who are at risk of developing a pressure sore. Alternative bed pads were sourced and are now in use for patients at risk of developing pressure sores. Staff training in the use of this equipment is ongoing to ensure competence and maintain patient safety. Infection Prevention and Control INDICATOR Number of patients admitted with MRSA bacteraemia Number of patients infected with MRSA bacteraemia during admission Number of patients admitted with clostridium difficile Number of in patients who contracted clostridium difficile 2012-2013 0 0 1 0 2013-2014 0 0 0 2* *not health care acquired 25 Excellent standards of infection prevention and control have been achieved again this year with no incidents of health care acquired infections. The two cases of clostridium difficile were not related and the infection control team completed a root cause analysis in both cases which confirmed that the incidents were not health care acquired and that patient care was in line with national guidance; this was confirmed by an independent review arranged by Woodlands. The Needle safe European Directive came into force in May 2013 in an attempt to reduce the incidence and risk of infection for health care workers from needle stick injuries. Woodlands Hospice successfully achieved the recommendations of this directive and had sourced and implemented needle safe alternatives for all procedures involving needles prior to the implementation date. Clinical Audit (see also section 2.2, Participation in Clinical Audit) The Hospice uses clinical audit to monitor quality and support service improvement. Where an audit identifies room for improvement, an action plan is developed, reviewed, and monitored to completion. In addition to internal audit, the Hospice participates in Regional and Supra-regional audits as part of the Merseyside and Cheshire Palliative Care Network Audit Group. The Hospice Board of Trustees support Quality Assurance and adherence to the Care Quality Commission’s Essential Standards of Quality and Safety by undertaking a rolling programme of unannounced Trustee Visits. During these visits, Trustees talk to patients, visitors, volunteers and staff, asking them about their experiences and observing practice. Trustees also look at policies, information and supporting documentation to enable them to produce a report of their findings with recommendations for improvement where necessary. An action plan is then developed from the Trustee recommendations and is again, monitored to completion. Patient and family feedback is also gathered through surveys, comments forms, the Patient Services Manager’s ward round and informal visits by the Chief Executive. These processes support the Hospice’s Quality Assurance framework. 26 The following table shows a sample of the audits and Trustee Visits undertaken during 2013/14 Patient Safety Audits Findings and Actions to be taken to improve compliance/practice Infection Control Safe handling & disposal of departmental waste The audit identified that all staff are aware of waste segregation procedures. However, a poster identifying correct waste segregation was not displayed at the time of the audit. This has since been rectified. Infection Control Inpatient environmental audit The audit identified that not all items in the clinical room December were stored above floor level. Storage was reorganised 2013 to address this. Some chairs were not covered with an impermeable material. A planned replacement with appropriate covers was completed. Medicines Management Selfadministration of medicines The audit identified overall good compliance with policy. However, the following improvements were identified and implemented: • Self-administration status was not identified on all drug cards. A new drug card to be introduced with a specific space to record administration status. • Policy and documentation needed update to support self-administration and storage of medicines by patients. January 2014 Safety Alerts Audit of receipt & handling of Safety Alerts A revised policy and procedure for receiving & handling Safety Alerts was introduced in January 2014. Compliance with the new procedure was audited in January and February 2014. The January audit identified that some elements of the procedure were not fully understood by staff, resulting in some uncertainty between clinical and non-clinical alerts. The procedure was reiterated to teams and a re-audit in February 2014 identified that adherence to the procedure had improved and documentation was accurate. February 2014 Infection Control Management of the ‘Dirty Utility’ room An audit carried out in May 2013 identified some inappropriate items being stored in the dirty utility room. The items were removed; staff were reminded of their responsibility to keep general areas clean; a regular inspection was introduced with a daily cleaning schedule. Re-audit in June confirmed that the room was free from inappropriate items. 27 Action plan completed June 2013 October 2013 Patient Safety Audits Findings and Actions to be taken to improve compliance/practice Documentation Care Plans An audit in March 2014 identified that the standards of completing Care Plans had slipped slightly from previous months and highlighted some incomplete entries. The Acting Ward Manager shared the results with all ward staff and reiterated the importance of completing Care Plans at handover & ward meetings. A re-audit in April showed an improvement. Medicines Management Administration of Medicines Regional Audits Pathological Fractures Psychological Support Services The audit was carried out following the introduction of a new medicines administration chart. The results of the audit were generally good although the following improvements were identified and implemented: • Improvements to be made to the recording of allergy and self-administration status on cards. • Improving legibility when a non-administration code is entered. • Adhere to the ‘new’ administration codes (some staff were still using the ‘old’ codes from the previous charts). Findings and Actions to be taken to improve compliance/practice This audit demonstrated a wide variation in referral and management of pathological fractures. New regional guidelines have been developed. These guidelines incorporated scoring systems to be used to help predict the risk of fracture and these have been laminated and placed in clinical areas. It also highlighted the consideration that should be given to the use of newer drugs such as Denosumab in these patients. This audit reviewed our provision of and access to Level 3 and 4 psychological support services. This audit highlighted the requirements for both adult and child support services. As a result of the audit we are reviewing our referral guidance and also the training available for psychological assessment and management strategies. 28 Action plan completed March 2014 April 2014 Action plan completed February 2014 In progress Trustee Visits May 2013: Outcome 7. Safeguarding people who use the services from abuse General Comments: The Trustee was very impressed with the Safeguarding Lead and her knowledge and experience of standards and practice. The Trustee was also happy that staff would be able to recognise signs of abuse and how to escalate a problem if it was necessary. September 2013 Outcome 9. Management of medicines General Comments: “I found the Management of Medicines on the In-patient unit robust, and all staff interviewed were well versed on policies and procedures”. January 2014: Outcome 12 Requirements relating to Workers. General Comments: “There is lots of enthusiasm within the Hospice and the ‘new build’ will bring people together. I was very impressed with the discussions I had about PDRs and 6-weekly 1:1s. The patients I met spoke extremely positively about their experiences. The new Well-being & Support Centre Manager appears to be embracing the changes”. Findings and Actions to be taken to improve compliance/practice Progress to date • Line managers need to re-iterate safeguarding information a little after induction to ensure it is clear to all staff. Completed • Staff to be reminded of the ‘No Secrets’ document and where it can be located in the hospice. • Spot checks on Safeguarding to be incorporated into the Patient Service Manager’s ward round. Completed Completed No specific improvements were identified from this visit but the Trustee highlighted: • That she had seen (from audits) an improvement in competency with controlled drug documentation. • And that the input of the pharmacist (a clinical specialist in palliative care medicines) was valued by all staff and had improved efficiency. • Recruitment and induction documentation and filing to be brought up to date. Completed • Improve the management of the documentation included in the ‘practicing privileges’ folder, ensuring that contracts are signed and copies of medical indemnity are taken and filed. Completed • Create a general induction checklist/record that new starters can sign, and which can be placed in their individual staff record. In progress • Improve the timeliness of staff contract development and signing so that a signed copy of an individual’s contract is available in their individual staff record within two months of starting. Completed 29 Trustee Visits March 2014: Outcome 2 Consent to Care & Treatment General Comment: “The hospice staff are very aware of the need for consent throughout their dealings with patients. I have no recommendations to make as the current system seems to be working well”. March 2014: Outcome 16 Assessing & monitoring the quality of service provision. General Comment: “All the staff I spoke to knew the importance of assessing and monitoring the quality of service provision. There were some excellent examples of good practice, e.g. the use of audit, KPIs and feedback.” Findings and Actions to be taken to improve compliance/practice • Training in ‘Consent’ to be introduced for all relevant staff and incorporated into relevant staff induction training. • Cascade training plan for Mental Capacity Act (MCA) and Deprivation of Safeguarding Liberties (DoLS) to be put in place for all relevant staff once training of senior staff is complete. Progress to date Training in Consent, MCA and DoLS is now in place for all clinical staff across the Hospice. Expected date of completion June 2014 • Audit reports need to be improved to demonstrate that actions are followed – this information needs to be shared across the organisation. In progress • Improve the reporting of near-miss incidents across the organisation. In progress • A ‘Quality & Improvement Brief’ should be developed to share results/action plans/audits etc with all staff. Completed • Press on with plans to deliver training on complaints handling to all staff. In progress Complaints The Hospice receives very positive feedback from the people who use our services, sometimes verbal but often in the form of letters and thank you cards. This type of feedback is most welcome and we make every effort to share it with our staff and volunteers. We actively encourage all types of comments and feedback, including complaints, so that we learn from these to make sure that our standards continually improve and mistakes are rectified. We take all complaints very seriously and during 2013/14 we updated our policy for handling complaints, as well as our ‘Comments, Compliments and Complaints’ form, to help us to improve the way complaints are dealt with consistently across the organisation. Training in the new complaints procedure is planned for all staff and volunteers during May 2014. 30 Number of complaints Written Complaints 2011-2012 2012-2013 2013-2014 Verbal Complaints 2011-2012 2012-2013 2013-2014 Total number received Total number received 2 4 11 11 6 9 There was an overall small increase in the number of written complaints received during 2013/14 compared to the two previous years, whilst verbal complaints fell marginally. The trends and themes of these complaints could broadly be divided into three categories. Trends/themes of complaints Theme Examples of resulting Numbers Actions/Improvements (NB - Some complaints raised more than one issue) • Following a problem which arose from the lack of communication within the team of telephone discussions with a carer, the process for documenting communication with 3rd party contacts was reviewed and revised. All staff are now working to the new process. Communication 7 Attitude 6 Processes and Procedures 11 • Following a complaint from a carer who was approached regarding fundraising whilst supporting a patient attending for an appointment, the sale of raffle tickets and other requests for donations are now restricted to the main reception (i.e. no longer to take place in clinical waiting areas). • During January 2014 when the Hospice was undergoing extensive building works, an increase in fire alarm activations caused a disturbance to local residents. Our on site builders took steps to ensure that alarms could not be accidentally triggered and no further accidental alarms were sounded. The Hospice generator testing process was also reviewed. All written complaints are acknowledged in writing by a member of the Senior Management Team within one working day of receipt. A full investigation is undertaken by the appropriate Senior Manager and resulting actions are monitored to completion. Verbal complaints are handled with the same level of importance as written complaints. An investigation is undertaken by the Manager of the service involved and the resulting outcome is recorded. An anonymised report of all complaints is reviewed regularly by the Board of Trustees and relevant committees. Learning from the management and handling of complaints is shared across the Hospice at team meetings. 31 3.1 What our patients and families say about the organisation The Hospice welcomes all comments and feedback from patients, carers and families and there are many ways in which people can send these to us. We have an organisational-wide ‘Comments, Compliments and Complaints’ form, which is given to all patients in information packs and is also available on reception for visitors, carers and family members to complete; traditionally we have received letters and thank-you cards from patients, carers and families; and of course, people have always been welcome to speak to us in person about their experiences. More recently however, as people become more familiar with social networking and other forms of communication, we are starting to receive comments by general email, through ‘just giving’ pages, via Facebook pages, and even through ‘Twitter’. The following are a selection of comments we have received over the past year, through a variety of methods. “To all, not forgetting “Thanks for volunteers. As a family, thank you all the care given to my from the bottom of our hearts for looking dad in his final days and after our mum. You looked after her so for the letters and leaflets well, you are special people.” you sent, helping us “Since my stay at through a very difficult period.” Woodlands I have appreciated everything they have done for me. I feel healthier because of good nursing, medication, food, doctors, “Thank you for all your care physio, hygiene, and pleasant surroundings. I am grateful to Woodlands.” and love you gave her whilst “I’m running the St Helens 10k she was at the hospice. for Woodlands because they do great Your support made a work and deserve support; they do a great difficult time much job caring for those in need.” easier, we will never forget everything you “I am so grateful for did for us all the skill, care and real belief in caring as a family.” for the person, not the disease, which is being shown here all the time – in what you do as individuals and as a “At Woodlands team. It’s easy to be cynical, and I’m as guilty of that as the next person, but being here has changed that. there are no Thank you for reminding me that there is so problems only much good in the world.” solutions" 32 “I had a great nurse. “We would like I must say she does an amazing job to thank you all very, very and gave me confidence. Thank you much for all you did for Mum to the Woodlands for having such over the years. It wasn’t just the lovely dedicated staff.” medical side of things, she loved the social side, making things, “As a family we talking, having her hair done to are very grateful for the name but a few. Thank you for compassionate care all your staff showed to our father. It was our wish all your friendship and support, not only to Mum but to us that dad remain at home and with as a family.” your help this was made possible, something we will always “Beautiful “Thank be very grateful for.” people and a you for the beautiful place; wonderful Woodlands looked “Knowing patients care, and carers have extra support after my sister with kindness, has given them the confidence to tender care and compassion.” attention and time choose to go home.” given to my partner Discharge Planner and me. Woodlands “The service has “They is in a league of its provided benefit to a great extent always treat own. Please let all to deal with emotional issues and us with your staff and practical issues for carers and utmost dignity volunteers know how patients.” GP and respect. very much we valued We are all as their hard work, “We particularly value a family so friendliness and the accompanied transfer proud and dedication.” home service. All of our patients/ pleased to relatives benefited from this have met such “I think the fantastic service.” lovely District Nurse service is an integral people.” part of the patient’s package “I can think Carer of care and proved a great of a number of cases source of psychological where patients would have been admitted to hospital if rapid intervention support for both the patient and family.” would not have been made”. Community Specialist Nurse Specialist Palliative Care Nurse 33 3.2 What our regulators say Woodlands Hospice is registered with the Care Quality Commission and as such is subject to regular review in the form of unannounced inspections. Please see section 2.5 for details of our most recent review (August 2013). 3.3 The Board of Trustees’ commitment to quality The Board of Trustees of Woodlands Hospice Charitable Trust is fully committed to prioritising the quality of patient and family care. All Trustees participate in the programme of unannounced Trustee Visits giving them an opportunity to familiarise themselves first hand with the workings of the Hospice and to hear the views of patients, families, staff and volunteers. The organisation has a robust Quality Assurance framework with Trustees taking an active role in ensuring that the Hospice provides the best possible evidence based care and fulfils its Statement of Purpose. 3.4 Supporting Statements Healthwatch Unfortunately, Healthwatch Sefton were unable to provide a commentary on this occasion. However they expressed their hope to work in partnership with us in the coming year. Comments from Healthwatch Liverpool and Healthwatch Knowsley are awaited. Clinical Commissioning Groups Woodlands Hospice has worked closely with South Sefton CCG, Liverpool CCG, and Knowsley CCG throughout the year and would anticipate supporting comments for the next Quality Account. 34 35 Woodlands Hospice Charitable Trust UHA Campus, Longmoor Lane, Liverpool L9 7LA Tel: 0151 529 2299 Charity No. 1048934 www.woodlandshospice.org