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
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Woodlands Hospice Charitable Trust
UHA Campus, Longmoor Lane,
Liverpool L9 7LA
Tel: 0151 529 2299
Charity No. 1048934
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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
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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
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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
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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
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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.
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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
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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.
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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.
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• 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’.
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• 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.
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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.
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• 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.
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• 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).
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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.
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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
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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.
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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