quality account 2011-12 - nhs · quality account 2011 / /12 1 part one our mission st. gemma’s...

St. Gemma’s Hospice, Leeds

Quality Account2011 / 12

“ Words will never express my feelings for the care and concern shown to my wife, myself and family at this incredibly difficult time.”

CONTENTS

PART ONE

Our Mission, Vision and Values ...................................................................................................... 1

Statement on Quality from the Chief Executive............................................................................... 2

PART TWO

Priorities for Improvement 2012/2013 ............................................................................................ 3

Statements Relating to the Quality of the Services Provided .......................................................... 6

Review of Services ........................................................................................................................ 7

Statements from the Care Quality Commission (CQC) ................................................................. 10

PART THREE

Priorities for Improvement 2011 / 2012 ....................................................................................... 11

Review of Quality Performance ................................................................................................... 14

Patient and Family Experience of the Hospice.............................................................................. 16

Staff Experience of Working at the Hospice ................................................................................. 18

PART FOUR

Statements from the NHS Airedale, Bradford and Leeds, ............................................................ 19Leeds LINk and Leeds Overview and Scrutiny Committee

References, Glossary and Further Information ............................................................................. 21

Quality Account 2011 / /12 1

PART ONE

Our Mission

St. Gemma’s provides compassionate and skilled specialist palliative care of the highest quality, both in the Hospice and in the community. We recognise each person’s need for respect, dignity and independence as we care for adult patients, from all backgrounds, with active, progressive, advanced illnesses, and provide continuing support for their families.

Our Vision

The vision of the Hospice is to promote life and enhance its quality within a welcoming, caring and safe environment. We work in co-operation with service users and colleagues to promote and influence high quality specialist palliative care locally, nationally and internationally. By contributing to research, sharing knowledge and good practice our aim is to improve patient care in all settings.

Our Values

We strive to

Create

• an ethos and environment which is inclusive, welcoming, supportive and respectful of all, where hospitality and compassion are hallmarks of care

Respect

• each person’s life, their intrinsic value, privacy, dignity, culture, autonomy, faith and beliefs

• all colleagues, internal and external as we work together to enhance the service

Meet

• the physical, emotional, spiritual and social needs of patients and families by working in partnership with them

• the patient and families need for regular communication and information

Support

• patients in making informed choices and decisions about their care especially at the end of life

• families having their needs assessed

• families including children, to access a high quality bereavement service

• patients and their families using a range of services that are free to patients, through the efficient use of income

Promote

• rehabilitation and independence using multi-professional team skills and resources

• continuing education and research

• continuing learning and development for employees and volunteers

• audit and quality assurance activities

• involvement of users at all levels of our service

• standards of good practice and accountability within professional codes of conduct, Hospice policies and external audit

2 Quality Account 2011 / 12

Statement on Quality from the Chief Executive

I am pleased to present St. Gemma’s Quality Account for 2011/12. In this our second Quality Account we report to the public on the quality improvements we have achieved in 2011/12 and set out what improvements we plan to deliver for 2012/13.

As I have worked with staff and volunteers over the past year it is evident the Hospice has made excellent progress against the priorities identified in last year’s account. This was endorsed by an unannounced inspection by the Care Quality Commission in November 2011 ; the Inspector agreed we were meeting all essential standards for quality and safety.

St. Gemma’s works closely with other providers and commissioners across the city and has contributed to the Palliative and End of Life Care Strategy that was launched earlier this year. Further detail of our progress against last year’s priorities is outlined in part three of the report. I have provided a brief summary :

Infection prevention and controlWe have reviewed and implemented updated training for all our staff, including diploma level training for two of our nurses. We have updated all our infection control policies and audits of infection control in practice show high levels of compliance. The Care Quality Commission reported the Hospice as fully compliant with infection control requirements in November 2011.

The St Gemma’s Academic Unit of Palliative Care This has been established in partnership with the University of Leeds. Led by Professor Mike Bennett, the Academic Unit brings together clinical research, clinical audit and palliative care learning and teaching. This brings quality of patient care to the forefront, integrating patient care with expert theoretical knowledge. Professor Bennett has already secured a major national research grant to develop and implement interventions for improving the management of pain for cancer patients.

The Day Hospice and community teams These are now merged, with increases in our medical and nursing staffing levels for both teams to allow clearer leadership, more flexible working across the teams and new models of care for patients, all of which are directly aimed at improving the quality of care for patients.

The Hospice will continue to build upon and monitor these improvements and we have identified four new priorities for 2012/13 as outlined in more detail in part two of this report. The priorities are to :

• increase the involvement of patients and their families in planning their care and recording their wishes• improve the ways in which we measure clinical outcomes and obtain effective feedback from patients and their families.• develop and begin the implementation of a new strategy for volunteers, such a vital resource for our Hospice.• improve transport to and from our Day Hospice for patients.

The last of these priorities – improving transport to and from our Day Hospice for patients – was a priority identified by our patients themselves.

The forthcoming year is likely to be challenging for the Hospice as with all charities in the current economic climate. I am confident that St. Gemma’s will continue, through astute financial management, to be a leading provider of high quality palliative and end of life care, with patients and their families being at the heart of our service.

This year’s account has been facilitated by our Clinical Audit Facilitator, working with patients, families and clinical staff across all of our services. The Hospice Leadership Team has been closely involved in setting our priorities for quality improvement and in delivering the improvement on the ground. The Board of Trustees has endorsed our Quality Account and I am able to confirm that the information contained in this document is, to the best of my knowledge, accurate.

Kerry Jackson Chief Executive


PART TWO

Priorities for Improvement 1st April 2012 - 31st March 2013

At St. Gemma’s we continually review our services and seek to improve and develop them. The Hospice has a five year strategy, developed in consultation with patients, public and staff which is supported by annual business plans. The strategy and plans outline our future vision and objectives and set out how we will achieve them. Reviewing service priorities and ensuring we continue to meet patient and carer needs at the end of life is a continuous process.

Clinical and support teams are fundamental to the delivery of the strategy and two way communication between all teams and the Hospice Leadership Team, Board of Trustees and the Chief Executive ensures delivery is monitored through mechanisms such as audit and project reports, activity data and feedback obtained through patient and family forums. Engagement with patients and families takes place through their respective forums which meet three times a year, in addition to continuous monitoring of levels of satisfaction via comments, compliments and complaints, surveys and informal feedback.

Priority 1 – Patient SafetyEnhancing patients’ and families’ involvement in discussions about care at end of life

It is essential that all patients and, with consent, their family, have the opportunity to have discussion about their care and decision making towards the end of life. This is often referred to as “advance care planning”. This will ensure that patients’ wishes are known, respected and communicated to those who need to know. Although we have made considerable progress, the Hospice will continue to review the processes for achieving effective advance care planning for our patients.

We will ensure :

• information is available to all patients (verbal and written)

• patients are supported with understanding information and making decisions

• appropriate documentation is in place, for example the electronic patient record and discharge letter

• patient information is updated and communicated to relevant members of the Hospice team

• communication takes place with members of the wider health and social care teams that support the patient

• the Hospice remains part of the team developing the Electronic Palliative Care Co-ordination System (EPaCCS) which supports this essential communication

• Hospice staff are trained in both communication and documentation requirements

Demonstrating improvements will be achieved by :

• audit of the assessment pathway to review whether all appropriate documentation is being completed

◊ Target 2012/13 – 80% of patients will have a record in their clinical notes referring to an advance care planning discussion

◊ Target 2012/13 – 100% of patients who have expressed the wish not to be resuscitated will have a Yorkshire and Humber Regional Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form in place

◊ Target 2012/13 – 80% of patients will have their preferred place of care and preferred place of death recorded

◊ Target 2012/13 – Clinical Nurse Specialists will support 80% of Gold Standards Framework meetings and utilise EPaCCS data

• review of training records

◊ Target 2012/13 – all registered clinical staff will have received advance care planning training

• obtaining patient feedback

◊ Advance care planning will be considered as part of the patient feedback processes

• case reviews of patients who have made statements about their wishes to ascertain to what extent their wishes are met will be undertaken


Priority 2 – Clinical Effectiveness

Measuring clinical outcomes and obtaining patient and carer feedback

The Hospice cares for over 2,500 patients and their families each year. To ensure the service is of high quality, it is monitored through clinical audits, staff surveys, internal and external inspections. The most influential evaluators of our service are the patients and their families.

Measuring feedback is essential in order for us to understand the needs of our users and their families. In palliative and end of life care this can be difficult as the patient is in the advanced stages of their illness and eliciting views can be seen as an additional burden (Hanson et al 2010, Dy et al 2008, Addington-Hall et al 2007). Understanding the patient and family experience of their care and their impressions of the environment help St. Gemma’s to target areas where improvements can be made. It will allow us to develop and implement appropriate patient reported outcome measures (PROMs) for the patients and families that are cared for by St. Gemma’s.

Our intention in the following year is twofold. We will :

• review the method by which we receive feedback from patients and families

• fully explore palliative care patient reported outcomes measures, identifying those which are most useful. We will introduce an appropriate PROM tool to the In-Patient Unit (IPU) and and further extend the use of the existing PROM – St. Christopher’s Hospice Index of Patient Priorities (SKIPP) in the Day Hospice and community

These will be achieved by :

• consultation with patients, families and staff to develop revised feedback mechanisms which can show validity and reliability

◊ Target 2012/13 – revised tool in use by March 2013 40% of IPU patients / 70% of Day Hospice patients / 40% of community patients using the tool

• developing ways whereby patients’ and families’ views can be elicited by those not directly involved in their care

◊ Target 2012/13 – trained non-clinical staff or e-technology in place

• analysis of the current SKIPP measure in the Day Hospice

◊ Target 2012/13 – analysis complete and results presented; action plans developed where required

• extending the use of SKIPP to patients in the community

◊ Target 2012/13 – SKIPP piloted in the community by December 2012 with 40% usage by end of March 2013


Priority 3 - Patient Experience

Enhancing the roles of clinical volunteers

We aim to provide care for more patients and their families within a challenging economic climate. Volunteers already work in the clinical environment and make an important contribution in supporting patients and families. Clinical volunteers currently undertake roles in the In-Patient Unit, Day Hospice, and complementary therapy team and in the bereavement and spiritual care services. The Hospice wishes to explore new roles for volunteers, to optimise the skills they offer, allowing in the long term, clinical teams to care for more patients and improve the patient experience. In order to do this we need to ensure :

• effective recruitment of volunteers, matching their skills and experience to the roles available

◊ Target 2012/13 – agreement of a volunteer strategy

◊ Target 2012/13 – revised role profile completed in Day Hospice and therapy teams

• support for the volunteer in his/her specific role

◊ Target 2012/13 – volunteer questionnaire developed

• development of training, both mandatory, such as confidentiality and infection control, and that required to support individual roles

◊ Target 2012/13 – clinical volunteers’ training fully explored

Priority 4 – Patient Experience

Transport to the Day Hospice

Ambulance transport for patients to attend the Day Hospice is an area of concern for our patients and staff. Most patients arrive at the Day Hospice using their personal transport or through the services of a volunteer driver provided by the Hospice. A small number of patients need to travel by ambulance. Ambulance transport arrangements can be unpredictable with delays for patients in getting to and from the Hospice, along with occasional protracted journeys, causing patients to be very tired. We intend to fully explore this issue by :

• gathering further evidence of the current service provision and obtaining verification of the number of patients who are affected

◊ Target 2012/13 – audit completed in Day Hospice on current service provision with action plans developed where indicated

• obtaining more detailed feedback from patients

◊ Target 2012/13 – obtain patient stories to gain their experiences of transport

As a result of the above an action plan for a long term solution will be developed.


Statements Relating to the Quality of the Services Provided

Statement of Assurance from the Board

The Board of Trustees is assured by the progress made in 2011/12 and supports the quality improvements planned for 2012/13. The Board is committed to the provision of high quality care for patients, families and staff across all Hospice services.

The Trustees have undertaken unannounced quality assurance visits of patient services. Trustees speak to patients and families with their consent and also with staff. The last visit took place 3rd February 2012 and the results were presented to the Clinical Governance Committee on 6th March 2012. The service scored 47/48 which was deemed as excellent. This has assisted Trustees in understanding the core business of the Hospice and has given the Board assurance of the quality of care provided.

The Board of Trustees will continue to monitor the progress against the priorities for quality improvement, as well as additional quality monitoring initiatives such as key performance indicators and the clinical risk register through the Clinical Governance Committee, a joint committee of Trustees and Clinical Directors.

Rosemary MacDonaldChairman of the Board of Trustees


Review of Services

In the following review there are statements (in italics) required by regulations which have to be included in the report. Explanations will be given where applicable.

During 2011/12 St. Gemma’s Hospice provided the following services

• In-Patient Unit which provides 24 hour care and support by a team of specialist staff

• Day Hospice which gives patients extra support to manage symptoms, gain confidence at home and maximise quality of life

• Out-Patients Service – an Out-Patient visit can provide a consultation with a Doctor, Advanced Nurse Practitioner or Therapist

• Community Services – the team consists of a Consultant in Palliative Medicine and Specialist Nurses providing support and advice in the home

• Therapies to support independence and promote comfort including :

◊ Physiotherapy

◊ Occupational therapy

◊ Dietetics

◊ Complementary therapy

• Social workers provide specialist support and counselling

• Bereavement services for adults and children

• Spiritual Care service supporting patients and their families

• Education and training for both Hospice and external staff

St. Gemma’s Hospice has reviewed all the data available to us on the quality of care in all of these services.

Financial Considerations

• The income generated by the NHS services reviewed in 2011/12 represents 31% of the total income generated from the provision of NHS services by St. Gemma’s Hospice for 2011/12

• St. Gemma’s receives an annual grant from NHS Leeds ; this is a fixed sum regardless of Hospice activity or the level of voluntary income

• 100% of the financial support we receive from the NHS is spent directly on patient services

• The running costs of St. Gemma’s are forecast to be £8.6 million in 2012/13. The majority of this has to be raised through donations, legacies, fundraising initiatives and our chain of charity shops

• St. Gemma’s Hospice’s income in 2011/12 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.


Participation in Clinical Audits

National

• During the period 2011/12 there were no national clinical audits or confidential enquiries relating to the services that St. Gemma’s provides.

Local

The Hospice is participating in the following regional audits :

• Yorkshire and Humber Do Not Attempt Cardiopulmonary Resuscitation Project

• Clinical Effectiveness of the Specialist Palliative Care Team (Yorkshire Sub-Regional Clinical Effectiveness Audit Group). This has now been completed.

• The Break Through cancer Pain (BTcP) Registry – a multi-centre programme to describe patients with breakthrough cancer pain for whom treatment with Abstral is started.

The Clinical Effectiveness Group at the Hospice oversees a programme of audit which includes the use of national audit tools and locally designed tools. There is a multidisciplinary approach to audit with dissemination of reports, monitoring of action plans and re-audit where necessary.

The reports of 30 local clinical audits have been reviewed in 2011/12 and the Hospice intends to take a number of actions as identified below to improve the quality of care.

Audit Result 2011 / 12 Result 2010 / 11 Actions

Controlled Drugs 90% 90% Immediate action was taken to ensure correct procedures were followed for amending corrections and ensuring signature sheets were updated

Accountable Officer 90% 84% Continued development of Standard Operating Procedures and clarification of information provided to patients about the safe storage and disposal of controlled drugs

Ensuring Safe Discharge Process (Discharge Pathway)

88% 52% Individualised feedback was given to staff where improvement was required

Infection Control – Hand Hygiene 91% N/A Immediate feedback was given to staff where improvement was required after low risk contact with patients

Management of General Medicines in Day Hospice 80% N/A Review of procedure for storage of patients’ own medicines and updating of Standard Operating Procedures

Positive Patient Identification 80% 100% Some inconsistencies with writing of personal identifiers on name bands according to a revised policy. Action taken to ensure compliance with policies

Documentation 84% 58% Action plans in place to address shortfalls in use of abbreviations, provision of specimen signature and amendments of alterations

Our focus is continually on the quality of life for patients, and their families, ensuring a positive experience of our care, and treating and caring for people in a safe environment. In our future audit programme we are committed to using the Quality Standards for End of Life Care from the National Institute for Health and Clinical Effectiveness (NICE) as the basis for audit criteria in order to assess and improve the quality of care we provide.

In addition to clinical audit a number of service evaluations have taken place. These include :

• Benefits of Clinical Supervision – a positive evaluation of members of the multi-disciplinary team receiving supervision

• Evaluation of the Experience of Clinical Supervisors – this report showed a positive experience for both supervisors and supervisees

• Secondment to the Community Team – demonstrating positive results from In-Patient Unit nurses who have had a range of relevant experiences by working with the community team

• Moving On and Beyond Programme in Day Hospice – the outcomes from this programme suggest that it has had a positive impact on patients up to four weeks after the end of the programme. A longer period of follow up may be possible following the next programme

• A Review of Patients attending Day Hospice – twenty patients were included and their symptoms and problems reviewed. Their length of attendance, the involvement of other professionals and the type of service offered were presented. This review contributes to understanding the service that is provided in order to meet the complex needs of patients.


Participation in Research

The number of patients receiving NHS services provided or subcontracted by St. Gemma’s in 2011/12 that were recruited to participate in research approved by a research ethics committee was nil.

This means that there have not been any national research projects in palliative care in which our patients were asked to participate.

The launch of the Academic Unit of Palliative Care led by Professor Mike Bennett will lead to increased involvement in regional, national and international research programmes.

The Hospice has provided data for the following ethically approved research project :

Diagnosis of depression in patients receiving specialist community palliative care : Does using a single screening question identify depression otherwise diagnosed by clinical interview ? This was completed in July 2011.


Statements from the Care Quality Commission (CQC)

St. Gemma’s 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

St. Gemma’s Hospice has the following conditions on registration :

• Only treat people over 18 years of age

• Only accommodate a maximum of 34 In-Patients

St Gemma’s Hospice is subject to periodic review by the Care Quality Commission. The last review was 14th November 2011.

The CQC’s assessment of the Hospice following that review was : St. Gemma’s Hospice, Leeds was meeting all essential standards for quality and safety.

“ During the visit we spoke to four people using the service. They told us they were very happy with the care and treatment they received at St. Gemma’s. They said they were involved in decisions about their care and treatment. People told us all the staff were kind and attentive, they said when they called for help staff responded quickly. People said the food was very good, they said the menu was varied and they were able to have their meals at times that suited them. They said the environment and facilities were good and it was always clean.” CQC inspection November 2011

Where the Care Quality Commission has carried out on-site inspections, these are available on our website.

The Care Quality Commission has not taken enforcement action against St. Gemma’s Hospice during 2011/12. St. Gemma’s Hospice has not participated in any special reviews or investigations by the Care Quality Commission during 2011/12

Data Quality

St. Gemma’s Hospice is not required to submit records during 2011/12 to the Secondary Uses service for inclusion in the Hospital Episode Statistics.

The Hospice deployed SystmOne in April 2010. This system supports an electronic patient record which can be shared with other external users of the system, for example, General Practitioners and District Nurses. The Hospice has internal arrangements to monitor the quality of the data. The system uses the NHS number as the key identifier for patient records.

Information Governance St. Gemma’s Hospice’s score for 2011/12 for Information Quality and Records Management, assessed using the Information Governance Toolkit version 9, is 67% which means the Hospice is fully compliant at level 2, the required national standard.

The Hospice, in improving patient safety, continues to develop electronic records and aims to be “paper lite” by 2013. The Hospice has shared records in accordance with the Data Protection Act and has in place Data Sharing Agreements. The Hospice continues to monitor handling of Personal Identifiable Data against the standards in the Information Governance Statement of Compliance.

St. Gemma’s Hospice was not subject to the Payment by Results clinical coding audit during 2011/12 by the Audit Commission.


PART THREE

Priorities for Improvement 1st April 2011 – 31st March 2012

Priority 1 – Patient SafetyInfection Control

This priority was identified because a high standard of infection prevention and control is a fundamental requirement in palliative and end of life care. Our internal infection control audit had demonstrated variable standards of practice and the Hospice has sought to achieve a consistently high standard across all clinical areas by implementing an action plan for improvement.

This priority has been achieved as follows :

• Our action plan has remained on schedule

• Training for all staff has been reviewed and updated

• Two Registered Nurses have undertaken diploma level study in infection control

• All infection control policies have now been reviewed and ratification is currently taking place

• Infection control re-audits achieved 90%

• The Care Quality Commission at the unannounced inspection in November 2011 saw the Hospice as fully compliant with infection control standards


Priority 2 – Clinical EffectivenessEstablishment of a Professorial Post and Academic Unit

This priority was identified as it was recognised that the key to making significant improvements in patient treatment is advancement in medical and other healthcare interventions. This can only be achieved by undertaking high calibre research in the field of palliative care and end of life care.

Progress in achieving this priority has been as follows :

• Professor Mike Bennett was appointed in July 2011. In addition to research and teaching activities, Professor Bennett is working as a Consultant in Palliative Medicine at the Hospice for two days a week involved in the direct care of patients and training of clinical staff

• The St. Gemma’s Academic Unit of Palliative Care (AUPC) has been launched in collaboration with the University of Leeds

• The National Institute for Health Research (NIHR) Comprehensive Local Research Network (CLRN) have agreed to support a research group in palliative care and chronic pain based at the AUPC to allow patients to take part in clinical studies. A Research Nurse has been appointed who will be based at the AUPC in the Hospice

• In addition, a £2 million NIHR programme grant has been awarded to Professor Bennett to develop and implement interventions for improving the management of cancer pain. This five year programme of work will be based at the AUPC and will lead to better quality of care for patients at the Hospice and surrounding areas

• Professor Bennett, in collaboration with Hospice staff, has clearly structured the AUPC into three areas – research, learning and teaching and clinical effectiveness. This structure encompasses all functions integral to the delivery of education both within and external to the Hospice as well as internal processes to achieve clinical effectiveness


Priority 3 - Patient ExperienceIntegration of Community and Day Services

This priority was identified in order to respond to changing patient need. In particular, the increase in non-cancer patient referrals, co-ordination of complex patient pathways and the need to improve continuity of patient care. There was also the requirement for a flexible workforce which is able to meet these changing needs.

Progress has been as follows :

• Clear Leadership

◊ The post of Community and Day Services Manager has been created to lead the integrated service. Together with the Consultant in Palliative Medicine for the service and the Advanced Nurse Practitioner, the Hospice Leadership Team provides clear vision and direction to the integrated service.

• Flexible workforce

◊ Knowledge and experience within all aspects of the service has been enhanced in a variety of ways. The Registered Nurses now work in both the Day Hospice and community service. This provides greater continuity of the service which is important for patients. Nurses also benefit from understanding the

patient’s needs at home and the co-ordination of care required between the service and the Primary Health Care Team. Nurses from the In-Patient Unit are now gaining experience in the integrated service. This has led to enhanced discharge planning and improved provision of out of hours advice to patients and professionals, as nurses now have a better understanding of community services across health and social care. Further expansion of nurse led Out-Patient clinics both in the Hospice and as satellites in community are now under development.

• New Models of Care in the Day Hospice

◊ One model focuses on psychosocial support for patients. Social Workers and Occupational Therapists have developed their roles to lead the changes required. They are supported by the Health Care Assistants who are also extending their skills. Benefits reported by patients include more acceptance of their diagnosis and situation, building more positive relationships with their families and gaining a sense of control and purpose.

◊ The second model focuses on problem solving and setting goals for those with physical and/or complex psychosocial symptoms. Patients have reported that the benefits include an increase in motivation and being more proactive in planning for the future.


Review of Hospice Data 2011 / 12 2010 / 2011

Overall Service – Patient Care

Total referrals (new and re-referrals) 2059 N/A

New referrals 956 1009

% cancer diagnosis (new referrals) 85% 89%

% non-cancer diagnosis (new referrals) 15% 11%

In-Patient Unit

Number of admissions 603 566

Average length of stay (days) 14.4 15.7

Day Hospice

Attendances 1657 1626

% places used 72% 68%

Community

Community Nurse Specialist and Consultant visits 3269 3140

Bereavement Support

Adult bereavement attendances 1458 1129

Young People’s Service attendances 683 N/A

Total bereavement attendances 2141 1129

Review of Quality Performance

The Hospice is committed to continuous quality improvement with leadership focused on professional development for the clinical teams, service improvements for the patients, planning, prioritising and ensuring best use of resources. The Hospice seeks to support patient choice and where possible deliver care where the patient wishes to be ; either in their own home with Specialist Nurse support or in the In-Patient Unit.

Reporting systems are in place to ensure robust governance arrangements. A Clinical Effectiveness Group oversees clinical audit and clinical developments. This group reports to the Hospice’s Clinical Governance Committee that in turn reports to the Board of Trustees.

Monitoring Activity – A Review of Hospice Data

Hospice data is submitted to NHS Airedale, Bradford and Leeds, on a quarterly basis.

The Hospice also submits annual information to the National Council for Palliative Care (NCPC) and Help the

Hospices. This enables comparisons with other specialist palliative care services locally and nationally.

Out of Hours Service

We offer patients a 24/7 admissions service to the In-Patient Unit. Patients, their families, and professionals can access specialist telephone advice through the In-Patient Unit out of hours. The nurse assesses each call and either gives advice or seeks support from the doctor on call. Monitoring this service continues in order to determine if there is a need to extend the face to face service to seven days a week. The community team service provides a face to face service 08.30 -17.00 Monday to Friday.

An evaluation of the out of hours service from November 2010 to October 2011 concluded that this remains a valuable service and the continued monitoring has helped to clarify the different aspects of the service. A number of recommendations are being addressed which include additional education for Hospice nurses receiving the calls, monitoring the quality of nursing and medical advice and use of the Consultant on call. The team will continue to explore the case for extending the community service to the weekend.


Key Quality Indicator 2011 / 12 2010 / 11

Number of patients on an End of Life Care Pathway 83% 78%

Complaints

Total number of clinical complaints 2 3

Number of complaints upheld 2 2 partial

Number of complaints not upheld 0 1

Patient Safety

Drug incidents / near misses (internal) 30 29

Number of slips, trips and falls 110 98

Number of patients developing pressure ulcers Grade 2 and above 37 25

Number of patients admitted with MRSA 1 (1 unknown if transferred

or acquired)

2

Number of patients infected with MRSA during admission 1 1

Number of patients admitted with clostridium difficile 3 ( unknown if transferred or acquired)

1

Number of in-patients who contracted clostridium difficile as above) 0

Key Quality Indicators

The Hospice encourages the reporting of drug incidents which may be near misses, internal incidents or external incidents, e.g. dispensing incidents or incidents witnessed in the community.

The majority of incidents in the Hospice are near misses ; this means there has been no patient harm and a potential incident has been avoided due to an error being identified before an incident occurred. Lessons from near misses are shared and practices modified as a result. Where Controlled Drugs are involved this is shared with the Local Intelligence Network – Controlled Drugs through occurrence reporting. All incidents are discussed by the Pharmacy Group and a report submitted to the Clinical Governance Committee.

Slip, trips and falls are monitored and each incident is reviewed to ensure all efforts have been made to minimise the risk of falls whilst maximising the patient’s level of independence. Trends have been monitored and steps taken to improve the patient environment to minimise the risk of falls. A reduction in falls has been noted in the latter

half of 2011/12. This may be the result of the introduction of a falls screening assessment for patients on admission. The tool has increased staff awareness and led to involving supportive services – physiotherapy, occupational therapy and pharmacy advice – sooner in the care pathway.

Predominantly patients admitted to the Hospice are at end stage disease, and are high risk of developing pressure ulcers. It is noted that the number of pressure sores recorded has increased ; this is due to improved data collection. All patients are now assessed within six hours of admission, this is audited, and a Watkinson score calculated, this is demonstrated through a continuous audit. Recording of pressure sores is done electronically on SystmOne (electronic patient records system) ; this has allowed effective monitoring and improved data collection. Pressure relieving equipment is provided where indicated and the care management plan reflects the high risk status and the nursing interventions required to minimise the risk of development of a sore.


The Patient and Family Experience of the Hospice

During 2011 Patient and Carers’ Satisfaction Questionnaires showed care to be either “excellent” or “very good”, however, the response rate was low. Response rates have been compared across the Yorkshire and Humber region where they range from less than 10% to 60% with the mode being less than 10%. The Hospice is keen to gain more informed feedback using validated and reliable tools. This will allow us to make a difference to the individual experience and also inform overall service development. Reviewing patient feedback processes is a quality improvement identified for 2012/13.

Feedback received in 2011/12.

In-Patient Unit

All patients felt that staff “always” or “most of the time” listened to them. They also felt that staff “always” made an effort to meet their individual needs and wishes.

All patients felt that they “always” or “most of the time” had the opportunity to make decisions about their care.

90% were satisfied with their involvement in the planning of their care.

90% of patients “always” or “most of the time” understood the explanations of their treatment.

Comments included :

Carer feedback In-Patient Unit

91% of carers were able to ask questions, raise concerns and were able to discuss how they were feeling.

91% of carers felt that they were fully included in the final days / hours of their relative’s life and were given the chance to discuss their understanding of what was happening.

Comments included :

“ Everyone working

here gives 100% at

all times. Excellent.”

“ I never expected to receive such wonderful care and personal attention. Your service is superb.”

“ Originally thought it was somewhere to come and die. Did not realise that pain management and rest and relaxation were

considered.”

“ We as a family were

given day to day

updates on her

treatment and care.”

“ Words will never adequately express my feelings for the care shown to my wife and family at this difficult time.”

“ The friendship and support provided by St Gemma’s staff was outstanding. The quality of care was just amazing and I cannot thank everyone enough. It is a shame that every person cannot

access this care in their final days.”


Day Hospice Patients

These patients have a regular opportunity to feedback to staff about their experience. Patients have also had the opportunity to speak to the Clinical Audit Facilitator who is independent of the Day Hospice team.

Patients enjoy all aspects of their day especially the good food, companionship, some activities which include Wi-Fit, quizzes, time spent in the garden and visits from outside speakers, for example, Leeds Museum. They feel well supported by all members of the multi-disciplinary team. Accessing a new prescription in a timely way and the good communication between the Day Hospice and GPs provides much reassurance for patients.

However, one area of concern voiced by a number of patients was the transport provided by the Yorkshire Ambulance Service. Unfortunately, the timing of journeys was often problematic causing some patients to be picked up too early or late. Likewise, for the return home, transport could be delayed leading to a long and tiring day. This also had an effect on carers and their ability to benefit from their respite time. The use of volunteer drivers was much appreciated. (Please see Priority 4, page 5 for further information about what the Hospice will do to try to resolve this problem).

Feedback from community patients is informal through thank you cards and letters; a structured approach to gaining community feedback is under development.

“ Takes the worries away.”

“ The whole

atmosphere

is good.”

“ It’s faultless

– has a nice

feeling.”

Bereavement Service Evaluation

An evaluation of the Bereavement Service took place in July 2011. The response rate was 33% and there was useful feedback :

• 63% felt that the Bereavement Worker had really listened to them

• 75% were able to say what was troubling them

• 63% felt that they were coping better following the period of support

There were also some individual comments – two clients would have preferred their support to have started earlier after their bereavement and there was some indication of mixed feelings about group sessions versus individual counselling.


The Staff Experience of Working at the Hospice

The Staff Survey took place in November 2011. The response rate was 54%. Although this is a lower response than our first staff survey of 2008 it presents a balanced view, being representative of staff regarding gender, length of service and area of work profiles. Overall, the results of the survey are positive

• 99% agree that the Hospice delivers a quality service to its users

• 94% consider the Hospice to be a good place to work

• 90% agreed they have job satisfaction

• 80% felt they knew “a lot” about Hospice values

The training to support managers to deliver effective appraisals, identified as a concern by the last survey which took place in 2008, has resulted in an increase in staff having annual appraisals from 71% to 82%. 60% of staff agreed that their appraisal was useful to them and 70% of managers felt competent to carry them out.

Within the current survey there were eighteen areas of strength identified. Two areas for improvement which have been identified for action are concerning workload and communication/staff engagement. The latter had previously been an area for improvement specifically

relating to overall Hospice communication. Concerns about communication are greater in specific work areas and so the survey has enabled the Hospice to identify those work areas / staff groups and plan how to better communicate with these areas in future. There is also an intention to review how the Staff Representative Forum operates and consider whether this is still an effective tool for staff communication / engagement.

Overall, staff feel satisfied that they work in a committed and supportive team.

80% of staff are satisfied with their work area and Hospice based staff benefit from an environment which is well maintained – a recent refurbishment of the catering facilities has provided a bright, welcoming and relaxing environment.

Staff turnover in 2011 was 9.6% (7% in 2010) and sickness absence is 3.2 % (3.9% in 2010).

Staff are supported by access to an Occupational Health Service, complementary therapy service and clinical supervision.

An evaluation of the implementation of clinical supervision conducted in October 2011 demonstrated benefits for clinical staff and in particular the nurses.


PART 4

Statement from Jo Coombs Director of Quality and Nursing NHS Airedale, Bradford and Leeds

NHS Leeds commissions palliative care services from St. Gemma’s Hospice and welcomes the opportunity to comment on this Quality Account.

We believe the account to be a fair reflection of the quality of services provided by St. Gemma’s Hospice. However, due to some reporting differences and timescales, we are unable to confirm the accuracy of the activity data published in the account.

We support the proposal to enhance patients and families involvement in discussions about care at the end of life, and we commend the specific standards that the Hospice aims to achieve.

Likewise, we also fully support the intention to introduce patient reported outcome measures, as increasingly commissioners will look to commissioning for outcomes rather than activity. Again, we are pleased to see specific measures and targets against which the Hospice intends to measure progress.

We are pleased to note the intent to enhance the roles of clinical volunteers and to support them through the provision of training and the development of a role profile. We are also supportive of the proposal to explore issues relating to ambulance transport.

With regards to quality performance over the past year, we are pleased to note the progress made with regards to infection control; however we believe that inclusion of the audit action plan and the related outcomes within the document would help to further inform service users of the intentions and associated progress, particularly in relation to the self-identified variable standards of practice mentioned.

We are impressed at the actions implemented and progress made in establishing a professorial post and academic unit. We believe that this outcome has major significance for palliative care services, and look forward to the enhanced outcomes that this may produce. We were pleased to note the work that had taken place with regard to the integration of community and day services.

We are also pleased to note the comparison of data that shows progress or otherwise with regards to complaints and aspects of patient safety. We note the increased number of slips, trips and falls and number of patients developing pressure ulcers grade 2 and above against last year’s figures, and recognise that the increased numbers may indeed be due to improved reporting and data collection. However, we think that the hospice should seek to satisfy itself and commissioners via monitoring meetings that this is the case.

We commend the inclusion of patient and staff feedback within the account. Some further examples of remedial actions taken where there were less positive comments would have been helpful and demonstrated to readers that the Hospice actively listens to concerns.

The forthcoming year will see changes in the way that health services are commissioned within the city. Commissioners look forward to a move towards more standardised service models, and collaborative working with other palliative care providers particularly in relation to equity of service and access.

We look forward to continued progress throughout the coming year with all priorities highlighted in this account, and would like to thank the Hospice for providing us with the opportunity to comment.

Statement from Leeds Local Involvement Network (LINk)

The Leeds LINk would like to thank St. Gemma’s Hospice for again submitting its Quality Account for comment to the Leeds LINk Steering Group. Following last year’s submission the LINk is pleased to note that St. Gemma’s Hospice has continued to develop its working relationship with the LINk through meetings with the Joint Chairs and regular communication updates via e-bulletins and newsletters. The Leeds LINk Joint chairs have been very impressed by the good practice evident in St. Gemma’s Hospice’s thoughtful way of approaching their work.


Statement from the Scrutiny Board (Health and Wellbeing and Adult Social Care)

Following the production of the previous year’s Quality Account, the Chair of the Scrutiny Board for 2011 / 12, Cllr. Lisa Mulherin, was offered the opportunity to visit the Hospice and see, first hand, the facilities and services on offer and the care provided. Cllr. Mulherin was pleased to take this opportunity and felt the facilities and commitment of staff provided a valuable service for service users and their families.

The Quality Account for 2011 / 12 has been submitted to the Scrutiny Board for consideration, but due to competing priorities the Scrutiny Board is unable to provide any comments at this time.

However, it should be noted that as part of its work programme for 2012 / 13, the Scrutiny Board intends to consider progress against the goals and targets set out in the quality accounts for a range of service providers. This may include the work and progress achieved by St. Gemma’s. As part of this process and to help the Scrutiny Board provide any future comments, the Scrutiny Board may also consider input from other stakeholders, such as service commissioners, the Care Quality Commission (CQC) and the Local Involvement Network (LINk).


ReferencesDepartment of Health (2008) End of Life Care Strategy : Promoting High Quality Care for all Adults at the End of Life. The Stationery Office, London.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/ @dh/@en/documents/digitalasset/dh_086345.pdf

National Institute for Health and Clinical Excellence (2011) Quality Standard for end of life care for adultswww.nice.org.uk/media/EE7/57/EoLCFinalQS.pdfInformation for patients - www.nice.org.uk/media/E9C/A9/EndOfLifeCarePatientInfo.pdf

Hanson, L., Schenck, A. P., Rokoske, F. S., Abernethy, A. P., Kutner, J. S., Spence, C., et al. (2010). Hospices’ Preparation and Practices for Quality Measurement. Journal of Pain and Symptom Management, 39 (1), 1-8.

Addington-Hall. (2007). Research Methods in Palliative Care. (J. M. Addington-Hall, E. Bruera, I. J. Higginson, & S. Payne, Eds.) Oxford: Oxford University Press.

Dy, S. M., Shugarman, L. R., Lorenz, K. A., Mularski, R. A., & Lynn, J. (2008). A Systematic Review of Satisfaction with Care at End of Life. The American Geriatrics Society, 56, 124-129.

Glossary

CQC Care Quality CommissionThis is the independent regulator of health and social care in England. It regulates health and adult social care services provided by the NHS, local authorities, private companies or voluntary organisations.

LINk Local Involvement NetworkThis is a network of local people and community groups whose aim is to improve health and social care in their locality. They are able to share their thought, ideas and concerns with those who plan and run services in order to improve them.

NCPC National Council for Palliative CareThis is an organisation for all of those involved in providing, commissioning and using hospice and palliative care services.

NICE National Institute for Health and Clinical ExcellenceNICE provides guidance which helps health and social care professionals to deliver the best possible care based on the best available evidence.

Further information

For further information about this Quality Account or to request a copy in large print please contact our Clinical Audit Facilitator, Edwina Gerry :

[email protected] or 0113 218 5500.

References, Glossary and Further Information

St. Gemma’s Hospice329 Harrogate RoadMoortownLeedsLS17 6QD

Hospice 0113 218 5500Fundraising 0113 218 5555

[email protected]

Registered Charity No. 1015941Company Number 2773867

Community

Palliative Care

Day Services

In-Patient Care

Bereavement

Support

Clinical

Teaching

and Research

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