quality account 2013-14 · helen & douglas house is a hospice service which provides specialist...

QUALITY ACCOUNT

2013-14

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Part 1: Statement of Assurance from the Chief Executive on behalf of the Board

Who we are and who we serve

Helen & Douglas House is a hospice service which provides specialist palliative and supportive care

to children and young adults (0-35 years), including support to their families and carers. Helen &

Douglas House is an independent charity based in Oxford and has been providing palliative care for

more than 30 years. We serve a wide geographical area centred on the Thames Valley but extend

care to patients from many counties and Clinical Commissioning Groups – in response to the needs

of the population, and reflective of our level of expertise and experience. We work in close

partnership with professionals in hospital and community settings to provide coordinated care,

alongside the public sector and other voluntary services.

Quality at the heart of the organisation

The pursuit of excellence in the delivery of care and the support services underpinning them is a

strategic aim of Helen & Douglas House. Performance against this aim is regularly reviewed by the

Charity’s Trustees either at full meetings of the Board or via ‘assurance’ committees. In July 2013

inspectors from the Care Quality Commission undertook an extensive review of the Charity’s work.

Children and young people using the service and their relatives told the inspectors that “staff are

amazing” and “it’s like home from home here”. The inspection report affirmed that children and

young people were protected and care was delivered safely. All standards inspected by the CQC

team were fully met.

Helen & Douglas House is the holder of the PQASSO Quality Mark. PQASSO (Practical Quality

Assurance for Small Organisations) is a quality assurance accreditation awarded by the Charities

Evaluation Service.

Following an extensive, objective review Helen & Douglas House was awarded the title of Thames

Valley Charity Business of the Year for 2012/13. In June 2013 the Charity was awarded the Oxford

Times’ Charity and Community Award. The assessors for both awards recognised excellence in the

business and administrative principles that underpin the delivery of care at Helen & Douglas House.

That care is based on the unique needs of each individual child or young adult, it is holistic in nature

and aims to ensure that each child or young adult is enabled to live life to the full.

Priorities for improving quality in the coming year include staff and user feedback programmes, and

realisation of a revitalised care environment through a £1.5million refurbishment of Helen House

(the children’s hospice). We are committed to ensuring continued compliance with national

standards, and to promoting consistently good practice.

The Quality Account

This is the organisation’s first published Quality Account. The Quality Account is a means by which

we are able to share information publicly about the quality of care we provide, in a format common

to other providers of services to the NHS. It is an assessment of the quality of our healthcare

services in the form of an annual report, demonstrating evidence of our achievements in the past

year and commitment to excellence through our quality improvement priorities.

This report has been prepared jointly by the Clinical Governance Lead and the Service Development

Manager, and is endorsed by the Board.

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To the best of my knowledge the information reported in this Quality Account is an accurate and fair

representation of the quality of healthcare services provided by Helen & Douglas House.

Tom Hill, Chief Executive

26th June 2014

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Part 2: Priorities for Improvement and Statements of Assurance from the Board

Priorities for Improvement 2014-15

This section presents our priorities for clinical quality improvement in the coming financial year, why

they have been identified, and how they will be achieved, monitored and reported. They span the

three key areas of Patient Safety, Clinical Effectiveness and Patient Experience.

Priority Area How identified as a priority

How priority will be achieved

How progress will be monitored

Patient Safety: Drug errors

Patterns in incident reporting; results of audits.

Implementation of Assessment of Medication Skills for Nurses Workbook (developed in-house, 2013-14).

Analysis of incidents. Annual appraisal and 1:1 interviews. Audit.

Patient Experience: Develop tools to monitor patient experience

Care Quality Commission and contractual requirements; good practice.

Develop and implement user feedback programme.

Annual report.

Information Governance: Improve information governance (IG) throughout the organisation.

IG audit process (2013-14).

Work with local Information Security company over the year to assess current situation and develop an Information Governance Improvement Plan.

Production and implementation of Information Governance Improvement Plan; annual assessment through Information Governance Toolkit.

Infection Prevention and Control

Care Quality Commission standards: “…everyone should be cared for in a clean environment with rigorous infection prevention and control in place…”1. Infection Control Audit.

Implement recommendations made in latest Infection Control Audit.

Annual audit using the Help the Hospices Infection Prevention and Control Audit Tool.

1 Care Quality Commission, 2008. Registering with the Care Quality Commission in relation to healthcare

associated infection. Guidance for Trusts 2009/10.

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Statements of Assurance from the Board

This section includes statements that all providers must include as part of their Quality Account.

Some statements are less applicable to providers of specialist palliative care, such as Helen &

Douglas House; where this is the case a brief explanation is included.

Review of Services

Services Provided

During 2013-14 Helen & Douglas House provided the following services (to the NHS and/or through

its charitable remit and funding).

Helen & Douglas House has provided specialist palliative and supportive care via an interdisciplinary

team that includes Consultants in Palliative Medicine (paediatric and adult) alongside registered

nurses, care workers, specialist therapists (physio, occupational, music, complementary), social

workers, teacher, chaplain and counsellors. Specialist trained volunteers are increasingly supporting

the holistic care of patients and families as a complement to contracted staff, enabling the

achievement of a higher quality and more responsive experience for service users beyond their

clinical needs.

In-patient services are provided at the two hospice houses (Helen House (0-18 years) and Douglas

House (16-35 years)). An increasing level and extent of care is also delivered “out of house” in local

communities and hospital settings, to support families and professionals in their provision of more

complex palliative care in those environments. Psychological and practical support is offered to

families through one-to-one and group interactions that take place at the hospice, in families’ local

settings, and at external venues.

Services provided include:

Symptom management (routine and complex).

Medically-supported short-break respite (at the hospice).

Stepped-discharge from hospital to the hospice to manage patients’ return home.

Emergency care (for medical or social emergencies, or for lack of capacity and expertise in

public sector provision).

Day care (in-house) and home visits.

End-of-life care.

24 hour telephone support for patients, families and professionals regarding symptom

management and end-of-life care.

Specialist medical and clinical advice to NHS community and hospital teams, and to other

hospice care providers. (This includes via honorary contracts with the Oxford University

Hospitals NHS Trust for senior clinicians at the hospice.)

Care coordination and planning (including Advance Care Planning).

Training and education (professionals and families).

Physiotherapy, occupational, music and complementary therapies to support individuals’

development, enable greater independence, and improve quality of life.

Psychological and spiritual support for patients and families.

Advocacy for service users (patients and families).

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Practical help for families (via a supported volunteer service run by the hospice).

Helen & Douglas House has reviewed all the data available to us on the quality of care in these

services.

Funding of Services

Services provided by Helen & Douglas House are funded through a combination of fundraised

income/voluntary donation and contributions from public sector bodies (health and social care).

Where a public sector contribution is made, this is only ever a partial contribution to the cost of an

individual’s care at the hospice. For the year 2013-14 public sector contributions to care2 represent

13% of the hospice’s total expenditure on care services.

100% of the income generated from the provision of services to the NHS has been spent on

providing those services.

In 2013-14 NHS commissioning contracts were in place for NHS Swindon and NHS Wiltshire Clinical

Commissioning Groups (CCGs) for children’s palliative care – via joint commissioning arrangements

with the respective Local Authorities. These commissioners contribute circa 30% cost of the in-

patient care that is provided to children from their CCGs who use Helen & Douglas House.

CCGs within the former South Central Strategic Health Authority (the hospice’s core catchment)

have continued to decline to fund children’s hospice care during 2013-14, despite representations

made by the hospice and via NHS South for an equitable and acknowledged contribution to

healthcare provision in the region. The hospice continues to seek a fair playing field that supports

the sustainability of specialist services through equity of access to, and of funding for, palliative care

for children and young adults.

Public sector contributions to the funding of young adults are typically negotiated on a case-by-case

basis with health and/or social services, or, increasingly, with the holder of a Personal Budget.

2 Excludes NHSE capital grant.

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Participation in Clinical Audits

National Clinical Audits

During 2013-14 Helen & Douglas House did not participate in any national clinical audits or national

confidential enquiries as there were none that related to specialist palliative care.

Local and In-House Clinical Audits – Frameworks for the Assessment of the Quality of Care

Within Helen & Douglas House, quality of care is monitored throughout the year via a governance

programme which includes weekly Executive Team meetings, monthly Clinical Governance meetings,

quarterly Clinical Assurance Committee meetings that feed in to the Board, and an annual schedule

of clinical audits. Staff and service users are encouraged to report any concerns, incidents or

exceptional practice (good or bad) within a supportive and open management culture.

The assessment of clinical quality is driven through a comprehensive audit programme managed by

the Clinical Governance Lead in support of legislative and regulatory requirements, and clinical best

practice. High quality clinical practice is supported by a suite of organisational policies and

guidelines which are reviewed regularly to reflect changing requirements. National and local quality

requirements are also defined within NHS Standard Contracts, which provide a framework for

external reporting. (See Appendices 2 and 3 for an outline of the contracts and audit frameworks.)

User experience feedback is encouraged on a continuous informal basis (through a model of

individualised care and user groups) and via more structured surveys and consultations. In 2013-14

this included engagement with the Help the Hospices user experience survey (validated by the

University of Kent) and the launch of a consultation with all service users regarding the planned

refurbishment of Helen House (refurbishment in process from November 2013). Key outcomes from

the user experience survey are outlined in Part 3 of the Quality Account.

Externally, quality of care is regulated and assessed by the Care Quality Commission who made an

unannounced routine inspection in July 2013 (all assessed standards met) and by those NHS

commissioners who make a funding contribution – to whom we report on a quarterly basis and with

whom we have a positive relationship.

Local and In-House Clinical Audits

Helen & Douglas House has an annual audit programme which ensures that, as an organisation, we

are continually improving our clinical services. During 2013-14, the following audits were

undertaken by Helen & Douglas House as part of the annual audit programme:

Record Keeping Audit and Re-Audit

Accountable Officer Audit

Drug Related Incident Audit

Data Protection Audit

Infection Prevention and Control Audit

Management of Controlled Drugs Audit

Management of General Medicines Audit

Complaints Audit

Hand Hygiene Audits

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Commitment to Research as a Driver for Improving the Quality of Care and Patient Experience

Helen & Douglas House demonstrates a strong commitment to research and innovation in the

provision of care services. Both Helen House and Douglas House have pioneered palliative care for

their respective patient age-groups and continue to evolve in response to user needs and to medical

and technological advances. Palliative care for children and young adults is a relatively young field;

Helen & Douglas House remains a regional/national centre of expertise – committed to the

furtherance of the specialty.

In 2013-14 Helen & Douglas House consolidated its Research Education and Development function

within its Clinical Directorate which is led by a senior Doctor and delivered through a Research

Coordinator and two Learning and Development Leads. All members of the clinical teams are

encouraged and supported to be involved in research at a level appropriate to their role and

experience – through daily practice, in-house training and forums, specific projects and university-

based courses. Significant numbers of staff study at Masters’ level and there is a high level of

support for fortnightly research forums.

In 2013-14 research projects carried out at Helen & Douglas House included:

Life story work with users of Helen & Douglas House.

An exploration of the experiences of transitioning from children's to adult healthcare services for young men with Duchenne Muscular Dystrophy.

Reaching out/Reaching in: Exploring the impact of accessible video conferencing on the lives of those using a hospice for young adults.

Boundary-spanning leadership and innovation: a case study of the development the oncology service for young adults at Douglas House.

Research proposals involving Helen & Douglas House staff, patients, and families (whether from

those working within or beyond the organisation) require consideration by an internal Ethics

Committee. This committee includes professionals (doctors, a solicitor, academics) from outside the

organisation. In 2013-14, one external research project was approved by the committee.

The number of patients receiving services (funded by the NHS) provided or sub-contracted by Helen

& Douglas House in 2013-14 that were recruited during that period to participate in research

approved by a research ethics committee was zero. This statement refers to research approved by a

research ethics committee within the National Research Ethics Service; Helen & Douglas House is not

aware of any of its patients that were involved in any such research.

Staff at Helen & Douglas House have also had work accepted for publication (5), and shared their

innovative work through presentations (12) and posters (4) at national/international conferences,

workshops and study days. Particular areas of expertise include Advance Care Planning, research

ethics, clinical supervision, and pain/symptom management.

Goals Agreed with Commissioners

Use of CQUIN Payment Framework

Helen & Douglas House income in 2013-14 was not conditional on achieving quality improvement

and innovation goals through the Commissioning for Quality and Innovation payment framework

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because NHS funding is only ever a contribution towards cost of care and commissioners did not

consider it appropriate to include in NHS Standard Contracts.

What Others Say about Us

Care Quality Commission

Helen & Douglas House is required to register with the Care Quality Commission (CQC); its current

registration status is unconditional. The Care Quality Commission has not taken enforcement action

against Helen & Douglas House during 2013-14.

Helen & Douglas house received an unannounced routine inspection from the CQC on 23rd July 2013

at which all inspected standards were met and registration compliance was confirmed. The CQC

inspected five essential standards:

Respecting and involving people who use services.

Care and welfare of people who use services.

Safeguarding people who use services from abuse.

Requirements relating to workers.

Complaints.

The CQC report for Helen House (children’s service) included the following assessment:

Children and young people using the service and their relatives told us they had a very positive experience, they told us "staff are amazing" and "it's like home from home here".

Children and young people were supported to make choices and preferences about their care and treatment. A young person told us "I choose when to stay so that I can meet my friends here".

Children and young people were treated with care and respect and received care in a way they preferred. One young person told us "they used to ask my parents but now they ask me what I like".

Children and young people were protected and care was delivered safely. One young person told us they felt ''safe'' when staying at the hospice. A relative told us "I know my children are safe here".

People were cared for, or supported by suitably qualified, skilled and experienced staff. A relative told us "the staff here are amazing, all of them".

Children, young people and relatives knew how to complain if they had a concern. One young person told us "if I wanted to complain I would go to my main carer but I don't have any complaints".

The CQC report for Douglas House (service for young adults) found the following:

We found that staff treated people with dignity and respect. For example we observed care workers involving people in conversations and people told us they were treated with respect. Staff ensured that people's privacy was protected when care tasks were undertaken. People told us that the hospice was flexible which enabled them to plan their care around their lives.

We found that staff were familiar with the risks described in people's care plans and knew how to support people appropriately. We saw people were assessed by the in-house

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occupational and physiotherapists when needed.

We found the hospice had suitable arrangements in place to protect people from the risk of abuse. Staff we spoke with knew how to identify abuse and how to implement the safeguarding procedure. We found that any identified or suspected abuse was addressed appropriately.

We found people were cared for, or supported by suitably qualified, skilled and experienced staff. The provider had undertaken the required recruitment checks. People we spoke with described staff as ''nice, good and friendly''.

We found that the service had a written procedure for managing complaints. We saw that all complaints had been investigated and appropriately responded to in line with the policy.

One person told us, ''Staff are always willing to listen to anything that I might not like when I am here. We always find a solution together''.

The full inspection reports are available on the CQC website.

There were no actions as a result of the inspection by the CQC.

Users’ Experiences

Further feedback from service users are provided below, in Part 3 of this report.

Comments from commissioners and local scrutineers have also been sought and are also presented

in Part 3 of this report.

Data Quality

Statement and Actions to Improve Data Quality

Helen & Douglas House acknowledges the importance of good quality information in supporting the

effective delivery of patient care and improvements to services. Actions during 2013-14 have

included:

A review of documentation and procedures for patient notes, with recommendations for a

new system to be piloted in 2014-15.

Consolidated implementation of the organisation’s administrative clinical database and

generation of a regular suite of internal performance reports.

Registration with the Information Governance Toolkit and an initial assessment of

compliance.

Analysis of user experience survey results (benchmarked against other hospices) and

development of an action plan to promote greater consistency of good practice.

Activity data in 2013-14 for Helen House affirms the increasing proportion of complex and specialist

care provided to children. Over 50% of the children on the Helen House caseload in 2013-14 were

assessed as requiring specialist palliative care. In addition, more than 25% bed-night activity was

associated with an emergency/urgent admission.

Initial assessment against the Information Governance Toolkit reveals some gaps in compliance, and

informs priorities for improvement in 2014-15.

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Helen & Douglas House will be taking the following actions to improve data quality:

Implementation of new patient notes systems (pilot in process).

Extension of the standardised reporting of performance data across additional areas of

hospice activity.

Development of an Information Governance Improvement Programme.

Review of feedback mechanisms to capture user experience and inform on-going

improvement.

NHS Number and General Medical Practice Code Validity

Helen & Douglas House did not submit records during 2013-14 to the Secondary Uses service for

inclusion in the Hospital Episodes Statistics which are included in the latest published data. Helen &

Douglas House is not eligible to participate in this scheme.

Clinical Coding Error Rate

Helen & Douglas House was not subject to the Payment by Results clinical coding audit during the

2013-14 by the Audit Commission.

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Part 3: Review of Quality Performance

Hospice Activity during 2013-14

During 2013-14 the following volumes of in-patient activity were recorded.

In-Patient Activity Helen House Douglas House Total

Bednights of care 1572 1494 3066

Emergency 437 147 584

Planned 1135 1347 2482

Patients in receipt of care (in-House) 128 111 239

In addition to in-patient activity, the Community Support Team cared for 38 patients through home

and hospital visits, and supported a further 20 through care coordination (including Advance Care

Planning). Community support focuses on more complex symptom management, coordination and

planning in liaison/partnership with families and local team(s); it has included teaching of hospital-

based and community teams to enable their local support of patients requiring complex and end-of-

life care.

Patient Caseload Helen House Douglas House Total

New Referrals 81 44 125

Referrals Accepted 53 20 73

Referrals Declined/Withdrawn 17 16 33

Deaths of Accepted Patients 32 5 37

Cases Closed during the Year (not deaths) 18 15 33

Total Patients on Caseload over the FY 176 121 297

Patients on caseload in any one month (range) 117-127 94-102 214-227

Three further children were referred directly for care post-death in the “Little Room” (chilled

bedroom) prior to their funeral.

[N.B. As referrals are continually received, some will be pending assessment at the start and

the end of a financial year. The number accepted and declined/withdrawn may therefore not

match the total new referrals during a year.]

The Family Support and Bereavement Team supported the following numbers of individuals during

2013-14.

Family Support Total

Individuals supported on a 1:1 basis (patients, family members, carers) 212

Siblings supported by the “Elephant Club” 59

Individuals supported by Helen & Douglas House social workers 21

In addition to individual support, a range of facilitated groups were convened during the year -

including for recently bereaved parents, for dads, and for grandparents. Three workshops were run

on topics that covered grief, spirituality, and the care of surviving siblings. Two residential sibling

camps were also run during the year: one for younger siblings; the other for adolescent siblings.

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Quality Monitoring Requirements for NHS Commissioners

Helen & Douglas House is required to report to NHS Commissioners on the quality of its services via

the NHS Standard Contract. The measures for 2013-14 are indicated in Appendix 2 along with the

associated reporting compliance and commentary.

Patient Safety and Clinical Effectiveness

One of the key drivers at Helen & Douglas House is the delivery of excellent, safe care.

Safety is not just about identifying risks after an event has occurred but also about looking at areas

we know can cause harm to patients, and being proactive in their management. It is about having

the systems to introduce changes and make improvements when they are needed, and to monitor

when changes are made to make sure they are sustainable and beneficial. 2013-14 has seen a great

deal of work to take this approach forward and to integrate these reactive, proactive and

improvement aspects of safety into the Clinical Governance Framework.

In order to monitor and continuously improve patient safety and clinical effectiveness, a programme

of audit and risk assessment/review is in place. These systems provide clear evidence for the Care

Quality Commission that the organisation takes patient safety and clinical effectiveness extremely

seriously and develops systems to support the continuous improvement in all aspects of service

delivery. Results from the 2013-14 Clinical Audit Programme are summarised below.

Record Keeping Audit

Audit Tool In-house tool based on standards and guidelines from Nursing and Midwifery

Council, Royal College of Physicians Health Informatics Unit, Department of

Health National Minimum Standards, and Health and Social Care Act (2008).

Target Continuous improvement

Result Initial audit: 71% Re-audit: 90% Previous: 82%

Commentary Compliance in the core criteria have been steadily improving against previous

years’ internal audits. However the initial audit revealed some shortcomings in

consistency of practice. Resultant staff training (May 2013) was followed by a

re-audit in September 2013. The re-audit showed improvement across the

board against the two previous audits.

Key

Recommendations

Implement a regular programme of Record Keeping update training.

Accountable Officer

Audit Tool Help the Hospices Accountable Officer Audit Tool

Target ≥90% compliance

Result 86% compliance Previous: 85% compliance

Commentary This audit ensures risks are identified in a timely manner, eradicated or

reduced. There are good processes in place which ensure the organisation

meets the requirements of current legislation in the management of controlled

drugs. The opportunity to improve monitoring systems has been highlighted.

Key

Recommendations

Develop systems to improve the accounting for controlled drugs purchased by

and administered by the hospice.

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Drug Related Incidents

Audit Tool In-house tool

Target Continuous monitoring to identify and reduce risks

Result 93 incidents Previous audit: 104 incidents

Commentary Helen & Douglas House has a positive, open culture of reporting and reviewing

drug-related incidents. The number of drug related incidents reported during

this period decreased by 5% compared to the previous year’s audit; drug errors

decreased by 25%. The relative predominance of errors of omission,

prescription and dosing reflect trends reported in the National Reporting and

Learning Systems.

Given the volume and complexity of drugs administered on a daily basis, the

number and nature of actual drug errors reported reflected minimal risk to

patients.

Key

Recommendations

Formalisation of expected practice within related policies and procedures.

Roll-out of Medicines Administration Competency Tool to all registered nurses.

Data Protection

Audit Tool Audit developed using the Information Commissioner’s Data Principles,

coupled with the Information Governance (IG) Toolkit. In parallel, the

organisation is working with a 3rd party information security company to assess

compliance and develop an Information Governance Improvement Plan.


Result Preliminary assessment

Commentary The preliminary result of the IG audit reflects some gaps in formalised

documentation of information policies and recording of data trails. However,

the initial 3rd party assessment suggests robust data security practices and IT

security. IT server security was reviewed as part of an upgrade in September

2013 in accordance with the security recommendations of the NHS N3

Network checklist. The risks to data security are considered low, although

enhancement to Information Governance is highlighted as a priority for

improvement in 2014-15.

Key

Recommendations

Development of an Information Governance Improvement Plan with expert

input from a 3rd party information security company.

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Infection Prevention and Control

Audit Tool Help the Hospices Prevention and Control of Infection Audit Tool

Target ≥90% compliance

Result 12/15 modules (80%) achieved > 90% Previous: 6/12 modules >90%

Commentary Standards have continued to improve with over half of the modules increasing

in compliance compared to the previous audit. Overall the areas of non-

compliance were aesthetic issues that do not pose a risk to patient safety or

the quality of the service delivered. The recommendations made in each of

the modules will address the issues identified.

Key

Recommendations

Re-audit the three pertinent modules by October 2014.

Management of Controlled Drugs

Audit Tool Help the Hospices Controlled Drugs Audit Tool


Result 100% compliance Previous audit: 98% compliance

Commentary Compared to the previous audit there was an improvement in compliance in

two topics: Procurement (11% increase) and Prescribing (5% increase).

Key

Recommendations

List of signatories, including doctors and pharmacist, to be made available and

kept up-to-date.

Management of General Medicines

Audit Tool Help the Hospices General Medicines Audit Tool



Commentary Whilst a high level of compliance is maintained, improvements are identified in

two areas.

Key

Recommendations

Improve information to patients about medications initiated during their stay. Update the Medicines Management Policy and Procedure.

Complaints

Audit Tool Tool developed by the Clinical Audit Support Centre

Target 100% compliance


Commentary Two complaints were received during 2013-14: one verbal, the other written.

Both complaints were dealt with in a timely manner in accordance with the

local Complaints Policy and Procedure.

Key

Recommendations

Maintain 100% compliance by continued attention to understanding and

responding effectively to users’ experiences and comments.

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Patient Experience

Helen & Douglas House offers a personalised model of care predicated on a holistic understanding of

each individual patient. This necessitates a high level of engagement with patients and their

families/carers to continually assess their needs and preferences, plan the care, and evaluate its

outcomes. Staff continually seek and receive feedback from users regarding the specifics of the care

required and provided, and this is recorded in individual patient notes.

The service as a whole is evaluated through periodic user surveys; in 2013-14 this included

participation in the Help the Hospices biennial survey (validated through the University of Kent). The

survey covered five themes:

Provision of Information about In-patient Services.

In-patient Staff Communication and Care.

In-patient User Involvement & Understanding.

Views of In-patients on the Support and Courtesy of Staff.

In-patient Facilities and Services.

Overall, Helen & Douglas House compared favourably with the cohort of other hospices (adult-

focused) who participated in the survey and scored particularly highly for user satisfaction in

activities available. Positive comments also included:

Descriptions of staff as professional, friendly, helpful, inclusive and trustworthy.

Advance Care Planning conducted with sensitivity (acknowledging differences in family

readiness for such conversations).

High levels excellence in providing respect, dignity and privacy to patients.

The survey also highlighted potential for greater consistency in upholding excellent standards of

communication and care planning across all staff. Actions resulting from the survey include:

A revision of staff uniform and name badge policy; introduction of prominent photo boards

to ease patients’ identification of staff.

Formalisation of expected communication and engagement best practice, with

reinforcement through associated staff training.

Increasing IT-literacy of staff/volunteers to support young people’s access to and use of

technology.

In May 2013 a consultation was initiated with all current service users and in-house staff/volunteers

regarding a proposed refurbishment of Helen House and the temporary relocation of children’s

services to the Douglas House building. The refurbishment itself was prompted by users’ experience

of providing care in a 30 year-old building which now needs to accommodate an increasing

complexity of care, plus associated equipment and technology, to meet current and future patients’

needs. Feedback from stakeholders has been used to shape the operational design of both the re-

formulation of Helen House and the transitional arrangements for care in Douglas House.

Specific feedback is also received via user-initiated compliments and complaints. There were two

complaints during the year 2013-14: one verbal and the other written. Both complaints were dealt

with in a timely manner in accordance with local policy; the internal Complaints Audit showed 100%

compliance in all areas. The Care Quality Commission inspection in July 2013 also included

assessment of the essential standard of “Complaints” (people should have their complaints listened

to and acted on properly). The CQC judgement was that:

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“The provider was meeting this standard. There was an effective complaints system available. Comments and complaints people made were responded to appropriately.”

Compliments received from families illustrate the value they attribute to the care and enablement

provided by Helen & Douglas House.

“Thank you so much for all your wonderful support and guidance. You are truly unique and

do an absolutely incredible job. The way you have supported us has been amazing and we

will certainly miss our trips to Helen House...”

“…my wife and I were totally impressed by the establishment, facilities and care ….. What a

truly remarkable place and staff who show kindness and care at all times…. We can’t find

words to describe how good a job you and the staff do, and we admire you all. It’s really

reassuring for us to know our friends and their baby are in such good, kind and

happy surroundings at this really difficult time. THANK YOU all so, so much and your truly

amazing devoted people.”

“Every second, minute, hour - night and day - that you have spent with [him] means so so

much and there simply aren’t enough ways to thank you.”

“You gave [her] 100% of your effort and care, it enables us to be together as a family both

before and after [she] passed away, and that support was invaluable to us all.”

Compliments from NHS hospital Consultants include:

“I wanted to thank you for the quite astonishing level of responsiveness, compassion and

quality of service that you provided to help [him] and his family. We really were very

impressed with all aspects of your set up at Helen House. We certainly took away many

learning points. It was also a pleasure to meet you and share some thoughts on service

configuration. Could you pass on our sincere gratitude to your amazing staff and I wish you

all the best in continuing to develop children's palliative care services within the UK.”

“I would like thank everybody that was involved in his care over the last weekend of his life

for the excellent, professional care that everyone provided him with in such an effective co-

ordinated way…. As his lead Consultant… I would just like to say a huge thank you to all the

individuals in the different teams who were involved in his care particularly in his last few

days.”

Compliments from other professionals include:

“Just a note to say thank you for the care of [her] and her family. Your advice and support

were essential for [her] care at home and I know the family greatly appreciated your

compassionate care of [her] at Helen House. The family also spoke very highly of all the staff

at Helen House – I know that they would have found the situation even more difficult

without the safety net you provided. ” (Family GP)

The families’ “…gratefulness for the help and support they’ve received from all the

dedicated staff at Helen & Douglas House.” (Social Worker)

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Statements from Commissioner and Local Scrutineers

Comment from the Clinical Commissioning Group with responsibility for largest amount healthcare

provided by Helen & Douglas House under a commissioning agreement:

From a commissioning point of view, NHS Swindon CCG and Swindon Borough Council are

assured that Helen & Douglas House is providing good quality services, in terms of:

• Patient Experience

• Safety

• Clinical Effectiveness

We are further assured that governance arrangements are robust in monitoring these areas

and that services are developed as issues and new practice arise.

High quality provision at the hospice has been evidenced through both external scrutiny and

sound internal practice for review and improvement. The Quality Account clearly

demonstrates that Helen and Douglas House is aware of priority areas for improvement, has

a clear action plan and demonstrates accountability in delivering against actions.

The service consistently provides highly valued support to children and young people in

Swindon with life-limiting conditions.

Caroline Little

Joint Children’s Health Commissioner

NHS Swindon Clinical Commissioning Group & Swindon Borough Council

Comment from local Healthwatch:

Healthwatch Oxfordshire is grateful to Helen and Douglas House for sharing the detail of the

draft Quality Account with us prior to publication. The Account is comprehensive and we

have no specific comments on the detail contained therein. We look forward to working

with Helen and Douglas House in the future.

David A Roulston

Interim Chief Executive

Healthwatch Oxfordshire

This Quality Account was also sent to the local Health & Wellbeing Board/Health Overview and

Scrutiny Committee for comment. No feedback has been received at the time of submission to NHS

England.

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Appendix 1 – Hospice Activity Data/Charts

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Appendix 2 – NHS Standard Contract Reporting Compliance against National and Locally-Defined Quality Measures

Continued….

Helen & Douglas House - Scorecard against 2013-14 NHS Standard Contract Requirements

NHS Standard Contract

Requirement Area Specific Requirement Format of Report Freq

Pre-

condition

Q1

Jul-13

Q2

Oct-13

Q3

Jan-14

Q4

Apr-14 Compliance Comment

Conditions Precedent CQC Registration Share 1 G

Business Continuity Plan: essential services/whole Provider Share 1 G

Indemnity arrangements Share 1 G

Arrangements for Counter Fraud & Security Management Share 1 G

Info Governance - agree plan for Level 2 compliance Plan 1 A Agreed statement on IG compliance and action plan. On-going work.

Details of Caldicott Guardian + Senior Risk Owner Share 1 G

Adult & Child Safeguarding Policy + updating Share 1 G

Infection Control Strategy compliance with national standards (incl. CQC) Text A G

Hand hygiene Text Q G

Complaints Number and type of complaints Text Q G

Audit, incl. feedback on findings Text A G

Publication of upheld complaints Text X G None to report.

Nutritional Screening Patients requiring nutritional needs assessment Text X G None to report.

NICE Guidance Compliance Text A G

EOL Care Identification of relevant national outcome measures Text Define A On-going national piece of work: to inform local implementation.

Quality Priorities Quality Account Text A A Quality report completed for 2012-13; not a formal Quality Account.

Patient Safety Incidents summary Text Q G

Never Events Text X G None to report.

Incidents Requiring Reporting Text X G None to report.

Patient Comms Audit of patient review letters Text H G

Clinical Audit Audit process &project plan; Annual Report Text / Gantt Chart A G

Premises Safety Premises walkabouts By agreement Define G No request received from Commissioners.

PLACE assessment Commissioner-led discussion Text X G No request received from Commissioners.

Patient Experience Recommendations from questionnaire Text A (2A) G

Workforce Staff sickness, absence and vacancy rates Stats A G

Psychological supervision Text A G

Clinical skil lset Text A G

Staff complement Stats A G

Francis Rpt #205 - impact of proposed major changes Text A G

Whistleblowing Policy Share Define G

Summary of concerns raised (anon.) Text X & A G None to report.

NHS Constitution Referral criteria/policy Share Define G

Pressure Ulcers Acquired in hospice Text X G None to report.

Medicines Management Annual Medicines Management report Text A G

Falls Incident report Text Q G

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NHS Standard Contract

Requirement Area Specific Requirement

Format of

Report Freq

Pre-

condition

Q1

Jul-13

Q2

Oct-

13

Q3

Jan-

14

Q4

Apr-

14 Compliance Comment

SIRI Clinical Risk Mgmt Ann. Rpt (trends, recommendations) Text A G

SIRI Policy Text Define G

Safeguarding Adults Safeguarding alerts/investigations Text X G None to report.

Staff training re safeguarding vulnerable adults & levels Stats A G

Safeguarding Lead report/achievements Text A G

CAS Alerts Alerts and actions Text A G

Risk Update from Clinical Risk Register Text A G

Inspections Advise CQC visit within 2 days Advise Date X G

Provide copy of CQC reports, feedback, remedial action Share X G Q2: CQC Inspection Report.

Equality Patient profile report (protected characteristics) Stats A G

Diversity self-assessment, objectives& work-plan Text A G

National Reports Action plans from national reports e.g. Francis Report Text A G

Safeguarding Children Staff training re safeguarding children & levels Stats A G

Audit proforma & Performance indicators Proforma / Text A G

Audit proforma & Performance indicators (new reqt during FY) Proforma / Text H G

Carbon Reduction Organisational policy Share A G

User Experience User involvement in major planned changes (90%) Text / Stats A G

Translation/Interpretation services required Text / Stats A G

Personalised care plan (100%) - spot check on request Text / Stats X G None requested.

User involvement in developing care plan (90%) Text / Stats A G

Activity Referrals, referral outcomes, discharges, deaths (HH/DH) Stats / Text Q G

Care provided at patient home Stats / Text Q G

Bed-night activity (specific to CCG) Stats / Text Q G

Caseload (specific to CCG, with user consent) Stats Q G

Surveys Friends & Family TBD TBD A The specific "Friends & Family" test not recommended & not part of user experience survey.

User G Helen & Douglas House participated in the national Help the Hopices user experience survey.

Carer G Helen & Douglas House participated in the national Help the Hopices user experience survey.

Staff 2A G

Exception Reporting Q N/A G

Exception Reporting Q G Q2: Advice re Helen House Refurbishment & organisational governance.



Frequencies Reporting Status

1 One-off Completed

2A Every other year Outstanding

A Annual Deferred

H Half-yearly (6 months)

Q Quarterly (3 months)

X By exception

Define One-off definition

User Experience Survey

User Experience Survey

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Appendix 3 – Helen & Douglas House Clinical Audit Programme 2013-2014

ID Task Name Start Finish DurationMay 2013

30/623/6 11/821/726/5 29/922/931/3 14/4 28/4 4/87/4 12/5 3/11

1 14.08d19/04/201301/04/2013Hand Hygiene Audit

2 14.72d19/04/201301/04/2013Record Keeping Audit

3 23.04d02/05/201301/04/2013Accountable Officer Audit

4 25.6d05/07/201331/05/2013Drug Error Audit

5 84.48d27/08/201301/05/2013Data Protection Audit


7 27.52d09/09/201301/08/2013Management of Controlled Drugs Audit


9 45.44d03/10/201301/08/2013Record Keeping Re-Audit


11 27.52d10/12/201301/11/2013Management of General Medicines Audit


13 27.52d07/02/201401/01/2014Complaints Audit


16 13.44d20/03/201403/03/2014Clinical Governance Report

17 13.44d20/03/201403/03/2014Doctors Issue Audit

14 25.6d10/02/201406/01/2014Infection Control Audit

7/7 6/1016/6 25/8 27/1019/5 28/7 13/105/5 20/10

Apr 2013 Jun 2013

21/4 2/6 15/918/814/79/6 8/91/9

Jul 2013 Aug 2013 Sep 2013 Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar 2014

10/11 17/11 24/11 1/12 8/12 15/12 22/12 29/12 5/1 12/1 19/1 26/1 2/2 9/2 16/2 23/2 2/3 9/3 16/3 23/3

quality account 2013-14 · helen & douglas house is a hospice service which provides specialist...

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