Wirral Hospice St John s. Quality Account 2014/15

Transcription

1 Wirral Hospice St John s Wirral Hospice St John s Mount Road Higher Bebington Wirral, CH63 6JE Registered Charity No Serving our Community 1

2 It is a privilege to have a loved one cared for in the Hospice. It is an amazing place and has a very special place in the heart of my family 2

3 CONTENTS SECTION 1: Statement on Quality page Statement on Quality from the Chief Executive 4 Wirral Hospice St John s Core Values 5 Philosophy of Care 6 SECTION 2: Priorities for Improvement 2015/16 Patient Safety 7 Clinical Effectiveness 8 Patient Experience 9 Statutory Information and Statements relating to the Quality of Services Statement of Assurance from the Board 10 Review of Services 10 Participation in Clinical Audits 11 Quality Improvement and innovation goals agreed with our commissioners 11 What others say about us 11 Data Quality 13 SECTION 3: Quality Overview Priorities for improvement 2014/15 14 Review of Quality Performance 14 Monitoring patient activity 18 Clinical Audits 22 Key Performance (Quality) Indicators 24 What our patients and families say about the organisation 26 Statements from Clinical Commissioning Groups 29 Statement from Health Watch 29 3

4 SECTION 1: STATEMENT ON QUALITY From Chief Executive At Wirral Hospice St John s, we endeavour to meet the physical, psychological, social and spiritual needs of those with progressive illness, and support their loved ones and carers without discrimination. In order to achieve these high ideals, and to meet the standards set out in the updating of national policies, all members of the Hospice staff undergo continuous scrutiny and training. Areas which need further attention to achieve the highest standards are being addressed. During the time covered by this Quality Account, a substantial building project was completed and commissioned. This included integrated team accommodation, allowing for the introduction of an Information Point, and, most importantly, creating facilities that allow for greater integration of Hospice services with those of other service providers such as counsellors, therapists and social workers. Our Hospice at Home service was expanded with an increase in the number of visits undertaken, and the installation of SystmOne patient information system, an integral IT system. It has been a time of extraordinary change at our Hospice. Palliative and end of life care is an area of healthcare which is constantly changing, particularly as its focus broadens out from cancer to other non-cancer conditions. Our Board of Trustees take a robust view on the maintenance of the highest standards with regard to clinical governance and audits, so that, as soon as a need is identified, improvements can be implemented quickly. This is the first formal Quality Account undertaken by Wirral Hospice St John s. In preparing for it, we identified three quality priorities: patient safety, particularly relating to tissue viability; clinical effectiveness, particularly relating to improvement in medicine management; and patient experience, where processes were developed, reviewed and updated to enable patients and carers to express their views. These priorities have been fully tested during the year. I confirm that, to the best of my knowledge, the information contained within this Quality Account is a true and accurate account of quality at Wirral Hospice St John s. We actively seek the views of our patients, their families and carers, and our staff so that we can continually monitor and improve our standards. Julie Gorry Chief Executive 4

5 Wirral Hospice St John s Core Values Promoting mutual respect for everybody, maintaining dignity at all times and ensuring the strictest confidentiality. Respect A feeling of deep admiration for someone or something elicited by their abilities, qualities or achievements Due regard for the feelings, wishes or rights of others Dignity I always consider peoples views and listen to understand their perspective I always respond to requests in a timely manner I always recognise people and take time to ensure they are attended to I welcome and greet patients, families, supporters and visitors ensuring they know who I am and what the next steps are The state or quality of being worthy of honour or respect I always put the patient, families, carers, supporters and visitors first in everything I do I ensure patients/colleagues are treated with dignity, ensuring their privacy and confidentiality are respected Developing relationships built on trust and acting with the utmost integrity in everything that we do. Trust Firm belief in the reliability, truth or ability of someone or something I always think the best of someone I advise others when things go wrong I maintain competency to ensure I am providing the best quality of care and or customer/user service at all times I always deliver on what I promise I always work in partnership to ensure everyone s choices are heard on all occasions. Integrity The quality of being honest and displaying strong moral principles I always uphold a consistent approach I am committed to ensure the best quality of care and, or, customer/user service and getting it right every time 5

6 Encouraging open, clear communication throughout the Hospice, ensuring that everybody feels they are being listened to and their opinions respected. Open Allowing unrestricted access, not closed or blocked Clear Easy to perceive, understand or interpret Transparent, unclouded Communication The imparting or exchanging of information by speaking, writing or using some other medium I go out of my way to ensure I always keep people informed to the best of my ability I always listen to others and seek to understand others views I listen and respond to all patients, colleagues and users feedback in a timely manner My communication style is clear, concise and is adapted to the particular person/audience Recognising that we are one team made up of committed, dedicated employees and volunteers who are working together to ensure the highest standards of care. One Team A single person or entity A group of players with a common purpose Two or more people working together I always act in the best interests of the Hospice, putting my own interests second I always work to support the Hospices/departments common goals I always look at how to make things work I always adopt a positive attitude and a can do approach I spend time working with colleagues to understand how I can help them within my role The Core Values are underpinned by the Hospice s obligation to uphold all legal and regulatory requirements. Philosophy of Care The aim of Wirral Hospice St John s is to warmly welcome people with progressive illness which has failed to respond to curative treatment, into the quiet calm of a highly professional, caring atmosphere which comforts always both them and those who are important to them. 6

7 SECTION 2: PRIORITIES FOR IMPROVEMENT The priorities for quality improvements identified for 2015/16 are set out below. 2a. Priorities for Improvement 2015/16 Patient Safety PRIORITY 1 Improvement in Safeguarding and issues surrounding Mental Capacity and Deprivation of Liberty Safeguards How was this identified as a priority? Mandatory Training highlighted gaps in staff understanding of what is required from a safeguarding point of view when a patient is admitted to the Hospice This priority for improvement will be achieved by:- Regular training on the Mental Capacity Act and Deprivation Of Liberty Safeguards (DOLS) and Safeguarding procedures in addition to mandatory training Establishment of a Safeguarding forum Safeguarding Forum Purpose the core purpose of the group will be to ensure patient safety in relation to any issues around safeguarding. This would include both adult and child safeguarding of patients, carers and families accessing the Hospice s services, Deprivation of Liberty safeguards (DOL s), the Mental Capacity Act and any other issues in relation to safeguarding. The Group will assume responsibility for the development of best practice in relation to safeguarding through the sharing of information and effective communication. The Group will aim:- 1. To ensure best practice through the development and update of policies that include current evidence and legislation 2. To ensure any new information or amendment to policy is communicated effectively and to ensure plans are developed that ensure ongoing competency in all staff 3. To ensure that robust audit plans are in place to ensure policies are being applied in practice 4. To ensure training and development is relevant, evidence based and effective. 5. To discuss clinical cases in relation to any safeguarding cases with the purpose of learning from experience, reviewing and disseminating any areas of good practice or improvement 6. To ensure Safeguarding issues are raised at Board level through regular reporting to the Clinical Governance group 7

8 How will progress be monitored and reported? Progress with this objective to be reported regularly to Clinical Governance group Clinical audit Clinical Policy process Clinical effectiveness PRIORITY 2 Care of people with dementia How was this identified as a priority? Caring for patients with dementia is a national priority and end of life care for patients with dementia is an area of increasing focus for hospices. Dementia is now acknowledged as a life limiting condition with most dementia being progressive in nature and no curative treatment to date. Estimations of deaths attributable to dementia within the UK are at around 66,000 per year. Improving end of life care for people with dementia has been the focus of UK policy and guidance for over a decade now. However, we still see many examples where people with dementia do not have fair access to palliative and end of life care services and support; or in their family or carers access of bereavement support after their death. A difficulty for services, such as hospices, is in understanding what it is they can offer to this group of people and when. Hospice UK 2015 : A guide to help hospices establish care for people with dementia, their families and carers Hospice UK in partnership with Hope for Home identified some key priorities in relation to caring for patients with dementia at the end of their life. These include: a corporate commitment to engage with the agenda of dementia care efforts to establish new partnerships creativity in the provision of care and services to meet the specific needs of people with dementia an evidence-based approach to care and the care environment investment in training of staff and volunteers At Wirral Hospice St John s there is a need to establish our position in relation to caring for patients with dementia who have specialist palliative care needs. This has been identified as a priority for 2015/16. This priority for improvement will be achieved by: The establishment of a working group Identification of areas for improvement in the management of patients with dementia Review of the physical environment in relation to the findings of the Patient Led Assessment of the Care Environment (PLACE) assessment (completed April 2015) Establishment of link nurses roles Identification of training needs for all staff and volunteers and provision of required training 8

9 How will progress be monitored and reported? Progress with this objective will be reported regularly to the Clinical Governance group. Actions required following the PLACE assessment to be implemented by Senior and Departmental managers. Action plans to be updated and reviewed regularly by departmental managers. Patient Experience PRIORITY 3 To review all patient information to ensure that people who use the Hospice services have accessible, current and comprehensive information about the services we provide when they need it. How was this identified as a priority? Over the last twelve months it has become apparent that there are a considerable number of leaflets that were either out of date or misleading in their content. Responses from our patient satisfaction surveys suggested that not all patients were receiving the necessary information on admission or at other key times during their time at the Hospice. This priority for improvement will be achieved by the following:- A review of all patient information leaflets currently utilised.to ensure they are up to date and accurate. This will be achieved in conjunction with the Patient Focus group. A review of how and when patients and their families are given information, written or verbal and how this could be improved. Identification of any information leaflets that may need to be developed Consideration of the introduction of patient information folders for use on the In-patient unit. How will progress be monitored and reported? Progress with this objective to be reported regularly to the Clinical Governance group Patient, Carers and Visitors engagement process. 9

10 2b Statement of Assurances from the Board and Statutory Information The following are statements that all providers must include in their Quality Account. Statement of Assurance from the Board The Board of Trustees supports the Quality objectives agreed for The Board is committed to high quality care for patients and their families throughout all areas of the Hospice. The Trustees undertake unannounced visits to the Hospice on a regular basis. Patients and families are asked whether they are willing to participate in these visits by sharing their views on the services they have received. The Trustees also speak with staff and volunteers to ascertain their views. These visits help the Trustees to gain a greater understanding of the clinical services provided and gives the Board assurance of the quality of care. The most recent visit took place in January 2015, with its main focus being on CQC Outcome 1 highlighting how the Hospice ensures patients are involved with the services and are treated with dignity and respect at all times. Comments received from patients and families interviewed were very positive. The Board of Trustees will continue to monitor progress against the priorities for improvement, in addition to our other quality monitoring processes including Key performance Indicators, complaints and incidents, and the clinical risk register through the Clinical Governance group and monthly Board meetings. Dr P.J.R Cuthbertson MBE Chairman Review of Services During 2014/15, Wirral Hospice St John s provided the following services:- In-patient services (16 beds providing 24 hour care and support) Out-patient Services Clinics -Providing consultation with Consultants in Palliative Medicine, Therapists and Counsellor. Day Therapy (12 places on 4 days a week) Hospice at Home Bereavement and family support PAIL (Professionals Palliative Advice and Information Line). Patient Carer and Family Advice and Information Line Wirral Hospice has reviewed all of the data available to them on the quality of care in all of these services. 10

11 Financial The income received from the NHS services reviewed in 2014/15 represents 35.1 % of the total income generated by Wirral Hospice St John s for 2014/15. The income generated from the NHS represents approximately 49.3 % of the overall running costs of the Hospice. The Hospice receives funding from Wirral Clinical Commissioning Group as a contribution to the overall cost of service provision. 100% of the financial support from the NHS goes towards patient services. All services are reviewed on an on-going basis to ensure we are providing them as efficiently as possible. Participation in clinical audits During 2014/15, Wirral Hospice St John s was not eligible to participate in any of the national clinical audits or national confidential enquiries, because none of the audits or enquiries related to palliative care. The Hospice clinical audit programme for 2014/15 included audits on medicine management, infection prevention and control, slips, trips and falls, documentation, bereavement support, patient environment, exercise classes, dementia, admission process, and bereaved relatives satisfaction with the end of life care provided. In addition, Wirral Hospice St John s participated in the Palliative Care Regional Audit programme. Research The number of patients receiving NHS services provided by Wirral Hospice St John s in 2014/15 that were recruited during that period to participate in research approved by a research ethics committee was NONE. There were no national, ethically approved research studies in palliative care in which we could participate. Quality Improvement and Innovation goals agreed with our commissioners Wirral Hospice s income in 2014/15 was not conditional on achieving quality improvement and innovation goals through the commissioning for quality and innovation Framework. Because it is a third sector organisation it was therefore not able to take part. What others say about us Wirral Hospice St John s is required to register with the Care Quality Commission (CQC) and its current registration is for the following regulated activities:- Treatment of disease, disorder or injury Diagnostic and Screening procedures 11

12 Wirral Hospice St John s has the following conditions on registration:- The organisation is registered for the provision of supportive and Palliative care services Provides overnight accommodation and treatment for a maximum 16 adults aged 18 years or over The Hospice provides Day Therapy services for 12 adults per day 4 days a week Wirral Hospice St John s is subject to periodic reviews by the Care Quality Commission (CQC) The CQC has not taken any enforcement action against Wirral Hospice St John s during 2014/15.The CQC has not carried out any inspection of Wirral Hospice during 2014/15. During December 2013, the CQC carried out an un-announced inspection and found that the Hospice was fully compliant with the following standards:- Outcome 4 Care and Welfare of people who use the services People should get safe and appropriate care that meets their needs and supports their rights. Patients said their care and treatment was agreed with them on admission and that any changes in treatment were discussed with them and any changes to the care plan were always agreed before being implemented. They also said the doctors and nurses were always available and willing to discuss any aspects of their treatment at any time. Staff members were knowledgeable about the patients needs and we observed staff supported people in a very dignified, caring and respectful manner. Outcome 5 Meeting nutritional needs Food and drink should meet people s individual dietary needs. Patients told us that the food was very good and they could have whatever they wanted to eat or drink at any time. One patient said The food is great and they always ask you what you want. 12

13 Patients and relatives also told us that they enjoyed the café facility as it enabled them to spend time with their family members away from the ward. Outcome 9: Management of medicines People should be given the medicines they need when they need them and in a safe way. When patients went home from the Hospice they were provided with two week s supply of medication and a personalised patient information sheet listing their medication with directions and information on what each medication was for. A nurse or the Pharmacist went through this with the patient or their carer. The patients we spoke to told us they received their medicines at times that they needed them and they were never kept waiting for pain relief. Outcome 21: Records People s personal records, including medical records, should be accurate and kept safe and confidential. People were protected from the risks of unsafe or inappropriate care and treatment because appropriate records were maintained. Outcome 12: Staffing There should be enough members of staff to keep people safe and meet their health and welfare needs. The Hospice employs a range of health and social care staff to meet the patients physical, psychological and social needs. Patients.and families were extremely complimentary about the staff Everyone s very pleasant and helpful They re very attentive They couldn t do anything more Call bells are answered promptly. Data Quality Wirral Hospice is not required to submit records to the Secondary Uses service for inclusion in the Hospital Episode Statistics. In accordance with the Department of Health it submits National Minimum Dataset (MDS) to the National Council for Palliative Care annually. During 2014/15, the Hospice has been in the process of implementing electronic patient records by way of SystmOne. All staff have received in-house training in the use of this system and ongoing training will continue in the coming months. 13

14 SECTION 3: QUALITY OVERVIEW Review of quality performance This section looks at:- Quality priorities for 2014/15 Data and information about the number of patients who use our services How we monitor the quality of care we provide What patients and families say about us What our regulators say about us 3.1 Review of quality priorities for 2014/15 The following highlight key areas in which the organisation has demonstrated and improved the quality of care for patients and their families in 2014/2015. PATIENT SAFETY Tissue Viability How was this identified as a priority? Wirral Hospice St John s aims to treat people in a safe environment and protect them from avoidable harm, maintaining high standards of skin care to minimise the risk of pressure area development. The clinical management recognised that more robust tissue viability procedures were required. Progress to date: A working group was established comprising Tissue Viability Link nurses. This group is now meeting monthly This group has reviewed all existing documentation relating to tissue viability including wound charts and patient care plans A new electronic wound chart has been developed as part of SystmOne Incident reporting of pressure ulcers Grade 2 and above is now implemented Photographic records of all wounds are now completed on admission The following will continue to be a priority in the next twelve months: On-going education of staff in the management and prevention of pressure ulcers Audit of all pressure ulcers Grade 2 and above on a monthly basis Patient Information leaflet on skin care to be developed Monitoring and review Progress will be monitored by on-going review of the incidence of pressure ulcers Action plans and progress will be reported to the clinical team and senior managers meetings on a monthly basis 14

15 CLINICAL EFFECTIVENESS Improvement in Medicine Management How was this identified as a priority? There had been a significant increase in the number of medicine incidents over the previous twelve months. A large number of these had involved omissions of medicines. The Pharmacist and Clinical managers were concerned that not all staff had received sufficient medicine management training on induction. Progress to date: A comprehensive review of all medicine management processes ensuring that all staff are familiar with current policies and procedures. Medicine management training has been provided for regular bank and agency staff The Induction programme for clinical staff has been reviewed to ensure that all staff are aware of the medicine management processes that are utilised within the hospice. The Pharmacist has developed competencies for all trained staff. On-going medicine management training updates have been provided. Mandatory training in medicines management has included Local Involvement Network (LIN) for controlled drugs representation, highlighting the importance of comprehensive documentation. How will progress continue to be monitored and reported? Number of incidents Audit programme Competency programme and training attendance Monthly reports to the Hospice Drugs and Therapeutics Group PATIENT EXPERIENCE Review, update and develop processes for patients and carers to express their views and be more involved in service developments How was this identified as a priority? Patient comments and views on the Hospice services had been sought on a regular basis, to ensure that the Hospice was providing the care that is needed. It had been noted however that there were only a relatively small number of completed Patient Satisfaction surveys and comment forms returned. There was no central forum for patients and carers to come together and discuss services and put forward ideas and views, enabling them to have a greater say in further developments to services. Progress to date: Review and re-design all Patient Satisfaction surveys for both In-patients and Outpatients/Day Therapy Volunteers to be trained to assist patients and families in completing satisfaction surveys Establishment of a Have your Say Patient and Carer Focus Group 15

16 . Development of links with local Health-Watch and the completion of a Patient- Led Assessment of the Care Environment (PLACE) Programme Provision of a Carer Drop-In facility Patient Stories Patient Focus Group A formal integrated user partnership was introduced in 2013/14 and this year has continued to engage with our service users and staff to gain better understanding of the needs of patients and carers. They have been instrumental in the new-building programme with provision of ideas/suggestions on colours, design, furnishings for the Outpatient department. Patient Satisfaction We have invested significant time in exploring patient and service user experience over the past year. Patient Satisfaction surveys for all areas of Hospice services have been reviewed and amended. User feedback has been sought in a variety of ways including the following: Patient questionnaires Face- to- face discussions with patients/families through service visits Focus group meetings Suggestion boxes Bereavement care questionnaires No negative feedback was received with the majority of feedback being extremely positive. A number of Volunteers have been trained in assisting people who use the services in completion of the satisfaction surveys. This has led to a significant increase in the number of comments received. Patient Stories During the last twelve months, we have also drafted a number of Patient Stories, interviewing people who use the services and asking them to give us more detailed accounts of their experiences in using Hospice services. These anonymised stories have been shared with the Board of Trustees to give them greater insight into patients views on the care they have received. Comments Log Any negative comments are now logged by the Quality team and referred on to the relevant manager for any actions required. How will progress be monitored and reported? Audit of number of surveys returned/completed Patient and carer interviews Weekly Service Visit Reports (by Registered Manager) Attendance at Have your Say group meetings 16

17 Other quality improvement areas in 2014/15 Nutrition and Hydration Group This group was established to ensure that people using our services were receiving good nutritional care and that our staff were fully aware of patients nutritional requirements. Actions have included: A review of the nutritional assessment tool used on admission. Provision of food for in-patients after hours fresh fruit, snacks, sandwiches. Development of a Hospice policy for nutritional care. Staff training, both clinical and catering staff on the nutritional needs of our patients Establishment of a Patient Focus Group, facilitated by the Dietician, to give patients and carers greater understanding of the need for good nutrition. Enforcement of protected meal-times Patients being encouraged to eat their meals together in the patient s dining room Further work in the coming months will involve the establishment of patient menus and the design of a patient leaflet on nutrition. Patient Information Point As part of the Department of Health grant awarded to Wirral Hospice St John s, a new patient information point has been established. Manned by Hospice volunteers it provides an easily accessible, light and welcoming space, close to the Hospice s main reception area for people to gain information on services available, signposting as appropriate to other agencies, financial matters etc. 17

18 3.2 Monitoring patient activity The Hospice submits annual returns to the National Council for Palliative care (NCPC) Minimum Data Sets. Patient Activity In-patients (16 beds) 2013/ /15 Total number of admissions % Occupancy 85% 89% Mean Length of stay (Days) Total number of discharges 174(54%) 114(47%) % urgent referrals within standard(admission within 2days) % of routine referrals within standard(admission within 5 days ) 99% 97% 97% 88% Wirral Hospice St John s has 16 in-patient beds, of which 7 are single rooms and there are three, three-bedded bays. The unit has a large bright patient and visitor lounge with dining facilities, relatives room and easy access to patio areas and gardens Patients are admitted for short term interventions following assessment by the multiprofessional team (MPT) whose needs cannot be met by specialist palliative care providers elsewhere. Patients are admitted under the care of the Palliative Care Consultant. 18

19 Multi-professional team meetings are held once a week. All patients are discussed and a management plan devised so as to address their complex symptoms and needs. In addition patients are reviewed daily by a doctor and twice weekly by a Consultant. Discharge planning commences at the point of (or even prior to) admission, and discharge occurs once the patient s specialist palliative care needs have been addressed.. The average length of stay is two weeks. Patients and their families are also able to make use of the restaurant facilities available in the Hospice hub providing an informal meeting place away from the ward environment. Patients are also encouraged to eat their meals in the patients lounge, should they feel well enough. Relatives of patients admitted to the In-patient Unit are able to stay overnight in a designated relative s room. 19

20 Day Therapy ( 48 places per week) Total number of available places Total number of allocated places % attendance of available places 65% 64% Mean length of stay (days) 54.41days days Day Therapy services are available on four days a week in a purpose built unit for 12 patients per day, provided by a specialist multi-professional team, working alongside patients and their families to enable them to live well with a life-limiting disease. Patients attend Day Therapy for a maximum of 8 weekly sessions during which they may access, aromatherapy, creative therapy, Occupational Therapy, Physiotherapy, Relaxation, exercise classes, breathlessness management, anxiety management, fatigue management, counselling, support with advance care planning and benefits advice. 20

21 Out-patients Total number of referrals New appointments Out-patient clinics are provided by a team of Consultants in Palliative Medicine, Bereavement Counsellors and an aromatherapist. Services are for patients under the care of the Primary Health Care teams requiring medical access to the wider multi professional specialist palliative care service through the specialist palliative care MDT. Hospice at Home 2013/ /15 Total number of referrals Accompanied Discharge Hospice at Day Hospice at night Total number of deaths Total number of deaths at home 239(72%) 123 (78%) 2014/15 is the third year of a pilot Hospice at Home service provided by the Hospice. Wirral Clinical Commissioning Group has continued to support the Hospice in 2014/15 in the delivery of Hospice at Home services for all Wirral residents. The Hospice at Home team continues to provide quality end of life care to patients wishing to remain at home, providing practical and emotional support to patients, families and carers in a variety of ways. Evaluation from service users, families and healthcare professionals provides positive qualitative feedback (see section 3.5). 21

22 3.3 Clinical Audit To ensure that we are continually meeting standards and providing a consistently high quality of service, Wirral Hospice St John s has an annual Audit Plan comprising audits on a variety of topics. Our audit programme reviews the effectiveness of our clinical care. A sample of clinical audits completed over the last 12 months Audit subject Rationale/ Outcome of Audit Actions/recommendations Dementia environmental audit Following on from Dementia Awareness Week and introduction of the PLACE assessment this audit made several recommendations for improvements to the Hospice environment in relation to Dementia. An action plan was devised to address patient environment and soft furnishings in relation to dementia patients care. Admission processes The audit was undertaken to ascertain compliance with completion of admission documentation. The audit highlighted some gaps in completion of assessment tools. Communicated to staff. Recommendation for further staff training in recording of assessments on new electronic system. PLACE assessment (Patient Led Assessment of the Care Environment) Audit carried out by patient representatives and Health-Watch. Audit findings: Food : 88.87%, Cleanliness : 100% Condition, appearance and maintenance: 95.16% Privacy, Dignity and Well-being: 95.74% Dementia: 82.12% Actions will be mainly focused on improvements in provision for Dementia patients (One of our priority improvements for 2015/16). Re-audit 12 months : 22

23 Infection Prevention and Controlcompliance with code of practice and policy. FAMcare11- (Family satisfaction with end of life care provided by specialist palliative care services) Controlled Drug Accountable Officer(CDAO) audit Monthly audits carried out against all 23 infection prevention and control policies have highlighted the following improvements required in :- Pathway documentation completion Cleaning rotas and checklist Laundry procedures Bare below the elbow policy and hand hygiene. Service evaluation of care in the last days of life, benchmarked against other hospices. In total 16 hospice in-patient units, 10 home care teams and 12 hospital support teams participated. Questionnaires were sent to 27 relatives of patients who had died at Wirral Hospice. Respondents were either satisfied or very satisfied with all domains of care perceived as relevant to them and their family member. In 15 out of 17 domains (88%) the proportion of very satisfied responses was greater at Wirral Hospice than for hospice inpatient care nationally. In addition, many positive free text comments were received. CDAO audits (quarterly) against Standing operating procedures/policy compliance in relation to ordering, transportation, storage, administration, documentation and destruction of controlled drugs (CDs). Requisition audits (monthly) to ensure transparency and reduce scope for CD diversion. Actions required in relation to:- Documentation in CD Register, Omissions of codes, CD ordering and use of calibration bottles. Staff communication via Team Brief Training updates as required by Infection Control Lead. Continue to audit monthly Results disseminated to all staff and recognition given to their tireless work in easing the distress of patients and their loved ones at such a difficult time Discussed at Drugs and Therapeutic group meetings Communicated to clinical teams Audits continue quarterly and monthly 23

24 3.4 Key Performance (Quality) Indicators Key performance(quality)indicators 2013/ /15 Complaints Total number of complaints Patient Safety 6(actual) 1(potential) 1(actual) 2(potential) Number of Medicine Incidents* * Number of slips, trips and falls Infection Prevention and Control Number of patients admitted with MRSA 2 5 Number of patients acquiring MRSA during admission Number of patients who developed Clostridium Difficile during admission Complaints received throughout the year did not relate to patient care but concerned dissatisfaction with a patient s relative wishing to have a memorial at the Hospice which is not encouraged. Wirral Hospice treats any complaints or dissatisfaction as important, seeking to learn from feedback from the people who use our services. Patient safety Medicine Incidents* Medicine management continues to be a priority for us. Wirral Hospice has a robust reporting process for medicine incidents to ensure a constant review of practice. All incidents relating to the management of medicines are strictly recorded to ensure patient safety, that lessons are learned and to reduce the risk of recurrence. In accordance with the CQC classification of medicine incidents in the Provider Information Return, 11 out of the 161 are reportable as medicine associated incidents Omissions, too much/too little or duplication, wrong medicine, wrong person, wrongly recorded or wrongly administered. The remainder are medicine incidents that are not directly related to patient care or well-being that have been identified by our rigorous reporting processes. For example 131 of the 161incidents reported were due to the omission of an initial or code, and others involved storage and delivery. The numbers and types of incidents will continue to be highlighted and reviewed at the monthly Drugs and Therapeutics group meetings. Training has been provided for regular bank and agency staff, in addition to the mandatory sessions and regular updates for all staff annually. The Pharmacist 24

25 has developed competencies for all trained staff which are to be implemented shortly and will be mandatory Slips, Trips and Falls The Hospice has a Slips, Trips and Falls multi-professional group who meet.quarterly to review all incidents involving slips, trips and falls and to consider and implement any necessary actions to prevent further mishaps. The Hospice Falls Policy has been developed and the group are looking at easier ways of completing falls care plans on the new electronic patient records system. Infection Prevention and control Infection rates continue to remain low. Patients are assessed prior to admission in compliance with our infection prevention and control admission, transfer and discharge policy. Patients are also routinely screened for infection on admission. Staff training in infection prevention and control is part of our mandatory training programme and hand-hygiene is continually promoted throughout the Hospice. The Infection Control lead carries out regular audits against the 23 policies, including responsibilities, hygiene, clinical care and procedures, laboratory specimens, linen laundry, cleaning/decontamination, sharps, isolation procedures and charity shops. Action plans are devised and communicated to managers, staff and volunteers monthly. 25

26 What our patients and families say about the organisation Patient Satisfaction surveys, Comment Forms and face- to- face interviews are utilised throughout all clinical areas of the Hospice including In-patients, Out-patients, Day Therapy and Hospice at Home to ascertain patient and family views on our services and any suggestions they may have for improvement. Responses and any actions taken are communicated to patients and families within the Hospice via the information notice boards. As a family, we were treated with great tenderness and consideration and despite the sad circumstances we have been left with such wonderful memories of our time spent with you all at the Hospice. He couldn t have been in better hands. Thank you for the wonderful care given to my son and for the support and comfort given to the whole family My wife s treatment and care was second to none. The palliative care team, no the palliative care family, were both professional and empathetic to every physical, emotional and psychological need that my father and our family had A special thanks to the cooks for fabulous meals It is a privilege to have a loved one cared for in the Hospice. It is an amazing place and has a very special place in the heart of my family On my visits to the Hospice to be with my daughter, I was very impressed with the treatment and tender care provided through her weeks of pain and suffering. My heartfelt thanks to everyone at the Hospice for providing such a wonderful environment for people in their desperate hour of need There is nowhere that I know of, or could be a better place for people with a terminal illness. You all work as a well-run team from doctors to cleaners. No wonder so many people feel the need to help in the Hospice You made my mum feel safe and that s all we can ask. Thank you for your care and kindness. She loved her time at the Hospice nothing was too much trouble when asking for that extra cuppa or a chat. To each and every member of staff you ve done it again! I came into the Hospice very poorly, and here I am going home feeling really, really well and that s all down to you all as a team. As a team, you would win the Hospice World Cup! Thanks for everything. 26

27 How did Hospice at Home help? Your interventions made such a difference to our Dad. You all do a fantastic job Just wanted to say a huge thank you for the care and support your team gave to mum in her final weeks. The service you provide is second to none. Your carers always went that extra mile Thank you to the Hospice at Home staff who spent time caring for my son. You are all a wonderful extension of the amazing support given to families throughout the Hospice The Hospice at Home team have supplied several significant benefits. It quickly became clear that due to their compassion, skills and caring professionalism, their presence gave my mother both emotional support and wonderful company. The service in my opinion is of a very high standard.it is difficult to know how it can be improved The night service was absolutely fantastic. The support and kindness they gave my partner was wonderful. It put him at ease and made him as comfortable as they could. It helped me and my son to get some sleep. Words cannot express what you have done for us They helped me with my journey home, showed me my meds, gave me information, phone numbers, etc. Lady who brought me home was lovely The service helped tremendously in providing much needed respite care to our family as well as providing support and reassurance to both myself and my elderly mother Allowed us to keep a promise made to my Dad about helping him to die at home 27

28 Bereavement support service The Hospice offers bereavement support both individually and in a group. The bereavement group comprises members whose partner or spouse have died. It is an open group that meets fortnightly, enabling people to join at any time. It is important that the Hospice establishes whether the group is meeting its aims and objectives and to this end a questionnaire has been devised, relatively short in nature, in order to maximise uptake. The following are some of the comments received this year both about the bereavement group and the individual bereavement support offered:- How did bereavement support help? " It s difficult to express how important the meetings were to me. I know that I could call if I needed to very reassuring I was made to feel at ease straightaway and it is a safe and comfortable environment. I have really benefited from this service. I received excellent support and care Very happy with my treatment at the Hospice from all the wonderful staff and obviously a special thank you to the bereavement counsellor who kept me going through a difficult period Thank you -your support was invaluable, knowing I could off load to you confidentially kept me from feeling as if I was going slightly mad at times. It is a long road but the support you gave me has made it easier to travel along I felt I was treated respectfully and really listened to I thought that I was strong enough to cope or I could just talk to friends. Having had counselling and seen first -hand how valuable it is, I have recommended it to friends and colleagues who have experienced bereavement Everything was planned in at my pace. I never felt rushed or under pressure and it made me feel safe to have that level of support Overall feedback is very positive and most importantly the service is meeting individual needs and enabling them to build a new and different life, the principal aim of our service. It is reassuring that our bereavement work, which is often challenging and requires lots of patience from the bereavement team, is enabling those who have lost a loved one to progress with their lives. An appointment was arranged with a doctor for me to discuss some medical queries, with the opportunity to discuss a range of issues Bereavement Support Co-ordinator 28

29 Statement from Clinical Commissioning Group Comments have been requested from Wirral Clinical Commissioning Group (CCG) and are awaited. Statement from Healthwatch Healthwatch Wirral would like to thank Wirral Hospice St John s for the opportunity to comment on their Quality Account for 2014/15 The Hospice core values were impressive and totally relevant and it was good to note that patient care, wishes and needs are at the forefront. Priorities for Improvement 2015/16 The 3 priorities were noted and we look forward to receiving the quarterly reviews on progress against these priorities. Review of Quality Priorities for 2014/15 It was positive to note that:- Tissue Viability A more robust tissue viability procedure has been introduced to protect people from avoidable harm and to maintain high standards of skin care to minimise the risk of pressure area development. The ongoing education of staff in the management and prevention of pressure ulcers. Monthly Audits of pressure ulcers Grade 2 and above. Action plans and progress will be reported to the clinical team and senior managers monthly. Medicines Management There has been a comprehensive review of all medicines management processes and training to ensure staff are familiar with current policies and procedures. Patient Experience User feedback has been sought in a variety of ways No negative feedback has been received with the majority being very positive. The introduction of The Hub and the Patient Information Point Nutrition and Hydration The establishment of a Nutrition and Hydration Group to ensure that people receive good nutritional care. Hospice at Home 29

30 The Hospice at Home Project team continues to provide quality support to patients. Key Performance Indicators Healthwatch were disappointed to see the number of medicine incidents and slips, trips and falls had increased. However, it was positive to note the appropriate steps being put in place to manage these issues. We would welcome more information and details of outcome measures that the Hospice will monitor against. Patient Satisfaction It was pleasing to note the positive comments from patients at the end of the report and the fact that any responses or action from patient satisfaction surveys are communicated to patients and families via the information notice boards. Finally Overall the Quality Account was positive. Healthwatch Wirral has enjoyed working alongside the Hospice including supporting the Patient-led assessments of the care environment (PLACE) and Wirral End of Life Charter. We recognise the value in our relationship and have utilised the functions, duties and powers of Healthwatch to provide challenge and assurances. We appreciate the opportunity to comment on the report as a "critical friend" and look forward to working with the Hospice to support the implementation of the Quality Account and strategic plans. Karen Prior Healthwatch Wirral Manager On behalf of Healthwatch Wirral June