The Darlington & District Hospice Movement

Transcription

1 St Teresa s Hospice The Darlington & District Hospice Movement Registered Charity No Quality Account for the Year 2015/2016 St Teresa s Hospice, The Woodlands, Woodland Road, Darlington, DL3 7UA (01325)

2 PART 1 CHIEF EXECUTIVE S STATEMENT 3 PART 2 PRIORITIES FOR IMPROVEMENT 2016/17 AND MANDATORY STATEMENT OF ASSURANCE FROM THE BOARD INTRODUCTION FUTURE IMPROVEMENT ASPIRATIONS FOR 2016/ PROGRESS ON IMPROVEMENT ASPIRATIONS FOR 2015/ MANDATORY STATEMENT OF ASSURANCE FROM THE BOARD 13 PART 3 REVIEW OF QUALITY PERFORMANCE 2015/ PATIENT SAFETY CLINICAL EFFECTIVENESS /16 PATIENT, CARER, STAFF AND VOLUNTEER EXPERIENCE 29 SUPPORTING STATEMENTS - ST TERESA S HOSPICE QUALITY ACCOUNT THE BOARD OF TRUSTEES STATEMENT 35 ENDORSEMENT BY SENIOR DIRECTORS 35 DARLINGTON CLINICAL COMMISSIONING GROUP STATEMENT 36 COMMENT FROM HEALTHWATCH, DARLINGTON 38 2

3 Part 1 Chief Executive s Statement I am pleased to present the Quality Account for St Teresa s Hospice ; this report looks back on the progress we have made during the past year, and also outlines future aspirations to improve services for patients and families. The Darlington & District Hospice Movement, also known as St Teresa s Hospice is an independent charity (registered number ) and Company limited by guarantee (registered number ). The Board of Trustees is responsible over all for Governance of the Charity. The Strategic Management Team of 5, led by the Chief Executive, is comprised of: CEO, Head of Nursing, Finance Director, Education Manager and Operations Manager. We have a strong focus on quality in the organisation and within our Hospice Team we employ a Data & Quality Manager. During this year, we have invested in the expertise of an external consultant as our Clinical Governance and Quality Assurance Advisor marks our 30 th year of providing hospice services in Darlington & District, and we remain completely committed to ensuring that the patients needs are at the heart of everything we do. We work in a collaborative culture, ensuring that we develop our workforce, integrate with other relevant agencies, and that we never lose sight that our Hospice belongs to local people, without whom, we simply would not be able to continue our vital services. One of our chief aims is to continually improve, and adapt to need. We measure what we do in a variety of ways, always trying to maximise the learning from Friends and Family questionnaires, from questionnaires used by all services, from suggestion boxes, from conversations with patients, carers and colleagues. We also conduct semi-structured interviews with carers, to assess their and their loved ones experience following an episode of care. This year, we introduced a who are we helping today? snapshot report, which is produced ad hoc with co-operation from every single Hospice department, and which has shown that we are consistently helping at least 80 people on any given day. I am responsible for ensuring that this report is compiled, and it is done so via a collaborative approach with service leaders throughout the Hospice, led by our Clinical Governance and Quality Assurance Advisor. To the best of my knowledge, the information reported in this Quality Account is accurate and is a fair representation of the quality of care services provided by St Teresa s Hospice. We simply could not achieve such high standards without an excellent staff team and the added value and expertise of our wonderful volunteer workforce. Thank you so much, to everyone who is part of our Hospice family. Jane Bradshaw Chief Executive 3

4 Part 2 Priorities for Improvement 2016/17 and Mandatory Statement of Assurance from the Board 2.1 Introduction All of the work that St Teresa s Hospice does is inspired by needs of people affected by a palliative or life limiting illness. This includes patients themselves, their loved ones referred to throughout the remainder of the document as carers, and the general public who may look to us for support around Public Health issues associated with palliative care. The Hospice has worked hard over recent years embedding a culture of continuous improvement. But we are not complacent and strive not only to maintain our exceptionally high standards today but to keep moving forwards, being innovative and developing our services so that we can meet needs in the future of an ever-changing population demographic, but also to keep apace of the changes in the commissioning landscape. We measure our performance internally using key performance indicators, soft intelligence and patient feedback, we also measure ourselves against other providers using local and national benchmarks, and we are measured by our commissioning colleagues and the Care Quality Commission. It is the results of these measures which are extremely positive that make us proud of the services we deliver, and motivate us to keep improving where possible. The following quality improvements you are about to read, and reports on quality performance, pertain only to clinical care and relevant support services necessary to provide care. The report does not take into account fundraising and administrative functions of the organisation where separate quality initiatives are employed. The Board of Trustees and Senior Management of St Teresa s Hospice are committed to the delivery of high quality care which is safe, clinically effective and provides the best possible patient experience. 2.2 Future Improvement Aspirations for 2016/2017 The following improvement aspirations have been developed with staff teams and people who use our services including patients, carers and volunteers, and are detailed across the domains of patient safety, patient experience and clinical effectiveness. Improvement Aspiration 1: To Fully Commission our 10 bedded In Patient Unit Quality Domain- Patient Safety, Patient Experience, Clinical Effectiveness How was this aspiration identified? The population is growing alongside changing demographics with an expected increase in life expectancy. By 2020 over 40% of the Darlington population will be over 50 years and 10% will be over 75 years. With a rise in life expectancy it is also expected that more people will have co-morbidities and will suffer with complex illnesses related to older age, such as Dementia; nationally it is widely recognised that a third of over 85 year olds will suffer from Dementia. The annual death rate is growing 4

5 and is expected to rise steeply from 2016; this will have a corresponding rise in the numbers of people requiring palliative and end of life care. The Hospice carried out a local needs assessment in July 2013, identifying the need for more In-patient beds for Darlington and District catchment area. The Cancer Care Alliance in 2005 carried out a needs assessment identifying the need for additional beds and the North Eastern Cancer network wide needs assessment indicates that based on epidemiology, demographics and socio-economic factors, considering a population of Darlington alone of 105,584 (St Teresa s Hospice serves Darlington and District including patients from Durham Dales Clinical Commissioning Group and Hambleton, Richmondshire and Whitby Clinical Commissioning Group) there should be between Inpatient beds. Historically, St Teresa s Hospice had, and today is still operating a 6-bedded In Patient Unit; although offering consistently high quality services, in its current location it poses some barriers to care due to accessibility restrictions and limitations of the Grade 2 listed building, and limitations due to capacity. In , the Board of Trustees agreed an ambitious plan for a purpose built 10 bedded in patient unit on the Woodlands Site. Planning permission was granted in November 2014 and the build programme began during 2015, finishing in April Although the physical building is now complete, at the time of writing further work is required before it is finally fit for purpose; bedrooms and the en-suite bathrooms need fully furnishing and commissioning, and the Garden also requires re-landscaping now that the construction phase is over, to ensure patients and their visitors are offered privacy and dignity and access to the peaceful outside space. How will it be achieved? During 16/17 we are ready to deliver our ambitious plan and fully open the Purpose build IPU in line with the following milestones: April June: Installation of furniture, fixtures and fittings May (tba): Visit by Care Quality Commission, prior to re-registration May: o o a series of orientation sessions for the IPU team, catering & housekeeping team, operations and security staff a series of visits for all hospice staff and volunteer teams in other departments May-June: re-landscaping June-July: Move to new unit and become fully operational A programme of open days will be held during this final commissioning period, taking advantage of the time between the building completion and the unit becoming fully functional, in order to give colleagues, supporters and local people the opportunity to see the new facility. How will it be monitored and measured? Monthly project team meetings, with bimonthly reports into the Board of Trustees will continue until the unit is fully-functional, and thereafter regular users meetings will take place to ensure the unit operates at maximum efficiency. The quality of care will continue to be measured through our already embedded assurance systems. 5

6 Improvement Aspiration 2: To develop a comprehensive Quality Assurance and Risk Management Framework Quality Domain- Patient Safety, Clinical Effectiveness, How was this aspiration identified? The Hospice has worked extremely hard in specific areas to improve patient safety. We have many examples of good practice, in our various services, all of which have driven up our patient safety and the quality of the services we deliver. The next phase is to bring together a One Hospice integrated framework for the management of the safety, quality, risk assessment, incident reporting and patient feedback. By doing this we will avoid duplication and also identify any work stream areas for development. Once this framework is in place, it will develop a culture of collective responsibility for patient safety across the Hospice. How will it be achieved? The Clinical Governance group will oversee the work and monitor on a quarterly basis. Design and Agreement of overarching framework June 2016 Use the Manchester Patient Safety Framework to assess culture of different departments August 2016 Develop Action plans following above exercise September 2016 Implement Developments February 2017 Reassess culture March 2017 Finalise and Implement RGN Core Competencies March 2017 How will it be monitored and measured? Progress against key milestones will be monitored at the Quarterly Clinical Governance Sub Committee. Improvement Aspiration 3: To implement OACC (Outcomes and Complexity Collaborative) Quality Domain- Clinical Effectiveness, Patient Safety: How was this aspiration identified? St Teresa s Hospice has many ways of measuring our services in terms of capacity or quality of patient experience, but it is very difficult to measure outcomes of care. In 2015/2016, we introduced MYCaW 1 as a patient-related outcome measure, which was a great success and elicits valuable feedback. However, the information is fairly basic, and is subjective as its patient perspective rather than clinical 1 The MYCaW ( Measure Yourself Concerns and Wellbeing ) is a patient reported questionnaire, devised by Dr Charlotte Paterson, which measures changes in levels of concerns and wellbeing. 6

7 outcomes. OACC has been designed and led by the Dame Cicely Saunders institute working in partnership with Hospice UK. OACC is a suite of fit for purpose, evidence based outcome measures to capture and measure the difference made to patient outcome by the palliative care service providers. The project will have many benefits and will be used to drive service improvement and deliver evidence on the impact of our services and hopefully achieve better results for patients and families. How will it be achieved? Identify Clinical Champion/s May 2016 Establish Task and Finish Group and agree work plan for implementation June 2016 How will it be monitored and measured? Progress against key milestones in the work plan once established, will be monitored at the Quarterly Clinical Governance Sub Committee. Improvement Aspiration 4: To explore the role of St Teresa s Hospice in Transitional Care Quality Domain- Patient Experience: How was this aspiration identified? St Teresa s Hospice is registered to provide services to patients age 18 and above. In 2013, a 17 year old Darlington resident was referred to the Hospice by the paediatric palliative care team at James Cook University Hospital. Unfortunately, as the patient was under age we were unable to provide care until the patient reached 18 years of age, although the Family Support Team were able to support their family. The population of young people with life limiting conditions is growing and it is vital that their needs are addressed and planned for as they transition into adulthood. Together for Short Lives 2 have begun to raise the profile of the need for better transition services nationally and the local Palliative and End of Life Steering group have also identified this as a priority. During 2015 NICE released guidance for providers on transitional care, further highlighting the need to improve services. St Teresa s Hospice has always been a pioneering Hospice, and our drive is to meet patient needs as safely and clinically effectively as possible. Therefore, the Hospice is keen to explore how and if we may serve this growing patient population and importantly how we can support them to achieve their on-going wishes and hopes for their future and their care as they live with their life limiting illness. How will it be achieved? Link/Network Local Paediatric Network June 2016 Review NICE Guidance on Transition June Together for Short Lives is the leading UK charity that speaks out for all children and young people who are expected to have short lives. 7

8 Ascertain locally available services /Gaps in services October 2016 Ascertain what young people need from Hospice Services February 2016 Recommendations for the Hospice relating to Transition March 2017 How will it be monitored and measured? Progress against key milestones will be monitored at the Quarterly Clinical Governance Sub Committee. Improvement Aspiration 5: To fully develop a Volunteer Visiting Scheme Quality Domain- Patient Experience: How was this aspiration identified? The Hospice at Home service has been reviewed over recent years, with a registered nurse employed to assess and develop the service. As a result, the referral type has changed over time i.e. previously, the patients were relatively stable although still with a palliative diagnosis, and their need was more social, but now, many more Patients referred to the service are more complex, and many are end of life patients. Due to capacity, these complex patients are prioritised, however, there are still those with a social need. During 15/16 a pilot service was established to assess the feasibility of a Volunteer Visiting Service, the pilot has evaluated very well and the service will be fully developed. How will it be achieved? Building on the success of the pilot, the Volunteer Visiting Service will be further developed. The service will provide trained volunteers who will visit patients in their own homes for 2 hours a week. The volunteers will provide social contact, preventing social isolation, and may do some light tasks such as making hot drinks, accompanying a patient to an appointment or collecting a prescription. Milestones will include: Recruitment of suitable volunteers July 2016 Review existing training programme July 2016 Volunteer Training September 2016 Service Promotion Commence September 2016 Service Evaluation March 2017 How will it be monitored? Monitoring of the Volunteer visiting service by the Hospice at Home Team leader will be on a weekly basis and reported on quarterly at the Clinical Governance meeting. 8

9 How will progress be monitored and reported on for all future improvement aspirations 2015/2016? St Teresa s Hospice Board of Trustees will monitor and report on progress through a variety of methods including: Annual return to the Charity Commission Annual review and audited reports and accounts Quality Account and reports to Clinical Governance Sub Committee Annual General Meeting Hospice Newsletter and other publications Events, such as open days Annual Staff and Volunteer workshop 9

10 2.3 Progress on Improvement Aspirations for 2015/2016 The purpose of the Quality Account is to not only set out future improvement aspirations but to also evidence achievements on aspirations for improvement for the previous year. In last year s report we set out 4 aspirations for improvements for our services. All aspirations were specifically selected as they would directly impact on the care our patients and carers received, through improving patient safety, clinical effectiveness or the patient s experience. The quality improvement aspirations for the previous year were: 2015/16 - Aspiration 1: To build a purpose built, 10 bedded In Patient Unit Quality Domain- Patient Safety, Patient Experience, Clinical Effectiveness What we have achieved: As reported on earlier, our new In Patient Unit was completed by April Some of the considerable advantages are summarised as follows: - 10 bedded unit (replaces 6 which weren t fully accessible) - All rooms are fully accessible - Including 1 bariatric room - All bedrooms with ensuite wet rooms - Specialist lighting in all rooms - Piped oxygen in all bedrooms - Wide corridors for patient, staff and visitor circulation areas - Designated visitors room with overnight stay facility - Dedicated reception area and car parking for up to 12 vehicles - Discrete ambulance door for access and egress out of public sight How we will continue to improve: Please refer to aspirations and milestones for 2016/ /16 - Aspiration 2: To develop a comprehensive Hospice-based Lymphoedema Service Quality Domain- Patient Safety, Clinical Effectiveness, Patient Experience Lymphoedema is a chronic inflammatory disease developed following obstruction or failure of the lymphatic system, resulting in swelling of limbs, trunk, head and neck, breast or genitalia. It can be classified as Primary (intrinsic defects of the Lymphatic system) or Secondary (due to extrinsic damage surgery, infection or disease). Impacts on patients suffering with Lymphoedema can be catastrophic including pain, cellulitis, significantly swollen and infected limbs, and impacts on body image and mental health and in some cases amputation. The need for a dedicated, comprehensive Lymphoedema service was identified primarily by patients. 10

11 What we have achieved: Excellent partnership working with Darlington CCG who have contributed to the funding to establish a Hospice based Lymphoedema service, training programme and support programme Secondment of RGN with specialist lymphoedema training to run the service Development of patient pathway from GP direct to clinic Lymphoedema clinics meeting patient need, providing four cornerstones of care Use of MYCaW tool pre and post treatment to assess effectiveness of care Comprehensive range of patient information Support group for ongoing maintenance management and peer support Lymphoedema Key Worker training delivered to Community Nursing Teams Delivery of Lymphoedema care into Nursing homes a previously unmet need Avoidance of Hospital admittance due to cellulitis Improved patient experience How we will continue to improve: Part-funding has been secured for 16/17, however this is non-recurring A full service evaluation will be carried out to indicate areas of future service development and to explore how the service can be made sustainable. 2015/16 - Aspiration 3: To explore the role of St Teresa s Hospice in Transitional Care Quality Domain- Patient Experience St Teresa s Hospice is registered to provide services to patients age 18 and above. In 2013, a 17 year old Darlington resident was referred to the Hospice by the paediatric palliative care team at James Cook University Hospital. Unfortunately, as the patient was underage we were unable to provide care until the patient reached 18 years of age, although the Family Support Team were able to support her family. The population of young people with life limiting conditions is growing and it is vital that their needs are addressed and planned for as they transition into adulthood. Together for Short Lives have begun to raise the profile of the need for better transition services nationally and the local Palliative and End of Life Steering group have also identified this as a priority. What we have achieved: St Teresa s Hospice has always been a pioneering Hospice, and our drive is to meet patient needs as safely and clinically effectively as possible. Our services are developed in line with Organisational Strategic Objectives, and it was decided that more time is required to explore the local need for both Transitional and Dementia care in our local community, so that we can ensure we are using our finite charitable funds to develop services where there is most need. Transitional Care will be further explored during 2016/

12 2015/16 - Aspiration 4: To develop a Day Hospice Satellite for North Yorkshire Patients Quality Domain- Patient Safety, Clinical Effectiveness, Patient Experience What we have achieved: The Hospice has successfully developed a Day Hospice Satellite service for 10 North Yorkshire patients at any one time, located in Scorton Volunteer driving service in place to enable patients to attend, even from rural areas Patients access the CHOICES 3 programme on a weekly basis for 12 weeks, when they are reassessed and either discharged or invited to attend further sessions depending upon need Every patient has an assessment, and a care plan is designed with their care needs; CHOICES provides a range of opportunities to support peoples physical, social, psychological and spiritual needs; carers needs are also assessed An 8 week respiratory clinic, for 6 patients at any one time has been offered in two localities within North Yorkshire (Scorton and Thirsk) How we will continue to improve: Funding has been secured for 16/17 Service promotion work will commence with all referrers to ensure that we reach those patients who need our services most 3 CHOICES is a bespoke, integrated, exercise, social activity and nursing assessment programme, for Day Hospice patients, devised by St Teresa s Hospice 12

13 2.4 Mandatory Statement of Assurance from the Board The following statements must be provided within the Quality Account by all providers. Many of these statements are not directly applicable to specialist palliative care providers including St Teresa s Hospice, therefore explanations of what these mean are given Review of Services During the reporting period 2015/2016 St Teresa s Hospice, Darlington provided the following services to the NHS: 6 Bedded In Patient Unit Day Hospice Service Day Hospice Satellite Hospice at Home Rapid Response Service Lymphoedema Services Family Support (including welfare benefits) Complementary Therapies During the reporting period 2015/2016 St Teresa s Hospice, provided or sub contracted 7 NHS services (no funding received for Complementary Therapies). The Hospice has reviewed all the data available to them on the quality of these NHS Services. The income generated by the NHS services reviewed in 2015/2016 represents 100 per cent of the total income generated from the provision of NHS services by St Teresa s Hospice, Darlington for 2015/2016. The income generated represents approximately 30% of the overall costs of running these services. What this means: St Teresa s Hospice is an independent Charity which provides all services free of charge. The income generated from the NHS (Darlington Clinical Commissioning Group and Hambleton, Richmondshire and Whitby Clinical Commissioning Group) in 2015/2016 represents 33.8% of the overall costs of service delivery, with the remaining income to fund our services from voluntary charitable donations, legacies, Hospice shops, the One Wish Lottery, events and community fundraising. St Teresa s Hospice for the accounting period 2015/2016 signed an NHS contract with Darlington CCG, and a voluntary sector grant with Hambleton, Richmondshire and Whitby CCG, similar arrangements are in place for 2016/2017. St Teresa s Hospice has taken full responsibility for the contract for Rapid Response in April 2016/17 (previous partnership service St Teresa s Hospice and Marie Curie). 13

14 2.4.2 Participation in Clinical Audit During 2015/2016 no national clinical audits or confidential enquiries covered NHS services provided by St Teresa s Hospice. During 2015/2016 St Teresa s Hospice participated in no national clinical audit and no confidential enquiries of the national clinical audits and national confidential enquiries as it was not eligible to do so. The national clinical audits and national confidential enquiries that St Teresa s Hospice was eligible to participate in during 2015/2016 was none. The national audits and national confidential enquiries that St Teresa s Hospice participated in, for which data collection was completed during 2015/2016, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of audit or enquiry. St Teresa s Hospice was not eligible to participate; therefore, there is no information to submit or list here. What this means: St Teresa s Hospice as a provider of palliative care was not eligible to participate in any national audit or confidential enquires as these have not pertained to palliative care during the accounting period. St Teresa s Hospice has not reviewed any national or local audits during 2015/2016 and therefore has no actions to implement Research The number of patients receiving NHS services provided or sub-contracted by St Teresa s Hospice in 2015/2016 that were recruited during that period to participate in research approved by an ethics committee was none. There was no appropriate, nationally, ethically approved research studies in palliative care in which St Teresa s Hospice could participate CQUIN Payment Framework Darlington CCG St Teresa s Hospice NHS income in 2015/2016 was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework for 2 elements within the contract. The 2 CQuINS represented 2.5% of the overall contract value. (CQuIN measures included Volunteer Visiting Scheme and Medicines Safety). Hambleton, Richmondshire and Whitby - St Teresa s Hospice NHS income in 2015/2016 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework because it had a voluntary sector grant in place Statement for the Care Quality Commission St Teresa s Hospice is required to register with the Care Quality Commission and its current registration status is for the following regulated activities: 14

15 Diagnostic and screening procedures Treatment of Disease, disorder or injury Personal Care St Teresa s Hospice is registered with the following conditions: Services are provided for people over 18 years old The maximum of 6 patients may be accommodated overnight Notification in writing must be provided to the Care Quality Commission at least one month prior to providing treatment or services not detailed in the Statement of Purpose St Teresa s Hospice is subject to periodic and unplanned reviews by the Care Quality Commission (CQC), the last on-site inspection was in December St Teresa s Hospice was fully compliant with all the essential standards of Quality and Safety as set out in the CQC registration and the Health and Social Care Act. The CQC has not taken any enforcement action during and St Teresa s Hospice has not participated in any special reviews or investigations by the CQC in this time period. The CQC has issued new regulations and the Hospice category Adult Social Care Services: Hospice Services. The Hospice has baselined current activity against new regulations and a development plan is in place in readiness for the new inspection process. The Hospice has also completed Provider Information Returns (PIR) and awaits the unannounced inspection Data Quality St Teresa s Hospice did not submit records during 2015/2016 to the Secondary Users Service for inclusion in the Hospital Episode Statistics. What this means: St Teresa s Hospice is not eligible to participate in the scheme. In the absence of this we have our own system in place to collect and monitor data through the electronic patient information system, SystmOne. St Teresa s Hospice also submits data to the National Minimum Dataset for Specialist Palliative Care Services collected by the National Council for Palliative Care on an annual basis Information Governance Toolkit Attainment St Teresa s Hospice participated in completion of the Information Governance Toolkit in 2015/2016, the outcome was satisfactory, with improvements made since last year s audit and an appropriate action plan for improvements for the forthcoming year has been developed which is timetabled for review on an annual basis. All clinical staff have completed annual top-ups for information governance as part of mandatory training Clinical Coding Error Rate St Teresa s Hospice was not subject to the Payment by Results clinical coding audit during 2015/2016 by the audit commission. 15

16 Part 3 Review of Quality Performance 2015/16 The review of Quality at St Teresa s Hospice can be considered across the three domains of Patient Safety, Clinical Effectiveness and Patient, Staff and Volunteer Experience. The following information provides information on these areas during the accounting period 2015/ Patient Safety Patient safety is of the highest importance at St Teresa s Hospice. During the past twelve months, further improvements to patient safety with the introduction of a patient safety group responsible for monitoring and continuously improving patient safety. A clinical risk register, and an annual work plan for clinical governance development are in place and are monitored at the Clinical Governance Subcommittee, which the medicines management group also reports into. Safe Staffing The right person, in the right job, in the right place at the right time is essential to ensure patient safety. Staffing levels are monitored constantly and a bi-annual staffing report is produced for the Board of Trustees which focuses on transparency, capacity and capability and actual and planned staffing levels which are further triangulated with occupancy and incidents. Dependency tools are in place so that additional staff needs can easily be identified for complex patients. Safeguarding and Deprivation of Liberty Safeguards All clinical and non-clinical staff have had training appropriate to their role. Safeguarding or DOLS incidents in the reporting period. There were no Risk Assessments Risk assessments are carried out as part of everyday practice with patients and organisationally. They are in place in clinical areas and to address health and safety hazards in all areas of the organisation. Additionally COSHH risk assessments have been carried out for hazardous substances. CAS alerts 4 monitoring system in place. Incident Reporting Incident reporting processes have been improved over the past twelve months with Root Cause Analysis training improvements in the investigation practices surrounding incidents. For the period 1 st April st March 2016 there were 57 health and safety and clinical incidents reported. There were no Never Events or Serious Incidents during the reporting period. All In Patient Unit incidents are reported via Safeguard System (incidents involving NHS Staff on the In Patient Unit) and also reported via internal governance processes and reviewed and monitored by the Clinical Governance sub group. 4 CAS alerts: The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care. 16

17 Table 1 Demonstrating Clinical Incidents during Accounting Period 2015/2016 Clinical Incident Number Slips, trips, falls and accidents - patients 9 Slips, trips, falls and accidents staff and volunteers, and visitors 3 Pressure ulcers 9 Infections 0 Drug errors and adverse effects 3 Incidents relating to medication 2 Other clinical incidents 16 Other non-clinical incidents 10 Information Governance 5 Slips, trips, falls and accidents There were 12 incidents involving patients, staff and volunteers in total, none of which resulted in major injury requiring reporting to the Care Quality Commission, Health and Safety Executive or North East Commissioning Support Unit. Of these, 9 were patient falls, 4 of which were on IPU and patients had appropriate falls assessment within 6 hours of admission and care plans in place. Pressure Ulcers Infections and pressure ulcers cause pain and distress to patients and families 9 pressure ulcers were recorded, 6 patients were recorded to be admitted with existing pressure ulcers, the remaining 3 were investigated and were deemed unavoidable. Infections There were no hospital acquired infections during the accounting period. Infection control practice is rigorously implemented and monitored by the Hospice and is assessed annually by an external auditor (the Senior Infection Prevention and Control Nurse NHS County Durham and Darlington CCGs Infection Prevention and Control Team). Incidents relating to medication There were 2 incidents relating to medication, (1 discrepancy in total amount when destroying controlled drugs, which was resolved, 1 patient transfer where drugs not supplied when prescribed). 17

18 Drug Errors There were 3 drug errors; all were investigated fully and improvements in practice implemented; however, all errors still fell within safe prescribing limits of the administered medications. Never Events and Serious Incidents There was no Never Events or Serious Incidents Safety Thermometer St Teresa s Hospice has voluntarily completed the patient safety thermometer for the past 12 months and reported its findings nationally to the Department of Health. The Safety thermometer is a snapshot measure taken across pre-determined domains on a different day each month. During April 2015-March 2016 time period, the following harms were recorded in domains measured: Clinical Pressure Catheter & VTE Falls Area Ulcer UTI IPU Clinical Effectiveness Many components contribute to demonstrating clinical effectiveness including quantitative data, Key performance indicators, audit and an overarching, strong clinical governance steer. Data collection at St Teresa s Hospice has developed significantly over recent years due to the installation of SystmOne patient information system. All departments are now paper light except IPU (paper systems are reduced, however are still necessary for Medication Charts and some patient held information such as DNACPR 5 forms). Hospice Performance against National Council for Palliative Care Minimum Dataset The Hospice collects statistical information on activity and submits this to the National Council for Palliative Care for inclusion in a National Minimum Dataset (MDS). This allows comparison of local data to the national average similar sized Hospices. The following table displays performance of St Teresa s Hospice to the National MDS from the previous reporting year, as the actual data for this accounting period will not be available until September Comparing St Teresa s Hospice to the National Minimum Dataset Area Inpatient Services Total number of Patients Admitted St Teresa s Hospice 2012/2013 St Teresa s Hospice 2013/2014 St Teresa s Hospice 2014/2015 St Teresa s Hospice 2015/ Nat l Min. Data Set 2014/15 Total New Patients Re-referred Patients Average Occupancy Bed 64% 69% 62% 74% 77% 5 DNACPR = Do Not Attempt Cardio Pulmonary Resuscitation 18

19 Area St Teresa s Hospice 2012/2013 St Teresa s Hospice 2013/2014 St Teresa s Hospice 2014/2015 St Teresa s Hospice 2015/2016 Cancer Diagnosis (%) 84% 83% 83% 93% 87% Non Cancer Diagnosis 13% 11% 17% 7% 13% (%) Average length of stay (days) Died in Hospice (%) 46% 51% 63% 68% 58% Discharge care home 5% 4% 4% 1% - (%) Discharge acute (%) 2.5% 5.5% 5% 1% - Discharge home (%) 33% 35% 27% 17% - Other 13.5% 5% 2% 13% 1% Day Hospice CHOICES Programme Total number of Patients treated Number of New Patients Total Days available places Total Places attended Nat l Min. Data Set 2014/15 Total Places booked DNA and CNA Average length of care (days)* Cancer Diagnosis (%) 65% 62% 64% 52% 73% Non Cancer Diagnosis 17% 36% 36% 43% 27% (%) Hospice at Home Total Number of Patients treated New Patients Patients died in 12% 22.5% 2% 0% - Hospice (%) Patients died at Home 68% 65% 95% 94% 90% (%) (achieving PPC) Patients died acute or 0 0 2% 6% - Community Hospital (%) Cancer Diagnosis (%) 55% 54% 78% 64% 80% Non Cancer Diagnosis 45% 40% 22% 29% 20% (%) Length of Care (days) *Day Hospice Transformation 14/15 figure represents CHOICES Programme only 19

20 No of Patients In Patient Unit - During the accounting period the Hospice had a total of 118 patients on the In Patient Unit, 110 of which were new referrals. - Bed occupancy was 74% similar to the MDS national average of 77%. - Patients with a Cancer diagnosis on IPU was 93%, an increase on previous years and is higher than the national average of 87%. - Average length of stay was 13 days, an increase on previous years but is similar to the national median of 12 days, however, the MDS includes planned respite which we do not currently offer due to limitations on capacity. - The number of patients dying in the Hospice is also higher than the national average at 68% compared to the MDS of 58%. - The majority of referrals were for End of Life Care, a change from the last reporting periods where the greatest reason for referral was Symptom Control. - The majority of patients either died in the IPU or were discharged home (many supported by Hospice at Home or Rapid response), significantly lower patients were discharged to the acute trust or a care home when compared to last year. - Of those who died on the IPU, for many it was not their first admission demonstrating we were able to support earlier in their patient journey. - The overall picture suggests that patients are coming into the Hospice and staying longer than previous years and also more patients are choosing the Hospice at the end of life, suggesting we are seeing more complex patients at the end of life. - We have had a waiting list in operation throughout the year. Bar Chart demonstrating Reason for Referral to In Patient Unit 2014/15 and 2015 / IPU Reason For Referrals Symptom Control End of Life Crisis Respite Not recorded 0 Qtr /15 Qtr /15 Qtr /15 Qtr /15 Qtr /16 Qtr /16 Qtr /16 Qtr /16 IPU has seen a significant increase in referrals, 177 referrals compared to 148 in the last financial year. This may be partially explained by a change in the way referrals are now received, however, despite the improvement overall referral rate has increased. The bar chart below demonstrates outcome of referral, where the referral was accepted and not admitted reasons include, patient choice, change in condition and limitations of the current IPU building where a stretcher lift is available only for 3 bedrooms. 20

21 No of Referrals IPU Outcome of Referral No of referrals received No of referrals accepted No of referrals admitted 10 0 Qtr /15 Qtr /15 Qtr /16 Qtr /16 Qtr /16 Qtr /16 Day Hospice - The Day Hospice was reviewed and underwent service development in 2014/2015, this year s data represents a full year s data following the transformation. - One of the strategic objectives in transforming day hospice was to REACH more patients with a non-cancer diagnosis. - The Day Hospice now includes the pioneering CHOICES programme 3 days per week of structured Day Hospice Days plus disease specific clinics, 2 days per week (Neurology, Respiratory, and Heart Failure). - The bar chart below demonstrates that the strategic objective has successfully been achieved, with a significant increase in non-cancer patients accessing Day Hospice. The Day hospice has supported 501 individual patients during the accounting period. 60% 50% 40% 30% 20% 10% Patient Primary Diagnosis, Year on Year Comparison 0% 2014/ /16 Cancer Non Cancer Carer 21

22 No of Appointments The CHOICES programme operates 3 days per week, and provides the patient with a care plan were they can choose to partake in activities all with a therapeutic benefit. The total number of places for CHOICES was 3020, with an attendance rate of 56%, which is an increase of 5% from the previous year. Looking at the graph below, it is clear that as the year progressed, booked appointments are very similar to capacity, which correlates with service promotion work with the referrers to the service. Average length of care was longer than the national median of 177 days with Hospice average length of care 194 days, however this is a reduction from 226 the previous year. The aim is that we provide the right service to the patient at the right time Choices Appointment Summary 2015/16 Capacity (no of Appts) No of Booked Appts No of Appts Attended Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 15 Feb 16 Mar 16 0 Feb-15 Apr-15 May-15 Jul-15 Sep-15 Oct-15 Dec-15 Jan-16 Mar-16 Hospice at Home - The Hospice at Home service supported 125 patients during the accounting period, 109 of these patients were new referrals. This is almost a 24% increase on the previous year when total number of patients accessing the service was 101. However, the bar chart below demonstrates that total number of planned visits was slightly lower. When we also consider average length of episode, we can see this has reduced. - The overall picture now suggests that the Hospice at Home service is truly meeting its objective to support patients at the end of life to stay in their preferred place of care (not with domiciliary care needs, see improvement aspirations). - 79% of patients reported home as their preferred place of care, were supported to die at home compared to a national median 89%. - Again the Hospice was able to support non-cancer patients extremely well with 29% of total patients having a non-cancer diagnosis, an increase on last year s figure of 22 %, this also compares favourably to a national median of 20%. 22

23 No of Patients No of Days No of Visits Bar chart showing total Hospice at Home Planned Visits, Year on Year comparison Hospice at Home Planned Visits / / /16 Average Length of Episode / / /16 Preferred Place of Care RIP PPC Achieved / /16 23

24 No of Patients No of Patients General Information The total number of patients accessing all services in the graph has increased from the previous year to 821 (2014/2015, 656 patients) and a significant increase in Day Hospice and Family Support referrals. Bar Chart of Total number of people accessing our services cumulatively (Patients, Carers and Bereaved) Individual Patients / / / / /16 Bar Chart of Total number of people accessing Hospice by service type 600 Number of patients accessing each service IPU Day Hospice/OP Hospice at Home Family Support OP / / / / /16 NB from onwards, Day Hospice includes Out Patients (previously reported separately) Key Performance Indicators (KPI) The Hospice reports quarterly on Key Performance Indicators to meet contractual requirements. A summary of the performance for the accounting period can be seen below. Performance against 24

25 KPI has been excellent in the majority of areas where there are shortfalls explanations are provided. Financial Year 2015/16 Measure Threshold Q1 Q2 Q3 Q4 Comments 1 Time for In patient referral to decision to admit/not to admit 90% within 2 hours 100% 93% 92% 100% 2 Number of In patients who have been offered an ACP 3 Number of In patients who are on LCP or equivalent at time of death 4 In patient bed availability (i.e. are all beds available for use- not vacant beds) 90% 100% 92% 85% 89% ACP not appropriate for EOL patients 90% 0% 0% N/A N/A The LCP has been phased out and priorities of Care replaced. 95% 81% 88% 84% 87% 5 In patient bed occupancy 85% 86% 77% 59% 73% 6 % of Day Hospice/Outpatients receiving a care plan 100% 100% 100% 100% 100% 7 Time from Day Hospice/outpatient referral to assessment >90% within 7 days 60% 63% 90% 88% Staff vacancies in Q 1 & 2 8 Hospice at Home- record made as to whether patient has an ACP 9 Hospice at Home- referral for assessment made to key worker within 24 hours for those patients who don t need an ACP 10 Hospice at Home- number of patients who the service are facilitating 100% 100% 100% 100% 100% >95% 94% 94% 90% 91% >85% 100% 77% 90% 87% 25

26 nursing care at their time of death whose PPC is achieved 11 FST and Bereavement client to be contacted within 7 working days of receipt of referral 12 FST and Bereavementclient assessment to commence within 15 working days of receipt of referral 13 FST and Bereavementwritten assessment of needs and action plan agreed with client >95% 100% 95% 100% 94% >95% 91% 89% 90% 94% 100% 100% 100% 100% 100% 26

27 Patient related Outcomes The Hospice will introduce additional patient related outcome measures (see future aspirations), however has been using MYCaW as a basic outcome measure of efficacy of patient care. The MYCaW tool allows a patient to score their individual problem for example pain, or nausea prior to treatment and following a course of 6 treatments from acupuncturists. The Graph below demonstrates that every patient using MYCaW receiving acupuncture has improved significantly as a direct result of treatment received. 35% 30% 25% 20% 15% 10% 5% Complementary Therapies Average % Improvement 0% Problem 1 Problem 2 General Wellbeing Local Audit To ensure high quality of services audit is important and the annual audit programme is now well established using nationally agreed formats such as Help the Hospice audit tools and also locally developed audit tools. For audits undertaken, action plans for improvement are developed, and monitored by the clinical governance sub group. This enables us to monitor quality and make improvements where needed. All clinical staff are encouraged to participate in at least 1 audit per annum and audit is on every staff meeting agenda. The audit programme for the forthcoming year will focus on patient outcomes as well as processes. Other Quality Initiatives During the accounting period the additional Quality Initiatives have been introduced: Business Continuity Plan developed and now in place Review of Lone Worker System both patient and staff safety are paramount. The lone worker procedure has been fully overhauled and replaced GSF attendance- Attendance at Gold standards framework meetings at GP practices to ensure we are reaching the right patients 27

28 Establishment of Service Promotion Group- to monitor referral trends and ensure that we are REACHING as many people as possible Care of Dying Patient Introduction and use of NICE guidance around Care of the Dying Patient Patient handover- Improvements to patient information handover between shifts using SBAR (situation- background-assessment-recommendation methodology) Full implementation of HCA Core Competencies ensuring all our HCA staff are working to the same standard Medicines management The Hospice procurement of medicines has been reviewed in light of new MHRA guidance. Pharmacy support is now in place Volunteer Training volunteers now receive training specific to their area of work and are included in patient handover. Protected Learning Event (PLT) for GP s- All Darlington practices attended a PLT in Palliative Care during April 2015, the programme was designed to provide education in symptom management at the end of life and to develop a strategic vision for integrated working. 28

29 /16 Patient, Carer, Staff and Volunteer Experience Staff Experience Staff experience is measured in three ways: Accurate monitoring, reporting and review of sickness levels Confidential annual staff experience survey Line management support including 1:1 contact meetings and annual Appraisal process. Hospice Staff Sickness levels The reporting system for staff sickness in all departments is now firmly established and a report produced quarterly for the HR Sub Committee of the Board of Trustees and monthly updates provided to department heads. Capability procedures and sickness monitoring systems enable any worrying trends to be identified; however, there are no current trend alerts. The average sickness rate was 3% per wte. The introduction of new HR software in 2016/17 will further improve sickness absence monitoring and reporting, and provide better insight direct to line managers. Confidential Annual Staff Experience Survey An annual staff experience survey was carried out with an 85% response rate. Overall, staff morale displays no worrying trends. Line Management and Appraisal The Hospice ensures all staff regularly meet with their line manager for contact meetings and have an annual appraisal, 96% of eligible staff received an annual appraisal during 2015/2016. The majority of those outstanding were due to long term leave and the phasing in of formal annual appraisals for bank staff, which was introduced in 2015/16 and well-received. The Hospice management also operates a vital open door policy. Clinical Supervision All patient and client-facing staff are offered the opportunity to partake in clinical supervision and this is a firmly established practice. Clinical supervision provision also extends to administrative staff in relevant roles, recognising that they can also have potentially distressing conversations with patients and their families, and are regularly exposed to information regarding patients conditions. Clinical supervised practice is reviewed annually to ensure it is effective. During the Housekeeping Team were introduced to Clinical Supervision, having identified that they would appreciate a de-brief session occasionally. These essential team members inevitably often have to access patients rooms (when they are occupied), are sometimes witness to quite emotional scenes when visitors are present, and are involved in the deep-clean of rooms, following a death. The Hospice now provides formal clinical supervision and also a clear line of ad-hoc support to this team. This has proved to be both effective as support for individuals and effective as team building/morale-boosting. 29