Saint Catherine s Hospice Quality Accounts 2012/13

Saint Catherine s Hospice Quality Accounts 2012/13 Your Community, Your Hospice, Our Care

Part 1- Statement from the Chief Executive On behalf of our Board of Trustees and the Senior Management Team, I am pleased to present the Quality Account for Saint Catherine s Hospice 2012/13. The continued work of our dedicated members of staff and volunteers enables the Hospice to deliver high quality services. Our team here continues to strive for excellence in all they achieve. Our patients, their families, and carers are at the very centre of our care and delivering quality care to them is our main focus. Our Vision is to be the provider of choice for excellent palliative and end of life care, which meets patient need and for which we have the skills and knowledge to make a difference. Saint Catherine s Hospice exists to provide care to improve the quality of life for patients and their families, facing their death, irrespective of their diagnosis. Quality is therefore a central feature of our work in that only if the service we provide is of the highest quality can we ensure that the quality of the patients life is improved. The Hospice has established a strong governance framework from that enables us to focus on the quality of our services. Our Board of Trustees is focussed on good governance and through both the Board and the Finance, Clinical Governance, Resources and Fundraising sub-committees play a key role to ensure the organisation is both viable and responsible. Our Executive Team delivers the operational assurances through a framework of clinical and corporate governance groups. Audit is a regular feature of the work that we do to ensure that policies and procedures are being carried out as they should and that they are still appropriate. Patient and carer feedback is sought regularly through our compliments, comments and complaints leaflet, through patient and carer questionnaires and by listening to patient and carer views through a range of supportive groups. During the last year we have been working with the newly emerging Clinical Commissioning Groups to pilot new ways of working which will enhance the quality of care for patients nearing the end of their life and those living with long term conditions. These pilots are subject to on-going monitoring and evaluation to assess the impact of these interventions and validate the quality of their delivery. Our regulators, the Care Quality Commission, have inspected our patient areas across all three sites and confirmed that they meet their demanding clinical standards. Our services are not simply about meeting standards and delivering high quality and excellence in all we do. They are about delivering holistic care and embracing people as individuals, providing care, improving their personal experience and ensuring dignity and privacy.

I am responsible for the preparation of this report and its contents. To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality of the healthcare services provided by Saint Catherine s Hospice, Scarborough. 1.1 Our Intent The hospice works under the banner of Your community, Your hospice, Our care Your community To take the lead in securing excellent end of life care for patients in our community. To work collaboratively with other healthcare providers to support integrated care for palliative and end of life care patients in our community. To enable patients to be cared for in the right place, at the right time for their needs. Your hospice To be a kite mark for quality and compassion wherever we work. To use our charitable endeavours to add value to statutory provision. To develop our volunteers and staff and support them in their roles. Our care To put patients at the centre of everything we do. To provide high quality specialist palliative care for those patients with complex needs. To support the provision of good end of life care and long term palliative care for patients with less complex needs. Part 2 Measuring Quality in Detail Saint Catherine s Hospice monitors the quality of care that is provided across the organisation via its Clinical Governance Committee. The importance of providing quality care is underlined by the membership of the committee which includes the organisations most senior clinicians, the Director of Patient Services and the Medical Director. The Clinical Governance Committee also has representatives from the Board and co-opted members who provide specialist input. On a day to day level the Senior Management Team support the development and improvement of services to ensure quality and to enable the organisation to meet the challenges within the health care economy of Scarborough, Whitby, Ryedale,

Bridlington and Driffield. To support this approach we measure quality against nationally agreed areas which are shown below: - Patient safety - Clinical effectiveness - Patient experience Priority 1- Patient Safety Utilising SystmOne to improve consistency of risk assessment and communication across the wider team On admission risk factors for all patients are assessed utilising all patients SystemOne. Risk associated with pressure ulcers, mobility, falls and the use of bedrails are considered at admission and reviewed throughout the patients stay. The multi-disciplinary team have moved from departmental specific assessments to a shared tool which has improved consistency and communication between professions. All records are recoded on SystmOne so that all member of the team have access to the same information Undertake audits of clinical services to ensure that the care delivered is safe and of a constant standard Saint Catherine s Hospice undertook a number of audits to ensure that the care that we provide is both safe and consistent in quality. This year our Quality Accounts focuses upon drug chart audits. This audit has taken place twice in 2012/13 and is designed to ensure that drug charts comply with national good practice guidelines which amounts many standards require that they are legible, have clinically safe dosages amounts and are fully completed. Changes to Medicine s Management Following a review of our medicine s management procedures we have purchased an additional medicine trolley to better facilitate the drug rounds two the two wings of our inpatient unit.

Priority 2- Ensuing Clinical Effectiveness Integrating specialist palliative care in the community and the Hospice This year the community Macmillan team formally joined Saint Catherine s Hospice after many years of being located within the hospice. This has facilitated improvements in clinical effectiveness by reducing duplication and enabling the development of a coordinated approach to identifying patient needs and delivering care in the most appropriate setting, be that at home or within the hospice. Furthermore we have moved from two care records to one unified record improving communication and enabling a more cohesive service to be delivered. Improving the quality of palliative care within care homes Our Clinical Nurse Specialist are currently providing training to staff within 11 nursing homes and 4 residential homes to enable staff to deliver improved palliative care, reduce the number of residents dying in hospital and enable more patients to die in their preferred palace of care. Between September 2012 and April 2013 82 training sessions have been undertaken, the number of residents dying in hospital has reduced from 25% to 12 % and the number of residents dyeing in their preferred place of care has risen from 80% to 98% Priority 3- Patient Feedback Measuring quality through paint feedback In 2012/13 232 patients completed our patient feedback surveys which cover all aspects of the care that Saint Catherine s Hospice provides. Key findings included: 92% of patients had confidence in the staff that was caring for them 74% of patients understood the explanations they were given about their care 96% of patients felt they were treated with respect 90% of patients felt that their privacy and dignity was respected 92% of patients rated cleanliness as good or excellent 85% of the patients rated the catering as good or excellent As an organisation was also receive many thank you cards and comments on facebook and twitter each of which are reviewed by the Senior Management Team.

The following comment provides a flavour of the responses we have received this year Thank you Saint Catherine s Hospice for caring for our special friend. You re a true blessing in disguise. Your work goes on unnoticed and you deserve a medal for the lives you look after and hearts you touch. I take my hat off to you as I know a lot of people do who have let their loved ones in to your hands Part 3- Regulatory Requirements and Assurance from the Board The following are statements that all providers of healthcare must include in their Quality Account. An explanation of what these statements mean are also given. Review of Services (Mandatory Statement) During 2012/13 Saint Catherine s Hospice has provided for the NHS: In-Patient Care Daycare Services Community Services Care Home Services Lymphoedema services Bereavement support Out of hours Telephone help-line Rapid discharge from hospital to Hospice at End of Life Carers Support What XXX This Means Saint Catherine s Hospice is funded through a combination of a grant from the NHS and fundraising activity. The grant that is allocated by the NHS is Participation 1015878 which In Clinical represents Audit approximately (Mandatory Statement) 22% of the hospice total income During the year 2012/13 Saint Catherine s Hospice participated in the following clinical audits or national confidential enquiries. Palliative Care Funding Review- collection of data regarding the resources provided by Saint Catherine s Hospice in the provision of specialist palliative care in order to develop an evidence base for per-patient funding mechanism for palliative care. National Council for Palliative Care Minimum Data Sets- collection of data regarding the activity undertaken by Saint Catherine s Hospice in terms of the number of patients cares and families that we provide support to. What This Means Saint Catherine s Hospice has participated in a number of National audit or National Confidential enquiries relating to specialist palliative care.

NHS Quality Improvement and Innovation Goals (Mandatory Statement) The grant received by Saint Catherine s Hospice was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework (CQUINS). What This Means As Saint Catherine s Hospice is a third sector organisation we were not eligible to participate in the CQUINS payment scheme. We do however produce activity figures for the Primary Care Trust in respect of the grant that we receive. In the period 2012/13 our bed occupancy target was 70% and we achieved 81%

What others say about us (Mandatory Statement) In October 2012 the Care Quality Commission inspected Saint Catherine s Hospice and provided the following inspection report: What This Means This was an unannounced inspection by the Care Quality Commission in October 2012. The inspectors spoke with patients, visitors, members of staff, the Chief Executive and the Registered Manager. The Inspectors judged us to have met all the required standards

What others say about us (Mandatory Statement) The Primary Care Trust / Clinical Commissioning Group said the following about Saint Catherine s Hospice: St Catherine s Hospice should be congratulated on their commitment to providing such a high quality, patient-centred service. We have always found them to be more than willing to work collaboratively with us and other health organisations, and the work we have undertaken jointly to provide care home link nurses is of particular note. As the new lead commissioner of NHS services in the area, it is very encouraging to see one of our care providers perform so well in their CQC inspection and it clearly demonstrates their dedication to providing excellent care for the patients they serve. I look forward to our continued collaboration. Dr Phil Garnett Chair NHS Scarborough and Ryedale Clinical Commissioning Group What This Means The Lead commissioner of services that we provide for the NHS is very happy with the quality of our work and outcomes for patients and has indicated future collaboration on similar lines.