quality account 2016-2017 - nhs choices home page · pdf file · 2016-07-01as part...

Quality Account 2016-2017

Registered Charity Number 1002878

www.peacehospicecare.org.uk

Peace Hospice Care provides outstanding specialist care and support to improve the quality of life for individuals, families and carers facing a life-limiting illness.Those who access our services are treated with respect for their dignity, beliefs and wishes and where possible in the setting of their choice.

Peace Hospice Care Quality Account 2016-2017

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Part 1Chief Executive’s Statement

On behalf of the Board of Trustees and Executive Team it gives me great pleasure to present the fifth Quality Account for Peace Hospice Care. The account looks back on progress that we have made during 2015-2016 and outlines some of our key priorities for improvements to services for patients and families in 2016-2017.

The period this report covers has been one of change for Peace Hospice Care. I came into position in June 2015 and joined a strong team of staff and volunteers delivering personalised and tailored care to not only individuals living with a life-limiting illness but also to their families and carers around them. Since I’ve joined there has been a period of change. To meet the needs of the future, we plan to do things differently while continuing to place patients’ goals at the heart of our holistic care and support. This report looks back at our successes and looks forward to our priorities to ensure we continue to deliver an outstanding service.

2016 is a landmark year for Peace Hospice Care as it celebrates its 25th anniversary. This birthday has enabled Peace Hospice Care to showcase and acknowledge its achievements since its inception. Peace Hospice Care has reached an important milestone, but we haven’t done it alone. It was built with the support of local people for local people and that is the only way it will continue. We believe that what we provide is priceless to the people we help because it’s about quality of life at a point at which life itself becomes limited and each moment, each day becomes precious. The high standards of care we provide would not be possible without the dedicated team of staff and volunteers around me and I would like to thank each and every one of them for their continued support.

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 healthcare services provided by our Hospice.

Declan CarrollChief Executive - June 2016


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Introduction

Peace Hospice Care provides specialist support for individuals and their families and carers facing a life-limiting illness across the Hertfordshire community. We provide three core services:

1. A 12 bed Inpatient Unit in central Watford

2. Our Starlight Outpatient and Day Services Centre which provides a range of rehabilitation, wellbeing, clinics and workshops as well as counselling and bereavement support sessions.

3. Our Community Services that consist of a Hospice at Home Visiting Service, single point of contact and co-ordination of all our referrals and clinical enquiries and the Herts Neighbours Service.

These are underpinned by our Quality and Education Team who support the above teams to provide high quality, safe, caring and effective well led services. This year Peace Hospice Care has reached an important milestone - its 25th anniversary. On 24th June in 1991 a group of passionate pioneers created the South West Hertfordshire Trust which ultimately evolved into the Peace Hospice Care organisation as it stands today. We continue to exist due to the outstanding support by the local community. Peace Hospice Care has more than 155 employees and over 600 volunteers. It is committed to supporting and developing its staff and volunteers to ensure the most effective use of its resources.


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Our Mission

We provide outstanding specialist care and support to improve the quality of life for individuals, families and carers facing a life-limiting illness.

Those who access our services are treated with respect for their dignity, beliefs and wishes and where possible in the setting of their choice.

Our Vision

Peace Hospice Care will be the leading provider of specialist palliative care services in its community.

Our Values

Peace Hospice Care wants individuals, its patients, their families and carers to be happy with the services it provides and that its staff, volunteers and external partners are proud to work with them. Its trustees, staff and volunteers sign up to these values, ensuring they are evident in all they do.

Innovation We encourage a creative approach by staff and volunteers to all our endeavours and foster a listening culture that welcomes and respects new ideas.

Responsive We are flexible, responsive and open to change in our engagement with individuals, patients, relatives, advocates, staff, volunteers and partners.

Integrity We strive to be open, fair, trustworthy, transparent and honest in all our activities.

Excellence We are committed to achieving the highest possible standards of care and support for all who use our services.

Respect We celebrate difference and diversity and treat all individuals with understanding and respect for their dignity.


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Part 1.1

Looking Forward:

Priorities for improvement 2016-2017

Peace Hospice Care is fully compliant with the Essential Standards of Quality and Safety as set out in Care Quality Commission (Registration) Regulations 2009 and the Health & Social Care Act 2008 (Regulated Activities) Regulations 2010.

The Care Quality Commission carried out an unannounced inspection in April 2016, and all standards assessed, were met. They undertook a thorough evaluation of our services, focusing on 5 key lines of enquiry:Are we safe?Are we effective?Are we responsive?Are we caring?Are we well-led?

Priorities of Care for 2016-2017

We have identified the top priorities to further improve the services delivered to our patients and their relatives for the year 2016-2017. We have selected priorities that will impact directly on each of the three domains of quality; patient safety, clinical effectiveness and patient experience and they are:-

Priority 1 – Patient Safety: Compliance to the required Information Governance Toolkit

As part of our new Patient Electronic Record System we have strengthened our compliance to the Health Social Care Information Centre regulations and wish to ensure that we are able to demonstrate that PID (Personal Identifiable Data) is transferred, handled and received in a safe and secure manner that protects the individuals confidentiality.

How do we plan to achieve this?

• Update and implement all of our information governance policies• Ensure information governance training and learning is disseminated across all directorates• NHS net adoption for certain key members of staff• Improve the security of PID data being transferred to outside organisations• Withdraw the use of faxes by March 2017


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Priority 2 – Clinical Effectiveness: Implementation of the OACC measures (Outcome Assessment and Complexity Collaborative)

How was this identified:

This is a collection of 6 Outcome Measures identified by a team of palliative care experts who believe that the collection of national data will enable comparisons between services and outcomes in different parts of the country for benchmarking and auditing purposes. They believe routine use of these outcome measures in palliative care could improve services provided to patients and families, as these services may then be better customised to individual needs based on the outcome data collected. The data can also be used as a feedback mechanism wherein clinical teams can make effective use of the data collected, both at an individual patient and organisational level to systematically improve the quality of palliative care services and to minimise variations in practice.

As part of our 15/16 strategic plan Peace Hospice Care agreed to introduce the use of OACC outcome measures. We have successfully introduced the phase of illness and AKPS (Australia-modified Karnofsky Performance Status).

As part of this 2016/17 account we wish to implement Integrated Palliative Care Outcome Scale (IPOS)/ Views on Care measure (VOC)/Zarit Carer Interview (ZCI).

We are working across Hertfordshire with other palliative care providers who are also introducing the OACC measures, and we aim to be able to use this data to share learning and demonstrate the effectiveness of palliative care.

How to plan:

As part of our new Patient Electronic Record System we have developed user friendly templates to help staff and patients to complete the required questionnaires.

We have purchased hand held devices so this can easily be done at the patient’s side.

We are part of the network OACC meeting which our Director of Patient Services chairs, and all progress and evaluation will be reported through this group.

Priority 3 – Patient Experience: Implementation of 2015/2016 nutrition and catering review recommendations.

Due to variable patient feedback on our catering provision we wish to undertake a full catering and nutritional review of the services we provide to our Inpatient Unit and in the Starlight Centre (Outpatient Centre). This will include:

• Update and review the nutritional and hydration policy• A review of the current catering hours, menus and nutritional content of the meals provided• Introduction of a revised nutritional assessment tool across all our services• A full education/training programme for all clinical staff and volunteers relating to the nutritional

needs of our palliative care patients

How we plan to achieve this:

• Set up a short term working group with user involvement• Recommission current catering company to provide appropriate menus and food requirements to

meet our patient’s needs• Provide a training programme for staff and volunteers• Undertake regular surveys across patients and carers• Review and update of the Peace Hospice Care nutritional and hydration policy


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Looking Back

In our last Quality Account we identified the following priorities for 2015 – 2016 and below we report on the progress we’ve made against them.

Priority 1 – Implement SystmOne

Achievements against our plans:

The SystmOne electronic system implementation began in October 2015, however there was a 3 month delay in meeting the required HISIC toolkit requirements and the installation of the secured data connection (N3). Hence, the project recommenced in March 2016, with the expectation that all patient services staff and designated volunteers would be using it by July 2016.

Our expectation is that once SystmOne is being fully utilised that it will be a huge improvement in sharing data securely with other palliative health care providers and improve communication between clinicians to support patient centred care planning.

Priority 2 – Implementation of the OACC measures (Outcome Assessment and Complexity Collaboration)

Achievements against our plan:

The use of the phases of illness and the AKPS is well utilised in our day to day communication by our MDT (multi-disciplinary team) for example - at the daily handover, in MDT discussion meetings, for referrals from other palliative care providers and finally in patient records.

Priority 3 – Bereavement Service

Achievements against our plan:

• A full bereavement audit was undertaken against the national bereavement standards and the recommendations have been implemented.

• We appointed a band 7 counselling and bereavement team leader as a member of the wider Starlight Centre. We have recruited a team of 12 dedicated accredited counsellors and a small team of volunteer befrienders.

• We are still contracted by Herts Valley CCG as a qualified provider (AQP) to be one of 12 providers offering a time limited counselling service. Our contract was extended until October 2016.


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Part 2Statement of assuranceThe following are statements that all providers must include in their Quality Account.

Many of these statements are not directly applicable to palliative care providers and therefore explanations of what these statements mean are also given.

2.1 Review of Services

For 2015 /2016 we have reviewed our services and now group them as:

• Inpatient Unit• Community Services (Community Liaison, Hospice at Home and Herts Neighbours Service)• Starlight Services (Wellbeing and Rehabilitation team and Bereavement and Counselling team)

These are underpinned by our Quality and Education Team who support the Peace Hospice Care staff to provide high quality, safe, caring and effective well led services.

Inpatient Unit

Our Inpatient Unit has had 259 admissions with an average bed occupancy of 76.8%.

Starlight Service

Our Starlight Service today is made up of 2 multi-disciplinary services – one to provide well-being and rehabilitation, and the other to provide bereavement support and counselling.

The rehabilitation and wellbeing team focus on providing individual and group sessions. Examples of the new groups and courses (as well as continuing with counselling and the traditional Day Care) are managing breathlessness (INSPIRE), two weekly exercise circuits for differing functional levels, Hope (self-management six week course), Friendship Group, Feel Good Friday (for yoga, beauty and massage amongst other things), creative company (creative craft and socialisation group) meditation and complementary therapy.

The Bereavement and Counselling Group continue to provide bereavement and have now extended their service to offer counselling to patients and their carers for such things as adjusting to illness, managing anxiety and depression.

Community Services

In the beginning of 2015 we were successfully awarded Cabinet Office funding to be part of the End of Life Social Action Research Evaluation Project. The Herts Neighbours Volunteer Scheme successfully appointed 40 volunteers and had 90 referrals. This service has been favourably evaluated and due to its success our Board of Trustees have agreed to continue the service.

In partnership with the NHS we undertook a nine month pilot scheme within our Hospice at Home team and extended their hours to work alongside district nurses to provide overnight rapid response support for palliative care/end of life care patients. This scheme was supported by the Prime Minister’s Funds. The evaluation of this pilot demonstrated that the out of hours care made a difference to the patient/carer experience and shared resources with the NHS. The pilot was deemed successful but due to tight resources the CCG and the Hospice were not able to take it forward. Learning has been shared with the CCG for future consideration.


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2.2 Income generated

The income generated by the NHS represents 20% of the overall cost of running these services. The balance is raised by the Hospice through voluntary donations, trust applications, its own retail outlets and other fundraising.

2.3 Participation in Clinical Audit

As a provider of specialist palliative care, Peace Hospice Care is not eligible to participate in any of the national clinical audits or national confidential enquiries. This is because none of the 2015/2016 audits or enquiries related to specialist palliative care. The Hospice will not be eligible to take part in any national audit or confidential enquiry in 2016/2017 for the same reason.

2.4 Local Clinical Audits

Clinical audits have taken place within Peace Hospice Care throughout the year and form part of the annual audit cycle programme within the overall Clinical Business and Governance Implementation Plan. The clinical audit cycle includes audits such as infection prevention and control, cleaning, lone working adherence, controlled drug accountable audits, falls and pressure ulcers documentation, and compliance to identified policies.

Any changes to practice that are recommended following the audits are monitored by the quality team to ensure care delivery is safe and effective. Further monitoring is part of the Clinical Governance Audit Cycle.

2.5 Research

As part of the End of Life Social Action Research Project with Lancaster University and the Cabinet Office, the Herts Neighbours Project was one of the 12 research evaluation sites. Peace Hospice Care was the highest recruitment site with 40 patients recruited. A full national report and recommendations are expected in June 2016.

The number of patients receiving NHS services provided or subcontracted byPeace Hospice Care in 2015/2016 that were recruited during that period to participate in research approved by a research ethics committee was: 40.

2.6 Use of the CQUIN payment framework

Peace Hospice Care income in 2015/2016 was not conditional on achieving qualityimprovement and innovation goals through the Commissioning for Quality andInnovation payment framework. However funding to provide out of hours IPU admissions 7 days a week was secured as the target of 35 admissions was achieved.


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2.7 The Care Quality Commission

Peace Hospice Care is required to register with the Care Quality Commission and its current registration status is unconditional. Peace Hospice Care has no conditions on registration. We actively report all CQC required notifications on the CQC portal.

The CQC made an unannounced visit to Peace Hospice Care in April 2016. Initial feedback was extremely positive and the following report rated Peace Hospice Care as outstanding for care and overall as good.

2.8 Data Quality

Peace Hospice Care did not submit records during 2015/2016 to the Secondary Users service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The Hospice is not eligible to participate in this scheme.

However Peace Hospice Care does submit data to the Minimum Data Set (MDS) forSpecialist Palliative Care Services collected by National Council of Palliative Care on a yearly basis, with the aim of providing an accurate picture of hospice and specialist palliative care service activity. This year we will submit data for our Inpatient Unit and Hospice at Home Services.

A snapshot of our activity is shown below:-

Inpatient Unit

Requests/referrals

Actual admissions

Deaths

Average Length of stay

Average Bed occupancy

2013-2014 2014-2015 2015-2016

375

243

151

13.7 days

88%

412

255

170

14.2 days

82.3%

387

259

184

11.4 days

76.8%


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Community TeamThis is the activity of our Hospice at Home team.

Starlight ServicesThis includes our outpatient and counselling services. Data collection has been recategorised over the last 3 years. There is a variance between 13/14 figures and those collected 2014 onwards.

2.9 Clinical coding error rate

Peace Hospice Care was not subject to the payment by results clinical coding auditduring 2014/2015 by the Audit Commission.

2013-2014 2014-2015 2015-2016

Number of referrals

New to the service

Single visits

Deaths

Of which at Home

2013-2014 2014-2015 2015-2016

Referrals

Attendees ( including counselling)

Clinics

Day Care

Wellbeing workshops/ groups

Rehabilitation

Self management

Counselling

173

1,947

56 appointments

443

163

163

37

587 AQ 1-1

385

305

2,255

145

122

525

298

2,681

206

168

477

271

2,985

189

140

291 (24)

2,279

173 appointments

407

1,090

481

94

1,053 1-1 sessions364 group attendees

653 (54)

2,634

281 appointments

260 attendees

1,145 attendees225 groups

599 attendees

293 attendees

1,644 1-1 sessions262 group attendees


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Part 33.1 Quality overview

Peace Hospice Care maintains its own monthly service data activity reporting and quarterly clinical commissioning group monitoring template reports.

3.2 Quality Markers we have chosen to measure

In addition to the limited number of suitable quality measures in the national data set for palliative care, we actively participate in the national Hospice (Hospice UK) quality benchmarking reporting. This provides a comparison with other similar hospices on falls, medicine and pressure ulcers incidences with agreed common descriptors. We have chosen to measure our performance against the following (in 2015/16):

Explanation

Falls:The number of falls on the unit does vary from quarter to quarter and we have noted that in the first three quarters of the year we were either in line with or below the average for Hospices of our size, but in the last quarter our figure is above the average. As with all the patient safety incidents, we constantly monitor against best practice and ensure all reported falls are reviewed to see if changes in practice are required. All falls are recorded and reviewed at the Health & Safety Committee with an annual falls audit reported to the Clinical Governance committee.

Pressure Ulcers:The number of pressure ulcers on the unit is in line with the average for a Hospice of our size. For both falls and pressure ulcers we are putting in place measures to investigate the effect of ‘phases of illness’ and its impact upon clinical incidents to monitor if there is any correlation and will put appropriate measures in place.

Medicine – Related Incidents:We noted that the number of medicine incidents in Quarter 2 increased and we immediately put into place a plan to reduce this with some further training and support given to staff. We saw an immediate reduction in quarter 3.

Occupancy

Falls per 1000 occupied beds

Pressure ulcers per 1000 occupied beds

Medicine incidents per 1000 occupied beds

Quarter 1 Quarter 2 Quarter 3 Quarter 4

PHC AV72.2%

11.4

3.8

8.9

78.2%

10.1

5.9

7.2

PHC AV68%

12.0

6.7

16

75.6%

11.1

4.5

7.6

PHC AV75.8%

4.3

2.9

2.9

79%

9.3

4.4

7.8

PHC AV90.7%

16.7

3.0

6.1

77.4%

9.7

6.0

6.0

Information from Hospice UK Benchmarking Project 2015-2016


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3.4 Other Quality Initiatives & Service Developments

Clinical Governance Framework

In 2015/2016 we continued to strive for quality improvement as set out in our annual Quality Implementation Plan as part of our Clinical Governance Structure. This included the work of all subgroups that have been set up to take responsibility for particular clinical governance/quality issues.

The focus of the subgroups has recently been revised to reflect current issues and now stands as being:

• Infection Prevention and Control• Medicine Management• Tissue Viability • Patient Safety (including falls, moving and handling, safeguarding now part of the health &

safety committee)• Clinical effectiveness/best practice (for latest practice / guidance that does not relate to any of

above groups)• Nutrition (short term as part of the catering & nutrition review recommendations)

The subgroups submit annual action plans detailing quality improvements, audits, and training to be undertaken throughout the year, specific to their area and based on the latest published guidance and evidence-based practice, to the Clinical Business and Governance Group.

The group membership is multi-disciplinary and includes staff of all grades, chaired by a member of the Senior Clinical team. This enables a cross-section of Hospice staff to participate in clinical governance.

The Clinical Business and Governance Group report to the Clinical Governance Committee to assure them of the quality of care, who report to the Board of Trustees.

PLACE: The annual PLACE (Patient-Led Assessment of the Care Environment) was carried out in April this year and included for the first time, an existing patient on the assessment team. The main finding from the assessment was the poor appearance of the Inpatient Unit bathrooms (the Hospice staff were already working on securing some funding to enable refurbishment). Plans are underway for our IPU bathrooms to be refurbished in 2016/17.


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3.5 Feedback from Service Users

Peace Hospice Care places great importance on feedback from people who use our services, and as such made it one of our Priorities for 2015/2016.

Feedback is gained from a variety of sources including patients, carers and other professionals.

Throughout 2015/2016 we continued to ensure that anyone who had used any one of our clinical services was offered the opportunity to complete a paper questionnaire.

However, paper surveys were not taken up as much as we had anticipated, therefore we introduced Real Time Surveys in our Starlight Centre and the Inpatient Unit.

This is where volunteers are on hand to ask patients to complete a web-based survey towards the end of their stay or group sessions. As the surveys are electronic, results can be collated in “real time”which enables us to respond swiftly to any concerns.

Thanks to the dedication of our small team of volunteers, this project has worked well.

• We have increased our survey response rate in the Starlight Centre from an average of 6 responses per quarter, to 20

• The Inpatient Unit real time survey was more recently set up so we do not have comparative data yet

• We plan to set this up in the Hospice at Home Team in the autumn

The findings from the Real Time Survey have been very positive:

• 100% believed they were getting the best care and treatment

For 2016/2017 we will continue with the Patient Facing ‘Real Time’ Surveys in the Inpatient Unit, Starlight Centre and also implement it in the Community Team with dedicated time periods to focus on each service. We also continue to provide survey leaflets which the patient/carer can fill in at their leisure and return to Peace Hospice Care.

We have also introduced comment cards throughout the Hospice to enable anyone who is visiting to comment on the service provided.

Any feedback from patients, families and carers we receive will continue to be monitored by the Clinical Business & Governance Group which reports to our Clinical Governance Committee. There is an annual plan for areas for improvement and initiatives to implement.


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Comments from patients/carers

“Until recently I had never been in a hospice. It really opened my eyes. What incredible work you do and what patience you have. I am in awe.”

June 2015

“I would just like to thank you for your time and taking the trouble to talk to me. You have installed some faith back into me about the medical profession in this country. You should be proud of yourself for what you do for others. Thank you so much.”

January 2016

“Thank you very much for looking after my dad for the last few days before he passed away and the wonderful support you gave me, my mum and the rest of the family. I truly appreciate the help and guidance you gave us all and the dignity you treated my father with at a very difficult time.”

January 2016

“Allowing mum to be looked after in her own home gave a great comfort to all the family. You were a lovely team who we could call on at any time and who advised us every step of the way on what was happening.”

March 2016

Complaints

Complaints are taken extremely seriously and we always try to identify learning that can drive improvements in the clinical areas. During 2015/16 we updated our wider Complaints, Concerns, Compliments policy and processes. Complaints are thoroughly investigated and reported at the Clinical Governance Group meeting and to the Board of Trustees. Immediate action is taken to rectify any shortfalls or concerns identified.

During the period April 1st 2015 – March 31st 2016 Peace Hospice Care received one written complaint about the attitude of a member of staff. This member of staff no longer works at the Hospice.


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3.6 Supporting Statements

“The clinical standards and performance of Peace Hospice Care are regularly and carefully monitored and scrutinized by the Clinical Governance Committee. The Quality Account for 2015-2016 gives an accurate account of the plans for, and the achievements in, outstanding care and the excellent services provided by Peace Hospice Care.”

Ginny Edwards, Chair of the Clinical Governance Committee, Peace Hospice Care

“Herts Valleys CCG sees Peace Hospice Care as a key partner in the delivery of integrated end of life care for the patients of west Hertfordshire. We value the excellent open and regular communication that we have and we are committed to working with them to continue to deliver a high quality and much valued service to our population.

During 15/16 Peace Hospice continued to provide high quality services that prioritised patient safety, clinical effectiveness and enhancing patients’ and their families’ experience. Looking forward to 16/17, Herts Valleys CCG is delighted to continue to work closely with the hospice as a key partner in helping us to achieve our End of Life Strategy. The strategy reflects the aims of both organisations to continually improve and provide good quality end of life care to its patients and the community.”

Gemma Thomas, Head of Planned & Community Care, Herts Valley Clinical Commissioning Group

If you would like a copy of this document in LARGE PRINT, Braille, or audio format, or if you would like this information explained in your own language, please contact us.

quality account 2016-2017 - nhs choices home page · pdf file · 2016-07-01as part...

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