Quality Account 2016/17
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Chief Executive
Statement of Quality
This Quality Account is for our patients, their families and friends, the general public as well as the local NHS organisations.
It is of note that only twenty-five per cent of our care costs are provided by the NHS and the remainder of our funding is from charitable donations.
The aim of this report is to give clear information about the quality of our services to demonstrate that our patients can feel safe and well cared for, that all of our services are of a very high standard and that the NHS is receiving very good value for money.
We could not give such high standards of care without our hardworking staff and over 1500 volunteers, and together with the Board of Trustees, I would like to thank them all for their support.
Our Director of Patient Care, Medical Director and all clinical managers are responsible for the preparation of this report and its content. To the best of my knowledge, the information in the Quality Account is accurate and a fair representation of the quality of health care services provided by St Peter’s Hospice.
Our focus is, and always will be, our patients, their families and carers and therefore we actively continue to seek the views of all who access our services in order to ensure we maintain the highest standards of quality.
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Who we are and what we do
St Peter’s Hospice (SPH) is Bristol’s only adult hospice. We have been looking after people in our area (greater Bristol, South Gloucestershire, part of North Somerset and the Chew Valley area of Bath and North East Somerset) for 39 years. Our commitment is to contribute to improving the quality of life of patients while extending care and support to their families and loved ones.
Our main building is at Brentry but our Community Nurse Specialist team have bases in Staple Hill, Long Ashton, Brentry and Yate making it easier for us to provide accessible care and support across this large geographical area.
Our purpose (Mission statement)
To provide care and support for adult patients, families and carers in our community living with life limiting illnesses in order to improve the quality of their living and dying. We do this working closely with other health and social care providers. Our aim (Vision)
St Peter’s Hospice will play a leading role in the development and delivery of the best possible care and support services for adult patients, families and carers living with life limiting illness in our community.
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Who we are and what we do
Services provided by St Peter’s Hospice
We deliver the following services exceeding the service level specifications agreed with the NHS. The NHS contributes 25% of our overall funding.
Triage Service: All patients referred to the hospice are triaged by a registered nurse to ensure that SPH is right for their needs and the patient is directed to the right service.
Inpatient Unit (IPU): 15 beds staffed by 26 RN’s (WTE) The number of beds reduced from 18 in Octo- ber 2016 due to staff vacancies and the complexity of the patients we care for. In September 2017 we will relocate the IPU for 12 months in order to refurbish our current IPU and convert to 15 single rooms. During this period we will be based in Keynsham and have 10 beds available. 24hr Advice Line: Offering specialist palliative care advice to healthcare professionals and carers. This became a partially commissioned service by the NHS in 2016/17, with Bristol, S Glos and B&NES contributing to some of the costs. Day Services: Up to 20 patients 4 days per week. Fatigue and Breathlessness programme x 1 day a week. We have introduced an Occupational Therapy role to the Day Services Team to offer a wider multi-disciplinary approach to patient care. Physiotherapy/Occupational Therapy: To help patients maintain a good quality of life for as long as possible. Hospice at Home: Enabling patients to die at home, and offer a small amount of respite care. Community Nurse Specialist Service: Providing advice, support and symptom control to more than 2000 patients per annum. This team began 7 day working in October 2016. Medical Team: Consultant led team covering the Inpatient Unit, Day Hospice, Community and 1 session a week with the UHB Palliative Care Team. Patient & Family Support (PFS) Services: Provide social, emotional and spiritual support for patients, families and carers, including bereavement care. This service includes music and art therapy, social work, psychological support and carers groups.
St Peter’s Hospice monitors all services on a monthly basis through collecting of data on number of patients seen, face to face contacts and telephone contacts.
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What we have achieved 2016/17 Priorities for improvement set for 2016/17 We had 4 areas prioritised for improvement this year
Priority 1 – Patient Experience Day Services—we will develop a new drop-in service for patients and their carers, who would like a more flexible model of contact with the hospice.
The ‘drop-in’ group for patients and carers began in October 2016. It runs on a Tuesday from 2-4pm by a Registered Nurse and Health Care Assistant. There have been 50 attend- ances in the 6 months it has been running. The group aims to provide an informal introduction to the hospice for patients and carers not already using our services. It is also an opportunity for patients to drop in with their carers to discuss any issues they may have, or share the experience of visiting the hospice together. Some patients who have attended the Day Hospice 12 week programme also use it as an opportunity to maintain contact with the hospice. Information regarding the day was circulated to all GP practices within the St Peter’s catch- ment area, and also via our Access Team and Community Nurse Specialists. Of those attending, 28 were patients already known to S Peter’s, 20 were carers and 2 were patients who were not previously known to the service. Positive aspects of the group: The group has provided an opportunity for 2 potential new patients and 20 carers to experience St Peter’s in a relaxed and informal way. Patients and carers have been able to attend together, access information and meet staff. Patients who have finished their 12 week programme have used the service as a way of maintaining confidence once discharged from Day Hospice. 6 of the attendees came more than once, showing benefit from the service. Two couples came more than once. Positive patient feedback received: “Staff very nice, very relaxing.” “Better than I expected, very informative, enjoyed gardens” “Enjoyed my afternoon” “Enjoyed chatting with you amazing staff” All attendees completing feedback forms said they would use the service again. Limitations of the group: Due to the drop-in nature of the group it is not possible to offer transport. This may limit attendance. Current lack of knowledge of how widely external health care professionals are promoting it. Next steps: Explore additional options for publicising the group to the wider community. Review attendance and feedback from both attendees and referrers at 12 months; acknowledging that new groups can often take time to establish.
5 6 What we have achieved 2016/17 Priority 2 – Effectiveness Hospice Community Nurse Specialists (CNS) Out of Hours Service Pilot: Oct 16 to Mar 17
The hospice CNS team has piloted an out of hours service as part of the 5 year hospice strategy which states that ‘7 day working by CNSs would answer a patient need and assist in improving the efficiency of the service’ which is in accordance with national guidance (NPEoLC Partnership, 2015-2020). The aims of this service are to promote preferred place of care and death, avoid inappropriate hospital admission, allow access to appropriate hospice admission and provide continuity of care for patients with complex palliative care needs at home. During the 6 month pilot 1 CNS worked from 09:00 to 17:00 on bank holidays and weekends. 52 patients were referred to the service for the assessment, advice and support of patient in the community with uncontrolled symptoms, rapid deterioration, emotional distress and need for hospice admission. 47/52 received the service of which 36/47 were visited at home. 1. Promote Preferred Place of Care (PPC)* or Preferred Place of Death (PPD)* The majority of the patients with complex needs who received this service achieved their preferred place of care, 27/32 or 84%. 2. Avoid inappropriate hospital admission This was achieved as hospital admission was appropriate for 5/5 or 100% of patients who were assessed as requiring treatment from secondary care. 3. Access for appropriate Hospice admission Appropriate admission to the hospice was achieved by 10/12 patients but 2 could not be admitted due to no hospice bed availability. Inappropriate hospice admission was avoided for a further 7 patients when admission was requested externally of whom 5 were supported by the 7 day CNS Service to stay at home and 2 were assessed as requiring hospital admission.
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What we have achieved 2016/17
Aims Outcomes
PPC/PPD achieved: Promote PPC*/PPD* 27/32 or 84%
Avoid inappropriate Hospital admissions: 5/47 or 11% hospital admission Admission appropriate: 5/5 or 100%
Requests for In Patient Unit admission: 19 requests Admitted to hospice: 10/19 requests Allow appropriate IPU x 2 admitted hospital admission x 2 no IPU bed
x 5 supported at home
Provide continuous Aims of referral met as assessed by CNS: care in complexity 43/44 or 98% strongly agreed or agreed
4. Provide continuous care in complexity CNSs strongly agreed or agreed that the aims of the referral were met for 43/44 or 98% of patients and families.
Conclusions: The results demonstrate the positive impact of this service on the urgent management of complex symptoms, distress, deterioration and promoting appropriate place of care. With additional funding, this service could be expanded to address the unmet need of patients and families who require interventions to sustain symptom control and support over weekends and bank holidays.
References: National Palliative and End of Life Care Partnership Ambitions for Palliative and End of Life Care: A national framework for local action 2015-2020
7 8 What we have achieved 2016/17 Priority 3 – Safety Medicines-we will benchmark our current practice against the new NICE guideline: ‘Controlled Drugs (CD); safe use and management’, and devise an action plan to ensure we meet best practice.
A controlled medicine or drug is a prescription medicine that is controlled under the Misuse of Drugs legislation. These medicines are called controlled medicines or controlled drugs and have stricter controls placed on them as they have high risk of being being misused, being obtained illegally or causing harm.
Throughout 2016/17 the Accountable Officer and Lead Pharmacist have worked through the new NICE guidance ‘Controlled Drugs: safe use and management’ assessment tool and have consistently reviewed and audited current practice. To improve on our current standards we have:
Rewritten the organisation’s Controlled Drug Standard Operating Procedures.
Developed a CD Stationery Register to ensure we have a clear audit of all CD Registers and CD Order books use, storage and destruction.
Organised a new annual audit plan for Controlled Drug management, including prescribing and use of FP10’s
Liaised with the Regional CD Accountable Officer in relation to our standards for CD stock destruction to ensure our current practice meets the level of governance required.
Developed a monthly staff bulletin ‘Medicine Matters’ to ensure staff are fully up to date with both local and national changes.
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What we have achieved 2016/17 Priority 4— Effectiveness Health Care Assistant (HCA) training-we will ensure that every new HCA who commences the post from January 2016 completes the new Care Certificate. The Care Certificate is aimed at ‘new staff, new to care’, but to ensure we can benchmark training needs of all support staff joining the organisation all HCA’s starting at St Peter’s Hospice will undertake the Care Certificate. The Care Certificate is an identified set of standards that health and social care workers adhere to in their daily working life. Designed with the non-regulated workforce in mind, the Care Certificate gives everyone the confidence that workers have the same introductory skills, knowledge and behaviours to provide compassionate, safe and high quality care and support.
From April 1st 2016 to March 31st 2017 there have been 16 candidates undertaking the Care Certificate, who have started at varying times in the year. 4 have now submitted completed Care Certificates. From the remaining 12, 10 have started and are at different stages working towards completing the certificate, 2 of the candidates have not yet formally started and are due to be inducted by the end of May 2017. Candidates on the programme have allocated mentors who oversee the assessment in practice and alongside the Practice Facilitator monitor progress and implement action plans accordingly. It is estimated that completing the St. Peter’s Hospice Care Certificate can take from 6 to 12 months. This programme is mapped to the organisation’s Orientation, Statutory & Mandatory training, Health Care Assistant 3 Day End of Life Care Course, evidence of observation in practice and reflections of clinical practice. The frequency and availability of places on these courses influence the completion time.
In February 2017, 23 of the In Patient Unit (IPU) Health Care Assistants (Band 2) attended a Clinical Skills training day on ‘baseline observations’. This model of training is designed to formally test knowledge gained via eLearning. This is followed by simulated assessment with an assessor testing knowledge, skills and behaviour. This is a standardised approach to ensure continuity and measurable outcomes. All candidates successfully passed. We have also planned a 2 Day Clinical Skills training course on Catheter Care, Basic Wound Care, Syringe Pumps and Topical Formulations which 11 of the Hospice at Home Health Care Assistants (Band 3) will attend in early April 17. This model of training is designed to test knowledge, skills and behaviour through the same format.
Going forward this model of training will be rolled out at regular intervals to enable all staff to access up to date evidence-based teaching in skills that are required daily for the role of the Health Care Assistant.
Whilst this training is not formally recognised as part of the Care Certificate it adds value and contributes to the observation and competency in practice. All candidates undertaking the Care Certificate have been advised to reference this in their Care Certificate.
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What we have achieved 2016/17
Other areas to highlight in 2016/17 Volunteers
Volunteers permeate nearly every aspect of work at St Peter’s Hospice. With approximately 20 roles covering the Hospice itself, our 51 retail units, EBay and Warehouse operations together with a strong team at our commercial office, our 1550 volunteers contribute over £2million of in-kind support.
This year we have developed a strand of our strategic 5 year plan that focuses on increasing volunteer presence within clinical settings, with a new Skilled Companion role based on the In-Patient Unit. Volunteers in this role provide company for those patients with few or no visitors, or who are frail and may need constant observation. They will support patients who have the early stages of dementia and would may benefit from extra companionship or need escorting on hospital or clinic visits. With 26 trained volunteers we aim to provide 7 day a week cover.
The role adds real value and an extra dimension to patient experience and utilises the extensive skills and experience of our volunteers. Consequently, it has freed up nursing staff and HCAs to concentrate on the increasingly complex clinical care needed by patients.
Without the amazing commitment and dedication from our wide range of volunteers the hospice would not be able to fund and deliver the care and support for patients and their families across Bristol.
Our youngest volunteer is 14 and oldest is 93 Hospice volunteers donated 26,720 hours of their time Shop volunteers donated 164,492 hours of their time an increase of 12,000 hours on last year. Hospice Neighbours volunteers made 960 visits to patients in their own homes Bereavement Support Volunteers provided 628 sessions for families and friends. Complementary Therapist volunteers gave 450 treatments to patients Volunteer drivers collected nearly 2000 tins worth over £41,000 EBay volunteers took 33,800 photos for posting on our site 310 Community volunteers supported our fundraising events, including Bristol Half Marathon, Midnight Walk and Tour de Bristol.
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Quality Assurance Quality Assurance 2016/17 Quality Improvement and Innovation Goals agreed with Commissioners A small proportion of our NHS income in 2016/17 is conditional on achieving quality improvement & innovation goals through the Commissioning for Quality & Innovation (CQUIN) payment framework.
CQUINS for 2016/17
CQUIN 1a Health and Wellbeing of Staff – Health and Fitness Initiatives.
Health & Wellbeing of Staff – Healthy Food for Staff, Visitors CQUIN 1b & Patients.
CQUIN 1c Health & Wellbeing of Staff- Uptake of Flu Vaccinations Dementia Staff Training (NB. this CQUIN was not added till CQUIN 2 Sep 2016).
Our progress against our CQUINs 2016/17 CQUIN 1a – Health and Wellbeing of Staff – Health and Fitness Initiatives. The provider will produce a plan concerning the initiatives by end of July 2016. The provider will report on the delivery of the plan quarterly, with a brief report to be delivered in the month after the quarter end – i.e. Q2 report delivered in October 2016. In April 2017, the provider will produce a brief summary of the scheme.
Summary Report
This CQUIN began with a staff survey to get their views. From this we achieved the following: We contacted local gyms to get reduced cost membership- Bristol and South Gloucestershire Council agreed a 20% reduction for all staff. Bristol City Council also offered staff MOT’s over a lunchtime session which 8 staff took part in. We developed an exercise poster for staff who have a more desk based role and encouraged them to engage with them regularly throughout the day. Some staff take short walks in their lunchtime break which has been encouraged by senior staff and a wider group has engaged with this. The employee wellbeing scheme has been promoted heavily throughout the organi- sation with a bigger uptake of staff using the Advice Line and getting valuable sup- port and advice on a wide range of issues. They also provide a wellbeing section on their website which has been put on our staff intranet www.livewell.optum.com . A low cost Complementary Therapy service for staff has been developed and runs every Weds evening. Treatments offered are: Massage, Aromatherapy, Reiki, Reflexology, Aromatherapy Facials and Bowen Technique. Whilst a new service, staff feedback so far has been very positive. SPH offer the private therapists free use of room, equipment and towels, and they charge lower than average costs.
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Quality Assurance
The Exec Team are currently discussing whether to support a wellbeing fund that could result in managers giving treatment vouchers to staff who are returning from long term sickness/ bereavement etc. in discussion with HR. Mindfulness and relaxation sessions have started at both Brentry and Long Ashton. They run weekly for a maximum of 20 mins and are facilitated by a broad range of staff on a rotational basis. It has become surprisingly popular with 4-8 people attending weekly on each site. ‘It’s great to have the regular opportunity to take time-out of the often busy working day, to quietly reflect, clear your mind and ‘reset’ yourself ready for whatever’s next!’ Tai Chi for Wellbeing continues every Monday evening at no cost. The hospice choir runs every Tuesday evening –open to everyone.
CQUIN 1b – Health & Wellbeing of Staff – Healthy Food for Staff, Visitors & Patients.
Provider will be asked to submit a brief report in October 2016 and April 2017 showing their progress in delivering the four points above. Summary Report
Survey sent out asking staff what healthier food options they would like to see the café offer. Small working group set up- interested staff and a member of the catering team. Audit of use- as our small café is used by both staff and visitors. Demonstrated that customers were spilt 50/50 in relation to staff and visitor use. Food suggestions trialled; increased variety of salads, wraps with lower fat fillings. Many high fat crisps have been swapped with lower fat baked crisps, plain popcorn, nuts and seeds and cereal bars. Increased variety of salads sold, all dressings provided separately so customers can make their own choice whether to have. Increased options of low/no sugar drinks. All soups gluten free and low fat (no cream/ full fat milk used). Reduced option of high sugar/high fat snacks. New menus designed-identifying foods that are gluten free lower fat options and can be ordered fresh from the kitchen if what they would like is not available. Increased amount of wholemeal vs white sandwiches being made and sold. Gluten free rolls and sandwiches can be made on request. Volunteers are also logging what visitors may ask for which we don’t currently sell and any feedback given. Free fruit bowls continue across the organisation for patients and visitors. Longer term goal of planning food options post IPU refurbishment when the cafe serving area will be bigger. Staff have clearly identified that they would like to have options of jacket potatoes, wraps/paninis. This has all been incorporated in the planning of the new café and kitchen space.
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Quality Assurance
CQUIN 1c— Health & Wellbeing of Staff- Uptake of Flu Vaccinations
To report percentage of staff vaccinated each quarter, one month after quarter end. Summary Report For the first time we used our own Infection Prevention Lead Nurse to deliver the vaccinations- she attended training in order to do this. Liaised with NBT to supply flu vaccinations, hired a separate fridge for storage. SPH Insurance checked, consent and information sheets checked. Emergency medication made available in case of anaphylaxis. PGD signed by Medical Director and IPC Nurse to cover organisational vaccination. Posters designed and placed around organisation to increase awareness, emails sent to all clinical staff. 115 staff across the organisation received flu vaccinations this year, involving 11 mini clinics. 100 via our Infection Prevention and Control Lead Nurse and 15 that staff had at GP surgeries. Of these 115 staff, 78 were frontline clinical staff giving a 57% take up this year (approximate uptake has been less than 25 % in 2014/2015 when offered on site by Occupational Health Service).
CQUIN 2—Dementia Staff Training (NB. this CQUIN was not added till Sep 2016) To design and deliver the above training. Summary Report
Dementia e-learning training developed by IPU and CNS Dementia Leads with sup- port from Education Manager benchmarking against the competencies set against the Dementia Core Skills Education and Training Framework (Skills for Health). 95% of clinical staff have achieved this in the 6 months we had to deliver it.
45 non clinical staff and volunteers attended Dementia Friend training we arranged over 2 sessions (December 16 and January 17). This was to increase non clinical staff knowledge, to encourage us to be more dementia aware/ friendly.
Meeting held between our lead nurses and Bristol Dementia Partnership late Sep 2016 - sharing of knowledge and discussion of documentation in relation to ACP. Aim for ongoing liaison and an offer of support in relation to IPU refurbishment.
Continual Professional Development evening for clinical staff held in January. Facili- tated by Dementia Care NBT, Bristol Dementia Partnership and St Peters Hospice, 22 staff attended – feedback was excellent and these teams will continue to network together.
A CNS is now leading a 3 month project in relation to assessing pain and distress in people with dementia and ensuring we use the best clinical tools available to do this. Commenced April 2017.
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Quality Assurance
Serious Incident (SI) Reporting
St Peter’s Hospice reported 23 serious incidents over the year and one significant near miss. Of the 23 SI’s , 22 were related to the development of Grade 3 or 4 Pressure Ulcers. 21 of these were assessed as unavoidable. Our patients are very poorly on admission and often very frail. 72 patients were admitted with existing Grade 2 Pressure Ulcers and therefore the deterioration to Grade 3 in the last days of life is often not preventable. The other SI was related to a patient who fell and had a resulting fractured neck of femur. This patient was transferred to hospital for surgery. All incidents were internally reviewed and reported to CQC, the CCG and safeguarding where necessary. The significant near miss related to a patient being prescribed and given an antibiotic they had a known allergy to. Fortunately no allergic reaction actually occurred , but we then reviewed all our internal processes and developed an action plan to prevent such an incident happening again.
Infection Prevention and Control
In 2016/17 we had 5 patients admitted to the Inpatient Unit with known infections:
2 patients admitted with MRSA 1 patient with Clostridium Difficile 1 Patient with ESBL 1 patient admitted with Gardia We had 2 patients who came in symptomatic of infection and were then tested and found to have:
1 patient with MRSA 1 patient with Clostridium Difficile All 7 patients were ‘barrier’ nursed in single rooms and there was no spread of infection. We had one outbreak in June 2016 when 4 patients and 1 member of staff suffered from diarrhoea and vomiting. Public Health England were informed and admissions stopped for 48 hours until everyone was symptom free.
Before Between After
Hand washing is the single most important measure in reducing infection.
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Quality Assurance
Duty of Candour
St Peter’s Hospice always aims to be open and transparent in our care. We have an open culture of reporting incidents, and being honest if we make errors in relation to care however small. Staff understand that incident reporting and near miss reporting allow for practice improvement and service development and are always encouraged to report any concerns.
Any ‘Serious Incidents’ are investigated thoroughly and discussed with the patient and family as a priority. When there has been any error in our care we will always acknowledge this and apologise for it, explaining what our reporting mechanisms are, and letting them know how we plan to learn from the incident.
We report any Serious Incident to the Clinical Commissioning Group (CCG), Quality team and Care Quality Commission (CQC) via a statutory notification. We liaise with the Quality team if we have any queries and need advice.
All complaints are managed in line with the Duty of Candour, and where possible we aim to meet the complainant in person to ensure we give them the opportunity to fully express their concerns and receive an apology in person.
Clinical Audits and Practice Improvement
We continue each year to develop our Quality Assurance through Clinical Audit; to ascertain whether we are meeting our set standards and looking for practice changes if not. We have conducted a combined total of 12 surveys and audits across our clinical services resulting in many areas of practice improvement.
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Quality Assurance
Clinical Surveys/Audits 2016/17
Subject/Title Mth
Audit of Patient Demographics and Equality Monitoring Feb 2017
Audit of Nursing Care Plans in the District Nurse Notes Oct 2016
Spot Audit of key elements of IPU prescribing guidelines. Re-Audit Nov 2016
Survey of Spiritual Care Documentation Mar 2017
An audit of patient NHS numbers on paper based documentation. Mar 2017
Audit of our attached documents sent out of SPH has the correct iden- tifiers and if all demographics are accurate on EMIS according to pa- Mar 2017 perwork either sent in or out of SPH.
May Steroid Audit - IPU Patients 2016
Audit of Discharge Summaries from Hospice Inpatient Unit. Dec 2016
Hand Audit Monthly
Performance against waiting time standards: from referral received to Nov 2016 first treatment offered.
Access Response time from referral to triage Jul 2016
Referral to Complementary Therapy Service. Mar 2017 Survey of Integrity.
We have also participated in 4 national surveys:
National End of Life Care Intelligence Network Survey of Care Home Support - views on how to support care homes to provide end of life care Our Next Phase of Regulation - Care Quality Commission Consultation Documentation Leeds university - National UK Study on factors influencing duration of hospice-based palliative care services from referral to death. Survey on pain management at home
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Quality Assurance
Education and Placements during 2016/17 This year the Education department continued to develop its delivery of external and inter- nal education and training. In total we saw an increase in the number of people attending our external courses when compared to last year, this included a 51% increase in the number of people attending our Higher Education modules thanks to funding made available by Health Education England. Other new developments have seen us launch a series of 3-hour bitesize End of Life Care courses for unregistered practitioners which 124 people attended. While demand for our 3-day End of Life Care programmes and 1-day long term condition study days has also grown. We continue to expand our offering for our staff, the new “practice educator” role has seen the introduction of clinical skills courses including; male catheterisation, pressure ulcer and blood transfusion training for registered nurses and we have held baseline observations training for our IPU Health Care Assistants and Catheter Care, Basic Wound Care, Syringe Pumps and Topical Formulations for our Hospice at Home Health Care Assistants. These clinical skills courses have involved simulated assessment with an assessor testing knowledge, skills and behaviour. This training has been supported by us purchasing an organisational subscription to clinicalskills.net which offers staff an up to date resource for guidance on clinical procedures. Thanks to the continuing development of our own in house e-learning courses, last year twice as many of our mandatory courses were completed by e-learning as opposed to traditional face to face courses. This has supported managers with releasing staff from practice and working around shift patterns. Last year saw us launch further new e-learning courses including Infection Control and Dementia with 154 people completing the later. Finally we have grown our support to volunteers and last year saw us running a new 3-day programme for Bereavement Volunteers. While an additional 70 volunteers attended our “I don’t know what to say course” to support them with their roles supporting patients and families. Data Quality
SPH provides a quarterly patient activity report in the agreed format to the local NHS Commissioners as well as an annual report as agreed in our NHS Community contract. Key patient service data is presented on a dashboard to quarterly Board meetings of trustees. Our clinical data is benchmarked both regionally and nationally against other hospices, through Hospice UK. Information Governance: Our score in 2016/17, against the NHS Information Governance Toolkit, was 66% which achieves the required standard for our organisation. We have plans in place to further improve our Information Governance and have set up a new Information Management Group to support this development. We have introduced a new Electronic Patient Record System EMISweb which went live to plan in April 2016. We are pleased to report that our services have seen considerable benefit from the introduction of data sharing with GPS which has been well supported by GPS across our community, we are now expanding data sharing to other community partners and this will continue over the next year. We have continued to develop the system throughout the year and recognise the need for ongoing optimisation of the system. And have plans to add in additional phases as new functionality is provided to us by EMIS. Using EMIS Web will enable improved data sharing with other health care providers which will enhance our patient care.
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Quality Assurance
SPH is not subject to all Department of Health/Government regulations but it is a registered company in England and Wales and is limited by guarantee. It is also a charity registered with the Charity Commission. SPH prepare reports and accounts in compliance with the accounting standard Statement of Recommended Practice (SORP 2005) and these are audited by a firm of independent auditors. Report and accounts, which are for the year ending 31 March, are filed with both Companies House and the Charity Commission.
All reports are also available on our website www.stpetershospice.org or upon request.
Monitoring
Monitoring Internal Board of Trustees Provider visits
Our trustees are appointed to ensure good governance of the hospice. In order to ensure they review the quality of treatment and care offered they visit the hospice at least every 6 months on an unannounced visit. The visits are conducted by 2 trustees, who base their visit on the care patients receive, interviewing staff members, and looking at the care environment and inspecting the records of any complaints. The outcomes of the visit are recorded in a report which is sent to the other Trustees, Chief Executive, and Director of Patient Care. The report is also discussed in the next Board meeting.
External
We were inspected by Care Quality Commission (CQC) in March 2016 and the final report was published in June 2016. The inspection focuses on 5 key questions of the service:
Are they safe?
Are they effective?
Are they caring?
Are they responsive to people’s needs?
Are they well led?
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We are very pleased to say that we received ‘Good’ in all 5 domains and the report was very complimentary about the care we deliver.
Please read the full report at http://www.cqc.org.uk/ and then enter St Peter’s Hospice in the search box.
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Monitoring
Patient Led Assessment of the Care Environment (PLACE)
We have completed our fourth PLACE Assessment (NHS initiative). This assessment is an equal collaboration between Hospice staff and patients, family and carers, focusing on:
Cleanliness
Building condition and appearance
Food & nutrition
Privacy, dignity and well being
Dementia
Disability
The PLACE team consisted of a volunteer from Health Watch Bristol, St Peter’s Hospice volunteers, a Day Hospice patient and staff. They walked around the hospice rating each of the key areas against the set criteria.
We were very pleased that we scored above national average in every category except ‘organisation food’ (see below). The scoring system changes each year with additional criteria for all areas of the assessment. This year saw a change in the requirement of access to dietetic services on site, previous years were un-scored but were included with this assessment. This meant that we saw a dip in the food score due to the nature of our patients. Disability was a new category for 2016-2017 that wasn’t included in previous years.
The up-coming refurbishment will see a future improvement on scores on privacy & dignity as we move towards single occupancy rooms.
Blue percentages = SPH , Purple percentages = Average across the UK
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User Involvement I Want Great Care (iWGC) St Peter’s Hospice uses a range of approaches to measure satisfaction. The main measure is via iWGC. There are 8 other regional hospices using this service who meet regularly to discuss results and gain best practice. Our reviews are available online at www.iwantgreatcare.org and we continue to be reviewed favourably. We use the same questionnaires for all services and groups and so maintain a standardised approach that is comparable to the work of others. The total number of reviews received this year is 580. We continue to exceed our yearly target of 400 responses.
How likely are you to Recommend Our Services to your friends & family?
Service Area Response Rate 2016/17
In response to questions about aspects of clinical care received, 96% respondents gave high ratings of 4 or 5, and 89% the highest rating of 5. The responses, in rank order starting with the highest, were Care, dignity, trust & support, and lastly as being involved and receiving information. 92% of those patients/carers who used our Advice Line gave high ratings of 4 or 5. 57% did not use this service or left it blank. St Peter’s Hospice Facebook: we also receive frequent reviews via social media. We currently have 227 reviews on our Facebook page with an average score of 4.8 out of 5. There have also been much positive feedback given via Twitter. Any concerns raised via social media are directly reported to the appropriate Senior Manager. For review and action as necessary.
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Aims and Priorities for Improvement 2017/18 Aims for 2017/18 Our Priorities for improvement
Our main priorities for improvement in 2017/18 are:
Priorities for improvement 2017/18
In September 2017 we are relocating our Inpatient Unit for one year to a wing of a Care Home in order to refurbish our current IPU .This will need modifications and a significant altered way of working for the Priority 1- Clinical effectiveness and clinical teams, but our aim will be to deliver Patient Experience the same quality of care throughout the year. We will monitor this via our I Want Great Care patient survey and our complaints process. Our aim is to meet the same level of positive feedback in 2016/17.
In 2016/17 we introduced a new electronic patient record called EMIS to our services. In 2017/18 we will train all our HCA’s in the use of EMIS in both the Hospice at Home and
IPU Services. This will increase the Priority 2 – Effectiveness effectiveness of our documentation within the IPU and reduce paper documentation. The Hospice at Home team’s documentation
within EMIS will enable other primary care services we data share with to view their care and remain up to date with the patients current care needs.
We will review all our current falls assess- ments and develop a new integrated Falls Priority 3 – Safety Bundle. All staff will be trained on its use prior to its introduction
Commissioning for Quality and Innovation (CQUIN) 2017/18
This year it has been agreed between the commissioners and St Peter’s Hospice that we will have a one year break from the CQUIN Programme.
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The Board of Trustees’ commitment to quality
The Board of Trustees is fully committed to delivering high quality services to all our patients whether in the community or at the hospice site. Our trustees are actively involved in monitoring the health and safety of patients, the standards of care, feedback from patients including complaints, and plans for future service development. They do this by carrying out regular unannounced visits, receiving regular reports on all these aspects of care and discussing them at Clinical Services Committee and full Board meetings.
We have continued, and will continue, to deliver service developments in accordance with our 2016-21 strategy. Having increased and improved our 7 day coverage in 2016 with enhancements to our Access Team and Community Nurse Specialists, the emphasis for 2017/18 will be on the rebuilding of our In Patient Unit to provide single en-suite rooms to all our patients. This major project will require the temporary relocation of the IPU to an alternative site in Keynsham, south Bristol. Although this necessitates reducing the number of beds we are determined to maintain the same standard of care that patients receive at our Brentry site.
The Board is confident that the care and treatment provided by St Peter’s Hospice is of a high quality and cost effective.
Care Quality Commission (CQC) St Peter’s Hospice is inspected under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. Inspections are planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. We were last inspected in March 2016. St Peter's Hospice is CQC registered to deliver the following regulated activities: Treatment of disease, disorder or injury and Personal Care under the Health and Social Care Act 2008.
Chris Benson Anjali Mullick
Director of Patient Care Medical Director
St Peter’s Hospice St Peter’s Hospice
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