Keech Hospice Care Clinical Governance Overview (April 2018 – March 2019)
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Quality Account 2018/19 Our Vision “Making the Difference When It Matters the Most” Our Mission statement: To lead the way in providing excellent care, supporting children and adults with life-limiting conditions and those affected by death and dying, helping them to live well and make every day count Table of Contents Table of Contents .......................................................................................................................................................................................... 3 Part 1: Report from the Chief Executive Officer and Clinical Director ................................................................................................................... 4 Part 1: Objectives .......................................................................................................................................................................................... 7 Part 2: Priorities for improvement ................................................................................................................................................................ 10 2a. Priorities for improvement in 2019/20 (Adults and Children’s) ............................................................................................................... 10 2b. Progress against Priorities for Improvement in 2018/19 ........................................................................................................................ 12 Part 3: Statements of assurance from the Board ................................................................................................................................................ 14 3a. Review of our services .......................................................................................................................................................................... 14 3b. Participation in Clinical Audit ................................................................................................................................................................. 18 3c. Research ............................................................................................................................................................................................... 18 3d. Use of CQUIN payment framework ....................................................................................................................................................... 18 3e. Statement on the Care Quality Commission .......................................................................................................................................... 19 3f. Data Quality ............................................................................................................................................................................................ 20 3g. Data Security and Protection Toolkit (DSPT) ........................................................................................................................................ 20 3h. Clinical coding error rate ........................................................................................................................................................................ 20 3i. Organisational Meeting Structure ........................................................................................................................................................... 21 Part 4: Review of Quality and Safety Performance............................................................................................................................................. 23 4a. Internal Audit Activity 2018/19 ............................................................................................................................................................... 23 4b. Trustee Visits ......................................................................................................................................................................................... 26 4c. Patient Led Assessment of the Care Environment (PLACE) ................................................................................................................. 26 4d. Workplace Inspections .......................................................................................................................................................................... 26 4e. Benchmarking ....................................................................................................................................................................................... 26 4f. Keech Hospice Care clinical governance overview (April 2018 – March 2019) ...................................................................................... 27 4g. What people say about us…… .............................................................................................................................................................. 30 Section 5: Feedback from our NHS Commissioners .......................................................................................................................................... 31 Part 1: Report from the Chief Executive Officer and Clinical Director I would like to start by thanking all of the staff and volunteers for their outstanding work throughout the year, and what a year it has been. The main highlight for us has to be our fantastic achievement in the Times100 Best Companies Survey. We were thrilled to be placed 18th Best Charity Non-Profit company to work for and to find out that we are the 21st best organisation to work for in the East of England region (out of all companies). This position includes all companies (large and small) and charities. I am so proud of what we have achieved and want to express my thanks to all our staff and our Trustees for being part of this journey. Last year I reported that we had been reviewing the capacity of the hydrotherapy pool, identify how we can meet the growing demands. The adult patient pathway and review of use of the pool has been completed and launched to care staff and local palliative care professionals. We have appointed an Aqua Therapist and a Senior Lifeguard and patient numbers in the pool are increasing. The children’s patient pathway is now being developed with the children’s team. This year discussions have started to take place with Adult and Children’s Services, reviewing the potential of the services we offer and potential locations within the community where they could take place. A location for adults has been identified, while the location for children’s is still being reviewed, meeting our objective of closer to home. We always like to look for new ways to engage with our service users and this year we are pleased to be working with Royal College of Paediatrics and Child Health (RCPCH) who run a ‘Youth Voice’ project, so far, we have held two workshops. We hope this project will help us to receive and act upon feedback received from the young people who use our services. We are pleased to confirm that we successfully submitted our information to the NHS Data Security Protection Toolkit (previously known as the IG Toolkit), scoring 100% against all mandatory criteria. During the year we have also reviewed our governance and well led objective, this included completing an audit with our trustees against the new Charity Governance Code Toolkit. In the last year, we have provided care to 2379 beneficiaries. This includes providing 244 adult and children’s patients with 2231 in-patient bed nights; we have undertaken 2093 community visits to children’s service patients; 204 patients have attended our Palliative Care Centre 1779 times; 1031 adult patients have been supported by our ‘My Care Co-ordination Service’. 4 Keech Hospice Care Quality Account 2018/19 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. Liz Searle Chief Executive Officer 5 Keech Hospice Care Quality Account 2018/19 Report from the Clinical Director Keech hospice care is proud to deliver specialist palliative care to children and adults, ensuring care is holistic and all the family are supported. Our focus over the last year has been to review who accesses our services, so that we can identify groups of people that do not and try to understand the reasons why. In adult services we noticed that if a patient needed support from several of our services it wasn’t as coordinated as it should be. As a team we have stream lined our processes, including the appointment of a Community Liaison Senior Sister, to ensure our patients receive a smooth and co-ordinated referral to Keech Hospice Care. We have also been working with external partners to help colleagues working with the homeless community, those experiencing dementia and liver failure and those who are severely frail to raise awareness of what services we can offer and how they can be accessed. In our children’s services we know that families wish to receive care closer to home. The team have worked hard to map where families live and where potential new families may be located. In these highly populated areas we are developing coffee mornings, and a new tots and toys group which is group for pre-school children. We have finalised our Advanced Care Plan paperwork and processes which enables us to support families to document choices