Quality Account 2015-2016 Our Vision is that “Everyone has choice and excellence on their journey towards the end of life” Our Mission statement: Keech Hospice Care exists to provide high- quality accessible specialist palliative care (SPC); and work in partnership to influence and educate others in End of Life Care Table of Contents Part 1: Report from the Chief Executive Officer and Clinical Director ................................................................................................................... 4 Objectives...................................................................................................................................................................................................... 6 Part 2: Priorities for improvement........................................................................................................................................................................ 11 2a. Priorities for improvement in 2016 – 2017 (Adults and Children’s) ........................................................................................................ 11 2b. Progress against Priorities for Improvement in 2015 – 2016 ................................................................................................................. 13 Part 3: Statements of assurance from the Board ................................................................................................................................................ 16 3a. Review of our services .......................................................................................................................................................................... 16 3b. Participation in Clinical Audit ................................................................................................................................................................. 19 3c. Research ............................................................................................................................................................................................... 20 3d. Use of CQUIN payment framework ....................................................................................................................................................... 20 3e. Statement on the Care Quality Commission .......................................................................................................................................... 20 3f. Data Quality ............................................................................................................................................................................................ 21 3g. Information Governance Toolkit ............................................................................................................................................................. 21 3h. Clinical coding error rate ........................................................................................................................................................................ 21 3i. Organisational Meeting Structure ........................................................................................................................................................... 22 Part 4: Review of Quality and Safety Performance............................................................................................................................................. 24 4a. Internal Audit Activity 2015/16 ............................................................................................................................................................... 24 4b. Trustee Visits ......................................................................................................................................................................................... 28 4c. Patient Led Assessment of the Care Environment (PLACE) ................................................................................................................. 28 4d. Workplace Inspections .......................................................................................................................................................................... 29 4e. Benchmarking ....................................................................................................................................................................................... 30 4f. Keech Hospice Care summary clinical governance overview (April 2015 – March 2016) ...................................................................... 31 4g. What people say about us…… .............................................................................................................................................................. 34 Section 5: Feedback from our NHS Commissioners .......................................................................................................................................... 35 Part 1: Report from the Chief Executive Officer and Clinical Director Together with the Board of Trustees, I would like to thank all our staff and volunteers for their achievements over the past year. Despite the current economic climate, the Hospice has continued to support people in need of our services whilst remaining financially sound. In February 2016 I commenced post at the Chief Executive having previously been the Clinical Director. We also have a new Chair of Trustees, Clive Medlam, and the wider experience of our board continues to serve us well. At Keech Hospice we strive to continually deliver safe and innovative services, whilst giving reassurance that the organisation as a whole has patient care and quality at its core. The safety, experience and outcomes for all our patients and those close to them are of paramount importance to us. We always try to reflect the needs of our diverse community and we are proud to be caring for 18% of adults and 31% of children from BME groups. We have also expanded our care to non-cancer patients who now form 36% of our adult patients. In the last year we have provided 175 adults and children with 2206 in-patient bed nights; we have undertaken 1269 community visits to children’s service patients; 234 adult patients have attended our Palliative Care Centre 2015 times; 1028 adult patients have been supported by our ‘My Care Co-ordination Service ‘. We are working on a tailor made development plan to help us to ensure our management and governance arrangements are robust. 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 4 Keech Hospice Care Quality Account 2015/16 Report from the Clinical Director Keech hospice care continues to provide high quality specialist palliative care to adults and children with progressive life limiting illness. We provide this to adults in Luton and south Bedfordshire and children in Bedfordshire, Hertfordshire and Milton Keynes. We have two in- patient units, community services and outpatient services. It is important to us that we always continue to look ahead and work with colleagues and service users to identify gaps and find innovative ways to fill them. During 2015-16 we have worked in partnership with Macmillan cancer support to develop an independence and wellbeing service to support adults from the beginning of their time living with a life limiting illness. We have also identified the need to provide support to bereaved people in Luton who may not have had a family member die with us but require bereavement support. Talking Elephants is a successful community support group and next year we hope to build on this. In children's service we have recognised the need for a co-ordinated approach by professionals to children's care and in Luton have lead on setting up and developing multi-disciplinary meeting to discuss caseloads and plan care. We have also worked with other professionals to develop an information leaflet for parents when their child dies. This will mean that wherever in Luton a child dies the information the parents receive will be the same. We plan to work with professionals in the other areas we cover to do the same. Our staff work with other health and education providers to ensure our young people have a special education plan. Elaine Tolliday Clinical Director 5 Keech Hospice Care Quality Account 2015/16 Objectives Achievements and highlights from 2015/16 were monitored against our strategic objectives: Objective 1 – Delivering Excellent Care Palliative Rehabilitation Service: An occupational therapist was appointed to Keech in December 2015 after a scoping exercise identified that a Palliative Rehabilitation service would benefit patients with a palliative diagnosis. The Macmillan funded service is to include a physiotherapist and an occupational therapist working with other allied health professional posts in hospital and community services. This quarter, services and models of practice for target patients have been fully researched, using information from other hospices with established rehabilitation services. These services are focused on improved physical function, self-management and health and wellbeing, which enhances knowledge, independence and self-care. The occupational therapist works 3 days weekly and the physiotherapist position, for the same hours, continues to be advertised.