Annual Quality Account April 2014 – March 2015 Page 1 Keech Hospice Quality Accounts 2014 - 2015 Table of Contents Table of Contents .................................................................................................................................................................................................................... 2 Report from the Chief Executive Officer ................................................................................................................................................................................ 4 Our vision................................................................................................................................................................................................................................ 5 Report from the Clinical Director............................................................................................................................................................................................ 5 Objectives ............................................................................................................................................................................................................................... 7 Objective 1 – Providing excellent care ................................................................................................................................................................................... 7 Objective 2 – Wider reach ...................................................................................................................................................................................................... 9 Objective 3 – Right choices .................................................................................................................................................................................................. 10 Objective 4 – Value for money ............................................................................................................................................................................................. 10 Objective 5 – Working together ............................................................................................................................................................................................ 11 Priorities for improvement and statements of assurance from the board ................................................................................................................................ 12 1a. Priorities for improvement in 2015 – 2016 (Adults and Childrens) ............................................................................................................................... 12 1b. Progress against Priorities for Improvement in 2014 – 2015 .......................................................................................................................................... 14 2. Review of services .......................................................................................................................................................................................................... 16 3. Participation in Clinical Audit........................................................................................................................................................................................ 17 4. Research ......................................................................................................................................................................................................................... 17 5. Use of CQUIN payment framework ............................................................................................................................................................................... 18 6. Statement on the Care Quality Commission .................................................................................................................................................................. 18 7. Data Quality ................................................................................................................................................................................................................... 18 8. Information Governance Toolkit .................................................................................................................................................................................... 19 9. Clinical coding error rate ................................................................................................................................................................................................ 19 10. Organisational Structure ............................................................................................................................................................................................. 20 ADULT SERVICES ..................................................................................................................................................................................................................... 21 11. Adult Service Statistics ............................................................................................................................................................................................... 22 Adult Inpatient Analysis ........................................................................................................................................................................................................ 22 Breakdown of patients using the service in 2013/14 ............................................................................................................................................................ 22 Keech Palliative Care Centre Patient Analysis ...................................................................................................................................................................... 23 Other activity undertaken by Adult Services ......................................................................................................................................................................... 25 12. Infection Control ............................................................................................................................................................................................................. 26 Page 2 Keech Hospice Quality Accounts 2014 - 2015 13. Safeguarding ............................................................................................................................................................................................................... 26 CHILDREN’S SERVICES ........................................................................................................................................................................................................... 27 14. Children’s Service Statistics ........................................................................................................................................................................................ 28 Children’s In-patient Unit activity statistics ......................................................................................................................................................................... 28 Total BME in 2014/15 = 30% ............................................................................................................................................................................................... 28 Children’s Community Activity ............................................................................................................................................................................................ 29 Children’s Service Day Support activity statistics ................................................................................................................................................................ 29 15. Accidents, Incidents, Complaints and Compliments ................................................................................................................................................... 30 Accidents ............................................................................................................................................................................................................................... 30 Incidents ................................................................................................................................................................................................................................ 31 Complaints ............................................................................................................................................................................................................................ 32 Compliments received ........................................................................................................................................................................................................... 33 16. Quality and Compliance .............................................................................................................................................................................................. 35 Standard of Care ..................................................................................................................................................................................................................