Quality Account 2012/13 “The Hospice has a dedicated and stable team of staff who collectively possess considerable skills, knowledge and experience – they are in turn supported by dedicated volunteers in all parts of the organisation. The key will be to ensure that they are all fully engaged with the external challenges, understand the part they can play and receive the learning and support they require. The management challenge is influenced by the complexity of the organisation, its range of services areas, the involvement of a large number of volunteers and the need to operate within the community including shops.” Investors in People 2012 “The people we talked with, who were using the services of the Eden Valley Hospice, all expressed satisfaction with the support and services they were receiving. People told us that the staff looked after them well and their needs were being met,” and “We observed staff engaging with people in ways that demonstrated that they were trained and experienced to deliver appropriate and sensitive support.” Care Quality Commission Inspection Report 2012
Contents 1. 2. 3. 4.
Introduction Chief Executive Quality Statement Background Information Strategy for 2012/15 4.1 Mission Statement 4.2 Purpose and Priorities 4.3 Key aims for the next three years 4.4 Delivering the strategy 5. 2012 Activity Data 5.1 Adult Inpatient Unit 5.2 Day Hospice 5.3 Outpatients 5.4 Eden House Children’s Hospice 5.5 Family Support Team 6. Review of Quality Performance 6.1 External Inspections 6.2 Self Assessment 6.3 Quality Framework 6.4 Incident Reporting 6.5 Slips, Trips and Falls 6.6 Medication Related Incidents 6.7 Infection Control 6.8 Safety Alerts 6.9 Appraisals and Training 6.10 Audit 6.11 Practice Development 6.12 Working with others 6.13 Awareness of external trends and developments 6.14 User Feedback 6.15 Complaints 6.16 Research 6.17 Finance 7. Stakeholders’ Comments 7.1 Cumbria Health Scrutiny Committee 7.2 Healthwatch Cumbria 8. Priorities for 2013/2014 8.1 Improving access to and in the Hospice 8.2 Improving fire safety 8.3 Implementing a planned programme of audit
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1. Introduction This Quality Account is a report about the quality of palliative care services provided by Eden Valley Hospice. Most organisations providing healthcare which is commissioned or funded by the NHS produce a Quality Account, including independent sector and charitable organisations. This is the first annual Quality Account for Eden Valley Hospice covering 2012/2013. The original aim behind developing Quality Accounts was to ensure that organisations providing NHS services focused their attention on quality as well as on financial balance. Although Eden Valley Hospice does not provide NHS services, the Hospice does receive some funding in the form of a grant from Cumbria Primary Care Trust, as well as a Section 64 grant from the Department of Health to support Eden House, Cumbria’s Children’s Hospice. Eden Valley Hospice is an independent charity which provides palliative care services for both adults and children. In 2012 the cost of running Eden Valley Hospice was £3,124,985. 26.5% of our funding came from the NHS. We welcome this opportunity to reflect on the quality of our services, to share these reflections with our stakeholders and to present our plans for the future. This is our first Quality Account and any feedback on the style and format will help us to improve it next year. 2. Chief Executive Quality Statement I am pleased to present the first Quality Account for Eden Valley Hospice. Maintaining and further developing high quality care is essential to the work of the Hospice. During 2012 we started to use the Care Quality Commission (CQC) Essential Standards of Quality and Safety as a Framework to review and develop the quality of our care. In a small organisation this has involved staff and volunteers at all levels. During 2012 the Hospice received a very positive report as part of the Investors in People revalidation. This was followed by Care Quality Commission unannounced inspection which found that the Hospice was meeting all the national standards. This report contains information from different working groups across the Hospice and to the best of my knowledge the information in the document is accurate. Janet Ferguson Chief Executive
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3. Background Information Eden Valley Hospice is dedicated to providing specialist palliative and end of life care to adults from the local area and children throughout Cumbria, as well as caring for their families, friends and carers. We aim to provide the highest standards of nursing and medical care, to sustain quality of life and dignity and to provide patients with relief from pain. Our aim is to control symptoms, relieve physical and emotional distress and provide support to both patients and their family. Eden Valley Hospice services include a 12 bedded adult In-patient unit, adult day hospice, out-patient clinics, family support team, complementary therapies, training and education. We aim to: Provide specialist palliative care in a therapeutic environment for people living with a progressive illness, supporting them to live life comfortably and fully. Extend care and comfort to families, supporting them as partners in care and recognizing their individual needs. As well as managing physical symptoms, we offer care for the spiritual, emotional, psychological and social needs of patients and carers. Provide bereavement care and support. Provide a local resource, as a centre of knowledge for the management and support of those requiring palliative care, from which the community can access help. Share our knowledge and beliefs to support each other, listening and communicating effectively. Be aware of and respect each individual’s strengths and weaknesses. Eden House Children's Hospice is an integral part of Eden Valley Hospice providing day to day palliative care and support to children and young people who are living with a life limiting illness. Family and sibling support are also important elements of our service. Care is provided in a home from home setting and each young person who is staying with us has their own bedroom. The ethos of Eden House is to work in partnership with the child, their family and other professionals. The aim of the care team is to maintain the child’s normal routine and make their stay as special and enjoyable as possible. We aim to: Provide a flexible, high quality and child/young person focused service of respite and palliative care across Cumbria. Work in partnership with the children, their families and all agencies involved with their care. Offer support to families as well as children. All our services are provided by qualified and experienced staff, supported by a large team of committed volunteers. Eden Valley Hospice – Quality Account 2012/13
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4. Strategy for 2012/15 4.1
Mission Statement Eden Valley Hospice will provide palliative care services for adults and children with incurable or life limiting illnesses, enabling them and their carers to live life as fully and independently as possible.
4.2
Purpose and Priorities Our purpose is to maintain and extend the availability of high quality palliative care services for adults and children. Against a background of significant shifts in health service policy and future funding, demographic changes and challenges in raising voluntary income, the Trustees and Management Team worked together to decide our direction and priorities for 2012/2015.
4.3
Key aims for the next three years Eden House Children’s Hospice aims to: Raise the profile and reach of our service. Plan transition arrangements for young adults. Develop links with paediatric medical services. Our Adult Hospice Services will: Extend the accessibility of our medical, non-medical and support services through increased outreach arrangements. Promote our experience and expertise with professionals in nursing homes, residential care services and other health care providers. Working with others we intend to: Further develop our collaboration and partnerships with other hospices and palliative care providers. Work with NHS and other providers to develop a local palliative care strategy. Play a key role with commissioners in establishing how services are commissioned across Cumbria. With stakeholders we will: Be alert and responsive to the views of those who use or share an interest in our services. Invest in promoting a significant increase in awareness about the nature, range and availability of our services.
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Maintain our commitment to the training and development of volunteers, staff and trustees. Continue to develop and maintain new and existing volunteer roles and initiatives within the Hospice and in the wider communities we serve. Our approach to funding will seek to: Ensure financial sustainability. Grow our capacity for community based fundraising. 4.4
Delivering the strategy Each year an operational plan is developed to describe the timescale and means of implementing the strategy and how progress towards achieving its aims will be measured.
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5. 2012 Activity Data 5.1
Adult Inpatient Unit Adult In-patient - 2012 No.beds 12 Total number of patients 239 Average length of stay (days) 12.1 % occupancy 75.8% % new patients 89.1% % cancer (new patients) *83.3% % non-cancer (new patients) *12.1% % patients discharged *50.7% % patients deceased *49.3% * discrepancy due to dual diagnoses and the 11 patients registered without a recorded diagnosis
5.2
Day Hospice Day Hospice - 2012 Total number of patients 109 Average length of stay (days) 140.6 % new patients 64.2% % cancer (new patients) *69.7% % non-cancer (new patients) *16.5% * discrepancy due to dual diagnoses and the 15 patients registered without a recorded diagnosis
5.3
Outpatients Outpatient - 2012 Total number of outpatient appointments scheduled Total number of appointments attended New patient appointments Follow up appointments Did Not Attend Blood transfusions administered as a day treatment (3 patients had two blood transfusions and 11 patients had a single blood transfusion)
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320 284 72 212 19
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5.4
Eden House Children’s Hospice Care provided for children and their families during 2012:
January February March April May June July August September October November December Total
Day Care
Nights of Care
82 84 82 86 90 90 95 94 82 88 80 86 1039
71 67 67 70 73 77 89 89 57 73 75 81 889
Total Episodes 51 43 48 42 37 46 46 44 31 41 48 49 527
Support is also offered to the families of children who attend Eden House. During 2012 there were 3 family support days and 4 siblings’ days, including the annual children’s outing. 5.5
Family Support Team Eden Valley Hospice Family Support team includes two Palliative Care Social Workers, Chaplain and Counsellor, supported by chaplaincy and bereavement volunteers. During the year we have been developing systems for collecting and presenting data about the activity in these areas which will be included in the Quality Account for 2013.
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6. Review of Quality Performance The provision of palliative and end of life care is complex, involving a number of different professionals and organisations. Moreover, the models of care for adults and children are very different. In health care the main domains of quality are patient experience, safety and effectiveness. A range of different processes and systems are used to support learning and development across all these areas of our work in Eden Valley Hospice. 6.1
External Inspections Both staff and volunteers contributed to the Investors in People accreditation process in 2012. The Assessor reported it was clear that staff and volunteers remain committed, energised and enthusiastic “all have successfully maintained the happy and caring atmosphere at the Hospice and there have been impressive improvements to the facilities since the last review�. He recognised a collective awareness and appreciation of the future role of the Hospice within the community it serves, improved communications and a changing culture. On 27 April 2012, inspectors from the Care Quality Commission (CQC), the independent regulator of health and adult social care services in England, paid an unannounced visit to Eden Valley Hospice to assess our compliance with the CQC standards that apply to hospices. They found the Hospice to be compliant with all the outcomes which were included in the inspection. The positive nature of the Care Quality Commission report suggests that the constructive approach we have taken to the standards, using them as a tool to bench mark and identify areas for improvement has been a constructive one which we will build on during 2013. This achievement reflects the ongoing commitment of staff and volunteers to provide consistently high quality care to all patients and their families. An Environmental Inspection of the kitchen took place on 01.03.2013. This was in conjunction with Carlisle City Council and the Food Standards Agency. The kitchen received a Food Hygiene rating of 5 stars, very good.
6.2
Self Assessment Different forms of self assessment have become part of the Hospice annual activity. During 2012/13 we assessed our information management processes against the NHS Information Governance Toolkit Version 10 for Voluntary Organisations. This involved reviewing our policies and procedures against the standards in the toolkit. We then had to provide evidence to demonstrate our compliance with the standards. This assessment demonstrated compliance with the different areas of data protection, confidentiality and information security. We also identified areas where we could develop and improve our systems.
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Along with partner organisations we also measured our multidisciplinary approach against proposed national Cancer Peer Review Standards for palliative and end of life care and recognised areas where we could work differently and develop together. This has resulted in a pilot of a new joint multidisciplinary meeting to review complex cases. 6.3
Quality Framework During 2012 we started using the CQC Essential Standards of Quality and Safety as a framework for assessing quality and identifying gaps and areas for action. This process was led by a small steering group and involved staff from across the organisation. Trustees were linked with specific outcomes. We have now established a process for reviewing an outcome at each monthly Management Team meeting to ensure our assessments and evidence remain accurate, relevant and up to date. The Hospice Clinical Governance Group meets three times a year. This group is chaired by a Trustee and supported by two other Trustees. The group has an overview of incidents, clinical developments and patient feedback. The infection Control Group and Food and Nutrition Group report directly into clinical governance and make sure we continually improve and develop our approach to these areas of care. Significant incidents are also reviewed by the Senior Management Team.
6.4
Incident Reporting There is a robust process for documenting, reviewing and reflecting on incidents. A summary of all accidents, incidents and near misses is submitted to the Clinical Governance Committee, chaired by the Vice Chair of Trustees.
6.5
Slips, Trips and Falls Slip, trips and falls are monitored and each incident is reviewed to ensure all efforts have been made to minimise the risk of falls whilst maximising the patient’s level of independence. Trends have been monitored and steps taken to improve the patient environment to minimise the risk of falls. In 2012 a total of 56 incidents involving patients were reported as detailed below: Reason for incident Patient trying to maintain level of independence (found by staff following the incident) Sudden change in patient’s condition Slip/trip/fall/poor balance Total
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Total number 37 (66%) 5 (9%) 14 (25%) 56
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6.6
Medication related incidents The Hospice encourages the reporting of drug incidents. The majority of incidents in the Hospice are near misses; this means there has been no patient harm and a potential incident has been avoided due to an error being identified before an incident occurred. Lessons from near misses are shared and practices modified as a result. Where Controlled Drugs are involved this is shared with the Local Intelligence Network for Controlled Drugs through occurrence reporting. All drug incidents are reported to the Clinical Governance Committee. In 2012 there were 19 incidents as detailed below: Reason for incident Error/omission in recording when medication administered e.g. incorrect entry in Controlled Drug register Incorrect dose of medication Omission of medication Discarded medication Error relating to frequency of administration Error relating to route of administration Total
Total number 8 3 5 1 1 1 19
A medication error was reported when a Fentanyl patch was not changed on time. The Head of Nursing reviewed the incident and developed a new monitoring form for this type of medication. All incidents were investigated and, where necessary, corrective action was taken. There were no serious consequences to patients from any of these incidents. 6.7
Infection Control Eden Valley Hospice asks about the patient’s infection status at the point of referral to the service, and monitors patients during their in patient stay. Patient Infection 2012 (Adult in-patient unit) Number of patients admitted with MRSA Number of patients infected with MRSA during admission Number of patients admitted with Clostridium Difficile Number of in-patients who contracted Clostridium Difficile
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Number of cases 1 0 2 0
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6.8
Safety Alerts The Hospice reviewed and actioned relevant alerts received from the Central Alerting System including drug safety alerts from the Medicines and Healthcare products Regulatory Agency and Medical Devices Alerts. In 2012, action was taken in relation to 26 alerts which were relevant to the Hospice.
6.9
Appraisals and Training There is an annual appraisal system in place for all staff. This identifies areas for development, new skills and training needs. Appraisal training was carried out in 2012, with the forms and process reviewed. Appraisals are cascaded through the organisation with the aim of 95% of all staff having an appraisal during 2013. Mandatory Training is provided internally for all staff and volunteers and reinforced by a booklet. Following appraisal, particular training is identified to meet the needs of individual members of staff and this is accessed from local and national sources.
The Head of Nursing is working towards her MSC in Palliative Care. Clinical Sister for the Adult In Patient Unit completed Palliative Care Nursing Degree in September 2012 Clinical Sister in Day Hospice and a Staff Nurse from the Adult Unit are working towards a Palliative Care Nursing Degree The Support Services Manager is working towards a BA in Voluntary Sector Studies The Hospitality Manager is working towards a Diploma in Management We currently have an apprentice working towards an NVQ in Business and Administration, through the Apprenticeship programme.
6.10 Audit A number of audits have been undertaken including an audit on the use of the Liverpool Care Pathway in end of life care and an audit of steroid prescribing. However the Hospice needs to develop a systematic plan for audits. Help the Hospices have a number of audits tools which could be used in the future. During 2012/2013 there were no national clinical audits or confidential enquiries which covered the services provided by Eden Valley Hospice, therefore we did not participate in any.
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6.11 Practice Development A new Team Leader post has been created and filled to support the nursing team in the Adult Inpatient Unit. The Practice Development Nurse post was vacant in Eden House, however this has now been filled, and the new post holder is exploring the training needs of staff and planning education sessions. Training has taken place about opioid conversions. Training was organised for Eden House staff about spiritual care, support for families and training about the management of specific disorders. 6.12 Working with others Eden Valley Hospice has participated in Cumbria wide development work together with the commissioners and other organisations. This has focused on developing palliative and end of life care across settings. We also proactively link with Cumbria and Lancashire Network End of Life Care Network as well as with other hospices in Cumbria and across the North West. The Hospice is involved in facilitating the roll out of Deciding Right across Cumbria. We have participated in the benchmarking against Palliative Care Peer Review standards together with other organisations and the wider Multi Disciplinary Team (MDT). This has led to the decision to trial a new format MDT across the north of Cumbria using the video conferencing equipment installed by the Cumbria and Lancashire Cancer network. 6.13 Awareness of external trends and developments During the second half of 2012 we monitored the criticism in the media about the Liverpool Care Pathway and were aware of the growing anxiety about its use. Staff carried out a risk assessment and agreed a careful approach, which was later followed by audit. 6.14 User Feedback A working group has been established to look at different ways of gaining user feedback. New questionnaires have been developed as well as simple comment forms. A volunteer has regularly carried out patient interviews every month. We are now revisiting this and plan to train a small group of volunteers to talk to patients and families about their experience of using the Hospice. Poor attendance at evening meetings for parents of children attending Eden House. Verbal feedback suggested parents found it difficult to attend because of the need for childcare. Our approach was redesigned to offer Family Support Days where the Eden Valley Hospice – Quality Account 2012/13
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child who is a patient, siblings and parents are all catered for with different activities and support. These have been successful and well received so far. 6.15 Complaints All complaints are recorded, documented and investigated. These are then reviewed by Complaints and Disciplinary Sub-Committee of Board of Trustees every six months. Last year we received 2 letters about the transfer of patients from Eden Valley Hospice to Care Homes. These highlighted that the patients were distressed at leaving the Hospice. A retrospective audit of notes of patients who were transferred or where transfer was discussed was undertaken by a member of the medical team. The results of this were used to modify our practice around nursing homes transfers. 6.16 Research During the year no patients were recruited to research studies. We have agreed to participate in an observational research study called Improving Hospice Environments for Older People. As a small organisation we have limited opportunities for research. However, we hosted a research workshop facilitated by End of Life Observatory to encourage awareness and interest in research in palliative and end of life care. We plan to establish stronger links with the research network over the coming months. 6.17 Finance The accounts of Eden Valley Hospice and its subsidiary company Eden Valley Hospice (Shops) ltd, are audited on an annual basis, in accordance with the Companies Act 2006 and the Charities Act 2011. The auditors have signed off the 2012 accounts, with nothing to report, confirming that the accounts reflect a fair view of the state of the charity’s affairs and are prepared correctly. An internal audit will be carried out by trustees during 2013, by members of the Finance and Audit sub-group of the Board. The 2012 accounts are available from Paul Cookson, Head of Finance at Support Services.
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7. Stakeholders’ Comments Eden Valley Hospice Quality Account was sent to Cumbria Clinical Commissioning Group, Cumbria County Council Scrutiny Committee and Cumbria Health Watch for comments which are listed below. 7.1
Cumbria Health Scrutiny Committee The Cumbria Health Scrutiny Committee welcomes the opportunity to comment on the Eden Valley Hospice’s Quality Accounts for 2012-13. In reviewing the draft document, members responded that the document was both readable and accessible, and the issues were clearly presented and commented upon in a practical way. In terms of the layout of the document, members felt that on the whole this was good, however in order to improve this further for the reader the headings could perhaps be clearer, helping to signpost the reader to the purpose of each section. There was also the suggestion that the text could perhaps be broken up more with pictures to illustrate the issues, and overall, these would make the document more readerfriendly. With regard to the level of detail contained within the document, Members felt that information on development of staff and the type of training that is provided in relation to the appraisal process would be beneficial. In addition, more emphasis could have been placed on the outcomes of the unannounced inspection. Other areas considered were whether the higher proportion of people attending the Hospice have cancer diagnoses, rather than other illnesses, given the percentages outlined in the document. One member also highlighted the issue of closer involvement with social workers and wondered whether this might be developed to the benefit of service users. Members were very supportive of the projected schemes identified going forward and are aware that the Eden Valley Hospice has a tremendous reputation for the care and support they provide. This is a detailed and comprehensive document, and overall we appreciate the work that has taken place over the recent year and look forward to continuing to work with the Hospice.
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7.2
Healthwatch Cumbria We were asked to provide some feedback on the Eden Valley Hospice Quality Account for 2012-2013. The following document details our comments and recommendations, although we would like to stress that Healthwatch Cumbria is an organisation still very much in its infancy and without a full staff team available. We therefore feel that in future, with greater resources available, we can produce a much more detailed feedback report. Overall, we feel that document is very clearly set out; it is easy to follow and is very understandable. The proportionate use of text and graphs has made it accessible, and we like the fact it is a concise document. We have a few questions regarding the content of the document. The strategy section lays out the key aims for the Hospice over the next three years. In the ‘Delivering the strategy’ section it says an operational plan will be developed. Will this be an internal plan, or will it be accessible to everyone? It would be interesting to see what the plan entails and if it is followed. In the section entitled slips, trips and falls, it mentions trends have been monitored and steps towards improvement have been taken. What are the trends and what steps have been take to ensure improvement? We feel this needs to be explained in a bit more detail. Under the medication related incidents section, it states that there have been 19 incidents. Is this number of incidents high or not in comparison to other small hospices? A percentage would have been good to show the difference and compare to number of patients. There is some evidence of patient infections, although it is good to see that nothing was contracted at the Hospice itself. There were some other questions we had in response to reading through this account: What did the audits show? Is this data available? You acknowledge some flaws in Liverpool care pathway. Are you continuing to use it? Could you include more patient feedback? How mainly complaints have been received? The exact number does not appear to be included, or is not in the most obvious place. Is the Hospice in profit or deficit? The issue appears to be skirted over, and an indication would be useful to know.
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Were staff, patients or family involved in Friends and Family survey about whether or not they agree that if a friend or relative needed similar treatment, they would be happy with the standard of care provided?
As mentioned, we feel this is generally a well laid out document that is easy to follow understand. It gives a good over view of the Hospice’s performance, but some extra detail with statistics to back it up might be useful. 8. Priorities for 2013/2014 Three priorities have been identified for the coming year.
Patient experience:
Improving access to the Hospice
Safety:
Improve Fire Safety
Effectiveness
Implementing a planned programme of audit
8.1
Improving access to and in the Hospice Eden Valley Hospice has been providing care since 1991. Over the years new areas have been added to the Hospice, parts have been redesigned and the levels of activity and complexity have increased. As a natural consequence of this the number of people coming to the Hospice by car has also increased. The specific areas for improvement, particularly the main entrances and car parking have been identified through incidents, observation and comments made by people coming to the Hospice. An application has been submitted to the Department of Health Capital Improvement Scheme. The Hospice has been notified that 68% of funding has been agreed and the detailed terms of the grant will be agreed in June. Improvement will include: Rebuilding of main entrance to Hospice to include wider automatic doors Replacement of entrance doors to adult inpatient unit Replacement of entrance doors to Eden House, so that doors open automatically Refurbishment of toilets near reception so they are accessible by wheelchair users Replacement of ambulance Garage for ambulance and Eden House vehicle and creation of turning circle
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8.2
Improve Fire Safety The improvement needed to the Fire alarm system has been identified following the recruitment and training of Fire Wardens and the establishment of regular Fire Warden meetings and feedback from staff. The fire warning system has been in place since the Hospice was first built and as new sections have been added to the building the system has become increasingly complex, with different fire panels in different areas. The system will be improved by: Replacing the original detectors in older parts of the building with new ones Both fire panels will be the same Panels will indicate exactly where the alarm is coming from Hold fire drills Continue weekly system test
8.3
Implementing a planned programme of audit It has been identified as part of the operational development plan that although audits are undertaken there is no clear plan for this to ensure different areas are covered and that areas of work are systematically re audited following changes in practice.
Calendar for clinical audit, with identified leads for each audit The audit calendar will be monitored The Clinical Governance Group will maintain the overview of this and agree any additional work Recommended changes in practice or areas for improvement will be noted
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