“Caring for the last years of life”
Ear l M ountbat t en H ospic e Quality Account 2015/ 1 6
“Every day of care you gave her, you did so with such compassion, kindness and love. At all times you maintained her dignity and always made her feel special and important” Feedback from family member
Contents
Part One Our mission, vision and values Statement on quality Part Two
1 2
Looking Forward
2.1
Priorities for improvement 2016/2017
3
2.2
Quality across our services
5
2.2.1 Review of services 2.2.2 Goals agreed with commissioners 2.2.3 Statement from the Care Quality Commission 2.3
Participation in clinical audits
12
2.4
Data quality
15
2.4.1 Minimum data set 2.4.2 Information governance Part Three Looking Back 3.1
Achievement against our priorities for 2015/2016
18
3.2
The patient and family experience of the Hospice and its services
21
3.3
Our staff and volunteers
26
3.4
Statements of assurance
27
3.4.1 Statement from the Isle of Wight NHS Clinical Commissioning Group 3.4.2 Statement from Isle of Wight Healthwatch 3.4.3 Independent statement from Shaun Stacey (Chief Operating Officer, IWNHS Trust) 3.5
Endorsement of Quality Account by Board of Trustees
30
Glossary and further information
31
How to give us your feedback
32
Acknowledgements
32
Part One In July 2015 Earl Mountbatten Hospice published its new 2015 - 2020 strategy outlining its future direction and aspirations against a backdrop of challenges and demands faced by our services. Our mission, vision and values are at the heart of this strategy and these guiding principles have been developed in partnership with our staff, volunteers and trustees.
Our Mission To promote and to provide good care and support for those people living with, affected by, or curious about death, dying and bereavement across the Isle of Wight
Our Vision … is of a world where all dying people and those close to them have access to expert, compassionate and cost effective care of the highest quality, whatever the illness, whoever they are and wherever they happen to be
We respect our community. We exist for our local population now and into the future, and we believe that we can achieve more together by working in partnership with others. Our values, which have been defined by our staff and volunteers, are underpinned by a set of expectations and behaviours, which we have all agreed to.
Strategic Aims We will : • Reach more people to achieve scale • Work in partnership to achieve our aims
Our Values We care about what we do. We appreciate that people are different and we are kind and compassionate to our patients and families, to our local community and to each other
• Ensure our services to, and our impact on, our Island community are sustainable for the future.
We are experts in our field. We are professional at all times, aspiring to be the best that we can be in everything that we do We are innovative and bold. We respond quickly and creatively to the changing needs of our society within the scope of our human and financial resources Patient and nurse in the Inpatient Unit
Quality Account 2015/16 - Part One
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Statement on Quality Earl Mountbatten Hospice sets out to provide the best possible care for people with life limiting illnesses and those close to them, and all of our staff and volunteers participate in this effort. As the lead provider of end of life care on the Isle of Wight, our mission is to promote and to provide good care and support for those people living with, affected by, or curious about death, dying and bereavement across our whole community. Primarily, we are here to offer care to those who are coming to the end of their life together with support for their families and friends, whatever the cause of their death or bereavement, and wherever they happen to be. We will all die and we will all be bereaved and therefore we are also here to challenge people’s perceptions of death, dying and bereavement and to enable each and every one of us to discuss our preferences as well as to plan well in advance for what will be an inevitable outcome for all of us. We are committed to continuously finding ways of improving and growing our services to patients, families and the local community, and we have a robust clinical governance framework that enables us to do this. During the course of the past year we have focussed on a number of key priorities for improvement and this account highlights our progress. Some particular highlights are outlined as follows: 1. As death, dying and bereavement change and people die over longer periods of time, it has been important for us to address the changing needs of our community. Our new ‘selfmanagement’ programmes within the John Cheverton Centre, a day, rehabilitation and self-help centre based on the hospice site in Newport, begin to offer new possibilities for people to lead in their own care, and our responsibility to support our community offer through new bespoke volunteer training packages is helping not only to support more people within the places that they live, but also provide potential career options for those people wanting to enter the health and social care workforce. 2. You will read of the awards which our Children’s Services Partnership has won over the past year. This important local partnership between the hospice, KissyPuppy and the local Children’s Paediatric Team leads the way across the UK for a new and sustainable model for hospice care. 3. During 2015/16, a new Rapid response pilot project has begun to show how we can provide solutions to the problem of ’bedblocking’ within the local hospital, through utilising our especially trained team of
Quality Account 2015/16 - Part One
domiciliary carers to discharge people who are inappropriately dying within hospital back to the places where they live. We have also supported other care agencies across the Island by providing bespoke training around end of life care delivered by our team of experts in the field. 4. A new community engagement programme provides regular weekly events in order to offer opportunities for our local community to come to the hospice and witness what goes on here. A concert series, an Art Gallery and discussion events such as ‘Death Chat’ are beginning to change attitudes towards the hospice and the work that it does. 5. We have continued to improve how we audit and evaluate our service through developing and achieving a robust audit plan, and the introduction of a new set of national outcome measures for hospice (OACCS) begins to further measure, demonstrate and improve care for all of those who rely on us for their care and support. Someone once said that care is not a commodity. Delivering good quality care and living on a day to day basis with the desire to continuously improve and develop the services we deliver needs to be rooted within the very fabric of the relationships we make with those people we support, as well as with those organisations which we provide services together with across the system and as many people as possible across our Island community. Our steadfast obligation is to continuously aspire to be the best we can be and this ambition, in turn, can hopefully enable others to be at their best also. This is at the heart of what we believe good quality looks like. In our Quality Account for this year, as well as reviewing our performance against the quality indicators we selected last year, we also identify our priorities for quality improvement for 2015-16. Myself and my team, together with a wide range of partners, have been closely involved in this review and in developing these measures, which have been endorsed by the Board of Trustees. I am able to confirm that the information in this Quality Account is, to the best of my knowledge, accurate.
Nigel Hartley CEO Earl Mountbatten Hospice
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Part Two - Looking Forward 2.1 Priorities for improvement 1 April 2016 – 31 March 2017 At Earl Mountbatten Hospice, we continually review the quality of our services to improve and develop them according to the needs of the community we serve. Understanding what is important to our local community is critical to developing future priorities. Therefore, our priorities are selected through a consultation process with a wide range of people. This has included holding an interactive focus group in December 2015, where we asked people to consider and develop nine priorities for improvement for 2016/17. This was attended by patients, service users (including potential service users) staff, volunteers, trustees and representatives from Healthwatch Isle of Wight. A detailed action plan has been produced identifying nominated key leads to work with staff, volunteers, patients and service users to drive the identified priorities for improvement. The Quality and Governance Committee will monitor this action plan on a quarterly basis.
Priority 1: Patient Safety Target
How we measure success
1.1 To promote dementia awareness through staff and volunteer training, modifying our environment and use of appropriate equipment, in line with national best practice for patients with dementia and their carers.
• Deliver two one-day Dementia Awareness Reaching Communities (DARC) training to EMH staff and volunteers. • Four trained members of staff to undertake and complete the European Certificate for Holistic Dementia Care. • An assessment of the environment and our equipment is made, with key recommendations to provide a dementia friendly environment.
1.2 To provide training and regular supervision for EMH administrative staff to enable them to support distressed patient and family telephone calls and enquiries.
• All clinical administrative staff have attended training to enable them to provide appropriate telephone support and manage complex and/ or distressed callers. • Programme of regular supervision is in place for administrative staff. • Staff evaluation of the training indicates increased confidence.
1.3 To develop an information leaflet for carers of patients being nursed at home to educate, inform and enable patient choice.
• Information leaflet is produced and approved by the Information Review Group and in use by the Community Team. • Feedback from the Community Patient and Family Experience survey indicates that carers have found the leaflet useful.
Quality Account 2015/16 - Part Two
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Priority 2: Clinical Effectiveness Target
How we measure success
2.1 To increase the number of Clinical • Clinical Nurse Specialist clinics take place at Nurse Specialist clinics held at EMH John JCC five days a week, including palliative Cheverton Centre (JCC), including early and other disease groups. triage of patients, to enable more patients • Feedback from the JCC Patient Experience to be seen and facilitate access to the full survey indicates patients have benefited from range of services provided at JCC. wider access to services in JCC. • Increase patient contacts with EMH Clinical Nurse Specialists within JCC by at least 15% compared with 2015/16. 2.2 To increase the number of blood transfusions and bisphosphonate treatments delivered in the JCC to offer more choice and facilitate in a day setting, reducing the need for an overnight stay.
• Increase the number of blood transfusions and bisphosphonate treatments by 10% compared with 2015/16. • JCC Patient Experience survey to demonstrate that patients are given a choice of where blood transfusions/bisphosonate treatments are carried out.
2.3 Develop a food and drink strategy to address the nutritional needs of people using the service.
• Food and drink strategy presented and approved at EMH Patient Services Committee with full recommendations for implementation.
Priority 3: Patient Experience Target
How we measure success
3.1 To develop JCC services to offer a more flexible bespoke and responsive service with a full programme of open access activities to reach more people with diverse life-limiting conditions of any age in our local community.
• A programme is in place at least five days a week which includes activities and sessions for all age groups and life-limiting conditions. • Patient survey for circuit exercise groups indicates value of new sessions and includes monitoring of demographic data.
3.2 To develop a patient and carer programme to encourage selfmanagement for patients with a range of life-limiting conditions and offer carers the opportunity to provide mutual support.
• Deliver three eight-week patient and carer programmes focusing on self management and peer support during 2016/17. • Evaluation report of programme in 2016/17 presented to Patient Services Committee, with recommendations for future service developments responsive to patient and carer need.
3.3 To develop skilled and well trained volunteer roles working across all clinical areas and into the community to support and enable patients and their families wherever they are.
• Volunteer code of conduct approved and adopted in practice. • A minimum of three training programmes delivered to current patient facing volunteers and all new starters during 2016/17 with a full evaluation.
Quality Account 2015/16 - Part Two
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2.2 Quality across our services 2.2.1 Review of Services During 2015/16 Earl Mountbatten Hospice provided a range of end of life services, including expert specialist, generalist and domiciliary care services within the following areas: • • • • • •
Inpatient Unit Day Services at EMH John Cheverton Centre (JCC) Community Outpatients St Mary’s Hospital Nursing/residential homes
These areas are supported by the following services: • • • • • • • • • • • •
EMH Community Team Psychological Services Chaplaincy Social Worker Physiotherapy Occupational Therapy Complementary Therapies Specialist Lymphoedema Service Creative Therapies Information Services Education Voluntary Services
Children’s Services - Local & National Awards During 2013 Earl Mountbatten Hospice engaged in a project which sought to develop a range of services offering, flexible, individualised end of life care and support for children and young people living on the Isle of Wight. EMH is privileged to be working in partnership with the Children’s Community Nursing Team at the Isle of Wight NHS Trust and local charity KissyPuppy to ensure that any child with a life shortening illness and their families get the local support that they need. We are committed to supporting and doing whatever we can to help improve and extend choices in end of life care for children and young people across the Island.
EMH is able to offer a bespoke, flexible room within the Hospice Inpatient Unit to be used as a location where children or young people could receive end of life care locally, delivered by the Children’s Community Team and/or as a resting service for after death care. Nothing can take away the unbearable pain of the death of a child, but how we care for a child and those around them during the last part of their journey can make a very real difference. Having time and the space to say goodbye is incredibly precious for families. The room, together with support from hospice and NHS staff, enables grieving parents, siblings and families to spend time with their child’s body before making the decision to transfer to the care of the Funeral Director. Feedback from families and the Children’s Community Team state that this is a highly valued extension of EMH’s role within the local community as their comments below endorse: “Just to know that we had a choice at the end. That WE could choose where our child went and how long we could stay with her. That WE could decide when the time was right to say goodbye. To have that choice at a time where all other choices were out of our hands was more important than we could have possibly foreseen.The kindness shown to us by the Hospice staff, who themselves were in unfamiliar territory, was extraordinary. It’s very hard to convey something so personal in words but at the lowest point in our family’s life when we felt so wholly alone they made us feel that we were anything but…” (Parents) “The provision of a resting space at the Hospice has given the families a sanctuary. A sanctuary where they can spend time with their loved one in an environment which is a home from home. Being able to access the expertise within the Hospice team is giving these families a choice that was not available before and the positives that come from this are immeasurable.” (Children’s Community Team Leader)
Quality Account 2015/16 - Part Two
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Earl Mountbatten Hospice won the Annual Hospice Innovation Award at the 2015 Hospice UK national conference in Liverpool in November 2015 for its unique partnership with KissyPuppy, and the Children’s Community Team, to develop services for children at the end of life and their families. The national award recognises the enormous contribution that both individuals and innovative programmes have made to hospice care in local communities across the UK. Antonia Bunnin, Director of Hospice Support and Development at Hospice UK, said: “There are some extraordinary individuals in our member hospices who, in their day-to-day activities, go above and beyond to transform care for terminally ill and dying people and their families.”
Reconfiguration of Hospice Inpatient beds During December 2014, in response to increasing system-wide pressures in the local NHS, an increase in hospice bed capacity was identified as one of a number of local solutions to this challenge. Initially, a grant was provided to EMH from Winter Pressure resilience funding to support the opening of two additional beds within the Hospice. The aims were to: •
increase flexibility and responsiveness to requests for patients to be admitted to the Hospice
•
provide additional support in the community for patients to remain at home, depending on individual preferences
•
provide an opportunity to deliver nurse-led care on the Inpatient Unit which would also support planned respite and crisis management in order to avoid unplanned admissions to hospital.
As a result the following benefits were recognised:
Example of a child’s bedroom
EMH also won the award for ‘Improving Services for Children and Young People’ and the ‘Chairman’s Diamond Award’ at the Isle of Wight NHS Trust Awards in March 2016. This award was in recognition of excellence and innovation by EMH staff, volunteers and partner organisations. Both awards are a tremendous accolade for EMH and all those who had been involved in the development of the children’s services over the past three years. Many staff and volunteers past and present contributed towards these awards, as well as children and their parents who both inspired and motivated us all to join together to create a bespoke service for dying children and their families across the Isle of Wight.
98 patients would not have been admitted to the Inpatient Unit if only 14 beds were available during 2015/16. Prior to 2015/16 approximately 20% of admissions came to the Inpatient Unit from St Mary’s Hospital. This figure is now over 35%. Some patients are being transferred to EMH from St Mary’s Hospital during the last hours of their life. Families tell us that they benefit from the wider support that EMH is able to give under these circumstances. Our service is clearly responding to the needs of more people more of the time. Noncancer admissions to the Hospice Inpatient Unit have increased during 2015/16; out-turn figures for 2014/15 were 25 compared with 82 in 2015/16. During 2015/16 87.95% of people who used EMH Inpatient and Community Services died in their preferred place.
Quality Account 2015/16 - Part Two
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EMH Rapid Response Pilot Project One of the key aims of Earl Mountbatten Hospice’s Strategy 2015-2020 is to achieve better integration in wider systems of care, as well as reducing unnecessary hospital admissions and timelier, effective hospice and hospital discharges. There was a need for end of life care to support people at the end of their life with their personal and healthcare needs at home, to enable rapid response discharge and prevention of admissions. Commencing in December 2015, the EMH Rapid Response Team met this need through the provision of additional Community Support Workers, to provide a rapid response element to the service. Referrals to the service are received from continuing health care for fast track eligible patients whose care needs cannot be met or only partially met by local Care Agencies. The Rapid Response Team has developed new ways of working collaboratively with local care providers through episodes of shared care. The values of EMH are extended into the wider local community by the delivery of high quality end of life care and the promotion of best practice. Delivery of care is not dependent on diagnosis and meets the continuing health needs of all patients eligible for fast track. This broadens the traditional hospice boundaries and aims to meet the ‘I cannot fault the needs of all patients support of all the staff including those who who attended L in his are frail and elderly hours of need.’ within our community. This project is in the early stages of inception, however, the service is quickly developing as a unique response to a local need with the benefit of being sustainable and replicable at scale.
Development of the Psychology and Bereavement Service The Psychology and Bereavement Service at EMH has developed a full lifespan service to provide support for palliative patients, their families and friends, including children, young people, adults and older people. The service offers both pre-bereavement and bereavement support and referrals are accepted from across the Isle of Wight. Service development during 2015/16 has included: • Opening up the referral system to the service from St Mary’s Hospital as previously there has been limited bereavement support for families who experience a sudden and traumatic death • Providing training and education on bereavement and psychological issues and end of life to other organisations. This has included bereavement training to Isle of Wight support groups and delivering Advanced Communication Skills training • Commencement of a children’s service is planned in May 2016, offering family and group support in pre-bereavement and bereavement. New staff have been recruited to develop the service and offer different therapeutic approaches including the use of art so younger children do not have to rely on talking to access support • Supervision and support offered both internally to clinical staff and volunteers and to external organisations, including the paediatric teams and oncology Clinical Nurse Specialists.
Quality Account 2015/16 - Part Two
‘The total care and respect we received was above anything we could have expected. The loving care continued after N had passed away. Thank you does not seem adequate but, thank you.’
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Nurse-Led Palliative Care
Chelsea Garden Project
Many end of life patients may prefer to die in a hospice but are unable to because they do not have specialist palliative care needs. Others may be unable to access a bed at an appropriate time due to the lack of medical capacity to admit them. Inpatient hospice units which were originally set up to provide care for the dying have evolved into specialist palliative care units with an increasingly medical focus.
In May 2015, it was announced that Earl Mountbatten Hospice would be the proud recipient of one of the wonderful gardens showcased at the Chelsea Flower Show.
Since November 2015 EMH has been piloting a new nurse-led initiative within the Hospice Inpatient Unit. Under this initiative, up to five beds have been assigned as nurse-led and have been designated to the care of people with a life limited diagnosis but without complex symptoms that require medical input. This caseload of patients is currently managed by the Deputy Sister of the Inpatient Unit who is a non-medical prescriber, working towards a Master’s degree in Advanced Clinical Practice. This lead nurse is able to admit patients, clinically assess them, initiate a programme of care and is able to prescribe the required medications. This has enabled more medical time to be deployed in the community in order to begin to keep patients with more complex needs within their home if this is their preferred place of care.
The Royal Bank of Canada Garden, which was designed by wellknown garden designer and Gardeners Question Time panellist Matthew Wilson, will be reconstructed at the Hospice in 2016 thanks to the charity Greenfingers. Greenfingers is a small national charity dedicated to supporting children who spend time in hospices around the UK, along with their families, by creating inspiring gardens and outdoor spaces for them to relax in and enjoy. Earl Mountbatten Hospice was chosen in recognition of its work developing services for children and their families on the Island.
Over the course of the next twelve to twentyfour months, we anticipate further development of nurse led care and palliative rehabilitation. Nurses and Allied Health Professionals can offer valuable leadership, particularly in the support of people whose main requirements are those of care, rehabilitation and enablement rather than diagnosis.
Royal Bank of Canada Garden reconstructed at Earl Mountbatten Hospice
Quality Account 2015/16 - Part Two
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Organisational Quality Plan EMH developed an Organisational Quality Plan during 2015 that incorporated key actions identified in a mock Care Quality Commission inspection in 2014. The Organisational Quality Plan is monitored and reviewed quarterly by the Quality and Governance Committee.
Patient Services Strategic Implementation Plan Year 1 Following the publication of Earl Mountbatten Hospice’s Strategy 2015-2020 and strategic implementation plan, fourteen members of the clinical team from across the organisation joined together to agree the priorities for the development of services during 2015/16. A total of 57 actions were agreed under the following key themes: • Demonstrating and evidencing compliance and quality improvements across the organisation • Exploring opportunities to become the Island’s main provider of bereavement care for adults, children and families • Developing a responsive community service model based on patient needs, goals and preferences • Utilising the John Cheverton Centre and local EMH charity shops to reach a wider population at lower cost, through developing group therapy and support programmes • Developing a responsive and flexible Inpatient Unit service model based on patients’ needs, goals and preferences • Developing new patient-facing volunteer role profiles for all clinical areas • Further developing and embedding the workforce development programme for generalist and social care staff across the Island, working in partnership with others.
A patient and volunteer in the art room
Financial Considerations Earl Mountbatten Hospice is a registered charity and our patient and family services are delivered free of charge to our Island community. These services cost £6.938 million in the financial year 2015/16. We rely heavily on the support of our community through donations, legacies and grants, and our charity shops. We raised over £1 million in our shops to enable us to continue to deliver compassionate and timely care to local people, in the place of their choice. EMH receives an annual sum from the NHS Isle of Wight Clinical Commissioning Group which equates to 37% of our total income for the year ended 2015/16. We review all our services on an ongoing basis to ensure we are delivering them efficiently and that we spend our money wisely. This is particularly important in the light of the challenging economic climate we currently face. High quality, compassionate care for our patients and their families remains our number one priority.
Quality Account 2015/16 - Part Two
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2.2.2 Goals Agreed with Commissioners Two quality improvement goals were agreed with the Isle of Wight Commissioning Group in 2015/16 and were linked to two of the Care Quality Commission’s (CQC) fundamental standards. These were: i) ‘Well Led’: Leading From the Middle project The theme of ‘well led’ is one of the CQC’s five key questions asked of all care services. A well-led organisation demonstrates a leadership, management and governance structure, which can assure the delivery of high quality person-centred care, supports learning and innovation, and promotes an open and fair culture. A bespoke leadership development programme, ‘Leading from the Middle’ was designed in which twenty middle managers across the organisation participated during 2014 as Cohort one. The quality improvement measure was further developed to enable a second cohort to undertake the programme during 2015/16. The qualitative evidence reveals specific and tangible examples of leadership development including: • Greater levels of confidence in both individual style and high performance team work
• Practical examples of learning applied to issues and challenges • Greater motivation and shared commitment to responding to challenges. A comparative study of Cohort 1 and Cohort 2 findings points to significant progress in individual leadership skills, team development and cultural awareness. The challenge for EMH is to sustain the benefits of ‘Leading from the Middle’ (LfM) and further develop the leadership potential across the organisation. The affirmation of success for Cohorts 1 and 2 has made an important contribution to the organisational resilience of EMH for the future. ii) Safe: Inpatient and day services medicines management review The theme of ‘safe’ is one of the CQC’s five key questions asked of all care services. A safe organisation ensures that people are protected from abuse and avoidable harm. EMH evaluated and developed a work plan for medicines management across all clinical areas. The work plan included actions relating to: • Prescribed medicines (including Controlled Drugs) are stored, administered and disposed of safely in line with current and relevant regulations and guidance and local policy
• Collaborative working across EMH which has resulted in innovative responses to operational challenges
• Policies and guidelines are reviewed and updated with pharmacist input
• Practical demonstrations of service development
• Patients, where appropriate, are supported to administer their own medicines safely in accordance with local policy
• Tangible evidence of capability and confidence in strategic thinking and analysis • Mid-level managers and professionals communicating their views and challenging the status • Concrete evidence of the potential and value of working with diversity • Improved ability to challenge, contribute, innovate and use feedback
Quality Account 2015/16 - Part Two
• There are clear local procedures for giving medicines in accordance with the Mental Capacity Act 2005 • Where people choose to use unlicensed medicines, staff follow any guidance regarding their use, supported by local policy. Income of £59,352 was conditional on achieving improvement and innovation goals through the Commissioning for Quality and Innovation Schemes (CQUINS) payment framework. Both quality improvement goals were achieved in full.
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2.2.3 Statement from the Care Quality Commission Earl Mountbatten Hospice (EMH) is required to register with the Care Quality Commission and its current registration is for the following registered activities: •
Personal care
•
Treatment of disease, disorder or injury
•
Diagnostic and screening procedures
EMH did not participate in any special reviews or investigations by the CQC during 2015/16 The CQC has not taken enforcement action against EMH during 2015/16.
We spoke with nursing, care and medical staff. Staff were aware of how people should be supported, their individual likes and dislikes and the help they required. Staff stated they felt they had sufficient time to meet people’s needs. Staff also told us they had attended relevant training and had all the necessary equipment to safely care for people. We found good recruitment and induction procedures were followed. Care plans and related care records were appropriate to people’s needs. People’s privacy and dignity were maintained and they or their relatives were involved in decisions about their care.”
EMH is subject to periodic review by the CQC and the last review was 7th May 2013. Their findings are shown in the table below. Respecting and involving people who use services
✓
Met this standard
Care and welfare of people who use services
✓
Met this standard
Meeting nutritional needs
✓
Met this standard
Requirements relating to workers
✓
Met this standard
Records
✓
Patient and Community Artist enjoying art together
Met this standard
The CQC’s statement following that review was as follows: “We inspected the following standards as part of a routine inspection. This is what we found: We spoke with four visitors and one patient receiving care from the inpatient service. They said they were very happy with the way they were cared for. They said ‘the staff are wonderful and know what care is needed.’ Patient and Nurse in the John Cheverton Centre
Quality Account 2015/16 - Part Two
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2.3 Participation in Clinical Audits National Clinical Audits During the period 2015/16 there has been one national clinical audit relating to the services provided by Earl Mountbatten Hospice. The Controlled Drug Self-Assessment Tool has been compiled by the Controlled Drugs Regulation Team. The tool is designed to help the Controlled Drugs Accountable Officer (CDAO) assess their organisation's arrangements for controlled drugs governance and identify areas requiring improvement. The tool covers the following aspects of controlled drugs governance: Access to controlled drugs; Standard operating procedures; Management of controlled drugs in hospital pharmacy; Management of controlled drugs in hospital ward/department; Transport of controlled drugs; Auditing (including recording and monitoring); Reporting of controlled drug incidents and information sharing. EMH has completed the controlled drug selfassessment tool and is compliant in all related areas.
Regional Audits There were no requests from NHS England or the Isle of Wight Clinical Commissioning Group for specific audits during 2015/16.
A quarterly comprehensive governance and assurance report informs the Patient Services Committee and the local Clinical Commissioning Group. The report includes completed audits, patient experience survey reports, data gathered from clinical incidents, compliments, complaints and concerns, mandatory training compliance, staff sickness rates and a summary of the status of the clinical risk register. Since January 2014 Earl Mountbatten Hospice has taken part in Hospice UK’s national benchmarking scheme. Using benchmarking data enables hospices to improve quality by comparing their performance to identify improvements that have been successful in other hospices. The benchmarking reports are used to assure and provide evidence of quality to the Board of Trustees, CQC and our local Clinical Commissioning Group. Two small working groups of clinicians working across all clinical settings in EMH have been set up during 2015/16 to monitor closely two metrics that are collected as part of the benchmarking data; hospice acquired pressure ulcers and patient falls. These groups evaluate national guidance, review all reported pressure ulcer and falls incidents and share good practice and lessons learnt with their clinical colleagues. For completed local surveys see section 3.2 of the report, ‘The Patient and Family Experience of the Hospice’.
Local Audits and Surveys The Quality and Governance Committee devised an annual clinical audit programme across all clinical areas in March 2015. The audit programme is monitored through the Quality and Governance Committee on a quarterly basis. The results of audits undertaken are reported and monitored at the quarterly Education and Research Committee meetings and are displayed in all clinical areas for staff, volunteers, patients and visitors to view. A chart showing a sample of completed audits can be found on page 14 of this report.
Quality Account 2015/16 - Part Two
Patient and volunteer reading together
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Participation in Research An exciting new opportunity has arisen to work in partnership with the University of Southampton Faculty of Health Sciences in the development of a Clinical Teaching Fellow post. The fellow will spend at least 50% of their time in clinical practice and the other fraction of time working as part of the Faculty’s pre-registration nursing team, developing and delivering clinically current education. EMH participated in a research project during 2015/16 conducted by a trainee Clinical Psychologist at Southampton University. This research has been part of a multi-site project focussing on compassion fatigue in nursing staff working in hospice and palliative care settings. The Hospice UK annual conference is an opportunity for all hospices to come together to network, share ideas and discuss innovations in practice. With the theme of ‘The Art and Science of Hospice Care’, this year’s conference focused on the many strategic options that are of interest to senior managers, clinical staff and trustees - and also on the shifts in service direction and workforce which hospices need to consider to stay relevant to the care agenda that lies ahead. EMH was represented at the national conference by: • delivering a session on ‘The Artist as a Leader’ • delivering two sessions on ‘More than just a room - providing services in an adult hospice to deliver end of life and after death care to children and young adults’ • displaying two posters entitled “When Horses Run Together; developing collective hospice leadership for the future” and “The Hospice ‘through the eyes of children’ changing a community’s attitude to death, dying and end of life care”.
Earl Mountbatten Hospice’s Hospice UK posters
With more than 700 delegates in attendance, and exhibitions including more than 200 posters, it was a real opportunity for EMH to showcase its work nationally.
Quality Account 2015/16 - Part Two
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Sample of Completed audits during 2015/16 Audit Subject
Area
Outcome Actions
Call Bell (Quarter 1, 2015/16)
Inpatient Unit
A call bell audit was completed in quarter 1 of 2015/16. The standard of call bells being answered within 2 minutes was met in 100% of cases. Call bells were found on average to be answered within 37.5 seconds (range, 20-90 seconds). Quarterly audits will take place in 2016/17 to monitor.
Community Referral Response Rates
Inpatient Unit
Between 91-100% of patients were contacted within the urgent standard referral response rates criteria during April to December 2015. All cases where standard not met fully investigated. Quarterly audits will take place in 2016/17 to monitor.
Community
Standard of less than 10% of visits made by the clinical team were unplanned/crisis met throughout 2015/16 (1.5-7.3%). Audit to be discontinued in 2016/17 as it is demonstrated the standard is consistently met.
Medical
Two audits have been completed during 2015/16. 100% of standards met in both audits. Paracentesis consent forms are to be updated following quarter 4 audit to include discussion of risks/benefits with the patient. Six monthly audits to take place in 2016/17 to monitor.
Controlled Drug (CD) Audit
Pharmacy
The Pharmacy team audit the CD order book, stock register, patients own CD register, returns/ disposal, prescribing CD’s and discrepancies quarterly. Feedback is given to the team where discrepancies are identified and fully investigated where applicable. Quarterly audit to continue in 2016/17 to monitor.
Death in Preferred Place of Care
Community
Target of over 80% patients dying in their preferred place met throughout 2015/16. Reasons investigated for patients not dying in their preferred place each quarter. Quarterly audits will continue in 2016/17 in the Community and Hospital Palliative Care Team.
Community Planned vs Crisis Visits
Consent to invasive procedures
Deprivation of Liberty Safeguarding (DOLS) Screening
Medical
A quarterly audit carried out and 100% of standards met in each audit where a DOLS safeguarding checklist completed. Quarterly audits will continue in 2016/17.
Infection Control (includes hand hygiene, personal protective clothing, peripheral venous access devices, MRSA, isolation, diarrhoea/C-Difficile, sharps, catheter management, catheter insertion, commodes audits)
Inpatient Unit
Monthly audits carried out - over 80% compliance demonstrated on each audit. Actions plans in place after each audit and work with nursing, housekeeping and facilities staff to ensure wide ownership of actions and improvements practice. An external audit carried out by IW NHS in October 2015 revealed standards met in >90% cases other than: clinical item safety (80%), bed space cleanliness (88%) and clinical waste (75%). Monthly audits will continue in 2016/17.
All Clinical Areas
Monthly audits were carried out and standards met increased during 2015/16 from 30 to 72%. A full action plan has been in place, including ongoing mandatory training and education (over 90% clinical staff and clinical administration staff attended) and changes made to documentation through a working party. Monthly audits to continue in 2016/17 and further improvements likely to be seen with the implementation of electronic patient records.
Multi-disciplinary Patient Records
Pharmacy Interventions
The Pharmacy team audit monthly interventions that they make and code using the pharmacy risk register. This information is shared with the clinical team for learning and improvements in medics management. Monthly audit will continue in 2016/17.
Patient Led Assessment of the Care Environment (PLACE)
Inpatient Unit 
 EMH JCC
Teams (including members of the User Group, clinical, housekeeping and facilities staff) carried out environmental assessments every quarter. Issues were identified and a full action plan put in place. Six monthly audits will take place in 2016/17 to monitor.
Venous Thrombo-embolysim (VTE) Prevention Audit
Pharmacy/
 Medical
Audits were undertaken monthly by the Pharmacy Team until quarter 3 and then quarterly by Consultants. Standards have been met in 100% of cases other than in June and September 2015 (75% and 91%). A training issue was addressed by the Consultant and Pharmacist. Quarterly audits will continue in 2016/17.
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2.4 Data Quality 2.4.1 Minimum Data Set In accordance with an agreement with the Department of Health, Earl Mountbatten Hospice submits a Minimum Data Set (MDS) for Specialist Palliative Care Services to the National Council for Palliative Care (NCPC) on an annual basis, with the aim of providing an accurate picture of hospice and specialist palliative care services activity. As this data has been collected in its current form since 2008/09, it is now reflecting the activities within the Hospice and specialist palliative care service for the Isle of Wight community. More information on the minimum data set is available from the National Council for Palliative Care www.ncpc.org.uk. The most recent data available from the National Council for Palliative Care was made available in November 2015 and relates to the year 2014/15. A review of this information, which includes benchmarking with similar sized services and inpatient units both nationally and in the Wessex region, details the extracted information shown below about Earl Mountbatten Hospice’s services. • Inpatient Services. During 2014/15, 306 patients were admitted to the Inpatient Unit, some 50 more than the national average. There were 253 new patients, 25 more than the national average of 228, and 29 more when compared to the number of new patients in 2013/14. The majority (63.7%) of new patients fell into the 65-84 age range compared with the national average of 57.5%. • Female patients numbered 169 compared with 137 male patients, higher than the national average of 128 but male patients outnumbered the national average of 126 by just 11. The average length of stay was higher for cancer patients (11.2 days) when compared to non-cancer patients (7.9) but both were less than the national average (13.3 days cancer and 12.2 days noncancer).
• The Community Clinical Nurse Specialists saw a total of 575 patients, some 91 more than in 2013/14, but 103 less than the Wessex region average. The average length of care was 117 days compared to the national average of 93.5 days and the Wessex region average of 67.6 days. • The Hospital Palliative Care Team saw 432 patients compared to the national average of 275. Of these 372 were new patients compared to the national average of 242. The average length of care was 12 days, close to the national average of 11.4 days. The majority of patients (61%) were in the age range 65-84 with the national average at 56.6% and Wessex region 58.4%. • Hospice at Home services saw a total of 317 patients, compared to the Wessex regional average of 160, of whom 304 (95.9%) were new patients compared to 136 (94.3%) in the Wessex region. The average length of care provided by the team was 51 days compared to the region’s average of 54.5 days. Home deaths numbered 162 compared to the average of 78 in the Wessex region. • Mountbatten Nurses saw a total of 109 patients of whom 101 (92.7%) were new. This is very much on a par with the national average of 108 patients and 99 (91%) new patients. Length of care at 58 days is also close to the Wessex region of 54.5 days. • Bereavement Support Services provided support to 301 users, some 188 more than the Wessex region average, 37.2% of whom where in the 65-84 age range compared to the national average of 17.1% in the same age range. Interestingly 51.5% of the users were in the 25-64 year age range compared to the national average of 43.9%. NB - All averages are median averages
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Inpatient Data 2015/16
hospice access is widened to those with any life limiting condition.
Data relating to patient occupancy, length of stay and number of admissions during 2015/16 is shown in the following graph.
Patient Contact Data 2015/16
EMH Inpatient Unit - Percentage Occupancy, Length of Stay & Admissions 2015/16
Numbers
140 120 100 80 60 40 20 0 Inpatient Occupancy (%) Average Length of Stay (days)
Quarter One 77.37
Quarter Two 76.44
Quarter Three 78.55
Quarter Four 78.55
11.7
9.48
9.93
10.28
99
120
117
110
No. of Admissions to IPU
The number of actual patient contacts by the clinical services offered by Earl Mountbatten Hospice is shown in the graph below. It should be noted that this is not the number of patients but the number of times contact is made with patients, which could be more than once for each patient and by each service. Patient Contacts 2015/16
1519
The total number of admissions to the Inpatient Unit increased during 2015/16 to 445 compared to 374 in 2014/15. Whilst the average bed occupancy decreased slightly in 2015/16 compared with the 80% average occupancy across the year in 2014/15, there has been a decrease in the average length of stay from 11.2 days in 2014/15 to 10.35 in 2015/16. This is due in part to an increased number of patients being transferred to EMH from St Mary's Hospital during the last days and hours of their life, which families tell us is of benefit in terms of the wider support they receive from EMH in these circumstances.
2697
7044
1001
Non-Malignant Diagnosis for 2015/16
2230
Community Services
Total Non-Malignant Diagnosis Admissions to IPU 1st April 2012 - 31st March 2016 100
JCC Patient & Family Services
82
80
Hospital Palliative Care Team
60
Allied Health Professional Services (Physiotherapy & Occupational Therapy) Psychology & Bereavement Services
40 20
19
25
8
0 2012/13
2013/14
2014/15
2015/16
The graph above shows a significant increase in the trend of patients with a non-malignant diagnosis admitted to the Inpatient Unit. This is due mainly to our two Consultants in Palliative Medicine and the Hospital and Community Nurse Specialists working proactively with health and social care colleagues to ensure
The total number of contacts for this year compared with 2014/15 has increased by 2178 (18%). This is mainly due to the expansion of Community Services and an increase in contacts in the JCC and Psychology and Bereavement Services.
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2.4.2 Information Governance (IG) During 2015/16 Earl Mountbatten Hospice achieved Level 2 compliance with the Department of Health Information Governance Toolkit Level 3 being achieved in six areas, an increase of two areas compared with 2014/15. This demonstrates that the organisation has improved its processes to maintain protection and confidentiality of its patient information and that it adheres to data protection legislation and good record keeping practice.
Data will be reported in the Quality Account in 2016/17 once this project is fully embedded within clinical practice. The Executive Clinical Support Team Leader and Head of Clinical Quality and Patient Experience attended an OACC outcome measures train-the-trainer workshop in March 2016 at the Cicely Saunders Institute, to assist with implementation of the OACC project at EMH.
During 2015/16 EMH appointed a Senior Information Risk Owner (SIRO); established an Information Governance Group that meets quarterly and information governance is monitored at every committee and at Board level. EMH now has its own, on-site, Caldicott Guardian appointed from within the Senior Management Team and the Head of Information and Communications Technology has undertaken specific Caldicott training at Hos with pice UK. EMH will continue to take action during 2016/17 to further improve information governance within the organisation and has developed a robust action plan to monitor this.
2.4.3 Outcome Measures In January 2015 EMH commenced piloting the use of standardised palliative care specific outcome measures across all clinical areas. The Outcome and Assessment and Complexity Collaborative (OACC project) is led by a team at the Cicely Saunders Institute, King’s College London working in partnership with Hospice UK. The OACC project seeks to implement outcome measures into palliative care services to measure, demonstrate and improve care for patients and their families. EMH has introduced two outcome measures from the OACC suite of measures to capture the phase of illness and the patient’s functional status.
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Part Three - Looking Back 3.1 Achievement against our Priorities for 2015/16 Priority 1: Patient Safety Target 1.1: To ensure multi-disciplinary team (MDT) documentation meets the NHS record keeping guidelines. The quality and safety of patient records has been a key focus at EMH over the last 18 months, following a mock CQC inspection that highlighted that improvements were required. A full review of MDT documentation was carried out in January 2014 by the Head of Clinical Quality and Patient Experience working with clinical and clinical administrative staff across all clinical areas. A MDT documentation working party was set up in March 2015 to drive forward the required changes and to increase ownership of quality improvements across the clinical teams. The working party have completed the following: • The patient record order was revised with an agreed contents list implemented. A system has been put in place to ensure all documents within the patient record are version controlled and in an agreed EMH format • A nursing assessment booklet was developed to be used across all clinical areas in EMH, to follow the patient’s journey through EMH services • Face to face mandatory training sessions for all clinical (including bank staff) and clinical administration staff on documentation standards and the implementation of the revised EMH patient records. Over 90% of relevant staff have attended these sessions. MDT patient record audits have been carried out monthly across the Inpatient and Community settings based on NHS record keeping guidelines.
The initial audit carried out in May 2015 showed only 30% compliance against the standards. This had increased to 72% by March 2016. The audit has also monitored whether the patient records are in chronological order when patients move across clinical settings and in March 2016 there was 100% compliance with this standard. The implementation of electronic patient records during 2016/17 will produce further improvements in the quality and safety of patient records and will also enable sharing of patient information between the Hospice and primary care. Target 1.2: To ensure that EMH’s sepsis management practice fully addresses patient safety and reflects national best practice. A new EMH Adult Sepsis procedure has been developed and was approved by the Quality and Governance Committee in October 2015. As part of this procedure, a patient observation chart encompassing the ‘Adult Modified Early Warning Score’ has been produced for the specific needs of patients being cared for in the EMH Inpatient environment. The observation chart is now in routine use. Two members of the Inpatient nursing team have undertaken additional training in the management of sepsis by participating in the Royal Marsden ‘Acute Oncology’ study day in March 2016. Sepsis management face to face teaching sessions were delivered by the Deputy Sister to fifteen relevant EMH clinical staff in February 2016 and further training sessions are planned for March and April 2016 to ensure that 90% of relevant clinical staff attend these sessions. This training has been underpinned by a resource pack.
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Target 1.3: To develop a plan of action to manage major incidents including evacuation procedures and practice drills. A robust Major Incident and Business Continuity Policy and Procedure has been developed and the Fire Policy and Procedure fully reviewed. Both were approved by the Quality and Governance Committee in January 2016. These policies and procedures were developed and reviewed through discussion and two major incident ‘table top’ exercises during 2015/16 with staff at all levels and across all departments. In addition a number of other actions have been taken to improve the safety of patients, visitors, staff and volunteers, which include: • Designated staff have received Fire Warden training in the correct procedure to manage an incident, including evacuating the building and accounting for patients, visitors, staff and volunteers • Face to face training on the correct use of fire extinguishers was provided by ‘Wightfire and Security’, a local company which specialises in all aspects of fire safety, to 20 staff across the organisation during September 2015 – March 2016 • Two full practice drills to evacuate all parts of the EMH building involving patients, service users and visitors were undertaken in September 2015 and February 2016. Lessons learnt from each practice drill have resulted in the updating of procedures in the Fire Policy and Procedure. These practice drills will continue to be carried out every six months and the Fire Policy and Procedure will be reviewed and updated again in May 2016 • Break out emergency bags and radios have been sourced and are kept in the Inpatient Unit and John Cheverton Centre receptions to ensure essential items and communication tools are to hand in the event of a fire.
Priority 2: Clinical Effectiveness Target: 2.1: To ensure that Inpatients and Day Services patients receive a balanced diet through the correct management of hydration and nutrition, and have choice and flexibility of food/drink. A working group of nursing staff from across the clinical areas within the Hospice and the Head Chef met during 2015/16 to review nutrition and hydration, both in the Inpatient Unit and in the Sunflower Cafe in the John Cheverton Centre. A number of key actions have been achieved by the working group: • Review of nutrition and hydration nursing assessment and care plans • Information sheet on the ‘signs of malnutrition’ developed and circulated to relevant clinical staff • Small china cups and saucers sourced for use on the Inpatient Unit as a result of patient feedback • Implementation of cooked breakfasts being prepared and cooked in the main kitchen by the catering staff • Teaching sessions delivered to Day Services staff and volunteers which has included promoting patient choice, flexibility and the social aspects associated with eating and drinking when they visit the John Cheverton Centre. The Inpatient Experience Survey that was undertaken in October 2014 – September 2015 indicated that 91% of patients felt that the choice of food offered on the Inpatient Unit was exceptional, excellent or good. The Day Services Patient Experience Survey undertaken in December 2015 showed a significant increase in satisfaction of the choice and affordability of the meals and drinks that patients purchased from the Sunflower Cafe with 100% of patients being totally satisfied. In the survey undertaken in 2014, it indicated that 47% of patients accessing Day Services were very satisfied, 32% satisfied, 5% neither satisfied nor dissatisfied and 5% fairly dissatisfied with the Café menu.
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The introduction of the ‘Light Bite’ menu that has been extended from the Inpatient Unit as well as implementation of daily specials of hot meals has improved choice for patients accessing Day Services. Auditing of nutrition assessments and care plans in the Inpatient Unit and Day Services will take place in 2016-17 following updating of the nutritional care plans. Development of a food and drink strategy forms part of the Quality Account priorities for improvement during 2016-17. Target: 2.2 To ensure that Inpatients’ end of life wishes and preferences are understood at an early stage of care by developing a ‘This is Me’ profile. A working party of nursing staff from across clinical areas within the Hospice met in September 2015 to consider a range of documents that are currently used either locally or nationally to ensure that patients’ end of life wishes and preferences are understood at an early stage of care. These included the ‘Anticipatory Care Plan’ used by GPs on the Isle of Wight, ‘My End of Life Book’ for use by those living in supportive care, ‘This is Me’ passport for use with people living with long term conditions on the Isle of Wight and the ‘My Life’ booklet developed by Birmingham Community Healthcare. The working party agreed to use the ‘Anticipatory Care Plan’ as this document gives the opportunity for the clinician to discuss and document the patient’s preferred place of care and death, resuscitation wishes and can be individualised to the person about their wishes and preferences. The ‘Anticipatory Care Plan’ is also an Island-wide document used across clinical settings, for example by GPs, in the hospital, and it was felt that it would provide consistency across services and avoid duplication for patients. In March 2016 a patient record audit was carried out to establish the use and evidence of the ‘Anticipatory Care Plan’ in the patients’ records, in a random sample of ten patients. The audit found that in 70% of patient’s records there was evidence of a completed ‘Anticipatory Care Plan’. This will continue to be monitored as part of the monthly multidisciplinary documentation audit and fed back
to staff to ensure that the 90% target compliance is met in quarter one 2016/17. Target: 2.3 To review multi-disciplinary discharge planning to ensure a seamless transition from the Inpatient Unit to home or other location. Discharge planning has been a key focus during the last year due to significant pressure of beds at EMH, St Mary’s Hospital and local nursing and residential homes. A review of the multi-disciplinary discharge planning at EMH was undertaken by the Social Worker and Community Clinical Team Coordinator. This review was to ensure a seamless transition for patients and their families from EMH Inpatient Unit either to home or another location, including nursing or residential homes, and led to the following actions: • To gain understanding of the need for effective discharge planning the Social Worker and Community Clinical Team Coordinator completed the IW NHS Trust Training e-learning module ‘Planning for Patient’s Discharge’ • The current EMH Discharge Procedure was reviewed and updated to reflect current working practices and prevent discharges from failing. The revised procedure will be reviewed by the Quality and Governance Committee in July 2016 • The Inpatient Unit discharge checklists have been streamlined and updated to reflect multi-disciplinary team working • A flow chart has been devised for use on the Inpatient Unit in order to illustrate the process for discharging patients who need a care package. Discharge planning training sessions will be delivered to all relevant staff and patient records audited to establish compliance of documenting the discharge plan in July– August 2016 following the approval of the revised Discharge Procedure.
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Priority 3: Patient Experience Target 3.1: To fully implement a social space for inpatients, including access to computers and Wi-Fi, following the quality measure set in 2014/15. Further work has been carried out to establish patient views about whether they would use a communal social space during their Inpatient stay at EMH, recognising that single en suite bedrooms can cause some patients a sense of social isolation. From October 2014 to September 2015, as part of the patient experience survey in the Inpatient Unit, 71 surveys were completed. 42% of respondents stated that they would use a communal social space if it were available, 24% stated they would not use it and a further 25% were unsure. The Inpatient Charge Nurse presented a full options appraisal for the creation of a social space for inpatients to the Quality and Governance Committee in January 2016. The options for social spaces included: • establishing a lounge and social space in one of the currently spare bedrooms on the Inpatient Unit • utilising the family room and overnight space as a multi-function space • utilising EMH John Cheverton Centre more effectively for patients on the Inpatient Unit • consideration of the establishment of a social space in any future building developments in the Inpatient Unit. It was agreed to use the EMH John Cheverton Centre for inpatients, day patients, visitors and the community to enjoy. Hours of opening of the Centre were increased during 2015 with the addition of Sunday lunches served in the Sunflower Café and development of a social programme of activities and events. Facilities in the JCC have been moved to enable an improved use of the building, incorporate more social spaces and provide two new public internet access points. The Centre opening hours are planned to extend further into the evenings and weekends during 2016.
Further inpatient experience surveys and focus groups will monitor the accessibility and use of the John Cheverton Centre as a social space for inpatients and their families during 2016/17. Target: 3.2: To provide all inpatients with a welcome pack containing relevant information for them and their families. The EMH Welcome Pack ensures all inpatients and their visitors have relevant and helpful information at their fingertips. Each room on the Inpatient Unit has its own copy of the pack. Each page is laminated in order to meet infection control standards, and the information is contained in a wipe-clean A4 folder. The information available to patients is wideranging but responsive, highlighting all of the day to day queries which may arise when a patient arrives at EMH. It is clear, easy to read and navigate. It includes the following information: • • • • • •
what our vision and values are an introduction to the key teams within EMH, including a visual guide to staff uniforms and the roles they represent a summary of why patient feedback is important facilities and services available in the John Cheverton Centre useful contact telephone numbers a map of EMH.
Information in the pack was agreed following consultation with staff, volunteers, and the EMH Service User Group. It was crucial to strike the right balance in terms of providing all the detail needed while at the same time making sure patients and families did not feel overwhelmed by too much information. From April 2016 the Inpatient Patient Experience Survey will include a question to monitor how useful patients and families find the Welcome Pack.
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3.2 The Patient and Family Experience of the Hospice and Its Services Patient and Carer feedback received in 2015/16 At Earl Mountbatten Hospice we always welcome feedback from our patients, their families and visitors. Patient Experience surveys are carried out in real time on the Inpatient Unit and six monthly in EMH John Cheverton Centre. Improvement action plans are developed from the feedback given by patients and families and fed back on ‘You said...We did’ boards displayed in both the Inpatient and John Cheverton Centre. A quarterly or six monthly report is also written by the lead clinician and shared with staff, volunteers, the Patient Services Committee and local Clinical Commissioning Group.
‘You Said, We Did’ board
The chart below details some of the feedback and actions implemented from the Patient User Experience surveys on the Inpatient Unit and EMH John Cheverton Centre:
You Said…..
We Did….
“We don’t like the red feature walls in two of the Inpatient bedrooms”
We had the red walls repainted with lighter colours in the Inpatient bedrooms
“I would like a notepad and pen in my bedroom”
A complementary EMH branded notepad and pen is now provided for each of the Inpatient rooms
“There aren’t enough hangers in the wardrobe in my room”
Additional hangers have been sourced for the Inpatient bedroom wardrobes
“A baby change facility in the ward area would be useful”
A baby change facility has been installed in the visitor’s toilet in the Inpatient Reception
“Extend the opening hours of the John Cheverton Centre"
The opening hours of the JCC have been extended to cater for Sunday lunches and a social programme of events. Further extension of opening hours in the evenings and weekends to commence in 2016/17
“Put additional shower rails in more ensuite bedrooms after a successful trial in one room”
Additional shower rails have been installed in three further ensuite bathrooms
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Earl Mountbatten Hospice acknowledges the importance of the service user voice in ensuring that our services and facilities are of high quality and meet the needs of users. During 2015 EMH developed some new and innovative ways of involving our service users at all levels in the development of our services and facilities. These include a number of new initiatives, including:
“Tell Us your Experience - Just One Thing” We introduced ‘Tell us Your Experience – Just One Thing’ forms into the Inpatient Unit and EMH John Cheverton Centre in March 2015. This form is now on the website as well as in paper copy. It gives another opportunity for our service users to tell us ‘just one thing’ that would have improved their stay or experience of the services EMH provides and feedback about a member of staff or volunteer who made a real difference. It is planned that the forms will be piloted in all EMH shops during 2016 following work with the retail managers and visits to shops by the Head of Clinical Quality and Patient Experience to establish ways to gain feedback from the wider community. The Head of Clinical Quality & Patient Experience reviews completed forms weekly and works with the teams to make improvements where possible and appropriate. The themes and actions from the forms are reported quarterly at the Patient Services Committee, Quality and Governance Committee and the Clinical Commissioning Group.
A patient in the art room with a Healthcare Assistant
Visitor’s Books Visitor’s books are now available in the Inpatient Unit and John Cheverton Centre for feedback and comments by any patient, family
member or visitor. The Head of Clinical Quality & Patient Experience reviews the books weekly and works with the wider EMH teams to make improvements where possible and as appropriate. EMH User Group A new user group has been set up facilitated by the Head of Clinical Quality & Patient Experience. The User Group provides some external scrutiny and reporting through our internal structures on whether EMH’s facilities and services are viewed as welcoming, userfriendly and of high quality to patients, families, visitors, staff and volunteers. The information provided by the User Group informs and assists with priority setting and service developments/changes to patient and user services and facilities. User Group members have taken part in ad hoc focus and discussion groups regarding potential service developments and changes, annual setting of Quality Account priorities and to seek the user voice on a range of emerging topics. The group have started to be involved in the ‘Patient-Led Assessment of the Care Environment’ (PLACE) tool from NHS England. This tool helps to look at the care environment in EMH through the eyes of patients and service users, capturing what a good quality care environment looks, sounds and feels like and is a method for creating positive improvements and dialogue about the quality of the care environment. Regular reports from the User Group are made to the Patient Services Committee and Clinical Commissioning Group to inform the priorities for Patient doing ‘Walk the Wight’ improvements. on the ‘MOTOmed’ exercise
Quality Account 2015/16 - Part Three
bike in our rehabilitation gym
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Quotes from Patients, Families and Carers “A special thank you for so willingly providing transport for all those weeks. Without that I would have struggled to be with my husband a while each day”
“All of the staff were wonderful, from the nurses and volunteer workers on reception, right through to the Chaplain who helped him to accept that he was dying. The Chaplain was also a great help to the family subsequently”
“I know she appreciated being able to maintain her privacy and independence for as long as possible, and for being allowed to die with dignity”
“It goes without saying that everyone from the team that came home were exceptional in their care for Dad, Mum and the wider family. They also gave Mum and I some much needed sleep and we appreciated that over four consecutive nights. It also gave Mum the peace of mind, that together, we were all doing as much as possible to keep Dad at home as promised”
“Although he was only with you a short time, you were very kind and compassionate to my husband, myself and our son”
“The ambience of the [John Cheverton] Centre and friendliness of the staff were a delight to experience” “A massive thank you to everyone involved in caring for my sister. From the nursing staff, doctors, volunteers and the team in the kitchen – thank you to each and everyone of you. It takes very special people to do what you do”
“A huge thank you to each and every one of you for the incredible kindness that you gave to my Mum during her last few weeks and for the support that you have given to my Dad on his daily visits. And special thanks for helping to make their Golden Wedding celebrations a happy occasion despite the sad circumstances”
“We would like to thank you all for all your care, help and support that my husband and I had during his very difficult time with Motor Neurone Disease. It was very difficult for both of us and we couldn’t have coped without all the care you all gave to us”
“She appreciated your honesty and humour and being allowed to be involved in making her own decisions regarding her treatment and care and for being allowed to die with dignity”
“Thank you for arranging the trip to the Owl and Monkey Haven. She was over the moon and sends her warmest thanks to the volunteers for making the visit possible and so very enjoyable”
Quality Account 2015/16 - Part Three
“In his last few months he spent time in the Hospice and everyone from nurses, doctors and Bev his cancer nurse were amazing. The whole experience at the Hospice and the JCC both for my husband and myself was brilliant” (Feedback via Healthwatch IOW - Cancer Survey December 2015)
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Lessons Learnt Sometimes we receive feedback from which we need to learn and improve our ways of working. For the year ended 31st March 2016 we received eight clinical complaints or concerns compared with fifteen in 2014/15. Complaints and concerns were received from four family members, two patients/service users and two external organisations either verbally or in writing.
sessions, which are open to all staff and volunteers working in both clinical and non clinical roles, are held every two months with additional bespoke sessions arranged if there is a specific incident. Each session focuses on learning together in an open and transparent environment from recent complaints, concerns and compliments received, and from incidents, accidents and near misses.
All complaints, whether written or verbal, are investigated thoroughly and reported anonymously to the Patient Services Committee and the local Clinical Commissioning Group. Where shortfalls are identified, immediate action is taken to minimise the risk of recurrence and a comprehensive action plan put in place, led by a senior clinician for the area concerned, working with staff and volunteers. Wherever possible, clinicians will try to meet with the complainant and share actions plans and lessons learnt in order that they can see how their feedback has been able to drive quality and enhance our service user experience. The complaints or concerns received covered a variety of themes that included the following actions to ensure improvements were made and lessons learnt: • A more robust checking process of Psychological Service referral forms and patient records for personal details implemented before contacting new patients • A more robust ordering process for lymphoedema supplies in the Purchasing Department implemented
Rehabilitation session in the gym
• Development of lymphoedema service leaflet detailing service provision • Changing internal processes to ensure that GP surgeries are informed in a timely manner of patient deaths in the Inpatient Unit • Development of EMH bank staff guidelines. New ‘Lessons Learnt’ sessions were set up in March 2015 facilitated by the Head of Clinical Quality and Patient Experience. These
Quality Account 2015/16 - Part Three
Patient having her nails manicured
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3.3 Our Staff and Volunteers Earl Mountbatten Hospice has a total of 132.13 whole time equivalent (WTE) members of staff and over 500 volunteers. The Isle of Wight Venus Awards “The Working Women’s Oscars” celebrating the incredible achievements of local Women in Business: EMH was one of three organisations shortlisted for ‘Employer of the Year’ award. Staff and Volunteer Support Staff and volunteer support is vital in ensuring that EMH develops a resilient workforce in order to deliver excellent care and meet new challenges such as caring for more people with multiple, complex heath needs. Hospice UK identifies three main sources of stress for hospice staff:The nature of the work - working with patients who are dying can lead to staff experiencing a sense of chronic anticipatory grief and loss • Organisational and management pressures. For example, challenges around internal communications and change, as well as the drive to increase capacity in hospice care • Changes to ways of working. For example, caring for more people with multiple, complex heath needs, including dementia. Resilience: A framework supporting hospice staff to flourish in stressful times - March 2015. Earl Mountbatten Hospice provides individual, team and group supervision in both structured and more informal formats: • Bespoke debrief sessions are facilitated by the Psychology Service with teams if there are particular incidents that require deeper reflection. • ‘EMH Rounds’ based on the ‘Schwartz Round’ concept are held every two months for any clinical or non-clinical staff from all backgrounds and levels of the organisation.
‘EMH Rounds’ are an informal but structured approach for staff to explore the impact that their job has on their feelings and emotions. The forum is not about problem solving; rather it is a dedicated time for reflection and a safe place to voice feelings not often shared during the working day with colleagues. Volunteer Training In January 2016 EMH began a new volunteer training programme, with an underlying focus on volunteers who support patients, families and members of the public directly. The programme provides comprehensive training, comprising six four hour sessions covering a wide range of topics, including communication skills, hospitality and customer care and spiritual care. There are three volunteer training programmes scheduled for 2016 and around 150 volunteers have attended the first training programme or signed up to attend one of the others.
“I find my work at the Hospice to be very fulfilling, knowing the dark tunnel of despair that many go through with the grief that comes when a loved one dies. The EMH team also exude friendship and goodwill which is equally inspiring” Volunteer
Staff Survey A staff survey was carried out in March 2016 and will be fully analysed in quarter one 2016/17. A full action plan will be developed following analysis of the results.
“....it’s also about having the opportunities to make a difference within the organisation. Sometimes within larger organisations you are not afforded this chance, however here at the Hospice if you have a well thought through idea you are encouraged to run with it which I find exciting” Member of staff
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3.4 Statements of Assurance
3.4.1 Statement from the Isle of Wight NHS Clinical Commissioning Group Isle of Wight Clinical Commissioning Group (CCG) welcomed the opportunity to participate in the governance ‘sign-off’ process and provide a statement in response to the presented Quality Account from the Earl Mountbatten Hospice (EMH). The Quality Account has been shared with representatives of the Clinical Commissioning Group; Clinical Executives, Heads of Commissioning, and CCG Clinical Leads for their comments. The 2015/16 Quality Account clearly articulates the organisation’s aspirations in an easy read format. It is well-written, with a strong focus on the importance of collaboration with and engagement of others in delivering high quality end of life care. The account sets out its values and aims, supported by a useful glossary of terms and acronyms. It highlights commitment to, not only patients and their families but to the local community, through local community engagement programmes, to the hospice movement in general through national events and its links with higher education. EMH has demonstrated within its account how, as an organisation, it can proactively recognise and respond to service requirements and test out new models and ways of working, to deliver person-centred end of life care in partnership with others.
Through regular contractual monitoring the CCG has been afforded opportunities to see quality improvements in practice, such as the ‘Leading from the Middle’ programme presentations and to attend other innovative presentations. The local clinical audit programme outlines the breadth of activity to aspire to evidence based practice and to monitor EMH service delivery against recognised standards to ensure that the best possible care is provided. EMH has demonstrated quality improvement in the priorities it set out in last year’s Quality Account; supported with examples. Where aspects of the priorities are on-going, actions have been clearly outlined. It is assuring to note the achievement of the 2015/16 Commissioning for Quality Incentive Schemes (CQUINS). It is evident from the account that feedback is highly valued; listening and responding to patient and family, staff and volunteer feedback drives continuous improvement and innovation. Overall, Isle of Wight Clinical Commissioning Group would agree that the Quality Report is an accurate reflection of EMH’s positive achievement across the quality agenda and the high level of commitment and effort across the organisation to constantly improve the quality of services provided.
The three priorities identified by EMH are considered to be appropriate. They provide an opportunity to drive improvement by taking a holistic view of how to achieve safe, effective and positively experienced services; patient focussed, staff focused, service focussed and clinically focused.
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3.4.2 Statement from Isle of Wight Healthwatch Healthwatch Isle of Wight continues to support the aim and objectives outlined within the Earl Mountbatten Hospice Quality Account for 2015/16. The Hospice continues to demonstrate a determination to ensure that the services it provides and the objectives that underpin them are interconnected, including the development of procedures that link with other service providers. The development of services in the community has further enhanced the choices available to people who have life limiting illnesses and has demonstrated a commitment by the Hospice team, to share their expertise and knowledge within the wider community.
Healthwatch Isle of Wight was pleased to be involved with several focus groups held at the Earl Mountbatten Hospice during the past year and it was evident that these were very much influenced and driven by the people who use their services. Engagement with the public has been a positive focus and community concerts and events have set to change people’s attitudes and perceptions towards the Hospice and the work it does.
Again we would also like to commend the Hospice on the way that the Quality Account is structured and for the clear language it uses. We fully support the implementation of actions contained within the Quality Account and look forward to developing our relationship further. Chris Orchin Chair Healthwatch Isle of Wight
Response to the Independent Statements of Assurance Earl Mountbatten Hospice would like to thank our Commissioners, Healthwatch and our Independent Adviser for their favourable and constructive comments. All recommendations will be subject to consideration and further reflection by the Management Team, the outcome of which will be reported in future Quality Accounts.
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3.4.3 Independent Statement Shaun Stacey, Chief Operating Officer, IWNHS Trust The Independent Reviewer has reviewed the EMH Quality Account 2015/2016 and believes the document to meet national requirements for Quality Accounts. A notable theme running through the account is an emphasis on partnership and collaborative working to help provide the best services for patients and families. The author of this statement believes EMH to have achieved requirements as set out in the NHS National Guidance ‘Quality Account Toolkit’ (DH 2010).
Overall review of the Quality Account The Quality Account gives a clear picture of what was achieved in the year, demonstrating a commitment to meet the changing needs of our local community. It also reflects some new achievements especially the Children’s Services Partnership award, the rapid response pilot and the community engagement program. The Quality Account is in place to provide the public with an opportunity to understand what the service did last year to improve quality, and what they will do this year. The presentation of data and information throughout the quality account is consistent and simple, providing a balance between positive and acknowledging areas for future improvement. The report is particularly commended for demonstrating the improvements made to the quality of care and services provided during 2015/2016 which demonstrates real patient, carer and staff involvement. The use of both qualitative and quantitative information has helped to present a rounded picture of the hospice services with the inclusion of patient, families and carers feedback making the quality account meaningful to the reader.
Section review of the Quality Account A Quality Account must include three key parts; Part 1 A statement on quality from the Chief Executive including a written statement signed by the responsible person for the provider that, to the best of that person’s knowledge, the information in the document is accurate. Part 2 Priorities for improvement are clearly identified with evidence of patient and carer input with evidence of why they are chosen. Part 3 Review of quality performance (for provider determination) – report on the previous year. The Quality Account provides comprehensive evidence of each element of these requirements for the reader. It demonstrates how the organisation has developed its capacity and capability for quality improvement to deliver the priorities described in the document. The document provides statements relating to quality of NHS services provided by the Hospice. There is a range of evidence provided to support the statements, in particular the reader will see the quotes from patients and relatives. There is clarity in the document around who the Hospice has involved (for provider determination) and engaged with to determine the content and priorities contained within this Quality Account (in line with current quality legislation and the Health Act 2009); this has been achieved to a high standard There is a range of quality performance information with good explanation which offers the reader the opportunity to understand the quality of services in areas specific to the Hospice; this is well presented with an excellent range of improvements showcased. It should be noted that the author of this review has not audited any data contained within the report. The review is written in good faith following review of the document, discussion with staff and knowledge of the organisation as a partner organisation. Shaun Stacey Chief Operating Officer, Isle of Wight NHS Trust 31st May 2016
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3.5 Endorsement of Quality Account by Board of Trustees The Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 require the Directors to prepare Quality Accounts for each financial year.
The Trustees confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the Quality Account.
The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the above legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010, (as amended by the National Health Service, (Quality Accounts) Amendment Regulations 2011)). In preparing the Quality Account, Trustees are required to take steps to satisfy themselves that: • this report presents a balanced picture of the Hospice’s performance over the period covered • the performance information reported in the Quality Account is reliable and accurate • there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice • the data underpinning the measures of performance reported in the Quality Account are robust and reliable, conform to specified data quality standards and prescribed definitions, and are subject to appropriate scrutiny and review, and • this Quality Account has been prepared in accordance with Department of Health guidance.
Board of Trustees Earl Mountbatten Hospice
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Glossary and Further Information AMEWS - Adult Modified Early Warning Score is standardised assessment of acute illness severity to facilitate early detection of deterioration in a patient and prompt nursing staff to request a medical review at specific trigger points CCG - Clinical Commissioning Group for the Isle of Wight. Clinical commissioning groups are NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. Controlled Drugs - Some prescription medicines are controlled under the ‘Misuse of Drugs’ legislation 2001 (and subsequent amendments) to prevent them being misused, obtained illegally or cause harm and to govern how they are stored, supplied and prescribed. Examples include morphine and methadone. CQC - Care Quality Commission is the independent regulator of health and social care in England. It regulates health and adult social care services provided by the NHS, local authorities, private companies or voluntary organisations. CQUINS - Commissioning for Quality and Innovation Schemes payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare provider’s income to the achievement of local quality improvement goals.
MDS - Minimum Data Set. The Minimum Data Set for Specialist Palliative Care Services is collected by the National Council for Palliative Care on a yearly basis with the aim of providing an accurate picture of hospice and specialist palliative care service activity. It is the only annual data collection to cover patient activity in specialist services in the voluntary sector and the NHS in England, Wales and Northern Ireland. MDT - Multi-Disciplinary Team is composed of members from different health and social care professions with specialised skills and expertise. The members collaborate to make treatment recommendations that facilitate quality patient care. MND - Motor Neurone Disease is a rare condition that progressively damages parts of the nervous system. This leads to muscle weakness, often with visible wasting. NCPC - National Council for Palliative Care is the umbrella charity for all those involved in palliative, end of life and hospice care in England, Wales and Northern Ireland. Outcome Measure - captures ‘change in health status’ as a consequence of healthcare or interventions. Sepsis - is a common and potentially lifethreatening condition triggered by an infection.
DH - The Department of Health is a ministerial department supported by 26 agencies and public bodies who help people to live better for longer.
Further Information
Fast track Continuing Healthcare - A primary healthcare need arising from a rapidly deteriorating condition that may be entering a terminal phase with an increasing level of dependancy.
Throughout this report there are statements (in italics) which have to be included in the report by law. There are a number of these statements which are not applicable to this Hospice they are:
JCC - EMH John Cheverton Centre. This is a centre integrated with Earl Mountbatten Hospice providing day services, open access groups and sessions and social space for patients, families and visitors.
• The number of national clinical audits and the number of confidential enquiries.
KissyPuppy - A local charity which was set up to fundraise for Sophie Rolf and her family in 2012. The charity continues to provide support to children on the Isle of Wight suffering from life shortening conditions.
• Records submitted to the Secondary Users service for inclusion in the Hospital Episodes Statistics. • Earl Mountbatten Hospice was not subject to the Payment by Results clinical coding audit during 2015/16 by the Audit Commission.
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How to give us your feedback This important document sets out how we continue to improve the quality of the services we provide. We welcome your views and suggestions on our Quality Priorities for 2016/17 as set out in Part 2 of this Quality Account. We welcome feedback at any time on our Quality Account; please contact Nigel Hartley, Chief Executive on 01983 529511 or email chiefexec@iwhospice.org. You can read more about the national requirements for Quality Accounts on the NHS Choices or Department of Health websites. You can download a copy of this Quality Account from www.iwhospice.org (About Us Governance)
Acknowledgements Thank you to all the members of staff, volunteers and public members who have contributed to this report. In particular: Linda Wright Becky McGregor Liz Arnold Laurie Rushton Stuart Nicol Peter Gilliam Dr Jane Hazeldine Jackie Whiller Stuart Cooke Tina Boyd Gary Barton Abigail Nelmes Christina Ginsberg Lisa Wardle Emma Topping Rob Bloomfield
Project Coordinator Head of Clinical Quality and Patient Experience Director of Patient Services Statistical Coordinator Head of HR and Facilities Charge Nurse Consultant Clinical Psychologist Deputy Sister Facilities Manager Nursing Lead JCC Head Chef Clinical Nurse Specialist Community Coordinator Head of Communications Head of Communications (from May 2016) ICT Operations Support Technician & Payroll Administrator
Board of Trustees Senior Management Team Staff, volunteer, trustee, patient and service user focus group members
Earl Mountbatten Hospice Halberry Lane Newport Isle of Wight PO30 2ER Telephone: 01983 529511 (Main switchboard) Registered Charity No. 1039086, Hospice Company No. 2929267, Trading Company No. 3083127
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