“Your care allowed our Dad to spend his last few weeks with our mum, not as her carer as he had been over the last two years, but as her husband.�
Quality Account 2015 - 2016 Total support for patients and families Clinical Financial Practical Emotional Spiritual
Chief Executive’s Statement Welcome to this year’s Quality Account which outlines Phyllis Tuckwell Hospice Care’s (PTHC) key quality achievements during the year April 2015 – March 2016. This is the sixth year that we have produced such a report, designed to give our local community a concise summary of what we have been doing to improve our services. We are always pleased to have any feedback on the document itself, or indeed, our services more generally, so please do feel free to get in touch. Patients and their families remain at the heart of what we do here at PTHC. We are proud of our strong track record and high levels of patient satisfaction summarised later in this document. Equally, we are not complacent and have a robust and long established clinical governance programme which takes a critical review of all our clinical work, seeks to improve our quality of care and to ensure we learn from our experience and patient feedback. 2015-16 has been a significant year for PTHC as we integrated the former Beacon Specialist Community Supportive and Palliative Care Service into Phyllis Tuckwell Hospice and renamed the organisation PTHC. You can read more about this on page 6 but we are delighted at the increase in the number of end of life patients and families we have been able to support this year as a result of the combined organisation. We are also proud of the way that we have developed our approach to nutritional care for patients this year and supported our nursing auxiliaries to develop their own skills and expertise, thereby improving patient care. As our services become more community based we have embraced technology to support our staff and all community staff now have tablets and smart phones to enable them to access patients’ records and enter data in real time. This gives the clinical teams greater flexibility in the way they work and are therefore more responsive to patients’ needs. 2016/17 is the start of PTHC’s next three year strategy which continues to have the patient and their family at the heart of all we do. We know we need to develop our services to respond to patient need, particularly in the evenings and weekends and have an ambitious plan to further improve and strengthen our services for this coming year – you can read more about this on pages 7-9. My thanks must go to not only our staff and volunteers who work tirelessly to provide high quality services but also to our faithful and committed supporters who enable us to raise the necessary funds to provide our services free of charge to patients and their families. I can confirm that I am responsible for overseeing the preparation of this report and its contents. To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality of healthcare services provided by Phyllis Tuckwell. Thank you for your interest in the work of Phyllis Tuckwell Hospice Care. Sarah Brocklebank, Chief Executive July 2016
Contents Section 1
Page Improvements - Current and Future
4
Quality Improvements 2015-2016
4
Improvement 1: Nutritional review Improvement 2: Auxiliary Nurse Competencies framework Improvement 3: ‘Smart working’ - Introduction of phones and tablets Improvement 4: Transition of the Beacon
4 5 6 6
Developments and Improvements for 2016-2017
7
Development 1: Utilising advanced technology - ‘Speak Set’ and ‘Aid call’ Development 2: Education for the future Development 3: Development of our research activity Development 4: Development of our services - responding to patient need
7 8 8 9
Section 2
Statutory Information
10
Review of Services Registration Participation in Clinical Audits Data Quality Research
10 10 10 11 11
Section 3
12
Quality Overview
The National Council for Palliative Care: Minimum Data Set In-Patient Unit Community Hospice Care at Home Day Services Bereavement Hospice Home Support Quality Markers Clinical audits and evaluations National audits (HospiceUK) National assessment tools What patients and families say about the services they receive Day Hospice Satisfaction Patient Survey VOICES Survey Feedback from the unannounced visit What our Regulators say about Phyllis Tuckwell External comments The Board of Trustees’ Commitment to Quality
12 12 13 14 15 16 16 17 19 21 21 23 23 24 29 30 31 32
Section 1
Improvements - Current and Future Every year we produce this PTHC Quality Account for our local community to report on the quality initiatives and improvements that have taken place in the last year. It also selects a number of improvements planned for the forthcoming year which will be reported in next year’s Quality Account. The following section reviews the progress made against the improvements listed in last year’s account in 2015-16 and describes some areas for improvement in this coming year 2016-2017.
Quality Improvements 2015-2016 Improvement 1
Nutritional review Many patients under the care of PTHC experience dietary difficulties and deficiencies related to or resulting from their illnesses. Phyllis Tuckwell Hospice Care aims to provide care and advice that optimises patients’ nutritional status and wellbeing. What we have done:• Introduced a new nutritional screening tool. • Updated our oral assessment tool - aimed to help improve the oral hygiene of patients. • Continued monitoring of patients’ intake every meal time. • Set up a PTHC nutritional steering group and link nurse. • Undertaken patient ‘food and drink’ surveys. • Recruited and trained more volunteers - to help with drinking and feeding. • Implemented training and awareness sessions for all care staff. The new nutrition policy and procedure details all the assessments and monitoring tools used at PTHC ensuring a coordinated approach to patient-centred nutritional care. All patients admitted to the Hospice undergo a thorough nutritional assessment using the new nutritional screening tool. Any appropriate interventions, necessary referrals e.g. dietician or speech or language therapist are identified and discussions as to appropriate dietary requirements undertaken. Care staff have attended nutritional awareness updates and been evaluated in this area as part of the new auxiliary nurse competencies framework. Fifteen volunteers have been trained to help with feeding and drinking, with some having undergone a shadowing process and now assisting with feeding in both our day centres and In-Patient Unit. The nutritional steering group is ensuring the effective implementation of screening, assessment and monitoring tools and continues to monitor the processes in place liaising with all services via link nurses. 4
The catering team continually reviews its menus and endeavours to be as flexible as possible – if a patient fancies a particular something at a particular time (which is often the case when feeling unwell) the team will do their very best to make it happen. In the recent VOICES survey 92% of respondents rated the food given to their relative as ‘exceptional’, ‘excellent’ or ‘good’. In the current In-Patient survey 88% of patients rated the food as ‘excellent’ or ‘good’. 98% said the service was flexible in terms of times food was available and the variations on offer. Patient comments “I am off my food at the moment but I woke up in the night and had a cornetto - it was lovely”. “I have been amazed at variety and presentation. Always hot. Well done”.
Improvement 2
Auxiliary Nurse Competencies framework The implementation of the Auxiliary Nurse (AN) Competencies framework aims to help ANs develop their skills through continuous professional development. ANs on the In-Patient Unit attend training and education sessions covering skills such as vital signs monitoring, blood glucose level monitoring and support for those patients who require feeding via the enteral route. Completion of competency assessments consolidates this learning and regular clinical supervision, using reflective practice and shared experiences, further advances professional development. In the community, ANs, new to the team, are supported by induction workbooks which, with the support of senior members of the team, enable them to identify the specific skills, knowledge and practical support required for their role. Appropriate training and support follows culminating in a competent confident team. PTHC is very supportive of professional development and is currently mentoring two ANs completing their foundation degree courses at the University of Surrey.
5
Improvement 3
‘Smart working’ - Introduction of phones and tablets PTHC is committed to providing high quality end of life care - offering a range of services to patients and families across a large catchment area. With the ongoing development and expansion of our community service operating across two sites we identified the need to invest further in ‘Smart’ technology. The introduction of smart phones to our community teams has been incredibly successful. The ability to access PTHC calendars - enabling the scheduling of future appointments whilst with patients and when attending meetings has been invaluable. The use of emails has also increased efficiency with staff able to receive ‘up to date’ information at a time that is convenient and whilst ‘on the move’. This has led to greater flexibility and swift working. The satellite navigation systems have come in pretty handy too! Many of the community team are also using 4G tablets – enabling them to access information without having to return to site. Being able to retrieve and enter clinical information whilst with the patient, at meetings or on an urgent visit, has enhanced practice and enabled a much more responsive approach. PTHC will continue to make further investment and upgrades in tablet/laptop use as technology advances.
Improvement 4
Transitition of the Beacon On 1st April 2015, the management of the former Beacon Specialist Community Supportive and Palliative Care Service was transferred to Phyllis Tuckwell Hospice, and we renamed the combined organisation, Phyllis Tuckwell Hospice Care. During 2015/16 considerable work has been done to combine the services to provide one integrated service operating across two sites rather than two separate services. We have created a “hub” for the Hospice Care at Home service (HCAH), based at the Beacon Centre in Guildford, and this serves as the single point of access for all HCAH referrals and the base for the whole team. The HCAH nursing team has been strengthened by a Social Work Advisor who helps ensure appropriate packages of care can be put in place in partnership with other agencies. The Clinical Nurse Specialist (CNS) team has been strengthened and now work as one team right across our catchment area as part of a multi-disciplinary clinical team, with a triage system for all patients resulting in better utilisation of the team’s time and expertise. The CNSs are aligned to individual GP practices which helps ensure continuity of care for GPs and patients. To provide a new service, an additional Occupational Therapist, Chaplain and Complementary Therapist have been employed by PTHC for services across the Guildford & Waverley CCG area. Day Services at both sites have been reviewed and streamlined and are now operating effectively out of both the Farnham and Guildford sites, incorporating many different group activities, as well as the more traditional day services model. 6
Developments and Improvements for 2016-2017 PTHC is committed to the delivery of high quality care. Listening to patient, carer and staff feedback, and continuously evaluating our work against national best practice, help us to identify areas where we would like to see service development and improvement. The Quality Account allows us to detail some of these planned improvements. We have chosen a number of these which cover a variety of areas and will be of interest to the general public and other groups.
Development 1
Utilising advancing technology ‘Speak Set’ and ‘Aid call’ In patients’ homes – Trial of the ‘Speak set’ system ‘Speak set’ is video connection from a health professional to a patient in their own home. The technology is user friendly – its beauty being it uses the patient’s own TV. Healthcare professionals can contact the patient by simply logging on to the website. ‘Speak set’ aims to: provide face-to-face contact without travel, help keep people independent at home; and potentially avoid unnecessary hospital/hospice admissions. PTHC is planning to buy ten devices - which will be set up in patients’ homes or used as portable units - enabling community nurses already in the patient’s home to seek advice from other Healthcare professionals on site at Phyllis Tuckwell. Next year we hope to be able to report the successful implementation of ‘Speak set’ including patient testimonials. On the In-Patient Unit – Aid Call (upgrade) Aid call (a patient call bell system) is currently used on the In-Patient Unit and has been effective; however some issues such as connectivity and noise levels, particularly at night, have prompted the purchase of a new upgraded system. The new system will work on its own radio frequency, improving connectivity and reducing interference. The handsets have large LED screens, are easier to operate and include a number of additional features. Pagers have larger screens and operate at different noise alert levels including vibrate. Two new control panels will be installed with increased information and all calls logged for any required auditing. It is envisaged that the new upgraded system will provide greater ease of use for both patients and staff.
7
Development 2
Education for the future Following the transition of the Beacon the new combined organisation, Phyllis Tuckwell Hospice Care, recognised that it was an opportune time to review our education strategy. Our vision is to be able to deliver education to all healthcare professionals within the organisation and for allied health professionals in the community, in order to meet the end of life care core competencies. The newly appointed Clinical Education Manager, will, with the support of her team, drive this forward, identifying what is required for all health professionals both within Phyllis Tuckwell and also the community, including care homes. Planned and ongoing work includes: • Delivering level 2 QCF (qualifications credit framework) which has replaced the NVQ, in collaboration with HospiceUK, Hospice Education Alliance (HEA) and the College in Poole and Bournemouth. • Work to kitemark our ‘education for end of life care’ - three day programme with the University of Surrey. • Joint working with SECAMB (South East Coast Ambulance Service) to increase their knowledge regarding end of life care and improve the sharing of patient information. • Working with the Higher Education Authority in shaping end of life training in Hampshire.
Development 3
Development of our research activity Phyllis Tuckwell Hospice Care recognises that research is essential to enable the specialty to deliver high quality care founded on reliable knowledge or evidence. PTHC has appointed a consultant as Research Lead in order to develop and support our research activity. In addition, a number of key staff have received research training (Good Clinical Practice training – a requirement for anyone involved in clinical research). In the coming year we will be working in collaboration with other local and national palliative care units in multi-centre trials (one has already been approved and confirmed), as well as supporting staff to develop and carry out their own research projects.
8
Development 4
Development of our services responding to patient need PTHC’s vision is to provide flexible and responsive holistic and compassionate end of life care. Our aim is to be able to provide 24/7 end of life care that is responsive to changes in patients’ conditions. In the community we intend to achieve this by: continuing to develop and expand our community teams; working in collaboration with other community providers; and strengthening our links with current out-of-hours’ services. In the In-Patient Unit we will be increasing our medical cover to allow us to routinely accept admissions 6 days a week (currently Mon – Friday) whilst continuing to accept emergencies as needed. This will be a huge benefit for patients, and for hospitals, as the transfer of patients will not be delayed until a Monday, when the opportunity to move may be lost, due to deterioration in the patient’s condition.
9
Section 2
Statutory Information This section includes: Information that all providers must include in their Quality Account.
(Some of the information does not directly apply to specialist palliative care providers).
Review of Services During 2015-2016 PTHC provided six services: • • • • • •
In–Patient Unit Day Services Out-Patients Community - including the development of our Hospice Home Support services Hospice Care at Home Bereavement
PTHC has reviewed all the data available to them on the quality of care in all of these services. The income provided by the NHS represented 20% of the total income generated by PTHC in the reporting period 2015-16.
Registration PTHC is required to register with the Care Quality Commission, a regulatory body that ensures that we meet our legal obligations in all aspects of care. The July 2014 report (latest report available) was very positive, with PTHC meeting the standards inspected.
Participation in Clinical Audits As a provider of specialist palliative care, PTHC is not eligible to participate in any of the national clinical audits or national confidential enquiries, as none of the audits or enquiries related to specialist palliative care. However PTHC’s own quality and audit programme facilitated many audits during 2015-16 including a number of ‘HospiceUK’ audits (a charitable organisation that supports hospices and palliative care professionals).
10
Data Quality For the year 2015-2016 PTHC submitted its Specialist Palliative Care Minimum Data Set to the National Council of Palliative Care. Results are available publicly from the National Council for Palliative Care. www.ncpc.org.uk/minimum-data-set Some of this data and comparative national data is presented later in this report.
Research Two research projects were submitted to the PTHC Clinical Governance Committee in 2015-16, and were granted internal approval: The Prognosis in Palliative Care Study II (PiPS2) – This study is led by Professor Paddy Stone at University College London, and we hope to commence recruitment towards the end of 2016. What are the facilitators and barriers to rehabilitative palliative care on a hospice inpatient unit? A qualitative study of the experiences and opinions of staff – This research is being led by the PTHC lead physiotherapist at PTHC. Recruitment should be completed by the end of 2016. As detailed earlier in this report PTHC has made a commitment to advance research activity and will be reporting on the progress made in this area in next year’s report.
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Section 3
Quality Overview This section provides: • Data and information about how many patients use our services • How we monitor the quality of care we provide • What patients and families say about us
The National Council for Palliative Care: Minimum Data Set The Minimum Data Set (MDS) for Specialist Palliative Care Services is collected on a yearly basis, with the aim of providing an accurate picture of hospice and specialist palliative care service activity. The PTHC MDS covers the period 1st April 2015 to 31st March 2016. The available national comparative data is from the previous year. The data below comprises of MDS data and PTHC collated statistics.
In-Patient Unit 2015/16 PTH & BS Combined
12
2014/15 Year-on-year 2014/15 MDS Change National Data
Total admissions
374
379
-1%
420 varies by size unit
% patients going home
29%
38%
-24%
n/a
% bed occupancy
75%
84%
-11%
78.9%
Average length of stay (days)
12.7
13
-2%
15.4
% non-cancer diagnosis patients
21%
20%
5%
14%
% patients dying on the Last Days of Life plan
85%
n/a
n/a
n/a
The In–Patient Unit continues to operate efficiently, supporting many patients and their families. The IPU underwent a major refurbishment during 2015/16 which necessitated the closure of some beds over a four month period to allow the work to be completed. Despite this the number of admissions has been fairly constant year-onyear. There has been a small increase in the number of non-cancer patients supported, reflecting our deliberate focus on increasing support for all patients regardless of their diagnosis. Occupancy levels dropped over the summer months but have increased since back to similar levels to 2014/15. Average length of stay remains under control. There has been an increase in the number of patients admitted for terminal care, particularly from one of our acute Hospitals.
Community (excluding HCAH) 2015/16 PTH & BS Combined
2014/15 Year-on-year 2014/15 MDS Change National Data
Number of patients supported
1,519
1,521
0%
766
Total contacts (face-to-face)
6,468
7,543
-14%
n/a
Total contact (telephone)
20,778
17,461
19%
n/a
% non-cancer diagnosis patients
24%
20%
21%
15.4%
% Home & Care Home deaths
56%
57%
-2%
57.7%
The Community Team includes Clinical Nurse Specialists (CNS), doctors, patient and family support team and therapists. Despite the organisational changes involved in integrating two services, we have continued to support over 1,500 patients and their families during the year. Effective working and communication with our community partners has resulted in strong referrals from GPs and community nurses with our links with local hospitals also remaining strong. There has been a significant increase in the number of non-cancer patients supported. As a result of merging the two community teams, we have introduced a telephone triage system for all new community patients. By ascertaining their needs and wishes by telephone, rather than an initial home visit, we utilise our resources effectively and ensure home visits are targeted most appropriately.
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Hospice Care at Home (HCAH) 2015/16 PTH & BS Combined Number of patients supported
2014/15 Year-on-year 2014/15 MDS Change National Data
543
596
-9%
234
Total contacts (face-to-face)
4,612
4,258
8%
n/a
Total contact (telephone)
5,551
3,505
58%
n/a
% Home & Care Home deaths
91%
93%
-2%
90.5%
The Hospice Care at Home Service is now an established provider of end of life care in the community and its ongoing development and expansion has allowed us to support patients and their families at home. There was some data capture missing within the HCAH team at the start of the year which would explain the reduction in the recorded number of patients supported. However, despite this, the number of face-to-face contacts has increased by 8% during the year. We have introduced a Social Work Advisor to the team who has proven invaluable in facilitating a patient’s’ discharge home and arranging packages of care, enabling patients to be looked after and die at home, and explains the significant increase in telephone calls. As a result of the expanded team we have been able to keep more patients at home for EoL care, impacting positively on the number of unscheduled admissions to hospital.
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Day Services Day Hospice, Out-Patients & Group work 2015/16 PTH & BS Combined
2014/15 Year-on-year 2014/15 MDS Change National Data
Total contacts (face-to-face)
7,325
6,743
9%
n/a
Total contact (telephone)
2,136
2,477
-14%
n/a
Combined
9,451
9,220
3%
n/a
% non-cancer diagnosis patients Day Hospice
38%
29%
28%
27%
% non-cancer diagnosis patients Out-Patients
22%
33%
-34%
12.7%
Our Day Services comprise a “traditional” Day Hospice Service, group work and Out-Patients. As a result of combining two clinical teams we have seen variations in the balance between these three service areas provided for patients and their families. We are finding that patient preferences are changing – e.g. some find the different Group activities better suits their needs than a more traditional Out-Patients appointment. We are currently undertaking a review of Day Services at both sites to make sure they meet the needs of patients, their families and their referrers. During 2015/16 we saw a 3% increase in total contacts, with a marked increase in the number of face-to-face support.
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Bereavement 2015/16 PTH & BS Combined
2014/15 Year-on-year 2014/15 MDS Change National Data
Number of clients supported
401
247
62%
179
Group work
452
391
16%
n/a
1,286
917
40%
n/a
310
296
5%
n/a
Face-to-face (individual support) Telephone contacts
The bereavement service has seen an expansion in its team this year which has been reflected in the significant increase in numbers of people supported. As well as oneto-one sessions, we now offer many different types of support groups to different client groups (including children & teenagers) which have been very positively received.
Hospice Home Support 2015/16 PTH & BS Combined
2014/15 Year-on-year 2014/15 MDS Change National Data
Number of patients supported
138
103
34%
n/a
Number of visits
818
631
30%
n/a
The Hospice Home Support service continues to grow and develop, providing more befriending support for patients such as helping with shopping, small jobs around the house or just sitting and chatting. This is proving a very popular and successful service and one that complements the work of the rest of the community team.
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Quality Markers We have chosen to measure our performance against the following metrics: Indicator
2015-2016
Complaints - across all services (13 resolved satisfactorily & 1 ongoing)
14 (3 previous year)
Patient falls
28 (40 previous year)
Patient safety incidents (Infection) Total number of patients known to have become infected with MRSA whilst on the In-Patient Unit
(3 patients admitted with MRSA)
Total number of patients known to have become infected with C. difficile whilst on the In-Patient Unit
(0 patients admitted with C.difficile)
0
0
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In addition ‘HospiceUK’ has developed a benchmarking tool – the In-Patient Unit Quality Metrics – recording falls, pressure ulcers, and medication incidents. The tool allows hospices to compare their data quarterly and annually with other similar size hospices. Below is the data for 2015-2016 (104 sites took part). Phyllis Tuckwell Hospice Care In-Patient Unit
Average
PTH 2015-2016
(For similar sized hospices taking part)
28
54
15
21
45
35
2015-2016
Incidents Total falls Total Pressure Ulcers
(Developed or worsened on site)
Medicine Incidents
As can be seen above, PTHC performed well in the falls and pressure ulcer categories, but was higher than the reported average in the medicine incident category. The data has been presented and discussed at the PTHC Clinical Governance Board Sub-Committee along with a more comprehensive data set collated by PTHC (more inclusive with a wider range of incidences). The SubCommittee are confident that the figure can be attributed to a strong reporting culture within the organisation. To help put the numbers into context, there were 0.06% medication incidents (including all those that were prevented from actually happening).
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Clinical audits and evaluations To ensure that we are continually meeting standards and providing a consistently high quality of service, PTHC has a Quality and Audit Programme in place. The programme allows us to monitor the quality of service in a systematic way, identifying areas for audit and evaluation in the coming year. It creates a framework where we can review this information and make improvements where needed. Regular Clinical Governance meetings provide a forum to monitor quality of care and discuss audit and quality evaluation results. Recommendations are made and action plans developed. The audit programme for 2015-16 covered a range of areas including: • PLACE (patient led assessment of the care environment). • In-patient – patient satisfaction survey (still in progress). • Day Hospice – patient satisfaction survey. • VOICES survey. • Prescribing audit (both medical and nurse prescribers). • Health Records (recording of information and management of storage and archiving). • Risk Assessments (completion of). • Wellbeing assessment tool (completion rates). • Infection control - various modules (HospiceUK national audit). • Mental Capacity – assessment and documentation (completion and quality of). • Use of rooms (evaluation measuring whether resource optimised). • Nutritional assessment tool (completion and quality of). • Access to medical records (availability and response to). • Blood Transfusion audit (adherence to the PTHC procedure). Evaluation of Heart failure model. •
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A small sample of some of the audits in more detail, are listed in the table below: Audit
Findings, recommendations and actions to be taken to improve compliance/practice
Audit of Health Records The PTHC Health Records Policy and Procedure sets out clear standards, created in accordance to the relevant legal and national requirements.
The results were excellent, with an overall compliance, over the 3 sections, of 96.5%. Information is written and recorded to a high standard on both the electronic records system (Crosscare) and paper notes – with a compliance of 93%.
The biennial audit looks at the recording of information on health records (both paper and electronic), the storage of records within PTHC and the external archiving process.
The audit found that there was some use of abbreviations outside those agreed by the abbreviations guidelines. The results will be discussed with staff and the guidance in place promoted. PCs were found to be locked at all times when unattended. The storage and destruction of records at PTHC was excellent and the external arrangements for archiving sound.
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Hand hygiene Hand hygiene is the single most important means of preventing the spread of infection. An audit looking at all aspects of hand hygiene is carried out annually. Topics include; staff training and awareness, equipment (sinks, soap, paper towels and bins etc.) as well as the actual process (when, how & quality of).
Result = 93% compliance The result of the audit confirmed that staff received regular training updates & understood the importance of good hand hygiene.
Risk assessments (June 2015) In-Patient Unit These are assessment documents to determine the risk factors associated with: moving the patient; the patient falling and the patient developing pressure ulcers and the measures we can take to reduce that risk
Overall result = 96% compliance The results were positive with an overall result of 93%. The results were discussed by the ward team and awareness heightened. It was agreed to monitor more regularly as part of the 2016 ward audit programme (a series of audits undertaken by nurses and repeated throughout the year).
Moving and handling (Assessment to determine patients mobility and the risk factors associated with).
Completed on admission Completed weekly or as circumstances changed
90% 100%
Falls risk assessment (Assessment to determine the risk factors associated with falling)
Completed on admission Completed weekly or as circumstances changed
90% 80%
Pressure ulcer (sore) risk assessment (Assessment to determine the risk factors associated with developing a pressure ulcer).
Completed on admission Completed weekly or as circumstances changed
100% 100%
From observation – staff used gloves appropriately and demonstrated good hand washing techniques. Areas for discussion and improvement include – upgrades to sinks.
National audits (HospiceUK) HospiceUK has developed a number of core audit tools which are relevant to the particular requirements of hospices and can be used for quality improvement and verification of standards. In this reporting year PTHC completed the infection control audit – assessing 4 areas. There is currently a lack of national data available for benchmarking - this is an area that has identified as a priority for development by HospiceUK. HospiceUK audits completed Infection control - looked at 4 areas including; Standard operating procedures, the sluice, use and disposal of sharps and hand washing.
Compliance 97%
National quality assessment tools PLACE (Patient Led Assessment of the Care Environment) PLACE is a tool, recommended by The Department of Health, for assessing the quality of the patient environment. It provides an annual snapshot to organisations of how their environment is seen by those using it, and provides insight into areas for improvement. It enables organisations to benchmark their performance nationally against a range of activities split between five domains: - cleanliness; condition and appearance of premises; food and hydration; privacy and dignity and the level of provision provided for patients with dementia or those with a disability. The PTHC assessment team comprised of patients, volunteers and staff and was conducted over two days. The assessment went very well with the Phyllis Tuckwell Hospice site achieving high levels of compliance. The Hospice was clean and well-maintained with an overall compliance of 96%, there were a few maintenance issues that are easily resolvable and it was noted that cleaning in non-clinical areas could improve. The provision of food and the quality of the food was good – 91% compliant. Results were discussed at the nutrition steering group and positive actions agreed – these include changes to the way menus are laid out and displayed, providing snacks more regularly and providing patients with individual hand wipes for use prior to meals. The dementia assessments was quite specific, and after discussion with the dementia steering group and the clinical leads, it is accepted that PTHC will not be able to achieve all the standards at this present time, however we can make some improvements and these will be actioned as soon as possible. The dementia assessment criteria is drawn from environmental assessments produced by ‘The King’s Fund’ and will be referenced in any future refurbishment. 21
96.60%
90.85%
91.04%
90.71%
93.33%
95.19%
80.02%
88.73%
The patients and volunteers involved in the assessment were asked a final question about their ‘lasting impression’ - they all said that they felt ‘very confident’ that the environment supported good care. They all reported to have enjoyed the assessment and ‘being of help’. The results and action plan was communicated the Clinical Governance SubCommittee and to department managers for cascading and action. NB We have not yet been able to benchmark against other similar organisation as the national results have not yet been published.
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What patients and families say about the services they receive The views and experiences of patients and their families are important to PTHC and enable us to look at how we can learn, develop and improve the services we provide. PTHC undertakes a series of questionnaires, surveys and focus groups on a regular basis. These are presented to the Clinical Governance Board Sub-Committee where the results and comments are discussed, recommendations made and any subsequent actions taken forward.
The Day Hospice Satisfaction Patient Survey 2015 (hospice site) The PTHC survey, designed for self-completion by patients, includes questions relating to information giving by staff; staff attitudes; involvement of patients in care planning; privacy and courtesy; catering; cleanliness and awareness of the process for complaints. A sample of some of the questions and the responses are detailed below: All patients (100%) stated that this ‘always’ happened
Did you feel you were treated with dignity and respect?
”They are always kind and supportive”
93% of patients said ‘yes’
Is there an opportunity to discuss the future e.g. where and how you would like to be cared for when you become less well?
“Yes and I have discussed my preferences to where I wish to be cared for”
All patients said ‘yes’
Do you receive enough support to help you cope with your feelings and emotions?
“All the staff are caring and willing to listen”
All patients thought the food was either ‘excellent’ (67%) or ‘good’ (33%)
How would you rate the quality of the food and drink?
“Lovely and tasty and well presented”
All patients rated the environment as ‘excellent’
How would you rate general environment and surroundings of the Day Hospice i.e. the space, décor and comfort?
“This is surely home from home. I always feel happy and secure”
All patients replied ‘yes’
Overall do you feel that attending the Day Hospice is beneficial to you and your family?
“My family and my life has been greatly enhanced by the continued care and support. I never feel that I am alone”
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VOICES Survey (carer and patient proxy survey) PTHC conducted The VOICES - HOSPICE survey for the second time in 2015. The questionnaire is a validated service evaluation and quality assurance tool for use in hospices. Its aim is to evaluate what bereaved relatives think about the quality of care provided by a hospice to patients and families before the patient’s death, and to themselves in bereavement. The information collated has provided PTHC a good insight in to what relatives think about the care provision in the last few months of the patient’s life and will be valuable in the future development of PTHC services. Some examples of the findings are listed below: In-Patient Unit Overall, what do you think of care s/he got from the doctors and nurses in the Hospice? 8%
Whilst s/he was in the Hospice, did you receive enough emotional support?
1% 1%
11% Exceptional
50%
4%
Yes, definitely
Good
Yes, to some extent No, not when I needed it
Fair
I didn’t need help
Excellent
Poor Don’t know 40% “The Nurses and Doctors were very attentive and nothing was too much trouble for them. Very kind, special people”.
How much of the time was s/he treated with respect and dignity by Hospice nurses and doctors? 10%
58%
27%
“All the staff (including housekeepers) were helpful, supportive and compassionate. My daughter was heavily pregnant and she received a great support whenever she visited”.
The bed area and surrounding environment had adequate privacy. 5%
2% 1%
2% Strongly agree
24% Always
Agree
Usually
Neither agree nor disagree
Some of the time
Disagree
Never Don’t know 87% 24
69%
During her/his stay how well was their pain relieved? 9%
Completely, all of the time
40%
During her/his stay did s/he receive enough support with symptoms other than pain? 25%
Yes definitely Yes to some extent
Completely, some of the time Partially Not at all
51%
75%
NB The two graphs above use the responses where this was relevant i.e. excluded ‘does not apply’ and ‘don’t know’ responses.
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Community (Care and support received from PTHC Nurse Specialists and the Hospice Care at Home team) Overall, what do you think of care s/he got from the PTHC Community team? 9%
Did s/he see the nurse as often as it was needed?
2% 1% Exceptional
48%
7%
3%
Yes, always
5%
Excellent
Only sometimes
Good
No
Fair
Don’t know
Poor 85%
40%
“It was perfect, my daughter and myself were very impressed indeed and made it possible for my husband to stay at home as he wanted”
Did you feel that the community team had time to listen and discuss things with you? 10%
Were you involved in decisions about his/her treatment and care as much as you wanted? 5%
2%
1% I was involved as much as I wanted
Yes, definitely
I would have like to have been more involved
Yes, to some extent No, not when I needed it
Don’t know
Don’t know 88% “The home care team we saw were unfailingly cheerful, caring, sensitive and supportive - I really don’t think we could have managed without them”
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94% “The ladies who visited my husband were so patience, caring and lovely. Truly exceptional and very much appreciated”
Whilst receiving care from the PTHC community team, how well was your pain relieved? 3%
Completely, all of the time
21%
Whilst receiving care from the PTHC community team did s/he receive enough support with symptoms other than pain? 8% 27%
Yes definitely Yes to some extent No not when needed
Completely, some of the time Partially Not at all
35%
41%
65%
NB The two graphs above use the responses where this was relevant i.e. excluded ‘does not apply’ and ‘don’t know’ responses. “The Hospice Care at Home Team were wonderful - they came every day during the last week of my husband’s life and were so kind and gentle with him. Our clinical nurse specialist was excellent and very supportive. I don’t know how I would have coped without her to give me advice and answers to our questions, from her first visit until after his death”
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Place of death On balance, do you think that s/he died in the right place? (Home 51%/Care home 7%/Hospice 36%/ Hospital 6%). 3%
3%
On balance, do you think that s/he had enough choice about where s/he died?
3%
3%
Yes
Yes
No
No
Don’t know
Not sure
94% “We were very lucky - not everyone gets the choice & her cancer not being diagnosed in time (4 weeks prior to death) she would have died in hospital which she would have hated”
94% “At the end, my husband died quite suddenly. My daughters and I felt very supported by the overnight help that was arranged at short notice”
In general, the feedback received from the 129 surveys reflects a high level of regard for the work of Phyllis Tuckwell Hospice Care, with the majority of carers very satisfied with the support provided to them and their loved one. Although the vast majority of comments were positive, we cannot get things right all of the time and if the organisation is to be responsive to the changing needs of patients and their families, it is important that the more constructive comments are considered. Discussion around this feedback can result in improvements and drive change. All comments were recorded and discussed at Clinical Governance and Senior Clinical team meetings (both have representation from all clinical services/ areas). Where necessary, action plans were discussed, disseminated and followed up by the relevant team/service lead.
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Feedback from the unannounced visit The Board of Trustees undertake annual unannounced visits to both PTHC sites (The Hospice in Farnham and The Beacon Centre in Guildford). Two members of the Board talk to staff, patients and carers. Patients and carers are asked about their views and experiences. Details of some of their observations and conversations with patients are detailed below the (January 2016 report):
In-Patient Unit One patient, who had been in for a few weeks, said her care in the In-Patient Unit had been more than marvellous, there were more nurses to look after her and they were experts in palliative care. She felt much calmer and was making progress and learning how to cope with her condition. She felt she was treated with dignity and respect and was fully involved with her care. She had asked for a special diet (without yeast) and the kitchen staff were excellent in ensuring that her needs were met. She had had a foot massage and although non-religious, she had appreciated a good discussion with the chaplain. Her husband had not used any of the services although he knew of that option. He visits her every day.
Dove Lounge/Day Hospice During the afternoon of our Hospice visit the Day Hospice was hosting a “Brush with Art” exhibition of paintings by patients, accompanied by refreshments and music. In the Dove Lounge we found a relaxing atmosphere surrounded by impressive art and bustling with enthusiastic patients, staff and volunteers. Two Day Hospice (DH) attendees, who were firm friends, having first met at the DH, shared their experiences: The first said that at Day Hospice he was respected and known for the skills he had before he became ill (an artist/sculptor) – rather than being simply a Day Hospice patient i.e. he felt respected and admired. He has been involved in a design which will be placed in the Day Hospice Garden. They both felt that the introduction of “Brush with Art” – along with Poetry - had made a significant difference to their lives and felt it was an inspirational development at PTHC. Coming to “Brush with Art” was the highlight of their week and they couldn’t imagine life without their weekly visit. Both commended the refurbishment of the Dove Lounge and in particular the garden access. They felt all the staff and volunteers without exception were very nice.
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What our Regulators say about Phyllis Tuckwell The Care Quality Commission (CQC) is a regulatory body that ensures that we meet our legal obligations in all aspects of care. The last report (July 2014) was very positive, with PTHC meeting the standards inspected.
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External comments Guildford & Waverley Clinical Commissioning Group Supporting Statement “It is, as in previous years, an absolute pleasure to read the Quality Account from Phyllis Tuckwell Hospice Care. Your organisation consistently performs at excellent levels both for quality and safety, and the compassion and care you have for your patients spills over throughout the various sections of the report. I am particularly impressed with a number of areas in this year’s report, all of which concur with our organisation’s understanding of quality at the organisation. They are in particular: • • • •
• • •
• • • •
Nutrition work streams and performance. Mobile and information technology developments to enhance community teams, and in particular the ‘speak set’ development for patients at home. The integration of services and the expansion of staff to serve the Guildford & Waverley locality. Enhancing education, and the particular focus on emergency staff in the Ambulance service – we are absolutely committed to reducing unnecessary hospital admissions and we feel this is critical for the success in this area. The move to medical cover and admissions over a six rather than five day week. The significant increase in bereavement support and Hospice Home Support. The significant reduction in falls and we would further support improvements in the numbers of falls risk assessments conducted – whilst recognising they are at good levels. Infection control standards as measured by rates of infection and inspections such as PLACE. The reduction, over time, in the numbers of pressure damage. A full and varied audit programme. Outstanding patient survey results and in particular the levels of dignity, respect and support to help cope with feelings, and symptoms of pain.
It is also very reassuring to see the continued programme of unannounced inspections by the Trustees, and hearing their own feedback on the services you provide. We are also reassured that you openly recognise areas that need further improvements (e.g. some aspects of your VOICES survey and the elements of dementia care), and look forward to hearing how these progress over the year. With the renewed NHS Contract we have with you, we look forward to collaborative working relationships to ensure the continued joint safeguarding of quality and safety within your organisation. To this end, we would like to also thank you for your agreement to permit our Associate Director of Quality to attend your Clinical Governance Committee. This demonstrates an excellent transparent and open culture, and will allow us to exercise our statutory obligations to quality with your organisation.” 31
The Board of Trustees’ Commitment to Quality The Board of Trustees is fully committed to the quality agenda. PTHC has a wellestablished governance structure, with members of the Board having an active role in ensuring that Phyllis Tuckwell provides a high quality service in accordance with its terms of reference. As detailed earlier members of the Board undertake an annual unannounced visit - gaining first-hand knowledge of what the patients and staff think about the quality of the service. The Board is confident that the treatment and care provided by PTHC is of high quality and is cost-effective.
www.pth.org.uk Phyllis Tuckwell Memorial Hospice Ltd. Limited by Guarantee. Incorporated in England and Wales. Registered No. 1063033 Registered Charity No. 264501 Copyright ŠPTHC 2016 32
September 2016
Phyllis Tuckwell Hospice Care Waverley Lane, Farnham Surrey, GU9 8BL Tel: 01252 729400