Saint Francis Hospice. Quality Account Registered charity no CQC Provider ID

Transcription

1 Saint Francis Hospice Quality Account Registered charity no CQC Provider ID

2 Our Vision Our Values Saint Francis Hospice is committed to helping anyone in our communities who is affected by life limiting illness receive excellent person centered care when they need it and ideally in a place of their choosing. Our Mission Saint Francis Hospice is an independent charity that provides the very best in specialist care for local people with complex needs related to life-limiting illness, and inspires and educates others to support a service provided completely free of charge to patients and their families. These values underpin all that our charity aspires to do and shape our external and internal behaviour. Support Work collaboratively with all parties in the provision of services to those affected by life limiting conditions. Sharing our expertise within the wider social and healthcare provision community to ensure the best possible outcomes and service for the people who need us. Fairness To treat everyone with dignity, trust and respect. To extend the ethos of the excellent people focused care we provide to all who work with or touch our hospice. Honesty Be open and accountable, working together for the benefit of our local community, partners and our most valued resources, our people. To communicate clearly, honestly and appropriately with our communities, colleagues and partners. We will also be obsessive about continuous improvement of our care, meaning we will review objectively our capabilities and actively seek to understand the needs of our communities and partners. 2

3 Part 1: Chief Executive Officer s Statement Welcome to the fifth edition of the Quality Account produced by Saint Francis Hospice. In July 2014 the hospice celebrated thirty years of care for people affected by a life-limiting illness. This significant milestone is a testament to the hard-work and dedication of hundreds of clinical teams, fundraisers, administration staff and volunteers who have worked at Saint Francis Hospice over those years. At the beginning of the 2014/15 financial year we were heartened to receive huge support from our local community as we launched a successful appeal to help fund repairs to the roof on our inpatient unit that had been damaged during winter storms. By the end of the financial year more than 213,000 had been raised. In May 2014 we were pleased to welcome HRH Princess Alexandra to the hospice to inaugurate our new Memory Tree a hand-carved sculpture with leaves that people can sponsor and dedicate to a loved one or mark a special occasion. Thanks to the generosity of Brentwood à Becket Rotary Club we now have our own Electrocardiogram (ECG) machine that will be used by our doctors and senior nurses to monitor heart rates and rhythms. This is used before prescribing certain medications and having our own ECG machine means that we can avoid some journeys to hospital. Our aim is to always deliver the best possible care to patients, relatives and carers. We know from our own patient and carer surveys how valued our services are and we also recognise the huge challenges ahead as we work with a growing and ageing population in our service catchment area. Once again I am particularly pleased and proud of the excellent feedback received from service users. All patients and carers are given the opportunity to complete a questionnaire regarding their Saint Francis Hospice experience, and the results show 98% - 100% satisfaction across our services. However we are not complacent and in March 2015 launched an extensive consultation process as we shared our vision for our service provision over the next five years with local health professionals, community groups, service users, staff and volunteers. In addition to caring for adults affected by life limiting illness; support is given to their families and carers, both during illness and after the death of the patient. Our aim is to alleviate suffering which may be physical, emotional, social and spiritual in order to enhance the quality of life of each patient. The hospice is also an education and resource centre. This last year we began training care home staff under the aegis of the Gold Standards Framework that we believe will mean many more people in our local communities will receive care that treats everyone with dignity. This Quality Account is the product of a number of individuals and individual audits, all working towards ensuring that we meet our strategic and business plan objectives. I am pleased to present this Quality Account for 2014/15 and, to the best of my knowledge, the information it contains is accurate. Mrs Pam Court Chief Executive Officer 3

4 Part 1a: Statement of Assurance from the Board The Board of Trustees clinical and corporate governance role is fulfilled through delegated governance committees: Clinical Governance, Audit and Investment, Voluntary Income and Corporate Governance. These committees meet quarterly and are updated on work done to maintain, improve and evidence the high quality services provided to our patients, their carers, our supporters, volunteers and staff. The Board also carries out its own half-yearly informal inspection, speaking to patients, relatives, staff and volunteers. Review of Services During 2014/15 Saint Francis Hospice delivered the following specialist palliative care provision to the communities we serve in Barking & Dagenham, Havering, Redbridge, Brentwood and West Essex. Inpatient Unit Services Day Therapy Services 24/7 Community and Crisis Support Services 24/7 Specialist Contact Centre and Helpline Hospice at Home Service Education Service Physiotherapy Service Occupational Therapy Service Complementary Therapy Service Spiritual Support Service Bereavement Support Service Child Bereavement Service Family and Carer Support including welfare advice and psychological support Carer Support Services Psychotherapy Service Outpatient Clinics Community Equipment Loan Service All the data available on the quality of care provided for these services has been reviewed. The income generated by the NHS services provided over the last financial year represents approximately 28% of Saint Francis Hospice s total income. The remaining income is generated by fundraising, investments and shops activity. This year we have drafted our next five year strategy and that will deliver a clear direction for the hospice. The Board appreciates that the staff and volunteers at our hospice often go above and beyond the call of duty as they are passionate about providing excellent care and I would like to add my personal thanks and gratitude for all that they do. Dr Robert Weatherstone Chairman, Board of Trustees 4

5 Part 2: Priorities for Improvement The staff, volunteers and Trustees of Saint Francis Hospice are committed to the delivery of high quality care, i.e, care that is safe, effective and provides patients and carers with a positive experience. Here are the key quality improvement projects we are going to prioritise in 2015/2016: Patient Safety Improvement Project Priority 1: To ensure that all relevant national drug and patient safety alerts are received reliably, and within a week of issue, and that all such alerts are discussed, with a plan of action identified, developed and executed within an agreed timeframe to identified staff and in line with the requirements of the alert. Standards: That the hospice has systems for capturing and managing relevant national drug and patient safety alerts and ensuring that any necessary alert is received by the appropriate team, that learning is disseminated quickly and effectively and within the nationally recommended time frame to the right staff, and that any action (including change in practice) is identified and processes agreed and implemented securely and within the nationally recommended time frame. How was this identified as a priority? We have realised that there are several National Alert systems that currently sit outside of our current system, also that the organisational response to national alerts is highly dependent on one or two individuals, making current systems highly vulnerable. We recognise the need for development of a more comprehensive and inclusive system as soon as is possible.. How will this priority be achieved? The hospice Medicines Management Group will together review the current pathway, identify what is currently not captured by way of National Alert pathways, and develop a new pathway towards a much more robust system. How will progress be monitored and reported? Progress will be monitored and reported by the Clinical Review Group, and their summary progress report will be brought to the Clinical Governance Committee through a system of quarterly reports. 5

6 Clinical Effectiveness Improvement Project Priority 2: To be sure that our referral process is user friendly, so that any referral can be easily made and any referral received can be processed quickly, for a timely response from our hospice services. Standards: 1) Referral criteria are clearly available for anyone who wants/needs to make a referral 2) Any concerned referrer knows or can easily find out how to make a referral to the service 3) The referral process is easy for the referrer 4) The referral process ensures that accurate contact information and relevant clinical information is supplied at referral to enable the hospice to quickly prioritise for urgency and complexity and to respond usefully and in an informed way to the referer s and the individual s needs. How was this identified as a priority? An easy referrals process is critical to the hospice being able to give responsive support to people who need hospice care, also timely and useful support to their clinical teams. Most referrals will come from a patient s clinical care team: usually the GP, district, community or long term conditions team, a care home or a hospital ward, with a good amount coming from local hospital specialist palliative care teams. A few will come by other routes (see the hospice website for further guidance as to who can currently refer). We are finding that many referral forms are poorly completed, leading to delay as the hospice team explores e.g. who the patient is/where they are, and what the issues are, and how urgently support is needed and from what service. Under the current system very poorly completed forms or those that give clinical information which is out of date or too thin to give a clear clinical picture of the situation are returned to the referrer, and lead to further delays. 6

7 How will this priority be achieved? Achievement of an easier referral system is in year 1 of our Clinical Strategy. We have just set up a referrals group to work towards the above standards, fully recognising flaws in the current system. Our first step will be to involve referrers in identifying their recommended best way forward for making a referral, by asking for feedback from/ drawing on the skills and experience of local GPs, specialist palliative care partners in care and community nurse services/care homes. Ideas to be explored will include website access, choose-andbook, online and telephone referral pathways, also acceptance of self referrals, as well as the current fax referrals system. We will review - and revise as needed - our referral criteria and service descriptions, then develop referrals processes according to feedback. Alongside developments we will ensure that the criteria, service descriptions and ways to make a referral are kept updated on the website - checking at each change that text is easy for service users to understand. Prospective referrers do have referral criteria but we still receive a significant proportion of out of area or not-for-our-service referrals, which takes up much staff time as we work to navigate the referee and prospective patient to an appropriate support service. How will progress be monitored and reported? This will be one of the strategic priorities for the hospice s Clinical Strategy and as such progress reports will be presented to the Clinical Governance Committee on a quarterly basis. 7

8 Patient Experience Improvement project Priority 3: To initiate and pilot a regular hospice LINK group for people who are being discharged from the Day Therapy Unit or the Inpatient Unit who feel worried and bereft at thoughts of discharge, and who would value keeping in touch by coming back to the hospice for regular meets. We will work to run the LINK group alongside a concurrent carer support group/session so that face-to-face support can be maintained or developed for LINK Group users carers too. Standards: Patients need support in managing serious illness at many times in the illness journey and not just at times of crisis. Much of this support comes from family and friends, and the care burden for both patient and family/friend carers can be heavy. The palliative care approach has evolved in response to the need to help people suffering from advanced illness so that they can live as actively as possible through the illness, recognising that they may need physical (symptom/practical) spiritual, emotional and social support at different points in the illness journey. Our own experience, and that of the World Health Organisation, is that by working to enhance quality of life, palliative care may positively influence the course of the illness and experience of life. Our own standard is to provide advice and support for people whose care needs/challenges have outstripped generalist services, but for some there is no obvious place or service to direct people to for ongoing support. We therefore want to set up and pilot a continuing face-to-face support group link with the hospice for people living with the threat of resurgence of their disease or their issues, even when things are more settled, and to run it concurrently with carer support.. How was this identified as a priority? Our user feedback surveys and our 1:1 work with patients are identifying that people who complete their course of care under the Day Therapy Unit can feel really worried about their discharge from the service, and can feel bereft when that weekly visit to the hospice goes. There are also people who have been treated as inpatients who feel equally worried about losing face-to-face links, but who do not meet the criteria now for ongoing face-to-face support by the Day Therapy Unit or the Community visiting team. Currently we are not always able to identify partners in care who can fill the gap these patients feel. We know that there can be real benefits for people living with advanced illness from sharing experiences and companionship, and from developing self-help skills and nonprofessional networks of support, as well as from staying in touch with professional support services. We also know that for many, thinking ahead, preparing for the future and advance care planning will be an ongoing process enhanced by regular contact in more stable times, rather than contact limited to crisis only times. How will this priority be achieved? The hospice will set up and pilot a LINK Group, in the Day Therapy Unit during the course of this year, and will monitor attendance, service user feedback and influence on development of advance care planning and the identification of/achievement of preferred priorities for care. If the pilot is successful (gives positive gain to people) we would ask for commissioning support to continue this service. How will progress be monitored and reported? This will be one of the strategic priorities for the hospice s Clinical Strategy and as such progress reports will be required for the Clinical Governance Committee on a quarterly basis. 8

9 Reflection of progress from year 2014/2015 The aim of the Quality Account is to look forward and to identify and share priorities for quality improvement in the forthcoming year. It is also to review and reflect on progress with the priorities for quality improvement identified at the beginning of last year. Here follow progress reports on those priorities. All were chosen for their direct impact on the quality of care that patients and families receive either through patient safety, clinical effectiveness or patient experience. Patient Safety Improvement Project Priority 1: To ensure that all hospice staff who order and prescribe blood products, take blood samples for transfusion purposes, collect and transport blood products and administer blood products do so in line with stringent guidance recently issued by our supplier Trust (Barking, Havering and Redbridge University Hospital NHS Trust) in their response to national directives, including the Department of Health Circular HSC 2007/001, Better Blood Transfusion, the National Patient Safety Agency (NPSA) Safer Practice Notice 14, Right Patient - Right Blood and the Blood Safety and Quality Regulations (BSQR-2005). Standards: That every institution doing blood transfusions should have an assurance framework for blood transfusion which includes stipulations for blood product safety to meet all the requirements set by the national agencies named above. Summary of Actions: The blood transfusion policy has been revised and updated along with current guidelines and BHRUT guidelines. A competency framework has been developed and depending on which part of the blood transfusion journey (taking blood, or collecting/delivering blood or prescribing blood or administering blood) a different competency has been developed. New documentation has also been introduced to improve practice and patient safety. All current staff and volunteers have now attended training sessions and undertaken competency assessments. These assessments are valid for 3 years and then they will undertake refresher training and redo their competency assessments. All new staff who are involved in any aspect of blood transfusion now undergo assessment either as part of their induction (doctors) or at the next available transfusion competency day. Ongoing training assessments and policy updates will be undertaken as needed by the hospice Practice Development Nurse and one of the hospice nurse Lecturers in Palliative Care. All feel much more secure in clinical practice and we feel proud to have achieved all of the above this year so that new skills and competencies absolutely meet with national standards and will be skills/competencies reviewed/sustained on an ongoing basis. 9

10 Clincal Effectiveness Improvement Project Priority 2: To enhance identification of low mood/depression in our patients, and the sharing of ongoing supportive care plans for low mood/depression to partners in care. Standards: Depression is common in palliative care prevalence estimate is that around 15% meet the criteria for a major depressive disorder, with many more patients having depressive symptoms. This compounds the physical consequences of advanced disease. It has been established that cases of depression in palliative care are often missed. We identified the need to raise the profile of low mood (it s prevalence, it s burden and the effectiveness of holistic care in better supporting patients with low mood) with our staff, and the need to develop systems to better share important information concerning low mood and a supportive care plan with external partners in care. Summary of Actions: After running an audit of our inpatient notes (in November 2012) on identification/assessment and management of depression we were left concerned that our noting of mood and anxiety was very low for inpatient unit admission, ongoing care and discharge. We were concerned; were we missing depression? Were we helping enough? We agreed 2 new support prompts to raise the profile of low mood as a common challenge for people with advanced disease and symptom challenges. 1) We introduced an expansion to our symptom assessment tool, the Support Team Assessment Schedule (STAS), to include a STAS prompt for mood/depression, and, 2) We revised our discharge summary template to prompt for broader issues than symptoms, such as mood,and coping/support for both family and carers. This extended tool to flag a problem area has really been embraced by staff. When we did a repeat audit of inpatient stays (an audit of referral forms and admission assessment/inpatient stays for hospice inpatient admission in Nov 2014) we could clearly see that low mood is often one of the key challenges for people needing an inpatient bed for care. As a comparison: In our 2012 audit (with no tool) 62% had mood mentioned as a concern pre admission but only 20% had mood identified as a concern on admission. It was often very unclear what was meant by mood and what care was given around mood during the stay. This year, in the repeat notes audit (Nov 14) we found that the new tool was well used: the difference now was that around 40% of patients were recognised as having significant struggles with low mood or anxiety on admission, and between 31 and 42 % of carers had the same issue A continued attention to low mood (and anxiety) was now much more evident in the notes of the patients time on the inpatient unit. 10

11 Patient Experience improvement Project Priority 3: To gain feedback on our patients experience of psychological services to know how effective our services are. Standard: We have a psychological service and it improves the care of our patients. Summary of Actions: Our hospice bereavement counselling team adopted the London Cancer Tool to record and evaluate the bereavement counselling services offered by the Hospice. It was sent to bereavement counselling clients at the end of their work along with the hospice bereavement service s own evaluation form. In the financial year to date we have had 183 counselling clients finish their work with the bereavement service: of those unfortunately only 18% responded to our evaluations. However even the 18% has given us really useful information that we did not have previously. Of those who responded 70% said that their experience of the psychology services they had was very helpful, with a further 21% saying that their experience was helpful. One recorded that the support had made no difference (3%), commenting: I realised during my counselling sessions at SFH that I had no need for them as I had had my therapy previously with my friends. I left the SFH of my own volition... (Two correspondents did not answer the question (6%). A more generic bereavement service evaluation form asked: How helpful was your counselling? 76% of respondents recorded very helpful, 33% recorded helpful. One respondent recorded that the bereavement counselling was unhelpful, but then went on to record that... the counsellor was very good to me. Talk about my husband, who passed away last year, helped so much. And one respondent indicated that the counselling was very unhelpful. They went on to record that... the counselling was not right for me at this time. However when asked how did you feel before counselling and how did you feel after counselling the respondent indicated that they had been not good at all pre-counselling, but after counselling had been good. This data shows us the importance of clinical data. We can use it to reassure ourselves of services that we find have offered much support/make a difference (as we would hope). We also need it to identify services that may not be doing what we need them to do and to identify ways we can improve our services and our reach. Services which give much support we would want to grow and develop of course, to reach and support all who might value it and benefit from it. We are due to provide an end of year report to the Clinical Governance Committee, which will give fuller details of both service evaluation forms for the bereavement counselling service and will discuss a plan for ongoing/sustainable service evaluation for the hospice bereavement counselling services. 11

12 The following are a series of statements that all providers must include in their Quality Account. 2a. Participation in Clinical Audits As a voluntary sector organisation Saint Francis Hospice is unable to participate in NHS led national clinical audits and national confidential enquiries. However clinical audit is high on our priority list. We recognise that for our services to keep up with best clinical practice, and to develop in quality and reach to support people with an increasingly wide and more complex range of life limiting conditions we need to be constantly evaluating our practice against the best standards possible. We have an active hospice clinical audit/service improvement programme. The local clinical audits that were reviewed in 2014/15 are listed in section 3c, along with the outcomes from each audit in terms of working to improve on the quality of care we deliver. We also run a rolling programme of audit against nationally recognised excellence standards which have been researched and developed by Hospice UK (a national charity). Hospice UK has developed supporting audit tools to enable specialist palliative care services such as ours to benchmark against best standards of excellence for a large range of health, safety and care delivery standards. In this last year we have conducted audits using these tools, on infection control, end of life care, the role of the Accountable Officer, the workings of the controlled and the standard drugs pathway, inpatient admission assessment and multi-disciplinary care review. Many of the hospice s national tools audits have been included into a rolling three year programme of presentations which have been incorporated into the mandatory training programme for clinical staff, so that results and learning and practice development can be widely owned and disseminated. (See section 3c for a full list of rolling audits achieved). The Hospice also submits annual service delivery data to another national charity, the National Council of Palliative Care, who have developed a national Minimum Data Set for specialist palliative care services. This allows us to compare our service throughput with hospices and hospice services of similar size, and with other local specialist palliative care services. See on to section 3a for our activity data for against national averages for similar services. Some service user data has now been incorporated into new Key Performance Indicators for the hospice Board of Trustees (referrals taken on to care and inpatient unit bed use). We have also included service user feedback (from patients who used any of our services, and from bereaved carers) concerning their experience of a hospice, including its responsiveness to their need. 2b. Research The hospice has active links with London South Bank University and Anglia Ruskin University, also with the Marie Curie Research Institute, and has nurtured a small Research Group which has been exploring the hospice contribution to research projects in the future, and which has secured a clinical research leaflet and pathway to support research ideas to development. Local or regional/multicentre Ethics Committee approval forms part of the clinical research pathway. One research project is under way. 2c. Use of the CQUIN Payment Framework Saint Francis Hospice income during 2014/15 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework because it is a third sector organisation and as such was not eligible to participate in this scheme during the reporting period. 12

13 2d. Statement from the Care Quality Commission Saint Francis Hospice is required to register with the Care Quality Commission and is currently registered for Treatment of Disease, Disorder or Injury and Diagnostic and Screening procedures. Saint Francis Hospice has the following conditions on registration: The service may only be provided for persons aged 17 years or over A maximum of 19 patients may be accommodated overnight Notification in writing must be provided to the Care Quality Commission at least one month prior to providing treatment or services not detailed in our Statement of Purpose The last Care Quality Commission periodic review of Saint Francis Hospice was in October Following that review the hospice was assessed as fully compliant with all CQC national standards. No further actions were required. Saint Francis Hospice has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period. We have recognised and prepared for the new way CQC are inspecting Hospices and are ensuring we are compliant with the new fundamental standards issued April This year Saint Francis Hospice has made a number of changes in relation to CQC requirements and has made changes to the statement of purpose and also to their Accountable People - Responsible Individual -Pam Court (CEO) and Registered Manager - Tes Smith ( Director of Quality and Care). 2e. Data Quality Saint Francis Hospice does have its own system for monitoring the quality of data which is kept in the clinical information system, icare. This is important because, with the patients consent, we share data with other health professionals to support the care of patients in the community. icare is also used to provide activity information to our commissioners and in the on-going development of services. 2f. Information Governance Toolkit Attainment Levels Saint Francis Hospice has maintained the Information Governance Toolkit level for 2015/16. 2g. Clinical Coding Error Rate Saint Francis Hospice was not subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission. 13

14 Part 3: Review of Quality Performance 3a. Activity Data Annual Saint Francis Hospice statistics Overall Service 2014/ / / / /11 Patients cared for by the Hospice % Patients cared for with non cancer diagnosis % Patients cared for with cancer diagnosis In-Patient Unit Services 26.4% 21.5% 16.5% 14.6% 13.2% 73.6% 78.5% 83.5% 85.4% 86.8% Total number of admissions National Median 2013/14* Total number of patients admitted % New patients 93.7% 93.5% 91.1% 95.9% 93.8% 89.6% % occupancy 80% 83.8% 80.5% 80% 88% 80.3% Diagnosis % Patients with a non cancer diagnosis 14% 13.2% 7.8% 6.8% 6.8% 13.2% % Patients with a cancer diagnosis 86% 86.8% 92.2% 93.2% 93.2% 86.8% Outcome of In-Patient Stays ending % Died 68.3% 69% 71% 72.3% 71.4% 60.7% % Discharged to home (including care home) 31.2% 29.4% 27.8% 26.6% 28.3% % Discharged to an acute hospital 0.6% 1.6% 1.2% 0.8% 0.3% % Discharged to another setting 0% 0% 0% 0.3% 0% Average length of stay 14.4 days 13.7 days 12.8 days 12.5 days 14.3 days 14.5 Day Therapy Services Total number of patients % New patients 71.5% 80.4% 66.1% 72.2% 66.9% 66.7% Specialist Community & Crisis Support Service Total number of patients supported % New patients 77.2% 77.9% 72.4% 74.1% 74.5% 70.6% % Patients with a non cancer diagnosis 23.2% 20.7% 16.2% 14.5% 12.9% % Patients with a cancer diagnosis 76.8% 79.3% 83.8% 85.5% 87.1% Number of face to face consultations with patient or relative/carer Number of face to face or telephone consultations with a health professional Average length of care (days)

15 Annual Saint Francis Hospice statistics Hospice at Home 2014/ / / / /11 National Median 2013/14* Total number of patients looked after % New patients 96.2% 94.5% 94.5% 95.9% 95.8% 89.3% % Patients with a non cancer diagnosis 27.9% 19% 16.3% 14.7% 9.3% % patients with a cancer diagnosis 72.1% 81% 83.7% 85.3% 90.7% Total number of visits ,486 2,609 2,579 2,694 Total hours of care during visits % Patients who died at home (including care homes) 99.4% 99.4% 98% 98.1% 97.9% 83.7% Average length of care (days) Bereavement Service Total number of clients: Adult Children Total Number of support/counselling telephone or face to face consultations (including health professionals) Specialist Multidisciplinary Support Services Number of face to face consultations with patient or relative/ carer by service: Chaplaincy/spiritual support Complementary therapy Family services (excluding bereavement) Occupational therapy Occupational Therapy equipment Physiotherapy The figures above provide information on the activity and outcomes of care for patients. *From the National Council for Palliative Care Minimum Data Sets. 15

16 Activity Data: Education During the Pepperell Education Centre has been extremely busy delivering a comprehensive programme of training and development for both our own staff and for external visitors. The education team also ensure that internal staff receive the necessary mandatory training to keep staff, patients and visitors safe. Below are some of our highlights for the year:- Study days - The Education Centre delivered over 40 study days last year and welcomed over 520 delegates to our events. Topics included Communication Skills, Symptom Management, Grief & Bereavement and other issues around End of Life Care. In addition we deliver study days to cover all the Mandatory Training required for our staff such as Health & Safety and Fire training as well as professional development training. London South Bank University - The Education Centre works in partnership with the university to deliver three degree modules on Symptom Management, Dementia and Non Malignant Conditions. We welcome health care professionals from various backgrounds such as community, hospital and hospice settings to attend as part of their degree pathway. Gold Standards Framework (GSF) Training - We are a regional training centre for GSF which is a training programme and are currently supporting around 75 care homes through the programme and also 28 Domiciliary Care agencies. This programme enables generalist frontline staff to provide a gold standard of care for people nearing the end of life. I found all the workshops to be very helpful. They were always concise and clear with enough time to go through everything. The course has been very informative and it is encouraging to see GSF starting to show within our home Advanced Communication Skills We have delivered several courses on advanced communication skills to doctors, nurses and other health care professionals. This is an intensive two day course which has been evidenced to improve confidence in practioners in managing complex conversations. Qualification Credit Framework (QCF) We are now able to offer a course in End of Life Care for Health Care Assistants which is accredited by City & Guilds. This was evaluated very well by the participants:- Meeting new people and getting to know their difference, experience and learning how we can look after people loved the course I am more confident on the subject matter Brilliant course material and knowledgeable approachable trainers lovely ladies! A very enjoyable training experience. 2014/ / / / /11 Education Service Total numbers attending training - Hospice staff Total numbers attending training - external 1,309 1,127 1, ,135 1,368 1,077 1,562 1,278 16

17 3b. Other Quality Indicators What people say about our organisation Feedback is essential for us to be clear we continue to deliver to the highest of standards. One measure we use is Questionnaires which have been updated and continue to be given to those discharged from the Inpatient unit, to current Community and Day Therapy patients and to carers two months after bereavement. This year we have encompassed the Friends and Family Test. This process gives us excellent constructive feedback on how we met the needs of individuals and carers at this time. We continue to hear that the opportunity to give feedback by way of a questionnaire is appreciated. During a total of 341 questionnaires were returned. I was glad to have the opportunity to give our feedback to an organisation that has helped us so very much. Source: Carers questionnaire 2014/15 My father was in the best place as his last weeks of life were difficult but I received specialist support from amazing telephone staff and community support in my time of need. I was not made to feel guilty for asking for support in the end it helped me to have special time without all the resulting stress. There was never anything negative about the service. Source: Carers questionnaires 2014/15 I can t sing your praises enough. I have been overwhelmed with the support and advice that I have received from all your staff. You cover everything and having a voice at the other end of the phone makes all the difference. Source: Specialist Community & Crisis Support questionnaire 2014/

18 100% of IPU, Community & Day Therapy service users said adequate written information was available. 100% of IPU, Community & Day Therapy service users said they had no concerns about being discriminated against. 98% of IPU, Community & Day Therapy service users and Carers agreed or strongly agreed that were given time to ask questions/voice concerns (334 of 341). 6 people (20%) were not aware that they could have a snack after evening meals and before breakfast. 6 people (20%) were not aware they could have a light meal between meal times. I think more food should be offered for those that need it and more at tea time other than a sandwich or eggs on toast. Source: Inpatient Unit Questionnaire 2014/15 Action taken: The Nutrition and Oral Care Group have been working with the hospice s caterers to improve meal options and to provide menu cards for all patients which will inform them on the reverse that snack options are available throughout the day. In addition, the prep room will be redesigned to ensure that it is a designated area for the preparation of food and drinks for patients. A new fridge-freezer, toaster and microwave will be purchased to increase the range of snacks available for out of hours and all nursing staff will have access to the prep room any time of the day or night. 18

19 I made about 5 phone calls. 4 were very good, one was not. I was told I was being transferred but that person could not answer me and transferred me to another extension that did not answer. I got fed up and hung up my phone. Source: Specialist Community & Crisis Support questionnaire 2014/15) Action taken: We evaluated the process and identified that a single CNS on the Specialist Advice line could not manage the volume of calls into the service so have increased daily Monday to Friday of 2 CNSs on the phone for incoming calls. There are organisational plans underway to update the phone system to increase line capacity. The following information indicates how we have performed during Complaints INDICATOR 2014/2015 Total number of complaints received 3 Number of complaints upheld in full 0 Number of complaints upheld in part 3 Patient Safety Incidents Number of patient safety incidents (excluding falls) Number of slips/trips/falls 29 Number of Serious Untoward Incidents (SUIs) Infection Prevention and Control Number of patients known to be infected with MRSA on admission to In-patient unit Number of patients infected with MRSA whilst on the In-patient unit Number of patients admitted to the Inpatient unit with C. Difficile Number of patients infected with C. difficile whilst in the In-patient unit

20 3c. Clinical Audit Programme The clinical audit group meets bi-monthly and, under the guidance of the Clinical Governance Committee, oversees local clinical audits (with standards locally or nationally set and where possible evidence based). The annual quality audit committee meets bi-annually and, under the guidance of the Clinical Governance Committee, oversees all annual rolling audits, a number of which are developed by Hospice UK and are cross referenced to the Care Quality Commission s outcome measures. Within the previous twelve months, the Clinical Audit Group and Annual Quality Audit committee have overseen a combined total of fourteen audits. Five of these were developed by Hospice UK. An audit notice board is maintained providing information on presentations and news about audits. In addition an audit update is published annually in the staff newsletter and an annual report provided to the Clinical Governance Committee. The overall aim is to help foster a culture that continuously encourages the merits and value of audit in the clinical setting. The following audits were completed during 2014/2015 CLINICAL AUDITS An evaluation of the breath-taking group An audit of the How, When & Why of our Non-malignant Respiratory Disease Referrals Gold Standards Framework Progress so far How do we know counselling works? Hospice at Home referrals A retrospective audit of hospice to hospital transfers An audit to look at the use and compliance of subcutaneous medication advice sheets one year after implementation ANNUAL QUALITY AUDITS Saint Francis Hospice Resuscitation Policy Learning Disability audit Hospice UK self assessment Accountable Officer Hospice UK Day Care admissions Hospice UK general medicines Hospice UK controlled drugs Hospice UK bereavement support audit Hospice UK IPU admissions audit Hospice UK Community admission - visiting Hospice UK Community admission telephone support Hospice UK Community ongoing support Hospice UK pain management Hospice UK pre-bereavement Hospice UK Infection prevention IPU Hospice UK Infection Prevention Day Therapy Progress on the action plans are monitored via the Clinical Audit Group or Annual Quality Audit Committee to ensure all actions are completed. Some of the above are repeat audits which look to embed/sustain positive practice change. 20

21 Statement from the Overview and Scrutiny Committees A copy of this Quality Account was sent to the Overview and Scrutiny Committees of: Brentwood Borough Council, the London Borough of Havering, the London Borough of Redbridge and the London Borough of Barking and Dagenham. We received the following response from the Health & Wellbeing Overview and Scrutiny Committee 2015, Thurrock Council: Thanks for the information. As you know, this is my first time in the chair of the Health and Wellbeing O&S Committee so I have a lot to take in and get up to speed on. I have read through the Annual Quality Account and it seems to be a very thorough and encouraging piece of work. It shows that, in terms of identifying issues and adopting measures to resolve them, the Hospice is on the ball and I am particularly encouraged by the amount of training undertaken to keep everybody up to date. I would like to see some more, in depth, patient feedback, though I appreciate that you are not totally in control of that. I also noticed that the amount of occupational therapy has dropped off consistently over the years, is there a particular reason? * Regards Cllr Graham Snell, Chairman, Health & Wellbeing Overview and Scrutiny Committee Thurrock Council *Saint Francis Hospice is currently looking at our Occupational Therapy and Community Services. Statement from NHS Commissioners/Quality Account Leads A copy of this Quality Account was sent to the Clinical Commissioning Groups of Barking & Dagenham, Havering & Redbridge, Basildon & Brentwood, Thurrock and West Essex. We received the following response from Barking & Dagenham, Havering and Redbridge CCG. Saint Francis Hospice is an essential part of BHR CCGs End of Life Care service delivery for patients in the Boroughs of Barking & Dagenham, Havering and Redbridge. The hospice provides high quality in-patient services, specialist community & crisis services, hospice at home as well as a number of other patient and family support services. In addition the hospice has provided Gold Standard Framework training in end of life care for care homes. This has contributed to a reduction in hospital admissions for patients living in care/nursing homes in Havering. The hospice works with BHR CCGs as a member of their End of Life Steering Groups, supporting the delivery and development of high quality end of life care in the boroughs. 21

22 We received the following response from Basildon & Brentwood CCG:

23 Statement from Healthwatch A copy of this Quality Account was sent to the Healthwatch Managers of Havering, Barking & Dagenham, Redbridge and Essex. We received the following response from Healthwatch Havering: Healthwatch Havering endorses this Quality report. We are pleased to be working with the Hospice on securing improved End of Life Care in residential care, nursing home and hospital settings and with initiatives such as Dying Matters Week. The Hospice has made our representative at their Governance Committee welcome. We look forward to even more co-working in future. Kind regards Ian Buckmaster, MA FCIS Executive Director & Company Secretary We received the following response from Healthwatch Essex: Healthwatch Essex is an independent voice for the people of Essex, helping to shape and improve local health and social care services. We believe that people who use health and social care services and their lived experience should be at the heart of the NHS and social care services. Although we have not undertaken any specific work with Saint Francis Hospice over the past year, from our reading of the Quality Account we are pleased to note that Saint Francis Hospice actively engages service users and families about the services they receive. In addition, the Hospice receives praise from service users and their families for the high quality services and invaluable support it provides. Saint Francis Hospice uses questionnaires as a way of capturing feedback, from those discharged from the inpatient unit, Community and Day therapy patients, and carers of people after bereavement. The improvement priorities in , included gathering patients experience of psychological services. To understand how effective the bereavement and counselling service is, the Hospice has been gathering feedback. Despite having a response rate of 18%, the feedback suggests the majority of people find the psychology services beneficial. Additionally, in March the Hospice launched a consultation looking at service provision over the next 5 years. In the priorities for the coming year, Saint Francis Hospice is looking to improve the experience of people who have completed a course of care at Day Therapy Unit and are worried about being discharged. To provide ongoing support, the Hospice will pilot a LINK Group which will allow these people to maintain regular contact and support. Healthwatch Essex believes that lived experience should be at the heart of services, and believes that listening to the voice and lived experience of patients, service users, carers, and the wider population, is a vital component of providing good quality care. We are pleased to acknowledge the work Saint Francis Hospice undertakes in this regard. Sarah Haines Information and Policy Officer Healthwatch Essex

24 Contact us Saint Francis Hospice The Hall Broxhill Road Havering-Atte-Bower Romford Essex RM4 1QH If you would like to know more about our services and what we can do for you, please contact us by telephone on or visit If you would like to know more about volunteering or fundraising for Saint Francis Hospice, please visit our website at Thank you. Tel: Web: saintfrancishospice