ACORNS CHILDREN S HOSPICE TRUST QUALITY ACCOUNTS

Transcription

1 ACORNS CHILDREN S HOSPICE TRUST QUALITY ACCOUNTS Page 1 of 41

2 Table of Contents Page Number Part one Statement from the Chief Executive 3 Enduring Principles 4 Part 2 Priorities for improvement and Statements of Assurance from the Board 6 Priority areas for Quality Improvement for Review of Quality Improvement Areas for Mandated Statements Statements of Assurance from the Board 11 Safeguarding 13 Participation in National Audits 16 Research 16 Quality Improvement and Innovation Goals agreed with Commissioners 17 What others say about us 18 Data Quality 22 Clinical Coding Error Rate 22 Part 3 Review of Quality Performance 23 The views of Acorns service users 30 Closing statement from Acorn s Director of Care Services 41 Page 2 of 41

3 Part 1: CHIEF EXECUTIVE STATEMENT Acorns Quality Accounts is intended to provide service users, the public and those organisations that support us financially, including the NHS, with information on the quality of the services we deliver. This account will demonstrate how we assess the quality of those services and ensure evidence based quality improvement on an on-going basis. The Quality Accounts have the dual function of looking both backwards and forwards. The narrative of the Quality Accounts will explain Acorns commitment to review its services and this then influences the priorities for further quality improvement. Acorns has provided specialist palliative care and support to children and their families since We welcome the opportunity to demonstrate the work of our dedicated and skilled workforce (including volunteers), the systems we have developed over more than a quarter of a century and to share our future priorities. Acorns Director of Care Services was responsible for the preparation of this report and its contents bringing together the information systems actively used across the Charity to measure and review quality. To the best of my knowledge, the information in the Quality Accounts is an accurate and fair representation of the quality of health care services provided by Acorns Children s Hospices. Quality is continually addressed at Executive level through the Care Governance Group and at Board Level through the Care Assurance Committee; they both meet on a quarterly basis to ensure a robust and rigorous review of quality and the monitoring of performance. Underpinning all our work at Acorns are Vision, Mission and Values statements which are further guided by our enduring principles. They are respectively as follows: VISION Every child and young person living in our region that is life limited or life threatened and their families should receive the specialist care and support they need. MISSON Page 3 of 41

4 To provide holistic, specialist, palliative care services to children, young people and their families. We will deliver these services in partnership with others wherever possible, championing the cause of palliative care for children and young people. VALUES Acorns is a caring, responsive and innovative charity, putting children and young people and their families first in all our services, while embracing the diversity of our regional communities, demonstrating professionalism, integrity and quality in all we do. ENDURING PRINCIPLES Staying focused on our vision, mission and values to provide an on-going sense of direction for our Strategy; Living within our means, especially by controlling our fixed costs; Ensuring our voice is heeded wherever the cause of palliative care for children and young people needs to be championed; Working in partnership with NHS and local authority commissioners and providers, other charities and like-minded private sector organisations; and, Maximising sustainable statutory, retail and lottery funding, while maintaining a robust fundraising portfolio and sufficient operational reserve. The children and their families are central to all we do at Acorns. Ensuring our services are responsive to needs has been the driving motivation of Acorns for 27 years. In order to support the child and his or her family Acorns allocates a family support professional for every family who will listen to the views of each and every individual family member. This ensures that the support is personalised and unique to the person concerned. Over the last 27 years we have more than trebled the number of children and families we have been able to support developing from one hospice with a family support team supporting families in the community in 1988 to our current three hospices, three family support teams and a hospice at home team of nursing care staff providing outreach care in families homes. We have achieved this while continuing to improve the quality of service and responding to children and their families in relation to their changing needs over the last three decades. Page 4 of 41

5 It is our intention to continue to increase and expand our services by offering a clinical outreach service and a comprehensive home volunteering service to support additional children and families; we will continue to work closely with all our service users and wider stakeholders to ensure this is achieved whilst maintaining the highest quality standards in care. David Strudley Chief Executive Page 5 of 41

6 PART 2: PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF ASSURANCE FROM THE BOARD The Board s strategic plan for Acorns, Realising the Vision , identified key priorities for the development of services for the next 5 years was the enabling year; we used this opportunity to ensure we had the workforce and systems in place to achieve our priorities. Quality is integral to any growth in, and development of, services. In we added additional resources and implemented the Acorns Integrated Care Model which involved the appointment of outreach nurse leads to support the development of clinical support being offered to children in home and hospital. The out-reach nurses have this year worked with colleagues from the hospice who know the children and families. We also appointed volunteer co-ordinators who have this year developed community out-reach volunteers supporting children and their families in the community. This year ( ) we are in our third year of implementing the vision strategy and continue to work towards achieving our offer of care to at least 1,000 children and young people a year by the end of the decade. There are sound and robust systems across Acorns that ensure safe high quality care. Acorns has a Standing Operating Procedures in response to the Implementation of Controlled Drugs (Supervision on Management and Use) Regulations Acorns has an established Care Governance Group which internally regulates and quality assures all work across its hospices. A Care Assurance Committee (comprising members from the Board of Trustees) meets quarterly with the Director of Care to rigorously monitor service delivery and quality of care services. There are also systems across the Trust which monitor and internally regulate Information Governance and ensure compliance under the Data Protection Act 1998 and the Human Rights Act Acorns is registered with the Care Quality Commission (CQC) which exercises external governance that must be met in order for Acorns to operate its services. Page 6 of 41

7 PRIORITY AREAS FOR QUALITY IMPROVEMENT FOR Following consultation with the care managers and hospice leaders and using feedback from service users, Acorns identified the following three priority areas for quality improvement in Quality Improvement Area 1 Real Time Reporting Service user feedback is integral to ensuring Acorns services are effective and responsive to children and their family s needs. Acorns have used annual and biennial satisfaction surveys and service user involvement to ensure our services are providing the appropriate level and standards of care. Real Time Reporting supports an interactive and timely feedback from parents and children using the service, by utilising technology and software which enables monthly summaries of service users views. The managers can then respond to any concerns or requests promptly. This will be achieved by: Identifying Real Time Reporting Champions at each hospice who will promote and support this project with service users. Reviewing questions every quarter to monitor targeted areas of hospice services. Outcomes from Real Time Reporting will be shared at the Acorns Research and Development Group with outcomes and responses being available to families via the family newsletter and the internet and to commissioners via the impact report. Page 7 of 41

8 Quality Improvement Area 2 Face to Face Service This is a new service providing parent to parent support for families with children with Palliative Care needs. The service will provide support at all stages of the palliative journey from diagnosis to bereavement, empowering parents to make decisions and choices at each stage including end of life. This will be achieved by: Recruiting parents with the time and skill sets to become befrienders Providing accredited training for all befrienders Outcomes will be evaluated by Acorns Lead Nurse for Governance & Quality Befriender s will receive ongoing support from Acorns Volunteer Co-ordinators. Quality Improvement Area 3 Expert by Experience The Care Quality Commission (CQC) have recruited Experts by Experience to be part of CQC inspection teams when undertaking unannounced visits to care providers. Acorns senior care management undertake compliance visits across the hospices to monitor quality. Acorns will recruit parents who use or have used the service to work alongside the senior managers on these compliance visits as an additional mechanism and perspective for quality assurance. This will be achieved by:- Page 8 of 41

9 Recruiting and briefing parents who have the time and skills for this role. Undertaking a compliance visit at each of the hospices with an Expert by Experience as a member of the Acorns inspection team. Producing a report on the compliance visit findings and submitting to Acorns Board of Trustees and CQC. Feeding back to CQC the learning of using Experts by Experience in a children s palliative care setting. REVIEW OF QUALITY IMPROVEMENT AREAS FOR Quality Improvement Area 1 Equality Impact Assessments (EIA) Public sector organisations are required to consider all legislated equality groups as part of their EIA to ensure their compliance with their duties as a public body. Acorns is not a public body, however under best practice, particularly with regard to the Equality Act 2010 and the Together for Short Lives Diversity Toolkit, undertaking EIA was considered to be evidence of our commitment to diversity for commissioning purposes, when public bodies are purchasing our services, and for Care Quality Commission inspections. What we did: Acorns devised and implemented an initial Impact Assessment screening template, the organisational panel has undertaken an EIA for every care policy reviewed and or developed this year. What the outcome was: Care policies have an Equality Impact Assessment where appropriate. This provides Page 9 of 41

10 another governance measure to ensure Acorns services and practices are none discriminatory and proactively support the equality of assess of services for all. Quality Improvement Area 2 Standardising End of Life (EoL) Referral Processes The aim was to ensure Acorns services offered a consistent and immediate response to all EoL referrals and requests from the West Midlands area. What we did: Guidance for the Acorns staff was developed to support the implication of this practice. The changes to process were further embedded in the form of workshop discussion sessions at staff meetings. A new EoL referral form was developed and used across all the hospices when a referral is made. What the outcomes was: When a child is now referred the new system ensures that all the required information is obtained and all the appropriate professionals in Acorns and partner organisations are involved in the decision and planning process, thus ensuring a more responsive and effective service at a time of crisis. Area 3 Environment Area 3 As a result of securing funding from the Department of Health Capital Appeals Bid we fitted out the new buildings and extensions for the three hospices. This improved facilities Acorns is able to offer to families primarily via complimentary and Page 10 of 41

11 therapeutic services. We intended to provide complementary service for an increase of a minimum 50 children and families across the region. What we did: 1. Acorns re-modelled the therapeutic rooms. 2. The referral processes were refined to promote increased use of complimentary and therapeutic services. What the outcomes was: Over 84% of people who accessed the therapeutic service/ sessions reported they had immediate improvements following a complimentary therapy session which resulted in 98% stating they would recommend this service for families and friends. STATEMENTS OF ASSURANCE FROM THE BOARD The following are statements that all providers must include in their Quality Account. Many of these statements are not directly applicable to specialist palliative care providers, and therefore explanations of what these statements mean are also given. Review of services During the hospice provided the following services to the NHS: Acorns hospices Acorns has three ten bedded hospices strategically located across the West Midlands: Walsall for the Black Country; Selly Oak for Birmingham and Warwickshire; and, Worcester for the Three Counties of Worcestershire, Gloucestershire and Herefordshire. All of the hospices include separate accommodation for families to stay with their children, if they desire, and each is specifically designed to create a home from home environment and atmosphere suitable for the care of children and young people with a diverse range of needs. The hospices provide skilled paediatric palliative nursing care offering the following services: planned short break/ respite care and support; emergency short break support; Page 11 of 41

12 end of life care; day care; pain and symptom control; medical support; hydrotherapy, physiotherapy and complementary therapies; access to interpreters; and, Outreach clinical care. Acorns family support services provided in the community and across our hospices Acorns also delivers care and support services to children and young people and their families, in the community, including: support to access End of Life Care services, including access to management of pain symptoms and the provision of psychological, social, spiritual and practical support; support and advice provided on a 24 hour phone basis via the hospice medical and nursing teams; family support team of professionals who provide support on a 24 hour basis by phone and/or home visits; access to physiotherapy; advocacy - the Acorns family support team and the hospice workers work closely with primary health care teams and the acute hospital teams as appropriate. pre and post bereavement support by registered/experienced professionals; sibling support by trained staff; home volunteers, offering support and befriending; a variety of support groups for parents, carers and grandparents; advisory resources to families and professionals; access to interpreters; preparation of young people for adulthood with trained youth workers; enable young people to transition to adult services supported by registered professionals; and, Face to Face service; with parents trained as befrienders supporting other parents for time limited period. Acorns Hospice at Home Services Page 12 of 41

13 Acorns offers hospice at home services based on the same holistic principle and incorporating all the services above, tailored to individual needs and delivered in the home. Such services are currently provided in specific geographical areas under contract to a local statutory body. Reporting processes Acorns reviews all the data available on the quality of care in all its care services. In addition to the Care Governance Group and Trustee Care Assurance Committee quarterly reports, the Director of Care and Head of Care Services undertake a minimum of 3 annual unannounced visits to all sites to measure and monitor quality in service delivery. All incidents are reviewed monthly by the Director of Care and reported to the Board directly as necessary. Acorns also work closely with service users through the established Parent Champions, and Young Ambassador and the newly formed Sibling Council. All services delivered by the Hospice are funded through a combination of fundraising activity and contracts with NHS. The NHS contracts mean that all services delivered by the hospice are part funded by the NHS. Where NHS funding is secured this contributes up-to 30% of the costs of care of children. Therefore 70% of all care costs are funded by charitable funds. We also benefit from having teams of skilled and trained care volunteers (over 400) who support non personal care work across the region. SAFEGUARDING Acorns Children s Hospice Trust wants a world in which children with life limiting and life threatening conditions have the same rights and opportunities as everyone else. This includes the rights of all children and young people to be safeguarded and protected from all forms of abuse and neglect. Acorns are committed to maintaining a safe environment for all the children. Acorns has a thorough and transparent child protection policy to afford all children who receive their services maximum safeguards. Acorns conforms to the requirements of safeguarding as referred to in the Prevent Strategy (HM Gov 2011) and to the requirements of the Role of Accountable Emergency Officers for Emergency Preparedness, Resilience and Response (EPRR) (NHS Operations 2012). Statement of Intent Acorns recognises that in protecting and safeguarding children, it is also providing a framework for all staff which identifies and promotes best practice and minimises uncertainty Page 13 of 41

14 for staff and volunteers working with children. Acorns has a robust policy which is designed to: Protect children Children should be assured of good standards of care and protection from all Acorns staff, volunteers and representatives. Protect Acorns Staff and Volunteers By following the guidelines and procedures everyone working within Acorns should be able to avoid inappropriate, misguided or wrong behaviour and know what to do if they are concerned about a child s welfare. Protect Acorns The policy forms part of Acorns commitment to best practice, promotes the organisation s integrity and ensures compliance with the Independent Health Care Minimum Standards and Regulations on Private Health Care. The effective implementation of Acorns approach to child protection is based on and reflects the principles recognised in UK legislation and in International Agreements, namely that: The welfare and protection of children is paramount whatever the circumstances. All children and young people, regardless of age, disability, gender, racial heritage, religious belief and sexual orientation or identity, have the right to protection from all types of harm and abuse. Recognition of the importance of working in partnership with parents, carers and other agencies including those of diverse communities. Safeguarding children is EVERYBODY S responsibility; the following reinforces the specific expectations of Acorns for the staff groups. All care team staff are responsible for ensuring: They are familiar with all relevant internal policies, safeguarding and child protection procedures, safeguarding guidance, documentation and access available training regarding safeguarding of children and young people from Acorns. They contribute in a case conference or strategy meeting regarding safeguarding issues relating to a child or young person. The Care Management Team are responsible for: Ensuring all staff and volunteers receive the appropriate levels of safeguarding training. (Every 2 years). Staff supervision and support is provided in accordance with the Acorns Safeguarding Supervision Policy. Page 14 of 41

15 Ensuring that the safeguarding child protection policy, procedures and guidance are accessible for all care teams. Acting in accordance to Acorns procedure when alerted to any safeguarding concerns; reporting to statutory services and informing Acorns designated Safeguarding Officer. Acorns Designated Safeguarding Officer (Acorns Director of Care Services) is responsible for: Maintaining overall responsibility for the review of the Safeguarding and Child Protection Policy and Procedures and Guidance for Acorns Children's Hospice. Chairing the Safeguarding Steering Group which monitors and reviews all safeguarding issues across the organisation. Offering support, advice and consultation to the Care Management team who may be reporting safeguarding concerns to statutory agencies. Ensuring the CEO and Trustee Board are informed of any safeguarding issues affecting an Acorns child. Working with the Head of Training and the Safeguarding Steering Group ensuing safeguarding training is in place across the Trust for all care staff. Ensuring Acorns is appropriately linked into the Safeguarding Children s Boards across the region. Receiving reports of child protection concerns or suspicions. Promoting an understanding of Child Protection issues within Acorns. Briefing management and staff on Acorns other procedures and legal requirements in relation to child protection. Reports all safeguarding incidents occurring on Acorns premises or involving Acorns staff to the relevant Local Authority Designated Safeguarding Officer and CCG. Ensures anyone with an offence is reported to the DBS. Acorns will ensure there is clear safeguarding documentation to: Clarify safeguarding procedures. Provide specific documentation for reporting. Ensure support and supervision for staff involved in safeguarding situations. Provide information for children and young people accessing Acorns services. Understand what to do when managing a disclosure from a child. Monitoring Compliance The Review of safeguarding training records is led by the Head of Training, the results are reported to the safeguarding steering group and through quarterly reports to the commisioners. Monitoring of safeguarding training and incidents takes place every quarter by Acorns Page 15 of 41

16 regional Safeguarding Steering Group and Care Governance Group. Unannounced compliance visits completed by the Designated Safeguarding Officer and Acorns Heads of Service take place annually during these visits staff are interviewed on their awareness of the safeguarding policy and reporting procedures. Associated documentation Safeguarding and child protection guidance Safeguarding and child protect leaflet Policy for Safeguarding Vulnerable Adults Policy for the confidentiality of records Policy for Good Record Keeping Policy for notifying local safeguarding boards child death overview panel (CDOP) of a clients death Policy for Domestic Abuse Policy for Managing Aggression Safeguarding supervision policy Policy for mental capacity Prevent Policy Whistle Blowing Policy IG Policy PARTICIPATION IN NATIONAL AUDITS During the hospice was ineligible to participate in the national clinical audit and national confidential enquiries. This is because there were no audits or enquiries relating specifically to specialist palliative care in RESEARCH Acorns has not conducted any Clinical Research which has needed favourable opinion from a research ethics committee within the National Research Ethics Committee. We are however able to consider working in partnership with universities in supporting research projects which could further advance the care and services available to the children and young people we work with. This year Acorns has developed a working relationship with the Network Support & Palliative Care Research Nurse, from the NIHR Clinical Research Network, West Midlands. Acorns may be approached and equally can approach this network if there are joint areas of work identified. Page 16 of 41

17 Acorns supported research with parent champion s involvement in research undertaken from Bournemouth University re Understanding the Impact of Children s Hospices on Parental Relationships of Life Limited and Threatened Children and Young People. QUALITY IMPROVEMENT AND INNOVATION GOALS AGREED WITH OUR COMMISSIONERS A small proportion of Acorns income in was conditional on achieving Commissioning for Quality and Innovation payment framework (CQUIN). Acorns is committed to working with the CQUIN framework to proactively engage in quality improvements with our commissioners. The goals and indicators for Acorns identified by the CQUIN were as follows: Supporting effective transition of those with life limiting /life threatening conditions Preparing and supporting parents/ carers and young people who are going through transition to adult services. Support transition through young people and parent/carer workshops/forums What has been achieved? Four parent carer workshops were held which 29 families benefited from. Eight groups for CYP were held with 63 children and young people attending. Reflection and Impact of Scheme As an organisation Acorns saw young people become more eloquent and confident in expressing themselves and getting their needs met. Young people were prepared for adulthood by helping to make choices, gain new experiences, understand money, transport, explore education opportunities, learn about their conditions and what to do in an emergency. This work has seen the young ambassadors motivated to pass skills on to younger peers, they reported they found mentoring new Ambassadors and speaking to other Acorns clients rewarding and identified they want others to learn from their experiences and not make the same mistakes. These lessons have been positive in enabling them as young disabled Page 17 of 41

18 people to speak up for themselves, and will provide life skills which will help in a variety of setting such as when they are employing and retaining their personal carers. This year young people supported each other when one of their peers; a long standing Ambassador died. This also led into an extremely in depth discussion on their own mortality and future wishes for their funeral preparations. Parents have responded well to meetings, this involved seeing new adult providers which has supported parents to accept they will need to engage with some adult providers when leaving Acorns. Parents have had an opportunity to hear other parent s experiences in relation to good care they and their son/daughter have received from adult services. This was identified as being inspirational to other parents who were just beginning to go through transition. Actions taken as a result of lessons learnt:- 1. There are plans to facilitate ongoing support groups for young people particularly in relation to mortality and the death of friends and peers. 2. There will be a short film produced by young people for young people in their role as ambassadors. In 2015 we are working with Birmingham CCG who wish to include a CQUIN in their contracts. The CQUIN is focusing the outreach lead nurses using capacity available within the hospice to provide an enhanced outreach service for children who have not engaged with palliative care services. WHAT OTHERS SAY ABOUT US The hospice service is required to register with the Care Quality Commission (CQC) and the current registration status is unconditional. The hospice service has no conditions on registration. The CQC did not take any enforcement action against Acorns during Acorns is subject to periodic reviews by the CQC and the last on-site inspections were in 2013 and 2014 all the hospices were fully compliant. There were no inspections in however there is an expectation unannounced visits will take place in Page 18 of 41

19 In 2014 two professional days were held at Acorns which was attended by 103 external professionals. The programmes consisted of Acorns specialist professionals providing an overview of the care and services available. Feedback from professionals attending the Black Country and Three Counties professional s day September/ October All 103 professionals across health and social care services (100%) identified they would be extremely likely to recommend Acorns to a family. The professionals were asked the reasons for this recommendation: Have referred families in previously so know the difference it can make to the lives of families-a life line to parents. To provide better care for the families I work with due to the services offered by Acorns Children's Hospice. Extremely professional and valuable services available. Positive parent feedback. All parents I have spoken to speak highly about Acorns. I work with a lot of children with life limiting conditions and feel they would benefit greatly from Acorns help and support. Working as a CCN I see life limited/ life threatened children, hospice for support/respite is always discussed, the family then decide. As a professional I feel hospice is beneficial to the child and family from referral to after the child s death. And the important care and support following death. Friendly staff, lovely hospice. Acorns offer so much and our babies/ children and families need to be aware of the option available to them. I think the support offered by Acorns is fantastic and invaluable to families and children in this area, especially the variety of support offered for the entire family. Family recommendation and reputation. Support for whole family. As a CCN I work closely with families. Because Acorns offer a lot more than short breaks. Page 19 of 41

20 As a social work practitioner I support children and their families and I feel that the support that Acorns can offer is valuable. Great feedback from children, young people and families. The link between home and hospice to help families to stay at home and child as long as they wish. The holistic approach of care for the whole family unit. Fantastic service, fabulous staff. Non-clinical environment; friendly family atmosphere, bespoke packages, appropriately trained staff who have time and experience. The hospice environment is something every family should have the opportunity of using, it provides such a valuable support for all the family. I am impressed with the site, professionalism and forward thinking I have heard talked about today. Welcoming with good knowledge & experience. Acorns can offer a family who are experiencing palliative care the support they require to make end of life care more bearable for the family by enabling them to seek advice and support as and when they require. It seems like a professional, beautiful and peaceful place. Extremely friendly and supportive staff - very privileged to visit and learn about a wonderful organisation. Acorns offers a great amount of support for families and the children throughout their whole journey. I have worked with a lot of families who have received care at Acorns over many years but this is the first time I have been able to visit and learn all you can offer families with life limiting conditions. I plan to offer the Oncology Support Group to all our families and work with the Birmingham CLIC team to develop this. Families who have accessed Acorns have always given very positive feedback about their experiences. Clearly a well-established, researched service to meet all the need of the child and family holistically. Holistic approach to practical care. Page 20 of 41

21 The total support that puts family at centre of care programme & wonderful facilities. More aware of holistic nature of service & how early intervention can have huge impact on EoL care and other services available i.e. support groups and transition work. "Part of my job role as a palliative care nurse is to support child & family. Acorns is an excellent support network for the child & family as well as for myself" "because you provide care and support for family & children when they are most vulnerable and enable them to make happy memories" Very impressed by the service offered, the location and venue. Friendly and understanding staff who genuinely are passionate about helping and supporting children & families. Been aware of your services for many years. Happy to recommend your support to our families. Knowing what is available how could I not? Caring, professional - lovely environment, welcoming. An invaluable support. Already involved with families who access our services & Acorns so aware of brilliant support and care Acorns offers. Part of my role is to support the family and families I work with are always full of praise for the role Acorns plays in their lives. In Acorns received 128 of compliments from service users in relation to the care and service provided to them and their children. In addition to the compliments a formal system of family feedback was undertaken with a focus on six services. The outcomes from this is available in the section; The Views of Acorns Services Users: Family Feedback for (page 30). Page 21 of 41

22 DATA QUALITY Acorns did not submit records during to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. This is because the hospice is not eligible to participate in this scheme. Acorns collects and submits the following internal activity/performance data: annual data to Together for Short Lives; child death data to Child Death Overview Panels; activity data via quarterly quality reports to 20 clinical commissioning groups (CCGs); annual activity data to 20 CCGs, and; data to evidence that Acorns meets the Key Lines of Enquiry (KLOES) standards as identified by the Care Quality Commission. CLINICAL CODING ERROR RATE The hospice was not subject to the Payment by Results clinical coding audit during by the Audit Commission. Part 3: REVIEW OF QUALITY PERFORMANCE There are three tables presented in this section. Table 1; identifies an overview on the quantity of work undertaken across Acorns in Table 2; identified the Quality Performance Indicators which are organised under the KLOES identified by CQC as the indicator categories they focus on measuring and monitoring quality and safety in services. Table 3; highlights the clinical audits undertaken across Acorns in the last 12 months which support the monitoring and management of clinical effectiveness. TABLE 1 Figures for April 2014 to March Total number of open cases at end of the 12 month period No of families actually supported at the end of the 12 month period Page 22 of current number of children being supported 866 families being supported An additional 240 bereaved families being supported

23 Total number of children supported for Total number of families supported for Number of new patients 188 Number of referrals made % accepted, % 205 referrals received declined 188 referrals accepted No of Beds Available (based on 30 beds) No of Beds Taken Number discharged from care Number in transition (16-18 years) Number of day care episodes Number of episodes of care in community Number of deaths 77 Number of episodes of end of life care Number of nights provided (in special bedroom) 17 declined 10,950 7,299 (67% occupancy) (this includes day care) 133 TOTAL 65 Bereavement Support Completed 1 Child No longer meets our criteria 3 Closed service 1 Death 10 Discharged to TT 3 Left District 9 No longer able to contact family 5 no longer life threatened 15 No longer requires support 19 Transferred to Adult Service 2 Transferred to other service 53 ( year olds and 1 18 year old) 1,237 (already included in above figure) Over 3,623 support sessions with families in the community with an additional 7,579 phone support calls made to families. Overall support contacts: 15, TABLE 2 The following Quality Performance Indicators (QPI) and Acorns Standards for quality of service are organised under the 5 domains identified by CQC as the indicator categories to focus on measuring and monitoring quality and safety in services; 1. ensuring care services are responsive to people s needs; 2. ensuring services are caring; 3. ensuring services are well led; 4. ensuring services are effective; and, 5. ensuring services are safe. Page 23 of 41

24 The progress of the QPIs is reported through quarterly reports by Senior Care Managers to the Care Governance Group and presented to Care Assurance Committee for quarterly updates. Ensuring our care services are responsive to people s need QPI INDICATOR Measure 1. All families and Young People receive an assessment, highlighting outcomes achieved from service intervention and or future desired outcomes, this will be reviewed annually. 2 Allocated worker responsibility for YP over 16yrs of age to be transferred to the transition team when the transition team worker is undertaking the majority of support to the family. 3 All siblings requiring 1:1 Bereavement Support will be assessed by the sibling manager and time limited support offered where appropriate. 4 Communication groups in each site to improve the experience for children and families. 5 Families with assessed need receive outreach support from clinical teams. 6 Out-reach nurse lead to support the increase the number of referrals 7 Increase in neonates offered a service from Acorns 8 Teams of volunteers to work with families to meet desired outcomes in the community. 9 Recruit and train volunteer drivers/mini bus drivers and escorts to support ; siblings to access support groups support families to access to hospices for short-breaks (via transporting equipment) 10 Recruit accredited complementary therapists as volunteers 11 Recruit and train volunteers with necessary therapeutic skills for sib groups, role description to be shared 100% Outcome data base, monthly data identified by each team via reports. 100% Report by exception in monthly reporting system. 100% Monthly report and quarterly reports 1 group each site 20 visits per hospice per month 12 referrals as year Additional 6 a year Providing support to 20 families per site 3 pairs per site to support the sibling groups Quarterly outcome based report to care governance Monthly report and quarterly reports to care governance. Monthly report and quarterly reports to care governance. Monthly report and quarterly reports to care governance. Monthly report and quarterly reports to care governance. Monthly report and quarterly reports to care governance. 4 per site Monthly report and quarterly reports to care governance. 6 per Monthly report and quarterly reports to care region governance. 12 Recruit and Train Face to Face Volunteers 12 Monthly report and quarterly reports to care governance. Page 24 of 41

25 Standards Standard INDICATOR Measure 13 Newly accepted families or families who have a child under 16 years of age to have an allocated CTW. 14 All newly accepted families will be contacted within 7 days 15 All emergency EoL referrals to be responded in accordance with the EOL referral process guidance. 16 Acorns to provide a minimum of 4 hours notice for any cancelled visit for hospice at home in the community. 17 Hospice at Home Bookings All families to have a minimum of 1 weeks notice of planned bookings 18 There is an annual review of individual care plans 19 There is an annual programme of audits to meet CQC and organisational requirements. 20 All young people aged over 14 receive an initial transition assessment/ transition review 21 All siblings receive an assessment and review annually highlighting outcomes achieved from service intervention and future desired outcomes 100% Data system identifies allocated worker per child. Concerns reported through exception reports 100% Data system Concerns reported through exception reports 100% None compliance to be reported through the incident reporting process 100% Data system and exception reports when this is not the case 100% Data system and exception reports when this is not the case 100% Audit 100% Reports to Care Gov. group 100% Data System 90% Data System Ensuring our services are caring QPI INDICATOR Measure Three Sibling residential bereavement groups 1 per Monthly report and quarterly reports per year to meet the highlighted outcomes Hospice from assessments and reviews 24 Sibling groups per year to meet the highlighted outcomes from assessments and reviews BASIL meetings to support the development of sibling service utilising sibling perspectives Support groups to be provided for parents and carers to meet identified outcomes Therapeutic bereavement group 8 per hospice 6 meetings a year to produce; BASIL Magazine 10 per hospice per year. 1 per hospice per year Monthly report and quarterly reports Monthly report and quarterly reports To be reported through quarterly reporting To be reported through quarterly reporting Standards INDICATOR Measure 24/7 OOH Psychosocial support is available 100% OOH collated weekly via first on-call Page 25 of 41

26 27 to all families. All communications to children and families 28 to be accurate, timely, respectful and confidential Reception areas provide a safe, secure but 29 warm welcome to the hospices 100% Record of incident, complaint or IG issue or quarterly sample feedback from family 100% Audit Ensuring our services are well led 30 QPI INDICATOR Measure Develop operational changes to shift patterns to utilize time effectively. change in shift patterns Full report with recommendations to be considered Increase and maintain Corporate engagement as part of Community Engagement Agenda Maintain Ambassador and Champion roles 15 groups per year per site Recruit and train for roles Monthly report and quarterly reports Monthly report and quarterly reports 33 Prepare young people and their families for transition into adulthood 34 Sibling council further developed to promote the work of the siblings and support other siblings Deliver 6 prep for adulthood events per hospice / 12 youth clubs per hospice/ 4 parent group event per hospice 6 meetings a year Monthly report and quarterly reports Sibling leaflets and resource pack for families and professionals developed Standards INDICATOR Measure Records and children s files are maintained 100% Audits ensuring they are confidential, accessible and stored in line with principles of information governance and CQC guidance. All staff have an Individual Performance 90% HR records Review and PDP annually which feeds into the annual training plan. Ensuring our care services are effective QPI INDICATOR Measure 37 2 nurse prescribers at each site 100% To be in process of being trained or operational 38 2 nurses each site each year to achieve accredited qualification in paediatric palliative Page 26 of % To be in process of being trained or operational

27 care and clinical assessment skills 39 Achieve occupancy at a level that will maintain funding from CCGs Monthly reports Report already in place Retaining a regional & national presence 2 published reports and or conferenc e representa tion Re- establish priorities for Lead Nurse Roles QPI s to be developed Monthly report and quarterly reports Monthly report and quarterly reports Standards INDICATOR Measure 42 All activity codes for children s data to be 100% System checks and end of year review. recorded in timely and in an accurate manner Ensuring our care services are safe QPI INDICATOR Measure 43 Develop links between dependency scoring and day to day staffing to support day to day occupancy and establishment planning. System to be in place. Quarterly update reports Standard INDICATOR Measure 44 All staff and volunteers attend identified core training on induction and updates as indicated in training plan. 100% L&D data base. OUR PARTICIPATION IN CLIICAL AUDIT To ensure that Acorns is providing a consistently high quality service, we undertake our own clinical audits, using national audit tools, where available, developed specifically for hospices, which have been peer reviewed and quality assessed. This allows us to monitor the quality of care being provided in a systematic way and creates a framework by which we can review this information and make improvements where needeeach year the Nurse Managers and the nurses with additional responsibilities agree the audit schedule with the Senior Nurse for Quality and Governance for the coming year, this is then reported to the Care Governance Group. Priorities are selected in accordance with what is required by our Page 27 of 41

28 regulators and any areas where a formal audit would inform the risk management processes within the hospice. Through the Care Governance report, the Board of Trustees is kept fully informed about the audit results and any identified shortfalls. Through this process, the Board has received an assurance of the quality of the services provided. The following audits were completed between 1st April 2014 and 31st March Clinical Audit -Audit of transition records. Outcome Re-audit to ensure changes in documentation have been embedded and improvements in documentation seen. New audit planned for Re-audit of Help the Hospice general medication audit tool all sites. Quarterly one module of Help the Hospices prevention and control of infection audit tool suite all sites. Yearly all sites external infection control audit from SLA Quarterly Hand hygiene all sites hospice staff audits Page 28 of 41 Hand hygiene hospice at home staff audit. Medicines Management policy and procedures reviewed and re-written to reflect the outcome of the audit. Re-audit undertaken in all sites for 2014 to ensure consistent good practice has been maintained. New audit planned for Audits for 2014 have highlighted areas of good practice and action plans implemented each quarter to remedy any areas not meeting required standard such as updating cleaning schedules. Audit of one module at each hospice quarterly continues through Yearly audit of on-going standards shows good practice and action plans for improvement have been implemented. Next audits due Quarterly audits of hand hygiene maintained to ensure good practice is observed. Continue through Additional hand cleaning items supplied to staff back packs for use in homes. Re-audit 2015.

29 Hospice at home yearly record keeping audit. Hospice at home audit of medicine charts. Resuscitation re-audit all sites Quarterly mattress audits all sites Record Keeping Audit across all sites in-house and community teams. Audit of record keeping for sibling records audit showed some improved practice, with some improvements recommended around devising new care plans audit produced an action plan for staff training updates on recording on medication charts. Independent non-medical prescriber identified and commenced training to improve further practice in this area. Following changes to policy the audit reviewed practice and identified further changes needed to be made to policy and practice to reflect the use of regional documentation around end of life plans and resuscitation. Re-audit due 2016 following completion of action plans. This continued across the sites in 2014 and actions on replacement of covers and mattresses are ongoing continue through Some areas of improvement identified across the teams in Additions to audit criteria made for 2015 around consent and parent/carer signatures and a larger sample recommended. Action Plan developed and being implemented, re-audit due Audit completed with some good practice seen, improvements to consistency of paperwork being implemented. New audit planned for Pain assessment and recording re-audit at Birmingham Hospices Re-audit showed some improvements in recording and assessment of pain and the use of charts following implementation of an action plan. Page 29 of 41

30 Pain assessment and recording audit at Black Country Hospice audit showed some improvements needed around consistency of completing paperwork action plan in place. Re-audit of tissue viability recording Black Country Hospice 2014 re-audit showed some significant improvement on completion of paperwork and staff understanding following training and revised paperwork. Audit of play and activity provision and recording across all sites. Reception area welcoming and friendly audit across sites audit produced an action plan for improving recording of activity, co-ordination of activity and increasing training on outcome recording of activity undertaken audit highlighted the need for an action plan to ensure areas have up to date literature available, a review of the areas to ensure they are friendly is required and also that staff/ volunteers greet all visitors consistently to the same standards that are expected. Page 30 of 41

31 THE VIEWS OF ACORNS SERVICES USERS In 2014 Acorns piloted a Real Time Reporting System for seeking children, young people and families views on services. This was in addition to the feedback postcards being utilised. The Real Time Reporting pilot system enabled service users to complete an electronic survey which takes only minutes to complete on a hospice ipad for by web link using a QR code at home. This is service user friendly and has resulted in an increased response from children and families in relation to Acorns services. The benefit of the process being real time means Acorns is able to respond quickly to comments in addition to providing an annual overview of service user views. This system of seeking service user feedback is one of the quality improvement areas for The following feedback has been collated by a combination of post card feedback and Real Time Reporting for the following areas: 1. Hospice at Home; 2. Support Groups; 3. Family Events; 4. Complementary Therapy; 5. Hospice Care; and, 6. Young person s satisfaction. Page 31 of 41

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