St Raphael s Hospice QUALITY ACCOUNT

St Raphael s Hospice QUALITY ACCOUNT 2015-2016 I FEEL THAT ST RAPHAEL'S COMPLETELY LOOKED AFTER ALL OF US THE CARE AND SUPPORT WAS FANTASTIC (2015 CARER / RELATIVE SURVEY) v1 issued 29-06-16 Page 1

Part 1 What is a Quality Account? The Quality Account for St Raphael s Hospice is a representation of critical elements of its dynamic cycle of continuous quality improvement as it strives to deliver excellent specialist palliative care. It provides an opportunity for us to share best practice and is driven by the experiences of both those providing and receiving our services. It allows us to demonstrate our commitment to engage with evidence-based quality improvement and to outline our progress to the public. We hope that our Quality Account will deliver an opportunity for scrutiny, debate and reflection as well as provide the public, our regulator and our commissioners assurance that we are routinely evaluating our services and concentrating on those elements that require the most attention. St Raphael s Hospice St Raphael s Hospice is a voluntary organization, part of the registered charity of the English Province of the Daughters of the Cross of Liege, providing an expert palliative care service to our community. Since 1987, St Raphael's has offered the special skills of Hospice care to those facing life-limiting illness living in the boroughs of Merton and Sutton (predominantly Wimbledon, Merton, Sutton and Cheam). The service is completely free of charge and provides high quality medical and nursing care, as well as support to patients' family and friends. St Raphael s fully recognises and respects cultural, ethnic and religious differences and patients of all faiths or none, are welcome. v1 issued 29-06-16 Page 2

Medical, nursing and support staff do everything possible to relieve pain and sustain quality of life in an atmosphere of peace and comfort. In each case, Hospice care is tailored to the individuals needs. Services include: Skilled clinical care provided by doctors and nurses Care at Home or in the Hospice The Jubilee Centre providing social and creative opportunities, as well as treatments including complementary therapies. Support for friends, family and children Pastoral care Counselling Costs associated with the running of St Raphael's Hospice and the services it delivers exceed 5 million every year and we are reliant on the generosity of our local community through charity fundraising, donations and legacies to continue providing high quality care. We receive a grant of about 20% of our costs from government sources but the rest must be raised from donations and fundraising activities. v1 issued 29-06-16 Page 3

Statement from the Chief Executive The philosophy and values of St Raphael s Hospice are based on the Christian Ethos of respect for human life and esteem for the unique value of each individual. We share these values with all people of goodwill. We welcome, respect and support patients and staff of any or of no faith. We aim to meet the physical, emotional, spiritual and social needs of patients, their families and friends. Bereavement support is also offered to those who might find it helpful. We value the contribution of each member of staff and Hospice volunteer and offer training and education in the principals of specialist palliative care, both within the Hospice and the wider community. We serve the local community in the London Borough of Sutton and the London Borough of Merton that have a combined population of some 401,500 people. Quality is an integral part of the services that we provide. Its assurance is communicated every 2 months to the Trustees of the Charity via our Advisory Committee through a number of reports on aspects of clinical, corporate and financial governance. To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality of the healthcare services provided by St Raphael s Hospice. Mike Roycroft Chief Executive St Raphael s Hospice v1 issued 29-06-16 Page 4

Part 2 1. Priorities for improvement 2016 2017 St Raphael s Hospice is fully compliant with the Fundamental Standards of Quality and Safety that support the section 20 regulations of the Health and Social Care Act 2008 and its subsequent amendments. Consequently, there were no areas of shortfall to include in its priorities for improvement in 2015-2016. Effective from 1 st April 2015, has been our responsibility to meet two groups of regulations: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) Care Quality Commission (Registration) Regulations 2009 (Part 4). These regulations introduce the new fundamental standards which describe requirements that reflect the recommendations made by Sir Robert Francis following his inquiry into care at Mid- Staffordshire NHS Trust. The Advisory Committee has endorsed the Management Plan for 2016-2017 and considers that its top three quality improvement priorities are: Future planning priority 1 Integrated Palliative Care Outcome Scale - An improvement project to demonstrate outcome evidence Standard: The Integrated Palliative Care Outcome Scale (IPOS) is the most recent development of the POS tool that was developed in 1999 for use with patients with advanced disease to improve outcome measurement by evaluating many essential and important outcomes in palliative care. It allows for a more concise determination of outcome evidence and can be completed by both patient and staff member. The tool was initiated on the inpatient unit in 2014/2015 and further work is required in order to effect its integration into the routine assessment process for the IPU, CPCT and H@H teams. v1 issued 29-06-16 Page 5

Measure: Integration of the tool into the individual patient assessment process and use by the IPU, CPCT and H@H teams. Audit Report /feedback at Quality Improvement Committee Review: Planned education on use of the tool and record in Crosscare planned for June 2016. Future planning priority 2 PAS system MDS - An improvement project for the Hospice s Patient Administration System Standard: The Hospice s Patient Administration System allows for the capture of patient activity data. Output data from the system informs the management, fundraising and commissioning processes as well as servicing other external uses of Hospice data such as the National Council for Specialist Palliative Care s national minimum dataset (MDS). Measure: MDS reporting for 2016/2017. Report into the Quality Improvement Committee Advisory Committee. Feedback from Users and Output Reporting. Review: The reporting integrity of the new PAS system to service the National Minimum Dataset (MDS) annual submission needs to be assessed in 2016/2017 Future planning priority 3 NG31 NICE guidance audit An improvement project for the Hospice s evidence base for demonstrating compliance against required standards Standard: To provide assurance of compliance against a selection of standards drawn from the NICE Guidance NG31 Care of Dying Adults in the last days of life Measure: Establishment of Electronic Patient Record Audits that service the evaluation of NG31 and demonstrate compliance and required actions Review: Audit Report and feedback to QIC v1 issued 29-06-16 Page 6

2. Statements of Assurance from the Advisory Committee The following are a series of statements that all providers are required to include in their Quality Account. Many of these statements are not directly applicable to specialist palliative care providers. 2.1 Review of Services During 2015/2016, St Raphael s Hospice provided 5 NHS funded services: In-patient Unit Jubilee Centre Day Care Outpatients Hospice @ Home Community Clinical Nurse Specialist Service St Raphael s Hospice has reviewed all the data available to it on the quality of care in all the above services. The income generated by the NHS services reviewed in 2015/2016 represents 100% of the total income generated from the provision of the NHS funded services by St Raphael s Hospice for 2015/2016. What this means St Raphael s Hospice is funded via a standard NHS contract and fundraising activity. The income generated from the NHS represents approximately 20% of the overall running costs of the Hospice. The remaining income is generated through legacies and support from our generous community and shops. v1 issued 29-06-16 Page 7

2.2 Participation in national clinical audits and confidential enquiries During 2015/2016, no national clinical audits and no confidential enquiries covered NHS services provided by St Raphael s Hospice. What this means There are no national clinical audits nor confidential enquiries that cover the specialist palliative care services either commissioned or provided by St Raphael s Hospice. However, St Raphael s Hospice carries out internal clinical audits throughout the year as part of its management planning process. 2.3 Participation in local clinical audits The undertaking of clinical audits at a local level feeds into the management planning round for St Raphael s Hospice. Details of projects undertaken in 2015/2016 can be found at section 3.2.1. 2.4. Participation in clinical research There have been no clinical research projects undertaken in 2015/2016. The number of patients receiving NHS services provided by St Raphael s Hospice in 2015/2016 that were recruited during that period to participate in research approved by the local research ethics committee was 0. In 2016/2017, there is no research currently being undertaken. v1 issued 29-06-16 Page 8

2.5 Goals agreed with commissioners St Raphael s Hospice s income in 2015/2016 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework. 2.6 What others say about us St Raphael s Hospice is required to register with the Care Quality Commission and has no conditions on its registration. The Care Quality Commission's last undertook an unannounced inspection of St Raphael s Hospice on 26 th September 2013. The Hospice was assessed as fully compliant with the required standards. The Care Quality Commission has not taken enforcement action against St Raphael s Hospice during 2015/2016. St Raphael s Hospice has not participated in any special reviews or investigations by the CQC during the reporting period. v1 issued 29-06-16 Page 9

2.7 Data quality St Raphael s Hospice constantly reviews the quality of its data to see if there are ways in which it can be improved. As a result, it will be undertaking the following action to further improve data quality: - Evaluating the production and integrity of information from the new PAS system that was implemented in December 2015. The system will automatically collate MDS data and facilitate user-defined data interrogation / report production. A high value is placed on the data and consequential information outputs that can be generated through the Hospice s information systems. St Raphael s Hospice did not submit records to the Secondary Uses service for inclusion in the Hospital Episode Statistics as this is not applicable. St Raphael s did not submit a National Minimum Dataset (MDS) to the National Council for Palliative Care in 2014/2015. It will not be submitting its MDS for 2015/2016 due to data integrity concerns that will be addressed by the application of the new PAS system that was implemented in December 2015. The expectation is for the MDS report to be submitted for 2016/2017. St Raphael s Hospice achieved level 2 compliance with the NHS Information Governance Toolkit in 2013. It is presently undertaking a re-submission of required evidence to ensure compliance with version 13 of the Toolkit. v1 issued 29-06-16 Page 10

Part 3 3. Quality Review 3.1 Review of quality performance in 2015/2016 This is the third year St Raphael s Hospice has published a Quality Account. Past priority 1 Incident reporting and review An improvement project for the Hospice s management of risk Standard: Dual systems separating the reporting of clinical and non-clinical adverse events have been merged into one system that captures ALL unexpected incidents and near misses. Measure: Feedback from Users via Heads of Department and Quality Improvement Committee. Review: The new system has been effected in June 2016 and its effectiveness will be demonstrated by its outputs and improvement in the connection between cause, effect, management, learning and consequential action. Minuted monthly meetings have been held since September 2015 to review clinical incidents, the action taken and triggers for additional audit. Dissemination and consideration of clinical incidents is routinely included in the clinical meetings that are minuted and overview considered at the Hospice s Quality Improvement and Drugs & Therapeutics Committees. A minuted falls meeting is held twice a year to review falls incidents. Non-clinical incidents and information incidents receive attention at the Health & Safety and Quality Improvement Committee respectively. v1 issued 29-06-16 Page 11

Past planning priority 2 PAS system - An improvement project for the Hospice s patient administration system Standard: The Hospice s Patient Administration System allows for the capture of patient activity data. Output data from the system informs the management, fundraising and commissioning processes as well as servicing other external uses of Hospice data such as the National Council for Specialist Palliative Care s national minimum dataset (MDS). Measure: Implementation of the new system was scheduled for 2015. Report into the Quality Improvement Committee and Advisory Committee. Feedback from Users and Output Reporting. Review: The new patient administration system Crosscare was implemented on 1 st December 2015. Configuration of the new system began in June 2015 and a project implementation team consisting of the Hospice s Community Team Lead and Consultant in Palliative Medicine, Matron and Deputy Director of Care Services, the Chief Executive Officer, Information Technology Manager, the Quality Development Manager, Director of Care Services, Practice Development Nurse, First Point of Contact Team Leader and the Education Secretary steered the project to completion. Review of inputs and the generation of outputs constitute an improvement project for 2016/2017. Progress is routinely fed into the Hospice s Quality Improvement Committee and Advisory Committee. v1 issued 29-06-16 Page 12

Past planning priority 3 Integrated Palliative Care Outcome Scale - An improvement project to demonstrate outcome evidence Standard: The Integrated Palliative Care Outcome Scale (IPOS) is the most recent development of the POS tool that was developed in 1999 for use with patients with advanced disease to improve outcome measurement by evaluating many essential and important outcomes in palliative care. It allows for a more concise determination of outcome evidence and can be completed by both patient and staff member. Measure: Report for use of ipos in the IPU reflected on data captured using the Patient version between November 2014 and November 2015. Review: The tool was initiated on the inpatient unit in 2014/2015 and report produced in 2016 consolidated opinion that greater value from use of the tool will come from its integration into the routine assessment process. The results of the audit undertaken demonstrated improvement in outcomes over time against 15 of the 17 largely symptom-based criteria. Learning points identified integration into routine assessment as the main element to be achieved across its continued use in the IPU and roll out to the Community and Hospice @ Home teams. v1 issued 29-06-16 Page 13

3.2 Quality Management Quality Improvement Committee The Hospice s Quality Improvement Committee steers the Hospice s approach to quality assurance and improvement. Chaired by the Quality Development Manager, it meets every 2 months and is attended by the Chief Executive. It s membership includes the Quality Development Manager, the Director of Care Service, the Deputy Director of Care Services, the Medical Director, the Community Team Medical Lead and Consultant in Palliative Care, the Sister for the Inpatient Unit, the Education Lead for the Inpatient Unit, the IT Manager, the HR Manager, and the Audit Support Officer. Standing items for this Committee include Information Governance, Clinical Audit, Clinical and Corporate Effectiveness including Policy Development, Practice Development and NICE Quality Standards / CAS /MHRA clinical safety alerts, Clinical Risk Management, Patient/User Feedback, Organisational and Regulatory Assurance, Infection Control and Complaints. Education Committee The Hospice s Education Committee steers the Hospice s approach to education and all forms of training. Chaired by the Director of Care Services, it meets every 3 months. Its membership includes the Director of Care Service, the Deputy Director of Care Services, the Sister for the Inpatient Unit, the Medical Director, the Community Team Medical Lead and Consultant in Palliative Care, the Quality Development Manager and the Education Lead for the Inpatient Unit. Standing items for this Committee include Funding Streams, Course Take Up, Course Applications, Induction Training, Mandatory Training and Course Provision. v1 issued 29-06-16 Page 14

Drugs & Therapeutics Committee The Hospice s Drugs & Therapeutics Committee steers the Hospice s approach to drug and therapeutic governance. Chaired by the Medical Director, it meets every 4 months. Its membership includes the Medical Director, the Director of Care Service, the Deputy Director of Care Services, non-medical prescribers, the Community Team Medical Lead and Consultant in Palliative Care, the Sister for the Inpatient Unit, the Education Lead for the Inpatient Unit, the Clinical Pharmacist and the Quality Development Manager. Standing items for this Committee include Safe CD prescribing & administration, Guideline/Policy updates, Therapeutic Governance including cost trending, Medication Incident Review, Non-medical Prescribing Update and MHRA Drug Alerts. Health & Safety Committee The Hospice s Health & Safety Committee steers the Hospice s approach to health and safety and supports the delivery of operational facilities for the site. Chaired by the Operational Facilities Manager, it meets every 2 months. Its membership includes the Operational Facilities Manager, the Health & Safety Officer, the Quality Development Manager, the Director of Care Services, the Deputy Director of Care Services, the Sister for the Inpatient Unit, House Manager, Head of Retail and both clinical and non-clinical link staff for Health & Safety. Standing items for this Committee include Health & Safety Advisor Update regarding legislation/innovative practice, Policies & Risk Management, Non-clinical Accident & Incident Review, Works Update, Health & Safety matters affecting staff, volunteers, systems and the environment. v1 issued 29-06-16 Page 15

Infection Control Committee The Hospice s Infection Control Committee steers the Hospice s approach to infection control. Chaired by a Consultant Microbiologist, it meets every 4 months. Its membership includes the Consultant Microbiologist, the Infection Control Nurse, the Medical Director, the Deputy Director of Care, the Operational Facilities Manager, the Quality Development Manager, the Sister for the Inpatient Unit, the Practice Development Nurse and the House Manager. Standing items for the Committee include Infection Control Issues, Sharps Injury & Body Fluid Exposure, Alert Organisms Surveillance, Facilities Update, Occupational Health Update and Regulatory/Best Practice Requirements. 3.2.1 Clinical Audit During 2015/2016, the Hospice undertook a number of clinical audit projects, amongst which were: Project Integrated Patient Outcome Survey Prescription Chart Documentation Hospice Carer/Relative Satisfaction Inpatient Satisfaction Audit of patients who have died before their first assessment Results/Actions/Comments Multiple points of learning identified from implementation, application, education and communication. Demonstrable evidence of improvement across 15 of the 17 criteria primarily directed at symptom management in the inpatient unit. Integration into the Crosscare system for 2016, incorporation into the routine assessment processes in the IPU and Community and use by IPU, H@H and the CPCT effected in June 2016. Weekly audit by the Hospice s Clinical Pharmacist shows 406 charts assessed in 2015 comprising 7796 prescription items and a respective evident prescription writing and error rate of 0.3%. On-going survey inputs into departmental reviews. Replaced by VOICES questionnaire in 2016. On-going survey. Routine completion is markedly improved but still remains an area for improvement. Results remain consistently high. Replaced by VOICES questionnaire in 2016. Comparative audits showed an improvement i.e. a reduction in the number of patients who died before they were first seen. The reason for not being able to see patients remains the same as previously: some patients are referred <48 hours before they pass away and that patients are referred from hospital that are never well enough to be discharged. v1 issued 29-06-16 Page 16

Project Audit of documentation of end of life care for community based patients Audit of VTE documentation Controlled Drug Audit Discharge Summary Audit DNR Documentation Audit SKIPP in the Jubilee Centre Results/Actions/Comments Results showed that the Hospice was very good at ensuring pre-emptive discussions and planning has occurred e.g. documentation of preferred place of death, discussions around DNAR and prescribing of injectable medication, with it taking place for almost 100% of patients. Areas for improvement are around documentation of a plan for food and drink and for the management of a patient and families psychological and spiritual need. There also needs to be better recording of what has been explained to a patient and relative and that they understand the patient is deteriorating and dying. As well as documenting that this is being revisited and reviewed on a regular basis. Results did not show improvement nor deterioration against previous audit. A number of action recommendations offset by introduction of electronic data capture in late 2015. Results showed that 66% of calculations for opioid breakthrough dose were written in the notes. The calculations and the breakthrough doses prescribed were all found to be correct. The number of breakthrough doses administered and effect noted in the patient notes was 78%. Snap shot audit of hard copy record identified areas for improvement that included Hospice and NHS ID numbers, medication upon discharge and follow up. Automated mail-merged discharge summary documentation replaced hard copy notes system in December 2015. Results demonstrated improvement upon re-audit with 3 standards being fully met and 3 requiring improvement compared to meeting 1 standard previously. Areas for improvement included documentation of capacity and reason for not discussing. Whilst the standard of compliance had not been achieved in evidencing dating, timing and signing of entry, compliance had improved upon the previous audit. Results in 2015 showed that the average rating for patients current overall quality of life rose from 3.5 in the first round of surveys to 4.4 in the second round of surveys. This quality of life indicator has consistently risen in each audit period. All patients reported in the first survey that their concerns had improved since attending the Jubilee Centre Pain management is singly the most common cause for concern or difficulty in both surveys. v1 issued 29-06-16 Page 17

Project Use and monitoring of steroids in the community Audit of Pressure Area Risk Assessment Hospice @ Home Carer/Relative Satisfaction Results/Actions/Comments Type of steroid prescribed and rationale recorded 100% standard Record of discussion about side effects and steroid card given 100% standard Record of plan for checking blood sugars 100% standard Record of plan for reduction and review 100% standard Record of communication with GP, DNs and other professionals 100% standard Results in 2015/2016 showed room for improvement across all standards. The hospice has converted from using paper patient records to a computer based electronic patient record and an equivalent to the green sheet has been developed as a window on the system. Report reflecting upon 2014 s data showed: Compliance on achieving the standard of inpatients being assessed at least every three days is 97% overall. Compliance with the standard that signatures be recorded on an assessment for every inpatient day is 89% (c.f. 87% in 2012). Compliance with the standard that a score be recorded every full inpatient day is 91% (c.f. 91% in 2012). Compliance achieved against the standard that all patients have evidence of a patient handling assessment form included in their records is 98% in 2014 Last reported in May 2016, results maintained a very positive picture of the team s value to the patients and carers aligned to its service. 3.2.2 Clinical Risk Management Project Accidents & Incidents Clinical Unexpected Incidents Continuous Improvement Log Actions Report drafted in June 2016. 100% of reported accidents or incidents showed evidence of action taken consequential to occurrence (c.f. 87% in 2014 & 91% in 2013). 58% of reported patient accidents or non-clinical incidents concern patient slips/trips or falls (c.f. 76% in 2014 & 89% in 2013). There have been no accidents that have required report to the CQC in 2015; all accidents were minor and received the appropriate medical attention. Report produced in June 2016. Trend for improved reporting of clinical unexpected incidents continues in 2015. In 2015, 54% of reported incidents (cf. 44% in 2014 and 46% in 2013 ) were drug incidents and documentation was the most common type of error. Multiple actions have been triggered over 2015 including: increased education, review of documentation, implementation of new systems and methodologies and revised policy. There was one notifiable incident made to the CQC. Triggered by information governance requirements to log information incidents. 13incidents were logged in 2015/16. v1 issued 29-06-16 Page 18

3.2.3 Clinical Effectiveness Clinical policy and guidelines have been incorporated into the central system of policy document management in 2015. As with all policy, review lead ownership is attributed to individual members of the multi-disciplinary team. A major exercise to instigate a house style to policy documentation has been effected and, as policy either requires or naturally comes to its review stage, the house style is effected as part of that review. Clinical policy/guidelines reviewed in 2015/2016 numbered 35 and include: CLINICAL TITLE ISSUE DATE CLIN01 Admission Procedure 29-01-2016 CLIN02 Care After Death Guidelines 17-07-2015 CLIN05 Consent 14-07-2015 CLIN06 Jubilee Centre Referral and Attendance 12-06-2015 CLIN07 Discharge 22-02-2016 CLIN08 Infection Control Manual July 2015 CLIN09 Referral to Hospice 10-06-2015 CLIN09a Summary Guidance for Referral 10-06-2015 CLIN10 Research Governance 13-07-2015 CLIN12 Safeguarding Children Policy 13-01-2016 CLIN13 Suicide 13-07-2015 CLIN14 Safeguarding Adults Policy 08-02-2016 CLIN15 Deprivation of Liberty Guidelines 08-02-2016 CLIN16 Mental Capacity Act Guidelines 20-05-2015 CLIN17 Management of Enteral Catheters and Feeding Systems 01-05-2015 CLIN18 Syringe Driver Policy (McKinley T34)) 15-06-2015 CLIN19 Midazolam Use in Palliative Care 15-06-2015 CLIN20 Analgesic Administration 10-12-2015 CLIN21 Anaphylaxis Management 11-09-2015 CLIN22 Antimicrobial Therapy 05-01-2016 CLIN25 Controlled Drugs 24-11-2015 CLIN26 General Drugs 24-11-2015 CLIN29 Preparing and Administering Injectable Medication 01-10-2015 CLIN31 Mouth Care 15-02-2016 CLIN33 Nurse Independent Prescribing 23-02-2016 CLIN34 Nutrition and Hydration 07-12-2015 CLIN36 Paracentesis 11-01-2016 CLIN37 Phenobarbital 22-01-2016 CLIN38 Pleural Aspiration 24-11-2015 CLIN39 Pressure Ulcer Prevention and Management 17-07-2015 CLIN40 Conservative Management of Malignant Small Bowel Obstruction 07-03-2016 CLIN41 Steroid Therapy 11-01-2016 CLIN42 Tracheostomy 01-04-2015 CLIN44 Venous Thrombo-embolism Prophylaxis 07-03-2016 CLIN45 Wound Management 10-12-2015 v1 issued 29-06-16 Page 19

Education is an on-going activity and is vitally significant to the care delivered at St Raphael s. There is a considerable amount of formalised and informal clinical education delivered across all service areas. Whilst not an exhaustive list, the clinical training delivered in 2015/2016 included: Medical training: Medical Journal club presentations: Oral Rivaroxaban versus Enoxaparin with Vitamin K antagonist for the treatment of symptomatic venous thromboembolism in patients with cancer (EINSTEIN-DVT and EINSTEIN-PE): a pooled subgroup analysis of two randomised controlled trials Pain management at the end of life: A comparative study of cancer, Dementia, and chronic obstructive pulmonary disease patients Acceptability of low molecular weight heparin thromboprophylaxis for inpatients receiving palliative care: qualitative study Cancer induced bone pain Is home always the best and preferred place of death? Assessment and management of behavioural and psychological symptoms of Dementia Clinical significance of e-gfr (estimated glomerular filtration rate) When and how to discuss do not resuscitate decisions with patients The Royal Marsden Hospital palliative care update covering symptom control in renal failure, drug induced adverse effects, palliative care in Cystic Fibrosis, management of Non small cell lung cancer, usefulness of palliative radiotherapy for symptom management, benefits and risks of using steroids Is there a role for subcutaneous Furosemide in the community and hospice management of end- stage heart failure? An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial Assessment and management of pain in Dementia Therapeutic advances in idiopathic pulmonary fibrosis Hydration at the end of life MDT journal club presentations Does involving volunteers in the provision of palliative care make a difference to patient and family wellbeing? A systematic review of quantitative and qualitative evidence If only we learned from our mistakes from doctors to politicians, we are scared to admit errors v1 issued 29-06-16 Page 20

Clinical team reflective forums Managing pain and distress in the dying stage Distressing, haemorrhagic patient death Patient with expanding primary brain tumour wanting to end his life Discussion on clinical reasoning skills The principle of fractional receptor occupancy in the use of combined opioid therapy Early recognition of serious opioid toxicity GP-Palliative care forums: Advance care planning in palliative care Clinical training: Pain and symptom management Spirituality Medicine management Sub-cutaneous fluids at end of life MCA and Safeguarding Outcome measures Non-invasive ventilation Tissue viability Blood transfusion Care of patients with a PEG/RIG Bowel obstruction Clinical Reasoning in Physical assessment Communication skills Dementia awareness Staff development programmes Neuropathic pain Infection Prevention Opioid toxicity Crosscare PAS system Reflective forums Oncology tutorials Palliative care emergencies v1 issued 29-06-16 Page 21

Community training: Neuropathic pain Pain and symptom management Nurse independent prescribing Communication skills/managing difficult conversations 3.2.4 Mandatory Training Whist the importance attached to clinical education is particularly high, all staff at St Raphael s and volunteers undertaking specific roles are required to attend mandatory training. Training delivered in 2015/2016 included such topics as: Fire Health & Safety Information Governance Patient Handling Resuscitation Infection Control 3.2.5 Clinical Research In December 2014, the Hospice Medical Director completed the data collection element of her research project approved by the London-Surrey Borders Research & Ethics Committee Evaluation of the efficacy of Trans-dermal Nitrate in reducing the severity of death rattle (i.e. terminal lung secretions) in patients dying from end-stage malignancy. With MHRA authorisation safely in place, the project had commenced its data collection in 2008. Its results are based on a recruitment number of 60 and a valid cohort of 33. Data is undergoing statistical interpretation and publication is expected in July 2016. Presentation of results is hoped to be undertaken at the Autumn Knowledge Exchange Seminar in the Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation at King s College, London. v1 issued 29-06-16 Page 22

3.2.6 Complaints Management There have been two written complaints and twelve oral complaints received in 2015 / 2016. Of the two written complaints, both were upheld and ten of the twelve oral complaints were upheld. All have been investigated by a senior member of staff and resolved to the satisfaction of the complainants. 3.2.7 User Feedback There are multiple feedback routes for patients, their carers and relatives. Routine surveys include: Inpatient Satisfaction Carer/Relative Satisfaction Hospice @ Home Service Carer/Relative Survey Jubilee Centre Patient Questionnaire Medical Outpatient Questionnaire Bereavement Service Questionnaire Feedback on the services provided and experienced is regarded highly at St Raphael s. User feedback is embraced as a spoke of the continuous quality improvement that the Hospice seeks to achieve. Actions arising from feedback either through survey or other route have informed plans amongst which are the development of a Volunteer Forum, the introduction of a staff survey, increasing the number of case reviews for the multi-disciplinary teams, changes to service provision, development of literature and improved forms of communication and engagement. 3.2.8 Information Governance Compliance to at least level 2 with the NHS Information Governance Toolkit demonstrates St Raphael s commitment to how it respects the confidentiality, integrity and availability of its information. There is an annual responsibility for the Hospice to ensure that required evidence is accurate and up to date. Consequential to the Hospice s adequate demonstration of its compliance with the NHS Information Governance Toolkit is its recognition as an NHS Business Partner and, in turn, its accessibility to the Connecting for Health via the N3 facility. With the patient s consent, this facility allows for the secure inputting of patient identifiable data on to the patient electronic care record at the end of life. v1 issued 29-06-16 Page 23

3.2.9 The National Minimum Dataset The National Council for Specialist Palliative Care has an established minimum dataset (MDS) of anonymised and aggregated patient data that represents Hospice patient level activity. Submission of the MDS to the National Council was not achieved in 2015/2016 due to PAS system deficiencies. An improvement project to remedy this is established. 3.2.10 Organisational Development St Raphael s Hospice was established in 1987 and is owned by the Daughters of the Cross. It shares a site with Spire St Anthony s Hospital, part of Spire s private hospital network. St Anthony s Hospital was owned by the Daughters of the Cross until its sale to Spire Healthcare in April 2014. Prior to that date, a number of support services including Facilities Management, Catering, Portering, Purchasing, Payroll, Human Resources, Accounts and IT were provided by St Anthony s Hospital to St Raphael s. With the exception of a small number of time-limited service level agreements, these services have been entirely provided by St Raphael s as a stand-alone specialist palliative care facility since February 2014. Organisational development is very much part of the management plan for the Hospice as it continues to establish its independent identity whilst remaining part of the good works delivered under the auspices of the Daughters of the Cross. 3.3 Who has been involved in the creation of this Quality Account? The Quality Account is an item for the Hospice s Quality Improvement Committee which includes representation from all clinical areas and the Hospice s Advisory Committee. The task of writing it was undertaken by the Quality Development Manager. Extensive consultation with managers constitutes the annual management planning process that feeds into the Quality Account. The Quality Account has been derived from the management planning process and the business of the Hospice s governance committees. v1 issued 29-06-16 Page 24