Quality Account 2015-2016 Karen Coles RGN Head of Care Jackie Turner Head of Family Support KEMP House Trust Limited 41 Mason Road Kidderminster DY11 6AG Registered Charity No: 1146310
Contents 1. Chief Executive s statement of quality 2. KEMP s purpose, mission and vision 3. Our Progress against our priorities for improvement for 2015/2016 4. Priorities for improvement 2016/2017 5. Review of services 6. Participation in clinical audits 7. Complaints and incidents 8. Quality review 9. What people say about KEMP Hospice 10. What Wyre Forest CCG says about our organisation 11. Statement of assurance from the Board of Trustees 2
1. Chief Executive s Statement of Quality It is my pleasure to present our quality account for KEMP Hospice which reports on the qualitative aspects of the care and services delivered by KEMP Hospice for the people of the Wyre Forest. This report is for our patients, their families, carers and friends, the general public and the local NHS organisations that provide 28% of the funding required to provide our wide range of services in the local community which are free to users. The balance of the monies required is met through Gifts in Wills, fundraising, trading activities and, currently, from the reserves we hold. We are indebted to local people who support KEMP and are, effectively, the prime commissioner of our services. The aim of this report is to give clear information about the quality of our services so that patients feel safe and well cared for, their families and friends are supported and reassured that all of our services are of the highest standard and that the NHS is receiving value for money. The high standards of care provided by KEMP Hospice would not be possible without the dedication of our hardworking staff along with the very many willing volunteers who give freely of their time and talents along with our Board of Trustees and I would like to take this opportunity to thank them all for their efforts. Our Head of Care, Karen Coles and Head of Family Support, Jackie Turner are mainly responsible for the preparation of this report and its contents. To the best of my knowledge, the information in the Quality Care Account is accurate and a fair representation of the quality of health services provided by KEMP Hospice. The safety, experience and outcomes for all of our patients and those who care for them are of paramount importance to us with us all seeking to ensure that we put the patient or service user at the heart of all we do. Terry Osborn Chief Executive July 2016 3
2. Kemp s purpose, mission, vision and organisational values KEMP hospice exists to meet the needs of people affected by life limiting illness or bereavement within the Wyre Forest and surrounding area. KEMP s care provision for those affected by serious life limiting illness and bereavement support are underpinned by four clear values: A patient and carer focussed service. The delivery of high quality care and support for which no charge is made. Care and support delivered with compassion, support and integrity. Autonomy and independence which ensures a prompt and flexible response to need. KEMP Hospice s Vision is: Access, quality and choice in palliative and end of life care and bereavement support for everyone in the Wyre Forest and surrounding areas. This vision is an aim we all share and will strive for, bringing together, with a sense of purpose, our staff, volunteers and supporters. KEMP Hospice s Mission is: KEMP Hospice works in partnership with patients, their carers and families to provide clinical, emotional and spiritual care for those in our community with life limiting illness along with practical assistance such as bereavement support for both adults and children. Our mission sets out what KEMP hospice s role is in helping to enable the excellence and choice described in our vision to be realised. KEMP Hospice s Organisational Values are: Professional Respectful Trustworthy Inclusive Positive Compassionate 4
3. Our progress against priorities for improvement 2015-2016 Priority 1 Implement new strategy Through a process of consultation we have further developed KEMP s role in the local community and during the year we have re-introduced specialist clinics, we have commenced a series of specialist days at the hospice for those with Parkinson s disease, Motor Neurone disease and the frail elderly who suffer with dementia and their carers as we recognise that they also require our help and support. We have responded to need and developed further new services which you can read about further within this report. Priority 2 Development of services We consolidated specialist day hospice from four to three days increasing daily numbers to above 10 per day with us seeing an enhancement to the care we provide. We commenced and continue to develop other models of care focussing on supporting patients with specific diseases along with their carers. Our Motor Neurone Disease Monday group is in its early stages but early feedback is encouraging with the members themselves keen to promote the service via social media. Our Care and Family Support teams have worked together to provide additional support and counselling sessions for those in our MND and Parkinson s groups. Our Family Support team further developed volunteer led group support work and such was the success of this that we introduced a second Thursday group which rapidly reached full capacity with further developments possible. 5
KEMP for Kids the planned residential weekend was held with excellent outcomes, we are planning to hold two of these during 2016 to expand the reach and reduce waiting times. Reunion sessions were commenced and the 2 day course was completed with an adventure day offsite and a therapeutic day at the hospice with positive feedback from those who participated. Priority 3 Development of befriending service We completed our trial, volunteer led, telephone based befriending service within our Family Support team with great success. 2 volunteers received communication skills training and the Family Support team identified clients to be contacted and supported. During the first 6 months a cohort of 11 people received one to one support with positive comments being received; A proposal to develop this into a core KEMP service for the local community was submitted to our Board of Trustees and received their support. Having someone to talk to when you are 95, have no visitors and trouble walking and getting out is helpful. Would like a befriending service that visits at home too. 6
4. Priorities for 2016/2017 Priority 1 - Development of Family Support services Bereavement Support Peer Mentoring cross-age peer mentoring programmes are an increasingly popular choice to create positive outcomes for youth. This coming year will see KEMP train Peer Mentors in High Schools across the Wyre Forest who will help and support students who have experienced a loss. Group Work building upon the success of our Thursday Groups (2) we plan to introduce a Tuesday evening group for parents who have experienced the loss of a child, a group for those who are in need following a suicide and a group for carers which will be developed in conjunction with our Care team. Drop Ins building on the success of KEMP being represented in GP surgeries (Northumberland House and Aylmer Lodge) we will have representation in the new Bewdley GP Centre and hope to expand this to the new Kidderminster Health Centre and would like to also gain a presence in Stourport and Hagley. Priority 2- Development of Dementia services Dementia is now one of the biggest global public health challenges facing our generation. There is now overwhelming evidence of a need to redress the poor care towards the end of life people with dementia experience because of their diagnosis. KEMP will respond to this challenge and 2016/17 will see us develop a group of local people with dementia and their carers here in the hospice. KEMP will also be working closely with the Alzheimer s Society joining their local Dementia Action Alliance and working with other local partners to make Kidderminster a Dementia Friendly Community 7
Priority 3 Hospice at Home KEMP will support the development of our Hospice at Home team by the appointment of a Team Leader and will seek to work closely with colleagues in the Clinical Commissioning Group and Health & Care Trust to further develop the role and scope of this vital service for local people. 5. Review of services Hospices are required to report against those services commissioned by their local NHS. KEMP Hospice has received grants from NHS Worcestershire/Wyre Forest CCG and currently provides: Day Hospice Outpatient facilities which also support specialist clinics Family Support Services encompassing both adult and children s bereavement support Bereavement Hub We have also included our KEMP Hospice at Home service in this report, although it does not currently attract a NHS grant, as it is an important and integral part of our community based services. 6. Participation in clinical audits KEMP has not participated in any national clinical audits. Audit of Day Hospice is an important part of developing services to meet patient s needs; there were no outstanding concerns from patients. One patient commented upon the frequency of questionnaires received. In future the plan is to review our questionnaire to include all services within the clinical team. Auditing of patient electronic notes was completed in May and December 2015 with 9 out of the 10 domains recorded at 100%. The domain for advance care planning discussion was recorded at 75% which is higher than the previous year. 8
7. Complaints and incidents There have been no complaints from patients/service users during this year. Two incidences were recorded in day hospice:- Patient slipped off the toilet onto the floor, but sustained no injuries. Actions put in place- patients at risk of falling must be chaperoned while use the toilet. Patient bumped her head on a cupboard in the patient disable toilet; but sustained no injuries, the cupboard has since been moved. 9
8. What others say about us Care Quality Commission (CQC) visits. There were no visits from the CQC during the year covered by this report however, KEMP had a visit from a CQC inspector in June 2016. The inspection was planned to check whether KEMP is meeting the required regulations for our Hospice at Home service. We met the requirements of the 5 questions asked about our service and there were no recommendations following the assessment. The inspector spoke to the Registered Manager and to Health Care Support Workers who deliver the service. An expert by experience will contact relatives of people who had used the service after the inspection by phone to gather their views about the care and support they received. The inspector found that staff records reflected that a formal application and interview process was in place and that the necessary checks to ensure that staff were suitable to provide care and support to people in their homes had been completed. Staff reported to the inspector that they felt very well supported in their roles and that there was a good learning environment and support for professional development. We await the final report but we were told that there were no issues. 10
9. Quality Overview 2015-2016 2014-2015 2013-2014 Total number of new referrals to KEMP (approx.) 589 FST (+ 148 children s service) 701 ( +140 children s service) 642 (+101 children s service) Total number of Day Hospice 1853 1749 1579 attendances Total number of KEMP 420 260 391 Hospice at Home shifts Total number of 1 to 1 adult 1522 1227 944 bereavement sessions Total number of child 1058 1048 1165 bereavement contacts Total number of complaints 0 1 2 Total number of complaints 0 0 1 upheld Total number of accidents & 1 3 3 incidents (patients) Total number of slips, trips 1 2 2 and falls (patients) Total number of clinical audits completed 6 3 3 Total number of services Surveyed 5 8 7 11
10. What patients and carers say about the organisation Day Hospice Following the consolidation of specialist day hospice from four to three days, increased patient numbers have been seen with enhanced care provided; patient s feedback has been positive day hospice provides me with friendship & support from other patients Kemp has given me back my confidence seeing all the other patients cope with their problems We are still looking at ways of utilising our Mondays; focusing on supporting patients with specific diseases & their carers. With this in mind, day hospice & family support are working collaboratively to provide a more holistic service. The Motor Neurone Disease (MND) Monday group is still very much in the early stages. The group are keen to promote the service to other patients via social media. Cardiology clinic will commence in April 2016; Wyre Forest GP s are aware of the service and we already have strong links with the Heart Failure Specialist Nurses, who will refer patients directly. Following a review of all KEMP services; day hospice has recruited a full time staff nurse with the added responsibility for the co-ordination of our Hospice at Home service. For the first time KEMP will employ its own Physiotherapist which will gives us the flexibility to meet patient needs. KEMP has shown its commitment to the local community, by signing up to the Dementia Action Alliance. Over this coming year we shall be working closely with other local organisations to support people affected by dementia and their carers. Hospice at Home During the year we have recruited new staff to the team; referrals into the service have been steady, towards the end of the year the service has been running at capacity and sadly we were unable to offer our service to some patients. We are in the process of recruiting a seventh member of the team to meet the increasing demand. Family feedback again has been positive. I was getting tired & needed a lot of help in the night I don t know what I would have done without the help Carers professional and caring with an air of confidence- exactly what was needed. 12
Advance Care Planning (ACP) The ACP Facilitators have started a new trial in two of the homes (Ravenhurst and Dunley Hall) meeting with residents/relatives at the point of admission to discuss ACP. This has encouraged the staff to regularly seek advice in difficult/complex situations. The residents have also benefited from the complementary therapy service offer to patients at the end of life. In recent months the ACP Facilitators have been more involved with reactive/crisis management situations. These residents often need daily visits/support to enable the staff to manage the dying process within the home to avoid unnecessary hospital admissions. Please keep this project going, little things make a big difference The education provided has given staff more confidence Family Support services It has been another busy year for the Family Support Team and our referrals for adult support have increased by 121 over the year. We have completed a pilot for a befriending service and due to its success we are planning to extend this over the next 12months. The Drop-in group that we run every week has had to be increased to 2 sessions a week due to its popularity. We have also established some outreach work in 2 local GP surgeries and upstairs in our Coventry Street Shop. This has enabled more of our clients to access support. We continue to gather feedback from our clients when support comes to an end to ensure that the service we provide is of a high standard, and also to ensure that any developments within Family Support are meeting the needs of the community we are here to support. Over the year evaluation forms were issued to adult clients who have received pre and post bereavement support. 75 Evaluation forms sent 42 returned - 56% response rate. Of that 42, 88% stated the support they received from the service made the experience More bearable. This is what some of our clients said about the support they received: It was good to talk through the difficulties I was experiencing keep up the excellent help and support Sue s support was first class 13
I could just be me and say whatever I was feeling. A safe place with someone who helped me in a time of great need. I will always be grateful.. The service is invaluable! The team of supportive people do an extremely special job without their support I would still be in a complete state of sadness and would not have moved forward into the much happier place I am now. KEMP for Kids We continue to develop the support we provide to children, young people and their families. Over the last year we have had a10% increase in referrals. We continue to offer group work and 1-1 work and have been able to take 25 young people and 6 parents on a residential weekend at Malvern Outdoor Elements. Following feedback from previous groups we also now run 2 follow up mornings to allow the participants to come together again and strengthen the new support networks that were formed over the weekend and this has meant that the support network has been stronger and the families feel that they have benefitted from this. The evaluation forms that we have sent out to young people at the end of the support have not been returned and handing them out at the last session has not worked either. We have decided to take another approach and we began a pilot at the end of March 2016 using some assessment forms from Child Bereavement Network that make an assessment at the beginning of support and then at the end and it includes feedback not just from the young person themselves but also from school and parents. We will be in a position to report on this in the next financial year. Welfare and Financial Advice We continue to provide legal and practical advice and support through our Palliative Caseworker (CAB). Evaluation forms are sent out at the end of every piece of work. 195 Evaluation forms sent 102 returned 52% response rate Of that 102, 87% stated they were extremely satisfied with the overall level of service. This is what some of our clients said about the support they received: Fantastic Service, kept in contact with me for the duration. Thank you Anne for your support! You Anne, are fantastic! 14
Advice was free and forthcoming very pleased! I have received nothing but kindness and understanding Everything was dealt with very efficiently and sympathetically. An excellent service 11. What Wyre Forest CCG says about the organisation A significant component of the work undertaken by NHS Wyre Forest Clinical Commissioning Group (WFCCG) includes the quality assurance of services provided for the population of Wyre Forest, that are all or part funded by the NHS. This includes steps to assure the public that the content of this Quality Account is an accurate reflection of the quality of services provided by Kemp Hospice. Throughout 2015/16 WFCCG has engaged in Quality Assurance walk through visits and Contract Quality Review meetings with KEMP Hospice and is therefore in a good position to confirm that, as far as it is possible, the content presented in this Quality Account appears accurate. The Quality Account for 2015/16 benefits from a clear, readable layout for members of the public. There is a good level of explanation for areas selected as improvement priorities and an appropriate selection of individual feedback within the document. WFCCG is pleased to support the improvement priorities for 2016/17 and is pleased to note the achievements made for priorities during 2015/16. The CCG continues to value the willingness of KEMP Hospice to work in partnership with others for the benefit of the local community. A priority to increase access to palliative care services for people living with dementia supports WFCCGs intentions to reduce barriers in achieving the right care in the right place for all members of its local community. KEMP Hospices contribution toward both the Dementia Action Alliance and the intention for Kidderminster to be a Dementia Friendly community is also welcomed. Increasing access to bereavement support services for young people is a valued improvement priority for 2016/17 as are the further promotion of access to support through GP Surgeries and the expansion of groups to support those with specific neurological conditions. In summary WFCCG considers KEMP Hospice Quality Account for 2015-16 to be a balanced and fair report that reflects the high quality of services delivered. WFCCG continues to wish the team at KEMP Hospice every success in continuing to deliver highly valued and well respected services for local people. NHS Wyre Forest Clinical Commissioning Group 15
12. The Board of Trustees commitment to quality The Board of Trustees is fully committed to delivering high quality services to all of our patients whether in the community or within the day hospice. Trustees are involved in monitoring the health and safety of patients, the standards of care given to them, feedback from patients including any complaints along with plans to develop and improve services in the future. They do this by receiving regular reports on all these aspects of care and discuss them at meetings of the Patient Services Committee and the Board of Trustees. Karen Coles RGN & Jackie Turner July 2016 16