Annual Quality Account - Hospiscare · greater insight into the care of the dying is a commendable achievement. NEW Devon CCG looks forward to the development of end of life services

1Hospiscare Quality Account 2016

Because every day matterswww.hospiscare.co.ukRegistered charity no. 297798

Annual Quality Account2016 / 2017

Hospiscare Quality Account 20162

Chief Executive’s statement

I am pleased to present Hospiscare’s Quality Account for 2016. I am delighted that the quality of our services has been recognised by an overall Outstanding rating from the Care Quality Commission following an unannounced inspection.

Our staff work tirelessly to deliver high quality and compassionate care to patients and their families and it is reassuring that this has been confirmed by our regulator. In particular this is a testament to our Director of Nursing, Mrs Liz Gibbons, who retired in 2016 and to our Medical Director, Dr Jim Gilbert.

“The service provided outstanding end of life care and people were enabled to experience a comfortable, dignified and pain-free death in their place of choice as much as possible”

Care Quality Commission Report June 2016

We have continued to follow the agenda set by our Model of Care Review in 2013 and in particular to develop care closer to home. This has progressed with Seaton Friends Hospiscare @ Home completing its first year of operation. The results from this partnership have been impressive; with 94% of patients who said they wanted to die at home doing so and the team’s intervention avoided 98 admissions to acute care out of hours.

We have addressed the shortage of specialist palliative care nurses by introducing a tailored education programme for senior nursing staff to ensure that we can continue to offer expert advice and support to patients and carers.

The evaluation of our volunteer care navigator project has shown that it provides additional support to isolated patients and carers; enriching their networks and enabling them to access a wide range of local services. The demonstrable success of this project has enabled Hospiscare to access charitable funds to extend it throughout Exeter, mid and east Devon.


A project supported by Heath Education South West enabled us to place hospice trained staff in local care homes to work alongside care home staff, teaching good practice in end of life care and passing on hospice skills and experience. This resulted in a 65% increase in advance care planning discussions being offered to residents and their families. Sadly this project has ended because the funding was time-limited but Hospiscare is seeking new funding to maintain this positive impact.

We have progressed our work to enable more people living with dementia to access palliative care. This has been supported by a grant from the St. James Place Foundation, which has enabled us to employ a clinical nurse dementia specialist.

In the coming year we plan to develop our day services to offer a rehabilitative approach which fosters self-management, self-care and resilience. We intend to develop hospice at home and dementia care as funding allows. We support the government’s commitments to end of life care which were published in July 2016 and will continue to advocate for improved end of life care locally.

None of the above would have been possible without our dedicated staff and volunteers who really understand that every day matters for patients and families in our care and go out of their way to make a difference every day. I am very grateful to them and thank them for their compassion, care and commitment.

Glynis Atherton

Chief Executive

“Words alone cannot express my thanks and gratitude to all members of staff and volunteers. You carried out every task with love and humanity, nothing was too much trouble. You all helped to make my wife, at peace.”


Devon CCG Statement September 2016Thank you for giving Northern Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG) the opportunity to comment on the 2015/16 quality account from Hospiscare.

Quality accounts are an important way for the local services that we commission to report on quality and demonstrate improvements to services.

It is clear from the Quality Account presented and from the work that we have been involved in together as organisations over the past 12 months, that your beliefs and values have allowed you to continue to build on the services delivered; often at the most difficult of times for patients and their families. In particular, the CCG would like to acknowledge the commitment of your Clinical Leadership team. Your clinical staff have consistently shown a willingness to engage and collaborate on issues, as well as help shape the future end of life development agenda.

The NEW Devon CCG stated, the regulator Care Quality Commission, following an unannounced inspection gave your organisation an ‘outstanding’ assessment. This is excellent evidence of the quality and consistency of the service provided by Hospiscare.

Your commitment to ensuring that patients are enabled and supported fully in respect of wishing to die at home or within the hospice setting and other community settings is clear. With the majority of your patients being supported at home, the work of the community teams must be acknowledged.


Reflecting on the priorities set out for 2015/16:

Priority 1: The Seaton Development has been a success and enabled a community service to be provided for the benefit of patients and families.

Priority 2: The development and review of day services has seen a positive re-shaping, recognising the continued shift away from dedicated inpatient services, to more people being able to be supported and rehabilitated with a community care focus enabling more people to remain in their own home setting.

Priority 3: The CCG welcomes the successful care home initiative and working in collaboration would wish to learn from this experience.

Priority 4: The spreading of good practice and enabling other practitioners to have greater insight into the care of the dying is a commendable achievement.

NEW Devon CCG looks forward to the development of end of life services in 2016/17 and will continue to work closely with Hospiscare to support the ongoing efforts to provide quality and timely end of life care for the people of Exeter, Mid and East Devon.

On a final more personal note, I would also like to acknowledge the contribution made by Liz Gibbons, Director of Nursing, who retired earlier this year. Liz has been unfailing in her compassion, commitment and professionalism. Liz’s insight and ongoing support has been exemplary and she has been a much-valued colleague and key contributor to the development and improvement of Devon end of life care.

Lorna Collingwood-Burke Chief Nursing Officer

Your clinical staff have consistently shown a willingness to engage and collaborate on issues, as well as help shape the future end of life development agenda.


What we believe Hospiscare’s values

Because we value dying as an important part of living and believe that every day matters to people approaching the ends of their lives, we will

✓ Put the needs of patients, and those close to them, at the centre of what we do

✓ Provide timely and accessible services

✓ Make the best use of our resources

✓ Act fairly according to the needs of patients and our staff; both paid and voluntary

✓ Be sensitive, honest and clear in all our communications

✓ Respect everyone’s contribution to our service and work co-operatively in teams

“Thank you all so much for enabling my relative to spend the last few weeks in an atmosphere of peace, laughter and love. You made her feel so safe and valued at a time when she could have felt frightened and alone.”A relative. September 2015.


What we do Hospiscare is a local charity that delivers adult end-of-life care across Exeter, mid and east Devon.

Our specialist teams at Exeter Hospice, the Royal Devon and Exeter Foundation Trust (RDEFT), at our day centres and in the community deliver expert treatment, care and support to patients and their families. All of our services are supported by the extraordinary efforts of our team of volunteers and are free at the point of delivery.

Hospiscare Community Nursing Teams

Hospiscare has a caseload at any one time of between 650-700 adults living with a life-shortening illness. Most of these people wish to remain in their own home, or within a familiar community setting, supported by the expertise of our community palliative care teams.

The teams are organised in 5 clusters based at GP surgeries, community hospitals or Hospiscare centres. They work closely with NHS and social care teams to meet the needs of individual patients and their families. The person with the illness is central to our care and the specialist nurses, registered nurses and assistant practitioners work together to provide the best possible personalised care, irrespective of diagnosis or circumstance.


Our community nurses have immediate access to Hospiscare’s multi-disciplinary team based at Exeter Hospice. The team provide a seven-day service and an overnight advice line for patients, carers and our health and social care colleagues in partnership with the hospice in-patient unit. This means that people can access our expert knowledge and advice whenever they need it.

Hospital Support Team (HST)

We employ and jointly fund with the RDEFT team of specialist nurses and doctors who work alongside colleagues at the Royal Devon and Exeter Hospital. Our specialist nurses and doctors visit patients and their families on the wards and recommend treatment and options for their future care.

The HST works closely with other services provided by Hospiscare, as well as NHS and social care teams. They do their best to ensure that, with the patient’s permission, appropriate information is shared with colleagues to achieve the best possible outcome for them and their families.

Searle House, Exeter Hospice In-Patient Unit

The Hospice provides 12 beds for patients whose symptoms are complex and difficult to manage or who require round-the-clock nursing care at the end of their life. Hospiscare employs consultants and doctors in palliative medicine who are available to assess and respond to patients’ medical needs 24 hours a day.

Searle House provides treatment and care in a pleasant, comfortable environment with maximum emphasis placed on comfort and dignity. Overnight accommodation is available for visitors and our staff will do everything in their power to meet the needs or wishes of patients and their families. Our chefs prepare and freshly cook all meals on the premises.

“My wife has been in hospitals many times over the years and she has never had such wonderful care and attention as she is getting in here’”A relative. May 2015


“The personal touch, thinking you were the only one they had to care for. I feel so much better after my day at the hospice”Day services patient

Hospiscare Day Services

Hospiscare provides day services at three centres; our Mid Devon Day Hospice, Pine Lodge, in Tiverton, Searle House, in Exeter, and Kings House, in Honiton. We offer sessional events, patient education, outpatients and individual patient-needs assessment, bathing, and a range of complementary therapies, craft and social activities. Our day services are staffed by trained nursing staff and volunteers. Where needed, transport to and from the centre is offered by volunteers.

Day services offer significant benefits to patients and their families when a life-shortening illness makes it hard to get out, curbs normal physical activities or causes social isolation and loneliness. Carers and families can enjoy time to themselves without worrying about their friend or loved one. Our Mid Devon Day Hospice, Pine Lodge, in Tiverton also offers a dedicated service for patients who have dementia as well as a life limiting physical illness. This provides quality care for patients and a vital period of respite for their families and carers.


“The care was excellent and really took me out of my usual environment”Day services patient


What we do (continued)

A Multi-Professional Team

We provide a range of services from the allied professionals who make up our multi-professional team. This includes care management and onward care planning, referral to other agencies, religious and spiritual care as well as bereavement care for the patient and family if required. These services are based at the Searle House but are available via our Day Hospices to any patient referred to us.

Complementary Therapy

We offer complementary therapies to patients and their families in Searle House; in our Day Hospices, at our support groups; in the Royal Devon and Exeter Foundation Trust; in community hospitals; at care homes and when the patient is housebound in the patient’s own home.

Hospiscare has approved the use of massage, reflexology, Indian head massage and aromatherapy. These therapies are used alongside conventional medicine to relieve stress and tension, to aid relaxation and to promote a sense of wellbeing. These therapies help patients to manage their symptoms.


Education and Learning

Our education team work together with local and regional colleagues to share good practice through education events on topics relating to end-of-life care. Hospiscare is committed to supporting our staff, volunteers and others in their professional and personal development. We offer a range of education events, placements and learning opportunities to help inform and educate.

“Loved every minute. Wonderful team. Not morbid at all. I thought that a hospice was where people came to die. I learned how to anticipate and recognise someone was dying and how to communicate with relatives in a gentler and kinder way.”A student nurse


Activity in 2015/2016Community team

People supported by Hospiscare’s community nursing team are twice as likely to be cared for, and reach the end of their lives at home than people who die in Devon without this type of expert support.

2114 patients supported

24,831 telephone calls

15,242 home visits

42% Home

25% Hospital

16% Care Home

17% Hospice

Place of death of patients in the care of Hospiscare’s community nursing team 2015/16


Hospital Support Team

Day Care Services

Exeter Hospice In-Patient Unit

634 patients supported

5295 day care places

348 admissions

44% of admissions to the hospice were from the RDEFT

1681 face to face visits

‘Throughput’ (number of admissions per bed, per annum) was 29, which reflects the acute nature of admissions.

Pine Lodge, our Mid Devon Day Hospice offers one day specifically for patients with co-morbidities including dementia

29

8Average length of stay 8 days


Priorities for Improvement 2016- 2017

Priority 1

Developing Hospiscare at Home Services

The Seaton Friends Hospiscare @ Home Service has been operating for 12 months. The management team have collated and studied service data and examined feedback from patients, carers and health and social care professionals.

Patients and their families feel very safe, well cared for and highly supported. The data (page 23) confirms that this model of service reduces unwanted admissions, provides vital advice and support out of hours and helps people to achieve their preferred place of death. Feedback illustrates how this service relieves patient and carer anxiety by building trusting relationships with a team of skilled and knowledgeable hospice nurses who respond quickly and compassionately to their end of life needs.

Our data indicates that this service would benefit patients in other areas and Hospiscare would like to extend it to them. We are exploring opportunities to do so through partnerships with local charities in five areas of the eastern locality. These discussions recognise and incorporate the service challenges, changes and redesign plans within the NHS and Devon County Council and complement their strategy.

‘The team were able to provide holistic care for people in the community as the staff team included a community nurse specialist team leader, community nurse specialists, registered nurses and health care assistants. This meant that people had more consistency and less professionals visiting them as there was less need for separate NHS district nurse visits.’

‘The Seaton hospice at home service enabled people to receive care from a team consistent throughout their care’.Care Quality Commission Report June 2016


Priority 2

Developing a rehabilitative model in day services

During 2015 Hospiscare reviewed its day services. Our review looked at changing patient and carer needs to ensure our centres were fit for the future.

Background to the review

Hospiscare offers day services at Searle House in Exeter, Pine Lodge in Tiverton and Kings House in Honiton. Exeter is the largest of our three day centres and is equipped with hoists and bathing facilities which means it can accommodate people with complex care needs.

Our current model of day care in Exeter is primarily aimed at meeting the social and psychological needs of patients. This is a structured day, 4 days a week, which focuses on social interaction, emotional support and enables carer respite.

Findings

The key issues that emerged from our research and consultation with staff, patients and volunteers were:

• Patient expectations of day hospice are changing

• Different models of day service are appropriate for different users, e.g. providing options for patients with different levels of dependency and complexity

• The potential for transition services to ease entry to, and discharge from, day services

• Considering a rehabilitative approach to day services and fostering independence – rather than dependence

• Providing options for carers

• The potential for nurse-led out-patient clinics

• Widening access to day services to include more people with non-cancer diagnosis

• Integrating day services with other Hospiscare services, particularly the volunteer care navigator programme

• The impact of the language used to describe day services

• The resource implications of change


Our plans for the future

Leadership

We have appointed a Day Services Manager to co-ordinate, lead and develop day services in our three centres. They will test change and report against agreed outcomes; explore and understand patient and carer needs; support and engage with staff and volunteers and maximise each centre’s potential in the community.

Palliative care rehabilitation

We are introducing a rehabilitative day service offer that will include goal setting and regular review, as described in Hospice UK publication ‘Rehabilitative Palliative Care’ 2015, thanks to a pump-priming grant from St James Place Foundation.

Eventually this will include input from a range of therapists, e.g. physiotherapy; occupational therapy; speech therapy; dietician and access to gym equipment.

Carer respite

Our current, whole day offer of day care provides respite for carers. Whilst our objective is to use our facilities more fully and provide services for more patients we do not want to lose this vital benefit of the service. We plan to extend our day services to include specific programmes for carers.

Integration

Our aim is to have a menu of day service activities, for patients and carers, across our three centres that integrates with our volunteer care navigator programme, bereavement and carer support services.


Priority 3

End of life care for people with dementia

Hospiscare is very aware of the benefits of palliative care to people with dementia and those close to them. Our dedicated day service for people with dementia and complex needs at Pine Lodge Day Hospice in Tiverton, offers a holistic palliative care nursing assessment, personal care including bathing, diversional therapies and psychological stimuli and respite for carers.

In 2015 Hospiscare successfully bid to Hospice UK for funding to support a year’s salary for a clinical nurse specialist in dementia end of life. The purpose of this role is to:

• raise awareness of the end of life care needs of people diagnosed with dementia

• support for people to engage in advanced care planning

• support care providers in enhancing the end of life care for those diagnosed with dementia

• where indicated, offer specialist comprehensive assessment, using dementia specific assessment tools

• educate and train those responsible for giving end of life care to people with dementia

‘Each person using the service had a ‘This is Me’ document devised by the Alzheimers Society which detailed person centred information to enable their individual needs to be met and trigger conversations. For example, to ensure their mug was half full, discreetly ensuring their clothes were on properly and facilitating personal care in a person centred way that reduced aggressive behaviour’’Care Quality Commission Report June 2016


We have employed a clinical nurse specialist in dementia.

A plan for services to people with dementia addressing these concerns has been developed to address the following:

• people with dementia are at very high risk of receiving poor end-of-life care

• dementia is often not recognised as a progressive or terminal illness

• people with dementia are less likely to be referred to specialist palliative care services

• people with dementia are at risk of poor symptom management and the inappropriate use of burdensome treatments such as use of restraints, use of some medications, artificial nutrition and hydration and being transferred to hospital inappropriately

• people with dementia have a unique set of care needs which need additional emphasis and skills

• people with dementia should have opportunities to make informed decisions about their future care at an early stage of their condition and have their palliative care needs addressed

• planning future care can optimise comfort care at end of life, enabling a person with dementia to live well until they die


Priority 4

Working to develop better access to end of life care

In July 2016 the government published its review of choice in end of life care. Hospsicare supports the key commitments outlined in this report and the government’s ambition that “every person nearing the end of their life should receive attentive, high quality, compassionate care, so that their pain is eased, their spirits lifted and their wishes for their closing weeks, days and hours are respected.”

Hospiscare will continue to advocate for improvements in end of life care locally. We are working collaboratively with the Devon adult hospices to achieve this and to share innovation and good practice.

We support the government’s commitment to:

• Developing more personalised care for people approaching the end of life

We will put in place measures to ensure everyone’s preferences are recorded and shared digitally. We will look to expand the availability of options for greater personalisation and control at the end of life enabling more people to decide how money should be spent to meet their needs. We will explore the potential for care coordinators at the end of life.

• Putting in place measures to improve care quality for all across different settings

We will ensure end of life care is part of all the major programmes to transform the NHS, including in the development of local plans and the focus on urgent and emergency care and seven day services in hospitals.

• Identifying and spreading innovation in the delivery of high quality care

NHS England will lead on identifying, adapting, promoting and sharing effective models of end of life care for dying people, including lessons from innovative ‘Vanguard’ sites and new models of care.

• Leading on end of life care nationally and providing support for local leadership, including commissioners, to prioritise and improve end of life care

Working through our commitment to end of life care in the Mandate to the NHS, we will promote and support the Ambitions for Palliative and End of Life Care Framework. We will also engage with Clinical Commissioning Groups and Health and Wellbeing Boards on improving end of life care provision through local strategic planning and commissioning.


• Ensuring we have the right people with the right knowledge and skills to deliver high quality personalised care

We have agreed deliverables on improving end of life care education, training and workforce provision and planning with Health Education England (HEE). HEE will develop a refreshed competency framework for end of life care, implement a national action plan to promote good practice and work with its partners to review end of life care within undergraduate and postgraduate curricula

• Working together with system partners and the voluntary sector to deliver this commitment

We will continue to work closely with our voluntary sector partners including specific projects to improve end of life care in hospital and out-of-hospital settings, promote a national conversation about death and dying and to develop local volunteer networks.

• Strengthening accountability and transparency to drive improvements

We will hold the NHS to account for improvements to end of life care through the Mandate to the NHS and we will hold HEE to account through its own Mandate. For the first time, we will develop a robust set of metrics that capture care quality, patient experience and personalisation in end of life care to track progress nationally on delivering high quality, personalised care. We will publish performance against key measures for every clinical commissioning group to drive up standards in every part of the country.


Review of Quality Performance 2015

Priority 1

Seaton Friends Hospiscare at Home Service

Adults registered with a Seaton GP have had access to this new service provided by Hospiscare and funded by Seaton and District Hospital League of Friends since July 2015. The team consists of registered nurses and an assistant practitioner and they are based at one of the Seaton GP surgeries, close to both surgeries and the community hospital. The service provides 24-hour specialist end of life care at the patient’s bedside backed up by support and expertise from Hospiscare’s multi-disciplinary team.

The aim of the service is to enable people to be cared for where they tell us they want to be at the end of their life and to prevent avoidable admissions when a person’s condition deteriorates or their symptoms become more complex.

This is what the people the team have supported and cared for tell us about the Hospiscare at Home service:

“Only one word covers the help I have received – EXCELLENT!” A patient.

“We have been privileged to receive professional care, advice and reassurance, delivered with compassion, cheerfully when needed, sometimes beyond the call of duty. We are extremely grateful.” A bereaved family.

“It has been wonderful from day one. The staff have given me confidence to me on spending the last short time I have left.”A patient.


Patients and their families are asked to provide real time feedback relating to this and all Hospiscare’s services using ‘I Want Great Care’. The Hospiscare at Home team have scored the maximum 5.00 in four of the last five months reports.

Since the service started the team have cared for and supported 65 people until they died and carried out 1,451 visits. The length of time each patient spent in the care of the team varied between 2-242 days. Each person was asked where they would prefer to be cared when they died.

77% of the people in the team’s care expressed a wish to die in their own home, and with the team’s support, 94% died achieved this. On at least 98 separate occasions an unwanted admission was avoided, almost all of these were at night or at the weekend. This is an excellent example of how two local charities can develop effective partnerships to the benefit of the community within which they serve.

‘People we visited couldn’t believe they were able to access such good care by just making a call and felt strengthened by the support’.Care Quality Commission report – June 2016.

“The care team were highly emotionally intelligent and built a strong connection with my wife and myself. They communicated clearly at all times keeping us all fully aware and involved”.A relative.


Priority 2

Volunteer Care Navigators

Following a successful grant application to the St. James’s Place Foundation a new type of volunteer role; care navigator, was introduced in May 2015. The care navigator role was designed to offer patients and their families practical and emotional support, sustained social contact and sign posting to local relevant organisations.

Volunteers were recruited specifically for the role and undertook a comprehensive five week training programme which covered communication skills, building long term relationships, advance care planning and advocacy, loss and bereavement, understanding patient equipment in the home, lone working, adult safe guarding and navigating and understanding health and social care. The east Devon care navigators are now 15 in number and are led and supported by an assistant practitioner having become a vital extension of the Hospiscare community team based at Kings House.

Our evaluation of the care navigator programme demonstrates that patients have benefited from an enriched one-to-one experience with the volunteer care navigators and have supplemented their existing personal networks. The care navigator’s support has reduced loneliness and isolation, helped to develop social resilience and engendered greater reassurance for the patient and family members alike.

Our staff have welcomed the additional support and have been able to restructure their workload and focus their skills toward the most complex of patients. Staff have been impressed by the level of support the care navigator has provided alongside their trust and professionalism.

“My family have benefited from the knowledge that someone is available to lend a ‘listening ear’. We enjoy a laugh together and she helps me to keep in touch with my family”. A patient.

“It has been a huge help having our care navigators in place. These volunteers have freed up my time, I am able to make more physical home visits and concentrate on the patients that are most poorly”. A Hospiscare nurse.


The volunteer care navigators know that support for them, from a member of the nursing team, is only a ‘phone call away and are offered ‘keeping in touch’ days where they can give and receive peer support, reflect on their experiences and problem solve.

A new cohort of 7 volunteer care navigators have now been recruited and trained to work as part of the Exeter based Hospiscare community service, and we are currently recruiting to the mid Devon area.

‘One person told us how pleased they had been to have been signposted and referred to a specialist breast cancer worker. As well as navigating through the health care and social services system, care navigators offered ongoing emotional and practical support.’Care Quality Commission Report June 2016.


Priority 3

Education programme for care home staff

This project ran from June 2015 until June 2016, was funded by Health Education South West and led by Hospiscare’s Education Manager. Two hospice trained assistant practitioners trained and supported care home staff to improve the quality of the end of life care they delivered and the quality of communication between the patient and family about advance care plans. The project aimed to create stronger links between care homes and Hospiscare services.

Care home staff had the opportunity to work alongside the assistant practitioners when caring for residents; identify gaps in their knowledge and skills; access workshops in their place of work; attend hospice based education courses and spend time in the hospice inpatient unit.

It became clear that this approach to on-the-job education was more successful when the care home manager understood and shared the project aims and prepared the way with their staff. Care home staff quickly realised that the assistant practitioners were there to help and only wanted the best for residents and staff alike. Warm and trusting relationships grew as a direct result of the abilities of the assistant practitioners and their quick understanding of the issues for care home workers.

24 care home providers took part in the project and were asked to complete a competency self-assessment tool. Although the care workers were not usually responsible for end of life discussions or care planning they were often in the best position to pick up cues and pass on information to the registered nurse.

In situations where there were no residents in the care home approaching the end of their life, the assistant practitioners were able to support the care home staff by reinforcing good basic care skills and sharing hospice tips which were useful in the care of frail or elderly residents.

The staff, managers and family feedback has been very positive. 94 care home staff received training and support from the assistant practitioners and 46 care home staff attended hospice based education courses as a direct result of the project. Two care home staff had recently been promoted to team leader roles and attended Hospiscare’s management development course to learn about delegating, coaching and goal setting for staff.


A review of resident records revealed:

• 67% increase in advance care planning discussions being offered to residents

• Increase of 33% in statements of preference and wishes at the end of life

• Increase of 20% in documented discussions with the resident’s family or those close to them when a deterioration was noted

Sadly the funding for this project was time limited. Hospiscare would like to continue given the project’s proven positive impact on the quality of end of life care and will seek opportunities to do so.

‘It was good to have instant feedback. After the shift the practitioner would feedback to me the positives and the improvements’. A care home manager.

‘There was an excellent training manager and education department. The training manager was clearly passionate about their work. The hospice was keen to share their expertise and pro-actively reached out to external stakeholders to provide specialist training. An excellent project was underway’.Care Quality Commission Inspection Report June 2016.

“We have learnt from the hospice staff how to ensure we give pain relief before a task and use distraction methods too”. A care home manager.


Priority 4

Clinical Nurse Specialist Development

The majority of our patients and families are cared for in their own homes by Hospiscare’s community nursing teams. These teams liaise with health and social care community services and have a proven impact on people achieving their preferred place of care and death.

We value our staff and offer them development opportunities wherever possible. We recognise the current national shortage of registered nurses is having a knock-on effect on the availability of senior registered nurses specialising in palliative care.

The nurse to patient ratio in our in-patient unit is higher than the NHS average and our community team continues to support people with a wide range of illnesses, treatment and care needs. Patient numbers have risen year on year and, although we have invested in our community teams, demand continues to outstrip capacity.

Hospiscare recognised the need to address the lack of clinical nurse specialists and to create an attractive career pathway for registered nurses looking for an opportunity to develop. In 2014 we created two new part-time clinical nurse specialist development roles in our Exeter community nursing team, followed by a third post in our mid Devon team in 2015.

These posts have proved very successful and our two clinical nurse specialist ‘graduates’ have both remained with Hospiscare. In future, we plan to develop similar career opportunities across the whole range of nursing roles at Hospiscare.

‘The community nurse specialist had excellent knowledge about them and their circumstances and had built up a good rapport and trust. They visited one person with their GP as a joint visit to manage complex symptoms and there was a sensitive discussion about difficult choices one person made about nutrition’.Care Quality Commission Inspection Report June 2016.


Hospiscare’s Education Manager, supported by our senior clinicians, has developed new Hospiscare master classes for clinical nurse specialists. These master classes cover a wide range of topics relating to palliative and end of life care, at the advanced level required for clinical nurse specialists. To date 134 attendees have enjoyed 7 master classes learning or updating their knowledge and skills in relation to complex pain management, motor neurone disease, clinical emergencies, organ disease, gastrointestinal symptoms and the last days of life. More are planned and this type of learning will be a permanent feature of the Hospiscare staff education prospectus.

“I feel that the Development programme gave me the knowledge and skills with expert advice and support to feel confident in my role developing as a CNS.

Having regular meetings with my Mentor allowed me to talk through scenarios and actively learn”.Tania Davies, CNS.

‘The nurse masterclasses were excellent and the support from both nursing and medical staff invaluable’.Masterclass participant


Quality Assurance and Improvement The Care Quality Commission (CQC) Inspection and Report

The CQC’s new approach to inspecting hospice services came into effect in October 2014 and includes gathering information from the hospice provider, the staff, other organisations they work with, patients and families before and during the inspection.

The inspectors consider six key areas in detail when examining the service under review:

✓ Is it safe?

✓ Is it effective?

✓ Is it caring?

✓ Is it responsive to people’s needs?

✓ Is it sensitive, honest and clear in all our communications?

✓ Is it well-led?

Hospiscare had its first unannounced inspection following this new approach between 21st March and 1st April 2016. The inspection team were present for four days and spent time talking to patients and families receiving treatment and care in the inpatient unit, in Pine Lodge day hospice, from Hospiscare @ home and from two of our community nursing cluster teams. The inspection team talked to staff and examined training and human resources records. The staff involved felt that the CQC’s new approach gave them an opportunity to demonstrate more fully the wide range of high quality treatment and care provided by Hospiscare and to highlight innovative practice.

The Care Quality Commission published Hospiscare’s inspection report in June 2016 and rated Hospiscare overall as ‘Outstanding’. We achieved a good rating for safety, and outstanding ratings for effectiveness, caring, responsiveness and well-led.

The full inspection report is available on the Hospiscare and Care Quality Commission websites.

The following are extracts taken from the full report which can be seen at: www.hospiscare.co.uk


Is the service safe?

The service was safe.

People told us they felt safe receiving the service. They said, “I am very safe here”, “I feel really safe and secure. I felt like I have come to heaven” and “I have faced up to dying and I don’t want to die alone, I’m happy here..

Thought was given to balance risk management and people’s preferences and comfort when they were at the end of their lives. Records showed clear involvement with people about safe management of risk that was also acceptable and proportionate to their needs.

Medicines were prescribed on dedicated treatment charts. These were appropriately completed by medical and nursing staff. There were systems in place for safe prescribing and use of ‘when required’ medicines, medicines administered in syringe drivers and non-prescription medicines for minor complaints. People’s medicines use was regularly reviewed and discussed at daily multi-disciplinary meetings.

The inpatient unit was cleaned to a high standard and records were kept to evidence frequent cleaning throughout the day. It was free from unpleasant odours. Cleaning standards were monitored to ensure people remained as safe as possible from risk of contamination.

Good

“I feel really safe and secure. I felt like I have come to heaven”A patient


Is the service effective?

The service was exceptionally effective.

People consistently said staff gave them outstanding care when they needed it. People’s comments included, “they are always there when I need them, I could not have managed without their support.”

A relative told us, “Thank you for the friendly, effective and supportive service with great care given to allow my relative to remain in the place they love so much”.

There was a beautiful garden area which people could access in their beds if needed, well maintained partly by a loyal group of volunteers.

There were clear assessments and measurable outcomes including increasing advanced care planning for more people, identifying preferred place of death, individualised end of life care planning and a decrease in avoidable admissions. At one nursing home involved in the project, the home manager told us how they had learnt new skills, for example, to aid hair washing and mouth care. They said if they had any questions they could ring the CNS team.

The service continuously looked at the local community demographic to see how best they could provide the service. The service had recognised a need to provide specialist training and end of life care for people living with dementia and their carers.

There had been outstanding work to ensure people living with dementia and receiving hospice services had their needs met.

Outstanding

“they are always there when I need them, I could not have managed without their support.”A patient


Is the service caring?

The service was exceptionally caring.

There were many testimonies in the iWantGreatCare website, a national website which services can sign up to collect online feedback which Hospiscare monitored. The hospice had achieved a five star rating (the highest available). People’s recent testimonies included, “The patient was always consulted and made to feel important and special. The relatives were advised and genuinely care about too. The next stage of the illness was predicted and equipment suggested to deal with it. It was therefore always available when we needed. We know we could call any time for help. The girls work well as a team.”

Staff were positive about the care they were supported to provide. Staff comments included, “It is a special place like an extended family, everyone supports each other. It’s rewarding being in other peoples’ lives at a difficult time, helping them through it, it’s a privileged job”. Staff all spoke about how it was a great place to work. Comments by a volunteer who was part of the ‘Welcome Team’ greeting people and showing people around, setting up rooms and putting people at ease included, “I’m a small cog in a big wheel, but it’s worth it”.

All staff had examples of how staff had overcome barriers to go the extra mile for people. The kitchen staff told us how they had catered for a 90th birthday party for one person and also for their daughter’s wedding. They had put up bunting in the day centre and made it a special day. There had been a 60th birthday party in the garden and kitchen staff had served baked potatoes and a buffet.

We saw during the inspection that care, consideration and compassion were high in the culture of everyone working for the hospice.

Outstanding

“It is a special place like an extended family, everyone supports each other. It’s rewarding being in other peoples’ lives at a difficult time, helping them through it, it’s a privileged job”.A Hospiscare staff member


Is the service responsive?

The service was exceptionally responsive.

People and their relatives told us the way staff responded to their needs was, “Amazing”, and “I can’t believe how supportive they have been”. They felt the Hospice at Home service and community nurse specialists in particular were easy to access and a lifeline for people and their families. People we visited couldn’t believe they were able to access such good care by just making a ‘phone call and felt strengthened by the support.

Hospiscare worked in partnership with other local services. For example, it had been recognised that Hospiscare met people at home who were vulnerable. Therefore they had recently entered into a partnership with Devon and Somerset Fire and Rescue Service. The partnership aimed to work together to share information to enable the provision of home safety visits to vulnerable members of the community and minimise fire risk in the home of vulnerable adults, providing appropriate advice regarding fire safety.

Hospice staff worked closely with local health professionals in a range of roles from GP’s to district nurse teams and domiciliary and care home providers. The discharge co-ordinator said, “It’s imperative we avoid a negative experience for people and get it right. We try to understand family expectations and fears, we listen to warning signs of anxiety and provide appropriate support that meets people’s need, such as a visit home for a day”.

A range of therapies were offered such as massage, aromatherapy, reflexology, reiki, relaxation techniques for patients carers and bereaved relatives. The therapies were adapted to suit the needs of the individual. The team of therapists, which included paid staff and volunteers, worked across the whole service.

Outstanding

“It’s imperative we avoid a negative experience for people and get it right. We try to understand family expectations and fears, we listen to warning signs of anxiety and provide appropriate support that meets people’s need, such as a visit home for a day”.A discharge co-ordinator


Is the service well-led?

The service was exceptionally well-led.

There was an open and positive culture which focused on people. This was reflective of the outstanding leadership and management of this service. People received care and support by leaders who held strong values about person-centred care, and positive connections were promoted that enhanced their experience of the service. People were placed at the heart of the service and the registered manager led by placing emphasis on continuous improvement in all aspects of their care.

The service was forward thinking and constantly looking at ways to improve the service for the local community and in a wider sense improving end of life as a whole. Hospiscare were clear about their values.

Staff commented on how well they felt listened to and supported by management. There was a culture of collective responsibility between teams and services, which was evidenced at the handover meetings with a doctor saying how everyone worked at the same level for the same goal. Staff were able to work across the service which helped them understand each other’s roles and they were trained and supported to do so.

Staff praised the provider and the leadership team for their approach and consistent, effective support. They said they could come to the registered manager, provider or any of the directors for advice or help. All staff felt valued working in the service, and felt motivated to maintain high standards of care.

Outstanding

Staff commented on how well they felt listened to and supported by management. There was a culture of collective responsibility between teams and services, which was evidenced at the handover meetings with a doctor saying how everyone worked at the same level for the same goal.Care Quality Commission Inspection Report June 2016.


What patients and families say about our serviceiWantGreatCare (IWGC)

We examine and review all feedback, both good and bad, to learn from it and make changes where needed.

iWantGreatCare (IWGC) is a tool that collects real time feedback from patients and families and it helps us to identify good practice and opportunities for improvement. Hospiscare is one of seven hospices in the south west which has commissioned this service; designing the questions and working together to improve outcomes for patients. IWGC reports are produced monthly and are reviewed by our Quality Assurance and Improvement Committee and circulated to staff.

Our user experience key performance question is:

‘Are our patients and families receiving good care?’

Our user experience key performance indicator is:

An I Want Great Care minimum monthly score of 4.80

Hospiscare received 335 iWGC posts during the period under review.

April 20154.94

May 20154.90

June 20154.90

July 20154.95

August 20154.98

September 20154.94

October 20154.93

November 20154.84

December 20154.97

January 20164.96

February 20164.98

March 20164.99


Significant event analysis Significant event analysis is conducted into an event or incident which could or did lead to an undesirable outcome for patients, staff or volunteers. The analysis is conducted in a manner of open enquiry to maximise learning and improve treatment and care.

Events are categorised as either External: mainly involving other agencies but reported by Hospiscare staff, or Internal: occurred on Hospiscare premises and involved Hospiscare staff or volunteers.

Significant event Outcome Learning/changes

1. Delayed access to Hospiscare@home service

Internal

Delay created distress for a family at home

Learning outcome for staff to ensure correct telephone numbers are given

2. Patient attempt to self-harm

Internal

Harm averted due to staff action. Full debrief for staff

Review of referral process to Mental Health Services completed

3. Hypoglycaemic eventInternal

Distress for a patient Review of diabetic documentation and staff training completed

4. Misplaced internal incident form

Internal

Delay in formal reporting of a pressure ulcer and discussion with family

Clear process for incident form reporting now completed

5. Verbal aggression to staff from visitors

Internal

Staff and family distressed

Route of miscommunication identified. Staff and family debriefed.

6. Relatives distress about bed availability on the unit for admission

Internal

Agreement about bed space reached

Bed availability monitored and communicated accurately

7. Delayed referrals received by Hospiscare

External

Delay created breach of Hospiscare’s initial contact standard by 2 working days

Agreed process of referring to be via fax and not paper forms

8. Incomplete ‘Just In Case’ prescriptions in the community

External

Delay in patients receiving symptom control relief medication

Improved, clearer prescriptions to enable timely medicines administration

Complaint Outcome Learning/changes

1. Feedback from a relative about communication style of a member of staff.

Partially upheld

Full investigation completed and written response given at their request.

Awareness of importance of communication skills within complex situations.

2. Feedback from a relative following reorganisation of Hospiscare Day Services.

Partially upheld

Full investigation completed, meeting and good discussion held with relative.


3. Feedback from a relative following reorganisation of Hospiscare Day Services.Partially upheld

Full investigation completed and formal written feedback given.


4. A relative raised two concerns: a) about the communication she received from a staff member and b) symptom control advice

Partially upheld

Full investigation completed and formal written feedback given

Staff awareness of appropriate action to take during a sensitive period for a relative. Staff awareness about communication with other professionals caring for a patient

5. Raised by arelative regarding communication within Hospiscare’s Inpatient Unit

Upheld

Formal written feedback given

Staff awareness of communication and receiving relatives who visit the unit


Complaints about our service We welcome complaints as they help us to review services, learn from experience and make changes where needed. We follow a documented complaints policy and offer the complainants an opportunity to meet with us to discuss their concerns. Complaints can be found to be upheld and found in favour of the complainant; partly upheld or not upheld. We received 8 formal complaints in the period under review and the following table describes the key emerging themes.


Complaint Outcome Learning/changes

6. Concern raised by a relative about care and support received from Hospiscare staff.

Ongoing

Full investigation completed with a meeting with external colleagues and family.

Staff awareness of appropriate action to take during a sensitive period for a relative. Staff awareness about communication with other professionals caring for a patient.

7. Concern raised by a relative regarding care received by her husband by Hospiscare.

Partially upheld

Full investigation completed and meeting held. Staff awareness of appropriate action to take during a sensitive period for a relative.

Changes in practice completed. Staff awareness of appropriate action to take during a sensitive period for a relative.

8. Concern raised by relative about support received for themselves and a patient.

Partially upheld

Full investigation completed and meeting held.

Changes in practice completed and awareness highlighted for importance of communication with external colleagues.

We are pleased to share such a positive quality account with you. Should you have further enquiries or want more copies please contact Tina Naldrett, Director of Care, Email: [email protected].


Hospiscare, Searle House, Dryden Road, Exeter, EX2 5JJTelephone: 01392 688000 Fax: 01392 495981www.hospiscare.co.uk

Registered charity no. 297798

Documents

Annual Quality Account - Hospiscare · greater insight into the care of the dying is a commendable achievement. NEW Devon CCG looks forward to the development of end of life services