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St Elizabeth Hospice

Quality Account

2015 - 2016

St Elizabeth Hospice 565 Foxhall Road Ipswich Suffolk IP3 8LX stelizabethhospice.org.uk Registered Charity Number: 289154

This Quality Account was endorsed by the St Elizabeth Hospice board of trustees on 24

th March 2016

Our last Care Quality Commission visit was in January 2014. We have had no visit during the period of this Quality Account.

“To all the wonderful staff, volunteers, fundraisers and anyone else that made it possible for me to have a week’s respite this year. Those two words “thank you” do not begin to cover my gratitude for the amazing care I received. I feel extremely honoured that I am a part of the St Elizabeth Hospice

family”.

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Framework for Quality Accounts Quality Accounts aim to improve organisational accountability to the public and engage boards in the quality improvements agenda for an organisation.

LEADS TO

There is a legal requirement under the Health Act 2009, for St Elizabeth Hospice, as a

provider of NHS services, to produce a Quality Account.

Public accountability

Leadership engaged with improvement of quality of services

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Contents Page

Information about St Elizabeth Hospice 1 Part 1 –Statement on quality 4

Our purpose, vision and principles 4 Statement on quality on behalf of the chief executive 5 Part 2 – Priorities for improvement and statements of assurance 6 from the board

2.1 Priorities for improvement 2016-2017 6

2.2 Achievement of priorities for improvement 2015-2016 9 2.3 Statement of assurance from the board of trustees 14 2.3.1 Review of services 14 2.3.2 Participation in national clinical audits 14

2.3.3 Participation in local audits 15 2.3.4 Research 16

2.3.5 Goals agreed with commissioners – use of the 16 CQUIN payment framework 2.3.6 What others say about St Elizabeth Hospice 16 2.3.7 Data quality 16 2.3.7.1 Information governance toolkit attainment 16 2.3.7.2 Clinical coding error rate 16

Part 3 – Review of quality performance April 2015 - March 2016 16

3.1 Quality overview 16

3.1.1 St Elizabeth Hospice governance policy statement 16 3.1.2 Quality overview 19 3.2 Who has been involved? 21 3.3 Statements provided by commissioning CCG, Healthwatch and OSCS 22

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Part 1: Statement on quality Our vision

Objectives and activities To further develop the high quality specialist and palliative care we provide for the people of Suffolk, Great Yarmouth, Waveney and surrounding areas.

Providing multi-disciplinary holistic specialist and dedicated palliative care services to patients,

their families and carers.

Working alongside other statutory and voluntary agencies to provide specialist and dedicated

palliative care, in a timely manner, where the patient wishes to be.

Acting as a resource to the local community regarding general and specialist palliative care to

increase confidence and competence in improving life for people living with a progressive

illness.

Providing care that respects the choices made by patients and their families so that patients

are treated in their preferred place and die in their place of choice where possible.

Working towards equitable provision of all services, leading to increased use of services by

people with non-malignant progressive disease, and those from seldom-heard communities.

(full version to be found on our website.)

“Improving life for people living with a progressive illness”

Our statement of purpose is: St Elizabeth Hospice aims to improve life for people living with a progressive

illness by:

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Statement from the Chief Executive

I am delighted to present our Quality Account for the past year. The quality of what we offer to our patients, families and carers is our number one priority. These are the people we seek to serve and crucial to the moral contract we have with all of those who work so hard to support us in many ways. I believe we have a strong system of audit and learning to be able to give ourselves, our trustees, patients and supporters, assurance that our standards are high and we strive to meet them. It is always encouraging to see the results of the audits we undertake and the positive feedback we receive. There is no room for complacency however. We cannot and do not pretend that we get it right 100% of the time for everyone. When things are not quite as they should be we need to do a number of things:

Deal with complaints and comments in a timely and open manner.

Accept responsibility, apologise and do everything we can to put things right for those affected.

Demonstrate that we have taken learning from the incident and made changes to prevent it happening again in the future.

Support our staff and develop a culture where it is OK to appropriately challenge each other when required.

This year in particular, we have faced challenges in staffing levels and turnover. We expect the labour market to continue to be a challenging constraint. It is paramount therefore that staff feel positive and proud about being part of the St Elizabeth Hospice team and of the quality of what we offer. I thank all of our staff for the effort and commitment they put into their work each day, and I thank our supporters for continuing to enable us to do what we do. CEO Mark Millar March 2016.

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Part 2 - Priorities for improvement and statements of

assurance from the board

2.1 Priorities for improvement 2016-2017

Areas for improvement for 2016-17 are set out below. They have been selected because of the impact they will have on patient safety, clinical effectiveness and patient experience. 2.1.1 Patient safety Priority one How this priority was decided Rehabilitative palliative care integrates rehabilitation, enablement, self-management and self-care. It is an interdisciplinary approach in which all members of the team work together to support the patient, relatives and carers in achieving their personal goals. It is a ‘whole team’ approach which is best achieved when all professions communicate together, the therapy team wanted to know just how well we are doing. The ‘how rehabilitative is your hospice’ outcome measure was used to rate our practice. This highlighted several areas of improvement:

Deciding, documentation and reflection of person-centred goals.

Supporting patients to maintain their normal routines of daily life whilst in day services, inpatient unit and outpatients.

Educating staff on the importance of providing patients the opportunity to make choices or do things for themselves before offering assistance.

Considering a graduated discharge on return home after a long inpatient admission.

All multi-disciplinary team (MDT) members aware of self-management strategies and upskilled to deliver the basics.

How the priority will be achieved

MDT to look at how person-centred goals are established, communicated and revised throughout the patient’s journey.

Establishing education to current and new staff on the importance of patient enablement.

Review discharge options for long admissions.

Upskill staff on basic self-management strategies and resources. How progress will be monitored and reported

Complete the ‘how rehabilitative is your hospice’ outcome measure.

Regular reports and discussion at the patient services committee.

Increase palliative rehabilitation Explore and improve palliative rehabilitation for patients across hospice services.

Patient safety: rehabilitation Patient effectiveness: cross working Patient experience: increase community volunteer provision

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Priority two How was the priority decided Patient services are delivered through community, inpatient unit and day services. In reviewing these services it has been identified there is a need to improve communication and understanding between the teams and across all the services. It has been highlighted that internal referrals between teams are not always appropriate, accurate and at times promise unrealistic outcomes. To make a start, we have recently published guidelines for each service with the aim of improving communication and understanding which in turn reduces delays due to time wasted going back to referrers for further information, or explaining to service users how they can help. Improvements will also improve respect for each other’s disciplines, knowledge and expertise and also foster good working relations. How the priority will be achieved

Improving communication, respect for roles/expertise/experience across teams.

Improve the knowledge and understanding of services across the teams and increase interdisciplinary working.

Review terms of reference, processes for meetings i.e. multi-professional meetings, case reviews etc. in line with NICE guidance and CQC requirements etc.

Guidelines devised for internal referrals to be utilised and promoted across the teams.

Review and ensure that there is a reliable method of recording referrals accurately.

Examine and review the internal referral process and revise processes accordingly to avoid/minimise delays by identifying what the issues are through audits, reviews and feedback i.e. referrals and waiting times for services, non-contact patients, user questionnaires etc.

Examine and review waiting times and set realistic targets for specific services. How will progress be monitored and reported

The patient services group will lead the project and report at its meetings. A work plan will be devised, agreed and project leads assigned. Activity reports will be produced and monitored. Audits, patient, users and staff surveys will be overseen by the quality assurance and improvement group.

Regular reports and discussion at the patient services committee.

Improve cross team working Explore and improve communication and understanding across all the teams providing services to patients and families.

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2.1.2 Patient experience Priority three How was the priority decided We recognise that volunteers bring with them a broad range of skills, life and work experiences in addition to their individual personalities which strengthen the services we can offer to people by giving more choice, increased resources and variation. In addition the hospice has a wealth of experience and knowledge around working with volunteers in all settings. There are a number of different volunteer positions already supporting patients and their families with their work in the community, such as drivers and befrienders. We believe there is a need to increase the number of community volunteers as well as broaden the range of services they can deliver. This would enable the hospice to provide additional care, emotional and social support to further enable people living at home. How the priority will be achieved

Establish needs by fact finding i.e. what demands do we have on the service we currently offer and whether there are unmet needs, requests for the service are not met through lack of resources.

Explore and look at what other hospices offer and other models in other areas i.e. the Midhurst model.

Review what skills we have in our current volunteer population and what skills do we need.

Establish the role of an emotional and wellbeing (EWB) staff member with skills to support and further develop the role of the community volunteers.

Devise a five year plan for the community volunteer services to include a target number of volunteers, identify training needs and improve coordination.

Community services manager to work with HR and volunteer services on recruitment process i.e. role descriptions, vacancies etc.

In liaison with the head of education, the EWB staff member and other disciplines identify and provide appropriate training.

How will progress be monitored and reported

The patient services group will lead the project and report at its meetings. A work plan will be devised, agreed and project leads assigned. Activity reports will be produced and monitored. Audits, patient, users and staff surveys will be overseen by the quality assurance and improvement group.

Regular reports and discussion at the patient services committee.

Increase community volunteers Explore and increase the number of volunteers to support patients and their families in their homes.

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2.2 Achievement of priorities for improvement 2015-2016

2.2.1 Patient safety Priority one

Recent audits and feedback from healthcare professionals has highlighted that some key information on patients’ management and progress during an inpatient stay could be conveyed to community or hospital teams more quickly and effectively. Minimum standards for producing a discharge summary are generally met using information recorded on the handwritten discharge medication prescription but it is felt that the ease of reading and completeness of this could be improved on. As discharge medication lists are handwritten, the information is not always as clear as it could be for pharmacy purposes or for recording medication lists for future review. This is due to carbon copies being scanned to the iCare computer system. As discharge medication is requested in a handwritten form, any alterations or adjustments are difficult to track and can be time consuming. A separate list of medication is routinely created by nursing staff for patient/relatives use. This duplicates work and creates a risk of differences between the two versions of discharge medication advice. A computerised method of producing both discharge letters and discharge medication prescriptions (TTOs) and a clear protocol for their use will remove or reduce these problems, improving communication with external professionals in addition to optimising safety, effectiveness and efficiency. The use of electronic prescribing systems for the hospice was considered but: evidence confirming its efficacy compared to risks for hospices is limited; and the timescale for investigation, procurement and implementation would be difficult to determine. As this will take a considerable amount of time, progress on electronic prescribing will be reported in the next Quality Account, if progress is made, but will need to be explored over the next few years, depending on external factors and success of this priority. 2015-16 We:

Developed a word based document with drop down menus for medications.

Trained all prescribers on the IPU in the use of the TTO form.

Created a discharge letter as a smart form on the iCare system for all to access and complete. This smart form is in a template that covers all the important holistic care aspects of the admission and is sent on the day of discharge to the GP, as well as a copy given to the patient and sent to the hospital.

Developed a pathway to enable staff to follow in order to complete the process properly.

Trained staff on following this pathway and the need, as well as the method, for completing the forms.

Reviewed these procedures with staff on an ongoing basis.

Created a central drive area for the forms to be stored and so accessed by all who needed it prior to being placed onto the patient’s iCare record.

Implemented checks to ensure that the final TTO was what was placed on the patient record.

Reviewed the format of the forms after about three months, following a trial period.

Discussed with the prescribers any changes needed to be made to the form to make it easier to complete.

Changed the pathway to accommodate the changes.

Started to send the TTOs as well as the discharge letters via NHS.net which resulted in a saving of money as well as time.

Electronic communication of medications and information on discharge Recent audits and feedback has highlighted that some key information could be conveyed to community or hospital teams more quickly and effectively. A computerised method of producing both discharge letters and discharge medication prescriptions will reduce these problems.

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Did we achieve these improvements?

By the prescriber completing the TTO form this has reduced duplication as the nurses do not produce one anymore.

Accuracy and legibility of the prescription is better.

Continuity of care is better as the letters are now sent to the GP on the same day in the vast majority of cases – in the past there was sometimes a delay of weeks to months and now over 90 per cent of letters go out on the same day, and a copy goes with the patient so that anyone who visits the patient as a health care professional has access to the latest information.

This enabled out of hours team to access information around the IPU admission on the day of discharge, as it was electronic, without having to wait for the letter to be processed as was done before.

This electronic documentation has recently expanded to include the respite patients as well as patients who have died in the hospice.

The use of electronic records as well as sending them via email to NHS.net addresses, has improved confidentiality and especially the possibility of it being breached.

2.2.2 Patient experience and clinical effectiveness Priority two The IPU has 18 beds, six of which are in single rooms and the rest in three, four bedded bays. The bays are serviced with its own overhead hoist and each bay has one hoist to be used across the four beds. The biggest problem with the hoist currently being used is that it has to be moved around the bay, so patients either wait or need to use a portable hoist, and this movement has led to equipment failure, causing problems to both patients and nurses. Therefore a decision has been made to replace the hoists, but a few at a time so that we can try out the replacements and ensure we have the best equipment before committing to all 18, if we decide to have each bed serviced by its own hoist. 2015-16 We:

Assessed the need for overhead hoists on IPU from the patients and staff’s perspective.

As a result the hospice installed overhead hoists above beds one and four in each bay this replaced the three mobile hoists which were shared between four beds per bay.

Patients who require hoisting are allocated to either bed one or four in the bays.

The above bed hoists in the six side rooms were also replaced as they were in excess of 10 years old, beginning to fail and due to their age spare parts were obsolete.

The main bathroom hoist was also replaced as it was also in excess of 10 years old, beginning to fail and due to age spare parts were obsolete.

The use of hoists in the inpatient unit (IPU) In the last refurbishment of the IPU, we installed an overhead hoist in each bay that could be used for all four beds. Those now need to be replaced. We wish to ensure we purchase replacements that are safe and comfortable and are easy to use for staff.

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Did we achieve these improvements?

The aim was to initially install hoists above beds one and four in each bay and then review – this was achieved.

The aim was to replace outdated hoists in the six side rooms and main bathroom – this was achieved.

A spare mobile hoist has been stored for times when the number of patients who need hoisting exceeds the above number of bed hoists that are available or for incidents where a hoist may be needed in another area i.e. patient falls/collapse in areas outside of beds one and four in the bays, the side rooms or bathroom – this has been achieved.

Patient and staff feedback has been positive in response to the hoists being installed above the beds.

The hoists have enabled patients to be hoisted more promptly and as such have improved comfort and dignity.

Staff are able to be more reactive and are using time more efficiently and effectively.

Following positive feedback and with the increasing dependency it is recommended that hoists are installed above the remaining beds two and three in each bay. This will ensure all beds have hoists thereby reducing the workload associated with moving beds when patients who are allocated bed two or three deteriorate and need hoisting so need to be moved to either bed one or four. Bed moves increase workload for nursing staff, the domestic team and also can cause patients/families distress.

2.2.3 Patient experience Priority three In the patient services group we have been exploring the need for seven day a week working across departments. Doctors, nurses, healthcare assistants and the spiritual care team are available seven days a week. What is the need for the emotional wellbeing team and the therapists to be also? Currently most referrals, received by the emotional wellbeing team (family support workers - social workers, art and music therapists, counsellors and bereavement co-ordinator) are for emotional support for patients and their families. The minimum response time for these referrals is three days. The reasoning behind this is that what may be deemed as emergency situations are the responsibility of statutory organisations and there are duty systems in place to deal with them as they arise, for example child or adult safeguarding or issues relating to mental health e.g. psychotic episodes, suicide attempts. Because of bank holiday weekends, in particular, response time can be longer than three days. There is also some discussion to be had around the skills and knowledge this team have which could support the larger multi-professional team that is currently unavailable at weekends and on bank holidays. The therapy team (physiotherapists, occupational therapists and complementary therapists) also work Monday to Friday currently. However some patients are admitted to the ward for rehabilitation, and do not receive the same level of support they have during weekdays. We also have a large and newly equipped gym, which could be utilised every day.

Seven day a week service To review our current service, investigate areas of expansion and to look at offering more services across seven days if appropriate, to meet service demand and needs of patients.

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2015-16 We:

Surveyed 10 other hospices exploring their service provision at weekends. Seven responded to the survey and none had social workers or counsellors available to work at weekends, or plans to do so. The reason for this was given around insufficient funding and/or no clear evidence of need.

Reviewed the referrals made to our emotional wellbeing team over 12 months. This showed the majority of need was met within the expected response times. The exception being on bank holiday weekends.

Have spiritual care staff/volunteers who work weekends or on call, and therefore are meeting patient and family emotional wellbeing needs well without the need to make a change.

We have identified that occupational and physiotherapy hours at weekends would be good to offer and could speed up discharges. However we have rehabilitative care plans, and the nursing team working on the inpatient unit are given training around issuing walking aides and will follow care plans.

Now provide a respite facility to young adults over the weekend.

Now have secretaries working up to 7pm weekdays and Saturdays, who support our advice line and referrals at the weekends

Reviewed admissions, discharges and waiting times on the inpatient unit. Waiting times were met for 70 per cent of referrals. 60 per cent of patients admitted were within three days of being discussed at the referral meeting. Nine per cent waited longer than eight days for an admission. Eight per cent of patients died waiting for a bed and were within hours/days of their lives when referred to us. The review concluded there were a very small number of patient admissions which could have been made at the weekend that was not. However, there are doctors working on the ward every weekend who see all inpatients and do admit urgent patients. A consultant is also on call and will visit as needed. Patients at home and in care homes are supported by specialist nurses seven days a week. The occupancy of the ward is very high, at 90 per cent, so there will be a balanced view to be had in this coming budget around the possible additional medical cost verses the need of more weekend admissions.

Also being considered is whether resources should be moved from weekdays to weekends.

Did we achieve these improvements?

We thoroughly reviewed the need, and added more resources with the highest gain, i.e. supporting the community nurses and our advice line, and young adults needing short stay breaks.

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Priority Four Patients and their families who receive our care have a right to provide feedback and input into that service provision. They also have a right to inform if what is being provided is of the standard that they want. Both national drivers, as well as encouragement from the board of trustees and our local CCG commissioners have led us to consider objective ways of measuring our impact on the people that we serve. Although we do already measure our service by other means such as activity data, key performance indicators, audits and surveys, Patient Related Outcome Measures (PROM) are regarded as being important measures of the service provided especially in end of life care. The PROM should measure that:

Pain and other symptoms should be controlled effectively.

The individual, carers and family should feel well supported.

The individual, carers and family should feel confident in the skills and knowledge of their health and social care professionals.

The individual, carers and family should know who to contact in an emergency.

The individual should be able to die in their place of choice. In this year we will focus on the first three measures suggested. 2015-16 We:

Trained two staff members in the integrated palliative care outcome measures. They attended training in Kings College around the development as well as the implementation of the PROM.

Transferred the iPOS to our iCare system and so created a smart form to match the paper copy.

Staff were trained in the use of the iPOS form.

This was initiated in day care and subsequently, the outpatient department.

Due to circumstances in the IPU as well as the community teams, the implementation has not been at the same pace but staff have been identified who will champion this; there has been some implementation already but not to the level as has occurred in day care and outpatients.

We have reviewed the implementation of the iPOS, as well as the impact and benefit of our services by repeating the iPOS and this has shown an improvement inpatient burden.

We continue to encourage and train staff to use the iPOS as an aid to their assessment.

The implementation of patient related outcome measures There is a need to demonstrate the quality of care that we provide. This is ever more required by our potential patient population as well as our donors and commissioners. The best people to judge the service that we provide is the people who receive it. This is validated by the annual VOICES survey as a useful data source and should be incorporated into local performance management structures. Also the DH (2009) paper as part of the end of life strategy “Quality Markers and Measures for EoLC” also recommends the development of local Patient Reported Outcome Measures (PROMs) for EoLC.

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Did we achieve these improvements?

The iPOS is an assessment from the patient’s perspective and so has helped us to see the benefit (if any) that we have had on the patients care.

It has been best implemented in day care and the average implementation rate is around 70 per cent (our target was 50 per cent).

Day care patients are particularly identifying that spiritual issues, family being worried, lack of energy and poor mobility are the problems causing the most concerns.

Patient benefit from our services is being identified using the iPOS, in particular around psychological support, providing of information and symptom control

The implementation is still lagging behind in the other service areas but staff are trying to encourage its use.

We will continue to increase the number of patients using this iPOS tool to assess them holistically.

2.3. Statement of assurance from the board of trustees

St Elizabeth Hospice is constantly aiming to improve quality of care and services to patients and their families. It demonstrates this through its governance structure. It has a culture of openness and learning by its mistakes and not apportioning blame. The following are statements that all providers must include in their Quality Account. Many of these statements are not directly applicable to specialist palliative care providers. 2.3.1 Review of Services During 2015-2016 St Elizabeth Hospice provided and/or subcontracted the following NHS services:

Inpatient unit

Day service unit

Hospice at home

Community clinical nurse specialists and healthcare assistant

Family support services, including bereavement service, art and music therapists and chaplaincy team

Therapy services, including, complementary, physiotherapy and occupational therapy

St Elizabeth Hospice has reviewed all the data available to it on the quality of care of these NHS services. The income generated from the NHS in relation to services reviewed in April 2015 - March 2016 represents 24% per cent of the total income generated for the provision of these NHS services by St Elizabeth Hospice for that period. 2.3.2 Participation in national clinical audits As a provider of specialist palliative care, St Elizabeth Hospice is not eligible to participate in any of the national clinical audits or national confidential enquiries as they did not relate to specialist palliative care. We will also not be participating in them next year for the same reason. (Mandatory statement).

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2.3.3 Participation in local audits The schedule below shows the local audits that St Elizabeth Hospice will carry out in 2016-17.

Audit diary chart 2016/17

Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sep 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

Inpatient unit (rolling) AO AO AO AO

Drug (quarterly) VJ VJ VJ VJ

Medical x 3 yearly SHO SHO SHO

H@H (rolling) AO AO AO AO

Staff survey (annual) SMT

Community audit (rolling)

AO AO AO AO

Incidents – patients (quarterly)

LL LL LL LL

Incidents – non-patients (6 monthly)

AO AO

Complaints, compliments concerns (monthly)

ST ST ST ST ST ST ST ST ST ST ST ST

Discharge (bi annual) LL

Documentation (6 monthly)

CNS FSW

Education/training (annual)

SA Edu

Day care (rolling) AO AO AO AO

Controlled drug audit VJ VJ

Infection control report LL LL LL

Quality Account VJ Additional Audits May be necessary

Diet & nutrition AO

Falls LL

Hospice UK – quality metrics (falls, pressure ulcers, medication incidents)

LL LL LL LL

Abbreviation Table H@H – Hospice at Home EWT – Emotional Wellbeing Team IPU- Inpatient Unit SHO – Senior House Officer DC – Day Care Edu – Education Department Coloured boxes with initials represent the members of staff in charge of audit

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2.3.4. Research There were no patients receiving NHS services provided or subcontracted by St Elizabeth Hospice in 2015-2016 recruited to participate in research approved by a research ethics committee. (Mandatory statement). There have not been any national research projects in palliative care in which our patients were asked to participate. 2.3.5. Goals agreed with commissioners St Elizabeth 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 because it is a third sector organisation. It was therefore not eligible to take part. (Mandatory statement). 2.3.6. What others say about St Elizabeth Hospice 2.3.6.1 No CQC inspection during this period. 2.3.7. Data quality

St Elizabeth Hospice did not submit records during 2015-2016 to the secondary uses service for inclusion in the hospital episode statistics which are included in the latest published data. (Mandatory statement).

This is because we are not required to submit data to this system.

2.3.7.1 Information governance St Elizabeth Hospice did not hold a formal contract with NHS Suffolk for 2015-2016 for information quality and records management, assessed using the information governance toolkit version. (Mandatory statement). The hospice achieved level two compliance during the year.

2.3.7.2 Clinical coding St Elizabeth Hospice was not subject to the payment by results clinical coding audit during 2015 - 2016 by the audit commission. (Mandatory statement).

Part 3 Review of Quality Performance 3.1 Quality overview 3.1.1 St Elizabeth Hospice governance policy statement;

The organisation aims to ensure the overall direction, effectiveness, supervision and accountability of the organisation by putting in place a system and processes which:

achieves continuous quality improvements by identifying and instigating best practice, learning through mistakes, and creating an environment in which excellence can flourish

ensures compliance with relevant regulations and legislation

ensures efficacy and effectiveness

ensures that the charity meets its objects as outlined in the memorandum of association.

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St Elizabeth Hospice governance structure;

The quality assurance and improvement group The quality assurance and improvement group has a rolling audit programme as well as the ability to prioritise new audits if this response is required. The partnership group The partnership group has now been established for over twelve years. During this time the group’s representation with both patients and carers with the addition of hospice staff on the committee has engaged the group to look at a number of issues and topics that affect both the patients and other service users. It is with sadness but a condition of this group that we lose members due to the nature that we have patients on the committee, and it does affect the group when this happens as the group does form a good friendship relationship with each other. On a positive note we did manage to complete a few tasks to improve facilities for patients with the hospice and this proves that we are succeeding in our role. We are always actively looking for new members to join the group and this does prove a difficulty but with the help of hospice staff who can identify patients and their family who may like to join the group and so therefore we can continue to represent patients and carers and assist the hospice in their duty in provision of care. Achievements:

Introduction of talking apps on iPads for patients who may be having difficulty communicating.

Finally settled on suitable TV remotes for patients on the IPU following a trial.

Assisted in the upkeep checks maintenance of the “possum room” a specialist room on IPU.

Board of trustees

Governance committee

Finance committee

Income generation committee

Patient services

committee

Nominations committee

Remuneration committee

Partnership group

Care agency board

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Confirmation that the adaption of the toilet flushes that we asked could be

done have been done and are working well and have made life easier for

patients and staff.

Write a blog and Facebook entry for the hospice social media site.

Some members have joined the ambassador program.

Continued to ensure that the patient information leaflet is available on the IPU

and the online one is up to date for access by families travelling out of the area to

find hotels, shops, restaurants etc.

Action Plan 2016

The hospice has undergone a major re-vamp in image and provision of service in the last year and the partnership group has really stood still for the last twelve years, so the plan this year is to bring the group up to the same provision of service as the hospice. We would like to interact with the young adult group and make the group cover all aspects of the hospice in full, and receive the information from all areas, so we can become more effective. The partnership group still strives to promote proactive partnership with the hospice, and we feel with this re-vamp the group will be able to provide a better listening ear in overcoming issues that we feel affect patients and carers who use the hospice services.

Ian Ewers-Larose MinstLM Chairman Partnership Group St Elizabeth Hospice.

The accountable officer is also the registered manager and a member of the locality intelligence network group. She monitors drugs incidents, makes three monthly drug incident reports and assesses the storage, destruction and use of controlled drugs formally every six months. Each directorate has a risk register which is updated regularly. Risk assessments and incidents are raised at the health and safety group.

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The hospice has its own responsible officer, Dr Kelvin Bengtson. All doctors are now expected to be appraised on a regular annual basis and then revalidated every five years. All systems and processes are in place to ensure that this happens. The Caldicott guardian is Dr Kelvin Bengtson. 3.1.2 Quality overview In 2015-2016 St Elizabeth Hospice cared for 2084 patients and their families across the range of services.

This is a selection of patient and carer comments on our services

Hospice at home audit

‘I had no preconceived expectations but I felt totally able to trust them and their expertise and judgements. Very grateful’

‘All of the One call team were excellent, allowing my dad to stay at home and when we wanted some advice day or night we got the help. My dad told me he got a lot more information from the nurses and he was more relaxed and happy’

‘The response from the team the last 12 hours before my mother’s death was exceptional. It was Christmas; we did not expect the support that we received that night. Mum died peacefully with her family around her. This has helped during the grieving process.’

‘Excellent 1st class service. My husband wanted to stay at home and we were able to do this with the help of H@H. Words cannot express how grateful I am. Thank you so much.’

Community nurse specialist feedback audit

‘We felt lost and then we were found (Don’t know what we would have done if no hospice help).’

‘What a group of wonderful people. More people could stay in their own homes to die if there were more of them.’

‘I was really impressed with the service and could not have coped without it. I thought you had got the whole service right.’

‘The nurses showed kindness and were the first people to listen and explain the pain than can accompany cancer.’

Day care survey

‘I have benefitted significantly as a result of my time at day care and the knowledge and help I received will be an enormous help in coping with my various medical conditions for the rest of my life.’

‘Outstanding day care centre – were maintained with superbly caring staff and volunteers. Also everyone was very cheery and smiley – so important. Thank you.’

‘Coming to the day care unit is the light of the week for me. I enjoy it so much it also gives my dear wife a day off as she looks after me almost 24/7. It is nice for her to have this day and she looks forward to it as much as I do. Thanks a million.’

‘I had an enjoyable time and appreciated their attention and thoughtfulness of everyone.’ Inpatient unit

‘I felt better as soon as I entered the hospice, wonderful people and always so nice.’

‘I live alone and was in pain 24/7. I feel better after a few days in the hospice’

‘Extremely well run and efficient organisation’

‘Care in hospice was just right as not coped at home’

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Complaints and compliments All complaints received at St Elizabeth Hospice are taken seriously, fully investigated and processed as laid out in our complaints procedure. We received 21 complaints throughout the year, covering all patient services. In the same period we received 220 compliments, covering all patient services, retail, volunteers and support staff. Two extracts are reproduced below: “A very big thank you to you all (community HCAs) for all the dedicated love, care and concern given to Colin and the support you have given to me in the four weeks you have been visiting. Every day there was happiness, laughter and lots of smiles, a real tonic to us both. Oh how we will miss you all. Thank you for your wonderful service”.

“May I offer my heartfelt thanks for the wonderful care given to my aunt during her three weeks in the hospice. I know she felt very vulnerable while dealing with her failing health and eyesight during that time but you all did your best to make her comfortable and listen to her concerns. …Fortunately you were able to stabilise some of her nasty symptoms which continued when she went home, at her request, with the wonderful assistance of the Hospice at Home team. We cannot thank you enough for the care and attention given to her and ourselves in the last days leading to her peaceful death with us around her bed.”

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Quality markers we have chosen to measure In order to inform the governance process St Elizabeth Hospice monitors outcomes across six different areas of the hospice work monthly, using recognised tools and national benchmarking data. This enables the board to look at areas of development over a period of twelve months to monitor progress and identify actions for any areas of concern. The hospice has outcome key performance indicators relating to inpatient unit and assessing outcome of pain, psychological, spiritual and social interventions. We also ask when collecting this data, if the patients feels they were treated as a person, and would recommend us to their families and friends.

Domain Outcome Tools

Patient experience Relief of symptoms - iPOS - patient surveys/questionnaires

Meeting patient’s needs - audit of complaints and compliments

Patient choice Achievement of preferred place for care

- audit of preferred priorities for care - audit of advance care plans - ensuring patients are part of the

decision making process by checking capacity and obtaining consent for every intervention and documenting it

Patient safety Maintain a safe environment

- audit of patient incidents - audit of drug incidents - audit of hospice acquired infections

audit of complaints, concerns and compliments

- implementation of regulations regarding deprivation of liberty

Effective workforce Employer of choice - staff retention - working days lost due to sickness - investment in training and education - staff survey - no blame culture

Financial sustainability Financial health - audited accounts

Organisational effectiveness

Widening access - increase in patients with non-cancer diagnosis

- expansion of geographical area

Use of resources - uptake of day care places - time in service - expansion to providing care closer to

the patient such as satellite clinics

3.2 Who has been involved

Chief executive officer

Senior management team

o Director of patient services

o Medical director

o Director of corporate services

o Director of income generation and marketing

Quality and improvement group

Partnership group

Governance committee

Board of trustees

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3.3 Statements provided from commissioning CCG, Healthwatch and OSCS The following statements were made in response to receiving this Quality Account.

Ipswich and East Suffolk Clinical Commissioning Group

Ipswich and East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group, as the commissioning organisations for St Elizabeth Hospice, confirm that the Trust has consulted and invited comment regarding the Quality Account for 2015/2016. This has occurred within the agreed timeframe and the CCGs are satisfied that the Quality Account incorporates all the mandated elements required. The CCGs have reviewed the Quality Account data to assess reliability and validity and to the best of our knowledge consider that the data is accurate. The information contained within the Quality Account is reflective of both the challenges and achievements within the Trust over the previous 12 month period. The priorities identified within the account for the year ahead reflect and support local priorities. Ipswich and East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group, are currently working with clinicians and manager from the Trust and with local service users to continue to improve services to ensure quality, safety, clinical effectiveness and good patient/care experience is delivered across the organisation. This Quality Account demonstrates the commitment of the Trust to improve services. The Clinical Commissioning Groups endorse the publication of this account. Barbara McLean Chief Nursing Officer HealthWatch

Healthwatch Suffolk has the roll to produce a statement on whether or not we consider, based on the views of local people and other information that we have access to on the provider, the QA report is a fair reflection of the full range of services provided. Healthwatch Suffolk has received very few comments about St Elizabeth Hospice this year and therefore will not be able to produce a statement. Please continue to send us future Quality Accounts as we may gather feedback on the service over the coming years. Many thanks Jenny Ward – Information Services Officer Healthwatch Suffolk Scrutiny Group

Suffolk Health Scrutiny Committee

As has been the case in previous years, the Suffolk Health Scrutiny Committee does not intend to comment individually on NHS Quality Accounts for 2016. This should in no way be taken as a negative response. The Committee has, in the main, been content with the engagement of local healthcare providers in its work over the past year. The Committee has taken the view that it would be appropriate for

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Healthwatch Suffolk to consider the content of the Quality Accounts for this year, and comment accordingly.

County Councillor Michael Ladd

Chairman of the Suffolk Health Scrutiny Committee

If you have any feedback on this document, please email our enquiries line on enquiries@stelizabethhospice.org.uk or visit our website stelizabethhospice.org.uk and complete our form for comments, compliments or complaints, which is found in the contact us section.