Quality Account 2014/15

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ContentsIntroduction...........................................................................................................................................4

Acknowledgements...............................................................................................................................5

Who we are and what we do.................................................................................................................5

The John Taylor Experience...........................................................................................................6

Community Interest.......................................................................................................................8

Part 1a The Owners’ Statement...........................................................................................................10

Part 1b The Chief Executive/Board Statement....................................................................................10

Part 2 Quality Improvement................................................................................................................11

Our People...................................................................................................................................11

Defining Qualities.........................................................................................................................12

External Scrutiny..........................................................................................................................13

Visits by our Commissioners, Local Area NHS Team....................................................................15

Community Interest and NHS Policy............................................................................................15

Patient Opinion............................................................................................................................16

Compassion.................................................................................................................................16

Commitment................................................................................................................................17

Courage........................................................................................................................................17

Communication...........................................................................................................................17

Competency (see also Our People)..............................................................................................17

Safeguarding in the Public Interest..............................................................................................18

Serious Incidents..........................................................................................................................18

Examples of how we have used Data and Analysis to Improve Patient Care...................................21

Pressure Ulcers............................................................................................................................21

Lessons Learnt and Actions Taken...............................................................................................22

Further Actions Suggested by Staff..............................................................................................22

Slips, Trips and Falls.....................................................................................................................22

Preventative Actions taken..........................................................................................................23

Our ‘People-based’ Systems for Ensuring Patient Safety.............................................................23

VTEs.............................................................................................................................................25

UTIs..............................................................................................................................................25

Medication Errors........................................................................................................................25

Never Events................................................................................................................................26

Our Never Events policy...............................................................................................................26

Patient and Staff Experience............................................................................................................26

Friends and Family Test...............................................................................................................26

Patient stories..............................................................................................................................26

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Patient Opinion............................................................................................................................26

Facebook......................................................................................................................................27

Direct feedback............................................................................................................................28

Complaints...................................................................................................................................28

Patient Reported Outcome Measures.........................................................................................28

Staff Survey results/feedback......................................................................................................28

Culture, being open, leadership and escalation...........................................................................28

Equality and Diversity..................................................................................................................28

Duty of Candour...........................................................................................................................29

Other Issues.....................................................................................................................................30

Political astuteness of local and national priority focus...............................................................30

What we will/are doing to prepare and contain Ebola................................................................31

What we are doing to focus on sepsis prevention and management..........................................31

Part 3 Our Priorities for the Next Year...........................................................................................31

Patient Experience.......................................................................................................................32

Clinical Effectiveness....................................................................................................................32

Part 4 The Quality of our Services - Data........................................................................................34

Other Quality Indicators..................................................................................................................34

Cross Infection Auditors...............................................................................................................34

Audited Account and Companies House......................................................................................34

CCG Quality Review Group..........................................................................................................34

Revalidation of Doctors................................................................................................................34

Environmental Health – Food standards – 5 star rating...............................................................35

External Health and Safety consultant once a year conducting an environmental audit.............35

Part 5 Statements...........................................................................................................................36

Mandatory and Legal Statements................................................................................................36

Statement of Directors’ Responsibilities......................................................................................36

Healthwatch.................................................................................................................................38

Appendices..........................................................................................................................................39

Appendix 1: The Duties and Authority of John Taylor Hospice Membership Council......................39

Appendix 2 Commissioning for Quality and Innovation for 2015 to 2016.......................................41

CQUIN 1: Every Moment Matters – Patient and family Access to Wi-Fi......................................41

CQUIN 2: Macmillan Values Based Standard...............................................................................41

Appendix 3 - Our Understanding of Accountability – the company handbook...............................42

Appendix 4 John Taylor Integrated Approach to Safeguarding.......................................................44

Essential Definitions in Law..........................................................................................................45

Safeguarding in the Public Interest..................................................................................................46

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Safeguarding and Whistle Blowing..............................................................................................48

Safeguarding in the Public Interest – Gifts and Hospitality..........................................................49

Safeguarding in the Public Interest – Identification and Security................................................50

Glossary...............................................................................................................................................52

Community Interested Company.....................................................................................................52

CQUIN..............................................................................................................................................52

Delayed Transfers of Care................................................................................................................52

Duty of Candour...............................................................................................................................52

Key Lines of Enquiry (KLOEs)............................................................................................................52

Performance Indicators...................................................................................................................52

Serious Incidents..............................................................................................................................53

The ‘6 Cs’.........................................................................................................................................53

‘Never Events’..................................................................................................................................53

PLACE audits....................................................................................................................................53

Patient Reported Outcome Measures.............................................................................................53

RAG Rating or Red Amber Green.....................................................................................................54

Re-admission within 28 Days...........................................................................................................54

TUPE................................................................................................................................................54

Urinary Tract Infection.....................................................................................................................54

Venous Thromboembolism..............................................................................................................54

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IntroductionWe are pleased to publish the first Quality Account for John Taylor Hospice Community Interest Company to report on the quality of the care we provide and to show the improvements in the services we provide to our patients and local community.

We would like to point out that in this account we have included subjects that are wider than the standard headings required of NHS organisations because, although we do deliver services on behalf of the Birmingham Cross City NHS Clinical Commissioning Group, we also work with other organisations, regulators, funders and community groups in our capacity as a community interest company.

As a CIC there are some subjects that NHS organisations are required to report in their Quality Accounts such as delayed transfers of care and readmissions that don’t apply to what we do, therefore, we have omitted them.

We believe this Quality Account gives you an ‘easy to understand’ description of the quality in a community interest company commissioned to deliver care on behalf of the NHS and providing care direct to the public, funded by taxpayers and direct investment by local people and grant-giving bodies and trusts. It is an affirmation of the purpose of our company and explains why we continually work to make ‘every moment matter’ in terms of the experience of people who come to us for care, work and volunteer and in compliance with national standards for patient safety and corporate governance.

Acknowledgements This is our first Quality Account and we would like to thank all of the care staff, managers, Membership Council and our stakeholders in the NHS Clinical Commissioning Group and the local Healthwatch group for their parts in writing this.

Who we are and what we do Founded in 1910 to assure dignity in death regardless of wealth, John Taylor Hospice is the oldest non-denominational hospice in the UK. Our foundation was based on reciprocity and the needs of local people. In 1948 our founders gifted us to the NHS and, with the passage of the Health and Social Care Act 2012, the employees at John Taylor Hospice became the owners of the hospice. John Taylor returned to its roots, becoming a social enterprise or community interest company limited by guarantee.

This means the company income can only be used for the purpose of the company – to reduce the personal and social cost of illness and death – there are no shareholders and no dividends are paid. Since 2011 the NHS has contracted directly with the CIC for care. The first three years, under the terms of the Health and Social Care Act, were a ‘spin-out’ contract. In that time the new CIC doubled the number of patient contacts annually, from 5,000 in 2011

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to 10,000 in 2014. We work with adults across the spectrum of illness that foreshortens life.

The care that we provide is funded by tax payers (through our NHS contract) and directly with investment or donation from individuals, companies and community groups. We deliver supportive care, end of life care, palliative care and specialist palliative care, providing a seamless journey with care that flexes with the needs of the patient. The NHS is a commissioner of this care and 95% of what we do in people’s own homes.

The John Taylor Experience Care from John Taylor for most people starts with our front of house team. They are the first people that people who want to use our service, want to support what we do or want to make a referral will speak to. The front of house team is skilled in ensuring callers on the phone and at the hospice are directed to the right person. They will take confidential messages and let people know who will phone them back and when.

Our website has confidential online referral.

We hold an inter-disciplinary daily triage meeting to review all new referrals, admissions that may have happened overnight and, on a red amber green rating system, a review of people whose needs are fluctuating or for other reasons may need a change in their care.

Social Media works for people choosing John Taylor.

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John Taylor means complete care - what you need, when you need it, where you need it up to 24 hours a day, seven days a week, in your home or at the hospice – your home from home. We are there all the way understanding what each person needs so that the decisions that are made are made on each person’s terms. This includes, friends, family, significant people and pets.

We use the evidence-based Macmillan Values Based Standard Framework consistently across everything that we do. In 2015, together with our NHS commissioners, we have put these standards together in the form of a CQUIN or quality measure.

We have a comprehensive annual audit programme that checks that what we do matches the standards set. Family comes first, whatever the make-up and size of your family, every moment really does matter. As well as our audit checks, we have a subcommittee of our company Board for Assurance, Regulation and Audit (ARAC). The committee has two working groups, our Clinical Governance Committee and Workplace Safety Committee.

We are externally inspected and externally regulated. This means that people can see online how we are doing. Visit the Care Quality Commission, Patient Lead Assessments of the Clinical Environment (PLACE) and Birmingham City Council Environmental Health inspectors.

We are also regulated by Social Enterprise UK. We are also a member of the Social Enterprise Mark and meet the Gold Mark standard, one of only three social enterprises to have achieved this.

All of our staff are professionally or vocationally qualified and everyone receives supervision from an appropriately qualified supervisor. We use a specially designed computer database to ensure all of our staff meet the annual training standards for their role. Continuity matters too, we use an electronic system to schedule when our staff work across every 24 hour day 365 days a year. This means that we can tell you who will be working with you and you can get to know a smaller team of our staff - building trusting relationships is what makes ‘every moment matter’ work in practice.

The first person most people meet at home is one of our community nurse specialists (CNS). A CNS is a qualified physical health nurse who has at least ten years’ experience post-qualification training and additional training in one or more specialties including palliative care, prescribing, tissue viability, respiratory care, emergency care, complementary therapies and UKCP accreditation.

Meeting a CNS means we will match your needs with other members of John Taylor’s inter-disciplinary team of occupational therapists, physiotherapists, clinical pharmacists, dietetics, social work and family care and spiritual care. Our palliative care assistants can support all of your personal care needs and, both at the hospice and at home, qualified nurses working closely with palliative care assistants will ensure that you are safe and supported on your terms. Meeting a CNS will also enable you to choose from a range of daytime support and short breaks.

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Community Interest As a Community Interest Company we are regulated to evidence our social impact. The Royal Bank of Scotland supports the nationally accepted measure of social impact called the RBS100. The maximum score for social impact on the RBS100 is 10/10. John Taylor Hospice became a CIC in 2011 and since 2013 we have met the 10 standard for social impact. We receive that score because

We are members of the Health and Wellbeing Partnership Board locality group

We have developed early intervention called ‘Why Wait?’ Volunteers can become apprentices and we recruit young people as

apprentices who go on to full-time employment after 12 months with us We provide real paid experience for graduate and undergraduate interns,

some of whom choose to volunteer We have a vibrant corporate social responsibility programme, teams of

volunteers from local companies and national companies with a local base help us keep our hospice and gardens in top condition all year round

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Local people make a direct financial contribution, matching investment from grants by undertaking challenges, team events and marathons, raising money which is then invested in what we do

We are a Travelwise and Bike North Birmingham partner - this together with our SE Gold Mark, evidences how we trade sustainably for people and the planet, from local procurement, cycling to work, growing vegetables and planting and maintaining wildlife habitats

In 2013/14 we were awarded RBS100 Trailblazer status for social impact. In 2014/5 we were awarded the RBS100 award for innovative storytelling and the regional Social Enterprise West Midlands award for ‘innovation beyond expectation’.

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Part 1a The Owners’ StatementThe owners of John Taylor Hospice are the people who work in the company. Since 2011 staff who are owners, elected by their peers form the Membership Council – the ultimate authority on the governance of the company. Ownership in public sector services is a relatively new concept in healthcare. Whilst mutuality was the basis on which we were founded in 1910, the journey to ownership has been a more recent one, in which we are entering our fifth year. The Articles of Association of our company set out twelve specific duties for all Membership Councillors - we have includes these accountabilities and a broader description of ownership at Appendix 1. Four of these duties are relevant to the quality account:

Maintain an up-to-date understanding of the priorities and aspirations of the company.

Hold the Board to account for operating with an up-to-date Company Plan.

Uphold the implementation of the Company Plan, company handbook, policies and priorities.

Participate in the governance of the company either and/or: As a member of the Membership Council As a member of the audit committee As a member of any sub committees, panels or fora from time to

time established In offering a contribution to the appointment of staff.

Part 1b The Chief Executive/Board Statement The people who work in John Taylor Hospice own John Taylor Hospice. Our core values are the same as NHS England: “High quality care for all, for now and for future generations.” As a community interest company we sit at the fulcrum of change in how that care is delivered. Care is funded by the tax payer (our contract with NHS commissioners) and directly by the public and grant-giving bodies. It means that we deliver care the NHS wants and needs to buy and we innovate in attracting specific sums of money to provide additional services that reduce the demand for other NHS-funded care. It means that we can deliver both health and social care free at the point of delivery. Ownership means:

Every moment matters. In practice this means “don’t say no say how?” and everything we do is measured against the Macmillan Values Based Standard Framework and the standards the regulators set.

We are open to scrutiny. We are externally inspected and regulated and we encourage reciprocal partnerships – the culture of our company has an annual temperature check by Birmingham University post-graduate students studying organisational structures in public and private settings. Our staff survey is given to every member of staff and was co-designed by our owners, the Board and Membership Council.

We are ‘more than a hospice’. Since 2011 we have worked closely with locality commissioners to describe and measure what we do. We are

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proud to have been alongside the people of Birmingham for four generations and we are proud of our shared history with the NHS.

Our company contract and company handbook are designed and developed together by our owners, the Board and Membership Council. We are a family-friendly company, with flexible contracted hours similar to those available to staff working in the NHS. We invest in our staff through deferred income with both a defined contribution pension scheme and an open directions body order for the NHS pension scheme. We remunerate staff at a flat rate for their flexibility, in order to provide services at home and in the hospice up to 24/7, seven days a week, 365 days a year.

A financial liability of £1 and a responsibility to elect six peers to form the Membership Council (the governing body of the company) and attendance at the AGM. Our governance structure is our fundamental contract of accountability to our owners, patients, families and the public. We are a company limited by guarantee, this means that the sole purpose of the company is community benefit. We describe that benefit in the following terms: to reduce the personal and social cost of illness and death, just a little every day. We measure that benefit with evidence-based measures and the decisions we make about what we do are based upon hard data and soft intelligence. Independence from the NHS and ownership means we are a commercial company with a social conscience.

This Quality Account comes as we enter our fourth year of independence. It is both a statement of progress and a statement of aspiration. The last four years have required root and branch change to regain our independence and we expect, for different reasons, the next four years to be as demanding. The Quality Account is our commitment to measure this change by the experience of the people who come to us for help, our staff and those members of the public who give directly in cash and in kind using data, hard and soft intelligence using clinical, experiential and commercial metrics.

Part 2 Quality Improvement

Our People The majority of staff deliver direct care. The company set a series of milestones to deliver an electronic rostering system, recruitment of a bank workforce equivalent to 20% additional capacity, dedicated investment in training, ‘live audits’ of practice, a targeted consistent approach to attendance and a clinical governance committee led and chaired by clinicians with the support of managers reporting to an Audit, Regulation and Assurance Committee chaired by non-executive director(s) directly accountable to the Board.

The management structure has been streamlined with two company-wide consultations, reducing the overall expenditure on management posts from when the hospice was part of the NHS by £120,000 recurrently over three years. This saving has been reinvested in clinical posts helping to deliver the growth in clinical activity from 5,000 patient contacts in 2011 to 10,000 contacts in 2014 at no extra cost to the NHS. The e-rostering system has saved

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expenditure on staffing the In-Patient Unit 24/7, 365 days a year by £30,000 a year recurrently. This saving is repaying dedicated Cabinet Office investment into the ICT infrastructure at the company. The staffing ratios on our In-Patient Unit are in excess of the RCN guidelines for adult medical wards. The company does not use external agency staff routinely and by measuring attendance at work as a quality standard linked to continuity of care, rather than measuring sickness absence, there has been a gradual and sustained improvement in attendance.

The company clinical strategy and the Company Plan are supported by a workforce plan. It is a plan underpinned by partnership with Macmillan Cancer Care and more recently Prostate Cancer UK to pump prime the development of new roles that can be funded recurrently through internal service redesign and provide long-term dedicated recurrent sponsorship to fund ongoing continuous professional development to support revalidation.

After three years, the company has a nursing career structure from clinically supervised volunteers with in-house training to vocationally qualified palliative care assistants and general nurses to clinical nurse specialists in palliative care, respiratory care, neurological care, emergency medicine, district nursing equivalents, through to modern matron, independent nurse prescribers and a nurse consultant. The clinical pharmacy career structure is from pharmacy technician to the equivalent of consultant pharmacist. Our psychological therapies and well-being career structure starts with clinically supervised volunteers who receive in-house training to UKCP registered psychotherapists in dynamic psychotherapy and art therapy. Our social and family work career structure has professionally supervised volunteers, vocationally qualified assistants and qualified social workers. We have dedicated occupational and physiotherapists and dietetics expertise.

The company secured grant funding in 2013 to put new first line managers through the Open University Management Certificate Course with four graduates in 2015. Dedicated investment has been made by the company to ensure internal expertise in COSHH, health and safety and fire safety, competence to write and develop computer software programmes and computer-based audit tools.

The slowest stream of development has been with medical staffing. We have dedicated medical cover at all times for our in-patient service. Having recruited a dedicated full-time consultant in palliative medicine, following his retirement we successfully recruited a full-time speciality doctor with supervision from a consultant in a neighbouring hospice. This post is a rotational post to provide experience to doctors in training to become palliative medicine consultants and is out to advert following the successful acceptance on the rotation of the previous incumbent. We have a visiting consultant anaesthetist, a visiting psychiatrist and a visiting consultant in public health medicine. The process to recruit a new consultant in palliative medicine in that last 18 months has been focussed on recruiting in partnership with a local acute trust. We now have a college-approved job description and a recruitment process in partnership with Sandwell and West Birmingham Hospitals NHS Trust. We have recruited additional general practitioners and are supporting their development as Macmillan GPs.

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Defining Qualities

‘Every Moment Matters’ is more than a strapline. It underpins our brand, how we work every day and our strategic vision. Being a community interest company means reciprocity is at the heart of what we do. When people are referred to us, our focus in upon them, who they are and what they give back to their family and community as well as what they need at every step of the journey. When people give of themselves in cash or kind we have a personalised immediate thank you.

Our Company Plan has a supporting clinical strategy which is concerned with supportive, end of life, palliative and specialist palliative care across all illness or conditions that foreshorten adult life together with practical help and support pre and post-bereavement. It is equally concerned with prevention and early intervention. Called ‘Why Wait?’ where the illness that will lead people to our care can be cured if caught early, we are trusted to care and we are also trusted to get people into screening, even if they do not believe in it. This approach applies to dementia, not because early intervention is about cure but because early intervention is about remembering the person before dementia fully takes hold. The third component of our clinical strategy is about evidence and measurement. We have a consultant in public health medicine in our clinical team and we have invested in specialist software that enables us to count, quantify and measure activity and correlate this with cost.

We joined the national standards programme run by Macmillan Cancer Care, the Macmillan Values Based Standard. Underpinned by evidence from research, Macmillan has developed a set of eight standards that define what quality means. We have been working with the toolkit since 2009 and are the only hospice that is part of the national programme. In 2014/15 our lead commissioner worked with us in order to take the learning into a formal CQUIN. (See Appendix 1 for a summary of this CQUIN).

We have invested through securing external grants in ICT. The company maxim is ‘In God we may trust, for everyone else bring data – triangulated data’. Computer-based technology is the way we communicate. It is the way we can drive performance (the volume of patient contacts and the nature of those contacts). As an independent organisation, we meet the requirements of the NHS Information Governance Toolkit and have our own N3 connection. We use secure mobile hand-held devices (tough pads) which allow direct dial into the live clinical information system. Clinicians use these to care plan in people’s homes and to remove the need for repeat journeys back to the hospice to maintain time real time clinical records. We have replaced the company ICT backup and storage with a system of three servers. We continue to use nhs.net to maintain security of information transit and our website now has a secure online referral for professionals. The Grange is a historic building; this means it has wall thicknesses that defy Wi-Fi but we have now secured the ‘booster’ technology to put Wi-Fi through the building. Our second CQUIN is concerned with safe and free access to the internet at The Grange for patients and families, everything from email and Skype to online internet gaming. (See Appendix 2 for a summary of this CQUIN)

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External Scrutiny

The emphasis of our offer is care at home throughout the experience of care for the person who is the patient, their family and significant others. We are part of a peer review network using Macmillan Cancer Care’s external review of patient experience standards. Of the 10,000 patient contacts in 14/15, 95% were where ‘people call home’, predominantly their family home and including home with warden support and home in residential and/or nursing care. The remaining 5% are people for whom The Grange (our hospice) is home and/or are attending the hospice on a day case basis.

The trend for care at home as the preferred offer is driven by the wishes of patients and families. Our ability to match this wish was accelerated in 2012/13 when internal efficiencies released £100,000 to be reinvested in our intensive home support service Hospice@Home. We saw both an increase in people being able to live at home until death and a reduction in admission to hospital and/or the hospice for 24/7 care. In 14/15 we have seen a further slight drop of 5% in the number of patients staying in our In-Patient Unit compared with the previous year. Overall our In-Patient Unit has had occupancy of over 70% in line with our 14/15 NHS contract. This allows for deep cleans, mourning and respect and care for the body after death. In our 15/16 NHS contract we have agreed a total number of patient contacts to be delivered in the patients preferred place of care, rather than occupancy target for in-patient beds.

Our performance indicators continue to show a significant increase in the volume of work in people’s homes. For example, H@H delivered 60% more face-to-face contacts in 14/15 compared to the same period last year (31/3/14). The success of e-rostering for day case and in-patient activity will be extended to H@H in 15/16.

Continuous measurement and quality control to support internal and external scrutinyis achieved through:

One integrated audit calendar across clinical, corporate and financial aspects of our services to ensure we are working to the highest standards. There is no duplication, internal and external scrutinisers can see the relationships between clinical, corporate and financial activities and it generates consistently the areas for improvement. Our Board is informed of the audit results as are our commissioners. This is a transparent exercise. The audit calendar results and actions from audits are held in a computerised audit calendar. Access to the spreadsheet is controlled according to the level of authority and role of the individual.

We run patient satisfaction surveys, subscribe to the Patient Opinion website and run ‘every story matters’ sessions to hear patients’ views about care and the company in order to make continuous improvements.

Our Company Plan is measured using a business balanced scorecard which informs the AGM annually. The current Company Plan has a three year horizon of 2014-2017. With the outcome of the election we hope that NHS commissioners are authorised to let five year contracts with

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break points; this would enable us to plan without financial risk for a five year period.

All our care activities are logged electronically on our secure patient record, SystmOne. We report on a quarterly basis to the NHS commissioners and also monthly to our own Board on all activities delivered.

Visits by our Commissioners, Local Area NHS Team Birmingham Cross City Commissioning Group (who have lead commissioner accountability for our NHS contract across five CCGs) visit John Taylor Hospice on a quarterly basis to review our clinical quality. The commissioners have an open invitation to visit John Taylor Hospice at any time and are invited to the CIC’s monthly mix and mingle sessions.

During their last visit the commissioners commended progress in demonstrating clinical quality over the past year and encouraged us to raise the thresholds in our quality audits even higher and to audit more broadly in order to improve quality even further. This has been incorporated into the Quality Account.

Community Interest and NHS Policy The company can evidence compliance against the recommendations of Francis and national NHS policy concerning quality. The illustration below concerns the ‘Five Cs’.

CareThe ‘every story matters’ fishbowl technique features a person who has received our care is supported to tell their story to a cross section of staff about what

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worked, what for them we missed even when the overall experience was positive and what improvements would not only address gaps for them but would improve our service overall. The improvements we can make based on these stories are used to compile a plan of actions. Below is set of recent examples arising from a story by Patient F which gave positive feedback as well as identifying potential improvements:

Issue: Information regarding the general running of facilities and events in JTH was lacking for relatives and carers whilst they are on the IPU. Relatives spend limited time in the foyer where the information is kept and that this was a missed opportunity for getting people involved and aware of the hospice’s work.

Action: Modern matron and the community fundraising manager invited Patient F to a quality circle as a patient to feed this back to staff so that staff could plan and make changes guided by the direct experience of the patient. This has also helped initiate a ‘Keeping in Touch’ project within JTH that reports to a steering group.

Issue: Noises on ward due to the opening and closing of doors were also reported.

Action: The modern matron was aware of the noise specifically caused by doors. Due to infection control standards, this cannot be rectified but the modern matron raised this at team meeting to ensure staff take more care when closing doors.

Issue: It was suggested that there was a need for details of support groups or nearby social groups for patients’ aftercare support and that it would be useful for information about such support to be at hand.

Action: Our Heart of the Hospice manager is looking into this, regarding collection and availability of information and ensuring that any such information is up-to-date.

Issue: Staff were not easily identifiable.

Action: This has now been addressed by the issue of names and position badges however not all staff have them. The modern matron will speak to staff and inform them if no name badge in their procession to obtain one from Workforce Team. Staff do maintain the Macmillan Values Based Standard of introducing themselves at first meeting.

Issue: Hospice access

Action: We have already simplified the referral process into JTH – there is now only one form to access all services and this can be done electronically. It is

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provided to GPs and hospitals and we have attended the Dying Matters event which targeted GPs and other healthcare professionals on hospice care. 

Patient OpinionWe use anonymous (Patient Opinion) options handled by our Brand and Media Team to reinforce their confidentiality and personal stories with consent on our social media. We also use satisfaction surveys.

In 2014 we adopted the Key Lines of Enquiry (KLOE) set out by the Care Quality Commission and portfolio of compliance evidence. Our first formal inspection using KLOEs is anticipated in May/June 2015.

At JTH care applies to our owners, staff and volunteers. Our Corporate and Commercial Services Team (CCS) lead quality circles and the workforce survey. Applying the well-used ‘you said we did’ feedback methodology, we have introduced mix and mingles monthly. These are held at different times and bring staff, volunteers and visitors together informally over food with a rolling presentation of what is happening in that month, the content of which is provided from individual staff and teams and the Board. We use a weekly brief and a quarterly in-depth brief, both suggested by staff and which have received positive feedback.

The Workforce Team within CSS have implemented standardised response times and letter formats that can be personalised to the individual from the process of recruitment through to personal development plans, return to work absence management and performance and conduct. All aspects of workplace safety are the responsibility of CSS including fire safety, display screen assessment and training, moving and handling, waste management, environmental health standards, food and the environment. As a CIC our Patient Lead Assessment of the Clinical Environment puts us in the top 20% nationally with 100% scores on cleanliness and food. The company audit calendar includes all these aspects of care.

CompassionJohn Taylor Hospice strives towards high quality compassionate excellence; it isn’t only about the care that we provide, but how we provide it. John Taylor Hospice understands that compassion is understanding what we say, how we say it and the potential impact of saying it, talking to patients in a professional way and being human in the way we say it. This includes respecting each patient’s boundaries, understanding their needs and creating a ‘Taylor-made’ experience for each patient. The Macmillan Values Based Standard also incorporates compassion.

Commitment E-rostering, our contract, investment in ICT, investment in training and development, our culture of celebration, setting business and clinical goals, audit and evaluation, our investment in both an inter-disciplinary workforce within the company and contribution to external inter-disciplinary forums like the Pan-Birmingham Cancer network, Local Intelligence network, area

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prescribing arrangements, Travelwise and the Health and Wellbeing Board evidence our commitment to quality to a consistent standard and our culture of innovation.

CourageTo truly improve our service commitment, compassion and care must be accompanied by courage. Supporting patients with a palliative diagnosis to come to terms with their disease progression can be a daunting experience for the patient, their family and loved ones. Since 2011 we have built up confidence between staff and managers to use and trust a weekly mindfulness session and reflective practice, together with the fishbowl processes. As a community interest company our owners must display courage in a very different way, that is the courage to talk about how what we do is funded in a way that does not compromise trusting professional relationships and to volunteer in their own time to become part of #teamjth - joining members of the public to pit themselves against a host of challenges including growing sunflowers, tandem skydiving and marathon running.

CommunicationThere is a strong evidence base that in terms of experience, it is the relational aspects of care that trump the transactional aspects. This was one of the main drivers in adopting the Macmillan Values Based Standard. These are backed by concise practice guides and FAQ sheets on everything from confidentiality to conduct. The practicality of accurate and timely information makes relational care meaningful, our commitment to ICT, to training in advanced communications through to our ‘thank you’ standards, our social media offer and our response and quality standards for front of house illustrate how communication is an underpinning programme in our company.

Confidentiality is a non-negotiable requirement that the conduct of staff, volunteers and contractors conduct themselves in compliance with the seven standards of public life1 in order to engender genuine trust and confidence that all personally identifiable information is collected and retained in accordance with the maintenance of the absolute privacy of the individual as laid down in the Data Protection Act 1998, the Human Rights Act 1998 and the Health and Social Care Act 2012.

Competency (see also Our People)Competency is the most effective way to ensure patient safety. Competency concerns our understanding of accountability (See Appendix 3) and the skill set of our staff and volunteers.

All of our staff are professionally or vocationally qualified and everyone receives supervision from an appropriately qualified supervisor. We use a specially designed computer database to ensure all of our staff meet the annual training standards for their role. Continuity matters too, we use an electronic system to schedule when our staff work across every 24 hour day 365 days a year. This means that we can tell you who will be working with you and you can get to know a smaller team of our staff; building trusting relationships is what makes every moment matter work in practice.

1 The seven standards of public life are integral to our company contract and explicit in every offer of employment and voluntary work

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The first person most people meet at home is one of our community nurse specialists (CNS). A CNS is a qualified physical health nurse who has at least ten years’ experience post qualification training and additional training in one or more specialties including palliative care, prescribing, tissue viability, respiratory care, emergency care, complementary therapies and accreditation with the United Kingdom Council of Psychotherapists.

Safeguarding in the Public InterestJohn Taylor has an integrated approach to safeguarding (Appendix 4). Competence is tested annually against an accredited online certificated module. DoLS, mental capacity and advocacy will be incorporated into online modules this year.

Serious IncidentsThe investment in information technology over the past two years has included investment in software that enables mathematical analysis of incidents using probability theory to deliver robust reports for assurance and dedicated targeted action to improve care. We do this by joining up ALL of the information we have so we can understand what improves our quality within the widest possible context. The system we use is called QPOP (short for Quality, Pathways, Outcomes and Performance) and the diagram illustrates how all of our information is joined to produce reports based on all the necessary information.

Over these two years it is not only our IT that has changed but the way we scrutinise our information, especially regarding all the incidents, risks and clinical care activity in our company. This has become significantly more robust and meaningful and has helped drive up the quality of our services and how we assure we are safe accountable organisation. In plain terms:

We use valid information, not guesswork, everywhere we can and, if we need information about what we do or about our local populations, we collect it.

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We use information to check how we make the best quality of care and patient safety through mathematical analyses, text analyses and reviews by experts in the relevant subjects.

We turn information into useable knowledge.

By keeping a cycle of collecting information, analysing and reporting it to our staff, commissioners, managers and regulators, we keep an onward progress to improving quality and safety on the basis of a rational approach, not leaving it to luck or guesswork.

As an example, we have calculated how may incidents we expect to be reported in our company each month. We did this mathematically and now we can be

“95% confident that there will be between eight and 19 incidents of all types reported in any month, so if there are more or less than that we must examine not just the incidents but how we report them understand them and learn from

them.”

This was tested when there was a month where there were only five incidents (that only happened once) and again there was 20 incidents in one month (that only happened once) and we immediately looked into why that was so. In each case we found the reason and addressed it. This immediate response had three main benefits on our approach to safety:

We had a tested and reliable way of seeing if things were changing for a normal pattern of events.

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All staff knew that the information on incidents was being used to create knowledge that could be used to improve care and safety and that supported their quality improvements.

We could assure our Board and commissioners that we had safe and tested system in place.

As an illustration of this change in our systems for ensuring patient safety over the past two years, the graph below shows the reduction in the number of incidents reported each month.

The blue ‘zigzag’ line shows the number of incidents reported each month and the upper and lower lines show the number of incidents we might expect to be reported. It shows that the number of incidents has reduced as has the minimum and maximum number of incidents we expect each month as a result of improvements we have made in how we work and how we understand our data and processes.

The chart shows the 9/2014 as the month when we had only five incidents reported.

The company also uses its analyses as part of reflective practice and appraisal in accordance with the guidance for the re-validation of doctors.

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Examples of how we have used Data and Analysis to Improve Patient Care

Pressure Ulcers

The company standard is that pressure sores should not develop when people are in our care - we set a 95% threshold for this standard because tissue viability and comfort can be contradictory interventions for some patients. Our action to prevent starts with any evidence of redness where cream is applied. Where people have developed pressure sores before coming to us our commitment is to treat and reduce the severity of the sore and if possible secure healing of the skin. John Taylor Hospice undertook training of every registered staff nurse in the past year, ensuring they were up-to-date with all aspects of tissue viability care. Given our close partnerships with district nurses we have adopted the Birmingham Community HealthCare pressure area guidance and record all patients’ skin condition on initial assessment and maintain consistency for patients. We have a range of pressure-relieving equipment in place to maximise the care and comfort of our patients. For example we have alternating mattresses and patient chairs that conform to both infection control and tissue viability standards. We promote mobility with in-house physiotherapist input and bespoke care plans to ensure patients that are unable to change their own position within the bed are assisted to do so frequently.

The company reports pressure sores both on admission, that is where a patient is admitted with a pressure ulcer or it develops within 72 hours of admission, and on ulcers developed during the time they are receiving care from the hospice.

By reviewing our own data we can see that there have been patients admitted with pressure ulcers and a few occasions where in the last few hours of life patients have developed pressure ulcers whilst in our care. Adhering to our principles of leaning from events and our duty of candour, we have taken steps to learn and avoid these incidents.

The use of measures to prevent a pressure ulcer developing are shown in this chart. It is important to note that every patient will have had some preventative action taken and most patients will have had a combination of measures taken.

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Lessons Learnt and Actions TakenConfirmed through discussion with staff and our own records, we can see that pressure area assessment, prevention and treatment is a normal aspect of care for all patients, both those that do not have an ulcer on admission and those who are admitted with a pressure ulcer.

It is also reported verbally by nursing and medical clinicians that many of the ulcers developed on the unit actually occur within the very final stages of a person’s life. Notes on the assessments of those patients indicate the following contributory factors: extreme frailty, poor tissue viability, immobility and difficulty with nutritional intake.

Further Actions Suggested by StaffThe actions for improvements identified by staff included:

Report all pressure ulcers as incidents from Grade 1 up whereas previously only Grade 2 + were reported.

Carry out a root cause analysis on all Grade 2 ulcers. Ensure that stock of pressure-relieving mattresses and mattress covers is

sufficient to supply all beds in the unit and to not be short of equipment due to laundry and repair.

Use ‘mattress wedges’ as pressure care equipment that requires the minimal movement of those patients who are within the very final stages of life for whom comfort is a high priority. This enables pressure area care to be provided to even the frailest and most sensitive patients who may otherwise find movement-based pressure area care too painful.

Slips, Trips and FallsReasons that may contribute to the increased likelihood of a fall at particular times of the day and night may be:

Patients are arising from sleep at their natural time and habitually try to mobilise independently for the toilet etc without adjusting for any changes in their mobility or without feeling the need to request assistance.

The initial effects of night time medication. Patients beginning to tire at the start of their natural sleep pattern. A reluctance expressed by some patients to cause a (perceived)

disturbance to others by asking for assistance during the night.

The chart below shows the times of the day when there are increased likelihood of a patient having a slip or fall:

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Preventative Actions taken The actions for improvements identified by staff included: Raise awareness of the issues and importance of continuing to use

preventative measures of : Use of crash mats Use of cot sides Use of lower beds

Ensuring all patients have a call bell or buzzer that they can use and are encouraged to use it.

Regular observations of all patients with raised frequency of observation who are assessed to be a higher risk of falling.

Increased observations at the higher probability times.

The use of measures to prevent the likelihood of a patient falling are shown in this chart. It is important to note that every patient will have had some preventative action taken and most patients will have had a combination of measures taken.

Our ‘People-based’ Systems for Ensuring Patient Safety In addition to the use of information and knowledge as described above, we have systems across our clinical and corporate departments to make sure that patient safety is always pro-actively managed though measures that are preventative. We always maximise our awareness and expectations for ensuring safety thorough checking and monitoring and learning from our experience and the knowledge of others. Clinicians, clinical managers, executives and corporate professionals including our housekeeping and fire and health and safety officer operate these systems.

The clinical parts of the patient safety systems include:

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Clinical governance meetings – where all incident are explored, audit findings and action plans are reported and all new NICE guidance is reviewed

Training, such as the Princess Alice certificate, specialist degree and advanced communication training

Safe staffing levels are monitored every day Safeguarding awareness is a constant We have a 12 month programme of clinical audits

The corporate parts of the safety system, some of which are carried out by both clinical and corporate staff include:

Housekeeping – Infection control audits to ensure a clean and safe environment is maintained.

Training – in-house and external training to ensure that staff are kept up-to-date and qualified including :-

Fire safety training COSHH (Control of Substances Hazardous to Health) Data protection Safeguarding Driving safely Waste management and waste handling Moving and handling and manual handling Linen training

Internal and external audit programme to monitor and maintain a safe environment for patients and staff including:-

Kitchen audits Medical gas audits Vehicles Environmental/premises including external grounds

Generator testing – to ensure the operational continuity of equipment in the event of mains electricity failure.

Ensure that premises and equipment are maintained in a safe working condition and that environmental requirements are met, equipment is serviced, calibrated and maintained in accordance with manufacturer’s guidelines.

Fire Safety – we complete an Annual Fire Risk Assessment and liaise with NHS Fire Safety Adviser and West Midlands Fire Service. We also undertake statutory fire safety testing of alarm system, emergency lighting, firefighting equipment and fire doors etc. There are monthly fire marshal checks to ensure compliance with requirements throughout the building.

Security of Premises – Maintain integrity of the door entry key fob system, door isolation alarms and internal/external CCTV system to assure safeguarding confidentiality and safety.

Patient Call Bell System – audit and maintain system to ensure that it operates effectively and reliably.

Water Quality – liaise with landlords and external suppliers to ensure that water quality is maintained and risk of disease is minimised including water flushing regime and testing programme.

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Food – internal and external audit programmes ensure that food hygiene regulations are met. Menus are designed in liaison with our internal nutritionist to provide a balanced diet suitable for our patients including hydration using the MUST tools.

Robust Incident and Risk Management - system in place to ensure that incidents and risks are proactively managed at the correct management and Board level.

PLACE audit – annual patient-led audit organised and managed to independently assess our care environment for cleanliness, food and hydration, condition and appearance and maintenance, patient privacy dignity and well-being.

Action plans are always produced and adhered to in order to ensure any shortfalls are addressed.

VTEsWe have experienced and speciality doctors who are able to assess if a patient is vulnerable to venous thromboembolism and able to nurse the patient if they are receiving treatment.

UTIsOur urinary tract infection prevention and control record is excellent and all staff are aware of the importance of meticulous hygiene care provision and catheter care. We have an SLA with City Hospital who receive and analyse all specimens and advise promptly should antibiotic medication be required.

Medication Errors We have a detailed programme of medicine management audits as part of the organisation’s commitment to providing highest quality clinical services and reducing risks of harm to our patients.

The in-patient has daily expertise from the specialist clinical pharmacists who ensure that prescribing decisions and practise are both safe and evidence-based. As well as a daily presence on the ward they participate in the patient review meetings. Our medicines management technician ensures that patients have timely access to medicines when they need them and we have increased our use of patients’ own medication by encouraging all patients to bring in their medicines thereby ensuring no delays in treatment, familiarity for the patient, better adherence and cost saving to us and the NHS. The Pharmacy Team work with patients to ensure that on discharge they are clear about what they are taking and they can be followed up in the community, reducing any risk of harm and re-admission.

There is an increased awareness of the importance of audit results in the company in particular the importance of ensuring doses of patients’ medication are not missed as well as an improved awareness of the incident reporting system.

Staff frequently approach the doctors and Pharmacy Team with queries involving medication, often needing confirmation that they are doing the right thing and highlighting any potential issues. It is a good indicator that patient

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safety is at the foremost of their thinking and that staff are planning ahead and anticipating issues before they occur.

As well as more frequent regular audits we have a programme of annual medicines management audits which include the Hospice UK audit tools for:General Medicines Audit ToolControlled Drugs Audit ToolSelf-Administration of Medicines Audit ToolMedical Gases Audit ToolSelf-Assessment of the Controlled Drugs Accountable Officer Audit Tool

Each year since leaving the NHS, the company’s results have improved as policies, processes, awareness and training develop. We have invested in better equipment such as new larger controlled drugs cupboards in response to audits, incidents and staff concerns to improve patient safety and reduce risk as far as we can.Where medication-related incidents occur these are investigated and practice is reviewed to ensure a pro-active approach to safety and quality.We aspire to consistent high quality, safe and responsive and treatment and harm free care provided in a cost effective way.We are working to do even better at incident reporting and providing better feedback to staff to raise our achievements on patient safety.

Never Events

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. John Taylor Hospice is required to monitor the occurrence of Never Events within the services provided and publicly report them on an annual basis, so we maintain an up-to-date list of NHS Never Events which are incorporated into our Never Events policy each year. Our Never Events policyImplementation of a policy on Never Events was identified in High Quality Care for All: NHS Next Stage Review Final Report as a key priority for the NHS in England. The purpose of our Never Events policy is to provide further impetus to improving patient safety through greater transparency and accountability when serious patient safety incidents occur. It also demonstrates how local commissioning can act as a lever for safer care. Implementation of the policy is expected to:

Increase awareness of patient safety Strengthen existing reporting and response processes for serious

incidents Increase implementation of preventative guidance by providers Reduce the risk of Never Events occurring Lead to more comprehensive reporting of Never Events

We record any Never Events through our incident reporting system which flags up any incident as a Never Event at the outset ensuring that immediate notice is taken and a full investigation into the causes of the event is carried out to

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ensure lessons are learnt for future prevention. An example of this is in the analysis on pressure ulcers outlined earlier in this report.

Patient and Staff Experience Friends and Family TestWe survey our whole workforce annually. The 13/14 survey was returned by 63% of our workforce. 96% said they would recommend us to their friends and family.

Patient stories We record patient feedback in a number of ways:

Patient OpinionPatient Opinion www.patientopinion.org.uk is an independent website where people are invited to ‘review’ health services. Patients and their families are given specific Patient Opinion forms which can be filled in and returned to any member or staff or sent via freepost. They can also text their reviews. These are then uploaded to the website and the hospice is able to respond. We ensure that we respond to every message that is posted.

Recent messages have included: ‘Everyone we met showed us great love and compassion during a very

difficult and heart breaking time.’ ‘The chefs at John Taylor Hospice cooked lovely meals for us which took

so much pressure off us all.’ ‘The staff at John Taylor Hospice all helped us as a family through such a

hard time, always giving support and someone to talk to.’ FacebookWe have a very lively Facebook page with patients and families commenting on many of the posts. There is also a review section where almost all the reviews we have received have been five stars. Recent comments have included:

‘A wonderful, calm and peaceful place with the most caring and empathetic staff you could possibly wish to meet. I would like to thank each and every one of you for all your time, love and care and dignity that you lavished on my husband, both in the day centre where he enjoyed his weekly visits and on the ward when he stayed for respite breaks and also for the kindness that was shown to us as a family whenever we visited, but especially in his last days with you.’

I will be forever in your debt.....’ ‘My brother in law recently lost his fight with cancer after a 2 year battle.

He passed away in hospice and from the very first day he went in there staff were absolutely amazing they took the time to know every patient on a one and one basis. We as a family will never forget any of you or what you did for such a young new family you made every minute as special as you could. From all of the families we thank you for taking care of our [name withheld]. we will never forget you Xxx’

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Direct feedbackWe also meet and interview patients and their families on a regular basis for stories and features for our website. Recent comments have included:

“We felt so supported by the hospice – the staff became like an extension of our family. They cared so deeply about us and took great care of [name withheld] in her final weeks.” Full story: http://www.johntaylorhospice.org.uk/about-us/latest-news/60-remembering-loved-ones-at-light-up-a-life

“I could work until I’m grey and will never be able to feel that I have paid back the brilliant care my husband received at the hospice. I cannot put it into words the comfort that having the nurses around gave and that is why we are here.” Full story: http://www.johntaylorhospice.org.uk/about-us/latest-news/73-families-celebrate-hospice-birthday

“Contacting John Taylor Hospice was first mentioned to me by a specialist but I didn’t want to go there as I was scared. I realise now that it is also about help and support and not that you are about to die.” Full story: http://www.johntaylorhospice.org.uk/about-us/latest-news/84-margaret-finds-hospice-a-real-help

“As well as our dad, we all know people who have been cared for at John Taylor Hospice and I don’t know what people would do without them.” Full story is at http://www.johntaylorhospice.org.uk/news/family-walks-to-remember.html

Complaints We have a clear unambiguous flow chart and process for complaints and concerns. This emphasises immediate resolution and the senior clinicians and/or managers are authorised to do this and to ensure investigation takes place. We review compliments as rigorously as concerns and formal complaints. We have had three formal complaints this year and all have been resolved.

Patient Reported Outcome Measures Patient Reported Outcome Measures (PROMs) are a means of collecting information on the effectiveness of care delivered to NHS patients as perceived by the patients themselves. John Taylor Hospice does not provide any of the services for which these are applied. Staff Survey results/feedback We survey our whole workforce annually. The 13/14 survey was returned by 63% of our workforce. 96% said they would recommend us to their friends and family. 99% said that they knew the CEO, the majority said they knew the Chairman. The majority said that their manager listened, cared for them and held them to account with an annual appraisal. The majority of staff could name at least one positive change to care in the preceding year and knew how to get involved in change and development. The 2015 staff survey and the results are just now being analysed.

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Culture, being open, leadership and escalation In a staff-owned company everyone really is equal. All owners have the same rights. This means equality is designed into the company structure and the company handbook and the company governance structure are at the heart of the company. The Nolan Principles are contractual and we all carry that accountability for public sector equality every day.

Equality and Diversity We scrutinise ourselves on the basis of transactional and relational data. Every visual communication from us includes a representation of diversity in age, gender and race. Every job description asks the ability to speak more than one language relevant to our population -we are never complacent and we are unequivocal about dignity in life and death. We have a range of training, information, reflection, guidance and support to keep the risk on prejudice on the agenda. The Equality Act 2010 and the Equality Duty place an obligation on all of us to treat each other well. This is common sense AND good business sense. We are part of a vibrant city.

Patient Led Audits of Care Environments

Duty of Candour Occasionally people in our care are involved in an incident, some of which have the potential to cause harm. Then we have a duty to inform our patients and their families what has happened. This is very much part of our open and honest culture.

We are committed to talking to patients and their carers at a very early stage following any such incident to understand what happened and, where necessary, learn the lessons that will prevent it happening again to improve the safety of our future patients. We have recently carried out a review of ALL of our incidents (even where not harm actually came about) to learn from “what might have happened” as a preventative approach, rather than only to learn after incidents have happened.

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If any harm happens, we investigate the incident and ask how much the patient and their relatives or carers wish to be involved in the investigation which includes: Review the patient’s medical and nursing notes.Talk to the staff involved in the patient’s care.Identify the cause(s) of the incident.We share our findings with the patient, their family or carers and share learning and improvements across the company.We are very careful to ‘analyse’ and learn but not to ‘judge’. This is essential to make sure that a culture of openness is established and preserved. Errors are seen as unfortunate events that we must learn from and not hide away for fear of reprisals.This means that duty of candour is also carried out with great sensitivity, assuring staff that openness is essential and is supported by learning, professional critical reflection and applies to all our staff, as well as our professionally qualified staff.

Other Issues

Political astuteness of local and national priority focus When John Taylor Hospice was authorised as a CIC in 2011, what became the Francis Report was in train. In anticipation of this, the CEO received Board support for five pieces of work and three consultation exercises. The first in 2011/12 were a review of temporary staffing, compliance with the working time directive and, respecting the requirements of TUPE, to move away from permanent nights which was the inherited system. In parallel all staff in nursing assistant roles were offered the opportunity to participate in a review of the three inherited job descriptions and person specifications to create a single career structure linked to NVQ competencies. These three pieces of work were completed in 2012, enabling the CIC to have in place a robust job description, competency framework and career structure. Staff chose the job title palliative care assistant for this role.

The fourth piece of work concerned patient-led standards. The Hospice@Home team were asked to ask people if they felt unsafe when having people knock on the door and what would make them feel safer. Two changes came about as a result - the transport from the hospice was changed, an old vehicle identified with the words JOHN TAYLOR HOSPICE in large livery was replaced by a people carrier and subsequently St John Ambulance so people were no longer ‘outed’ as dying to their neighbours. A single uniform in the community and at the hospice for all staff was introduced including outer-wear so that the logo of the hospice is clearly but subtly visible through door fish eyes and immediately on opening the door.

The final piece of work was to move from manual rostering to rules-based rostering. The CIC commissioned a review of staff rostering systems and staff contracts inherited from the NHS for nursing assistants and contracted with a specialist provider funded by a national grant to implement the efficient-rostering system (e-rostering) now in place.

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The CIC has to meet regulatory standards to trade “ethically for people and the planet”. The Board of the CIC set up a task and finish group to look at ICT efficiency and safety. The PCT had supported the hospice to participate in a programme of mobile working using handheld secure mobile devices with direct dial into the live clinical record. This system has now been rolled out across the hospice with a saving of £10,000 recurrently in travel costs and an increase in availability of time with patients and families contributing to the doubling of patient contacts from 2011 (5,000) to 2014 (10,000).

The CIC has embraced online and social media both as a communication vehicle with people who need our help through to secure electronic referral launched in 2015.

Patient opinion about where people want to be at the end of their life has been known nationally and locally for over ten years to have a single predominant response. To be able to be at home – the national KPI being preferred place of death. The Company Plan for 2012 set the trajectory to shift the balance of clinical activity firmly into the community by securing internal efficiencies and external funding and to deliver in the hospice interventions to enable people to improve the level of comfort and care within their own control together with a choice of ‘time out’ to join a social network and/or to take break with a short admission as an ‘MOT’ to bring symptoms back into tolerable control. The target was not to reduce unplanned admission at the end of life; the target was to increase comfort and control. The consequence has been sustained increase from 83% of people using Hospice@Home in 2011 to 93% of people using Hospice@Home in 2014 as well as a shift to 95% of all activity being in the community and a reduction in the number of unplanned admissions at the end of life for the patient cohort referred to the hospice.

As a CIC we are ‘more than a hospice’. Our work since 1910 to date is public health work. What is different now is that the illnesses that only have one outcome, an early death, have changed. The CIC has since 2013 been developing a programme of work called Why Wait? People trust us to be there at the end of life and they trust us when we say early detection will save a life. Two programmes, Benjamin’s Brothers which is concerned with citizens of African-Caribbean heritage among whom the risk of prostate cancer is double the risk of the male population as a whole, and a second concerned with dementia will take this work forward in 2015/17. What we will/are doing to prepare and contain Ebola. Ebola virus disease (EVD), a viral haemorrhagic fever (VHF), is a rare but severe infection caused by Ebola virus. Since March 2014, there has been a large outbreak of Ebola virus in West Africa. This is the largest ever known outbreak of this disease prompting the World Health Organization (WHO) to declare a Public Health Emergency of International Concern in August 2014. John Taylor Hospice has reviewed advice within The Advisory Committee on Dangerous Pathogens (ACDP) guidance which is the principal source of guidance for clinicians risk assessing and managing suspected Ebola cases. The guidance aims to eliminate or minimise the risk of transmission to healthcare workers and others coming into contact with an infected patient. In the event a patient is admitted with suspected or confirmed Ebola infection, infection control measures appropriate to the patient’s risk category, symptoms

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and clinical care procedures will be put in place. In all cases, the incident will be reported and the individual referred urgently to the local clinical virologist, clinical microbiologist or infectious disease physician, who will advise regarding intervention and follow-up required.

What we are doing to focus on sepsis prevention and management Sepsis was previously known as septicaemia or blood poisoning. Sepsis is the body’s reaction to an infection and means your body attacks its own organs and tissues. Mild sepsis can result from chest infections, urine infections and other minor illnesses. However other patients develop severe sepsis, which means they become seriously ill and need hospital treatment straight away.John Taylor Hospice considers and adopts all relevant NICE guidance at its monthly clinical governance meeting. NICE recommendations are based on systematic reviews of the best available evidence.All registered staff nurses working at John Taylor Hospice In-Patient Unit have received training on the identification and management of neutropenic sepsis.

Part 3 Our Priorities for the Next Year To continue to be a trusted provider of NHS-funded care across the

pathway of care and the spectrum of illnesses that foreshorten life. To maintain a standard of 95% of activity at home in people’s own homes.

(We have an agreed total volume of patient contacts that will be purchased in 15/16 by the NHS and NHS support to direct our income generation to develop services that will reduce demand for other NHS care.)

A minimum threshold of 95% for external audits measured in percentage compliance and a minimum standard of 95% compliance for internal audits measured in percentage compliance.

To consolidate the evidence of ‘what works’ by using two new CQUINs, this includes co-ordination and re-launch of the Macmillan Values Based Standards Framework led by our Corporate and Commercial Services Team (because it is a company-wide standard set).

To complete our workforce plan with recruitment to a dedicated consultant in palliative medicine and establish up to two Macmillan GPs.

To consolidate our weekly mindfulness sessions with Leadership at the Point of Care.

To secure a good rating in our first KLOES assessment: the volume and scope of data required is the same for every organisation regardless of size. We aim for outstanding by 2018.

To maintain our status at ‘ten’ for social impact in the RBS100. To develop, in partnership with the lead CCG, data sets that would

underpin future tariff development. To deliver our new income targets against our five year community

investment plan.

Patient Experience

Our key themes for innovation are: a clear focus on symptoms a service that fits around the family rather than the other way round

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a trusted relationship between the provider, the patient and their family proactive and immediate response to health crisis that enables the crisis

to be managed safely at home integrated health and social care up to 24/7, 7 days/week, 365 days/year

with the ability to flex capacity up and down quickly innovative ways to broker difficult conversations the importance of practical support innovations such as specialist clinics.

For example, pain makes a massive impact upon motivation and well-being. To ensure the best anaesthetics were available to patients we went from that idea to the first patient in clinic called Pari Passu in six weeks.

Clinical Effectiveness We have a number of ways that we can be sure of the actual effectiveness of what we do in terms of benefits to our patients, they are:

Checking with each patient that all of the care we are providing them is meeting their needs and bringing them benefit. This is a part of the cycle of assessment, care planning, care-giving and evaluation that takes place each time a patient is seen at their own home or in a clinic, and every day if they are in our in-patient ward. All patients in our in-patient ward also have a medical review every day. Every patient:

Has their individual needs assessed as to what ‘Taylor-made’ care they need.

Is listened to in order to check that their needs and wishes are being met.

Has their care changed as soon as their needs change.

Providing evidence-based practice, meaning that all of the care we provide has a rationale and has been shown to be effective in helping patients, physically, psychologically, socially and spiritually. This evidence is in the research, national clinical guidelines and examples of good practice that are shared throughout the care professions and is one cornerstone of our clinical governance including:

Making sure our policies and procedures are up-to-date and have an evidence base for being effective.

Ensuring our staff group is the right size and is made up of the right skill mix to be able to carry out care to the standards our patients need.

Making sure all staff have up-to-date training to maintain their current knowledge and skills and to acquire new skills that lead to new care options that we can offer to our patients.

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Part 4 The Quality of our Services - Data

Other Quality Indicators External Inspections and Audits

Cross Infection Auditors Infection prevention and control is paramount to securing patient safety. John Taylor Hospice can demonstrate risk-reducing strategies in accordance with the Health and Social Care (Safety and Quality) Act 2015 and policies, processes and procedures are in place. Universal practices are standard within the hospice and ensure that current evidenced-based knowledge is utilised. This is achieved through educational programmes and regular updates for new and existing staff. The ultimate aim is to prevent cross-infection.In support of this John Taylor Hospice has a service level agreement with Heart of England Foundation Trust to annually audit our infection prevention and control standards. Their infection control lead also provides advice and information, direct training and support.

Audited Account and Companies HouseAs a community interest company (CIC) we are required to file annual audited accounts with Companies House each year.

In our first three years of independent trading we received clean, unqualified audit reports from our external auditors, Baker Tilly. We are now in our fourth year and expect the same result in the next external audit which will happen in November 2015.

The auditor’s opinion states that: Our financial statements give a true and fair view of our affairs and have

been properly prepared in accordance with the requirements of the Companies Act 2006.

Adequate accounting records have been kept and they have received all the information and explanations they require for their audit.

The directors have prepared the accounts on a ‘going concern’ basis because NHS funders have provided contracts until 31st March 2016. The directors have no reason to believe that contracts will not be renewed after that date.

CCG Quality Review Group

Every three months we provide a detailed report to our commissioners, the Birmingham Cross City Clinical Commissioning Group, on the extent to which we meet the clinical standards of our commissioners and regulators and the evidence- base and expertise upon which our care is based.

Those reports cover the same subjects as this Quality Account but with three monthly reporting are able to show improvements we make for quality and safety in a more rapid way, giving our commissioners an assurance about the quality of our services that complements our reports to them on our activity and performance.

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Revalidation of Doctors Revalidation is the process by which all licensed doctors are required to regularly prove that they are up-to-date in their knowledge, are fit to practise and able to provide a good level of care. We do this for our doctors through regular reviews by the company’s associate medical director using a set of questions that have been set out by the NHS and the General Medical Council.

As part of their appraisal reviews our doctors are also required to submit a probity self-declaration that requires them to make known any cautions, criminal offences or any professional body finding against their registration for fitness to practise.

Furthermore as part of the health declaration the doctors are reminded to follow the good medical practice guide to protect patients and colleagues from any risk posed by their own health.

Our process of revalidation is itself checked and validated by NHS England to we are a robust part of the national system for validation of doctors.

Environmental Health – Food standards – 5 star rating

We have achieved a 5 star rating for the last three years, the most recent being awarded in May 2015. These audits are unannounced and conducted by the local authority and check that we meet the requirements of food hygiene law. A food safety officer inspects a business to check that it meets the requirements of food hygiene law including:

How hygienically our food is handled – how it is prepared, cooked, re-heated, cooled and stored

The condition of the structure of the buildings – the cleanliness, layout, lighting, ventilation and other facilities

How we manage what we do to make sure food is safe and so that the officer can be confident standards will be maintained in the future

Each of these three elements is essential for making sure that food hygiene standards meet requirements and the food served or sold to you is safe to eat.A rating of 5 means the hygiene standards are very good.

External Health and Safety consultant once a year conducting an environmental audit.

We abide by health and safety practices as laid down by the Health and Safety Executive. In addition to this our company’s competent person, as required under the Management of Health and Safety at Work Regulations 1999, is KeyOstas.

They work in partnership with us to ensure our health and safety policies and procedures are robust and each year they undertake an inspection of the premises testing our procedures and providing advice and guidance.

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Part 5 Statements Mandatory and Legal Statements During the period of this Quality Account (1 April 2014 to 31 March 2015) John Taylor Hospice CIC provided end of life care through part NHS-funded services.

The percentage of NHS funding is on average in the region of 85% of the company’s income. The rest is provided by John Taylor Hospice charitable contributions.

The income generated by the NHS services reviewed in the period 1 April 2104 to 31 March 2015 represents 100% of the total income generated from the provision of NHS services by John Taylor Hospice for the period 1 April 2014 to 31 March 2015.

During the period 1 April 2014 to 31 March 2015 there were no national clinical audits or national confidential enquiries covering the NHS services that John Taylor Hospice provides and John Taylor Hospice has not participated in any special reviews or investigations by the Care Quality Commission.

John Taylor Hospice sets an annual core audit programme that runs for this report period. The core audit programme includes:

Missed Dose Observational Audit of Infection Control Practice (HEFT) Staff Survey Data Protection Audit Medical Gasses Use of Patients own Drugs Patient Led Assessment of Care Environment Self-Administration of Medicines Pain Assessment and Analgesic Effectiveness Appropriate use of pressure relieving equipment General Medicines Infection Control Documentation Audit Controlled Drugs

Statement of Directors’ Responsibilities In preparing the Quality Account, directors are required to take steps to satisfy themselves that this Quality Account presents a balanced picture of the period covered and that the information reported in the Quality Account is reliable and accurate. There are proper internal controls over the collection and reporting of the information included in the Quality Account and these controls are subject to review to confirm that they are working effectively in practice. The data underpinning the Quality Account is robust and reliable and is subject to appropriate scrutiny and review and the Quality Account has been prepared in accordance with Department of Health guidance. The directors confirm to the best of their knowledge and belief they have complied with the requirements in preparing the Quality Account. The company has a monthly ARAC with direct reporting to the Board and Membership Council that satisfies this requirement.

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Statements from our Stakeholders Clinical Commissioning Group As coordinating commissioner Birmingham CrossCity CCG has welcomed the opportunity to provide this statement for the John Taylor Hospice (JTH) Quality Account for 2014/15. The review of this Quality Account has been undertaken in accordance with the Department of Health guidance and Monitor’s requirements. The statement of assurance has been developed in consultation with neighbouring CCGs, the Birmingham, Solihull and Black Country Area Team and the Birmingham CrossCity CCG Patient Council.

Ensuring high quality care for all is a fundamental component of improving patient outcomes and experiences and therefore Birmingham CrossCity CCG is committed to working with providers such as JTH to drive forward best practice in respect to clinical quality, patient safety and patient experience. Hence during 2014/15 we have continued to work closely with the hospice’s clinicians and managers, monitoring the delivery of care through reviewing the quality and performance through the quarterly Clinical Quality Review Group meetings, addressing any issues around the quality and safety of patient care with the hospice, as and when they have occurred.

We note that this is the first Quality Account that the hospice has produced and feel that this is a positive step for the organisation, demonstrating a real commitment to the wider quality agenda. The CCG suggests that the hospice looks to include a small number of clear and measurable quality priority areas for the coming year and that these are revisited within next year’s Quality Account to demonstrate progress.

Through reading the Quality Account it was obvious that the hospice has worked hard to improve its standards and quality. We noted how the service has successfully achieved the Social Enterprise UK Gold Mark standard, one of only three social enterprises in the country to have achieved this. Additionally we were pleased to learn that during 2014/15 the hospice received the Royal Bank of Scotland 100 award for innovation and the regional Social Enterprise West Midlands Award for innovation beyond expectation.

It was positive to note how the hospice currently utilises social media eg websites such as Patient Opinion and Facebook to both communicate with patients and carers and to receive feedback on the care and treatment provided. Many of the comments these sites generated demonstrated clear evidence of the hospice’s delivery of high quality, compassionate care within the final weeks of life and how this support was appreciated by families.

We welcomed the work the hospice has undertaken in respect to prepare and contain any cases of ebola virus disease and viral haemorrhagic fever and to ensure that all registered staff nurses have received training on the identification and management of neutropenic sepsis.

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Healthwatch

It is with pleasure that Healthwatch Birmingham has reviewed John Taylor Hospice Quality Account for 2014/15.

Firstly, we are pleased to learn that 95% of patients are choosing to have care in a place where they call “home” which demonstrates that patients have a real choice about where they have their care. We are also pleased to learn that the “Hospice @ Home” had a 60% increase in use this year and shows a significant increase than last year.

We note the £30,000 saving through the E-rostering system and implementation use of technology has positively impacted on patients through the reduction in inefficiencies. We are delighted to learn the hospice’s PLACE inspection scores with particular attention to cleanliness and food both scoring 100%. We also commend that the hospice’s staffing ratios are in excess of RCN guidelines which increases quality and patient safety.

We are also pleased to read that patient safety has improved this year and the hospice has a good system for analysing trends and incidents. However we would be keen to see specific monthly figures to see how much patient safety has improved by over the year. Patient safety is of upmost importance and Healthwatch Birmingham is delighted that the hospice has invested both time and effort to reduce incidents. Similarly we note the hospice’s actions on slips and trips and we are keen to see if the actions put in place will make an impact this year.

We note the hospice’s figures around pressure sores and number of patients being admitted with early signs. We wonder if other hospices demonstrate similar figures and if so, would urge the hospice to share the data more widely to see if there is an appetite for systems improvement in this specific area. Healthwatch Birmingham would be potentially interested in supporting the hospice in this work.

The “Mix and Mingle” scheme also appears to be a good mechanism to be engaging with staff and patients. However we would keen to learn about the model further and precise figures about how many patients the hospice has engaged with and what the impact of this engagement has been. We would urge the hospice to continue listening to staff and patient feedback in order that services can continue to be shaped around patients.

We highlight the relatively low number of formal complaints (3) and ask if this is a change from last year. Similarly, medication errors and “Never Events” figures were not available at the time of writing so cannot be commented on. Again, Healthwatch Birmingham would be keen to see these figures. We look forward to reading the CQC report when available.

Healthwatch Birmingham would like to congratulate John Taylor Hospice on a successful year and if we can be of any support, please do contact us.

Yours Sincerely, Candy PerryDirector, Healthwatch Birmingham

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Appendices Appendix 1: The Duties and Authority of John Taylor Hospice Membership Council

The Executive Directors of the Company are accountable for the governance of the company. In a CIC this includes accountability for ensuring that a Membership Council is established.

The Membership Council and the Board are required to meet at least four times each year, one of which will be the Annual General Meeting. At each Council meeting and at the Annual General Meeting of the company, the Membership Council will appoint one of their number to be the Chair of the Meeting.

The preparation of the agenda for the Membership Council meeting and reports to be considered is the responsibility of the company secretary in partnership with the CEO (or representative of the CEO) and the appointed Chair of the Membership Council.

There are 12 specific duties for all membership councillors.

(1) Appoint one of their number as Chair of the Council, who will chair each Council meeting and the company AGM.

(2) Attend every full Membership Council meeting.(3) Maintain an up-to-date understanding of the priorities and aspirations of

the company.(4) Work in partnership with the CEO in setting up the AGM.(5) Attend the Annual General Meeting and be prepared to act as Chair if

nominated by fellow Membership Council members.(6) Hold the Board to account for operating with an up-to-date Company

Plan. (7) Uphold the implementation of the Company Plan, company handbook,

policies and priorities.(8) Carry out their duties serving all members of the company equally, fairly

and without discrimination.(9) Find ways of effectively and regularly communicating with the

membership about what happens at Council meetings and in the process of preparing for Council meetings.

(10)Campaign actively to support the aims of the company.(11)Participate in the governance of the company either and/or:

As a member of the Membership Council As a member of the audit committee As a member of any sub committees, panels or for a from

time to time established In offering a contribution to the appointment of staff

(12)If authorized by the Board to undertake official duties or act as representatives of the company.

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The Executive Directors are accountable in constituting the Council for determining a ratio of members to councillors to can ensure that the Council can attain the objects of the company and must all ensure that prospective councillors evidence that they have an interest in the attainment of the objects of the company.

Everyone who has been admitted as a member of the company can put themselves forward for election to serve on the Membership Council for at least one year and no more than three years. Councillors can put themselves forward for an election for a second term of one year or a second term of no more than three years.

Membership Councillors and Non-Executive Directorships in our company are voluntary positions. We set up our first Council by election with five councillors. This took into account that there are five Non-Executive Directors and the ratio of members to councillors. Our company handbook recognizes the Membership Council role as a public service. Up to five days of leave can be taken from paid work for Membership Council business. The manager of the team in which the councillor works is accountable for approving this leave and for assuring continuity of care or service.

The Membership Council has six specific duties in the governance of the company:

Is accountable for the appointment of the Chairman. (The NHS facilitated this process in 2011 because the company was not formed and there was no Membership Council).

The Membership Council can also propose and resolve a resolution that the Chairman step down on the ground that his or her continued Chairmanship is harmful to or is likely to become harmful to the interests of the company.

The Membership Council are accountable for working with the Chairman to appoint Non-Executive Directors.

The Membership Council as a whole holds the Board of the company to account for the delivery of the annual plan and the regulatory and financial duties of the company.

The Membership Council are authorised to consult with the Executive Directors and Non-Executive Directors of the company when they deem necessary or appropriate to assist in the achievement of the object of the company.

The Membership Council and the Company Audit Committee are authorised to appoint and reappointment of the auditors within the terms of the procurement process at each Annual General Meeting.

The Non-Executive Directors on the Board are accountable for the safe stewardship of the company and therefore have specific authority by majority decision to expel any person, entity or body from the Membership Council on the grounds that their continued involvement is harmful to or is likely to become harmful to the interests of the company.

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Appendix 2 Commissioning for Quality and Innovation for 2015 to 2016

CQUIN 1: Every Moment Matters – Patient and family Access to Wi-Fi

Communicating with family and friends over the internet, including emails, social media as well as gaming online and working remotely are activities people in the In-Patient Unit and their visitors do when at home. People on In-Patient Unit and visitors tell us installing Wi-Fi would make a profound and positive impact to the ease of visiting, enabling close relatives to move in and work ‘from home’ when the hospice is home for their relatives. Young people can do what they do at home – homework, online gaming and social media, making it easier for them to spend the maximum time with their parents and relatives. Installing Wi-Fi is not easy because the walls of the building are thick and signal strength is variable, however we have done all the survey and preparation work and the installation of Wi-Fi will be completed over the summer of 2015. Part of the reasons for this CQUIN is that The CCG 2014 consultation on end of life care was designed to lead to improved outcomes in the experience of patients and families. Improving experiences is one of the five domains against which the NHS is held to account and this CQUIN will help bring about changes to improve people’s experience.

CQUIN 2: Macmillan Values Based Standard

John Taylor Hospice has recently adopted the Macmillan Value Based Standard Framework. In 2009 Macmillan Cancer Support commissioned work to research and develop a standard for cancer care services, expressing human rights principles as specific behaviours.

The Macmillan Values Based Standard has been developed through an 18 month engagement process with over 300 healthcare staff and people living with and affected by cancer across the country. In a report called Improving Outcomes: A Strategy for Cancer Care the Government has confirmed its support for the Macmillan Values Based Standard, recognising that the application of human rights to the delivery of cancer care focuses on ‘what matters’ to patients and has the potential to create more equitable care outcomes by changing the nature of the relationship between patients and professionals.

Birmingham Cross City Commissioning Group has now accepted this as a CQUIN at John Taylor Hospice, which means that we measure, audit and evidence how we meet the standards set in delivering the outcomes that patients have described as important to them.

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Appendix 3 - Our Understanding of Accountability – the company handbook

The following is part of the company handbook:

In the UK assurance that a public service can be trusted, is tested by holding people employed or volunteering against the seven standards of public life. Everyone at the company is held to account against them, in their individual objectives. Each standard and the public duty of accountability that relates to each standard are summarised:

Standard DutyDon’t bend or break the rules RISKPut in place and follow clear procedures SAFETYIf approval is needed, get it first SAFETY & RISKDon’t allow a conflict of interest to affect a decision

RISK & SAFETY

Don’t use public money for private benefit QUALITYBe even-handed QUALITYAlways record the reasons for decisions SAFETY

Director posts in our company that hold statutory accountability at an individual level have the additional title of Executive (Director). Statutory accountabilities are regulatory and legal duties governing the company are grouped into three areas: Quality, Safety and Risk. Executive Directors have formal accountability for one of these duties, which is why these posts are members of the company Board.

The Chair and Non-Executive Directors use Quality, Safety and Risk to hold CEO and Executive Directors to account for the effective running of the company to give assurance to the public that choosing John Taylor Hospice for your care, the care of your family of the care of your patient is a good decision. The company governance structure shows how accountability for Quality, Safety and Risk works in practice.

Posts with a Director title are posts which carry accountability for a distinct area of the company business and typically will be accountable for more than one set of functions. All other management posts are posts that support a Director or CEO; they can be responsible for a large or small number of functions. They do not usually carry sole accountability for these functions.

The work of everyone in the company is set out each year in the Company Plan. Individual and team accountability is set out in objectives that stem from the Company Plan. The terms of the regulation of the company mean that all staff are required to participate in regular formal supervision against an agreed set of objectives, attend and contribute to team meetings and complete an annual appraisal. Everyone in the company will have an appraisal at least annually to formally agree the objectives and review delivery against them.

All staff are individually accountable for working to their contract, which includes information governance, confidentiality, conduct and equality as well

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as professional codes of conduct, their professional registration, adhering to the company handbook and for ensuring that they complete all statutory and mandatory training for their role. All staff are accountable to and supported by their immediate line manager. The accountability for the running of the company is set out in the company governance structure.

Each priority in the Company Plan is set out in the form of smart objectives which match the Board assurance framework. The governance of the company is structured in the domains of Quality, Risk and Safety. Each of the company priorities is aligned to one of these domains.

Company Priority Board Assurance Framework

i Setting the standard Safetyii Community investment Qualityiii Money Matters Riskiv Sustainable Trading Safetyv Brand Development Quality

The legitimacy of the community interest Company comes from the QUALITY of the connection that John Taylor Hospice has with the people who come to us for help and the public. This is measured by the Board, Membership Council and the regulators in real time feedback from patients and families, what the company does about complaints and incidents, the level of investment individuals and companies give to John Taylor Hospice annually in cash and in kind and the recruitment and retention of skilled staff and skilled volunteers.

The SAFETY of the company is measured by Board, Membership Council, Clinical Governance Committee and the regulators on the basis of routinely reported clinical activity data and external inspections at least annually on compliance with environmental standards, safeguarding, statutory and mandatory training, professional registration, infection control, environmental health and workplace safety, ethical trading and sustainability (or ‘green’ credentials).

RISK has three main dimensions - care, money and reputation. The company contract to deliver clinical care on behalf the NHS requires annual improvements in quality, evidence of innovation, increases in productivity and achievement of the annual performance targets. A proportion of the income received from the NHS is only payable if these targets are met. Staff in a job with budget holder responsibility are supported by and accountable for the management of that budget in line with the Company Standing Operating Procedures. The Membership Council appoint auditors who objectively assess the viability of the company as a going concern.

ALL MEMBERS of the company are invited to attend the company AGM to understand how the company has performed annually. The auditor presents the company accounts. The AGM is chaired by a Membership Councillor.

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Appendix 4 John Taylor Integrated Approach to Safeguarding

The following is an extract from the company handbook:

Our company believes that if we hold dignity in mind, it makes it easier to act with understanding and kindness and see and get to know everyone as an individual in their family and cultural context. Valuing the uniqueness of each individual, our diversity and difference encourages people to choose John Taylor because people who have made this choice will tell their friends, their doctors and their families that they were welcome AND that our services will be better and safer as a result. As a Community Interest Company we believe that everyone who contacts John Taylor must be able to recognise themselves in John Taylor, this means our services fit around the lives of people and families not the other way round.

Respecting and remembering dignity means: that we look out for each other, we say thank you and we celebrate success, we want to be the best in what we do, we never consciously miss an opportunity to be kind or an opportunity to learn. Respecting and remembering dignity means that rudeness is addressed and harassment or bullying is stopped. It means we have a company uniform for our staff as a whole, rather than by individual discipline. To model and reinforce that what we do requires the collective, co-ordinated and consistent approach from everyone, and we identify ourselves to the public by our name and our specific accountability with name badges.

Company conduct at John Taylor Hospice CIC requires that the duty of confidentiality, consistent with the Data Protection Act is absolute. The only exceptions are those in law concerning risk to the public and public interest and the company; Caldecott Guardian is the only person who can authorise such exceptions. The duty of safeguarding means that all staff will be assessed in relation to the disclosures and barring service (DBS) and be subject to a DBS check before they can commence duties.

Our company invests in team work, training and development, reflective practice and openness to mitigate the everyday risks of misunderstanding, prejudice and conflict to create a culture of confidence. Our approach is underpinned by the seven standards of public life or the Nolan Principles which form part of our company terms and conditions and our commitment to safeguarding the public (Part IV Section 1.4).

The Nolan Principles apply to everyone acting on behalf of John Taylor Hospice CIC as a volunteer, employee or contractor.

SELFLESSNESSWe act solely in the public interest and should not act to gain additional financial or material benefits from our work for family, friends, or ourselves.

INTEGRITYWe cannot act under any financial or other obligation to individuals or organisations that might seek to influence us in the how we do our work.

OBJECTIVITY

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In carrying out public business, choices about making public appointments, awarding contracts or recommending individuals for rewards and benefits are made on the basis of individual or organisational merit.

ACCOUNTABILITYWe are accountable for our decisions and actions to the public and subject to public scrutiny through regulation.

OPENNESSWe should give reasons for our decisions and restrict information only when the wider public interest clearly demands this.

HONESTYWe declare private interests relating to their public duties and resolve any conflicts arising in a way that protects the public interest.

LEADERSHIPWe promote and support these principles by leadership and example.

Everyone who acts on behalf of the company, employees, volunteers and contractors has a responsibility to conduct themselves in line with these standards of behaviour and people in leadership roles have a responsibility to role model these standards. By accepting a post with the COMPANY as a volunteer or paid staff member, you are agreeing to uphold these standards.

Everyone is accountable for ensuring that his or her own behaviour could not be construed as personal harassment acting unfairly and or in a discriminatory way. Everyone is human, it means all of us using our judgement to correct standards of conduct or behaviour and to remind each other and ourselves these standards in addition to understanding and upholding their professional codes of conduct. Working in this way protects dignity and safeguards all of us.

Essential Definitions in Law

Under the Equality Act 2010, harassment occurs where A engages in unwanted conduct related to a protected characteristic (or of a sexual nature) that has the purpose of effect of violating B’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for B. Whether the conduct has that effect is judged subjectively from B’s viewpoint, subject to a test of reasonableness.

The protected characteristics are:Age SexDisability Marriage and civil partnershipGender reassignments Religion or beliefPregnancy and maternity Sexual orientation

Bullying is defined as offensive, intimidating, malicious or insulting behaviour involving the misuse of power that can make a person feel vulnerable, upset, humiliated, undermined or threatened. Power does not always mean being in a position of authority but can include both personal strength and the power to

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coerce through fear or intimidation. In all cases the experience of the recipient is what decides whether the conduct or another person or group of people is described as harassment and/or bullying.

“At work” means any place where the occasion can readily be identified with either the requirements of the employer or with social events linked to the same employment. “At work” includes any place where care is delivered, in the hospice or the hospice campus and in the home of a patient or family who is in receipt of care from the company. Safeguarding in the Public InterestSafeguarding has several components:

Everyone has specific legal duties to safeguard children and vulnerable adults from harm

There is a Duty of Candour for public services to report openly about the services provided to the public

General requirements about conduct and operation of public services and the conditions for collecting and sharing information designed to protect the individual, the public and staff and to create the conditions for trust and confidence between the public and staff employed to deliver services to them and/or on their behalf.

Our company handbook puts everything from recruitment and support to pay and terms and conditions in one place. The handbook shows everyone how the values and ethos of our Company come to life in our workforce. Our company handbook is based on seven principles:

Foster entrepreneurship Respect family life Everyone is equally important Always hold diversity and dignity in mind Kindness is at the centre of excellence Expect the best Don’t say no, say how?

John Taylor Hospice CIC is a service for the public that is regulated, to provide for the public, patients, families and commissioners independent assurance of quality, safety and financial probity. Our company handbook should be read in conjunction with policy and procedures, practice guides and frequently asked questions sheets stored on the shared drive. The rule of thumb? If in doubt - ask

Safeguarding in the public interest is everyone’s responsibilitySafeguarding and Information GovernanceIG is the acronym for the framework we must use every day for the handling of information. IG or Information Governance brings together UK and European laws passed to protect individuals and companies and the security of data:

The Data Protection Act 1998. The common law duty of confidence. The Confidentiality NHS Code of Practice. The NHS Care Record Guarantee for England. The Social Care Record Guarantee for England.

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The international information security standard: ISO/IEC 27002: 2005.

The Information Security NHS Code of Practice. The Records Management NHS Code of Practice. The Freedom of Information Act 2000.

Assurance for the public of compliance with IG is the responsibility of the Information Commission. All NHS organisations, GP practices and councils providing social care must be registered directly with the Information Commission and have a registered person on the National Register of Caldicott Guardians. Other organisations providing health and social care services like us have the option of registering a guardian. Our Board believes the best guarantee of security for the public and commissioners is to register with the Information Commission and meet the national IG standards.

Our CIC registered directly with the Office of the Information Commissioner as a “data controller” and a Caldicott Guardian in 2011. In 2013 we were approved as fully compliant with the IG standards.

Achieving IG compliance means the Information Commissioner (the equivalent of a regulatory body like the CQC) has approved that our company can evidence competence to maintain the confidentiality and security of information that we collect, hold and use and we have systems in place to govern individual daily practice.  This means that John Taylor Hospice CIC is considered to be trustworthy and competent to use, hold and collect personal and corporate information. This includes all the legal requirements of compliance including evidence of assurances on:

Data protection and confidentiality; Information security; Information quality; Health / care records management; Corporate information

A breach of information governance can have severe consequences, from disciplinary action, loss of public trust and confidence and a fine of up to £500,000. To protect everyone acting on behalf of the company and the company itself, in all aspects of your work you will encounter systems and processes that ensure our on-going compliance in our daily work.

We do Disclosure and Barring Checks We have named functions and accountabilities Every employee has a contractual obligation for facilitating and

maintaining confidentiality and security of information at all times – this includes a CLEAR WORK STATION

Access within The Grange is controlled with electronic door locks and key fobs

Password protection is required for access to your email, electronic patient records and the internet and access to information held by the company is commensurate with role

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We are aspiring to be paperless to reduce risk of loss of paper records in storage/transition

Everyone must have an up-to-date IG training Professionals employed at JTH must have to up-to-date professional

registration We have explicit guidance for recording patient identifiable information

(see below) We have explicit procedures for DNACPR and Mental Capacity, access

patient records, sharing patient information with others and informed consent

There is a built-in systematic electronic back-up capacity through a local area network of computer servers

We have access to secure storage with a registered provider (Iron Mountain)

We undertake audit to assure compliance We can all enter data (report incidents for example) about risks or

breaches

Safeguarding and Whistle Blowing

Whistleblowing is the colloquial term for safeguarding in the public interest. The term whistleblowing means that the confidentiality of the person raising the concern is protected. Whistleblowing is a mechanism formally incorporated into UK public service regulations to protect the public from the risk that staff may not report all incidents or learn from mistakes and complaints. The Francis Report set out a Duty of Candour.

Safeguarding in the public interest (or whistleblowing) means alerting a manager in person or with a dated and signed letter if any aspect of the care of a patient is a cause for concern. Telling a member of staff or a manager in person is the first step in making sure the concern is looked into, it means the company can put it right. Concerns can often be resolved quickly, openly and positively. Reporting a concern in person or with a signed and dated letter will also trigger the company serious incident investigation policy.

Safeguarding in the public interest means everyone working for the company is responsible for fulfilling their job role, contributing to team meetings, attending supervision and training, for reporting incidents, correcting mistakes and to support and challenge each other constructively if practice we observe is falling below the standards in this handbook and company policy. It also means accurate record keeping (including electronically captured records) and collecting “real time patient feedback” and learning from this. The company governance structure has a membership council. A company board and a clinical governance committee to assure this takes place.

These structures and process are there to hold everyone in the company to account and means that is safe and always appropriate to raise concerns and questions, if in doubt ask. There are no daft questions, all questions will be answered and/or investigated and resolved by the managers who are held to

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account by the Board and the Membership Council for quality, risk and safety and the results reported back to the individual and the company.

It is the responsibility of managers to conduct the investigation when a concern is reported to them or to a member of staff and to protect the confidentiality of the person reporting the concern and keep them informed throughout the investigation and the outcome.

Safeguarding in the public interest is also called “open practice”. Open practice places a duty upon everyone in the company to report such concerns in person to a manager as quickly as possible so that they can be looked into and resolved and where there are any risks to patient care these risks are immediately identified and addressed. Information about the Independent Mental health Advocacy Service, Healthwatch and PALS is made clear in the hospice. Deprivation of Liberty and Mental Capacity are mandatory modules for all staff.

If approaching a member of staff or a manager for any reason is not possible, you must approach one of the Executive Team directly or if you prefer the CEO or the Chairman.

Safeguarding in the Public Interest – Gifts and Hospitality

Local people and businesses invest in John Taylor Hospice and because we are privileged to help people at a time when the impact of death can mean they are at their most vulnerable, in the nature of the human spirit, people want to say thank you with gifts.

We rely on gifts of kindness, cash and gifts that help us to raise funds; these gifts are an investment in the care for people today and for future generations. This means that everyone must be confident about how to receive such gifts in a way that respects the giver and does not compromise the Nolan Principles. All public services are subject to national guidance on the acceptance of gifts and hospitality because public resources cannot be used for personal benefit. Public servants are in a unique position, giving people a service or an experience that they value and it is a service that is free to the public at the point of delivery.

In addition to the Nolan Principles, the UK government published “Regularity, Propriety and Value for Money” in November 1994. It says: “….the way in which our public services goes about business, including the way individual employees go about theirs, is of prime importance ….the public expects the conduct of staff employed on their behalf to be above reasonable reproach.”

Public service employees must not use public resources for personal benefit or receive gifts or benefits in kind from a third party which may be seen to

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compromise their judgement, integrity or impartiality. The reputation of the company risks being damaged because personal gain from a public position is considered a breach of public trust and confidence.

In order to comply with this requirement, this company operates the simple principle that staff and volunteers should respect the offer of a gift, HOWEVER, they should also desist from responding in a way which might give rise to the impression that they have been influenced by a gift or show bias for or against any person or organisation because of gifts. If in doubt, always consult a manager.

For employees this means all gifts must be handled in line with the company “banking and thanking” procedure. The company also has a standard template letter for a gift that is available on the company shared drive. Failure to comply with this procedure will trigger a serious incident review.

Care should also be taken to avoid actual, potential or perceived conflicts of interests. Under the seven standards of public life, all employees and volunteers must openly declare to their manager if they have a blood relationship or personal relationship with another member of the company.

In every company some people will be related in some way, the company will apply common sense and line managers will review the seven standards with employees who find themselves in these circumstances to identify any potential scenarios where they might be a conflict of interest to protect the employee(s) and the company from any potential criticism.

Budget holders should be satisfied that any expenditure on gifts and hospitality incurred is in the best interest of the organisation, provides value for money and complies with company standing operating procedures. Where there is doubt about any particular event, budget holders should seek advice from the Chief Finance Officer.

Hospitality at meetings and flowers for staff, if paid for by the company, are a gift from the company. These gifts must not paid for by the company as a gesture of reciprocity. To minimise the risk of criticism, the provision of hospitality and gifts by the company should be limited to a meal or light refreshments and with individual gifts, a sum of less that £25. It is not practical to draw up a sliding scale for everything falling under the umbrella of provision of hospitality. Some circumstances will justify a much greater outlay than others and judgements on the scale of provision should be based on common sense considerations what is required is that the invoicing and procurement follows the company standing operating procedures.

The Chief Finance Officer and Director of Corporate and Commercial Services are authorised to ensure the company standards for gifts and hospitality are met and that any possible conflicts of interest are reported by staff and managers, reviewed by these two post holders and recorded. They are also authorised if necessary to take appropriate action to resolve any conflicts of interest and to report such action to the audit committee.

The Director of Corporate and Commercial Services is accountable for a ‘Register of Gifts and Hospitality Offered To Us’ recording all gifts and

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hospitality offered and the action taken for inspection by the Membership Council and annual inspection by the auditors.

The Workforce Team maintains a confidential register of staff, their blood relations and partners who also work in the company or are members of the League of Friends for inspection by the Membership Council and annually by the auditors and where staff change roles or teams within the company will advise managers of there is a potential conflict of interest.

Safeguarding in the Public Interest – Identification and Security

Our company is registered directly with the Office of the Information Commission as a data controller. This means that we must submit and meet the Information Governance Standards and this is why information governance and confidentiality is specified in everyone’s contract. The security of personally identifiable information is an accountability that is absolute and the company has a specific practice guide and FAQ to support everyone in the company to understand, adhere and comply as well as online certificated training and annual appraisal to confirm continued understanding and up-to-date knowledge.

All clinical information is contained in SystmOne. All clinical and paper records must be compliant with data protection and information governance standards. This is part of our contract of employment. Clinical records cannot leave the building. The company uses a secure mobile tablet system and mobile telephones for staff working outside of The Grange.

Staff and volunteers are subject to employment and Disclosure and Barring Services checks (previously CRB). They are issued with an identity card which bears their name, the company logo and their photograph.

From reception the company operates a “fob security system”. The fobs control access into the building. Individual access is authorised on the basis of job role by their manager. The company also operates a key policy for controlled drugs and standing operating finance procedure.

The company has a uniform to help the public to visually identify staff working on their behalf from John Taylor Hospice. The provision of uniforms is set out in the section of the company policy and procedures concerned with care of patients. All staff and volunteers will be advised of the uniform requirements and/or options commensurate with their role on commencement of duty. From reception through onto the In-Patient Unit, the photographs of senior staff on duty are displayed and updated.

On leaving the company or if suspended from duty, staff and volunteers are required to return fobs, mobile tablets and telephones, uniforms and identity cards and any other property of the organisation to their manager or the Workforce Team.

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Glossary

Community Interested Company A CIC is a special type of limited company which exists to benefit the community rather than private shareholders. As such, it makes a legal promise stating that the company’s assets will only be used for its social objectives, setting limits to the money it can pay to shareholders.

CQUIN Its full name is a “Commissioning for Quality and Innovation payments framework” and was set up by NHS England as a way of encouraging care providers to share and continually improve how care is delivered and to be open about overall improvement in healthcare. CQUINS take the form of agreements between care providers and their NHS commissioners for the care provider organisation to make changes that have a direct improvement on the quality of patient care for which the care providers receives payment when those changes are fully made.

Delayed Transfers of Care A Delayed Transfer of Care is experienced by an in-patient in a hospital who is ready to move on to the next stage of care but is prevented from doing so for one or more reasons. The arrangements for transfer to a more appropriate care setting (either within the NHS or in discharge from NHS care) will vary according to the needs of each patient but can be complex and sometimes lead to delays. We record any such delays and report them to our commissioners.

Duty of Candour This became a regulatory requirement in November 2014 to ensure that care providers are open and transparent with the “relevant people” when certain incidents occur in relation to care and treatment. It is a direct response to the Francis Inquiry report into Mid Staffordshire NHS Foundation that defines the duty of candour as ensuring that:

…any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has

been made or a question asked about it…

Key Lines of Enquiry (KLOEs)The CQC has established a review process in which adult care services are inspected around five key questions which inspectors use to help establish whether a service is providing the high standard of care expected of them. The five key questions are as follows. Is a service:

Safe? Effective? Caring? Responsive? Well-led?

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Performance Indicators These are measures of how efficiently a care provider is providing the services for which it is commissioned. They include basic quantitative indicators like the number of people who will be provided care each year and how frequently we see them, to more qualitative things like how quickly we respond to a patient being referred to us and how fully we understand and meet the needs of our patients. Performance Indicators are typically used in the business contracts between care organisations and commissioners so tend to have an emphasis on being “measureable”. Performance indicators are different but closely related to “Quality Indicators”. Serious Incidents The NHS defines a serious incident as one which resulted in one or more of the following;

(1) The unexpected or avoidable death or severe harm of one or more patients, zstaff or members of the public. (2) A never event – See ‘Never Event’.(3) A situation that prevents an organisation’s ability to continue to deliver healthcare including data loss, property damage or incidents in programmes like screening and immunisation where harm potentially may extend to a large population. (4) Allegations or incidents of physical abuse and sexual assault or abuse. (5) A loss of confidence in the service, adverse media coverage or public concern about healthcare or an organisation.

The ‘6 Cs’ This is the acronym for Care, Compassion, Competence, Communication, Courage and Commitment. These six things are self-explanatory but were used in this phrase to re-emphasise the NHS vision and strategy for all care staff for helping people to stay independent, maximising well-being and improving health outcomes by making sure that people have better experience of care and that care providers provide high quality care, measure the effect of what they do, build leadership, have the right number of staff with the right skills and support their staff. ‘Never Events’ Never events are serious, largely preventable patient safety incidents that should not occur if the correct preventative measures have been implemented. There are 25 explicit events considered as Never Events by the NHS such as wrong site surgery or wrong route administration of medication. Incidents are considered to be Never Events if there is evidence that the event has occurred in the past and is a known source of risk or if there is guidance which if followed would prevent a Never Event. Not all Never Events necessarily result in severe harm or death PLACE audits Every patient should be cared for with compassion and dignity in a clean, safe environment and where standards fall short, they should be able to draw it to the attention and hold the service to account. So, April 2013 saw the introduction of PLACE, which is the new system for assessing the quality of the

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patient environment in hospitals, hospices and day treatment centres providing NHS funded care.

Patient Reported Outcome Measures Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering four clinical procedures, PROMs calculate the health gains after surgical treatment using pre- and post-operative surveys. The four procedures are:

Hip replacements Knee replacements Groin hernia Varicose veins

John Taylor Hospice does not carry out any of these procedures.

RAG Rating or Red Amber GreenThis is a commonly-used way of reporting information that uses ‘traffic light colours’ to denote a level of urgency of an item being reported or as a degree of completion of any outstanding tasks. For example:

1. A risk or issue that is reported as red may require attention within a 24 hour period, an amber issue in five working days and a green rated issue in 20 working days.

2. A task that is part of a wider project or programme of works that is rated green usually denotes that task has been completed, amber means that it is partially completed and red means there is no progress on that task at all.

Re-admission within 28 Days This is not a Key Performance Indicator in the local NHS contract with hospices. TUPEThis refers to the ‘Transfer of Undertakings (Protection of Employment) Regulations’ as rules that apply to organisations of all sizes and protect employees' rights when the organisation or service they work for transfers to a new employer.

Urinary Tract Infection A urinary tract infection (UTI) is also known as acute cystitis or bladder infection. It is an infection that affects part of the urinary tract. Venous Thromboembolism Venous thromboembolism (VTE) is a condition that includes both deep vein thrombosis and pulmonary embolism. A deep vein thrombosis is the formation of a blood clot in a deep vein and the most serious complication is that the clot could dislodge and travel to the lungs, becoming a pulmonary embolism.

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