Adding life to days ………

Quality Account 2010 - 2011

Waverley Lane, Farnham,

Surrey, GU9 8BL Tel: 01252 729400

www.phyllistuckwellhospice.org.uk

Phyllis Tuckwell Memorial Hospice Ltd. Limited by Guarantee. Incorporated in England and Wales. Registered No. 1063033 registered Charity No. 264501

Both my wife and I were very satisfied with

the way all the staff showed us both respect,

understood the problem, had the ability and

desire to help resolve the problem and

throughout my stay with you, showed genuine

love and care for us both at all times

Patient survey 2010

Chief Executive’s Statement On behalf of myself and the Board of Trustees, I am delighted to introduce our first Quality Account for the year April 2010 – March 2011. This is the first time we have produced such a document and we hope that you will find it interesting and encouraging to read how we have been striving to provide high quality and cost effective patient care as well as to learn about the quality improvement work that we have recently completed. Phyllis Tuckwell Hospice has a well-established and effective clinical governance function, incorporating a quality and audit programme, which acts as the driver for continuous improvement in the quality of patient care. The views, experiences and outcomes for patients and their families are paramount to quality improvement and are of great importance to us. Questionnaires, surveys and feedback cards are just some of the ways we listen. From this we are able to learn, develop and improve the services we provide. I would like to thank all of our staff and volunteers for their hard work and achievements over the past year. Despite the current economic climate, the hospice has continued to provide high quality services to an ever increasing number of patients. Thanks to the generous support from our local community we continue to be financially sound as an organisation but recognise there is no room for complacency and work hard to ensure that we use our resources wisely and efficiently. I am responsible for overseeing the preparation of this report and its contents. To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality of healthcare services provided by our hospice. Thank you for your interest in the work of Phyllis Tuckwell Hospice. Sarah Brocklebank Chief Executive August 2011

Section one – Improvements present and future

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Quality initiative: Quality and Audit Programme We wanted to introduce a more structured approach to service evaluation and so have developed a Quality and Audit programme to allow us to monitor the quality of service in a systematic way. The programme acts as a framework which identifies areas for audit. The findings are discussed, recommendations made and action plans developed. This is a continuous process and has resulted in raising standards and improving the quality of care. Quality initiative: Training for care home staff

The need for palliative care training in care homes was identified by both care home and hospice staff. Patients (and their carers) resident in care homes, particularly those known to the hospice, were also of the view than more training was required. Training is now delivered, by an experienced clinical nurse specialist, in varying aspects of palliative care. The sessions have been rolled out to many of our local care homes consisting of both visits to homes themselves and study days at the hospice. The training has been a great success with care home staff reporting that they are more knowledgeable and confident in end of life care. Quality initiative: Ward Audit programme

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through the systematic review of care. To achieve ownership by staff, it is preferable that staff themselves conduct audits and influence change. The ward audit programme comprises 6 clinical audits identified by the team as possible areas for improvement. The audits are conducted by nurses every four months, enabling discussion and change to be implemented throughout the year. This programme has proved very successful and has increased staff morale and consistently raised standards. Quality initiative: Clinical Management system (patient’s records)

The need for a more coordinated approach to the information stored in patients’ records has long been high on the agenda for both patients and health care professionals. Crosscare (a computerised clinical records management system) has been phased in over several years at the hospice supported by an education programme and user reviews/evaluations. All multidisciplinary team members are competent users and are able to access patient information from password protected terminals throughout the hospice. The system is efficient and effective in promoting a coordinated approach to care whilst providing valuable data for service and patient outcome analysis. ‘

Quality improvements Phyllis Tuckwell Hospice has been working on

Phyllis Tuckwell Hospice (PTH) has undertaken a series of quality initiatives, all with the aim of ensuring that care is safe, effective and provides patients and

carers with a positive experience

Section one - Improvements present and future

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Areas that we have identified for improvement in the coming year

PTH is committed to the delivery of high quality care. We know that the cornerstone of improvement is listening to what patients tell us about our services. Guided by what we have been told and by looking at our work over the last year, we have been able to identify key areas where we would like to see service development and improvement – three of these priorities are detailed in the following section.

The first two priorities are about looking ahead and developing our service with a focus on flexibility and choice. The third is an example of the day to day issues that effect patients on the ward. We believe that it is important to look at all processes, and how they affect the people involved - often small changes make a big difference.

Priority one:

Development of the ‘Dove Centre’ - To offer more choice and flexibility to community patients and their carers about where and when they can receive

care, treatment and advice.

How was the priority identified?

The collation of patient activity data and the feed back from several focus groups, attended by patients, carers and health care professionals.

How will the priority be achieved?

The Dove Centre, a new community focussed outpatient facility has been developed. The centre comprises a day hospice and a selection of outpatient treatment and consulting rooms. Patients and carers will be able to access therapies such as physiotherapy, complementary therapies and counselling. Medical and specialist nurse consultations will be available and in addition a new ‘drop in’ service is being developed.

How will progress be monitored?

A series of questionnaires will provide feedback from patients, carers and healthcare professionals. Patient activity data will identify how and when services are being accessed enabling modifications to be made.

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Priority two:

The development and delivery of a ‘Hospice Care at Home’ service - supporting and caring for patients in their homes

How was the priority identified?

The Hospice Care at Home Service - research has found that the preference of many patients is to receive care in their own homes. The Hospice conducted a small ‘Hospice at Home service’ pilot in 2009 and received positive feedback from patients and other healthcare professionals. The hospice concluded that there was a need for a responsive service and has since been raising the necessary funds to set up a small service

How will the priority be achieved?

The service will be developed in the coming year, enabling patients known to PTH to remain at home and feel confident that their palliative care needs will be met in their place of choice. The care will be coordinated and delivered in conjunction with the Primary Health Care Team and complement any existing care package.

How will progress be monitored?

The continued development and hopeful expansion of the service will be determined by patient, carer and health care professional feedback and analysis of patient activity data, as well as the availability of sustainable ongoing funding.

Priority three:

Review of meal times - to ensure the best possible experience for patients while making the delivery quick and easy for staff

How was the priority identified?

Feedback from staff and patients initiated this review. The different departments involved in the delivery of patient meals feel that higher standards could be achieved if a more coordinated approach was adopted. Patient survey results indicated high levels of satisfaction with the catering service but again it was felt we could improve the overall patient experience.

How will the priority be achieved?

A working group will review the meal time experience for patients using the Productive Ward Series – Department of Health. The results of catering questionnaires and observation of the current processes in place will indicate areas for review and refinement. In addition a recent refurbishment of the hospice kitchen will ensure more efficient cooking and preparation and a higher quality end product.

How will it be monitored?

A series of questionnaires will provide feedback from patients and staff will be given the opportunity to discuss and review the new systems put into place.

Section Two – Statutory Information

This section includes:

Information that all providers must include in their quality account (Some of the information does not directly apply to specialist palliative care providers).

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Review of services

During 2010 – 2011 PTH provided five services

• In – Patient - Unit

• Day Hospice

• Out - Patients

• Community

• Bereavement

PTH has reviewed all the data available to them on the quality of care in all of these services. The income generated by the NHS represented just 12 per cent of the total income required to provide the services which were delivered by PTH in the reporting period 2010/11.

Participation in clinical audits

As a provider of specialist palliative care PTH is not eligible to participate in any of the national clinical audits or national confidential enquiries. This is because none of the audits or enquiries related to specialist palliative care.

PTH’s quality and audit programme facilitated many audits during 2010. The Hospice also used a number of ‘Help the Hospices' Audits Tools - Infection Control, Management of Controlled Drugs, General Medicines, and Medical gases. The tools are relevant to the particular requirements of hospices, allowing our performance to be benchmarked against that of other hospices. PTH is a member of a regional audit group and benchmarks the results of these audits on a regular basis. Our compliancy results have been high - achieving above average in all the audits compared in 2010.

Data quality

For the year 2010 -2011 PTH submitted audit data to the National Minimum Data Set for specialist palliative care. Results are available publically from the National Council for Palliative Care. www.ncpc.org.uk

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What others say about us

PTH is required to register with the Care Quality Commission, a regulatory body that ensures that we meet our legal obligations in all aspects of care. In March 2011, PTH was contacted by the Care Quality Commission (CQC), and asked to provide evidence that the hospice was complying with the Essential Standards of Quality and Safety. This was followed by an unannounced inspection in May. The CQC found that PTH was meeting all the essential standards of quality and safety. It also reported very positive feedback from both patients and their families.

Research

There were no opportunities for PTH to take part in any local or national ethically approved research but we are establishing links locally to facilitate contributing to multi-centered research in the future. Whilst not research in its purest form Dr Helen Burgess (Locum Consultant in Palliative Medicine) undertook a service development project to evaluate potential ways to achieve PTH’s clinical strategy of broadening the delivery and availability of specialist palliative care (SPC) to all disease groups by being a partner in shared care with other healthcare professionals. There were three main aspects to the project; a review of the literature, discussions with national SPC providers, and discussions with local stakeholders. The project reported to the Clinical Strategy Board Sub Committee and ultimately to the Board where the recommendations where accepted. As a result of this project, the Hospice is in the process of recruiting a third Consultant to lead on this important service development.

Quality improvement and innovation goals agreed with our commissioners

PTH’s income in 2010/11 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework.

Section Three – Quality overview This section provides:

• Data and information about how many patients use our services

• How we monitor the quality of care we provide

• What patients and families say about us

• What our regulators say about us

The National Council for Palliative Care; Minimum Data Series

The Minimum Data Set (MDS) for Specialist Palliative Care Services is collected on a yearly basis, with the aim of providing an accurate picture of hospice and specialist palliative care service activity.

Phyllis Tuckwell Hospice (PTH)

2010- 2011 2009- 2010 %

Increase

In – Patient - Unit (18 beds)

Total number of patients 374 331 13%

New patients 332 309 7%

% Occupancy 76% 73% 4%

Patients returning home 31% 40% -9%

Average length of stay - cancer 11 11 -----

Day Hospice

Total number of patients supported 98 114 -14%

% New patients 63% 75% -12%

% Places used 59% 60% -1%

% Places booked but not used 18% 21% -----

Average length of stay 183 Days 159 -----

Community service: All clinicians and therapists

Total number of patients supported 787 733 7%

New patients 550 509 8%

Face to face contact 3057 2276 34%

% Home deaths 36% 37% -----

% Care Home deaths 12% 13% -----

Bereavement Service

Total number of users supported 246

% Of New Patients

Non – Cancer diagnosis 2010- 2011 2009- 2010 %

Increase

In – Patient - Unit 15% 10% 39% Day Hospice 16 15% 5%

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In – Patient - Unit In the In – Patient - Unit the average length of stay for patients is 12 days although there is wide variation according to need. The majority (72%) of patients who were discharged from the unit returned to their homes. There was a significant increase in the number of new patients admitted to the inpatient unit with a non – cancer diagnosis. Day Hospice The Day Hospice continues to support patients and their carers. The total number of patients attending Day Hospice fell by 14% from the previous year. The average attendance was 59% and patients attended for an average of six months. The percentage of patients unable to attend their day hospice place was 15%. This is because patients may not be well enough to attend or because they have to attend hospital appointments. In response to this the hospice is in the process of expanding its outpatients facility, offering patients more choice and flexibility about where and when they can receive care, treatment and advice. It is expected that as a result patients will feel more comfortable about accessing the available services earlier in their disease. Community The number of patients supported in the community continues to increase, with face to face contact increasing by 34% from the previous year. There have also been significant increases in the number of patients supported by our patient and family services team and therapists.

Quality Markers

We have chosen to measure our performance against the following metrics.

Indicator 2010 - 2011

Complaints Total number of complaints 3

All three complaints were resolved satisfactorily

Patient safety incidents The number of serious patient safety incidents (excluding falls)

0

Number of falls No falls per bed per year

52 2.88

(Average % of 5 local hospices – 4.3)

The number of patients who experienced a fracture or other serious injury as a result of a fall

0

Indicator 2010 - 2011

Patient safety incidents Total Number of patients know to be infected with MRSA whilst on the In - Patient - Unit

0

Total Number of patients know to be infected with C. difficile whilst on the inpatient unit

0

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Clinical audits 2010 - 2011

To ensure that we are continually meeting standards and providing a consistently high quality of service, PTH has a Quality and Audit Programme in place. The programme allows us to monitor the quality of service in a systematic way, identifying areas for audit in the coming year. It creates a framework where we can review this information and make improvements where needed. Regular Clinical Governance meetings provide a forum to monitor quality of care and discuss audit and quality evaluation results. Recommendations are made and action plans developed.

National audits (Help the Hospices)

These audits are benchmarked with other hospices in the south, enabling us to discuss results and action plans promoting development and learning. Help the Hospices audits completed Compliancy Infection control Assessment of environment 96%

Compliancy with the Health and Social Care Act 2008, Code of Practice on the Prevention and Control of Healthcare Associated Infections

98%

Medicines Management Medicines Management 98% Management of controlled drugs 100% Management of medical Gases 89%

A sample of clinical audits completed at Phyllis Tuckwell

Audit Findings, recommendations and actions

to be taken to improve compliance/practice

Action plan Completed

Health records Good compliancy - 96% Minor shortfalls will be addressed by the newly established computerised record system

Completed

Documented consent

100% compliancy in 3 out of the 4 areas. Shortfalls identified in the final area have been fed back to staff and will be re-audited as part of the continuous ward audit programme

Completed

Patient information leaflets

All leaflets are managed by the relevant department manager and undergo a formal review annually. All leaflets met the criteria stipulated in the assessment tool. No action required.

N/A

Blood transfusion monitoring (re-audit)

Actions from a previous audit had been completed. Significant improvements have been achieved. Recommendation – to re-audit annually

Completed

Recording of resuscitation status

Minor shortfalls identified; these will be addressed by the newly established computerised record system. To continue will biannual audits

Completed

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Ward audit programme results

The nursing staff completing these audits embraced the idea of evaluating standards of care and the processes in place. They discussed the results as a team, made recommendations and initiated change where needed. All areas experienced improvements in compliancy with the exception of one where further discussion has taken place; this will be audited on a continuous basis for the rest of the year.

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Audit Findings, recommendations and actions

to be taken to improve compliance/practice

Action plan Completed

Nurse dispensing The audit found that the policy was complied with well. Recommendations included review of medications for nurse dispensing list (some medications are becoming more common). Maintenance of a training log

Completed

Documentation of patients preferred priorities of care

The audit highlighted that information was being stored in too many places and not easily accessible to all of the team. It was recommended that the new electronic patient record system store this information in a specific window, accessible by all. The importance of recording this information was reiterated to staff. For re-audit annually

Completed

Ward Audit programme 2010 Audit 1 Feb

Audit 2 May

Audit 3 Nov

Hand washing (standard required 100%) 87% 87% 93%

Sharps - looking at several areas, i.e. Boxes, disposal (Standard required 100%)

80% 88% 98%

Unqualified staff entries - are signatures countersigned (Standard required 100%)

30% 70% 100%

Risk assessment documents (standard required 100%) 63% 87% 95%

Consent – catheterisation (standard required 100%) 70% 100% 100%

Bowel management (Standard required 80%)

73% 70% 85%

What patients and families say about the services they receive The views and experiences of patients and their families are important to the Hospice and enable us to look at how we can learn, develop and improve the services we provide. The hospice undertakes a series of questionnaires, surveys and focus groups on a regular basis.

Patient Survey

The PTH survey includes questions relating to information giving by staff, staff attitudes, involvement of patients in care planning, privacy and courtesy, catering and cleanliness. The surveys are designed for self-completion by patients. One survey evaluated Day Hospice services and another Inpatient’s services. In - Patient - Unit The results revealed high levels of patient satisfaction. All patients said they understood explanations about their care always or most of the time. Patients reported high levels of courtesy and efforts to meet their needs. Ninety-five per cent of patients felt their privacy was respected and 100% thought that the different health care professionals involved in their care were aware of updates and changes to their care always or most of the time. There were high levels of satisfaction with cleanliness with 85% reporting it as excellent. There were somewhat lower levels of satisfaction with food with 43% scoring the food as excellent and 40% as good. However all patients surveyed reported the flexibility of the catering service as excellent. Day Hospice The results were very positive with many complimentary comments. The survey revealed that the majority of patients didn’t know what to expect on their first visit but 89% left feeling more relaxed and reassured. The patients who used PTH transport reported prompt pickups, and felt comfortable and safe during the journey. Patients experienced high levels of courtesy and felt their individual needs were met.

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Individual comments:

"Every member of staff makes you feel important.”

"The care was very good; I particularly like all the banter, the staff are fun."

"The Day Hospice is absolutely wonderful. The support to patients is second to none."

Day Hospice focus sessions

The aim of running the focus groups was to look at how we could promote the service more effectively, so patients feel encouraged to access therapeutic input earlier and subsequently feel better able to cope with their deteriorating illness when the time comes. The group consisted of both patients and health care professionals from the community and local hospitals.

The feedback indicated that the service needed to have a less ‘hospicy’ feel and be more flexible (this was key in the development of the Dove Centre). There were new ideas on how to promote the Hospice, engaging public and healthcare professionals’ interest.

Feedback from the unannounced provider visit

The Board of Trustees undertake two unannounced visits to the Hospice annually. Two members of the Board talk to staff, patients and carers. Patients and carers are asked about their views and experiences, the following is an example of one of the reports from 2010:

“We jointly interviewed a patient whose son was visiting at the time. It was her third period of stay in the In-Patient-Unit. She found PTH “wonderful” especially compared with hospital. There was a welcoming, relaxed atmosphere, immediate treatment, very good pain control and responsive staff who gave honest answers. The food was excellent with good choice. All the staff were friendly (she mentioned the cleaners as well as the nurses). Her son felt the Hospice offered a great period of respite care and shared his mother’s dislike of hospitals. He liked the cafeteria sandwiches and is keen to help us in raising funds.”

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What our regulators say about Phyllis Tuckwell Hospice

The Care Quality Commission (CQC), a regulatory body that ensures that we meet our legal obligations in all aspects of care. In March 2011, PTH was contacted by and asked to provide evidence that the Hospice was complying with the Essential Standards of Quality and Safety. This was followed by an unannounced inspection in May. During the visit the CQC observed how people were being cared for, talked with people who use services, talked with staff, checked our records, and looked at records of our patients. The CQC found that PTH was meeting all the essential standards of quality and safety. It also reported very positive feedback from both patients and their families, reporting:- “Patients that spoke to us advised that staff had discussed their personal needs and involved them in agreeing a plan of care. All the patients that responded to our questions felt that they were safe in the Hospice and that they had been involved in decisions regarding treatment and care. One patient said that he definitely felt very much that the staff treated him with dignity and respect and said “Staff go that extra mile.” Although compliant in all areas the CQC suggested that we review our system for recording the maintenance of equipment. This will be actioned as a priority and an audit completed within six months.

The Board of Trustees’ commitment to quality The Board of Trustees is fully committed to the quality agenda. The Hospice has a well established governance structure, with members of the Board having an active role in ensuring that the Hospice provides a high quality service in accordance with its terms of reference. As above, Members of the Board undertake an unannounced visit twice a year - gaining first hand knowledge of what the patients and staff think about the quality of the service. The Board is confident that the treatment and care provided by the Hospice is of high quality and is cost effective.

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Phyllis Tuckwell Hospice: Some pictures from our album