QUALITY ACCOUNT

2016 - 2017

Rainbows Hospice for Children and Young People Lark Rise, Loughborough, Leicestershire. LE11 2HS Tel: 01509 638000 Fax: 01509 216472 Website: www.rainbows.co.uk Registration Company in England and Wales Number: 2743297 Registered Charity Number: 1014051 Care Quality Commission Provider ID: 1-101728495

This Quality Account has been endorsed by the Hospice Board of Trustees

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Our Mission Statement:

This statement was developed with the help of families who use the services of the hospice and with members of staff. Enriching Lives: to be here always and strive to meet the needs of children, young people and their families in our care.

“I am always happy to recommend Rainbows to anyone, your day to day care and commitment is very special. Rainbows has been such a support and lifeline to our family. Telling people about the good work you do all year round is very easy to do.” (Parent)

“I have gained the reassurance that I’m not the

only sibling with a brother or sister with life restricting circumstances. It gives me more confidence, so thank you Rainbows and thank you to all the siblings.”

(Sibling)

“It’s a fantastic opportunity for both children and parents/carers to relax, recharge and de-stress, all of which are vital for the cohesion of the family.”

(Parent)

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Contents

Page No.

Part 1 Statement of Quality from Chief Executive 4 Part 2 Priorities for Improvement 5 - 6 - Priority 1 (Patient Safety) 5 - Priority 2 (Patient Experience) 6 - Priority 3 (Clinical Effectiveness) 6 Progress against Improvement Priorities Identified in 2016/17 7 - Priority 1 (Patient Safety) 7 - Priority 2 (Patient Experience) 7 - Priority 3 (Clinical Effectiveness) 7 Statements of Assurance from the Board 8 - 10 - Review of Services 8 - Participation in National Audits 8 - Research 8 - Quality Improvement and Innovation Goals agreed with our Commissioners 9 - What Others Say About Us 9 - Data Quality 9 - Information Governance Toolkit 10 - Clinical Coding Error Rate 10 - Duty of Candour 10 Part 3 Review of Quality Performance 11 Local Quality Measures 12 - Referrals 12 - Our Participation in Clinical Audits 12

Quality Metrics/Quality Markers We Have Chosen to Measure 14 - Patient Safety 14 - Clinical Effectiveness 15 - Patient Experience 15

Staff Satisfaction 17 The Board of Trustees Commitment to Quality 18 Statements from Local Involvement Networks (LINks) 18

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Part 1 Statement of Quality from Chief Executive

Welcome to our 5th annual Quality Account, a summary of our performance against selected quality measures for 2016/17 and our initiatives and priorities for 2017/18. Rainbows is an independent local charity. Babies, children and young people with life-limiting and life-threatening conditions come to the hospice for specialist respite stays, symptom management, palliative and end of life care. Their families are also supported and helped by Rainbows on their difficult journey. The aim of this report is to give clear information about the quality of our services, to demonstrate that our children, young people and their families can feel safe and well cared for and that all of our services are of a very high standard. We were delighted to be awarded an ‘Outstanding’ review by the Care Quality Commission in August 2017. We could not provide such high standards of care without the hard work of our staff and over 350 volunteers and, together with the Board of Trustees, I would like to thank them all for their support. Rainbows Hospice for Children and Young People is actively engaged with the NHS and other stakeholders in determining how the quality of children’s palliative care can be developed and improved in the future. These relationships are important to how we plan and deliver our services, and we will continue to develop and widen the scope of our stakeholders going forwards. As part of that commitment we are proud to host the East Midlands Children and Young People’s Palliative Care Network and remain an active member of this and the wider NHS England Palliative Care and Local Leadership Group. Our focus is, and always will be, our children, young people and their families. We actively continue to seek the views of all who access our services and respond to this feedback in a proactive way in order to ensure we maintain the highest standards of quality. Rainbows Board is supported by the Clinical Quality Assurance Committee and the Corporate Governance Committee. The Clinical Quality Assurance Committee has a particular remit to ensure that the hospice has a culture of continuous improvement. The vast majority of our funding comes from supporters in our communities, so the opinion of the general public is greatly valued to us all here at Rainbows. We thank all of the people across the East Midlands who raise the vast majority of the funding required to maintain our services, your contribution is vital to the ongoing care for babies, children, young people and their families.

Rainbows’ Director of Care is responsible for the preparation of this report and its content. To the best of my knowledge, the information in the Quality Account is accurate and a fair representation of the quality of care provided by Rainbows Hospice for Children and Young

People.

Mandy Ashton (Professor) Interim Chief Executive Officer

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Part 2 Priorities for Improvement and Statements of Assurance from the Board The hospice was last inspected, by the Care Quality Commission, against the Essential Standards of Quality and Safety on 31st May, 1st and 2nd June 2016 and was found to be compliant in all standards inspected. The overall rating for the hospice was Outstanding.

In line with Rainbows’ Five Year Strategic Plan, the following improvement priorities have been identified for 2017 – 2018:

Future Planning Priority 1(Patient Safety):

DEVELOPMENT OF A CLINICAL GOVERNANCE GROUP WITH A

FOCUS ON PATIENT SAFETY

We plan to establish a clinical governance group to provide a focus on clinical

governance, quality and patient safety activities in order to provide assurance

and raise concerns (if appropriate) to the Senior Management Team.

The group will have alternate weekly meetings and the main priorities of the

group will be overseeing clinical performance and ensuring that Rainbows

responds to the clinical issues raised in national/local reports, patient/family

surveys, complaints or feedback and any serious untoward incidents.

This group will ensure that patient safety is a priority and that anything which

may affect this is dealt with in a timely and structured way providing feedback

and assurance to the Senior Management Team and the Clinical Quality

Assurance Committee.

Clinical systems and processes will be reviewed by this group to ensure

Rainbows meets its statutory and regulatory standards, particularly in relation to

the Care Quality Commission’s Essential Standards. It will develop and promote

the vision, values and culture of clinical governance, quality, patient safety and

clinical standards and promote clinical leadership and engagement in the

development and delivery of Rainbows’ strategy.

The group will also aim to improve quality through ensuring that lessons are

learned with the continued use of Root Cause Analysis and Significant Event

Audit.

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Priority 2 (Patient Experience):

FOCUS ON TRANSITION

As a continuation of the work that has already been undertaken at Rainbows, we pledge to keep transition as a clinical priority going forward into 2017/18.

Many of the children and young people who visit Rainbows are now living into teenage years and adulthood. Whilst Rainbows supports them up to the age of 30 years, there are currently few services for those who reach the age of 30 years, to which transition can be made and their complex and palliative care needs met.

We plan to work with adult hospice stakeholders to plan and design future services for life-limited young people in transition to adult care. We will start by working with the adult hospice in Leicestershire to develop a model of care which will enable young people from the age of 25 to transition smoothly from one service to another and to provide the right care to them and their family through this journey. Adult and children models of palliative care vary and therefore respite in the adult hospice will not be possible, however plans will ensure that day care and care at the end of life can be. It is recognised that the young people and their families who access a children’s hospice have a unique set of complex needs and our partnership working with the adult hospice will involve identifying specific staff and volunteers to work with these families and the provision of specific training. Day care and hospice services will be available to these young people following a pathway which will be developed.

Priority 3 (Clinical Effectiveness):

DEVELOP SERVICES THAT ARE RESPONSIVE AND ADD VALUE

During 2017/18 we plan to develop aspects of our service responsive to the needs of our families.

Following a recent scoping exercise in which the palliative care outreach provided by community paediatric nursing teams across the East Midlands has been evaluated, Rainbows will be starting an end of life outreach service to complement existing community services and make provision where need cannot currently be met.

This service will involve unregistered staff providing care and support to children and young people aged 0 to 30 years in their own homes at the end of life. The service will be staffed using existing resources until it is clear how much need there is.

Working in families own homes presents staff with a unique set of challenges and considerations and therefore relevant training is being delivered to ensure they are prepared and confident in providing care outside the hospice.

Families will continue to be given a choice, whenever possible, of where they would like their child to be when they die. If they choose to be at home Rainbows will be able to provide episodes of care during the day or at night to allow families to be at home during this time. Care will always be led by the community team and supported by Rainbows staff.

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Progress against the improvement priorities identified in 2016-2017

Progress against the quality improvement priorities for 2016 - 2017 is discussed below:

Progress made against Priority 1(Patient Safety): Introduction of New Root Cause Analysis Investigation and Reporting process In conjunction with the Significant Event Audit work that was introduced in 2015/16, we have now implemented a new Root Cause Analysis (RCA) investigation and reporting process and used this to manage a recent serious incident which we believe could have resulted in serious harm had we not intervened.

The RCA process enabled Rainbows to fully evaluate the incident, learn from it and create actions for improvement and changes to practice and to share learning with the wider organisation.

Priority 3 (Clinical Effectiveness): Development of Dependency Rating Tool The new dependency rating tool has been written and is now being used to inform bookings and to manage capacity and demand. The process involved carrying out assessments on over 250 children and young people in order to give them a dependency score.

The tool has been piloted in four other children’s hospices and the feedback is being collated into a report. This report, plus the results of a Rainbows review following its use over the next four months, will be used to make further changes.

The tool will be used as part of a wider examination of hospice services through discussion at Senior Management Team and Board of Trustees meetings.

No additional funding has been required.

Progress made against Priority 2 (Patient Experience): Development of Sexuality Policy The Sexuality Policy has been written and is now in use in the hospice. The group of staff involved in writing and implementing the policy have been involved in a very successful sexuality workshop in November 2016. The policy has been discussed in support groups of parents/carers to enable the opportunity for open discussion and questions.

Our documentation has been reviewed and amended to include sections on personal identity and sexuality. This is appropriate for all ages of children and young people and is being utilised across the hospice.

Supporting the ongoing work of the Open University around young people and issues relating to sexuality, we have agreed that our focus will now be on identifying what further support is needed for young people themselves, looking at sexuality in the wider context of social, emotional and mental well-being.

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Statements of Assurance from the Board

The following are statements that all providers must include in their Quality Account. Many of these statements are not directly applicable to specialist palliative care providers, and therefore explanations of what these statements mean are also given.

Review of Services (mandatory statement): Rainbows is a nurse led hospice providing care and support for children and young people with life-limiting conditions from birth to 30 years of age, and their families. Medical care is provided through a 24/7 on-call service from a team of 4 GPs with training and expertise in palliative care. The Lead GP and Medical Director is based at the hospice on one day per week.

During 2016/17 the hospice provided the following services to the NHS:

In-patient services

Day care services

Psycho-social family support services

Specialist palliative care advice and support

The hospice has reviewed all the data available to us on the quality of care in these services.

Rainbows’ Clinical Quality Assurance Committee receives bi-monthly reports, which enable them to review the quantity of care provided by all clinical services. A report on all clinical incidents is also provided, and regular clinical audits are carried out. The Clinical Quality Assurance Committee submits a bi-monthly report to the Board of Trustees.

All services delivered by the Hospice are funded through a combination of fundraising activity and contracts with NHS and Social Care Commissioners. The NHS contracts mean that all services delivered by the hospice are part funded by the NHS. Where NHS and Social Care funding is secured this only partly contributes to the costs of clinical care of children and young people. The cost of provision of a holistic family focused service are borne by the charity through fundraising activity, for example, family support, sibling support, cultural link work, spiritual support, play and recreational services, music therapy; complementary therapy, family accommodation, hospitality and bereavement support. On-going supplies and provisions, costs of maintaining the hospice buildings and gardens are all reliant upon fundraising/charitable income.

Participation in National Audits (mandatory statement): During 2016/17 Rainbows was ineligible to participate in the national clinical audit and national confidential enquiries. This is because there were no audits or enquiries relating specifically to specialist palliative care in 2016/17.

Research (mandatory statement): Rainbows undertook a PhD Research Project in partnership with De Montfort University. This work, led by Helena Dunbar, which gained ethical approval was entitled: ‘Children’s Hospice Provision in the East Midlands’. The research explored

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how the needs, experiences, use and acceptability of children’s hospice and palliative care services can inform new ways of delivering services. It also explored, from the perspective of parents of children with life threatening/life limiting conditions, experiences of existing palliative care services, the barriers and facilitators in accessing hospice services, types and characteristics of services that parents want and how best these services can be delivered to maximise impact to children and families in the East Midlands region. The thesis has been submitted and is being shared by Helena internationally. It will also help Rainbows to plan services to reach as many families as possible over the East Midlands who have a child or young person with palliative care needs.

Our Medical Director, Dr. Sat Jassal, has agreed to be a part of an advisory panel for a research project being undertaken in Leicestershire and Nottinghamshire looking at medical treatments in advanced illness. This research, being led by LOROS adult hospice, will explore barriers and enablers in end of life care planning with patients and families from black, Asian and minority ethnic backgrounds.

Quality Improvement and Innovation Goals Agreed with Our Commissioners (mandatory statement): A proportion of hospice income in 2016/17 was conditional on achieving quality improvement and innovation goals (CQUIN) agreed between the hospice and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through Commissioning for Quality and Innovation payment framework.

No goals or indicators were identified by the CQUIN for the hospice.

What Others Say About Us (the provider) (mandatory statement): The hospice is required to register with the Care Quality Commission (CQC) and its current registration status is unconditional. The CQC has not taken any enforcement action against the hospice during 2016/17. COPE Children’s Trust (known as Rainbows Hospice for Children and Young People) has been registered by the CQC under the Health and Social Care Act (2008) and has the following conditions of registration that apply: - Treatment of disease, disorder or injury

The hospice is subject to periodic reviews by the CQC and the last review and unannounced on-site inspection took place on 31st May, 1st and 2nd June 2016. The hospice was fully compliant and rated as low risk. The overall rating for the hospice was Outstanding.

The hospice has not participated in any special reviews or investigations by the CQC during 2016/17.

Data Quality (mandatory statement): The hospice did not submit records during 2016/17 to the Secondary Users Service for inclusion in the hospital episode statistics which are included in the latest

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published data. This is because the hospice is not eligible to participate in this scheme.

In 2016/17 Rainbows collected and submitted the following data:

Internal activity/performance data to Clinical Quality Assurance, Corporate Governance and the Board of Trustees

Patient specific data to CCG’s

Annual data to Together for Short Lives

Child death data to Child Death Overview Panel

Information Governance Toolkit (mandatory statement): Rainbows commissioned an independent review of compliance with the requirements for information governance management, confidentiality and data protection assurance, information security assurance and clinical information assurance identified in the Information Governance Toolkit for Voluntary Sector Organisation Version 14 (2016-2017).

The hospice has always been committed to a culture of Information Governance and a vast amount of work has been undertaken by the hospice. Work is currently progressing on the Information Governance Toolkit and this is being co-ordinated by an external expert together with our Director of Business Resources (who is the hospice SIRO). A framework, data mapping template and business continuity plan are all part of this work, along with training needs analysis, improvement plan and audits.

Clinical Coding Error Rate (mandatory statement): The hospice was not subject to the Payment by Results clinical coding audit during 2016/17 by the Audit Commission.

Duty of Candour: The Francis Report and the investigation at Morecambe Bay Hospitals NHS Foundation Trust in 2015 both highlighted staff’s fear of speaking out as contributory factors in poor care and patient safety. As a result, the Department of Health has published a report called ‘Learning not Blaming’ which includes a recommendation that there should be a Freedom to Speak Up (FTSU) Guardian in every NHS Trust and NHS Foundation Trust by 2017. As Rainbows provides some NHS funded care we have appointed an independent FTSU Guardian for the hospice who took up post in April 2017. The FTSU Guardian role has been created so that staff can feel safe to speak out about patient safety, as well as learning lessons by listening to those who have experiences to share, both positive and negative. Our FTSU Guardian has led an organisation wide training session to explain her role. She also talks to new staff on induction days about her role. As an independent FTSU Guardian, she will work alongside Rainbows’ Senior Management Team and Board Members to ensure that the hospice is an open and transparent place to work, where all staff are actively encouraged and enabled to

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speak up safely, feel confident that their concerns are acted upon and receive timely and ongoing feedback about the issue they have raised. The hospice Public Interest Disclosure (Whistle Blowing) Policy has been changed to include this role and this has been implemented across the hospice.

Part 3 Review of Quality Performance

Total number of children and young people served during the year

470

Number of new referrals received – % accepted, % declined

60% accepted 21% declined

Number of children/young people aged 0 – 17 years

330

Number of adults aged 18 – 30 years

140

Number of bed nights used

2,902

Number discharged from service during the year

1

Number of day care episodes

1,152

Number of episodes of end of life care

14 *

Total number of deaths during the year Number of deaths that occurred at the hospice

23 8

% of total deaths in patients with diagnosed palliative condition % of deaths at the hospice in patients with diagnosed palliative condition

100% 100%

Number of parental complaints 3

Number of parental concerns 16

* Many children with known palliative care needs can make an unexpected recovery from an acute

infection or deterioration in their condition, and may require a number of admissions where end of life is anticipated during the final stages of their illness.

The majority of children and young people who visit Rainbows have on-going therapy needs, including respiratory conditions, positioning, feeding and posture needs. The hospice currently has two Physiotherapists to support named young people with specific therapy interventions.

In 2016/17, Rainbows supported a total of 76 children and young people receiving long term ventilation. This includes 21 with level 3 (life sustaining) needs and 1

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complex respiratory who require a 2:1 ratio of care when awake with one nurse and one carer allocated. We provided 156 nights of level 3 ventilation and 36 nights of complex respiratory care requiring nurse allocation making a total of 192 nights for the year. This showed an increase in the amount of nights where children with ventilation needs were supported.

Local Quality Measures

Rainbows has chosen to measure performance against its peers using the Together for Short Lives Core Care Pathway. The following measures reflect our performance:

Referrals: During 2016 the overall number of children and young people who were referred to the hospice once again remained static. Those that were then declined, as they did not meet the hospice criteria, has also remained similar. In reality this means every year we are reaching significantly more families in need.

Our Participation in Clinical Audits: To ensure that the hospice is providing a consistently high quality service, we undertake our own clinical audits, using national audit tools, where available, developed specifically for hospices, which have been peer reviewed and quality assessed. This allows us to monitor the quality of care being provided in a systematic way and creates a framework by which we can review this information and make improvements where needed.

Each year the Clinical Quality Assurance Committee approves the audit schedule for the coming year. Priorities are selected in accordance with what is required by our regulators and any areas where a formal audit would inform the risk management processes within the hospice.

Through the Clinical Quality Assurance Committee report, the Board of Trustees is kept fully informed about the audit results and any identified shortfalls. Through this process, the Board has received an assurance of the quality of the services provided.

The following audits were completed at the hospice between 1st April 2016 and 31st March 2017:

CLINICAL AUDIT OUTCOME

Drug Storage Audit

Regular audit carried out every three months. Tool devised to carry out audits and action plan produced following each audit if appropriate.

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CLINICAL AUDIT OUTCOME

Placement Audits Annual audits are carried out by the University of Nottingham and De Montfort University.

All standards are met to an exceptionally high standard, with a note of thanks from Nottingham University Link Lecturer acknowledging how the Education and Nursing Teams at the hospice have supported students so positively.

Mattress Audit A mattress audit was carried out in August 2016 against a multiple criteria to ensure mattresses remain safe, robust and meet IPC standards.

Mattress covers were replaced as a result and spares ordered. One mattress was condemned and disposed of.

The Hospices’ housekeepers continue to monitor via monthly checks using the Rainbows monitoring form and escalate any concerns.

Controlled Drugs Audit Audit carried out in October 2016. Issues regarding crossing out in the CDR noted, CD keys should not be on the same fob as other keys.

As a result of the audit, the hospice Standard Operating Procedures for Controlled Drugs and Risk Assessments were reviewed. A ’10 @ 10’ (10 minutes at 10am) session was carried out with nurses with reminders around the Standard Operating Procedure and good practice.

Record Keeping Audit A record keeping audit of the clinical care plans was carried out in November 2016. A sample of 86 case notes were reviewed by the audit team against set criteria.

There was high compliance around use of black ink, legibility and inclusion of specific daily plans. An action plan has been developed to ensure higher compliance with naming, dating and signing every document within the care plan.

Knowledge Audits (clinical policies)

There were two re-audits with the clinical team around knowledge of the policies – Medicines and Mental Capacity Act – during January 2017.

Knowledge audits are questionnaires circulated to the clinical team to demonstrate awareness of key policies and highlight any gaps in knowledge that may inform training.

There was a 14% improvement of correct responses and understand of the policy from January 2016 for the Mental Capacity Act Policy and a 7% improvement in correct responses for the Medicines policy, now standing at 96% compliance.

Annual training, awareness and competencies are on-going.

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CLINICAL AUDIT OUTCOME

Mixed Sex Accommodation Audit carried out in January 2017 accordance with the Mixed Sex Accommodation policy. This is an annual audit which seeks to ensure compliance against the standards set by the Department of Health who requires all providers of NHS funded care to confirm that they are compliant with the national definition ‘to eliminate mixed sex accommodation except where it is in the overall best interests of the patient or reflects the patient’s choice’.

Rainbows is committed to maintaining the privacy and dignity for males and females staying at the hospice. Rainbows has implemented a number of processes that support the sensitive management of males and females whose bedrooms are located in the same area of the hospice.

The audit demonstrated compliance with these processes.

Children and Adults Health Safeguarding Assurance Template

This template outlines assurance against key safeguarding requirements for adults and children and to identify areas for development or where additional assurance is required.

The hospice demonstrates compliance with the Children Act 2004 and the Care Act 2015.

Safeguarding at Rainbows is managed safely and effectively. Safeguarding reports are presented bi-monthly to the hospice Clinical Quality Assurance Committee and Board of Trustees. The Director of Care and hospice Safeguarding Lead meet regularly with Leicester/Leicestershire Nurse Consultant for Safeguarding and have reviewed the Safeguarding Assurance Template in March 2017.

Quality Metrics/Quality Markers We Have Chosen to

Measure

Patient Safety:

Number of patient safety related incidents/accidents, including medication errors

169 incidents* (of

which 57 were near misses)

33 drug errors**

Number of reportable (to local safeguarding services) safeguarding incidents occurring in the organisation

0 ***

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Infection Prevention and Control rates: Total number of children admitted with known infection This includes

Number of C-Dif Number of MRSA

Total number of children who developed symptoms whilst staying at the hospice This includes

Number of C-Dif Number of MRSA

21 0 5

1 0 0

* The majority of incidents were ‘no’ or ‘low harm’ and none were serious ** These were all assessed against the National Patient Safety Agency (NPSA) definitions of harm (2011) and found to be ‘no’ or ‘low harm’

*** The hospice had 0 internal safeguarding incidents relating to staff but had 3 incidents which took place at the hospice during this period. Social Care plus/minus the police were contacted at the time. All were 3rd party incidents; but managed by staff at Rainbows. In total 6 referrals have been made to Social Care during this period.

Additional Information:

The referrals were all to Children’s Social care and made as a result of staff vigilance and information shared/observed when the child/young person was accessing Rainbows. All were referred as potential Safeguarding issues and one involved an altercation between parents - all have been acted upon appropriately. One referral did not meet the Threshold, the rest are been supported at a level of Early Help / Support or Child In Need. Three of the referrals are of a Domestic Abuse nature; but the children are not seen as at significant risk. We are actively involved in a case which is historic for Safeguarding and this went to Conference and is being currently managed as at risk of significant harm and may be re- graded following further assessment after May 2017. We have a few children who are on plans; but are being supported and these are either historic or relate to siblings and we are invited to reviews/receive updates for these but not

actively involved otherwise.

Clinical Effectiveness: Please see section above on local audits.

Patient Experience: An annual Family Feedback Survey is undertaken to secure feedback on the quality and range of services provided by the hospice. In 2016/17 the response rate was 30% and an action plan is currently being developed to address issues raised.

Below is some of the feedback received from families through the survey:

“Staff are very friendly and welcoming always with a smile. That really helps with people like us that struggle on a daily basis as we are always stressed out. Love how everyone cares and love the children.”

“More outings during stays for those children who could benefit from new opportunities.”

“The support we receive from Rainbows as a family helps us to plough on with this emotional rollercoaster of a journey we are on.”

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“Wish more weekends are available when requested.”

“Always confident that the staff fully understand our son’s medical condition and are able to fulfil his needs.”

“There is nothing quite like Rainbows available.”

The ‘Friends and Family Test’ was also included within the survey, the results are demonstrated below: How likely are you to recommend Rainbows to Friends and Family if they needed similar care?

In addition, the hospice encourages regular feedback from children, young people and their families through our family satisfaction survey and readily accessible feedback forms that are available throughout the hospice during every stay. Below is some of the feedback we have received during the year from families through the feedback forms available around the hospice:

“We cannot thank you enough for your kindness and support. You made us feel really welcome in such a short time. We will never forget Rainbows’ help and will be our chosen charity. Thanks again.”

“You are all so kind, helpful and hardworking people that I can’t believe. I and my family shall always be grateful to you all for looking after/helping us.”

“This has been our first stay at Rainbows and we think it is truly amazing! We felt a little nervous on arrival but every single member of staff we came across was more than welcoming. Our son was so settled through the night which made us feel 100 times better. He must like it here like we all do! Thank you so much for everything, we will definitely be back.”

“Really had a fabulous time but second time no key or fob and had to chase around asking for them.”

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Staff Satisfaction In January 2017 the Staff Satisfaction Survey was issued to 170 members of staff and of this number 112 responses were received.

My Role - This year, 93.8% of respondents stated Rainbows is a welcoming place and they enjoy working here and 94.6% can recognise the difference they are making to the lives of children and young people. Values - In terms of Rainbows values “Working together with integrity and commitment to achieve excellence”, 97.3% feel they demonstrate these values in the way they work (up from 94.9% last year). But 18.7% of staff indicate that they feel unable to challenge behaviour (down from 28.5% last year). Communication – 88.4% of staff reply they understand where Rainbows is heading and how Rainbows are going to get there, furthermore 85.7% of staff feel able to share ideas, suggestions and concerns within Rainbows (both figures up from last year). However, 14.3% are feel unable to contribute. Training and Development – 72.3% of respondents indicate that their training and development needs are discussed regularly and are met by attendance at internal and external training courses or other events/professional association meetings (a slight decrease on last year from 78.1%). Organisational procedures – Almost all employees recognise that it is their responsibility to stay abreast of the policies, procedures and legislation changes that affect their area of work (99.1%) and also how to access policies, procedures and legislation that affect their area of work (98.2%). 97.3% of staff feel able to make adjustments in their day to day work to meet the equality and diversity needs of the people they encounter (all marginally increased from last year). Health and Safety – 96.4% of respondents agree that Rainbows proactively manages Health and Safety and that Rainbows is a safe place to work. Income Generation – 97.3% know how Rainbows is funded and their role in helping to fund the Organisation, 91.1% are aware of the work of the income generation team including the events and initiatives they promote (a big increase from 76.6% last year). 92% agree if their family or friends were in a position to support Rainbows they would ask them. Caring – Almost all employees feel if their friends or family needed Rainbows services they would recommend Rainbows (98.2%) and additionally feel the hospice has a positive approach to the promotion of dignity and respect (98.2%). Working – 89.3% would recommend Rainbows to their friends or family if they were in a position to apply to work or to volunteer.

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Senior Management Team and Trustees - Overall 75.9% feel supported by the Senior Management Team (up from 71.5%). However 36.6% do not know who the Trustees are (improved from 43.8% previously), and 21.2% do not understand the role of the Trustees (improved from 27.0% last year). In addition to the responses above many of you also added comments and responses to specific questions, such as suggestions for improvements.

The Board of Trustees Commitment to Quality

The Board is fully committed to provide the best service for our children/young people in order to achieve our aims. The hospice has an established governance structure, with members of the Board sitting on both clinical and corporate governance committees. The board has an active role in ensuring that Rainbows provides a high quality service in accordance with its Statement of Purpose which is updated regularly and displayed in hard copy format at the hospice. The Board of Trustees regularly reviews the meetings structure across the organisation to ensure the appropriate committees and groups are in place with clear lines of accountability and input from members of the Board as required. In addition, the hospice has a comprehensive Risk Register which is monitored by the governance committees who regularly update the Board in relation to areas of high risk. The Board is confident that the treatment and care provided by Rainbows is of a very high quality and cost effective.

Statements from Local Involvement Networks (LINks)

This is the fifth year that Rainbows has been required to submit a Quality Account. The hospice has engaged with West Leicestershire Clinical Commissioning Group which has the responsibility for the largest number of persons to whom we provide relevant services. The Quality Account will be shared with all three Clinical Commissioning Groups in Leicestershire (West Leicestershire, Leicester City and East Leicestershire & Rutland) and their comments will be included here when received.