Quality Account 2018/19€¦ · 4 Keech Hospice Care Quality Account 2018/19 Part 1: Report from the Chief Executive Officer and Clinical Director I would like to start by thanking

Quality Account 2018/19

Our Vision

“Making the Difference When It Matters the Most”

Our Mission statement:

To lead the way in providing excellent care, supporting children and adults with life-limiting conditions and those affected by death and dying, helping them to live well and make every day count

Table of Contents Table of Contents .......................................................................................................................................................................................... 3

Part 1: Report from the Chief Executive Officer and Clinical Director ................................................................................................................... 4

Part 1: Objectives .......................................................................................................................................................................................... 7

Part 2: Priorities for improvement ................................................................................................................................................................ 10

2a. Priorities for improvement in 2019/20 (Adults and Children’s) ............................................................................................................... 10

2b. Progress against Priorities for Improvement in 2018/19 ........................................................................................................................ 12

Part 3: Statements of assurance from the Board ................................................................................................................................................ 14

3a. Review of our services .......................................................................................................................................................................... 14

3b. Participation in Clinical Audit ................................................................................................................................................................. 18

3c. Research ............................................................................................................................................................................................... 18

3d. Use of CQUIN payment framework ....................................................................................................................................................... 18

3e. Statement on the Care Quality Commission .......................................................................................................................................... 19

3f. Data Quality ............................................................................................................................................................................................ 20

3g. Data Security and Protection Toolkit (DSPT) ........................................................................................................................................ 20

3h. Clinical coding error rate ........................................................................................................................................................................ 20

3i. Organisational Meeting Structure ........................................................................................................................................................... 21

Part 4: Review of Quality and Safety Performance............................................................................................................................................. 23

4a. Internal Audit Activity 2018/19 ............................................................................................................................................................... 23

4b. Trustee Visits ......................................................................................................................................................................................... 26

4c. Patient Led Assessment of the Care Environment (PLACE) ................................................................................................................. 26

4d. Workplace Inspections .......................................................................................................................................................................... 26

4e. Benchmarking ....................................................................................................................................................................................... 26

4f. Keech Hospice Care clinical governance overview (April 2018 – March 2019) ...................................................................................... 27

4g. What people say about us…… .............................................................................................................................................................. 30

Section 5: Feedback from our NHS Commissioners .......................................................................................................................................... 31

4 Keech Hospice Care Quality Account 2018/19

Part 1: Report from the Chief Executive Officer and Clinical Director

I would like to start by thanking all of the staff and volunteers for their outstanding work throughout the year, and what a year it has been. The main highlight for us has to be our fantastic achievement in the Times100 Best Companies Survey. We were thrilled to be placed 18th Best Charity Non-Profit company to work for and to find out that we are the 21st best organisation to work for in the East of England region (out of all companies). This position includes all companies (large and small) and charities. I am so proud of what we have achieved and want to express my thanks to all our staff and our Trustees for being part of this journey. Last year I reported that we had been reviewing the capacity of the hydrotherapy pool, identify how we can meet the growing demands. The adult patient pathway and review of use of the pool has been completed and launched

to care staff and local palliative care professionals. We have appointed an Aqua Therapist and a Senior Lifeguard and patient numbers in the pool are increasing. The children’s patient pathway is now being developed with the children’s team. This year discussions have started to take place with Adult and Children’s Services, reviewing the potential of the services we offer and

potential locations within the community where they could take place. A location for adults has been identified, while the location for children’s

is still being reviewed, meeting our objective of closer to home.

We always like to look for new ways to engage with our service users and this year we are pleased to be working with Royal College of

Paediatrics and Child Health (RCPCH) who run a ‘Youth Voice’ project, so far, we have held two workshops. We hope this project will help us

to receive and act upon feedback received from the young people who use our services.

We are pleased to confirm that we successfully submitted our information to the NHS Data Security Protection Toolkit (previously known as

the IG Toolkit), scoring 100% against all mandatory criteria.

During the year we have also reviewed our governance and well led objective, this included completing an audit with our trustees against the

new Charity Governance Code Toolkit.

In the last year, we have provided care to 2379 beneficiaries. This includes providing 244 adult and children’s patients with 2231 in-patient bed

nights; we have undertaken 2093 community visits to children’s service patients; 204 patients have attended our Palliative Care Centre 1779

times; 1031 adult patients have been supported by our ‘My Care Co-ordination Service’.


I am responsible for 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.

Liz Searle Chief Executive Officer


Report from the Clinical Director

Keech hospice care is proud to deliver specialist palliative care to children and adults, ensuring care is holistic and all the family are supported. Our focus over the last year has been to review who accesses our services, so that we can identify groups of people that do not and try to understand the reasons why. In adult services we noticed that if a patient needed support from several of our services it wasn’t as coordinated as it should be. As a team we have stream lined our processes, including the appointment of a Community Liaison Senior Sister, to ensure our patients receive a smooth and co-ordinated referral to Keech Hospice Care.

We have also been working with external partners to help colleagues working with the homeless community, those experiencing dementia and liver failure and those who are severely frail to raise awareness of what services we can offer and how they can be accessed. In our children’s services we know that families wish to receive care closer to home. The team have worked hard to map where families live and where potential new families may be located. In these highly populated areas we are developing coffee mornings, and a new tots and toys group which is group for pre-school children. We have finalised our Advanced Care Plan paperwork and processes which enables us to support families to document choices regarding their child’s care in the future. Our clinical education team is flourishing, having scoped the palliative care training needs of health and social care professionals we are designing the 19/20 education programme. As part of our review we looked at the accessible information available to patients and their families. To improve this our website now has a translation function and we have a 3600 film available so everyone can see what the environment at Keech Hospice Care is like before they come. Elaine Tolliday Clinical Director


Part 1: Objectives Achievements and highlights from 2018/19 were monitored against our strategic objectives:

Palliative Care Centre: The patient caseload for the Palliative Care Centre had dropped in previous quarters. Reasons for this were not entirely clear but may have been influenced by a greater range of outpatient services being offered on site. The challenge of access to volunteer drivers to facilitate our patients being able to attend the growing range of outpatient service options led to a review of our current staffing establishment. As result we now have a Transport Co-ordinator whose role is to manage the transport requests for all the Adult Services.

My Care Co-ordination Team (MCCT): The number of patients registered to MCCT remains relatively static at around 500 patients. It is known that approximately 1% of patients in Luton are in the last 12 months of life, which given the population size equates to 2000 people that could be on the register. The team continue to attend the community multi-disciplinary meetings to maintain a presence to offer support and encouragement to our colleagues to have the conversation with their patients and to answer any questions raised.

We were given the opportunity to step in at short notice and support Cambridge Community Services in providing the day time PSCW service to patients in South Bedfordshire last summer. The Team worked hard to demonstrate our ability to provide this service effectively and we are delighted to have been offered a 2yr contract to continue to provide this service by Bedfordshire CCG. We have successfully recruited to the vacancy for this contract and expect the new member of staff to join the team in June 2019.

Rare Neurological: In May, Keech Hospice Care made the decision to support the Rare Neurological Coordinator CNS role, after the commissioned pilot project concluded. This specialist support had been unavailable to this cohort of Luton patients prior to the pilot project and the positive feedback from patients, family, carers and other healthcare colleagues involved in their care was immense. This demonstrated the value of such a specialist support role and the current gap in service provision for this complex group of patients. The caseload continues to grow, and they have worked hard to develop links with the local Consultant Neurologists and encourage their participation in the Rare Neurological Multidisciplinary meetings, now held at the Luton and Dunstable Hospital. They are notified of new patients at the point of diagnosis, which means that these patients now get the specialist support they need from the start.

To demonstrate our commitment to the Hospice Strategy to deliver excellent care, and to educate, innovate and research, they have introduced a Multidisciplinary Clinic for patients with a rare neurological diagnosis, involving both internal and external healthcare colleagues appropriate to the needs of the patients attending, such as physiotherapy, occupational therapy, speech and


language therapy and dietician, in addition to access to our specialty doctors. This approach helps the patient avoid multiple appointments, telling their story several times over, and the healthcare professionals to agree a collaborative plan of care focussing on the priority needs of the patient.

Independence and Wellbeing: This is a Macmillan funded service which started in 2016 comprising of an Occupational Therapist,

a Physiotherapist and a Rehabilitation Assistant. During 2018/19, 221 patients were supported by this service. With a redesign of office space within the Palliative Care Centre, we have been able to relocate the Independence and Well-being Team into the department. This has enabled the teams to work more collaboratively and is timely ahead of the proposed Gym development due to start in May 2019.

Adult In-Patient: The unit continues to support as many patients as possible with pain and symptom management as well as end of life care. The patients we care for on the adult in-patient unit often have challenging and complex healthcare needs, this offers good learning opportunities for our staff, expanding their knowledge and enhancing their patient care. We continue to work collaboratively with community and hospital colleagues, to ensure that we remain responsive and supportive to the needs of the patients within our community.

Children’s In-Patient: The unit continues to support as many children and their families as possible. The Children’s Inpatient Unit works closely with the children’s community team to provide support to families in their preferred place of care. As a service, we work with other agencies across Hertfordshire, Bedfordshire and Milton Keynes to provide holistic care to our caseload of families.

Children’s Community Services: The workload for the community team has been busy throughout the year. The team continue to

care for patients across Bedfordshire, Hertfordshire, Luton and Milton Keynes. 2018/19 saw an increase of 12% in the number of patients cared for by the Community Team. The team have supported a number of children and young people at home for end of life care, they have also worked with hospitals in our area to support symptom management.

There has been a promotion within the team, undertaking the new role of Community Matron. This post will be managing both the Community and Day Support Teams whilst working closely with the Children’s Senior Sister to ensure the Children’s service works and develops together as a whole. They will also support the development of Day Support services in the Hertfordshire community as the BraveHerts project develops. We have been looking at and liaising with staff at potential venues to hold a Tots and Toys type session within Hertfordshire as the next step on delivering Keech services in the local community.

Children’s Day Support: The Day Support team continue to provide very valuable input to an identified group of patients and a range of activities have been open to them and a wider group of children and families. These have included a visit from Shetland


ponies, The Rock Steady Foundation providing a fantastic morning of musical entertainment at the hospice, a farm animal experience capturing the lambing season and Mother’s Day activities morning supported by staff from Woburn Center Parcs with pottery painting for the children and manicures and nail painting for parents. There is lots planned for the coming months.

Supportive Care Services: This year has seen the introduction of a second “Talking Elephants” support group, a bereavement service for members of the community. We have also introduced a focus group for bereaved Dads who have previously accessed Keech support services, the group has met on several occasions. Discussions included gaps in support for bereaved Dad’s, who should be invited for support, structure and content of support. The focus group now forms part of the “Dads Cry too” support group. Newly bereaved Dads are invited. They meet monthly with one-month formal support and one month informal (walking, drinks, trips out). The group is due to meet in November, where they plan to review “Dads Cry too”.

The three Remembrance events (Light up a Life, Daffodil Sunday for Children’s Services and Streatley Service for Adult Services) were all well attended, with positive feedback. A total of 998 patients and relatives have been supported this year by the Supportive Care Team.

Schwartz Rounds: Schwartz Rounds™ continue for all staff at the Hospice. Rounds™ continue to be well attended and well

evaluated by staff that attend. We have increased staff representation on the steering group this quarter, and two members of the group attended the annual Schwartz Rounds™ conference hosted by the Point of Care Foundation in London.

Safeguarding: Keech Hospice Care takes a serious approach to safeguarding to ensure all adults and children are protected from harm. We have a Safeguarding Policy and Procedure which is regularly reviewed and updated in accordance with legislation and with local protocols in Bedfordshire, Luton, Hertfordshire and Milton Keynes and we maintain links with local Safeguarding Leads.

Our Clinical Director is our Safeguarding Lead. The Children’s Lead Nurse is our designated Child Sex Abuse and Exploitation Lead.

We run mandatory safeguarding training across the organisation which is tailored to the requirement of the role, for which attendance

is recorded. We also have a number of security/safeguarding measures in place which are recorded on our Safeguarding Risk

Assessment. Our staff also have access to various levels of staff support.


Our strategic themes from 2018/19 were:

1. To deliver excellent care and support. 2. To educate, innovate and research. 3. To be well funded. 4. To attract, retain and engage our people, valuing difference. 5. To be well governed and well led.

Part 2: Priorities for improvement The Board of Trustees is committed to the delivery of high-quality care that is safe, effective and provides patients and carers with a positive experience.

2a. Priorities for improvement in 2019/20 (Adults and Children’s) Priority 1: Youth Voice Project

Target: To actively engage young people who access our services, in offering feedback and embedding Youth Voice in Keech Hospice strategy

How was this identified as a priority? When assessing gaps in user feedback, we realised there was minimal input from young people who access our services How will this priority be achieved? We will recruit young people from a variety of areas We will work with RCPCH to run a project to receive feedback We will act on feedback We will agree a process to embed Youth Voice

How will progress be monitored?

Through feedback from the young people after each workshop. After all the workshops feedback will be given to performance committee.


Priority 2: Children’s MDT across all areas

Target: To have an effective MDT in each locality

How was this identified as a priority? This supports the co-ordination of patient care and the promotion of Keech Hospice Care services to ensure access is available to all. This part of our strategy and recognised from feedback that at times families are not made aware of services available

How will this priority be achieved? Working with partners each area we will develop the MDT meetings with a standard proforma and agreed processes.

How will progress be monitored?

Children’s comminute team are involved in each MDT and will feedback to the children’s lead nurse.

Priority 3: Provision of spiritual care

Target: Spiritual support is easily available to all those (patients, families and carers) that access Keech Hospice

Care services irrespective of religion, culture or background.

How was this identified as a priority? Gaps in service identified from staff consultations

How will this priority be achieved? To recruit a team of volunteer pastoral support workers To liaise and work collaboratively with the Bishop of Bedford to allow for the local vicar to coordinate services and provide supervision of volunteers

How will progress be monitored? Through the clinical effectiveness group


2b. Progress against Priorities for Improvement in 2018/19 To Deliver Excellent Care Progress in 2018/19

Priority 1 To have a dedicated children’s service 24-hour advice line

Target: To provide a dedicated 24-hour support to professionals and families 24-hour telephone advice line is up and running. We are

monitoring calls received.

Priority 2: To ensure an efficient and co-ordinated response to incoming referrals

Target: To have 1 central point for incoming referrals to the adult service to ensure patients are seen quickly by the service most appropriate to care for their needs

We have introduced a Senior Sister, Community Liaison role. The purpose of this role is to be a single point of contact for healthcare professionals to refer in to. This has seen a more structured response to referrals and inpatient admission requests and we have been collecting the data to demonstrate the impact this change has had.


Priority 3: To develop information for professionals

Target: To develop a Directory of Services for professionals wishing to access/refer to our services

As part of this piece of work we have updated our information for professionals on our website, this is regularly reviewed and updated. We have also added a translation service and a 3600 tour of the hospice. Professionals also receive a quarterly newsletter containing relevant updates and information.

Priority 4: To continue our ‘Good to Great’ Journey

Target: To embed our Values into our recruitment and appraisal process To Link our values to staff and volunteer recognition schemes

Our ‘Good to Great’ work has led to lots of changes that has focussed on: communication; more joined up working; better decision making; and a refresh of our Values.

In 2018 we took part in the Times 100 Staff Survey for the

second time. This time we improved our score from 71st to 18th,

a result that we are extremely proud of.


Part 3: Statements of assurance from the Board 3a. Review of our services

During 2017/18 Keech Hospice Care provided the following specialist palliative care services to the NHS: Adult Service In-patient unit Palliative Care Centre Care Co-ordination Services Drug Therapies Independence and Wellbeing Service Rare Neurological Children’s Service Inpatient unit Day Support Community Nursing Team In addition, we have also provided the following services through charitable funding: Hospice at Home Complementary Therapy Music Therapy Family and Carer support Bereavement Care Spiritual Care Hydrotherapy pool





3b. Participation in Clinical Audit

• During 2018/19 no national clinical audits or confidential enquiries covered NHS services that Keech Hospice Care provides

• During 2018/19 Keech Hospice Care participated in no national clinical audits and no confidential enquiries of the national clinical audits and national confidential enquiries as it was not eligible to participate in. However, we ensured that key audits were completed using nationally recognised excellence audit tools for hospices developed by Hospice UK.

• The national clinical audits and national confidential enquiries that Keech Hospice Care participated in during 2018/19 are as follows:

N/A • The national clinical audits and national confidential enquiries that Keech Hospice Care participated in and for which data collection

was completed during 2018/19 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry: N/A

• The reports of 0 national clinical audits were reviewed by the provider in 2018/19. This is because there were no national clinical audits

relevant to the work of Keech Hospice Care. • Keech Hospice Care was not eligible in 2018/19 to participate in any national clinical audits or national confidential enquiries and

therefore there is no information to submit. • The local clinical audits that were reviewed in 2018/19 are listed further in the document.

3c. Research

The number of patients receiving NHS services provided or sub-contracted by Keech Hospice Care in 2018/19 that were recruited during that period to participate in research approved by a research ethics committee was NONE.

3d. Use of CQUIN payment framework

A proportion of Keech Hospice Care income in 2018/19 was conditional on achieving quality improvement and innovation goals, as specified by our Commissioning Partners. We believe we will have achieved our agreed CQUIN targets, although still waiting for


confirmation of Q4 from our CCGs.

3e. Statement on the Care Quality Commission

Keech Hospice Care is required to register with the Care Quality Commission and is currently registered to carry out the regulated activities:

Treatment of disease, disorder or injury

Personal Care

There are no restrictions on our registration.

The Care Quality Commission has not taken any enforcement action against Keech Hospice Care in 2018/19.

Keech Hospice Care has not participated in any special reviews or investigations by the Care Quality Commission in 2018/19. Keech Hospice Care last had an unannounced inspection from the Care Quality Commission in June 2016. We were been awarded the following ratings. A copy of our full Inspection Report can be found on the Care Quality Commission website.


3f. Data Quality

Keech Hospice Care did not submit records during 2018/19 to the Secondary Users Services for inclusion in the Hospital Episodes Statistics which are included in the latest published date because it is not eligible to participate in this scheme. We do however have our own system for monitoring the quality of data. We continue to use SystmOne, electronic patient record system, which is also used by many healthcare professionals in the community meaning that we can share information from and with other services (with given consent from the patient). SystmOne is also linked with the NHS spine which makes for an easier registration process when a patient is referred into the service, it also means that our doctors can access test results online.

3g. Data Security and Protection Toolkit (DSPT) As a condition of our NHS commissioning contracts, we are required to demonstrate we uphold high standards of data security and protection by completing an NHS assessment called the Data Security and Protection Toolkit (DSPT) once per year. The DSPT (previously known as the NHS ‘IG Toolkit’) was revised in 2018 to modernise it in line with the new General Data Protection Regulations (GDPR) and the 2016 National Data Guardian Review. Our first assessment using the new DSPT was due by end of March 2019. We submitted our assessment in March with100% compliance.

3h. Clinical coding error rate Keech Hospice was not subject to the Payment by Results clinical coding Audit during 2018/19 undertaken by the audit commission.


3i. Organisational Meeting Structure

Trustee Board

Audit and Risk Committee

Senior Leadership Team

Information Governance

Steering Group

Medical Gases Committee

Clinical Effectiveness

Group

Care Management Team

Management of Medicines

Group

Infection Control Group

Moving and Handling

Group

Notes Audit Group

Joint Consultative Committee

SystmOne Development

Group

Team Briefings

= Accountability = Reporting/Feedback

= Governance = Management

= Operational = Consultative

Nutrition Group

STAR Group

Legend

1 – All Health & Safety Reps are members of RMHSC

Safety First Group

Remuneration Committee

Risk Management and Health and

Safety Committee1

Performance Committee

Hydrotherapy Pool Group



Part 4: Review of Quality and Safety Performance

4a. Internal Audit Activity 2018/19 During 2018/19 we have undertaken the audit activity listed in the table below, for most audits we use the approved Hospice UK Audit Tools. The Clinical Managers meet quarterly as the ‘Clinical Effectiveness Group’, the meeting is chaired by the Clinical Director. All clinical audits are presented to the group; the group also monitors action plans which arise from recommendations made through audit and progress with the annual audit program. Progress with our audit program is then reported quarterly to our Audit and Risk Committee which is made up of trustees, senior leadership team, lay persons and Head of Quality and Governance. Since April 2018 the following audits have been conducted and presented to the above groups:




4b. Trustee Visits Our Trustees take their role very seriously and are committed to a programme of four trustee visits a year. The visits last a full day and are conducted by 2 trustees on a rotational basis, they provide an excellent opportunity for trustees to observe the day to day activity of the hospice and talk to patients, visitors, staff and volunteers about their experiences and concerns (what do we do well and not so well).

4c. Patient Led Assessment of the Care Environment (PLACE)

Keech joined the PLACE programme in 2015, our latest assessment took place on 3rd May 2018. We invited 10 service users (patients and relatives), and 2 independent assessors to conduct our PLACE Survey, they were supported by 6 staff members who guided and assisted them around the building. Areas covered included: Children’s IPU; Adult IPU; KPCC; Communal Areas (reception, Valerie’s, public corridors and toilets); Catering, and; Dementia. Overall, the feedback was very positive from all assessors. Everyone stated they were “very confident” that our environment supports good care. Some minor issues were spotted here and there, such as markings/stains on walls, dust in corners, faulty cupboard doors and lack of signage in certain places, all of which have been put onto an action plan for correction.

4d. Workplace Inspections

Six monthly workplace inspections continue to take place and are conducted by the Health and Safety Co-ordinator, a member of the Quality and Compliance team and a Representative of Employee Safety (ROES). The Chief Executive attends both inspections. The Clinical Director conducts ‘safe care’ checks quarterly within the care areas. Any issues observed or raised are recorded on an action plan which is regularly reviewed by the Risk Management and Health and Safety Committee. The care team also conduct monthly safety checks in their areas.

4e. Benchmarking

We take part in the national Hospice UK Benchmarking project. We benchmark against falls, and medication incidents with similar size organisations. We continue to submit monthly data to the NHS Safety Thermometer.


4f. Keech Hospice Care clinical governance overview (April 2018 – March 2019)


ummary of Patient Falls April – March 2018/19 All of our patients are at higher risk of falls; therefore, we aim to work with the patients to minimise that risk. In the last 12 months our 'Safety First Group' introduced:

a new falls prevention care plan; a ‘Please call, don’t fall’ patient sign placed into rooms for patients at particular risk of falling, or needing reminding; an updated moving and handling assessment; a pathway to follow in the event of a patient falling, including a checklist to follow, a post fall assessment tool and a post fall observation

chart. Despite these changes, falls continued to occur in quarter 3, so, to further ensure the safety of our patients we started to audit falls as they happen to ensure the measures introduced by the safety-first group have embedded. The audits found that:

Although patient call alarms are within reach in the rooms, patients often choose not to use them (in order to maintain their independence) or have become too confused to use them.

We have 'falls mats' in place but a confused patient can see these as an obstacle that needs to be avoided, causing more of a hazard. All of our beds need replacing as they do not comply with health and safety recommendations and we have been given the opportunity to purchase a bespoke exit alarm bed, this will give the team an earlier warning that a patient is beginning to get up. The first has been purchased, however, the challenge remains as to which patient to allocate it to and how to prioritise its use between patients at equal risk of falls. A forward plan is in place to replace all of our beds with exit alarm beds over the next 2-3 years.

We are pleased to report that there was only 1 patient fall in quarter 4 with no harm to the patient. Benchmarking: in the accompanying graphs, benchmarking data is shown for adult services only as there are currently only 2 children’s hospices taking part in Hospice UK Benchmarking. The data shows that our number and level of falls are in line with other hospices of a similar size.

Summary of Medication Incidents April – March 2018/19 No patients have been harmed as a result of a medication incident taking place, although 1 incident in quarter 4 was graded as ‘moderate harm’ due to an incorrect calculation of methadone resulting in an adult patient being administered a double dose in error. The patient was closely monitored but did not present any adverse reaction or change in clinical status. A reflection was held with the doctor who made the error. The majority of incidents have been 'non-patient', i.e. recording errors and running balance issues. Action:

staff involved in incidents have taken part in reflective practice;


staff reminded of processes for signing in medication; process for dealing with the delivery of new medication has been reviewed and updated; plans for the redesign of the storage of medications in Adult IPU have been signed off, we are now waiting for confirmation of a start

date. A new, draft medication incident was introduced in September and we are developing our reporting with the additional information this

provides. In KPCC we are about to trial a system which may reduce the number of times we are required to measure liquid medicines, we

currently do weekly checks which can increase the losses due to thick liquids adhering to the sides of measuring cylinders. If this is successful we will roll it out to AIPU and CIPU.

3rd party incidents: 3 of these have been 3rd party incidents that we have raised with the hospital in relation to patients admitted to our adult inpatient unit. The hospital has investigated these incidents and our Adult Lead Nurse and one of our doctors will be meeting with them to hear of their learning and recommendations. Benchmarking: shown for adult services only as currently only 2 hospices taking part in Hospice UK Benchmarking exercise for children’s services.

Summary of Pressure Ulcers April – March 2018/19 In the last 12 months 2 ‘new’ pressure ulcers have been reported as serious incidents to the CCG and CQC as category 3 pressure ulcers

(one of these developed from a category 2 which was present on admission), 1 has been reported as a category 4. In all of these instances

the care provided to the patients was reviewed and in all 3 cases it was found that appropriate care and treatment had been provided, the

patients had been admitted for end of life care and had multiple contributory factors.

During the last 12 months we have developed our reporting of pressure ulcers and are encouraging staff to report them. The reporting also

includes other tissue damage including moisture lesions, deep tissue injuries, device related injuries and ungradable pressure ulcers. This is

an area of reporting that is currently being developed.


4g. What people say about us……


Section 5: Feedback from our NHS Commissioners Requests for feedback were sent to Bedfordshire Clinical Commissioning Group, East and North Hertfordshire Clinical Commissioning Group, Herts Valleys Clinical Commissioning Group, Luton Clinical Commissioning Group and Milton Keynes Clinical Commissioning Group. Received from Anne Murray, Chief Nurse, (Bedfordshire, Luton and Milton Keynes), on behalf of NHS Luton CCG Luton Clinical Commissioning Group (LCCG) welcome the opportunity to comment on the 2018/19 Draft Quality Account for Keech Hospice care. The Quality Account was shared with CCG Board Lay Members (lead for patient safety), Executive Directors, Performance, and Quality Teams. The Quality Account and Response from the CCGs will be shared for the attention of the respective Boards. The LCCG Patient and Safety Quality Committee (PSQC) reviewed the account to enable development of our commissioning statement. The CCG has continued to work closely with the Trust during the past year to gain assurance on the delivery of safe, effective and responsive services. LCCG has reviewed the information contained within this quality account and checked this against data sources, where this is available to us as part of our existing monitoring discussions and confirm this to be accurate. This has been undertaken in accordance with the NHS (Quality Accounts) Regulations 2011, and the Amended Regulations 2017, In reviewing the Quality account, we acknowledge the overall strategic themes were to deliver excellent care and support, educate innovate and research, to be well funded, attract, retain and engage our people, valuing difference and to be well governed and well led. We commend the Trust on the work undertaken in 2018/19 to support the Palliative care centre and the My Care Co-ordination service. We are particularly pleased with the introduction of the Rare Neurological Coordinator CNS role, and will be interested in the future developments and scope of the role. We also recognise the significant improvement work undertaken for children’s services and also note the increase in patient activity across both in-patient and outpatient services. The CCG also comment the work undertaken by the Supportive Care Services and the introduction of new bereavement and support groups. We are pleased to see the introduction of a 24-hour advice line and will be interested to see the extent of this activity and the support it offers to patients and families. We are also pleased to see the introduction of the Senior Sister, Community Liaison role. The purpose of this role is to be a single point of contact for healthcare professionals to refer in to which is resulting in more immediate referrals and response. We acknowledge the work undertaken to improve the information provided to professionals on their web site and in particular the introduction of a translation service.


The CCG would particularly like to comment the organisation in its achievement of 18th place in the Times 100 staff survey. We recognise the improvement priorities for 2019/20 and in particular look forward to the introduction of the Youth Voice project. We will be interested to see the learning and future development that emanate from this work. The CCG also looks forward to the development introduction of locality-based MDT,’s and how this positively affects patient care in the future and how this may improve the uptake of some services that some patients and families are not aware. We also comment the priority to improve the range and access to spiritual services through the recruitment of volunteer pastoral support workers. Luton CCG supports the Trust’s quality priorities and indicators for 2019/2020 as set out in this annual account. Luton CCG will monitor the progress of the Trust robustly in driving forward these initiatives and improvements to ensure high quality healthcare and outcomes for the population of Luton.

Documents

Quality Account 2018/19€¦ · 4 Keech Hospice Care Quality Account 2018/19 Part 1: Report from the Chief Executive Officer and Clinical Director I would like to start by thanking