Quality Account 2018–19 · 2019-08-27 · 2 Dorothy House Quality Account 2018–19. 03 05 ....

Quality Account 2018–19


2 Dorothy House Quality Account 2018–19

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Contents

Part 1: Chief Executive Statement of Quality

Part 2: Priorities for Improvement 2019–20

Part 3: Review of Quality Performance 2018–19

Appendix 1

Appendix 2

Appendix 3

DOROTHY HOUSE (formerly THE DOROTHY HOUSE FOUNDATION LIMITED)

Company number: 1360961 Charity registration: number 275745 Principal address: Winsley, Bradford on Avon, Wiltshire BA15 2LE

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3 Dorothy House3 Dorothy House Quality Account 2018–19

Part 1 Chief Executive Statement of Quality

4 Dorothy House


Chief Executive Statement of Quality

Welcome to our tenth Quality Account which summarises the quality and breadth of our services over 2018-19.

In April 2018 Dorothy House Hospice Care launched its new Strategic Plan, “Everyday, Everyone” 2018-25, providing us with a strong framework for our future work so we can better meet increasing patient need, grow as an organisation and generate more money for services.

Over the last year, the Strategic Plan has been rolled out both internally and externally and our aspirations for the future are now well understood. As part of the annual planning and reporting cycle at Dorothy House, we will plan and measure our impact against the 7 year Strategic Plan.

In this report, the quality of Dorothy House (DH) services is measured by looking at patient safety, clinical effectiveness and patient/family experience over the financial year 2018-19. It is written for our patients, their families and carers, the general public and the local NHS organisations with whom we contract and who contribute to around 20% of our health and social care costs.

Last year we made progress in the priorities set out in our Quality Improvement Plan 2017-18 in areas such as 7- day working and the implementation of an Always Event® – an aspect of care identified that should always happen – following discharge from the Inpatient Unit (IPU).

Not only does this report chart the progress we have made with our priorities last year, but it also sets out our clinical improvement priorities for 2019-20 which

are guided by our Strategic Plan. These include an improvement in our collection of real-time patient and family feedback and the continuation of our work identifying and achieving Always Events® in our provision of care.

To achieve our strategic goals, we will need ever greater collaboration with key external stakeholders; fellow health and social care providers, Third Sector partners, businesses and more. Over 2018-19, our work with our CCGs, GPs, Macmillan, East Mendip Alliance members and more are indicative of our growing partnerships work to ensure quality of care for our community.

We will also need to look internally to achieve our goals. Our strength lies in our workforce and their skillsets and we have invested accordingly; 10% more expenditure to add resilience and build capability. Aligned to the NHS Agenda for Change pay scales, we are committed to recruiting the health and social care workforce that we need.

Alongside this investment though, we will need to make cost efficiencies in our service delivery. Over 2018-19 we have made savings through improving many of our clinical processes and for this coming financial year, every Head of Department has a 3% efficiencies target on prior year levels to achieve.

With a growing elderly population living longer with life-limiting illnesses, the challenge facing all health and social care providers, as recognised in our Strategic Plan, is how to ensure the continued provision of high-quality services to growing numbers.

I trust this report is testament to our continued quality of care to patients, their families and carers.

Wayne De Leeuw (Interim) Chief Executive



Part 2 Priorities for Improvement 2019–20


Priorities for Improvement 2019–20

As always, our focus in all our care remains on the quality domains of patient safety, clinical effectiveness and patient and family experience. Dorothy House Hospice Care has agreed a Quality Improvement Plan for 2019-20 (Appendix 2). This plan has been approved by the Clinical Audit and Quality Improvement Group (CAQIG), a working group of the Clinical Governance Sub-Group, which reports to a sub-committee of the Board of Trustees (the Patient Services Committee) set up to monitor quality and development of patient services. Key priorities within this improvement plan have been agreed with these groups and include the following:

Priority 1 – Future Improvement: Introduction of an Always Events®

Quality domains – patient safety, clinical effectiveness, patient experience Always Events®, initially conceived in the US by the Picker Institute and now led by the Institute for Healthcare Improvement (IHI), a world-wide body, are defined as those aspects of the care experience that should always occur when patients, their family members or other care partners and service users interact with health care professionals and the health care delivery system. IHI’s Always Events® Framework provides a strategy to help health care providers, in partnership with patients, care partners, and service users, to identify, develop, and achieve reliability in person- and family-centered care delivery processes. NHS England has been working with IHI and Picker Institute Europe to look at how healthcare organisations in England can develop consistent ways to meet the individual needs of patients to make sure that care is patient-centred and delivered in partnership with patients and those close to them.

How was this priority identified? This has been identified as a priority by our NHS Commissioners.

How will this be achieved? By the end of June 2019 we will:

• Review the Always Events® Toolkit • Follow steps as set out and deliver report and proposal

to Commissioners which demonstrate: • Process followed to arrive at the proposed project(s) • Clear rationale for the proposed project(s) • Proposed project measurements, to include KPI(s) around patient experience

• Develop action plan leading to delivery of project

How will this be monitored? There will be quarterly reports submitted to the NHS Commissioners.

Priority 2 – Future Improvement: Introduction of ‘Establishment Genie’

Quality domains – patient safety DH will introduce Establishment Genie, an online NICE-endorsed workforce planning tool which will allow teams to review, compare, remodel and report on their staffing care levels and costs.

How was this priority identified? It has been recognised that there is a regulatory requirement to review clinical staffing establishments at regular intervals, using best practice guidance.

How will this be achieved? Establishment Genie will be introduced to clinical teams throughout 2019-20.

How will this be monitored? There will be quarterly updates to DH’s Improving Care Forum.


Statement of Assurance from the Board of Trustees

Priority 3 – Future Improvement: Improving gym facilities

Quality domains – clinical effectiveness, patient experience DH will improve the gym facilities to include making the gym bigger.

How was this priority identified? DH recognises that there has been an increase in the number of patients using the gym. In 2017-18 there were 635 gym attendances. This is projected to rise to nearly 1100 for 2018-19.

How will this be achieved? A project team consisting of multidisciplinary clinical staff has been established to plan the project.

How will this be monitored? Monthly progress reports will be given to the Patient and Family Services Directorate meeting.

Priority 4 – Future Improvement: Introduction of IWantGreatCare

Quality domains – clinical effectiveness, patient experience DH will ensure that we are obtaining real-time patient and family feedback, across all frontline clinical services, using IWantGreatCare.

How was this priority identified? DH has recognised that there is no consistent approach to obtaining real-time feedback across clinical teams.

How will this be achieved? DH has subscribed to the IWantGreatCare service.

How will this be monitored? There will be six-monthly reports to DH’s Improving Care Forum and Patient and Family Services Directorate meeting.

The Board of Trustees is fully committed to ensuring that DH delivers high quality services and its responsibility is one of governance, strategy and policy. The Board monitors the health and safety of patients and the standard of patient care, ensuring services are continuously evaluated and improved.

The Board of Trustees meets quarterly and this is supplemented by the work of seven Trustee-led sub-committees who meet in advance of each Board meeting. Effective Governance has become a core component and driver of how the Hospice operates, reflected in the appropriate recruitment of subject matter experts who deliver a balance of knowledge across the committee process and the conduct of regular audit and inspections.

DH’s Governance Review, conducted in FY17/18, included a review of the Trustee committee structure to avoid duplication of work, improve efficiency and streamline Trustee time spent in committee. In line with the Charity Governance Code, DH now has 13 rather than 15 Trustees.

Changes were also made to Trustee recruitment and the induction process and a new Governance handbook was developed for Trustees, setting out more clearly their roles, duties and responsibilities, ET’s role and the DH Governance framework.

Twice a year two Trustees visit the Hospice and other settings where services are delivered. Please see page 31 for further details.


Everyday, Everyone: Dorothy House Strategic Plan 2018–25

Working with The Centre for Charity Effectiveness at Cass Business School, we formally launched our Strategic Plan in April 2018.

The Strategic Plan has been rolled out internally over 2018-19. In order to chart DH’s progress over the life of the 7 year Strategic Plan, we have developed a set of Key Organisational Outcomes (KOOs), linked to the 5 strategic goals against which we will measure our performance.

The Trustees have, and continue to play, a significant part in this strategic planning process, helping to ensure that the Hospice can plan for the future and provide the right care and support for patients, their families and carers.

The Board is confident that the care and treatment provided by DH is of a high quality, cost effective and can be sustained in the foreseeable future.

Our strategic vision, mission, goals, enablers and values are detailed below:

A society where death is a part of life

VISION Why we exist

What we contribute to To ensure that everyone has access to

outstanding palliative and end of life care MISSIONachieve the

vision

How we will achieve our Death is a

part of life Living well

Peaceful death

Supported bereavement income

Increase in GOALS mission

What we Education andneed to Governance Leadership Engagement Sustainability Excellence ENABLERSResearch ensure

Our People Partnership Innovation Financial stewardship

VALUES foundations


Review of Services

Over 2018-19 we have reviewed our clinical services in line with our new Strategic Plan launched in April 2018. With an ageing population and increasing patterns of long-term illness, the Hospice will have to respond to increasing demand for its services, raising its income accordingly. To respond properly to community need, we need to work collaboratively within what we see as eco-systems of local service providers/stakeholders. To help build partnerships within the community, DH aims to form a set of “Alliances” as steering groups for co-working within different areas.

The first such alliance is the East Mendip Alliance, now established with nine stakeholders attending monthly meetings. The aim is to map local need, test new ways of working and develop collaborative/sustainable models of care to meet this need. The emerging DH eco-system model has been presented to Somerset CCG End of Life Strategy Board and was well received.

Following on from last year’s launch of the Clinical Coordination Centre (CCC), a single point of access to the Hospice’s services, this year has seen the merging and co-location of CCC and Hospice at Home teams to enable closer working. 2018-19 also saw changes to CCC’s triage system, ensuring that initial


Our services

conversations with a patient occur at the start of each referral process.

Over the next year we will be developing our Access to Services policies and processes to ensure that each patient, family member or carer receives the right level of support.

Mindful of the growing demand for some of our more informal, less medicalised services, it is important that access to our support (via a referral or not) is clear and straightforward for all concerned and the impact of all our services is properly captured.

We also need to make cost efficiencies in our service delivery. Over 2018-19 we have made savings through improving many of our clinical processes including appointment scheduling, referral management, booking of bank staff and more effective procurement. For the next financial year, every Head of Department has a 3% savings target on prior year levels to achieve.

During 2018-19 DH provided services that have agreed service level specifications with the NHS commissioners. We have reviewed all the data available to them on the quality of care for all of these services.

Below is a list of the services we currently provide at Winsley, our outreach centres or out in the community. All of these help us to achieve our overall purpose and objectives and provide the best care we can for patients, their families and carers.

DH continually monitors the effectiveness of these services through number of patients seen and contacts made, clinical audit, patient/carer feedback and specific service reviews.

Medical Team: Our doctors are involved in the assessment, treatment and management of complex symptoms/issues. They provide patient consultations on Hospice premises, at the Royal United Hospital (RUH) Bath and within the community. In addition they provide 24/7 availability of advice to other professionals about any palliative care issue. They are involved in the delivery of professional training and mentoring to medical students, junior doctors in training and qualified doctors working in the community and acute hospitals. They provide support to a neighbouring hospice through the provision of the Responsible Officer role. We participate in the annual High Level Responsible Officer Quality Review.

Inpatient Unit: The management and delivery of a 10-bed Inpatient Unit (IPU) using a Multi-Disciplinary Team (MDT) approach. The IPU provides assessment, treatment and management of complex symptoms/ issues, planned or acute respite care and rehabilitation/ adaptation to the effects of disease progression and terminal care.

Day Patient Services: Patients can attend a nurse-led unit on the same day each week to achieve planned goals based on initial assessment, at which they benefit from specialist MDT assessment and the management of their complex issues. DH also provides a growing range of informal wellbeing, relaxation, exercise and social groups across its three sites.

Clinical Nurse Specialists (CNSs) operating within the community: Our CNSs work in partnership with General Practitioners (GPs) and District Nurses across the region to support patients, families and carers in a variety of community settings through initial assessment, education and ongoing management of complex needs until discharge or death. The team also offers advice, information and support to professionals and assesses the initial bereavement needs of families and carers after the death of a DH patient.

Hospice at Home Service: Our Hospice at Home service provides care delivered by highly trained healthcare assistants within the patient’s home or residential care setting. We support patients with a palliative diagnosis in the last year of life. We can provide:

─ Respite Care: Two nights’ overnight respite care per week in last 12 months of life

─ Crisis Care: Up to 24/7 rapid response in last 12 months of life (max 28 days)

─ End of Life Care: Up to 24/7 care in last 2 weeks of life

This service enables patients to be cared for and die at


home, can help avoid hospital admissions and enable discharge from hospital. A key part of the service is our work with the Royal United Hospital Bath NHS Foundation Trust (RUH) Specialist Palliative Care Team to facilitate patients’ discharge from the RUH at end of life to their preferred place of care/death.

Family Support Services: The Family Support Services provide access to:

─ Adult social work ─ Children and Young People’s services

─ Bereavement services ─ Psychological support (pre-bereavement) ─ Chaplaincy/spiritual care ─ Companions service.

The services operate five days a week, Monday to Friday, although spiritual care is available at all times and weekend activities are available for bereaved children and their families.

Family Support Services are provided at Winsley (through the Inpatient Unit and Day Patient Services), at the outreach centres in Trowbridge and Peasedown St John and in the community. The length of referral is determined by the patient and family need which in turn may also depend on stage and nature of illness, family function and resources, levels of support, etc. Social workers and counsellors/therapists liaise with GPs and other health and social care professionals and schools when needed.

The Hospice continues to develop a range of more informal bereavement and psychological support groups, for example, the monthly Teens Group and newly formed Friends in Grief.

Therapies Physiotherapy (PT): This service is offered to patients to provide ways to help maintain and improve independence and manage symptoms. Our approach to patient rehabilitation, resilience and longevity of quality of life has been commended by NHS England and is recognised as a pioneering approach to patient care.

Occupational Therapy (OT): The Team offers help to patients in order to address problems that impact on independence, safety and quality of life. They provide assessment in the home environment for equipment and adaptation, setting priorities and promoting independence and choice. The Team also offers a range of activities and courses.

Lymphoedema Service: Our palliative and non-palliative service enables DH to provide nurse-led services at local clinics, our three Hospice sites and a range of community settings.

Complementary Therapy (CT): This team provides a range of complementary therapies to patients, families, carers and bereaved clients. The service, designed to complement conventional treatments and promote wellbeing, is led by a Registered Nurse who is also a qualified complementary therapies practitioner. Therapies are given by qualified volunteer therapists and include reiki, aromatherapy and reflexology.

Creative Arts: The Creative Arts Team gives patients, their families and carers the chance to explore a variety of creative arts which can provide focus and diversion at a difficult time and can help address practical, psychological, social and spiritual needs. Activities include the making of creative keepsakes, hand casts and life stories.

Nutrition: DH clinical staff undertake on-going nutrition assessments and provide advice and support to patients, their families and carers. Complex cases are referred to the DH Dietitian.

Education, Research and Professional Development: Education remains a key pillar of our services, offering:

─ Support to all DH clinical staff in their professional development and palliative care updates

─ A range of educational programmes to enable colleagues across all health and social care settings to increase their knowledge and understanding of caring for people with a life-limiting illness and at end of life

─ Research, debate and publication

─ The facility to host education programmes and visits as required by DH professionals.


Clinical Audit and Quality Improvement Group

Like any health or social care organisation, Dorothy House aims to keep improving the care it provides for patients, families and carers. To do this, we need to collect and analyse information about our work which is overseen by the Clinical Audit and Quality Improvement Group (CAQIG) and may take one of the following forms:

─ Clinical audit: This measures patient care against explicit clinical standards-national, local or internal.

─ Service evaluation (often via user experience): Typically taking the form of questionnaires/surveys to patients, families and carers regarding their views of the care they have received

─ Patient, family and carer outcomes: DH is starting to collect information directly from patients through the Outcome Assessment and Complexity Collaborative (OACC) suite of tools. This system records how they feel or function in relation to a health condition and its therapy without interpretation by healthcare professionals or anyone else. OACC now sits within the remit of CAQIG.

DH has an annual Clinical Audit Plan which contributes to the overall Quality Improvement Plan. It provides a means to monitor the quality of our care in a systematic way and creates a framework to review our services and make continuous improvements where needed.

How did we do in 2018-19? Over 2018-19, CAQIG oversaw 35 activities – a mix of clinical audit, service evaluation and patient and carer experience – across the Patient and Families Services Directorate.

Decisions on which clinical audits and service evaluations to conduct are reached based on standard contract requirements, CQUIN requirements, best practice goals, in response to an adverse clinical incident or the redesign of a service.

Last year we had 3 CQUIN goals set by our NHS Commissioners, the delivery of which was supported by audit activity:

1. Always Event® (Wiltshire CCG): In consultation with patients, the Always Event® project for the year was ‘I know who to contact if I have a problem when I am discharged from the Inpatient Unit.’ As per the plan, by March 2019, 100% of patients discharged from the IPU knew to phone the Dorothy House Advice Line with any concerns.

2. Personalised care and support planning for long-term conditions (Virgin Care on behalf of BaNES CCG and Somerset CCG): A two year CQUIN focusing on providing support to patients on our caseload with a non–cancer diagnosis who would benefit most from the delivery of personalized care and support planning, including completion of Advance Care Plans (ACP).

CAQIG’s audit in this area demonstrated an improvement in the number of BaNES and Somerset patients having a personalised care and support planning conversation. The benchmark at April 2018 was 69%, increasing to a mean of 82% at the end of Q3.

The CQUIN has also promoted use of OACC providing evidence of the impact of our interventions, with 76% of patients having an improvement in one or more symptoms. We continue to roll out the introduction of OACC across all clinical teams.

3. Uptake of flu vaccinations (Somerset CCG): This is also a two year CQUIN focused on flu vaccine uptake by clinical staff. This year there was a 76% uptake by clinical staff against a target of 75%.

Clinical Audit is an essential tool in improving quality and patient safety, and prescribing is an area that can be particularly prone to error. The Medicines Management Audit, carried out in January, identified that compliance had decreased from previous year on recording a patient’s date of admission on the patient drug chart. On investigation it appeared that there is no place to record admission date on the newly introduced RUH drug charts. DH has since designed its own prescription chart.

Infection control is another area pertaining to safety that is systematically audited every quarter. This year saw some good results in hand hygiene. The audits concentrated on staff being able to identify the 5 Moments of Hand Hygiene. The first three audits concentrated on the Inpatient Unit where there was an increase from 73% to 86% of staff knowing the 5 Moments.

Antimicrobial stewardship has a high profile in the public health agenda due to the potential impact of antimicrobial resistance globally. DH has been monitoring antibiotic use on the IPU against recognized standards,


and reporting quarterly. In Q1 we demonstrated an improvement against the previous Q4 results. It showed an awareness of microbial stewardship and appropriate prescribing practices. The next two quarters demonstrated reduced compliance, but new prescribers in the IPU have now been properly briefed by the Infection Control Lead.

DH repeated an audit on the way we diagnose and manage urinary tract infections on the IPU using guidance within National Institute for Health and Care Excellence (NICE) Quality Standard 90 ‘Urinary Tract Infections in Adults’ and SIGN 88 ‘Management of suspected bacterial urinary tract infection in adults’. The audit demonstrated a significant change in practice with a great improvement in outcomes including no antibiotics prescribed for urinary tract infections.

We repeated the assessment of NICE guidance NG31 ‘Care of dying adults in the last days of life’ during February 2019 for a sample of IPU patients. There are 75 recommendations from this guidance in total. DH now meets 98% compared to 92% in 2017. The one area requiring improvement was the absence of a validated pain assessment tool for patients with learning disabilities or dementia. Our Dementia Working Group has since identified a suitable tool and this is now in place.

Following on from our Wiltshire CQUIN last year we have continued to audit Preferred Place of Death (PPD) for our Wiltshire patients and over 80% of patients with a recorded PPD are now achieving this. During Q2 we also did an audit of our Somerset and BaNES patients; we found that where PPD was recorded, 83% of

BaNES patients and 90% of Somerset patients were achieving this.

In 2018-19, DH reviewed its delivery of clinical supervision for staff via a staff survey. Of those who responded to the survey, 75% attended their diarised face-to-face supervisory meetings regularly and 25% attended infrequently or never. Non-attendance was either due to timing of the session or staff unwillingness to take time out from patient care to attend. This has led to an extensive action plan with the aim to provide a choice of ways to receive clinical supervision.

In 2018-19, DH undertook an audit of the meals produced for patients at DH to test our compliance with the International Dysphagia Diet Standardised Initiative (IDDSI). The methodology and audit tools were downloaded from the IDDSI website and a resources folder provided for relevant staff and volunteers. To ensure full understanding of IDDSI for staff, face-to-face training was provided to all link workers and volunteers, an online mandatory training package constructed, posters circulated and information made available on the DH intranet.

As a result of the audit and to make us compliant with IDDSI, our Dietician has worked closely with our catering department to ensure that we are able to meet the needs of people who require food and drink with a modified texture. Staff have had awareness training and our policies modified accordingly. The IDDSI Framework was adopted by DH in April 2019.

Patient Experience As part of the second pilot project run by the Nuffield Department of Medicine and the University of Oxford on patient experience of care, between February and July 2018 DH used their ‘Patient Experience of Care’ questionnaire with inpatients and patients attending gym sessions. Our feedback regarding the questionnaire was submitted to the project team and the feedback from patients has been analysed internally. The results were overwhelmingly positive, but identified potential areas for service improvement and development, including further training for staff to set patient-focused goals, a more consistent holistic assessment and an information leaflet about the gym facility.

DH is not currently participating in any national confidential enquiries.


Research Duty of Candour

In 2018-19, we made great strides in building our research capability to enable us to participate in and lead future research studies, which will help innovate our practices and lead to better patient end of life care. We built strong networks locally and agreed a memorandum of understanding with the University of Bath to collaborate on joint research. We are actively recruiting a jointly managed Research Fellow to support this.

In addition, we signed a consultancy agreement with University of Bath, enabling their Research & Development department to provide free research advice and consultancy on all aspects of our research activity. We adopted their comprehensive Research Policy template and established a new DH Research Governance Committee, which has already met several times to guide and govern on all research related matters.

In 2018-19 we joined the Bath Research and Development Consortium. This is a local body of health care organisations (CCGs, care agencies, research funding bodies, other health care providers) working together to collaborate on areas of common research across BaNES and Wiltshire.

DH secured funding in FY 18/19 from National Institute of Health Research (NIHR) for developing research capability within DH. We also met with NIHR representatives to further network on primary and secondary care research and to solicit more support for DH as we build our capabilities to deliver and participate in research.

In 2018-19, we participated in five research studies and reviewed a further seven study proposals. We are currently reviewing two DH-led research proposal hypotheses with a strong desire to launch at least one in FY 19/20.

All healthcare professionals have a duty of candour; a professional responsibility to be honest with patients when something goes wrong with their treatment or care.

DH has introduced a Duty of Candour Register in order to comply with Duty of Candour requirements in relation to notifiable patient safety incidents. In this reporting period there have been no incidents meeting this requirement.


Quality Improvement and Innovation Goals Agreed with Commissioners for 2019–20 Data Quality

A small proportion of our NHS income in 2019-20 is conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework (CQUIN). The agreed CQUINs (below) for all CCGs follow on from some of last year’s, namely a CQUIN to introduce an Always Event® (DH to identify) and a higher target (80% rather than 75%) on the uptake of flu vaccinations by clinical staff.

CQUIN 1 – Wiltshire CCG, Somerset CCG and Virgin Care on behalf of BaNES CCG:

Quality domains – patient safety, clinical effectiveness, patient experience To introduce an Always Event®. (see p6 for further details)


How will this be achieved? By the end of June 2019 we will:

• Review the Always Events® Toolkit • Follow steps as set out and deliver report and proposal

to Commissioners which demonstrate:

─ Process followed to arrive at the proposed project(s) ─ Clear rationale for the proposed project(s) ─ Proposed project measurements, to include KPI(s)

around patient experience • Develop action plan leading to delivery of project.

How will this be monitored? Quarterly reports will be submitted to the NHS Commissioners.

CQUIN 2 – Wiltshire CCG, Somerset CCG and Virgin Care on behalf of BaNES CCG:

Quality domains – patient safety, clinical effectiveness To monitor and therefore improve the uptake of flu vaccinations to 80% for frontline clinical staff.


How will this be achieved? DH will provide an employee vaccination programme and raise staff awareness of the importance of being vaccinated.

How will this be monitored? There will be one report in March 2020 following the vaccination programme.

DH provides quarterly contract activity data in the agreed format to local NHS organisations.

Data is stored and utilised in accordance with the DH Information Governance and Security policies and an annual audit of Information Governance is undertaken with a report and recommendations approved by the Information Governance Steering Group. Compliance with the Data Security and Protection Toolkit was achieved in March 19; this is a requirement of our NHS contracts. GDPR requirements are being fully implemented within DH with the support of an external organisation.

DH is not subject to the payment by results clinical coding audit by the Audit Commission.



Part 3 Review of Quality Performance 2018–19


Priorities for Improvement 2018–2019

The following is last year’s improvement priorities as agreed and an update on progress made.

Priority 1 – Future improvement: Introduction of Always Event®

Quality domains – patient safety, clinical effectiveness, patient experience

How was this priority identified? This was identified as a priority by one of our NHS Commissioners.

How will this be achieved? This was agreed as a CQUIN for 2018-19 with our Wiltshire NHS Commissioners. By the end of June 2018 we will:

• Review the Always Events® Toolkit • Follow steps as set out and deliver report and proposal to Commissioners which demonstrate:

─ Process followed to arrive at the proposed project ─ Clear rationale for the proposed project ─ Proposed project measurements, to include KPI(s)

around patient experience • Produce an action plan leading to delivery of project.

How will this be monitored? There will be quarterly reports submitted to the NHS Commissioners.

Update: The Always Event® for 2018-19 was defined as ‘I know who to contact if I have a problem after I am discharged from the Inpatient Unit’. A baseline assessment indicated that this happened in 50% of

discharges. Following implementation of the Always Events® framework, 100% of patients discharged knew who to contact.

Priority 2 – Future improvement: Introduction of a catheter passport

Quality domains – patient safety DH Infection Prevention and Control Team will introduce a catheter passport for all patients discharged from the Inpatient Unit

How was this priority identified? The Infection Prevention and Control Lead is responsible for ensuring our practice is in accordance with the latest guidance. Review of National Institute for Health and Care Excellence (NICE) Quality Standard 61 ‘Infection Prevention and Control’ identified this as an area for improvement.

How will this be achieved? The Infection Prevention and Control Lead will develop an implementation plan which will include standards.

How will this be monitored? There will be quarterly updates to the Infection Prevention and Control Committee and clinical audit of the standards.

Update: We are awaiting revision of the National Catheter Passport before implementing at Dorothy House.


Complaints

Priority 3 – Future Improvement: 7 day working

Quality domains – patient safety, clinical effectiveness, patient experience DH will introduce 7-day working into relevant clinical teams.

How was this priority identified? DH recognises that health care needs to operate within a 7-day framework in order to provide a responsive service.

How will this be achieved? A project team consisting of multidisciplinary clinical staff has been established to plan the project.

How will this be monitored? Monthly progress reports to the Patient and Family Services Directorate meeting.

Update: Advanced Nurse Practitioners now working 7 days a week on the Inpatient Unit. Clinical Coordination Centre is now open 7 days a week.

Priority 4 – Future improvement: Equality and diversity

Quality domains – clinical effectiveness, patient experience DH will ensure that we are offering an equitable and appropriate service to minority and disadvantaged groups.

How was this priority identified? The CQC review ‘A different ending. Addressing inequalities in end of life care’ (2016) concluded that there are inequalities in end of life care faced by some groups in our society and recommended that hospices champion an equality-led approach.

How will this be achieved? DH has implemented working groups aligned to those groups identified in the report. These will be working to identify ways of achieving equality of care provision. For example developing stronger links with relevant bodies representing minority and disadvantaged groups.

How will this be monitored? Six monthly reports will be given to the DH Improving Care Forum and Patient and Family Services Directorate meeting.

Update: Key minority and disadvantaged groups have now been identified. All terms of reference for working groups reviewed. All working groups now report into the Improving Care Forum and meeting minutes stored centrally.

All letters of complaint received are investigated thoroughly, discussed at the Clinical Governance Sub Committee and reported to the Patient and Family Services Committee, the Board of Trustees and NHS commissioning organisations. Where shortfalls are identified, immediate action is taken to minimise the risk of recurrence.

We have received nine complaints about our services since publication of the last Quality Account, all from relatives of patients. These were investigated and responded to within the time limits laid out in our Complaints Policy. They were also shared, anonymously, with the Clinical Commissioning Groups and our Board of Trustees.

Feedback and an apology were given to the complainants. Lessons learned were fed back to relevant teams and changes in practise were made where necessary.


Other Outstanding Achievements

Patient safety ─ DH has reviewed its fire evacuation procedures

for Winsley, with particular focus on the Inpatient Unit. An intensive training programme has been implemented and fire evacuation drills undertaken.

─ Clinical team leaders have had training to enable them to undertake Root Cause Analysis of clinical incidents. Key clinicians on the Inpatient Unit performed a Root Cause Analysis of medication incidents this year and have developed an improvement plan.

─ DH has introduced a Non-Medical Prescribing Group. The purpose of this group is to ensure that governance at Dorothy House is appropriate; to include training plan, provision updates, ongoing support and mentoring, implementation (including use of SystmOne and communication with primary care), safe keeping and ordering of FP10s and monitoring (including of errors and any issues). It will also collect evidence of the benefit of Non-Medical Prescribing at Dorothy House and in the wider community and will support the building of a business case looking at obtaining additional funding sources.

Clinical effectiveness ─ DH has continued to roll out the Outcome

Assessment Complexity Collaborative (OACC) across clinical teams. Reports are very positive and show the beneficial impact of our interventions.

─ DH has undertaken a review of our non-palliative lymphoedema services to ensure that we are operating in a cost effective manner.

─ DH has worked in partnership with local community volunteers to launch three Friends in Grief bereavement support projects across our patch. The volunteers have been trained by DH and will be self-supporting.

─ We have been taking a strategic approach to working with schools and young people across all departments as part of the wider effort to build a Compassionate Community. Schools and Young People’s Working Group is now established which brings coherence to this work and improves communication between teams. We have commissioned ‘Participation People’ to help us assess existing links with young people and to explore how to engage and support more young people in the future. A report was circulated in May with recommendations.

Patient experience ─ Evolving Communities continues to provide

a User Advisory Group for DH and undertakes a number of activities to inform our service development. The group consists of a project lead and trained volunteers. During 2018-19 they have been involved with the Chaplaincy Strategy, an engagement exercise on behalf of our Education Department, and have supported us to undertake the Kings Fund environment audit.

─ DH has installed a coffee machine in our Day Patient Unit. This encourages patients to be active, making their own beverages independently, if they are able to do so.

─ DH has developed a Chaperone Policy and we are training key staff to enable them to act as chaperones if needed.


Friends and Family Test - IPU (2018–19)

How likely are you to recommend our ward to friends and family if they needed similar care or treatment? 28 people surveyed:

─ 27 people said “extremely likely” ─ 1 person said “likely”

Can you tell us why you gave What would have made your that response? visit better?

“High quality personal care”

“First class care and first class staff”

“Such a peaceful and tranquil place. A safe place to come to terms with very difficult and complicated feelings.”

“The staff of this hospice have been exceptional, their dedication to my care and treatment has been absolutely overwhelming.”

“I have been extremely well looked after since I have been here. I can’t fault the care.”

The majority of respondents had little to suggest that could have improved their visit. There were a few suggestions made:

“More notice if a room change is necessary.”

“We came in to have a pain management plan put in place, which as we leave is still ongoing. The visit would have been better had the plan had quicker results. I cannot fault the staff or the facilities.”

“Location nearer home.”

“Some of the food was half cold and some very spicy.”

“I would have preferred more activities at the weekend.”

“A café here.”


Cancer versus Non-Cancer Referrals

0.6%

21.4%

79.2%

20.8%

78.6%

2018/19 Total patients 2,271

2017/18 Total patients 2,246

Cancer

Non-Cancer


Patient New Referrals 2018-19 DH

Age Age Count Age%

18–24

25–64

65–74

75–84

85+

1 0.06%

370 20.43%

455 25.12%

577 31.86%

408 22.53%

Total 1811 100.00%

Religion Religion Count Religion %

(135..) Religious Affiliation

(1352.) Roman Catholic

(1354.) Atheist

(1355.) Jewish

(1357.) Jehovah’s Witness

(135A.) Christian

(135B.) Sikh

(135G.) Methodist

(135P.) Agnostic

(XA6OH) Religious movement and beliefs

(XaC00) Buddhist

(XaC43) Church of England

(XaP4Y) Church of England, follower of religion

(XaPUC) Catholic, non Roman Catholic

(XE0oe) Religion NOS

(XE2v0) Anglican

(XM1ax) Anglican religion

(Y4993) Religion (Other)

Not Stated

2

4

6

3

1

186

1

1

3

2

2

11

8

1

33

13

1

2

1531

0.11%

0.22%

0.33%

0.17%

0.06%

10.27%

0.06%

0.06%

0.17%

0.11%

0.11%

0.61%

0.44%

0.06%

1.82%

0.72%

0.06%

0.11%

84.54%

Total 1811 100.00%

Gender Gender Count Gender%

Female 863 47.65%

Male 948 52.35%

Total 1811 100.00%

Ethnicity Ethnicity Count Ethnicity %

Asian/Asian Brit: Chinese – Eng+Wales ethnic cat 2011 census 1 0.06%

Asian/Asian Brit: Indian – Eng+Wales ethnic cat 2011 census 1 0.06%

Asian/Asian Brit: Other Asian – Eng+Wales ethnic cat 2011 census 3 0.17%

Asian/Asian Brit: Pakistani – Eng+Wales ethnic cat 2011 census 1 0.06%

Black/African/Caribbn/Black Brit – Eng+Wales ethnic cat 2011 census 5 0.28%

Mixed: White+Black Caribbean – Eng+Wales ethnic cat 2011 census 1 0.06%

White: Irish – England+Wales ethnic cat 2011 census 4 0.22%

White: Other White Background – Eng+Wales ethnic cat 2011 census 21 1.16%

White: Eng/Welsh/Scot/NI/Brit – Eng+Wales ethnic cat 2011 census 1054 58.20%

Not Stated 720 39.76%

Total 1811 100.00%


Performance during Financial Year 2018–19

Key Services Activity

IPU Occupancy rate

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

No.

of C

onsu

ltatio

ns

Medical Consultations

500

450

400

350

300

250

200

150

100

50

0 FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19

Medical consultations remained static in FY18/19 in part due to staffing considerations and also the development of less “medicalised” services more appropriate for many of our patients. A Medical Team Review will be conducted in FY19/20 to examine our medical services in more detail and plan for the future.


Nurse Specialist Visits Hospice at Home Visits

7400 7000

7200 6000

7000

FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19 FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19

No.

of N

urse

Spe

cial

ist v

isits

No.

of H

ospi

ce a

t Hom

e vi

sits 5000

4000

3000

6800

6600

6400

6200

6000

5800

5600

Similarly to medical consultations, with the development of our less medicalised, open access services which do not require a referral, Nurse Specialist visits have remained static.

2000

1000

0

Our Hospice at Home service continues to grow in line with rising demand. We have seen a 33% increase in Hospice at Home visits overall.


800

24/7 Advice Line Therapy Visits

2000 7400

1800 7200 1600

7000 1400

FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19

No.

of c

alls

to th

e Ad

vice

Lin

e

No.

of T

hera

py v

isits

1200

1000

6800

6600

6400 600

400

200

0

Accessible to professionals, patients, families, carers and the wider public, this has grown steadily over the last five years. In FY18/19, we have seen a 3% increase in calls on previous year.

6200

6000

5800

In FY18/19, we have seen a 15% increase in therapy visits on previous financial year as we develop our rehabilitative care offer. Gym use and OT appointments have increased in particular, along with a 30% increase in physiotherapy sessions.


Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

No.

of F

amily

Sup

port

Team

vis

its

Key Organisational Outcomes

Family Support Team (FST) Visits Death is a part of life

Palliative care need met 3500

6,000 2024/25 Target

5,0003000

0

FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19

Num

ber o

f Pat

ient

s

4,000

2500 3,000 2018/19 Target

2,0002000

1,000

1500

1000

No. of DH patients cared for (2,271 in FY18/19) 500

ACP conversations offered routinely 0 100% 2024/25 Target

75% 2018/19 Target

0

Num

ber o

f Pat

ient

sWe have seen an overall 39% rise in FST visits over the last five years. In FY18/19 there was an increase of 3% on previous FY.

50%

25%

ACP conversations offered routinely to referred DH patients (64% in FY18/19)


500

Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Death is a part of life (continued) Living well

A health and social care sector trained in palliative care Equitable palliative care for non-cancer patients

2,500 60% 2024/25 Target 2024/25 Target

50%

0 0

2,000

Num

ber o

f Atte

ndee

s

40%

% o

f Pat

ient

s

1,500 2018/19 Target 30% 2018/19 Target

1,000 20%

10%

No. of external health and social care professionals % of Dorothy House non-cancer patients cared for (21% in FY18/19) receiving DH education / training (973 in FY18/19)

Care provided based on patient outcomes

80% 2024/25 Target

70%

60%

0

2018/19 Target

% o

f Pat

ient

s50%

40%

30%

20%

10%

% of patients cared for with at least one OACC suite completion (52% in FY18/19)


500

Apr 18

May 18

Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Peaceful death Supported bereavement

DH supporting more deaths Support for DH family members and carers 2024/25 Target 2,000 2024/25 Target

0 Num

ber o

f of F

amily

mem

bers

and

Car

ers 1,000

750

500

250

1,500

Num

ber o

f Dea

ths 2018/19 Target

2018/19 Target

1,000

0

Number of DH patient deaths (1,204 in FY18/19) Direct bereavement support for DH family members & carers (582 in FY18/19)

DH patients dying in Preferred Place of Death (PPD)

100%

2024/25 Target

2018/19 Target

Num

ber o

f Pat

ient

s 75%

50%

25%

% of DH patients with recorded PPD achieving this (57% in FY18/19)

0


Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Apr 18

May 18

Jun 1

8

Jul 1

8

Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 1

9

Feb 19

Mar 19

Increase in income

DH care spend to meet needs of community

£16M

Volunteering

As ever, our volunteering workforce continues to make a vital contribution to the care and support we provide to our local community and our wider social value. As at the end of 2018-19, our volunteer figures stood at 371 volunteers in Hospice and outreach and 695 volunteers in Retail, making a current total of 1066 volunteers.

2024/25 Target

were asked to log volunteer hours for a week in October £12M

2018/19 Target

0

To update our volunteering statistics, volunteer managers £14M

2018. In this week, our volunteers gave us 3,329 hours,

Car

e Sp

end £10M

similar to having an extra 90 people working full time. We £8M estimated that taking into account the cost of training,

£6M support, supervision and expenses, volunteers bring

£4M added value of over £2 million a year to Dorothy House. £2M This is in addition to the wider social impact generated

for volunteers themselves, with research suggesting it can boost self-esteem, employability and health.

New to the volunteering offer in 2018-19 has been theIncrease in DH care spend (£9.1M in FY18/19)

development of a Compassionate Companion Service to end of life patients in the RUH who have no or limited

Efficient delivery of services maximising money spent on care family support. With additional funding from the RUH £4,500 Forever Friends Appeal, this pilot will launch in FY19/20 £4,000 with a team of 12 volunteers in three pilot wards. By

2018/19 Target

2024/25 Target

year three the plan is for this to be available for all wards £3,500 across the hospital.

Cos

t per

Pat

ient £3,000

£2,500 Over FY19/20, the DH Volunteer Services Team has £2,000 made more regular visits to our shops, developed £1,500

£1,000

£500

resources to support recruitment and advertised opportunities more widely. The result in this increased contact has been an upwards trend in retail volunteering enquiries, better record-keeping and communication with retail volunteers and improved safeguarding

Reduction in average spend per referred DH patient (£4,000 cost per patient in FY18/19)

0


Education

measures to support vulnerable volunteers in our shops. To support Retail Managers, we have newly launched a Volunteer Toolkit containing a handbook along with supporting documents to use in recruiting, supporting and managing volunteers.

DH is fortunate to have a number of volunteers with specialist skills who we have successfully placed in roles across the organisation, ranging from IT to marketing. We are developing a more systematic approach to managing data on volunteers’ specialist skills.

Communicating with volunteers on their roles is important to DH. A new Volunteer Strategy has been developed in 2019 through a series of consultations with Managers, the Volunteer Forum and a Strategy Workshop attended by participants from all areas of the organisation. This strategy is now being used to inform the Volunteer Services Action Plan for 2019 onwards.

In 2018-19, DH delivered 58 different end of life care related courses for its staff, the community and academia.

1,098 professionals attended various programs of education, which included 973 external participants. This represented 5,614 teaching hours of which 4,838 were delivered to these external participants and achieved a satisfaction rating of 100%. The Education & Research Team also contributed to DH income with a growth of 12% from £136k to £152k.

We ran three new successful courses in 2018-19 related to managing grief, nutrition in end of life care, and cognitive behavioral therapy related to palliative and end of life care.

Key to 2018-19 has been the setting up of a new online learning management system, based on a Moodle platform, to enable delivery of online e-Learning courses and to showcase and offer a more blended learning approach. We plan to further enhance this system and platform next year.

As we develop our educational support it is important that we understand community need. In 2018-19 the DH User Advisory Group worked with us to explore how we might develop our educational offer to patients, families and support networks. Managed by Evolving Communities, this independent group of trained volunteers seeks the views and ideas of our services users, volunteers and staff.

Our links to academic education have strengthened. As we continue to teach on the nursing courses at the University of West of England and the University of Bath,

we are also exploring opportunities to deliver teaching on their social science courses. In 2018-19 we have formed a relationship with Wiltshire Further Education College regarding apprenticeship accreditation and are exploring options to deliver on a variety of their programmes.


Community Partnerships Board of Trustees Visits

In 2018-19 we have started to gain a better understanding of the wider social value generated from our community partnerships.

A vital link between Dorothy House and the communities we serve, the Community Partnerships Team was instrumental in commissioning and managing a needs analysis in the Mendip area, lead by Community First, in partnership with other local organisations in 2018-19. Understanding local need around end of life services has been key to DH setting up the East Mendip Alliance – the first of a series of partnership alliances to drive change and new models of care across our communities.

Another example of our strong partnerships work which drives social value is our DH clinicians’ collaboration with the Macmillan Information Team on their Bertie bus which visits towns across our catchment area, providing advice and support to people who drop-in.

In 2018-19 we established a Friends in Grief (FIG) support group model. Manned by Dorothy House trained volunteers, the aim of FIG is to facilitate a safe and supportive group environment for bereaved people in the local community at a weekly drop-in session. Crucially, this is aimed at all bereaved people as we widen access to the support and value we provide across communities. FIG is now well established in North Wilts and two more groups are planned for Corsham and Shepton Mallet using High Street Cafés as venues.

DH provides wider value to its community on a daily basis, from gifting the use of our outreach centre meeting rooms to other charities, to providing allotment produce to the Alzheimer’s Support day care group.

Social value works both ways though and DH benefits from the gifts in kind we receive from individuals and other organisations in the community. Recycle your Cycle (a social enterprise refurbishing bikes) gift us their bikes to sell in our shops and our local fire services provide home safety advice and equipment at no charge to DH patients, families, carers, staff and volunteers. These are just some of the growing examples of social value, made possible through our community partnerships.

We continue to develop an account of our social value and consider how best to build on this so that as a health and social care provider, a charity, a retailer and community partner we can play a pivotal role in helping to build a sustainable community.

Twice a year two Trustees visit the Hospice and other settings where services are delivered, for example patients’ homes and the outreach centres. These visits are unannounced and a written report is considered by the Board with recommendations monitored by the DH Audit and Risk Committee. During the visits, Trustees speak to patients, carers, staff and volunteers ensuring they have first-hand knowledge and experience of what patients and carers think about the quality of services provided and feedback from staff and volunteers.

In March 2019, DH Trustees Simon Burrell and David Cavaliero visited the Fundraising Team, the IPU, the Communications Team and DH shops in Chippenham.

Their Report Summary for March 2019 visits was as follows:

“Overall, we felt there was energy and enthusiasm in all the teams. They were all in line with the new strategy and understood the aims of it. The local nature of the organisation seemed important to most staff and a feeling they were part of a caring organisation in that local context.

“All the staff seemed content and dedicated and there was a strong message that they valued a significant degree of autonomy, whilst having the clear aim of supporting the role and aims of Dorothy House.”


Staff

What staff say about the organisation DH has a Staff Consultative and Information Forum (Our Voice) where, as well as discussion on issues that directly affect staff (e.g. pay award, HR policies and terms and conditions of employment), staff views are sought on a range of wider areas including the overall organisational direction and strategy, staff support and staff communications. This is attended and supported by the Executive Team to demonstrate commitment to the staff voice.

Communication A range of communication strategies are in place:

─ Monthly staff updates from Chief Executive and Executive Team to the Heads of Departments who are accountable for cascading information. This also includes updates provided to the Board of Trustees

─ Increased reporting and auditing of communications through the intranet

─ Better communications through the Health and Safety Committee, Our Voice and the Volunteer Forum

─ Use of technology to ensure the DH outreach teams have access to key updates

─ Monthly coffee mornings where staff receive updates on projects and celebrate success

Managing Change DH has experienced a period of change with two Executive Leaders leaving in 2018-19. Robust interim arrangements are in place and recruitment is progressing

with these key posts. Recruitment and turnover overall is positive.

Working conditions and arrangements DH adopts Agenda for Change terms and conditions and is aligned with the local and national scheme. DH is not tied to NHS pay awards, yet for the last two years pay uplifts and awarding of increments has been in line with the national awards.

New initiatives for 2019-20 include:

─ Leadership plan and programme ─ Development of career pathways ─ Further investment in wellbeing and a focus on

mental health ─ Talent and succession planning strategy ─ Development of role-specific and core behavioural

competencies ─ Quarterly staff survey

Staff training and appraisal All staff receive an annual Performance and Development Review (PDR) with their Line Manager and this is monitored by our HR Department. At the appraisal meeting, objectives are agreed for the following year along with a personal development plan which is sent to the Education and HR Departments. These plans feed into the annual Education and Training Plan for the organisation.

A Training Tracker system records all education and training, sends reminders to staff when their mandatory

training is due and informs the Line Manager if it is overdue. This system has helped to increase compliance by staff and reduce the time spent by managers to ensure that their staff undertake their mandatory training. Staff, including bank staff, who have overdue mandatory training are managed very carefully to ensure only competent staff support patients, their families and carers.


What our regulators say What the commissioners about the organisation say about the organisation

DH is currently registered as an independent healthcare provider under the Care Standards Act 2000. In 2018-19 DH was registered for three regulated activities with the Care Quality Commission (CQC) under the Health and Social Care Act 2008.

DH received an unannounced CQC inspection in September 2016; this led to an excellent report with a rating of ‘Outstanding’.

Key Questions:

Is the service safe? GOOD

Is the service effective? OUTSTANDING

Is the service caring? OUTSTANDING

Is the service responsive? OUTSTANDING

Is the service well-led? OUTSTANDING

Outstanding is the highest available rating and places DH in the top 6% of adult social care providers nationally.

The inspection included an unannounced three day visit by four inspectors to Winsley and our outreach centres in Trowbridge and Peasedown St John. The inspectors assessed patients’ personal care records and talked to patients, carers, family members and staff as well as measuring DH performance against five essential standards of quality; that it is safe, effective, caring, responsive and well-led.

The CQC reported that DH was “committed to continuous improvement”:

“The provider had a range of robust systems to monitor the quality of care provided, which included feedback surveys, audits and quality monitoring checks. They continuously made changes and improvements in response to their findings.” (p4)

(http://www.cqc.org.uk/sites/default/files/new_reports/INS2-2473766548.pdf)

The CQC noted the improvements that DH had made in terms of end of life care for people living with dementia and its move to full use of electronic records (SystmOne) on the Inpatient Unit – completed in January 2017. Both of these were Future Improvement Priorities in last year’s Quality Account.

Deborah Ivanova, Deputy Chief Inspector of Adult Social Care, CQC said:

“We found that Dorothy House Hospice Care is providing an outstanding and very caring service and the staff had the expertise to provide individualised care to the people they support in a way that suits them. The team should be extremely proud of the work they do.”

Please find below extracts from the NHS Wiltshire Clinical Commissioning Group. For full letter see p.45

‘NHS Wiltshire Clinical Commissioning Group (WCCG) has reviewed Dorothy House’ (DH) 2018-19 Quality Account. In doing so, the CCG reviewed the Account in light of key intelligence indicators and the assurances sought and given in the quarterly Contract Review Meetings attended by DH and Commissioners. The CCG supports DH’s identified quality priorities for 2019-20. To the best of our knowledge, the report appears to be factually correct.’

‘It is the view of the CCG that the Quality Account reflects DH’s on-going commitment to quality improvement and addressing key issues in a focused and innovative way...’

‘In addition to the progress against 18/19 priorities, the CCG recognise a number of other positives, in particular the introduction of a joint post with Royal United Hospital and Macmillan to support people at the point of diagnosis of secondary or metastatic cancer and the introduction of Nurse Clinics for routine referrals within an outreach setting.

The CCG notes and commends DH on the focus on infection prevention and control and for reporting no cases of acquired MRSA bacteraemia, Clostridium Difficile or MSSA during 2018/19.’

‘Wiltshire CCG is committed to ensuring collaborative working with Dorothy House to achieve continuous improvement for patients in both their experience of care, safety and outcomes.’

http://www.cqc.org.uk/sites/default/files/new_reports/INS2-2473766548.pdf


Strategic and Operational Intent 2019/20

Linked to our strategic goals and following on from last year’s aims, our organisational objectives for 2019-20 are as follows:

1. Death is a part of life: Deliver year two of the 2018-25 Strategic Plan through proactive engagement across the community that influences the NHS Long Term Plan with the effect of coherent end of life coordination across the strategic landscape (SW Region, STPs and emerging bodies).

2. Living well: Lead a charity that is CQC “Outstanding” across all five key requirements and to operate effectively, delivering a minimum of 3% savings by Q4 on track by Q2.

3. Peaceful death: Influence and shape the community across our 700sq miles, creating an environment through a partnership landscape, where “Preferred Place of Death” is a credible choice, delivered through a sustainable community programme.

4. Supported bereavement: Develop education, support, DH centres and communication tools, which inform in an equitable manner on issues, capability, entitlement and access pre- and post death for all patients, families and carers.

5. Increase in income: Deliver an effective 2019-20 financial plan that is sustainable and builds on 2018-19.

Ruth Gretton Director of Nursing June 2019

Quality Account 2018–19 35 Dorothy House35 Dorothy House Quality Account 2018–19

Appendix 1


Dorothy House Hospice Care – Quality Improvement Plan Year 1: April 2018 – March 2019

Patient Safety Action By When Expected Outcome Achieved

Participate in Hospice UK Patient Safety March 2019 Evidence that we continually monitor and Achieved and embedded within core Metrics benchmarking learn from adverse patient events business.

Commit to ‘Sign Up To Safety’ March 2019 Evidence that Dorothy House is committed Policies updated, nominated staff are to ensuring safe patient care now trained as Independent Guardians.

Introduce ‘catheter passport’ for patients March 2019 Improved communication and transition Pending – waiting for revised National discharged from Inpatient Unit between care environments Catheter Passport to be circulated and then

will roll out the Dorothy House equivalent.

Review clinical competencies, training March 2019 Patients will experience safe care. For roll out during 2019/20. and assessment framework

Exploring potential of expanding pharmacist role March 2019 Most effective medicine management for our patients

New pharmacist appointed – Commences June 2019. New contract in place to support post, role and responsibilities.

Effectiveness

Action By When Expected Outcome Achieved

Introduce new post, working jointly with Royal United September 2018 Patients and families will have earlier In post since May 2018. Embedded Service. Hospital and Macmillan to support people at point of access to hospice services Positive outcomes for patient referrals to diagnosis of secondary or metastatic cancer Dorothy House and community Services.



Effectiveness (continued) Action By When Expected Outcome Achieved

Work in partnership with our community to March 2019 More people will be supported in their Malmesbury self-help hub opened in develop Friends In Grief bereavement hubs bereavement August. New hubs to open in Shepton

Mallet and Corsham during 2019.

Work in partnership with Royal United Hospital March 2019 Peaceful death Completed and current volunteers are to develop end of life companions for patients undergoing the induction process. Due to in the acute hospital start in RUH in May 2019. 12 companions

working on 3 wards between 09.00 and 21.00hrs 7 days per week.

There will be an increase in numbers of patients who March 2019 Evidence that people are supported to Respect Nurse in place. are offered an Advance Care Planning conversation consider their end of life care wishes CQUIN completed and achieved for

Somerset and BaNES.

Ongoing development of Clinical Coordination Centre March 2019 Patients will have their care experience coordinated

Went live April 2018. Services Advice Line. Coordinates IPU respite admissions. Coordinates H@H referrals. Twice weekly MDTs for non-urgent referrals.

Ongoing – reviewing and streamlining of processes. 5 Day Nurse Specialist Cover in place.

Implementation of 7-day working across relevant March 2019 Evidence that Dorothy House is committed Advanced Nurse Practitioners working clinical teams to providing a responsive service 7 days per week on the Inpatient Unit.

CCC is now 7 days per week. Review of CCC processes underway and phase 2 developments.



Effectiveness (continued) Action By When Expected Outcome Achieved

Introduction of Advanced Nurse Practitioners September 2018 Evidence that Dorothy House is committed Commenced 2 Full Time ANP’s to providing a responsive service Evaluation currently taking place.

Personalised care and support planning for patients with March 2019 Increase in the numbers of this cohort who Increase in the numbers of this cohort non-cancer conditions, as part of NHS CQUIN initiative have Advance Care Plans, to include Preferred who have Advance Care Plans, to include

Place of Care, Preferred Place of Death and Preferred Place of Care, Preferred Place Treatment Escalation Plans of Death and Treatment Escalation Plans.

Collaboration with other hospices in the region to March 2019 Dorothy House will be able to benchmark Poster went to Hospice UK. develop a set of quality metrics quality against other hospices Ongoing work with Regional Quality Group.

Introduce clinical apprenticeships March 2019 Improving workforce resilience Achieved; two apprentices started during January 2019.

DH to commission a “needs analysis” of the first area September 2019 Developing evidence based services Achieved; needs analysis undertaken to be developed as an eco-system in Mendip by Community First and

findings will be considered as part of strategic development.

Alliance working group to be established with March 2019 Develop local services that meet the needs Achieved. key partners from the community of people without duplicating existing offers

Participation in updating ‘The Palliative Care March 2019 To ensure best practice across our region Under review and in current work plan. Handbook A Good Practice Guide’ with Wessex Palliative Physicians



Patient Experience Action By When Expected Outcome Achieved

Ongoing participation in pilot of ‘Patient Experience March 2019 Evidence that we are providing high quality Phase 2 completed. Awaiting Feedback. of Care’ questionnaire in conjunction with Oxford care to patients and that we respond to University and Nuffield Institute feedback

Introduction of an Always Event® as part of NHS March 2019 Evidence that we are committed to improving Achieved. Introduction of patient discharge CQUIN initiative the patient experience pack including Advice Line phone number.

Review of Equality and Diversity working groups March 2019 To ensure we are offering an equitable Key groups identified. All terms of reference linked to the CQC “A Better Ending” report, to include and appropriate service at end of life for of working groups reviewed. All groups now frailty and dementia disadvantaged and minority groups report into the Improving Care Forum and

meeting minutes stored centrally.

Ongoing collaboration with BEMSCA with a member March 2019 To better meet the needs of local BAME people Ongoing work. of staff embedded in the team one day a week

DH to collaborate with Macmillan using their March 2019 To better understand local needs through Achieved. Members of DH clinical team engagement bus to meet local communities interviews and questionnaires and Live Well Partnership post support this.

Steering group set up to investigate the potential March 2019 To improve the patient experience Ongoing. To work with new pharmacist with expansion of non-medical prescribing across the development of services. organisation

Planning to participate in the doctoral research March 2019 To contribute to the palliative care research We have participated in the project and are project ‘Affect and materiality in therapeutic spaces. agenda waiting to see the final report. A contemporary archaeology of hospices’


Appendix 2



Patient Safety Action By When Expected Outcome Achieved

To introduce improved fire doors and safety into May 2019 To improve effectiveness of fire doors and IPU area safety of patients during any fire event

To introduce the use of the online Marsden Clinical April 2019 To ensure safe, consistent and evidence Policies and Procedures to all clinical teams based practice to all nursing teams

To develop a Business Impact Plan for the organisation May 2019 To improve communications between all services within major incidents

To undertake regular audits of clinical records across April 2020 To ensure that clinical recording within all all teams teams is accurate, consistent and meets

best practice and regulatory standards

To introduce Establishment Genie – a NICE endorsed September 2019 To ensure that we have the correct skill workforce modelling tool mix and to enable us to remodel services

with improved care and costs

To improve our medicines management following December 2019 To ensure safe patient care recruitment of pharmacist



Effectiveness

Action By When Expected Outcome Achieved

To roll out specialist palliative care e-learning November 2019 To reduce avoidable admissions module to 5 East Mendip Nursing Homes To increase knowledge of staff within

nursing homes

To develop Venepuncture skills within the March 2020 To reduce unnecessary referrals to community setting community teams and Primary Care

Provide a responsive service to patients

Introduce foundation degree clinical apprenticeship model March 2020 Improving workforce resilience

Introduce consistent model to all MDT meetings September 2019 To improve communications between within CCC, the community and Inpatient setting departments

Introduce Nurse Clinics for routine referrals in July 2019 To provide a responsive service for patient outreach setting pathway of care

To review organisational Clinical Supervision model September 2019 To evidence that we are providing a supportive environment to our staff

To scope out the need for a specialist frailty identification September 2019 To reduce avoidable admissions to the tool within Specialist Palliative Care services acute services

To enhance patient and family assessment

To develop gym facilities within Dorothy House September 2019 To increase the numbers of patients being able to access wellbeing services to enable patient to Live Well



Patient Experience Action By When Expected Outcome Achieved

To introduce IWantGreatCare July 2019 To collate real time patient feedback from all clinical teams and be responsive to patient concerns

Upgrade IPU facilities September 2019 To improve the patient experience

To seek user involvement for next year’s Quality March 2020 To work in partnership with service users Improvement Plan

References [1] Gomes B. et al. 2008. Where people die (1974-2030): past trends, future projections and implications for care. Palliative Medicine 2008; 22: 33-41.

[2] ONS. 2015. Deaths Registered in England and Wales, 2014 Deaths Registered in England and Wales, 2014. See: http://www.ons.gov.uk/ons/rel/vsob1/ death-reg-sum-tables/2014/sb-deaths-first-release--2014.html

[3] NHS England. 2015. Actions for End of Life Care: 2014-16. See: http://www.england. nhs.uk/wp-content/uploads/2014/11/actions-eolc.pdf

[4] Alzheimer’s Society. 2015. See: http://www.alzheimers.org.uk/site/scripts/ documents_info.php?documentID =535&pageNumber=2

[5] Natcen. 2013. British Social Attitudes survey. See: www.dyingmatters.org/sites/ default/files/BSA30_Full_Report.pdf

www.dyingmatters.org/sites

http://www.alzheimers.org.uk/site/scripts

http://www.england

http://www.ons.gov.uk/ons/rel/vsob1


Appendix 3


Statement from Wiltshire Clinical Commissioning Group on Dorothy House 2018-19 Quality Account

NHS Wiltshire Clinical Commissioning Group (WCCG) has reviewed Dorothy House’ (DH) 2018-19 Quality Account. In doing so, the CCG reviewed the Account in light of key intelligence indicators and the assurances sought and given in the quarterly Contract Review Meetings attended by DH and Commissioners. The CCG supports DH’s identified quality priorities for 2019-20. To the best of our knowledge, the report appears to be factually correct.

It is the view of the CCG that the Quality Account reflects DH’s on-going commitment to quality improvement and addressing key issues in a focused and innovative way, as well as utilising the nationally set CQUIN schemes to support the achievement of many of the 2018-19 quality priorities.

DH’s priorities for 2018-19 have outlined achievement in:

• Patient experience through successful completion of an Always Event® to ensure all patients discharged from the Inpatient Unit know who to contact if they had a problem after discharge

• Introduction of 7 day working for Advanced Nurse Practitioners on the Inpatient Unit

• Opening of the Clinical Co-ordination Centre 7 days a week

• The implementation of working groups to achieve equality of care provision for patients in response to the CQC review, ‘A different ending. Addressing inequalities in end of life care’ (2016)

The CCG welcomes continued focus on:

• Plans to introduce a catheter passport for all patients discharged from the Inpatient Unit following revision of the National Catheter Passport

• Ongoing development of the Clinical Coordination Centre

• Roll out of specialist palliative care e-learning to nursing homes reduce avoidable admissions

In addition to the progress against 18/19 priorities, the CCG recognise a number of other positives, in particular the introduction of a joint post with Royal United Hospital and Macmillan to support people at the point of diagnosis of secondary or metastatic cancer and the introduction of Nurse Clinics for routine referrals within an outreach setting.

The CCG notes and commends DH on the focus on infection prevention and control and for reporting no cases of acquired MRSA bacteraemia, Clostridium Difficile or MSSA during 2018/19.

Wiltshire CCG is committed to ensuring collaborative working with Dorothy House to achieve continuous improvement for patients in both their experience of care, safety and outcomes.

Yours sincerely

Linda Prosser

Interim Chief Officer NHS Wiltshire Clinical Commissioning Group


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