Quality Account2013/2014

Image: New Inpatient garden

Inset: Members of the clinical team in new uniforms

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Rowcroft Hospice Quality Account 2013/2014ContentsChief Executive’s introduction .........................................................3

What our organisation is doing well and our approach to Quality Assurance ........................................................4

Patient safety — delivering care ................................................................................................. 4

Clinical effectiveness — measuring impact .......................................................................... 5

Getting staffing right and measuring staff experience .................................................... 5

Care Quality Commission (CQC) inspection ....................................................................... 5

Audit ........................................................................................................................................................ 5

Research ................................................................................................................................................ 5

Education 2013/2014 ....................................................................................................................... 6

Statutory information and some facts and figures .......................7

How we have performed against last year’s priorities for improvement .................................................................................8

Patient safety ....................................................................................................................................... 8

Getting staffing right ........................................................................................................................ 8

Clinical effectiveness — measuring impact .......................................................................... 8

Patient, family, friends and staff experience ......................................................................... 8

Outpatients .......................................................................................................................................... 8

Where we feel we can improve and our priorities for 2014/2015 .......................................................................................9

Patient safety — delivering care ................................................................................................. 9

Patient family and friends experience ..................................................................................... 9

Rowcroft Hospice at Home .......................................................................................................... 10

Chapel area .......................................................................................................................................... 10

Wi-fi provision in the Inpatient Unit ........................................................................................ 10

Chairman of the Board of Trustees statement ..............................11

Annex ....................................................................................................12

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Chief Executive’s introductionRowcroft Hospice is the Independent Charity providing Specialist Palliative Care to patients and their families in South Devon. Over 75% of the service delivery is funded through the charitable giving of the people of South Devon; the balance being funded through a block contract from the local NHS. Wherever possible, we seek grant income for specific projects and were fortunate to secure funding this year to improve access and interaction in our gardens for the benefit of our patients and their visitors. You can see a small part of this on our front cover.

This, our fourth annual Quality Account, aims to demonstrate to our patients, their families and friends, the people of South Devon and our NHS Commissioners, that Rowcroft Hospice delivers safe, effective, high quality care. Whilst good care is, in reality priceless, we consider our care to be responsible by representing very good value, in return for the community’s charitable investment.

All of this is only made possible by the dedication of our staff and volunteers, the Executive Team and our Board of Trustees. They are passionate in their aim to deliver the best possible care to those who need it, whilst maintaining the highest standards in Corporate, Financial and Clinical Governance.

This document is a fair and accurate account of the quality of service provided by Rowcroft Hospice, an organisation of which I am deeply proud to be a part.

Giles Charnaud CEO Rowcroft Hospice

What our organisation is doing well 4

What our organisation is doing well and our approach to Quality AssuranceOur focus, as always, remains on the quality domains of patient safety, clinical effectiveness and patient / family experience.

Patient safety — delivering care• Our Quality and Patient Safety Committee

continues to meet monthly. Clinical Incidents are examined, using root cause analysis where indicated to ensure that our processes reflect best practice and to minimise risk. Our incident reporting system is now sited on an electronic database to ensure robust investigation and reporting.

• We are pleased to report that, for the fourth consecutive year of reporting for the Quality Account, no patients acquired the reportable infections MRSA, Clostridium difficile, ESBL, Salmonella, Pseudomonas or Klebsiella Pneumonia whilst in the care of the Inpatient Unit.

• We have continued to report data to benchmark slips, trips and falls, medication incidents and pressure ulcers with our regional hospice colleagues. We are pleased to report that, from April 2014, this will be benchmarked with hospices nationally via Help the Hospices.

• At the time of publication, the benchmarked figures have not yet been reported. We will be pleased to supply them on request once they are to hand.

We were concerned that we had reported more drug incidents1 than the average for south west hospices last year, so a medications management task and finish group was established to look for any underlying themes or trends that required action.

• Every incident for the twelve month period was revisited and re-analysed. No incident resulted in harm to a patient, nor in any change in their clinical condition.

It was also clear that some incidents were beyond the organisation’s control, eg equipment failure. However, we strive to be a learning organisation and will continue to monitor all incidents.

• An audit of controlled drug records noted areas for improvement and a new process for the recording of controlled drugs brought into the hospice by patients is now in place.

• All registered nurses will attend a two day medicines management course on appointment, unless they have recently attended training with their previous employer. All existing staff will have access to ongoing training online.

The results of this review are encouraging and we plan to repeat the process in 2014/2015.

2013/14 2012/13

Number of patients who developed new pressure sores (grade 2 and above, per 1,000 occupied bed days) whilst cared for on IPU.

6.1 1.4

Number of patient falls per 1,000 occupied bed days (Includes slips, trips and falls).

7 7.4

Number of patient medication incidents per 1000 occupied bed days.

5.9 5.8

We are always vigilant in recording these statistics, but realise that they must be taken in context. All of our Inpatient beds are occupied by people with acute and complex needs, either because of a progression in their illness or because they are in the last few days of their lives. At the end of life, multiple organ failure can occur, including breakdown of the skin.

We remain vigilant in assessment and planning. A review of the pressure ulcers that occurred in the hospice showed that all were unavoidable. We have recently purchased several additional high specification mattresses as part of our rolling programme of equipment replacement.

1Any incident where there has been an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicines advice, regardless of whether any harm occurred or was possible. This is a broad definition and most errors result in no or low harm. (National Patient Safety Agency. Safety in Doses. (2007) pg.9.)

What our organisation is doing well 5

Clinical effectiveness — measuring impactA consultation with Inpatient nursing staff was carried out to identify the best model for nursing our patients, taking into account our staffing levels, skill mix and geography of our Inpatient Unit. Our aim is to ensure that our care is always person centred, with a named nurse for each patient on every shift. The new model was piloted from October 2013 and fully implemented in January 2014. Patients reported satisfaction with the quality of care experienced to the Care Quality Commission (CQC) Inspectors during their inspection.

Getting staffing right and measuring staff experienceThe model discussed above has been well received by staff, who have worked in smaller teams with well documented lines of accountability. Although it is too soon to measure the effect on their job satisfaction, the Care Quality Commission Inspectors commented that staff were satisfied with improved team working.

Care Quality Commission (CQC) inspectionRepresentatives from the CQC carried out a routine inspection of the Inpatient and Hospice at Home Services in November 2013 to check that essential standards of quality and safety were being met. The inspectors made their judgements by a combination of methods including observation, talking to patients, carers and staff and reading documentation.

We were pleased that their report confirmed compliance with the domains inspected, including consent to care and treatment, care and welfare of people using our services, cleanliness and infection control, staffing and record keeping.

The full report can be viewed at: http://www.cqc.org.uk/sites/default/files/old_reports/1-106245011_Rowcroft_Hospice_INS1-910153924_Scheduled_11-12-2013.pdf

Audit19 Clinical audits were carried out during 2013/2014 and 7 are ongoing. All audits are scrutinised by the monthly Quality and Patient Safety Committee, who make recommendations to ensure clinical effectiveness and best practice are at the forefront in our approach to patient care.

In addition, the Infection Prevention Practitioner manages 10 audits per month in respect of the environment and working practices. Five annual Infection Prevention audits are carried out, including the Help the Hospices Policies and Procedures audit to ensure that we are compliant with current best practice.

We are also a member of the South West Informatics Project. This comprises 10 South West Hospices who participate in data collection, surveys and audits. The surveys are used to compare practice and set standards for future care.

ResearchSocial workers in the community team have been taking part in a national research study: ‘Carer Assessment Study’ conducted by research teams from the Universities of Manchester and Cambridge. The study is helping health professionals to make use of a carers needs assessment tool that helps family members looking after a person with a life-limiting illness to identify their own needs.

The director of patient care has been acting as an advisor on a study undertaken by the University of Nottingham on ‘Cascading knowledge about end of life care at home: the development and piloting of a training programme for those who help carers and a carer resource pack’. The hospice education department are hoping to pilot the training programme which has been developed later this year.

“A very profe ssiona l a nd welcome job providing exa ctly the right leve l of ca re”

What our organisation is doing well 6

“ Excellent presentations and summarising of evidence. Good discussions and giving of insight into GPs viewpoint”Participant at GP and Hospital Doctor Study Day

This year has seen further growth in our educational provision with a further increase in participant numbers.

We have also broadened the interest for our courses and attracted more physiotherapists, occupational therapists, social workers and hospital doctors than in previous years

All education is linked to the national end of life core competencies and underpinning principles1, delivered through interactive workshops, study days and more formal programmes. We also work in collaboration with colleagues from other specialist fields so that we can include education about specific diagnoses such as dementia, motor neurone disease, Parkinson’s disease and chronic obstructive pulmonary disease (COPD).

The educational events [124 in total] range from 2 hour Palliative Care Updates, to 5 day taught programmes with 2 day clinical placements with Specialist Palliative Care Teams [Enhancing Palliative Care Skills]

Our courses, study days and workshops have evaluated well:

• Level of interest/stimulation: average score of 4.5 [1 – poor/uninteresting; 5 – very good/stimulating].

• Participants also reported significant increases in their confidence levels as a result of attending sessions across all End of Life Care competencies1 and about different diagnoses.

In addition to the formal courses provided, many healthcare staff and students access education placements with the hospice Multi Disciplinary Teams.

Education 2013 / 2014

1 National End of Life care Programme (2009) – Common core competences

and principles for health and social care workers working with adults at the end

of life. Available at http://www.nhsiq.nhs.uk/resource-search/publications/

eolc-competences.aspx

Care Home Proprietor/ Manager 35 2%

Other 27 2%

Educators 14 1%

Paramedic 1 0%

Doctor (GP, Hospital, Devon Doctors) 72 4%

Skilled non-registered 632 36%

Administration (e.g. coordinators of electronic EoL register)

33 2%

Volunteers 123 7%

Physiotherapists 27 2%

Occupational therapists 51 3%

Registered Nurse 666 39%

Dietitian 7 0%

Speech Therapists 1 0%

Social Workers 25 1%

Therapists (e.g. complimentary, art, music) 18 1%

“ I do think that this has been invaluable in my line of work”Participant at Diagnosing and Discussing Dying workshop

Designation of delegates at Rowcroft Education 2013/14

Annual participant numbers

2009/10 2010/11 2011/12 2012/13 2013/14

1000

1800

200

400

600

800

1200

1400

1600 1747

1465

12351118

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Statutory Information 7

Statutory information and some facts and figuresThis section includes statutory statements about how Rowcroft Hospice is regulated and also describes where we believe we can make further improvements in the quality of care we provide.

Rowcroft Hospice is required to register with the Care Quality Commission and is currently registered (2010) under the following categories: treatment of disease, disorder or injury; diagnostic and screening procedures; transport services, triage and medical advice provided remotely and ‘personal care’ for our enhanced Hospice at Home service.

Rowcroft Hospice has the following conditions on registration:

• The establishment may provide overnight beds for a maximum of 19 patients at any one time. We are currently equipped to care for a maximum of 17 inpatients.

• The establishment may not treat patients under the age of 18 years.

• The prior written approval of the Care Quality Commission must be obtained at least one month prior to providing any treatment or service not detailed in the statement of purpose.

Rowcroft Hospice is subject to periodic review by the Care Quality Commission (CQC). The last inspection was in November 2013 as detailed in part one.

Rowcroft Hospice provides the following services:

• 17 bedded inpatient unit.

• Community specialist palliative care service.

• 24/7 Hospice at Home service.

• Outpatient services.

• Chronic Oedema service.

• Bereavement service.

• Education and training for health and social care staff, volunteers and carers, in palliative and end of life care.

Numbers of patients receiving care in 2013/2014• The Inpatient Unit admitted 317 patients.

• The Community Team received 1106 referrals, 887 being new patients to the service.

• Rowcroft Hospice at Home had 376 patients referred, nursing people mainly in their own home or care home in the last weeks of life.

• The Bereavement Service provided support to 181 bereaved people.

• Outpatient Centre — 225 patients were seen by various services, a majority for multiple visits.

These figures are taken from the Minimum Data Set supplied annually to the National Council for Palliative Care and do not include patients with Chronic Oedema, who also receive care from our service, an average 160 outpatient appointments per month.

“ When the ‘tea m’ ca me, the a nxiety was lifted a nd we had re spite from a physica lly tiri ng a nd emotiona lly dra in ing situ ation.”

How we have performed against last year 8

How we have performed against last year’s priorities for improvementIn the Quality Account for 2012/2013, we set out our priorities for 2013/2014 and the following is a report of what actions have been taken to achieve our aims.

Patient safetyMedicines Management — A task and finish group have examined all drug incidents and established training needs for current and new staff. Minor changes have been made to prescription of medicines outside normal drug rounds and to documentation.

Initial results from the audit of pressure ulcer documentation and care planning showed an encouraging correlation between education delivered and standards being met. This audit will therefore be repeated during 2014/2015.

Audit of inpatient falls. As the data collection for this audit was completed at the end of 2013/2014, the results and recommendations will be carried forward.

Getting staffing rightWe identified the need for additional Occupational Therapy and Physiotherapy hours. We have appointed to these hours and are now fully staffed in these disciplines.

A further Specialist Practitioner in Education has been appointed.

A Speciality Doctor has been appointed to provide additional medical cover for the Community Team

Clinical effectiveness — measuring impactA new nursing model has been piloted and implemented. Measurement of patient and staff satisfaction subsequent to this is ongoing.

Non Medical Prescribing. The first Clinical Nurse Specialist has recently completed the training. Governance procedures are in place to support this practice.

Patient, family, friends and staff experienceAn independently facilitated Hospice User Advisory Group has been established and is now meeting regularly.

Following a successful bid for department of health funding, the garden area to the Inpatient Unit has undergone significant transformation, making it more attractive and accessible to bed bound patients and wheelchair users.

OutpatientsAn Outpatient Strategy has been written and will continue to be reviewed.

Additional signage has been placed to assist new patients to find the Outpatient building.

SMS text reminders for Outpatients. We will implement the reminder service on 1st July, once appropriate policies are in place to ensure compliance with data protection and patient consent.

9Our priorities for 2014 / 2015

Where we feel we can improve and our priorities for 2014/2015

Priority for 2014/2015

• To agree a core set of workable competencies for all staff.

• To agree a set of discipline specific workable competencies or where these do not currently exist, to agree a mechanism for developing these as part of a planned programme.

Outcome Measure

• Set of workable competencies documented and agreed by 31/3/15.

Patient safety — delivering careWe consider that we deliver excellent care, but need to have robust measures for evidencing that this is the case. We are currently in the process of defining the knowledge, skills and attitudes (competencies) required for all roles within our service so staff can be further supported in their professional development. We have explored the evidence base and the competencies defined in other Specialist Palliative Care services.

Priority for 2014/2015

• Patient feedback system to commence 1/4/14.

Outcome Measure

• Every patient / carer offered opportunity to feed back (audited).

• Full year benchmarked feedback available.

Patient family and friends experienceFor the past two years, we have gained valuable periodic feedback from users of our services supported by Picker Institute Europe. However, we would like to give all patients and carers at least one opportunity to feed back on the care received from our services. We have identified a system (iWantGreatCare) that seems to meet our needs. Patients and carers can complete a simple card or feed back their views online. We can benchmark our feedback with 7 other hospices in the south west region.

“ The kindness shown was wonderfu l a nd the he lp we rece ived made things ea sier a nd ena bled u s to be ca lm.”

“ Ou r fa mily was so lu cky to ga in a ccess to Rowcroft a nd you r su perb tea m.”

10Our priorities for 2014 / 2015

Wi-fi provision in the Inpatient UnitDue to the layout of our Inpatient Unit, we have experienced problems with the Wi-fi provision on the unit. This was installed to enable patients to use their own laptops /tablets or make use of the two iPads available to patients.

Priority for 2014/2015

• Diagnose and fix the problem with the Wi-fi provision. As the router is in a patient area, it is proposed to carry out this work during the annual summer ward maintenance programme.

Outcome Measure

• Wi-fi available to patients and relatives following ward maintenance programme.

Priority for 2014/2015

• Evaluation completed, needs identified and options evaluated.

Outcome Measure

• Plan written and agreed.

Rowcroft Hospice at HomeRowcroft Hospice at Home has evolved and grown over the two years since the enhanced service was launched in Dec 2011, and many more people have been offered an increased level of care in the place of their choice. Over the coming year, we will re-evaluate the service to determine what further developments are needed and achievable.

Priority for 2014/2015

• Refurbishment plans agreed and work undertaken.

Outcome Measure

• Work progressed and completed or near completion by the end of March 2015.

Chapel areaIt is felt that our Chapel requires refurbishment to make this a brighter spiritual / quiet space for patients and families of all faiths or none. Funds have been set aside for this project.

“ Words ca nnot express the difference the Rowcroft Hospice at Home tea m made to u s. I ca nnot tha nk them enough”

“ It was so rea ssu ri ng to have the tea m not only visit him, but a lso me. Having a phone nu mber to ri ng day or night made su ch a difference.”

“ We were equ a lly embra ced by the staff, whose wa rmth a nd hu manity made it a very specia l pla ce to be”

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Chairman of the Board of Trustees statementThe Board of Trustees is pleased with the progress made in the last year and remains committed to developing services in line with the needs of our patients and their families and friends.

To this end, we are introducing a new patient feedback system this year and every patient and carer will be offered the opportunity to tell us what they think of our services and, importantly, how they feel improvements could be made.

We have invested in increased Occupational Therapy and Physiotherapy provision for patients in the Community and plan further development of our Hospice at Home Service. This investment in Community based services is being made with a view to offering real choices about where people wish to be cared for. For many, this will be well beyond the physical walls of our Inpatient Unit. Rowcroft Hospice is a service, not a building.

As Chairman of the Board of Trustees, I endorse this report. The Board will continue to support the Executive Team and the Staff of Rowcroft Hospice in achieving the key priorities for 2014/2015.

Mrs Sue Newman Chairman, Board of Trustees

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AnnexNHS South Devon and Torbay Clinical Commissioning Group statement:

Quality Accounts 2013-14

South Devon & Torbay Clinical Commissioning Group (SD&T CCG), as the lead NHS commissioner for Rowcroft, is pleased to provide our commentary on this Quality Account for 2013-14. SD&T CCG has taken reasonable steps to corroborate the accuracy of the data provided within this Quality Account and considers it contains accurate information in relation to the services provided.

We have reviewed and can confirm that the information presented in the Quality Account appears to be accurate and fairly interpreted, from the data collected regarding the services provided.

SD&T CCG see Rowcroft as a key partner in the delivery of integrated end of life care, and we value the excellent open and regular communication we have with them. For 2013 onwards, we have agreed a unique, three-year rolling contract (reviewed annually) as a clear commitment to working together.

Looking Back:

Rowcroft Hospice committed last year to prioritising eleven key areas relating to patient safety, clinical effectiveness and enhancing patient and their families’ experiences of their hospice services. As commissioners we monitored these improvements through the contract review meetings we held with Rowcroft.

Through the year we have seen evidence of this commitment and we recognise that Rowcroft continues to benchmark quality requirements against other SW hospices, and will be comparing quality performance with hospices nationally from April 2014.

We are pleased to note that Rowcroft undertook an audit of medication during the year. We are pleased to see that they have focused on improving systems and training in relation to medicines management.

The CCG is pleased to see the additional staffing that has been provided, with the appointment of a further Specialist Practitioner in Education, and a Specialty Doctor for the Community Team. The changes to the nursing team, with the introduction of non-medical prescribing, and a new nursing model, along with the implementation of the Outpatient Strategy, should bring real benefits to patients, families and carers, and we look forward to seeing the results of the on-going measurement of patient and staff satisfaction. SD&T CCG were also pleased to see the positive CQC report demonstrating that Rowcroft was compliant with the domains that were inspected.

Looking Forward

The CCG is happy to support the quality improvement priorities chosen for next year as set out in the Quality Account. We are pleased to note the continued focus on patient safety and improved experience.

We look forward to the implementation of the patient feedback system and will take an interest in the feedback received, trends identified and what Rowcroft will do in response to this information.

We acknowledge the important role of the Hospice at Home service and look forward to working with Rowcroft to further develop this service.

General Comments

Quality Accounts are intended to help the general public understand how their local health services are performing and with that in mind they should be written in plain English. Rowcroft have produced a comprehensive, attractive and well written Quality Account which is easy to read and clearly set out.

Overall we are happy to commend this Quality Account and Rowcroft for its continuous focus on quality of care.

NHS South Devon and Torbay Clinical Commissioning Group

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AnnexThe Torbay Carers Forum statement:These Quality Accounts demonstrate the difference that Rowcroft has made to people’s lives. They describe well your strong commitment to your objectives, and Carers across Torbay recognise your compassion and care.

Torbay Carers Forum appreciates the fine work being done by Rowcroft Hospice to support Carers and those they care for.

Accordingly, the Forum would like to thank the staff, volunteers and management of Rowcroft Hospice for their work with Carers, and those they care for, in our three towns. We, consequently, take pleasure in endorsing these Quality Accounts.