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St Christopher’s Group

Quality Account 2011-12

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St Christopher’s Group Quality Account 2011-12

Part 1

Statement on quality from Barbara Monroe, Chief Executive St Christopher’s and Harris HospisCare set out to provide the best possible care for people with life-limiting illnesses and those close to them, and all our staff and volunteers participate in this endeavour. Our mission is to promote and provide skilled and compassionate palliative care of the highest quality and we have a national and international reputation for providing care, delivering teaching and engaging in research. We are committed to finding ways continuously of improving our services to patients and families and we have a robust clinical governance framework that enables us to do this. We have delivered a wide range of courses to increasing numbers of generalist and specialist health and social care professionals. In particular we have this year delivered 11 courses for a Department of Health funded social care pilot, resulting in ongoing contracts to train social care staff in the boroughs of Southwark, Lewisham and Bromley. We are in the process of running a ‘Training the Trainers’ course in partnership with Help the Hospices and the Department of Health to achieve a national roll out of our successfully evaluated programme for acute trusts, ‘Quality End of Life Care for All’ (QELCA) to improve end of life care in this setting. Eighteen acute trusts and 21 hospices are involved. Our care home programme has now supported 160 nursing homes with an ongoing improvement in care home deaths, and two thirds of these homes have the Gold Standard Framework accreditation. We are delighted to have launched an evaluation into the application of Namaste, a scheme of intensive sensory stimulation for older people with advanced dementia, which builds on our previous research on dementia. We are delighted to have been successful in our bid to lead one of the 6 pilot projects set up nationally by the Department of Health to collect detailed and complex activity data with the ultimate aim of creating a per patient tariff for end of life care following the Palliative Care Funding Review that was published in July 2011. In this, our second Quality Account, we identify our priorities for quality improvement for 1012-3, and review our performance against the quality indicators we selected last year. I and my team of senior managers have been closely involved in this review and in developing these measures, which have been endorsed by the Board of Trustees. I am able to confirm that the information in this Quality Account is, to the best of my knowledge, accurate.

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Part 2

Priorities for improvement We have identified four areas for improvement in the coming year, under each of the domains of quality set out in the Department of Health Report High Quality Care for All: patient safety, clinical effectiveness and patient experience.

1. Patient safety i) In response to a National Patient Safety Alert we are in the process of changing the syringe drivers we use from Graseby to McKinley T34. All relevant staff on the inpatient unit and in the community teams have been trained in their use. What are we aiming to achieve? We will ensure that this transition takes place smoothly without compromising patient safety. How will we know what we have achieved? We will monitor medication incidents and compare the rate of errors relating to the use of syringe drivers in 2010-11 with that in the current year, and undertake an analysis of any such errors to ensure that avoidable errors are prevented. ii) St Christopher’s is an NHS business partner and therefore is required to meet the NHS Information Governance toolkit requirements. We want to ensure that all our clinical staff are fully aware of their responsibilities in relation to information governance. What are we aiming to achieve? We plan in the course of 2011-2 to ensure that all clinical staff have completed and passed the NHS Connecting for Health IG Training Toolkit. How will we know whether this has been achieved? We will monitor the number of staff who have completed and passed the module and compare this figure with the total number of clinical staff.

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2. Clinical effectiveness We now have data in relation to more than 1000 completed SKIPP patient- reported outcome measures and are able to show how results over time have remained broadly constant (see Part 3). We want to undertake a more detailed analysis of these data. What are we aiming to achieve? During 2012-13 we will commission a statistician to help us find out, for example, which symptoms patients say we improve and what relationship there is, if any, between the existence of the different symptoms and patients’ assessment of their quality of life. How will we know whether we have achieved this? We will report on the results of the analysis which we expect will enable us to concentrate our care on the issues that matter most to patients.

3. Patient experience What are we aiming to achieve? During 2012-13 we will set up an effective nutrition group that will ensure that: - nutritional screening takes place on admission - a wider range of high-calorie meal supplements for suitable patients is on offer - we review the timing and process of meal ordering and availability of food outside set meal times How will we know whether we have achieved this? We will undertake an audit of patient notes to ascertain that screening is taking place, and survey inpatients about the range and acceptability of food on the menu

We will review progress in relation to each of these 3 priority areas at Board meetings twice a year.

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Review of indicators for 2011-2

Patient safety Last year we said that we would test out our major incident plan, purchase ski pads for the evacuation of non-ambulant patients, and train staff in their use. What we did: We undertook a table top exercise of an emergency scenario with representatives from every Hospice department. This enabled us to see where we needed to modify our major incident plan. We have written a fire evacuation policy with advice from the Fire Service and our health and safety consultant. We have purchased ski pads for non- ambulant patients and staff have been trained to use them as part of their manual handling training. We plan to undertake a further drill of the emergency incident plan during 2012-3.

Clinical effectiveness Last year we said that we would develop a programme of workshops to support nurse managers make use of the nursing competency tools that we had developed in 2009-10. What we did: In 2011-12 we ran 4 workshops and assessed the quality of appraisals and sought feedback from nurses and their managers. As a result we have developed a targeted approach to the use of the competency document which we are implementing this year.

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Patient experience Last year we said we would organise a national conference to disseminate information about the two new tools we began using in 2010-11 to measure patient experience of care: SKIPP, a patient-generated outcome measure VOICES-SCH, a validated survey used to measure the quality of care from the point of view of bereaved carers. We said we would aim to achieve the same high standards we reached in the first 6 months of results. What we did: We organised a conference that attracted 32 delegates from all over the country and invited representatives from hospices and palliative care units using SKIPP to talk about their experiences of implementation. As a result, several more organisations have started using SKIPP and VOICES-SCH- this means that we will soon be in a position to compare the results we are getting with those of others. We have maintained the good results we achieved in the first 6 months of use of SKIPP and VOICES-SCH. Further details are available in Part 3- Review of quality performance. We also said: We would evaluate our ‘Community Support Volunteers’ pilot which involves recruiting, training and placing carefully selected volunteers with patients who have been discharged from our services, or who would benefit from some additional support. These volunteers are available to spend up to three hours a week with patients, befriending them, and offering practical help with straightforward tasks at home or accompanying them to appointments. They work closely with the patient’s home care nurse. What we did: We obtained feedback from patients and volunteers involved in the pilot. Several themes emerged from what patients told us. Patients very much appreciated the time the volunteers spent with them. One said ‘Nobody else just sits with me’; another commented ‘I have not felt listened to before’. Some patients who were wary of healthcare professionals felt it was easier to accept help from a volunteer. Volunteers were surprised to find that ‘just being’ with patients could be so rewarding for both parties. They sometimes found it hard to strike a balance between friendship and contact as volunteers, and many found it hard to come to terms with the death of a person they had come to know well.

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We are ensuring that volunteers receive regular supervision and support and have recruited to a new post of volunteer officer to coordinate this work. We are also continuing to recruit volunteers to this project which is providing added value to a new social care pilot we are delivering in Croydon Borough to frail elderly people in their last year of life.

Participation in clinical audits

As an independent hospice, St Christopher’s does not participate in the national NHS clinical audit programme that covers subjects that do not apply at the hospice. However, we regularly undertake audits which we select according to network, local or internal priorities. Audits and evaluations we have carried out in 2011-2: Subject matter Implication for practice/outcomes of

audit Follow-up actions

Review of admissions –October 2011-March 2012

In this period 79% of admissions met the target we have set ourselves. We have made this target more demanding as we are now admitting patients categorized as emergency and urgent admissions 24 hours a day.

Continue to monitor

Delayed discharges

This audit was undertaken in order to establish the reasons for delays in discharging patients from the inpatient unit. It found that discharges are delayed mainly by circumstances outside the control of the Hospice (such as the fluctuating condition of the patient or delays in equipment being installed in the home)

No action required by the Hospice

Out of hours calls

This audit resulted in refresher teaching sessions being delivered to home care nurses undertaking out of hours duties

No further action required

Blood/urine monitoring charts on the inpatient unit

Routine blood sugar monitoring on admission of known diabetics and people on steriods has now been halted. Where possible urine rather than blood monitoring of people on steroids is being undertaken.

Review guidance and reaudit practice in 2012-3 Teaching session delivered to nurses ad doctors (Feb/May 2012)

Meeting with Diabetologist planned for June 2012. St Christopher’s Consultant is one of

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palliative care representatives at Parliamentary Launch of the Older People's Diabetes Network, 18 June 2012 at the House of Commons

Audit of anti-convulsant medication

Most prescribing not done by Hospice. Guidelines written for use by staff in acute sector

Liaison with Acute Trust.

Asepsis This nursing audit showed that staff were following good practice guidelines.

Audit annually to ensure good practice is maintained

Audit of compliance with regulations pertaining to controlled drugs

Overall practice was found to be good although some improvements in the way in which nurses were making entries on the Controlled Drug Register were recommended

Re-audit in 12 months to ensure good practice is maintained

Cleaning audits A high standard of cleanliness was found in all clinical areas

New handwash sinks to be installed in 2012-3 to meet infection control requirements; sluice doors to be installed

Audit of patient falls

Evidenced that falls risk assessments were taking place and that staff were using a range of strategies for preventing falls in patients who were assessed as being at high risk of doing so

Audit of care home deaths

The project team working in collaboration with local care homes is undertaking a long-term programme to reduce the number of inappropriate deaths in hospital of care home residents. To date there has been a 20% rise in care home

deaths and subsequent reduction in inappropriate hospital deaths between 2008 and 2011

Continue to audit

Pressure sore audit

One hundred and thirty eight patients had a pressure sore on admission to the hospice between October 2011 and March 2012. Only 4 pressure sores deteriorated to levels 3 or above while under the Hospice’s care. In each of these cases, the patient’s skin had been assessed regularly and treated correctly, and the exacerbation of the wound was the result of the deterioration of the patient’s condition.

Continue to audit.

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Participation in clinical research St Christopher’s has been involved in conducting six clinical research studies, either alone or in partnership with university departments. All studies received appropriate research ethics approval. Our earlier work with the Maudsley Hospital is the largest study of depression in palliative care population and has given rise to seven peer-reviewed publications to date, with more to follow. This year has seen the publication of two books that are the first in their field: a textbook on the palliative care of patients with dementia was edited by two members of our staff, and a textbook on the use interventional pain techniques in cancer pain was edited by one of our staff in association with colleagues from King’s College Hospital. Both books were published by Oxford University Press.

Goals agreed with commissioners Use of the CQUIN framework A proportion of St Christopher’s income during 2010-11 was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework. Each of these was achieved as follows:

CQUIN1: To improve internal communications at St Christopher’s and between the Hospice and PCTs in relation to continuing care funding for patients. Achieved. CQUIN2: To undertake an audit of pressure sores of grade 3 and above that develop in patients under the care of the hospice. Achieved. (See audit section above) CQUIN3: To record the volume and nature of bereavement support activity delivered to bereaved carers. Achieved.

What others say about St Christopher’s St Christopher’s is registered with the Care Quality Commission (CQC) and is registered to provide the following regulated activities: o Treatment of disease, disorder or injury (St Christopher’s and Harris

sites) o Personal care (St Christopher’s site) o Diagnostic and screening procedures (St Christopher’s and Harris

sites) o Transport services, triage and medical advice provided remotely (St

Christopher’s and Harris sites)

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The CQC has not taken enforcement action against St Christopher’s during 2011-12. St Christopher’s is subject to periodic reviews by the Care Quality Commission, the last of which was on 14th February 2012. The CQC’s assessment of St Christopher’s following that review is awaited. (The previous review in 2009 showed that all the standards inspected had been met). St Christopher’s has not participated in any special reviews or investigations by the CQC during the reporting period. Data quality St Christopher’s is not required to submit records to the Secondary Uses service for inclusion in the Hospital Episode Statistics. In accordance with the Department of Health, it submits a National Minimum Dataset (MDS) to the National Council for Palliative Care. The Hospice undertakes regular quality assurance checks of its data. We have monthly meetings of representative users of our electronic patient record system as a result of which any integrity issues are identified and corrected. In addition we regularly quality assure the data provided to PCTs (patient demographics, inpatient, day care and home care activity summaries, place of death etc) Information Governance Toolkit attainment levels St Christopher’s is an NHS business partner and therefore is required to meet 29 of the Information Governance toolkit requirements. We have met all the IG requirements for 2011-12. Clinical coding error rate St Christopher’s was not subject to the Payment by Results clinical coding audit during 2011-2 by the Audit Commission.

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Part 3

Review of quality performance We review all our services regularly and our clinical governance scorecard is one of the ways in which we keep track of trends in relation to quality and patient safety (See page 12 for the scorecard covering the 6-month period to March 2012). This is evidence of the way in which we track critical areas of care. It also highlights that we have low rates of complaints, infection rates on our inpatient unit, and medication errors. We assess each patient on admission to the inpatient unit in order to put measures in place to reduce the likelihood of a fall while allowing them the freedom to move around as they wish. Our falls rate in the inpatient unit is 0.015 falls per occupied bed per 6 months, which is very similar to that of other hospices and palliative care units. Our audit programme reviews the effectiveness of our clinical care as does feedback from patients and carers. The result of the 12 months to October 2011 of the SKIPP patient outcomes measure shows that of patients surveyed within 3 days of admission to the inpatient unit 35% (n= 84) said that that in relation to the problem that was of greatest concern to them ‘things had got much better’; 41% (n=100) said that ‘things had got a little better’ and 12% (n=30) that there had been ‘no change’ since their admission. The hospice had made a ‘great’ or a ‘very great difference to how things are going at present’ to 55% of those surveyed. In home care, 30% of patients surveyed within a month or so of initial contact said that in relation to the problem that was of greatest concern to them ‘things had got much better’ (n=80) since the nurse started visiting them; 42% said that ‘things had got a little better’ (n=113) and 16% (n=42) that there had been ‘no change’. The home care team had made a ‘great’ or a ‘very great difference to how things are going at present’ to 62% of those surveyed.

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St Christopher’s and Harris HospisCare Summary clinical governance overview ( Oct 2011- March 2012)

Written complaints Number received: 6 - number upheld: 2 -number partly upheld: 1 - unsubstantiated : 3 Written complaints by 6-month period

April-September 2011

Oct 2011-March 2012

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Oral complaints n= 3 (one upheld) Wider actions taken by the hospice following complaints during this period. - Training for home care staff and night coordinators on responding to out of hours situations in the community. - Written information to be developed for relatives planning a funeral without a funeral director. SKIPP - in relation to their most pressing concern IPU: Things have got much better since admission = 28% (n=167) HC: Things have got much better since the nurse started visiting = 37% (n=119) VOICES-SCH 90% of carers (n= 120) thought that the patient had received exceptional or excellent care from the ward nurses 82% of carers (n =196) said that the care the patient received from the SCH/HH home care team was exceptional or excellent

Incidents: April-

Sept

2011

Oct

11-

Mar

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Total clinical incidents: 127 126

Total non-clinical incidents: 32 47

Total medical device incidents: 3 1

Total fire-related incidents: 2 4

Total security incidents: 5 -

Total information security incidents - 4

Total medicine- related incidents 66 59

Total violence /aggression incidents: 3 6

Total n of RIDDOR reports: 2 6

Completed actions arising from incidents, alerts and risk

assessments, and after event reviews

- New patient property forms have been printed and staff reminded to record all valuables and sign disclaimer forms.

- EPR procedures have been changed to ensure home care teams are advised when a patient is discharged from IPU

- We are using bags to transport oxygen cylinders securely in our ambulances

- Diarrhoeal management and outbreak policies amended to reflect advice from HPA.

Alerts

Total alerts from CAS

15

CAS alerts on which action required and taken

0

Total MHRA drug alerts

25

n. MHRA alerts on which action required and taken

4

Infection control n patients during period who developed C Diff/ MRSA while on IPU*:

C Diff 0 MRSA bacteraemia

0

* = patients admitted with

unknown infection status who

develop symptoms 3 days or more

after admission.

During this period, we had an outbreak of Norovirus, with 2 positive samples out of 11.

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Feedback from patients and carers Feedback from patients and carers is one of the most important ways in which St Christopher’s and Harris HospisCare measures the quality of the care they give. We receive many compliments and positive comments from patients and families. Here is a selection from the most recent survey of bereaved carers:

I have received helpful support from a bereavement counsellor for which I am extremely grateful. She is an enormous help to me at this time and I appreciate her visits. (Bereaved husband)

We found the team exceptional. It was reassuring to know that they were in touch with the hospital and District Nurses and out GP. If ever we were in need of help they were who we turned to. And they always came up trumps. Well done. (Family of patient)

“Coming here helped me to discover

who I am. I am not treated like a

cancer patient but as a person, this

care extends to my home. Although

I’ve got cancer and I know I’m going to

die soon, they are not focusing on the

dying but on what matters to me. St

Christopher’s has the art of helping

you find yourself without realising

you’re doing it.” (Patient)

I can't begin to deserve the feelings of relief I experienced when he was transferred from hospital to the hospice. Just knowing he was getting exceptional care in the last days of his life, made such a difference to all the family. I could actually sleep at night. (Wife of patient)

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The inpatient care that my mother received was amazing. The Ward Sister, nurses, doctors, auxilliary staff were all exceptional! They were so caring and nothing was too much trouble for them. The help and support that I have received from the social worker has been tremendous. Thank you! Thank you! Thank you! (Wife of patient)

All the home care team were exceptionally professional and caring. A credit to care services. The care my husband received from the home care team and the hospice staff was always excellent, which is a rare statement today. Support was/is given not only to the patient but to the family as a whole. We cannot thank them enough. Always my husband wanted to die at home; it was not practical towards the end. I couldn't have given him the same excellent care the hospice staff gave. He had immediate care when symptoms were treated as they arose. He couldn't have had that at home. Therefore his death was more comfortable and dignified. (Wife of patient)

The home care team were fantastic. As soon as they became involved I felt a weight of responsibility lift off my shoulders. To have people to discuss things with, and who helped my father, who was able to trust the nurses. That brought him a measure of comfort. To know that his wish to stay at home would be respected meant that we could stop worrying about it. Thank you. (Daughter of patient)

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Statements from external bodies

Bromley LINks comments on St Christopher’s Group Quality Account 2011/2012

Bromley LINk welcomes the opportunity to comment on St Christopher’s Quality Account. We think the Quality Account for 2011/2012 gives a true representation of the quality of the services offered by St Christopher’s. We are very fortunate in Bromley to have a hospice group that is at the forefront of development and provision of high quality end of life services. Bromley LINk appreciates the willingness of St Christopher’s Hospice to involve the LINk in the services for end of life care and look forward to developing a good working relationship over the coming year before the LINk evolves into HealthWatch.

Bromley PCT comments on St Christopher’s Group Quality Account 2011/2012

The PCT follows the national Quality and Innovation framework (CQUIN), which enables commissioners to reward excellence, by linking a proportion of provider’s income to the achievement of local quality improvement goals. This allows on-going commissioner and provider discussions to create a culture of continuous quality improvement, agreed on an annual basis. For 2010/11 this included improving communication, audit of pressure sores, and analysis of bereavement support, all key outcomes for both the hospice and the PCT. The PCT welcomes the fact that having a world leading organization in close proximity, has helped improve the awareness of End of Life care issues in Bromley, particularly amongst health and social care practitioners. This has led to all GP practices using a nationally accredited care pathway for their palliative and End of Life patients, and crucially care homes are also

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engaged. In fact, with the help of the hospice, the PCT has been able to develop care homes to become beacon sites for End of Life Care.

Opportunities to give feedback on this quality account

We welcome feedback on this quality account. If you would like to do this, please email b.monroe@stchristophers.org.uk or write to: Dame Barbara Monroe Chief Executive St Christopher’s Hospice 51-59 Lawrie Park Road Sydenham SE26 6DZ