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Wakefield Hospice Quality Account
2013- 2014
“It’s perfect”
Patient to CQC Inspector – Sept 2013
Together with the Board of Trustees, Staff and Volunteers it gives me great pleasure to
present Wakefield Hospice’s Quality Account for the period 2013 – 2014. This is the second
year that we have produced a Quality Account and I hope that it will provide you with a
summary of how the Hospice Team are continually striving to develop and improve the
experience of Hospice care for those who use our services.
We aspire to provide excellence in all that we offer to our patients and their families, however
we appreciate that this cannot be achieved in isolation. It is essential that the Hospice Team
communicates and works in collaboration with other health and social care providers to
achieve the best possible outcomes for patients approaching the end of their life. To this end
we are actively engaging with new commissioning practices, are involved with cross
organisational working groups and are forging ahead with joint projects to ensure that local
people can achieve independence and autonomy when making their end of life care decisions
and be at all times supported by high quality palliative care services.
This year we were very proud to unveil the complete refurbishment of the Hospice Day
Therapy Unit. Our service users are delighted with the new and improved environment, whilst
staff are enthusiastically considering the possibilities of developing new services to maximise
the potential of the reconfigured unit. You will learn more of this as you read our Planning
Priorities for the forthcoming year.
My thanks as ever goes to not only our staff and volunteers who give tirelessly to ensure that
we deliver on our promise to provide outstanding care for patients and their families, but also
to our loyal local supporters who enable us to generate the 70% shortfall in our required
income. This makes the people of Wakefield our major stakeholders and as such our major
responsibility to deliver evidence based, high quality end of life care is directed at them.
This Quality Account is a true reflection of the work that has been undertaken at Wakefield
Hospice during the last twelve months. I am responsible for the production of this report and
to the best of my knowledge the information contained in this Quality Account for 2013 - 14
is an accurate and a fair representation of the healthcare services provided by Wakefield
Karen Crawshaw
Chief Executive Officer
8 May 2014
Wakefield Hospice is fully compliant with the National Minimum Standards (2002) and during
a scheduled regulatory inspection held in September 2013 provided evidence to the Care
Quality Commission that the regulatory standards had been met and as such, the Board do
not have any areas of shortfall to include in the priorities for improvement for 2014 - 2015.
However, we continually review and monitor our services and seek to improve and develop
them. In addition the Hospice has a three year strategic plan which outlines our vision and
plans for the future. The Quality Improvement Priorities identified for the purpose of this
report are encompassed within our strategic plan and as such are subject to continual
monitoring by the Hospice Senior Management Team and The Board of Trustees.
1.1 Clinical Effectiveness - 24/7 Out of Hours Hospice Admissions Project
A twelve month extension of an existing project has been granted to both the Wakefield and
Prince of Wales Hospices to increase the number of 24/7 admissions into their in-patient
units. The original project outline has been revised by the Hospices’ Management Teams and
NHS Wakefield CCG, as a result the project now has a wider scope of application. Crucially
the project will go forward without the participation of the third member of the original
project. Information will be collated to evidence the benefits to patients and their families of
24/7 access into both Hospices’ in-patient units, as well as to assist the CCG in determining if
the project has an effect in reducing the number of inappropriate admissions into acute
hospital beds by patients at the end of life. Wakefield Hospice’s aim continues to be to secure
ongoing substantive funding for this element of the Hospice service.
How was this identified as a priority?
The 12 month extension to the project was given because despite a sound evidence base that
had determined the demand for 24/7 access to hospice in-patient units, the two Hospices did
not manage to achieve the target number of admissions during the initial pilot phase of the
project. This was due to well documented circumstances and issues that arose with the third
partner of the original project which were out of the control of both Hospices.
How will this priority be achieved?
The scope of the original project has been widened to enable access for more patients. This
will now include patients from all Wakefield Hospice’s usual geographical areas of referral
which had previously been limited. Further, patients may now be transferred from acute
hospital settings over weekends and bank holidays, the initial project having precluded such
hospital transfers. Significantly, the local Community Specialist Palliative Care Nurses are
moving towards seven day working which will inevitably increase the demand for more
hospice inpatient admissions outside normal weekday working hours. The third party member
of the original project is no longer party to this extension of the project which has removed
the issues and circumstances that had hampered the progress of the Hospices 24/7 element
of the project.
How will this priority be measured?
The project will continue to provide quantitative and qualitative evidence of the benefits and
cost effectiveness of this service to secure mainstream funding. The two Hospices are
managing the project in-house and have set key performance and quality indicators to ensure
that targets are met, reports and audit of which will be made quarterly to the Hospices’ Boards
of Trustees and monthly to NHS Wakefield CCG. The project will be reviewed in Quarter 3 to
determine if the project has evidenced the need for ongoing future substantive funding.
1.2 Clinical Effectiveness - To Extend the Remit of In-patient and / or Day Services to
Include Increased Provision of Intravenous Medications
At the present time it is not possible to care for patients on the in-patient unit who require
regular intravenous (IV) medications, or to administer these in the context of the Day Therapy
Unit. This is because the Hospice’s qualified nurses are not competently trained to administer
drugs intravenously and would therefore require the costly availability of a doctor over a 24
hour period to administer the injections.
How was this identified as a priority?
Because the Hospice’s qualified nurses do not have access to annual IV competency training,
patients who are waiting for transfer into the Hospice from acute hospital services must
complete their course of intravenous medications before they are transferred into the
Hospice in-patient unit. Similarly patients in the community who require intermittent
intravenous medications such as bisphosphonates could appropriately have these
administered in the Day Therapy Unit which would free up clinic time in the acute Hospital
Trust. Facilitating for patients to have intravenous medications whist an in-patient at the
Hospice could reduce the number of inappropriate hospital admissions or the number of bed
days for palliative care patients and provide a better experience of care.
How will this priority be achieved?
A Hospice IV Administration Project Team will be convened to establish and source the
knowledge and skills training requirements for nursing staff. Essentially this must also include
a means of assessing ongoing clinical competency in IV medication administration. We will
liaise with Mid Yorkshire Hospitals Acute Trust to ascertain whether it is possible for Hospice
nurses to link into the Hospital Trust IV competency training programme for nursing staff. A
Hospice Intravenous Medications Policy will be produced which will be supported by the
Hospice’s existing Medications Administration policy.
How will this priority be measured?
The Project Team will assess the feasibility of implementing this priority and will provide a
report to the Hospital Clinical Governance Committee as well as to the Board of Trustees. If
it is possible, senior Hospice nurses will be trained and assessed
to be competent to administer intravenous medications to patients. Ongoing competency
training will be arranged for the nurses. Patients who require hospice care as well as
intravenous medication will not have to wait until they have completed their course of
intravenous medication before they can be admitted to the Hospice in-patient unit. Records
of IV competency training will be retained and maintained.
1.3 Clinical Effectiveness / Patient Experience - To Review and Extend the Current
Configuration of Day Therapy Services and Implement Changes
Wakefield Hospice Day Therapy Services had an impressive 2732 attendances during the year.
The Unit currently opens on four days of the week, Monday to Thursday. There is an excellent
attendance record and uptake of therapies from Monday through to Wednesday, but
Thursdays are not as well attended. This could be due to the reduced number of available
therapies for service users to access on Thursdays. The Day Therapy Unit has just undergone
an extensive refurbishment which has widened the scope for extending and reconfiguring
services for patients, carers and the bereaved.
How was this priority identified?
The Hospice Team undertook a SWOT (Strengths, Weaknesses, Opportunities and Threats)
and a PESTEL (Political, Environmental, Social, Technology, Environmental and Legal) analysis
of the day service. This confirmed the current general trend in healthcare which is based upon
the premise of care closer to home and avoiding unnecessary admissions into acute hospital
services. The analyses also identified a gap in the statutory provision for timely access to
physiotherapy services for palliative care patients. As a result, we are exploring the possibility
of extending the remit of our current specialist physiotherapist provision to include an
outpatient service which would operate out of the Day Therapy Unit. This service would
provide patients with rapid access to palliative physiotherapy to meet rehabilitation needs,
or re able people to continue with their activities of daily living. Access to specialist
physiotherapy would enable patients to maintain maximum physical functioning and
independence for as long as it is possible and to optimise their quality of life. This may provide
the additional support that palliative care patients require to remain at home for their end of
life care period, thus avoiding an unnecessary hospital admission.
How will this priority be achieved?
We will work with statutory physiotherapy services and local providers of community
palliative care services to scope the need for a specialist physiotherapy service for palliative
patients. We anticipate that the new service would include one to one appointments as well
as group sessions. Dedicated time will be given to the Hospice physiotherapists to plan and
commission the new service. The Hospice will provide specialist physiotherapist staff and a
dedicated rehabilitation unit to trial the project for 12 months.
After which if the project is successful we will have hopefully collated a sound evidence base
upon which to propose a case for the ongoing funding of this service to the CCG.
Consideration could also be given to extend the service to provide a domiciliary specialist
physiotherapy service in the future.
How will this priority be measured?
Evidence will be sought to base a case of need for this service. Further the 12 month project
will demonstrate a better experience of care for patients and their carers. Demographic and
clinical information will be collated in respect of patient characteristics, service activity and
quality outcomes. Cost effectiveness of the service will be provided. The project will be
overseen by the clinical members of the Hospice Senior Management Team and reports will
be made available to the Board of Trustees and to the Hospice Clinical Governance
1.4 Patient Safety & Clinical Effectiveness - Reduction in the Level of Staff Sickness and
The Hospice requires £4.2 million to remain operational in the forthcoming financial year. We
receive 30% of this sum (£1.2million – this includes restricted funding received for two
projects in addition to the main grant) from statutory funds and must fundraise for the
remaining 70%. The largest area of expense is attributable to staff salaries at a cost of £3.2
million (equating to 76% of total expenditure). Given that there is no flexibility within the
budget, there is concern that unpredicted costs incurred through high staff sickness and
absence is becoming financially unsustainable.
How was this priority identified?
Over the last few years we have experienced increasing costs associated with staff sickness
and absence. We have benchmarked the Hospice figures for sickness and absence against
those of NHS staff and were surprised to find that the percentage sick time is comparative.
We had expected that as the Hospice generally offers better working conditions and available
support than is available in the NHS, the Hospice staff sickness and absence costs percentage
should be less. We are therefore committing to reduce the Hospice level of staff sickness and
absence in the next 12 months.
How will this priority be achieved?
The Senior Management Team have utilised and explored different tools for managing
sickness and absence over the years and have concluded that despite some criticism of its
application, introducing the Bradford Factor of monitoring and dealing with staff sickness and
absence would offer a workable solution to managing short term sickness and absence. An
external company has been sought to deliver a training programme which will inform
managers and staff why this system is to be implemented and
to instruct managers in its use. A staff group will be convened to cascade the implementation
of the Bradford Factor into departmental use. The Hospice has also agreed to take part in a
benchmarking exercise with other Yorkshire Hospices to establish whether or not Wakefield
Hospice has a higher than average level of sickness and absence or not.
How will this priority be monitored?
Monthly monitoring and stringent management of sickness and absence in accordance with
the current Hospice Sickness and Absence Policy will be introduced. Monthly costs and
percentage sick time will be collated and shared with staff. Monthly statistics will be shared
with the hospice that is collating the shared data for the Yorkshire Hospices Sickness and
Absence benchmarking project. The training for staff to be able to competently use the
Bradford Factor System will take place and the system will be introduced. Quarterly reports
will be shared with the Board of Trustees.
"The staff are very good. They treat me very well and always sort things out
for me.
"Service User Quote September 2013
1.5 Planning Priority 1
24/7 Rapid Response Team and Out of Hours Hospice Admissions Project
To continue to develop 24/7 admissions to the in-patient unit, collating the information
required within the scope of the project outline; to work collegiately to support the
development of the Marie Curie Out of Hours Rapid Response Nurse Team within the district;
to meet the outcomes of the project with the aim of securing
ongoing substantive funding for the service.
This objective was achieved in part and remains ongoing with an amended project remit. (See
1). It was unfortunate that due to some internal factors as well as external obstacles
the Marie Curie Rapid Response Team element of the project failed to deliver its expected
outcomes. This failure had a direct impact on the Hospices’ 24/7 element of the project
which resulted in fewer out of hours admissions into both Hospices than was expected.
Despite this, the project was able to demonstrate the value of out of hours admissions into
the Hospices for patients, their families and carers. As a result the CCG and the Hospices have
revised the remit and scope of the original project and funding has been provided for a further
12 month period of time in which to evidence the need for the service.
1.6 Planning Priority 2
Education Post
To develop and recruit a dedicated Hospice Palliative Care Educator to provide end of life care
education and training programmes for Hospice staff and volunteers and the wider health and
social care community; to income generate from the programmes as is appropriate.
Achieved and ongoing;
This post was advertised twice during the year before a successful candidate was recruited.
The post holder will take up the position in May 2014 and will undertake a training needs
analysis of the Hospice staff and will develop in service education and training programmes
as determined by the outcomes. The new post holder will also work with the Wakefield and
Mid Yorkshire Palliative Care Education Forum and take forward initiatives to develop a
Hospice programme of end of life care training and education for the benefit of the locality.
“it’s the knowledge that she received such exemplary care that allows me to
begin to cope with her passing”
Patient’s Husband 2013
1.7 Planning Priority 3
Extend Mechanisms of Patient Feedback
The Hospice will develop a more robust Patient / Carer Service User Group and widen the
scope of available mechanisms of achieving patient feedback.
The Hospice Service User Group has become much more
established during the last year. During this time Group Members have been co-opted onto
several of the Hospice’s operational committees and have assisted with patients and carer
satisfaction audits including Wakefield Hospice Report on the Patient Led Assessment of the
Care Environment (PLACE) 2013. The Group has reviewed patient literature including the
Medicines Advice leaflet which is given to patients and carers upon discharge home from the
in-patient unit. They have worked with the Hospice’s Web Site developer to include a page
about the role of the Service User Group which invites feedback on the care and services that
are provided by the Hospice and encourages new service users to join the Group.
1.8 Planning Priority 4
Infection Control
Good infection control is an essential requirement in terms of providing good palliative care,
maintaining registration with the Care Quality Commission and patient confidence.
Achieved. Spot checks have been undertaken using the Kairos system. This is a device
preloaded with hospice specific audits which has been in use during the year to assess,
monitor progress and to benchmark against other Hospices. We have been able to
demonstrate a continuing improvement in the consistency of infection control standards.
Further to this the Bare Below the Elbows and Hand Washing audits are undertaken monthly
and are regularly achieving 100% compliance.
1.9 Planning Priority 5
Refurbishment and small building extension for the Day Therapy Unit
Funding from a non-recurrent capital grant has been made by the Department of Health to
enable the existing facility to be completely reconfigured by removing dividing walls and
building a small extension. This will provide a new relaxation room and create physiotherapy
and complementary suites. The reconfiguration of the area will create a quiet communal
space as well as a dedicated arts and craft area.
Achieved; the Day Therapy Unit refurbishment and building project was completed on time
and in budget, it was re-opened to service users in January 2014. Service Users are hugely
enthusiastic and report positively about the new unit. The reconfigured unit has provided
much more workable space and has already enabled the development of new services with
the appointment of a Music Therapist, whilst a specialist physiotherapy outpatient service is
currently under consideration.
“ It was a hard decision placing our dad in the Hospice but we now have the
comfort that it was the right decision, a huge heartfelt thank you, not only for
caring for him, but for supporting our family”
Patient’s family 2014
Statements of Assurance from the Board
The following are a series of mandatory statements that all providers must include in their
Quality Account. Many of these mandatory statements are not directly applicable to
Explanations (in italics) of what the mandatory statements mean are given as appropriate.
2.1 Review of Services
During 1st April 2013 to 31st March 2014, Wakefield Hospice provided the following service:
In–Patient Service
Day Therapy Service
Family Care Service
Bereavement Services
• Education and Training
• Occupational Therapy
• Physiotherapy
• Complementary Therapies
• Music Therapy
The income generated by the NHS services reviewed in 2013 – 2014 represents 30% of the
total income generated from the provision of NHS services by Wakefield Hospice for 2013 –
2014. (Mandatory Statement)
Wakefield Hospice received an annual grant from NHS Wakefield Clinical Commissioning
Group; this is a fixed sum regardless of the Hospice’s activity or the level of voluntary income.
This means that 100% of the financial support that we receive from the NHS is spent directly
on patient services. The remaining 70% of income required is generated through generous
donations and support from our local community, legacies, fundraising initiatives, and our
chain of charity shops.
2.2 Participation in Clinical Audits, National Confidential Enquiries
During 2013 - 14 there were no national clinical audits and national confidential enquiries
covered by the NHS services provided by Wakefield Hospice. (Mandatory Statement). This
means that as a provider of specialist palliative care Wakefield Hospice was not eligible to
participate in any of the national clinical audits or national confidential enquiries. This is
because none of the 2013 – 2014 audits or enquiries related to specialist palliative care.
However, Wakefield Hospice carries out a plan of internal clinical audits throughout the year
as a means of measuring the quality of the services it provides.
2.3 Research
The number of patients receiving NHS services provided by or subcontracted by Wakefield
Hospice in 2013 – 2014 that were recruited during that period to participate in research
approved by a research and ethics committee was 0. (Mandatory Statement). This means
that In 2013 – 2014 there was not any local or national ethically approved research projects
that patients at Wakefield Hospice were eligible to participate in. However, the Hospice has
registrars on placement from the Leeds Deanery who are undertaking local research as part
of their studies.
2.4 Goals Agreed with Commissioners
Wakefield Hospice’s statutory income in 2013 – 2014 was not conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and Innovation
payment framework. This is because Wakefield Hospice as a third sector provider of services
does not use any of the NHS National Standard Contracts and therefore is not eligible to
negotiate a CQUIN Scheme. (Mandatory Statement). However, the high quality of services
provided by Wakefield Hospice has always been central to the organisation’s intent and as a
result the Hospice has always been open to scrutiny and readily shares the results of its own
internal quality and improvement programme with CCG Commissioners.
2.5 What Others Say About the Hospice
Statement from the Care Quality Commission:
Wakefield Hospice is required to register with the Care Quality Commission and is registered
as an Independent Hospital, Hospice for Adults. Wakefield Hospice’s current registration
service is for the following activities:
Diagnostic and Screening Procedures
Transport Services, triage and medical advice provided remotely
Treatment of disease, disorder or injury
Wakefield Hospice was subject to an unannounced inspection on 19 September 2013 and was
found to be fully compliant with the standards by which it was measured. The Care Quality
Commission has not taken any enforcement action against Wakefield Hospice during 2013
2014. (Mandatory Statement).
2.6 Data Quality
Wakefield Hospice did not submit records during 2013 - 2014 to the Secondary Uses service
for inclusion in the Hospital Episode Statistics which are included in the latest publication data.
This is because Wakefield Hospice is not eligible to participate in the scheme. However, in the
absence of this and with our patients consent, the Hospice utilises the electronic patient
information system SystmOne to share information on patient records with our colleagues in
primary and secondary care settings to support seamless patient care. The system uses the
NHS number as the key identifier for patient records. In accordance with the Department of
Health, additionally, Wakefield Hospice submits a National Minimum Data Set to the National
Council for Palliative Care. (Mandatory Statement).
2.7 Information Governance
The staff at Wakefield Hospice have undertaken a considerable amount of work over the last
twelve months to improve the organisation’s information governance and to become
compliant with NHS Information Governance Toolkit. The Hospice made its first submission
as an NHS Business Partner in March 2014 and was assessed to be satisfactory at compliance
level two with a score of 66%.
2.8 Clinical Coding Error Rate
Wakefield Hospice was not subject to the Payment by Results clinical coding audit during 2012
- 2013 by the Audit Commission. (Mandatory Statement).
“I loved her (still do) very much, as do the kids and it broke my heart, but
without you it would have been so much worse”
Patient’s Husband 2014
This section provides information about how many people use our services, how we monitor
the quality of care that is provided and what our patients and families and regulators say
about us.
The Hospice is regulated by the Care Quality Commission and was last inspected on 19
September 2013 when no shortfalls were identified and the Hospice was found to be fully
compliant in meeting all of the essential standards of quality and safety. The inspectors
routinely talked to patients and relatives during the inspection process and were told that the
Hospice staff communicated with them well and that they understood the care and treatment
choices available to them.
The Minimum Data Set (MDS) for Specialist Palliative Care Services is collected on an annual
basis, with the aim of providing an accurate picture of hospice and specialist palliative care
service activity. The Wakefield Hospice MDS shown here covers the period from 1 April 2013
to 31 March 2014 with comparative data from the previous year.
MDS In-Patient Unit 2013-2014
Wakefield Hospice In
– patient Unit
2013 - 2014
Hospice Wakefield
2012 -2013
Hospice National Median 2012
– 2013
Total No of
Total No of
Completed Stays
Total No of Patients
New Patients
% Bed Occupancy
Average length of
11.6 days cancer
8.0 days non cancer
12.3 days cancer
13.6 days non cancer
12.8 days cancer
11.5 days non cancer
179 - 58.5%
181 – 61.2%
173 – 59.3%
Patient deaths
% patients with a
non-cancer diagnosis
MDS Day Therapy Unit 2013- 2014
New Clients
Continuing Clients
Total Number of Attending Patients
Total Number of Attending Carers
Total number of patients with a cancer diagnosis
Total Number of patients with a non-cancer diagnosis
Total number of deaths / discharges
Number of day therapy sessions per year
Number of actual attendances in the year
MDS Bereavement Services 2013 – 2014
New Service Users
Continuing Service Users
Re accessing service users
Total Service Users
Telephone contact lasting more then 10 minutes
Face to face group work (facilitated)
Face to face individual counselling by professional accredited person
Other forms of contact
Number of discharged service users
Number of continuing service users at the end of the year
To ensure that the Hospice is providing a consistently high quality service we undertake our
own clinical audits using national audit tools which have been developed specifically for
hospices. This allows us to monitor the consistency and quality of the care that is provided
to our patients and their families, as well as providing a cyclic quality framework upon which
to base our judgements and seek improvement if necessary. The Hospice has an Audit and
Policy Group which takes responsibility for undertaking and managing the audit cycle,
preparing reports and highlighting any areas of shortfall or risk. Clinical audit reports feed
into the Clinical Governance agenda which in return reports to the Hospice Board of
During 2013 – 2014 the following audits were undertaken:
Controlled Drugs
Repeated 3 monthly and is undertaken with
Required Hospital Pharmacist.
Medicines Chart
Minor documentation omissions by nursing
and medical staff found. Reminders to all
staff to ensure documentation is completed.
Repeat in 6 months.
Satisfaction Survey
June 2013
High level of satisfaction expressed. Repeat
in 6 months.
Accountable Officer
February 2014 None
Syringe Driver Audit
Wound & Pressure
Area Audit
March 2014
Excellent audit report – all patients had
Required pressure areas checked and swabbed if
required within the recommended 6 hours of
admission, appropriate well documented care
plans initiated.
Hand Washing Audit
March 2014
100% compliance. Audit is undertaken
Required monthly.
Bare Below the
Elbows Audit
March 2014
100% compliance. Audit is undertaken
Required monthly.
Nutrition Audit
January 2014
Bowel Assessment
Excellent Audit report, 100% score for
Required documentation, care planning and evidence
that appropriate use of aperients had negated
the need for rectal interventions in the
sample of records audited.
DTU Patient & Carer
Satisfaction Audit
March 2014
High Satisfaction levels recorded. Conclusion
suggests adapting the questionnaire to reflect
changes to the new environment.
Preferred Place of
Care & ICP Audit
April 2014
100% of in-patients had the opportunity to
discuss advance care planning including
preferred place of death. 100% of patients
had resuscitation status discussed with them
and / or their family.
Consider updating the Syringe driver
prescription chart to allow more space to
record completed checks.
Excellent Audit report, but minor omissions in
documentation were reported.
PLACE (Patient Led
Assessment of the
Care Environment)
August 2013
The hospice building (24 years old) does not
meet the standard for the visually impaired
which is required for newer buildings. Plan to
seek grant funding to bring the Hospice up to
current requirement set for new buildings.
2013 -2014
Total Number of Complaints
Total Number of Complaints Upheld
Total Number of Complaints Upheld in Part
Number of patient accidents excluding falls
Number of slips, trips and falls
Number of accidents reportable under RIDDOR
Number of patients, clients, and families reported to Social
Services because of safeguarding concerns
The Board of Trustees is fully committed and supportive of the Hospice Quality Agenda. The
Hospice has a well-established governance structure, with members of the Board having
active roles in ensuring that the Hospice provides a high quality service in accordance with its
Statement of Purpose.
“The staff talk to us about my care and give us options. We can ask questions
and the staff explain things”