Quality Account 2018-19 · 2019. 7. 9. · St Cuthbert’s Hospice Quality Account 2018-19 Care...

Quality Account

2018-19

St Cuthbertrsquos Hospice Quality Account 2018-19 Care Quality Commission Certificate of Registration No CRT1-450728467

of 68

Our Mission To make every day count for those affected by life-limiting illnesses Our Vision To be a centre of excellence within our community and to provide all-embracing compassionate and individualised care to all those affected by life-limiting illnesses at a time and a place that is right for them Our Values

Respect

Professionalism

Choice

Compassion

Reputation

Integrity Our Philosophy of Care St Cuthbertrsquos Hospice acknowledges the single focus of our services is to ensure that we provide a safe environment in which to deliver excellent care for every individual who uses our services We recognise that care must be delivered to reflect the individualrsquos unique needs and that they and their loved ones must be treated with courtesy respect and dignity Our aim is to support each person and their family and friends to make informed choices about their care and decisions affecting their lives Care is planned to support the total well-being of each person taking into account his or her physical psychological social and spiritual needs We will work together to provide a warm and welcoming atmosphere that accommodates diverse cultures and lifestyles within a calm and compassionate environment As a team we will strive to provide care of the highest standard by ensuring staff are up to date with current research practice development and training We are aware of the valuable work undertaken by individuals and agencies in the community and we will work in partnership with them to provide excellent services for the people of Durham We see life ndash and death ndash as a journey to be made in the company of others We are rooted in our local community and we approach life and death through a philosophy based on support and hospitality


Page 2 of 68

CONTENTS

Section Page

Part 1 Quality Statement 4

Part 2 Key Aspirations for Improvement 2019 -20 5

Part 3 Review of Quality Improvement 2018-19 21

31 Report on Aspirations for Improvement 2018-19 21

32 Report on New Service Developments 2018-19 33

33 Statement of Assurance from Board of Directors 36

34 Review of Service Quality Performance 2018-19 38

35 Board of Directorsrsquo Statement 48

36 Statement of Assurance from North Durham Clinical Commissioning Group

49

Appendix 1 Mandatory Statements not relevant to St Cuthbertrsquos Hospice 50

Appendix 2 Clinical Audit ndash Table 10 51

Appendix 3 Comments from Hospice Suggestion Boxes 52

Appendix 4 Friends and Family Test 56


Page 3 of 68

PART 1 Quality Statement Welcome to our Quality Account for 2018-19 This report is for our patients their families and friends the general public and the local NHS organisations that give us forty six per cent of our costs The remainder of money required to pay for our services is raised through fundraising legacies and our nine shops The aim of this report is to give clear information about the quality of our services so that our patients can feel safe and well cared for their families and friends are reassured that all of our services are of a very high standard and that the NHS is receiving very good value for money It also underlines our commitment to continually review our services finding ways to improve them and ensuring patients remain at the centre of what services we provide and how we provide them In this document we give an account of how we have maintained our high standards followed through on ways in which we can raise those standards even higher and very often exceeded the expectations of those who have used our services We also identify some priorities for continuing our progress towards excellence during the coming year We could not give such high standards of care without our hardworking staff and our volunteers and together with the Board of Trustees I would like to thank them all for their support The Account also details a number of initiatives that have taken place during the year to improve the quality of the service we offer It is pleasing to see that the work being done in County Durham is attracting national and international recognition Our Clinical Services Manager is responsible for the preparation of this report and its contents To the best of my knowledge the information in the Quality Account is accurate and a fair representation of the quality of health care services provided by St Cuthbertrsquos Hospice Paul Marriott Chief Executive


Page 4 of 68

PART 2 Key aspirations for improvement during the period 1st April 2019 ndash 31st March 2020 St Cuthbertrsquos Hospice will continue to strengthen processes across all levels of the organisation that support and demonstrate an ethos of continuous clinical quality assurance and enhancement We aspire to provide excellent care to all our service users provided by qualified and well-trained medical nursing allied health counselling and social care staff that is underpinned by research evidence and sector leading best practice in an environment and culture that supports compassionate person centred care We take our lsquoduty of candourrsquo seriously We therefore aspire to reduce risk prevent harm and promote safety as the foundation for providing excellent and responsive care services that meet the unique needs of each of our service users We will openly and honestly identify any shortfalls in our services to individuals in our care We commit to act promptly to address or resolve such shortfalls and where necessary report them and our actions to resolve them to patients and their families and to relevant partners or regulatory agencies Our service users need to know that they will be treated with compassion dignity and respect in clean and safe care settings that are effectively managed to protect them from the known harms avoidable accidents recognised clinical risks (such as pressure ulcers falls and acquired infections) associated with health systems They need to be confident that agreed and consented clinical interventions identified to meet their unique needs will be underpinned by research and sector leading best practice such as National Institute for Health and Clinical Excellence (NICE) guidance that aims to make every day count and enhance their quality of life Over 2018-19 we progressed work to fulfil CQUIN requirements agreed in partnership with

our Clinical Commissioning Group (CCG) for 2017-19 which were

CQUIN 1 Developing the effectiveness of palliative and end of life care multidisciplinary team (MDT) meetings Met in 2017-18

CQUIN 2 Development and implementation of an effective lsquolinkrsquo nursepractitioner framework This CQUIN ran over two years 2017-18 and 2018-19 and was fully met in 2018-19

CQUIN 3 Development and implementation of the Impact Chain framework

including areas within the National End of Life Care Intelligence Network Palliative

care clinical data set This CQUIN ran over two years 2017-18 and 2018-19 and was

fully met in 2018-19

We have continued to make significant progress in strengthening clinical governance at St Cuthbertrsquos Hospice see Figure 1


Page 5 of 68

We have now fully implemented the suite of internationally validated palliative care outcome measures including Phase of Illness Australia Modified Karnofsky Performance Score (AKPS) Integrated Palliative Outcome Score (IPOS) Views on Care Barthel Index Zarit and Carer Measures We have integrated core components of these outcome measures across our care services including our in-patient care day care in our Living Well Centre Family Support Team and Dementia Services see Figure 2

Figure 2 ndash Palliative Care Outcome Measures

In 2017-18 we incorporated the internationally validated

suite of palliative care outcome measures into our SystmOne care records and MDT case review meetings

In 2018-19 we revised and enhanced our acuity

and dependence tool

In 2018-19 we further strengthened clinical

incident reporting processes and enhanced

the design of our Incident Log

Phase of Illness AKPS

IPOS

Views on Care

Barthel Index

(In-patients only)

Zarit Carer Interview and Carer measures

Figure 1 ndash Strengthening Clinical Governance


Page 6 of 68

During 2017-18 we embedded the internationally validated suite of palliative care outcome measures into our SystmOne care records and now routinely use them as the basis for care review at our multi-disciplinary team meetings and in shift handover reports In 2018-19 to strengthen our ability to report on the findings from the palliative care outcomes data we collect as part of our strategy to develop impact reporting we recruited a data scientist to develop a lsquodata warehousersquo and using R Script a live dashboard reporting process for our Board Clinical Governance Committee and Senior Management Team In 2018 we revised our In-Patient Unit (IPU) dependency and acuity tool first developed in 2016 and designed around the principles outlined in the Safer Care Nursing Care Tool as recommended by NICE

httpswwwniceorguknewspress-and-mediafirst-toolkit-endorsed-by-nice-for-safe-staffing

In the design we included Phase of Illness AKPS and adopted the palliative care modified Richmond Agitation-Sedation Scale RASS-PAL as proxy measures of acuity and dependence lsquoRichmond Agitation-Sedation Scale modified for palliative care inpatients (RASS-PAL) a pilot study exploring validity and feasibility in clinical practicersquo

Bush SH Grassau PA Yarmo MN Zhang T Zinkie SJ Pereira JL BMC Palliative Care March 2014

We have reviewed the two yearsrsquo worth of data collected by the acuity and dependence tool from 2016 and after analysing the data we have made further revisions to include the multiple factors that contribute to acuity and dependence We have now aligned this data to our incident reporting dashboards to help identify where acuity and dependence staff establishment and skill mix impact on the likelihood of a clinical incident occurring We have also been able to use the data to produce future workforce projections in modelling plans for the development of a larger in-patient unit

In 2018 we again worked with a Business AnalystSolution Designer from Durham University to strengthen our incident log and our capacity to provide detailed incident analysis and reporting including dashboard reporting of clinical incident trends and patterns to our internal clinical governance structures and processes and external partners St Cuthbertrsquos Hospice accepts it is accountable for the standards of care it provides and has developed robust systems and processes to monitor review report and act in response to all clinical issues and incidences as outlined in Figure 3 below


Page 7 of 68

Figure 3 ndash Organisational processes and approaches to monitoring and responding to care service delivery

We have met or made substantial progress in meeting all of our key aspirations for improvement as outlined in our 2017-18 Quality Account However we recognise that to maintain and continually improve our care services we must ensure that the knowledge skills and competence of our staff and volunteers and the evidence that underpins our practice is updated in line with current best practice and research To reflect best practice we have adopted the following NICE Guidance or Standards to inform both policy development and procedures and enhance our practice

Improving supportive and palliative care for adults with cancer NICE Cancer service guideline [CSG4] March 2004

Nutritional support in adults oral nutritional support enteral tube feeding and parenteral nutritional (NICE) Clinical Guidance 32 (2006) wwwniceorgukGuidanceCG32

Pressure ulcers prevention and management NICE Clinical guideline [CG179] April 2014

Care of dying adults in the last days of life NICE guideline [NG31] December 2015

Medicines optimisation the safe and effective use of medicines to enable the best possible outcomes NICE guideline [NG5] March 2015

Controlled drugs safe use and management NICE guideline [NG46] Published date April 2016

Operational Managment Group (OMG - Weekly)

Senior Mangement Team (SMT - monthly)

OMG conducts weekly reviews on incidents breaches of contract and complaints

SMT reviews and reports on all policies and procedures organisational and clinical risks and business continuity plans Monitors trends and patterns in clinical incidents accidents and complaints

The Chief Executive Officer has established an ethics committee with an indepedent chair and lay members to advise us on ethical issues and concerns in palliative and end of life care and as a forum to support reflection of anonymised challenging clinical concerns

Clinical Governance Group (CGG - Quarterly)

Consults on policy and procedure review update and implementation and clinical priorities

Monitors quality of care analyses clinical incidents drug errors and complaints

Monitors clincial audit and quality performance indicators

Reviews and reports on clinical risk and reduction

Clinical Governance Committee (CGC - Quarterly)

Strategic review of quality of all hospice care services

Monitors and reports on trends patterns and issues in clincial incidents drug errors and complaints

Reviews clincial audit and quality performance indicators

Risk identification reduction and mitigation are reported reviewed and discussed

Board (Quarterly)

Strategic review of CGG and CGC agenda minuted and reports

Clinical Commissioning Group

Compliance with contract quality amp performance targets

Commissioning for Quality and Innovation (CQUIN) framework targets

Safeguarding and Complaints


Page 8 of 68

Palliative care for adults strong opioids for pain relief NICE Clinical guideline [CG140] May 2012 Last updated Aug 2016

Falls in older people NICE Quality standard [QS86] Published March 2015 Last updated January 2017

NHS Improvement

Pressure ulcers revised definition and measurement Summary and recommendations NHS Improvement June 2018

During 2018-19 our Board of Directors (Trustees) the Clinical Governance Sub-Committee Senior Management Team Clinical Governance Group and Clinical Commissioning Group received and reviewed comprehensive quarterly progress reports about care delivery clinical audit incidents accidents investigations and complaints Each group has been rigorous in monitoring and critically reviewing the evidence provided about the safety and quality of care services and where necessary approved detailed action plans to support a culture of continuous service development and quality improvement We consider feedback from service users as being central in helping to ensure we are responsive to the needs of those who access and use our services We routinely collect lsquoFriends and Family Testrsquo feedback as part of our specific service user questionnaires The summary of findings can be seen at Appendix 4 During 2018-19 St Cuthbertrsquos Hospice was not subject to external inspection by the Care Quality Commission (CQC) or our Commissionersrsquo quality assurance team at North Durham Clinical Commissioning Group (CCG) During December 2018 the CCG lead for Infection Prevention and Control conducted an external lsquoinfection control inspectionrsquo of the hospice care settings and reported no concerns or requirements for remedial action


Page 9 of 68

Awards

In 2018-19 St Cuthbertrsquos Hospice is proud to announce that the work of the Hospice has been recognised through the award

County Durham Volunteering Kite mark awarded in September 2018

Northumbria In Bloom Care Residential Convalescent Homes Hospices and Day Centres Award St Cuthbertrsquos Hospice - Gold and overall category winner

Deputy Chief Executive shortlisted for Charity Times Supporting Executive of the Year As part of our NHS contract requirements St Cuthbertrsquos Hospice provides North Durham CCG with quarterly Service Contract Quality Performance Reports and six-monthly Workforce Assurance Reports These are available on the website (wwwstcuthbertshospicecom) Publication of these reports helps fulfil our duty of candour and enables our service users and those who support the Hospice to view and measure the quality of our performance over each quarter Over 2018-19 we progressed work to fulfil CQUIN requirements agreed in partnership with our Clinical Commissioning Group (CCG) for 2017-19 and these were



CQUIN 3 Development and implementation of the Impact Chain framework including areas within the National End of Life Care Intelligence Network Palliative care clinical data set This CQUIN ran over two years 2017-18 and 2018-19 and was fully met in 2018-19

The views of service users staff volunteers and were taken into account in determining the Hospicersquos aspirations for improvement in the period 1st April 2019 to 31st March 2020 as outlined below Future planning aspirations for 2019-20 Safety We have strengthened our clinical governance processes to monitor our patientsrsquo symptom load as recorded in palliative care outcome measures and the data from our acuity and dependence tool to better match our workforce and skill mix to clinical need and the impact that that might have on reducing trends in clinical incidents ASPIRATION 1 REDUCING FALLS PRESSURE ULCERS (PUs) URINARY TRACT INFECTIONS (UTIs) AND THROMBOEMBOLISMS Rationale for choosing this aspiration


Page 10 of 68

St Cuthbertrsquos Hospice continues to view harm-free care for patients as an important priority The principles outlined in the NHS Patient Safety Thermometer remain an effective method for surveying patient harms and analysing results via completion of an electronic spreadsheet for one day on a monthly basis This measures harm in relation to four key areas falls pressure ulcers and for in-patients with catheters acquired urinary tract infections (UTIs) and incidence of thromboembolism VTE assessment see Table 1 Although no longer required to report via the national patient safety thermometers spreadsheet we continue to collect and monitor information on known harms associated with health care This includes all falls as and when they occur the incidence of acquired deteriorating pressure ulcers UTIs and thromboembolism VTE assessment during and following admission and on a weekly basis thereafter Table 1 below provides a summary of our progress in reducing known harms incidents Table 1 Safe care targets and achievement

Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19

Avoidable falls We reported 17 unavoidable falls and no avoidable falls

We reported 11unavoidable falls and no avoidable falls

We report 38 falls of which one was avoidable (fourteen of these falls were for 5 patients)

Pressure ulcers (PUs) developed or deteriorated during stay in the Hospice

We reported 6 PUs deteriorating post admission and 1 PU acquired after admission

We reported 7 PUs acquired post admission with 0 PUs deteriorating post admission This represents an increase of one case

We report 4 PUs acquired post admission and 3 PUs deteriorating after admission

Urinary tract infections (UTI)

We again reported a zero incidence of acquired UTI


Zero incidence of hospice acquired UTI

Thromboembolism Assessments (VTE)

We reported 843 of patients had a VTE assessment completed with 24 hours of admission For the last six months of the reporting period we achieved 100

100 of patients had a VTE assessment within 24 hours of admission


What will we do to achieve this aspiration Falls We again aspire to have a zero rate of avoidable falls and to help us achieve this on admission all patients will be assessed for their individual risk of falls using a Falls Risk Assessment Tool (FRAT) and where appropriate a falls risk care plan is put in place to try and reduce the incidence of avoidable falls In spite of this falls can and still do occur Many of our patients have limited mobility or are frail as a consequence of their illness but retain lsquocapacityrsquo and express their wish to remain as independently mobile as possible In respecting patient preferences we also have to balance the need to keep our patients safe with the need to respect and promote their independence In such situations some falls remain unavoidable


Page 11 of 68

Actions proposed for 2019-20 are

We now conduct on admission and periodically review falls risk and mobility assessments We document findings and actions in our revised SystmOne care record

We have introduced and will continue to use lsquoCall avoid the fall signsrsquo

We will place known falls risk patients under close observation near to the nursesrsquo station to ensure prompt responses to the Nurse Call system

We will continue to use the new state of the art ultra-low profile bed (purchased in May 2016) We will purchase a second such bed in 2019

During 2017-18 we increased our stock of lsquochair bed floor and remote sensorrsquo movement alarms and we will continue to deploy them in the coming year

We have made available falls crash mats

We will conduct formal falls review for every patient at our weekly multi-disciplinary team meeting

One of our physiotherapists acts as our lsquofallsrsquo link practitioner

To encourage increased reporting of ldquonear-missesrdquo ndash where a fall did not occur but might have done

Following an update of the Falls Prevention Policy and Procedure we now include and use in practice a lsquoclose observation monitoring chart to ensure close supervision of those deemed at high risk of falls

We will investigate the feasibility of using a new nurse call system to enhance remote monitoring of patient movement and early detection of falls

Pressure ulcers new definitions We again set an ambitious target of zero incidence of pressure ulcers (PUs) being acquired or deteriorating following admission for 2018-19 We recognise the challenges associated in meeting this ambitious target Following the publication in June 2018 by NHS Improvement lsquoPressure ulcers revised definition and measurement Summary and recommendationsrsquo we have adopted the best practice for the categorisation of pressure ulcers and as recommended in the report no longer describe lsquoKennedy Terminal Ulcers We recognise the difficulty of balancing the rights of patients with capacity and or the wishes of their loved ones who after being made aware of the risk of harm still decline positional change regimes or pressure relieving equipment in the final stages of end of life care against the goal of preventing avoidable injury or harm Consequently there will continue to be occasions when despite the implementation of a pressure ulcer risk reduction care plan unavoidable pressure damage may still occur Such measures include risk assessment the use of pressure relieving equipment regular positional changes pressure prevention monitoring and the use of measures to protect the integrity of skin over bony prominences

In 2018-19 we continued to apply NICE Guidance to support monitoring management of PUrsquos and to promote best practice we implemented a number of measures including


Page 12 of 68

Risk assessment with validated tool lsquoWaterlow Risk Assessment toolrsquo pressure area mapping charts and rounding charts in patient rooms to record regular positional change regimes

Incident reporting and photographing with consent all pressure ulcers graded at 2 or above noted on initial admission assessment or acquired following admission as an in-patient

Implementation of a revised policy for the prevention and management of pressure ulcers that adopts the best practice as outlined by NICE lsquoPressure ulcers prevention and management of pressure ulcersrsquo Issued April 2014 NICE clinical guideline 179 httpguidanceniceorgukcg179

We have adopted the Hospice UK (released April 2016) pressure ulcer audit tool to our clinical audit schedule and continued to audit using this tool over 2018-19

We will continue these interventions over 2019-20 Prevent health care acquired urinary tract infections We again report a zero incidence of acquired urinary tract infections for 2018-19 One of our senior staff nurses acts as our link practitioner for infection control and conducts quarterly infection control audits as outlined in our audit schedule that are reviewed by an infection control group and then reported to our Clinical Governance Committee We again aspire to maintain a zero incidence for 2019-20 and to maintain the effective best practice established and maintained since 2015 Conducting VTE Assessments on patients admitted to IPU In December 2014 we commenced formal VTE (Venous Thromboembolism) assessments on patients to evidence decisions made with regard anticoagulation therapy

Percentage of patients achieving VTE assessment within 24 hours of admission 2015-16 2016-17 2017-18 2018-19

82 of our patients had a VTE assessment recorded within 24 hours of admission

Over the first six months of 2016 843 of our patients had a VTE assessment recorded within 24 hours of admission Following amendment to SystmOne we report 100 compliance over the second half of the reporting year


99 of our patients had a VTE assessment completed within the first 24 hours after admission

How will these aspiration be measured

All falls pressure ulcers acquired or deteriorating following admission acquired urinary tract infections and failures to complete a VTE assessment will be reported and recorded as clinical incidents


Page 13 of 68

All falls acquired or deteriorating pressure ulcers will be recorded on our incident log and investigated and any lessons learned will be reviewed with staff

Results will be reported and monitored quarterly to the

o Clinical Governance Sub-Committee (CGSC) o The Clinical Governance Group (CGG) o Senior Management Team (SMT) and to our o Clinical Commissioning Group in our quarterly Contract Quality Performance

Reports for 2019-20 and made publicly available on the Hospice website

All pressure ulcers acquired or deteriorating following admission and graded at 3 or above and any falls that results in serious harm to a patient will be

o Internally investigated adopting root-cause analysis methodology and a report

compiled for SMT and CGSC o Statutorily notified to CQC by completion of lsquoStatutory Notification of Injury to a

Service User formrsquo o Reported to the Commissioners via North East Commissioning Support Unit

(NECS) in line with NHS Englandrsquos Serious Incidents framework ASPIRATION 2 PREVENT ERRORS ASSOCIATED WITH THE ADMINISTRATION OF CONTROLLED DRUGS Rationale for choosing this aspiration St Cuthbertrsquos Hospice offers symptom control and end of life care in its In-patient unit (IPU) Drug therapy is an important part of this care and we prescribe and administer a variety of drugs including controlled drugs (CDs) Errors in CD administration are extremely rare but because of the nature of the drugs and dosages involved such errors can have serious unintended outcomes During 2018-19 we had no controlled drug administration errors involving maladministration of controlled drugs We again aspire to achieve a zero incidence of controlled drug administration errors this for 2019-20 What will we do to achieve this aspiration Actions proposed for 2019-20 are

Continue to engage the services of a qualified pharmacist on a professional activity session basis to assist us to

o Achieve improved clinical and cost effective prescribing o Conduct review of stock drug holdings and prescribing practice o Support our medical prescribers o Provide expert medicines advice to colleagues at multi-disciplinary team

meetings o Conduct audits of prescribing and administration practice o Review policy and procedure used to record and manage administrations of

controlled drugs


Page 14 of 68

Report all incidences of CD mal-administration and or incorrect stock control tallies to our CD Local Intelligence Network

Internally investigate any CD misadministration errors adopting root-cause analysis techniques and report to CGSC

Implement quarterly audit adopting the Hospice UK CD Audit Tool

To record and review medication near misses

Assess the drug calculation competence of our nursing staff on an annual basis

Launch a new Medicines Management Group How will this aspiration be measured

We will be able to demonstrate that all staff have had the opportunity to comment on the existing policy and procedure that is used to administer controlled drugs and make suggestions for improving it prior to completing the review

Clinical staff involved in CD administration will pass the annual drug calculation assessment with a 100 pass mark

We will undertake o Weekly CD stock audit and review of CD registers against stock levels o Four lsquoadministration of controlled drugsrsquo audits using a recognised audit tool o The reports of the audit and actions arising from them will be reported to all

stakeholders ASPIRATION 3 PREVENT AVOIDABLE HARM FROM USE OF MEDICAL EQUIPMENT DEVICES WITH KNOWN FAULTS OR DRUG QUALITY TAINTED OR COMPROMISED IN PRODUCTION The risk of harm to patients and staff through incorrect use of or using medical equipment and devices known to be faulty and or tainted compromised drugs is well recognised ever present and avoidable St Cuthbertrsquos Hospice receives medical equipment device and drug alerts from NHS central alerting systems and will respond promptly to all alerts these include

Department of Health CAS httpswwwcasdhgovukHomeaspx

Medicines amp Healthcare products Regulatory Agency

httpswwwgovukgovernmentorganisationsmedicines-and-healthcare-products-regulatory-agency

From the Local Intelligence Network

What we will do to achieve this aspiration We aim to prevent avoidable harm to our patients and staff associated with the use of faulty medical equipment and devices and tainted compromised drugs We have developed a robust procedure to minimise such risks by

Communicating all electronic alerts to all medical nursing and allied health professional staff via email with open and read receipts to confirm that staff have read the alerts

Printing off producing and updating of lsquoAlert Filesrsquo one available in both IPU and day hospice


Page 15 of 68

Recording of an alert action log for those alerts that impact on medical equipment devices and or drugs used in our services

o We now also receive estates related alerts and action these via our estates team

Recording lsquoAlert updatersquo as a standing agenda item on the IPU ward team meeting

Alert update and action logs are a standing agenda item for CGSC and CGG How will this aspiration be measured

Action logs will record any such medical equipment device fault alerts andor drug alerts pertaining to products used by our services and what has been done to respond as per procedure

There will be no reported incidences of harm to patients and staff as a result of incorrect use of or using faulty medical equipment devices and or tainted compromised drugs

All incident alerts that require action and recording in the alert log will be reported to CGSC

Effectiveness ASPIRATION 4 MEASURE THE EFFECTIVENESS OF OUR CARE PALLIATIVE CARE INTERVENTIONS AND OUTCOMES Rationale for choosing this aspiration Those who use our services need to know that the interventions and care we implement to meet their individual needs is responsive informed by evidence and best practice and makes a difference to their symptoms and quality of life We want people to feel confident to discuss their health needs with staff This is important to ensure that people are regularly involved in monitoring changes in their health status or needs and that these are fully discussed with them Review of care plans already happens on a regular basis The implementation of palliative care outcome measures will better inform us and the patient about the clinical effectiveness of our care and interventions Over 2018-19 we continued to collect and collate the set of data from the suite of palliative care outcome measures These included Phase of Illness Australia Modified Karnofsky Performance Status (AKPS) Integrated Palliative Outcome Score (IPOS) and lsquoViews on Carersquo We shared our findings with other Hospice partners and provided advice and support on setting up palliative care outcome measure in SystmOne and use of R Script to generate reports How will we achieve this aspiration Action proposed for 2019-20

To continue data collection analysis and interpretation for the outcome measures already implemented


Page 16 of 68

Share our findings with sector colleagues our CGSC and those who use our services

How will this aspiration be measured

We will be better able to evidence our care interventions for the outcome measure(s) implemented to date

We will provide detailed reports to CGSC CGG SMT and Commissioners of outcomes measures achieved

ASPIRATION 5 MEASURING PATIENT DEPENDENCY AND ACUITY TO BETTER INFORM OUR WORKFORCE PLANNING Rationale for choosing this aspiration The Board of Trustees and Senior Management Team (SMT) of St Cuthbertrsquos Hospice recognise that patient numbers levels of dependency and acuity of care need impact on the number and skill mix of care staff needed at any one time to meet care needs They also acknowledge that patient dependency changes dynamically and the care needs of patient and their loved ones changes over time St Cuthbertrsquos Hospice aspires to incrementally increase the number of beds open to admissions on in-patient unit from ten to thirteen and thus better data about the impact of acuity and dependency will enhance our workforce planning and modelling During autumn of 2015-16 we implemented a new in-patient unit (IPU) dependency and acuity tool The tool has been designed and adapted from the principles of the Shelford Group NHS lsquoSafer Care Nursing Care Toolrsquo as recommended by NICE httpswwwniceorguknewspress-and-mediafirst-toolkit-endorsed-by-nice-for-safe-staffing We have also adapted the Richmond Agitation-Sedation Scale modified for palliative care inpatients (RASS-PAL) to acknowledge the known increasing levels of dependency and acuity associated with terminal agitation in the dying patient How will we achieve this aspiration Action proposed for 2019-20

Continue data collection analysis and interpretation from the Dependency Acuity tool

Review finding against data obtained from palliative care outcome measures

Review the staffing establishment based on the data from the acuity tool How will this aspiration be measured

We will be better able to use dependency acuity data to review predict our workforce modelling and needs

Review dependency and acuity data over time and review how effective our current shift patterns are in meeting care needs


Page 17 of 68

We will be able to provide detailed reports to CGSC CGG SMT and Commissioners of acuity as measured against palliative outcomes measures

ASPIRATION 6 TO REDUCE THE NUMBER OF SERIOUS INCIDENTS AND PREVENT ANY AVOIDABLE INCIDENTS OCCURRING Rationale for choosing this aspiration St Cuthbertrsquos Hospice takes the provision of safe care seriously and recognises there is no room for complacency During 2018-19 in fulfilling our duty of candour we reported three serious incidents to the North East Commissioning Service (NECS) see Table 6 page 31 We have established robust processes for incident reporting using a standard incident report form and recording all details on a central spreadsheet incident reporting log Hospice staff are diligent and professional in ensuring all incident reports are completed in a timely manner and that appropriate follow-up actions are logged as and when they occur However to be more proactive in anticipating and minimising the risk of incidents occurring we will continue to ensure comprehensive reporting of lsquonear-missesrsquo ndash in other words incidents that could have developed into an accident but for a fortunate break in the chain of events What will we do to achieve this aspiration Actions proposed for 2019-20

We will continually review our incident reporting policy in light of lessons learned from near misses and reported incidents

Create a consolidated electronic version of our accident and incident reporting forms

Use real-time dashboards to monitor the link between incidents and staffing How will this aspiration be measured

e will report trends and patterns to CGSC CGG SMT and Commissioners and on progress towards increasing the number of near-misses reported and whether this leads to a reduction in the number of incidents occurring


Page 18 of 68

Responsiveness ASPIRATION 7 Improve the care and practical support of carers by implementing

the aims outlined in the Hospice lsquoCarer Strategyrsquo

Rationale for choosing this aspiration St Cuthbertrsquos Hospice recognises the important contribution that informal carers can make to

the care support and wellbeing of individuals with life limiting illness and those approaching

end of life We recognise that the extent to which individual carers engage in lsquoinformal carersquo

varies considerably ranging from befriending and social companionship to direct involvement

in all aspects of personal care and complex technical aspects of care

We also know there is a growing body of evidence that indicates that being an informal carer

carries with it significant physical emotional psychological and financial burden Evidence

lsquoFacts about carersrsquo Policy Briefing May 2014 Carers UK Many carers donrsquot recognise

themselves as carers and rsquodriftrsquo into the role over time often taking on an increasing lead as

a carer lsquoWho cares Support for carers of people approaching the end of lifersquo The National

Council for Palliative Care 2013

What we also know is that number of carers is rising as is their age with 1 in 5 being aged

between 56 - 64 and that females make up more than 58 of all carers They also make a

significant contribution to social care and estimates suggest that the care they contribute is

worth some pound119 billion across the United Kingdom Carers UK and the University of Leeds

(2011) lsquoValuing Carers 2011 Calculating the value of carersrsquo supportrsquo

What will we do to achieve this aspiration Actions proposed for 2019-20

Establish a strategy implementation team to establish a baseline intelligence of lsquocarer burdenrsquo by coordinating the collection and interpretation of data about the extent of carer burden for those informal carers supporting patients who access our in-patient care or Living Well Centre services

Work alongside Durham County Carers in order to identify how we can collaborate for the benefit of carers in the County

How will this aspiration be measured We will create a baseline of outcome reporting using a specially adapted version of the Carer Support Needs Assessment Tool (CSNAT) We will use this data to agree an evidence-based plan for the delivery of services for Carers Aspiration 8 Opening Up Hospice Care St Cuthbertrsquos Hospice is committed to promoting equity in the delivery of services


Page 19 of 68

The biggest Black and Minority Ethnic Community in County Durham is the Traveller Community Gypsies and Travellers live shorter lives and experience poorer health than the general population The resident GRT population in County Durham based on household survey and GRT Education records is estimated in the Durham Health Needs Assessment (HNA) as being between 2200 and 2940 (059 of the total population) However due to the reluctance of Gypsies and Travellers to self-ascribe this is almost certain to be an underestimate The last documented estimate of the national GRT population also most certainly an underestimate is over 300000 (06 of the total population) There are six local authority owned and managed caravan sites in County Durham providing a total of 126 pitches A buildings-based service like the Hospice can feel inaccessible to parts of this community Although the number of rough sleepers in County Durham is relatively low (12 according to the count in 2016) the Local Authority accepts around 250 people per year as homeless However this number of people actually homeless is likely to be higher People who are homeless will often have complex health issues that can be life-limiting Homelessness is often occasioned by grief or loss As with the traveller community a buildings-based service is not necessarily perceived as accessible by people with a more chaotic lifestyle

Durham is home to three prisons The Hospice has already got a memorandum in place with the Prison Service which supports prisoners who are at end of life or who have a life-limiting illness and complex symptoms to access the Hospice and this is working very well Those aged over 60 are the fastest-growing segment of the prison population increasing 125 between 2004 and 2014 Those aged over 50 are the second-fastest-growing segment increasing by 104 in the same timeframe while the overall prison population increased by just 15 The Ministry of Justice projects the population in prison aged over 60 to increase from 4100 in 2015 to 5500 in 2020 Two of the main drivers for this demographic shift are longer sentences and more late in life prosecutions for historic sex offences The ageing of the prison population shows no signs of abating leading to an increase in deaths from natural causes in prisons and increasing social care needs of elderly and infirm prisoners This has been recognised in the Care Act 2014 parts of which came into force in April 2015 The Act makes local authorities responsible for assessing and meeting the eligible social care needs of adult prisoners although prisons will need to make referrals first The aim is to bring the delivery of social care in prisons in line with the care of those in the community

Our aspiration is to make Hospice care more available to these three populations


Work with front-line workers working with the traveller community to identify pathways to hospice care for this community

Support front-line workers working with the homeless community with the skills and knowledge to recognise and support people with a life-limiting illness


Page 20 of 68

Investigate the feasibility of extending our Dementia Services into at least one prison


We will evaluate the sessions with front-line workers to identify whether they feel better equipped with the knowledge and skills needed to support people with a life-limiting illness or who are experiencing unresolved grief We will have identified possible pathways through which the services offered by the Hospice can be made more accessible to these communities


Page 21 of 68

PART 3 Review of Quality Improvement during the period 1st April 2018 - 31st March 2019 Opened in 1988 St Cuthbertrsquos Hospice provides specialist medical and nursing care for the people of North Durham living with life-limiting conditions The Hospice is based in the historic Park House close to Durham city centre Patients and relatives are welcome to enjoy the several acres of beautiful grounds with views across the Durham countryside

Our team of highly qualified and trained staff and volunteers work together to provide individual high-quality care in a peaceful environment and to provide care and support for relatives and carers St Cuthbertrsquos Hospice provides

A medically supported 10 bedded in-patient unit plus 1 respite care bed offering 24-hour care with the capacity to increase to thirteen

A new rehabilitative day care service in our refurbished Living Well Centre that offers o Social work advice and support o Care support including physiotherapy occupational therapy and complementary

therapies o Specific care interventions including lymphoedema clinic and day care treatments

such as intravenous infusions for blood transfusions and bisphosphonates o Community support including specialist Dementia support

Family Support Team providing pre- and post-bereavement counselling as well as social support for patients families and carers

In 2017-18 we successfully bid for and secured the contract from County Council of Durham top provide a children and young personrsquos bereavement service for those bereaved as a consequence of suicide or sudden unexpected and traumatic death This contract was renewed in February 2018 and again in February 2019

31 Report on Key Aspirations for Improvement during the period 1st April 2018 to 31st March 2019 Safety We have strengthened our clinical governance processes to monitor our patientsrsquo symptom load as recorded in palliative care outcomes and the data from our acuity and dependence tool to better match our workforce and skill mix to clinical need and the impact that that might have on reducing trends in clinical incidents ASPIRATION 1 REDUCING FALLS PRESSURE ULCERS (PUs) URINARY TRACT INFECTIONS (UTIs) AND THROMBOEMBOLISMS


Page 22 of 68

Rationale for choosing this aspiration St Cuthbertrsquos Hospice continues to view harm-free care for patients as an important priority The principles outlined in the NHS Patient Safety Thermometer remain an effective method for surveying patient harms and analysing results via completion of an electronic spreadsheet for one day on a monthly basis This measures harm in relation to four key areas falls pressure ulcers and for in-patients with catheters acquired urinary tract infections (UTIs) and incidence of thromboembolism VTE assessment What we said we would do to achieve this aspiration Falls We again aspire to have a zero rate of avoidable falls and to help us achieve this on admission all patients will be assessed for their individual risk of falls using a Falls Risk Assessment Tool (FRAT) and where appropriate a falls risk care plans is put in place to try and reduce the incidence of avoidable falls In spite of this falls can and still do occur Many of our patients have limited mobility or are frail as a consequence of their illness but retain lsquocapacityrsquo and express their wish to remain as independently mobile as possible In respecting patient preferences we also have to balance the need to keep our patients safe with the need to respect and promote their independence In such situations some falls remain unavoidable Actions proposed for 2018-19 were

We now conduct on admission and periodically review falls risk and mobility assessment We document findings and actions in our revised SystmOne care record








To encourage increased reporting of lsquonear-missesrsquo ndash where a fall did not occur but might have done

Following an update of the Falls Prevention Policy and Procedure we now include and use in practice a close observation monitoring chart to ensure close supervision of those deemed at high risk of falls

We investigated the feasibility of installing a new nurse call system to enhance remote monitoring of patient movement and early detection of falls and after securing funding will see this installed during quarter 1 in 2019-20


Page 23 of 68

All of the above actions were successfully completed In addition we were able to secure additional funding for the purchase and installation of a new nurse call system that will be introduced during quarter one of 201920 We also sought an external review of our falls policy and procedures and enlisted the local County Durham and Darlington NHS Foundation Trust lead falls coordinator to subject our falls management processes to scrutiny She fed back that our systems and processes were in line with best practice evidence Pressure ulcers We again set an ambitious target of zero incidence of pressure ulcers (PUs) being acquired or deteriorating following admission for 2018-19 We recognise the challenges associated in meeting this ambitious target Following the publication in June 2018 by NHS Improvement lsquoPressure ulcers revised definition and measurement Summary and recommendationsrsquo we have adopted the best practice for the categorisation of pressure ulcers and as recommended in the report no longer describe lsquoKennedy Terminal Ulcers We also recognise the difficulty in balancing the rights of those patients with capacity and or of their loved ones who after being made aware of the risk of harm still decline positional change regimes or pressure relieving equipment in the final stages of end of life care against the goal of preventing avoidable injury or harm Consequently there will continue to be occasions when despite the implementation of a pressure ulcer risk reduction care plan unavoidable pressure damage may still occur Such measures include risk assessment the use of pressure relieving equipment regular positional changes pressure prevention monitoring and the use of measures to protect the integrity of skin over bony prominences

In 2018-19 we continued to apply NICE Guidance to support monitoring management of PUs and to promote best practice we implemented a number of measures including




We have adopted the Hospice UK (released April 2016) pressure ulcer audit tool to our clinical audit schedule and continued to audit using this tool during 2018-19


Page 24 of 68

Prevent health care acquired urinary tract infections We again report a zero incidence of acquired urinary tract infections for 2017-18 One of our senior staff nurses acts as our link practitioner for infection control and conducts quarterly infection control audits as outlined in our audit schedule that are reviewed by an infection control group and then reported to our Clinical Governance Committee We again aspire to maintain a zero incidence for 2019-20 and to maintain the effective best practice established and maintained since 2015 Conducting VTE Assessments on patients admitted to IPU In December 2014 we commenced formal VTE (Venous Thromboembolism) assessments on patients to evidence decisions made with regard anticoagulation therapy





We aim to maintain 100 of our patients having a VTE assessment completed within the first 24 hours after admission











(NECS) in line with NHS Englandrsquos Serious Incidents framework


Page 25 of 68

The results for 201819 are set out in Table 1 on page 10 ASPIRATION 2 PREVENT ERRORS ASSOCIATED WITH THE ADMINISTRATION OF CONTROLLED DRUGS Rationale for choosing this aspiration St Cuthbertrsquos Hospice offers symptom control and end of life care in its In-patient unit (IPU) Drug therapy is an important part of this care and we prescribe and administer a variety of drugs including controlled drugs (CDs) Errors in CD administration are extremely rare but because of the nature of the drugs and dosages involved such errors can have serious unintended outcomes During 2017-18 we had no controlled drug administration errors involving maladministration of controlled drugs We again aspired to achieve a zero incidence of controlled drug administration errors this for 2018-19 What we said we would do to achieve this aspiration Actions proposed for 2018-19 were

Use the services of a qualified pharmacist on a professional activity session basis to assist us to



controlled drugs





We assess the drug calculation competence of our nursing staff on an annual basis How was this aspiration measured

We are able to demonstrate that all staff have had the opportunity to comment on the existing policy and procedure that is used to administer controlled drugs and make suggestions for improving it prior to completing the review

Clinical staff involved in CD administration must pass the annual drug calculation assessment with a 100 pass mark

We undertook o Weekly CD stock audit and review of CD registers against stock levels o Four lsquoadministration of controlled drugsrsquo audits using a recognised audit tool o The reports of the audit and actions arising from them were reported to all

stakeholders


Page 26 of 68

ASPIRATION 3 PREVENT AVOIDABLE HARM FROM USE OF MEDICAL EQUIPMENT DEVICES WITH KNOWN FAULTS OR DRUG QUALITY TAINTED OR COMPROMISED IN PRODUCTION The risk of harm to patients and staff through incorrect use of or using medical equipment and devices known to be faulty and or tainted compromised drugs is well recognised ever present and avoidable St Cuthbertrsquos Hospice receives medical equipment device and drug alerts from NHS central alerting systems and will respond promptly to all alerts these include





What did we do to achieve this aspiration We aimed to prevent avoidable harm to our patients and staff associated with the use of faulty medical equipment and devices and tainted compromised drugs We implemented a robust procedure to minimise such risks by






Alert update and action logs are a standing agenda item for CGSC and CGG How was this aspiration measured

Action logs recorded any such medical equipment device fault alerts andor drug alerts pertaining to products used by our services and what was done to respond as per procedure

There were no reported incidences of harm to patients and staff as a result of incorrect use of or using faulty medical equipment devices and or tainted compromised drugs

Any incident alerts that required action and recording in the alert log were be reported to CGSC


Page 27 of 68

Effectiveness ASPIRATION 4 MEASURE THE EFFECTIVENESS OF OUR CARE PALLIATIVE CARE INTERVENTIONS AND OUTCOMES Rationale for choosing this aspiration Those who use our services need to know that the interventions and care we implement to meet their individual needs is responsive informed by evidence and best practice and makes a difference to their symptoms and quality of life We want people to feel confident to discuss their health needs with staff This is important to ensure that people are regularly involved in monitoring changes in their health status or needs and that these are fully discussed with them Review of care plans already happens on a regular basis The implementation of palliative care outcome measures will better inform us and the patient about the clinical effectiveness of our care and interventions Over 2017-18 we continued to collect and collate the set of data from the suite of palliative care outcome measures These included Phase of Illness Australia Modified Karnofsky Performance Status (AKPS) Integrated Palliative Outcome Score (IPOS) and lsquoViews on Carersquo In 2016-17 we developed our capacity to construct palliative care outcome measure reports and include a summary of findings for 2017-18 as an embedded PDF 1 on page We shared our findings with other Hospice partners and provided advice and support on setting up palliative care outcome measure in SystmOne and use of R Script to generate reports How did we achieve this aspiration Action proposed for 2018-19



Appointment of a data analyst We completed all of these actions and now have live interactive dashboards that support operational and strategic improvement

How was this aspiration measured

We are better able to evidence our care interventions for the outcome measure(s) implemented to date


ASPIRATION 5 MEASURING PATIENT DEPENDENCY AND ACUITY TO BETTER INFORM OUR WORKFORCE PLANNING


Page 28 of 68

Rationale for choosing this aspiration The Board of Trustees and Senior Management Team (SMT) of St Cuthbertrsquos Hospice recognise that patient numbers levels of dependency and acuity of care need impact on the number and skill mix of care staff needed at any one time to meet care needs They also acknowledge that patient dependency changes dynamically and the care needs of patient and their loved ones changes over time St Cuthbertrsquos Hospice aspires to incrementally increase the number of beds open to admissions on in-patient unit from ten to thirteen and thus better data about the impact of acuity and dependency will enhance our workforce planning and modelling During autumn of 2015-16 we implemented a new in-patient unit (IPU) dependency and acuity tool The tool has been designed and adapted from the principles of the Shelford Group NHS lsquoSafer Care Nursing Care Toolrsquo as recommended by NICE httpswwwniceorguknewspress-and-mediafirst-toolkit-endorsed-by-nice-for-safe-staffing We have also adapted the Richmond Agitation-Sedation Scale modified for palliative care inpatients (RASS-PAL) to acknowledge the known increasing levels of dependency and acuity associated with terminal agitation in the dying patient How did we achieve this aspiration Action proposed for 2018-19

Complete sense check on how effective the tool is at measuring dependency acuity and revise too or make adjustments where needed


Review finding against data obtained from palliative care outcome measures We completed all of these actions and used machine learning to identify the association between staffing levels acuity and incidents How was this aspiration measured

We are now better able to use dependency acuity data to review predict our workforce modelling and needs

We continue to review dependency and acuity data over time and review how effective our current shift patterns are in meeting care needs

We are able to provide detailed reports to CGSC CGG SMT and Commissioners of acuity as measured against palliative outcomes measures

ASPIRATION 6 TO REDUCE THE NUMBER OF SERIOUS INCIDENTS AND PREVENT ANY AVOIDABLE INCIDENTS OCCURRING Rationale for choosing this aspiration


Page 29 of 68

St Cuthbertrsquos Hospice takes the provision of safe care seriously and recognises there is no room for complacency During 2017-18 in fulfilling our duty of candour we reported five serious incidents see Table 6 page 31 We have established robust processes for incident reporting using a standard incident report form and recording all details on a central spreadsheet incident reporting log Hospice staff are diligent and professional in ensuring all incident reports are completed in a timely manner and that appropriate follow-up actions are logged as and when they occur However to be more proactive in anticipating and minimising the risk of incidents occurring we will continue to ensure comprehensive reporting of lsquonear-missesrsquo ndash in other words incidents that could have developed into an accident but for a fortunate break in the chain of events What will we do to achieve this aspiration Actions proposed for 2018-19



Design a new database that is automatically completed when staff use our electronic accident and incident form to record accidents incidents

We completed all these actions How was this aspiration measured

The re-designed database will allow us to establish comprehensive baseline data for the number and severity of incidents or near-misses reported

We review the database quarterly and use this for reflective sessions with staff to identify any further steps the Hospice can take to improve safety

We report trends and patterns to CGSC CGG SMT and Commissioners and on progress towards increasing the number of near-misses reported and whether this leads to a reduction in the number of incidents occurring

ASPIRATION 7 IMPROVING THE EXPERIENCE OF STAFF AND VOLUNTEERS On alternate years we conduct either an annual staff or volunteersrsquo survey These are completed anonymously In 201819 we conducted a volunteer survey receiving a total of 165 responses around 42 The survey covers 6 categories listed below

Friends and family test

General questions taken from the previous action plan to identify progress

Volunteer Engagement

Organisation and Communication

People Management and Hospice Relationships

Morale and Volunteering


Page 30 of 68

Development and Reward

Health Wellbeing and Safety The information below demonstrates a snap shot of the main results for the period 20182019 conducted in January 2019


Page 31 of 68

It is important to note that ldquowhere we could do betterrdquo were the lowest percentages received from the entire questionnaire and will form part of the action plan for improvement derived from the responses

We believe it important to acknowledge that the majority of respondents told us they would recommend the Hospice as a care provider because of our excellent reputation service staff and volunteers the high standard of care lovely environment and through volunteering at the Hospice know the care the Hospice provides and how much it benefits the local community The main reasons respondents would recommend the Hospice as a place to volunteer

included friendly lovely atmosphere and people worthy cause a good use of time they enjoy

it feel volunteering is rewarding fulfilling a valuable experience and they feel appreciated

and valued for their contribution


Page 32 of 68

The full survey results and action plan are available on our website at httpwwwstcuthbertshospicecom We monitor and compare year-on-year key human resource performance indicators for staff see Table 5 These are reported to the Board of Trustees and Human Resources sub-committee quarterly The Hospice proactively manages absence within a supportive culture and has continued to implement a number of initiatives to support staff with stress depression and anxiety Mental health awareness continues to form part of induction as well as dementia training and staff and managers have accessed additional training such as Mental Health First Aid Other initiatives include an Employee Assistance Programme which is now well established with staff who have accessed it recommending it to others hence the increased take up and range of services accessed Staffrsquos mental wellbeing is promoted and supported with the introduction of a Wellness Action Plan (WAP) ndash a tool developed by MIND All staff are encouraged to complete one and it forms part of the Hospice induction process It appears reasonable to suggest the majority of staff are comfortable talking about their mental wellbeing and trained to notice changes in their colleagues and offer support where appropriate Factored into the policy review timetable is a Bereavement Policy and Flexible Working Policy aimed to support staff improve attendance as well as productivity engagement and retention To support business continuity changes to terms and conditions were implemented effective from 1 April 2018 This included changes to sick pay provision which was decreased with flexibility and discretion built in Existing staff were provided with 2 years protection in relation to this which will come into effect late next year Table 5 ndash Key human resources performance indicators Key performance indicator 2015-16 2016-17 2017-18 2018-19 Change

Staff turnover 82 142 20 147 Staff sickness absence 418 41 68 55 Staff involved in disciplinary procedures

4 6 4 4 -

Staff involved in grievance procedures 0 0 1 1 -

Staff involved in capability procedures 3 0 1 0


Page 33 of 68

32 New Service Developments during the period 1st April 2018 to 31st March 2019 Carer Strategy During 2017 the Board of Trustees approved a Carer Strategy during the year and implementation commenced in 201819 We have strengthened our social work team and the new social work lead supported by our specialist dementia nurse and Namaste project worker will lead on the implementation of the carer strategy MyPals The development of an innovative online platform to improve outcomes for people with life-limiting illnesses was further developed during the year with input from patients and volunteers The prototype was subject to beta testing during the year and findings from the test are being incorporated into an updated version which will be ready for concept testing in 2019 The project aims to provide a web based platform to link those with life limiting illness in the community who have care needs to a range of volunteers who can provide help support and companionship Namaste Care In 2017 our Admiral Nurse resigned after securing a regional nurse consultant post with Dementia UK To maintain our dementia service we recruited an experienced specialist dementia nurse and secured funds from two Trusts to maintain for a further year our Namaste Care Service We recruited an experienced lead and to date six volunteers have been trained in the principles and practice of Namaste care and are now developing their caseload of new patients in the community living with Dementia We secured additional funding to o continue the project for the next three years Children and Young Persons Bereavement Service In 2016-17 we bid for and secured a new commission from Durham County Council for a one year delivery of a Children and Young Persons (CYP) bereavement service for those bereaved through suicide and sudden unexpected traumatic death Due to the impact of our work and without being required to retender for the service the commissioners of the service have annually extended the contract with St Cuthbertrsquos Hospice Strengthening clinical care Following negotiations with our CCG we secured funding to support the recruitment of a palliative care consultant and recruited to this post in 2018 Following a review of our family support team we identified a need for additional qualified social worker input to improve our existing resource We recruited a senior social worker to lead a re-configured family support team with greater social work resources We are extending the skill set of our cohort of senior nurses to be trained as non-medical prescribers and two nurses achieved their qualification in 2018 We believe the addition of these new team members and enhancing and extending the knowledge skill and competence of our nursing team will strengthen clinical care and enable us to better meet the needs of those with life limiting illness access our Hospice services We also agreed to recruit to a new post of Nurse Consultant and wo we now have very strong clinical leadership in the Hospice The strengthening of our clinical team will mean we can offer for example consultant led outpatient services work out into the community and better plan for and support discharge for those rehabilitated to cope better with life limiting illness


Page 34 of 68

Improving effectiveness through performance management In 2018-19 we further enhanced organisational effectiveness by developing our approach to performance management We have developed and implemented a suite of performance management tools and resources We recruited a data analyst for 12 months to help us better understand the extensive range of data sets we produce This has helped to inform and strengthen evidence of performance of our services and the impact these have on those who use our services Strengthening Internal Governance The Hospice has continued to improve internal governance Notable this year has been the development of auditable governance standards The standards have been developed taking into account good practice in the public voluntary and private sectors The Trustees and Senior Management have continued to develop the Hospicersquos approach to the identification and management of risks which in turn makes the Hospice a safer place to work and receive services as well as more resilient in the face of adverse incidents The Board Clinical Governance and Ethics Committees considered the implications of the findings of the

Gosport War Memorial Hospital The Report of the Gosport Independent Panel June 2018 The Clinical Services Manager (CSM) as Controlled Drug Accountable Officer presented a paper to the Board Clinical Governance and Ethics Committees to outline the robustness of systems and processes in place to mitigate the risk of a clinician practicing and prescribing opioids beyond recommended best practice guidelines The CSM also presented and shared this learning with the regional Controlled Drug Local Intelligence Network annual conference

The implications of the 2018 Supreme Court judgment and definitive answer to an increasingly pressing question ndash when is it necessary to seek the approval of the court before withdrawing Clinically Assisted Nutrition and Hydration (lsquoCANHrsquo) from a person with a prolonged disorder of consciousness (lsquoPDOCrsquo) Importantly in so doing it has also answered the wider question of when it is necessary to go to court before withdrawing or withholding any form of life-sustaining treatment from a person lacking the capacity to consent to or refuse such treatment

New appointments During the year we recruited four new Trustees bolstering the legal public sector financial and digital skills and experience of our Board During the year we made a number of important nursing allied health staff and support post appointment to replace posts vacated due to people leaving or retiring from St Cuthbertrsquos Hospice We increased staffing in the Living Well Centre and have agreed to increase staffing in the Family Support Team Collaboration and engagement with other providers We continue to host the Marie Curie Rapid Response Team at St Cuthbertrsquos Hospice This service aims to prevent avoidable hospital admissions and provides support at home to help patients in their preferred place of care


Page 35 of 68

In 2018-19 we reviewed the jointly developed lsquomemorandum of cooperationrsquo and procedures and processes with Durham Prisons to manage access to hospice care for prisoners at end of life We also provided placement experience in palliative and end of life care setting for a number of Prison Health staff nurses We engage regularly with colleagues in other Hospices in our region and nationally to share good practice and support one anotherrsquos continuing commitment to quality and practice service development St Cuthbertrsquos Hospice hosts the quarterly Hospice UK northern region Executive Clinical Leads in Palliative Health Care (ECLiPH) and the annual Hospice UK Annual Roadshow for the northeast We are an active member of a formally agreed Collaborative between the 9 independent Hospices in the region We have been active members of the Countywide strategic Palliative and End of Life Care Group which is a sub-group of the Durham Health and Well-Being Board As part of this group we have been able to support developments to provide more lsquojoined-up care identify and meet unmet needs and promote good practice During 201819 this Group has reviewed middle grade medical cover across the County We continue to develop our partnership with Northumbria University to support achievement of goal three on page 14 of our Strategic Plan 2016-2021 ldquoOutstanding Palliative Carerdquo helliprsquoto create a high quality learning and research programmersquo We continue to have two funded research projects in collaboration with Northumbria University one evaluating our Namaste Care Project and the second an impact evaluation of our community project Everything in Place We have joined the Hospice UK network of research active hospices to begin to raise our profile and presence in presenting at conferences and increasing professional publications in the palliative care literature The clinical services manager attended the Local Childrenrsquos Safeguarding Board and completed level three adult and children safeguarding training St Cuthbertrsquos has a partnership agreement with Dementia UK to support the delivery of Admiral Nursing in the County Conference speakers Sharron Tolman amp Nicola Kendall conference presentation lsquoNamaste Care in the communityrsquo Dementia Conference in Edinburgh 18th April 2018 Publications Nursing Older People lsquoA relationship-centred approach to managing pain in dementiarsquo Sharron Tolman Admiral Nurse St Cuthbertrsquos Hospice Durham England Karen Harrison Dening Head of research and publications Dementia UK London England Accessed 4 April 2018httpsjournalsrcnicomnursing-older-peoplearelationshipcentred-approach-to-managing-pain-in-dementianop2018e985 Commissioned book Author Nicola Kendall lsquoNamaste Care for people living with advanced dementia A practical guide for carers and professionalsrsquo Jessica Kingsley Publication due out 2019


Page 36 of 68

33 Statement of Assurance from the Board of Directors The following are statements that all providers must include in their Quality Account Many of these statements are not directly applicable to Hospices and therefore they are included at Appendix 1 where further clarification is provided as appropriate During the period 1 April 2018 to 31 March 2019 St Cuthbertrsquos Hospice provided the following services

A 10 bedded In-patient Unit offering 24-hour care

Day care in our Living Well Centre offering treatment advice support and activities Including

Physiotherapy Occupational Therapy social care counselling and a wide range of cognitive therapy and memory work arts and crafts exercise and breathlessness groups fatigue management sessions and complementary therapies

Community Support ndash Everything in Place project

Family Support Team providing pre- and post-bereavement counselling as well as expert social care support for patients families and carers

The Children and Young Persons bereavement service commissioned by Durham County Council

During the period 1 April 2018 to 31 March 2019 St Cuthbertrsquos Hospice provided or sub-contracted four NHS services (no funding was received for Lymphoedema or Complementary Therapy services) We continued to deliver a separately commissioned Durham County Council contract to provide bereavement services for young children and persons bereaved as a consequence of sudden traumatic such as suicide trauma and drowning The income generated by the NHS services received in 2017-18 represents 100 per cent of the total income generated from the provision of NHS services by St Cuthbertrsquos Hospice Durham for 2018-19 The income generated represents approximately 46 per cent of the overall costs of running these services What this means St Cuthbertrsquos Hospice is funded by both NHS income and by Fundraising Activity The grants allocated by the NHS funding contribute to approximately 46 per cent of Hospice total income needed to provide these services This means that all services are partly funded by the NHS and partly by Charitable Funds For the accounting period 2018-19 St Cuthbertrsquos Hospice signed an NHS contract for the provision of these services Goals agreed with Commissioners A proportion of St Cuthbertrsquos income in 2018-19 was conditional on achieving quality improvement and innovation goals agreed between St Cuthbertrsquos Hospice and any person or body they entered into a contract agreement or arrangement with for the provision of NHS services through the Commissioning for Quality and Innovation payment framework


Page 37 of 68

Two year CQUNS were agreed in 201718 In the accounting period 2018-19 CQUIN measures within the NHS contract we were set three goals

CQUIN 1 Developing the effectiveness of palliative and end of life care multidisciplinary team (MDT) meetings Met in 2017-18 CQUIN 2 Development and implementation of an effective lsquolinkrsquo nursepractitioner framework This CQUIN runs over 2017-18 and 2018-19 CQUIN 3 Development and implementation of the Impact Chain framework including areas within the National End of Life Care Intelligence Network Palliative care clinical data set This CQUIN runs over 2017-18 and 2018-19

St Cuthbertrsquos Hospice met or made progress against the requirements for the CQUIN goals identified above for the period 1 April 2018 to 31 March 2019 The Clinical Commissioning Group are again adopting the Commissioning for Quality and Innovation (CQUIN) framework for some of our contract payment 2019-20 National Initiatives St Cuthbertrsquos Hospice is required to register with the Care Quality Commission and its current registration status is for the following regulated activities

Diagnostics and screening procedures

Services for everyone

Treatment of disease disorder or injury The Care Quality Commission has not taken enforcement action against St Cuthbertrsquos Hospice during the period 1 April 2018 to 31 March 2019 St Cuthbertrsquos Hospice has not participated in any special reviews or investigations since registering with the Care Quality Commission in 2010 St Cuthbertrsquos Hospice has not been subject to an unplanned inspection by the Care Quality Commission over 2018-19 Data Quality A Service Quality Performance Report was submitted to the Commissioners in each of the four quarters within the period 2018-19 Information relating to patient datasets Hospice quality and performance indicators (key performance indicators) as well as the data collection for CQUIN measures has been included in these reports This information has been collected from several sources extracted from SystmOne (our clinical recording system) with additional back-up using Excel spread sheets St Cuthbertrsquos Hospice has complied with submitting data and for the reporting of incidences in accordance with local quality requirements


Page 38 of 68

Information Governance Toolkit Attainment St Cuthbertrsquos Hospice has complied with the standards outlined in the NHS Data Security and Protection Toolkit in 201819

34 Review of Service Quality Performance during the period 1st April 2018 to 31st March 2019 St Cuthbertrsquos Hospice opened in 1988 It provides specialist medical and nursing care for people with life-limiting conditions from across County Durham The Hospice is based in the historic Park House close to the centre of Durham Patients and relatives are welcome to enjoy the several acres of beautiful grounds with views across the Durham countryside Our team of highly qualified and trained staff and volunteers work together to provide individual high-quality care in a peaceful environment and to provide care and support for relatives and carers The purpose of sharing the review of our Quality Performance during the period 1 April 2018 to 31 March 2019 is to demonstrate what we are doing well as well as to identify the areas that need improvement and how this will be achieved The review considers safety clinical effectiveness and patientcarer user experience St Cuthbertrsquos Hospice views harm-free care for patients as an important priority We adopt the principles of the Safety Thermometer along with the collection of other internal data outlined above allows us to record details of patient harm so that the evidence can be analysed in order to identify if any measures can be implemented in order to minimise the risk of harm for patients in our care Performance ndash Patient Safety In order to measure how safe our service was during the period 1 April 2018 to 31 March 2019 we adopted the principles of the former Safety Thermometer This measures harm in relation to three key areas falls pressure ulcers and urinary infection In-patients with catheters Whilst we are no longer required to submit this data on a monthly and quarterly basis we still routinely collect data internally on all falls including slips and trips as and when they occur Health Care Associated Infection (HCAI) We recognise that there are a high number of factors that can increase the risk of acquiring an infection but seek to minimise the risk of occurrence by ensuring high standards of infection control practice This will ensure that residents are cared for in a safe clean environment by addressing any deficits in standards requiring further action We have adopted the following systems and processes for Infection Prevention and Control within the Hospice


Page 39 of 68

A nominated Senior Nurse acts as our link practitioner for Infection Prevention and Control across all clinical and non-clinical areas within the Hospice The Infection Control Group continued to meet during 2018-19 and reported to the Clinical Governance Committee on a quarterly basis The Infection Control Group is represented by clinical and non-clinical members including a recently retired Consultant Medical Microbiologist The terms of reference for this group are as follows

To review existing polices and ensure that these are updated as required

To develop new policies in line with national guidelines and submit to the Clinical Governance Sub Committee (CGSC) on a quarterly basis for approval

To hold quarterly Infection Control Meetings and submit minutes to the infection control lead for the CCG on a quarterly basis

To promote and raise awareness of Infection Prevention and Control across all areas of the Hospice eg signage for hand hygiene

To undertake Infection Prevention and Control Audits from Help the Hospices Audits from Help the Hospice are carried out on a three-monthly basis across clinical and non-clinical areas This enables the Hospice to be compliant with legislative and regulatory requirements from the Care Quality Commission Department of Health and the Code of Practice for health and social care (on the prevention and control of infections under the Health and Social Care Act 2008)

Audits are submitted to the Audit Group meetings and are also submitted to the infection control lead at the CCG on a quarterly basis

Lead Nurse to participate an annual audit for Infection Control from external auditor and act on recommendations

We have established close links with the Lead Infection Prevention and Control Nurse from North Durham Clinical Commissioning Group External Lead Nurse has undertaken an external Infection Prevention and Control Audit at the Hospice on an annual basis and we have requested that this should continue for 2019-20 Infection Prevention and Control is a mandatory training requirement for staff and volunteers and is delivered twice annually We also use e-learning and workbooks in relation to Infection Control for staff and volunteers who have been unable to attend the mandatory training A county-wide Infection Prevention and Control Audit has been carried out by an external Senior Lead Nurse for Infection Control from Durham County Council at our request This audit is comprehensive covering thirteen domains requiring compliance This enables our organisation to monitor our compliance and put systems in place with infection control standards and policies where this has not previously been the case thereby reducing the risks of healthcare-associated infections We have achieved and met the standards required


Page 40 of 68

Clinical Incidents during the period 1 April 2018 to 31 March 2019

St Cuthbertrsquos Hospice had no ldquoNeverrdquo events during 2018-19 The following serious incidents were reported during 2018-19

Table 3 Summary of serious potentially serious incidents and complaints

Incident log number

Brief details of incident complaint Reported to Yes No Date STEIS Number

Outcome

20180139 Independent and with capacity fainted after going to toilet Minor laceration to head and fracture left hip

CQC X 29518 Transferred to UHND no internal fixation for conservative management Patient discharged from UHND to rehabilitation bed in the community hospital NECS confirmed closed

NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome

20180189 Diabetic patient with spinal cord compression and extensive limb sacral oedema with capacity to make decisions despite being informed of high risk of acquiring PUrsquos declined pressure-relieving interventions Subsequently acquired deep tissue injury grade 2 deteriorated to grade 3 on sacrum

CQC X 240918 No STEIS number visited by Community Specialist TVN who confirmed end of life PU ungradable who noted patient has capacity to make decisions and declined interventions confirmed all interventions offered Informed staff there was no need for STEIS report or safeguarding NECS notified for audit trail purposes via minimum incident details form and 72-hour reports

NECS X 240918 No number

Safeguarding X

CGC SMT

Incident log number


Outcome

20180231

IPU temporarily closed due to extended period of high bed occupancy at 92 and acuity and dependence tool data that indicated that the care needs were high and identified 64 staff would have been required to meet ongoing needs We were unable to secure additional staff and to safeguard the welfare of patients and staff the CSM took the decision to close IPU

CQC SMT also notified and chair of Clinical Governance Committee IPU re-opened after acuity and dependence improved

NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome

Lady at end of life with fluctuating capacity made an serious allegation to a staff nurse who asked the patient to repeat this to another staff nurse the patient could not Dr notified and spoke to patient who made allegation of assault The patientrsquos son and sister disclosed that the patient had made a recent disclosure to police of historic sexual assault of her and her sister who confirmed this Next of kin felt this was reference to historic assault as the patient had been recalling this Agreed to raise with adult safeguarding and notify CQC

CQC X NA Safeguarding lead notified First Contact First contact open up an adult safeguarding case which after consultation with police and given recent history was closed with no further action recommended The CSM spoke with relationship officer at CQC with no further action required expect confirmation of outcome same conveyed to officer

NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome

Near miss with Midazolam wrong dose vials 2mg in 2ml instead of 10mg in 2ml supplied in the wrong box from local nursing home CQC verbally notified but no error on our behalf

CQC NA Pharmacist discussed with NECS CD-LIN concern that GP prescriber had prescribed the wrong dose despite NECS guidance NECS to safeguard not to prescribe 2mg in 2ml NECS were to raise safeguard against the prescriber CQC to be informed of the care home who supplied the wrong vials in the box so the adult social care team could review

NECS X

Safeguarding X

CGC SMT


Page 42 of 68

Performance - Clinical Effectiveness The purpose of sharing the review of our Quality Performance during the period 1st April 2018 to 31st March 2019 is to demonstrate what we are doing well as well as to identify the areas that need improvement and how this will be achieved Measuring clinical effectiveness is important to St Cuthbertrsquos Hospice as it enables us to have an accurate picture and understanding at all levels of activity across all the services provided This helps us to identify areas for improvement and demonstrate to members of the community that we serve that the Hospice is meeting its goals Full data reports have been submitted in accordance with data set requirements to the Commissioners Specific key performance indicators (KPIs) with threshold targets allow our goals to be measured on a quarterly basis We have submitted the full data sets from 1 April 2017 to 31 March 2018 so that comparisons can be made within the specified period Where we have not met the threshold target this has been highlighted in red and a summary below the box highlights the reasons why these targets have not been met Although the National Minimum Dataset (MDS) is no longer formally collected following the merger between Hospice UK and the National Council for Palliative Care (NCPC) on an annual basis we have continued to collect a similar dataset please see Table 8 page 45 MDS groups returns from individual units against number of beds and number of patients seen across the different services provided so that comparisons can be made like for like We have been included as a small category since we have fewer than 11 beds on the In-patient Unit All other services have been included as medium categories due to the total number of patients seen The KPIs highlighted below in the Table 7 page 43 and reported to our Commissioners provide one method for measuring clinical effectiveness within our organisation to identify areas for improvement as well as benefitting the Hospice and the community we serve that our services are achieving what we intended to achieve Please note that those KPIs that have not been met are clearly identified and the reasons why are explained in the comments column of the Table concerned


Page 43 of 68

Table 7 - Results of Key Performance Indicators during the period 1 April 2018 to 31 March 2019

Table 7 ndash Hospice activity 2018-19

End of Year 2018-19 quarterly performance

MEASURES Threshold 2017-18

Met ndash Not met

Q 1 Q 2 Q 3 Q 4 End of

year

Comments Year 2017-18 Performance

In-Patient Unit (IPU)

Number of Inpatients who have been offered an Advance Care Plan (ACP)

90 942 Met 938 974 925 934 942

Inpatient bed availability 95 945 Not met 987 985 996 998 992

Inpatient bed occupancy

85 768

Not met 74 904 867 83 835

Report percentage of people who died in the Hospice and have preferred place of death recorded

NA for monitoring purposes

928 Not met 929 96 929 889 926 This threshold is difficult to achieve as there are patient admitted who are so near end of life we are unable to confirm their preferred place of death

Report percentage of people who died at the Hospice who stated their preferred place of death and achieve it


942 Met 100 958 962 833 94 From Q1 2019-20 Report onwards

Total Number of Patients admitted to IPU


162 - 48

38 41 44 171 Following meeting with CCG management plan in place to monitor bed occupancy and spreadsheet developed to review reasons why admissions declined

Living Well Centre (LWC) - Day Care Services of Living Well Centre patients Outpatients receiving a care plan

100 100 Met 100 100 100 100 100

Time from LWC Outpatient referral to assessment gt=90 within 7 days

Living Well Centre (100) 90 742 Not met 883 935 882 975 919


Page 44 of 68

Total Number of patients attending LWC

416 - 113 130 152 144

Physiotherapy (100) 100 Met 100 100 100 100 100

Specialist Dementia Nurse (100) Note as only one practitioner 15 days more realistic

Within 15 days

937 Not met 100 886 91 100 949 New appointee to the post of specialist dementia nurse We have now agreed with Dementia UK to use the term Admiral Nurse

Total number of patientsclients attending dementia services


210 - 16 43 44 66 169 Reduction in numbers related to gap in response times due to new referrals following the appointment of our new Admiral Nurse

Family Support Service

FST Bereavement ndash client to be contacted within 15 working days of receipt of referral

gt=95 775 Not met 100 100 100 100 100

FST Bereavement- client assessment to commence within 15 working days of receipt of referral

gt=95 426 Not met 163 419 233 275 273 Following consultation with FS team senior management are looking to new team leadership commenced in the quarter management action plan to be developed

FST Bereavement- written assessment of needs and action plan agreed with client

100 100 Met 100 100 100 100 100

Total number of clients accessing FST

NA 335 - 83 82 88 90 343


Page 45 of 68

Table 8 - Comparing St Cuthbertrsquos Hospice Minimum Dataset to National Minimum Dataset Individual Reports 2018-2019

Service Area Indicator Hospice 2017-18

Hospice 2018-19

Inpatient Services Total Number of Patients within a year treated 162 171

Inpatient Services Total New Patients 140 147

Inpatient Services Re-referred Patients 22 9

Inpatient Services Average Bed Occupancy () NB Length of Spell greater than 15 days increased year from 317 in 16-17 to 416 in 17-18

821 83

Inpatient Services Cancer Diagnosis () 83 836

Inpatient Services Non Cancer Diagnosis () 17 164

Inpatient Services Average Length of Stay (days) 166 179

Inpatient Services Died in Hospice () 623 635

Inpatient Services Discharge Care Home () 44 35

Inpatient Services Discharge Acute () 13 12

Inpatient Services Discharge Home () 32 306

Inpatient Services Discharge Hospice () 0 12

Day Hospice Total Number of Patients Treated 200 268

Day Hospice Number of New Patients 130 175

Day Hospice Total Available Places 3600 3675

Day Hospice Total Places Attended 3139 3424

Day Hospice Total Booked Places DNA 1412 1521

Day Hospice Average length of care (Days) 212 72

Day Hospice Cancer Diagnosis () 445 463

Day Hospice Non-Cancer Diagnosis () 555 537

Day Hospice Access to Physiotherapist (total number of Hospices in UK) Yes Yes

Day Hospice Access to Medical Consultant (total number of Hospices in UK) Yes Yes

Day Hospice Access to Occupational Therapist (total number of Hospices in UK) Yes Yes

Day Hospice Access to Spiritual Support Worker (total number of Hospices in UK) Yes Yes

Day Hospice Access to Complementary Therapist (total number of Hospices UK) Yes Yes

Bereavement Services[1] Total number of patients seen within year 228 186

Bereavement Services[1] Total new patients 172 146

Bereavement Services[1] Total continuing patients 56 43

Bereavement Services[1] Face-to-face by trained amp professionally accredited counsellor 1171 973


Page 46 of 68

Hospice Quality and Key Performance Indicators Information relating to patient datasets Hospice quality performance indicators and CQUIN targets has been submitted to the Commissioners on a quarterly basis during the period 1 April 2018 to 31 March 2019 This information has been collected from several sources extracted from SystmOne with additional back-up using Excel spreadsheets

Clinical Audits Clinical Audit is defined as ldquoa quality assurance and enhancement processrdquo It is a means of reviewing performance to ensure that what should be done is being done and provides a framework to enable improvements to be made A comprehensive programme of clinical audits have been undertaken over the period 1 April 2018 ndash 31st March 2019 This audit timetable will be repeated over 2019-20 An overview of clinical audits undertaken 2017-18 is included at Appendix Two at the end of this document

Patient and Carer Experience Safety experience and positive outcomes are of vital importance to our Hospice and it is essential that our environment and the delivery of high quality care meet the needs wishes and preferences for all our patients carer and service users We deal with all complaints as per our Complaints Policy and Procedure and over 2018-19 dealt with one formal complaint the finding and outcome are summarised in Table 9 page 47 We value the feedback of patients carers and visitors about their experiences whether this is positive or not which will not only provide a framework against which we can gauge our current performance but also serve as a basis from which to continuously improve our services Analysis of the data which we collect from a variety of sources allows us to identify areas where we are recognised as providing an optimal service (so we can ensure that standards are maintained) and to make progress in areas where this is not the case This year we include Friends and Family Test service user feedback collated for all services please see Appendix 3 Analysis and evaluation of data collated during the period 1 April 2018 to 31 March 2019 has provided valuable information in order to continue our commitment to continually develop our services During this period we have used a range of methods (questionnaires as well as interviews) to collect information from patients and carers across the range of services including the In-patient Unit day services in our Living Well Centre Family Support Team and our dementia and Namaste services We collect service user feedback from a variety of different sources including comments made in questionnaires from one to one interviews and comments made in letters and cards received during the period 1 April 2018 to 31 March 2019 In order to facilitate further improvements for engaging with patients families carers and friends we have updated our website to make this more interactive and have increased the use of social media to include Facebook and Twitter and have suggestion boxes which are left in communal areas across the Hospice The comments made in the suggestion boxes are attached as Appendix 3


Page 47 of 68

Table 9 Complaints We received one formal complaints during 2018-19

Brief details of complaint Outcome

Family member complained that a previous complaint had not been published in the Quality Account for 201516

Investigation carried out concluded that the complaint referred to had been made informally and therefore was not reportable The complaint was not held The complainant indicated they were dissatisfied with the outcome but did not use the appeal process outlined in the organisationrsquos Complaints Policy and Procedure Closed


Page 48 of 68

35 The Board of Directorsrsquo Statement

It is my pleasure to endorse the Quality Account for St Cuthbertrsquos Hospice for 2018-19 It will be evident to all our patients their families and carers that Quality remains at the centre of everything that we do and the Board of Directors has a commitment to ensure that the highest standard of palliative care is delivered to those in need of our services This incorporates clinical corporate and information governance It was an added assurance that several members of the Board have spent time in clinical services on ldquoback to the floor daysrdquo which has given the Board a good insight into the high quality of work done and added reassurance that the reports from Management are truly reflective of the day to day experience of our patients staff and volunteers Whilst targets and objectives are an important element in the service we provide it is the human service that is such an integral part of our mission particularly ensuring that patients are treated with respect compassion and dignity Our vision remains the same To be a centre of excellence within our community and to provide all-embracing compassionate and individualised care to all those affected by life-limiting illnesses at a time and a place that is right for them We will remain focussed on achieving this vision by a continued focus on quality and by continuing to listen to the community we serve Angela Lamb Chairman Board of Directors of St Cuthbertrsquos Hospice Durham


Page 49 of 68

36 Statement from North Durham and Durham Dales Easington and Sedgefield Clinical

Commissioning Groups for the St Cuthbertrsquos Hospice Quality Account 201819

NHS North Durham and Durham Dales Easington and Sedgefield CCGs are pleased to have had the

opportunity to review and comment on the Quality Account for St Cuthbertrsquos Hospice for 201819

Commissioners felt that the report was well written and presented in a meaningful way for both

stakeholders and service users The CCGs would like to commend the hospice on its achievements in

201819 particularly the continued structured approach to quality improvement The report provides an

open account of where improvements in priorities have been made

The hospice are congratulated on their success on achievement of various awards during the year including

the Northumbria in Bloom CarResidentialConvalescent Homes Hospices and Day Care Centre Award in

which you were awarded the gold and overall category winner

The results demonstrated from the safe care targets in relation to falls pressure ulcers UTI and VTE are very

pleasing Whilst we note that there has been an increased in reported falls we believe this is a result of

more open reporting It is encouraging to read that these remain priority areas in the coming year

It is pleasing to read the positive results from the annual volunteers survey the hospice have scored

extremely highly in the majority of domains and it is reassuring to note that where improvements have

been identified these will be taken forward in the form of an action plan

We acknowledge the positive reduction in the hospicesrsquo human resources performance indicators which

have been supported by initiatives introduced by the hospice such as Mental Health First Aid

The hospicersquos achievement of set Commissioning for Quality and Innovation (CQUIN) goals is commended

around the development and implementation of an effective link nursepractitioner and the Impact Chain

Framework Continued engagement on CQUIN for 1920 is recognised and appreciated

Although the NHS Safety Thermometer was not developed directly for hospices St Cuthbertrsquos continue to

embrace the principles of the Safety Thermometer which are reflected as further improvement priorities

for 201920

The CCGs welcome the quality priorities identified for 201920 in the quality account and support the

inclusion of these to ensure a high quality of service for patients and carers We look forward to continuing

to work in partnership with the hospice to assure the quality of services commissioned in 201920

Gillian Findley

Director of Nursing and Quality

North Durham Clinical Commissioning Group (CCG)

Signed in consultation with North Durham CCG and Durham Dales Easington and Sedgefield (DDES) CCG


Page 50 of 68

Appendix 1

Mandatory Statements that are not relevant to St Cuthbertrsquos Hospice The following are statements that all providers must include in their Quality Account but which are not directly applicable to Hospices and are therefore included as an appendix (Appendix 1) with clarification provided Participation in Clinical Audits During 2018-19 no national clinical audits and no national confidential enquiries covered NHS services provided by St Cuthbertrsquos Hospice During 2018-19 St Cuthbertrsquos Hospice did not participate in any national clinical audits and no national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in Consequently the national clinical audits and national confidential enquiries that St Cuthbertrsquos Hospice was eligible to participate in during 2018-19 are not listed below St Cuthbertrsquos Hospice was not eligible to participate and therefore there is no information or data to list or submit St Cuthbertrsquos has not reviewed any national audits during 2018-19 and therefore has no actions to implement Research The number of patients receiving NHS services provided or sub-contracted by St Cuthbertrsquos Hospice in 2018-19 that were recruited during that period to participate in research approved by a research ethics committee was none There were no appropriate nationally ethically approved research studies in palliative care in which St Cuthbertrsquos Hospice could participate


Page 51 of 68

Appendix 2

Table 10 - Annual Clinical Audit Schedule

Audit tool Source Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Person responsible for audit and reporting

PatientCarer experience CCG FSTM EC

Controlled Drugs Hospice UK CSM PSM

Day Hospice admission Hospice UK PSM DHMN

In-patient Admission Hospice UK PSM

Medicines management Hospice UK PSM SSN

Nutrition Hospice UK PSM SSN

Pain Hospice UK PSM

Infection Control (4 per quarter) Hospice UK SSN DHN GSM

Bereavement Internal FSTM

Mattress Internal HCAs

Pressure Ulcer (new April 2016)

Hospice UK PSM SSN


Page 52 of 68

Appendix 3

Table 12 Summary of suggestion box comments

2018-19 Source Individual Idea Benefits Additional comments Action

Quarter 1

April No suggestions received

May Reception Volunteer Can we put or offer wooden forks when selling salads in Kitchen

Anyone eating out not always have a fork

Disposable and biodegradable cutlery is now available in the coffee shop

Reception Volunteer A big sign to say St Cuthbertrsquos Hospice are here saying Coffee Shop Not enough advertising we are here Advertise on Radio as well

The sign saying St Cuthbertrsquos is so small you are past it before you notice it I would be willing to fund raise to help pay for more signage

We have on a number of occasions approached the council for better signage but they are unable to support this The coffee shop has signed up to the County Durham Breast Feeding Scheme and our details are available on their database when anyone searches for coffee shops in the area This may bring greater publicity to the coffee shop

Reception Staff Member

Bike racks outside front of hospice for guests Visitors

Currently people are attaching bikes to disabled sign are assembly point

Bike rack at back of Hospice to be reviewed and re-sited near the front of the Hospice

June Reception Unknown A selection of different gifts etc in display cabinets

To sell more There are two bike racks available at the back of the Hospice outside the kitchen We will attempt to make one available at the front of the Hospice

Quarter 2 July No suggestions received


Page 53 of 68

August Post room Staff Member

Can we please get the tap in the post room kitchen fixed Its really frustrating not being able to turn it off properly - plus not very environmentally friendly wasting all that hot water

This has been repaired

Ladies toilet near finance

Staff Member

Also please fix the light in the Ladies loos near Finance Its awful going in the dark especially now Autumn is on its way

This is scheduled for service and repair

September No suggestions received

Quarter 3

October IPU Anonymous Bell push canrsquot tell if you pushed it Really needs red light so you know you pushed for assistance and donrsquot push again by mistake

We are looking to introduce a

new nurse call system for the In

patient unit which should resolve

this issue

IPU Anonymous

Bed tables donrsquot fit over electric chairs Tables need to be more manoeuvrable

This has been investigated and there are no other available widths on the market to the specification we require These are used for the beds and the chairs Staff have inclined patients chairs or offered a cushion pillow for greater comfort and accessibility when using the electric chairs

IPU Anonymous

More staff needed More breaks for staff Sometimes working 12 hours with no break When staff are called sometimes there are numerous issues but they

Patients are attended to

more quickly and not left in

bed for long periods of time

Thank you for your comments We are treating this as a complaint and the concerns raised are being investigated


Page 54 of 68

are too rushed and donrsquot give time to ask or disappear for a long time Staff need to not take frustrations out on patients regardless of what else is happening

Reception Anonymous

A memory wall in reception pictures of patients with their names Would be a nice memorial

We have a number of ways for friends and family to memorialise their loved ones at the Hospice Three times a year our Family Support Team host our Time to Reflect for those who have died in the Hospice in the preceding months To the side of the Hospice building is our peaceful in memory garden where our in memory tree is situated The garden is available to visit at any time and loved ones are able to dedicate a leaf in memory of a loved one if they wish We also have our annual Light up a Life event in the Winter and the Sunflower campaign in the Spring to which we invite people to make a donation in memory of a loved one Names remembered as part of Light up a Life are included in our annual book of remembrance which is permanently displayed in the quiet room There is no minimum donation amount for someone featuring is this book The names of people remembered as part of Sunflower campaign are written on sunflowers which are displayed in the Hospice grounds throughout June amp July When developing these memorials we have thought carefully about their locations particularly how our patients and their friends and family would feel about encountering them We have also considered the space that would be needed if a memorial grew over time It is felt that a permanent memorial display on the in-patient unit would be difficult for our current patents and their visitors to avoid if they did find this upsetting as well as there being limited space available for such a display


Page 55 of 68

November There were no suggestions in November

December Unknown Anonymous Christmas CDs because itrsquos Christmassy

There were a number of events and activities to celebrate the festive season including visiting carols singers music in the Hub Christmas decorations and trees were visible in all areas of the Hospice including reception

Quarter 4

January No suggestions received

February Reception Staff member

Coat hooks on back of toilet doors along FSTEDU Suite corridor

Dont have to put coatbag on floor

Discussed with Central Support Services Manager to review requirements and explore option of adding coat hooks

March Living Well Centre

Anonymous Better selection of food in cafeacute more varieties in sandwichessalads maybe a new springsummer menu Offering more choice might encourage customers to spend more in coffee shop

Guests using coffee shop several days a week would benefit from different options of food available menu has remained the same for ages

Discussed with Guest services manager who will review and refresh cafeacute menu

Friends and Family test feedback 2018-19 Appendix 4


Page 56 of 68

Q1 Comments None received Q2 Comments None received

Q3 Comments None received Q3b Comments None received

0

20

40

60

80

100

Male Female

1 Are you n=7620182019

IPU Admiral Nurse Family Support Team Living Well Centre

0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range

Q2 What age are you n=7620182019


0

20

40

60

80

100

Yes No No Answer

Q3 Do you consider yourself to have a disability n=76

20182019


020406080

100

Q3b Which of the following best describes your ethnic background n=76

20182019



Page 57 of 68

Q3c Comments None received Comments Q 4 Thinking about your response to this question what is the main reason why you feel this way

Questionnaire IP2 I would recommend based on friendly professional staff Questionnaire IP5 Excellent service throughout This is the standard which other providers should try to achieve Questionnaire IP7 Everything and everyone was perfect Questionnaire IP8 Staff were absolutely fantastic They were lovely to my mum and they made her laugh and smile every day Questionnaire IP9 Service excellent Questionnaire IP10 The dedication and wonderful care given by all staff Their meticulous personal care given to each patient Questionnaire IP11 Excellent professional caring service could not be better No request refused Well done Questionnaire IP12 Facilities staff and care provided are exceptional Questionnaire IP13 I have only recently been discharged after being admitted for symptom control My family were overwhelmingly impressed by the treatment I received As a result I would highly recommend any family or friends to use St Cs if they needed similar care or treatment Questionnaire IP14 Great care for my wife from everyone from consultants doctors cleaners nurses chefs etc Questionnaire IP15 Because of the extreme kindness and care I received while in the hospice

0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely

Likely Neitherlikely orunlikely

Unlikely ExtremelyUnlikely

DontKnow

No answer

How likely are you to recommend the care received at St Cuthberts Hospice to friends and family if they needed similar

care or treatment n=76 20182019



Page 58 of 68

Questionnaire - NM1 This is the only service I have seen that places the patients and carers emotional and social needs above their medical needs which is hugely important and brings great relief The care provider is also excellent Questionnaire - NM2 Very friendly and professional service Questionnaire - FST 1 My husband and I both received excellent care during the 5 weeks he was in St Cuthberts Questionnaire - FST 2 Nothing was a problem Excellent level of care All staff from receptionists cleaners doctors nurses are amazing (Sorry if Ive missed anyone out) Did not feel like a clinical place no horrible hospital small or feeling You are well looked after here when you call for help you dont wait long at all like a hospital Questionnaire - FST 3 Hospice is extremely inviting No expense has been spared when furnishing and all staff are amazing and always found time for on both times that she was in the hospice Questionnaire - FST 4 The manner in which was treated from her initial arrival to the last goodbye for the family was absolutely brilliant The staff were caring from the nurses doctors ladies in the cafeacute and the pastor who provided words of comfort In gratitude to the way in which treatment were undertaken I enclose a small donation with heartfelt thanks from all her family Questionnaire - FST 5 Personal attentive care by compassionate staff Dignity maintained at all times Questionnaire - FST 6 Simplehellipquality of care for both patient and family was outstanding nothing was too much trouble and the pain was relieved by the happy nature of the staff who felt part of the family Questionnaire - FST 7 The care and attention given to my husband the late was wonderful - a big thank you to nurses and doctors who were involved I was looked after too Thank you to all Questionnaire - FST 9 My dad was treated so kindly by all the staff we were made to feel so welcome and everything was discussed with us about dads care The environment was calm and soothing Questionnaire - FST 10 All staff were exceptional and service received was well above expected Questionnaire - FST11 Compassion and care given by staff to my father and family Questionnaire - FST12 Kindness and sensitivity shown by staff Excellent standard of care Support shown to my dad myself and brother Very professional Questionnaire - FST13 Gave me exceptional support which allowed me to be my husbandrsquos wife not his nurse or carer - something that was very important to us and let us build good memories even in his final days Questionnaire - FST14 Excellent kind care given to by hospice staff and support to family Questionnaire - FST15 The staff were wonderful to Doreen and me and all the family They were caring kind professional and so hard working Questionnaire - FST16 Everyone from senior staff to volunteers and domestic staff were so friendly and helpful They took time to listen chat and try and sort out any problems It was so comforting to know that Tom was being so well cared for Questionnaire - FST17 My mother had cancer and was an inpatient for the last few weeks of her life The doctors and nurses took exceptional care of her and I was able to stay with her from family support came to meet both off us which was reassuring Following her death support from the team has been sensitive and non-judgemental at a difficult time Questionnaire - FST18 Overall the service provided made a difficult time very manageable Questionnaire - FST20 Relief that my husband was in genuine caring hands The whole family were cared for We were able to relax and enjoy our time together


Page 59 of 68

Questionnaire - FST21 Very caring people everyone was helpful Questionnaire - FST22 This service was a lifeline to me My husband was in need of 24 hour care and at the end of a very long illness Due to my own illnesses I would have been unable to give the care needed at this time With no capable adults there was no one else to give this care The care was beyond our expectations There was expert support for him at all levels to allow him to pass peacefully without pain Questionnaire - FST23 The care given to my mam was exceptional the kindness patience supportive and genuine respect shown to her made me feel at ease and comfortable to allow myself to hand her care over Myself and family where all treated so well by staff and felt that we had known them for ever They were very professional discreet helpful easy to approach answered all my questions and supportive The environment was five star Questionnaire - FST25 My mother was looked after amazingly and I will be externally grateful Questionnaire - FST26 Superb service - thank you Questionnaire - FST27 It was comforting to know that my father was receiving excellent care in a relaxed and supportive environment in his final weeks This enabled his family to spend as much quality times possible with dad Questionnaire - FST28 Very helpful caring and kind Questionnaire - FST29 Pleasant staff Questionnaire - FST30 St Cuthberts provides high quality nursing care to both patient and family alike Questionnaire - FST31 My father was well cared for and treated well in his last few days Questionnaire - FST32 Everyone we encountered at the hospice was so caring helpful and understanding to our needs at a very sad time Questionnaire - FST34 My wife was well cared for in pleasant surroundings in the last 3 weeks of her life Questionnaire - FST35 Everyone gave my husband 100 care Questionnaire - FST36 Everything and everyone was so helpful and supportive both to my mum and my family Her and our comfort was their priority and meant that we could relax knowing that she was being looked after compassionately Questionnaire - FST37 Care Questionnaire - FST39 My wife was well cared for and family and friends were also well cared for Questionnaire - FST40 Excellent professional service Questionnaire - FST41 was made to feel at home in the hospice the staff were extremely professional but also were able to have a laugh with Kelly and her family which helped a lot I would like to say a huge thank you to all the staff at St Cuthberts Hospice and also the doctors I have told all of my family and friends about our experience with St Cuthberts and how in such a difficult time they were all there for us Thank you Questionnaire - FST42 We felt very supported The care was excellent Nothing was too much bother Also the after care has been very very good 20 out of 10 Questionnaire - FST43 The care given to my mother in her last days was really lovely The staff all staff but especially the nursing team who looked after her so well it was such a shame she was I think unaware of her comfortable surroundings Questionnaire - FST44 My mam received fantastic care The staff treated her with complete compassion and dignity Although this was a devastating time for us we were glad the staff werent glum They had the right mix when appropriate Thank you Questionnaire - FST45 Caring and supportive staff Very comforting and thoughtful Grateful for the 3 comfortable dayrsquos husband had in hospice


Page 60 of 68

Questionnaire - FST46 Care and support services are second to none Our father was cared for by a wonderful team of staff who were passionate about service delivery and genuinely cared about the wellbeing of the patient and family members I would highly recommend St Cuthberts Hospice and continuously sing the praises of the staff and work they do Questionnaire - LWC 1 The staff are very friendly and approachable They listen to your needs and requirements and do there utmost to accommodate them They always go that extra mile to make sure your visit is a happy one Questionnaire - LWC 2 I feel this way as the staff look after you very well and cant do enough for you Questionnaire - LWC 4 Very friendly Questionnaire - LWC 5 Helpful and friendly staff Look forward to company Questionnaire - LWC 6 Good support friendly people good banter Questionnaire - LWC 7 Due to the staff running the Living Well Centre Questionnaire - LWC 8 Because of the care offered by the staff both to the patient and the patients family Questionnaire - LWC 9 Makes me feel good about myself Questionnaire - LWC11 Mainly because everyone is very kind and caring towards me I feel very lucky to be able to come to the hospice (itrsquos a lovely peaceful restful place to visit) Questionnaire - LWC13 CaringKnowledgeableUnderstanding Questionnaire - LWC14 A caring and supportive environment place with caring loving professional staff wonderful wonderful volunteers and guests who become family and friends Welcoming clean and well equipped hospice in superb location surrounded by amazingly tended gardens Questionnaire - LWC15 I felt down and low when I first came and now I feel wonderful

IPU and Living Well Centre service user questionnaire feedback 2018-19


Page 61 of 68

0

20

40

60

80

100

Yes No Cant Remember No Answer

Q5 During your time in our care did you receive

an information packleaflet n=30

Apr - Jun Jul - Sept Oct - Dec Jan - Mar

0

20

40

60

80

100

Yes No Cant remember No answer

Q6 If you received an informationleaflet was it easy to understand (if you ticked No please indicate why) n=30


0

10

20

30

40

50

60

70

80

90

100


Q7 Was the information pack leaflet helpful (If you ticked No please indicate why) n-30


0

20

40

60

80

100


Q8 Was there anything in the information packleaflet that you found to be incorrect (If you ticked Yes please indicate

why) n=30



Page 62 of 68

0

20

40

60

80

100

Always Most of thetime

Some of thetime

Never No Answer

Q9 When you accessed our services did the staff introduce themselves to youyour loved one n=30


0

20

40

60

80

100

Always Most of the time Some of the time Never

Q10 Did you have confidence in and trust the staff who were caring for youyour loved one n=30


0

20

40

60

80

100


Q11 Did you have the opportunity to ask questions when you your loved one wanted to n=30


0

20

40

60

80

100


Some of thetime

Never No answer

Q12 Did our staff treat youyour loved one with respect and dignity n=30



Page 63 of 68

Do you have any further comments you would like to make Questionnaire - IP3 Because both myself and husband both have cancer Staff knew and concerned you have a really good team Questionnaire - IP 5 Totally professional as well as being friendly and caring Questionnaire - IP8 I cannot praise the staff at St Cuthberts highly enough Every visit was a pleasure despite the circumstances Questionnaire - IP10 We were all grateful for the warm and respectful welcome and approach Questionnaire - IP12 Very friendly very approachable Nothing too much trouble Questionnaire IP13 I am still emotional about my time at St Cs It was an absolutely incredible experience in my life I was very ill and had completely lost confidence Gently and steadily your staff built me up allowing me to be ill and too rest etc Symptom control ie medication tweaking was ongoing and discussed with me My family was completely reassured about me being at St Cs Questionnaire IP14 Superb one and all Questionnaire - LWC 2 I have loved my time here Both staff and clients have been really helpful Questionnaire - LWC 7 Brilliant Questionnaire - LWC10 Itrsquos a pleasure to attend Questionnaire - LWC13 Very professional staff Questionnaire - LWC14 Above was answered as a living well guest

0

20

40

60

80

100


Some of thetime

Never No answer

Q13 Were youyour loved one treated with

respect and courtesy n=30


0

20

40

60

80

100


Some of thetime

Never No answer

Q14 Was you your loved ones privacy respected during discussions with our staff n=30


0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer

Q14b Were our staff well informed about you or your loved ones condition or treatment n=30



Page 64 of 68

Do you have any further comments you would like to make Questionnaire - IP3 Unsure of 1 or 2 answers Overall excellent service Staff all great some of best ever (gold star) Questionnaire - IP8 See above Questionnaire - IP10 We were all wonderfully cared for Questionnaire - IP12 If the nurses were busy they made every effort to advise my wife that they would be back after dealing with another patient Questionnaire - IP13 The practical care and routine was second to none However for me the care gentleness efficency etc of the staff - all- was understanding They never made me feel guilty about asking for anything and came immediately if I did buzz for help I made an effort not to abuse however The nurses are full of love and they talk with the patients The fact that they are also receiving therapies eg reiki and mindfulness etc is great These complementary therapies are very helpful Questionnaire - IP14 Just one thank you Questionnaire - LWC10 Excellent care and concern Questionnaire - LWC13 Very caring staff Questionnaire - LWC14 Above answeredNot answered as not been an inpatient or had loved ones as patients

0102030405060708090

100


Some of thetime

Never No answer

Q14c Did our staff respond promptly when you or your

loved one neededcalled for assistance n=30

Apr - Jun July - Sept Oct - Dec Jan - Mar

0

20

40

60

80

100


Some of thetime

Never No answer

Q14d Did our staff try to meet yours or your loved ones individual needs and preferences n=30


0102030405060708090

100


Some of thetime

Never No answer

Q15 Did our staff offer explanations about the care and treatment provided to you or your loved one n=30



Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100

Poor Adequate Good Very Good Excellent na No Answer

Q16 The cleanliness of our premises n=30


0

20

40

60

80

100

Poor Adequate Good Very Good Excellent na

Q17 The general environmentsurroundings n=30


0

20

40

60

80

100


Q18 The facilities in patients rooms to support patient care n=30


0

10

20

30

40

50

60

70

80

90

100


Q19 The quality of our catering n=30



Page 66 of 68

0

20

40

60

80

100


Q20 Access to food and drink outside of set

meal times n=30


0

20

40

60

80

100


Q21 Were our facilities able to support you staying overnight if needed n=30



Page 67 of 68

Do you have any further comments you would like to make Questionnaire - IP1 All the staff where friendly and very good in every way with my mother Questionnaire - IP3 Too long sitting (know it was for safety) had to buzz everytime needed toilet Difficult when on Furosemide Questionnaire - IP5 5 star accommodation Questionnaire - IP7 My husband was treated so well with respect and outstanding care All staff were just wonderful Questionnaire - IP8 Overall care was excellent Staff were helpful friendly and accessibly Questionnaire - IP9 The bed I used was noisy due to air pressure on bed Questionnaire - IP12 More car parking spaces requiredotherwise an excellent facility Questionnaire IP13 I am only sad to have left I keep listening for the trolleys with medicaitons or cups of tea My room became my universe in fact I only left the IPU once to walk arund the grounds with my brother The bed was so comfortable and I slept well and safely I loved the nurses doctors cleaning staff and vlunteers honesty and felt so safe I do hope I can be readmitted when my time comes and want to extend a massive thank you to you all (I have no fear of death after being at St Cs) Questionnaire IP15 Only that the love and care I received where of the highest quality Questionnaire - LWC 6 Always felt safe and able to talk to people if needed Questionnaire - LWC 7 From day one it has been brilliant Questionnaire - LWC 11 Just thank you for having me Questionnaire - LWC12 Can get very hot in the hub no air conditioning Questionnaire - LWC14 Hospice is vital to assist affected people who suffer their individual illnesses I can only speak so very highly of St Cuthberts Hospice it hasmade an enormous diffrence to my well being and care and Im so very very grateful to each and every member of this vital establishment Questionnaire - LWC15 I am a picky eater and struggled with the menu sometimes in the coffee shop

0

10

20

30

40

50

60

70

80

90

100

Yes No No answer

Q22 Are you aware of what to do if you wanted to make a complaint n=30



Page 1 of 68

Our Mission To make every day count for those affected by life-limiting illnesses Our Vision To be a centre of excellence within our community and to provide all-embracing compassionate and individualised care to all those affected by life-limiting illnesses at a time and a place that is right for them Our Values

Respect

Professionalism

Choice

Compassion

Reputation

Integrity Our Philosophy of Care St Cuthbertrsquos Hospice acknowledges the single focus of our services is to ensure that we provide a safe environment in which to deliver excellent care for every individual who uses our services We recognise that care must be delivered to reflect the individualrsquos unique needs and that they and their loved ones must be treated with courtesy respect and dignity Our aim is to support each person and their family and friends to make informed choices about their care and decisions affecting their lives Care is planned to support the total well-being of each person taking into account his or her physical psychological social and spiritual needs We will work together to provide a warm and welcoming atmosphere that accommodates diverse cultures and lifestyles within a calm and compassionate environment As a team we will strive to provide care of the highest standard by ensuring staff are up to date with current research practice development and training We are aware of the valuable work undertaken by individuals and agencies in the community and we will work in partnership with them to provide excellent services for the people of Durham We see life ndash and death ndash as a journey to be made in the company of others We are rooted in our local community and we approach life and death through a philosophy based on support and hospitality


of 68

CONTENTS

Section Page










49






Page 3 of 68



Page 4 of 68











Page 5 of 68






and dependence tool





IPOS

Views on Care

Barthel Index

(In-patients only)




Page 6 of 68








Page 7 of 68
























Board (Quarterly)







Page 8 of 68



NHS Improvement




Page 9 of 68

Awards










Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 2 of 68

CONTENTS

Section Page










49






of 68



Page 4 of 68











Page 5 of 68






and dependence tool





IPOS

Views on Care

Barthel Index

(In-patients only)




Page 6 of 68








Page 7 of 68
























Board (Quarterly)







Page 8 of 68



NHS Improvement




Page 9 of 68

Awards










Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 3 of 68



of 68











Page 5 of 68






and dependence tool





IPOS

Views on Care

Barthel Index

(In-patients only)




Page 6 of 68








Page 7 of 68
























Board (Quarterly)







Page 8 of 68



NHS Improvement




Page 9 of 68

Awards










Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 4 of 68











of 68






and dependence tool





IPOS

Views on Care

Barthel Index

(In-patients only)




Page 6 of 68








Page 7 of 68
























Board (Quarterly)







Page 8 of 68



NHS Improvement




Page 9 of 68

Awards










Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 5 of 68






and dependence tool





IPOS

Views on Care

Barthel Index

(In-patients only)




of 68








Page 7 of 68
























Board (Quarterly)







Page 8 of 68



NHS Improvement




Page 9 of 68

Awards










Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 6 of 68








of 68
























Board (Quarterly)







Page 8 of 68



NHS Improvement




Page 9 of 68

Awards










Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 7 of 68
























Board (Quarterly)







of 68



NHS Improvement




Page 9 of 68

Awards










Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 8 of 68



NHS Improvement




of 68

Awards










Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 9 of 68

Awards










of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















Page 11 of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 10 of 68


Safe Care Measures

Actual for 2016-17

Actual for 2017-18

Actual for 2018-19


















of 68
















Page 12 of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 11 of 68
















of 68














Page 13 of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 12 of 68














of 68













controlled drugs


Page 14 of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 13 of 68













controlled drugs


of 68



















Page 15 of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer




Page 14 of 68



















of 68











Page 16 of 68












Page 17 of 68








Page 18 of 68
























Page 19 of 68








Page 20 of 68





Page 21 of 68











Page 22 of 68














Page 23 of 68








Page 24 of 68



















Page 25 of 68





controlled drugs









stakeholders


Page 26 of 68

















Page 27 of 68










Page 28 of 68










Page 29 of 68

















Page 30 of 68




Page 31 of 68







Page 32 of 68



4 6 4 4 -




Page 33 of 68



Page 34 of 68






Page 35 of 68



Page 36 of 68










Page 37 of 68








Page 38 of 68




Page 39 of 68











Page 40 of 68




Incident log number


Outcome



NECS X 29518 201813214

Safeguarding X

CGC SMT X

Incident log number


Outcome




Safeguarding X

CGC SMT

Incident log number


Outcome

20180231



NECS

Safeguarding

CGC SMT X 031018


Page 41 of 68

Incident log number


Outcome



NECS

Safeguarding X

CGC SMT X

Incident log number


Outcome



NECS X

Safeguarding X

CGC SMT


Page 42 of 68



Page 43 of 68





Met ndash Not met


year




90 942 Met 938 974 925 934 942



85 768

Not met 74 904 867 83 835









162 - 48



100 100 Met 100 100 100 100 100




Page 44 of 68


416 - 113 130 152 144



Within 15 days







gt=95 775 Not met 100 100 100 100 100




100 100 Met 100 100 100 100 100


NA 335 - 83 82 88 90 343


Page 45 of 68



Hospice 2018-19





821 83



























Page 46 of 68





Page 47 of 68






Page 48 of 68




Page 49 of 68

























for 201920




Gillian Findley





Page 50 of 68

Appendix 1



Page 51 of 68

Appendix 2









Pain Hospice UK PSM





Hospice UK PSM SSN


Page 52 of 68

Appendix 3



Quarter 1
















Page 53 of 68





Staff Member




Quarter 3





this issue

IPU Anonymous



IPU Anonymous







Page 54 of 68


Reception Anonymous




Page 55 of 68




Quarter 4












Page 56 of 68



0

20

40

60

80

100

Male Female

1 Are you n=7620182019


0

10

20

30

40

50

60

0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ No answer

Axi

s Ti

tle

Age Range



0

20

40

60

80

100

Yes No No Answer


20182019


020406080

100


20182019



Page 57 of 68



0102030405060708090

100

Thepatient

Arelativeor carer

thepatient

andrelativeor carer

Other NoAnswer

Q3c Are you n=76

20182019


0

20

40

60

80

100

Extremelylikely



DontKnow

No answer





Page 58 of 68



Page 59 of 68



Page 60 of 68




Page 61 of 68

0

20

40

60

80

100





0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100



why) n=30



Page 62 of 68

0

20

40

60

80

100


Some of thetime

Never No Answer



0

20

40

60

80

100




0

20

40

60

80

100




0

20

40

60

80

100


Some of thetime

Never No answer




Page 63 of 68


0

20

40

60

80

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0

10

20

30

40

50

60

70

80

90

100


Some of thetime

Never No answer




Page 64 of 68


0102030405060708090

100


Some of thetime

Never No answer




0

20

40

60

80

100


Some of thetime

Never No answer



0102030405060708090

100


Some of thetime

Never No answer




Page 65 of 68

0

10

20

30

40

50

60

70

80

90

100




0

20

40

60

80

100




0

20

40

60

80

100




0

10

20

30

40

50

60

70

80

90

100





Page 66 of 68

0

20

40

60

80

100



meal times n=30


0

20

40

60

80

100





Page 67 of 68


0

10

20

30

40

50

60

70

80

90

100

Yes No No answer



Quality Account 2018-19 · 2019. 7. 9. · St Cuthbert’s Hospice Quality Account 2018-19 Care...

Documents

Transcript of Quality Account 2018-19 · 2019. 7. 9. · St Cuthbert’s Hospice Quality Account 2018-19 Care...