Welcome to the Quality Account for Royal Trinity Hospice 2024-25. This report represents an accurate reflection of our care and support activities over the last year.
This year was the first year that our new clinical model of care, introduced in 2023 following our Transform Programme, was fully integrated as business as usual across the hospice. In addition to new services, such as our Rapid Response Community Nursing team, Clinical Hub and speciality offers such as dietetics, we now offer enhanced bereavement and outpatient services to our patients and their carers. Thanks to this new model, we have reached more people, with more services and been more responsive for those in urgent need.
Our new Rapid Response team aims to respond to priority calls within two hours. Last year, the team supported 485 patients, preventing unnecessary admissions to hospital, managing pain and other crisis symptoms faster and providing reassurance to patients and families. This includes people like David* and his wife Helena*, who felt “saved from sinking under the enormity of it all from the very beginning” thanks to Rapid Response Nurse Kim coming out to visit David when he was in crisis.
The new Rapid Response team also means that the Specialist Community Nursing team has visited more than 200 more patients at home and made nearly 300 more home visits, ensuring those patients who are not in urgent need receive a responsive and timely service. This includes people like Farhad*, who, with the help and guidance of the Specialist Community Nursing team over a period of five months, was able to die “peacefully at home, pain-free and with dignity”, surrounded by his loved ones.
This year we have introduced the Patient Safety Incident Response Framework (PSIRF), bringing a more robust and responsive quality monitoring system to the hospice, with weekly incident meetings, SWARM huddles and new systems to accurately embed learning from incidents and feedback in a timely manner.
I am proud of the work we outline in this report and of the fact Trinity has reached more people over the past year without compromising on safety and quality.
As ever, we are grateful to our community of supporters and volunteers, without whom we would not be able to ensure that people approaching the end of their lives can live and die well.
Emily Carter Chief Executive Officer
June 2025
1.2 Overview of Royal Trinity Hospice
Royal Trinity Hospice provides free specialist palliative and end of life care, on our 26 bedded unit; to outpatients both in the hospice and virtually, and in people’s homes and other community settings such as care homes, hostels, and prisons.
Our care helps our patients to live as well as they can and to die well, in the place of their choosing. We also provide care and support to our patient’s families and friends throughout their journey with us, including a range of specialist bereavement support.
We provide a range of internal clinical teaching which are open to healthcare professionals locally to improve their knowledge of specialist palliative care and the ways in which Trinity can be help.
Our specialist Dementia Services support people with dementia in the community and in the hospice through a Community Dementia Nursing team and a specialist dementia bay in the inpatient unit, offering short-term respite stays for people with dementia.
We are commissioned by South West London Integrated Care Board (ICB), South East London ICB, and North West London ICB to deliver services on behalf of the NHS.
We run programmes across our catchment aimed at improving awareness of the hospice’s services and improving death literacy in the community. This includes a community befriending service, “Compassionate Neighbours” which is volunteer-led and aims to tackle isolation and loneliness among people approaching the end of the lives.
1.3 Headline numbers 2023-2024
We cared for 2,492 patients
In total, 3,561 patients, carers and family members directly received our care and support
At any one time we were caring for 660 patients
2,371 patients received care in their own homes, which is where over 85% of our patients receive their care
The Community Nursing team made 2,708 home visits; which was over 10% more than the number of visits they made the previous year
332 patients received care in the inpatient unit
633 patients received physiotherapy, occupational therapy, complementary therapy or dietetic support in the hospice and in the community, which was over 10% more than the previous year
203 people received formal bereavement support and 1,359 attended bereavement support sessions
We supported 1,069 carers and family members, a 22% increase on last year
114 patients living in Wandsworth were supported by the Royal Trinity Carers and 384 received care coordination support
The youngest patient we cared for was 19 and the oldest was 107
75% of patients who died, died in their preferred place of death
100% of respondents to our annual survey would recommend us to friends and family if they needed similar care of support and 98% of respondents felt they were treated with dignity and respect
1.4 Stories of our care:
Zana’s story
“During mum’s stay, we were met by humanitarian hospice staff, all of whom respected mum as a whole being, and made us both feel at home practically, emotionally and spiritually.
Early on, Trinity’s Community Palliative Care team never failed to get back to me, and always responded to the level of urgency that mum’s health was presenting. I appreciated the intuitive response to mum’s changing care needs. When mum was eventually referred to stay in the inpatient unit, the hospice was a refuge, giving mum and myself space to better connect. The Patient and Family Support team was also brilliant. They supported me whilst mum was cared for in the community and our chats helped me to keep myself together and keep going. They also connected us with the Imam from the local mosque in Balham, who visited mum’s bedside.
The hospice created a space in which mum could still be a grandma to her grandchildren. I was able to decorate mum’s room for her grandson’s birthday with homemade bunting, whilst hospice staff provided art materials for the children.
On the morning that mum died, a nurse woke me up gently saying that ‘there’s something I need to tell you.’ She told me that mum had
died in peace just ten minutes beforehand. I hugged her and she then gave me time alone with mum.
In Islamic tradition the body is laid in white shrouds and there is no coffin. It was important that mum’s body was prepared for this, with the next step being a ritual wash at the mosque with holy water and rose and camphor essences. For practicing Muslims, it is important that a form is signed off immediately to facilitate quick burial, ideally the next day. Trinity knew this and helped me to register mum’s death and inkeeping with Islamic tradition, we could bury mum the next day.
For mum, the hospice became not only a place for her to die in peace, but also a place for her to live with more meaning.”
Robert’s story
“None of us really understands how important the hospice is until we are faced with the prospect of death, nor do we understand how deeply the death, and its manner, affects the immediate family. I certainly had no idea what a hospice was or what they could do in the home as well as in the physical hospice. What surprised me most was that it was possible to have an extraordinary, shared experience of a beautiful death, with the right support.”
Section 2: Quality of care
2.1 Patient safety
All clinical incidents are scrutinised at the weekly incident review meeting, highlighting any trends and monitoring any identified actions from those incidents. The trends are reviewed at the monthly Clinical Risk meeting. Our Quality Committee and Patient Services Committee oversee our compliance with patient safety standards and ensure that identified learning has been rolled out within the organisation.
Hospice UK benchmarking
Each year, we submit data to Hospice UK as part of their national benchmarking project. Last year, Hospice UK made changes to the reporting requirements that provided the comparative data required. However, this benchmarking continues to review the main areas of falls, pressure ulcers and medication incidents:
Falls: In the past, we would report falls graded by no harm, low harm, moderate harm, severe harm and death. This has now been condensed to total number of falls and the number of falls resulting in severe harm (now noted as level 4) and death (now noted as level 5).
Pressure ulcers: Previously we were required to report on the number of pressure ulcers based on completion of stay per month, this has now changed to date reported.
Medication: Previously we were asked to report on a breakdown of Levels 0 to 5, but this has now been reduced to only reporting if an incident was a level 4 (severe harm) and level 5 (fatal). Unlike falls, there is no longer an option to record all incidents relating to medication incidents.
The Hospice UK benchmarking has therefore not been included in this report due to Royal Trinity Hospice not reporting any incidents that are covered by their new criteria.
In response to the NHS Patient Strategy that was published in 2019, the Patient Safety Incident Response Framework was launched in August 2022, with an eighteen-month implementation timeframe for providers of NHS funded secondary care. In 2023-24 we began the process of embedding PSIRF within our governance framework across all clinical areas of the hospice.
Trinity’s identified patient safety priorities continue to be:
Pressure ulcers
Falls
Medication errors
What we did in 2024-25:
Introduced weekly incident meetings to review all the clinical incidents in greater detail to identify any trends, learning and actions.
Ensured staff in key PSIRF roles completed the recommended training to support the implementation of the PSIRF.
Introduced SWARM huddles to the inpatient unit. These are carried out promptly following a patient fall to establish any immediate actions and learning.
Set up a process to share monthly learnings with clinical teams
Our plan for 2025-26:
Commence roll out of PSIRF e-learning training for staff in clinical leadership roles (team leads and those at Agenda for Change Band Six level and above).
Incorporate patient/carers involvement in the PSIRF process.
Analysis of Trinity safety incidents
Overall incidents and near misses: green
Overall incidents and near misses: amber
In 2024-2025, 477 clinical and near miss incidents were reported for the hospice. This is an increase from the total number of 415 reported in 2023-2024.
We delivered several incident reporting training sessions throughout the year, including as part of the induction for new staff. The increased awareness of incident reporting could be a major contributing factor to the increased number of incidents reported overall. There was an overall increase in the number of amber clinical incidents. This is proportionate to the overall increase in total incident numbers. The most significant increase was seen in pressure ulcer incidents, where we have changed the criteria used for incident grading this year compared to last year. This change of criteria has resulted in a higher proportion of pressures ulcers being reported as amber incidents.
Analysis of Trinity safety incidents
Health and safety incidents
Health and safety incidents are discussed at the bimonthly health and safety meeting and include both patient and staff related incidents recorded for the hospice (excluding our retail business).
Key trends from the reported health and safety incidents:
Staff or visitor related minor slips, trips and falls remained the most reported incidents. These are reported under facilities incidents.
There is a noticeable reduction in fire-related alarms due to increased fire safety awareness and staff training
Manual handling and sharp-object related incidents slightly decreased following targeted talks
There was an increase in the reporting of incidents of aggressive and antisocial behaviour. All patient-related incidents in these catagories are discussed both at the clinical risk and the health and safety meeting. Where necessary, staff will refer to the managing unacceptable behaviour policy to help manage patient and visitors’ behaviours. The increase in reporting for these incidents may be linked to the hospice’s ongoing “Report It Sort it” campaign to encourage staff to report incidents of unacceptable behaviour.
What we did in 2024-25:
Introduced monthly health and safety walkabouts with key team members. This promotes a joint up approach to managing health and safety in the hospice.
Improved signage across the hospice for fire safety and hazard zones which now provides clearer information
Reviewed and updated the accident and incident reporting process to ensure a swifter and more robust response
Our plan for 2025-26:
Review and enhance contractor health and safety induction to make this process more robust
Launch regular fire drill refreshers across all departments and ensure regular fire drills
Analysis of Trinity safety incidents
Community incidents: amber
This graph highlights the amber incidents that were reported by the Community team this year. Community is an umbrella term that includes the Specialist Community Nursing team, the Rapid Response team and the Wandsworth End of Life Care Coordination team.
2024-25
2023-24
Many of the total incidents reported under community are related to external factors (Trinity recording incidents that our staff witnessed but had no involvement in) however, the key trends for internal incidents are:
Two incidents reported regarding the mismanagement of tasks on Trinity’s electronic patient record system, resulting in missed appointments or follow up from the team
Three incidents reported relating to the processes around the management of Medicines Authorisation and Administration (MAAR) charts not being followed correctly resulting in either incorrect information on the charts or not being requested in a timely manner
What we did in 2024-25:
Transitioned the appointment booking process from individual Microsoft Outlook calendars to the electronic patient record appointment management system. Teams now have access to the whole system rather than only their individual calendars
Trained teams working in the community on the process of prescribing anticipatory medications and medical administration record charts
Our plan for 2025-26:
Develop a standard operating procedure regarding the management of MAAR charts. This will provide a clear framework for the team to work within
Develop a standard operating procedure for out of hours working for the Specialist Community Nursing team (including Rapid Response)
Analysis of Trinity safety incidents
Medication incidents
Reporting takes place for medication incidents that happen both internally within the hospice and externally. All external incidents are fed back to the appropriate organisation e.g. GP surgery or the District Nursing team.
Most of the medication incidents reported internally related to the inpatient unit, which is the focus of this section. All medication incidents are analysed at the monthly medication review meetings.
Medication incidents (inpatient unit): green
There has been an increase in the reporting of medication incidents over the year from 135 reported in 23-24 to 249 incidents reported in 24-25.
The data provided correlates with how the incident was initially reported on our incident reporting system however, because any one incident may fall under several different classifications depending on how the member of staff interprets the classification, this can lead to some discrepancies. For example, an omitted/delayed medication may be reported under “omitted/delayed medications” or under “drug administration”.
Analysis of Trinity safety incidents
Medication incidents
The key trends have been extracted from the data, regardless of the initial reporting category. The key trends identified for 2024-25 are:
Omissions or not signing for medications in drug charts
Syringe drivers not functioning properly
Prescribing of medications
Documentation in the controlled drug book
What we did in 2024-25:
Implemented a new reflection form for nurses to complete after a medication incident, looking at identifying any wider contributing factors as to why the incident occurred
Changed our annual mandatory medication tests to include staff from both the Inpatient team and Community Nursing team
Shared key learnings via a monthly update from the weekly incident meeting
Changed the equipment used with syringe drivers
Our plan for 2025-26:
Conduct an in-depth investigation into medication incidents, identifying recommendations to promote safer practice
Implement new medication charts on the inpatient unit
Implement electronic prescribing for the Community team via our patient records system
Deliver further training on incident reporting, including defining the classification catagories more tightly
Analysis of Trinity safety incidents
Pressure ulcers
We reintroduced the Tissue Viability Group which meets monthly to scrutinise incidents over the month for any trends, identify any learning and training needs, review policies and processes and consider any new quality improvement projects. The group includes members from both inpatient and community settings.
There has been a slight decrease in the number of pressure ulcers reported that developed at the hospice. There was however an increase in the number of those incidents that were graded as amber. This is due to a change in the way that we assess and grade these incidents, for example, for any pressure ulcer assessed as a category two or above, the incident would be graded as an amber amber whereas previously it would have been graded as green. We made this change in reporting to reflect the negative impact of pressure damage.
For each patient admitted to the inpatient unit, once consent is gained, a skin assessment is completed. If a patient is found to have a pressure ulcer, follow up is carried out with the relevant clinician, for example the hospital or the District Nursing team.
A safeguarding notification and a referral to the CQC will be made in all incidents reporting multiple category two and above pressure ulcers, both those found on admission and that have developed at the hospice.
Provided pressure ulcer management resources for both the inpatient and Community teams
Reviewed the current dressings available on the inpatient unit
Our plan for 2025-26:
Set up a rolling programme of training for all clinical staff on key areas of pressure area management
Review the pressure area care templates on the electronic patient records system to ensure that they capture all the information needed to support safe and effective record keeping
Analysis of Trinity safety incidents
Inpatient falls
The Falls Group meets on a bimonthly basis. Any training needs or new processes are discussed at this meeting as well as analysing any incident trends. This helps to identify ways to consistently improve clinical practice and reduce the number of falls.
Inpatient falls: actual and near misses There has been an increase in reported patient falls in 2024-25, but a significant reduction in the reporting of near misses. The increase in reporting reflects the increase of patient occupancy on the inpatient unit. Work is being done by the Falls Group to try and identify why there is a reduction in the reporting of near misses. The hospice uses a variety of measures to reduce the risk of patients falling, including fall monitoring equipment, signage in the rooms and the provision of anti-slip socks. The risk will never be fully removed as we want to allow patients to maintain their autonomy and independence.
What we did in 2024-25:
Purchased new beds for the inpatient unit with a falls prevention mode
Set up SWARM huddles that take place promptly after a fall occurs on the inpatient unit
Delivered targeted training for all inpatient unit staff regarding falls reporting
Our plan for 2025-26:
Development of a falls prevention leaflet for use both in the inpatient unit and for community patients
Identify a falls prevention eLearning module for all clinical staff to complete
Safeguarding adults
Throughout 2024-25, we upheld our commitment to safeguarding, ensuring that individuals associated with the hospice are protected from harm, abuse or neglect. Our efforts have provided a safe and supportive environment for our patients, their families, our staff and visitors. The safeguarding team consists of:
Executive Lead, Safeguarding: Isatta Sisay, Director of Patient Services and Chief Nurse
Designated Safeguarding Lead: Paul Sullivan, Head of Living Well
Deputy Safeguarding Leads (DDSL): The Social Workers within Trinity’s Patient and Family Support team
Total safeguarding concerns raisedinternal and external
All safeguarding concerns reported in 2024-25
Concern categories Neglect and acts of omission
Of those recorded as neglect and acts of omission, 75% were pressure ulcers, either that were present on admission or that developed at the hospice. All safeguarding concerns are scrutinised at the Clinical Risk meeting, allowing us to highlight any trends.
What we did in 2024-25:
Neglect and acts of omission
Delivered focused training for inpatient unit nursing staff regarding safeguarding and the reporting of pressure ulcers
Ensured the hospice safeguarding lead attends weekly incident meetings
Reviewed and updated the safeguarding level one and level two mandatory training modules
Our plan for 2025-26:
Amend the safeguarding template on the electronic patient record system to ensure that the right level of information is recorded
Roll out safeguarding for children training for the Retail team
Freedom to Speak Up Guardians
Freedom To Speak Up Guardians provide a route to support anyone to speak up about anything they may be concerned about. We have seven trained Freedom To Speak Up Guardians who are available to help anyone who has something they wish to raise.
The hospice submits data to the National Guardian’s Office each quarter which includes the number of cases brought to guardians and, within very broad definitions, what the cases were about and any issues, learning or lessons from them. The information is also reported to Trinity’s Patient Services Committee.
The total number of cases raised by staff in 2024-25 was 9 (compared to 4 the previous year). These included themes of worker safety, wellbeing and bullying and harassment.
Guardians help to:
Protect patient safety and the quality of care
Improve the experiences of workers
Promote learning
By ensuring that:
Staff are supported in speaking up
Barriers are addressed
Issues raised are used as opportunities for learning and improvement
What we did in 2024-25:
Continued to provide support to all members of staff as and when needed
Promoted the guardians across internal communications platforms
Introduced a simple and confidential framework for guardians to document cases
Our plan for 2025-26:
Introduce quarterly support meetings for guardians
2.2 Effective care
Outcome framework
Our quality outcome framework measures impact, gathers feedback from those experiencing our care and gathers the data that allows us to measure how well we are engaging with the communities we serve. We continue to find ways to listen to these communities and to identify any barriers to people receiving the inclusive, responsive care that they deserve.
Core patient-centred outcome measures for palliative care (PCOMs for palliative care)
The hospice continues to use the PCOMs suite of outcome measures to describe patient status over time (these measures including the iPOS, phase of illness, and the Modified Karnofsky performance scale).
The CSNAT (Carer Support Needs Assessment Tool) which measures support needed by those caring for the patient is used by our Patient and Family Support team and the Bartel Index for activities of daily living is used for patients on the inpatient unit. The CSNAT and the Bartel are measures used in addition to the PCOMs measures.
All patients admitted to the inpatient unit complete an iPOS and this is repeated regularly during admission and then on discharge. If the patient dies, an iPOS is completed by the Nursing team following the death.
iPOS scores are discussed at inpatient interdisciplinary team (IDT) meetings and are used both to reinforce what the patient thinks is most important and to give a numerical score to pressing symptoms. Over time, the score is used to monitor the clinical status of the patient and to ensure any pressing issues for the patient are being addressed. The Modified Karnofsky performance scale and the phase of illness assessment tool are used regularly at daily handover meetings to reinforce verbal updates.
In the community, the iPOS is completed at first assessment and then at any review of patient symptoms or whenever a clinical change is felt to have occurred. As with patients on the inpatient unit, the measures are used to check that issues identified by the patient are being addressed, to reinforce the impact our care is having and to prompt specific symptom review.
What we did in 2024-25:
Embedded PCOMs review at the inpatient IDT
Embedded iPOS completion for our community patients
Our plan for 2025-26:
Embed IPOS review in the community IDT
Use anonymised case reviews to reflect the quality of care given in team feedback sessions
How we use iPOS
A young man in his 30s with metastatic cancer was seen by numerous teams across the hospice. He had two admissions to the inpatient unit. On his first admission he had an initial iPOS score of 47/80, which reflected overwhelming pain and poor mobility. No follow up iPOS was conducted during his first admission.
On his second admission 4 weeks later, his iPOS on admission was 36/80 (including overwhelming pain and anxiety). His follow up iPOS score four days later was 14/80 (with verbal report of much improved pain and feeling much calmer).
Mortality review
The hospice continues to have two separate mortality reviews: one for the community and one for the inpatient unit. Both reviews focus on the quality of care given to patients once under our care and the cases are brought for review in a number of ways:
Inpatient unit: cases can be highlighted by any member of the team caring for the patient and may follow discussion at the weekly IDT. Cases may also be chosen if the length of stay for a patient was longer than average, or much shorter.
Community: cases are highlighted by any member of the team at the monthly ‘Discussion of Community Death forum’ (a recently introduced reflective session for the Community team which provides a space for members to discuss any recent patient death, focussing on what went well, what could have gone better and any specific learning). The community mortality review also looks at any patient death occurring in hospital.
Each review uses a structured judgement review approach with specific phases of care reviewed.
For the inpatient unit, the phases are:
Admission and initial care in first 24 hours (including action plan, nursing assessments completed and Consultant review within 24 hours of admission, or 48 hours if the admission is at weekend
Ongoing care, including regular medical review and consultant ward round, one nursing entry per shift, risk assessments completed and reviewed
Care during a procedure (catheter insertion, blood transfusion, syringe pump, including consent, assessment of effectiveness of interventions)
End of life or discharge care
Communication with family (documentation and regularity)
Assessment of care overall (including medication changes if outcomes were documented, medical capacity assessment and Deprivation of Liberty Safeguards if appropriate, appropriate IDT discussion
For the community, the phases are:
First assessment (including ACP documentation and demographic data collection) and initial plan
Ongoing care (including frequency of review and discussion at IDT)
Communication with family
Communication with other healthcare providers
End of life care
Communication after death
Learning from these reviews included-
Poor communication between a hospital and Trinity, negatively impacted patient care prior to death which was followed up directly with the hospital
Review of first assessment requirements for patients who may be primarily seen by Trinity’s Living Well (non-nursing) services
Inconsistent documentation around the effectiveness of medications
Good process in communication around discharge for patients
Review of IDT process to ensure patients are discussed when required
Good nursing documentation around falls with appropriate updated risk assessments following falls
Reinforcement of need to state in the notes if a patient is felt to be dying
What we did in 2024-25:
Embedded the new phases for review in each area
Began the process of collating the learning from both reviews for dissemination
Our plan for 2025-26:
Refine how we share with staff not only the learning but also awareness that these reviews take place
Encourage team members to attend reviews to understand the depth of each review and how learning is identified
Education, learning and development
What we did in 2024-25:
We saw two more cohorts pass through and complete our internal management development programme, which is available to clinical and non-clinical managers. The programme was also made available to aspiring managers to better equip them when an opportunity for progression presents itself
We developed our learning and development calendar with the introduction of “Learning @ Lunch” sessions to offer additional learning opportunities ranging from art therapy through to understanding about neurodiversity
We delivered policy-specific HR courses using our internal expertise to better-inform our managers
We embedded our new learning management system, TalentLMS and saw our mandatory training compliance rate increase by over 25% to a target exceeding 96%
Clinical education
We offer clinical workshops to other hospices, local authorities and care homes as well as for Trinity staff. In addition to our scheduled open training sessions, we also delivered some bespoke training to the new care home group KYN. The number of people who attended is outlined below, broken down by training module.
We launched a Development Funding Panel, which oversees a centralised development budget with an application process open to all Trinity staff. Over the last year we have seen almost 40 members of staff benefit from funded development. Our plans for 2025-26:
Review the current clinical workshop offer and add more workshops for both internal and external delegates
Streamline the development fund application process
Attendees
Implement “phase two” of the review into staff one-to-one meetings and annual reviews, to include the creation and use of personal development plans for all staff based on the core competencies and behaviours for each role
Share the data from these personal development plans to allow themed learning opportunities to form the basis of next year’s learning and development calendar
Clinical effectiveness
The hospice’s programme of audits, compliance checks and quality improvement projects (QIPs) ensures regulatory compliance and enables us to continuously assess and improve the quality of our care. During 2024-25, the Clinical Effectiveness Committee continued to oversee audits, compliance checks and QIPs within the organisation.
Clinical audits
This year’s audits included areas relating to health and safety, infection prevention and control, information governance, pharmacy, and organisational. The clinical audits we delivered this year are detailed in the table below.
The Clinical Effectiveness Committee regularly reviews the audit programme. This year the committee streamlined the hospice’s audit plans to maintain the highest possible standards and ensure that projects are completed in a timely manner. This year therefore, several audits have been redesigned as compliance checks.
The current audit schedule includes:
Clinical: antimicrobials, falls, nutrition and hydration, pressure area care, mental capacity, steroid use, end of life care (inpatient unit and community).
Patient and family support: bereavement, safeguarding and counselling.
Clinical Audit
Clinical Audit Date conducted Action plan
Nutrition and hydration
July 2024
Falls July 2024
Pressure area care July 2024
Safeguarding September 2024
- Nutrition support tool redesigned and personalised eating and drinking plans developed
- Training for inpatient unit staff
- Training for inpatient unit staff regarding risk assessment and documentation
- Updated falls risk assessment on EMIS
- Changes to hospice incident reporting system according to Hospice UK falls audit information
- Identification of alternative falls management devices
- Introduction of SWARM huddles.
- Configure a multidisciplinary group focusing on tissue viability
- Review EMIS templates for wound care and Waterlow Score
- Reminder for staff regarding weekly risk assessments.
- Review of EMIS safeguarding templates
- Review of process for reporting pressure ulcers on the inpatient unit
- Hospice-wide training regarding documentation of safeguarding concerns on EMIS
- Safeguarding lead to attend weekly incident meetings to monitor compliance regarding safeguarding referrals for pressure ulcers
Bereavement
September 2024
Counselling
January 2025
Steroids March 2025
- Include links on the hospice’s website for other external agencies that offer bereavement support
- Development of a bereavement training policy
- Review how support activities for staff/volunteers are delivered
- Amend outcome measures on EMIS to support the capture of distress categories
- Review of demographic information at a PAFS team meeting to explore patterns reflecting culturally specific or culturally sensitive themes
- Review of the current service user questionnaire
- Set up task and finish group for use of steroid cards on the inpatient unit
- Review discharge summary follow-up and medication sections including training elements.
Compliance checks
This year, we have embedded our programme of regular compliance checks and significantly increased the number of compliance checks we undertake to improve monitoring in a range of areas. Several compliance checks have developed as outcomes from previous audits.
Our current regular compliance checks are:
Pharmacy
Infection control
Community compliance checks
Other clinical compliance checks
Quality improvement projects
oxygen, steroid prescribing, analgesic patches, antibiotic prescribing, controlled drug count, drug expiry date check, storage and documentation of controlled drugs, Local Intelligence Network controlled drugs report, CQC controlled drugs self-assessment, transportation of controlled drugs between the hospital trust and Royal Trinity Hospice, delivery of controlled drugs, non-medical prescribing
vascular devices, catheter care, hand hygiene (inpatient unit and Royal Trinity Carers) and sharps on the inpatient unit
non-medical prescribing, personal protective equipment
use of the Modified Richmond Agitation and Sedation (MRaSS) score for assessment of delirium and terminal agitation on the inpatient unit, blood transfusion and documentation of discussion regarding parenteral fluids at the end of life
During 2024-25 we undertook the following quality improvement projects:
Mandatory medication tests for the inpatient unit and community
Review of the process for discarding waste from syringe drivers and breakthrough medications
Review of signage on the inpatient unit
Review of medical and nursing induction programme
Checking of MAAR charts
Review of patient menus
Introduction of eating and drinking plans
Introduction of infection control packs for the Community team.
Review of current reflection template used by the Inpatient Nursing team
Our plan for 2025-26:
Continue the work in sharing audit actions and learning throughout clinical teams
Improve staff engagement with the completion of audits and QIPs by embedding them within staff one-to-ones and annual reviews.
Research
The Research Group meets monthly and reviews all requests for collaboration from external individuals and organisations. The group also supports staff members with their own research projects.
In addition, the group has taken on a role in supporting any member of staff or volunteer to submit abstracts to conferences. In March the group hosted a ‘Research Awareness Week showcasing posters from previous conferences and discussing the importance of research and how individuals can get involved.
What we did in 2024-25:
Completed our research participation in the CHELsea II trial, looking into whether giving patients in the last days of life clinically-assisted hydration is effective at preventing them from developing delirium
Continued our engagement with NHS Blood and Transplant in their Hospice Eye Donation project
One Clinical Nurse Specialist completed her dissertation (receiving a distinction) around the use of the RUN PC triage tool. This tool has since been introduced by the Specialist Community Nursing team
Our plan for 2025-26:
Encourage more in-house research
Host ‘Research Cafes’ to continue conversations around research for everyone
2.3 Patient experience
It is important for the hospice to have processes in place to ensure that it seeks and responds to feedback about all the services that it provides from patients, carers, staff and stakeholders.
We have previously experienced challenges in consistently receiving formal patient feedback, with low response rates from previous surveys. To address this issue, we have been working on a range of different ways to make this process easier and increase the response rate.
Patient experience of care survey
This is sent out once a year to all patients who have used any of our clinical services at the hospice. It can be completed either electronically or in a paper format. Responses are anonymous, but there is an option for respondents to include their details for any follow up. The results are then analysed for key trends and shared with the clinical Heads of Service who go on to agree any actions.
From our 2023- 24 survey the following actions have been taken in response to the feedback:
You said
Need clear guidance about how all the different community services work together
Further training is needed for staff, so they know how to manage out of hours calls
Information about the services the hospice provides for patients in the community could be clearer
Need clear standards regarding how each clinical team provides their services
More choice and better-quality food on the inpatient unit
A more structured approach to managing dementia respite admissions on the inpatient unit
Patient experience of care survey 2024-25
We did
Put together a booklet for patients regarding the coordination of different community services
Training provided for key staff regarding the management of out of hours calls
Designed a leaflet intended for all service users
Standard operating procedures have been produced for all the clinical community services
New menus listing a greater choice of options have been introduced on the inpatient unit
Work in progress looking at respite admissions on the inpatient unit and incorporating therapies input.
The latest patient survey was sent out in July 2024
We sent the survey in both physical and electronic formats:
204 by post 322 by email 526 in total
This survey will close in May 2025 and so far, we have received 51 responses
Carers survey
The content of the previous carers survey has been reviewed and updated. This survey will be sent to bereaved family members named as key contacts of patients who have used any of our clinical services.
What we did in 2024-25:
Introduction of a three-question survey “Take Three” that is accessible via a QR code on signage throughout the hospice and on patient literature.
Our plans for 2025-26:
Continue to embed the Take Three survey within our correspondence and leaflets
Share the completed actions from the 2023-24 survey throughout the hospice
Identify and implement the actions from the 2024-25 survey
Complaints, concerns and compliments
Complaints and concerns may be raised by patients or their families and friends and other service users throughout the year.
This year, three complaints were raised and investigated compared to eight the previous year. The key trends identified were:
• Management of symptoms
• Challenges with the coordination of care across services
• Challenges with ineffective communication
For each of these complaints, a series of recommendations were agreed, including:
• Introduction of a new patient care assessment process for the Community teams
Introduction of a daily huddle which now takes place with key members of the Community team to agree their priorities and discuss any concerns relating to the patients on the list to be seen that day
Training for the Community team to be set up including advanced communication skills and telephone and email communication skills for the Care Coordination team.
Thirty-one concerns were raised last year. Two of the concerns that were addressed at the time then resulted in a formal complaint investigation. The key trends for the concerns were:
• Staff behaviour and attitude
Challenges with ineffective communication
• Difficulties in contacting the hospice for advice
For each concern raised, follow-up was carried out by the head of the service involved, and the outcomes were shared with the person who raised the concern.
What we did in 2024-25:
Key staff attended complaint investigation training
We began embedding a more robust process of identifying and monitoring any complaint actions
Our plans for 2025-26:
Review our process of managing complaints, focusing on further involvement of the complainant
Establish a clear process of sharing and embedding any learning from complaints and concerns within the clinical teams
Set up a rolling programme of complaint investigation training for all clinical managers
Compliments
Compliments received by patients and families are anonymised and reported to the Clinical Risk Management Committee and summaries are shared with staff. During 2024-25 we recorded 209 written and/or verbal compliments (compared with 131 in 2023-24).
Family, carer, relative and stakeholder comments received:
“As a family we would never have been able to cope with our mother’s illness and death had it not been for you.”
“The doctors, day staff, night staff, cleaners, physiotherapists and kitchen staff have all played a part in making my husband’s transition from this world to the next that much more serene and peaceful, in allowing him to ‘drift away’ just as he had requested.”
“There are no words with which I can express my deepest gratitude for making my husband’s end of life so peaceful and comforting. Your selfless actions have touched my heart and made a lasting impression on my life. Your willingness to give and your thoughtful gestures have shown me the true meaning of kindness.”
“Your guidance has helped shape me into a more compassionate and confident student. As I move forward in my nursing journey, I will carry the lessons i have learned from you always.”
“I have spent the last year desperately trying to find the words that would adequately sum up the heartfelt gratitude our family feel for the professional, compassionate, loving care given to him and all the family during his stay at Trinity. There are so many people who went above and beyond to help us all through this most challenging time.”
“She spent two weeks with you following a stint in St Georges, and your kindness, attentiveness and beautiful facility helped to restore her. You treat your patients with the patience, dignity and care they deserve and it’s heartwarming to see. Thank you for making us all feel like family.”
Section 3: Our review of 2024-25
Progress against priorities for improvement
We successfully delivered the third year of activity against our five-year strategy with the goal “To expand our reach to all of the people in our community who would benefit from our services, through an inclusive and collaborative approach to delivery while maintaining outstanding quality and financial balance..”
Trinity’s 5-year objectives
1. To invest in expanding our services, workforce and facilities.
2. To strengthen our collaboration with partners, utilising innovative pathways.
3. To extend our reach across all of our diverse communities – particularly those who traditionally do not access palliative and end of life services.
4. To make the best use of our existing workforce model and facilities, utilising digital and virtual working.
5. To ensure fundraising, retail operations and NHS income match growth in activity and associated operational costs.
Objective 1
To make the best use of our existing workforce model and facilities, utilising digital and virtual working.
What we did in 2024-25
We ensured that post-death care standards and recommendations from the Sir Jonathan Michael Mortuary review were embedded in operating procedures prior to deciding to close our mortuary at the beginning of 2025-26
We embedded the Patient Safety Incident Response Framework across the organisation
We developed a new estates strategy, which includes a five-year maintenance plan, to ensure adequate investment is made to our ageing infrastructure to reduce incidents
Our plans for 2025-26
We will explore a collaboration with Continuing Healthcare to make some of our inpatient unit beds available to Fast Track Patients
We will take further steps to improve efficiency with more virtual working
We will undertake more QIPs and embed the learning from them across the organisation
Objective 2:
To strengthen our collaboration with partners utilising innovative pathways.
What we did in 2024-25
We proactively engaged with referring partners (hospitals, GP, district nursing) to make sure we support everyone who could benefit from our services including via webinars and regular communication
We embedded electronic patient records sharing with more primary care providers to improve collaborative working
Our plans for 2025-26
We will work to build patient record sharing agreements with local hospitals referring into our service
We will continue to strengthen our relationship with other hospices, particularly those across London via a formalised network to share and collaborate
We will continue to proactively engage with healthcare professionals to highlight our services and care
Objective 3:
To extend our reach across all of our diverse communities-particularly those who traditionally do not access palliative and end of life services.
What we did in 2024-25
We collaborated with King George’s Hostel in Westminster on an art project which aims to improve death literacy among homeless men living in our catchment area
We continued to host events and activities aimed at bringing people into the hospice with a specific focus on key audiences and communities that we do not currently reach e.g. Talk & Tour, Carers Week, Pride Week
We worked to improve the care experience for deaf and hard-of-hearing patient through our hearing loss working group
Our plans for 2025-26
We will introduce structured processes to embed the learning from our community engagement activity through the new Community Inclusion Group and implement a network mapping project to identify underserved populations and groups
We will focus on engaging specific groups of people in our community with custom Talk & Tour events
Objective 4:
To invest in expanding our services, workforce, and facilities.
What we did in 2024-25
We continued working towards becoming an Employer of Choice with ongoing commitment to investing in our people through the People Plan II
We expanded the operational hours and reach of our Rapid Response service to a 12 hours, 7 days service
We launched a Development Funding Panel, which oversees a centralised development budget with an application process open to all Trinity staff. Over the last year we have seen almost 40 members of staff benefit from funded development
We introduced a working group to look at ways we can optimise and improve our electronic patient record system
Our plans for 2025-26
We will introduce new ways of working to support patients in the community virtually
We will invest the one-off funds allocated from HM Government for capital expenditure into projects that will enable our long-term sustainability, improve our facilities and positively impact on patient experience of care
We will continue to implement our sustainability strategy across all areas of the hospice to reduce costs in the long-term and reduce our environmental impact
We will develop a new FREDIE (fairness, respect, engagement, diversity, inclusion and engagement) strategy, to guide the experience received by our patients, visitors, customers, staff and volunteers
Objective 5:
To ensure fundraising, retail operations and NHS income matches growth in activity and associated operational costs.
What we did in 2024-25
We continued to discuss with commissioners the urgent need to increase the proportion of our funding that comes from the NHS
We launched Royal Trinity Hospice Retail Consultancy Services to provide personalised, results-driven solutions to charity retailers
We participated in the national hospice legacy campaign, facilitated by Hospice UK, to raise awareness of the importance of gifts in wills
Our plans for 2025-26
We will continue to lobby our NHS commissioners for increased statutory funding towards our core and specialised services and a fairer funding model
We will aim to further increase the profit made by our retail business, through strengthening our stock pipeline, attracting new customers and opening new shops
We will further increase the amount raised through our fundraising activity, by refining our existing activities and introducing new opportunities for our communities to support us, with particular focus on legacy giving and corporate support
We will continue to identify new opportunities to generate income for the hospice including by relaunching the hospice cafe to the public
Section 4: Trinity governance and compliance
4.1 Board of Trustees
Royal Trinity Hospice’s Board of Trustees has ultimate responsibility for the governance and leadership of the organisation. The Board makes strategic decisions, monitors the organisation’s performance, and ensures that it complies with its Articles of Association and applicable laws and regulations.
The Board works closely with the Chief Executive Officer and the Executive team to set our strategy and monitor performance and risk management. The Board meets quarterly and works through four board committees (People and Culture Committee, Finance and Resources Committee, Fundraising Development Committee and Patient Services Committee) and closely with the board of the retail subsidiary.
Trustees receive no remuneration for their services, nor do they have any business or personal interest in the charity’s contracts. Trustees normally serve for a maximum of six years and are subject to re-election after three years. Trinity currently has thirteen trustees from a variety of professional backgrounds.
(as of Jan 2025)
Board of Trustees
4.2 Care Quality Commission (CQC) regulation
Royal Trinity Hospice is regulated by the CQC. The named nominated individual is the Associate Director of Quality. Due to a change in personnel, the Registered Manager is in the process of being transferred to the Director of Patient Services and Chief Nurse. Trinity was last inspected by the CQC in August 2019, where the service’s overall rating was Outstanding.
4.3 Data management
Trinity has been using EMIS Web as our clinical record database since October 2022. We continue to proactively contact and encourage GPs within our catchment area to sign our data sharing agreement and enable patient record sharing within EMIS. Smartcards have now been deployed to allow access to the patient demographic service, thereby ensuring the use of NHS numbers for unique identifiers.
We are obliged to meet the standards of the Data Security and Protection Toolkit. We completed this year’s Data Security and Protection Toolkit return by 30 June 2024, in line with the deadline.
Our Information Governance Committee ensures we consistently meet national requirements and reviews and oversees the implementation of information governance practices, new policies, and training. In 2024, an external audit of our Data Security and Protection Toolkit and data protection practice was carried out to ensure we meet the highest standards.
Annexe 1: The Board of Trustees and Lead
Commissioner’s Statements 2024-25
The Board of Trustees is fully committed to the provision of a high-quality service at Royal Trinity Hospice. The hospice has a robust clinical and corporate governance structure, with members of the Board playing an active part in ensuring that Royal Trinity Hospice fulfils its mission, according to its charitable intentions and in ensuring that the organisation remains responsible and compliant in all areas of CQC registration, health and safety, employment law and other relevant legislation.
Signed Karen Proctor
Chair of the Patient Services Committee, Royal Trinity Hospice
Date: June 2025
Lead Commissioner Statement
The Commissioners have reviewed Royal Trinity Hospice’s Quality Account for 2024/5 and acknowledge the high standard of care provided. They welcome the specific priorities for 2025-6 as appropriate areas for continued improvement that link with clinical commissioning priorities.
Signed Darren Jones
Director of Nursing NWL ICB
Date: June 2025
Signed Hannah Pearson Lead Primary and Community Care Delivery Manager - Merton and Wandsworth SWL ICB
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