Quality Account 2024 - St Luke's Hospice

Poppy was everything in my life…

Mos Pracdel tells us about the extraordinary love he had for his wife, Poppy, and how a first visit to St Luke’s and to our peaceful gardens took away her fear of going into a Hospice.

“Poppy was wonderful – she was really an extraordinary person. She was unique, special and different to anyone I had met before. She enriched my world beyond words. I started looking forward to life and the future and that was all thanks to her.

When Poppy was in her late 20s she was diagnosed with skin cancer and needed an operation and a skin graft on her lower leg. She was recuperating and decided to attend dance classes to regain strength and mobility. That is when we met and my life changed forever.

Sadly, in 2002 Poppy started having problems with her leg again. She had ulcers that were taking longer to heal. The doctors were puzzled, her pain was getting worse and we were having to change her dressing every day. At the time we didn’t know that it was cancer. By 2016, her leg gave way and her bone had disintegrated completely. Very sadly she needed an amputation. We then thought she was cured but in a later follow-up appointment having noticed some enlarged groin nodes, we were given the devastating news that she wasn’t cancer-free.

After trying further treatments that were unfortunately also not successful, Poppy was referred to the Hospice by her GP but at the time she didn’t want to come. She didn’t want to accept that things were only heading one way and, in all honesty, neither did I. The cruel reality in front of our very eyes was so unpalatable. It wasn’t until she was feeling very unwell and she was referred to the palliative care team in 2019 that I said to her, “Poppy, my love, why don’t we just go and look around and find out about what they can offer?”

I wanted Poppy to try the Hospice’s alternative therapies. We were shown around and I distinctly remember the moment when we saw the garden. It is forever imprinted on my mind, it was so peaceful, serene, calm, and so wonderful. She regularly started coming back in as an outpatient in order to control her symptoms.

Poppy also had many visits at home by the Hospice’s palliative care team. As her pain became worse they admitted her to the Hospice’s Inpatient Unit but sadly, while in the hospice she lost consciousness. They then moved her to a private room, and from that moment on I was by her side until she tragically passed away.

I can never thank the hospice staff enough for their kindness, professionalism and the humane way they treated Poppy in her last days of life. That will stay with me for as long as I live. I still remember all their faces. They looked after me and were so supportive all the time, so kind and gentle. They made what was clearly a terrible experience so much easier to bear.

“

I wanted Poppy to try the Hospice’s alternative therapies. We were shown around and I distinctly remember the moment when we saw the garden. It is forever imprinted on my mind, it was so peaceful, serene, calm, and so wonderful.

“

I think people have a misconception that a hospice is somewhere you just go to die, but there is so much more on offer. Patients may still have many years ahead of them and live fulfilling lives, so they can benefit enormously from the therapies that are available at St Luke’s. People should know about these things.

Poppy was everything in my life and losing her shattered my world but my lasting memory of the last few days of her life are thanks to the wonderful care that she got from everyone at St Luke’s. I will always have a somehow happy memory. I will cherish the last few days of her life, clearly not because of the experience itself, but because of the way that the wonderful staff looked after her. That will always stay with me.”

Part one: Achievements in quality

1.1 Statement of quality by the Chief Executive 1. Achievements in quality

I am pleased to present St Luke’s Hospice annual Quality Account which I believe demonstrates our commitment to being an organisation that delivers high quality care with a culture of continuous learning and improvement.

The CQC inspection in April 2022 identified ongoing areas for improvement in relation to the well-led domain of the inspection. The organisation has continued to transform and embed changes through 2023-24. I appointed a new senior leadership post in August 2023, Director of Quality and Governance. We have taken forward a review of our governance structures, establishing a new internal framework for quality improvement.

The priority for improvement to implement the Vantage incident management database supports the management of risk, improving our reporting on trends and themes. The training provided to all staff has raised the importance of reporting incidents and near misses and we anticipate an uplift in the reporting of incidents in the next year.

This year has seen us focus our operational plans around three ambitions: Build Strong Foundations for the Future; Embed Quality; Value and Develop our People. The Priorities for Improvement achievements in 2023-24 and those identified for 2024-25 align with these ambitions.

We have continued to work collaboratively with our colleagues across community and hospital services. This work has included supporting the North West London Integrated Care System with their consultation regarding Community-based specialist palliative care for adults: Codesigning a new, improved model of care. During the next twelve months we will consider how this consultation impacts the delivery of care to the boroughs we serve and how we may need to adapt and respond.

To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality services we provide.

Lindsey Bennister Chief Executive

1.2 Our vision, values and mission

Our vision:

A world where people experience the best possible last phase of life.

Our values:

• Caring – Care for all those who deliver and need our services.

• Respect – Demonstrate respect and be open minded, inclusive and approachable.

• Excellence – Create an environment of continually achieving our goals.

• Inclusivity – Strive to reach all sections of our community in all areas of our work.

• Empowerment – Empower our community to live a better life.

Our mission:

• Reach more people.

• Constantly improve what we do.

• Extend our impact through collaboration, innovation and education.

• Be an accountable and sustainable organisation.

1.3 Our services

St Luke’s provides specialist palliative care to the people of Brent and Harrow facing life limiting illnesses.

Our range of clinical services include:

• Inpatient care: we have a 12 bedded unit that provides symptom management and end of life care to patients and support to their families and friends 24 hours a day, 7 days a week

• Wellbeing services: we provide a range of outpatient services including physiotherapy, complementary therapy, art and gardening groups

• Community care: we provide a Specialist Palliative Care team in Brent, Hospice at Home services, domiciliary care service and the St Luke’s Palliative Helpline (Pall24) that offers a 24 hour single point of access and advice to patients, carers and healthcare professionals

1.4 Care Quality Commission (CQC)

The organisation was last inspected by the CQC in April 2022 and is rated as Good.

1.5 Data quality

The hospice uses the NHS Data Security and Protection Toolkit (DSPT) to provide assurance that we are practicing good data security and that personnel information is handled correctly.

The organisation was compliant with the standards for the DSPT in 2023. The organisation will complete the annual DSPT self-assessment in June 2024 and expects to meet the required standards of data processing and the handling of personal information.

1.6 Service activity data

Clinical Services

The hospice supported 2069 service users in 2023-24, a slight increase compared to previous years.

1. Achievements in quality

Inpatient Unit

Our focus is on admission responsiveness so that patients can access a bed when they need one.

Inpatient Unit

Of the completed stays of care on the inpatient unit in 2023-24 we saw 34% of patients discharged and 66% of patients dying on the unit. This compares to 24% of patients being discharged in 2022-23 and 74% of patients dying.

Brent Specialist Palliative Care Team (BCT)

A team of palliative care Clinical Nurse Specialists supported by the medical team who assess and support patients providing complex symptom management and psychological support by telephone and face to face. The BCT collaborates with GPs and other statutory services to support and co-ordinate the delivery of specialised palliative care to patients in the community. The team have increased the number of patient visits offering 7 day working.

Brent Specialist Palliative Care team

Place of Death

Hospice at Home and Brokerage

Hospice At Home (H at H) provides end of life care in the patient’s home to support urgent bridging for personal care, respite care, night care, and companionship, emotional and psychological support by trained and experienced healthcare assistants. The Brokerage service arranges packages of care for patients.

Hospice at Home and Brokerage

PALL24

The Palliative Helpline Service provides 24-hour advice and support to patients, carers, healthcare professionals. The service also includes rapid home assessment and crisis visit from 7.30am-9pm.

Pall 24

1. Achievements in quality

Social Work

Social Work

Social work sessions

Physiotherapy

Physiotherapy

There appears to be a decline in activity in 2023-24 for both Social Work and Physiotherapy. However, a review of data collection this year identified there had been some double counting of interventions within both services within 2021-22 and 2022-23. The data is therefore not directly comparable.

Complementary Therapy

Complementary Therapy

2023-24 has seen the introduction of a number of groups within wellbeing services including relaxation, which has meant less patients and families have needed to access individual complementary therapy sessions.

Improvements have been made this year in recording family members contact details, which means information on bereavement support can be provided to more people. In order to meet the anticipated increase in demand for support in 2024-25, the service has trained additional volunteers.

1.7 Learning and development

Training delivery to support internal and external clinical staff to deliver high quality patient care:

• Developed a new collaborative partnership with Middlesex University, which enabled our nursing staff to access a simulation laboratory and use state of the art training resources to develop their clinical skills. Staff feedback included: ‘Thank you for arranging this day for us. It was a really great learning environment and because none of us were under pressure as none of us were covering the ward, it created a relaxed environment that was extremely good to learn in.’

• Delivered clinical workshops for our staff on topics including telephone assessment skills, managing deterioration, sepsis awareness and care and management of peripherally inserted central catheters (PICC). The managing deterioration workshop was supported by our medical consultants to facilitate staff to develop their communication skills through role play, enabling them to practice such skills in a psychologically safe environment. One student said: ‘I was able to feel the real intensity of the call and learnt to apply SBAR to assist individuals over the phone to get support they need.’

• Ran two cohorts of the Principles of Palliative Care Module. This module is accredited by the University of West London, run in collaboration with Rennie Grove Peace Hospice and aims to support the development of a specialised palliative care workforce.

• Delivered a tutorial programme for the hospice Senior House Officer (SHO) to help support them with their competencies and clinical learning objectives - “5/5, Likely to change my practice”. Delivered a training programme for an incoming Specialty Registrar as part of her Supported Return to Training - “This induction has really improved my confidence, especially of weekend working”.

• Collaborated with local care homes to work to ensure that all patients and families have access to good palliative and end of life care in their preferred place of care. We successfully completed a year-long project (funded by the Derek and Jean King Trust) supporting the training of care home staff in having compassionate advance care planning (ACP) conversations. Over 110 care home staff were trained across 11 care homes in Harrow: over 90% of the staff felt their knowledge and confidence had been increased following the course. We have provided bespoke training sessions to two local care homes on syringe driver management and buccal midazolam administration to enable them to support palliative patient needs within the care home setting.

Supported staff development:

• 2 x Band 6 development Clinical Nurse Specialists (CNS’s) in Brent Community Team (BCT) were supported to gain their competencies in specialist palliative care.

• New Band 5 nurse in the Inpatient Unit (IPU) was successfully supported through their probationary period.

• Initiated and promoted peer review for CNS’s in BCT to support reflective clinical practice, promote professional growth for individual CNS’s and as a team, and enhance the quality of nursing care.

• Established a Clinical Practice Educator post to support the development of a skilled and able workforce.

• Facilitated 58 student placements and clinician taster days/ weeks to support the development of the future healthcare workforce and improve awareness and understanding of palliative care amongst healthcare professionals. Feedback received included: ‘Excellent learning of emergency and chronic palliative care, considering various techniques in doing this. Thank you for an excellent day!’ Our partnership with the London Ambulance Service has enabled our staff to have the opportunity to spend taster days with them.

explanation

Hospice placements (clinical)

April 23 - March 24

Development of education networks:

• The Education and Professional Development Facilitator received the award of Queen’s Nurse in December 2023.

• Established a Community of Practice with local palliative care services to share knowledge and best practice.

• Visited local hospices and joined the London Region End of Life Care Facilitators Forum to develop collaborative working relationships.

1.8 Governance structures

This year has seen a review of the governance structures across clinical services to provide robust assurance to the Board of Trustees. This review has seen the introduction of three new governance groups: Clinical Governance and Quality Group, Clinical Audit and Quality Improvement Group and the Policy and Procedure Group.

A review of all the committee and groups terms of reference has been completed (see Annex 1 for a summary of the role of each group).

Governance structure

Komal Patel Home Care Manager

Part two: Priorities for improvement and statements of assurance from the board

2.1 Priorities for improvement 2024-25

Priority One - Patient Safety

Developing a safety culture

Why?

With the new CQC single assessment framework being rolled out for all care providers, it is important to know what the new quality statements mean to the hospice and to prepare the organisation for the forthcoming assessment process. Within this, we recognise that there is an opportunity to do further work in this area to include strengthening some of the mechanisms and processes in place to be able to embed a positive safety culture at the hospice.

Priority Two - Clinical Effectiveness

What success looks like

• Strong staff awareness of the new CQC methodology and their role in an inspection/ contribution to gathering evidence.

• Successful onboarding of the CQC Vantage module which enables a real time view of self-assessment and the Vantage incidents module.

• Increase in incident reporting with no harm low harm incidents.

• A range of Quality Improvement projects completed.

Implementation of non-medical prescribing (NMP) in the Brent Community Specialist Team

Why?

The development of NMP within services enables suitably trained healthcare professionals to enhance their roles and effectively use their skills and competencies to improve patient care in a range of settings, including management of long-term conditions and palliative care.

Clinical Nurse Specialists (CNS) have the appropriate pre-requisites to be trained in this skill and this will empower them to improve patient care and prescribing, where appropriate, for community patients.

What success looks like

• Brent manager to have completed a physical assessment module and a nonmedical prescribing module and to become a role model for other CNS’s within the team.

• 50% of existing Brent CNS’s facilitated to have become non-medical prescribers.

• Patients and clinicians having timely access to medications at end of life.

• CNS’s to have increased job satisfaction and supporting the upskilling and professional development of the CNS team.

• Non-medical prescribing would become an essential skill for all CNS’s recruited (or a requirement to complete).

Priority Three - Clinical Effectiveness

Implementation of a new clinical database, EMIS

Why?

The current clinical database, iCare, no longer has the functionality to support the requirements of the organisation. iCare does not have the interoperability requirements to access shared patient records; cannot meet the data requirements of the Community Services Data Set (CSDS); limited functionality to support the implementation of electronic care plans on the inpatient unit.

Priority Four - Clinical Effectiveness

What success looks like

• Building of the database to meet both the clinical and data reporting requirements of the organisation.

• Production of user manuals and training resources. Delivery of training to all clinical staff.

• Migration of data to the new database.

• Deployment of the new database.

Competency Framework development and implementation: community services and inpatient unit nursing staff - Year 2

Why?

To ensure staff are achieving the requirements of their post in relation to knowledge, skills and experience. To ensure the consistent delivery of high quality palliative and end of life care.

What success looks like

• All existing Brent Clinical Nurse Specialists (CNSs) to have completed the CNS competency framework by documenting and providing evidence of meeting the specified outcomes within the framework.

• To have implemented competency frameworks for all bands of nursing staff (Band 2 – Band 8A).

• To rollout a training programme to support the effective implementation of the competency framework document.

• Monitor completion of competencies against timeframes specified on an individual basis to support inclusiveness.

Development of a user involvement strategy

Why?

To ensure we have a robust User Involvement Strategy that supports service user involvement at all levels giving the hospice an opportunity and the tools to make collaboration between staff and service users part and parcel of what the hospice does to make a real difference to people’s care and treatment. It demonstrates our commitment to actively involving service users, their families and carers in shaping, delivering and evaluating care. Feedback is key in enabling us to fill any gaps in training, launch new services and continue to position patients at the centre of everything we do. The implementation of a User Involvement Strategy will be critical in achieving the new CQC quality statements.

What success looks like

• A consolidated and defined organisational approach to user involvement, coproduction and community engagement.

• Strong staff awareness and understanding of User Involvement and their role.

• A range of feedback surveys and mechanisms available to all services.

• A strong range of evidence/assurance is collated helping shape User Involvement for Year 2.

2.1 Priorities for improvement achievements

2023-24

Priority

One - Patient Safety

Implementation of an incident management database

Why?

To ensure a more robust incident reporting and management system to support the organisation’s response to the implementation of the Patient Safety Incident Response Framework (PSIRF).

What success looks like Achievements

• Improving reporting and management of incidents.

• Increase awareness across the organisation of the importance of risk and incident management.

• Updated policies and procedures.

• Improved organisational learning and improvements from incidents.

• ‘Vantage’ incident management software went live across the organisation 1st April 2024.

• The Incident record was developed to reflect PSIRF requirements with a clear section in relation to learning/improvements.

• Training delivered to all hospice services in Q4

• Incident reporting policy updated and awaiting approval April 2024.

Priority Two - Clinical Effectiveness

Competency Framework implementation across community services

Why?

To ensure staff are achieving the requirements of their post in relation to knowledge, skills and experience. To ensure the consistent delivery of high quality palliative and end of life care.

What success looks like Achievements

• Agree competency framework for all grades of registered nurses.

• All staff informed about the framework process and plans for implementation.

• Commencement of the role out of the framework and monitoring of progress of completion.

• Share the learning to inform the development of competencies for the Inpatient Unit.

Priority Three - Patient Experience

• We reviewed the ‘NHS England Career Pathway, Core Capabilities in Practice and Education Framework, incorporating a Qualification in Specialism Standard, for Palliative and End of Life Care’ was circulated in draft in January 2024 against our draft competency framework and revise accordingly.

• In March 2024, the finalised draft competency framework was circulated amongst internal stakeholders for comment and feedback.

• The next phase will be to rollout the framework in April 2024 and then evaluate the usability and impact.

Caring Matters – improve the quality of support provided to unpaid carers

Why?

To ensure we consistently identify, reach, support and value carers who support patients known to the hospice, in doing so enhancing the experience of our patients.

What success looks like Achievements

• Completion of a consultation with carers and professionals to inform the development of services for carers.

• Provision of regular groups and events for carers.

• Production of a carer newsletter.

• Carers having a strong organisational narrative.

• We now open records for carers on our electronic record system.

• We held 642 carer/family support discussions.

• We delivered 25 wellbeing recreational/family carer group sessions.

• We have produced 3 carer newsletters.

• We held 73 family/carer follow up assessments.

• We have liaised with local agencies providing support to carers and invited them to our Open Days.

1. Achievements in quality

2.3 Statement of assurance from the Board

I am proud to have taken over the Chair of the Clinical Governance Committee in February 2024, having served as a member of the Committee for since August 2020. On behalf of the Board of Trustees I am pleased to be able to present this year’s Quality Account and the review of the quality of services provided by St Luke’s in 2023-24.

Our commitment to the continuous improvement of our services and the care we provide will be enhanced through the internal clinical governance structures that have been established this year. The Committee have endorsed the Priorities for Improvement for 2024-25 and will monitor the progress and impact regularly at the Committee meetings.

The Clinical Governance Committee are grateful to our staff and volunteers for the high standards of palliative and end of life care they provided.

Sarah Livingston Chair, Clinical Governance Committee

Part Three: Overview of

3.1 Patient safety

Patient safety and high quality care is central to practice at St Luke’s Hospice. We recognise that a strong incident reporting system supports a positive safety culture. We are committed to investigating and learning from our incidents as we drive for continuous improvement. The internal clinical governance group reviews the themes, trends and improvements relating to incidents every quarter with monthly safety infographics reports with key learnings identified.

Patient safety incidents and data are reviewed by the hospice’s Clinical Governance Committee to provide oversight and quality assurance. 269 clinical incidents and patient related nonclinical incidents were reported and investigated during 2023-24, with the majority of them reported as near misses or no harm, compared to 167 incidents reported during 2022-23. This demonstrates a move towards a positive safety culture at St Luke’s.

Some incidents are not attributable to the hospice and involve external health care professionals, for example, pressure ulcers found on admission. We are committed to providing feedback on incidents to our partner organisations to collaboratively improve patient safety. We aim to strengthen this process moving forward as part of our PSIRF work.

PSIRF (Patient Safety Incident Response Framework):

PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety events. This newly launched framework has been developed to aid learning from incidents and improving patient safety. The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:

• Compassionate engagement and involvement of those affected by patient safety incidents.

• Application of a range of system-based approaches to learning from such incidents.

• Considered and proportionate responses.

• Supportive oversight, focused on strengthening the functioning of the response system and ongoing improvement.

We worked in partnership with the North West London Integrated Care Board to introduce the new Patient Safety Incident Response Framework (PSIRF), which went live in November 2023. We developed a PSIRF policy and Response plan based on local priorities, to maximise learning and improvement.

We are part of a local hospice working group set up to pool resources and provide a network of support to facilitate the development and implementation of PSIRF. Like other hospices, we experienced challenges with completion of the required training, time and resource allocation. Key roles were established in the organisation for Engagement, Systems and oversight of PSIRF. Comprehensive training was completed for these key roles in March 2024 and 95% clinical staff have completed patient safety e-learning. We have also aligned our new Vantage incident reporting system to PSIRF.

Overall summary and number of patient incidents

Table 1 Total number of patient incidents reported 2023-24

National benchmarking with other hospices (this covers Inpatient Unit incidents only):

Patient safety is a key domain of quality in hospice care. Quality indicators are useful to demonstrate safe and harm-free care. St Luke’s Hospice uses Hospice UKs’ Clinical Benchmarking toolkit to benchmark against three core patient safety metrics: falls, pressure ulcers and medication incidents.

Number of patient related slips, trips and falls 20 17 St

Hospice UK Benchmarking Falls per 1000 occupied bed days (for Hospices of the size of St Luke’s)

We have seen a decrease in falls on the Inpatient unit in 2023-24.

The hospice reports a low level of patient falls. Mobility and the risk of falling are assessed for every inpatient, supporting them to make an informed decision about using mobility aids, adjustments to beds/chairs and/or requesting help from staff when needed. Where informed decision-making is compromised, we take additional actions to reduce the risk of falls including the introduction of falls sensors.

Medication incidents:

We receive support for medication safety from a pharmacist 2 days a week. Our Registered Manager is also the Accountable Officer for Controlled Drugs; a further quarterly audit is completed by them and reported to NHS England. We maintain robust links with the Local Intelligence Network and have received support in the management of CD (controlled drug) incidents during 2023-24. All medication incidents are reviewed for learning in our medication safety group.

We have seen an increase in the number of medication incidents reported compared to the previous 12-month period. This year, we reported 141 medication incidents, a significant increase from the previous year. Our medication incidents increased significantly between April-September 2023 as 17 medication incidents were reported via the St Luke’s Hospice incident reporting system and there were a further 102 incidents logged by the pharmacist on a separate pharmacy system from their twice weekly audits, checks and observations.

We have subsequently ensured that the data from these two separate databases have been aligned for data analysis and learning. From the pharmacist interventions, it was identified that no harm was caused to patients. Of the 141 medication incidents reported, 83 of these were reported to Hospice UK for clinical benchmarking.

Learning and Quality Improvement:

Variation in prescribing practice - action undertaken in this domain includes daily end of day drug chart reviews and emails to all prescribing Doctors to highlight errors and request higher vigilance and that frequency and maximum dose of drugs are both recorded. Some significant improvements seen in Q4.

Dose omissions - action undertaken include daily checking of drug charts at shift changes. Common types of drugs omitted involved laxatives, cream application, eye drops, nystatin and paracetamol. Significant improvements were seen in Q4. Training commenced mid-January for all nurses on Medicines Management covering dose omissions.

CD (controlled drug) liquid measurements discrepancies - actions undertaken include installation of a window in CD drugs room, ordering of a new CD book for patient’s own CDs, liquid measurement training, and implementation of a training program for registered nurses. A drug viscosity issue was found to be affecting CD losses. Further solutions for liquid measurements were explored as part of a Quality Improvement project.

New Pressure Ulcers:

Hospice UK Benchmarking Pressure Ulcers per 1,000 occupied bed days (for hospices of the size of St Luke’s )

This year we reported 28 new pressure ulcers, which is lower than the previous year. We reported 33 pressure ulcers present on admission compared to 65 the previous year.

We report on newly acquired pressure ulcers and those found to be present on admission, which are not attributed to the hospice. Age, hydration, overall health and nutrition all contribute to our skin becoming less elastic. This in turn means that if we sit or lie for prolonged periods in the same position the risk of pressure injuries increases and the healing process can be slower and more difficult. Skin assessments are carried out on admission to the Hospice and some patients may already have developed pressure related skin damage. We have procedures that we implement to care for these patients, including special mattresses and turning plans. Our first priority is prevention where possible and secondly promotion of healing to reduce the severity and impact of the ulcer for the patient.

Learning and improvement:

After action reviews (AAR) are undertaken for all newly acquired category 3, 4, ungradable and deep tissue injury pressure ulcers. Key learning identified the need for refresher training for all staff on the management of pressure ulcers and their documentation and managing situations when patients decline repositioning. The Hospice uses Oska Series 5 pressure relieving mattresses, which have tilting properties, which provide some relief to those patients who find it difficult to tolerate repositioning.

Safeguarding

There were seven safeguarding incidents reported to the local authority in 2023-24.

Alison Birt St Luke’s Inpatient Unit Nurse

Infection Prevention and Control

2023-24 saw one Covid-19 outbreak on the Inpatient Unit. The outbreak was among staff members, with no transmission to patients being cared for on the unit. No patients have contracted Clostridium difficile whilst on the Inpatient Unit.

Duty of Candour

The duty of candour underpins a strong safety culture. Being open and transparent when something has gone wrong is essential for demonstrating that we are an open, transparent and learning organisation, and upholding patient and service user confidence in care and service delivery. In the case of any serious clinical incidents reported, they will be subject to the statutory duty of candour. There were no statutory duty of candour incidents reported in 2023-24.

Speaking Up

Freedom to Speak Up Guardians provide an additional route to support workers to speak up when they feel unable to in other ways. Q4 of this year has seen the Hospice appoint Neel Radia, Trustee, to be the organisation’s first Freedom to Speak Up Guardian. As required by the National Guardian’s Office, Neel has undertaken the programme of training. We will look to promote and embed the role in 2024-25.

3.2 Service user experience

Service user feedback surveys:

This year we completed a small number of user feedback surveys. We recognised that this was a Priority for Improvement for 2024-25. Here are some examples of user experience. Homecare survey- brokerage feedback April 2023-March 2024

Brokerage feedback (Apr 23 - Mar 24)

Are they happy with the carers - overall?

Do the carers wear uniform?

Do they wear full PPE? Do you think you are treated with dignity and respect?

Carer consultation:

We carried out a survey consultation with 10 carers to identify what is important to them and how we might work in partnership to meet their needs as part of our Priority for Improvement Caring Matters - improve the quality of support provided to unpaid carers. The survey identified that care of self, cost of caring, mobility, loss and bereavement and memory/legacy where the areas of most importance to carers. Support and information sessions will be considered around these key areas.

Woodgrange Centre - introductory session feedback:

We received feedback from those who attended 1:1 introductory sessions in the Woodgrange Centre in the latter half of the year.

3.3 Complaints, concerns and compliments

Complaints

We take all complaints received seriously, investigate them, work to engage with the complainant and focus on learning and improvement from the issues raised. We have an open and transparent approach, encouraging reflection to look at all aspects of the complaint,and review areas for improvement.

Examples of actions and learnings following complaints/concerns during 2023-2024 include:

• Focus on clearer communication regarding the services we offer and the remit of these, to ensure expectations of our services are understood.

• Focus on clearer communication in between departments through multi-disciplinary team meetings.

• Training on advanced care planning communication skills.

• The introduction of a new transdermal patch monitoring form.

• The nursing team have received opportunities for senior nurse observation when going on clinical visits. 2022-23 2023-24

Total

of

Concerns

Concerns that were raised have provided us with the opportunity to demonstrate that we are a listening and responsive organisation focused on improving.

Compliments

Here are some examples of the compliments our staff and services received:

“Visiting my best friend in Room 6. Coming to the hospice brought back memories. My mother was here 20 years ago and the care was absolutely fantastic and I can see the same level of care here today visiting my friend. I work from the NHS and it’s good to know the care 20 years ago is still the same today. Well done, continue to keep up the amazing work.”

“I have been in St Luke’s for just over a week and I cannot fault the care I have received. The domestics, catering team, HCA’s and nurses have all been wonderful. They have all played a part in aiding my recovery. The consultant and doctors have also been amazing. Thank you to you all for the great work you do.”

“They say angels are in the skies, but we have seen and met angels on earth. You are the angels, beautiful souls, pure people with how committed you are to making our father happy and comfortable.”

“Our father’s favourite thing to say is “I didn’t see anything but beauty” and we know for sure he appreciates your beautiful smiles and is grateful for everything you do.”

Brent Community Team

“Our dear mother passed away peacefully last Thursday evening while in your wonderful hospice.”

“On behalf of our sick Father and all the family we would like to express our sincere appreciation for all you did to support our mother in the 2 weeks and 2 days she was with you. And also for the wonderful support from your palliative team who made the move from home to the hospice possible.”

“All the staff need to be highly commended from the reception ladies and gent, cleaners, carers, nurses, doctors and all the behind the scene staff and volunteers too.”

“The respect and care in which our mother was given far exceeded our expectations. You truly all deserve medals and so much more for your vocational work. It was a pleasure for us to go in daily and sit with Mum. From the bottom of our hearts we thank you all. Her last days were made comfortable and that is all we asked.”

“We will never forget what you all did to support not just Mum but us too. We will be requesting donations at her funeral and look forward in joining all the fundraising events where we can.”

Homecare

“My sister and I would like to thank the two carers who have just handed over the care to an agency for their compassion, kindness, sense of humour and care for our Dad. Their support was superb and there was never a moment where we felt our Dad was not in good hands. Their exceptional dedication to their role went truly above and beyond and we would like to thank them via this email.”

“Thank you for all that you have done for my dad. He was so delighted to be asked to be your “current poster boy” on your Facebook site and hospice literature”

Patient Family and Support Service

“St Luke’s Hospice is a wonderful place for the community. I met all the staff from clinical to front reception and each of them were so warm and welcoming. It is so beautiful and peaceful here. I would recommend St Luke’s to anyone who is thinking of palliative care and support for their loved ones.”

“Sincere care is at the heart of what you guys do, so I cannot see any improvements needed, you make difficult situations that much easier.”

“Back in May my Dad took his last breaths at St Luke’s Hospice with my Mum and my brother at his bedside. I wasn’t able to be there which I found incredibly difficult.”

“The Patient and Family Support Service phoned me and talked me through everything that was happening and helped me to feel connected through every moment. You gave my Dad a small knitted heart to hold which I now have and treasure.”

“It means so much to me that I wanted to crochet some hearts for you to use as you did with me. They have been made with so much love and I hope they can provide some small comfort in peoples’ darkest hours.”

“Thanks so much for your warmth, support and kindness.”

3.4 Audit and research

Participation in clinical research

The hospice was not involved in clinical research between April 2023 and March 2024.

Participation in National Clinical Audits

The reports of 0 national clinical audits were reviewed by the provider in April 2023-March 2024*. The hospice was not eligible to participate in any national clinical audits.

Participation in Clinical Audits

An annual cycle of clinical audits is carried out particularly evidencing care standards on the Inpatient Unit. The hospice responds to findings from the Audits to ensure the highest possible practices by celebrating evidence of excellent, alongside implementing change and driving actions that address concerns raised by the audit results. For 2024-25, there is a more comprehensive clinical audit and quality improvement programme.

The report of 6 local clinical audits were reviewed by the provider in April 2023 – March 2024 and St Luke’s Hospice intends to take the following actions to improve the quality of healthcare provided as detailed in the table below*.

(*mandatory statements for inclusion) Audit Title Learning and improvement

1. None identified

2. Recording of ethnicity Awareness of the importance of documenting ethnicity through education in local multidisciplinary team meetings and introduction of an equality monitoring form. We have developed a quality improvement project to support improving the recording of ethnicity.

3. Hand hygiene IPU Implementation of hand hygiene audits across our community services, audit results available to staff in real time.

4. Infection Control - Environmentexal audits Focus on decluttering departments. Audit against national standards for healthcare cleanliness.

5. Transdermal patch audit Raising awareness of the importance of documenting twice daily checks of patches.

6. Live view pharmacist medicines interventionsrolling programme Doctor vigilance with checking prescriptions.

Hospice UK self-assessments completed 2023-24:

Audit Title

1. Hospice UK - Self-assessment, controlled drugs accountable officer

2. Hospice UK - Medical Gases

Audit and Quality Improvement Group

Members of the Multi-Disciplinary Team are encouraged to consider aspects of service improvement in the form of Quality Improvement Projects (QIPs). We have a core Audit and Quality Improvement Group membership, which helps with audit and quality improvement project design and ensures that learning and need for change is captured and implemented.

This group meets monthly and was established in December 2023. During this time, we supported and empowered staff in quality improvement methodologies and we received a number of exciting quality improvement presentations in the form of storyboards. This is a simple, engaging visual aid to evaluate proposals and outcomes of QIPs as seen in the next page.

Quality Improvement Projects (QIP) storyboard highlights:

1. Making Cost Savings For The Hospice By Using Cost Effective Diluents

This QIP explored potential savings that could be made using the most cost effective diluent, switching to water as a diluent can potentially save the hospice £2280 per year.

2. Improving and Standardising the Management of Acceptable Losses of Liquid Controlled Drugs

This QIP explored the most efficient method of measuring CD liquids given the number of manipulations made and the number of CD discrepancies being reported. We researched a number of publications on measures taken in different organisations and we implemented solutions to ensure consistency with measuring reducing the number of unaccountable losses during Q4.

3. Safe Storage Of PODs (patients own drugs) on Admission To IPU

This QIP looked at safely securing patients’ own drugs to reduce the risk of medication being misplaced as current practice was to leave PODS in the IPU office. A lockable cupboard where PODs can be stored was made available which is kept in the clinic room, the IPU office is now free from medication, therefore the risk of misuse of drugs e.g. being stolen has been eliminated.

4. Improving Confidence and Knowledge of Harrow Care Home staff in ACP (Advanced Care Plan) discussions

This QIP aimed to support Harrow Care Home staff with improving their confidence and knowledge in having compassionate ACP conversations. We designed an education programme for Harrow Care Homes. Each Home received one workshop and one reflective session. A total of 114 care home staff across 11 homes attended the ACP education. 36% of staff were Nursing and Midwifery (NMC) registered nurses and 64% were

non-registered care staff. The project focused on embedding the 4W’s plus one conversational framework to support conversations with residents and family and clinical supervision. Staff reported improved confidence levels in having ACP conversations at evaluation.

5. Benefits of Reflective Practice Session to Support Advance Care Planning (ACP) Discussions in Harrow Care Homes In addition to ACP education sessions for Care Homes as above, 11 Harrow Care Home staff were offered to engage in a 60 minutes duration reflective practice session to discuss issues around having ACP conversations. 111 care home staff participated in reflection. Themes were captured; the reflective component provided a rich insight into the challenges that Care Home staff faced in engaging in ACP.

Care Home staff reported very limited engagement with reflective practice including clinical supervision yet felt the reflection was beneficial. Impact of culture on engagement with ACP was raised in almost every Care Home. Many staff felt they lacked cultural competence. Care Home staff discussed their own culture’s impact on engagement with ACP discussions and in some cases, recognised this was a barrier to ACP.

6. Improving the Recording of Ethnicity and Religion on the Clinical Patient Information System

This QIP explored mechanisms to improve the recording of ethnicity. We decided to establish whether we have all the relevant ethnicities in the system, ask patients to complete an equality monitoring form and ask clinicians to gather relevant information on their 1st assessment.

Elizabeth

3.5 Statements from Scrutiny

Dear Ms Bennister,

The NHS North West London Integrated Care Board (NWL ICB) has welcomed the opportunity to respond to the St Luke’s Hospice Quality Account for 2023/24 which was received on 2nd May 2024. The ICB has reviewed the following quality priorities identified by the hospice for 2023/24;

Priority 1. Implementation of an incident management database

The new Patient Safety Incident Framework (PSIRF) went live in November 2023 and the ICB note staff completion of the PSIRF Training module. The successful implementation of Vantage alongside the hospice’s revised governance structure will be ensure a continued focus on learning and quality Improvement. We are pleased to note the culture of incident reporting.

Priority 2: Competency Framework implementation across community services

It is acknowledged the hospice have developed a qualification in Specialism Standard for Palliative and End of Life Care against their competency framework. The ICB look forward to seeing the impact of the framework rollout and subsequent evaluation in 2024/25 with a continued focus on education and collaboration with other hospices.

Priority 3: Caring Matters – improve the quality of support provided to unpaid carers

The ICB notes the hospice work in opening the records for carers on electronic record system and the on-going focus on support for carer, family needs and engagement with the wider NWL system. The ICB commend the hospice for continuing to deliver a positive end of life experience for both patients and their carers.

On behalf of NWL ICB, we can confirm that to the best of our knowledge, the information contained in the report is accurate. The ICB supports the quality priorities for 2024/25 and looks forward to working closely with the hospice in exploring further quality improvement initiatives to build on the provision of safe and effective services for our patients.

I would like to take this opportunity to thank the hospice for its continued focus on quality in 2024/25

Celebrating love at St Luke’s

Harsukh and his wife, Anjana, celebrated their 51 year Blue Sapphire wedding anniversary in the Hospice gardens this summer

Despite significant challenges posed by his health, Harsukh and his wife, Anjana, joyously celebrated five decades of marriage with their family in the gardens of the Hospice this summer. On that day, the terrace of Harsukh’s hospice bedroom was livelier than ever, with colourful bunting, a beautiful cake, and children happily running around – a perfect celebration of their 51st wedding anniversary.

Having spent only three days being cared for in our Inpatient Unit, Harsukh and Anjana were determined to mark the occasion and to celebrate their love during one of the most challenging times they have ever experienced. Surrounded by the love of his wife, children and grandchildren and close family, the day was a beautiful way to create some extra cherished time together. Anjana told us: “It’s a memory to treasure, especially within our family.”

The recollections of the afternoon, together with many other precious family moments, hold a special place in their hearts. They shared this with us during an intimate conversation by Harsukh’s bedside. Ever since they started their family over five decades ago, they made it a priority to create and treasure moments like these.

Following a memorable holiday in Mauritius in December 2022, dental problems prompted a sequence of medical check-ups for Harsukh. Despite the absence of any apparent issues or pain, he was shockingly diagnosed with cancer in his jaw in the middle of February 2023.

Their strength as a family saw them through that terrible time. “We told ourselves we’ve got this. Even though everyone is upset and falling apart, we will do whatever it takes to support each other.”

It was with this determination that they navigated the emotionally draining phases of radiation and two serious incidents that led to a stay in hospital. After spending some days at hospital, the family then received the heartbreaking news that there was nothing more

that could be done to fight the cancer and Harsukh was referred to St Luke’s.

They are all so kind and compassionate. You can sense the love and dedication of those who genuinely care for you. “

“

Although hesitant at first, Anjana describes how they were comforted by the warmth they all felt from St Luke’s staff, “They are all so kind and compassionate. You can sense the love and dedication of those who genuinely care for you.”

Harsukh very sadly passed away just over three weeks later and Anjana told us she felt that St Luke’s was the right place for him to be. “The comfort of having the children close by, seeing them play with him, is something that may not be possible in other places, and even their grandson asking the nurses for ice cream,” she says “all helped to create moments to remember from that sunny afternoon”. She added, “Just all being together with him at his end... that’s the memory I want to keep.”

Annex 1: Governance structures

Clinical Governance Committee

To provide assurance to the Board that the appropriate clinical and quality governance systems are in place that encourage and foster a greater awareness of clinical governance and clinical safety throughout the organisation. To ensure the organisation’s commitment to both reduce and prevent harm.

To provide strategic leadership and direction on all matters relating to quality and governance in relation to the delivery of high quality patient services.

Clinical Governance and Quality Group

The purpose of the Clinical Governance and Quality Group is to monitor, review and provide assurance to the Clinical Governance Committee that clinical services are being delivered in a high quality and safe manner, and to promote a culture of continuous improvement and innovation by focusing on the three quality domains: Patient Safety, Patient Experience, and Clinical Effectiveness.

Medicines Safety Group

The group is responsible for ensuring safe and efficient management of medicines in the Hospice. To provide assurance that medicines are used safely in the Hospice.

Infection Prevention and Control Group

To provide strategic leadership, direction and oversight on infection prevention and control activities across the Hospice to ensure that the risks posed by the transmission of avoidable infection are minimised and appropriately managed.

Clinical Audit and Quality Improvement Group

To promote a culture of continuous improvement and innovation with respect to safety of services, clinical effectiveness and patient experience. Collaborate and identify clinical audit and quality improvement opportunities promoting and monitoring activities. Embed processes in a range of Quality Improvement (QI) methodologies, guiding and supporting staff conducting clinical audits and quality improvement projects. Delivering the annual plan of audit and quality improvement.

Policy and Procedure Group

To facilitate processes to ensure that policies and procedures provide a framework for safe, effective and acceptable practice and which comply with regulatory and mandatory requirements. Ensure governance arrangements for policy and procedure production/review, consultation, approval and ratification.