QualityAccount 2021-2022
P3 StatementfromtheChiefExecutiveOfficer P4 WhatisaQualityAccount? P5 AboutStLuke’sHospice P10 StatementsofAssurancefromtheBoard P11 ReviewofPriorities2021 22 P12 ClinicalGovernanceOverview P13 CareQualityCommissionReport P14 EqualityandDiversity P16 InfectionPreventionandControl P17 CommunityEngagement P19 ClinicalData P22 FeedbackfromPatientsandRelatives P25 PrioritiesforImprovement2022 2023 P27 StatementsonthisQualityAccount P28 OpportunitytoProvideFeedback Page2 Contents
NeilWright ChiefExecutiveOfficer
StatementfromtheChiefExecutiveOfficer
Qualitycontinuestositatthecentreofallthatwe do.Weaimtoachievehighstandardsnotjustbymeetingtargets,butbyensuringthatthe servicesweprovidearepersoncentred;anapproachthathumblesusandremindsustoputour patients'needsandpreferencesfirst,abovethoseoftheorganisation.
WehavearobustgovernancesystemofTrusteesubcommitteeswho overview,interrogateandchallengeacomprehensivesetofmonthlydatatoensurethatweare providingquality,valueformoney,sustainablecare.Youwillalsofindcommentsthatpeople havemadeabouttheirownpersonalexperienceoftheservicethatweprovideanditisthis,as muchasanything,thatprovidesuswithalevelofassuranceofthequalityofthecareprovided bytheHospice
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Asweemergefromtheshadowofthepandemic,welookforwardtoimplementingthequality initiativesdetailedlaterintheaccountstomakeourserviceevenbetter.
LivingwithCovidhashighlightedthelimitationsofourenvironmentinprovidingthatperson centredcareandwehaveplanstoimprovethequalityoftheenvironmentoverthenext12 monthsandbeyond
Iwouldliketothankallthoseinvolvedincludingstaff,volunteers,ourthirdpartypartners, supportersandstakeholdersforthecontinuedsupportinthedeliveryofthespecialcarethatwe providetoourpatientsandtheirlovedones.Iwouldalsoliketothankthegovernmentthrough one offspecialgrantfundingaswellasFurloughandretailgrants,alongwiththegenerous supportofourlocalcommunity,whichhasenabledustoremainfinanciallystableinthemidstof challengingeconomiccircumstances
OnbehalfofeveryoneatStLuke’sHospice,I’mpleasedtointroduce ourQualityAccountsfor2021/22andconfirmthatourBoardof Trusteesagreesthatitisanaccuratereflectionofourperformance overthepastyear.
AlthoughournormalserviceswererestrainedbyCovidrestrictions,governmentregulationsand stafftestingpositive,adversityhastaughtustobecomemoreresourceful,creativeandresilient. WeadoptedflexibleworkingwherewecouldtoensuretheHospiceremainedoperationaland adoptedtechnologicalsolutionstoprovideamoreresponsiveserviceforourpatientsandtheir carers.Werealisedthatwecouldn’tfacethepandemicaloneandhavestrengthenedour collaborationswiththecommunityandhospitalteamstofacethesechallengestogether We havealsoprovidedmoreresourcesforthirdpartypartnerships,withorganisationssuchasThe Christie,toextendthereachoftheirservice
Thelast12monthswasthesecondyearoftheCovidpandemicand continuedtobeachallengingyear.Despitethedifficulties,wehave triedtoturnchallengesintoopportunitiesbyadaptinganddeveloping ourservicestoensurethattheyremainedresponsive,safeand compassionatethroughout.
ProducingaQualityAccountisarequirementoftheHealthCareAct(2009)andaccordingtothe DepartmentofHealth,QualityAccountsaimto'enhanceaccountabilitytothepublicandengage theleadersofanorganisationintheirqualityimprovementagenda’.
Asetofkeyprioritiesforimprovementnextyear.
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WhatisaQualityAccount?
Whattheorganisationisdoingwell.
Whereimprovementsinservicequalityarerequired. Whataretheorganisation’sprioritiesforimprovement. Howtheorganisationhasinvolvedpeoplewhousetheirservices,staffandotherswithan interestintheirorganisationindeterminingtheseprioritiesforimprovement
TheQualityAccountcoverstwomainareas: Thepublic,patientsandotherinterestedpartiescanusetheQualityAccountto understand:
Areviewofhowweperformedlastyear,coveringthreemainareasofquality;reachoutto morepeople,makeourbuildingsbetterandcareforandsupportmorepeople.
ThemainpurposeoftheQualityAccountistoencourageproviderstotakearobustapproachto qualityandprovideinformationaboutthequalityoftheservicesthattheorganisationdelivers. AllprovidersofNHShealthcareservices,includingindependentorganisationssuchasStLuke’s (Cheshire)Hospice,shouldproduceaQualityAccount.Indoingsoeachprovider,ledbytheir board,iscommittingtoimprovethequalityofcareitdeliverslocallyandinvitesthepublicto holdthemtoaccount.
ThehospiceisregisteredwiththeCareQualityCommission.TheIPUhas provisionfor10palliativecarebeds. TheIPUhasacomfortablesmallloungeandconservatoryareaforpatientsandfamiliestousefor restanddining.Theconservatoryleadsdirectlyoutontoapatioareawithcomfortableseating andwellstockedflowerborders
Thereisashelteredsmokingareawithseatingforpatientsto use. Thereare4individualusesideroomswhicheitheroverlookthebackpatioareaorfrontaspectof thehospice.EachsideroomhasasinkwithremotecontrolledTV,radio,airconunitandriser recliningchair Thereare2bayswhichaccommodate3beds,eachwiththeirownprivacycurtains Eachbedin thebayhasapersonaluse,overbedTVandariserreclinerchair.Thebaysoverlookthefront aspectofthehospice.
Page5 AboutStLuke's(Cheshire)Hospice
In1988StLuke’swasfoundedontheprinciplesofcombiningexpertpainandsymptomrelief withholisticcaretomeetthephysical,social,psychologicalandspiritualneedsofourpatients, andthoseoftheirfamilyandfriends
Allhospicepatientbedsareelectronicforcomfortandcanbeadjustedusingahandsetbyeither thenurseorthepatient Eachprofilingbedhaseitheranairwaveorfoampressure relieving mattress.Eachhaveanursecallbell,overbedtable,wardrobeanddrawerunitforpersonal belongings Thereare2comfortablechairsandcoffeetableinbothbaysthatpatientsorvisitors canuse.
InpatientUnit(IPU):
DayHospice:StLuke’sDayHospiceoperatesMondaytoThursdaysupportingpatientsandcarers througharangeofpalliativeandsupportivecareservices,includingWellbeingDays, ComplementaryTherapy,AcupunctureClinics,groupandtelephonesupport Ourunitincludesa largeloungearea,dining/multipurposeroom,ComplementaryTherapyroomsandawell establishedgarden.DayHospicefacilitiesaresuitablefordisabledusewithaccesstoarangeof movingandhandlingequipment.TheDayHospiceunitisalsoabaseforTheChristie'soutreach serviceonWednesdaysandFridays.
Mealsarevariedandprovidedfreetoallpatients
Thereisasmallkitchenforaccesstoteaandcoffeefacilities.Thehospicecateringteamwillalso providemealsforrelativesatasmallcost
ThisteamprimarilysupportsdirectusersoftheHospiceandlocalMacmillanteams,butinsome areas,suchasBereavementSupport,reachesfurtherintothelocalcommunity.TheFamily SupportTeamworkcloselytogether,sharingdifferentskillsandknowledge Consequentlyitis abletoofferjoinedupservicestopatientsandtheirfamilies,aswellastocolleagueswithinthe hospicecommunity AboutStLuke's(Cheshire)Hospice
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Individualnutritionalrequirementsandpreferencesareaccommodated.
Therearespecialisttoilet,bathingandshowerfacilities,whichaccommodatephysicaldisabilities andpromoteindependence.Thereare2comfortablevisitorroomseachwithbedsetteesfor relativestobeabletostayovernightonanindividualisedneedsbasis.
FamilySupportTeam:TheFamilySupportTeamcomprisesarangeofservicesincluding Counselling,BereavementSupport,SocialWorkSupport,SpiritualCareandChaplaincy, BefriendersandFinancial/BenefitsAdvice.
Thereisadedicatedquietareaforreligiousrequirementsandnonreligiousspiritualcareneeds, thisisavailable24hoursadayforquietreflection,prayerandreligiousservices.
TheBefriendingServiceofferscompanionshipandfriendshipfromvolunteerswho visitpatientswithintheirownhomesforacoupleofhourseachweek reducinglonelinessand isolationformanywithinthecommunity Eachandeveryoneofthevolunteersmakeahuge differencetopatients'lives.
Page7 AboutStLuke's(Cheshire)Hospice
TheStLuke'sLymphoedemaServiceisheretotreatandsupportpatientsaged18 yearsandoverwithprimaryandsecondarylymphoedema.TheserviceisrunjointlybyStLuke's Hospice,CheshireCommunityIntegratedCarePartnershipandMacmillanCancerCare. Lymphoedemaisaswellingofthetissueswhichcanoccuranywherewithinthebody,causedbya failureofthelymphaticsystem
TheStLuke'sLymphoedemaTeamisbasedatStLuke's Hospice,butwealsohavesatelliteclinicsinAlsager,CreweandNantwich.Followingthefirst assessmentpatientswillbeseenasclosetohomeaspossible. Whenareferralisreceivedbytheteam,patientswillbeinvitedtotheHospicefortheirfirst appointmenttohaveaninitialassessment,inwhichadetailedhistorywillbetaken.An individualisedlymphoedemamanagementplanwillbedrawnupwiththepatienttoincrease supportedself managementoftheirlymphoedema.Initiallypatientsmaybeseeneveryfewweeks untiltheirlymphoedemaisstabilised,treatmentswillvaryfrompatienttopatientdependenton theirneeds. Befriending:
Benefits:TheBenefitsService,whichispartoftheSocialCareService,isopentoanyoneinthe Hospiceareawhohasalifelimitingillness Wealsohelprecentlybereavedrelatives Weoffer telephone,emailandfacetofaceadviceeitheratthehospiceorhomevisits,tohelppatients identifyandaccessbenefitstheyareentitledto,grantsandanyothermeansofmaximisingtheir income.TheserviceislinkedtoCitizensAdviceCheshireEastsoreferralscanbemadefordebtand otherareasofadvice.Weacceptreferralsfromlocalmedicalprofessionalsandpeoplecanalsoself referbyphoningthenumberontheHospicewebsite
Lymphoedema:
Thiscanbeduetoaninheritedgeneticfault,treatmentofcanceror traumaasresultofinjuryorinfection.
Page8 AboutStLuke's(Cheshire)Hospice
Homelessness:Thisserviceworkswithindividualsexperiencinghomelessnessandwhoare expectedtobeintheirlastyearoflife. Itisknownthatpeopleexperiencinghomelessnesssufferfromdisproportionatepoorhealthand oftenexperiencemanybarrierstoaccessinghealthcare.Theseindividualsarealsoknowntodieat amuchyoungerageandtheirdeathsareoftenunplannedwithaccesstopalliativecare uncommon Ourserviceaimstoreachouttotheseindividualswithaviewtoimprovetheirqualityoflifeandto helpthemtomakeinformedchoicesabouttheircare.Thisisensuredinanumberofways includingadvocacyandsocialsupport,reconnectingwithlovedones,accesstoHospiceday servicessuchascomplementarytherapiesandcounsellingservicesalongsidespecialistendoflife care.Theseservicesareoftenextendedtotheirfamilies. Inadditiontothis,thereissupportandeducationavailabletoanyoneworkingwithpeople experiencinghomelessnessandadvancedillhealth.Trainingisofferedtosupporthowtodealwith endoflifeissuesincludingbereavementsupportandidentifyingwhenaclientmaybedying.
Page9 Wehavefourmainstrategicaims Careand supportformore people Reachout Besustainable Makeour buildingseven better Caring Collaborative Resourceful Excellence OurStrategyis "Helpingpeopletolivethelifetheycan" OurVisionis forallpeoplewhoarelivingwithalifelimitingillnessinCheshireandthose closetothemtohaveaccesstothecareandsupporttheyneed,wheneverand wherevertheyneedit. OurMissionis toenablepeopleinCheshiretolivethelifetheycan,informedandsupported untiltheendoftheirlifeandtobethereforthosewhoareclosetothem. Ourvaluesunderpineverythingwedo RInnovative espectful KnowledgeableHonest ThevaluesofStLuke’sareattheheartofeverythingwedoandunderpinourstrategies, policiesandwaysofworking Embeddingourvaluesthroughourrecruitment,induction, trainingandcommunicationsalsohelpstocreatetheappropriateenvironmenttoworkin partnershipwithothers
Finally I must recognise the enormous efforts, particularly of our “frontline” staff, in keeping our services open as far as possible while recognising the restrictions placed upon us by the COVID epidemic. We have supported staff in a number of ways and we continue to recognise the real sacrifices made by so many in order that we are able to care for those in greatest need It is my privilege to present this report on behalf of the Hospice Board.
MikeRidley Chairman
Page10 StatementsofAssurancefromtheBoard Thefollowingareformalstatements,undervariousheadings,thatallprovidersofNHShealthcare servicesmustincludeintheirQualityAccountevenifthestatementisnotdirectlyapplicabletous asaSpecialistPalliativeCare.
On behalf of St Luke’s Hospice I am delighted to provide this Board Assurance Statement of our oversight of the quality of our service provision as detailed in our Quality Account. The ongoing quality of our clinical services is monitored monthly by our Care Committee which in turn provides a summary to monthly Board meetings. I am very happy with the level of discussion, and challenge from trustees at both meetings. An important source of information at these meetings is the monthly publication of our “Management Data Pack”. Over thirty pages of monthly performance information is produced ranging from bed occupancy statistics and Day Hospice activity to safeguarding incidents and EPaCCS data on “Preferred place of death” and other important data They provide a valuable basis for both informing ourselves and challenging various aspects of the Hospice’s work. The Care Committee on behalf of the Board considers and discusses a whole range of performance issues and provides a more detailed opportunity to question and challenge information contained in the Management Data. One regular area of discussion is the level of staffing available to meet our full range of clinical services. A prime concern of all trustees is not only the numbers of staff in post to provide our services, but also the availability of an appropriate range of medical, nursing and other skills. Recent discussions have also centred on our future clinical strategy as part of our planning for the future of the Hospice itself One key discussion has led to the establishment of a new “St Luke’s at Home” service, where we will carry our end of life care into more residential settings.
Quality governance is also a key concern of all Board members. All formal policies with clinical implications, either new or for renewal, are considered by the committee followed by a recommendation to the Board Our governance is also fulfilled by our monthly review of all clinical “incidents” and their outcomes. We also closely review the level of risk that could be faced within our care services, making recommendations to minimise all risks as appropriate One particular area which is reviewed on a regular basis is “Medicines Management”.
In regularly reviewing our services we also take careful account of the external requirements of the Care Quality Commission and also our local Integrated Care Board (previously Clinical Commissioning Group) The Trustee Board is made aware of their requirements and monitors any changes or corrective action required by the statutory bodies and also other external organisations such as the Famcare Audits
During2021/22westartedtodevelopourcommunityhospiceservicesincludingStLuke’sat Homeandourweekendspecialistpalliativecarenurseservice:
StLuke’satHomeisaservicethathasbeendevelopedandfundedbyStLuke’sHospiceto initiallyprovideanightsittingserviceforpatientsinourareawhorequirecare,adviceand supportovernightwithintheirownhomes.
Page11 ReviewofPrioritiesforimprovement2021-2022
Theweekendpalliativecarenurseserviceisasinglepointofcontactforpatientsatthe weekendwhomaybeknowntothehospiceorcommunityMacmillannursingteamswho requireadvice,supportand/orhomevisitstomanagesymptomsorprovideholisticcare andsupport.
PriorityTHREE-CareandSupportformorepeople
PriorityONE-Reachout
During21/22wecompletedanumberofprojectsattheHospice
During21/22WelookedatmakingourHomelessnessServiceasustainablyfundedcore servicewithinStLuke’sHospice.WealsodevelopedourLGBTQ+Co ordinatorroletoimprove accessforthiscommunitytopalliativeandendoflifecarewithinthehospiceenvironment. BothrolesarecollaborativeprojectsacrossCheshirewithourneighbouringhospicesatEast CheshireandWestCheshire.
WehaveanLGBTQ+Facilitatorinpostwhoworkscollaborativelyacrossthehospicesto supportthedevelopmentofchampionsacrossthehospices,developaprogrammeof educationandawarenesswiththeaimofimprovingaccesstohospiceservicesforthis community. WehavebeensuccessfulinattainingtheNavajoCharterMarkwhichisasignifierofgood practice,commitmentandknowledgeofthespecificneeds,issuesandbarriersfacing lesbian,gay,bisexualandtransgender(LGBTQ+)peopleaccessingourservices.
PriorityTWO-Makeourbuildingsevenbetter IntheInpatientunitatWinsfordwereplacedflooring,decoratedtheunit,upgradedthe lightingandceilingtothenurses'station,replacedalloftheprivacycurtains,refurbisheda bathroomintoawetroom,decoratedthechapel,installednewbedsforthepatients, suppliednewlargeTVscreensforthepatients(includingatWinterley),fixednewdoor signage,fittednewfiredoorsandupdatedthefirealarmsystem,re linedthecarparkand replacedbrokenfencingpanels.InadditiontothiswedecoratedtheDayHospiceand suppliednewreclinerchairsforpatients
Medicineincidents:
Eachfallincidentisreviewedandoverseenbyseniorstaff.Althoughtheeliminationofallfallsis unlikely,stepsaretakentolearnfromtheincidentsandintroducemeasurestoreducefuture numbers.
Patientfalls:
Page12 ClinicalGovernanceOverview
Allmedicineincidentsarereviewedmonthlyatourmedicinemanagementmeeting.Thereview isinanonjudgementalwayinordertounderstandtheincident,findsolutionstoimplementto avoidanyfuturerepeatsandimprovethequalityofourmanagement
Page13 CareQualityCommissionReport StLuke’sisregulatedbytheCareQualityCommission(CQC)whoseroleitistocheckthatthe servicesweprovidemeetfundamentalstandards. StLuke’sHospicewaslastinspectedbyCQConthe21stMarch2016withtheirfullinspection reportbeingavailableat: CareQualityCommission|StLuke'sCheshireHospice|StLuke’sCheshireHospice (slhospice.co.uk) OurlastinspectionbyCQCresultedinthefollowingratingofourservices: InlinewithCQC'scurrentregulatoryregime,weholdregulartelephonereviewmeetingswith ourlocalinspectorwherewearealwayslookingforwaystoimprovethequalityofourcare.
1. 2. 3. StLuke’sHospicecontinuestorecognisetheimportanceofconsistencyintheeliminationof discrimination,harassmentandvictimisation.OurEqualityandDiversityPolicyevidencesthe hospice’seffortstoensurethatno onereceiveslessfavourabletreatmentonthegroundsof age,disability,gender,marriageandcivilpartnership,pregnancyormaternity,race,religionor belief,sexorsexualorientation.Thiscommitmenttopromotingequalityanddiversityis consistentacrossorganisationalpolicy.Effortshavebeenmadetoensurethiscommitmentis explicitacrosspoliciesandisspecificallyreferencedinourDignity&RespectatWorkPolicy, AnnualLeavePolicy,AppraisalPolicy,CapabilityPolicyandDisciplinaryPolicy&Procedure. Ensuringthisinclusionisconsistentacrossorganisationalpolicyworkstoeliminateunlawful discrimination,harassmentandvictimisationwhilealsoadvancingequalityofopportunityfor allthoseworkingin,visitingandusinghospiceservices.
Further,theHospicehastakenstepstofostergoodrelationsbetweenpeoplewhosharea protectedcharacteristicandthosewhodonot AkeypartoftheLGBTQ+inclusionprojecthas beenprovidingStLuke’sHospicestaffwithLGBTQ+awarenesstrainingandestablishing LGBTQ+Champions.BoththetrainingandChampionrolesinviteallstaff,regardlessofgender andsexualorientation,toengageinimportantconversationsaroundinclusivityand organisationaldevelopment.Theseconversationshavealsopromptedthehospicetotakea closerlookathowweconsiderintersectionalitywithindecisionmakingprocesses.
In2021/2022StLuke’sHospicecontinuedinitsendeavourtoadvanceequalityofopportunity. AnLGBTQ+DevelopmentFacilitatorwashiredusingfundingprovidedbytheMasonic CharitableFoundation.Thisrolehasallowedthehospicetoworkcollaborativelywithfellow CheshirehospicestoreducethebarriersLGBTQ+individualsfaceaccessingendoflifecare. Thisprojecthasmadepositivechangestostaffawareness,policiesandhospicematerialsas wellasbuildingconnectionswithLGBTQ+communitygroups.
Page14 EqualityandDiversity
Advanceequalityofopportunitybetweenpeoplewhoshareaprotected characteristicandpeoplewhodonotshareit.
Eliminateunlawfuldiscrimination,harassment,victimisationandanyotherconduct prohibitedbytheEqualityAct2010.
StLuke’sHospicerecognisesandcomplieswiththeequalityrequirementsoftheEqualityAct 2010.Therefore,StLuke’sHospiceisactiveinensuringfunctionsarecarriedoutwhile remainingconsciouslyawareoftheneedto:
Fostergoodrelationsbetweenpeoplewhoshareaprotectedcharacteristicand peoplewhodonotshareit.
Thepromotionofhealthandwellbeinghascontinuedmorewidely,with staffprovidedwitharangeofsupportmaterials/resources.Aswellasthis,wehaveMental HealthFirstaiderstrainedandavailableasasupportivetoolacrosstheorganisation.Allstaff haveaccesstothesesupportoptions,regardlessofwhethertheydoordonotsharea protectedcharacteristic.
Toembedthis,StLuke’sHospicehasintroducedandutilisedanEqualityImpactAssessment forallnewandreviewedpolicies.Thisworkstoensureourpolicies,practicesanddecisionsare fairandgenuinelymeettheneedsofourstaffandpatients.Aswellasworkingtoensureweare notinadvertentlydiscriminatingagainstanyprotectedgroup
Thehospicehascontinuedinourcommitmenttosupportingpatientandstaffspiritualcare; withstaffbeingsupportedtoutilisetheChapeltopromotetheirwellbeingwhethertheyhavea religiousfaithornot
Page15 EqualityandDiversity
Toextendthispositivework,St Luke’sHospiceintroducedacalendarofawarenesscampaignsforvarioustopics.Thisincludes, butisnotlimitedto,StressAwareness,Men’sHealthAwareness,DisabilityAwarenessand LGBTQ+Awarenessevents.
Page16 InfectionPreventionandControl TheCovid 19pandemichasbeenahugechallengefortheHospice,impactingthecarewe providetoourpatients,aswellashavingadirectimpactonouremployeesandvolunteers.Our prioritythroughoutthepandemichasbeenthesafetyandwellbeingofeveryoneatStLuke’s, includingpatientsandtheirfamilies,ouremployeesandvolunteers Ouremployeesandvolunteershaveparticipatedinregulartestingregimes,inlinewith nationalguidance,toensurewereduceriskasmuchaspossible.Allemployeeshavebeen supportedthroughanyperiodsofisolationtoensuretheyprotecttheirownhealthand wellbeing,enablingthemtoreturntotheworkplacesafelywhenable.Wehaveprovidedclear guidelinestoensureeveryoneisawareoftheexpectationsinrelationtogoodhygiene practicesandtheuseofPPE.
Page17 CommunityEngagement
Schoolsandnurseries GroupssuchastheWI,Rotary,Freemasons Sportsclubssuchaslocalfootballandrugbyteamsandgolfclubs Crematoriums Localbusinesses Religiousgroups Corporatepartners Page18
CommunityEngagement
Asacharitywemakenochargeforourservices,butrelyonourownfundraisingeffortsandamodest contributionfromtheNHS Thismeansthatmorethan85%ofthefundsrequiredtoensurethe continuationofthespecialistpalliativecareservicesweprovidecomefromourcommunity eithergiving donations,takingpartinfundraisingevents,supportingourshops,playingtheLotteryandleavinggiftsin Wills. Communityengagementandsupportisanimportantpartoftheworkwedo Inadditiontoourcore servicesforpatientsandtheirfamiliesprovidedbyourInpatientUnit,DayHospiceandFamilySupport Services,wealsohostoutreachChristieClinicsatthehospiceinWinsfordeveryWednesdayandFriday. Hostingtheseclinicsmeansthatlocalcancerpatientsrequiringchemotherapydon'thavetomakethe tiringjourneytothehospitalinManchesterfortheirtreatment. Wealsolooktoengagewiththelocalcommunitytoinform,educate,consult,raiseawareness,raise supportandinvolvetheminthefutureofthehospiceandthecareitprovidestheircommunity Duringthe pastyearwehaveruneventsinthecommunity,notjusttobenefitthehospicefinancially,butalsoto bringthecommunitytogetherinacommongoal.WeengagewiththecommunitythroughtheStLuke’s Lottery,whichhasmorethan16,000players,andthroughourtencharityshopsandWarehouse. Thanksmustgotoeveryonewhohasgotinvolvedandsupportedourhospiceoverthepastyear.Without peoplejoiningin,volunteeringtheirtime,effortandfinancialsupportwewouldnothavebeenableto providetheHospiceservicesthatmanypeoplerelyupon Weaimtodemonstratetoourcommunitythat StLuke’sistheirhospiceandtheyshouldbeproudofwhatisachievedthankstotheirongoingsupport. ThefollowingarejustsomeofthecommunitygroupsourCommunity/Corporate/EventsTeamsregularly engagewith:
%Patientswithnon cancer Page19 ReferralActivity 2021/22 2020/21 2019/20 Numberofreferrals 314 %Patientscancerprimary diagnosis 10% 21% 11% ClinicalData Thebelowdataprovidesanoverviewofourin careservices: 256 205 84% 89% 83% Numberofadmissions 2021/22 2020/21 2019/20 Numberofpatients admitted 175 173 236 %PatientswithCancer PrimaryDiagnosis 82% 90% 74% 18% 10% 26% OccupancyhasbeenlowerthanpreviousyearsinordertocomplywiththegovernmentCovid restrictions.OurInpatientUnithadtoclosedownforashortwhileduetotheincidenceofCovid amongstourstaff.
Page20 ClinicalData OutcomeofAdmissions(Noof pts) 2021/22 2020/21 2019/20 %Patientsdied 58% (99) 61% (104) N/A %Patientsdischarged 42% (71) 39% (67) N/A Theaveragelengthofstayhasgoneupoverthelasttwoyearsowingtothedifficultiesin dischargingpatientsduringthegovernment'sCovidrestrictions.
Page21 ClinicalData %Patientswithnon cancer diagnosis DayHospiceActivity 2021/22 2020/21 2019/20 Numberofreferrals 346 %Patientscancerprimary diagnosis 15% 23% N/A 116 265 73% 58% N/A %PatientswereCarers 12% 19% Numberofpatients supportedacrossallareasof DayHospice 526 211 492 Encounters 1039 339 677 FamilySupportUnitActivity 2021/22 2020/21 2019/20 Numberof Referrals:FSC/SCC 290 388 342 359 251 N/A Familysupportand ChaplaincyPatients supported 58 60 106 SocialWorkerpatients supported 83 87 157 SocialWorkers Numberofreferrals Comparedtolastyearwhenwehadtoclose/changethedeliveryofanumberofourcare servicesinlinewithgovernmentguidelines,wearenowlearninghowto'livewithCovid'and supportourpatients'needs
Thispastyearwehave startedusingournewiPadstodeterminetheextenttowhichourserviceuserswould recommendStLuke’sHospice.
Page22 FeedbackfromPatientsandRelatives
CommentsaboutStLuke’sHospiceMadebyPatientsandCarers
Everybody we have had dealings with at St Luke's have been very helpful, caring and kind. Thank you for your help and caring support, you have really inspired me. Fabulous caring service. Exceptional care. Thank you St Luke's staff are amazing They were extremely friendly, courteous and helpful and even managed to provide information I wasn't aware of. My complementary therapy was extremely relaxing and exceeded my expectations and just what I needed Thank you so much St Luke's
Throughout2021/22wehavesoughtfeedbackfromPatientsandCarers
Asyoucanseeinthebelowgraphthehospicehasachieveda100%'Recommended'rating overthepastyearfrom62responses. HowlikelyareyoutorecommendStLuke'sservicestoyourfriendsand family,shouldtheyneedsimilarcare?
Very clear understanding of my issue followed by excellent advice and guidance on how to manage my condition. Carol Thayer provided a concise, but thorough explanation of lymphoedema causes and all aspects of treatment in a very professional, but caring wayexcellent. Always get a warm welcome and honestly is so professional at the same time
Reassurance and the time to listen to my concerns is a positive as I spend too much time alone I feel better about my problems and my confidence is better
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FeedbackfromPatientsandRelatives
Over the last few years I have required support following my surgery. Kirsty has been brilliant at informing me and guiding me I have now adjusted my work life balance and by looking after myself between the support we had has really helped me.
Thank you to everyone involved at St Luke's.
For22/23 ThereareanumberofcompletedandongoingprojectsfortheHospice.This includes: AtStLuke’sweareimprovingthestandardsattheHospiceensuringthecareandcompassion forourpatientsismetinasuitable,safeandeffectiveenvironment
WeareconvertingthecurrentdiningroomintheInpatientUnitintotwo,creatingadrugs roomandabistroarea.Thedrugsroomwillbeapurpose builtnewfacilitycreatingthe bestsolutionforthehospiceanditspatients.TheBistroareawillcreateavibrant, friendlier,invitingenvironmentwherefoodanddrinkscanbeobtainedandeaten. OngoingflooringanddecorationprojectthroughouttheHospice.
WehaveinstalledairconunitsintheInpatientUnittoensuretheoptimumcomfortforthe patients,familiesandstaff.
Page25 Priorityimprovementsfor2022-2023
PriorityTWO-Makeourbuildingsbetter
For2022/23-wewillcontinuetodevelopourcommunityservicesasfollows: EstablishourStLuke’satHomeserviceprovidingnightcareservicesforpatientsintheirown homes EvaluateandreviewtheStLuke’satHomeserviceandbegintoconsiderthedevelopmentof thisservicetoincludecarecallsorotherhospiceoutreachservicessuchascomplementary therapy. Continuewithourweekendworkingserviceanddevelopcloserlinkswithcommunityservices toensureaseamlessandsustainableservicecanbedevelopedwithaccesstospecialist palliativecare7daysaweek.
PriorityONE-Reachout
Reviewsofourservicehelptoinformthedevelopmentandidentifythepriorities forfutureimprovementsatStLuke’sHospice.
Weareinstallingtwosmokingsheltersforpatientstouse Wewillbeupgradingthegardenfurnitureforpatientsandfamiliestouse.
TheHospicehasidentifiedthroughsuchreviewsthreeprioritiesforQuality Improvementfor2022 2023asfollows:
WeareupgradingthewoodenwindowstonewUVPCwindowsandreplacingsomeofthe doorsanddamagedfasciaboards.
Wehavemadeanumberofchangestosomeofficeareastocreatebetterworking environmentsforstafftouseandworkin. WehavevolunteersworkinginthegardensatbothWinsfordandWinterleyensuringan abundanceofseasonalplantsandcolour
UtilisingtheLGBTQ+facilitatortodrivetheagendatoreducebarriersinaccessinghospice careforthosewithinthiscommunity Thisincludesworkingtowardstheobjectives outlinedwithintheNavajoCharterMarkaward.TheNavajoCharterMarkrecognisesthat anorganisationisworkingtoreduceinequalitiesandgivespracticaladvice,supportand assessmentofwheretheneedsoftheorganisationlie. WewillcontinuetosupportthosewithintheCheshireareawhofindthemselveshomeless andlivingwithapalliativediagnosis.
Page26 PriorityTHREE Careformorepeople
For2022/23-ourexistingprojectsaroundimprovingaccesstohospicecareforthosewho experiencebarrierstoservicesincluding:
StatementsonthisQualityAccount Page27
Werecogniseyourgreatcommitmenttodevelopingthecommunityhospiceserviceswiththe successfulimplementationof“StLuke’satHome”andtheweekendspecialistpalliativecarenursing servicesofferingadviceandsupporttopatientsintheirownhomes.
NHSCheshireandMerseysiderecognisestheunprecedentedchallengeCOVID 19hascontinuedto bringtohospicestaff,patients,theirfamilies,andthewidercommunity.Despitethisthehospicehas workedhardtodevelopnewwaysofworkingandcontinuedtomakeprogressinplanned improvementgoalsandcollaborativeworking.
NHSCheshireandMerseysiderecognisestheimportanceofequalityandinclusion.Yourcollaboration andpartnershipworkingwitheastandwestCheshirehospicestodevelopimprovedaccessand patientpathwaystopalliativeandendoflifecareforthehomelessandLesbian,Gay,Bi sexual, TransgenderandQuestioning/Queer+(LGBTQ+)communitiesistobecommended Wewouldliketo taketheopportunitytocongratulateyouonachievingtheNavajoCharterMarkrecognising outstandingpracticeandcommitmenttoequality
Thecontinuedrefurbishmentworktomaintainandimprovein patientanddayhospicefacilitiesfor patients,visitorsandstaffiswelcomed.
Ascommissionerswewelcomethehospice’stransparentandresponsiveapproachtopatientsafety andclinicalgovernance,thatprovidesassurancethatthedeliveryofpatientcareissafeandeffective. Wesupporttheareasthehospicehasidentifiedasprioritiesfortheforthcomingyear. Wevalue workinginpartnershipwithyoutoassurethequalityofservicesforthegrantagreementfor2022 23.
NHSCheshireandMerseysideResponsetoQualityAccountReport2021-2022 forStLuke’sHospice
Feedback FeedbackfromserviceusersandthegeneralpubliconourQualityAccountisvery welcome.Ifyouhaveanycommentsorqueriespleasedonothesitatetocontact: ChiefExecutiveOfficer StLuke’s(Cheshire)Hospice GrosvenorHouse Queensway Winsford Cheshire CW71BH Telephone:01606551246 www.slhospice.co.uk Westrivetodeliverexcellentcareandwelcomefeedbackviaourregulatorthe CareQualityCommissiononyourexperienceofourcare.Detailscanbefoundat www.cqc.org.uk/give feedback on care