Part Two Quality Improvement Priorities
2.1 Model for Quality Improvement
As a hospice we always work to deliver outstanding care. A key part of this is embedding quality improvement methodology and implementing best practice.
To provide a consistent approach to achieving Quality Improvement Priorities we have adopted the ‘Plan, Do, Study, Act’ (PDSA) cycle as our Quality Improvement approach. Our teams have used the PDSA template for completing Quality Improvement projects throughout the year.
We have collected and analysed feedback from staff who have used the PDSA template. In the 2024-25 period, our objective is to refine and release a second version of the Quality Improvement PDSA template, incorporating the valuable feedback we have received. This iterative process underpins our commitment to continuous improvement and the delivery of outstanding care.
2.2 Quality Improvement Priorities (QIPs) for 2024-2025
There was multi-professional involvement in identifying the QIPs. The process involved identifying themes from complaints and incidents to see where areas of practice could be improved. Our QIPs relate to the hospice’s annual operational plan and reflect our core values.
Integrate the principles of the Patient Safety Incident Response Framework (PSIRF)
Why?
• Across our organisation, there has been an increase in low-level incidents across all patient safety metrics.
• To enhance our understanding of safety by analysing insights from patient safety incidents.
• Sussex Hospice Collaborative has agreed to work collaboratively with the Integrated Care Board (ICB) in adopting the four main principles of PSIRF.
• To maintain an unwavering organisational commitment to continuous Quality Improvement and learning from safety incidents and events.
How?
• Establish a collaborative PSIRF implementation group with St Michael’s Hospice.
• Create a comprehensive Patient Safety Incident profile summarising incidents from the past two years.
• Complete and obtain approval for a PSIRF Training Matrix at each hospice.
• Create a Patient Safety Response Plan and share it with the Integrated Care Board (ICB).
• Conduct PSIRF awareness sessions at both St Wilfrid’s and St Michael’s Hospice, aiming for an 85% compliance rate among all hospice staff.
• Create a Patient Safety Policy across both hospices and share it with the ICB.
• Foster a learning culture.
• Enhance clinical risk assessments.
• Initiate the scoping process to ensure that all incidents receive appropriate levels of investigation.
• Ensure that all designated individuals complete the required training aligned to the PSIRF Training Matrix by the end of the fourth quarter, achieving a 95% compliance rate.
In collaboration with
Quality Improvement Priorities 10
Our nurse has been exceptional. She has taken time to support my wife. I couldn’t do without the support of the hospice.
Develop a comprehensive dependency tool that integrates structure, safe staffing regarding palliative complexity, and carer need
Why?
• There has been a rise in referrals and the complexity of cases within our services. Recruitment challenges are requiring a fresh approach to enhance our agility and responsiveness in meeting the needs of patients and carers.
• To safeguard the wellbeing and capacity of teams throughout periods on heightened activity.
• To always ensure clinical safety and effective patient care.
• To explore the collaboration opportunities of working with St Michael’s Hospice.
How?
• Establish a collaborative working group focused on the implementation of a joint staffing tool across both hospices.
• Conduct a comprehensive review of existing literature and dependency tools.
• Develop a dependency tool based on best practice for testing within the Inpatient Unit.
• Actively engage and train staff in the use of the pilot dependency tool.
• Conduct a comprehensive pilot of the dependency tool across both St Wilfrid’s and St Michael’s Hospice.
In collaboration with
Further improve our capture of patient and family demographics
Why?
• To meet our strategic objective: ‘across our communities we will lead improvements in end of life care.’
• Understanding our current patient and family demographics helps us understand need.
• Being able to compare the demographics of our current patients and families with the demographics of the local population will show us discrepancies. This will help us develop our service and improve access.
• We currently have demographics information for around 13% of patients and families.
How?
• Set a target for collecting demographics data and review progress regularly.
• Task and finish group to oversee and drive initiatives to significantly improve data capture.
• Develop the clinical team’s understanding of the importance of demographics capture and what current data is telling us / how it is being used.
• Develop regular messaging regarding data capture.
Quality Accounts 2023-2024 / Part Two 11
2.3 Feedback on Quality Improvement Priorities (QIPs) for 2023-2024
The following section describes the activity that has taken place through the reporting year to address the QIPs.
1. To further develop and embed our Quality Improvement methodology model
• Our chosen Quality Improvement methodology – ‘Plan, Do, Study Act’ (PDSA) – was used to help achieve three of the 2023-24 Quality Improvement Priorities:
- Promoting a Quality Improvement culture.
- Establishing a palliative care virtual ward at St Wilfrid’s Hospice.
- Enhancing opportunities for MDT learning in relation to complex case management.
• The PDSA approach was also used for new Quality Improvement projects:
- Improving conversations on sex and intimacy in palliative care.
- No Barriers Here workshops.
- Virtual Reality.
• Posters about the Virtual Reality project were displayed on Quality Matters board located in the Living Well corridor and on the Inpatient Unit. The Virtual Reality used patient feedback to look at the benefits of using a VR headset to provide escapism, relaxation and achieve ‘bucket list’ experiences.
• We have held monthly meetings for people completing a Quality Improvement project. Individuals who are in the process of initiating a Quality Improvement project have also attended these meetings and found them beneficial.
• A poster on the development of a standardised Quality Improvement tool that uses the PDSA methodology was showcased at the Hospice UK National Conference in November 2023 .
• Our bi-monthly Clinical Effectiveness meetings include discussions about the progress of Quality Improvement projects.
• Individuals supporting Quality Improvement projects in 2024/2025 will include the:
- Quality Lead.
- Associate for Clinical Services.
- Associate Director for Quality and Governance.
• We delivered a ‘story so far’ event to staff, showcasing the evolution of Quality Improvement projects. Discussions were held regarding the successes and challenges encountered during Quality Improvement projects.
• Individuals who had used the PDSA template completed a questionnaire. The findings will inform the development of a revised template for future use in 2024-25.
2. To introduce and establish a virtual (hospice) ward
• The project team used the PDSA template. This was added to at each project meeting to allow for updates.
• The virtual hospice plan of implementation was followed. The pilot started in October 2023 and finished at the end of March 2024.
• We completed an interim evaluation, which was presented at the strategy spotlight meeting in February 2024. We are now completing the final evaluation following the end of the pilot. This will inform conversations surrounding the feasibility and the shape of a future service.
• The virtual hospice team asked patients for feedback after they have been discharged from the virtual hospice.
• ‘From the virtual to reality – establishing a palliative care virtual ward in a hospice/community setting’ poster was displayed at the Hospice UK conference in autumn 2023.
Quality Improvement Priorities 12
3. To fully integrate and embed a new patient electronic records system, enabling meaningful and purposeful data to be obtained
• The hospice moved to a new electronic patient record system (SystmOne) in mid-March 2023.
• Staff across all clinical areas were trained prior to the go-live date.
• The team are successfully getting data from the front-end and for strategic reporting.
• We have developed and regularly updated a User Guide for current data extraction.
• For the past year the Report and Data Network (RADNET) group has been conducting quarterly meetings that have been useful for the Data Analysts who attend.
• We held drop-in sessions and offered 1:1 support to help users with the new system, but there was poor uptake. We continue to have a regular presence at Multi Disciplinary Team meetings and team meetings to highlight any common themes that are being seen.
• We have completed the archiving of Crosscare (our previous electronic patient records system) records into SystmOne. Crosscare was disabled on 31st December 2023 and decommissioned in the spring of 2024.
• A small group visited a hospice with electronic prescribing. Given the project’s vast scope, the decision was made to reassess once SystmOne was fully integrated.
4. To enhance opportunities for Multi-Disciplinary Team (MDT) learning; building competence and confidence in the clinical workforce
• The project team used the PDSA template. This was added to at each project meeting to allow for updates, and has now concluded.
• We have created Rapid Response Group reviews. The outcome of the review meetings have provided a clear plan of care for the patients, and staff have fed back that they feel they have been listened to. Patient care has been consistent and well-documented, both in the patient electronic records and in the patient room.
• We have devised a ‘learning from events’ algorithm, which illustrates where this initiative sits within the Patient Safety Incident Response Framework (PSIRF) of the organisation for the year ahead.
• Work within the group has included reviewing incident reports where injuries have happened. Staff have identified how these types of incidents can be reduced in the future. They have used live scenarios to play out and reflect upon the incident. There has been positive feedback from these sessions.
• There have been three simulation exercises completed. Further simulation exercises are planned for 2024-25. A case scenario ‘bank’ is being built, so that completed cases can be used for training and learning in the future. We are also working with Eastbourne District General Hospital in a reciprocal agreement for running simulation clinical scenarios.
• Evaluations of simulation exercises to date are generally positive, with continued learning for facilitators. We anticipate that learners will increase in confidence and become more willing to take part as this becomes a more familiar style of learning.
• ‘Just like the real thing? Using simulation as a resource for enhancing MDT learning’ poster was displayed at Hospice UK conference in autumn 2023.
Quality Accounts 2023-2024 / Part Two 13
The two nurses who I have been spoken with have been very kind and helpful. If they say they are going to do something, like contacting my GP, there is an immediate response.
Quality performance overview for
2023-2024
3.1 Review of services
Inpatient services
Our Inpatient Unit (IPU) continued to provide end of life care to patients with the most complex needs. We had 198 admissions within the reporting year, compared to 206 in the previous year. The reduction is due to our bed capacity being relatively consistent at 12, instead of 15 beds. Activity has been disrupted due to the ongoing challenges of recruiting to Registered Nurse (RN) roles on the Inpatient Unit. We have responded by flexing the number of beds available to ensure we maintain safe staffing levels.
We held a recruitment day, and we received a positive response. We have also produced several recruitment films, which describe what it is like to work at the hospice, and describe some of the opportunities available.
We have been able to support two Trainee Nursing Associates to start a two-year foundation degree. This role will work across the clinical services team, and we will continue to develop this role within our service provision.
The average length of stay has been 23 days, compared to 21 days in the previous year. We have maintained our medical consultant-led specialist palliative care beds, as well as our NHS continuing care healthcare-supported nurse-led beds. The hospice has seen a 98% bed occupancy based on 12 beds.
Over the year, there have been 150 deaths (77%) of patients on the Inpatient Unit, along with 47 discharges to other care providers.
The Inpatient Unit team has had a focus this year on raising the awareness of corneal donation with the patients who were admitted. 15 patients consented to corneal donations, and this will remain a focus.
Community services
Community nursing services
Our community services have had a year of activity, with the Hospice Line pilot progressing. Virtual Hospice – an in-house six-month pilot led by our community consultant and ANP (Advanced Nurse Practitioner) – has been completed.
The hospice has supported 1,009 patients; in patients’ own homes, in care homes, as outpatients, and as virtual consultations. This is compared to 1,201 the previous year.
The Community team structure involves small teams established in clinical hubs that support primary care neighbourhood areas. Staff within the hubs have the responsibility to manage and review their caseloads. The re-organisation of the hubs has improved effectiveness. A duty Registered Nurse (RN) and Healthcare Assistant (HCA) are available from 7am-7pm seven days a week. This provides the team with the ability to respond to urgent patient need in a timely manner.
The hospice continues to show a strong response to urgent referrals, with 95% being responded to within 24 hours of the referral being received.
Quality Accounts 2023-2024 / Part Three 15
Nurse Line
The hospice 24/7 Nurse Line has continued to provide support to patients, families, and health and social care professionals. The hospice has handled 13,718 calls, compared to 17,713 calls in the previous year. This is due to the way the calls have been recorded since we transferred to the new electronic patient record system in March 2023. More comparable and comprehensive data will be available following the introduction of a new telephone system planned for 2024-25.
The feedback received through VOICES surveys demonstrated the hospice 24/7 Nurse Line has remained a highly valued hospice support service. A large number of respondents (96%) felt that it was always easy to get a response from Nurse Line (2022-23 = 95%). 2% stated that they felt this was only sometimes the case (2022-23 = 5%). 2% did not feel it was easy to get a response.
We have also had positive feedback through Views on Care.
We are taking part in a collaborative project, Hospice Line. The long-term aim is to provide a single integrated telephone advice and support service across three local hospices. This would ensure that patients have the same level of access to advice and support regardless of where they live. It would also give us the opportunity to improve the patient experience across all three hospices.
Feedback has been positive, and the SystmOne database has proved effective in allowing us to access information and offer advice to another hospice’s patient.
Team development
Two of our three Development Clinical Nurse Specialists have completed the two-year programme and are now in post as full Clinical Nurse Specialists. We have introduced a collaborative teaching programme with St Michael’s Hospice, which is also available to hospice Clinical Nurse Specialists and those in the local trust.
Our first two Health Care Assistants took up the position of Trainee Nursing Associate. This is a role introduced to support Registered Nurses and to enhance skills within our workforce in providing person-centred care across Community and Inpatient services.
The hospice maintained a high level of attendance at primary care meetings in GP surgeries. And we have very good attendance from community nurses, hospice-trained nurses and Clinical Nurse Specialists at the Advance Care Planning and Respect quality forums.
We have participated in teaching sessions for two-day long sessions which provide an overview of hospices services to our community nurses, paramedics, and hospital nurses.
No Barriers Here Quality Improvement project
No Barriers Here is for people who are sometimes excluded by their identity, ethnicity, culture or race. It is a new concept of advance care planning, using arts-based methods to deepen conversations and relationships. A small group of clinical and non-clinical staff attended a facilitator training session run by Mary Stevens Hospice.
The group decided to run three workshops, and invited six patients who had previously attended a Living Well programme. The feedback from the group was positive. They loved the art materials and the concept, and they felt well supported.
Quality Performance Overview for 2023-2024 16
Feedback from one participant:
‘Thank you for the opportunity to explore my feelings. At times I felt sad and gloomy while doing the tasks but at the same time there was positivity about being able to look at these feelings in such a safe and comfortable space. After the sessions I spent time thinking about the themes we had been encouraged to explore and it helped me talk to my family about what I wanted.’
No Barriers Here workshops will take on two strands. Through Community Links we will offer the workshops to external community groups, focussing on those who would not normally access hospice services. And we will invite participants from Living Well to come back.
The group will present the No Barriers Here project at the next PPE (People with Personal Experience) / Clinical Audit session in June 2024.
Care at home
We have had the opportunity to expand our Care at Home service within this reporting year, due to a grant from the St James Place charitable foundation, and in collaboration with Continuing Health Care (CHC) who fund the packages of care.
The grant enabled us to start a project to look at how we could provide vital personal care to patients in the rural north of our catchment area. The initial planning work started in September 2022, with the aim of providing a dedicated care run in this particular part of our catchment area. This was to be in addition to the two runs we have in the remaining parts of our catchment area.
The aim of the project was to improve patient and family experience at end of life, help more patients to achieve their preferred place of care, help to decrease unplanned hospital admissions, improve partnership working with the wider multi-disciplinary team, and promote improved equity and diversity.
Following successful recruitment to the Care at Home team we were able to expand the service from January 2023. New staff received specialist training before we extended the service, which has enabled them to deliver supportive end of life care. Since the expansion of the service, we have seen an increase in our capacity and the number of people we have supported to provide care at home in the rural north of our catchment area.
In the reporting year, across the whole catchment area we have supported 187 patients, with 8,596 face-to-face individual care visits.
Quality Accounts 2023-2024 / Part Three 17
Living Well
The Living Well service continues to grow and is a true Multi Disciplinary Team effort.
A priority for the Living Well service over the past year has been to continue to empower our patients and their families to access support outside of the traditional hospice day therapy model. In practice this means that individuals have the option of accessing the clinically-led Living Well groups, the hub drop-in, and to link in with other community groups and organisations at a time and place that best meets their needs. There has been 615 Living Well contacts in the reporting year.
Established groups facilitated by the Therapies team, such as the Fatigue and Breathlessness Clinic and Living Well Matters, continue to generate high volumes of referrals and the two gym groups (the Seated Exercise Group and Thrive) are popular and well attended.
The Living Well Hub drop-in, a group for patients and carers known to the hospice, continues to be popular. There is access to a Clinical Nurse Specialist (CNS), our Community Engagement team and palliative rehabilitation, without the need for a referral or appointment. Some of the patients have spoken to our digital health lead to get advice on their digital legacy and to experience the virtual reality headset. We have also welcomed speakers from a local dementia charity, care for the carers and hands on history. There has been a steady growth in attendance and a small survey confirmed that attendees value the social aspect and the opportunity to discuss issues with the CNS.
The conventional way to access support remains, and is still important. The Therapies team is triaging and offering hospice initial assessments for patients referred directly into the Living Well service. These referral numbers are growing, and we receive as many referrals for assessment and intervention under the Living Well service from external referrers as we do from our own hospice teams.
Relieved that his wife is having a rest.
Therapies
The Therapies team continues to work with our patients and their families across all areas of clinical practice in the hospice. Our team consists of Occupational Therapists, Physiotherapists, Rehabilitation Assistants, Complementary Therapists and a Living Well co-ordinator role.
The Living Well co-ordinator role is a fairly new role and has been developing over the course of the last year. It offers clinical admin support for the Therapies and Living Well team, but has a unique patient facing aspect as well. The co-ordinator has an important hand in supporting the facilitation of some of the Living Well groups.
Responding to urgent need in the community continues to be both an area of growth and pressure for the Therapies team. Our main remit is to provide a goal-orientated palliative rehabilitation service, but we experienced a sustained growth in urgent referrals for community patients during the pandemic which has not slowed down. These referrals can be highly variable and our work ranges from offering rehabilitation after long hospital stays, to supporting rapidly deteriorating patients to remain safe and independent at home as they approach end of life.
The Therapies team continues to work closely with our statutory partners in the community to ensure referral pathways for palliative Occupational Therapy and Physiotherapy are up to date and fit for purpose.
Community engagement
Established in 2019, our Community Links Network is a network of organisations within the hospice’s catchment area. We share information about our services with them, and learn about groups and activities they offer which may be beneficial to those we support.
Over the reporting year, the network has expanded to include over 95 local organisations, showcasing a rich diversity. This growth underpins our commitment to fostering a supportive and interconnected community.
The community engagement team regularly reaches out to underserved groups. For example:
• The Community Links Navigator has attended a local mosque to meet with the Iman. She shared information about the hospice and our services in Arabic and English. This is now available in the mosque for those who may need it.
• The Community Links Navigator has attended five Eastbourne Foodbank satellite sessions to speak to people about the hospice and our wider support. This led to referrals to bereavement support from those who had not previously know about the service.
• We have worked with Community Link organisations to provide training for staff on reaching diverse populations e.g refugee and asylum seeker support, vision awareness, hearing awareness. Local asylum seeker and refugee charity, Sanctuary, ran an information session at the hospice. It was attended by a range of staff members to ensure that we are aware of how to support equity of access for people from these groups in need of our care.
• We have translated an FAQ document about the hospice, to ensure those who are unable to speak English are still aware of our services.
Quality Accounts 2023-2024 / Part Three 19
Learning and development
It has been a significant year for the Learning and Development team. The recruitment of a new Learning and Development Manager, Learning and Development Co-ordinator, and Clinical Skills Facilitator allows for an enhanced focus in the area.
The implementation of the new Learning Management System, iLearn, has allowed us to focus on reporting of training compliance rates and targeting key areas for improvement. This has seen compliance rates increase significantly in targeted areas, contributing to a 91% completion rate for mandatory training.
The impact of introducing iLearn has been very positive but has required a period of acclimatisation for staff at the hospice. The Learning and Development team has committed a significant amount of time to ensure everyone is confident and competent in using the platform. We have also developed additional areas within iLearn’s capabilities to increase use, such as the introduction of a manager’s dashboard, an events portal, and additional safeguarding training and professional revalidation recording options.
We have continued to deliver a wide range of training for our clinical employees, including Clinical Skills Days for Care Assistants, Healthcare Assistants and Registered Nurses. We have also worked in collaboration with local partners to introduce an educational programme for Clinical Nurse Specialists. In February, two Healthcare Assistants enrolled on the Trainee Nursing Associate programme with the University of Brighton. Newly qualified Registered Nurses have also been given access to development programmes with St Christopher’s Hospice.
Several staff have completed university modules in the past year, including Advanced Physical Assessment, Post Graduate Certificate in Leading Practice Education and Non-Medical Prescribing. Internally, staff continue to work on competency frameworks; for our Care Assistants we have delivered The Care Certificate.
We have delivered a wide range of face-to-face and online training activities including dementia awareness, sex and intimacy workshops, IV medication and line workshops, bladder and bowel workshops, and grief and loss support workshops. We have started delivering simulation Exercises for the MDT on complex case scenarios. All clinical staff are encouraged to attend the Journal Club and can also attend forums for reflection; ‘learning from incidents’ and ‘learning from deaths.’ Registered Nurses can also attend the quarterly Respect Quality Assurance Forums which provides opportunities for reflection and learning. Schwartz Rounds are open to all staff.
We have also delivered a wide range of additional training, including First Aid, THRIVE, and Conflict Resolution, and have begun engagement with Team Leadership and Management Courses for our hospice leaders.
We have hosted students from universities, and these have included pre-registration nurses, therapy students, paramedics and a social worker. We have also provided placements for Foundation Year Doctors and trainee GPs. As well as this, we have enhanced our student engagement programme, to ensure we have a robust process in place for all who wish to spend some time engaging with the hospice. One of the developments has resulted in the delivery on our first ever SPOKE Training Day, a free one-day awareness course for health professionals wanting to learn more about hospice and end of life care, with further dates planned.
Quality Performance Overview for 2023-2024 22
3.2 Clinical governance
During the reporting year the established clinical governance structure continued to ensure safety, effectiveness and evidence-based practice across clinical services.
In October 2023, we welcomed a new member to our team; Evelyn Prodger, the Joint Clinical Services Director. This role is shared with St Michael’s Hospice, Hastings and Rother. The Deputy Director for Quality and Infection Prevention from NHS Sussex was reappointed to the Clinical Governance Committee (CGC) as a co-optee for the second year.
The Assistant Director of Nursing for the community NHS trust stepped down in their role as co-optee, due to changes in their responsibilities. A Nurse Consultant specialising in palliative and end of life care from the Sussex Community NHS Foundation Trust has been appointed to the Clinical Governance Committee (CGC) as a co-optee.
One of the key discussions in a recent meeting revolved around a serious incident which occurred in April 2023. The meeting provided an overview of the incident and discussed the subsequent outcomes that impacted both the staff and the organisation as a whole. This incident served as a focal point for understanding and improving the organisation’s response to such events.
3.3 Risk management
Our hospice utilises a web-based system, Sentinel, for reporting accidents, incidents, and near misses. This system is the primary reporting platform for all our staff, including those in retail.
Patient risk assessments are readily accessible through our electronic patient record system. We have set up notifications within the electronic patient record system to prompt staff to complete and review these assessments.
Most of our risk registers are held within the Sentinel reporting system. This arrangement allows our CEO and Leadership team to oversee all active risks, including those specific to their departments.
Our Leadership team reviews the strategic risk register biannually, which is subsequently presented to the Board of Trustees.
Active risks identified within our two Sub Clinical Governance Groups - Quality and Safety, and Clinical Effectiveness – are regularly discussed, reviewed and updated at their retrospective bi-monthly meetings.
High-rated risks added to a risk register trigger automatic notifications to our CEO and Registered Manager. The Board of Trustees are informed of the high-rated risks and the controls measures to mitigate the risk by the CEO.
In the 2024-2025 period, we aim to review our risk management platform to further enhance our risk management capabilities. We are committed to ensuring that risks are managed effectively and efficiently.
Quality Accounts 2023-2024 / Part Three 23
3.4 Care Quality Commission
St Wilfrid’s Hospice is registered with the Care Quality Commission (CQC) and is currently registered for the following regulated activity:
• Treatment of disease, disorder or injury.
The Associate Director for Quality and Governance is the Registered Manager for the hospice. We have displayed the Registered Manager Certificate at the entrance of the hospice, along with our current rating from the latest inspection.
The hospice has updated its Statement of Purpose describing:
• What we do.
• Where we provide the service.
• Who we provide the service to.
St Wilfrid’s Hospice’s current rating is outstanding. There have been no conditions attached to registration, or any special reviews or investigations that have impacted on our registration status during 2023-2024.
I feel at peace. I am very grateful for all they have done and will do for me. The young doctor spent over an hour with me explaining everything, which was very helpful.
3.5 Data protection and security
The hospice places great importance on data protection and security and strives to be open, honest and transparent about how we process personal data in compliance with the Data Protection Act.
Having moved onto our new electronic patient record system (SystmOne) in March 2023, we maintained the previous electronic patient record system (Crosscare) until the end of the year. It was decommissioned in the spring of 2024. We have a secure archive of patient records, which are maintained in line with our Retention Policy schedule.
Our new Information Asset Owners received formal external training in January 2024, with a follow up session from the Information Governance Lead, both of which were well received. We aim to do further work with Information Asset Owners to review our compliance documentation over the coming year.
We published our annual Data Security & Protection Toolkit submission at the end of March 2024, ahead of the June deadline. The early submission was timed to align better with the Learning and Development training schedule, and we may continue to submit early in future years. This year’s submission completed the mandatory items to achieve ‘Standards Met.’ This was a step down from the ‘standards exceeded’ in the previous year, as the hospice does not currently have a Cyber Essentials Plus certification. We will continue to put all the necessary IT configuration in place (for example patching/updates, penetration testing, Multi-Factor Authentication).
The Finance and Facilities Director has taken over the role of Senior Information Risk Owner (SIRO).
Multi-Factor Authentication (MFA) was enforced on the hospice network in the spring of 2024. MFA will also be enforced for NHS email before the deadline in June 2024.
Legitimate Interest Assessments were moved to a new module within Sentinel online system.
Change requests for SystmOne can now go through a change request module within Sentinel online system.
Risk Registers on Sentinel now have a reminder email process triggered if any risks are overdue for review.
The communications department has helped to update our data security film which can be found on the hospice’s SharePoint page.
A new Smartcard Sponsor (Digital Health Lead) has been trained and we may consider training for a further sponsor in the coming months ahead of the retirement of the Clinical Information Officer.
The number of data security and protection incidents raised on Sentinel increased significantly within the reporting year, with 88 incidents logged between April 2023-March 2024 (compared to 51 in the previous period). Whilst 36 of the 88 (41%) were reported external scam/phishing calls and email attempts, a significant number of others were essentially human error incidents.
Over 95% of staff, trustees and volunteers (with IT access) completed Data Security Awareness Level 1 in the past year. In light of the incidents raised, everyone has been reminded to be aware of their data protection responsibilities and the risks of causing a data breach. In some cases a breach could be significant enough to report to the Information Commissioner’s Office (ICO), with a potential for reprimands, fines and loss of reputation.
Quality Accounts 2023-2024 / Part Three 25
3.6 Participation in clinical audits
Summary of clinical audits
We maintain an annual audit timetable, overseen by our Quality Lead. These audits are an example of our pursuit of excellence. Throughout the reporting year, we have conducted additional audits as part of our proactive approach to quality assurance.
Following a systematic audit process allows us to continually assess our service quality and identify areas for improvement. We believe this approach to quality management significantly enhances our service delivery and benefits those we serve.
Upon completion, audit findings are shared with our staff and volunteers during Audit and PPE feedback sessions. These sessions, conducted both in-person and virtually, aim to foster engagement and increase understanding of the clinical audit process. They serve as a platform for reflection on clinical practice, identification of areas for growth, and gathering evidence to support changes in practice.
Audits have been completed by a variety of patient facing and non-patient facing staff as illustrated below.
Hospice UK general medicines audit
Annual audit assessing the quality of medicines management.
Aim
The management of non-controlled medicines will meet the requirement of the Medicines Act (1968), Misuse of Drugs Regulations (2006) and the Health Act (2006).
Outcomes
• Overall compliance over 95%.
• Limited documentation of medications received on admission.
• Limited evidence of recording drug suitability.
• Inconsistent recording of temperatures of storage facilities.
• Patient identity wrist bands not used. Asked verbally, if able to respond.
Changes in practice / next steps
• Post-migration to new electronic patient record system, identify the most effective way of reconciling medicines to improve compliance.
• Review of the drug suitability documentation to ensure it is effective and to improve compliance.
• At safety huddles, Multi-Disciplinary Team meetings and team meetings, reintroduce the importance of identification wrist bands.
• New process for induction introduced, along with a new induction workbook (safe administration of medicines) for Registered Nurses and Registered Nursing Associates.
• Medicines optimisation support role to be agreed, with the successful recruitment by April 2024.
• To continue to audit this area of practice annually.
Quality Performance Overview for 2023-2024 26
Hospice UK controlled drugs audit
Aim
The management of controlled drugs will meet the requirements of the Misuse of Drugs Regulations (2021) as amended on 16th August 2007, The Health Act (2006) and the Controlled Drugs (Supervision of Management and Use) Regulations (2006).
Outcomes
Overall compliance 100%. This was completed in collaboration with St Michael’s Hospice.
Changes in practice / next steps
• New staff induction workbook (safe administration of medicines) for Registered Nurses and Registered Nursing Associates.
• The assessment of competence of the Registered Nurse for controlled drug administration is a new process to ensure the safe administration of controlled drugs. This is to be completed by Registered Nurses on induction and then annually.
• Quarterly controlled drug record keeping audit completed to monitor compliance and identify themes and trends.
Medication charts audit
Aim
To look at all aspects of the medication charts and ensure we are compliant with the national guidance and St Wilfrid’s Hospice Medicines Management policy and procedure.
Outcomes
• Compliance over 95%.
• Duration times for steroids and antibiotics not always recorded.
• On one occasion a different allergy documented on electronic patient record to what was documented on the medication chart.
• Evidence of the completion of ‘effect box’ not being completed regularly.
Changes in practice / next steps
• Joint working with St Michael’s Hospice to promote the importance of completing the effects box after a stat dose has been given.
• To have a ‘stats month’ to highlight the use of medication in this way.
• Revised inductions with new staff across the MDT.
• Clinical pharmacist provides training for new members of staff and meets with staff after significant errors.
• Re-audit six monthly.
Controlled drug administration times against prescribed times
Aim
To ensure all controlled drug medications are administered within one hour of the actual prescribed time.
Outcomes
• Overall compliance 100%.
• Sample size x 5.
• Limitations of the audit: small sample size.
Changes in practice / next steps
• Frequency of audit remain at six-monthly
Quality Accounts 2023-2024 / Part Three 27
Review of diabetes management on the Inpatient Unit (IPU)
Aim
A re-audit, looking at how patients with diabetes were managed on the Inpatient Unit, taking into the consideration the recommendations of the previous audit and re-evaluating aspects of diabetes management such as review of Capillary Blood Glucose (CBG) monitoring and appropriate prescribing.
Outcome
• 35 patients audited in total.
• 11 patients had a diagnosis of either type 1 or type 2 diabetes.
• 24 patients were on steroids only.
• CBG checked every day during entire admission: 3/35 (8.57%).
• Sporadic measurements of CBG in diabetes chart: 27/35 (77.14%).
• CBG in drug chart 2/35 (5.71%).
• Hypoglycemia emergency medication prescribed in 4 out of 5 patients who required it.
• Average CBG percentage = 34%.
• Median CBG percentage = 18.18%.
• Only 1/35 (2.85%) with 100% CBGs taken at correct time.
• Large variability in CBG recording.
• 8/35 (22.86%) had no CBGs recorded despite being on steroids/diabetic.
• 2/35 (5.71%) had more CBGs recorded than minimum amount necessary.
• 7/35 (20%) had CBGs done. 80% (28/35) had less than 50% of CBGs done.
Changes in practice / next steps
• Review of blood glucose monitoring chart.
• Education session for staff.
Completion of risk assessments (re-audit)
Aim
To ensure all patients have initial risk assessments completed within 24 hours of admission and re-assessed weekly/daily depending on assessment within their Electronic Patient Record.
Outcomes
• Sample size x 7.
• Documented evidence of over 90% of risk assessments completed on admission with the Electronic Patient Record.
• Reduction in the PURPOSE T risk assessment being completed and reviewed compared to initial audit.
• Reduction in the number of risk assessments which are being reviewed within the identified time frame.
Changes in practice / next steps
• More training identified on the completion and review of risk assessments, in particular the PURPOSE T within the Electronic Patient Records.
• To raise awareness of the ‘Train Notification’ function of the Electronic Patient Record, which identifies when risk assessments are due for review and/or overdue.
• To explore if there is a more effective and time efficient way of completing the PURPOSE T risk assessments.
• Commencing a monthly record-keeping audit which encompasses the completion rate of risk assessments on admission and within their identified review time frames.
Quality Performance Overview for 2023-2024 28
Corneal donation
Aim
The aim of the audit was to identify any possible causes for the low percentage of corneal donations, previously identified within the hospice. Once established, solutions can be put forward to see how these numbers can be improved.
Outcomes
The audit showed that it is likely more discussions are being had with patients, however these might not be being documented (no evidence could be found in the patients’ notes or their ReSPECT forms).
One possible cause for the discussions not taking place is staff not being comfortable discussing corneal donation with patients.
Changes in practice / next steps
• Staff would like further training in this area, as they are not sure on the criteria and also feel uncomfortable about bringing up the conversation about corneal donation with patients and carers.
• To consider extending the training to the wider community services.
Oxygen monitoring audit
Aims
To ensure we have the correct amount of oxygen supply equipment in relation to our prescriptions and safe management of cylinders.
Outcomes
• Cylinders not always accounted for and whether they had been returned to Dolby or with a patient.
• Use of door signs on patient rooms not always displayed when on oxygen.
• Identified that certain members of staff are required to transport oxygen for assessments in the community.
Changes in practice / next steps
• Medical gases policy reviewed, and section added on the safe transportation of oxygen ensuring car insurance. Cylinder restraints and care signage all in place. Designated pool car for transporting oxygen.
• Tracking system for ambulatory cylinders identifying location, sign in and out sheet, when cylinders returned to Dolby. Monthly cylinder stock checks against: cylinder barcodes, expiry date, missing/returned/new cylinders, update tracking sheets.
• Door signs redesigned and the use of door signs on patient rooms promoted.
• Closed audit cycle. Commence the Hospice UK Medical gases audit six-monthly.
Quality Accounts 2023-2024 / Part Three 29
ReSPECT audit
Aim
• Explore the quality and use of ReSPECT Forms on the Inpatient Unit.
• Explore if hospice admission is being used as an opportunity to ensure these advance care plans are still appropriate for the patient and their circumstances and in line with their wishes.
Outcomes
• Sample size: 11.
• Number of cases audited: 11.
• Inclusion criteria: planned discharges from the hospice in one year to any location.
• Exclusion criteria: unplanned self-discharges (2).
• How was the sample identified: retrospective data report generated from electronic patient record.
• 16 patients had a ReSPECT form, either on admission or completed during their admission.
• 12 out of 16 patients had their ReSPECT forms reviewed during their admission.
• Majority reviewed within patient’s last week on the Inpatient Unit.
• 2 patients reviewed on admission and discharge.
• 4 patients did not have their ReSPECT forms reviewed.
• Reviewing forms:
– 75% of forms were reviewed at some point during admission.
– Unreviewed forms appear to be less thorough and/or complete.
– 1 unreviewed form was missing details of an existing Lasting Power of Attorney (LPA).
• Quality of forms:
– 100% of reviewed forms had a clear ceiling of care.
– 100% of all forms had a documented CPR decision.
– Forms completed in the hospital were completed to the lowest quality.
• Of ‘spot audit’
– 75% up-to-date, but quality not analysed in this audit.
– Is section 9 being used?
Changes in practice / next steps
• Promote through Multi Disciplinary Team discussions that during a patient’s admission process and prior to discharge from hospice are key times identified as an opportunity to review ReSPECT forms.
• Staff to take on the responsibility of reviewing the document on admission and prior to discharge to ensure the forms are as thorough and accurate as possible.
• Areas for improvement: condition-specific interventions and utilising section 9 (documenting a review).
• Emphasis should be made on this being a process.
• Ongoing review of ReSPECT forms.
• Patient education and shared decision making.
Quality Performance Overview for 2023-2024 30
Nutrition support and provision for Inpatient Unit patients
Aim
To ensure compliance with the NHS 10 key characteristics of good nutrition and care for patients on the Inpatient Unit.
Outcomes
• Some discrepancy between the patient information board in the Inpatient Unit pantry and the kitchen’s patient information board. The discrepancies were sometimes due to lack of space on the kitchen board, as there was limited space for a larger board without compromising patient confidentiality.
• Relevant and pertinent information is detailed in both the patient records and on the pantry boards.
• Patients really appreciate the interaction from the catering team.
Changes in practice / next steps
• Further work with the clinical team to ensure that when the nutritional assessment is carried out cultural requirements are addressed, and clear information is given as to what the dietary requirements may be.
• When patients have been diagnosed with diabetes or a physical condition which can affect their ability to eat and drink that this has been recorded in their nutritional assessment.
• Reviewing the location of the kitchen board to ensure all relevant information is displayed to the kitchen team.
• Following this audit, we will be reviewing the location of the kitchen board to ensure all relevant information is displayed to the kitchen team.
Guardian24 audit review
Aim
To ensure all staff who are issued with a Guardian24 have had the correct training to enable them to use and maintain this piece of equipment and ensure their personal safety.
Outcomes
• Not all devices are being charged daily or prior to use.
• Usage of the Guardian24 is mandatory for all staff who go on community visits.
• Staff need to be reminded at huddles to check that devices are charged and switched on.
Changes in practice / next steps
• To continue with the champions for Guardian24.
• To provide group and one-to-one training, including: charging, switching on/off the devices.
• Promote the practice of using Guardian24 at huddles.
• Consider devising a pro-forma for staff to sign to say they take responsibility for the care and maintenance of the device, and that they will take it out with them when doing external visits.
Quality Accounts 2023-2024 / Part Three 31
Call bells re-audit
Aim
To ensure that all call bells are answered within a two-minute timeframe. This objective aligns with our commitment to prioritising patient needs and continuously improving the quality of care we deliver. By achieving this target, we aim to demonstrate our dedication to prompt and efficient patient service.
Outcomes
Overall, responses are timely. There are various factors affecting response times.
• 141 call bells answered over three days.
• 11% of bells took longer than two minutes to answer.
• Longest time taken to answer a call bell was six minutes 29 seconds.
• Dependency score was either amber or green on all days.
• There were 10 patients, no staff shortages.
• The amber status was due to the double checking of controlled drugs.
Changes in practice / next steps
• Bi-monthly audit to explore further and identify themes. More data will help us understand whether there is a need for improvement or not.
• Results from audits will be displayed for patients, visitors and staff to see.
Clinical uniform
Aim
To ensure compliance to uniform policy is consistent throughout the organisation. It aims to reduce the risk of infections and ensure health and safety compliance.
Outcomes
• Sample size: 14 respondents answering 18 questions.
• From the possible 252 responses, only 19 non-compliances were observed.
• The overall rating from this audit is ‘good,’ with an 89% compliance.
• There were 2 non-compliances with wrist adornments. One person was wearing a fit bit, and another was wearing a charity band.
• 1 person had multiple sets of earrings and 1 was wearing non-stud earrings.
• A member of staff had a long-sleeved t-shirt visible under their uniform.
Changes in practice / next steps
• The overall success of this audit should be celebrated with staff.
• Uniform policy reviewed.
• Reminders for staff on the standards for uniform.
• Continue to re-audit quarterly.
Quality Performance Overview for 2023-2024 32
Urinary catheterisation: daily care
Aim
To ensure safe practice on the ongoing management of catheters in the Inpatient Unit. Reduce the risk of infection and need for antibiotics use for the management of catheter-related Urinary Tract Infections.
Outcomes
• Catheters not always secured correctly.
• Documentation not always completed as per standard.
• Care plan not updated or used appropriately.
Changes in practice / next steps
• Clinical skills facilitator to work alongside team to promote best practice.
• Continue to discuss at ward meetings and huddles to remind people of the importance of documentation and updates of care plans.
• Add to mini teaching sessions planned for Inpatient Unit.
• Monthly audit, to change to quarterly when compliance increases.
Isolation
Aim
Ensuring the safe management of patients in isolation. Reducing the risk of infection transmission within the Inpatient Unit to staff and patients.
Outcome
The audit sample is naturally limited, so only one isolation was observed. There was one patient being cared for in isolation due to Covid 19.
The overall rating from this audit is ‘very good’ with a 100% compliance.
Changes in practice / next steps
No issues were identified.
All isolation precautions were adhered to, and staff were aware of the additional requirements for the management of the patient.
Management of sharps
Aim
Ensure the safe management and disposal of sharps to prevent cross contamination and infection.
Outcome
• Sample size: there were 5 members of clinical staff observed, answering 18 questions.
• From the possible 22 responses, no non-compliances were observed.
• The overall rating from this audit is ‘very good’ with a 100% compliance.
• From question 5 (are sharps bins below the fill line?), it was identified that there were no new sharps bins available. However, we were awaiting a delivery at that time.
Changes in practice / next steps
The previous audit had identified areas for improvement in staff knowledge of the management of sharps. This was communicated with clinical staff and the compliance has now improved. The audit has now returned to quarterly.
Quality Accounts 2023-2024 / Part Three 33
Management of clinical waste handling and disposal
Aim
To ensure safe practice in the management of waste and to maintain health and safety compliance.
Outcome
• Compliance: 87%.
• Paper towels in offensive waste.
• Not all clinical waste bags were double tied correctly.
Changes in practice / next steps
• Continue with quarterly audit.
• Promote the clinical waste segregation video on SharePoint within safety huddles and facilities team meeting.
• Audit to be published in the next infection prevention and control newsletter.
External Audit
The Infection Prevention Society (IPS) Process Improvement Tool (PIT) 2016
Discussed within the infection prevention section (3.13)
Aim
To ensure infection prevention and control practices are compliant with current legislation and national guidelines. Good practice of infection prevention.
Outcomes
• 21 sections, 445 standards / questions were used, some of these were repeated (this contributed to the overall compliance).
• 34 standards / questions were non-compliant.
• Overall compliance 92%, demonstrating a slight decrease in compliance against the same audit carried out in June 2022.
Changes in practice / next steps
• Action log and plan has been created with the recommendations from the audit.
• Some of the actions completed within the reporting year include:
o Waste Management Policy reviewed and updated and now called Safe and Sustainable waste policy and procedure.
o Water pipes have been redirected to ensure regular flushing and reduce the risk of water contamination.
o Fit-testing sessions (to ensure respiratory protective equipment fits properly) have been completed for staff, aligning with guidance that staff to be fit-tested as least two-yearly.
o Hand sanitiser dispensers on the Inpatient Unit now have a label on the front for easier identification.
See the Infection Prevention and Control section 3.13 for further analysis of the outcome of the audit.
Quality Performance Overview for 2023-2024 34
3.7 Research
St Wilfrid’s Hospice is committed to research into palliative and end of life care and is a researchactive hospice. We recognise the contribution that research makes to the development and quality of care delivery within specialist palliative care and end of life care services. This a subject within the terms of reference of the Clinical Effectiveness & People with Personal Experience (PPE) Group, a sub-committee of the Clinical Governance Committee.
The Research Group has overseen participation in the CHELSea II Study and monitors opportunities for involvement in other research activity. The hospice is represented at the Surrey/Sussex Research Collaborative and has links with the research team at East Sussex Healthcare NHS Trust.
The Clinical Research Policy and Procedure at St Wilfrid’s Hospice serves as a comprehensive guide for conducting research. Following approval from the Clinical Governance Committee, we have initiated a collaborative effort with St Michael’s Hospice to develop a Joint Research Policy. This collaboration underpins our commitment to enhancing research practices and outcomes.
The hospice has introduced a quarterly Journal Club for staff and volunteers. The aim of the sessions is to inform participants on up-to-date clinical practices through critical analysis of research and how it can be applied in our setting.
Research activity
Current research activity
CHELSea II Trial
This is a cluster randomised trial of clinically assisted hydration in patients in the last days of life. It is run by the University of Surrey and recognised by the National Institute for Health Research. St Wilfrid’s started to recruit patients in May 2023 and the study closes in November 2024.
Upcoming research studies
Exercise and Nutrition based Rehabilitation (ENeRgise)
This study is still seeking funding but is an international, open label, randomised trial of an Exercise and Nutrition based Rehabilitation programme (ENeRgise) delivered by health professionals, versus standard care.
We have been accepted into the research study as a locality team involving two hospices in East Sussex – St Wilfrid’s Hospice (Eastbourne) and St Michael’s Hospice, Hastings – along with East Sussex Healthcare NHS Trust. By joining together as a research site, we will increase opportunities for recruitment. It will also ensure access to the components of the intervention, with physiotherapy coming from the hospices and dietetic support from the NHS Trust.
Quality Accounts 2023-2024 / Part Three 35
It’s excellent care. We are very lucky to have you. It’s really helpful that we can call Nurse Line at any time.
3.8 Medical revalidation
Doctors who work at the hospice have all undertaken appraisal and medical revalidation, as set out in General Medical Council (GMC) guidance in the reporting year.
Doctors employed directly by the hospice (the designated body they have a prescribed connection with) all undertake appraisals through the support of East Sussex Healthcare NHS Trust (ESHT) with the Responsible Officer being the ESHT Medical Director. A Service Level Agreement and policies support this process.
Some of our consultants are employed directly by East Sussex Healthcare NHS Trust, so this is their designated body. Doctors in training have a prescribed connection with the Deanery.
All consultants contributing to the second medical on-call have prescribed connections with their host organisations.
In the reporting year the process of monitoring all non-training doctors was transferred to Human Resources. This includes preparing transfer of information forms for individual doctors, then obtaining completed appraisal output statements from them. Doctors in training are supported through their respective online training portfolios (HORUS for foundation doctors, Fourteen Fish for GP Trainees).
3.9 Clinical professional registration
Where a clinical profession is regulated by a professional body and is employed in that professional capacity, they are legally bound to meet the requirements of the body and their employment is dependent on meeting these requirements.
Each month Human Resources (HR) check, via the appropriate portal, whether members of staff have renewed their registration. They then notify the individual, their line manager, the HR Manager and the Registered Manager of any who have failed to re-register.
3.10 Medicines management
The Medicine Optimisation Group (MOG) meets at six-week intervals to oversee practices across the hospice. Membership includes the Clinical Pharmacist and a Pharmacist Technician, fostering a better understanding and collaboration across the multi-professional teams.
We have monthly mini-MOG meetings. The aim of the group is to ensure standardisation and scrutiny of medication-related incidents. The process of scrutiny ensures investigations are consistent, with relevant patient and environmental factors taken into consideration. Mini-MOG allows debate about why and how an incident had been graded, which deepens understanding and will generate consistency over time. All medication incidents are then reported to the Medicines Optimisation Group.
In early 2023 we set up a joint Medicines Group with St Michael’s Hospice, Hastings and Rother. Our mission was to learn, grow and enhance the safety and care of our patients through medicines optimisation. The group is co-chaired by the Associate Director for Quality and Governance and her counterpart from St Michael’s Hospice. Everyone in the group has embraced a culture of openness. Group members have had an opportunity to see how each other works and time to think about how we continuously improve. Within the group, learning from incidents has been shared. Both hospices now have a medication awareness poster which St Wilfrid’s implemented following a medication incident. Additional work which has also been completed is:
• development of joint medication charts and syringe pump charts,
• participation in audits in each other’s hospices.
Quality Accounts 2023-2024 / Part Three 37
One of the five goals of our ‘living well at the end of life’ strategy is we will continue to strive for excellence in all that we do. This joint group is a vessel in this voyage towards excellence, and we’re excited about the journey ahead to achieve this.
During the reporting year, a small team visited another hospice to explore the feasibility of integrating a new prescribing module into the electronic patient records system. Given the projects vast scope, the decision to reassess was made once SystmOne (our electronic patient record system) is fully integrated. This exercise aims to enhance digital technology adoption.
We undertook a comprehensive review of our Controlled Drug competency practices for Registered Nurses. This resulted in the integration of a Controlled Drug competency framework into our annual performance expectations for Registered Nurses, effective from April 2024. This review will enhance the nursing team’s proficiency in the execution of Controlled Drug-related practices, including ordering, requisition, administration, and disposal processes.
The hospice continues to be part of Hospice UK’s national benchmarking for medication incidents. The frequency of reported incidents has remained consistent, with 57 incidents reported in the Inpatient Unit this year, compared to 56 in the previous year. Importantly, over 89% of these reported incidents did not result in any adverse effect to the patients.
In response to a significant medication incident that occurred in April 2023, we implemented a Controlled Record Keeping audit. This measure has notably enhanced our compliance since commencement. Encouraged by these positive outcomes, we have decided to move to a quarterly audit starting from April 2024.
As from April 2024 we will have two medicines optimisation support nurses working a combined total of sixteen hours over a four-week period. As they gain more experience and knowledge in their roles, they aim to initiate Quality Improvements projects, and in so doing so, continue to improve our patients’ health outcomes and the quality of our services.
Accountable officer for controlled drugs
The Associate Director for Quality and Governance holds the responsibility of the Controlled Drugs Accountable Officer (CDAO). This individual has completed formal training for the CDAO role. Additionally, the Quality Lead has also undergone the same formal training in May 2023 and has assumed the responsibilities of the Deputy CDAO.
The CDAO is committed to staying current with the latest legislation and guidelines for Controlled Drugs. This includes active participation in Local Intelligence Network (LIN) meetings and Controlled Drug LIN learning events. The CDAO has completed the Hospice UK self-assessment audit tool for the Controlled Drugs Accountable Officer). Quarterly reports of Controlled Drug incidents have been consistently submitted.
The annual Controlled Drugs audit was successfully carried out during the reporting year. The audit was conducted by the CDAO from St Michael’s Hospice, Hastings and Rother. This collaboration was instrumental in ensuring our adherence to compliance standards.
The CDAO, along with the Associate Director for Clinical Services, has conducted quarterly checks of controlled drugs stock levels.
Authorised witnesses have been adequately trained to supervise the destruction of Controlled Drugs on the premises. When Controlled Drugs are no longer required, a qualified representative from the pharmacy provider carries out their destruction, under the supervision of an authorised hospice witness. The hospice has renewed its T28 certificate, which allows for the denaturing of controlled drugs on the hospice premises within the reporting year.
Quality Performance Overview for 2023-2024 38
They have been very helpful getting through to our GP, getting our GP to visit and sorting out the medications.
3.11 Falls
The falls risk assessment is now integrated into our electronic patient record system. When patients are admitted to the Inpatient Unit, a falls risk assessment is completed. Staff are encouraged to identify why an individual person is a falls risk so that more effective and individualised action plans can be created to reduce risk and harm.
The Inpatient Unit holds ‘safety huddles’ at least once daily, to highlight potential concerns, including patients at a high risk of falls. Patients admitted to the Inpatient Unit often have a higher level of dependence and are typically more unstable prior to admission, making them more susceptible to falls.
In the reporting year of 2023/24, there has been a noticeable increase in the number of falls. However, it’s crucial to highlight that all these incidents have resulted in either no harm or low harm, with no instances of moderate harm reported.
The surge in the number of falls can be attributed to two primary factors:
• Firstly, we are treating a larger number of younger patients who are keen on preserving their independence as much as possible, despite the inherent risks.
• Secondly, the patient demographic is evolving, with an increase in patients having multiple co-morbidities, including cognitive impairments.
Due to this increased risk of falls, we have acquired equipment to help alert staff to vulnerable patients getting up, and equipment to minimise harm if they fall. We have also established a mini-falls group tasked with investigating patterns in falls and developing strategies to reduce them. All fall incidents are reported at the Quality and Safety Group.
Quality Accounts 2023-2024 / Part Three 39
3.12 Pressure ulcers
Throughout 2023/24 we have continued to focus on pressure area care, aiming to find causes and reduce risks where possible. Each patient has an individual risk assessment completed on admission. This is reviewed as and when their condition changes. We have started using tablets to complete risk assessments and skin checks at the point of care. With the implementation of SystmOne, detailed skin and risk assessments have been updated and there are prompts in place for repositioning each patient as per their individual plan of care.
We have focused on identification of early skin breakdown, which includes category one and two pressure damage. Training has been given to Community and Inpatient staff, through small group discussions and an information display board. We have used online and in-person training from OSKA, who supply our mattresses and air cushions.
Our pressure relieving mattresses have been updated to those with a higher specification, and we have new air cushions for the recliner chairs. Additionally, we have new improved falls sensor mats which are placed under the mattress. This is less detrimental to patient skin.
We have supported staff to identify and report all skin damage via the Sentinel reporting system. This helps us to review care needs and make any adjustments if necessary. We have also established a mini-pressure ulcers group tasked with investigating patterns in pressure ulcers and developing strategies to reduce them. All fall incidents are reported at the Quality and Safety Group.
In 2023-24, there has been a consistent number of new pressure ulcers reported compared to past years. This remains at an average of 5 per month. We have seen a slight increase in category one and two pressure ulcers reported since focused training. There have been fewer caused by a medical device and these are mostly related to devices, such as podiatry aids, which were in place prior to patient admission.
An increasing number of patients are experiencing multiple areas of skin breakdown either prior to or following admission. Several have been directly admitted to the hospice from Intensive Therapy Unit (ITU) or other acute setting. We have seen an increased number of pressure ulcers which have healed, this is potentially related to increased length of stay.
3.13 Infection prevention and control
St Wilfrid’s Hospice is committed to ensuring that effective prevention and control of healthcare associated infections (HCAIs) is embedded into everyday practice. The hospice’s Board of Trustees recognises and agrees its collective responsibility for minimising the risks of infection and has agreed the general means by which it prevents and controls these risks. The responsibility for Infection Prevention (IP) is designated to the Associate Director for Quality and Governance.
At St Wilfrid’s Hospice there have been no cases of patients with a new diagnosis of Clostridium Difficile infection or a blood stream MRSA infection. No vomiting and diarrhoea outbreaks took place at the hospice from April 2023 to March 2024.
This is the first full reporting year that the Infection Prevention Control support has been in their role. They are a visible and accessible role model for infection prevention and control within the hospice. The role promotes high standards and professionalism in the hospice’s responsibility for minimising the risks of infection.
The Infection Prevention Control support has achieved several significant milestones, including:
• Revising the cleaning rota on the Inpatient Unit to include the 2021 National Standards for Healthcare Cleanliness.
• Creating a video to educate staff on the correct segregation of healthcare waste, reinforcing our commitment to environmental responsibility.
Quality Performance Overview for 2023-2024 40
• Designing and displaying posters to highlight uniform standards. This was done after an audit identified a need for improvement in staff compliance with the uniform policy and the expected standards within the hospice.
• Creating a resource page on the learning hub to provide up-to-date information on infection prevention and control. This resource is accessible to all staff via SharePoint.
• Producing a quarterly Infection Prevention and Control newsletter, along with a Donning and Doffing video for staff and volunteers, further enhancing our communication efforts.
• Establishing a regular IPC annual auditing timetable, which includes:
o Monthly audits on urinary catheterisation daily care and hand hygiene.
o Quarterly audits on clinical uniform, isolation, management of sharps, urinary catheter insertion, clinical waste handling and disposal, and an environmental audit of the nurses’ station.
An external auditor completed the Infection Prevention Society (IPS) Process Improvement Tool (PIT) (2016) on 28th September 2023. The tool reflects current legislation, national guidelines, and good practice of infection prevention within a healthcare environment.
21 sections were audited, and 445 standards/questions were used, some of these were repeated.
34 standards/questions were non-complaint, providing the hospice with an overall compliance score of 92%.
Since the audit, work has taken place to address the areas of improvement to ensure a high compliance in specific sections.
It’s very, very good. The nurse is outstanding, going over and above.
3.14 Data quality
High-quality data is key to delivery of patient care and in enhancing the quality of care. One of our primary objectives is to establish and agree on a set of reports that enable precise activity reporting.
Throughout 2023-2024, we have monitored and scrutinised data quality via our Clinical Governance structure. St Wilfrid’s Hospice independently reports its clinical activity dashboard, offering a comprehensive overview of all clinical activities and supporting service development and Quality Improvement Projects (QIPs).
We have developed a suite of Statistical Process Control (SPC) charts for falls, medication, and pressure ulcers. Not all charts are included in the Quality and Safety report presented to the Clinical Governance Committee; we focus on the SPC charts that exhibit variation or raise concerns.
The hospice remains committed to contributing data on reported falls, medication incidents, and pressure ulcer cases to Hospice UK for national benchmarking. This shows our dedication to being transparent and to looking for continuous improvement in patient care.
Over the next year, we will be refining our data procedures to make sure we have the right analysis to further delivery on the hospice’s strategy and Quality Improvement initiatives. One way of enhancing this development is by introducing a Data Development and Insight Lead.
As a specialist palliative and end of life care provider, the hospice does not submit data information to the Hospital Episodes Statistics (HES) database. Hospices are not eligible to participate in the data collection.
Integrated Palliative Outcome Scale (IPOS) average score comparisons
The Integrated Palliative Outcome Score (IPOS) is one of a suite of outcome measures used at the hospice to measure changes over time, in relation to what patients are thinking and feeling. This holistic assessment covers many areas, including physical issues, their main concerns, psychosocial issues, wellbeing, other symptoms and whether they have any unmet needs such as practical issues or wanting more information.
Item scores (from 0 to 4) are taken at certain points during the patient’s care, with the hope that the scores have reduced over time, indicating an improvement. The seventeen elements shown in the charts below show average scores taken in Inpatient Unit or Community settings, for cases where more than one IPOS has been collected.
In 2024-2025, we aim to encourage more IPOS data collection and provide additional training. We also plan to capture eight appropriate IPOS items for patients in the dying phase.
Quality Performance Overview for 2023-2024 42
3.15 Safeguarding
The focus on safeguarding as an organisation-wide priority has continued. Oversight and governance of whole-organisation safeguarding has been tightened, with the Safeguarding Steering Group changing its structure to a Board of Trustees Sub-Committee.
The hospice Freedom to Speak Up Guardian (FSUG) scheme has been further embedded, with four FSUGs now in place across different areas within the hospice; this gives broad accessibility and visibility.
The focus on risk related to organisation-wide safeguarding continues, with good control measures in place. A dedicated risk register is regularly reviewed and includes risks related to clinical safeguarding as well as, for example, HR and Retail related safeguarding. The hospice’s participation in the Sussex Hospices Safeguarding Self-Assessment and Peer Audit has provided reassurance about risk. Overall, the peer audit found areas related to clinical safeguarding to be of a particularly high standard.
The number of safeguarding concerns for patients or family members followed through with a referral to statutory services, has hovered at a similar level for the last four years. Interestingly, the number of concerns identified and followed through internally, with no referral to Adult Social Care or Children Services, has increased significantly in the last year. This often involves significant input from the hospice team and complex decision making. This indicates a maturing level of alertness to and confidence amongst the clinical staff regarding safeguarding matters.
On-going training for patient facing and non-patient facing staff, volunteers and trustees, in line with national guidance, continues to play a key part in ensuring increased confidence in dealing with safeguarding matters.
In April 2023 the hospice switched to a new learning platform, which has increased our ability to closely monitor completion rates for training, and further improved reporting.
As of March 2024, 87% of patient-facing staff had completed Safeguarding Adults level 2 elearning, and 96% had completed Safeguarding Children level 2 elearning. 99% of relevant patient-facing staff have completed Prevent level 3 elearning.
Participatory safeguarding learning for patient-facing staff, in the form of reflections on recent or current cases, is firmly embedded and popular, with excellent attendance rates.
All patient-facing volunteers are now also expected to undertake safeguarding elearning. Non-patient facing staff and volunteers equally undertake safeguarding learning, including bespoke safeguarding training for Retail staff, tailored to their specific circumstances.
Finally, gaining feedback from patients or family members regarding their safeguarding experience can be challenging, for obvious reasons. We were delighted to be told:
‘There is nothing that could have been done better. Without the sheer determination of [the hospice social worker’s] repeated phone calls with my ex-partner until he brought me into St Wilfrid’s it would have been a different story. I owe my life to both [hospice nurse] & [hospice social worker]. To continue living is the only repayment I can give them & I will do so for as long as I can.’
(Feedback given by patient in coercive-controlling relationship, after successful safeguarding intervention. Patient now separated from ex-partner and in new accommodation.)
Quality Accounts 2023-2024 / Part Three 43
Thanks to everyone who organised [Rainbow Run] as well as all those who volunteered and those who ran and supported. We had a wonderful day and will be back again next year!
3.16 Income generated
While some of our funding comes from the NHS, over 70% of the £19,000 a day we need to provide our care is generated through fundraising, legacies and trading activities.
During the reporting year, income was generated in a variety of ways. Our events programme included mass participation events like the Rainbow Run, and sporting and overseas challenge events, such as the Camino de Santiago. We also ran social and artistic events, including the ‘Art on a Postcard’ event which ran for the first time.
It was a particularly successful year for Community Fundraising. We are grateful to the wide range of community organisations who fundraised for us and who supported activities, including our Open Gardens season.
We ran a number of direct mail appeals, including our spring appeal, which focused on supporting patients to be cared for at home. The Local Hospice Lottery continued to provide a stable source of income.
Grant funding for specific projects included funding for the Seahorse Project from Children in Need, and from the St James’s Place Foundation towards providing personal care to patients in the rural north of our territory.
The year saw investment in our retail activity including a new shop in Polegate, a refit of some of our existing shops and an expansion of our ecommerce activity.
Quality Performance Overview for 2023-2024 44
© Sam Khan photography
Part Four Feedback about our organisation
4.1 Duty of candour
St Wilfrid’s Hospice recognises that the effects of harming a patient can have devastating emotional and physical consequences for patients, their families, and carers. It can also be distressing for the professionals involved.
The hospice’s Duty of Candour Policy and Procedure provides guidance to staff and volunteers around being open and honest with patients and their families following an incident which has resulted in harm.
All incidents are thoroughly discussed within the Quality and Safety Group and subsequently summarised to the Clinical Governance Committee. Serious incidents are reported to the Care Quality Commission, along with other statutory bodies as necessary.
During the reporting year the hospice reported one serious incident, in April 2023. The CEO and the Chair of Trustees were promptly informed and were kept up to date with the investigation’s progress. A comprehensive overview of the serious incident was presented to the Clinical Governance Committee in August 2023 for information assurance. The investigation report underwent rigorous scrutiny and validation from the Integrated Care Board.
4.2 Freedom to speak up
The hospice is committed to proactively enabling any employee or volunteer to raise reasonable concerns about any aspect of our service. All staff and volunteers are encouraged to raise any matter that is, or has the potential to be, detrimental to their work or to the quality of the services that we provide including:
• Actions that may cause or present a risk to the provision of safe patient care.
• Unsafe working conditions.
• Unethical behaviour.
• A bullying culture.
Staff are supported in doing this without fear for their future role in the organisation or of any form of retribution. They can raise their concerns through their line manager, the Human Resources (HR) team or the trained Freedom to Speak Up Guardians (FSUGs). The FSUGs are based in a variety of different patient facing and non-patient facing areas. They may be approached in person, by phone, email or in writing. We are continuing to raise the profile of FSUGs – using posters, emails and drop-in sessions where capacity allows. There are regular pieces in Hospice Voice (our internal newsletter) and a FSUG suggestions / concerns box is planned. The supporting policy makes it clear that individuals can raise their concern anonymously and in confidence.
The FSUGs continue to analyse and share themes arising from reports with the CEO and Associate Director of People, with whom they meet bi-annually.
We have received a total of seven concerns formally raised by seven individuals via FSUG within the reporting year. One of these concerns was raised anonymously.
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In a PULSE survey, the majority of responses were positive. Out of 65 respondents, 34 expressed high confidence (scoring 4 or 5 out of 5) in approaching a FSUG. Furthermore, 44 out of 62 respondents did not believe that voicing a concern would negatively impact their work life. Most respondents were aware of how to contact the FSUGs. Interestingly, 20 respondents were unsure of the FSUGs’ identities, yet knew how to reach them, indicating possible confusion in the question’s phrasing. The same survey will be repeated in Spring 2024.
FSUG training
All four FSUGs have completed the training online. In addition all four FSUGs have arranged and met (virtually) with a mentor as per the National Guardian’s Office (NGO) requirement for new Guardians. These were useful meetings and all Mentors have offered ongoing advice and support if required.
4.3 Service user feedback and engagement – VOICES and Views on Care
Voices
St Wilfrid’s Hospice uses VOICES as a tool for gaining user feedback. The survey is adapted from a validated service evaluation and quality assurance tool for use in hospices, developed jointly between the Southampton University School of Health Sciences and St Christopher’s Hospice, London. It is based on the national bereavement survey conducted by the National Office of Statistics.
In the most recent reporting period (2023-24) an overall response rate of 32% was achieved.
Key findings included:
• 91% of respondents felt the care they received on the Inpatient Unit from the Inpatient team was above good (68% outstanding and 23% excellent).
• 83% of respondents felt that they and their family got as much advice and support from the Community team as they needed.
• Satisfaction with food on the Inpatient Unit has grown for the third year running, with 61% stating that it was exceptional or excellent.
96% (88% for 2022-23) of respondents said they were extremely likely to recommend St Wilfrid’s Hospice to friends and family if they needed similar care and support. 6% (8% for 2022-23) were likely to do so.
Views on care
The hospice uses the recognised Views on Care (VoC) tool to assess patients’ own rating of their quality of life, their views of the impact of the service on their main problem(s), and their wellbeing.
In the reporting year there have been 163 assessments completed (54 Inpatient Unit, 109 Community). 17 patients were declining, or it was not clinically appropriate to assess them at the time. The total number of assessments completed is slightly up compared to 2022-23, with significantly more in the Community but fewer in the Inpatient Unit. The reduction in the Inpatient Unit could be contributed to the increased length of stay of patients.
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Key Findings
97 out of 163 (60%) feel things are a little or much better.
135 out of 163 (83%) feel they are getting some or a lot of benefit from the hospice.
Inpatient Unit Word cloud below taken from VoC responses for the year:
Community Word cloud below taken from VoC responses for the year.
Quality Performance Overview for 2023-2024 48
Care is excellent – had not realised the hospice offered such care.
4.4 People/Patients with Personal Experience (PPE)
There continues to be a commitment from staff to obtaining and acting on feedback from PPE. There have been ten People with Personal Experience initiatives completed. Feedback from the work that has been completed is presented at the Quality and Audit Forums.
The forums are open to all staff and volunteers to attend.
4.5 Trustee visits
At least two trustees have visited the hospice each quarter to meet front-line staff. The visits provide an opportunity for staff to give feedback on working at the hospice. Throughout the year staff from all clinical areas, including therapies and medical team, have spoken to trustees.
Areas that have been explored were:
• Patient experience.
• Quality improvement and research.
• Safety and staffing levels.
• CQC readiness.
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Highlights of good practice
• All participants commented on the positive and open culture. None of the participants had any significant concerns.
• The Living Well Service has been transformed since the pandemic to enable better access for service users.
• Some staff have been trained to implement the ‘No Barriers Here’ art project to facilitate conversations about end of life choices. The next stage is to roll this out, probably via Community Engagement as a wider public health initiative.
• Engagement in the CHELsea II research trial was positive, with patients recruited. Staff had received training on the trial inclusion criteria and data to be collected.
Reports are discussed at the Clinical Governance Committee and an annual report of the feedback themes and actions taken following the Trustees’ visits have been shared with the Board.
4.6 Complaints and compliance
The hospice welcomes comments, suggestions and complaints.
During the reporting year we received seven formal complaints related to clinical support. There were no themes identified through these complaints. All were investigated and an outcome provided to the complainant within the hospice’s stated timeframe.
During the year we also refreshed our approach to so-called ‘concerns,’ where we are made aware of some low-level dissatisfaction with our support but where people did not want to go down a formal complaint route. As with complaints, these provided us with rich information and some opportunities for learning or changes to practice. Again, these were wide-ranging, and no particular themes were identified.
We are committed to maintaining open communication and actively listening to feedback as part of our ongoing efforts to improve our service delivery.
The hospice has been brilliant. It is helpful to know that there is always someone I can call at any time.
4.7 Hospice UK national benchmarking programme
St Wilfrid’s Hospice submits data to the Hospice UK national benchmarking programme quarterly.
Data that is compared includes:
• Inpatient bed occupancy.
• Patient throughput.
• Patient falls.
• Level of harm following a patient’s fall.
• Medication incidents.
• Level of harm following a medication incident.
• Pressure ulcers on admission.
• Pressure ulcers acquired during admission.
• Categories of pressure ulcers damage.
Outcomes of the data received are reported to the Quality and Safety Group, Medicines Optimisation Group and the Clinical Governance Committee for further analysis and scrutiny.
Over the reporting year, the hospice has had a slightly higher number of falls compared to other hospices of similar bed capacity. All of the falls resulted in either no harm or low harm.
The number of medication incidents is very slightly higher compared to other hospices of similar bed capacity. A large proportion on the number of medication incidents were level one: no harm incident not prevented.
The number of patients admitted to the Inpatient Unit and who have developed pressure damage is very slightly higher compared to other hospices of similar bed capacity.
4.8 Staff – pulse survey
The hospice maintains a yearly schedule for sending surveys to its staff. Each survey focuses on a different topic and includes two consistent questions designed to assess our net promoter score. Recent surveys have explored areas such as employee benefits and wellbeing.
Typically, we see a 55% response rate to these surveys, with insights coming from patient facing, non-patient facing staff, and retail staff members. The feedback and suggestions we receive contribute to identifying areas for improvement, implementing changes, and launching new programs that align with the requirements of our workforce.
Actions that have been taken based on the feedback from these surveys include:
• Sharing information about the hazards of a sedentary lifestyle and supplying posters illustrating desk-based exercises.
• To assist with Musculoskeletal (MSK) conditions, we sent an email to all staff members, which included a link for self-referral MSK assessment and treatment through Sussex MSK Partnership Central. Additionally, we have a specialist Physiotherapist who offers discounted services to staff during working hours.
• A neurodiversity training session for managers is scheduled, to equip them with the confidence to support their team members effectively.
• Sharing educational materials to all staff about alcohol consumption and the recommended guidelines.
• Constantly updating and sharing information with our staff about our Employee Assistance Program (EAP) and the new services they offer.
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4.9. Feedback from Integrated Care Board
Thank you for providing NHS Sussex Integrated Care Board (ICB) with the opportunity to comment on St Wilfrid’s Quality Account for 2023/24.
NHS Sussex appreciate the ongoing collaborative working and open communication with St Wilfrid’s Hospice during this period.
NHS Sussex would like to thank the organisation for its commitment to consistent quality improvement and its achievement of the 2023/24 objectives for Sussex residents.
The Hospice has achieved many successes in 2023/24 across the five key Quality Improvement Priorities, most notably:
• Implementation of a Quality Improvement Methodology Model offering consistency and commitment to continuous quality improvement.
• The piloting of a virtual (hospice) ward from October 23 – March 24, with ongoing evaluation including from discharged patients.
• The introduction of new digital systems particularly adoption of SPC reporting, patient electronic records system and online training systems which supports oversight and further learning opportunities.
• Opportunities for working more closely with Multi-Disciplinary Team (MDT) members with several initiatives introduced i.e. working with acute services regarding live simulation training.
• Work undertaken in relation to No Barriers Here looking at how to reduce health inequalities through more meaningful conversations.
I am grateful for the hospice back up. Everybody I have spoken to have been most helpful and reassuring. They understand what I am going through and listen without judging. I can ring anytime to talk to somebody if I get a bit panicky or concerned about something. I do not feel so alone when I am worried.
Additionally, NHS Sussex recognise St Wilfrid’s commitment to enabling people to live well at the end of life through their five-year strategy framework published in 2023.
St Wilfrid’s Hospice Quality Account outlines the priorities for improvement in 2024/25 and NHS Sussex would like to acknowledge some of these key priorities:
• Integrate the principles of the Patient Safety Incident Response Framework (PSIRF)
• Develop a comprehensive dependency tool that integrates structure, safe staffing regarding palliative complexity, and carer need
• Further improve capture of patient and family demographics.
NHS Sussex is supportive of these priorities and how these will be achieved. My colleagues and I look forward to the continued collaborative working with St Wilfrid’s and wider system partners in the future.
Allison Cannon Chief Nursing Officer NHS Sussex
Colin Twomey Chief Executive
