Compton Hospice Quality Account 2014/15 · 2015. 11. 16. · to complete second medication checks which has improved the timeliness of symptom management for ... The document has

1 Compton Hospice Registered Charity: 512387

COMPTON HOSPICE

QUALITY ACCOUNTS 2014/2015

Our Purpose Compton Hospice is committed to providing quality palliative and end-of-life care to people with incurable conditions and

frailty and providing support to their families.


Statement from our Chief Executive, Ron Middleton

Compton Hospice continues to be a highly respected organisation providing palliative care to patients over

the age of 18, which extends to families and carers. Our care is provided without cost to those that need it.

The hospice has been established for 32 years and is recognised as a leader and innovator in the provision

of palliative care.

The Hospice provides palliative care services to patients from Wolverhampton, South Staffordshire,

Walsall, Dudley, Sandwell and Shropshire. Approximately one third of funding has been provided from the

six Clinical Commissioning Groups that we work with. The remaining funding is provided through voluntary

donations from members of the public, other fundraising activities carried out by the hospice, the

operation of 25 retail charity shops, and a weekly lottery company and legacy income.

Our eligibility criteria make no distinction for any group irrespective of ethnicity, religion, disability or

sexual orientation. Our clinical and fundraising teams continue to work hard to promote hospice care to

the whole of the areas we serve to ensure equity of access.

The last year has been extremely busy and we have made great progress in achieving our priorities, but we

have also seen other achievements. For example I am extremely proud to announce that our In-Patient

Unit (IPU) received the Inaugural Sue Pembrey Award for a project they implemented through the

Foundation of Nursing Studies. The project considered the benefit of providing Healthcare Assistants (HCA)

to complete second medication checks which has improved the timeliness of symptom management for

patients whilst on the IPU.

We continue to work in partnership with a number or organisations including Mary Stevens Hospice,

Beacon Centre for the Blind and have strong links with The Royal Wolverhampton Hospitals NHS Trust in

particular through our medical provision.

It gives me great pleasure to present this Quality Account for

Compton Hospice. This report reviews progress against our priorities

described in last year’s account and sets out some of our key quality

priorities to improve services for patients and families in the coming

year.

The aim of this report is to give clear information about the quality

of our services so that the people using them can feel safe and well

cared for, that their families and friends are reassured that all of our

services are of a very high standard and value for money. Public trust

and satisfaction with our service is essential.

The hospice is an independent charity (registered number 512387)

and is constituted as a company limited by guarantee (registered

number 1607631). The charity is run by a board of Trustees who are

also Directors of the Company.


I would particularly like to thank all our staff and volunteers for their continued commitment and

achievements during the last twelve months. We could not give such high standards of care without our

hardworking staff and volunteers.

To the best of my knowledge, the information reported in this Quality Account is accurate and a fair

representation of the quality of healthcare services provided by Compton Hospice. The safety, experience

and outcomes for all those using our services are of paramount importance to us, and whilst we believe

that the care we deliver is of the highest quality, we also recognise that there is always room for

improvement and are fully committed to continually reviewing our services to ensure that our services are

safe and that our patients always receive the care they need.

The document has been forwarded and commented upon by Wolverhampton City CCG (our Lead CCG).

Ron Middleton, Chief Executive

June 2015


About Compton Hospice

The History of Compton Hospice

With help from National Cancer Relief, the Regional Health Authority and Wolverhampton Rotary, a

staggering £454,000 was raised, making the necessary building works possible to transform the old hall

into a 16-bed unit. Compton Hospice welcomed its first patients in February 1982 and was officially opened

by the Duchess of Kent on November 9th 1982.

2015 at Compton Hospice

Compton Hospice has been open for 32 years and in this time has cared for in excess of 22,000 patients,

our catchment area covers predominately the Wolverhampton area, reaching out to South Staffordshire,

Dudley, Walsall, Sandwell and Shropshire.

Compton Hospice has an in-patient unit set in the grounds; the in-patient unit was completely refurbished

in 2011 and now provides 18 single purpose built rooms with en-suite facilities.

Compton Hospice also operates outpatient facilities which include:

Day centre on-site which is registered for up to 16 patients per day

Community Nurse Team

Hospice at Home Team

Lymphoedema Clinic.

Both in-patient and community teams are supported by a team of medical staff, physiotherapists, social

workers, spiritual care and bereavement service.

Compton Hospice has an education department which delivers a wide range of courses for Health

Professionals up to Masters Degree level.

Compton Hall, along with its stables, coach houses, yard,

servants' quarters and lodge, was built between 1840 and

1850 and is set in four-and-a-half acres of woodland and

gardens.

After housing evacuees during the war, it became a home

for nurses working at the Midlands County Eye Infirmary.

When this provision was no longer needed, a health

council working group, led by Councillor Stephen Morton,

petitioned for it to be used as a care facility for

terminally-ill patients.


Our Purpose

Compton Hospice is committed to providing quality palliative and end-of-life care to people with incurable

conditions and frailty and providing support to their families.

Our Values

We believe the patient and their family come first

Our focus is on excellence of care

We value diversity

We value and recognise the contribution of all our people and promote the importance of their

professional development

We believe in team working

We believe in equal opportunities for all

We strive to maintain our good reputation

We value open, honest, transparent communication

We believe in sharing responsibility appropriately

We value evidence based and continuous improvement

We believe we should share our knowledge and expertise with other


Statement of Trustees’ responsibilities in respect of the Quality Account

The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year.

In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

the Quality Account presents a balanced picture of the Hospice’s performance over the reporting

period;

the performance information reported in the Quality Account is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of

performance included in the Quality Account, and these controls are subject to review to confirm

that they are working effectively in practice;

the data underpinning the measures of performance reported in the Quality Account is robust and

reliable, conforms to specified data quality standards and prescribed definitions, and is subject to

appropriate scrutiny and review; and

the Quality Account has been prepared in accordance with Department of Health guidance.

The directors confirm to the best of their knowledge and belief they have complied with the above

requirements in preparing the Quality Account.

Date Signature Chairperson

Date Signature Chief Executive


Part 1 Priorities for Improvement

1.1 Looking Forward: Priorities for Quality Improvement 2015/16

Compton Hospice has developed an overall five year operational strategy for 2015 – 2019; Our Strategic

Aims include to:

Through the development of our resources maximise our capacity and extend our reach across the

seven day week to meet the increasing end-of-life care requirements of our community based on

need rather than diagnosis;

Develop expertise in the health and social care workforce who care for those in the last years of life

through education and training;

Maximise the effectiveness of limited resources across the health and social care economy by

forming partnerships whenever possible with others whose aims and values are congruent to ours.

We have identified various quality initiatives for the coming year; those detailed below are a summary of

our priority quality initiatives.

Our Quality Improvement Priorities for 2015/16 Safety Priority Quality Priority To reduce the risk of patients falling whilst on our in-patient unit.

How will we measure?

Incident data. In-patient dashboard. Benchmarking using National Council for Palliative Care: Minimum Datasets. Performance measures against timeliness of initial and subsequent falls assessments. Performance measures against timeliness of initial and subsequent falls assessments. Audit of care plans and risk assessments.

How will we do this?

Develop and implement a falls policy on our in-patient unit

Use investigation tools to review falls incidents to identify learning

Network with other hospices to share learning and good practice

Engage with the falls prevention service in Wolverhampton


Safety Priority

Quality Priority We want to strengthen our systems for monitoring and improving infection prevention and control


Performance data relating to infection prevention and control In-patient dashboard Revised policy embedded Attendance at network meetings Training data Attendance at network meetings Training data


Revise our infection control policy Review our infection prevention and control audit plan

Review our infection and prevention control training

Develop an annual infection prevention and control improvement plan

Engage with our partners and experts infection prevention and control

Participate in local infection prevention group

Safety Priority Quality Priority We want to review our mandatory training programme for all staff to ensure that it

is fit for purpose


Training evaluation feedback Training compliance data Supervision and appraisals


A working group will oversee a review of mandatory training

The working group will develop a mandatory training matrix for clinical and non-clinical staff

Source alternative methods of training provision to support core training

Link training and competency to staffs annual appraisal


Patience Experience Priority Quality Priority We want to improve the way in which we engage and seek views from our patients

and carers of the services that we provide.


Ratified strategy and implementation plan. Each service will be represented by patient experience champions. Annual report relating to patient experience that details how we use information gathered to improve services for our patients and carers.


Develop a 5 year patient experience strategy which will set out our commitment to seeking views on our services and methods that we will use to do this. Identify patient experience champions throughout the hospice including Board level. Actively listen to views to improve our services. Develop patient and carer outcome measures using:

Carer Support Needs Assessment Tool Palliative Care Outcome Scale Tool

Patience Experience Priority

Quality Priority Wolverhampton is a multi-cultural and multi-faith city, we therefore want to change our emphasis from religious to spiritual care


Training data Patient and family feedback Links with religious leaders in our local community


Revise our core training program for staff

Provide monthly support sessions for volunteers including mandatory training relating to spiritual care

Chaplaincy Team will become Spiritual Care Team

The sanctuary will be reconfigured to provide a peaceful spiritual space to

offer sanctuary for those of religious faith and none

Invest in resources that are important to the religious practice of other faiths

Engage with religious leaders in our local community

Effectiveness Priority

Quality Priority We want to extend our community service provision to better serve the population we cover.


Attendance will be measured through our activity data. Patient and carer experience reports.


Workforce data.


Increase community nursing team by 50%

Increase education provided to patients and staff in nursing homes

Implement the electronic record system

Increase support offered to carers through collaborative working with social workers

Development of Clinical Nurse Specialist Out-patient clinics

Increase the use of our day centre through education with staff and

promotion with our patients


Quality Priority To implement a rehabilitative palliative approach within our in-patient unit across the multi-disciplinary team to optimise patient function and wellbeing and to enable them to live as independently and fully as possible, with choice and autonomy, within the limitations of advancing illness.


Length of stay data Audit of care plans Patient feedback


Integrate rehabilitation, enablement, self-management and self-care into our model of care

Utilise a multi-disciplinary team approach

Include patients and relatives in care planning

Revise care plans to include patient goals, priorities, and limitations


Quality Priority We want to review our audit programme to ensure that we select appropriate audits and improve our services as a result of audits.


Number of completed audits Monitor through Clinical Audit & Guidelines Group


Review the process for identifying audits

Maintain a comprehensive audit program

Strengthen the way in which we evaluate and implement the learning from audits


1.2 Looking Back: What did we achieve in 2014/15?

Our Quality Priorities for 2014/15

Patient Experience Priority Quality Priority Improvements to outpatient facilities.

What did we want to achieve?

We wanted to build a new orangery for patients and visitors with funding from a specific legacy. We sought to create an area away from the individual in-patient rooms for patients and families to enjoy the view of the gardens in peaceful and welcoming accommodation. We also wanted to relocate the doctors’ office to a purpose built room directly adjacent to the Orangery, thus releasing additional space to allow extension of the new reception area.

What did we do? Installed the orangery extension to the ward area

Installed a lift in out-patient area

Relocated doctor’s office

What was our outcome?

The creation of the orangery has provided an additional area for patients and visitors which gives access into the hospice grounds and gardens, patients and relatives utilise this area for family activities such as picnics and quiet time to enjoy the fresh air.


Quality Priority Improvement in the admission, length of stay and discharge process of the in-patient unit.


Currently the systems for admitting patients and indeed their ultimate discharge did not support consistent achievement of performance indicators set by the Board of Trustees and senior management in respect of occupancy and length of stay. We wanted to bring about changes in working practices and how we communicate with patients and their families before admission to better achieve these performance indicators.

What did we do? Appointed a Liaison Nurse for the in-patient unit to co-ordinate, lead and facilitate effective and timely discharges.

Strengthened admission process between the Acute Hospital and In-patient Unit.


Improving length of stay remains one of our strategic objectives and priorities for the following year. The Liaison Nurse has strengthened processes in respect of discharge and has integrated discharge documentation into the Electronic Patient Administration System.


Safety Priority

Quality Priority Implementation of the Electronic Patient Administration System (CrossCare).


We wanted to create a patient electronic record system for use across all clinical services that is fully compliant with the Data Protection Act 1998 and Information Governance requirements.

What did we do? Worked with service leads to ensure that the CrossCare system meets the requirements of the service and is fit for purpose

Implemented the electronic record system in all clinical areas, making refinements at each stage of the project

Provided training to staff

Created reporting and audit mechanisms within the system


The project to implement CrossCare is a long term vision which spans across 3 years, we have key milestones within the project, and the project will continue into 2015/16. To date the system has been implemented across all clinical areas; however some services are not yet using the system to the full potential. Cross care has provided us with:

Access to accurate information

Timely access to information regarding patients care and treatment

Access to comprehensive information Effective working through enhanced exchange of information between services

Effectiveness Priority Quality Priority Development of services aligned to the In-patient Unit.


Implement an assessment tool that allows us to assess the level of nursing staff required per shift, and develop a flexible workforce to achieve safe staffing levels

Strategies to manage risks associated with patient safety

Improve documentation of care

What did we do? Implemented an evidenced based tool to identify required staffing establishment

Increased establishment on in-patient unit

Developed a crib sheet that has been recognised as good practice and adopted by other hospices

Introduced shift rotation

What was our The use of an evidence based tool to assess the level of staff needed on the in-patient


outcome? unit each day has meant that we can be sure that we have the right amount of staff with the appropriate knowledge, skills and competence to provide high quality care to our patients every day. The introduction of the tool means that we can be flexible and revise our workforce to meet the needs of the service on a shift by shift basis.


Part 2 Statements of Assurance

Compton Hospice is required to register with and is regulated by the Care Quality Commission (CQC) and

its current registration status is unconditional. The CQC has not taken enforcement action against

Compton Hospice during 2014/2015.

The most recent CQC inspection was November 2013, the results of this inspection were extremely

positive with all standards being met with no action required due to any areas being highlighted as being of

concern.

2.1 Mandated Statements

The following are a series of statements that all providers must include in their Quality Account. Many of

these statements are not directly applicable to specialist palliative care providers.

Review of services

During 2014/15 Compton Hospice was contracted to provide six core services to the NHS:

The services were as follows:

Clinical Nurse Specialist Community Team

Hospice at Home services

Day Hospice

Outpatient care

Lymphoedema Clinics

In-patient care

Bereavement Service

The Clinical Issues Committee meets bi-monthly to develop and monitor the work of the clinical services at

Compton Hospice; the Committee informs the Chief Executive and Board of Trustees on clinical issues

within the hospice through the Development and Governance Group. The Pharmacy Committee directly

reports to the Clinical Issues Committee.

What this means

The hospice received a contribution from the NHS equalling 36% of the full cost of the contracted

service provision. The remaining funds were generated by contributions from the local community

through fundraising and the Hospice’s own subsidiary companies.


The Clinical Issues Committee:

Reviews developments in palliative care including the national and local End of Life Care Strategies,

appropriate research, audit and clinical guidelines.

Develops quality indicators

Monitors clinical incidents and complaints and makes appropriate recommendations to inform

practice

Recommend task and finish groups for key work areas as required

2.2 Participation in Clinical Audits

As an independent hospice, Compton Hospice does not participate in the national NHS clinical audit

programme as there are no national clinical audits or national confidential enquiries covering NHS services

relating to palliative care. However, we regularly undertake audits, as part of our annual forward audit

programme which we select according to network, local or internal priorities.

The number of patients receiving NHS services provided or sub-contracted by Compton Hospice in

2014/2015 that were recruited during that period to participate in research approved by a research ethics

committee was 0. There was no appropriate, national, ethically approved research in palliative care in

which the hospice could participate.

What this means

Delivering the very highest quality of care is at the heart of everything we do, our Board seek assurance

through the Board meetings that this high standard of care is consistently delivered, the Board

challenge where they identify improvements may be required and monitor and remedial action

required.

We meet twice a year with our lead commissioners to review performance and provide assurance

relating to:

Quality of care

Effectiveness of Service

Experience of those using our services

No concerns have been raised at these meetings.

What this means

As a provider of specialist palliative care Compton Hospice was not eligible to participate in any national

clinical audits or national confidential enquiries, however to ensure high quality of services a local audit

plan is established. Where necessary local action plans for improvement are developed.


2.4 Use of CQUIN Payment Framework

The contract for Compton Hospice NHS income for 2014/15 was not conditional on achieving quality

improvement and innovation goals through the Commissioning for Quality and Innovation payment

framework.

2.5 Data Quality

Compton Hospice did not submit records during 2014/2015 to the Secondary Uses Service for inclusion in

the Hospital Episode Statistics.

In accordance with agreement with the Department of Health, Compton Hospice submits a National

Minimum Dataset (MDS) to the National Council for Palliative Care. This information is detailed in section

3.

2.6 Information Governance

Compton Hospice’s score for 2014/2015 for information Quality and Records Management was not

assessed using the Information Governance Toolkit. This toolkit is not applicable to palliative care.

2.7 Payment by Results

Compton Hospice was not subject to the Payment by Results clinical coding audit during 2014/2015 by the

Audit Commission


Part 3 Review of Quality Performance

3.1 The National Council for Palliative Care: Minimum Datasets April 2014 – March

2015

The National Council for Palliative Care: Minimum Datasets are the only annual data collection to cover

patient activity in specialist services in the voluntary sector; the aim is to provide an accurate picture of

hospice and specialist palliative care service activity. It allows us to benchmark our services with other

similar hospices.

We submit data for our In-patient Service and Hospice at Home Service.

3.2 Compton Hospice Quality Performance Information 2014/15

Activity

Referral Information

The total number of patients referred to our services between April 1st 2014 and March 31st 2015 was

1,758.Our patients predominately live in Wolverhampton; they are referred to our services by their GP,

District Nurse and Hospital or Community Consultant.

Referral activity is shown in the tables below; the majority of our referrals continue to be from residents of

Wolverhampton. We have seen an increase in our referrals in comparison to the previous year.

The number of patients referred by Commissioning Group is tabled below.

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

7

Others 1 1

4 5 0 1 4 2

30 25 32 36

Shropshire 8 2 3 3 2

3

South

Staffordshire30 20 33 20 23 29 30 25

0 1 2 3 4 4

3 1 3 5

Walsall 2 3 2 1 2

3

Sandwell 2 0 3 0 1 3 3 1

5 7 7 2 4 7Dudley 3 7 7 5 5

112 112 98 95 118 138

Patients referred by Clinical Commissioning Group Area (Total 1,758)

AreaNumber of referrals

Wolverhampt

on112 91 104 101 85 102


Length of Stay Information

Activity relating to our In-patient Unit is detailed in the table below; reducing average length of stay is one

of our quality priorities for improvement this coming year.

3.3 Updates from our Services

Clinical Nurse Specialist Community Team

We have a team of specialist palliative care nurses that provide holistic assessment of our patients, and

their family’s needs, identifying any physical, psychological, spiritual or social needs.

The team work closely with other health and social care professionals to help patients and their families

coping with adjusting to living with a life limiting illness. The emphasis is on maximising the quality of life

of the patient and their family.

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Average

Length of

stay (days)

15 15 11 12 17 13 17 17 16 12 14 20

506388 491 417 457 442 421

Total

Occupied

Bed Days

438 395 393 406 417

4 12 0 0 20

23

Shropshire 28 19 12 23 20 3 0

96 102 110 124 33 25Staffs 111 54 91 141 88

0 0 35 28 31

32

Walsall 14 30 17 0 2 10 0

48 18 0 13 0 10Sandwell 12 0 12 36 47

44 70 68 59 33

367

Dudley 11 6 5 32 69 6 42

225 329 259 238 306 299Wolverhamp

ton262 286 256 174 191

In-patient Unit Activity

AreaActivity

Clinical Nurse Specialist Community Team key achievements

Continued training and development for staff to ensure we have a highly skilled and competent

workforce

Participated in a partnership project with Macmillan Cancer to facilitate provision of seamless

and high quality care for offenders with palliative and end of life care needs

Implemented the Integrated Patient Care Outcome Scale (IPOS) to capture how input from the

team has improved outcomes for patients


Hospice at Home Services

Our hospice at home service aims to do exactly that - bringing hospice care into the home environment.

It enables patients with a life limiting illness to be cared for at the end of their life in their own home and

works alongside other community teams to provide health and social care and emotional support for the

patient and the family.

Day Hospice

Compton Hospice Woods Centre provides a holistic service to help maintain a sense of independence, well-

being and quality of life whilst adapting to advanced illness. Each patient has an individual program to

address patients concerns which may include therapies and services such as pain and symptom control,

relaxation therapies and confidence building.

Physiotherapy Service

The physiotherapy service aims to improve patients’ quality of life by promoting independence and helping

people adapt to their changing condition. Physiotherapy aims to make the most of peoples abilities,

physical, psychological and emotional, to keep them as independent as possible.

We work in patients’ own homes, day therapy, out-patients and in-patients.

Hospice at Home Team key achievements?

We continue to provide support to the In-patient Unit and Day Therapy Centre

We provide day support service to South Staffordshire, and have extended this to the entire

catchment area when there is available capacity

We have increased our operational hours for the day support service to 07.30am – 9.30pm and

can now offer support 24 hours per day, 7 days per week

Day Hospice key achievements

We have integrated with Community, In-patient Unit and Day Therapy Centre

Our patients attend the day centre whilst an in-patient which supports the transition from in-

patient to home, this forms part of the preparation for discharge.


Lymphoedema Clinics

The lymphoedema service at Compton set up in 1996 has continued to grow and is now one of the largest

specialist lymphoedema units in the UK treating around 200 adults per week.

In-patient care

The in-patient unit (IPU) continues to deliver the high quality care which exceeds expectations of our

patients and families.

Physiotherapy Service key achievements

We received excellent feedback through the audit of our breathlessness self-help service.

90% of patients receiving the breathlessness self-help service felt that they had learned

something new about managing breathlessness and 94% felt better able to manage their

breathlessness.

The service is a key member of the regional project which is reviewing end of life care for

patients with Chronic Obstructive Pulmonary Disease.

Lymphoedema Clinic key achievements

We have invested in technology to ensure we are able to measure outcomes effectively for

those suffering from trunkal/head and neck oedema

We have improved the quality of life questionnaire to ensure we are able to treat patients

holistically

We continue to register approximately 250 new patients each year.

We have a nurse on the in-patient unit with specialist Lymphoedema skills which has improved

the service to in-patients

We have developed group clinics for patients referred to the service who are low priority to give

advice on self-management of Lymphoedema

Staff have successfully completed various levels of education such to

We continue to be instrumental in developing Lymphoedema care on a national scale through

specific degree modules developed and provided through Compton hospice Education Centre


Bereavement Services

The bereavement services continue to offer support and counselling to relatives after the death of a loved

one, which can be individual or group sessions, provided at the hospice or in families own homes. We also

provide a specialist bereavement service for children.

3.4 Quality Indicators

Quality is central to everything that we do. In addition to national quality indicators we have chosen to

measure our performance against the following:

Inpatient Unit key achievements

We have continued to train and develop our staff to ensure we have a highly skilled and

competent workforce

We have improved risk management processes to support continual learning

We are listening to what our patients say about our care to improve for the future

We are piloting the electronic record system

We are embedding “Time to Care”

We have strengthened the discharge process with introduction of the Discharge Liaison Nurse

role

We participated in the Foundation of Nursing Studies (FoN’s) Project and were awarded the

Inaugural Sue Pembrey Award for our work to train healthcare assistants to second check

medication

Bereavement Services key achievements

5 bereavement visitors for adults and 2 volunteers for children were trained in September 2014.

There is a drop in coffee morning held monthly which has been extremely successful and is

continuing to grow, the group offers a safe place to meet other people who are also grieving.

The coffee morning is led by the bereavement visitors.

The Bereavement Coordinator has assessed and benchmarked the bereavement service against

the new bereavement service standards.

Scoping work in terms of children’s bereavement services has been completed and a proposal

has been developed to expand the children’s bereavement service.


What our patients and families say about us

How we monitor and use safety information to make improvements – falls, meds errors, pressure

ulcers, infections, safety alerts, safeguarding

How we make sure that our staff are skilled and competent to work in the hospice

How we review our systems and processes and make changes to the way we work

How we prevent and control infection

Complaints and Concerns

During the year our complaints procedure has been reviewed and updated.

Sometimes we hear feedback that helps us to learn and improve the way we work.

In 2014/15 we received four complaints, one was not related to our clinical services, however related to

our Compton Hospice Promotions Service, the complaint was responded to and the issue was resolved.

Three complaints related to Compton Hospice Clinical Services, these were fully investigated, although this

is only a small number of complaints they generally indicated a perceived lack of communication, further

training has been targeted where necessary to prevent reoccurrence.

All complaints were responded to and resolved within 20 working days.

Compliments

We receive compliments in various ways, sometimes by letter or card, other times by talking to patients or

families. Compliments help reinforce positive messages to our population and staff about the work that we

do.

A snap shot of compliments received are provided in the comments section below.

Safety Information

We encourage an open and transparent culture where reporting of accidents and incidents provides us

with an opportunity to identify where we can make improvements.

Whilst extremely small in numbers our top 3 incidents reported relate to:

Patients falling

Patients developing a pressure ulcers


Medication Incidents

There were no incidents which resulted in serious harm, most incidents result in no harm, and one fall

resulted in moderate harm; however we take the opportunity to review care provided to ensure that we

continually learn from incidents and use the information to improve our services.

We recognised that preventing patients falling was a high priority and we have included this as our priority

for 2015/16.

Education and Training

Compton Hospice has an established education centre that provides training for staff that directly relates

to patient care.

Local Audits

We have undertaken various audits and surveys during 2014/15; we have an audit group which:

Monitors progress against our annual audit plan

Reviews the outcome of completed audits

Oversees the implementation of actions

Outcomes from completed audits are shared with staff through the audit presentation meeting, multi-

disciplinary reviews and team meetings.

Infection Prevention and Control

The Infection Prevention Nurse oversees the hospices work program in relation to infection prevention and

control; this includes a program of audits such as environmental audit, sharps audit and handwashing

audit, the infection prevention nurse also acts as a port for advice and support for clinical staff.

We want to strengthen our work program and arrangements relating to infection prevention and control in

the coming year, this is one of our safety quality improvement indicators for 2015/16.


3.6 What people say about our service?

What patients and their families say about our service?

In-patient Unit

“To all the lovely people at Compton Hospice who made our mothers last few months as comfortable as

possible and provided us with support, we want to thank you so much.”

“I don’t have sufficient words to express my gratitude for all the care you gave my husband. Doctors, nurses

and volunteers – you are a special family.”

Hospice at Home Services

“Words can’t describe how overwhelmed we are with the outstanding service; all members of the team

have provided. Very caring, compassionate and treated my mother as their own.”

“I felt reassured going to bed knowing my husband was having professional care throughout the night.”

Lymphoedema Clinic

“My thanks go to the nurses at Compton Cedars for their constant monitoring of my Lymphoedema.”

“I have found the service amazing. The Nursing staff are a credit to the service. Always pleasant and

cheerful, able to sit and have a chat with a cup of tea if required. Lots of useful advice for continuing

treatments and personal to individual patient.”

The building itself since its refurbishment is a very serene and relaxed area, always clean. Ladies in

reception always recognise patients on sight, making it a very personal appointment.”

What our Staff say about our Service

“I have been privileged to work at Compton Hospice alongside dedicated and caring staff. I am proud to

have been associated with the modern hospice movement and this hospice in particular and to be able to

boast and speak with great pride of the amazing work which we do. I am constantly humbled to be witness

to the special care given lovingly and freely, to our patients and their families.”

What our Volunteers say about our Service

“I just love it!”

What our Trustees say

“The Board of Trustees of Compton Hospice is fully committed to prioritising the quality of patient and

family care and continued development of services developing services in line with the needs of our patients

and their families and friends and our updated strategy.

“To this extent we have invested in our nursing and medical workforce to expand our community services,

which recognises our aim to deliver palliative care to patients in need in the most appropriate location. We

appreciate that people will not always want to be cared for in our In-Patient Unit; this investment affords

people choices about where they wish to be cared for.

“We are pleased to introduce our new quality improvement plans for 2015/16 in this quality account which

support our persistent drive to improve the quality of services.


“The Board is confident that the care and treatment provided by Compton Hospice is of a high quality, is

cost effective, and can be sustained in the foreseeable future, and they fully endorse this Quality Account.”

C J Harris

Chairman – Compton Hospice Board of Trustees

What our Comissioners say about our Service

Quality Account 2014/15 – Commissioner Statement

The achievements outlined in the quality accounts for services particularly Physiotherapy, Hospice at Home

Team, Day Hospice, Lymphoedema Clinic and Bereavement Service confirm many successes.

The on-going commitment of Compton Hospice to provide quality palliative and end of life care is testimony

to the achievements we recognise from 2014/15 including:-

• Quality improvements in out-patient facilities including an orangery extension to the ward area

along with a lift and relocation of the doctor’s office. These changes have enabled patients and their visitors

have access to the grounds and gardens.

• Improvements to the admission, length of stay and discharge process in the in-patient unit through

improved processes and documentation that is now electronic.

• Implementation of the Electronic Patient Administration System has enabled access to accurate

information, access to each patient’s care & treatment and the ability to exchange information efficiently

between services.

• Services have been developed and aligned with the in-patient unit through utilising a staffing

establishment tool, increased staffing on the in-patient unit and use of a crib sheet that is also being used in

other hospices.

We recognise that the CCG are one of a number of stakeholders working with Compton Hospice, CQC have

not visited in year nor have they taken any enforcement action. Delivery of very high quality care is a

priority for the Board who seek assurance that this is consistently achieved. The CCG maintain regular

contact and meet periodically to ensure those standards are being maintained. We were impressed with

the Hospice at Home Service reviewed during February 2015, this confirmed the level of rigour that is given

to ensuring high quality care is provided to patients in the community.

In 2015/16 the priorities for quality improvement are to maximise capacity and extend reach across the

seven day week, development expertise in health and social care workforce and maximise effectiveness of

the limited resources available.

Thank you for sharing the Quality Accounts with the CCG for 2014/15, we

as a commissioner value receipt of these and the opportunity to comment

and congratulate you on the progress you have made and your vision for

2015/16 that seeks to improve services for patients.


Quality initiatives will include reducing the risk of patients falling, infection prevention and control,

undertake a review of mandatory training for all staff, engage and seek views from our patients and carers

and to change emphasis from religious to spiritual care. The CCG are confident in the hospice’s ability to

sustain the standards already being achieved and to embrace the challenges that their priorities for

2015/16 will bring.

The CCG developed an End of Life Care Strategy in August 2014, with its partner organisations including

Royal Wolverhampton Trust and Compton Hospice. We are now looking to refresh this strategy to reflect

the national guidance Ambitions for Palliative and End of Life Care: A national framework for local action

2015-2020 which has been developed by the National Palliative and End of Life Care Partnership. This

framework has at its heart 6 ambitions for developing End of Life Care. These are:

1 Each person is seen as an individual

2 Each person gets fair access to care

3 Maximising comfort and wellbeing

4 Care is coordinated

5 All staff are prepared to care

6 Each community is prepared to help

We will work together to ensure that locally the 6 ambitions for developing end of life care are fundamental

to our commissioning and desire to secure the highest quality of care for our patients.

Yours sincerely

Dr Helen Hibbs

Chief Officer

Wolverhampton Clinical Commissioning Group

Compton Hospice Quality Account 2014/15 · 2015. 11. 16. · to complete second medication checks which has improved the timeliness of symptom management for ... The document has

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