Quality Account 2019 - assets.nhs.ukHalton Haven Hospice has not participated in special reviews or investigations by the CQC during 2018/19. Halton Haven Hospice was last inspected

Quality Account

2019

Halton Haven Hospice,

Barnfield Avenue, Murdishaw,

Runcorn, Cheshire,

WA7 6EP

Tel: 01928-712728

www.haltonhavenhospice.co.uk

Registered Charity No. 702654

http://www.haltonhavenhospice.co.uk/

Quality Account 2018 - 2019

Contents

Statement from the Chief Executive Officer

What Is a Quality Account?

About Halton Haven Hospice

Statements of Assurance from the Board

Review of Priorities for Improvement 2018 – 19

Feedback from Patients and Relatives

Clinical Governance Overview

Care Quality Commission Report

Equality and Diversity

Infection Prevention and Control

Community Engagement

Priorities for Improvement 2019 – 2020

Statements on This Quality Account

Opportunity to Provide Feedback


Statement from the Chief Executive Officer

Viv Culleton

Chief Executive Officer

On behalf of Halton Haven Hospice, I would like to welcome you to our annual Quality Account

and thank you for your interest in the Hospice. I hope you find this report informative.

Patients and their families are at the heart of all we do at Halton Haven Hospice and we

endeavour to ensure that all our care is both patient centred and of the highest standard. We

strive to provide an evidence based palliative care for all patients, regardless of diagnosis or

protected characteristics and to be an exceptional resource within the community of Halton.

The Hospice has always provided care at no cost to our patients and families thanks to the

income generated by local community engagement and contribution from the NHS. This will

continue this coming year and I would like to take this opportunity to express gratitude to all

who have contributed, in any way, to enabling the services Halton Haven Hospice provides.

Each year we set ourselves a set of priorities with the obvious aim of achieving them and then

building upon them in the upcoming year. This Quality Account sets out those priorities and

reports back on progress. We are pleased to report that in 2018 – 2019 we achieved our stated

goals and you will find within this document our priorities for the year ahead.

There is always more to do and with your continued support we look forward to providing safe,

effective, responsive, caring and well-led services to meet the future needs of the local

population.

I must also take this opportunity to thank all of our staff and volunteers for their ongoing passion

and commitment, which enables us to continue raising the bar and achieving great outcomes

year on year.

I am responsible for the preparation of this report and its contents, and to the best of my

knowledge the information contained herein is accurate and a fair representation of the quality

of the NHS healthcare services provided by Halton Haven Hospice.


What is a Quality Account?

Producing a Quality Account is a requirement of the Health Care Act (2009) and according to

the Department of Health, ‘Quality Accounts aim to enhance accountability to the public and

engage the leaders of an organisation in their quality improvement agenda’.

The Quality Account should provide information about the quality of the services the organisation

delivers and its main purpose is to encourage providers to take a robust approach to quality.

All providers of NHS healthcare services, including independent organisations such as Halton

Haven Hospice, should produce a Quality Account and in doing so each provider, led by their

Board, is committing to improve the quality of care it delivers locally and invites the public to hold

them to account.

The Quality Account covers two main areas:

A review of how we performed last year, covering three main areas of quality; patient

safety, patient experience and clinical effectiveness

A set of key priorities for improvement next year

The public, patients and other interested parties can use the Quality Account to understand:

What an organisation is doing well

Where improvements in service quality are required

What the organisation’s priorities for improvement are for the coming year

How the organisation has involved people who use their services, staff and others with an

interest in their organisation in determining these priorities for improvement


About Halton Haven Hospice

Halton Haven Hospice is a registered charity with its origins in the vision of one man, Dom Valdez.

Activity started on our present site in 1981 with the first element of the Hospice building becoming what

is now our Day Hospice.

The Inpatient Unit (IPU) was originally built in the early 1990s and has had a full refurbishment completed

in 2018. This has resulted in substantial development of the original structure of the Hospice.

The latest new build development has been the Family Support Service building, which has grown out

of the Hospice’s desire to expand the services we offer.

In Patient Unit (IPU): The Hospice is registered with the Care Quality Commission and the IPU has

provision for 12 palliative care beds.

The IPU has a comfortable lounge leading directly into a conservatory and then out into the well-

developed garden areas. IPU bedrooms are single rooms with en-suite facilities, some having an en-

suite shower and additional space to accommodate patients with physical disabilities. All rooms have

remote control television, radio, CD player and an electric fan.

There are specialist bathing and shower rooms to enable patient choice. A comfortable visitors’ room,

with access to tea and coffee making facilities, is available. The Hospice has made provision of a

dedicated Quiet Room within the IPU, which is available 24 hours a day for quiet reflection, prayer and

religious services.

Day Hospice: The Day Hospice is licensed to accommodate up to 12 patients per day. It operates

throughout the week and accommodates a Specialist Outpatient Clinic on one day. There is a

comfortable lounge, a dining area, activities area, Complementary Therapy and Physiotherapy

Rooms and well-established gardens. Day Hospice has its own toilet and shower facilities which are

suitable for disabled use.

Family Support: The Family Support Service is the department through which the Hospice maintains its

provision of Listening Services, Patient and Carer Support, Bereavement Counselling and Financial and

Benefits support.

The Service operates from a dedicated building, which is the newest development on the Hospice

site, and is primarily aimed at those known to the specialist palliative care team (i.e. Hospice and

Macmillan teams). The service does, however, have a 10% non-palliative capacity that can be utilised,

as appropriate.

The focus of the Family Support team is to provide an accessible and flexible service tailored to the

needs of the individual clients.


The Hospice’s key objectives are to:

Provide a flexible and adaptive approach to Specialist Palliative Care Services.

Provide expert care at the highest standard, thereby enhancing the quality of life for patients

faced with life-limiting illnesses.

Respect patient choice and autonomy and to be mindful of the individuals’ need for dignity,

independence and privacy.

Respect and acknowledge individual spiritual and religious beliefs.

Provide a system of support which enables the person to live as actively as possible and

supports the family and other carers.

Work in conjunction with other professionals in order to provide a seamless service.

Ensure care is provided by a team who have undergone appropriate Palliative Care training.

Contribute to the education and development of the Hospice’s own staff and to the local

palliative care education programmes.

Evaluate and improve our services through analysis of feedback from patients, relatives, other

professionals and staff questionnaires.

Hospice Vision, Mission and Aims:

Our vision is that people in Halton facing life-limiting illness will have quality of life and dignity in death

Our mission is to care for people living with life-limiting illness by providing safe, specialist end of life care

and supporting their families. We will lead and inspire excellent care wherever people chose to die

Our aims are:

To provide and develop quality and cost-effective End of Life services for the people of Halton

To sustain and develop Hospice services that are fit for the future

To promote the excellence of the work of the Hospice and celebrate success

We will deliver this by:

Valuing and developing our people

Making the most efficient use of our resources


Statements of Assurance from the Board

The following are formal statements, under various headings, that all providers of NHS healthcare

services must include in their Quality Account even if the statement is not directly applicable to us

as a Specialist Palliative Care provider.

Review of Services

During 2018/19 Halton Haven Hospice provided Specialist Palliative Care Services to the NHS.

Halton Haven Hospice has reviewed all the data available to us on the quality of care in these NHS

services.

The income generated by the NHS services reviewed in 2018/19 represents 55% of the total income

generated from the provision of NHS services by Halton Haven Hospice for 2018/19. This 55%

represents only part of the funding required to provide services at Halton Haven Hospice; the

remaining 45% of income was generated through fundraising and the generosity of the local

community.

Participation in Clinical Audits

During 2018/19 no national clinical audits and no national confidential enquiries covered NHS

services that Halton Haven Hospice provides.

During that period Halton Haven Hospice participated in 0% national clinical audits and 0% national

confidential enquiries of the national clinical audits and national confidential enquiries which it was

eligible to participate in.

The national clinical audits and national confidential enquiries that Halton Haven Hospice was

eligible to participate in during 2018/19 was none.

Research

The number of patients receiving NHS services provided by Halton Haven Hospice in 2018/19 that

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

committee was none. The Hospice would be open to participate in research projects subject to

eligibility.

Use of the CQUIN Payment Framework

A proportion of Halton Haven Hospice’s income in 2018/2019 was not conditional on achieving

quality improvement and innovation goals agreed between Halton Haven Hospice and the

commissioning bodies they entered into a contract, agreement or arrangement with for the

provision of NHS services, through the Commissioning for Quality and Innovation payment

framework.

Care Quality Commission (CQC)

Halton Haven Hospice is required to register with the Care Quality Commission and its current

registration status is Independent Hospice for Adults. It is registered to provide the following

regulated activities:

Diagnostic and screening procedures


Treatment of disease, disorder or injury

Halton Haven Hospice has the following conditions on registration:

The establishment is registered for the provision of supportive and palliative care

services.

The establishment will provide overnight treatment to a maximum of 12 (twelve) persons

aged 18 (eighteen) years or over.

The establishment may provide day services for 12 (twelve) patients at any one time for

patients aged 18 (eighteen) years or over.

The prior written approval of the Care Quality Commission must be obtained at least 4

(four) weeks in advance if providing any treatment or service not detailed in the

Statement of Purpose.

The CQC has not taken enforcement action against Halton Haven Hospice during 2018/19.

Halton Haven Hospice has not participated in special reviews or investigations by the CQC

during 2018/19.

Halton Haven Hospice was last inspected by the CQC on the 1st March 2016 and at that time

received an overall rating of GOOD.

Data Quality

Halton Haven Hospice did not submit records during 2018/19 to the Secondary Uses Service for

inclusion in the Hospital Episode Statistics which are included in the latest published data.

Information Governance Toolkit Attainment Levels

The latest Halton Haven Hospice Information Governance Assessment Report overall score was

66%.

The Information Quality and Records Management attainment levels assessed within the

Information Governance Toolkit (IGT) provide an overall measure of the quality of data systems,

standards and processes within an organisation.

The Information Governance Toolkit is available on the Connecting for Health website as follows:

https://www.igt.hscic.gov.uk/Home.aspx?tk=428144399468925&cb=4553c4b1-adaf-49b0-b3ec-

70fb79d055b7&lnv=7&clnav=YES

Clinical Coding Error Rate

Halton Haven Hospice was not subject to the Payment by Results clinical coding audit during

2018/19 by the Audit Commission.

https://www.igt.hscic.gov.uk/Home.aspx?tk=428144399468925&cb=4553c4b1-adaf-49b0-b3ec-70fb79d055b7&lnv=7&clnav=YES

https://www.igt.hscic.gov.uk/Home.aspx?tk=428144399468925&cb=4553c4b1-adaf-49b0-b3ec-70fb79d055b7&lnv=7&clnav=YES


Review of Priorities for Improvement 2018 - 2019

PRIORITY ONE

Our aim was for all our Health Care Assistants (HCAs) to have gained the Care Certificate. It had

been the Hospice policy that any new HCAs undertake the Care Certificate where they hadn’t

already, but going forward we wanted it to be mandatory for all HCAs, regardless of how long

they had worked at the Hospice, to have gained the Care Certificate.

We are pleased to report that we have achieved 100% success with this priority with all 13 of our

HCAs having shown their commitment to improvement and gaining the Care Certificate.

PRIORITY TWO

We set our self the task of developing a new Patient menu this past year, which would introduce

new recipes, further enhance patient choice and look to ensure that the nutritional value of the

menu was optimised through the use of more fresh produce in “home-made” food.

As far as possible processed foods have been eliminated from use in the Hospice kitchen and

the range of items offered at service each day has been increased. The kitchen team also strive

to accommodate any patient request regardless of the menu on offer and we are pleased with

the feedback from patients and families, such as the following examples from our Patient and

Carer Survey:

“Friendly, helpful staff. Make visitors and dog very welcome. Food/menu excellent. Grounds well

kept. Services on offer excellent”

“The food is amazing and if you don’t want what they are having that day you can ask for

anything you want”

PRIORITY THREE

The third priority for 2018/2019 was to implement and embed an updated Data Protection Policy

taking into account the new General Data Protection Regulations (GDPR).

A new Policy was drafted, ratified and introduced at the Hospice in time for the implementation

of the new regulations.

The Hospice has nominated a Data Protection Officer (DPO) who is available to monitor

compliance with the policy and the Regulations and to consult on Data Protection issues. The

DPO raises awareness on Data Protection to ensure that all staff have an understanding of Policy,

Law and Regulations and know what is expected of them.

The Hospice’s Privacy Statements have been reviewed and updated to ensure that they take

into account GDPR. These are available on the Hospice website.

We aim to ensure that patients, and anyone else who interacts with the Hospice, can have

confidence that staff here work in a manner that takes into account appropriate consent and

that personal and sensitive data is processed in a manner that secures privacy and

confidentiality.


Feedback from Patients and Relatives

Throughout 2018/2019 we have sought feedback from Patients and Carers. This past year we

have continued to use the Friends and Family Test to determine the extent to which our service

users would recommend Halton Haven Hospice.

As can be seen in the graph below the Hospice has achieved and maintained a 100%

Recommended rating over this past year.

2015 / 2016 2016 / 2017 2017 / 2018 2018/2019

% WOULD RECOMMEND 99.5 99.7 100 100

% WOULD NOT RECOMMEND 0.5 0.3 0 0

99.5 99.7 100 100

0.5 0.3 0 0

Pe

rce

nta

ge o

f R

esp

on

de

nts

Year

Halton Haven Hospice IPU Friends

and Family Test

Would You Recommend Our Hospice To Your Friends And Family If They

Needed Similar Care Or Treatment?


Comments about Halton Haven Hospice

Made by Patients and Carers

“You are treated with dignity. All

staff are caring. Nothing is too

much trouble. Staff are so loving

and caring to patients. Family are

made so welcome. As a carer you

are made to feel you are not alone.

This is very comforting, especially if

it’s a loved one’s end of life”

“The staff are so friendly,

welcoming and professional. The

care and support was fantastic.

Having tried to care for mum at

home without much support it was

such a relief to see how much

more comfortable and peaceful

she was in your care. The big

problem was her medication,

which you immediately improved

and she was much better,

although we initially had resisted

transferring to you”

“The Hospice has “the human

touch”, providing good clinical

care whilst never losing sight of the

fact that this is end of life care. The

patients are treated with dignity

throughout and families are

supported during and afterwards”

“Halton Haven is a really well run

establishment, that provided

excellent care for my late wife. All

the staff, from the doctors, nurses of

all orders of seniority and the Hospice

auxiliary teams provide a first class

service – all being professional,

caring, polite and informative. What

else could anyone wish for”

“Friendly, helpful staff. Make visitors

and dog very welcome.

Food/menu excellent. Grounds

well kept. Services on offer

excellent”

“Because you are looked after

110%. Nothing is any trouble to any

member of staff. You never feel

alone, there is always someone

there for you from a small problem

to a bigger one. The food is

amazing and if you don’t want

what they are having that day you

can ask for anything you want. The

visiting is excellent, you’re never

alone. The job all the staff do is

outstanding”


“Despite the circumstances of the

cancer effect on my wife the

members of staff were fantastic in

the way they treated my wife and

by the way they went the extra mile

to make the family feel

comfortable and well. My wife lost

her battle in the Hospice but she

died in comfort. Thank you all”

“Having seen first-hand how

patients are cared for, I would

recommend Halton Haven to

anyone who needed help with

treatment”

“Having experienced the fantastic

care and dedication the Hospice

provides I only have the most amazing

things/comments to relay back to you.

The kindness shown by all staff (not just

nursing staff) was second to none.

Everyone who works at the Haven are

very special and dedicated to their

job. They give 100% to each and every

patient and treat them and their family

with extreme care and kindness”

“Not only are the staff considerably

caring and efficient in their care of

patients but they also take the time

to ensure the family and friends of

the patient are consulted and

taken care of when visiting”

“The entire staff from cleaners, carers, caterers, helpers, nurses and doctors treated my

wife, myself and visitors with kindness, sympathy and respect throughout my wife’s stay.

Special thanks go to the nurses who were extremely caring and respectful to my wife and

nothing was too much trouble for them. I must also thank the doctors who attended to

my wife. They were amazing. They kept me and my wife very well informed of what was

happening and what was likely to happen. Their dedication to their profession and

patients was excellent. I cannot praise the Halton Haven team enough for what it has

meant to myself and my family. Right up to her passing my wife expressed that she was in

the best place she could be”

“The care you provided for my

husband was first class. Everyone

presented a genuinely caring,

professional and cheerful manner.

You were patient and

understanding towards both him

and me, which was truly

appreciated by us both. Thank you

for everything”


Clinical Governance Overview

Never Events and Serious Untoward Incidents:

2016 / 2017 2017 / 2018 2018/2019

Never Events (No) 0 0 0

Serious Untoward Incidents (No) 0 1 0

0 0 00

1

0

Nu

mb

er

of

Inci

de

nts

Period

Never Events / Serious Untoward Incidents

We are pleased to be able to report that during 2018 – 2019 the Hospice had no Never

Events or Serious Untoward Incidents.


Medication Incidents:

2015 / 2016 2016 / 2017 2017 / 2018 2018/2019

No of Incidents 17 35 27 15

17

35

27

15Nu

mb

er

of

Inci

de

nts

Period

Medication

Incidents Involving Patients

(Prescribing / Administration)

The number of Medication Incidents has been much reduced over the past two years.

The incidents that have occurred, as seen in the graph above, did not result in any

adverse effect / harm to Patients or in any change to their clinical status.


Patient Falls:

2015 / 2016 2016 / 2017 2017 / 2018 2018/2019

No of Falls 16 15 17 31

16 1517

31

Nu

mb

er

of

Falls

Period

Patient

Falls

We have had 31 Patient falls this year:

11 Patients had 1 fall each

1 Patient had 3 falls





Halton Haven Hospice defines a fall as when a patient is found on the floor, is lowered to the floor,

lowered themselves to the floor, slipped from a chair or rolled from bed. This past year the 30 falls

we have had were as follows:

19 instances where a patient was found on the floor having been mobilising

unassisted

2 instances where the patient had slipped from their chair

10 instances where the patient was found to have rolled from their bed.

There were a number of instances where Patients were assessed to lack mental capacity and

whose diagnosed condition was making them confused. This resulted in the Patients not always

being aware of their physical abilities and attempting to walk unassisted when they are not always

capable of doing so, which led to falls.

There were no injuries to Patients as a result of falls and in all cases appropriate actions to help in

preventing further falls were taken.


Pressure Sores Developed After Admission:

Again, we are pleased to report another improvement at the Hospice over the past year.

Even though skin is an organ that can be one of the first to fail at the end of life, which may lead to

pressure damage or Kennedy Ulcers* despite optimal pressure relieving interventions, this does not

mean that the Hospice treats skin deterioration as acceptable. It is always our aim that no Patients

develop a pressure sore while in our care.

The Hospice also works closely with the Tissue Viability Team and with the OSKA Company

(identifying new/best pressure relieving equipment, such as lateral tilting mattresses, which provide

automatic repositioning) to help with patients receiving the most appropriate care.

* Kennedy Ulcers

A Kennedy ulcer is a pressure ulcer that some people develop as they are dying. It has a sudden

onset and is associated with imminent death. Although further research is required it is thought to

be caused by a blood perfusion problem and may reflect what is going on in the body as part of

the dying process. It is unlikely that a Kennedy ulcer will heal but individualised care can aim to

minimise further damage.

http://www.kennedyterminalulcer.com/

2015 / 2016 2016 / 2017 2017 / 2018 2018 / 2019

Total Number of Pressure Sores 24 20 22 9

Of Which Were Grade 1 3 0 6 3




Of Which Were Ungradable 0 2 0 0

Of Which Were Suspected DeepTissue Injury

0 0 0 0

2420

22

93 0 6 3

19 1816

61 0 0 01 0 0 00 2 0 00 0 0 0

Nu

mb

er

of

Inci

de

nts

Period

Pressure Sores

http://www.kennedyterminalulcer.com/


Infections Outbreaks:

2015 / 2016 2016 / 2017 2017 / 2018 2018/2019

No of Outbreaks 0 0 0 0

0 0 0 0

Nu

mb

er

of

Ou

tbre

aks

Period

Infection

Outbreaks

An outbreak of infection is where two or more patients develop the same infection at

the same time.

The Hospice is proud of our continued record of Infection Prevention and Control, with

no outbreaks of infection occurring, as can be seen in the graph above.


Medicines and Healthcare Products Regulatory Agency (MHRA) Alerts:

2015 / 2016 2016 / 2017 2017 / 2018 2018/2019

Total Number of Alerts That RequiredAction

2 0 0 0

Number of Which Were Drug Alerts 0 0 0 0

Number of Which Were Device Alerts 2 0 0 0

2

0 0 00 0 0 0

2

0 0 0

Nu

mb

er

of

A

lert

s

Period

MHRA

Alerts

During 2018 – 2019 there were no alert received that required the Hospice to take any actions.


Complaints:

2015 / 2016 2016 / 2017 2017 / 2018 2018/2019

Total Complaints Received 0 0 0 2

0 0 0

2

Nu

mb

er

of

Co

mp

lain

ts

Period

Complaints

We are saddened and disappointed to report that this past year, after many years

without, we received two formal complaints.

Both complaints received were in respect to separate communications between staff

members and Patients or their Family.

The nature of the care provided at the Hospice requires that communication is

delivered in a sensitive way. It is also essential that communication is clear and not

open to misinterpretation. However, the two complainants felt that this was not always

the case.

All staff members have been made aware of the complaints received so that they can

reflect on what had occurred. Our staff attend Advanced Communication Skills

training and have appropriate updates on this.


Care Quality Commission Report

The Hospice is regulated by the Care Quality Commission (CQC) whose role it is to check that the

services we provide meet Fundamental Standards.

Halton Haven Hospice was last inspected by CQC on the 1st March 2016 with their full inspection

report being available at:

http://www.cqc.org.uk/location/1-134598723

Our last inspection by CQC resulted in the following Rating of our services:

http://www.cqc.org.uk/location/1-134598723


Equality and Diversity

Demonstration of Due Regard

It is a requirement of the Equality Act (2010) that Halton Haven Hospice demonstrates due regard for

the following three aims;

1. Eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited by the

Act

Halton Haven Hospice recognises that while we cannot solve the problems of discrimination within

wider society, we can aim to take practical steps to minimize the potential of it occurring within our

own organisation.

To help us to achieve this, we acknowledge our responsibility to equality and diversity and to adhere

to the various legislation that governs this. The Hospice is committed to promoting equality,

embracing diversity and viewing fair treatment not only as a legal duty but as a moral responsibility

and business imperative.

We are committed to providing equality for all, with our services being open to all sections of the

local community and by striving to have a workforce that is representative of the communities from

which it is drawn. Halton Haven Hospice will not tolerate any kind of direct or indirect discrimination,

harassment or oppressive practices and is committed to eliminating these wherever possible.

To actively demonstrate this commitment, the Hospice has a number of equality and diversity policies

in place and undertakes a comprehensive equality impact assessment on each of the Hospice’s

policies. Any breach of Hospice policy is taken very seriously and can lead to disciplinary action and

possible dismissal.

The Hospice adheres to a robust recruitment system, which aims to ensure fair treatment for all

applicants.

All Hospice employees undertake mandatory equality and diversity training.

2. Advance equality of opportunity between people who share a protected characteristic and people

who do not share it.

At Halton Haven Hospice no one, staff or service user, receives less favourable treatment on the

grounds of disability, gender, age, religion or belief, race, sexual orientation, gender reassignment,

marriage and civil partnership status, pregnancy and maternity status, nationality, caring

responsibilities, political opinion or part time/fixed term working status.

The Hospice is committed to ensuring that no one is disadvantaged by unjustifiable provisions, criteria

or practices. This commitment extends to all areas of employment e.g. recruitment and selection,

pay, benefits and other terms and conditions of employment; supervision and performance,

appraisal, opportunities for promotion/transfer, access to training, discipline and dismissal (including

redundancy and retirement) and also to all areas of our service provision.

It is the policy of the Hospice to recruit and promote people on the basis of their suitability for the

role, as defined by a comprehensive and contemporaneous job description and person

specification. Vacancies are advertised to the widest possible audience and utilise sources that, as

far as is reasonably practicable, ensure that all sections of the community have the opportunity to

apply.


All applicants for employment or volunteering vacancies receive an equal opportunities monitoring

form as part of the recruitment process.

If under-representation of any particular group (e.g. disabled people, people from ethnic minorities

or people of a certain gender or age) is found we will, where appropriate, make every effort to:

Include a statement in our job advertisements, positively encouraging people from those

groups to apply

Ensure our job advertisements reach them

Consider using targeted or specialist media for our job advertisements

Consult specialist agencies, such as Job Centre Plus, for advice

Make sure the criteria for selection are entirely job-related

Review and revise the organisation’s policies, practices and procedures; and consider

taking positive action to provide training specifically for under-represented groups

In line with current legislation, Halton Haven Hospice reserves the right to take positive action that

will help or encourage people who share a protected characteristic to gain employment or benefit

from service provision on an equal basis to those who do not share a protected characteristic.

3. Foster good relations between people who share a protected characteristic and people who do

not share it.

In addition to all of the details noted above, the Hospice provides ‘Spiritual Care’ training to make

staff aware of the possible diverse spiritual, religious and cultural needs of patients and their families.

It is our aim that this increased awareness and understanding of diversity leads to better relationships

and more positive outcomes for all concerned.

The Hospice also has a policy and procedure in place to make sure that the kitchen is aware of the

dietary requirements of each patient whatever their personal needs, whether this is due to allergies,

intolerances, cultural or religious requirements or simply due to personal preference.

Equality Objectives 2017 – 2021

Halton Haven Hospice works towards specific equality objectives every four years. Between April

2017 and March 2021 the Hospice will work towards the following:

To continue to promote the work of the Hospice across the local community in ways that

are accessible to as many people as possible.

To continue to provide the highest quality Palliative and End of Life Care services to people

from the local community, irrespective of the absence or presence of protected

characteristics.

To actively recruit more male nurses, as this group are currently under represented within our

services.

To implement an Autism Strategy, in line with the Autism Act (2009), which will look to ensure

equity of opportunity in both service provision and employment in this respect.

To ensure that Equality and Diversity training is part of mandatory training for all Hospice staff


Infection Prevention and Control

As documented earlier, in the Clinical Governance Overview section of this Quality Account, there

were no infections outbreaks at the Hospice during the year 2018 / 2019. Therefore, no actions in

respect to outbreaks were necessary at the Hospice during this period.

The Hospice’s Infection Prevention and Control Policy was reviewed in September 2018 and is again

scheduled for review in September 2019.

Infection Prevention and Control Training has taken place for staff at the Hospice with attendance

as follows:

There is more Infection Prevention and Control training scheduled for the coming year 2019 / 2020.

The Hospice undergoes an Infection Prevention and Control audit done by the Infection Prevention

and Control Team from Bridgewater Community Healthcare NHS Foundation Trust. This is arranged

to provide the Hospice with an added level of governance in respect to Infection Prevention and

Control, through engagement with an independent specialist.

The external Infection Prevention and Control Audit 2018 report summary, provided by the team

from Bridgewater Community Healthcare NHS Foundation Trust, is set out below:

Infection Prevention and Control Training

Non – Clinical Staff

18

Clinical Staff

19

1 Management 78%

2 Outbreak Management 100%

3 Environmental Cleaning 73%

4 Sluice 100%

5 Treatment Room 88%

6 Bedrooms 100%

7 Bathrooms and toilets 92%

8 Hand Hygiene 100%

9 Personal Protective Equipment 100%

10 Management of Sharps 100%

11 Management of Blood and body fluid spills 100%

12 Decontamination 100%

13 Management of Laundry 90%

14 Waste Management 86%

15 Hydration 100%

16 Enteral Feeding. 100%

17 Urinary Catheters. 100%

Overall Score

94%


Scores 85% and above are compliant

Scores between 76% and 84% are partially compliant

Scores 75% or below are non – compliant

Action plans have been put into place to rectify minor variances identified by this audit.


Community Engagement

As previously mentioned 55% of the funding required to provide NHS healthcare services at Halton

Haven Hospice this past year actually came from the NHS. The remaining 45% needed to be generated

by the Hospice and we have a dedicated team working to raise the income required to ensure the

continuation of the Specialist Palliative Care services we provide for the community of Halton.

Community Engagement always will be an important activity for the Hospice. Our Core Services for the

community of Halton includes the In Patient Unit and Day Hospice. These core activities provide multi –

disciplinary treatment and support for patients and their families referred for direct service provision.

However, it is our belief and our commitment that the role of the Hospice extends beyond the provision

of our core services, with Halton Haven Hospice looking to engage with the local community through

information, consultation, involvement, collaboration and empowerment.

We aim to be the acknowledged local source of expert, balanced and objective information on end

of life care issues and through consultation with stakeholders, working in partnership and through

collaboration, we want to empower the local community to make informed decisions on end of life

care. Working together we can identify concerns and aspirations and develop preferred solutions.

During the past year we have been initiating ways to engage with people that not only benefit the

Hospice financially but help to create an enhanced sense of togetherness amongst disparate elements

of the local community. Taking part in these events has seen people working together, in fun ways,

towards a common goal and has provided a real sense of achievement and involvement with Halton

Haven Hospice in those who have taken part.

Many of the event participants have first-hand experience of the services we provide and they have

been very keen to do what they can to make sure the Hospice is able to continue its work into the

future.

Thanks must go to everyone who joined in and contributed to our successes over the past year. Without

the help of everyone who got involved and volunteered their time, effort and financial support we

would not have been able to provide the Hospice services that many people in Halton rely upon.

Halton Haven Hospice aims to continue with its community engagement activities over the coming year

and will look to engage with and involve an ever greater number of local people in what we do. It is

our aim to show people that this is their Hospice and that the local community can be proud of what

has been achieved over the years as a result of their various contributions.

The following are just some examples of how we take the work of the Hospice out into the local

community, engaging with the people of Halton through:

Family Support

Bereavement Support

Patient and Carer Support Groups

Relationship with local media

Relationship with Halton Borough Council

Relationship with Halton Clinical Commissioning Group

Hospice Volunteers

Patient and Carer Representatives

Hospice Events

Hospice Shops

Hospice Merchandising

Corporate Engagement

Hospice Lottery



Priorities for Improvement 2019 - 2020

Reviews of our service help to inform the development and identify the priorities for future

improvements at Halton Haven Hospice.

The Hospice has identified through such reviews three Priorities for Quality Improvement for 2019 –

2020 as follows:

PRIORITY ONE – Specialist Palliative Health Care Assistants / Administration of Medicines

Over the past two years our Health Care Assistants (HCAs) have been working towards

Apprenticeships and the Care Certificate, which has been documented in previous Quality

Accounts. This coming year the Hospice intends to build upon the work already done with our HCAs

and develop their role further through establishing, over time, Specialist Palliative Health Care

Assistants, a role that will be synonymous with Nurse Associates only, of course, specialising in

Palliative Care.

This will involve upskilling our HCAs to be competent in various Palliative Care related domains, the

first of which will be Administration of Medicines and it is our aim to make this domain the priority

during 2019 – 2020.

Training will be provided on Administration of Medicines so that eventually our HCAs can support

our Registered Nurses in this and allow the expertise of our Nurses to be variously deployed

elsewhere if and when required.

It is envisaged that this may allow for future expansion of our services into other areas, such as, for

example, taking the Hospice further out into the community and allowing for enhanced patient

choice at end of life within Halton.

Training of HCAs on the Administration of Medicines will be co-ordinated through the Hospice

Education and Training Department.

PRIORITY TWO - Patient Transport

The Hospice operates a Patient Transport service, which is used predominantly by the Day Hospice.

Its main purpose is to collect patients from their homes, take them to attend their allocated day at

the Hospice and then take them home at the end of their day there. It is a free service, which can

be used by patients who cannot make their own way to attend the Hospice.

We currently have one driver for the Patient Transport service, which can be problematic when that

staff member takes annual leave or is ill as it is the case that not anyone can drive the minibus used

for patient transport.

To ensure that Patients are safe when using the service the bus must be driven by someone with

appropriate training and we are making it a priority for this coming year to ensure that we have

more staff members available who can safely and appropriately transport Patients using the

minibus.

It is proposed that three further staff members undertake the Minibus Driver Awareness Scheme

Course, which includes Accessible Driver Training. This covers, amongst other things, Disability

Awareness, Disability Discrimination, Communication issues, Driver Etiquette and the Safe Use of

Wheelchairs, Passenger Equipment and Lifts.


We want to ensure that our Patient Transport is as accessible as possible, for our patients to be safe,

to feel respected and treated with dignity. The proposed training aims to realise this priority and will

contribute a safe and caring enhancement of our service provision.

PRIORITY THREE - Patient and Family Pets

The Hospice deploys Pet Therapy as a part of the service we provide to patients in our In Patient

Unit and Day Hospice. Pet therapy is guided interaction between a person and a trained animal,

which also involves the animal’s handler. The purpose of pet therapy is to help someone recover

from or cope with a health problem and the benefits can include:

making patients happier, lessening depression, and improving outlook on life

decreasing loneliness and isolation

reducing boredom

reducing anxiety because of its calming effects

We regularly have Pet Therapy dogs visiting the Hospice with their handlers and we have also had

owls and even a pony visit with good outcomes for patients. We have found that our patients

really enjoy this and we have become aware, through feedback, of how many patients have

dogs themselves and of the difficulties it can sometimes present for them and their family when

they are admitted to Hospital or to the Hospice, with limited scope for having their pet looked

after while they are an In Patient and their family are working, visiting them, or on a vigil at end of

life.

With this in mind we have been scoping what we could do to enhance patient experience of the

Hospice in respect to looking after their dogs while they are with us. Our solution, after much

thought, is to work at setting up and establishing a Day Care facility for dogs, which will include a

number of places specifically allocated for our patients’ dogs, that they can use free of charge

while they are with us.

It is envisaged that this will be a facility that will help to alleviate any distress or concerns our

patients may have in regard to their pets’ welfare while they are at the Hospice. We would want

the facility to develop the same reputation for outstanding care that the Hospice itself has, so that

it can be used with confidence that pets are safe and well looked after during their stay.

We will work to ensure that this facility is in suitable premises, will be compliant with all appropriate

legislation and associated regulations and staffed with experienced, qualified and competent

personnel.

Work on these priorities for the Hospice this coming year will be monitored and reported upon by

the Hospice Executive Management Team.


Statements on This Quality Account

The following organisations were offered the opportunity to comment on this Quality Account:

Healthwatch Halton

Health Policy and Performance Board

Halton Clinical Commissioning Group

At the time of publication of this Quality Account Halton Haven Hospice has received the following

statements:

Healthwatch Halton Statement

Statement to be added when received

Halton Clinical Commissioning Group Statement

I am writing to express my thanks for the submission of Halton Haven Hospice Quality Report for

2018-2019. Stakeholders acknowledged the unforeseen circumstances preventing the Hospice

from presenting at the stakeholder Quality Account Event on 10th May 2019. This letter provides the

response from NHS Halton Clinical Commissioning Group to the Quality Account Report 2018-2019.

NHS Halton CCG understands the pressures and challenges for the Hospice and the local health

economy in the last year and would like to congratulate and thank you and your staff for the level

of partnership working and support in this year.

NHS Halton CCG noted the Priorities and progress made in 2018 – 2019:

Priority One

For all Health Care Assistants (HCAs) to have gained the Care Certificate.

o Achieved with 100% success. All 13 HCAs having shown their commitment to improvement

and gaining the Care Certificate.

Priority Two

To develop a new Patient menu which would introduce new recipes, further enhance patient

choice and look to ensure that the nutritional value of the menu was optimised through the use of

more fresh produce in “home-made” food.

o As far as possible processed foods have been eliminated from use in the Hospice kitchen

and the range of items offered at service each day has been increased.

o The kitchen team also strive to accommodate any patient request regardless of the menu

on offer and feedback from patients and families has been really positive with examples

given.


Priority Three

To implement and embed an updated Data Protection Policy taking into account the new General

Data Protection Regulations (GDPR).

o A new Policy has been ratified and introduced at the Hospice in time for the

implementation of the new regulations.

o The Hospice has nominated a Data Protection Officer (DPO) who is available to monitor

compliance with the policy and the Regulations and to consult on Data Protection issues.

The DPO raises awareness on Data Protection to ensure that all staff have an understanding

of Policy, Law and Regulations and know what is expected of them.

o The Hospice’s Privacy Statements have been reviewed and updated to ensure that they

take into account GDPR. These are available on the Hospice website.

o The hospice aims to ensure that patients, and anyone else who interacts with the Hospice,

can have confidence that staff here work in a manner that takes into account appropriate

consent and that personal and sensitive data is processed in a manner that secures privacy

and confidentiality.

Stakeholders highlighted the exemplary feedback from patients in regard to the care receive and

also form friends and carers which was seen as an area of good practice.

For patient safety, clinical effectiveness and patient experience the following achievements were

noted:

NHS Halton & NHS Warrington CCGs noted the Trusts Improvement Priorities for 2019 – 2020:

Priority 1 – Specialist Palliative Health Care Assistants / Administration of Medicines

further through establishing, over time, Specialist Palliative Health Care Assistants.

Priority 2 – Patient Transport Service.

of staff in undertaking the Minibus Driver Awareness Scheme Course, which includes

Accessible Driver Training. This covers, amongst other things, Disability Awareness, Disability

Discrimination, Communication issues, Driver Etiquette and the Safe Use of Wheelchairs,

Passenger Equipment and Lifts.


Priority 3 – Pet Therapy

the animal’s handler. The purpose of pet therapy is to help someone recover from or cope with a

health problem and the benefits can include:

o making patients happier, lessening depression, and improving outlook on life

o decreasing loneliness and isolation

o reducing boredom

o reducing anxiety because of its calming effects

NHS Halton CCG recognise the challenges for providers in the coming year and we look forward to

working with the Hospice during 2019-2020 to deliver continued improvement in service quality,

safety and patient experience and also on strengthening integrated partnership working to deliver

the greatest and fastest possible improvement in people’s health and wellbeing by creating a

strong, safe and sustainable health and care system that is fit for the future.

NHS Halton & Warrington CCGs would like to congratulate the Hospice on the hard work of its staff

and their commitment to the care of the people of Halton, thanking local staff and managers for

their on-going commitment locally and for the opportunity to comment on the draft Quality

Account for 2018/2019.

Yours sincerely,

Michelle Creed

Chief Nurse

Health Policy and Performance Board Statement

Statement to be added when received


Feedback

Feedback, from service users and the general public on our Quality Account is very welcome.

If you have any comments or queries please do not hesitate to contact;

Registered Charity No. 702654

A company limited by guarantee

Chief Executive Officer

Halton Haven Hospice

Barnfield Avenue

Murdishaw

Runcorn

Cheshire

WA7 6EP

Telephone: 01928 – 719454 or 712728

www.haltonhaven.org.uk

http://www.haltonhaven.org.uk/

Quality Account 2019 - assets.nhs.ukHalton Haven Hospice has not participated in special reviews or investigations by the CQC during 2018/19. Halton Haven Hospice was last inspected

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