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Woodlands Hospice

www.woodlandshospice.orgWoodlands Hospice Charitable TrustUHA Campus, Longmoor Lane,Liverpool L9 7LA

AnnualReport2013 - 2014

Tel: 0151 529 2299Charity No. 1048934

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Contents

Chairman’s Introduction

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Chief Executive’s Comments

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Clinical Services

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Support Services

13

Volunteer Services

18

Fundraising

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External Relationships andCollaborative Working

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Education and Research

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Financial Summary

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Governance and Statement ofInternal Controls

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Organisational Charts

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Appendix AQuality Account 2013 - 2014

Woodlands Hospice Charitable Trust is anindependent charity committed todelivering the best possible practice anddevelopment of Specialist Palliative Carefor people with cancer and other life-limiting illnesses with complex needs.

It honours people’s right to dignity and respect atwhatever stage of their illness, by its aim to improvethe quality of life for Hospice patients and their carers.

Woodlands is based in the grounds of Aintree Hospitaland covers a population of over 330,000 in NorthLiverpool, South Sefton and Kirkby in Knowsley . Thepopulation served by Woodlands Hospice includessome of the most socially deprived communities in thecountry with some of the worst rates of cancer andheart disease in the UK.

Welcome to Woodlands HospiceAnnual Report 2013/14

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CHAIRMAN’S INTRODUCTIONIt gives me great pleasure to once again introduceour Annual Report which outlines the significantachievements of the Hospice over the last twelvemonths and the progress we have made againstour strategic objectives.

As Chair of this organisation I am delighted that during afairly disruptive year with building works and so manychanges to healthcare that the staff and volunteers havecontinued to provide the highest level of care to all ourpatients and their families.

I enjoyed reading the Quality Account which presents soclearly the achievements of the teams but in particular whatstruck me was the positive experience our patients andfamilies felt at such a vulnerable time in their lives. Ourschedule of Trustee visits has continued during the year andagain they demonstrate to me on a month by month basisthat the care of our patients remains our highest priority.

The Annual Report gives a detailed account of allachievements in the year and it is clear for all to see that theobjectives we set ourselves for a two year period were prettywell achieved in full which in itself is very rewarding.

I know that the tender process for the Hospice at Homecontract was new and very challenging for us as anorganisation but with clinicians and management workingclosely together the successful outcome gave the team amajor boost.

Of major significance this last year was the refurbishmentprogramme. The vision of all staff, volunteers and serviceusers at the first meeting of the capital projects committeestands before us now and has enabled total integration of allservices and new and refreshed facilities for patients andfamilies to enjoy. I know the small project team, led by theChief Executive and supported by the Operations andFacilities Manager and Volunteer Services Manager,dedicated so much of their own time to ensuring the success

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Mr Ken HoskissonChairman

of this project within budget and time constraints and for thisI am very grateful.

My thanks are also extended to the Chief Executive, ClinicalLead, Managers, Staff and Volunteers for the ongoingcommitment they show to the Hospice, I am very proud oftheir achievements.

Sadly during the year our President, Robin Downie, passedaway but I take this opportunity to publicly recognise thededication and support he showed to Woodlands Hospicesince the early days of its development and to express thethanks of all Trustees, Staff and Volunteers for his influentialinvolvement with our charity which we know was so close tohis heart.

The financial position this last year was boosted by thesuccessful grant applications Woodlands put forward for thecapital works but in reality the revenue funds fell short of therequired budget and consequently we have reviewed thefundraising strategy further and appointed a new Head ofIncome Generation to take the voluntary income generationto a new level. We remain confident that we will be able togenerate sufficient income in the coming years to ensure ourfuture sustainability.

Finally I would like to acknowledge the ongoing support ofthe NHS Clinical Commissioning Groups with whom wehave developed excellent relationships in year and who Iknow fully support the work that we do.

I hope you enjoy reading our Annual Report which will giveyou the ongoing assurance that Woodlands Hospiceremains a very well respected and high achievingorganisation dedicated to the care of our patients and theirfamilies.

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CHIEF EXECUTIVE’S COMMENTS

As Chief Executive of Woodlands Hospice, onceagain I am able to look back with great pride on ourachievements during a very eventful year for us.We have grown so much as an organisation duringthe year in terms of the development of ourservices, the winning of a formal tender process forour South Sefton Hospice at Home service, a majorpremises refurbishment taking us forward in amodern environment and an increased profile outin our communities.

Despite all the changes and the inconvenience of thebuilding works we, as always, maintained our very strongethos of high quality care for all our patients and theirfamilies. This is to the absolute credit of all managers, staffand volunteers who have always kept the care of ourpatients at the very core of everything we do.

Our clinical services achievements again this year aredocumented clearly and fully in our Quality Account(Appendix A) with overwhelming positive feedback frompatients and families about all our services and yet again apositive report from the August Care Quality Commissionunannounced inspection.

One area that has shone for me this year is the cateringteam. Whenever I sit and talk with patients they cannotpraise enough the choice and standard of the food providedfor them together with the friendly and helpful conversationsthey have with the catering staff. Clinicians often tell me howmuch of a difference a good meal can make to our patientsand this is very clear when meeting with them, they arelooking forward to their meals.

Our newly developed Well-being and Support Centresuccessfully went live in May last year. Whilst activity hasnot reached maximum levels as yet, patients who haveaccessed the service are full of praise for the care they havereceived and many have enjoyed our newly introducedgroup therapies. We continue to respond to patient needand are committed to help keep patients independent intheir own homes.

Early in 2014 we weredelighted to have won,following a formal tenderprocess, a three yearcontract for the Hospice atHome service in SouthSefton. The success of ourachievements in pilotingthis service in the previoustwo years helped ourtender applicationconsiderably and the teamshould be very proud ofwhat they have achieved inthis short time.

Another area of greatimportance to the Hospiceis the environment in whichwe provide all our servicesand this year provedparticularly challenging forall our staff and volunteersas we embarked on a majorbuilding project for eightmonths. Firstly I would liketo say thank you so muchto the Housekeeping teamwho despite dailydisruption, dust and difficultenvironments managed tokeep the premises cleanand presentable at all timesand helped maintain ourexcellent record of infectioncontrol and prevention.

The building project wasmade possible as a resultof successful grantapplications to NHSEngland, the Henry SmithCharity and the Wolfson

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Mrs Rose H MilnesChief Executive

Foundation. Details of the improved facilities are containedwithin this report but suffice to say every single personworking/helping here at the Hospice and all patients andfamilies are so appreciative of the improved modernenvironment and the provision of new much neededfacilities. My sincere thanks to everyone for the way theyhandled this project and the positive spirit shownthroughout.

My report would not be complete without showing myabsolute gratitude to our volunteer workforce. WoodlandsHospice would not be able to provide the service it doeswithout the support of our amazing volunteers. They can beseen in every area of the Hospice and out at our CharityShop and they add something special to our organisation.Our Chair and Board of Trustees are volunteers too and Iam indebted to them all for the time and energy they haveso freely given to the Hospice over the year steering ourfuture direction and overseeing our day to day activities.

Fundraising has remained a challenge for all charities overrecent years and we all have to work harder for every poundwe raise. The support shown to Woodlands across thecommunity has increased considerably during the year asour profile has grown and we are indebted to so manypeople and organisations for supporting us in achieving overhalf a million pounds in voluntary income. Sadly this is notsufficient to ensure our future sustainability and we need tomove to the next level of fundraising and raise nearer onemillion pounds. The appointment to a new role of Head ofIncome Generation will hopefully ensure we bridge the gapmoving forward.

Our relationships with the newly developing ClinicalCommissioning Groups have gained in strength throughoutthe year and we work well together and across thecommunities we serve. The transition from the previousPrimary Care Trusts has been fairly smooth to date and weare very appreciative of the financial support shown to theHospice from these NHS organisations and look forward toworking together in the coming year.

It only remains for me to say thank you so much to everyonewho has helped Woodlands Hospice to deliver high qualitycare to all our patients and families throughout the year. Welook forward to the coming year with enthusiasm andcommitment.

Services providedThroughout the year we have continued to provide specialistpalliative care for our Inpatients and in May 2013 we launchedour newly developed Well-being and Support Centreincorporating our previous Day Therapy, Out Patients andOutreach services to ensure a more flexible and accessibleservice for our day patients.

In early 2014 we learned that our application, under tenderprocesses, for continuing our Hospice at Home service inSouth Sefton had been successful and we are delighted tohave gained this contract for a further three years.

The Lymphoedema service we provide continued during theyear for patients with secondary Lymphoedema.

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CLINICAL SERVICESOver recent years a seriesof national reviews havedeveloped policies andstrategies to ensure thehighest standards of carefor those peopleapproaching the end oftheir lives. Hospices areregularly cited as theshining example to othercare providers for showingbest practice in deliveringSpecialist Palliative Careservices with great dignity,respect and compassionand for caring not only forthe patients but also theirloved ones.

Woodlands Hospice hasalways maintained theseexpected high standards ofclinical care and our multiprofessional clinical team hasoffered their expertise, skillsand support in a variety ofsettings with excellent results.2013/14 was no exception tothis excellent record asevidenced in our QualityAccount (see Appendix A).

In order to stay ahead of ourspeciality and keep pace withchanges nationally we stayvery close to new nationalpolicies and during 2013/14responded positively to allrecommendations in theFrancis Inquiry* and morelatterly the Independentreview of the the LiverpoolCare Pathway led byBaroness Neuberger, MoreCare Less Pathway**. Boththese reviews had asignificant impact for the careof patients and the team

recognised the benefit of reviewing our own systems andprocedures to conform to those recommended in theaforementioned reports.

Our multi professional team including doctors, nurses, therapistsand a family support worker work in an integrated mannerthrough all the services we provide and pride themselves onbeing able to provide specialist holistic assessment of thepalliative care needs of all our patients regardless of theirdiagnosis and irrespective of setting.

** http://www.midstaffspublicinquiry.com/report** https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf

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The 15 bedded Inpatient Unit is in its fifth year since openingin June 2009 and has steadily integrated with the longestablished day services, ensuring joined up care for patientsmoving through the Hospice services. Occupancy of theInpatient beds is always at a high level with flexible admissionsand discharges 24 hours per day, all year round. A change ofthe senior nursing structure on the unit last year has ensuredour high levels of care have continued through a somewhatturbulent time for healthcare, and patient feedback remains atthe highest standard. The Inpatient Unit was affected during theyear by the building works (detailed on pages 14 and 15) in thata small number of beds were unavailable for short periods oftime but we managed to maintain patient flow well and staffcoped extremely professionally with the builders’ presence andpatient care still remained their priority at all times.

The Well-being and Support Centre launched in May 2013with its new model of care for our day patients, varying existingservices to ensure we retained the excellent multi professionalteam approach but delivered the care in a variety of settings totry and accommodate, more readily, patients’ individual needsand preferences. The Multi Professional Assessment dayscontinued two days per week and a number of group sessionssuch as chair based exercises, breathlessness management,supportive living and creative therapy were successfullyintroduced.

Outpatient clinics were set up within the Well-being andSupport Centre for all professionals so that patients onlyneeding specific professional input could attend for that oneappointment without having to attend for a full day. The activityin these clinics was lower than anticipated during the year and itis important that we raise their profile with referring clinicians aswe are certain patients would benefit from attending theseclinics.

During the year we also continued working with the WaltonCentre NHS Foundation Trust in our Regional Joint PainPalliative Care clinic with Consultants from both servicesworking collaboratively to ensure the best outcome for ourpatients.

The Community Outreach team has continued to providetherapeutic interventions in the patient’s home includingOccupational Therapy, Physiotherapy and ComplementaryTherapies. This service continues to be invaluable to thosepatients who are too unwell to attend the hospice but whobenefit from our specialist services. Complementary Therapiesare also provided, as appropriate, to carers and this often takesplace in their own homes.

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The Family Support Worker and our Counsellor have bothcontinued to provide the much needed support to patients andfamilies and in particular addressed Bereavement issues. Inaddition our well attended Bereavement Group has provided somuch support to so many that we are currently consideringexpansion of this service.

Our established Lymphoedema outpatient service struggleda little during the last year as two longstanding, qualifiedmembers of that team retired during the year. They both,however, provided ongoing support on ad hoc contracts to thenewly appointed Lymphoedema Practitioner and the service isslowly getting back up to speed. The Lymphoedema SupportGroup continued during the year.

Our South Sefton Hospice at Home service commissioned bySouth Sefton Clinical Commissioning Group includes crisisintervention and prevention by our medical team, accompaniedtransfers home from hospice or hospital by a registered nurseand a sitting service by our specialist healthcare assistants. TheHospice at Home service is in addition to, and complements,existing services in the community. The aim of this service is toensure patients can remain in their own homes at the end oftheir lives where they so wish and avoid unnecessary hospitaladmissions. To date, of those involved with the service only 2%of patients have died in hospital compared with nationalaverages of over 50% of patients dying in hospital. Thesuccessful tender process gave the team a great boost and weare delighted to have secured the contract to continue thisservice for the next three years at least.

We also continued this yearwith our South Sefton CareHome project which wehave been commissioned torun on a short termcontractual basis. This is aneducational programme forall care homes andresidential homes in this areato increase their confidencein dealing with their patientsat the end of their lives andavoid unnecessary hospitaladmissions. We are hopefulof continuing this programmepast its current end date ofSeptember 2014.

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2013/14 was year two of our two year strategy and the principal objectives for Patient Serviceswere as follows:

• To maintain the highest standards of quality and safety for all our patients

• To continually strive to maintain high standards of Infection Control and minimise the incidence of healthcare acquired infections

• To maintain an average bed occupancy at a level greater than 85%

• To strive towards average length of stay being 10-12 days

• To review cases requiring longer length of stay and negotiate with commissioners re approving niche services

• All patients to be offered the opportunity to discuss andformulate an advance care plan stating their wishes andpreferences at the end of life

• To be flexible with admissions including at weekends

• To restructure Nursing Teams to reflect the new strategy

• To improve access to the multi-professional team within theDay Hospice offering Day Therapy/Outpatients in a variety ofways to facilitate greater choice and enhance patientexperience

• To further develop a cross organisational therapy team withcentralised facilities

• To expand Hospice at Home services to all our patients

• To further integrate all hospice services

• To ensure robust Governance and Quality Framework

Standards of ServiceOur Quality Account (Appendix A) demonstrates how well wehave met the 2013/14 objectives in relation to Patient Servicesand has been published, as required, by the Department ofHealth, on NHS Choices

(http://www.nhs.uk/aboutNHSChoices/professionals/healthandcareprofessionals/quality-accounts/Documents/2014/woodlands-hospice-qa.pdf)

Overall, we believe that we have achieved the majority of thepatient service objectives we set ourselves for the year with the

exception of being able toexpand Hospice at Home toall our patients but wecontinue to work withLiverpool and KnowsleyCommissioners to try andaddress this issue. We havealso not completed theobjective to help patientswith developing an AdvanceCare Plan as we wish toensure we do this in anintegrated way withhealthcare colleagues in thehospital and out in thecommunity to ensure it workswell for patients. Thisobjective will be carriedforward to our new two yearstrategy.

Regular reviews and surveyshave continued to evidencehigh quality, compassionatecare for our patients withoverwhelmingly positivefeedback on all our services.We have continued with ourrobust programme of‘Trustee Visits’ where allTrustees of the Hospice, whoare independent of our dayto day services, visit allelements of the service on arotational basis and assessthe care given against theCare Quality CommissionEssential Standards ofQuality and Safety, reportingformally on their findings.The feedback from thesevisits is consistentlyextremely positive but alsoincludes suggestions tofurther develop any area orrespond to suggestions frompatients or families. ThePatient Services Manager

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also undertakes weekly ‘ward rounds’ obtaining feedback frompatients on key areas of their care. Again the consistentfeedback makes us very proud as an organisation to havesatisfied our patients’ needs at this vulnerable time in theirlives.

The Hospice’s robust governance structure ensures we stayabreast of any clinical concerns or developments and we reactto any areas of concern or change. Patient safety has alwaysbeen high on our agenda and the ongoing development of theclinical working groups addressing such areas as InfectionControl, Medicines Management, Tissue viability, Falls andNutrition has kept us focussed on these areas. The introductionof our Clinical Effectiveness Group this year includingConsultants and Senior Clinical Managers has ensured highstandards of care and patient safety remain our priority.

Late last year we developed a new role of Quality andImprovement Manager recruiting to that post in November2013 and with this postholder now driving the Quality Agendaacross the Hospice we are expecting regular detailed reportson progress in all areas and action plans addressing any areasidentified for improvement.

During the year the Clinical Manager left her post and we tookthe opportunity to review and revise the senior clinicalmanagement structure appointing one overarching PatientServices Manager overseeing all clinical services including theInpatient Unit, Well-being and Support Centre, the Hospice atHome team and our Care Homes Facilitator. The PatientServices Manager was our previous Inpatient ServicesManager who brings a wealth of Specialist Palliative Careexperience with her and as an existing member of the Senior

Management Team is wellaware of the challenges theHospice faces in the comingyears and how we plan toaddress the changes inhealthcare generally. Thisrole also carriesresponsibility as the CareQuality CommissionRegistered Manager andControlled DrugsAccountable Officer.

The two main ClinicalService Managers alsochanged in year with theDeputy Ward Manager beingappointed as Ward Managerfollowing the departure of theprevious Ward Manager andthe appointment of a newWell-being and SupportCentre Manager to lead thedevelopments within dayservices.

We believe that during theyear we have continued withour highly skilled, competentworkforce delivering highquality care to all.

The retrospective audit westarted in 2012/13 regardingpatients who had stayed inthe Inpatient Unit over 20days was presented in yearand showed no one group ofpatients falling into thiscategory but more clearlydemonstrated that for somepatients their complexongoing symptoms need tobe continually managed byWoodlands and we are indiscussion with the clinicalcommissioners of our serviceregarding these patients.

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HousekeepingWoodlands Hospice prides itself on thehighest standards of cleanliness across allservices. During a difficult year with buildingworks ongoing for 8 months theHousekeeping Team did an exceptional job inmaintaining their consistent high standardsacross all areas of the Hospice. Our QualityAccount (Appendix A) evidences the excellentachievement with infection prevention yetagain and the Housekeeping teams play abig part in this achievement keeping areasspotless and ensuring robust procedures arefollowed with regards to infection prevention.

In all patientsurveys wereceive regularpositivefeedback aboutthe highstandards ofcleanliness andthe warmreception givento all patientsfrom theHousekeepingteam.

CateringThis service also receives regular exceptionalfeedback from all our patients, in particular inrelation to the individualised service provided,offering a wide range of meals and snacksand the team going the extra mile to satisfy apatient’s particular needs or desire. So oftenwe receive glowing reports about the foodand the Catering team. This high level ofservice is also backed up with yet another 5star Environmental Health rating in year.

The planning for the new café at the Hospicetook place during 2013/14 and will open inApril 2014 following completion of thebuilding works. We are expecting this canonly add positively to the catering services ofthe Hospice and provide service for familiesand visitors as well.

SUPPORT SERVICESWe set the following objectives for Support Services for 2013/14.• To ensure the best possible environment for patients to ensure dignity and respect with qualityand safety paramount

• To refurbish/redevelop Day Therapy facilities to accommodate new strategy• To create improved refreshment facilities for patients/relatives and staff• To create one reception for visitors and consider separate entrance for ambulance admissions• To relocate the two bedrooms away from the main kitchen• To consider alterations to drugs room for efficiency and safety purposes• To promote Leadership and Management education to senior members of staff• To encourage the studying for professional qualifications• To implement the appraisal system across the Hospice• To extend Sigma patient information system across the Hospice services and develop a robustdata collection/reporting system

• To extend computer services across Day Therapy and Outpatients

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Premises and Facilities Having secured major grant monies from NHS England, theHenry Smith Charity and the Wolfson Foundation, we embarkedlast year upon a significant refurbishment project for 8 months ofthe year, the results of which will be enjoyed from April onwardsby all patients, visitors, staff and volunteers.

New facilities include:

Reception area which is far more spacious and modern in feel,has a separate more discreet entrance for ambulance crews toallow patients being admitted to the Inpatient Unit a moredignified and discreet way, straight to the ward, without having towait in the reception with all other visitors.

The café/hub area with its modern décor and new colourful butrestful furniture serves a number of purposes. It is centrallylocated in the Hospice with open access allowing all patients andvisitors to flow freely across all services. It gives Inpatients andtheir families a comfortable place to relax away from theirbedrooms and patients visiting the Well-being and SupportCentre for day services, outpatients or group sessions a place tosit with other patients, family and friends.

The café is a new venture for the Hospice, manned mainly byVolunteers, with a small but varied menu and has easy access toour main gardens.

A vibrant hub was the vision when we first worked with theArchitects on the drawings and we are confident that this is whatwe will see in 2014/15 as it becomes established.

The newly created TherapyRoom joins together theneeds of the OccupationalTherapists and thePhysiotherapists for patients’assessments and groupsessions. It has been newlyfurnished within the projectand will open in April too.

The Garden Room andPatio Room are previousspaces converted into light,modern relaxing rooms withviews of our lovely gardens.

They have given our patients in the Well-being and SupportCentre services the opportunity to sit with each other in quietspaces and enjoy the garden. The Garden Room also convertsinto an Art Room for the Creative Therapy sessions.

The Quiet Room brings together our two previous chapels andis a little oasis for quiet reflection, tucked away behind thereception but within easy reach of all services.

Overnight Accommodation is now available for relatives whichis something visitors have regularly requested and we arepleased to now be able to provide.

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Main kitchen extension -one regular source of patientand family concern was theposition of two of thebedrooms on the Inpatientunit being situated directlyopposite the main kitchen.We have now extended theback of the building taking allkitchen activities to a littlehub at the back area andcreated a new entrance/exitto/from the ward away fromthe bedrooms. This also freedup the small dining room onthe ward for families to relaxin when wanting to stay nearrelatives and when thecafé/hub is not open in theevenings.

A newly created andrefurbished Drugs Roomhas addressed patient issuesregarding noise heard in theadjacent bedroom and safetyissues regarding efficiency ofprocesses in the layout of theroom.

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Maintenance and Gardens

During the year we have been fortunate yet again to have sucha dedicated service from volunteers looking after day to daymaintenance including painting and decorating, externalcleaning, gardening etc as we do not have the funds for a paidposition. Our volunteers all take great pride in keeping theHospice well cared for and offer so much of their free time tobe available at all times of the day to suit the needs of theservice.

We have also been very fortunate to have corporate teams ofvolunteers from within the community helping on communitydays and they have undertaken many annual tasks, including ateam of KPMG employees who worked tirelessly all day in anumber of activities including reorganising the Fundraisingstorage areas, tidying external storage areas and supportingthe work on the garden makeover.

For more contractual and specialised maintenance such asplumbing, electrics, water, we continue to contract withUniversity Hospital Aintree estates and maintenance teamwhich works well.

Operational and Financial services

Our small but very committed operational team includesfacilities management, health and safety, informationgovernance, volunteer management, secretarial support,reception, personnel and administration and financial services.The team cross covers for each other and remains lean toensure maximum funds are spent on clinical services. Theteam have coped well in year with the building project supportalso coming from within this team but ongoing development ofregulatory requirements may mean this team will require reviewnext year to ensure we can keep pace with external demands.Often in the background, this team quietly keeps the engineticking over and they deserve credit for the dedication andcommitment shown throughout the year particularly theOperations and Facilities Manager and the Volunteer ServicesManager who played such a big part in the premises work.

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Human resourcesAs the only HR qualified individual in the organisation, theChief Executive has assumed responsibility for all employmentlaw policies and processes in the organisation until such timeas the hospice is in a position to employ this resource. HRadministration is provided by the Operations and FacilitiesManager currently but this will also require review in the newfinancial year to ensure spread of workload across the team.

Some managers have received leadership and managementtraining during the year and the Hospice Clinical Lead andPatient Services Manager have both successfully taken part inthe local Palliative Care Leadership Impact programme.

Staff are encouraged and supported to study for professionalqualifications wherever possible but regrettably the Hospice isnot able to provide a high level of financial support for thisalthough we continuously look for grant opportunities foreducation.

The appraisal and personal development system has maturedwell in the year but needs to be further infiltrated through allmanagement levels to the required standards.

Patient Information Systems/ITinfrastructureThe introduction of computerised systems in the Well-beingand Support Centre was completed successfully in year andthe switch to the Sigma electronic patient data system was alsosuccessfully implemented. The reporting systems stemmingfrom this data collection system remain outstanding as they arereliant on the University Hospital Aintree information team

assisting with developing theproformae for Woodlandsand they have had conflictingpriorities. We have managedto develop some reportingsystems ourselves but arelooking to improve thesefurther next year. Our KeyPerformance Indicators(KPIs) reporting hasimproved considerably overthe year and Trustees arepleased with thepresentation to date.

In year The Data Officer, inaddition to her normalworkload, gave considerablesupport to the Hospice atHome tender process.

During the year Woodlandshas actively participated inall discussions locally aroundthe Electronic Palliative CareCoordination system(EPACCs) in preparation forintroduction as soon aspossible to help shareinformation across thehealthcare sector locally.Further work will beaddressed with this systemin the next year.

Information Governanceprocesses and procedureswere reviewed in year as weare aiming to achieve Level2 of the NHS InformationGovernance Toolkit as soonas possible as this is a goalfor all Hospices receivingany funding from the NHS.

The IT infrastructure remainspart of our Service LevelAgreement with UniversityHospital Aintree as we sharetheir IT network, systemsand processes.

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VOLUNTEER SERVICES

Woodlands Hospicerelies heavily on itsvolunteer workforceand set itself thefollowing Objectivefor 2013/14.• To review the roles ofVolunteers to supportnewly developed services

Volunteers are such an integral part of Hospice day to day runningand without them we would not be able to provide the services wedo for our patients and their families. Whether it be that welcomingface on reception, offering cups of tea and support when mostneeded, assisting professional staff and support services in manydifferent ways, driving our patients for appointments or assisting withfundraising in the Hospice, in our Walton Vale charity shop or out inthe community every single volunteer adds value to our Hospice.

The year has been a challenging one for all our volunteers for anumber of different reasons. Firstly the changes to our day servicesand the development of the Well-being and Support Centre meanta change to all the volunteer roles previously established in DayTherapy and Outpatients. With new role descriptions available forthe new services some volunteers expressed an interest in switchingto these new roles and others chose to become Honorary Volunteerswho are volunteers with an ongoing interest in Woodlands, able toattend all volunteer meetings and celebration events but with noactive role.

In addition to these significant changes the Volunteers had to workthrough the building works, constantly changing locations during thefour phases and adapting to temporary processes and procedures.They accepted these interim measures with humour and resilienceand we are extremely grateful for their positive attitude during thisperiod. They are excited to move back into the new premises in Apriland looking forward to benefiting from the changes. We are currentlyrecruiting additional volunteers for the new café/hub area which isproving to be a popular role.

Volunteer roles include:Administration AssistantsCatering AssistantsClinical Admin support DriversFinance supportFundraising supportincluding Charity shopand LotteryGardenersHandymenReceptionistsWard HelpersWell-being and SupportCentre helpers

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The volunteers at the charity shop have also had a difficult year aswe had planned on moving premises in year but negotiations onthe new property fell through at the last minute and we were unableto proceed. The volunteers had to regroup to carry on in the existingpremises but they kept their spirits held high and we continue tofundraise from that existing shop.

National Volunteers Week falls in June each year and we take thisopportunity to celebrate with our volunteers their untiring contributionto the Hospice providing long service awards and a summer party.The summer party was the last to be held at the Hospice prior to thebuilding works commencing and in keeping with the name of themain room prior to refurbishment (the Green) we had a greenthemed party and volunteers enjoyed a meal provided and servedby our catering staff and entertainment afterwards, singing anddancing. The awards were presented by the Chief Executive.

In December we hosted our usual Volunteers Christmas party butdue to the building works this time it was offsite at the LongmoorSocial Club locally and our catering staff provided a specialChristmas buffet.

It is difficult to put into wordswhat volunteers bring to ourHospice but we know forabsolute certain that it issomething special withoutwhich we would be totally lost.We publicly take thisopportunity to thank each andevery volunteer for the role theyplay in Woodlands, they are agreat credit to the team.

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FUNDRAISING

Raising funds at times ofgreat austerity is verychallenging andregrettably despite a fullrestructure and investmentin the fundraising team wedid not achieve therequired financial target in2013/14. Full details of allfundraising income can befound in our AuditedAccounts.

We set the following objectives for Fundraising for 2013/14• To restructure the fundraising team to reflect new income strategy

• To enhance our profile in the community

• To improve our Website/social media presence and activity

• To expand our programme of Trusts applications to include revenue grants

• To develop and implement a Legacies strategy

• To review lottery financial viability

• To undertake a feasibility study for a second hand furniture shop

• To review the current charity shop lease

• To increase the sale of promotional goods sales within the Hospice

• To further develop our eBay sales

Fundraising team structureTowards the end of the year we further considered the revisedteam structure and the leadership role within the team and fromApril next year we will have a new role of Head of IncomeGeneration at a more senior level to stimulate new ways ofworking and concentrate more proactively on the return oninvestment ensuring the effort expended by the fundraising teamis commensurate with the income generated. New ways ofworking will be inevitable and traditional events and activities maybe superceded as society changes how it wishes to supportcharitable funding.

Fundraising CampaignDuring November, we made a determined effort to get our name out in thecommunity and try and raise much needed cash through our ‘We can’t do itwithout you’ campaign.

Staff and volunteers were out inthe community with a variety ofevents, promotions, bucketcollecting and bag packs.We were fortunate thatJamie Carragher agreed tobe the face of thecampaign and our profilewas raised through mediacoverage. The campaignraised more than £20,000.

Good progress was seen in year with the majority of these objectives as detailed.

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Fundraising activitiesThe successes within the team last year revolved around a greaterprofile within the community and our presence within social media on

Facebook and Twitter together with a steady growth inindividuals participating in challenge events and individual

sponsorships. Grant applications for capital monies were extremelysuccessful but revenue applications remain a challenge.

Hospice arranged events did not grow as anticipated and this has ledus to consider revising the traditional programme of events for theforthcoming year identifying new events that appeal to the public andtake us to the next level of fundraising. We did however enjoy theevents we did arrange and income generated continued to contributetowards the targets set.

As well as the long established Starlight Walk, John Parrott GolfDay and Summer and Christmas Fayres bringing in £40,000 intotal, we staged the School Choir of the Year competition in arevised format and raised £650 whilst encouraging healthycompetition amongst the local schools. We continued with theWoofs and Wellies walk in Croxteth Park in September generating£4,500, and whilst those who took part had a most enjoyable day, weneed to increase numbers in the future to ensure we achieve therequired income levels for this event. A new event this year was theShankley Sportsmans Dinner, celebrating 100th birthday of BillShankley which was a very successful dinner bringing in £4,500.

One of our favourite times of the year is Christmas and we alwayslook forward to our Light Up A Life campaign and evening ofcelebration in December. This year however, due to the buildingworks we had to move the actual event away from the Hospice andwe hosted two separate services in the Community, one at StTheresa’s church in Norris Green and the other at St Andrew’s inMaghull, and we were very fortunate to have the Mayor of Sefton andthe Mayor of Maghull join us. Our massive tree of lights still shonebrightly at the Hospice for our patients and families to enjoy and wehad additional trees lit in the respective churches to support ourcelebrations. We anticipate bringing the service back to the Hospicethis year as this is something those taking part particularly enjoy,seeing the moment the hundreds of lights on the magnificent tree arelit up. It always creates the ’wow’ moment despite it being veryemotional too. This event is one of our largest and last yeargenerated £15,000.

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Challenge EventsThese events are becoming a key part of our events calendar withmany of our supporters choosing to push themselves to the limit toraise funds for Woodlands. From marathons to mountain climbing,swims to triathlons, toughmudders and other assault courses wehave seen them all and are so grateful to those who have raisedmoney in this way.

During the year we encouragedteams of people to take part in anAbseil down Liverpool Cathedraland a Zip Line across theManchester Ship Canal. We enlistedthe support of retired local footballer,Jamie Carragher for the Zip lineraising the profile of that eventconsiderably. These were bothexciting days with personalambitions achieved for many whotook part and great sums of moneyraised.

Community Support groupsWe have a number of Community Support Groups made up ofgroups of individuals running fundraising events and activities outin the community with proceeds coming directly to Woodlands.

During the year third party events included the successful annualStrictly Ballroom and Summer Ball organised by the AintreeSupport Group, the Irish Night organised by Alice Manley at StJohn Stone Church and the regular Bingo Nights run by theMaghull Support Group all of which involve a great deal oforganisation and support bringing in much needed funds for theHospice for which we are extremely grateful.

Last year, Sadie Jones, our longstanding volunteer who hasorganised the Bingos in Maghull formany, many years, decided to retirefrom this event and hand over thereigns to Woodlands. We are sograteful to Sadie for all the hardwork and effort she has put in overmany years with this event and arepleased that we will continue to seeher around the Hospice as a continuing volunteer.

We are always looking to establish new Support Groups out in thecommunity and would encourage any family, group of friends,community group wanting to support us to contact the Fundraisingteam to see how they can help.

Third PartyEvents andActivitiesSometimes individuals orgroups of people run one offevents or participate inpersonal challenges forWoodlands, quite often inmemory of a loved one whohas received care atWoodlands. 2013/14 was noexception and we saw manysuch events and challengesbeing run/organised withWoodlands benefittingconsiderably from the incomegenerated. Funds raised inthis way are so important to usand we are always keen tohelp wherever possible andsupport where we can.

OngoingSupport Woodlands Hospice reliesheavily on the support of ourlocal community and we takethis opportunity to thankeveryone out there who is, orhas been, working so hard forour Hospice to ensure itsfuture sustainability for thosein need now and in the future.

There are too manyindividuals to give personalthanks to in this report buteach and every contribution istruly important to us here atWoodlands

We are always looking to growour income from voluntarysources and would welcomeany ideas/thoughts you mayhave about how we cancontinue to enlist your supportand reach the levels of incomewe require.

The manager and volunteersat the shop continue to workhard with the donated goodsand are keen for the shop todo well.

During the year we suspendedour eBay operations but arehopeful of reinvigorating this inthe forthcoming year withvolunteers knowledgeable andexperienced with this onlineselling.

Sale of newgoods

We have always had a smallnumber of items including giftsand cards for sale at thehospice but this year ourVolunteer Shop Helpers andCommunity FundraisingManager took these goods outto table sales in thecommunity increasing theincome from this source.Unfortunately due to thebuilding works our Christmassales suffered as they couldnot be easily displayed at thehospice but with therefurbishment works nowcompleted we have a newmodern area in reception forthe sale of new goods and areconfident income from thissource will increase furthernext year.

Legacies A legacy can be a great way of supporting a charity andtraditionally Woodlands Hospice has not highlighted to itssupporters why it is so important for us to be remembered in willsto ensure our future sustainability. During the year we started workon our legacy strategy seeking guidance from other hospices whobenefit significantly from legacies as part of their incomegeneration. Our plan is to develop this further in the forthcomingyear and more openly advertise our need in this respect.Woodlands would be delighted to be included in your Will if, afterlooking after those important to you, you are able to bequeath asmall sum to our Hospice. This would make a real difference toour funding.

Hospice LotteryMost Hospices run their own lottery and thecontribution this makes to the Hospicevoluntary income can be significant but thisrequires year on year growth of membernumbers. Whilst our Hospice lottery last yearcontributed £50,000 to the Hospice income we believe it has thepotential to contribute far more. To do this we need to promote thislottery out in the community on a regular basis. Last year werecruited a lottery canvasser to help us grow the membership butunfortunately the recruitment was not successful and we havereconsidered our approach. This next year we will be working withestablished canvassers who have proven history of success withother Hospice lottery canvassing. This is an area of growth wehave great confidence in. In addition to signing up new membersthere is also a market for weekly single ticket sales which due tolong term sickness last year of 2 members of the team we did notprogress this area of sales to its full potential. Again we will belooking to develop this in the coming year.

Charity ShopThe charity shop on Walton Vale has continued to struggle duringthe year and as mentioned earlier in this report our attempts toopen a new shop, from whichwe planned to sell secondhand furniture, last year werethwarted at the last minute.We, however, continue to tryand develop new ways ofworking in the current shop toensure it is a key contributorto our fundraising income andthat we retain a presence onthe high street for the future.

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April 2013 saw the major changes to the structure within thehealth service for commissioning of services and WoodlandsHospice NHS funding contribution was passed to the control ofthe Clinical Commissioning Groups in Liverpool, South Seftonand Knowsley. New relationships were to be built following thedemise of the long established Primary Care Trust teams andwe were very pleased to develop these new relationships veryearly in the year and continue with the same level of supportpreviously received.

The agenda for the three catchment areas we serve was forthe commissioners to ensure a more locally focussed healthservice which meant each of the three groups established theirown groups to review and revise end of life services within theircommunity. Woodlands Chief Executive and Senior teamensured that they were members of all developing groupsdiscussing end of life strategies and operational processes andwe have been keen to show these groups how Woodlands

EXTERNAL RELATIONSHIPS ANDCOLLABORATIVE WORKING

Woodlands continues to develop its relationshipsexternally and is very keen to work in partnershipor collaboration with others to ensure the bestpossible outcome for our patients and theirfamilies

We set the following objectives for ExternalRelationships for 2013/14.

• Develop new relationships with emerging ClinicalCommissioning Groups who will commission our servicesfrom April 2013

• Further develop relationship with Aintree University NHSFoundation Trust and seek opportunities to work together

• Respond to Government changes to provision andpurchasing of Healthcare

• Work closely with neighbouring Hospices re development ofservices

• Continue relationship with Local LINK networks and raiseour awareness of Local Health Watch.

• Maintain the role of Community Engagement Lead for thelocality, based at the Hospice

working with statutoryservices can make adifference to patients in theirlocalities.

During 2013/14 wecontinued with our verystrong collaborative workingwith University HospitalAintree NHS FoundationTrust, contracting with thehighly specialist palliativecare medical team andtherapy teams to provide thehigh level of service we prideourselves on.

As previously mentioned inthis report we have a servicelevel agreement with Aintreehospital for the maintenanceand estates services whichworks extremely well.

We were fortunate in year toenlist the support of theAintree Estates team foradvice and support on ourbuilding project including thetendering process and theongoing management of thecontract. We truly valuedtheir expertise and input.

Until January 2014 the ChiefExecutive of WoodlandsHospice was an AppointedGovernor (representingWoodlands Hospice) onAintree Hospitals Council ofGovernors but with changesto their constitution this rolecame to an end and anyfuture Governor role wouldhave to be in the capacity asa public governor.

We maintain our ongoing relationship with the Walton CentreNHS Foundation Trust in relation to the Joint Pain ManagementClinic which is a very strong relationship and beneficial to ourpatients.

In March 2014 we launched our Patient and Family Forumencouraging participation by Patients and Carers in shapingfuture services of the Hospice. Participants of this forum areexternal to the Hospice and we very much look forward toseeing how this group develops over time and to listening totheir ideas and thoughts for service development andimprovement.

We always work closely with other independent Hospices andWoodlands Chief Executive is an active member of theRegional Hospice Advisory Group sharing strategies andprocesses across the region to gain mutual understanding ofchallenges and proactively addressing common concerns andissues.

During the year the Patient Services Manager at Woodlandsinstigated the development of a local forum for Hospice ClinicalManagers to share best practice on clinical policies andstandards and this group is now an active group with commonaims and objectives.

Woodlands Hospice has been working closely in the year withWillowbrook Hospice to demonstrate to the Knowsley ClinicalCommissioning Group the benefits of both Hospices providinga joined up Hospice at Home service across Knowsley anddiscussion continues in this respect.

Through our Hospice at Home service and the Care Homeseducation programme we have continued to work closely withhealthcare colleagues in the community and would wish to

develop this relationshipfurther in the future whereverpossible for the benefit of ourpatients.

We host weekly integratedmulti-disciplinary teammeetings at Woodlands toencourage the sharing ofinformation and plans forcare for all our patients andthese arrangements workextremely well.

We are an active member ofHelp the Hospices nationalorganisation and regularlycontribute to surveys,benchmarking exercises etc.Our Patient ServicesManager was an activemember of the Help theHospices Infection Controlgroup last year contributinglearning wherever possible.

Regrettably we have notbeen as active this last yearwith the newly establishedLocal Healthwatch Groupsbut we are keen to reignitethis relationship movingforward.

Woodlands has contributedin year to the Dying Mattersprogramme locally in liaisonwith Aintree Hospital on anumber of initiatives.

We consider ourselves to bea key service within the localcommunity and continue towork hard raising our profilewith other providers toachieve the best possibleoutcome for our patients.

We will continue to developexternal relationships in thecoming year.

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EDUCATION AND RESEARCH

EducationAs a specialist service Education remains a keypart of our service and we actively participatewherever possible. If funding could be secured thiswould be an area of our work that we would bekeen to develop further.

We set the following objectives for 2013/14.

• To continue to educate within all our specialistresponsibilities

• Actively participate in all Education programmes funded andsupported by the Aintree Integrated Clinical Network (TheICN changed its name in 2013/14 to the Aintree SpecialistPalliative Care Services Group)

• Active participation in Dying Matters week to promote agreater awareness of issues around death and dying

• Actively promote educational/development opportunities for all staff

We regularly take studentplacements for Nurses ,Occupational Therapists andPhysiotherapists from localuniversities and thefeedback on theseplacements is always of anexceptionally high standardand we have developedexcellent relationships withthe universities. In the pastwe have also taken nurses inpreceptorship and will bedoing so again in the comingyear.

Woodlands has hostedvarious educationprogrammes in the yearincluding a new programmeof mandatory training aroundthe Mental Capacity Act andDeprivation of LibertySafeguards. We have alsoprovided Social Worker Endof Life Workshops and havebeen heavily involved ineducation about the newregional unified DNA CPR(Do Not AttemptCardiopulmonaryResuscitation) policy.

There have been a number of initiatives throughout the yearwhich we believe have met our objectives.

As in previous years we participate fully in the training ofdoctors and are very happy to support the training programmesfor registrars and other doctors in training. We are keen for alldoctors in training to experience the Specialist Palliative Careservices first hand to help future care of our patients.

Research and auditThe Hospice has a policy to cover inclusion in research but,during this period, there was no appropriate national, ethicallyapproved research study in palliative care in which we couldparticipate.

However, Woodlands senior medical staff are involved inresearch into decision making for patients with advanced headand neck cancer jointly with University Hospital Aintree, andinto the benefits of interventional pain management for cancerpain. Senior medical staff are also leading on generaldevelopment of research opportunities in palliative care in theregion on behalf of the Cheshire & Mersey End of Life carenetwork.

Staff from the Woodlands therapy team are conductingresearch into the rehabilitation of lung cancer patients jointlywith University Hospital Aintree and the Liverpool Heart andChest Hospital. In addition, staff have contributed to a numberof publications in peer reviewed scientific journals andparticipate in a regular weekly joint journal club. We have alsohosted an academic clinical fellow from the Merseysidepalliative care rotation.

The Hospice uses clinical audit to monitor quality and supportservice improvement.

Where an audit identifies room for improvement, an action planis developed, reviewed, and monitored to completion. Inaddition to internal audit, the Hospice participates in Regionaland Supra-regional audits as part of the Merseyside andCheshire Palliative Care Network Audit Group.

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Woodlands has also collaborated with Willowbrook Hospiceand Marie Curie Hospice Liverpool to produce a programme ofeducation for GPs about palliative care in conditions other thancancer. Palliative care for non-malignant disease is an area weare keen to expand further within the hospice and increaseawareness in these patient groups about what WoodlandsHospice can offer. Our Clinical Lead also attends the regionalnetwork education strategy group to be involved in the planningof education at a regional level.

In June last year Woodlands was delighted to cohost theNational Council for Palliative Care Roadshow with greatsuccess.

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Woodlands Hospice relies heavily on its ownfundraising efforts but also on grants from the localNHS and other grant making trusts. It is thereforeimportant to ensure that the services we deliver providepublic benefit without prejudice. This is demonstratedin the services of the Hospice being free at the point ofdelivery and accessible through clear referral criteriabased on clinical need.

In January 2012 the Board of Trustees agreed a two year strategyfor the Hospice which included investment in the fundraising teamto increase income from voluntary sources as expenditure for theHospice would likely increase in line with inflation and servicerequirements. A new fundraising team structure includingadditional income generation roles was developed andimplemented with final recruitment to new roles taking place inAugust 2012. The expectation that the fundraising income wouldincrease in 2013/14 to reach expected budget levels did not comefully to fruition and with the team achieving income of £576k (anincrease on last year), the shortfall of £145k put pressure on theoverall financial position at year end.

The achievement of the £576k was only made possible by theongoing generosity of our supporters and their willingness to raisemoney for Woodlands in many varied and challenging ways. Weare so grateful to all those who helped us achieve this income.Unfortunately we still need to find new and innovative ways ofraising more to ensure our future sustainability as costs inevitablyrise year on year.

A further review of the fundraising team was undertaken early2014 and the Board of Trustees approved a more senior Head ofIncome Generation role to supersede the existing Fundraisingand Communications Manager role. The experience, skills andknowledge required for the new role together with a proven trackrecord in high levels of income generation will hopefully leadWoodlands to make the leap from current levels of fundraising tothe aspirations we have and the levels of income commensuratewith Hospice colleagues in similar communities.

We remain very appreciative of the NHS grant monies of£2.3million received from South Sefton, Liverpool and KnowsleyClinical Commissioning Groups (CCG) paid to us under a jointService Level Agreement. Although we did not receive any uplift tothe NHS grant monies we were grateful not to have had a Cost

FINANCIAL SUMMARY

Improvement reductionpercentage applied as NHSCommissioners seek ways ofmaking limited funds stretchacross all services. Fundingfrom the NHS has been rolledover at the same level for2014/15.

Having submitted our firstformal tender application inlate 2013 for continuation ofthe South Sefton Hospice atHome Service we hadprovided as a pilot for theprevious two years, we weredelighted to secure the £720k(£240kpa) contract for a threeyear period commencing April2014. This complex financialprocess was a steep learningcurve for us all but broughtClinicians and Managerstogether to achieve the bestpossible outcome for ourpatients in their own homes.

In addition to the Hospice atHome monies received in yearpending the outcome of thetender we received temporaryfunding from South SeftonCCG of £45k for a CareHomes End of Life Facilitatorfor one year. With the Hospiceat Home and the Care Homeseducation programme wehave been able to put ourspecialist service out into thiscommunity. We are very keento expand these servicesacross Liverpool andKnowsley and continue indialogue with theircommissioners.

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The financial statements include capital grant monies from NHSEngland of £498k, The Henry Smith Charity of £100k and theWolfson Foundation of £30k for the Hospice refurbishment projectwhich took place in year. We are so grateful to have received suchsupport and are delighted with the results of the project which hasadded over £600k in value to our organisation.

The Trading Company last year had mixed results. Overall theprofit for the year, covenanted to the Charitable Trust, was £54k, asignificant increase on the previous year. The majority of thismoney came from the Hospice Lottery which increased itscontribution to £50k in 2013/14. This was mainly due to theprevious year’s decision to reduce the prize funds until such timeas membership was positively growing. A targeted approach tocanvassing will be introduced in 2014/15 which should yield fargreater monies from the lottery in the future. The charity shop inWalton Vale continued to simply break even and as our attempt tomove to new premises was thwarted at the last minute by Healthand Safety issues, we continue to search for new property for ouranticipated second hand furniture shop. Meanwhile we continuewith the lease on the current shop with some changes to be madeto trading there in the next financial year.

The surplus for the year of £494,164 reflects the capital grantmonies received in the year with the value of the fixed assets ofthe organisation increasing substantially through the application ofspend to the balance sheet.

The day to day running costs still require a significant increase inrevenue income (as detailed above) and every effort is made toensure value for money in all expenditure which is monitoredclosely throughout the year. We remain confident that ourinvestment in Fundraising will reap the rewards we need for ourfuture sustainability but a close watch is kept on all financesthroughout the year.

The Pharmacy Contract we have held with Liverpool Heart andChest NHS Foundation Trust since January 2012 has beencontinued for a further three year period without tender, waived onthe basis of continuity of service being paramount so early into thearrangement. The drug costs remain well managed under this newcontract.

£ Cost % Cost

Costs in furtherance of charitable objectives 2,798,345 80.8%

Fundraising and publicity 289,403 8.3%

Management & Administrationincluding Governance 189,128 5.5%

Interest on loan 13,666 0.4%

Depreciation 172,806 5.0%

Total 3,463,348 100.0%

In 2013/14 we setourselves thefollowing objective:

• To restructure the financialservices team tostreamline financialprocesses across theHospice and accommodatenew strategy anddeveloping needs ofcommissioners.

Whilst we did not manage tomeet this objective in 2013/14the restructure is alreadyunderway for 2014/15

The documented aim of theTrustees last year was toreach a level of free reservesequating to 6 months runningcosts of the organisationwithin the next 3 years andthis financial year we havemanaged to sustain the levelof free reserves at £602K(approx 9 weeks runningcosts). Our fundraisingstrategy will hopefully helpincrease the reserves over thenext 2 years. The position iscontinually monitored by theTrustees.

The Investment portfolio of£471,009 managed byInvestec Wealth andInvestment Limited producedan estimated yield of 4.19%,slightly less than last year butnevertheless a goodperformance which theTrustees were pleased with.They continue to review theInvestment portfolio on anongoing basis.

We look forward to anotherchallenging year ahead withconfidence that we cancontinue to deliver our highquality service within thefinancial resources available.

A set of the full AuditedAccounts is available onrequest.

The total running costs for Woodlands Hospice during the yearwas £3,463,348 broken down as follows:

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GovernanceThe charitable and company status of Woodlands Hospice Charitable Trust, along with theTrust Deed and the Memorandum & Articles of Association, define the responsibilities ofthe Trustees.

• Charity CommissionWoodlands Hospice Charitable Trust is a charity, registered with the CharityCommission (registration no: 1048934), and bound by the Charities Act.

The governing body of the charity is the Board of Trustees, which comprises 12members.

An annual return is filed with the Charity Commission each year.

• Companies HouseWoodlands Hospice Charitable Trust Ltd. is also a company limited byguarantee (registration no: 3063721) and bound by company law. The governingbody of Trustees are also Directors of the limited company.

Woodlands Hospice Ltd. is the Hospice’s subsidiary trading company(registration no: 3278425) through which the hospice shop and lottery areoperated. All profits from the trading company are covenanted to the charity.

Annual returns are filed for both companies with Companies House each year.

In addition, the Trustees must ensure that the trust is fully compliant with a number of otherstatutory agencies.

• Care Quality Commission (CQC)The CQC carried out its regulatory responsibilities under the Care Standards Act(2000) until 30th September 2010. From 1st October 2010 the Health and SocialCare Act (2008) became the governing legislation and as a result all health careproviders registered with the CQC were required to re-register.

An initial Self Assessment in 2010/11 was completed successfully at the time ofre-registration, designed to identify possible risks or non compliance withstandards, although no formal inspection by the CQC was carried out at thattime.

In August 2013, we had a CQC unannounced inspection and were delighted withthe results which confirmed we were fully compliant with the five standardsexamined. Full details can be found in the Quality Account (Appendix A)

GOVERNANCE AND STATEMENT OFINTERNAL CONTROLS

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Other statutory bodiesRegulation by MONITOR Following national advice, consideration was given in year to whether WoodlandsHospice would need to register with NHS regulator MONITOR as a CommissionerRequested Service (CRS) but after advice from the three Clinical CommissioningGroups we did not proceed at this time but will keep this under review.

Merseyside Fire and Rescue serviceThe Hospice Fire Safety policy and training model was revised, approved andimplemented during 2013/14, taking into account recommendations following aFire Safety Inspection carried out in January 2013. A routine review of Fire Safetyin February 2014 (undertaken by the Fire Brigade) identified no areas of concern.

Liverpool City CouncilAn inspection from Environmental Health in January 2014 resulted in usmaintaining yet again our 5 star rating for catering services.

Health and Safety Executive There was one RIDDOR reportable injury reported to the HSE during this period.

NHS PartnersWe continue to maintain close links with our NHS partners and meet regularly to reviewagreements for the provision of specialist palliative care services.

Umbrella and professional organisationsWoodlands Hospice is a member of Help the Hospices, a national charity which supports thework of independent Hospices. We are also a member of the National Council for Palliative Carewhich is an umbrella charity for all those involved in palliative, end of life and Hospice care inEngland, Wales and Northern Ireland.

Individual members of staff are members of professional organisations such as NationalAssociation of Fundraisers, National Association of Voluntary Services and the Association forPalliative Medicine.

Woodlands Hospice is registered with the online ‘Disclosure Services’ for checking andprocessing of Criminal Records Disclosures.

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Statement of Internal Controls

The Board of Trustees met 6 times during the year. In advance of thesemeetings the Trustees each received detailed reports on the financial position,clinical services and fundraising.

The Board has established formally constituted sub-committees, each with specific terms ofreference and functions, delegated by the Board and with a Trustee as Chair.

• Personnel Committee – met 6 times during the year• Finance Committee – met 4 times during the year• Clinical Governance Committee – met 5 times during the year• Governance Committee – met 7 times in year• Health and Safety Committee – met 5 times in year

An induction programme is provided to all new Trustees to ensure that they are aware of thecharity’s objectives, strategy and activities and their responsibilities as Trustees.

The Trustees delegate the day-to-day management of the hospice to the Chief Executive whoworks with the Clinical Lead and Patient Services Manager as a Senior Management Team.

As detailed in the Quality Account (Appendix A) the Trustees continued with their rollingprogramme of reviews of the compliance with Care Quality Commission standards during thisyear.

Risk Management

The Board of Trustees recognises that processes are needed to mitigate anyrisk to the organisation:

• Policies and procedures are developed, approved by the Trustees or delegated subcommittees and reviewed at defined intervals – or sooner if circumstances change

• There is a scheduled Clinical Audit programme together with a Non -Clinical programmeand audits are regularly carried out, documented and fed back to staff, sub-committeesand the Board e.g. medicines management, falls, documentation, infection control,fitness of premises, fire safety

• Risk Register – the formal Risk Register is monitored by the Governance Committeeand overseen by the Board of Trustees at every Board meeting

• Staffing – care is taken to ensure that staff are employed with the required skills,knowledge and experience. All staff complete an induction programme and annualmandatory training in accordance with statutory requirements

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Mrs Rose H Milnes

Dr Graham Whyte

Ms Carole Slocombe

BOARD OF TRUSTEES ANDSENIOR MANAGEMENT STRUCTURE

Mrs E McDonald

Dr B L Roberts

Rev N Wilde

Mr W J Wood

Board Of Trustees

Chief Executive

Senior Management Team

Mr R DowniePresident(Deceased October 2013)

Mr K HoskissonChairman

Mr C BrennandTreasurer

Dr C HubbertVice-Chairman

Mrs J Byrne (Resigned 25th March 2014)

Mr R Kenyon

Ms G Lanceley

Mrs A Manley

Chief Executive

Clinical Lead and Consultant in Palliative Medicine

Patient Services Manager

Mrs Rose H Milnes

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WOODLANDS HOSPICE ORGANISATIONAL STRUCTURE

Board of Trustees

Patient Services Manager (8a)

(Registered Manager CQC)

Denotes Senior

Managem

ent Team

Secretary to C. E.

Fundraising

Team

Lottery

Team

Charity

Shop

Well-being and Support

Centre Manager (7)

Quality and

Improvem

ent

Manager (7)

Nurses

RGNs

Nursing

Assistants

Senior

Nurses

AHPS

Adm

inistrator

HCAs

Clinical Adm

inOfficer/ Clinical

Support W

orker

Hospice at Hom

eCoordinators (6)

Deputy Ward

Manager

Consultant in

Palliative Medicine

Medical

Staff

Aintree University Hospital

NHS Foundation Trust

Head of

Income Generation

Volunteers Services

Manager

Catering Manager

Operations and Facilities

Manager

Ward Manager

(7)

Finance

Team

Adm

in /

Reception

Volunteers

Catering

Staff

House Keeping

Staff

Chief Executive

Ward Clerk

1

Woodlands Hospice

www.woodlandshospice.orgWoodlands Hospice Charitable TrustUHA Campus, Longmoor Lane,Liverpool L9 7LA

Quality Account 2013 - 2014

Tel: 0151 529 2299Charity No. 1048934

“Thank you for the wonderful care, kindness, attention andtime you gave us. Woodlands is in a league of its own. Pleaselet all your staff and volunteers know how very much we valuedtheir hard work, friendliness and dedication”.(Letter from a relative, March 2014)

Incorporating Priority Areas for 2014/15

Appendix A

2

3

Contents

Chief Executive’sStatement4 - 5

Section 1Priorities forImprovement6 - 16

Section 2Statutory Information andStatement of Assurances from the Board17 - 20

Section 3Quality Overview and What others say about us21 - 34

Welcome to Woodlands HospiceQuality Account 2013/14

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CHIEF EXECUTIVE’S STATEMENTWoodlands Hospice Charitable Trust is an independent charity committed to deliveringthe best possible practice and development of Specialist Palliative Care for people withcancer and other life limiting illnesses. It honours people’s right to dignity and respect atwhatever stage of their illness, by its aim to improve the quality of life for patients andtheir carers.

Woodlands is based in North Liverpool and covers a population of over 330,000 in NorthLiverpool, South Sefton and Kirkby in Knowsley.

Our key priority here at the Hospice is to ensure high quality care for all patients and theirfamilies and we pride ourselves on the excellent standards achieved on a consistentbasis. We are always looking for ways to develop and further enhance every patientexperience and have progressed well with the three priorities we set ourselves in theQuality Account for last year.

The progress we have made through the Tissue Viability working group to minimise therisk of pressure ulcer development has been very pleasing with results indicatingimprovement with reduced incidents. Staff training in this area has been heightened andall nursing staff are now even more proactive in the identification and management ofdeveloping ulcers.

Measuring the difference we make to patients’ outcomes has always been difficult toachieve and there is much discussion locally and nationally about the best tools to dothis. Our second priority last year to introduce the use of the Patient Outcome Scaleversion 2 (POS2) and the Palliative Performance Scale (PPS) helped us to make goodstrides to measure the difference we make and using them has assisted with ongoingclinical decisions, The professional team are keen to keep abreast of developmentswithin the tools and will be adopting the updated version of the POS tool throughout thisyear, keeping us at the forefront of this important quality measure.

It has always been our intention to develop a Patient and Family Forum and our thirdpriority last year ensured we worked towards this in a structured way. Getting such agroup off the ground takes good preparation to ensure the membership is open to avaried representation and we were delighted to have hosted our first meeting of theForum in March 2014 with excellent feedback. It is really important to Woodlands that welisten to those who use, or have used, our services and encourage them to influence ourfuture services and developments. The Forum has got off to a great start and we lookforward to working with the members over the coming years.

One of our key areas of quality and safety is our continuing focus around infectionprevention and I am delighted once again to report that we have had no Hospiceacquired infection at all during the year. This is reflective of all the hard work the team putin to ensuring these highest standards are maintained.

Every day we receive positive comments regarding the high quality, personalised servicewe provide, whether this be through talking with patients and/or families, cards andletters and even now via social media for all to see. It makes me extremely proud to beleading an organisation which shows such care and compassion and which treats all

5

patients with great dignity and respect. It humbles me that patients say they feel ‘lucky’ tobe with us here at Woodlands and that families repeatedly talk of the warmth, comfortand support they feel in such a safe environment.

From time to time we are not able to fully meet individual’s expectations and anynegative comment or complaint is taken extremely seriously and looked into thoroughly.We did have a small increase in the number of written complaints during the year but weopenly encourage all concerns to be raised so that we can continually learn fromfeedback to ensure our high standards of quality and safety are consistently applied to allpatients in all services.

Our quality assurance framework is very robust and with the appointment of our newQuality and Improvement Manager in year whose role it is to continually drive andmonitor the Quality agenda, we are confident that despite regular development to keeppace with the ever changing healthcare provision and expectations we will retain ourfocus on ensuring high quality care for all our patients and their families.

Every year brings new quality priorities to concentrate on and this coming year we havedecided on the three priorities which are also of national importance.

Our first priority is to extend the good work we progressed last year on the Inpatient Unitwith nutrition and hydration into all our services. Linking nutrition to tissue viabilityensures we follow on from our pressure ulcer work of last year.

There has been much publicity and debate over the last 12 months regarding theLiverpool Care of the Dying Pathway (LCP) and its ultimate withdrawal from use in July2014 and we, like all health care providers, will be developing more individualised careplans for patients at end of life and working in the coming year on other aspects of therecommendations which were published last year. This will be our second priority for theQuality Account.

Finally our third priority centres round the sharing of clinical information across all ourservices to ensure we minimise the number of times a patient has to tell their story whenaccessing any of our services. Over the last year our non-Inpatient services have movedto a new computer system to integrate more fully with the Inpatient Unit and this year wewill be working on developing the information systemsfurther.

Woodlands Hospice is absolutely committed to deliveringthe highest standards of quality and safety for all ourpatients and we have a strong ethos to ensure dignity andprivacy at all times. We continue to strive for continuousquality improvement whilst maintaining the high standardswe are very proud of.

I confirm that to the best of my knowledge, theinformation contained within this Quality Account is a trueand accurate account of quality at Woodlands HospiceCharitable Trust.

Mrs Rose H Milnes

Chief ExecutiveMrs Rose H MilnesChief Executive

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Section 1: Priorities for ImprovementThe priorities for quality improvements identified for 2014/2015 are set out below andhave been identified by the Senior Clinical Team in agreement with the SeniorManagement Team following feedback from patients, carers and staff.

1a. Priorities for Improvement 2014-2015

Patient Safety

How was this identified as a priority?

The Hospice clinical team acknowledges the importance of appropriately assessingthe nutrition and hydration requirements of patients using the service and providingnutrition and hydration appropriate to the patient’s needs whilst maintaining dignityand promoting independence and choice. In order to achieve this, a multiprofessional steering group was established and a baseline audit of nutritional careon the Inpatient Unit was completed highlighting areas for improvement. Thisincluded the completion of an evidence based nutrition policy and procedure and thepublication of a patient information leaflet providing nutritional advice. The policyprovides guidance for staff in relation to clinically assisted nutrition and hydration andconsideration of benefits, burdens and risks of this treatment for patients in the lastdays of life. Staff training in relation to assessment of a patient’s nutritional needs andimplementation of care in accordance with the nutritional policy has been completedon the Inpatient Unit.

Following evaluation of these improvements on the Inpatient Unit, the hospice clinicalteam recognises the need to extend improved practice in nutritional care to the Well-being and Support Centre (incorporating day therapy and outpatients). This willensure best practice for patients across all services.

How will this be achieved?

• Completion of staff training in relation to the nutritional assessment tool, care planand nutritional policy and procedure

• Introduction of the nutritional assessment tool and care plan to the assessment ofpatients attending the Well-being and Support Centre

• Establishing a regular audit of nutritional care within the Well-Being and SupportCentre

Priority 1: Nutrition & Hydration – the Hospice will extend improved practicein nutritional care to the Well-being & Support Centre

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How will progress be monitored and reported?

Progress will be monitored through evidence of audits including patient feedback andachievement of actions following audit. Reports of progress against the above planincluding staff training and audit results will be submitted to the Clinical GovernanceCommittee and Board of Trustees bimonthly.

Clinical Effectiveness

How was this identified as a priority?

The Neuberger Report about the Liverpool Care of the Dying Pathway (LCP)suggested that the LCP should be phased out in July 2014. The report makes anumber of recommendations that all organisations involved in end of life care shouldaddress. Woodlands Hospice developed and implemented an action plan based onthis report and its recommendations. An End of Life (EoL) care communication recordwas created and implemented on the Inpatient Unit and has been in use from March2014. This document highlights areas that are important for discussion with patientsand families in the dying phase, for example agreeing a plan of care, explanation whythe team feels that the patient is dying, comfort measures to be put in place,hydration and nutrition needs and spiritual care. The document is mainly completedby the medical staff at the hospice. However the delivery and documentation of thecommunication record needs to be implemented further to include all end of life caredelivered by the care team at the hospice. This is particularly important for any carereceived after initial discussions about the dying phase have taken place and theplan of care has been completed, and also for care given after the patient has died.This needs to also be accompanied by revised written information for carers.

In addition to the Hospice plans for managing EoL communications, further guidanceon EoL care is expected from the Leadership Alliance in the coming months.Depending on the recommendations they make, a further action plan may need to bedeveloped to improve end of life care documentation at Woodlands Hospice.

How will this be achieved?• Sustained implementation of the EOL care record.

• Integration of EoL care into existing nursing care plans and documentationincluding immediate bereavement care. This will be done jointly with the AintreePalliative Care Team to guarantee consistency of approach in this area.

• Development of a relevant information leaflet around coping with dying for carers.

• Implementation of an action plan depending on further guidance from theLeadership Alliance.

Priority 2: Care of the Patient who is Dying – the Hospice will furtherintegrate its revised end of life care documentation into all relevant domainsof clinical care.

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How will progress be monitored and reported?

Progress will be monitored through audit of the use of the EoL communication recordand the revised nursing care plans once implemented.

Trustee visits (by medical and lay representatives) will be introduced to review EOLcare on the Inpatient Unit on a regular basis.

Reports of progress against the above plan and audit results will be reviewed by theClinical Effectiveness group and submitted to the Clinical Governance Committeeand Board of Trustees bimonthly.

The Clinical Effectiveness group will also develop and oversee implementation of therelevant action plan for new recommendations by the Leadership Alliance.

Patient Experience

How was this identified as a priority?

A significant amount of work has been done over the past 12 months to aligncomputer systems across Woodlands Hospice clinical services and as a result allservices with the exception of our Hospice at Home Service now use SIGMA. Thiswas chosen as this is the system used within University Hospital Aintree with whichthe Hospice has very close working relationships and it was already established onthe Inpatient Unit. This has enabled much better collation of data and activity but ithas also highlighted that there remains a disparity in how clinical information frompatient assessments is documented and shared across hospice services. Forexample if a patient is well known to Outpatient services through the Well-being andSupport Centre and is then admitted to the Inpatient Unit the relevant informationfrom Outpatient assessments doesn’t always follow the patient for that transition intheir care.

This can result in patients having to repeatedly go over details about their illnessincluding discussions that may be distressing when they are already known to otherHospice services and in addition potentially important information which could impacton their care may not be handed over.

We therefore feel this is a priority area to focus on to enhance the patient experienceand minimise the number of times a patient is asked to repeat personal details whenthey are already known to our services. It is important that patients feel there is aseamless integration when they are moving between services and better sharing ofclinical records is a key component of this.

Integral to this is also the sharing of any documented wishes and preferences madeas part of an Advance Care Plan (ACP). Not every patient will wish to formulate an

Priority 3: The Hospice will ensure Integrated Sharing of Clinical Information(including Advance Care Planning) between hospice services to ensure weminimise the number of times a patient has to tell their story.

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ACP but where this is done it is essential that this is shared with all relevanthealthcare professionals and hence how any ACP information is shared betweenservices within and external to the hospice will also form part of this patientexperience priority.

How will this be achieved?

• Consideration of the introduction of standardised multi-professional initialassessment documentation which could follow the patient across hospiceservices.

• Explore the possibility and challenges of electronically scanning clinical recordsfrom the Well-being and Support Centre through the Electronic DocumentManagement System currently used by the Inpatient Unit.

• Consider introducing an electronic pro forma for Outpatient initial assessmentwhich would allow the sharing of this information via SIGMA which would make itreadily accessible to all services across the hospice.

• Collaborate where possible with other health care providers to produce consistentdocumentation to support ACP and effective sharing of that information.

• The Hospice is looking to appoint an ACP Facilitator who will predominately have acommunity focus but will also be able to support the structure and process of ACPwithin the Hospice.

How will progress be monitored and reported?

• Patient Experience Surveys will include questions to ascertain patients’perceptions as to how well their personal information is shared across hospiceservices

• A baseline audit of the existing arrangements for ACP will be carried out

• Improvements to initiating, recording, documenting and sharing End of Life andAdvance Care Plans will be guided by the Clinical Effectiveness Group andsupported by the Documentation Group

• Regular ongoing audit of progress against the above plans to be carried out

• Reports of achievements against the above plans, including audit results and anypolicy or procedure revision, will be reported to the Clinical GovernanceCommittee and Board of Trustees for approval and ratification.

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1b. Priorities for 2013-14 Review of progress

Patient Safety:

• A tissue viability working group was established to manage this priority.

• Following review of data collection and audit tools relating to patient risk andincidence of pressure ulcers, a more comprehensive system has beenimplemented.

• We have had an independent review of tissue viability in the hospice andaddressed the recommendations which included: integration of tissue viability witha nutritional link role, clarity of responsibilities for nursing staff roles in theprevention and management of pressure ulcers and improved data collection.

• Facilities for photographing pressure sores and reporting through UniversityHospital Aintree’s DATIX incident reporting system have been implemented.

• We have commenced a review of the policy for prevention and management ofpressure ulcers. It is envisaged that this will be completed and implemented by theend of June 2014.

• All relevant nursing staff have completed prevention and management of pressureulcer training.

• A patient and carer information leaflet in relation to preventing pressure ulcers hasbeen developed.

• Progress against this priority, including audit of pressure ulcer incidence, has beenreviewed. Results indicated improvement with reduced incidence of pressureulcers.

• Tissue viability will remain a key and ongoing priority for the Hospice with regularaudit and review.

Clinical Effectiveness:

• Patient Outcome Scale version 2 (POS2) and Palliative Performance Scale (PPS)have now been implemented for multi-professional day therapy patients in the Well-being & Support Centre, and for Inpatients.

Priority 1: Tissue Viability – The Hospice will maintain high standards of skincare for patients and minimise the risk of pressure ulcer development

Priority 2: To introduce the use of Clinical Outcome Measures – the hospicewill incorporate the use of outcome measures into clinical practice to aid multi-disciplinary team working, clinical decision making and help assess quality ofcare.

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• The scores are collated weekly for these patients and are presented as part ofweekly clinical meetings to assist with clinical decision making.

• A summary sheet is used to identify trends and also help focus where particularinterventions may be required

• By keeping abreast of national developments on outcome measures for palliativecare we are now looking to adopt an updated version of the Patient OutcomeScale (IPOS)

• Education around the use of outcome measures is ongoing and additionalmethods to support learning including the possibility of e-learning are beingexplored

Patient experience:

• Different ways of delivering patient involvement forums were investigated andplanning meetings were held to agree the format and recruitment process for thefirst meeting.

• The first meeting of the Woodlands Patient & Family Forum was held at theHospice on 26th March 2014.

• As well as patients and carers, there was also representation from localHealthwatch organisations, Person Shaped Support, a local Carer’s Associationand a local student social worker.

• The Aintree Hospital Patient & Carer Representative joined the group as a guestspeaker to talk about the achievements of patient and carer groups she has beeninvolved in.

• The aim of the group was agreed as:

• To support achievement of the aim, the group agreed Objectives, Terms ofReference and Ground Rules.

• Members of the group reviewed and commented on draft Hospice leafletsincluding ‘Care of the Dying’ and ‘Advice on Hand Washing for Visitors’.

Priority 3: Development of a Patient and Family Forum to ensure that peoplewho are using our services have a more active role in the planning,development and evaluation of services.

“To engage with patients, carers and the public who are interested in theongoing development and quality of services delivered at

Woodlands Hospice”,

…and to provide

“Information from the community, for the community”.

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• Comments from attendees at the meeting included:

• Feedback from the first meeting was shared with all attendees, staff, the SeniorManagement Team and the Clinical Governance Committee.

• The group agreed to meet bi-monthly for the first six months to enable it to developand establish membership, develop its strategic plan, and start to influencechange and improvement. Meeting dates for the first six months of 2014/15 wereagreed.

• Work will continue to support the group to become an active and essential part ofservice development at Woodlands.

• Consideration will be given to sharing the planning of future Quality Accountpriorities with the group.

Other Quality improvements 2013-14Monitoring of Quality

• The annual clinical audit plan and non-clinical audit plan continued to bedeveloped (and supported by relevant working groups where appropriate).

• All audit results and resulting action plans were reviewed by the Governance andClinical Governance committees (as relevant).

• The review of Care Quality Commission (CQC) Provider Compliance Assessmentscontinued as services developed.

• Monthly Trustee visits continued throughout the year to review compliance withCQC Essential Standards of Quality and Safety.

• The Risk Register was maintained and regularly reviewed by Governance andClinical Governance committees and the Board of Trustees, highlighting areas ofconcern and identifying actions to be taken.

• A Clinical Effectiveness Group was established, consisting of Senior Clinical Teammembers, to monitor and advance Hospice clinical priorities.

• The Chief Executive Officer carried out interviews with patients, and the PatientServices Manager carried out regular patient ‘ward rounds’, to ensure that patientexperience of services was included in the monitoring of quality.

• Incident report monitoring continued throughout the year. No Serious UntowardIncidents were reported.

• A Quality and Improvement Manager role was identified, and recruited to, to leadthe quality agenda.

“Excellent meeting; greatinformation and presentation;look forward to the next one”

“Sharing of ideas;Friendliness; Open& honest approach”

“Excellent– glad tobe here”

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Working groupsMulti-professional working groups continued to meet regularly to support quality andimprovement across all services. Outputs during 2013/14 included:

Dignity• The multi-professional Dignity Working Group met four times during the year tosupport the prioritisation of dignity throughout the hospice; both in the care givento patients and their families, and in the workplace.

• The Group reviewed and revised the Dignity Policy.

• The Group developed and agreed a Dignity Charter. This is now displayed in allInpatient bedrooms and in clinical areas of the Well-being & Support Centre.

• The Group is currently reviewing patient satisfaction surveys across theorganisation with a view to developing one cross organisational survey that can beused to survey patients from all our services annually and replace the individualsurveys that are currently completed for each service.

• The Group produces quarterly reports in relation to dignity in care performance forthe Clinical Governance Committee.

Infection Control• The Infection Prevention group met regularly with membership from all services.

• The comprehensive annual audit programme was reviewed and implemented.Monthly audit results were generally good with most achieving at least the required95% pass rate. Where opportunities to improve were identified, an action planwas developed and monitored to completion. (Some examples of improvementare included in the table of patient safety audits included in Section 3).

• A staff training programme was initiated and is currently ongoing.

• Ongoing review of audit results and action plans by this group and the ClinicalGovernance Committee continued throughout the year.

• The Hospice group linked in to Aintree University Hospital Infection Control groupfor advice and support.

Nutrition• A multi-professional steering group met regularly to support the maintenance ofadequate nutrition and hydration to patients.

• A training package was developed and implemented for clinical staff.

• A nutritional care audit was carried out, using the Help the Hospice audit tool,which identified the need for a co-ordinated approach to nutritional care.

• As a result of the audit, a new policy and procedure for Nutritional Care wasdeveloped and implemented and a patient information leaflet was approved.Printed versions of leaflets are now available on the ward.

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• Re-audits using the same tool identified an improvement in nutritional care.

• The steering group is currently developing our own audit tool, to be used for futureaudits, to demonstrate compliance with the Hospice policy and procedure fornutritional care.

.

Falls

• A Multi-professional Falls Group met quarterly to review the management of fallsacross all services.

• All patients have falls risk assessment completed, and their ongoing care plannedaccordingly.

• Falls system equipment was reviewed and replaced in accordance with warrantyrequirements.

• The Falls Link Nurse has delivered staff training on the use of new falls equipmenton the Inpatient Unit. Falls training continues to be a part of induction training forall clinical staff (including bank staff).

.

Medicines Management

• A multi-professional group continued to meet monthly to review medicinesmanagement across the hospice with good attendance across all disciplines.

• The group continued to review policies such as the Self Administration ofMedicines policy, which was updated to ensure the safe storage of medicineswhen patients are participating in the scheme.

• An improved medicines chart was developed and safely introduced to the InpatientUnit. The chart now includes a colour-coordinated section specifically for syringedriver medicines to mitigate errors.

• The Hospice Pharmacist provides medicines management training for nursingstaff, and a comprehensive medicines audit programme continues.

Documentation

• Following recommendations from the CQC on the need to have moreindividualised Care Plans in place for patients, Care Plans on the Inpatient Unitwere reviewed and updated. A regular audit was established and hasdemonstrated improvement in this area.

• The audit tool for the review of nursing documentation on the Inpatient Unit wasreviewed and improved to correlate with the documentation sheets in use. Thisenabled audits to be completed easily, and problems to be resolved faster.

• An audit tool for Hospice at Home documentation was developed and will beimplemented in 2014/15.

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• The group recognised the need to audit Well-being & Support Centredocumentation. An audit tool will be developed and incorporated into the 2014/15clinical audit plan.

• A multiprofessional group continues to meet regularly to review clinicaldocumentation across the organisation.

Patient InformationWoodlands continued to develop information forpatients on a wide range of clinical and non-clinicaltopics; this includes leaflets on Nutritional Advice,Bereavement Support, and a range of leaflets aboutthe support groups available to patients such as theCreative Group and the Supportive Living Programme.A selection of those leaflets can be seen here.

EducationOver the past 12 months, Woodlands Hospice staffhave contributed to a wide range of education, both inhouse and also to that provided by Aintree SpecialistPalliative Care Services Group on a wider footprint.The education sub group of the Palliative CareServices Group is chaired by Clinical Lead forWoodlands Hospice, Dr Graham Whyte and is hostedat Woodlands. Education provided includes:

• A collaborative programme of GP education, working in conjunction withWillowbrook and Marie Curie Hospices, to produce a series of evening sessionson Palliative Care for non-malignant conditions.

• The delivery of the ‘Six Steps to Success’ programme of education for care homestaff in South Sefton.

• ‘Opening the Spiritual Gate’ – a series of 1 day workshops, (plus an e-learningoption provided by Queenscourt Hospice), exploring spirituality at the end of life.

• End of Life Workshop for Social Workers.

• Core and Intermediate Communication Skills Training.

• Education to support the implementation of the new regional unified ‘Do NotAttempt Cardio-Pulmonary Resuscitation’ (DNA CPR) policy.

There is also an ongoing programme of in house education for hospice staff whichhas included Consent to Care & Treatment, the Mental Capacity Act and Deprivationof Liberty Safeguards (key features of the CQC’s strengthened focus for 2013-16).

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Community Engagement• The Hospice actively participated in Dying Matters Week, May 2013, to raiseawareness of issues around death and dying and promote Advance CarePlanning.

• The hospice actively promoted Hospice Care Week in October 2013, involving allstaff and volunteers.

• The Hospice continued to promote Hospice at Home in locality meetings.

• The recently appointed Well-being and Support Centre Manager is activelyengaged, along with her team, with external referrers to continue to raiseawareness of the redesigned service within the community.

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Section 2: Statutory Information andStatement of Assurances from the Board

The following are statements that all providers must include in their Quality Account.(Not all of these statements are directly applicable to specialist palliative careproviders.)

2.1 Review of ServicesDuring 2013/14, Woodlands Hospice Charitable Trust provided the following services

• In-patients

• Well-being and Support Centre (incorporating day therapy, outreach, outpatients and group sessions)

• Lymphoedema

• Bereavement, family support and counselling

• Hospice at Home (In South Sefton only)

Woodlands Hospice has reviewed the data available to them on the quality of care ineach of these services.

The income generated by the NHS services reviewed in 2013/14 represents 73% ofthe total income required to provide services which were delivered by WoodlandsHospice Charitable Trust in the reporting period.

2.2 Participation in clinical audits During 2013/14, Woodlands Hospice was not eligible to participate in any of thenational clinical audits or national confidential enquiries. This is because none of theaudits or enquiries related to palliative care.

The Hospice clinical audit programme for 2013/14 included audits of MedicinesManagement, Controlled Drugs, Infection Control, and Care Plans. A retrospectiveaudit of Hospice inpatient ‘length of stay’ was also carried out. We have continued touse the Help the Hospices Audit Tools where possible; these are particularly relevantto the requirements of hospices and enables performance to be benchmarkedagainst other hospices.

In addition to its own clinical audit programme, Woodlands Hospice also participatesin a number of Regional and Supra-regional audits as part of the Merseyside and

What this means: Overall, 73% of our total costs are currently funded by theNHS. The majority of NHS funding is related to the In-patient Unit whichtransferred over from the NHS in 2009 with a three year funding arrangementwhich has been rolled over annually since. We rely on Fundraising activitiesto generate the remainder of our income.

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Cheshire Palliative Care Network Audit Group. Results of some of the auditsundertaken and/or presented in 2013/14 can be seen under ‘Clinical Audit’ in Section 3.

2.3. ResearchDuring 2013/14, no patients receiving NHS services provided by Woodlands Hospicewere recruited to participate in research approved by a research ethics committee.The Hospice has a policy to cover inclusion in research but, during this period, therewas no appropriate national, ethically approved research study in palliative care inwhich we could participate.

However, Woodlands senior medical staff are involved in research into decisionmaking for patients with advanced head and neck cancer jointly with UniversityHospital Aintree, and into the benefits of interventional pain management for cancerpain. Senior medical staff are also leading on general development of researchopportunities in palliative care in the region on behalf of the Cheshire & Mersey EOLcare network.

Staff from the Woodlands therapy team are conducting research into therehabilitation of lung cancer patients jointly with University Hospital Aintree and theLiverpool Heart and Chest Hospital. In addition, staff have contributed to a number ofpublications in peer reviewed scientific journals and participate in a regular weeklyjoint journal club. We have also hosted an academic clinical fellow from theMerseyside palliative care rotation.

2.4 Quality Improvement and Innovation goals agreed withour commissioners.Woodlands Hospice’s income in 2013-14 was not conditional on achieving qualityimprovement and innovation goals through the Commissioning for Quality andInnovation payment framework because it is a third sector organisation; it wastherefore not eligible to take part (Mandatory statement).

2.5 What others say about usWoodlands Hospice is required to register with the Care Quality Commission and itscurrent registration is for the following regulated activities:

• Diagnostic and Screening procedures

• Treatment of disease, disorder or injury

Woodlands Hospice is subject to periodic reviews by the Care Quality Commission.During August 2013, the Care Quality Commission carried out an unannouncedinspection and found that the Hospice was fully compliant with the followingStandards:-

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Outcome 2: Consent to care and treatment - Before people received care or treatment they wereasked for their consent and the provider acted inaccordance with their wishes.

“The people we spoke with told us that they werefully informed about the care they received and thateverything had been fully discussed before anyprocedure had been carried out.”

Outcome 4: Care and welfare of people who useservices - People should get safe and appropriatecare that meets their needs and supports their rights.

“Care and treatment was delivered in a way thatintended to ensure people’s safety and welfare.Staff demonstrated a strong understanding ofpeople’s needs and how to support them. Wefound that each person using the service had acare file which contained a set of care plansappropriate to their care and support needs.”

Outcome 8: Cleanliness and infection control - People should be cared for in a clean environment andprotected from the risk of infection.

“During our visit we undertook a tour of the unitand inspected a number of bedrooms, bathroomsand communal areas. We found them to be cleanand tidy. People we spoke with gave us verypositive feedback about the cleanliness ofWoodlands. Staff told us that they received regulartraining in infection prevention and controlincluding training in hand hygiene.

Outcome 12: Requirements relating to workers - People should be cared for by staff who are properlyqualified and able to do their job

“Appropriate checks were undertaken before staffbegan work. People told us that they felt safe andconfident in the care they received from theprovider. Staff we spoke with understood the careand treatment people needed and were passionateabout the support they offered people atWoodlands.

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Outcome 21: Records - People’s personal records, including medical records,should be accurate and kept safe and confidential

“People’s personal records including medicalrecords were fit for purpose. Staff were aware ofthe need to ensure clear records were maintainedand stored safely and securely.

We saw a leaflet that was provided for people whoused the service to explain what information waskept on a person and how it was used.

Environmental HealthOnce again, the high standards of kitchen hygiene and catering have beenmaintained and an Environmental Health inspection undertaken in January 2014awarded the Hospice a 5 star rating.

Fire SafetyThe Hospice Fire Safety policy and training model was revised, approved andimplemented during 2013/14, taking into account recommendations following a FireSafety Inspection carried out in January 2013. A routine review of Fire Safety inFebruary 2014 (undertaken by the Fire Brigade) identified no areas of concern.

2.6 Data QualityWoodlands Hospice did not submit records during 2013/14 to the Secondary UsesService for inclusion in the Hospital Episode Statistics which are used to provide non-clinical and administrative data for analysis by a range of organisations includinglocal commissioners.

Woodlands Hospice score for Information Quality and Records Management was notassessed in 2013/14 using the Information Governance Toolkit but work commencedon compliance with the toolkit in preparation for signing-up to an NHS StandardContract for all Hospice at Home services commencing in April 2014. Our aim is toachieve level 2 for 2014/15.

Why is this? This is because Woodlands Hospice is not eligible to participatein this scheme. However, in the absence of this we audit our clinical recordsregularly and submit annually National Minimum Dataset reports to ensureour data is as accurate as possible.

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SECTION 3 – Quality overview

Review of quality performanceWoodlands Hospice is committed to continuous quality improvement.

This section provides:

• Data and information about the number of patients who use our services

• How we monitor the quality of care we provide

• What patients and families say about us

• What our regulators say about us

Monitoring activity The Hospice submits information annually to the The National Council for PalliativeCare (NCPC) Minimum Data Sets which is the only information collected nationallyon hospice activity.

Inpatient Unit (15 beds) 2012-2013 2013-2014

Total number of patients 284 220

%New patients 87.7% 86.3%

% occupancy 85.9% 86%

% Patients returning home 55% 63%

Average length of stay 13.3 days 14.3 days

Inpatient UnitIn the Inpatient Unit, where there are 15 beds, theaverage length of stay in 2013/14 was 14.3 days whichis slightly higher than last year. The multi professionalteam are proactive with discharge planning andsupporting patients to achieve their preferred place ofcare. A retrospective audit of patients with prolongedlength of stay identified that these patients havecomplex symptom control issues at the end of life andrequire ongoing specialist palliative inpatient care. Theunit admits patients 7 days per week and has aconsistently high occupancy level of 86%. During theseven months from September 2013 to March 2014,198 bed days were lost whilst building work wasundertaken. This affected the total number of patientsthat could be admitted.

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Day TherapyFollowing the reconfiguration of services, the data indicates a reduction in daytherapy activity from 2012/13 to 2013/14. This is due to day therapy services (nowreferred to as multi-professional assessment days) being reduced to two days aweek with just 15 places on each day (was previously 100 places per week spreadacross four days).

New services have since been introduced to provide attendance for patients on theremaining days. The activity from these services is described by the outpatientservices data, where an increase is seen.

Well-being & Support Centre (incorporating Day Therapy, Outreach, and Outpatients)

A redesign of services within the Well-being and Support Centre has beenundertaken. A combination of multi-professional assessment days, outreachtherapies, group programmes and nurse/therapy led clinics are now available whichenables more focus on individualised care planning. Feedback from the recentpatient survey has been very positive about these services.

Day Therapy (30 places week from May 2013) 2012-2013 2013-2014

Total number of patients 329 142

% New patients 70.2% 79.6%

% Places used (patient attendances) 50.3% 60.3%

Average length of stay 158 days 158.5 days

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Outpatient services 2012-2013 2013-2014

Number of patients 415 502

% new patients 28.9% 58.2%

Number of clinics 148 748

Number of outpatient attendances 1082 2066

% non-cancer patients 6.1% 5.6%

Outpatient Services

The increase in activity from 2012/13 to 2013/14 is due to the introduction of newoutpatient services (identified from a review of all day therapy services) which includeindividual Outpatient Clinics and therapy groups such as the Breathlessness Groupand the Supportive Living Programme. These new services replace two of theprevious day therapy days and are being actively promoted to increase attendance.

Bereavement services 2012-2013 2013-2014

Total number of users supported 101 151

% new service users 62.3% 80.8%

Total contacts 565 639

Bereavement Services

Individual support is offered to bereaved people by members of the clinical team whohave been key workers to the families. In addition a Bereavement Group is heldmonthly at the Hospice and a ‘Celebration of Life’ service is held annually.

Bereavement services saw a 50% increase in the total number of users supported in2013/14, compared to the previous year. The percentage of new users of the serviceincreased by 18.5% and the total number of contacts increased by 74.

Community Outreach ServiceThere is a Community Outreach service providing Occupational Therapy,Physiotherapy and Complementary Therapy interventions in the patient’s home, forthose patients who are unable to travel to the Hospice.

The data from these services demonstrates an increase of 9.6% in the number ofpatients enabled to die at home (bringing the total percentage closer to the findingsof the British Social Attitudes survey, published May 2013, which identified that 67%of patients would prefer to die at home). The percentage of non-cancer patientsreceiving services has also increased.

Community Outreach Services 2012-2013 2013-2014

Total number of patients 227 200

% New patients 86.3% 92%

% patients who died at home 53.6% 63.2%

% patients with non-cancer 13.2% 14.5%

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Hospice at Home The Hospice at Home service is currently provided only in South Sefton, offeringescorted discharge home from hospital or hospice, a 24 hour sitting service andconsultant led crisis intervention/prevention.

The number of ‘sits’ provided topatients by the Hospice at Homeservice increased by almost a thirdin 2013/14, taking the total numberfrom 650 to 863. The percentage ofpatients enabled to die in their ownhome (or place of residence)increased from 76.1% to 84.6% andthe number of patients needing tobe transferred to hospital to diereduced from 7.5% in 2012/13 tojust 2.1% in 2013/14.

Hospice at Home 2012-2013 2013-2014

Total number of patients 138 139

Crisis intervention home visits 53 52

Accompanied transfer home (from Hospice or Hospital) 15 10

Sitting service 85 patients 91 patients

(650 sits) (863 sits)

% Home deaths (place of residence) 76.1% 84.6%

% Hospital deaths 7.5% 2.1%

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Quality Markers we have chosen to measureIn addition to the quality measures used to provide information to the nationalpalliative care minimum dataset, we have chosen to measure our performanceagainst the following:

Patient Safety Incidents

The Multi-professional Falls Group continues to meet on a regular basis to review theincidence of slips, trips and falls across all services and further develop localstrategies to reduce the incidence of falls.

Whilst the number of falls in this period is the same as the previous year, the numberof serious patient safety incidents or injury as a result of a fall reduced to zero.

A falls risk assessment is completed for all in-patients, those attending the Well-beingand Support Centre and Hospice at Home patients. Where risk of falls is identified,action is taken to minimise that risk.

A falls prevention system in use on the Inpatient Unit identified that the bed padsattached to the alarm had to be placed on top of the mattress and were not suitablefor patients who are at risk of developing a pressure sore. Alternative bed pads weresourced and are now in use for patients at risk of developing pressure sores. Stafftraining in the use of this equipment is ongoing to ensure competence and maintainpatient safety.

Infection Prevention and Control

INDICATOR 2012-2013 2013-2014

Number of serious patient safety incidents 2 0

Number of slips, trips and falls 43 43

Number of patients who experienced a fracture 1 0or other serious injury as a result of a fall

INDICATOR 2012-2013 2013-2014

Number of patients admitted with MRSA bacteraemia 0 0

Number of patients infected with MRSA bacteraemia 0 0during admission

Number of patients admitted with clostridium difficile 1 0

Number of in patients who contracted clostridium difficile 0 2*

*not health care acquired

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Excellent standards of infection prevention and control have been achieved againthis year with no incidents of health care acquired infections. The two cases ofclostridium difficile were not related and the infection control team completed a rootcause analysis in both cases which confirmed that the incidents were not health careacquired and that patient care was in line with national guidance; this was confirmedby an independent review arranged by Woodlands.

The Needle safe European Directive came into force in May 2013 in an attempt toreduce the incidence and risk of infection for health care workers from needle stickinjuries. Woodlands Hospice successfully achieved the recommendations of thisdirective and had sourced and implemented needle safe alternatives for allprocedures involving needles prior to the implementation date.

Clinical Audit (see also section 2.2, Participation in Clinical Audit)The Hospice uses clinical audit to monitor quality and support service improvement.Where an audit identifies room for improvement, an action plan is developed,reviewed, and monitored to completion. In addition to internal audit, the Hospiceparticipates in Regional and Supra-regional audits as part of the Merseyside andCheshire Palliative Care Network Audit Group.

The Hospice Board of Trustees support Quality Assurance and adherence to theCare Quality Commission’s Essential Standards of Quality and Safety by undertakinga rolling programme of unannounced Trustee Visits. During these visits, Trusteestalk to patients, visitors, volunteers and staff, asking them about their experiencesand observing practice. Trustees also look at policies, information and supportingdocumentation to enable them to produce a report of their findings withrecommendations for improvement where necessary. An action plan is thendeveloped from the Trustee recommendations and is again, monitored to completion.

Patient and family feedback is also gathered through surveys, comments forms, thePatient Services Manager’s ward round and informal visits by the Chief Executive.

These processes support the Hospice’s Quality Assurance framework.

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Patient SafetyAudits

Infection Control Management ofthe ‘Dirty Utility’room

Infection Control Safe handling &disposal ofdepartmentalwaste

Infection Control Inpatientenvironmentalaudit

MedicinesManagement Self-administration ofmedicines

Safety AlertsAudit of receipt &handling of SafetyAlerts

Findings and Actions to be takento improve compliance/practice

An audit carried out in May 2013 identified someinappropriate items being stored in the dirty utility room.The items were removed; staff were reminded of theirresponsibility to keep general areas clean; a regularinspection was introduced with a daily cleaningschedule. Re-audit in June confirmed that the room wasfree from inappropriate items.

The audit identified that all staff are aware of wastesegregation procedures. However, a poster identifyingcorrect waste segregation was not displayed at the timeof the audit. This has since been rectified.

The audit identified that not all items in the clinical roomwere stored above floor level. Storage was reorganisedto address this.Some chairs were not covered with an impermeablematerial. A planned replacement with appropriatecovers was completed.

The audit identified overall good compliance with policy.However, the following improvements were identifiedand implemented:• Self-administration status was not identified on alldrug cards. A new drug card to be introduced with aspecific space to record administration status.

• Policy and documentation needed update to supportself-administration and storage of medicines bypatients.

A revised policy and procedure for receiving & handlingSafety Alerts was introduced in January 2014.Compliance with the new procedure was audited inJanuary and February 2014.The January audit identified that some elements of theprocedure were not fully understood by staff, resulting insome uncertainty between clinical and non-clinicalalerts. The procedure was reiterated to teams and a re-audit inFebruary 2014 identified that adherence to theprocedure had improved and documentation wasaccurate.

Action plancompleted

June 2013

October2013

December2013

January2014

February2014

The following table shows a sample of the audits and Trustee Visits undertakenduring 2013/14

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Patient SafetyAudits

MedicinesManagement Administration ofMedicines

DocumentationCare Plans

Findings and Actions to be takento improve compliance/practice

The audit was carried out following the introduction of anew medicines administration chart. The results of theaudit were generally good although the followingimprovements were identified and implemented:• Improvements to be made to the recording of allergyand self-administration status on cards.

• Improving legibility when a non-administration codeis entered.

• Adhere to the ‘new’ administration codes (some staffwere still using the ‘old’ codes from the previouscharts).

An audit in March 2014 identified that the standards ofcompleting Care Plans had slipped slightly fromprevious months and highlighted some incompleteentries. The Acting Ward Manager shared the results with allward staff and reiterated the importance of completingCare Plans at handover & ward meetings.A re-audit in April showed an improvement.

Action plancompleted

March2014

April2014

Regional Audits

PathologicalFractures

PsychologicalSupport Services

Findings and Actions to be takento improve compliance/practice

This audit demonstrated a wide variation in referraland management of pathological fractures. Newregional guidelines have been developed. Theseguidelines incorporated scoring systems to be usedto help predict the risk of fracture and these havebeen laminated and placed in clinical areas. It alsohighlighted the consideration that should be given tothe use of newer drugs such as Denosumab inthese patients.

This audit reviewed our provision of and access toLevel 3 and 4 psychological support services. Thisaudit highlighted the requirements for both adult andchild support services. As a result of the audit weare reviewing our referral guidance and also thetraining available for psychological assessment andmanagement strategies.

Action plancompleted

February2014

Inprogress

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Trustee Visits

May 2013:Outcome 7.Safeguarding people whouse the services fromabuseGeneral Comments:The Trustee was veryimpressed with theSafeguarding Lead and herknowledge and experienceof standards and practice.The Trustee was alsohappy that staff would beable to recognise signs ofabuse and how to escalatea problem if it wasnecessary.

September 2013Outcome 9.Management of medicinesGeneral Comments: “I found the Management ofMedicines on the In-patientunit robust, and all staffinterviewed were wellversed on policies andprocedures”.

January 2014: Outcome 12Requirements relating toWorkers. General Comments: “Thereis lots of enthusiasm withinthe Hospice and the ‘newbuild’ will bring peopletogether. I was veryimpressed with thediscussions I had aboutPDRs and 6-weekly 1:1s.The patients I met spokeextremely positively abouttheir experiences. The newWell-being & SupportCentre Manager appears tobe embracing the changes”.

Findings and Actions to be takento improve compliance/practice

• Staff to be reminded of the ‘No Secrets’document and where it can be locatedin the hospice.

• Line managers need to re-iteratesafeguarding information a little afterinduction to ensure it is clear to all staff.

• Spot checks on Safeguarding to beincorporated into the Patient ServiceManager’s ward round.

No specific improvements were identifiedfrom this visit but the Trustee highlighted:• That she had seen (from audits) animprovement in competency withcontrolled drug documentation.

• And that the input of the pharmacist (aclinical specialist in palliative caremedicines) was valued by all staff andhad improved efficiency.

• Recruitment and inductiondocumentation and filing to be broughtup to date.

• Create a general inductionchecklist/record that new starters cansign, and which can be placed in theirindividual staff record.

• Improve the management of thedocumentation included in the‘practicing privileges’ folder, ensuringthat contracts are signed and copies ofmedical indemnity are taken and filed.

• Improve the timeliness of staff contractdevelopment and signing so that asigned copy of an individual’s contractis available in their individual staffrecord within two months of starting.

Progress to date

Completed

Completed

Completed

Completed

In progress

Completed

Completed

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Trustee Visits

March 2014: Outcome 2Consent to Care &TreatmentGeneral Comment:“The hospice staff are veryaware of the need forconsent throughout theirdealings with patients. Ihave no recommendationsto make as the currentsystem seems to beworking well”.

March 2014: Outcome 16Assessing & monitoring thequality of service provision. General Comment: “All the staff I spoke toknew the importance ofassessing and monitoringthe quality of serviceprovision. There weresome excellent examples ofgood practice, e.g. the useof audit, KPIs andfeedback.”

Findings and Actions to be takento improve compliance/practice

• Training in ‘Consent’ to be introducedfor all relevant staff and incorporatedinto relevant staff induction training.

• Cascade training plan for MentalCapacity Act (MCA) and Deprivation ofSafeguarding Liberties (DoLS) to beput in place for all relevant staff oncetraining of senior staff is complete.

• Audit reports need to be improved todemonstrate that actions are followed –this information needs to be sharedacross the organisation.

• A ‘Quality & Improvement Brief’ shouldbe developed to share results/actionplans/audits etc with all staff.

• Improve the reporting of near-missincidents across the organisation.

• Press on with plans to deliver trainingon complaints handling to all staff.

Progress to date

Training inConsent,MCA andDoLS is nowin place for allclinical staffacross theHospice.Expecteddate ofcompletionJune 2014

In progress

Completed

In progress

In progress

ComplaintsThe Hospice receives very positive feedback from the people who use our services,sometimes verbal but often in the form of letters and thank you cards. This type offeedback is most welcome and we make every effort to share it with our staff andvolunteers.

We actively encourage all types of comments and feedback, including complaints, sothat we learn from these to make sure that our standards continually improve andmistakes are rectified.

We take all complaints very seriously and during 2013/14 we updated our policy forhandling complaints, as well as our ‘Comments, Compliments and Complaints’ form,to help us to improve the way complaints are dealt with consistently across theorganisation. Training in the new complaints procedure is planned for all staff andvolunteers during May 2014.

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There was an overall small increase in the number of written complaints receivedduring 2013/14 compared to the two previous years, whilst verbal complaints fellmarginally. The trends and themes of these complaints could broadly be divided intothree categories.

Number of complaintsWritten Complaints 2011-2012 2012-2013 2013-2014Total number received 2 4 6

Verbal Complaints 2011-2012 2012-2013 2013-2014Total number received 11 11 9

Trends/themes of complaints

Theme

Communication

Attitude

Processes andProcedures

Numbers (NB - Some complaintsraised more than one issue)

7

6

11

Examples of resultingActions/Improvements

• Following a problem which arose fromthe lack of communication within theteam of telephone discussions with acarer, the process for documentingcommunication with 3rd party contactswas reviewed and revised. All staff arenow working to the new process.

• Following a complaint from a carer whowas approached regarding fundraisingwhilst supporting a patient attending foran appointment, the sale of raffle ticketsand other requests for donations arenow restricted to the main reception (i.e.no longer to take place in clinical waitingareas).

• During January 2014 when the Hospicewas undergoing extensive buildingworks, an increase in fire alarmactivations caused a disturbance to localresidents. Our on site builders took stepsto ensure that alarms could not beaccidentally triggered and no furtheraccidental alarms were sounded. TheHospice generator testing process wasalso reviewed.

All written complaints are acknowledged in writing by a member of the SeniorManagement Team within one working day of receipt. A full investigation isundertaken by the appropriate Senior Manager and resulting actions are monitoredto completion. Verbal complaints are handled with the same level of importance aswritten complaints. An investigation is undertaken by the Manager of the serviceinvolved and the resulting outcome is recorded.

An anonymised report of all complaints is reviewed regularly by the Board ofTrustees and relevant committees. Learning from the management and handling ofcomplaints is shared across the Hospice at team meetings.

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3.1 What our patients and families say about theorganisationThe Hospice welcomes all comments and feedback from patients, carers andfamilies and there are many ways in which people can send these to us. We havean organisational-wide ‘Comments, Compliments and Complaints’ form, which isgiven to all patients in information packs and is also available on reception forvisitors, carers and family members to complete; traditionally we have receivedletters and thank-you cards from patients, carers and families; and of course, peoplehave always been welcome to speak to us in person about their experiences. Morerecently however, as people become more familiar with social networking and otherforms of communication, we are starting to receive comments by general email,through ‘just giving’ pages, via Facebook pages, and even through ‘Twitter’. Thefollowing are a selection of comments we have received over the past year, througha variety of methods.

“Thanks forthe care given to my

dad in his final days andfor the letters and leafletsyou sent, helping usthrough a verydifficult period.”

“I’m running the St Helens 10kfor Woodlands because they do great

work and deserve support; they do a greatjob caring for those in need.”

“Thank youfor all your care

and love you gave her whilstshe was at the hospice.Your support made adifficult time mucheasier, we will neverforget everything youdid for us as a family.”

“To all, not forgetting volunteers. As a family, thank you all

from the bottom of our hearts for lookingafter our mum. You looked after her so

well, you are special people.”

“Since my stay at Woodlands I have appreciated everything

they have done for me. I feel healthier becauseof good nursing, medication, food, doctors,physio, hygiene, and pleasant surroundings.

I am grateful to Woodlands.”

“I am so grateful forall the skill, care and real belief in caring

for the person, not the disease, which is being shownhere all the time – in what you do as individuals and as ateam. It’s easy to be cynical, and I’m as guilty of that asthe next person, but being here has changed that.Thank you for reminding me that there is so

much good in the world.”

“AtWoodlands there are no problems only solutions"

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“We would liketo thank you all very, very

much for all you did for Mumover the years. It wasn’t just themedical side of things, she lovedthe social side, making things,talking, having her hair done toname but a few. Thank you forall your friendship and support,not only to Mum but to us

as a family.”

“I had a great nurse.I must say she does an amazing joband gave me confidence. Thank youto the Woodlands for having such

lovely dedicated staff.”

“I can thinkof a number of cases

where patients would have beenadmitted to hospital if rapid intervention

would not have been made”.Specialist Palliative Care Nurse

“Knowing patientsand carers have extra supporthas given them the confidence to

choose to go home.”Discharge Planner

“We particularly valuethe accompanied transfer

home service. All of our patients/relatives benefited from this

fantastic service.”District Nurse

“The service hasprovided benefit to a great extentto deal with emotional issues andpractical issues for carers and

patients.” GP

“As a family weare very grateful for the

compassionate care all your staffshowed to our father. It was our wishthat dad remain at home and withyour help this was made possible,

something we will always be very grateful for.” “Thank

you for thewonderfulcare,

kindness,attention and timegiven to my partnerand me. Woodlandsis in a league of itsown. Please let allyour staff and

volunteers know howvery much we valuedtheir hard work,friendliness anddedication.”

“Beautifulpeople and abeautiful place;Woodlands lookedafter my sister withtender care andcompassion.”

“Theyalways treatus with

utmost dignityand respect.We are all asa family soproud andpleased to

have met suchlovelypeople.”Carer

“I think theservice is an integral

part of the patient’s packageof care and proved a greatsource of psychological

support for both the patientand family.”

Community Specialist Nurse

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3.2 What our regulators sayWoodlands Hospice is registered with the Care Quality Commission and as such issubject to regular review in the form of unannounced inspections. Please see section2.5 for details of our most recent review (August 2013).

3.3 The Board of Trustees’ commitment to qualityThe Board of Trustees of Woodlands Hospice Charitable Trust is fully committed toprioritising the quality of patient and family care. All Trustees participate in theprogramme of unannounced Trustee Visits giving them an opportunity to familiarisethemselves first hand with the workings of the Hospice and to hear the views ofpatients, families, staff and volunteers. The organisation has a robust QualityAssurance framework with Trustees taking an active role in ensuring that the Hospiceprovides the best possible evidence based care and fulfils its Statement of Purpose.

3.4 Supporting Statements

Healthwatch

Unfortunately, Healthwatch Sefton were unable to provide a commentary on thisoccasion. However they expressed their hope to work in partnership with us in thecoming year.

Comments from Healthwatch Liverpool and Healthwatch Knowsley are awaited.

Clinical Commissioning Groups

Woodlands Hospice has worked closely with South Sefton CCG, Liverpool CCG, andKnowsley CCG throughout the year and would anticipate supporting comments forthe next Quality Account.

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www.woodlandshospice.org

Woodlands Hospice Charitable TrustUHA Campus, Longmoor Lane, Liverpool L9 7LA

Tel: 0151 529 2299Charity No. 1048934