The Daffodil Standards: A breakdown by standard

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Please familiarise with each standard and use you the 'How to get started guide' found on the resources page, to work through each of the key eight steps to get your started. If you haven’t already do so, please sign up to the Daffodil Standards to recourse access to the how to get started guide and additional learning resources.

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Standard 1: Professional and competent staff

Purpose: To create an infrastructure in the practice which a supportive end of life support strategy can be built upon.

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Standard 2: Early identification

Purpose: To identify patients approaching/ in end of life to enable audits and targeted interventions.

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Standard 3: Carer Support before and after death

Purpose: Identification of other patient groups who may benefit from EOLC improvements - i.e. carers.

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Standard 4: Seamless, well-planned, coordinated care

Purpose: To suggest ways of improving proactive EOLC supported by infrastructure beyond the practice.

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Standard 5: Care is based on the assessed unique needs

Purpose: To create a personalised, holistic and reflective approach to EOLC through care planning.

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Standard 6: Quality Care during the last days of life

Purpose: To support patients at the end of their life, and reflect on recent deaths.

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Standard 7: Care after death

Purpose: To improve support for people experiencing bereavement and making supportive links with the community.

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Standard 8: General practice being hubs within Compassionate Communities

Purpose: To integrate and embed general practice and EOLC practices into the wider system and community.

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Full breakdown by standard

Standard 1: Professional and competent clinical and non-clinical staff required to provide high quality, safe and compassionate care in Advanced Serious Illness and EOLC

The General Practice commits to: To meet this standard the practice commits to: Self-Assessment
1.1 Ensure that each individual staff member (clinical and non-clinical) understand their role and responsibility for Advanced Serious Illness and EOLC 1.1a Ensure individuals can demonstrate an understanding of which skills relate to their role and consider staff training requirements to support Advanced Serious Illness and EOLC core standards
  • Agree as a practice, which clinical and non-clinical staff are involved in caring for people and care-givers.
  • Training needs assessment for staff.
  • Relevant Learning action plan for staff with SMART objectives.
1.1b Individuals have completed training on the standards that relate to their role
  • Evidence of training and learning completed and impact.
1.1c Demonstrate the application and impact of using the standards

Examples include:
  • Case history(s) presented at MDT meeting.
  • Patient/ carers and professional feedback presented at MDT meeting.
1.1d Demonstrate assessment, induction training on standards, appropriate to role, for all new staff.
  • Induction procedure.
  • Consider mentoring opportunities.
1.2 Ensure all staff understand the feelings and communication needs of people approaching the end of life and their families/carers 1.2a Improve the understanding and sensitive communication of individual staff and the team collectively, around dying, death and bereavement.
  • The practice has access to a range of methods to increase understanding of experiences of people and carers at the end of life. e.g. articles, books, resources
  • The practice demonstrates reflection on sensitive communication, appropriate to people's needs
1.3 Have practice clinical and non-clinical leads for Palliative & EOLC 1.3a Appoint clinical and non-clinical leads with relevant leadership, skills, knowledge and understanding to do this role
  • Leads known to whole team.
  • Where possible, has time allocated.
  • Coordinate agreed ambition for quality improvement activity via the standards, in the practice
1.3b Lead(s) responsible for coordinating implementation of the standards An action plan/Gantt chart for implementing quality improvement activity via the standards

Standard 2: There is early identification and recording that a person, has an Advanced Serious Illness, or EOLC needs.

The General Practice commits to: To meet this Standard the practice commits to: Self-Assessment
2.1 Early identification of patients 2.1a Understand how to identify people who have an Advanced Serious Illness, or EOLC needs
  • An agreed protocol for identifying people with an Advanced Serious Illness, or EOLC needs.
  • Include seamless transition of practice supportive care registers, such as those for: dementia, frailty, disease specific long-term conditions, recurrent admissions, palliative care.
  • Demonstrate active use and timely, regular reviews of people identified on the register.
2.2 Practice Advanced Serious Illness and EOLC register 2.2a Have a robust system in place to record and review patients requiring EOLC
  • Easily accessible register.
  • Staff aware of how to access and code on the register.
  • System to flag identified patients to all staff to enable quick, effective decision-making and access.
  • The practice register size represents an expected proportion of people in the practice with Advanced Serious Illness and EOLC needs or reasons recorded why this does not align with the local population.
2.2b Have a robust system in place to record and review patients requiring EOLC
  • Patients have a named GP.
  • Offer 'What Matters Most to You and Yours' conversations.
  • Patients have capacity assessed and recorded.
  • Patients have documentation recorded, e.g. ADRT, LPA for health & welfare, DNACPR.
  • Age of patients recorded.
  • Diagnosis recorded: highlighting cancer/ non-cancer.
  • Inequality group recorded.
  • Communication and information needs, e.g. any sensory loss or disability (including learning disabilities)
  • Patients' care and support holistic needs and preferences are recorded.

Standard 3: Carer Support – before and after death.

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The General Practice commits to: To meet this standard the practice commits to: Self-Assessment
3.1 Early identification of carers 3.1a Achieve consistent identification of carers
  • An agreed protocol for identifying carers of people who have advanced serious illness or who may be approaching the end of life.
3.2 Identification of carers' needs 3.2a Enable (conduct/sign-post to) holistic carer assessments
  • Where possible, record a holistic carer assessment, that is, to identify problems from their perspective: both in terms of their needs as 'clients'(a patient) and their needs as 'co-workers'(caring for a person).
3.2b Support carers both as 'clients' and 'co-workers'
  • Information provided to carers which can include understanding of the patient's illness, how to manage symptoms and medicines, what signs to look out for, when to make a call for help.
  • Make contact with the carer after the patient's death to assess what ongoing support is required.
3.1c Develop inter-practice communication
  • A system for communication between practices to address when the patient's carer does not belong to the same GP practice as the patient.

Standard 4: Seamless, well-planned, coordinated care.

The General Practice commits to: To meet this standard the practice commits to: Self-Assessment
4.1 Multi-disciplinary team meetings 4.1a Understand the role and optimum outcomes of the MDT meeting in Advanced Serious Illness and EOLC
  • Practice agreement for MDT meetings, for example, how often, who attends, goals etc
  • Objectives of MDT agreed by practice team and recorded.
  • Assess effectiveness of meetings by obtaining feedback by attendees.
4.1b Hold regular Advanced Serious Illness, and EOLC MDT meetings
  • Evidence of holding regular practice MDT for people with ASI + EOLC needs.
  • The meetings include an effective mechanism to review patients and carers on palliative/ supportive care register in a timely manner. Record date of review and any change/outcome and include in patients notes.
4.1c Have input from interface teams, for example, hospice, community nursing, social prescribing etc. Minutes/notes of MDT meetings showing:
  • Community nursing attending MDT regularly.
  • Evidence liaisons and partnerships built with other services to attend MDTs and/or provide multidisciplinary and cross-sectoral care, for example, specialist palliative care/hospice, geriatricians, mental health, social care, local voluntary sector services, social prescribing, paediatrics
  • Established route for advice /referrals to senior clinicians in specialist palliative care/hospice, geriatrician, psychiatrists, paediatrics etc.
4.2 Coordination of care across all care settings 4.2a Communicate across care settings
  • System in place and recorded to coordinate care across all care settings. For example, EPaCCS, Emergency Care Summary (Scotland) or hand-held notes.
  • Case examples showing evidence of active use, regular and timely reviews and updating
4.3 Data Collection 4.3a Achieve consistent data collection
  • Agree and have recorded standardised coding list for ASI + EOLC within the practice.
4.4 Data Sharing 4.4a Have a system for data sharing
  • System in place and recorded for sharing clinical information and PCSPs for people on the palliative / supportive care register – available to Out of Hours and Emergency Services.
  • System in place and recorded for sharing clinical information and PCSPs for people on the palliative / supportive care register – available to cross-sector integrated services, for example, EPACCS/KIS.
4.5 Monitor the quality of care provided to people who died over the year 4.5a In practice consistent MDT template and annual retrospective death review You can use the following documents found on the learning resources page to assist you in collecting data.
  1. Daffodil Standards: Example EoLC audit dataset SMART goals.
  2. RCGP Marie Curie EOLC example audits MDT template - to prospectively collect and monitor relevant information for people on palliative/ supportive care register
  3. Example after death audit report template - use relevant criteria from MDT template to audit deaths, for example last 20 deaths (all causes, on and off palliative/ supportive care register)
  4. Presentation of audit and share learning outcomes at MDT.
  5. Share learning outcomes with wider stakeholders, as necessary. For example, other practices in primary care networks/ federations/clusters (Wales), Clinical Commissioning Groups/ HSCP (Scotland), acute providers and community providers
4.6 Specialist Palliative Care (SPC) – acute, community and hospice teams 4.6a Have access to SPC / hospice team(s)
  • Guidance available to practice team on how to access specialist palliative care services 24/7 for both adults and children, for example, for advice; referral criteria and process
  • Enable clear, consistent coding and recording of SPC contacts
  • Consider how practice and SPC/ hospice team(s) coproduce on issues such as teaching, shared resources, and MDTs.

Standard 5: Care is based on the assessed unique needs of the patient, carer and family.

The General Practice commits to: To meet this standard the practice commits to: Self-Assessment
5.1 Implement Personalised Care and Support Planning (PCSP) 5.1a Understand the role and optimum outcomes of Personalised Care and Support Planning (PCSP)/Anticipatory Care Planning (ACP)
  • Objectives of Personalised Care and Support Planning (PCSP)/Anticipatory Care Planning (ACP) agreed by practice team and recorded
  • Objectives need to cover: Medical planning Demedicalised (non-health) Wellbeing planning, such as mapping care and support networks to enable care preferences
5.1b Achieve consistent PCSP / ACP process for patients
  • Use a holistic PCSP / ACP template to identify and record the key medical and 'demedicalised' information for PCSP
  • Holistic PCSP/ACP template used relevant to age, diagnosis, cultural and psychosocial needs
  • Offer sensitive conversations on items in minimum dataset and record on PCSP/ACP template
  • Use of PCSP/ACP recorded for people on Practice Register
  • The practice team have constructed a process map of PCSP/ACP
  • Learning tools and videos available including Advance Care Plan
  • Offer copy and/or access (if available) of PCSP/ACP to patient
5.1c Achieve consistent quality of PCSP/ACP, including DNACPR The recorded plan, including EOLC dataset, once started is completed and regularly reviewed and updated, in a timely manner and includes:
  • Medical plans including assessment of pain, other physical symptoms and emergency health and care planning.
  • Demedicalised plans, such as mapping care and support networks to enable care preferences.
  • Assessing and reviewing mental capacity.
  • Benefits guidance, e.g. DS1500.
  • Sensitive involvement and communication with patients, families and carers.
  • DNACPR documentation, where appropriate.
  • Holistic needs, including: practical, communication and disability, psychological, social, spiritual and cultural needs.
  • Date and place of death recorded within 2 weeks of death.
5.1d Achieve person-centred care
  • 'What Matters Most' and 'Goals of Care' conversations are commenced and recorded early.
  • How care is aligned to those goals recorded.
  • Information on self-management and enhanced care models available to patients and their carers.

Standard 6: Quality care during the last days of life.

The General Practice commits to: To meet this standard the practice commits to: Self-Assessment
6.1 Provide care in the Last Days of Life, that aligns with the Five Priorities for Care:
  1. The possibility that a person may die within the coming days and hours is recognised and communicated clearly, decisions about care are made in accordance with the person's needs and wishes, and these are reviewed and revised regularly.
  2. Sensitive communication takes place between staff and the person who is dying and those important to them. Conversations are appropriately documented.
  3. The dying person, and those identified as important to them, are involved in decisions about treatment and care.
  4. The people important to the dying person are listened to and their needs are respected.
  5. Care is tailored to the individual and delivered with compassion – with an individual care plan in place
 A practice policy agreement on caring for patients and those important to them in the last days of life, to recognise the objectives from the Five Priorities of Care above, to include:
  • Timely recognition of imminently dying person
  • Care is safe, effective, responsive and appropriate
  • Care plans are developed, implemented and reviewed regularly to support people who are imminently dying, their families and carers
  • Timely symptom control assessments using best-practice guidance and tools
  • Evidence that patients, family and carers are provided with information and support in accessible ways
6.1b Implement the five priorities of care (or equivalent in Wales)
  • Audit to evidence implementation.
  • Invite and review feedback from patients and those important to them.
  • Have an escalation process in place to raise issues and concerns with relevant stakeholder.
6.2 Provide treatment appropriate to the needs of the patient in the last days of life 6.2a Be able to prescribe and have readily available medications to control symptoms and for anticipatory prescribing in the last days of life
  • Local guidance within the practice on how to prescribe anticipatory medications.
  • Shared practice agreement on how to access palliative drugs in and out of hours.
6.2b Be able to access someone to set up and use a syringe driver.
  • Local guidance within the practice on the use of syringe drivers.
6.3 Monitor the quality of care per death provided to include the whole EOL period 6.3a In practice mortality review for all patients using RCGP Marie Curie EOLC example audits MDT template and Example after death audit report template found on the learning resources page.
  • At each MDT, discuss, complete and record mortality reviews on all deaths between MDTs, ideally monthly.
  • SEA for deaths covering the last days of life, written up and discussed with the practice team.
  • Share learning outcomes with team and wider stakeholders, as necessary. e.g. CCG, GP cluster group (Wales), HSCP (Scotland), hospitals, community providers.

Standard 7: Care after death and Bereavement Support.

The General Practice commits to: To meet this standard the practice commits to: Self-Assessment
7.1 Have understanding and be able to manage grief and bereavement 7.1a Understand the process of anticipatory grief and bereavement
  • Roles and responsibilities for each team member discussed and recorded
7.1b Understand how all staff can support bereaved people
  • Practice policy of what patients and carers can expect from the practice to support their individual anticipatory grief and bereavement needs e.g. compassionate bereavement response, condolence letters, information leaflet, death certification, bereavement call/ visit, referral to services
  • Practice plan on verification of death and certification
7.2 Knowledge of local systems 7.2a Ensure the bereaved are aware of how the practice can support and also local support available Practice support information available:
  • How the practice can support a bereaved person
  • Local / National offer signposting to available bereavement support in the community and services

Standard 8: General Practice being hubs within Compassionate Communities.

The General Practice commits to: To meet this standard the practice commits to: Self-Assessment
8.1 Support the development of compassionate communities 8.1a Develop the practice itself as a compassionate community
  • Discussion in practice meeting what would be expected within a practice to actively support practice team (clinical and non-clinical) in personal death, crisis, loss.
  • Practice plan documented for supporting staff in loss.
  • Plan annually reviewed.
  • Staff survey.
8.1b Learn lessons from patients and their carers System is in place to actively debrief staff and wider team on deaths, particularly where death is unexpected or goes wrong:
  • This could be as part of discussion of deaths at practice meeting or MDT.
  • Survey of patients and/or bereaved relatives and carers.
  • SEA recorded and shared when one has occurred.
  • Respond to any compliments or complaints and share lessons learned.
  • Evidence a system is in place to record and track actions of incidents/ compliments/ complaints/ feedback in order to understand and learn from the care and experience of people who died within the practice over the year, for example, against SWOT analysis.
  • Patient / carer with lived experience sensitively invited to be on an active PPG.
8.1c Utilise wider community resources
  • Has information on the benefits of primary care practice models for social prescribing.
  • Has information showing how to access to community support groups to combat issues such as, isolation and loneliness.
  • Refers to community support groups.
  • Practice system in place outside consultations, to actively support people affected by life-limiting illness, death and dying, long term caregiving and bereavement by for example, having at least one of the following:
  • Patient groups, for example, carers, bereaved, people living with life-threatening illnesses or the very old, to meet each other so that they may seek support from each other.
  • Practice volunteers, for example, rotating neighbourhood volunteer groups.
  • Practice register of patients with relevant experience who may wish to be involved.
  • Support to the wider community, for example, offering support to formal and informal carers.
  • Services offered by voluntary sector linked with the practice.
  • Services offered by practice (+/- in collaboration) as part of primary care network/ federation, social prescribing or community development services.