Company no: 1921087
292058
Charity no:
QUALITY ACCOUNT 2012/13
Mildmay Mission Hospital
Registered office;
2 Austin Street
London
E2 7NB
“This Hospital is very clean, well maintained, patient-focused and has a
caring environment”. Quote from an Independent assessor undertaking the
2013 Patient Led Assessment of the Care Environment (PLACE).
“Staff treat you as an individual with respect and dignity”. Quote reported
from a patient in the 2013 unannounced Care Quality Commission inspection.
“I sincerely hope that Mildmay Hospital will continue to open its doors for a
long long time, bringing Health and Care to those in need”. Quote from
family member of patient.
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Part 1 – Responsible Individual’s Statement
Mildmay Mission Hospital (herein after referred to as ‘Mildmay’) is a voluntary
charitable hospital and rehabilitation unit that delivers services to the NHS through
the mechanism of a multilateral contract with 24 London Primary Care Trusts (PCT’s).
It also accepts duly scrutinised spot purchased referrals from any other UK source
that could include PCT’s, acute hospitals, self payers or E.U. funding sources.
It is a tertiary healthcare provider of specialist care and rehabilitation of people
living with complex HIV related conditions, particularly HIV Associated Neurological
Disorder (HAND) also known as HIV Related Neurological Impairment (HNCI) or AIDS
Dementia.
On behalf of the board of trustees, I would like to thank all our staff and volunteers
for their achievements over the past year. Despite the very challenging current
economic climate, Mildmay has continued to provide high quality services and, at a
parliamentary enquiry, has been recognised to be a valuable resource to the NHS.
Mildmay has a robust scrutiny of income and expenditure involving all budget
holders in partnership with the senior management team to monitor and manage its
budget.
Quality and Patient Safety are paramount for Mildmay and the Spencer House Unit is
an international beacon of good practice in the specialist field of HIV related
Neurological Disorder. Mildmay has hosted international visitors and had medical,
nursing & therapy interns from Europe, Africa & Canada in the past year.
Mildmay is registered with the Care Quality Commission to deliver services under four
regulated categories, they are;
Long Term Care (LTC) – this is a category that encompasses our work in
the ongoing medical & nursing care and support of people, living with
complex HIV related conditions.
Rehabilitation (RHS) this is aimed at people living with complex HIV
related conditions and HIV related Neuro Cognitive Impairment (HNCI)
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Palliative Care (HPS)- Mildmay continues its pioneering work in the field
of hospice end of life care of people with HIV related conditions.
Diagnostic & Screening Services (DSS) – this category enables Mildmay
to assess, screen, stabilise and rehabilitate people with complex HIV
related conditions.
An unannounced inspection by the Care Quality Commission (CQC) on 14th
February 2013 identified that ALL the indicators that they scrutinised were fully met.
The senior management team attributes this to the hard work of staff who continue
to embrace the challenge of change and respond appropriately to embed quality
improvements into practice at our Spencer House Unit.
The safety, care and support experience and the outcomes for patients and day
service users are of paramount importance in the understanding of what Quality
looks like at Mildmay, and Mildmay voluntarily completed a Patient Environment
Action Team assessment in February 2012 which has contributed actions to the
continuous improvement action plan for the Unit. The score of ‘GOOD‘ at 82% was
limited by some design issues limiting day service use and which will be significantly
addressed when we move to the new unit in the Autumn of 2013. This mechanism
was replaced by the Patient Led Assessment of the Care Environment (PLACE) and
a team of independent assessors including day clients, will review the unit on the 27th
May 2013 and conduct an online assessment.
Infection control standards have been consistently high throughout the year and are
indicative of an attention to detail that makes Mildmay the assessment,
rehabilitation and recovery unit of choice for many referring health care
professionals.
Through effective clinical governance, the Mildmay Clinical Governance
Committee, chaired by a board member, oversees the clinical & nursing care and
practice and the rehabilitative care and support delivered by Mildmay by receiving
reports and scrutinising a range of internal and external groups and key officers.
The 2011 House of Lards select committee on HIV in its transcript to Question
500 heard testimony that: “Mildmay because it is a jewel and we need more of them.
There is going to be a need for more of those for one particular reason, which is that, as people
are living longer with this disease, it would appear that HIV-related cognitive impairment—that
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is brain impairment—is beginning to happen. As people are getting into their third decade with
this virus, it would appear that we are beginning to see things that we never really anticipated
before. One thing that Mildmay is trying to become a centre of excellence in is cognitive
rehabilitation—that is supporting people in recovery and living in the community with perhaps
irreversible brain impairment, with learning and memory problems. So, this is just beginning to
surface.
I am responsible for the preparation of this report and its contents. To the best of my
knowledge, the information reported is accurate and compliant with the
requirements of the Health Act of 2009, and the NHS (Quality Accounts) Regulations
2010 and the 2013 amendment ‘The Quality Accounts reporting arrangements for
2012/13’.
Michael Albero
Operational Director
Registered ‘Responsible Individual’
Mildmay Mission Hospital
20th June 2013
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Part 2 - Planned Priorities for Improvement 2013-14
2.1 Objectives
2.1. 1 Objective 1- Maximise Occupancy & Consolidate services
We will seek to achieve a sustainably occupancy profile. Occupancy is the key to
financial and quality stability for Mildmay. As a small unit, subtle variations of referral
can have a significant effect on cash flow and viability.
The challenges of the reorganisation of the NHS and the need to connect with and
respond to the new architecture of the NHS will add to the uncertainties and the
need to renegotiate contract in 2013/14 for the year 2014/15 is a paramount
concern as it has been five years since Mildmay was able to achieve a full cost
recovery contract value, meanwhile demand for our services has seen increases in
complexity and in greater experience of challenging behaviours.
Mildmay acknowledges that investment may be needed to significantly change the
mechanisms for patient acquisition in the new architecture of the NHS.
2.1.2 Objective 2 - Maximise Voluntary income
We will seek to increase voluntary income to the charity. Diversification of income is
a step that can reduce the risk of dependency on a single contract and can
contribute to achieving other objectives such developing an education and training
resource, & innovation in service delivery. This work is underway with a fit out cost
capital fundraising appeal for our new hospital. We will explore scope for
sponsoring of some therapeutic functions of the hospital.
2.1.3 Objective 3 – Awareness Raising
We will seek to raise awareness of the HAND work of Mildmay building our
stakeholder base, creating tranche of training and development materials and
develop a media engagement strategy. We will focus our marketing on the launch
of the new Unit in the autumn of 2013 and will seek to develop a marketing strategy
that balances the needs of confidentiality and awareness.
To this end Mildmay has been undertaking the ‘NHS Information Standard’ kite mark
assessment process and is hopeful that we will be assessed as compliant with the
strenuous expectations of the provision of information aimed at the production of
good quality information that is clear, relevant, evidence based, authoritative,
complete, secure, accurate, well-designed, readable, accessible, up-to-date.
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Mildmay will also seek to re-launch its education function as part of a planned
continuation of the teaching function heritage of the original 1866 Mildmay Mission
Hospital Charity.
2.1.4 Objective 4 – Safe & efficient move to new Site
We seek to achieve an effective and efficient move to the new hospital on part of
our former site at the end of 2013. We will oversee the fit out and manage the
building handover and systems testing in a four week window to maximise safety
and to ensure scope for learning about systems and equipment in the new unit. We
wish to minimise disruption to the patients on site at the point of move but to
participate in the build process to ensure the management need and functionality
of the new building meets the needs of our service and enables future flexibilities.
2.1.5 Objective 5 –Innovation
We will continue to explore the design of new services. We will build on our
experience of innovation in the delivery of appropriate services for people living with
complex HIV conditions.
We have achieved funding for a specialist Black African Male Support Worker post
that will deliver outreach services to the most vulnerable cohort of patients, the
group most likely to have late diagnosis or be undiagnosed and the group most
likely to experience advanced medical and psychological intervention from the NHS
as a result of stigma, discrimination, poor access to health education and complex
sociological pressures.
We shall also explore the potential for an additional mental health service at the
new unit that could respond to the continuing complex experience of late stage HIV
infection and which would seek to address an identifiable gap in current health
service provision in London.
2.2 Statements of Assurance from the Board.
During the period Mildmay submitted quarterly reports to commissioners, key
gatekeeper stakeholders and referring officers in the form of a traffic light key
performance indicate table with commentary. It has also submitted appropriate
notifications to the Care Quality Commission and other key stakeholders.
Mildmay senior management team also submitted quarterly reports to the board
including snapshots of cases, budget statistics and a progress report on meeting key
objectives and explanations about opportunities and obstacles encountered. It
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received risk management reports and risk profiles that assist in addressing area of
concern and improving quality in the Unit.
Mildmay delivers services under contract and in accordance with a service
specification embedded in that contract, five care and treatment pathways
agreed with our commissioning stakeholders and which form part of our unique
service specification.
The Unit Medical Director, Dr Simon Rackstraw, was elected a Fellow of the Royal
College of Physicians in the period and continues to be in demand for knowledge
sharing and information exchange.
The closing of the year had no reportable ‘red indicators in the key performance
indicator profile. This year has been a roller coaster with some PCT’s being very
defensive in their spending and some diversion of potential patients to different and
possibly less specialised facilities. That has led to the board’s increased scrutiny of
the Unit’s financial sustainability, mindful that in such a small unit, the even small
variations in numbers have a dramatic effect on cash flow.
The Senior Management Team meet monthly to review incidents, staff performance,
operational issues, to drive progress on strategy and the business plan. It oversaw the
work of a number of standing committees (Risk Management, Clinical Governance,
Staff Forum, Budget & Resource Review) and it ensured that a range of monthly
internal audits were presented as well as the quarterly Morbidly Audit.
The 2012-13 year has seen an efficient consolidation despite a challenging financial
environment, and while the need to achieve more financial efficiencies is part of the
sustainability plan of the unit, the quality of service experienced by patient and day
clients remain the focus of the service delivery in the Unit.
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Part 3 - Review of Quality Performance 2012-13
3.1 Objectives
3.1. 1 Objective 1 Maximise Occupancy
We will seek to achieve a more sustainably occupancy profile. Occupancy is the
key to stability for Mildmay. Investment may be needed to significantly change the
mechanisms for patient acquisition.
A 35% improvement of the previous year evidenced greater efficiency in patient
acquisition, as did the use of a clinically trained admission officer to smooth the
access route into the unit.
3.1.2 Objective 2 - Maximise Voluntary income
We will seek to increase voluntary income to the charity. Diversification of income is
step that can reduce the risk of dependency on a single contract and can
contribute to achieving other objectives such developing an education and training
resource, & innovation in service delivery.
This work is underway with a fit out cost capital fundraising appeal for our new
hospital. We will continue to explore scope for sponsoring of some functions and
roles of the hospital.
3.1.3 Objective 3 – Awareness Raising
We will seek to raise awareness of the HNCI/HAND work of Mildmay building our
stakeholder base, creating tranche of training and development materials and
develop a medial engagement strategy. We will focus our marketing on the launch
of the new Unit in the autumn of 2013 and will seek to develop a marketing strategy
that balances the needs of confidentiality and awareness.
Mildmay continued to be highly commended as a nursing placement for 22
students and 9 therapeutic placements where achieved in the period.
The number if external ‘talks’ far exceed previous years and therapists were
encouraged to speak in their own professional sub group meetings, conferences
and events and also to write for their respective periodicals.
Mildmay was invited to speak at a number of regional events to explain its work and
practice.
Journal articles by our Medical Director and by our senior Occupational Therapist
have all contributed to professional awareness raising in the year.
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Mildmay also connected to a range of key stakeholder’s top keep its profile high
amidst uncertainty about the future of its contract and as part of relationship
building with new officers, structures and mechanisms in the new NHS.
3.1.4 Objective 4 – Move to new Site
We seek to achieve an effective and efficient move to the new hospital on our
former site. We will oversee the fit out and manage the building handover and
systems testing in a four week window. We wish to minimise disruption to the patients
on site at the point of move but to participate in the build process to ensure the
management need and functionality of the new building meets the needs of our
service and enables future flexibilities.
This objective reappears as 2.1.4 (above) as the planning and contract allocation
processes delayed the start on site of the new build. The new build is now visible
and planning in underway to affect an efficient transfer to the new site before
Christmas 2013.
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4. Commentary
4.1 Patients and Day Service User feedback
Day service clients have a client forum that can call any officer of Mildmay to
account. It can comment about any aspect of the experience of being a service
user and it can hold to account the programme, policy & management of the day
service team.
Feedback from in-patients is obtained from a range of methodologies; Independent
Patient Champion interviews, exit interviews, feedback forms (with anonymity)
feedback to key workers, contribution to care planning and access to senior staff or
feedback via their community nurse specialist are all processes where a patient
engagement strategy can be evidenced.
Patient/day client involvement in the Patient Led Assessment of the Care
Environment (PLACE) will occur in the year ahead, drawing the service user
perspective into the self assessment and eternal assessment process of Mildmay.
A new Independent Patient Advocate is being recruited to by the board in the
hope of embedding a patient champion at the heart of the policy, strategy and
work of Mildmay.
Feedback from next of kin, carers, friends, visitors, relatives and significant others is
encouraged in face to face encounters and by the provision of feedback forms and
suggestion boxes on the Unit.
4.2 Mandated statements
4.2.1 Review of Services
During 2012-13 Mildmay had capacity for 5840 in-patent bed nights and 3200 day
service placements.
In 2012/13 we provided 4602 in-patient bed nights for 118 people and 2238 day
service placements for 81 community clients and 40 inpatients.
In 2011/12 we provided 3414 in-patient bed nights for 101 people and 2139 day
service placements for 77 community clients and 35 inpatients.
Of these services, 98% were funded by the NHS and 2% by social services (continuing
care).
The Mildmay has reviewed all the data available to them on the quality of care, and
its entire management team have responded to lessons learned from incidents,
admission difficulties & reviews. The senior management team at Mildmay take
account of the reports from its risk management committee and clinical
governance committee as well as the staff forum, to seek to improve practice on
site.
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The income generated by the NHS services reviewed in 2012-13 represents 100% of
the total income generated from the provision of NHS services by the Mildmay for
this reporting period.
4.2.2. Clinical Audits
During 2012-2013 NO national clinical audits and NO national confidential enquiries
covered NHS services that the Mildmay provides. During this period Mildmay UK
participated in 0% of national clinical audits and 0% of national confidential
enquiries of the national clinical audits and national confidential enquiries which it
was eligible to participate in.
The national clinical audits and national confidential enquires that Mildmay was
eligible to participate in during the reporting period are as follows; NIL.
The local clinical audits and local confidential enquires that Mildmay was eligible to
participate in during the reporting period are as follows; NIL.
4.2.4. Research
The number of patient receiving NHS services provided or sub contracted by
Mildmay in this period that were recruited during that period to participate in
research approved by a research ethics committee was 20.
Mildmay was involved in conducting one area of clinical research studies in HIV
during the reporting period. The Senior Occupational Therapist was that clinical staff
member who participated in research approved by a research ethics committee at
Mildmay during this period.
4.2.5 CQUIN
NONE of the income of Mildmay Mission Hospital UK in 2012-13 was subject to
CQUINs (Commission for Quality & Innovation payments) due to the complex nature
of the service delivery. Therefore NO income was conditional on achieving quality
improvements and innovation goals through the Commission for Quality and
Innovation payment framework.
The 2014/15 contract may contain CQUIN stipulations; Mildmay awaits clarification
from its commissioning group.
4.2.6 Statement from the CQC
Mildmay has met the published ‘Essential Standards of Quality & Safety’ and its 2013
unannounced inspection is available for scrutiny to the public on the CQC website.
4.2.7 Data Quality
Mildmay’s in house records system (Palcare) was replaced by iCare in the period. It
is compliant with NHS records good practice requirement but Mildmay maintains a
mainly paper based record system at present. It meet information governance
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requirements and ids a mechanism used by a range of health & social care
providers, including specific NHS bodies to provide robust, accurate and data in
particular ‘outcome’ data.
Mildmay follows the UK Rehabilitation Outcomes Collective (UKROC) data
acquisition processes and provides data that is compliant with UKROC peer group
comparison frameworks and which contribute to evidencing outcomes for patients
who access Mildmay’s services. This reporting mechanism addresses inpatients only
at present and needs to be rolled out to day services in 2013/14.
4.2.8 NHS Number & General Medical Practice code validity
Mildmay has not submitted records during the reporting period to the secondary
uses service for inclusion in the Hospital Episode Statistics which are included in the
latest published data as it is not a requirement of the contract with our
commissioners, and it a measure which protects the confidentiality of people living
with a condition which still experiences stigma and discrimination in the community.
4.2.9 Clinical Coding error rate
Mildmay was not subject to the Payment by results clinical coding audit in 2012/13
by the Audit Commission.
4.2.10 Complaints & Incidents
A total of 72 comments were received of which 19 were treated as complaints that
were satisfactory resolved by the second stage in complaint handling. Other
comments resulted is some changes of process, practice and in procedural reviews
as well as praise to staff, teams and decision makers.
A total of 62 untoward incidents and 2 serious untoward incidents were reported;
they were reviewed by the Senior Management Team and resulted in improvements
in practice.
Three medically adverse incidents were analysed by the Medical Director and
resulted in the identification of training needs and better induction of rotation
doctors, agency & bank nursing staff.
4.2.11 Summary hospital-level mortality indication (SHMI)
The value, banding and supporting palliative care data which is used as a hospital
level indicator which measures whether mortality associated with hospitalisation was
in line with expectation does not apply to Mildmay as a tertiary health service
provider.
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Only 4% of patients admitted in the period were admitted for palliative care, each
died with a detailed end of life care plan agreed with them, their families and or
their referring community nurse specialist.
4.3 Mildmay’s action in the NHS Outcomes Framework domains;
4.3 1. Domain 1 Preventing people from dying prematurely
The British HIV Association (BHIVA) ‘Standards of Care for People Living with HIV 2013’
states that late and very late diagnoses is a major cause of diminishing life
expectancy for people with HIV. Late diagnosis (less than 350 CD4) represents 66%
of Mildmay patient throughput; very late (less than 200 CD4) represented 29% of
Mildmay patient throughput.
The Mildmay caseload addresses immediate interventions to stabilise the condition
of an individual and to assess and rehabilitate, and, where possible, to significantly
improve that condition by the encouragement of and education about adherence
to an effective regime of medication and the achievement patient cooperation
with medical and therapeutic care.
4.3.2. Domain 2 Enhancing quality of life for people with long-term conditions
Mildmay achieve that goal of enabling people to have access to and engage with
specialist care for these experiencing HIV and chronic related conditions. The
service contributes to the preventing of complications of HIV and if/when they occur
initiating prompt and appropriate management that contribute to the minimisation
of HIV morbidity.
The teaching of self management skills in our day service with its expert patient
group and programme of community orientation, physiotherapy and independent
living skills all contribute to the empowerment of the individual to make informed
choices about their future care.
Coordination with community services for those with long term health & social care
needs is part of the purpose for people being discharged from acute units to the
Mildmay. As a discharge pathway of choice for two acute hospital units, part of the
function of Mildmay is to undertake assessment & rehabilitation and or make
recommendations for the future long term care and support of people living with
HIV.
4.3.3. Domain 3 Helping people to recover from episode of ill health or injury
Mildmay has particular experience in supporting and treating people with an
experience of a wider range of complications resulting from the direct effects of
HIV, its treatment and an increasing range of associated co morbidities/ As part of
that provision of prompt and specialist care for complex treatment, Mildmay
contributes by engaging its multidisciplinary team across a wide range of
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professions with the person with HIV being at the centre of care planning that
address the physical, psychological and spiritual impact of living with a serious illness.
Helping people acquire self management skills is an element of this domain and is at
the heart of our service delivery. Rehabilitation is a partnership approach aiming to
achieve restoration of skills & ability whole or partially, to enable the individual to
have more choices in their future care and support options.
4.3.4 Domain 4 Ensuring people have a positive experience of care
The use of key working is vital to maintain excellent caring & professional
relationships which are holistic and person centred and places the person living with
HIV as the co-constructor of the care plan for their engagement with Mildmay.
The Mildmay dignity code provides a framework for engagement with all
patients/clients and acts as a beacon of good practice that underpins activity such
as protected mealtimes to ensure effective nutrition and the use of person centred
timetables to prompt patients to engage with a range of therapists while using the
services provide evidence of its application.
The engagement of patients as positive partners in the design of their care, rather
than passive recipients is at the heart of service delivery but the cognitive and
behavioural elements of neurological disorder can limit the capacity of an individual
to engage, a key element of service delivery and can prompt the use of the
Deprivation of Liberty Standards (DOLS) procedures and the use of an independent
capacity advocate (IMCA) and best interests assessors to intervene where a person
lacks capacity.
4.3.5 Domain 5 Treating and caring for people in a safe environment & protecting
them from avoidable harm
Working with patients / day clients to understand the mechanism of passing on the
virus can lead to counselling to consider working to engage with families & partners
to ensure appropriate disclosure and to prevent fear and stigma interfering with safe
practice and knowledge sharing with other services.
Counselling to enable fluid communication between HIV specialist care and other
secondary and primary care teams is part of the approach to prevent the harm.
Continued Professional Development is also a key element of maintain skills and
abilities to update on continued improvement in practice.
Confidence in the security of their data and confidentially about their diagnoses,
condition or even their presence in the unit are part of the relationship building that
contributes to protection from harm and maintaining a safe environment for all
service users.
5. ANNEX sources of supporting statements
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In compliance with the regulations, Mildmay sent copies of our Quality Accounts to
the following stakeholders for comment prior to publication.
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The lead commissioner of our Pan London multilateral Contract
All 16 known commissioner part of the Pan London Mildmay Commissioning
Group
All 25 referring CNS’s in receipt of monthly & quarterly performance reports
The Overview & Scrutiny Committee (OSC) of the London Borough of Tower
Hamlets or its Health Board.
Health watch
The Quality Assurance Directorate
The Friends of Mildmay
At the point of publication no consultation comments had been received 20- June
2013
End
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