INVESTOR NEWSLETTER ISSUE N°3 FALL 2005
Nothing seemed too much trouble to make my wife's last days comfortable. The care was compassionate, the care was flexible, the care was holistic. The Hospice made the last days dignified, precious and amongst the most treasured of our lives together”
Carer’s comment about Inpatient Services
1

Our Mission, Vision and Values
Statement on Quality from the Chairman on behalf of the Trustees and
Chief Executive
2.1
2.2
2.3
2.4
Priorities for Improvement 2015/2016
Priority 1: Patient Safety
Priority 2: Clinical Effectiveness
Priority 3: Patient Experience
Statements of Assurance from the Board relating to the Quality of the
Services Provided
2.2.1. Review of Services
2.2.2 Quality Improvement and Innovation Goals Agreed with
Commissioners
2.2.3 Statement from the Care Quality Commission
Participation in Clinical Audits
Data Quality
2.4.1 Minimum Data Set
2.4.2 Information Governance
3.1
Review of Priorities for Improvement 2014/2015
Priority 1: Patient Safety
Priority 2: Clinical Effectiveness
Priority 3: Patient Experience
3.2
3.3
3.4
3.5
The Patient and Family Experience of the Hospice and its Services
Our Staff and Volunteers
Statements of Assurance
3.4.1 Statement from Isle of Wight NHS Clinical Commissioning Group
3.4.2 Statement from Isle of Wight Healthwatch
3.4.3 Independent Statement from Sarah Johnston, Deputy Director of
Nursing, IOW NHS
Endorsement of Quality Account by Board of Trustees
Glossary and Further Information
How to Provide Feedback on this Quality Account and Acknowledgements
1
2
3
5
9
12
15
18
22
23
26
27
28

We are here for you and those you love, to help you to live well and die at peace in the place you choose
Building on the foundations of more than 30 years …
To lead and develop services which ensure an effective and timely response to the needs of those in our Island community with life- shortening illnesses
• We will reach more people
• We will meet the needs of more people affected by death and bereavement
• We will ensure that as long as we are needed, we will be here for future generations
At Earl Mountbatten Hospice we strive to be:
Patient-focused - understanding the needs of each patient, their family and carers
Community-focused - recognising and appreciating the contribution of staff, volunteers and Island people
Accessible - offering care, support and advice to anyone with a life-shortening illness
Positive - compassionate and responsive, promoting the enjoyment of life
Efficient - using our resources wisely
EMH John Cheverton Centre Sunflower Cafe Decking
Quality Account 2014/15 - Part One 1

I am very pleased to present the third Quality Account for Earl Mountbatten Hospice.
We are extremely proud of the high quality of services we provide to Isle of Wight patients and their families. We are not complacent and we work hard to continually improve the care and quality delivered by our staff and volunteers.
The quality of our care is only as good as the skills, compassion and leadership of the people delivering it. In 2014 we invested in a leadership programme for twenty of our managers and have been impressed with the impact this has had across the organisation; and it is already directly improving the quality of care. You can read more of the detail in the following report.
We have made good progress in achieving our priorities for 2014/15. The increased training and support has helped to implement the new Islandwide symptom control guidance. More patients in their own homes are benefiting from the increased occupational therapy we have secured in 2014 and we are expecting to expand this provision going forward. We still have some improvements to make with regard to access to Wi-Fi and internet across the Hospice and we have yet to implement a social space in the Inpatient area but we are confident that both these priorities will be addressed early in 2015.
I am particularly pleased that the priorities for 2015/16 have been developed following discussion with, and involvement of, patients, service users, families, staff, trustees and volunteers. They follow the three themes required by the regulations of
Patient Safety, Clinical Effectiveness and Patient Experience and are detailed in part two of this Quality Account. These priorities are designed to ensure EMH provides the highest quality of care and progress in achieving them will be carefully monitored through the Patient Services Committee.
The Board and Earl Mountbatten Hospice’s team of senior managers have been closely involved in this review and in developing these priorities, which have been ratified by the Board of Trustees. I am able to confirm that the information in this
Quality Account is, to the best of my knowledge, accurate.
Quality Account 2014/15 - Part One 2

1 April 2015 – 31 March 2016
At Earl Mountbatten Hospice we are continually reviewing the quality of our services to improve and further develop them. In consultation with patients, service users, staff, volunteers and Trustees, through our interactive focus groups, eight areas for improvement have been identified that are considered essential to enhance the provision of high quality care. An action plan has been produced identifying nominated key leads to work with staff, volunteers, patients and service users to drive the identified priorities for improvement. This action plan will be monitored by the Patient
Services Committee on a quarterly basis.
Target How we measure success
1.1 To ensure multi-disciplinary team (MDT) documentation meets the NHS record keeping guidelines
• Audit of MDT documentation achieving 90% compliance against the NHS record keeping guidelines
• The audit will also consider continuity by ensuring documentation is in chronological order when patients move across the clinical areas.
1.2 To ensure that EMH’s sepsis management practice fully addresses patient safety and reflects national best practice
• Policy document is in place
• 90% of relevant clinical staff have attended sepsis management training sessions.
1.3 To develop a plan of action to manage major incidents to include evacuation procedures and practice drills
• Approved policy and procedure describing the management of major incidents is in place
• Two practice drills take place during 2015/16 and any adverse actions are recorded and acted upon.
Quality Account 2014/15 - Part Two 3

Target
2.1 To ensure that inpatients and Day
Services patients receive a balanced diet through the correct management of hydration and nutrition, and have choice and flexibility of food/drink
2.2 To ensure that inpatient’s end of life wishes and preferences are understood at an early stage of care by developing a
‘This is me’ profile
How we measure success
• 90% compliance of completed documentation of nutrition assessment and care plans in the
Inpatient Unit and Day Services
• 80% of patient experience surveys in the
Inpatient Unit and Day Services indicate satisfaction with the choice and flexibility of food/drink.
• Approved profile is completed and used for every patient on the Inpatient Unit
• 90% compliance of use of the profile or documented reason for it not being used, measured through the MDT documentation audit.
2.3 To review Multi-disciplinary discharge planning to ensure a seamless transition from the Inpatient Unit to home or other location
• An updated discharge policy and procedure is in place
• 90% of relevant staff attend discharge planning training workshops
• MDT documentation audit demonstrates 90% compliance with a documented discharge plan.
Target How we measure success
3.1 To fully implement a social space for inpatients, including access to computers and Wi-fi, following the quality measure set in 2014/15
• A social space with computers and Wi-fi is available for use by inpatients
• A comments book is available in the newly developed social space inviting feedback from patients.
3.2 To provide all inpatients with a welcome pack containing relevant information for them and their families
• A welcome pack, including all current and topical information relevant to the services
EMH provides, is available for all inpatients and their families
• Feedback from the Inpatient Experience
Survey indicates that more than 80% of patients received the pack
• An opportunity for patients to feedback any changes/improvements to the welcome pack they would wish to see as part of the survey.
Quality Account 2014/15 - Part Two 4

During 2014/15 Earl Mountbatten Hospice provided specialist palliative care services within the following areas:
• Inpatient Unit
• Day Services at EMH John Cheverton
Centre (JCC)
• Community
• Outpatients
• St Mary’s Hospital
• Nursing/residential homes
These areas are supported by the following services:
• EMH/Macmillan Specialist Care at Home
Team
• Psychological Services
• Chaplaincy
• Care Manager
• Physiotherapy
• Occupational Therapy
• Complementary Therapies
• Specialist Lymphoedema Service
• Creative Therapies
• Information and Support Centre
• Education
• Voluntary Services
The ethos of high-quality education and training underpins the provision of care across all settings. Hospice staff are supported in their mandatory training requirements and are actively encouraged to advance their continuing professional development.
In January 2014 an “organisational climate” report outlined clear recommendations for leadership development that had the potential to develop the leadership capability of Earl
Mountbatten Hospice to meet the future challenges of delivering end of life and hospice care. A bespoke leadership development programme, ‘Leading from the Middle’, was designed for twenty middle managers across the organisation which incorporated the following objectives to:
• explore the role of middle managers in developing the organisation
• appreciate the styles of leadership required in the future
• develop collaborative skills, both internally and externally
• learn and practice action learning for the benefit of hospice teams
• apply learning, knowledge and skills to a strategic imperative and achieve a practical outcome
• experience working as part of a project team and transfer learning to other hospice teams
• present project findings to senior leaders both executive and trustees
• promote leadership development as a dynamic process which could be sustained rather than a ‘one-off’ investment.
The programme enabled and empowered staff operating in the middle of the organisation to work on operational challenges and deliver tangible outcomes. Key middle managers worked in collaboration with the Executive
Team and Trustees (key individuals acted as team coaches and champions), focusing on three strategic priorities and the crafting of four projects which would enable the Leading from the Middle team to ‘influence upwards’.
EMH Leading from the Middle Group, cohort 1
Quality Account 2014/15 - Part Two 5

The programme commenced in July 2014 and culminated in a Learning Forum on 7th
November 2014, led and organised by the
Leading from the Middle Group. During this one-day event, the teams shared their project outcomes and team learning with a wider audience. It was a celebration of success with coaches and champions supporting the event.
The project titles were as follows:
• ‘Mind the Gap’: researching the gap in living beyond a person’s diagnosis
• ’50 Shades of Volunteering’: researching and developing a strategy for Voluntary Services at EMH
• ‘Reduce, Reuse, Recycle’: an in-depth investigation to explore ways to reduce and recycle waste more effectively and cost-efficiently, identifying opportunities to create a revenue stream from these activities
• ‘Beyond the Walls’: research into how the philosophy and practice of local hospice care can reach more people, more of the time.
The programme will be evaluated in April 2015 following a period of reflection on learning by programme participants, coaches and champions. In this context, the purpose of evaluation is to provide evidence of learning that has been applied and sustained over a period of time. A second cohort of staff will commence the programme in April 2015.
“The Leading from the Middle programme has given middle managers at EMH a new zest for life” 2014 course participant
The Palliative Care Clinical Nurse Specialists,
Hospice @ Home team and the Mountbatten
Nursing Service were amalgamated in April
2014 to form the integrated EMH/Macmillan
Specialist Care at Home team. This coincided with a successful bid to Macmillan Cancer
Support to become one of six innovation centres across the country to implement an innovative model of palliative care in the community. Medical Consultants are now an integral part of the team and carry out regular domiciliary visits and liaise closely with primary care colleagues. We now treat many more complex symptoms in the home setting. We are developing the service to deliver blood transfusions at home (if appropriate) and other interventions. This ensures patients can spend precious moments of life at home rather than in an acute care setting if this is their preference.
A new post, Head of Clinical Quality and
Patient Experience, was created and the new post holder commenced in January 2015. The role was developed to provide leadership of nursing and healthcare professionals across the EMH clinical teams, to achieve continual quality improvements in EMH’s services for the experience of our patients and their families.
During 2014/15 EMH provided five NHS specialist care services:
1.
Inpatient Palliative Care
2.
Hospital Palliative Care
3.
Community Palliative Care
4.
Lymphoedema Service
5.
Psychological Services
EMH has reviewed all the data available to them on the quality of care in these five services. This has included carrying out a full service review of the Lymphoedema and
Occupational Therapy Services by an external expert.
Becky McGregor - Head of Clinical Quality and Patient
Experience in our family overnight room in the Inpatient
Unit
Quality Account 2014/15 - Part Two 6

The Schools Project, a partnership between the Hospice and local primary schools, was piloted in 2013 and during 2014 five projects have been delivered. A group of up to twelve primary school pupils from a local school, accompanied by their teaching staff, come to
EMH John Cheverton Centre for a series of eyes of children’. At the end of each programme, families, carers, school teachers and governors are invited into the JCC to see and hear about the work that patients and pupils have shared together. afternoons to learn about the Hospice and take part in a themed creative activity with Day
Services patients. Learning activities include a tour of the Hospice and Inpatient Unit, demonstrations of medical and nursing equipment, and learning to hoist their teacher!
The children are encouraged to take their learning and discussion back to their homes and into the wider school community, promoting the work and philosophy of the
Hospice and educating others ‘through the
• Earl Mountbatten Hospice is a registered charity and our patient and family services are delivered free of charge to our Island community. These specialist end of life/ palliative care services cost £6 million.
• We rely heavily on the support of our community through donations, legacies and grants, and our charity shops raise over £3.5 million each year to enable us to continue to deliver compassionate and timely care to local people, in the place of their choice.
• The income generated by the NHS services reviewed in 2014/15 represents
37% of the total income generated from the provision of NHS services by Earl
Mountbatten Hospice for 2014/15.
• EMH receives an annual sum from the
NHS Isle of Wight Clinical Commissioning
Group.
• We review all our services on an ongoing basis to ensure we are delivering them efficiently and that we spend our money wisely. This is particularly important in the light of the challenging economic climate we currently face. High quality, compassionate care for our patients and their families remains our number one priority.
Quality Account 2014/15 - Part Two 7

Two quality improvement and innovative goals were agreed with the Isle of Wight
Commissioning Group in 2014/15. These were: i) Organisational Development Plan following a mock Care Quality Commission
(CQC) inspection in February 2014.
Under the Health and Social Care Act 2008, there is a requirement for EMH to be registered with the CQC. The CQC monitors, inspects and regulates services to ensure that they are safe, effective, caring, responsive and well led.
The Leadership Team at EMH developed an organisational development plan with key timed actions. These actions were based on the recommendations for improvements made in the mock CQC inspection report to enhance compliance with CQC. ii) Hospice UK Patient Safety Data
Collection.
The Hospice UK benchmarking tool enables hospices to report, share, compare and learn from each other. The tool collects data for three quality metrics from the Inpatient Unit: falls, pressure ulcers and medication incidents.
Using the benchmarking data enables hospices to improve quality by comparing their performance to identify improvements that have been successful in other hospices.
Income of £58,770 in 2014/15 was conditional on achieving improvement and innovation goals through the Commissioning for Quality and Innovation Schemes (CQUINs) payment framework. Both quality improvement goals were achieved in full.
Further details on the agreed goals for 2014/15 and for the following 12 month period are available on request.
Earl Mountbatten Hospice (EMH) is required to register with the Care Quality Commission and its current registration is for the following registered activities:
• Personal care
• Treatment of disease, disorder or injury
• Diagnostic and screening procedures
EMH did not participate in any special reviews or investigations by the CQC during 2014/15.
The CQC has not taken enforcement action against EMH during 2014/15.
EMH is subject to periodic review by the CQC and the last review was 7 th May 2013. Their findings are shown in the table below.
Respecting and involving people who use services
Care and welfare of people who use services
Meeting nutritional needs
Requirements relating to workers
Records
✓ Met this standard
✓ Met this standard
✓ Met this standard
✓ Met this standard
✓ Met this standard
The CQC’s statement following that review was as follows:
“We inspected the following standards as part of a routine inspection. This is what we found:
We spoke with four visitors and one patient receiving care from the inpatient service. They said they were very happy with the way they were cared for. They said ‘the staff are wonderful and know what care is needed.’
We spoke with nursing, care and medical staff.
Staff were aware of how people should be supported, their individual likes and dislikes and the help they required. Staff stated they felt they had sufficient time to meet people’s needs. Staff also told us they had attended relevant training and had all the necessary equipment to safely care for people.
We found good recruitment and induction procedures were followed. Care plans and related care records were appropriate to people’s needs. People’s privacy and dignity were maintained and they or their relatives were involved in decisions about their care.”
Quality Account 2014/15 - Part Two 8

During the period 2014/15 there have been no national clinical audits and no confidential enquiries relating to the services provided by
Earl Mountbatten Hospice, therefore no work was undertaken in this area.
There were no requests from NHS England or the Isle of Wight Clinical Commissioning Group for specific audits during 2014/15.
In September 2014 a Clinical Quality and
Governance Committee was formed consisting of clinical leads. The Committee has devised an annual clinical audit programme across all clinical areas, which includes audits covering infection control, documentation and medication errors. A standard EMH reporting template for clinical audits has also been devised.
Clinical staff at all levels undertook audit training during 2014/15 to improve their skills in this area. The results of audits undertaken are reported at the monthly Clinical Quality and
Governance Committee meetings and displayed in all clinical areas for staff, volunteers, patients and family members to view.
A comprehensive governance and assurance report informs the Patient Services Committee meetings and the local Clinical Commissioning
Group. The report also includes completed audits, data gathered from clinical incidents, compliments, complaints and concerns, current mandatory training compliance, a summary of the status of the clinical risk register and a quarterly report of the Clinical Quality and
Governance Committee.
Since January 2014 Earl Mountbatten Hospice has taken part in Hospice UK’s national benchmarking pilot. Using benchmarking data enables hospices to improve quality by comparing their performance to identify improvements that have been successful in other hospices. The benchmarking reports are used to assure and provide evidence of quality to the Board of Trustees, CQC and our local
NHS CCG.
A chart showing a sample of completed audits can be found on page 10 of this report.
For completed local surveys see section 3.2 of this report, ‘The Patient and Family Experience of the Hospice’.
There were no opportunities for Earl
Mountbatten Hospice to participate in any local or national ethically approved research or clinical trials.
Throughout this report there are statements (in italics) which have to be included in the report by law. There are a number of these statements which are not applicable to this Hospice. These are listed in the final section of this report “
Glossary and Further Information.”
Quality Account 2014/15 - Part Two 9

Actions in an unexpected deterioration – documentation audit
Consent to invasive procedures
Medical 100% compliance other than completion of step plan in place (93%). Further education
& discussion with the clinical team about use of the step plan
Medical 1 00% of standards met but decision making process standard has been reviewed as a result of the audit
Standardised IW NHS Trust consent form
& patient information leaflet use implemented following audit
Medical 100% of standards met in all audits Deprivation of Liberty Safeguarding
Screening
Infection Control
Infection Control
(includes hand hygiene, personal protective clothing, peripheral venous access devices, MRSA, isolation, diarrhoea/C-Difficile, sharps, catheter management, catheter insertion, commodes audits)
Pharmacy Interventions
Environmental & Patient Feedback
(February 2015)
Venous Thrombo-embolysim (VTE)
Prevention Audit
EMH John
Cheverton
Centre
(JCC)
Inpatient
Unit
82–97 % compliance in clinical areas in
JCC
Full action plan in place following each audit with full team involvement
Action plans in place after each audit and work with all nursing, housekeeping and facilities staff to ensure wide ownership of actions and improvements to practice.
External audit by IW NHS Trust Infection
Control Team on 31/3/15 achieved full compliance (94%)
Pharmacy The Pharmacy team audit monthly the interventions that they make and code using the pharmacy risk register. This information is shared with the clinical team for learning and improvements in medicines management.
Inpatient
Unit
I ssues identified & full action plan put in place, working with clinical, housekeeping and facilities staff
Consider using standardised national
Department of Health tool for future audits
Pharmacy 1 00% of patients assessed for VTE in 11 out of 12 months
Quality Account 2014/15 - Part Two 10

Members of the Board of Trustees regularly undertake unannounced visits to gain insight into our hospice services. They talk to patients and their relatives/carers, staff and volunteers and ask them to share their views and experiences. The following examples are taken from several such visits undertaken in the last twelve months.
John Pulsford, Trustee, made an unannounced visit to EMH John Cheverton Centre where he was shown artwork in different media by one of the volunteers and chatted to some patients in the day services area . One patient said he comes in twice a week for physiotherapy and had nothing but praise for the services on offer.
He said that he enjoys the visits which give him a change of scenery, different company and the chance to take part in activities . John said that he learnt a lot about the people and services provided by the Centre through his chat with both the patient and the volunteer running the art class. In particular he learnt how patients benefit from the positive experiences associated with their visit to the department which helps them to express their feelings. He also spoke to one of the nurses about the work of Day Services and how it interacts with other services. The visit gave
John a better perception of the excellent facilities offered to day patients and how it fits into the rest of the work of EMH.
Sara Weech, Chair of the Board of Trustees, made several unannounced provider visits.
On 27th December 2014 she visited the
Inpatient Unit where she found the ward was quiet in terms of the numbers of patients but those who were in were very poorly and she was only able to speak to two patients. Both patients were very pleased with the care they were receiving. During her visit it became apparent that there would be no cover on the reception desk for a period of time because the volunteer receptionist had called in sick. This gave the nursing staff a problem which is now being addressed by ensuring that cover is available to cover unforeseen staff absence.
Sara spent some of the time with Dr Isaac
(duty doctor) and the staff in the staff room.
They said they enjoyed their work and that they felt the atmosphere in the Hospice was improving. Sara also spoke to the catering team, both of whom were bank staff. They regularly provide cover in the Hospice kitchen but as there were few patients over the
Christmas period they were not busy. Sara said ‘all the staff I met were polite, welcoming and patient focused’.
On 4th February 2015 Sara visited EMH John
Cheverton Centre where she spoke to a number of patients and volunteers. When she asked them for feedback on how they were being treated and what if anything could be improved, all the patients and volunteers were extremely complimentary about the JCC and the facilities available. One patient asked how she could make a donation or pay for the pampering services. She asked if a donation box could be available in the JCC, or she would leave it at reception. Most of the patients came in for just one day a week and really appreciated the time there. The staff were actively involved with the patients and there was a gentle and relaxed atmosphere in the
Centre. The patients and volunteers thanked
Sara for taking the time to visit.
Sara also spent a morning with the Hospice at
Home Team out in the community. She visited three patients, all of whom were very ill, and shadowed Steve, a nurse, who she found to be kind, patient, extremely thoughtful and conscientious. She also found he was mindful of the family dynamics in every household she visited and how they, as well as the patient, were coping. Sara commented “It was no less than I was expecting in some ways but it was powerful to see it in action. The families were all extremely positive about their experience of the Hospice”. Sara noted several minor points that she felt needed attention, including the nurse’s ability to contact staff for advice from the Hospice team and two families also reported problems with contacting the Hospice for help or advice. This has now been remedied via the development of a patient welcome pack which contains essential information including contact details.
Quality Account 2014/15 - Part Two 11

In accordance with an agreement with the
Department of Health, Earl Mountbatten
Hospice submits a Minimum Data Set (MDS) for Specialist Palliative Care Services to the
National Council for Palliative Care (NCPC) on an annual basis, with the aim of providing an accurate picture of hospice and specialist palliative care services activity. As this data has been collected in its current form since
2008/09, it now reliably reflects the activities within the Hospice and specialist palliative care service for the Isle of Wight community. More information on the minimum data set is available from the National Council for
Palliative Care www.ncpc.org.uk
The most recent data available from the
National Council for Palliative Care was made available in November 2014 and relates to the year 2013/14. A review of this information, which includes benchmarking with similar sized services and inpatient units both nationally and in the Wessex region, details the extracted information shown below about Earl
Mountbatten Hospice’s services.
• Inpatient Services . During 2013/14, 269 patients were admitted to the ward, some 25 more than the Wessex region average.
There were 224 new patients, an increase of
13 in comparison to the Wessex region median average of 211, and 23 when compared to the number of new patients in
2012/13. The majority (60.2%) of new patients fell into the 65-84 age range compared with the national average of
57.5%.
• Female patients numbered 126 compared with 143 male patients, close to the national average of 124 and male patients outnumbered the national average of 129 by
14. The average length of stay was just slightly higher for cancer patients (11.8 days) when compared to non-cancer patients (11.3) but both were less than the national average
(13.3 days cancer and 11.7 days noncancer).
• The Community Clinical Nurse Specialists saw a total of 484 patients, some 144 more than the national average, but some 294 less than the Wessex region average. The total number of visits (986) made to patients was below the national average (1060) by 74. The average length of care was 109 days compared to the national average of 94.6 days and the Wessex region average of 95.4 days.
• The Hospital Palliative Care Team saw
32.5% more patients (322) when compared to the national average of 243; the average length of care was18 days.
• Hospice at Home services saw 40 out of
191 patients with non-cancer diagnoses compared to the Wessex region average of
34 of also 191 patients. The average length of care provided by the team was 50 days compared to the region’s average of 44 days.
Home deaths numbered 165 compared to the average figure of 104 in the Wessex region.
• Psychological Services provided support to
276 users, some 135 more than the Wessex region average, of whom 33.3% were in the
65-84 year age range compared to the national average of 16.2% in the same age range. Interestingly 56.9% of the users were in the 25-64 year age range compared to
37.9% of the national average.
NB - All averages are median averages
Quality Account 2014/15 - Part Two 12

Data relating to patient occupancy, number of admissions and Non-Malignant Diagnosis for
2014/15 is shown in the following graphs.
Whilst this shows an increased trend since
2012 our two consultants in palliative medicine and Hospital and Community Nurse Specialists continue to work proactively with health and social care colleagues to promote the Hospice
Palliative care services available to patients with Non-Malignant Diagnosis.
The number of actual patient contacts by the clinical services offered by Earl Mountbatten
Hospice is shown in the graph below. It should be noted that this is not the number of patients but the number of times contact is made with patients, which could be more than once for each patient and by each service. The total number of contacts for this year compared with
2013/14 has increased by 19.7% (2598 contacts). This is mainly due to the increased capacity of the Community Team and Non-
Malignant diagnosis referrals.
Quality Account 2014/15 - Part Two 13

EMH is not required to submit records to the
Secondary Uses service for inclusion in the
Hospital Episode Statistics. In accordance with the Department of Health, it submits a
National Minimum Dataset (MDS) to the
National Council for Palliative Care.
Earl Mountbatten Hospice will be taking the following actions to improve data quality:
• The Hospice undertakes regular quality assurance checks of its data
• The Clinical Governance and Quality
Committee receives incident reports related to quality of data
• A Performance Information Officer and
Statistical Assistant are in post to enable robust data quality and reporting
• All new clinical staff are trained by the IW
NHS Performance Information Department in data input.
During 2014/15 Earl Mountbatten Hospice achieved Level 2 compliance with the
Department of Health Information Governance
Toolkit in most sections with Level 3 being achieved in two areas. This demonstrates that the organisation has robust processes to maintain protection and confidentiality of its patient information and that it adheres to data protection legislation and good record keeping practice.
EMH will be taking the following action during
2015/16 to improve IG within the organisation:
• working towards Level 3 compliance overall in 2015/16
• appointing a Senior Information Risk Owner
(SIRO) during 2015
• establishing an Information Governance
Group which will be led by an identified IG lead from the management team
• devising an action plan that will meet these commitments to IG which will be monitored at
Board level.
EMH Nursing staff reviewing patient documentation
Quality Account 2014/15 - Part Two 14

Target: To reduce preventable medicinesrelated incidents or harm to zero and enhance our ability to deliver multiprofessional medicines-related advice working with St Mary’s Hospital and local pharmacies
Medicines safety has been a key focus over the last year. Within the Hospice, the
Medicines Optimisation Team have instigated regular medicines management training, underpinning this with updated supporting guidance. Further, we have benefited from significantly increased pharmacy support which has streamlined the whole medicines pathway and significantly strengthened our second and third level checks to detect and avert safety concerns.
The team have also worked hard to deliver new Islandwide symptom control guidance tailored to the islands needs (e.g. ensuring use of familiar medicines where possible; clearly identifying which teams to approach for specific interventions), again underpinned by training sessions with community and hospital colleagues.
We have worked with colleagues from commissioning, general practice and community pharmacy to improve access to urgently required symptom control medicines for patients at home. Whilst our target was to reduce preventable medicines-related incidents to harm or zero we are working towards this target.
In 2014/15 we had ten reported level 0 medication incidents (errors prevented by staff or patient surveillance) and ten level 1 medication incidents (errors occurred with no adverse effect to patients).
Target: Carry out a robust review of current fire and safety procedures and address any issues following recent redevelopment work to ensure that EMH is a safe environment for our patients
A robust review of current fire and safety procedures was carried out following recent building redevelopment work and the following actions were completed as part of this review:
• Installing a new main fire alarm panel for the
Inpatient Unit which integrates with the other panels in the Hospice as part of the last phase of our redevelopment work which was completed in April 2014. The fire detectors within the Inpatient and Resources areas were also renewed to complete our update of the fire detection and alarm system.
• Reviewing and updating (where necessary) the signage for exit routes, fire extinguishers and assembly points for all areas following completion of the redevelopment work and the phased occupation programme.
• Linking our security system to our fire alarm system to ensure automatic unlocking of doors in the event of a fire and the automated production of a fire muster list in the event of fire alarm activation.
• Reviewing and updating our Fire Policy together with training requirements for our staff and volunteers.
• Testing our evacuation processes between
April and September 2015 as part of our review of emergency procedures.
• Fire safety forms part of our Health and
Safety meetings throughout the year, to ensure that there is an ongoing review of our fire safety precautions and procedures.
Quality Account 2014/15 - Part Three 15

Target: To widen access for palliative care patients in the community who may benefit from the skills and expertise of an occupational therapist
We have secured the services of an experienced Occupational Therapist (OT) for
15 hours a week. This brings expertise to enable more people to remain at home, more comfortably and safely, by supplying the right equipment in a timely manner and enables us to foresee future problems. The Occupational
Therapist plans to develop the service so that all patients are assessed for future need and their care is part of a seamless service alongside the EMH/Macmillan Specialist Care at Home. In order to extend the service to more patients the OT has trained one of our
Health Care Assistants (HCA) to become a trusted assessor. The HCA is now able to carry out low level assessments and we would envisage that other care assistants will be similarly trained in the next year.
Julie Morris, Senior Occupational Therapist (Community)
Target: Develop a new electronic patient recording system
Earl Mountbatten Hospice aims to improve patient care through improved communication between health professionals by implementing electronic records. Achieving this is a challenge because of the need for EMH to be able to integrate any system it uses with St
Mary’s Hospital as well as other Isle of Wight health services including General Practices and the Ambulance Service. During 2014 EMH investigated a number of options and liaised closely with the Information Technology
Department at St Mary’s Hospital.
The Hospice’s doctors and hospital and community palliative care nurses have been trained in ISIS (the hospital’s partially implemented electronic records system) and use this on a daily basis to access diagnostic images, pathology results and outpatient letters. EMH medical correspondence including discharge, outpatient and home visit letters are now also uploaded on to this system and provisional plans are in hand to record the clinical details of hospital consultations and community visits in ISIS rather than on paper.
Quotes have been requested from the IT
Department at St Mary’s for mobile internetenabled Windows 8.1 tablets so that ISIS may be used within patient’s homes. However, due to the large workload of the IT Department this has not progressed past the initial discussion stage.
The Inpatient Unit at EMH has explored the possibility of replacing paper prescriptions with electronic prescribing using the JAC system at
St Mary’s Hospital. This has been approved and an appropriate fibre-internet connection to
St Mary’s Hospital is being ordered as a first step in implementing electronic prescribing.
The second phase of introducing electronic prescribing is being planned and will include the purchasing of ward laptops for prescribing and training the ward nurses in e-dispensing.
Overall there has been significant progress in the move towards a paperless electronic records system at EMH. However, due to the complexities, costs and importance of integrating with other Isle of Wight health organisations, this may well take a number of years to implement fully.
Quality Account 2014/15 - Part Three 16

Target: To create a social space for patients on the Inpatient Unit
Patients and family members gave feedback to suggest that a communal social space on the
Inpatient Unit would be beneficial, especially as all the bedrooms are single rooms. Patients and families do utilise the facilities and social spaces of the attached EMH John Cheverton
Centre during the centre’s opening hours but for some patients the privacy and choice of a designated communal space on the ward area would better suit their needs.
In a recent Inpatient Experience Survey (July –
September 2014) 40% of respondents suggested that they would use a social space in the ward area if it were an option, with a further 13% reporting that it was not applicable to them.
Options for implementing a social space on the
Inpatient Unit will be considered during April/
May 2015. The aim is to have a social space in place by June 2015 as well as further opening up the JCC for longer hours into the evenings and weekends for patients, their families and visitors.
Target: To enable patients and visitors to use mobile devices and phones when in the
Hospice
Patient and visitors are able to use mobile devices and phones in the Hospice. Improved
Wi-fi access was not achieved during 2014/15 as we were awaiting a decision on the progression of the implementation of electronic prescribing on the Inpatient Unit, which also required significant investment in improved Wifi. It was more practical and cost effective to have wireless access points (WAPs) installed for both EMH and St Mary’s Hospital at the same time. The WAPs will be installed in April
2015 and the public Wi-fi improved in May
2015. EMH also plans to upgrade broadband connection to fibre, which will improve the speed of connection. Despite investigating improvements on the use of mobile phones,
EMH was unable to progress this as it was outside of our control.
Target: To provide all patients referred to community palliative care services with an individualised welcome pack
A new individualised welcome pack for all patients referred to the EMH/Macmillan
Specialist Care at Home Team, including all patients who access EMH John Cheverton
Centre, was devised during 2014. This priority was in direct response to patients requesting more information and communication when they are referred to hospice services. This piece of work has been led by the Clinical
Centre Manager in EMH John Cheverton
Centre working closely with the EMH/
Macmillan Specialist Care at Home Team and an outsourced specialist design and copywriting company. Patients and service users have also been consulted on the concept and format of the folder and its contents.
A welcome folder with both the EMH and
Macmillan Cancer Support logo was specially designed to give to each new patient on the first assessment home visit or appointment at
EMH John Cheverton Centre by the Macmillan
Clinical Nurse Specialist (CNS). Each folder is customised with a welcome letter addressed to the patient with a photo and contact details of the individual patient’s Macmillan CNS. The
Macmillan CNS, after discussion with the patient and their family members/carers, will add further leaflets and information to the folder throughout the patient’s journey with hospice services as appropriate. This may include details about Day Services at EMH
John Cheverton Centre (JCC) and a complimentary hot drinks voucher to use in the
JCC Sunflower Cafe; or it could include further information about the patient’s condition if this information is requested by a patient or their family/carers. The Macmillan CNS can utilise the information resources in the JCC
Information & Support Centre, which stocks a wide range of up-to-date and accurate information for patients, family members and carers.
The Welcome Pack will be reviewed in October
2015, six months after its introduction, by the
EMH/Macmillan Specialist Care at Home
Team, consulting with service users to establish how to further improve its use.
Quality Account 2014/15 - Part Three 17

At Earl Mountbatten Hospice we always welcome feedback from our patients, their families and friends.
Patient Experience surveys are carried out in real time on the Inpatient Unit and six-monthly in Day Services in EMH John Cheverton
Centre. Improvement action plans are developed from the feedback given by patients and families and fed back on ‘You said...We did’ boards displayed in both the
Inpatient and Day Service areas. A quarterly or six-monthly report is also written by the lead clinician and shared with staff, volunteers, the Patient Services Committee and local Clinical Commissioning Group.
The chart below details some of the feedback and actions that we have implemented from the Patient User Experience surveys on the
Inpatient Unit and EMH John Cheverton
Centre.
You Said....
We Did....
“I’d like a greater variety of X-box games”
“I would like a greater variety of magazines to read whilst at JCC”
We purchased an X-box game that you chose and we set up a workshop for children and young people to choose toys and games that they would like on the Inpatient Unit
We polled Day Services patients as to what the most popular magazines to read are and have sourced new subscriptions
“I’d like rails in the en-suite shower room so that
I can shower independently when I come in for
Respite”
We fitted rails to one of the en-suite shower rooms working with the patient, Occupational
Therapist, Nursing and Facilities teams to trial
“We’d like an increased variety of menu on the ward”
“We would like an option of a daily traditional style hot meal on the menu in Day Services”
The Catering Team have introduced a ‘Light
Bites’ menu and adjusted working hours to enable a more bespoke service to patients on the Inpatient Unit
We now provide an option for Day Services patients to order a traditional style main meal of the day as well as ‘Light Bites’
“There was a lack of equipment for my husband to be able to eat unaided”
We ensured that there is appropriate adaptive feeding equipment in the kitchen for patients who require it and also made our staff aware of where to locate this
Quality Account 2014/15 - Part Three 18

Earl Mountbatten Hospice acknowledges the importance of the service user voice in ensuring that our services and facilities are of high quality and meet the needs of the users. During 2015 EMH plans to develop some new and innovative ways of involving our service users at all levels in the development of our services and facilities. These include a number of new initiatives, including:
‘ Tell Us Your Experience – Just One Thing’
We introduced a ‘Tell us Your Experience –
Just One Thing’ form in the Inpatient Unit and
EMH John Cheverton Centre (JCC). This form will be available on the website and in paper copy. It will also be revised for use in the community once piloted in the Inpatient Unit and JCC. It gives another opportunity for our service users to feed back to us about ‘just one thing’ that would have improved their stay or experience of the services EMH provides.
The Head of Clinical Quality & Patient
Experience reviews completed forms weekly and works with the clinical teams to make improvements where possible and appropriate. The themes and actions from the forms are reported monthly to the Leadership
Team and quarterly at the Patient Services
Committee.
Creative Therapies in the EMH JCC Art Room
EMH Macmillan Specialist Care at Home
Service Questionnaire
In March 2015 EMH/Macmillan Specialist
Care at Home Service, working in partnership with the University of Nottingham, introduced a questionnaire as part of the two-year project
‘The Voices’ survey, to assess the quality of care provided by the community team. This validated questionnaire is sent out to bereaved carers four months after the patient has died and focuses on the experiences and care that they and the person they cared for received from the community team.
Feedback from this questionnaire will be used to improve future care for patients and their families through an annual report which will be shared with the community team, Macmillan
Cancer Support, the EMH Patient Services
Committee and local NHS Clinical
Commissioning Group.
User Group
It is planned that a new user group will be developed and facilitated by a member of the community, working with the Head of Clinical
Quality & Patient Experience during 2015. The user group will provide external scrutiny and report on whether EMH’s services and facilities are welcoming, safe, user-friendly and of high quality to patients, families, visitors, staff and volunteers. They will regularly walk around internal and external facilities of the Hospice and EMH John
Cheverton Centre. The user group will primarily use a number of validated tools to undertake this work, including the ’15 Steps
Challenge’ toolkit, produced by the NHS
Institute for Innovation and Improvement and
‘Patient-Led Assessment of the Care
Environment’ (PLACE) from NHS England.
These tools will help them to look at care provided in the Hospice through the eyes of patients and service users, capturing what good quality care looks, sounds and feels like.
These tools are a method for creating positive improvements and dialogue about the quality of care. Regular reports from the User Group will be made to the EMH Patient Services
Committee and Clinical Commissioning Group to further inform priorities for improvement.
Open Access yoga class in EMH JCC
Quality Account 2014/15 - Part Three 19

“The Hospice is like a really expensive hotel that you couldn’t normally afford”
“Thank you is such a small word for the nursing skill and gentle care you showed my husband during his days at the Hospice. It meant so much to us to be able to spend all our time with him. Your support was immeasurable and so appreciated.”
“He really appreciated the support that the Occupational Therapist and
Macmillan Nurse, along with many others, gave him and always looked forward to the care, inventive ideas and humour that he knew he would receive on his trips to visit the Physiotherapy team”
“Without the incredible compassion, care and kindness shown by your team, Mum would not have been able to spend her last few weeks at home and we know that being at home was really important to her”
“It is a huge asset for carers to know they have the support of the Hospice team when looking after a loved one at home in their final days, during what can be a potentially quite a daunting time”
“Thank you for the care and attention I received on my recent stay. You dug me out of a deep, dark hole and I will never forget the many kindnesses. EMH is a very special place”
“Thank you is hardly enough for all the wonderful care and attention given by all the staff. Even the smallest thing can mean so much when you are feeling poorly.”
“Thank you for the gentle and sensitive way in which you nurtured our family. Your kind words and gestures meant more to us than you will ever know. For all of us, this was our first encounter of EMH and so we walked through your doors for the first time, full of trepidation. It was as if we became embraced by a soft hug of love and understanding”
“Thank you for making my brother’s last days so peaceful and comfortable, with love and care, and for supporting me”
Quality Account 2014/15 - Part Three 20

Lessons Learnt
Sometimes we receive feedback from which we need to learn and improve our ways of working. For the year ended 31 st March 2015 we received nine complaints and six concerns relating to clinical services. Complaints and concerns were received from seven relatives, two patients/service users, one GP and four volunteers either verbally or in writing. Two complaints received affected multi-agencies, of which EMH was one. The Clinical
Commissioning Group is leading on the investigation and coordination of one of these complaints and the case is ongoing. The other multi-agency complaint was led and investigated by the IW NHS Quality Team and this complaint has been resolved satisfactorily.
All complaints, whether written or verbal, are investigated thoroughly and reported anonymously to the EMH Patient Services
Committee and the local Clinical
Commissioning Group. Where shortfalls are identified, immediate action is taken to minimise the risk of recurrence and a comprehensive action plan put in place, led by a senior clinician for the area concerned, working with staff and volunteers. Wherever possible, action plans and lessons learned are shared with the complainant so that they can see how their feedback has been able to drive quality and enhance service user experience
The complaints or concerns received covered a variety of themes that included the following actions to ensure improvements were made and lessons learnt:
• A facilitated discussion between staff and volunteers to rectify a space utilisation issue for the Bereavement Group in EMH John
Cheverton Centre
• Documentation training, one-to-one support and supervision and the setting up of a
Documentation Working Party to improve patient-related documentation
• Review of procedures for when staff need to work in pairs overnight
• Producing a flow chart for volunteer drivers showing the steps to be taken if a patient deteriorates whilst being driven home
• Improved procedure for recording telephone messages that require action to be taken by the Community Team with staff education.
A new quarterly ‘Lessons Learnt’ session was introduced in March 2015, facilitated by the
Head of Clinical Quality and Patient
Experience. These sessions are open to all staff and volunteers, working in both clinical and non-clinical roles, and focus on learning from recent complaints, concerns and compliments that we receive as well as from incidents, accidents and ‘near misses’.
The Francis Report and Earl Mountbatten
Hospice
The Francis Report (2013) is the result of a public inquiry, chaired by Robert Francis QC, under the Inquiries Act 2005, into serious failings at the Mid Staffordshire NHS
Foundation Trust. The report made 290 recommendations, many of which were applicable to the care that EMH provides.
EMH already complies with many of the relevant recommendations but in 21 of the recommendations the Director of Patient
Services identified areas for further improvement and developed a robust action plan. This plan was regularly presented and reviewed at both the Leadership Team and
EMH Patient Services Committee. At the end of March 2015 all the actions were achieved apart from the introduction of a ‘cultural care barometer’ which will be completed once the tool is widely available from the Department of
Health.
Quality Account 2014/15 - Part Three 21

Earl Mountbatten Hospice has 132.31 whole time equivalent (WTE) members of staff and over 400 volunteers. The staff turnover as at
31st March 2015 was 1.87%.
Volunteer and staff awards
On 20 th November 2014 an EMH Staff and
Volunteer Awards evening was held to celebrate the significant contribution of staff and volunteers across the organisation.
Forty-three volunteers were honoured for their long service to the Hospice, of between 5 and
25 years, along with nine staff commended for being unsung heroes, best newcomers, special sunflowers or employees of the year. The evening took place at the Isle of Wight
Community Club in Cowes, and was compered by the Hospice Interim Chief Executive.
Awards were presented by Trustees and staff. and emotions. Typically the session will involve a team which has cared for a patient telling their story and this is followed by open discussion, over refreshments, exploring issues that have arisen. The forum is not about problem solving; rather it is a dedicated time for reflection and a safe place to voice feelings not often shared, such as frustration, anger, guilt, sadness, joy, gratitude and pride.
“It is great to have the opportunity to share experiences and feelings that colleagues have had” member
Staff
“Staff spoke authentically and with real emotion, and shared some very personal experiences. I was struck by the care expressed by audience members to each other, particularly from clinical staff to administrators” Schwartz Round external Evaluator
Staff receiving their Sunflower awards
Feedback from guests has been very positive, and next year’s event promises to be even bigger. All staff and all volunteers are welcome to the awards evening, whether or not they have been nominated for an award.
“Very thought provoking and positive discussion.
Thank you” Staff member
Staff Support
‘Schwartz Rounds’ is a regular forum held at
EMH for clinical and non-clinical staff from all backgrounds and levels of the organisation, to come together in an informal setting to explore the impact that their job has on their feelings
Staff and Volunteer Survey
A full staff and volunteer survey will be carried out in 2015.
Quality Account 2014/15 - Part Three 22

Isle of Wight Clinical Commissioning Group
(CCG) welcomed the opportunity to participate in the governance ‘sign-off’ process and provide a statement in response to the presented Quality Account from the Earl
Mountbatten Hospice (EMH). The Quality
Account has been shared with representatives of the Clinical Commissioning Group; Clinical
Executives, Heads of Commissioning and
CCG Clinical Leads for their comments.
It is felt that as a ‘public facing’ document, the
2015 Quality Account is easy to read, informative and is written with a strong focus on the importance of inviting the views and involvement of patients, carers, staff and volunteers; it clearly sets out its values and aims, supported by a useful glossary of terms and acronyms.
The three priorities identified by EMH are considered to be appropriate. They provide an opportunity to drive quality improvement in different areas such as, assurance that systems and processes within the organisation are effective; enhancing the social experience of in-patients through Wi Fi connectivity and social space, whilst ensuring good basic care, such as nutrition, is maintained.
It is positive to note that EMH has acted upon external reports with very effective outcomes.
The ‘Leading from the Middle’ programme is a good example of this; empowering staff to make a difference. The CCG attended the presentations from this programme which was very refreshing.
Commitment has been demonstrated, through the local clinical audit programme, to review evidence based practice and monitor EMH service delivery against recognised standards to ensure that the best possible care is provided.
EMH has demonstrated quality improvement in the priorities it set out in last year’s Quality
Account; supported with examples. Where aspects of the priorities are outstanding, actions have been clearly outlined to continue towards achievement.
It is assuring to note the achievement of the
Commissioning for Quality Incentive Schemes
(CQUINS). The CCG is supporting the continuation of an Organisational Development
Plan CQUIN in 2015/16, which builds on previous successes.
There is also a good balance of patient and family, staff and volunteer feedback within the
Quality Account. The CCG is assured by the regular gatherings of volunteers which provide a forum for sharing experiences and emotions to ensure volunteers feel supported and valued.
Overall, Isle of Wight Clinical Commissioning
Group would agree that the Quality Report is an accurate reflection of EMH’s positive achievement across the quality agenda and the high level of commitment and effort across the organisation to constantly improve the quality of services provided.
Quality Account 2014/15 - Part Three 23

The Independent Reviewer has reviewed the
EMH Quality Account 2014/2015 and believes the document to meet national requirements for Quality Accounts. National guidance is provided for NHS Trusts and not specifically for the Hospice setting. The guidance can, and has been, interpreted to enable the Hospice to provide a clear account of quality to the public.
The author of this statement believes EMH to have achieved requirements as set out in the
National Guidance for Quality Accounts.
Overall review of the Quality Account
A Quality Account is in place to provide the public with an opportunity to understand what the service did last year to improve quality, and what they will do this year. It is a document which should reflect the important quality issues for patients that use the service and provide meaningful information to those patients.
The document achieves this very well; the
Hospice should be particularly commended for its approach to setting the quality goals for
2015/2016 which demonstrates real patient, carer and staff involvement in setting priorities important for them. In addition the recommendations made last year have been acted upon and clearly evidenced in the document.
The Earl Mountbatten Hospice Quality Account for 2014/2015 achieves the national requirements as set out in the Quality Account
Toolkit (DH 2010).
Quality Accounts are public documents and while their audience is wide ranging the Quality
Account should aim to present information that is accessible to all. Data presentation should be simple and in a consistent format.
Information should provide a balance between positive information and acknowledgement that some areas need improvement. Use of both qualitative and quantitative data will help to present a rounded picture and the use of data, information or case studies relevant to the local community will help make the Quality Account meaningful to its reader.
The Board (or equivalent) is accountable for the Quality Account and, therefore, they must assure themselves and then state publicly within the document that the information presented is correct. To provide further assurance, the lead Clinical Commissioning
Group, Healthwatch and Overview and
Scrutiny Committee must all be offered the opportunity to comment on the report ahead of publication and a statement, if offered, must be presented in the Quality Account.
Section review of the Quality Account
A Quality Account must include three parts as indicated below and all items are included, as required. One recommendation is provided to support future development of the Quality
Account.
Part 1
• A statement on quality from the Chief
Executive which includes the organisation’s view of the quality of services provided or sub-contracted by the provider during the reporting period
(2014/2015).
• A written statement at the end of Part 1, signed by the responsible person for the provider that, to the best of that person’s knowledge, the information in the document is accurate.
Part 2
• Priorities for improvement are clearly identified with evidence of patient and carer input with evidence of why they are chosen.
Recommendation : the document could indicate if there is any negative feedback that has prompted any of the priorities.
Evidence is provided to show how the organisation is developing capacity and capability for quality improvement to deliver these priorities; this is demonstrated through their training priorities and measures for success.
Quality Account 2014/15 - Part Three 24

• Statements relating to quality of NHS services provided are included in the document.
A recommendation was made in the
2013/2014 Quality Account that the organisation should provide a statement on how it will improve data quality. This has been included in the
2014/2015 Quality Account
Part 3
• Review of quality performance (for provider determination) – report on the previous years
Quality performance offering the reader the opportunity to understand the quality of services in areas specific to your organisation; this is well presented with an excellent range of improvements showcased.
• An explanation of who you have involved (for provider determination) and engaged with to determine the content and priorities contained in your
Quality Account (in line with current quality legislation and the Health Act
2009); this has been achieved to a high standard
• Any statements provided from your
Clinical Commissioning Group,
Healthwatch or Overview and Scrutiny
Committee (in regulations) including an explanation of any changes you made to the final version of your Quality
Account after receiving these statements.
It should be noted that the author of this review has not audited any data contained within the report. The review is written in good faith following review of the document, discussion with staff and knowledge of the organisation as a partner organisation.
Sarah Johnson
Deputy Director of Nursing, Isle of Wight
NHS Trust
14th May 2015
Healthwatch Isle of Wight fully supports the aim and objectives contained within the Earl
Mountbatten Hospice Quality Account and is particularly pleased to note the interconnectedness of objectives and proposed actions. Once implemented these will further enhance the quality of services provided for those requiring the specialist services of the
Hospice. We would also like to commend the
Hospice for the clear and engaging presentation of the Quality Account.
Healthwatch Isle of Wight looks forward to finding ways of working with the Hospice over the coming year that will support the implementation of actions contained within the
Account.
Chris Orchin
Chair Healthwatch Isle of Wight
Earl Mountbatten Hospice would like to thank our Commissioners, Healthwatch and our
Independent Adviser for their favourable and constructive comments. All recommendations will be subject to consideration and further reflection by the
Management Team, the outcomes of which will be reported upon in future Quality
Accounts.
Quality Account 2014/15 - Part Three 25

The Health Act 2009 and the National Health
Service (Quality Accounts) Regulations 2010 require the Directors to prepare Quality
Accounts for each financial year.
The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the above legal requirements in the Health Act 2009 and the
National Health Service (Quality Accounts)
Regulations 2010, (as amended by the
National Health Service, (Quality Accounts)
Amendment Regulations 2011)).
In preparing the Quality Account, Trustees are required to take steps to satisfy themselves that:
• this report presents a balanced picture of the Hospice’s performance over the period covered
• the performance information reported in the
Quality Account is reliable and accurate
• there are proper internal controls over the collection and reporting of the measures of performance included in the Quality
Account, and these controls are subject to review to confirm that they are working effectively in practice
• the data underpinning the measures of performance reported in the Quality
Account are robust and reliable, conform to specified data quality standards and prescribed definitions, and are subject to appropriate scrutiny and review, and
• this Quality Account has been prepared in accordance with Department of Health guidance.
The Trustees confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the
Quality Account.
Quality Account 2014/15 - Part Three 26

CCG - Clinical Commissioning Group for the Isle of Wight . Clinical commissioning groups are NHS organisations set up by the
Health and Social Care Act 2012 to organise the delivery of NHS services in England. They have replaced Primary Care Trusts.
CQC - Care Quality Commission. This is the independent regulator of health and social care in England. It regulates health and adult social care services provided by the NHS, local authorities, private companies or voluntary organisations.
CQUINs - The Commissioning for Quality and
Innovation Schemes payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare provider’s income to the achievement of local quality improvement goals.
DH The Department of Health is a ministerial department supported by 26 agencies and public bodies who help people to live better for longer.
HCA - Healthcare Assistants work in hospital or community settings, under the guidance of a qualified healthcare professional.
ISIS - Integrated Services Information
System. This is St Mary’s Hospital’s online medical records system enabling the sharing of patient information.
JAC System - a medicines management system which allows multiple sites to use a single system, with a common master drug catalogue, supplier file and patient file. It is intended to improve continuity of care as patients’ dispensing history can be viewed as they move between sites.
JCC - EMH John Cheverton Centre. This is a centre integrated with Earl Mountbatten
Hospice providing day services and information and support for patients, families and their carers.
MDS - Minimum Data Set . The Minimum
Data Set for Specialist Palliative Care Services is collected by the National Council for
Palliative Care on a yearly basis with the aim of providing an accurate picture of hospice and specialist palliative care service activity. It is the only annual data collection to cover patient activity in specialist services in the voluntary sector and the NHS in England, Wales and
Northern Ireland.
MDT - Multi-Disciplinary Team. A multidisciplinary team is composed of members from different healthcare professions with specialised skills and expertise. The members collaborate to make treatment recommendations that facilitate quality patient care.
NCPC - National Council for Palliative Care.
The National Council for Palliative Care
(NCPC) is the umbrella charity for all those involved in palliative, end of life and hospice care in England, Wales and Northern Ireland.
Sepsis - is a common and potentially lifethreatening condition triggered by an infection.
The following statements are required by law to be included in the Quality Account. They currently do not apply to Earl Mountbatten
Hospice:
• The number of national clinical audits and the number of confidential enquiries.
• Records submitted to the Secondary Users service for inclusion in the Hospital Episodes
Statistics.
• Earl Mountbatten Hospice was not subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission.
Quality Account 2014/15 - Glossary and Further Information 27

This important document sets out how we continue to improve the quality of the services we provide.
We welcome your views and suggestions on our Quality Priorities for 2015/16 as set out in Part 2 of this Quality Account.
We welcome feedback at any time on our Quality Account; please contact Nigel Hartley, Chief
Executive on 01983 529511 or email chiefexec@iwhospice.org.
You can read more about the national requirements for Quality Accounts on the NHS Choices or
Department of Health websites.
You can download a copy of this Quality Account from http://www.iwhospice.org/governance.aspx
This Quality Account is available as an Easy Read document on our website.
Thank you to all the members of staff, volunteers and public members who have contributed to this report.
In particular:
Linda Wright
Becky McGregor
Liz Arnold
Laurie Rushton
Project Coordinator
Head of Clinical Quality and Patient Experience
Director of Patient Services
Statistical Coordinator
Jill George
Graham Grove
Nurse Manager, EMH/Macmillan Specialist Care at Home Team
Consultant in Palliative Medicine
Paul Howard Consultant in Palliative Medicine
Erika Campbell-Burt Director, Strategy and Development
Stuart Nicol
Peter Gilliam
Head of HR and Facilities
Charge Nurse
Board of Trustees
Senior Management Team
Staff, volunteer, trustee, patient and service user focus groups
Earl Mountbatten Hospice
Halberry Lane
Newport
Isle of Wight
PO30 2ER
Telephone: 01983 529511 (Main switchboard)
Registered Charity No. 1039086, Hospice Company No. 2929267, Trading Company No. 3083127
Quality Account 2014/15 - Glossary and Further Information 28

Workshop with schools Family overnight suite
- Inpatient Unit
Celebrating a Patient’s Birthday
‘Look Good, Feel Better’
Sessions
Creative Therapies
in the Art Room
- EMH JCC
Delicious Cakes in the Sunflower Cafe
- EMH JCC
Schools’ Walk the Wight’ Medals
‘Go Yellow Day’ Charity Bag Packing in Cowes Co-op with Cowes Primary School
Quality Account 2014/15 - Glossary and Further Information 29