Quality Account
2014 to 2015
Vision
Patients, families and carers in our community experience a journey towards
end of life and into bereavement that is supported, comfortable, safe
and personalised and is in a place of their choice
Mission
The Mary Ann Evans Hospice will provide comprehensive, high quality
support and end of life care across our community through all the services
we provide to patients and those close to them
We will do this in collaboration with others where appropriate
We are committed to training, supporting and encouraging our staff
and volunteers to achieve our mission
The Mary Ann Evans
Hospice will be
recognised as being the
lead provider for
comprehensive and high
quality community end of
life care and support
Strategic Aims
The Mary Ann Evans
Hospice will promote
open attitudes in our
community towards death
and dying and provide
bereavement support to all
that need it
Mary Ann Evans Hospice
Eliot Way, Nuneaton
Warwickshire CV10 7QL
Charity Number: 1014800
The Mary Ann Evans
Hospice will maximise
organisational impact
through robust financial
management and
growing support of
our community
Index
Description
Page No
Hospice Board Chair’s Statement
3
Priorities for Improvement 2015 - 2016
4-6
Progress on priorities for improvement 2014 - 2015
7-8
Statement of Assurance from the Board 2015 - 2016
9 - 12
Participation in Clinical Audits
11
Research
11
Statement from the Care Quality Commission
11 - 12
Data Quality & Review of Quality Performance
12 - 16
Quality Markers
17
An explanation of those involved in this Quality Account
18
Statements
18
2
Part 1:
Hospice Board Chair’s Statement
I am pleased to present this Quality Account for the Mary Ann Evans Hospice for the
year 2014-2015. Quality of care for our patients, their families and their friends is the
top priority for all Hospice staff and volunteers.
This report provides details of improvements made in 2014-15 and
summarises ambitious improvements planned for 2015-16.
Yet again in the history of the Mary Ann Evans Hospice, services in 2014 developed
significantly, with improvements in all departments; Day Hospice, Lymphoedema,
Hospice at Home, Bereavement and Complementary Therapies. These
improvements are due entirely to the dedication and diligence of everyone involved
with delivering care.
In 2014 the new Hospice extension was opened and the extra space provided has
enabled improvements across all services provided within the Hospice.
We were particularly pleased to receive a "GOOD" rating following a Care Quality
Commission (CQC) inspection in August 2014.
As always financial viability continues to be a priority for the Board of Trustees.
Requiring to raise approximately 70% of our expenditure via Fund Raising and with
an ever increasing workload, financial balance is a challenging target. However, I am
pleased to be able to report that for the first time in several years the Hospice budget
showed a balanced position for 2014-15. However on-going financial stability for a
charity such as ours is never likely to be a secure proposition. There are very many
variables that can affect our position. Significant investment has been made in the
Fund Raising Department in 2014-15 in an attempt to ensure our financial future.
To the best of my knowledge, the information provided in this Quality Account is an
accurate and true account of the quality of services provided by the Mary Ann Evans
Hospice.
Duncan Phimister
Chair of the Board of Trustees
29th May 2015
3
Part 2:
Priorities for Improvement and Statement of Assurance from the
Board 2015 to 2016
The Mary Ann Evans Hospice received an overall rating of “Good” from the Care
Quality Commission inspection under Section 60 of the Health and Social Care Act
(2008) in August 2014 for the care services provided. The Hospice Board and all
involved with providing a service continuously strive to improve and develop services
for the benefit of our local community.
The priorities for improvement that have been identified for 2015/16 are outlined
below. These priorities have been identified in conjunction with patients, carers, staff
and stakeholders. They have been approved by the Clinical Governance and Service
Development Committee, a working group of the Hospice Board to monitor quality
and plan ahead.
Future Planning Priority 1
Further develop existing and new partnership working
The Hospice recognises the patient and family carer benefits achievable through
working with key partners in extending and developing core services for people in
Nuneaton, Bedworth and North Warwickshire approaching the end of their lives.
Measures:
1. Positive feedback from our hospice care services generic satisfaction survey.
2. An evaluation report of key partners and collaboration projects/services the
Hospice has engaged with for the people accessing Mary Ann Evans Hospice
care services.
3. An impact analysis of community engagement role initiated April 2015.
4. Further developed clinical care and services provided for family carers of those at
the end of life.
Future Planning Priority 2
Day Hospice service review
The Mary Ann Evans Hospice vision statement necessitates the development of
contemporary Day Hospice services that are able to fulfil the needs of the diverse,
multiple co-morbidity local population. The Day Hospice care services will be
reviewed and transformed to maximise opportunities for local people predominantly
with any life limiting illness to benefit from the care and support available.
Measures:
1. An exploration report will be completed to establish the options to consider which
will have the most impact on care provision for local people.
2. New initiatives will be piloted to establish success of any project before any
conclusions on care services are reached.
3. Patient, carer and professional feedback will be actively sought as part of the
review.
4. Revitalise the Day Hospice environment to ensure this is safe, homely and
comfortable.
4
Future Planning Priority 3
Widen awareness to care services
The Mary Ann Evans Hospice wishes to be recognised as being the lead provider for
comprehensive and high quality community end of life care and support. Many local
professionals and general public remain unaware of the value and impact hospice
care may have on individuals. Ultimately raising understanding to care services will
widen awareness and enable local people to benefit from the support and care on
offer. The Mary Ann Evans Hospice will also be ensuring local people are given an
opportunity to optimise their individual well being and support those with care needs
to live as independently as possible – a paramount principle of the Care Act 2014.
Measures:
1. Participation in external key stakeholder events to improve the understanding of
hospice care services – professional and public.
2. An impact analysis of the community engagement role initiated April 2015.
3. Clinical services to work in partnership with fundraising and marketing to ensure
full remit and benefits of services are communicated.
4. Increases in all aspects of service activity – clinical (especially hospice care at
home) and non clinical, including new cohorts of people whom do not typically
access hospice care e.g. dementia, learning disability
Future Planning Priority 4
Clinically effective care services
The Mary Ann Evans Hospice is regulated by the Care Quality Commission and
under Section 60 of the Health and Social Care Act (2008). To ensure hospice
services are clinically effective i.e. safe, caring, responsive and well-led the hospice
gives serious regard to satisfactorily meeting the Care Quality Commissions
requirements.
Measures:
1. The Head of Clinical Services and Team Leads will complete a full review of
current requirements and Hospice compliance.
2. Clinical Governance and Service Development meetings will be reported through
an agreed format to ensure all aspects of patient safety, effective, caring,
responsive and well-led services are monitored and evaluated.
3. Systems and processes will be implemented and embedded to ensure rigour and
robustness of all aspects of care to guarantee quality is continuously improved
upon. For example introduction of the Care Certificate for all newly employed
Health Care Assistants and existing staff, End of Life care competencies for all
levels of care staff, readiness assessment for Registered Nursing revalidation
requirements and a dedicated clinical risk register.
5
Future Planning Priority 5
Bereavement services
The Mary Ann Evans Hospice aims to have established a sustainable Children’s
bereavement support service during 2015. We will be assisted by a grant from
Children in Need allowing the Hospice to work closely with The Sycamore Centre,
based in Nuneaton who specialise in Children’s work.
Measures:
1. Train a team of volunteers up who will shadow two members of the Sycamore
Centre team through an 8-week bereavement course which is being offered to
children.
2. Ensure our stakeholders become aware of this new strand of service whilst
maintaining a manageable level of referrals.
Future Planning Priority 6
Chaplaincy
The Mary Ann Evans Hospice is increasingly aware of the importance to expand our
pre-bereavement service which is presently offered by the Hospice Chaplain. With
the emphasis on giving patients the choice to die at home we need to be increasing
this facility.
Measures:
1. Over the next year we will train a small team of volunteers to offer prebereavement support for those approaching end of life and their carers.
6
Part 3:
Priorities for Improvement 2014 to 2015
To meet the increasing need of our local community the Mary Ann Evans Hospice
identified in conjunction with patients and carers, staff and stakeholders the following
areas to improve care and support to those who accessed our services during
2014/15.
The outcomes for the areas identified are outlined below:Priority 1
Hospice at Home service
The Mary Ann Evans Hospice anticipates receiving the Warwickshire North Clinical
Commissioning Group review report of the Hospice at Home project which
commenced in October 2011 which will include recommendations for future service
provision for local people.
Whilst awaiting this review the service continues to work in partnership when
required with Continuing Health Care and community nursing colleagues providing
agreed “fast track” care packages rapidly for patients in need. In 2014-15,
approximately 90% (163) of new referrals from the total 186 received by the service
were “fast track”. 139 patients across Nuneaton, Bedworth and North Warwickshire
were cared for and died at home with support from Mary Ann Evans Hospice in this
period. The service embraced people anticipated as being in the last 12 months of
life; however a twilight service (between 17.00 – 22.00) has not been established.
Bank staff recruitment has been continuous throughout the year with several staff
becoming permanent employees.
Priority 2
To develop a more structured and coordinated approach to our Day Hospice
Supportive Services
The activity therapies and introduction of complementary therapy service has been
highly successful and immensely popular with patients, carers and bereaved clients
receiving care and support from the Mary Ann Evans Hospice. Over 1000
complementary therapy treatments have been administered – some of which were
domiciliary. Initial steps have been taken to introduce volunteer therapists to the
service. The personal programme of therapies and activities has been diverse, well
structured, and embedded and continues to be based on feedback from our service
users. Additionally, the Day Hospice has hosted their first cohort of “Progressive
Relaxation Therapy” group sessions provided once a month for a six month
programme which is currently being evaluated.
7
Priority 3
Clinical Effectiveness
Development of Education
Education continues to be a priority area for our workforce to enable them to
continue providing high quality care for our patients and their families. To ensure this
we recognise the need to equip Hospice clinical staff with the appropriate up to date
knowledge, skills and attitudes. Several new initiatives and approaches to training
have been achieved including accessing courses provided by local colleges such as
North Warwickshire and Hinckley College. The Mary Ann Evans Hospice continues
to give great importance to personal staff development and staff have the opportunity
to explore their education and training needs through the hospice appraisal process.
Priority 4
Enhancing the role of volunteers
The volunteer workforce of Mary Ann Evans Hospice is in excess of 300 without
whom Mary Ann Evans services would be extremely compromised. A volunteer
strategy has started to be explored by our Board and Senior Leadership Team.
All volunteers are supported in their roles by paid employees and receive
personalised training packages.
Our popular Lymphoedema service for example, have empowered and supported a
small number of enthusiastic clients in a voluntary capacity to develop further
dedicated support groups through social media and a purpose built website to
enable self support mechanisms.
In August 2014 the Hospice opened an extension which is named The Warren. This
building’s reception area is manned purely by volunteers who had accessed the
Hospice’s bereavement services and now choose to give something back to the
organisation.
8
Part 4:
Statement of Assurance from the Board 2015 to 2016
The following are statements that all providers must include in their Quality Account.
4.1: Review of Services
During 2014/15 the Mary Ann Evans Hospice was part funded by the Warwickshire
North Clinical Commissioning Group commissioning priorities with regard to the
provision of local End of Life and Palliative Care by providing:
Day Hospice
Complementary Therapies
Hospice at Home
Bereavement Service
In addition the Hospice has provided the following services solely through charitable
funding:
Lymphoedema
Lymphoedema Support Group
Healthy Steps Programme
Progressive Relaxation Therapy
The income generated by the NHS, reviewed in 2014/15 represents approximately
32% of the cost of the provision of NHS Services by the Mary Ann Evans Hospice.
The Mary Ann Evans Hospice values the feedback received from patients and their
families/carers as this is an important way in which staff can identify issues, resolve
problems and improve the quality of care we provide. Some comments received from
patients and their families are shown below:
Families of a Hospice at Home patients:
“I met the team at what was possibly the lowest time of mine and my husband’s
health experience. Feeling abandoned at home and exhausted, I felt that there
was little more to live for and my whole life was consumed with caring. With your
care, support and encouragement you chased me out the door to go back and
join the world. I don’t think I can properly convey exactly what you have all done
except to say that I’m alive again and you played a major part in that.”
“I was in the solicitors and on their notice board was a laminated poster for
Hospice at Home and a “thank you” letter from someone who had lost her mum. I
thought to myself that I could have written that letter; she used the words that I
would have and called you “the angels who took care of mum”. That is exactly
how we all think of you. Even though mum was lying in bed and not always
feeling well, I will remember forever hearing the laughter. Thank you from the
bottom of our hearts for the exceptional care and friendship you gave to mum and
all our family.”
9
Day Hospice patients:
“When I first started coming I never thought I would enjoy it …oh but I do! Nothing
is too much trouble, all the staff are so caring, I have no qualms with them, and
they are all brilliant. When you think about the word hospice you think that’s
where you go to die, but there’s no looking back for me now.”
“Thank you to all concerned for giving me a very pleasant and happy day every
Friday, I would really miss coming now as I enjoy it so much.”
Comments from Lymphoedema patients:
“Very personal care, tailored for me individually. Staff always very friendly,
supportive and caring.”
“A very caring service, staffed by the most supportive, competent and
understanding team. They were hugely helpful during some dark times.”
Bereavement client comments:
“It has really helped me to have someone not associated with the situation. An
invaluable service that literally put me back together at my most vulnerable”
“Cannot fault the support that I have had over the last 18 months, both 1:1 and
Sanctuary”
10
4.2 Participation in Clinical Audits
During 2014/15 there were no national audits or confidential enquiries covering NHS
services relating to palliative care. The Mary Ann Evans only provides palliative care
and therefore was ineligible to participate.
Hospice Audits that occurred during 2014/15
Infection prevention and control – June 2014
Lymphoedema users satisfaction questionnaire – March 2015
Bereavement service users satisfaction questionnaire - an evaluation form is sent
out to every client once they have finished using the service.
4.3 Research
The numbers of patients receiving NHS Services provided or sub–contracted by the
Mary Ann Evans Hospice in 2014/15 that were recruited during that period to
participate in research approved by a research ethics committee was 3.
The Mary Ann Evans Hospice lymphoedema service in conjunction with Consultant
Mr Makam Kishore, Consultant General, Breast and Endocrine Surgeon, George
Eliot Hospital are contributing to the PLACE trial (Prevention of Lymphoedema after
Axillary Surgery by External Compression). Mr Makam Kishore is the Primary
Investigator for the study, which is a national trial.
4.4
Statement from the Care Quality Commission
The Mary Ann Evans Hospice is required to register with the Care Quality
Commission (CQC) and is currently registered for three regulated activities under the
Health and Social Care Act (2008).
Nursing Care
Personal Care
Treatment of Disease, Disorder or Injury
The Mary Ann Evans Hospice had an announced inspection under Section 60 of the
Health and Social Care Act (2008) on 13 August 2014. The CQC looked at the
overall quality of the services and rated these as “Good”. The new inspection
process was used which looked at five main parameters:
Is the service safe?
Is the service effective?
Is the service caring?
Is the service responsive?
Is the service well-led?
11
During the visit the inspectors spoke with people who used the hospice and their
relatives advised them they were happy with the services provided by the hospice.
They felt the staff understood their needs and they felt safe.
People’s wishes and preferences were taken into account and recorded in care
plans. Risk management procedures were in place to ensure people’s health risks
were identified and plans were in place to manage those risks.
Staff demonstrated a good understanding of the needs of people with life limiting
illness. They had received good training and support to meet people’s needs.
The organisation demonstrated they were working well with other health and social
care providers to ensure people’s needs were met.
The CQC found appropriate policies and procedures in place to support people
should they ever have a need to complain or raise concerns. When concerns had
been raised, they had been dealt with effectively.
The CQC also reported they had found systems in place to assess and monitor the
quality of support provided for people.
The final report was published in January 2015 giving the Mary Ann Evans
Hospice a final overall rating of services as ‘Good’.
4.5 Data Quality
The Mary Ann Evans Hospice did not submit records* during 2014/15 to the
Secondary Users service for inclusion in the Hospital Episode Statistics which are
included in the latest published data.
* The Hospice is not eligible to participate in this scheme
The Mary Ann Evans Hospice submits data as requested on an ongoing basis to the
National Council of Palliative Care (NCPC): Minimum Data Sets (MDS), local
Commissioning Support Unit and Local Intelligence Network.
Part 5: Review of Quality Performance
The National Council of Palliative Care (NCPC): Minimum Data Sets (MDS)
The Mary Ann Evans Hospice has chosen to present information from the NCPC
Minimum Data Set which is the only information collected nationally on hospice
activity. The figures below provide information on the activity and outcomes of care
for patients.
12
5.1
Day Hospice
2013/14
Hospice
2012/13
National
Hospice
median
National
median
Total patients
97
84
139
140
New patients
41
43
83
91
% New patients
42.3%
59.9%
59.7%
63.2%
% New patients 16 - 24
2.1%
0.0%
1.2%
0%
% New patients 25 - 64
27.8%
25.4%
20.5%
27.0%
% New patients 65 - 84
59.8%
58.8%
65.1%
56.4%
% New patients over 84
9.3%
12.6%
13.3%
13.3%
All female patients
57
45
44
47
All male patients
40
37
39
41
All cancer diagnoses
70
58
61
66
27.8%
21.2%
26.5%
23.3%
Day care sessions
241
154
235
196
Day care places
3615
1839
3,525
2,985
Day care attendances
2023
1009
1,901
1,647
56.0%
58.6%
53.9%
56.4%
Deaths and discharges
39
41
84
101
Average length of attendance (days)
n/a
237.5
% New patients with non-cancer diagnoses
% Places used
13
157.1
5.2 Hospice at Home
2014/15
Hospice
2012/13
National
Hospice
median
National
median
Total patients
164
119
211
231
New patients
153
104
195
211
% new patients
93.3%
95.2%
92.4%
90.5%
% new patients 16 -24
0.6%
0%
% new patients 25 - 64
23.8%
19.2%
22.1%
21.4%
% new patients 65 - 84
59.1%
59.1%
66.7%
55.1%
% new patients over 84
16.5%
20.5%
11.3%
22.3%
All female patients
68
53
80
101
All male patients
96
62
115
109
All cancer diagnoses
150
87
178
168
All non-cancer diagnoses
14
18
17
32
8.5%
20.0%
8.7%
16.7%
Deaths and discharges
152
108
219
220
Deaths
142
71
157
157
83.1%
90.1%
87.3%
87.3%
n/a
25.5
n/a
24.8
% all patients with non-cancer diagnoses
% home and care home deaths
Average length of care
14
0%
5.3 Bereavement
2013/14
Hospice
National
2012/13
Hospice
median
National
median
Total service users
145
159
113
70
New service users
98
121
80
46
67.6%
70.8%
70.8%
69.1%
All female service users
107
113
61
29
All male service users
38
50
19
13
Cancer diagnoses of deceased
123
123
76
26
Non-cancer diagnoses of deceased
22
16
4
4
% of deceased with a non-cancer diagnoses
15.2%
8.5%
5.0%
9.3%
Total contacts
1,206
1,092
674
366
Contacts per service user
8.3
6.2
6
5.8
Phone calls per service user
0.4
1.6
0.8
1.1
32.0%
6.9%
41.8%
10.7%
47
102
57
40
32.0%
59.1%
48.7%
59.3%
% new service users
% of contacts which were group sessions
Discharged
% discharged
15
5.4 Lymphoedema
2014/15
2013/14
Total patients
216
185
New patients
93
109
% New patients
43%
59%
% New patients 16 - 24
0%
N/K
% New patients 25 - 64
55%
N/K
% New patients 65 - 84
45%
N/K
% New patients over 84
5%
N/K
All female patients
193
N/K
All male patients
23
N/K
All cancer diagnoses
216
185
% New patients with non-cancer diagnoses
0%
0%
Appointments (1 hour average)
% Appointments used (including DNA and
cancellations)
Clinic
H/V
Clinic
H/V
2319
143
2125
193
92.7%
90.4%
Support Group Attendance
104
83 (Sept-Mar)
Healthy Steps Attendance
494
254 (Nov-Mar)
% Places used (maximum of 12 clients per session)
64%
60%
Deaths and discharges
67
30
Average length of attendance (days)
N/K
N/K
16
Part 6:
6.1:
Quality Markers
Complaints
INDICATOR
2014/15
2013/14
Number of Complaints (clinical)
0
1
Number of Complaints (non-clinical)
6
4
2014/15
2013/14
Complaints
6.2:
Patient Safety
INDICATOR
Patient Safety Incidents
Number of Serious Patient Safety
Incidents (excluding falls)
0
0
Number of Slips, Trips and falls
3
2
Number of Patients who experience a
Fracture or other Serious Injury as a result
of a Fall
0
0
Other Incidents
4
4
17
Part 7:
An Explanation of those involved in this Quality Account
The Quality Account priorities were considered at the Clinical Governance and
Service Development Group meeting on 16th March & 13th April 2015 having been
discussed by the Hospice Senior Leadership Team and the clinical services Team
Leads.
The Quality Account was drafted initially by the Head of Clinical Services and
circulated to the Chair of Trustees, Chief Executive, Head of Chaplaincy and
Bereavement and all clinical services Team Leads.
The Quality Account was then finalised and discussed at the full Board meeting on
21st May 2015.
Following this the Quality Account was distributed on 3nd June 2015 inviting feedback
by June 17th 2015 for inclusion in final published report, externally to:
Warwickshire North Clinical Commissioning Group
Nuneaton and Bedworth Borough Council
Warwickshire County Council
North Warwickshire Borough Council
Warwickshire HealthWatch
Coventry & Warwickshire Partnership Trust
Chief Executive, George Eliot Hospital, Nuneaton
Part 8:
Statements from Local Stakeholders
On 3rd June 2015 a copy of this Quality Account was sent to local stakeholders, as
listed above, requesting a response for inclusion by 17th June 2015.
As at 25th June 2015, no statements, relating to this Quality Account, had been
received from local stakeholders. One stakeholder requested a slighter longer
response time frame, which was agreed, however no other correspondence
followed.
HEAD OF CLINICAL SERVICES
18