QUALITY ACCOUNT 2014/15
Mildmay Mission Hospital
Registered office:
19 Tabernacle Gardens
London E2 7DZ
Company no: 1921087
Charity no: 292058
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Part 1 – Responsible Individual’s Statement
Mildmay Mission Hospital (hereafter referred to as ‘Mildmay’) is a voluntary charitable
hospital and rehabilitation unit that delivers services to the NHS through the mechanism of
multilateral contracts with over 20 London Clinical Commissioning Groups (CCGs) and Local
Authourities. It also accepts duly scrutinised spot-purchased referrals from any other UK
source.
Mildmay is registered with the Care Quality Commission to deliver services under two
regulated categories, they are:
Diagnostic and screening procedures
Treatment of disease, disorder or injury
It is a tertiary healthcare provider of specialist care and rehabilitation for people living with
complex HIV-related conditions, particularly HIV Associated Neurological Disorder (HAND)
also known as HIV-Related Neurological Impairment (HNCI) or AIDS Dementia.
On behalf of the Board of Trustees and Senior Management Team, I would like to thank all
our staff and volunteers for their achievements over the past year - embracing both the
challenge of change and the opportunity to enhance quality. Despite the very challenging
funding climate, Mildmay has continued to provide high quality services while at the same
time changing settings by moving into a new 26-bed hospital in Shoreditch. This occurred
on 1st September 2014.
Clinical excellence, the patient experience and safety are of paramount importance for
Mildmay, as well as developing new and existing services appropriate to patient needs.
The Board of Mildmay, The Mildmay Clinical Governance Committee (chaired by a Board
member), and the Risk Management Committee, all meet regularly (quarterly, quarterly and
monthly respectively) to ensure that there is adequate oversight of the services provided by
the organisation, as well as the management of inherent risks.
I am responsible for the preparation of this report and its contents. To the best of my
knowledge the information reported is accurate.
Ross White
Executive Director
CQC Nominated Individual
Mildmay Mission Hospital
22nd June 2015
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A statement from Mildmay about the quality of the service provided
Mildmay provides a modern setting where the safety of patients, visitors and staff; the
effectiveness of our interventions; and our responsiveness to patient need, remain the focus
of providing a caring and well-led environment.
Patients who are referred into Mildmay come to us in very poor health, with HIV infection
and other co-morbidities having caused physical and cognitive impairments, often coupled
with psychological ill-health. Through our experience with a multi-disciplinary team
approach (which involves nursing, medical and therapeutic interventions, as well as social
and spiritual support) over 80% of patients can leave Mildmay’s rehabilitation programme
for independent living in their own homes. Even for patients who require a longer-term
nursing home placement following their rehabilitation at Mildmay, we can evidence (through
the use of UKROC patient data) improvements in their dependency upon other people and
gains in cognitive function.
Our Friends and Family Test shows that 100% of Mildmay patients surveyed stated that ‘they
would recommend our service to a family or friend if they needed it’.
On the basis of the above, I believe that Mildmay provides and maintains a high quality
service.
Dr Simon Rackstraw, Medical Director
Captured Comments 2014-15
‘I came here on a trial for four weeks as promised. May God bless the team who have worked
with me throughout my stay. This is a place where I won’t forget your kindness’ – Patient
Feedback Form on discharge.
‘I have never worked in this kind of setting before (rehabilitation). It was intriguing to see the
kind of work that Mildmay does. Today I attended a physiotherapy session, an art therapy
group and an inclusive service in the chapel’ – Student Nurse
‘I joined the keep fit class today led by the physiotherapist and was very impressed with the
way that the class, while structured, was tailored to each client’s needs’ – Keith, Volunteer
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Part 2 - Planned Priorities for Improvement 2015-16
2.1 Objectives
2.1. 1 Objective 1- Maximise Occupancy & Improve Quality
We will continue maintain high occupancy levels while maintaining and improving the
quality of our work.
High occupancy is a key contributor to financial stability for Mildmay. As a small unit, subtle
variations of referral can have a significant effect on cash-flow and hence viability.
Demand for our services over recent years has gone hand in hand with increases in
complexity of the conditions we treat.
We see quality as not only being essential in maintaining standards for the people who use
our services, but also as a means to an end in ensuring that Mildmay remains a preferred
place in the minds of NHS Commissioners, Clinical Nurse Specialists (CNSs) and other
referring agencies.
2.1.2 Objective 2 - Maximise Voluntary Income and Awareness Raising
We will seek to increase voluntary income to the charity. Diversification of income, both
restricted and unrestricted funds from charitable sources, can contribute to achieving new
objectives such as the development of innovative services, purchasing essential items of
equipment and long-term stability.
We will seek to raise awareness of the work of Mildmay by creating a visible presence at key
conferences, and maintaining training and development (both internally and externally). We
will seek to develop marketing materials which promote the organisation which protecting
patient confidentiality.
2.1.3 Objective 3 – Learning and Research
To establish a Research Group (chaired by our Medical Director) that will report into the
Clinical Governance Group
To establish an Education Committee (chaired by our Medical Director) that will report into
the Clinical Governance Group
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2.1.4 Objective 4 – Extend the Scope and Activities provided in Day Services:To extend the opening hours of Day Services to 5 days a week
To pilot and roll out a Cognitive Skills Group to Inpatients and Day Services clients
To extend the physiotherapy input into Day Services
To set up a digital inclusion IT-suite and to run a digital inclusion programme as part of
‘Aspects of Daily Living’
2.1.5 Objective 5 –Upper Ward Development
We will continue explore options to open the upper 12-bed ward at Mildmay, which will
expand the hospital from 14 to 26 operational beds. This upper ward development might
involve a diversification to a non-HIV use, OR a diversification of service provision within the
HIV-field. Both are being explored.
2.2 Statements of Assurance from the Board.
Mildmay delivers services under NHS contracts and in accordance with a service specification
embedded within that contract. Four care and treatment pathways form part of our service
specification: These are:

Assessment and Rehabilitation

Complex Symptom Control

Respite Care

End of Life Care
The Unit Medical Director, Dr Simon Rackstraw, is a Fellow of the Royal College of Physicians
of London and continues to be in demand for knowledge sharing and information exchange.
During the period, Mildmay submitted Quarterly Performance Reports to NHS
Commissioners and referring clinical nurse specialists (CNSs) in the form of a Key
Performance Indicator (KPI) table with additional narrative and commentary.
At the closing quarter of the year of the year we had no reportable red indicators in the key
performance indicator profile. During the year we had one quarter (Q1) where patient
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feedback was scant (reportable to commissioners) and one reportable exception in Q2 that
our agency spend was 6% (the limit is 5% of the staffing budget)
Mildmay’s Senior Management Team also submitted quarterly reports to its own Board
including snapshots of cases, statistics, management accounts and progress reports on key
objectives. The Board received Risk Management Reports and Risk Profiles as well as reports
on actions taken to limit/eliminate risk and improve quality.
The Senior Management Team meets fortnightly to discuss incidents, staff performance,
operational issues, and to drive forward the business plan. It oversees the function of a
number of standing committees (Risk Management and Clinical Governance) and it ensures
that a range of monthly internal audits are undertaken as well as the quarterly Morbidly and
Mortality meeting.
The 2014-15 year has seen a staff restructure as we move to a new hospital. The structure is
designed to permanently staff one ward, with surge capacity onto the second ward. (NHS
contract levels are not currently large enough to permanently run two wards). A permanent
use for the upper ward is a key developmental target.
The quality of service experienced by people who use our service is central to the way we
work. Financial stability is also an ongoing concern for the Board. We are pleased to report
a balanced financial position for the 2014/15 year.
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Part 3 - Review of Quality Performance 2014 -15
3.1 Objectives
3.1. 1 Objective 1 Maximise Occupancy
We will continue maintain occupancy levels appropriate to the needs of the community we
serve.
Demand for our services over recent years has gone hand in hand with increases in complexity
and challenging behaviours. As a small unit, subtle variations of referral can have a
significant effect on cash flow and viability.
Mildmay maintained a high in-patient occupancy of 82% in 2014/15 and an even higher Day
Service take-up of 89%. However, the complexity of patient referrals also increased,
meaning that we had more long-stay patients. This meant an overall decrease in patient
numbers during the year of 18%, while at the same time an overall increase in the length of
admission to Mildmay.
All indications point to patient demand increasing in the future due to the profile of the
HIV+ population in the UK (both age and late diagnosis).
Mildmay is currently operating on one of its two wards (a 14-bed ward), due to funding
levels. A focus during the 2015/16 year is to open the second 12-bed ward.
3.1.2 Objective 2 - Maximise Voluntary income
We will seek to increase voluntary income to the charity. Diversification of income can
contribute to achieving other objectives such as developing outreach work & innovation in
service delivery.
Mildmay’s non-statutory income decreased from £692k in 2013-14 to £536k in 2014/15 (22.5%). This was due in the main to our hospital development campaign coming to an end
in month five when we moved to the new hospital. It also reflects the extremely challenging
economic environment in which Mildmay operates. Mildmay has just expanded its
fundraising team by one-post in the run up to ‘Mildmay 150’ – a campaign marking 150
years of providing compassionate care from our base in the East End of London.
3.1.3 Objective 3 – Awareness Raising
We will seek to raise awareness of the work of Mildmay, by creating a visible presence at key
conferences, enlarging our stakeholder base, and maintaining training and development. We
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will seek to develop marketing materials which promote the organisation while maintaining
patient confidentiality.
Mildmay was granted the ‘NHS Information Standard’ kite mark in spring 2013 and this was
reviewed and re-issued in October 2014. This is a quality mark for information that is clear,
relevant, evidence based, authoritative, complete, secure, accurate, well-designed, readable,
accessible, and up-to-date.
Although a small unit, Mildmay continued to be highly commended as a training placement
for 18 nursing students (18 last year), 20 medical students (14 last year), 6 GP doctors in
training (6 in 2012/13), 2 dietetic students (3 in 2012/13), 1 OT student (2 in 2012/13), 2
psychology students (0 in 2012/2013) and 3 social care students during the period (8 in the
previous period). This helps raise awareness of Mildmay’s services when people qualify and
move into their professions.
The number of external talks and presentations were maintained at a high level as health
professionals were encouraged to speak to their own professional sub-group meetings,
conferences and events. Talks to non-clinical audiences also held up, most notably to
churches.
Mildmay also had promotional stands at the BHIVA (British HIV Association) conferences in
Liverpool and London, at the NHIVNA (Nurses HIV Association) conference in Cardiff, PRIDE
in London and at the Big Church Day Out in Steyning 2014.
3.1.4 Objective 4 – Move to new Site
We seek to achieve an effective and efficient move to the new hospital in mid-2014/15. We will
oversee the fit out and manage the building handover and systems testing in a four week
window to maximise safety and to allow scope for learning about systems and equipment in
the new unit. We wish to minimise disruption to the patients on site at the point of the move.
We will ensure that the management and functionality of the new building meets the needs of
our service and enables future flexibility. We will provide an environment fit for purpose for
patients and their families: clean, safe and with the staffing levels and training appropriate to
the setting. We will uphold standards of care, learn from any mistakes, strive for improvement,
and place the patient at the centre of our decision making.
Following a CQC inspection of the new Mildmay hospital on 7th August 2014, we received the
certificate required to occupy the site. We moved on 1st-3rd September 2014. Apart from a
challenge with the phone and IT system at the time of moving (for which a temporary
solution was identified), the move went smoothly.
Each ward room has an on-suite shower room and wc, eight of the 26 en-suites are
wet rooms for wheelchair users, and both wards have an assisted bathroom, assisted
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shower room, a day room, office, etc. The hospital also has a gymnasium, chapel, a
large day room, dining room, counselling room and an IT suite. This surrounds a
secure and secluded garden.
The previous hospital is in the process of being demolished.
3.1.5 Objective 5 –Innovation
We will continue to explore the design of new services. We will build on our experience in the
delivery of appropriate services for people living with complex HIV conditions.
We will seek to extend funding for the specialist Black African Male Support Worker to deliver
outreach services.
We shall also explore the potential for an additional mental health service at the new unit that
could respond to the continuing complex experience of late stage HIV infection and which
would seek to address an identifiable gap in current health service provision in London.
Additionally, we will look to pilot aspects of our day-service provision in other parts of London.
In the first instance this is likely to take the form of a Peer Support Group.
Much of objective 3.1.5 was not achieved during the year. We did seek funding to extend
the Black African Male Support programme, but this was not forthcoming and the
programme was curtailed at the end of the grant period in early 2015.
In connection with mental health registration, this was deferred until we had moved into the
new setting and had been operating in that setting for over a year.
In connection with off-site day services, this has not been possible to fund and has now
assumed a lower priority than the development of new Day Service programmes within the
new hospital.
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4. Commentary
4.1 Feedback Mechanisms
Feedback from patients and day service users is obtained from a range of methodologies:

Anonymous Exit interviews/feedback forms (this includes the Friends and Families
Test)

Discussion with Key Workers and front line staff

Our complaints mechanism

Feedback via their clinical nurse specialist

Day service client forum.

Patient/day client involvement in the Patient Led Assessment of the Care
Environment (PLACE) will occur in the year ahead, drawing the service user
perspective. It did not take place on 2014/15 due to our hospital move in September
2014.

Our Board includes an HIV positive trustee who not only can act as a Patient
Champion, but importantly contributes to the governance and strategy within the
organisation

Feedback from next of kin, carers, friends, visitors, relatives and significant others is
encouraged in face to face encounters and by the provision of a Suggestion Box
4.2 Mandated statements
4.2.1 Review of Services
During 2014-15 Mildmay had capacity for 5420 in-patent bed nights and 4320 day service
placements.
In 2014/15 we provided 4483 in-patient bed nights for 98 people (82% occupancy) and 3880
day service placements (89% occupancy) for 80 community clients and 44 inpatients.
Notably Mildmay had more longer-stay patients in 2014/15 than in the previous year.
In 2013/14 we provided 4514 in-patient bed nights for 120 people and 2927 day service
placements for 65 community clients and 61 inpatients.
In 2012/13 we provided 4602 in-patient bed nights for 118 people and 2238 day service
placements for 81 community clients and 40 inpatients.
Mildmay has reviewed all the data available to them on the quality of care, and have
responded to lessons learned from incidents, admission difficulties & reviews.
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Patients readmitted to the service
NO patient was readmitted to Mildmay from home within 28 days of being discharged to
home from Mildmay (Mildmay doesn’t receive referrals in the 0-14 reporting category, so
this statement refers to the 15+ category). The figure for 2013/14 was 0.
Mildmay considers that this data is as described for the following reasons: the patients were
discharged at the correct time, having benefitted from a rehabilitation programme to a point
where they were able to be discharged home to live independently. Each patient’s discharge
was planned with the relevant support agency being involved.
In order to maintain this standard Mildmay will continue to ensure that discharge planning
remains effective and will liaise with referring agencies to ensure that the length of admission
is appropriate to the needs of the patient.
Patient Safety Incident
There was ONE patient safety incident recorded during the year (one last year). A patient
was not given fluids for six hours during a referral to an outpatient appointment at another
hospital. No permanent damage caused, but concern about a series of disconnected events
(which were not within our control) which led to this situation arising. Mildmay reported this
as a matter of process.
There were NO patient safety incidents which resulted in any harm, be they mild, severe or
death.
Mildmay, as a voluntary sector provider, was not able to identify any nationalised data
source to give accurate comparators.
4.2.2. Clinical Audits
During 2014-2015 NO national clinical audits and NO national confidential enquiries covered
NHS services that Mildmay provides. During this period Mildmay UK participated in 0% of
national clinical audits and 0% of national confidential enquiries which it was eligible to
participate in.
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The national clinical audits and national confidential enquires that Mildmay was eligible to
participate in during the reporting period are as follows: NIL.
The local (internal) clinical audits and local confidential enquires that Mildmay was eligible to
participate in during the reporting period are as follows: 12
4.2.3 Research
The number of patients receiving NHS services provided or sub contracted by Mildmay in
this period, that were recruited during that period to participate in research approved by a
research ethics committee was NIL
Mildmay was involved in conducting NO clinical research studies in HIV during the reporting
period.
NO clinical staff participated in research approved by a research ethics committee at
Mildmay during this period
Mildmay did participate in a number of conferences throughout the year, participating in
panel discussions and presenting posters.
4.2.4 CQUIN
NONE of the income of Mildmay Mission Hospital UK in 2014-15 was subject to CQUINs
(Commission for Quality & Innovation payments) due to the complex nature of the service
delivery. Therefore NO income was conditional on achieving quality improvements and
innovation goals through the Commission for Quality and Innovation payment framework.
The 2015/16 contract also contains no CQUIN provisions.
4.2.5 CQC Inspection
The last unannounced routine CQC inspection occurred on 13th December 2013 (as reported
in last year’s Quality Account), and were assessed across five areas:





Consent to Care and Treatment
Care and Welfare of People who use Services
Safeguarding People who use Services from Abuse
Requirements relating to workers
Complaints
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Mildmay met the published ‘Essential Standards of Quality & Safety’ and its December 2013
unannounced inspection is available for scrutiny to the public on the CQC website.
Mildmay moved settings to a new hospital in September 2014, and in connection with this
move received a planned CQC inspection on 7th August 2014, which approved the setting as
being appropriate for the on-going provision of services.
4.2.6 Capturing and Measuring Data for Measuring Quality
Mildmay’s uses iCare for recording some patient information, although it maintains paperbased notes as well - providing an archive which goes back to the first admission of HIV+
patients in 1988. iCare meets information governance requirements and is a programme
used by a range of health & social care providers, including specific NHS bodies, to provide
robust, and accurate outcome data.
Mildmay follows the UK Rehabilitation Outcomes Collective (UKROC) data acquisition
processes and provides data that is compliant with UKROC peer group comparison
frameworks. This contributes towards the evidencing of outcomes for patients who access
Mildmay’s services.
The Caldicott Guardian at Mildmay is Dr Simon Rackstraw – Medical Director
The Senior Information Risk Owner is Ross White - Executive Director
4.2.7 NHS Number & General Medical Practice Code Validity
Mildmay has not submitted records during the reporting period to the secondary uses
service for inclusion in the Hospital Episode Statistics which are included in the latest
published data as it is not a requirement of the contract with our commissioners. Mildmay
safeguards the confidentiality of people living with a condition which still experiences stigma
and discrimination in the community.
4.2.8 Clinical Coding error rate
Mildmay was not subject to the Payment by Results clinical coding audit in 2014/15 by the
Audit Commission.
4.2.9 Complaints & Incidents
a) There were 5 complaints during the reporting period (6 last year)
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b) There were TWO deaths of inpatients at Mildmay during the reporting period (None
in 2013/14)
c) There were 40 general incidents recorded in 2014/15 (65 last year), of which 35%
were falls (14 in total (40% the previous year, 26 in total)), 2.5% (1 in total) was a
medication/drug chart error (11 last year), 7.5% (or 3 in total) were verbal/physical
abuse of staff (8 or 12.4% in 2013/14)
d) One Serious Untoward Incident (SUI) was reported to the CQC which was also a risk
to patient health (one SUI last year – no risk to patient health). A patient was not
given fluids for six hours during a referral to an outpatient appointment at another
hospital. No permanent damage caused, but we had concerns about a series of
disconnected events (which were not in our control) which led to this situation
arising. Mildmay reported this as a matter of process.
e) There was one medically adverse incident (please see d above AND the patient safely
incident in section 4.2.1 (same incident)) – (one in 2013/14)
f)
There were two applications to Deprive Someone of their Liberty (five in the previous
year)
g) Mildmay reported two incidents to the CQC which affected the safe running of the
service for more then 24-hours. These related to, respectively, the phone line and
internet lines at the point of moving hospitals. The previous year there was one
similar incident when a power surge took out some phone lines.
4.2.10 Summary hospital-level mortality indication (SHMI)
The value, banding and supporting palliative care data which is used as a hospital level
indicator which measures whether mortality associated with hospitalisation, was in line with
expectation, does not apply to Mildmay as a tertiary health service provider.
4.2.11 Patient Led Assessment of the Care Environment (PLACE)
Due to an impending move to the new hospital in mid-2014, it was agreed with inspectors
that a PLACE inspection would be deferred for a year. Many of the recommendations of the
May 2013 inspection were addressed upon moving to the new setting. The previous PEAT
assessment of 2012, gave an aggregate score of 82%.
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Mildmay scored 'GOOD' in the previous PLACE Assessment in May 2013 (the highest level)
with the exception of:






Car park - signage bays and surfaces (the new hospital doesn’t have visitor parking)
No separate treatment room in the ward areas for minor procedures/wound dressing.
Transport management plan – (now complete).
Patient access to IT – (new hospital has Wi-Fi access for portable devices as well as an
IT suite)
Patient access to a telephone.
Access to meals/snacks for family, relatives – (the new hospital has a vending
machine)
4.2.12 Infection Control
Infection control standards are regularly externally audited throughout the year, with any
recommendations either acted on immediately. These inspections took place in both our
old setting and new setting. There are no outstanding concerns in respect of infection
control at Mildmay.
4.2.13 Information Standard Kite Mark
Mildmay was awarded the Information Standard Kite Mark in Spring 2013. This was
reassessed in October 2014 and a new certificate of compliance awarded on 13th October
2014
4.3 Mildmay’s Action in the NHS Outcomes Framework Domains;
4.3 1 Domain 1: Preventing people from dying prematurely
The British HIV Association (BHIVA) ‘Standards of Care for People Living with HIV 2013’ states
that late and very late diagnoses is a major cause of diminishing life expectancy for people
with HIV, as well as ‘loss to follow-up’. The vast majority of patients referred to Mildmay are
presenting with neurocognitive impairment relating to either late diagnosis or ‘loss to followup’.
Mildmay had two deaths in the reporting period and none in the previous year. This level,
which is around 2%, is well within the limits we would expect.
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4.3.2 Domain 2: Enhancing quality of life for people with long-term conditions
Over 82% of patients referred to Mildmay return home to independent living following
Mildmay’s intervention.
The service aims to prevent health deterioration caused by HIV, by initiating prompt and
appropriate management of HIV morbidity.
The teaching of self-management skills and independent living skills contribute to the
empowerment of the individual to make informed choices about their future care.
As a discharge pathway of choice for two London Hospital Trusts, part of the function of
Mildmay is to undertake assessment & rehabilitation and/or make recommendations for the
future long term care and support of people living with HIV.
4.3.3 Domain 3: Helping people to recover from episode of ill health or injury
Mildmay has particular experience in supporting and treating people with a wide range of
complications resulting from the direct effects of HIV, its treatment and prolonged exposure
to treatment, age, and an increasing range of associated co morbidities.
Mildmay applies a multidisciplinary team approach to care that addresses the physical,
psychological and spiritual impact of living with a serious illness.
Rehabilitation is a partnership approach (between the team and patient) which aims to bring
about the restoration of skills & ability (fully or partially), to enable the individual to have
more choices in their future care and support options. Self-management in the long-term is
part of this approach.
4.3.4 Domain 4 Ensuring people have a positive experience of care
The use of key-working is vital in maintaining tailored care at Mildmay
The engagement of patients as positive partners in the design of their care, rather than
passive recipients, is at the heart of service delivery, although the cognitive and behavioural
elements of neurological disorder can limit the capacity of an individual to engage.
In some cases the use of the Deprivation of Liberty (DOLS) procedures can assist in the safe
care of patients, in cases where they lack capacity.
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4.3.5 Domain 5 Treating and caring for people in a safe environment & protecting
them from avoidable harm
This is achieved in a number of ways, by:

Providing a safe and secure environment with experienced, trained and caring staff

Working with patients / day clients to educate them about the mechanism of passing
on the HIV virus, of the importance of adherence to medication, and the role of
nutrition

Discussing issues of disclosure and stigma

Continuing professional development of Mildmay staff and providing mandatory
training

Dealing with incidents and complaints quickly yet thoroughly, and seeking ideas for
service improvement

Protecting patient data and maintaining confidentiality (HIV still remains stigmatised

Identifying risks and reducing/eliminating them
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5. ANNEX sources of supporting statements
In compliance with the regulations, Mildmay sent copies of our Quality Accounts to the
following stakeholders for comment prior to publication.

The lead commissioners, commissioners and CNS

The Overview & Scrutiny Committee (OSC) of the London Borough of Tower Hamlets
or its Health Board.

Health watch

The Friends of Mildmay
At the point of publication no specific feedback had been received.
Ross White
22nd June 2014
End
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