ST MARY’S HOSPICE
QUALITY ACCOUNT 2015/16
I knew he was getting 24 hour care
which took stress away from me. He
had no pain and that meant the world
to his children and grand-children.
We were told about the bereavement
support service as soon as my partner
was admitted. My worker was
marvellous. I cried quite a lot and
talked over everything with them. It
helped immensely. Eventually my
tears became less.
Caring for someone at the end of
life creates many emotional and
physical difficulties . Therapies
acted to reduce these and get
things back to ‘normal’. I found the
therapist easy to talk to.
“Support, care and hope for local people
and those who love them”
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Quality Account 2015/16
Part 1
Chief Executive’s Statement
Welcome to the 5th Quality Account for St Mary’s Hospice, a document designed to show
stakeholders how we measure quality, involve patients, carers and staff and strive to continually
improve our care.
A Quality Account is required as an annual report to the public from providers of NHS healthcare
about the quality of services they deliver. It is important to note that St Mary’s Hospice only receives
around 22% of its funding from the NHS while the rest (around £2 million each year) is donated by
the local community. The majority of services described in this document are funded by charitable
donation rather than by the NHS. However St Mary’s Hospice regards it as important to ensure that
all patients and families using our services are assured of the quality of these and can see easily the
ways in which we strive, year on year, to improve what we offer.
Quality sits at the centre of all that the Hospice does. Our vision is that everyone in South Cumbria
with a life-limiting condition will have high quality care and support at the end of their life in the
place that they choose.
We asked patients, families, volunteers and staff to sum up in one word what St Mary’s means to
them. Their key words form the backbone of our mission statement:
Work carried out in 2014-15 identified the Values of St Mary’s Hospice as:
Caring – we will make every contact count by treating each individual with kindness, empathy,
compassion and respect.
Aspiring- we will continually learn and develop and we will strive for excellence in everything we
do.
Professional – we will deliver high standards through team work, a skilled workforce and
managing with integrity.
Our Governance structure ensures that we have both the systems and processes in place to ensure
our clinical services are of the highest quality and meet the aspirations of our mission statement
whilst maintaining a viable and responsible business.
This year in our Quality Account we give an update on work proposed in the Quality Account for
2014-15 as well as showing where we will focus development during 2015-16.
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Quality Account 2015/16
Our goals for the next twelve months have been developed by looking at national research on
improving hospice care as well as conversations with service users and local health professionals.
The next paragraphs are in response to last year’s local Healthwatch feedback where they asked for
additional information to be shared on:
Ensuring safety
The hospice has a formal Assurance Programme consisting of Risk Assessments and Risk Registers for
all activities and services. These are reviewed during the year and increases in risk levels brought to
relevant committee meetings for analysis and resolution or escalated to Board.
The hospice management take a pro-active approach to managing risk and works within a no blame
culture where we seek to identify and resolve issues openly. The hospice has always believed there
is a moral Duty of Candour towards others and actively seeks open and honest relationships with
families and other stakeholders.
There is also a mandatory training programme in place at the hospice to ensure staff and volunteers
are able to deliver care safely.
Ensuring clinical effectiveness
The hospice considers it to be good practice both individually and as an organisation to stay aware of
changes in clinical practice and to question and challenge our own delivery in various ways e.g.:
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Contact with professional bodies of staff
Participation in local multi-professional groups
Leading regular peer review meetings locally
Regular Multi-Disciplinary Team meetings locally
We also gather feedback and outcomes from those using our services and measure this against
other services nationally and locally. Hospices in the North West of England work together closely
and support each other in identifying best practice.
I am responsible for the preparation of this report and its contents. To the best of my knowledge,
the information contained in this Quality Account is accurate and a fair representation of the quality
of healthcare services provided by our Hospice.
Val Stangoe
Chief Executive
June 2015
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Quality Account 2015/16
Part 2
Our three priorities for improvement 2015/16
Priority 1
Reaching out to the community
Ensuring more people can access support closer to home
In October 2014 the CCG increased funding to allow us to deliver more hours of care in our Hospice
at Home team. We are now able to have two teams of nurses working in the community to reduce
travel time and increase care hours. There are also 10 night sits available weekly, up from the
previous 4. As part of this funding we now have senior doctors and nurses visit Furness General
Hospital 3 times a week to identify patients who might be supported by the hospice.
Community (previously Hospice) Neighbours was originally commissioned for the South Lakes area
only. During 2014-15 we accessed funds from the St James Place Charity to allow us to roll this
project out across our whole catchment area. More people will now be able to benefit from this
service.
St Mary’s Hospice provides Positive Living Groups; 6 week courses for patients and carers teaching
tools to support wellbeing and maintain independence. During 2014-15 6 courses were delivered in
Ulverston with a trial held of delivering one course in Ambleside. Success in external provision has
led to a timetable being developed for delivery in other community venues across the coming
months.
We were grateful to the Sunflower Trust for providing funding to allow us to deliver Reiki therapy for
1 day each week in the hospice and 1 day each week in the oncology unit FGH. During the year this
supported 106 individuals and funding has now been extended for another year.
Priority 2
Improving access to Specialist Palliative Care
Making our doctors more available
Due to fluctuations in medical staff numbers across the year we have not been able to push medical
support out into the community as much as we would have liked. However since October 2014 one
of our senior medical staff has attended the Furness General Hospital on a weekly basis to discuss
individual cases with hospital staff.
We also have two Advanced Nurse Practitioner trainees who, once qualified, will function in the role
of junior medical staff.
Priority 3
Implementing a dementia strategy
Meeting patient and family needs
The hospice is working with the local Dementia Group to identify where best use could be made of
the hospice in providing services for people with dementia and their family carers.
As part of this the hospice is undergoing a rolling programme of delivering Dementia Friends training
to its staff and volunteers to ensure we are able to respond supportively to those using, visiting or
accessing any of our services.
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Quality Account 2015/16
Priorities for Improvement 2015/16
Suggestions for priorities for work for the coming year came from our NHS commissioners, our own
audits and growing national awareness of the demographic changes we are to see over the next 10
years.
Priority 1
Continuing to develop increased access to community care
More care close to home
This will continue to be a theme for hospice care over the coming years. There is a need to work with
other health providers to increase numbers of referrals and encourage referrals to the hospice
earlier after diagnosis in order that patients and families can benefit from our support.
As part of this we will:
Deliver Hospice at Home care to an increased number of families across the next 12 months
Deliver Positive Living Groups in Coniston, Millom and Barrow in addition to Ulverston
Increase access to emotional support and therapeutic activities in the community
Work closely with local Care Navigators employed within Primary Care Communities
Priority 2
Hearing the community’s view on hospice care
Listening to the experts
During this 12 months we will invite the community in different ways to tell us what they think of
current services and where they think there may be gaps we need to fill. We will do this through
public events, social media and targeted questionnaires.
Priority 3
Using the Hospice building effectively
Continuing to grow our services
We will continue to work to make best use of our new Cavendish building by developing an
increased number of activities for patients and carers and supporting local health related
groups with provision of meeting space.
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Quality Account 2015/16
Part 2 (Continued)
Statements of Assurance from the Board
Quality Accounts have a series of statements that must be included. Many of these statements do
not apply to St Mary’s Hospice. Explanations of what these statements mean are given where
appropriate.
During 2015/16 St Mary’s hospice provided the following services:
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In-Patient Unit
Hospice at Home Service
Day Hospice
Positive Living Groups
Complementary Therapy
Family Support and Bereavement Services
“Drop in” Groups
Education and Training
Community (Hospice) Neighbours support
St Mary’s Hospice provides 78% of the funding for these services. The remaining 22% comes from
the NHS via the Clinical Commissioning Groups (CCGs) responsible for South Lakes and Furness.
St Mary’s Hospice has reviewed all the data available to them on the quality of care in all these NHS
services. (This is a mandatory statement)
Participation in Clinical Audits
During 2014/15, St Mary’s Hospice was ineligible to participate in the national clinical audits and
national confidential enquiries. (This is a mandatory statement)
Participation in Local Audits
The Clinical Audit Group oversees a programme of internal audit which uses national, local and
regional audit tools. Where issues are identified during an audit, an action plan is developed to put
any problems right. Progress on this action plan is then monitored by the Governance Group to
ensure that actions are completed.
Research
The number of patients receiving NHS services provided or sub-contracted by St Mary’s Hospice in
2014/15 that were recruited during that period to participate in research approved by a research
ethics committee was NONE (This is a mandatory statement, this type of research does not apply
to St Mary’s Hospice.)
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Quality Account 2015/16
Use of the Commissioning for Quality and Innovation (CQUIN) Payment Frame
St Mary’s Hospice NHS income in 2014/15 was not conditional on achieving quality improvement
and innovation goals through the CQIN payment framework because it is a third sector organisation
and as such was not eligible to participate in this scheme during the reporting period. (This is a
mandatory statement in 2014/15 CQUIN payments did not apply to St Mary’s Hospice)
Statement from the Care Quality Commission
St Mary’s Hospice is required to register with the Care Quality Commission to carry out the regulated
activities:
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
Treatment of disease, disorder or injury
Diagnostic and screening processes
St Mary’s Hospice has the following conditions on registration:
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Only treat people over 18 years old
Only accommodate a maximum of 9 in-patients
We have agreement from the CQC that we can treat patients aged between 16-18 years of
age if they are not able to access an equivalent service in this area.
There has not yet been an unannounced visit by the CQC in 2015 but our last visit in March 2014
found no areas of concern.
Data Quality
St Mary’s 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.
(Mandatory statement)
However, St Mary’s Hospice does submit data to the Minimum Data Set (MDS) for Specialist
Palliative Care services collected by the National council for Palliative Care on an annual basis, with
the aim of providing an accurate picture of Hospice and Specialist Palliative Care service activity.
Information Governance Toolkits
The following statement does not apply to St Mary’s Hospice but must be included in our Quality
Account:
St Mary’s hospice Information Governance Assessment Report overall score for 2014-15 was (%) and
was graded (insert colour from IGT grading scheme).
(Mandatory statement)
Clinical Coding Error
The following statement does not apply to St Mary’s Hospice but must be included in our Quality
Account:
St Mary’s hospice was not subject to the payment by results clinical coding audit during 2014/15.
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Quality Account 2015/16
(Mandatory statement)
Part 3
Review of Quality Performance
In this section, we have benchmarked St Mary’s Hospice data with figures from the National Council
for Palliative Care Minimum Data Set, (MDS) from 2010-11. Although there is more recent data
available the format of reports has altered and differentiation between smaller and larger units has
been lost. This makes the recent data less useful in comparing our performance against similar sized
UK hospices.
In Patient Unit St Mary’s Hospice is classified as
a small In Patient Unit < 10 beds
Total number of patients
Number of new patients
% Occupancy
% Patients returning home
Average length of stay
St Mary’s Hospice is classified as
a medium Hospice at Home
provider (129 to 297 patients.)
Total number of patients
Number of new patients
Total number of patient visits
% new patients
% of patients who died at home
St Mary’s Hospice is classified as
a small category Day Hospice
provider < 126 patients
Total number of patients
% new patients
Average period of attendance
ST Mary’s Hospice
2013/14
2014/15
160
170
138
150
70%
66%
51%
62%
9.74 days
8.4
National Mean
2010/11
163
116
78.5%
48%
11.05 days
Hospice at HomeSt Mary’s Hospice
2013/14
2014-15
National Mean
2010/11
232
222
1,777
96%
78%
248
221
1,852
89%
79%
Day HospiceSt Mary’s Hospice
2013/14
2014-15
58
65.4%
62.75
107
85%
49.5 days
234
1,768
90%
79%
National Mean
2010/11
94
60.3%
137 days
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Quality Account 2015/16
In early years of collation MDS did not gather Family Support Service data therefore we have used
data from a more recent MDS dataset
St Mary’s Hospice
National Mean
2013-14
2014-15
2012/13
Referrals
389
570
283
Contacts
2807
2392
776
Caseload
78
82
-
IPU visits
1365 *
1517
-
116 ( 2 events)
75 (1 event)
-
Family Support Service
Afternoon tea
attendances
* NB change in way recorded during this period as now logged as individual visit to each
patient/family and not one overall visit to IPU in which 8 families may have been seen.
Diagnosis
It is recognised nationally that those with non-cancer diagnoses (heart, lung or neurological disease)
are much less likely to receive palliative or end of life care from a hospice in contrast to those with
cancer diagnoses. Figures are therefore gathered nationally and locally on the percentages of
cancer/ non-cancer diagnoses in each service.
St Mary’s Hospice 2014-15
National Mean
2012/13
Cancer
Non-Cancer
% Cancer : % Non-Cancer
IPU
78%
22%
87 : 13
Day Care
52%
48%
77 : 23
Hospice at Home
75%
25%
79 : 21
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Quality Account 2015/16
Feedback from Staff
St Mary’s Hospice is recognised as a good local employer and when we do have a vacancy, we
receive a high volume of applications.
An annual staff survey has been conducted for the last three years. Following the 2013-14 survey a
Staff Forum was formed. There are also regular staff briefings and consultation on issues involving
change. After some staff changes e-newsletters are again becoming a regular hospice feature and
help to keep staff up-to-date on hospice changes and to encourage people to be involved in decision
making.
51 identical questions were asked in 2013-14 and 2014/15 with comparisons made between results
which showed that:
32 questions in 2014 had more positive responses than in 2013
2 questions remained unchanged since 2013
18 questions in 2014 had less positive responses than in 2013
Many of the changes were slight. However participation in the survey had dropped from 60% of staff
to 44%. It has been agreed that the survey will not be carried out again until 2016-17 with stronger
efforts at that time to encourage wider participation.
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Quality Account 2015/16
Feedback from Patients and Carers
Feedback from patients and carers is one of the most important ways in which St Mary’s Hospice
measures the quality of its care. Those who use our services are asked to give formal feedback of
their experience in order that we can identify how to improve services. There are also Feedback
forms available around the hospice which can be completed by anyone and placed in a locked box
which is regularly checked. St Mary’s Hospice is lucky to be a frequent receiver of compliments.
In 2015-16 we will encourage service users and health colleagues to also comment on things we do
which they may find less useful in order that we can improve.
Here are some examples of comments in our most recent surveys in our patients’ and families own
words:
Using Complementary Therapies is
one of the best things I have done.
More people should try it.
As we had no immediate family the
support given was much appreciated
especially in the last few days of my
husband’s life.
My ‘visitor’ phoned every
night at first. She was always
kind and gentle in her manner
and was led by my needs
without being intrusive.
I’d just like to say thank you.
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Quality Account 2015/16
Complaints
We monitor all complaints whether clinical or non-clinical and discuss them at our Governance
meetings, complaints are also reported regularly to the Board of Trustees:
Clinical Complaints
2013/14
1
Total number of
complaints
Number of complaints
upheld in full
Number of complaints
upheld in part
2014/15
0
0
0
1
0
St Mary’s Hospice is always keen to use formal complaints as a tool for service improvement.
In 2014-15 we were very pleased to have no clinical complaints at all.
However while we don’t want complaints it would be really helpful to have feedback that indicated
where we could make changes to benefit patients and families. We continue to ask people to give
feedback on how well our service met their expectations. It is only by reviewing any situations
where we did not meet expectations that we will be able to improve.
Clinical Audits
A Clinical Effectiveness group is being commenced, which will support the clinical audit process by
regular review of the evidence base for our practice. This will inform updating of Standard Operating
Procedures and Policies, as well as identifying areas for audit, within an annual clinical audit cycle.
Audit
Completed
Action Plan
Examples of action taken to improve practice
Infection
Prevention &
Control Audit
Yes
Yes
Repair work to be done to some areas to ensure
they are easier to keep clean
Controlled Drug
Audit
Yes – but
on-going
on annual
cycle
Yes
Renewed CD signature list to ensure up to date as
new staff in place
Controlled Drug
Prescribing Audit
Yes:
quarterly
Yes
Minor changes required as above re: CD record
Pressure Sore
Audit
Yes – but
on-going
Yes
No pressure sores began in hospice over previous
period. Staff training needs have been identified
around assessment of risk of pressure ulcer
development.
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Quality Account 2015/16
Bereavement
audit
Yes
Yes
Bereavement policy, how to review Bereavement
Volunteers performance, mandatory training for
volunteers
Prn prescribing
Yes
completed
It was agreed to change previous practice and
state the timescale of repeat drug delivery in
order to ensure clear instructions available
Food and
Nutrition
Yes
Yes
The hospice has also bought a new tool <iBenchmarking> to support audit for compliance against
the new CQC structure. This tool when complete shows compliance levels against the 5 key
questions. In future our Quality Account will contain information on how well we comply against the
5 questions and on our action plans to reach full compliance.
Opportunities to give feedback on this Quality Account
We welcome feedback on our Quality Account. If you have comments, please email:
val.stangoe@ stmaryshospice.org.uk
Or write to:
Val Stangoe
Chief Executive
St Mary’s Hospice
Ford Park Crescent
Ulverston
Cumbria
LA12 7JP
Annex – consultation on our Quality Account
This document was sent to the Cumbrian Healthwatch and the Cumbria CCG to review but
by the point of being uploaded no response had been received.
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Quality Account 2015/16