2014/15
St. Michael’s Hospice (North Hampshire)
Quality Account
CONTENTS
Part 1
Page
Chief Executive’s Statement
3
Mission Statement and Vision
4
Priorities for Improvement 2014 - 2015
4
Review of Priorities for Improvement 2013 - 2014
6
Part 2
Statement of Assurance from the Board
6
Review of Services
7
Participation in Clinical Audit
7
Research
8
Quality Improvement and Innovation Agreed With Our Commissioners
8
What Others Say About Us
8
Data Quality
9
Part 3
Quality Overview
9
What Our Patients Say About St. Michael’s Hospice
12
What our Staff Say About The Organisation
13
What Our Regulators Say About St. Michael’s Hospice
14
The Board of Trustees Commitment to Quality
14
Comments From Other Stakeholders
14
SMH Quality Account Feedback
15
Page 2 of 15
Part 1
Chief Executive’s Statement
Welcome to our fourth annual Quality Account which highlights some of the main quality
improvements we have achieved during 2014/15 and the priorities we have identified against the
three domains of quality: patient safety, clinical effectiveness and patient experience for clinical
development in 2015/16.
Quality is central to the care that we provide. Our approach is forward thinking, flexible and
responsive to the local health care environment and we continue to build upon a well established
corporate and clinical governance framework. I am committed to promoting and developing an
environment of openness, honesty and transparency to ensure we fulfil our duty of candour.
Our new hospice 5 year strategy plan will support us to fulfil our goal of delivering high quality
clinical care. This will be influenced by the patients’ choice both in terms of the nature and the
location of the delivery of that care. In collaboration with a number of stakeholders, we have
developed new exciting initiatives to implement our new strategy which focuses in particular on
supporting and providing more specialist services into the local community.
Most importantly, we actively engage the patients who use our service and their relatives, gaining a
significant amount of positive and constructive feedback on how we can shape services in the
future. Our 2014 VOICES survey highlighted that 94% of relatives would be either extremely likely
or likely to recommend St Michael’s Hospice care (In Patient Unit and Hospice at Home) to friends
or family.
Our people are our biggest resource. I would like to acknowledge and thank not only our staff and
volunteers who work tirelessly to provide high quality services but also our committed supporters
who enable us to raise the necessary funds to provide our services free of charge to patients and
their families.
David Monkman
Chief Executive
May 2015
Page 3 of 15
Mission Statement
St. Michael’s Hospice (North Hampshire) enables people faced with a life limiting illness, their
families and carers, to attain the highest possible quality of life by providing a choice of specialist
care and support.
Our Vision
St. Michael’s Hospice will endeavor to influence and lead all aspects of palliative care provision in
North Hampshire. It will do this by working in partnership with all stakeholders, particularly service
users, who will be actively involved in the development and delivery of services which, as far as
possible, will be user lead.
Priorities for Improvement 2014 - 2015
Our services are not simply about meeting standards and delivering high quality in all that we do.
They are about delivering holistic care and embracing people as individuals, improving their
personal experience and ensuring dignity and privacy.
The quality improvement priorities we identified for 2014 - 15 are set out below. Three key areas
are identified: Patient Safety; Clinical Effectiveness; and Patient Experience. The focus around
these priorities will ensure significant enhancements in the quality of care for our patients and their
families.
Future Planning
Our targeted quality improvement priorities for 2015 - 2016 are:
Patient Safety
Priority 1: Organisational Review of Tissue Viability Provision
How was this Priority identified?
Recently we have seen the needs of patients using hospice services becoming ever more complex
and thus ever more challenging for our multidisciplinary team. This combined with an increasing
length of stay, means patients may be more at risk of developing pressure ulcers whilst in the
hospice.
How will Priority 1 be achieved?
All aspects of tissue viability provision will be reviewed and a multidisciplinary working party will be
convened to undertake this review. As part of this review, a bed and mattress replacement
programme will be undertaken and staff will undergo training both at the bedside and in the
Page 4 of 15
classroom. Recommendations will be made to the Clinical Effectiveness Committee and the
necessary resources allocated accordingly.
.
Clinical Effectiveness
Priority 2:
The North Hampshire Six Steps Education and Practice Development
Programme
How was this Priority identified?
Following a consultation process and development of the new St Michael’s Hospice Strategy
(January 2015 to December 2020) Strategic Objective 3 was agreed - ‘To develop and enhance
partnership working with local statutory, independent and voluntary sector organisations; to
maximise quality and efficiency of care’. Care homes are an area where the hospice has limited
input, yet 22% of all deaths in Hampshire occur in these facilities. The North Hampshire Six Steps
Education and Practice Development Program has been developed by the hospice to support local
nursing homes to improve end of life care for their residents.
How will Priority 2 be achieved?
A clinical nurse specialist will facilitate this project with nursing and residential homes in the local
area. Education and support will be provided for staff working in these homes to improve their
advanced care planning with residents and through this process develop strategies to prevent
inappropriate hospital admissions.
Patient Experience
Priority 3: St Michael’s Community Palliative Care Project
How was this Priority identified?
The St Michael’s Hospice Strategy (January 2015 to December 2020) Strategic Objective 5: To
proactively increase access to hospice services for patients and their families, who historically
have not benefitted from this input, whilst maintaining valued current hospice services’ was in
response to supporting the majority of people’s wish to die in their own home. While we now have
a 24/7 Hospice at Home Service which is very much appreciated by patients and their families it is
currently, due to resource constraints, limited in its reach.
The St Michael’s Community Palliative Care project was developed to expand our community
service to allow more patients and families to benefit from high quality end of life care at home.
How will Priority 3 be achieved?
A specialist multidisciplinary team including medical, nursing, occupational therapy and social care
input will work in conjunction with community nursing teams in the Odiham and Alton area to
Page 5 of 15
provide specialist palliative care services for patients in the final phase of their life. If this project is
successful it will be rolled out to cover the rest of North Hampshire.
Review of Priorities for Improvement 2013 – 2014
Improvement Priorities
The key improvement priorities undertaken during 2013 - 2014 were:
Priority 1: Further enhancement of Risk Management Systems
A central risk register, which follows the National Patient Safety Association (NPSA) risk
assessment process, is now in place. All incidents are recorded using this system and reviewed on
a monthly basis at the multidisciplinary Clinical Effectiveness meeting. Action plans and lessons
learnt from each incident are also monitored and reviewed.
Priority 2:
Systematic review of Patient Documentation
The nursing documentation was extensively reviewed and new contemporaneous documentation
implemented. Improvements included opportunities for patients and relatives to participate in, view
and comment on aspects of care planning ensuring that it is tailored to the individual. A number of
evidence based risk assessments for patients on admission have been introduced such as the
modified Macmillan Durham Cachexia nutritional assessment tool. Key aspects of medical
documentation have now been amalgamated with nursing documentation to support continuity of
care.
Priority 3:
Review of Patient / Relative Feedback
The St Michael’s Hospice VOICES Survey has now been fully implemented. All relatives whose
loved ones have used the hospice services are being surveyed three months after the patient has
died. We plan to have this survey available electronically on the new website.
Results from the responses to date have been very positive and an action plan has been
developed to address the issues raised. All patients who are discharged from the In Patient Unit
are also asked to complete a patient satisfaction survey and patients who complete the day
services therapeutic programme are also surveyed. This is in addition to the ‘How Are We Doing?’
leaflets displayed around the hospice.
Part 2
Statement of Assurance from the Board.
The following are sections that all providers must include in their quality account, as mandated by
the Department of Health. Many of these sections are not directly applicable to specialist palliative
care providers but those that are applicable are identified below.
Page 6 of 15
Review of Services
During 2014 - 2015, St. Michael’s Hospice supported local NHS commissioning priorities with
regard to the provision of specialist palliative care by providing:











In Patient Unit Services
Day Care
Day Service Programs
Out Patient Services
Hospice at Home
Complementary Therapy
Physiotherapy
Occupational Therapy
Psychological Therapy
Bereavement Services
Chaplaincy
St Michael’s Hospice is an independent charity that provides all services free of charge. The
majority of income generated to fund our services comes from voluntary charitable donations,
legacies, events, corporate and community fundraising, hospice shops and lottery. The remaining
22% of the overall service delivery is funded by the NHS.
Participation in Clinical Audit
National Audits
During 2014 - 2015, no national clinical audits or national confidential enquires were conducted
covering the NHS services directly relating to palliative care. There has therefore been no
requirement to submit cases to national audits and the percentage of the number of registered
cases has therefore not been included in this document.
Local Audits
To ensure high quality of services, an annual audit programme has been established and a variety
of quality and audit activities were undertaken using either nationally agreed hospice specific
formats or locally developed tools.
Audit Topic
External Audit of Health &
Safety (Ellis Whittam)
Infection Control Audits
(using Hospice UK audit
tools)
Controlled Drug Audits
Hospice UK audit tool
Audit Outcomes



No immediate action identified.
All priority 2 actions now completed.
Overall result: 88% compliance, a 6% improvement from
2013.

Minor work required on the Standard Operating Procedures.
Page 7 of 15
(Accountable Officer)
Prostate Clinic mid-way
review
Privacy, Dignity and
Respect while receiving
Complementary Therapy
Preferred Place of Death
and Actual Place of Death
Dementia Friendly
Environment
Controlled Drug Audits
(pharmacist external
auditor)
Well being Tool

Overall positive impact on patients attending the clinic. Final
review required.

All patients stated they were treated with dignity & respect
at all times.

75% of those who had a stated Preferred Place of Death
achieved this. However more Preferred Place of Death data
requires recording.
Window restrictors renewed and improved lighting in
bathrooms now in place.
Improvements noted in documentation and continued
improvements are on-going.



Evidence suggested that the Sheffield Profile for
Assessment and Referral to Care (SPARC) tool would be
more effective. This is now in place.
Research
No patients receiving NHS services provided by St Michael’s Hospice in 2014-15 were recruited
during that period to participate in research approved by a research ethics committee. There were
no national, ethically approved research studies in palliative care in which we participated.
Quality Improvement
Commissioners
and
Innovation
Agreed
with
Our
The hospice’s NHS income in 2014 - 2015 is not conditional on achieving quality improvement and
innovation goals through the Commissioning for Quality and Innovation payment framework
(CQUIN Framework). We do however participate in regular quality reviews with North Hampshire
Clinical Commissioning Group (CCG) as part of a joint quality assurance process.
What Others Say About Us
St Michael’s Hospice is registered with the Care Quality Commission (CQC) to provide the
following services:

Treatment of disease, disorder or injury.

Diagnostic and screening procedures.
St Michael’s Hospice registration status is unconditional. The Care Quality Commission (CQC) last
visited on the 4th February 2014 (unannounced) and the hospice was assessed to be fully
compliant against the requirements of the five measures reviewed which were:
-
Care and welfare of people who use services
Page 8 of 15
-
Meeting nutritional needs
Requirements relating to workers
Supporting workers
Assessing and monitoring the quality of service provision
All of the above standards were met with no areas for improvement identified.
Part 3 Review of Quality Performance
Data Quality
In accordance with the agreement with the Department of Health, St Michael’s Hospice (SMH)
submits a National Minimum Dataset (MDS) to the National Council for Palliative Care.
Minimum Data Set Tables for Palliative Care 2014 – 2015 (Small Units)
Table 1 St Michael’s Hospice In Patient Unit
In Patient Unit
New Patients
% Occupancy
% Patients Non Cancer
Average Length of Stay (days) – Cancer
Average Length of Stay (days)
Non Cancer
Day Case Admissions
Currently available
national median
2013/14
SMH
SMH
2013/14
2014/15
147
77.4%
11%
12.6
10.3
187
81%
7%
11.8
8.2
187
82%
12%
13
11
0%
14%
4.8%
Discharge Audit Data
This section is a requirement for the Quality Account.
The NHS traditionally examines measures to reduce re-admission rates and often view…
‘emergency re-admission to hospital within 28 days of discharge’ as having a negative impact on
patient care.’ NHS Institution of Innovation and Improvement (2013).
This model is not necessarily applicable to a hospice setting as it may often be entirely appropriate
that patients are re-admitted to the St Michael’s Hospice In Patient Unit (IPU) within 28 days of
discharge due to symptoms worsening at the end of their life. However, it is good practice to
examine the discharge process in any health care setting to identify learning opportunities which
could improve the quality of discharge planning.
The discharge audit of all patients re-admitted to the St Michael’s Hospice In Patient Unit from 1st
April 2014 - 31st March 2015 (using the readmission within 28 days indicator), found that of the 14
re-admissions during this period, there were no discharges that potentially could have been
improved upon. The only point of note is that one patient had to be admitted to the acute hospital
Page 9 of 15
as the hospice could not admit them at the time they required admission. This audit report will be
reviewed by the Clinical Effectiveness Committee
Table 2 St Michael’s Hospice Day Care Service
Day Care Service
New Patients
% Places Used
Currently
Available
National median
2013/14
SMH
SMH
2013/14
2014/15
43
58.6
15
51.2
53
48.2
Table 3 St Michael’s Hospice Hospice at Home
Hospice at Home
Total Number of Patients
New Patients
% Patients with a Non Cancer
Diagnosis
Average Length of Care (days)
% Patients Died at Home (including
care homes)
Currently
available
national median
2013/14
SMH
SMH
2013/14
2014/15
445
285
16
302
265
24.5
307
263
25.4
77
57.4
50.8
97.8
33
92.3
Chaplaincy
The chaplain is involved in all areas of the hospice and works with patients, their families and
friends. She is a spiritual support and is available to all who need a listening ear. Weddings and
funerals are a regular part of the ministry of the chaplain at the hospice. To improve and develop
our spiritual support to people in the hospice, we are currently in the process of selection and
training of volunteer chaplains. In addition, we have increased chaplaincy provision by a third.
Therapy Services
St Michael’s Hospice continues to benefit from the provision of occupational therapy and
physiotherapy services in all areas of its work. These include: – the In-Patient Unit, Outpatients,
Hospice at Home, Day Services and the Motor Neurone Disease clinic.
The number of patients with increasing complexity has led to the requirement for more specialist
therapy intervention. We have seen an increase in the number of complex neurological patients
referred to the team and a steady demand for lymphoedema management.
The Day and Out Patient Services include education programmes to advise patients on symptom
control.
Page 10 of 15
The therapy service is working with final year occupational therapy students from Southampton
University to evaluate the therapeutic impact for patients with motor neurone disease who attend
the clinic.
The Prostate Cancer Programme has now been completed and a total of 85 people attended the
course. The programme data is still being evaluated but the initial feedback is overwhelmingly
positive.
Complementary Therapy Service
As part of our commitment to provide a choice of specialist care and support to patients, their
families and the bereaved, we offer a range of complementary therapies to help with relaxation,
symptom control and to induce a sense of wellbeing. Therapies offered may include: Massage,
Indian Head Massage, Aromatherapy, Reflexology, Reiki, Yoga (patients only), Bach Flower
Remedies, Acupuncture and Deep Relaxation.
This year around 3,300 complementary therapy interventions have been carried out treating
inpatients, outpatients, families, carers, and the bereaved at St. Michael’s Hospice, Odiham
Cottage Hospital and in patient’s homes.
Ongoing support and training is provided by the Complementary Therapy Manager for 25 plus
volunteer therapists. Training in simple hand massage and relaxation techniques has taken place
for Day Service volunteers, those involved in the Befriending Service in the Odiham area, as well
as for Hospice at Home Nurses and Health Care Assistants. The Complementary Therapy
Manager continues to support fundraising by providing a team of therapists at fundraising events
and participating in teaching for schools that visit the hospice.
Additional Data
In addition to the quality metrics in the national minimum data set, St. Michael’s Hospice analyses
additional care indicators, as shown below.
Table 4. Number of In Patient Unit and Hospice at Home Patients by Age Analysis
120
100
19-24yrs
80
25-64yrs
60
65-74yrs
40
75-84yrs
20
85yrs +
0
IPU
H@H
2012/13
IPU
H@H
2013/14
Page 11 of 15
IPU
H@H
2014/15
Table 5 Overview of Key Governance and Activity Data
2013 -2014
2014-2015
Total Number of Patients Admitted to the In Patient Unit
276
228
% of Patients Who Went Home
46%
38%
Total Number of Attendances by Patients at Day Care
423
628
Total Number of Hospice at Home Visits
1539
1517
Total Number of Complaints
2
2
Total Number of Serious Patient Safety Incidents
(excluding falls)
Slips, Trips and Falls
0
0
30
20
Total Number of Patients Known to be Infected with
MRSA on Admission to the In Patient Unit
0
0
Total Number of Patients Infected with MRSA Whilst on
the In Patient Unit
Number of Patients who Developed Pressure Sores
Whilst in the In Patient Unit (Grade 3 & above)
0
0
1
2
11.2
12.8
Average Length of stay on In Patient Unit in Days
St. Michael’s Hospice is committed to achieving high quality care for all of our patients and their
families. We are pleased to highlight that:

Complaints remain continue to remain low with only one clinical and one non clinical
complaint received this year.

Patient falls continue to decline. Measures introduced during this period to reduce patient
falls include a Falls Policy and a Falls Risk Assessment on admission to the In Patient Unit.
What Our Patients Say About St. Michael’s Hospice
From October 2014, all patients discharged from the In-Patient Unit are surveyed regarding their
satisfaction with the In Patient Unit care and facilities. To date we have had 11 responses.
Key Points:
91% (n=10) were extremely likely or likely to recommend the In Patient Unit to family and friends if
they needed similar care or treatment.
Comments included:
You treated me as a person (not a patient).The care me and my family received was exceptional.
Nothing was ever too much trouble.
Respect and dignity were always number 1 on my list and I thank all staff for achieving this on my
behalf.
Page 12 of 15
Everything exceeded our expectations, including the care, compassion and dedication by doctors
and staff alike.
Feedback on issues raised such as noise and parking have been addressed.
VOICES Survey 2014
A total of 113 responses were obtained during 2014 (37% response rate) from relatives of patients
who had died in the care of the hospice, both in the In Patient Unit and under Hospice at Home
care.

All benchmarked results either compared favourably or exceeded the National VOICES
Survey (2013) results, with pain control in the community being particularly well achieved.

94% of relatives would be either extremely likely or likely to recommend St. Michael’s
Hospice care (In-Patient and Hospice at Home) to friends or family.

Overall they felt that the care they received from the nurses in the In-Patient Unit was either
excellent or exceptional (94%).

Overall the care from the Hospice at Home team was rated as excellent or exceptional by
89% of respondents.
Comments include:
‘Everything was better than I expected, it was such a relief to get away from the bustle and noise of
the hospital ward and find peace and quiet and kindness’.
‘I received exceptional care and support at all times and mum was treated with very high levels of
care compassion, dignity and respect.’
‘1st Class care. Without their support I would not have been able to keep and nurse my husband at
home’.
‘The support we had from the team was like a gift from God, and it helped us to bear the
unbearable situation’.
What Our Staff Say About The Organisation
The last staff survey was conducted by Bird Song Charity Consulting in March 2014. A good
(hospice comparable) response rate was achieved of 56%.
Comments from staff include:
‘I enjoy working at the Hospice, because I able to give care and spend time with the patients.’
‘Patients are put first and everyone is working to give them the best standard of care.’
‘Communication between all grades of staff, management, professional staff could be improved.’
Action taken to address issues raised, such as improving communication, included the
establishment of an employee led forum as well as the introduction of a bi-monthly Chief Executive
Forum. All staff are encouraged to attend and minutes of the meetings are distributed via email and
Page 13 of 15
displayed on notice boards. The employee forum is also looking at how communication can be
improved across the hospice and has strengthened the staff’s voice within the organisation.
What Our Regulators Say About St. Michael’s Hospice
See section 2.5 for the outcome of our last successful Care Quality Commission inspection.
The Board of Trustees Commitment to Quality
The Board of Trustees have a robust approach to the monitoring of the quality and safety of
hospice services provided to patients and their families. Their role is to ensure that the hospice
continues to provide a comprehensive range of high quality, cost effective services, and offers
significant specialist return on investment and benefit to the local community.
St. Michael’s Hospice has developed a strong corporate and clinical governance framework and
has a culture of continuous quality monitoring, in which any shortfalls are identified and acted upon
quickly. This ensures that we continue to challenge ourselves by considering how we can offer the
best quality service to those we care for and recognising the need for service adaptation.
The Trustees achieve this through representation on appropriate governance committees and
through their active involvement in the quality of care review processes. Quarterly board reports
are presented to the Trustees by the Chief Executive and senior managers and these are
appraised at the meetings. Additionally there are monthly meetings, held by the Board Chairman
and the Chief Executive, to review any current clinical and corporate governance issues. The Chief
Executive undertakes a daily ‘walk round’ of the hospice thus making himself available to staff both
on a formal and informal basis.
These strategies ensure that the Board of Trustees have a good understanding of the quality of the
care provided to patients and their families. This enables them to be confident that quality is
integral to all of the hospices internal governance arrangements.
Comments from Other Stakeholders
Comment from the North Hampshire Clinical Commissioning Group (NHCCG):
North Hampshire Clinical Commissioning Group (NHCCG) commissions community and hospice
palliative care provision from St Michael's Hospice(SMH).
One of NHCCG's priorities is to enable people to die in their preferred place of care which is often
their home or the hospice. SMH is a vital resource to help us achieve this outcome. Hospice at
Home allows specialist palliative care nursing to be delivered in patient's homes supporting
patients and relatives. Sometimes dying at home is not possible due to complex nursing and social
needs and the inpatient unit is invaluable in this situation offering a more appropriate place of care
than a general hospital. The extension of facilities at SMH has improved patient experience and
also provided space to deliver valuable education events and training which improve palliative care
knowledge in the local workforce as well as in the local community. As commissioners we regularly
evaluate the quality of care that SMH provides. CQC inspections, patient and relative feedback and
Page 14 of 15
our regular meetings with both management team and clinical staff provide evidence that it
provides excellent care particularly with respect to dignity and respect for patients.
I believe that SMH is an essential part of palliative care provision and education in North
Hampshire.
Dr Charlotte Hutchings, End of Life Lead , NHCCG
Comment from Healthwatch Hampshire:
We’re pleased to see the progress St Michael’s has made towards implementing your main quality
improvement priorities from 2013/14 in the areas of patient safety, clinical effectiveness and patient
experience for clinical development. In particular your active engagement with patients and their
families and carers in getting feedback at different stages in their care, through numerous written
surveys such as VOICE. Following up specific issues with individuals and also translating feedback
into chosen priorities such as the St Michael’s Community Palliative Care Project. The expansion
of the community service means that even more people will be able to choose to access quality
end of life care at home with dignity.
The report gives a good account of our observations of the quality and safety of care in an open,
honest and transparent manner. Evidence seen demonstrates your commitment to continued
improvements across the Hospice’s services and your commitment to putting patients at the heart
of your services.
Healthwatch is the independent consumer champion for health and social care in England, created
to gather and represent the views of the public. We look forward to further opportunities to work
with you in the coming year.
Libby Thomas
St. Michael’s Hospice Quality Account Feedback
If you would like to comment on the content or format of the St. Michael’s Hospice Quality Account
for 2014- 2015, please submit your comments via the St. Michael’s Hospice website or to the St.
Michael’s Hospice Chief Executive at this address:
St. Michael’s Hospice (North Hampshire)
Basil de Ferranti House
Aldermaston Road
Basingstoke
Hampshire
RG24 9NB
Website: www.stmichaelshospice.org.uk
Page 15 of 15