ST MARY’S HOSPICE
QUALITY ACCOUNT 2011/12
“Support, care and hope for local people
and those who love them”
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Quality Account 2011/12
Part 1
Chief Executive’s Statement
It gives me great pleasure to present this, the first Quality Account for St Mary’s Hospice, Cumbria.
Although it is now clear that for the reporting period 2011/12, St Mary’s Hospice is not required to
produce a Quality Account, we have chosen to develop one this year in order to demonstrate our
commitment to quality and continuous improvement. In this report our aim is to show how the
Hospice measures quality, involves patients, carers and staff and strives to always look for areas
where we can improve our care.
A Quality Account is 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, the rest (around £2million) is donated by the local community. The
majority of services described in this document are funded by charitable donation rather than by the
NHS.
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:
“Support, care and hope for local people and those who love them”
Our Corporate and Clinical Governance structures ensure that we have both the systems and
processes in place to maintain a viable and responsible business, whilst ensuring that our services
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Quality Account 2011/12
are of the highest quality and meet the aspirations of our mission statement. Our services are
subject to unannounced inspections at any time. In order to prepare for this, during the 2011/12
period we instigated a “peer review” mock inspection by colleagues from The University Hospitals of
Morecambe Bay Trust. It is important to us that we are viewed as part of a wider healthcare
community and are not seen to work in isolation. The findings from our peer review were welcomed
and used to ensure continuous improvement for patients and families.
This year we are proud to have achieved:
An increase in the number of patients dying in their preferred place of care
A complete re-structure of our senior leadership team
A new IT system that links us to our NHS colleagues and the wider healthcare community
An increase in partnership working with healthcare colleagues across Cumbria
The adoption and implementation of a new syringe driver model
Procurement of state of the art pressure relieving equipment
Improvements to our reception area in consultation with patients, families and carers
Our goals for future improvement include:
An improvement of the patient and family experience on our In Patient Unit
An expansion of our Day Hospice provision
An expansion of our Education provision
A re-invigoration of Volunteer support, particularly in areas with direct patient and family
contact
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.
Sue McGraw
Chief Executive
10th May 2012
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Quality Account 2011/12
Part 2
Priorities for Improvement 2012/13
The priorities for improvement we have identified for 2012/13 are set out below. These have been
developed in conjunction with patients, carers, staff and stakeholders. We have expressed our
priorities in terms of the three domains of quality:
Patient safety
Clinical effectiveness
Patient experience
Priority 1 – Patient Safety & Patient Experience
Review and Improve the patient experience on the In Patient Unit (IPU.)
This will include looking at the physical aspects of the building, equipment and resources in the
rooms and the communal areas
How was the priority identified?
The IPU has been open for 20 years. Comments from the team, comments from patients and
families in surveys and observations by visitors have led us to identify this as a priority for
improvement. Whilst there is no doubt that the IPU is extremely safe and clean, there are aspects
where a small change may make a big difference. These are the areas we will focus on in the next 12
months.
How will progress be monitored and reported
Patients, staff, visitors and volunteers will be invited to tell us how we can improve the experience.
We will do this by conducting 1 to 1 interviews, providing places where people can leave their
feedback anonymously and by group consultations.
A staff working group will look at ways to improve the working environment.
Surveys will be changed to capture information that specifically relates to the physical environment
on the IPU.
A budget has been identified so that changes can be made.
Progress will be reported to the Clinical Governance group and the Board of Trustees.
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Quality Account 2011/12
Priority 2 – Patient Experience & Patient Safety
Develop Day Hospice Provision
This will include a review of the current model of Day Hospice provision and the development of
new programmes and opportunities where a need is identified.
How was the priority identified?
There is high demand for Day Hospice places. We currently offer a 10 week programme on
Wednesday afternoons for a group of up to 10 patients (and their carers) with a mix of life limiting
conditions. We conducted a consultation exercise with Day Hospice patients and carers and it
became clear that the current model is not appropriate for everyone. We have piloted a condition
specific session for patients with Chronic Obstructive Pulmonary Disease (COPD) and this has been
extremely well received. It is clear that “one size does not fit all” and that it is time for a review of
the current model of provision.
Day Hospice management is part of our Matron’s broad role. During her appraisal it was highlighted
that the current structure does not give Day Hospice provision the importance it deserves. We know
that if patients form a relationship with the Hospice early in their journey with a life-limiting
condition, they usually have a better end of life experience. The Board of Trustees have agreed to
fund a post specifically to support Day Hospice provision.
How will progress be monitored and reported?
Day Hospice patients, carers and volunteers will be consulted.
Data will be gathered and recorded.
A dedicated staff member will lead the improvement.
Developments will be evaluated by staff, patients, carers and volunteers.
Progress will be reported to the Board of Trustees and the Clinical Governance Committee.
Best practice from other Hospices will be adopted.
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Quality Account 2011/12
Priority 3 – Clinical Effectiveness
Develop End of Life Education & Training
Review the way our team are developed to ensure that we are at the cutting edge of clinical
effectiveness
Review opportunities for partnership working with regard to training and development.
Develop and provide training opportunities for colleagues outside the Hospice so that palliative care
skills and knowledge are cascaded throughout South Cumbria.
How was this priority identified?
The End of Life Care Strategy Quality Markers task specialist palliative care providers with ensuring
they have robust mechanisms in place to identify training needs in their team. There has always
been an appraisal and skills analysis process in place at St Mary’s, but as part of our commitment to
continuous improvement, our Board has asked us to conduct a review of the way we identify the
team’s learning needs internally.
Externally, our Hospice at Home team have identified the development of our education function as
a priority in the community because they work alongside colleagues who have little or no training in
end of life conditions and who then make decisions that are too late or result in inappropriate
hospital admissions. Again, the End of Life Care Strategy Quality Markers suggest that it is best
practice for specialist palliative care teams to act as educators for their community colleagues. This
is an area where we feel the hospice could make a great impact and really help to improve the care
and support patients receive at the end of their life.
The Trustees will fund a post specifically designed to ensure that we are at the cutting edge of
clinical effectiveness and learning. Our Education Manager will be responsible for developing a core
programme for our staff and for developing a programme of learning for community colleagues. We
will also continue to support and facilitate the “6 Steps to Success” programme for care homes
throughout South Cumbria.
How will progress be monitored and reported?
Through involving staff in a review of the appraisal process
Through evaluation of training programmes we develop and deliver
Through contributing to the reduction in inappropriate hospital admissions across South Cumbria
Through the number of care homes successfully adopting the “6 Steps to Success” end of life training
programme in South Cumbria
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Quality Account 2011/12
Priority 4 – Patient Experience
Re-invigorate Volunteer Support
Invest in a full time Volunteer Management position
Review the roles Volunteers currently undertake
Explore opportunities to use Volunteers in areas with direct patient and family contact
Take part in a national research project with the End of Life Observatory at Lancaster University
“Volunteer management in palliative care: Meeting the specific challenges of involving Volunteers in
palliative care roles which require direct contact with patients and their families.”
How was this priority identified?
The current economic climate means that we must explore using Volunteers in roles which
traditionally have been fulfilled by paid staff. Using Volunteers in roles with direct patient contact
means that there is a need to develop robust processes and procedures on a scale that has not been
necessary before. During a Volunteer Workshop, we asked Volunteers whether there were roles that
they felt could undertake – suggestions included ward clerks, respite sitters, good neighbour roles
etc etc.
How will progress be monitored and reported
Feedback from patients and families.
Feedback from Volunteers
Recruitment and development of Volunteers in new roles
Peer review with other Hospices involved in the University of Lancaster Volunteer research project
Priorities for Improvement 2011/12
As this is the first Quality Account produced by St Mary’s Hospice, there was no formal statement of
priorities for improvement in 2011/12. However, we constantly strive to make improvements for
patients and families. Below are just three examples, expressed in terms of the three domains of
quality, where we made improvements in 2011/12.
1. Patient Safety
Safer Ambulatory Syringe Drivers
Work with colleagues across Cumbria to choose a syringe driver to meet the requirements of
the NHS patient safety alert, December 2010.
Purchase, train staff and implement use of the new Syringe drivers by the 31st March 2012.
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Quality Account 2011/12
Ambulatory syringe drivers are widely used for palliative care and long term therapy in all clinical
settings and at home. Some ambulatory syringe drivers have rate settings in millimetres (mm) of
syringe plunger travel and require manual calculation to set the correct dose, which introduces the
risk of errors. On the 10th December 2010, the NPSA recommended that these syringe drivers should
be phased out within five years.
Working in partnership with healthcare colleagues across Cumbria and the PCT, it was agreed that
the McKinley T34 syringe driver should be adopted on a pan-Cumbria basis. St Mary’s Hospice was
tasked with buying the syringes, training all staff and being ready to work with the new syringe
drivers by the 31st March 2012. The Hospice invested £12,000 of charitable funds to pay for the new
syringe drivers and all staff were trained and ready to use the McKinley’s by the 31st March 2012.
2. Clinical Effectiveness
Prevent and treat pressure sores by providing state of the art mattresses and chairs
Involve patients and carers in the selection of a range of pressure relieving
mattresses and chairs
Aim to replace at least half the in-patient rooms by the end of March 2012.
During 2011/12 we involved patients and carers in the selection of a new range of pressure-relieving
mattresses and chairs. A number of samples were tested and feedback was recorded. Patients told
us that the old mattresses:
“Are too noisy”
“Make me feel sea-sick”
“Have too many lumps and bumps”
After testing and consultation, the range that was chosen was the Oska Cirrus alternating pain
therapy mattress and chair. We have not achieved our target of replacing at least half of the inpatient rooms by the end of March 2012 as this was the most costly range. To date we have invested
£18,000 of charitable funds and bought 2 mattresses and 5 chairs. We have made a grant application
to Help the Hospices, we hope to buy another 3 mattresses in the current financial year.
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Quality Account 2011/12
3. Patient and Carer Experience
Improve Hospice branding and make this consistent across all public areas
Make the reception area more welcoming
Display staff pictures and names
Introduce a new uniform to differentiate between staff members
Working in consultation with Day Hospice patients and carers, in 2011/12 we designed and
developed a new look logo and brand for St Mary’s Hospice. With the help of a local design company
who provided their services free of charge, we asked our patients to choose a new logo. They chose
a modern yellow and blue forget me not design which has now been adopted across the Hospice on
our literature, on all our signage and on all our staff uniforms. We asked Day Hospice patients what
their first impressions of the old reception area were. They told us:
“It’s a bit clinical”
“We need a place to sit when we’ve walked up the hill”
“It would be nice to see photographs of the staff”
“It’s hard to tell who’s who in the Hospice”
Based on this feedback, we carpeted an area just inside the front door and provided some
comfortable chairs. We painted a “feature wall” blue to match the forget me not blue of our logo.
We took photos of all the team (including non-clinical staff) and these pictures are displayed in the
reception area. With the help of a legacy donation, we provided all the nursing team with new
uniforms which incorporate the new logo and differentiate between nurses and healthcare
assistants.
Sue and Fiona model our new uniform
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Quality Account 2011/12
Welcome to St Mary’s, meet the team
Reception seating area
Service Information Point
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Quality Account 2011/12
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 2011/12 St Mary’s hospice provided the following services:
In-Patient Unit
Hospice at Home Service
Day Hospice
Complementary Therapy
Family Support and Bereavement Services
“Drop in” Groups
Education and Training
St Mary’s Hospice provides 78% of the funding for these services. The remaining 22% comes from
the NHS via the PCT and Locality Commissioners in 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 2011/12, 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 utilises the use of national
audit tools (Help the Hospices) and locally and regionally designed 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 Clinical Governance Group to ensure that actions are completed.
The following are examples of audits conducted in the 2011/12 period:
Audit
Completed
Action Plan
Infection Prevention &
Control Audit
Yes – but on-going
cycle
Yes
Medical Gases Audit
Yes
No
Controlled Drug Audit
Yes – but on-going
Yes
Examples of action
taken to improve
practice
Legionella contract
now in place.
Sign-off sheet to
release rooms for the
next patient
Some minor changes
required
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Quality Account 2011/12
on annual cycle
Yes
Yes
Minor changes
required
Hospice at Home
Documentation Audit
Yes
No
Nutrition and
Hydration Audit
Yes – but on-going
Yes
Pressure Sore Audit
Yes – but on-going
Yes
Small changes made
to categories on the
documentation
Pilot a new tool
which will be more
suitable for our
patients
Develop policies and
procedures to match
new tool
Purchase of pressure
relieving mattresses
and chairs with interchangeable seat
cushions and posture
support backs etc.
Verbal Order Reports
Audit
Yes
No
Controlled Drug
Prescribing Audit
Research
The number of patients receiving NHS services provided or sub-contracted by St Mary’s Hospice in
2011/12 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.)
Use of the CQUIN Payment Frame
St Mary’s Hospice NHS income in 2011/12 was not conditional on achieving quality improvement
and innovation goals through the Commissioning for Quality and Innovation 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 2011/12 CQUINN 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 we are registered to carry
out the regulated activities:
Treatment of disease, disorder or injury
Diagnostic and screening processes
St Mary’s Hospice has the following conditions on registration:
Only treat people over 18 years old
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Quality Account 2011/12
Only accommodate a maximum of 9 in-patients
The Care Quality Commission has not taken any enforcement action against St Mary’s hospice during
2011/12.
Data Quality
St Mary’s Hospice did not submit records during 2011/12 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.
It is anticipated that an IT system to allow all healthcare professionals to share patient information
will be adopted in the 2012/13 period across South Cumbria, (EMIS Web.) This project is being led by
the GP Commissioner for Furness Locality.
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 (reporting period)
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 2011/12.
(Mandatory statement)
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Quality Account 2011/12
Part 3
Review of Quality Performance
In this section, we have chosen to provide data benchmarking St Mary’s Hospice with figures from
the National Council for Palliative Care Minimum Data Set, (MDS.) The figures below provide
information on the activity and outcomes of care for patients. Whist we show data from 2011/12,
the MDS figures are not currently available for the same period. We have used 2010/11 data for
benchmarking purposes.
St Mary’s Hospice is classified as a small In Patient Unit (fewer than 10 beds.)
In Patient Unit
Total number of patients
Number of new patients
% Occupancy
% Patients returning home
Average length of stay
2011/12
197
133
74%
48%
11.34 days
National Median 2010/11
163
116
78.5%
48%
11.05 days
St Mary’s Hospice is classified as a medium category hospice at Home provider (between 129 and
297 patients.)
Hospice at Home
Total number of patients
Total number of patient visits
% new patients
% of patients who died at home
Average length of care
2011/12
212
1829
86%
90%
54.42 days
National Median 2010/11
234
1768 (our figure from 10/11)
90%
79%
25 days
2011/12
2859
2010/11
2963 (our figure from 10/11)
Telephone Advice Line
Calls handled (NB These figures
represent actual calls handled.
We have not counted anyone
who leaves a message for us to
call back)
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Quality Account 2011/12
St Mary’s Hospice is classified as a small category Day Hospice provider (fewer than 126 patients.)
This is an area we hope to improve in the coming year.
Day Hospice
Total number of patients
% new patients
Average period of attendance
2011/12
58
69%
140.5 days
National Median 10/11
94
60.3%
137 days
St Mary’s Hospice also provides bereavement and family support. In 2011/12 the MDS data was not
recorded due to a bereavement in the team. Data will be available for 2012/13.
Feedback from Staff
St Mary’s Hospice is recognised a good local employer, staff turnover is low and when we do have a
vacancy, we receive a high volume of applications.
An annual staff survey is conducted and a number of staff consultation and involvement sessions
have been held. The top 3 statements from the 2011/12 survey that staff agreed with were:
1. I am pleased to let others know I work at St Mary’s hospice
2. I get a lot of satisfaction from the job I do
3. I feel I am valued by the organisation
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Quality Account 2011/12
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. Here are some examples of comments in our most recent surveys in
our patients’ and families own words:
In-Patient Unit:
The care is first class 24/7 and always
110%. Absolutely wonderful, I cannot
praise you enough
Very attentive, very
caring without
being intrusive
Marvellous chefs
Home from
home
There is no
improvement on
perfection
Calm and peaceful
I had difficulty visiting with
no transport, local buses etc
timetable
Cannot improve on your
wonderful work
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Quality Account 2011/12
Hospice at Home:
We are very fortunate to have this service
in this area. Massive difference we
looked forward to them coming, for
myself and my husband being able to get
a good night’s sleep was invaluable. The
night sitters are a wonderful asset to the
Hospice
I cannot find the words to express my thanks
for the wonderful peace and comfort your
nurses brought to my Husband in his last
days and the huge support they gave me and
my family
The care was paramount to
Mam being able to die at
home and this was her
wish. It was important to
us to fulfil this
Your support, care and empathy
was so comforting for me. I could
not have done it without you
Well thought out but when
other services are involved,
one service should be in
overall charge
We knew the staff names and felt
they were like family. Just
brilliant.
Valuable support however
GP and District Nurses
were not co-ordinated
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Quality Account 2011/12
We monitor all complaints and discuss them at our Clinical Governance and Quality improvement
meetings, complaints are also reported to the Board of Trustees:
Complaints
Total number of complaints
Number of complaints upheld
in full
Number of complaints upheld
in part
2011/12
1
0
2010/11
0
0
1
0
We are keen to use formal complaints as a tool for service improvement. The complaint we received
this year related to a patient who did not like the mattress on his bed, he found it noisy and
unsettling when we moved him. We have addressed this issue by buying state of the art mattresses
that are virtually noiseless. To date, we have no comments or complaints about the new equipment.
Opportunities to give feedback on this Quality Account
We welcome feedback on our first Quality Account. If you have comments, please email:
Sue.mcgraw@stmaryshospice.org.uk
Or write to:
Sue McGraw
Chief Executive
St Mary’s Hospice
Ford Park Crescent
Ulverston
Cumbria
LA12 7JP
www.stmaryshospice.org.uk
Annex
Comments from Cumbria LINk on the Quality Accounts of St
Mary’s Hospice, Ulverston, Cumbria
This is probably the most well laid out with accessible information of all the quality accounts I have
seen. Of course, easier for them in one sense because they are a small organisation.
A bit more hard data wouldn’t go amiss. Perhaps not surprisingly there is only one complaint, but
maybe this needs to be clarified as one formal written complaint, i.e. the term has, to the lay reader,
a wide meaning, but suspect in this case it is restricted to formally submitted ones, rather than
complaints made by patients and family informally.
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Quality Account 2011/12
This appears to be an excellent document, well laid-out, clear data. I note that patient safety &
involvement criteria are both given prominence also.
Cumbria Overview and Scrutiny Committee were offered the chance to comment but declined this
year. They had not expected to comment on Hospice Quality Accounts and did not feel able to
schedule another consultation.
Cumbria PCT were asked to comment but no comment was received.
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Quality Account 2011/12