Martlets Hospice
Quality Accounts 2012-2013
Part 1
CHIEF EXECUTIVE STATEMENT
Statement by Caroline Lower, Chief Executive
Welcome to the Quality Account Report, 2012-13, of the Martlets Hospice.
The Martlets Hospice continues to fulfil its vision for supporting all those in
Brighton & Hove who are facing the end of life, in particular those with complex
needs regardless of their diagnosis. Through its ability to generate significant
income from a variety of sources the Martlets also continues to supplement the
NHS in providing end of life care to the level of over £3.4m a year.
On behalf of myself and the Board of Trustees, I would like to thank all of our
staff and volunteers for their achievements over
the past year. Despite the huge challenges
arising from the on-going economic austerity in
the country the Hospice has continued to provide
high quality services to a greater number of
people.
Our report provides you with a summary of our
performance against selected quality measures
for 2012/13 and our initiatives and priorities for
2013/14.
The Martlets Hospice is highly committed to
quality improvements at all levels of its services.
We have developed this approach to quality over
many years and have worked hard to embed a
culture of clinical improvement within all our services. This is achieved in two
ways through the Clinical Governance Group, made up of representatives from
all of the services, which meets bi monthly and undertakes all audits and
ensures implementation of desired quality improvements. Secondly a formal
Sub-Committee of the Board, chaired by a Trustee maintains a watchful
overview of all clinical governance and quality improvement processes.
This report demonstrates our continued commitment to ensuring patients
receive the best possible care. Within the clinical practice of the Hospice there
is a culture of continuous quality improvement, in which shortfalls are identified
and acted upon quickly and complaints used as opportunities for learning. Our
priorities last year included:
1. Increasing volunteer involvement.
2. Becoming more proactive in gaining service users views.
3. Increasing the safety and well-being of patients by the installation of an
updated nurse call system.
This report demonstrates how these priorities have been achieved and also
features the work of the Bereavement Counselling Service with particular
emphasis on the experiences of the users of the service.
I am very pleased to have the opportunity to convey all that we are trying to
achieve and to confirm my personal commitment to continuous improvement. I
am responsible for the preparation of this report and its contents. To the best of
my knowledge, the information reported in this Quality Account is accurate and
a fair representation of the quality of healthcare services provided by our
Hospice.
Caroline Lower
Chief Executive
June 2013
Part 2
LOOKING FORWARD: PRIORITIES FOR IMPROVEMENT 2013 – 2014.
2.1 Priorities for improvement
Throughout the previous year we have identified many quality improvements
that could be made over the next 12 months. In selecting our priorities we have
been mindful of national and local policy as well as those issues which are of
concern to our service users, our workforce, our partners and our Trustees.
The priorities we have selected will impact directly on each of the priority areas:
Patient safety; Patient experience; Clinical effectiveness
Following our assessment the top priorities for the year 2013-2014 are set out
below:Priority 1: Achieving access to the NHS electronic network.
Priority 2: Improve access to hospice services
Priority 3: Increased engagement with service users.
Priority 1: Patient safety
Achieve access to the NHS electronic network (N3/COIN).
Access to N3/COIN will greatly improve information flow and subsequently the
quality of care provision.
How was this identified as a priority?
The Hospice is now working closer with NHS providers than ever before. Access
to N3/COIN will improve efficiency between teams and ultimately improve the
patient/carer experience. For example all teams caring for a person will be able
to electronically access blood tests; X-ray and scan results, which will have
direct benefit to the effectiveness of patient care.
How will this be achieved?
The Hospice needs to be compliant with all information governance
requirements. To evidence this, the Hospice needs to successfully complete the
NHS Information Governance Toolkit annually.
Priority 2: Clinical Effectiveness
Improve access to Hospice services
The Palliative Care Partnership is a partnership between Sussex Community
NHS Trust and the Martlets Hospice. The partnership started in April 2013 and
provides a 7 day week specialist palliative care visiting service, and 7 day a
week central telephone access point (hub) with a single telephone number for
advice, support and referrals. The partnership will give access to wider support
services for palliative and end of life care patients, irrespective of diagnosis,
including pre and post bereavement support, welfare benefits advice, spiritual
care, social worker, creative therapies, complementary therapies and volunteer
visiting services.
How was this identified as a priority?
Although there has always been a close working partnership between Sussex
Community NHS Trust and the Martlets Hospice, this partnership formalises the
arrangement which will include shared electronic patient records and a single
telephone number for access to end of life care services.
How will this be achieved?
The partnership has only just started but by collecting accurate statistics and
feedback from service users we aim to evidence increased numbers of people
dying in their preferred place; an increase in patients accessing care with
conditions other than cancer; and reduction in inappropriate hospital
admissions.
Priority 3: Patient Experience
Increased engagement with service users.
The Martlets Hospice values the views of all its service users. We already gain
feedback from patients and carers about their experiences of the Hospice
services. Generally the feedback is excellent although there are times where we
do not get it right and there are always things that we can improve upon.
How was this identified as a priority?
It is essential that the hospice works with service users to ensure that the
hospice is delivering what service users need and want.
How will this be achieved?
We would like to form a users group who advise the Hospice on any userrelated matters. The group will use its experience to provide feedback on
potential changes and to propose enhancements to existing services and
facilities. The group would also be involved in reviewing patient/carer feedback
and reviewing documentation.
LOOKING BACK: PROGRESS MADE 2012 – 2013.
Following our assessment the top priorities for the year 2012-2013 were as
follows:
Priority 1: Increasing volunteer involvement.
Priority 2: Becoming more proactive in gaining service users views – both
positive and negative.
Priority 3: To increase the safety and well being of patients by the installation of
an updated nurse call system.
Priority 1:
Increasing volunteer involvement.
This is an ongoing aim of the Hospice but in the last 12 months we have made
progress. We now have a volunteering visiting service which started in January
2012 and to date the service has had 37 referrals and made contact with 35
people. Within the Hospice itself we have volunteers facilitating art activities to
In-Patient patients and carers. This has been especially poignant when patients
and families work on a piece of art together that then becomes a lasting
memorial after their loved one has died.
Priority 2:
Becoming more proactive in gaining service users views – both positive
and negative.
One of the ways we wanted to gain feedback from those who use our service
was through a simple focussed discussion. This is valuable in that it puts the
feedback into context and face to face discussions are always more meaningful.
To do this the person in charge of the In-Patient unit was going to meet with
patients and families a few days after admission onto the In-Patient unit.
The person in charge is meeting with the majority of patients/carers early in their
admission. This was originally purely to gain feedback however the focus has
changed and it has also become a valuable way of forming a very basic but
important relationship with patients/carers early on in their stay with us.
Priority 3:
To increase the safety and well being of patients by the installation of an
updated nurse call system.
The new nurse call system has been installed and is working well. The greatest
visible benefit is for patients who want to remain as independent as possible and
are able to walk in the garden or other parts of the Hospice but still need the
security of a mobile nurse call bell system where they can call for nurse
assistance when needed.
PART 3
STATEMENT OF ASSURANCE
The following are statements that all providers must include in their Quality
Account. Many of these statements are not directly applicable to palliative care
providers, however, we are still required to include specific statements.
3.1 Review of Services
During 2012-2013 the Martlets Hospice supported the NHS commissioning
priorities with regard to the provision of end of life care by providing:


Hospice at Home services which includes end of life care as well as
respite care.
18 bed In-Patient Unit which also includes NHS Continuing Healthcare
Funded Beds
In addition the Hospice has provided the following services through charitable
funding:


Bereavement Support Services through professional counsellors and
bereavement volunteers.
Volunteer visiting service
3.2 Income generated
The income generated by the NHS
services reviewed in 2012-2013
represents less than one third of the
total income generated by Martlets
Hospice for 2012-2013.
The NHS provided funding through a
grant for the partial running costs of InPatient beds. Through contracts,
funding was also provided for two
NHS continuing healthcare beds and
the Hospice at Home services. The
remaining income is through charitable
donations and through fundraising
events, shops and lottery.
3.3 Participation in Clinical Audit
During 2012-2013 no national clinical audits or confidential enquiries covered
NHS services provided by the Martlets Hospice. The Martlets Hospice only
provides palliative care.
During the 2012-2013 period the Martlets Hospice participated in no national
clinical audits and no confidential enquiries as it was not eligible to participate in
any.
The national clinical audits and national confidential enquiries that the Martlets
Hospice was eligible to participate in during 2012-2013 are as follows: None.
The Martlets Hospice was not eligible in 2012-2013 to participate in any national
clinical audits or national confidential enquiries and therefore there is no
information to submit. As a provider of specialist palliative care the Martlets
Hospice is not eligible to participate in any of the national clinical audits or
national confidential enquiries. This is because none of the 2012-2013 audits or
enquiries related to specialist palliative care.
The Hospice will also not be eligible to take part in any national audit or
confidential enquiry in 2013-2014 for the same reason.
3.4 Hospice Clinical Audits
Clinical audit is a way in which the organisation can learn and improve the
delivery of its services, the outcomes for patients and the experience they have.
The Martlets Hospice has undertaken a programme of audits during 2012/13.
Clinical staff are involved in the audit processes and a number of staff have led
audits; in particular infection control audits. If issues are identified during audit
an action plan is developed and reviewed. Progress on the action plans is
monitored through the Clinical Governance Group to ensure that they are
completed. We will then undertake a further audit to see if the actions we have
taken have resolved any issues that were identified.
Audit/review
Date reported
Electronic record keeping audit
July and
September 2012
Achievement of preferred place of care
Recording of informed consent
May 2012
June and October
2012
Medication – controlled drugs
April 2013
Medication – general
April 2013
Medication – accountable officer
Medication – syringe driver
Medical gases audit.
Infection control audits
Hospice at Home feedback from carers audit
Ongoing
May 2012
November 2012
May 2012
May 2012
Uniform audit
November 2012
In-Patient Unit carers feedback report
September 2012
Discharge process audit
September 2012
Reviewing of all complaints whether informal or formal
Reported every 4
months
Reviewing of all accidents, incidents and near misses recorded
Reported every 4
months
Reviewing of all drug errors/near misses
Reported every 4
months
3.5 Research
The number of patients receiving NHS services provided or subcontracted by
the Martlets Hospice in 2012-2013 that were recruited during that period to
participate in research approved by a research ethics committee was: None.
3.6 Use of the Commissioning for Quality and Innovation (CQUIN) payment
framework
The Martlets Hospice income in 2012-2013 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.
3.7 The Care Quality Commission
The Martlets Hospice is required to
register with the Care Quality
Commission. The Martlets Hospice is
required to undertake only regulated
activities at the following location:
Martlets Hospice, Wayfield Avenue,
Hove, East Sussex. BN3 7LW.
The Martlets Hospice is subject to
periodic reviews by the Care Quality
Commission and the last on-site
inspection was 31st October 2012.
The report can be viewed on the Care
Quality Commission website.
The Martlets Hospice has not
participated in any special reviews or
investigations by the Care Quality
Commission during 2012-2013.
3.8 Data Quality
The Martlets Hospice did not submit
records during 2012-2013 to the
Secondary Users service for inclusion
in the Hospital Episode Statistics
which are included in the latest
published data. This is because the Martlets Hospice is not eligible to participate
in this scheme.
However, the Martlets Hospice does submit data to the Minimum Data Set
(MDS) for the Specialist Palliative Care Services collected by National Council
of Palliative Care on an annual basis, with the aim of providing an accurate
picture of Hospice and specialist palliative care service activity. The service
activity for the Bereavement Counselling Service is in Part 4.
3.9 Information Governance Toolkit attainment levels
The Martlets Hospice achieved Level 2 compliance for the year 2012-2013. This
means that we are compliant with Connecting for Health’s standards and this
should provide patients with the confidence that their information is dealt with
correctly and safely.
3.10 Clinical coding error rate
The Martlets Hospice was not subject to the Payment By Results Clinical
Coding Audit during 2012-2013 by the Audit Commission.
Part 4
QUALITY OVERVIEW
We have chosen to present an evaluation of the Bereavement Counselling
Service. It is very important that we get feedback on all our services and
counselling is no exception. Bereavement counselling is offered to all families
that have been in contact with the hospice via the In-Patient unit or Hospice at
Home. Most people are supported through bereavement by their family and
friends, but some people may need input from a specialist, like a counsellor.
Data collected from January 2011–December 2012
Evaluation sent 1-2 weeks following ending of counselling/assessment sessions
included.
Number of evaluations sent: 119 Number of client responses: 63 (52%)
Length of counselling:
2011
2012
Up to 3
months:
17
21
3-6
months :
4
11
Over 6
months :
5
4
Average number of sessions per client: Approx 9 [this number not completely
accurate it is only an estimate based on data given by clients which in some
cases has been guessed]
Number of evaluations received back per counsellor:
****
15
****
29
****
18
1 returned blank
Client’s impressions on number of sessions received:
Too many:
Too few:
About right:
1
0
62
Impressions of the counselling
Number of
Clients
Rating
0 not at all
Percentage
10 very much
Average
To express feelings
35
13
10
3
1
10
9
8
7
6
56%
21%
16%
5%
1%
9.2
To feel listened to
38
10
11
2
1
10
9
8
7
6
61%
16%
18%
3%
1%
9.5
To explore worries
and concerns
38
11
11
2
1
10
9
8
7
6
61%
18%
18%
3%
1%
9.3
To cope with loss
31
10
12
5
1
1
1
2
10
9
8
7
6
5
3
blank
51%
16%
19%
8%
2%
2%
2%
8.9
Overall was the
counselling helpful
46
8
5
1
1
10
9
8
7
3
75%
13%
8%
1%
1%
9.5
Rating of the service in general
Number of
Clients
Rating
0 poor
5 excellent
Percentage Average
Initial Impressions
49
12
1
1 blank
5
4
3
79%
19%
1%
4.7
Ease of access
52
6
3
2 blank
5
4
3
85%
10%
4%
4.8
Waiting times
53
9
1 blank
5
4
85%
14%
Frequency of
sessions
47
11
3
2 blank
5
4
3
77%
18%
4%
4.7
Environment in
which counselling
took place
48
13
1
1 blank
5
4
3
77%
20%
2%
4.7
4.8
Clients were asked to add anything else about how the counselling has
helped:
 I found it comforting and nice to speak to someone other than family.
 I found the book - A Time to Grieve that ***** loaned me extremely helpful
and it helped me to address and discuss many of the emotions I was feeling.
I will continue to refer to the copy I then bought for myself as time goes on.
 It was just lovely to have someone to talk to who was very understanding to
how I was feeling, as not having anyone close to me that I could really talk to
it was great that **** got me on the start of the road to recovery. Thank you
again x
 When I first went to see **** I was in a very BAD place. She was absolutely
EXCELLENT. I did approach CRUSE before I phoned the Martlets and was
told I had to wait 3 months, I saw **** within 1 week. Many thanks.
 I have many friends and family to talk to but if I cry with them I cut it off fairly
quickly. With **** I could just cry for the whole hour if that was how I was
feeling.
 A marvellous service - can't thank you enough - **** is an excellent
counsellor. It normalised and contextualised my experience. I am enclosing
a donation.
 **** has helped me see me for myself, to understand life and how to cope
with it. Without her help I would have given up, she is a total credit to your
team and I will always be grateful to have had **** as my counsellor at the
worst time in my life. **** made me feel normal I thought I was going mad, but
I felt very safe seeing **** thank you.
 The counselling has helped me move on with my life, I can now move
forward. I would like to thank **** for helping me through a difficult time.
 Although I only saw **** twice (absolutely enough) the experience was so
positive that even three months on I still reflect on some of the issues we
went through and because of her amazing skills I feel so positive and have
moved on considerably thanks to ****.
 I am young and the fact that the counselling was free meant that I was able to
have the help I needed when my Mum died without worrying about the cost. I
was also grateful that the Martlets was so easy to contact, they always called
me back and were flexible with dates and times for appointments.
 The first session was helpful. I left the second session feeling angry and
upset.
 I felt relieved to express my feelings, emotions and fears to someone not
connected to my family and friends and reassured that should I ever need it
there is someone to turn to.
 I think it would have been better to have one more session, but 1 has made
me feel good.
 The Counselling helped by taking some of the weight of the loss, it enabled
me to share out the load rather than keeping my grief all in or loading it into
those close to me. It has been a safety valve and a safety net.
 I am very grateful that I was able to access **** support and advice and
counselling skills over the last year or so. For my particular circumstances,
her support has been crucial in helping me deal with the death of my partner.
I still feel I have a long way to go, but knowing that **** was there when things
were really bad has made a significant difference and helped me to feel less
alone.
 Good to feel you could talk without having to take anyone's feelings into
consideration. Family members are also grieving and so being entirely
honest is sometimes difficult. **** was a good sounding board and helped me
a lot.
 It helped because she wasn't anything to do with the family. It was private.
 I am so impressed with the counsellor's skills in bringing out my feelings. It
has helped me think about life and carrying on without the sadness that was
weighing me down. An extremely good service. I'm very grateful.
 It was a big support.
 Gave me 'tools' and skills to cope. Taught me to 'live in the moment' and not
to race ahead. Allayed any fears of how I'd cope in the future as help would
be available for me. Helped me sleep better as I could offload. Invaluable to
me, excellent service, thank you so very much.
 I was awash with grief. I can't thank **** enough for the counselling. She
was superb - as is the service provided by the Martlets.
 It helped me to quantify my grief and get things into perspective. I was made
to feel I could continue past 6 sessions if I needed it and ending the sessions
was mutually agreed.
 Without the counselling from **** I don't know what I would have done. ****
has helped me re-integrate with the world around me and made me positive
about the future.
 I found it very helpful in so many ways, it's a wonderful service you provide
and it's nice to know it's still there if I feel like I need to go back.
 It was very kind of you to help me! I miss my mum and will never stop. I look
at life differently now and it has made me feel half the man I was but we must
carry on! Maybe she is watching, but thank you for taking the time out for me,
I would like to do some work for you but not until the summer. Maybe you
need a driver to pick up and take people home after visits. I would love to
help!
 Q 1: Due to not contacting me earlier. 5: How to deal and help my children
in their grief. Without this service I'm sure I would have ended up having a
nervous breakdown. I cannot thank and praise the Martlets enough.
 It was really helpful that my first counselling session took place before my
father's death. I was able to explore how I was coping with my father's
terminal illness as well as looking at how I would take over full-time caring
role of my mother. **** helped me through life changing events and has
taught me the importance of taking care of myself. **** has also made it
possible for me to contact her in the future should I feel the need of her
counselling service again.
 The support was very helpful.
 I feel that having counselling at the time I did was a great help - it is wonderful
that it is available at any time, placing 'no limit' on the length of time grieving
takes.
 The counselling helped me through a very difficult period of facing the reality
of the death of my husband. This continues to be helpful in facing my loss
and changes to my life.
 **** is very kind and is a great listener.
 I felt I could talk about anything. **** helped me understand a lot of how I was
feeling, and took the time to explain why.
 I have found my sessions with **** incredibly constructive. Thanks again.
 Excellent service - I am grateful for the concern and care I received- thank
you very much.
 Counselling has helped me move on.
 To have had it at the Martlets.
 I don't feel alone in my sadness, I know I can call anytime and an
appointment will be arranged for me to see someone. This helps me a lot.
 I feel that this is a wonderful service offered by the Martlets – thank you very
much. It has helped me immensely after losing my Dad. The counselling also
helped me address other problematic areas in my life that I was finding hard
to cope with whilst grieving.
 Counselling helped me greatly to understand and cope with the process of
grieving. The support
 I feel that the counselling process has enabled me to accept and live with my
sadness and loss. Question 4a & 4d were difficult to answer so I have left
them blank. I have always been able to express my feelings and I am still
unsure as to how I am coping with my loss. I am extremely grateful to the
service. Thank you very much.
 I thought that **** was a very caring and understanding counsellor. She was
extremely professional in her approach.
 **** helped me through a very difficult time in my life, not only was I grieving
my mother I was in trouble with the police and other problems. I couldn't have
got through this difficult period of my life without the help and understanding
of ****.
 Sorry for the delay in my reply... I found my whole experience at the Martlets
truly amazing... Especially as I was only a friend of the bereaved, I feel really
grateful to have been offered counselling. It got me through some very
difficult times, as I am a single parent and found the support and
understanding invaluable and I felt the counselling really empowered me in
helping the bereaved family and also helped me support my own daughters in
their grief too! Thank you so much for offering me this service.
 It was good to be asked if I would like the counselling - I probably wouldn't
have initiated it myself and it has been very beneficial.
 You do not need to improve the service you provide. You are angels and help
everybody you meet.
 With the help of **** and her wonderful insight I was able to feel a sense of
strength and clarity through the grief and confusion in the early days of my
loss. Coming in to see her for our regular sessions over this year has been
like having a safe harbour to come in to from the turbulent seas all around. I
honestly believe that it has helped me and my children to cope so much
better and to truly believe that we can go on to a future of meaning and
fulfilment.
 I was at the lowest time of my life and at breaking point myself, so
heartbroken. **** has taught me how to live a day at a time and to look to the
future but to still hold on to all my precious memories.
 I appreciated the flexibility - occasionally re-arranging and agreeing to
continue for rest of year although less frequently. Might be good in central
Brighton re access but maybe it is more appropriate in Hospice.
Clients were invited to comment on anything they felt had not helped:
 You cannot improve on perfection.
 I left the second session feeling very angry and upset.
 N/A
Suggestions for how the service might be improved:
 Because of my part-time working hours it was sometimes difficult to arrange a
mutually convenient time, but **** did everything she could to accommodate
me.
 I really can't think of anything that could improve this wonderful service except more funding to help even more people. Thank you.
 Counselling should be more understanding.
 I think you have it just right because I have options to ring **** up to have
more if I want.
 In relation to e) above, it was difficult returning to the place where my Mum
died - but **** was aware of how I might be feeling and, in the end it gave me
a 'safe' place to cry and explore my feelings of loss and fears.
SUPPORTING STATEMENTS
As required by the regulations, this document has been sent to the Brighton and
Hove Clinical Commissioning Group for comment.