Quality Account
2012 to 2013
Vision
To be the preferred “Voluntary” provider of palliative care
services for Warwickshire
Mission
Using exceptional staff and volunteers we will provide the best
possible care, resources and services to our patients, their
families and carers
Intent
To grow our palliative care services, to ensure their continued
excellence and the future financial security, of the Mary Ann
Evans Hospice, with a passionate “can do” team approach that
builds honest, open and profitable relationships through local
presence and knowledge
Mary Ann Evans Hospice
Eliot Way, Nuneaton
Warwickshire CV10 7QL
Charity Number: 1014800
Index
Description
Page No
Hospice Board Chair’s Statement
3
Priorities for Improvement and Statement of Assurance from the Board
2013 to 2014
4
Priorities for Improvement 2012 to 2013
7
Statement of Assurance from the Board 2013 to 2014
9
Participation in Clinical Audits
10
Research
10
Statement from the Care Quality Commission
10
An Explanation of those involved in this Quality Account
11
Review of Quality Performance
11
Quality Markers
13
Statements
14
Page 2 of 14
Part 1:
Hospice Board Chair’s Statement
I am pleased to present this the second, Quality Account for the Mary Ann Evans
Hospice. All staff, and volunteers at the Hospice view quality as the most important
aspect of all that we do.
Securing a sound financial footing for all the Hospice’s services continues to be the focus
for much of the Board of Directors attention. Only by achieving this will we be able to
ensure the highest quality service for all we currently provide, whilst also enabling us to
further develop and improve our services.
The Hospice continues to offer the highest standard of service in Day Hospice,
Bereavement Support, Lymphoedema and Hospice at Home. All of these have achieved
significant success and improvement in the last year and all staff, and volunteers involved
are to be thoroughly congratulated. Probably the most notable success has been in the
delivery of the Hospice at Home service where over 85% of our terminally ill patients were
enabled to die, with dignity , at home in a familiar environment surrounded by their loved
ones. Increasingly the service avoids patients being admitted to hospital whilst also
enabling early discharge.
We at the Mary Ann Evans Hospice are also very excited about the success of our
Bereavement Service, which has shown very significant development over the last year.
With our success in achieving funding for a new, bespoke, building for bereavement,
which will hopefully be completed by April 2014, we are confident of offering a first class
service not only for the families of our patients but also for the George Eliot Hospital and
the wider community.
To the best of my knowledge, the information provided in this Quality Account is an
accurate and true account of the quality of services provided by the Mary Ann Evans
Hospice.
Duncan Phimister
Chair of the Board of Trustees
17th May 2013
Page 3 of 14
Part 2:
Priorities for Improvement and Statement of Assurance from the
Board 2013 to 2014
The Mary Ann Evans Hospice continually seeks to improve and develop the services, to
ensure that the care and support we provide evolves around patient and carer needs.
The priorities for improvement that have been identified for 2013/14 are outlined below.
These priorities have been identified in conjunction with patients, carers, staff and
stakeholders. They have been approved by the Clinical Governance Committee, a
working group of the Hospice Board, a clinician and service user, set up to monitor quality
and plan ahead.
Future Planning Priority 1
Review of Lymphoedema Service
In January 2009 the Mary Ann Evans Hospice set up a Lymphoedema Service, using
charitable funds. Prior to this service being set up patients suffering from this debilitating
condition had to be referred outside of the area for treatment. This nurse led clinic
provides specialist care, at present, to patients who develop Lymphoedema secondary to
cancer or its treatment.
The Board of the Mary Ann Evans Hospice recognises the importance of providing a local
Lymphoedema Service, but raises concerns regarding the sustainability of continuing to
run the service without financial support. At the same time the Board is aware of the need
to widen the scope of the service to include Primary Lymphoedema.
It is however important that this service continues to develop, as since its conception in
2009, the service has seen a 138% increase in patient contacts made during the year.
The number of patient contacts per month has risen from 62 to 144.
Measures:
1. To secure long term statutory funding for the service to enable the Hospice to employ
additional staff to ensure sustainability
2. To provide an equitable service to patients with primary and secondary Lymphoedema
3. To reduce the waiting time between referral and first appointment
4. To provide a budget for each patient to receive their first hosiery garment from the
clinic
5. To work alongside Tissue Viability Nurses in Leg Ulcer Clinics, Practice Nurses and
District Nurses to provide shared care
6. To provide education sessions for at risk patient groups – raising awareness for
patients who have undergone lymph node dissection, groin or axilla
7. Analysis of stakeholder questionnaires
Future Planning Priority 2
Review of Bereavement Service
The Hospice submitted a grant application for £779,216 to help fund the building of a new
Bereavement Centre and was successful in being granted 68% of their application bid.
This build is crucial to the expansion of the service allowing for more flexible and frequent
levels of support to all patients, carers and families not only during the daytime but also at
evenings and weekends.
.
Measures:
1. Establish a visionary group to identify and plan the next stage of the service with the
new building in mind
2. To work towards advertising the service which will include looking at involving different
sections of the local communities
Page 4 of 14
3. Ongoing recruitment and training of additional volunteers
4. Look at offering new strands of Bereavement support alongside the groups and
one to ones
5. Analysis of stakeholder feedback
6. Liaise with other Bereavement Service providers
1. Future Planning Priority 3
Service Awareness
The Mary Ann Evans Hospice provides a wide range of patient clinical services which
include:Day Hospice
Hospice at Home
Lymphoedema
Bereavement
We recognise that to ensure a co-ordinated seamless service to our patients and their
families, and to expand these services, we need to enhance our professional working
relationships with other healthcare providers, and to raise awareness of our services.
Patients and their families that visit the Hospice often comment that “they wish they had
heard about our services before” or “they didn’t know we (the Hospice) were there”
Measures:
1. To develop a continuous programme of interaction with our stakeholders
2. To ensure we promote our services within the Warwickshire North Clinical
Commissioning Group (WNCCG) and other health professionals
3. To ensure funding continues to enable sustainability of the service
2. Future Planning Priority 4
Hospice at Home Service
Phase 2 of the Hospice at Home project is now in its 3rd quarter. The demand for high
quality nursing care to patients who have end of life needs (all diagnoses) is increasing.
By extending our Hospice at Home service we hope to provide additional high quality care
during the day to people in the community, including much valued and needed respite for
family/carers.
Measures:
1. To review recruitment requirements for additional bank healthcare assistants
2. Induction training
3. To increase the number of visits offered during the day
4. To ensure a safe and sustainable service for the future
3. Future Planning Priority 5
Development of a Compassionate Community Model in conjunction with
Warwickshire HealthWatch
The Mary Ann Evans Hospice was approached in November 2012 by Warwickshire LINk,
which became HealthWatch Warwickshire in April 2013, to help develop a model of a
Compassionate Community in North Warwickshire. The model will be based on similar
models running successfully elsewhere in the country. The Mary Ann Evans Hospice will
be working in partnership with HealthWatch Warwickshire, local GP Practices and the
local community as a whole.
Initially the Mary Ann Evans Hospice supported by the HealthWatch Warwickshire would
take on the role of champion offering support to those who expressed an interest in the
Page 5 of 14
project and begin the process of identifying and training the volunteers, eventually this
role will be taken on by a co-ordinator.
It is envisaged that this service will offer support, assist with tasks of daily living (excluding
personal care), and simple signposting, focusing towards reducing “social isolation” and in
doing so, averting a “crisis” that such isolation may cause. Initially this development will
commence in Atherstone.
Measures:
1. To liaise with GP practices in the identified area
2. Recruit volunteers from within the community
3. Ensure adequate and relevant training to enable high quality, personal, safe and
consistent support is offered
4. To monitor and audit the project to enable continuous improvement and growth
5. Future Planning Priority 6
Implementation of a Preferred Priority of Care Document within the Day Hospice
The Mary Ann Evans Day Hospice recognises that it is essential that all patients, and with
consent their family, have the opportunity to have discussion about their care and decision
making towards the end of life. This is often referred to as “advanced care planning”. This
will support recommendations from the End of Life Care Strategy 2008. The Day Hospice
staff have begun making progress to achieve discussion around advanced care planning
but needs to review this process to ensure its effectiveness
Measures:
1. Conduct a baseline audit to establish what proportion of Day Hospice patients had
discussed the Preferred Priorities of Care (PPC) document
2. To provide advance care planning and communication training to Hospice staff
3. To pilot the PPC document as a tool for advance care planning within Day Hospice
4. Patient information updated and communicated to members of the Multi Disciplinary
Team
5. To ensure information is available to all patients (written and verbal)
Page 6 of 14
Part 3:
Priorities for Improvement 2012 to 2013
To meet the increasing need of our local community the Mary Ann Evans identified in
conjunction with patients and carers, staff and stakeholders the following areas to improve
care and support to those who access our services during 2011/12.
Areas identified for development are outlined below with examples of how we achieved
these.
Priority 1
Extension of Hospice at Home – Night Service
To enable us to meet the identified unmet needs of our night service we have successfully
recruited
1. One Healthcare Assistant moved to permanent nights increasing the number of
permanent night staff to three. This has led to a 25% increase in available nights per
week
2. Two Bank Healthcare Assistants recruited to enable us to meet the increasing need for
night support visits
3. Five bank healthcare assistants recruited to meet the increasing demand on days
Induction training for new staff completed.
Priority 2
Review of Day Hospice
This was identified as a priority to enable the Day Hospice to develop and go forward to
meet the needs of our patients and their families/carers.
An update of this review is as follows:
1. Feedback from patient questionnaires remained positive as it had done over previous
years
2. Visited Myton and Treetops Hospices to review and discuss their services – following
this we reviewed and updated our Hospice literature and forwarded to other service
providers
3. Meetings with other health providers (District Nurses, Allied Health Professionals and
Hospital CNS) to discuss service and patient requirements
4. The Day Hospice has seen an increase in the number of referrals from additional
sources and has also seen an increase in referrals with diagnoses other than cancer
5. Greater understanding of Day Hospice requirements and future direction
6. Unannounced CQC Inspection took place in October 2012 with a very positive
outcome
Priority 3
Review of Bereavement Service
This priority was identified in order to respond to the increasing demand of the service.
Progress has been as follows:
1. The service has undergone a further review
2. Analysis of stakeholders’ feedback continues to remain positive
3. Regular, steady increase of volunteers to match the ongoing demand
4. Grant application has been submitted to Department of Health for a Bereavement
Extension build
Page 7 of 14
Priority 4
Increased Engagement with Service Users
This priority was identified as it was recognised that the Mary Ann Evans Hospice
services needed more formal lines of engagement with our service users.
The outcome of this is as follows:
1. A service user has been recruited and attends the Clinical Governance Group
2. Annual patient surveys continue to provide constructive and positive feedback
3. Lymphoedema Support group developed and Cancer Survivor Group continues to do
well
4. User Group still needs to be developed
5. More work required to ensure greater user involvement across all services
Page 8 of 14
Part 4:
Statement of Assurance from the Board 2013 to 2014
The following are statements that all providers must include in their Quality Account.
4.1 Review of Services
During 2012/13 the Mary Ann Evans Hospice was part funded by the Warwickshire PCT
commissioning priorities with regard to the provision of local palliative care by providing:
Day Hospice
Hospice at Home
Bereavement Service
In addition the Hospice has provided the following services solely through charitable
funding:
Lymphoedema
Surviving Cancer Support Group
The income generated by the NHS, reviewed in 2012/13, represents approximately 28%
of the cost of the provision of NHS Services by the Mary Ann Evans Hospice.
The Mary Ann Evans Hospice values the feedback received from patients and their
families/carers as this is an important way in which staff can identify issues, resolve
problems and improve the quality of care we provide. Some comments received from
patients and their families are shown below:
Family of a Hospice at Home patient: “Thank you seems such an insignificant way to
explain exactly what you did for our mum. Mum was such a dignified person, from day 1
you were so kind, caring and respectful towards her. You allowed her to maintain her
dignity and pride right to the end of her life. It was the little things you did for her that
made all the difference. We felt the care you gave extended to us, the family, and we
never felt we were putting you out if we needed to talk or have a cry. Thank you for the
care you gave washing, dressing and laying her out when mum had died….she looked so
peaceful and that was down to you. The work you do is phenomenal”
Husband of a Day Hospice patient (non cancer): “My wife looks forward to attending
the Hospice each week to meet up with other service users and staff for various activities.
She enjoys her painting which gives her a feeling of ‘achievement and purpose’, the
concentration and focus she uses when painting have helped to control her movements.
Attending the Day Hospice gives her a sense of independence all be it with a little help
and something to tell her friends”
Comments from Lymphoedema patients:
Excellent service and treatment
Efficient, effective and informative
Very well run clinic, staff operate in a very expert and sympathetic way
Friendly, informative and well run
I felt very supported
Bereavement comment from a Client: “Thank you for inviting me last week – it was
good to talk to others who are travelling down the same path. It helped to hear other
people’s attitudes and ways they were finding to cope. It wasn’t a morbid get together and
I think we all benefited as we are all in the same boat and they really understand”
Page 9 of 14
4.2 Participation in Clinical Audits
During 2012/13 there were no national audits or confidential enquiries covering NHS
Services relating to palliative care. The Mary Ann Evans only provides palliative care and
therefore was ineligible to participate.
Hospice Audits that occurred during 2012/13
Infection Control – June 2012
Day Hospice patients Questionnaire
Lymphoedema Questionnaire
Bereavement Service
4.3 Research
The number of patients receiving NHS Services provided or sub-contracted by the Mary
Ann Evans Hospice in 2012/13 that were recruited during that period to participate in
research approved by a research ethics committee was NONE*
*There were no appropriate national ethically approved research studies into palliative care that the Hospice
could participate in.
4.4 Statement from the Care Quality Commission
The Mary Ann Evans Hospice is required to register with the Care Quality Commission
(CQC) and is currently registered for three regulated activities under the Health and Social
Care Act (2008)
Nursing Care
Personal Care
Treatment of Disease, Disorder or Injury
The Mary Ann Evans Hospice had its first unannounced visit in October 2012 and the
following standards were inspected as part of a routine inspection:
Respecting and involving people who use services
Care and welfare of people who use services
Safeguarding people who use services from abuse
Staffing
Assessing and monitoring the quality of service provision
Records
During the visit the inspector looked at the personal care or treatment records of people
who use the service, observed how people were being cared for, talked to staff, reviewed
information from stakeholders and talked to people who use the services. The inspector
reviewed standards that related to appropriate care, protection from abuse and noted that
quality systems were in place. The final report was published in November 2012 and
stated that ‘The Mary Ann Evans Hospice was meeting all the essential standards
inspected’.
4.5 Data Quality
The Mary Ann Evans Hospice did not submit records* during 2012/13 to the Secondary
Users service for inclusion in the Hospital Episode Statistics which are included in the
latest published data.
* The Hospice is not eligible to participate in this scheme
Page 10 of 14
4.6 An Explanation of those involved in this Quality Account
The Quality Account priorities were discussed at the Clinical Governance Group Meeting,
which included a service user, on the 14th March 2013. Discussion was also held with
team leaders of the core services.
The Quality Account was then written and discussed at the full Board Meeting on May 16th
2013.
The task of writing the Quality Account was designated to the Clinical Services Manager
with input from the Chief Executive.
Following this the Quality Account was distributed, on 29th May 2013, externally to:
Warwickshire North Clinical Commissioning Group
Warwickshire County Council Overview and Scrutiny Board
Nuneaton and Bedworth Borough Council Overview and Scrutiny Board
North Warwickshire Borough Council Overview and Scrutiny Board
HealthWatch Warwickshire
Warwickshire Health and Wellbeing Board
Part 5:
Review of Quality Performance
The National Council of Palliative Care (NCPC): Minimum Data Sets (MDS)
The Mary Ann Evans hospice has chosen to present information from the NCPC Minimum
Data Set which is the only information collected nationally on hospice activity. The figures
below provide information on the activity and outcomes of care for patients.
5.1
Day Hospice
The figures continue to show a steady increase in the number of referrals especially for
those with a non- cancer diagnosis
2010/11
Hospice
National
Hospice
Median
Total Patients
New Patients
% New Patients
% New Patients 16 - 24
% New patients 25 - 64
% New patients 65 - 84
% New Patients over 84
New Female Patients
New Male Patients
New Cancer Diagnosis
% New patients with Non-Cancer Diagnosis
Day Care Sessions
Day Care Places
Day Care Attendances
% Places Used
Deaths and Discharges
Average length of Attendance (Days)
138
78
56.50%
n/a
26.90%
51.30%
20.50%
40
38
63
19.20%
245
3,675
1,811
49.30%
78
232.4
Page 11 of 14
143
90
64.00%
0.00%
27.50%
59.60%
11.80%
49
40
74
16.90%
202
2,912
1,765
58.30%
100
141.7
National
Median
123
75
61%
0%
25.30%
65.30%
9.30%
37
38
63
16%
245
3,675
1,831
49.80%
72
188
94
51
60.80%
0%
28.10%
60.90%
12.00%
28
24
40
14.50%
153
2,024
1,221
56.30%
62
183.1
5.2 Hospice at Home
2011/12
Hospice
National
2010/11
Hospice
National
Median
Total New Patients
New Patients
% New Patients
% New Patients 16 -24
% New Patients 25 - 64
% New Patients 65 - 84
% New Patients over 84
New Female Patients
New Male Patients
New Cancer Diagnosis
New Non-Cancer Diagnosis
% New Patients with Non-Cancer Diagnosis
Deaths and Discharges
Deaths
% Deaths at Home
Average Length of Care
225
201
89.30%
0%
21.40%
55.20%
19.40%
99
102
188
13
6.50%
201
134
85.80%
37.5
252
219
88.80%
0.40%
20.30%
58.00%
19.80%
106
113
185
31
15.20%
227
157
79.60%
35.8
Median
234
209
89.30%
0%
39.20%
60.80%
13.10%
96
113
192
17
8.10%
255
147
90.50%
35.8
235
207
91.20%
0%
18.80%
59.70%
20.80%
99
108
171
26
17.80%
232
141
84.00%
27
5.3 Bereavement Service
2011/12
Hospice
National
95
33
34.7%
26
7
33
n/a
n/a
321
3.4
2.1
23.7%
56
58.3%
67
41
71.9%
23
12
23
2
7.1%
314
5.5
1.0
5.7%
35
60.3%
2010/11
Hospice
National
60
59
98.3%
0
0
60
n/a
n/a
390
3.9
1.3
11.1%
63
63.4%
60
42
71.4%
24
11
Median
Total Service Users
New Service Users
% New Service Users
New Female Service Users
New Male Service Users
Cancer Diagnosis of Deceased
Non-Cancer Diagnosis of Deceased
% of Deceased with a Non-Cancer Diagnosis
Total Contacts
Contacts per Service User
Phone Calls per Service User
% of Contacts which were Group Sessions
Discharged
% Discharged
Median
24
3
330
5.0
1.0
5.2%
34
58.3%
From August 2011 our current Bereavement Service of One to Ones and Group Sessions
commenced
Page 12 of 14
Part 6:
6.1:
Quality Markers
Complaints
INDICATOR
2012/13
2011/12
Number of Complaints (clinical)
0
1
Number of Complaints (non-clinical)
5
5
6.2:
Complaints
Patient Safety
INDICATOR
Number of Serious Patient Safety
Incidents (excluding falls)
2012/13
Patient Safety Incidents
2011/12
0
0
Number of Slips, Trips and falls
3
0
Number of Patients who experience a
Fracture or other Serious Injury as a result
of a Fall
0
0
Other Incidents
12
4
Page 13 of 14
Part 7:
Statements from Local Stakeholders
On 29th May 2013 a copy of this Quality Account was sent to Local Stakeholders, as listed
below, requesting a response by 21st June 2013:
Warwickshire North Clinical Commissioning Group
Warwickshire County Council Overview and Scrutiny Board
Nuneaton and Bedworth Borough Council Overview and Scrutiny Board
North Warwickshire Borough Council Overview and Scrutiny Board
Warwickshire HealthWatch
Warwickshire Health and Wellbeing Board
As at 27th June 2013 no Statements, or other correspondence relating to this
Quality Account, had been received from Local Stakeholders
Page 14 of 14