ST MARY’S HOSPICE
QUALITY ACCOUNT 2013/14
“Support, care and hope for local people
and those who love them”
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Quality Account 2013/14
Part 1
Chief Executive’s Statement
This year it becomes a legal requirement for St Mary’s Hospice to produce a Quality Account to show
how we measure quality, involve patients, carers and staff and strive to continually improve our
care.
A Quality Account is required as an annual report to the public from providers of NHS healthcare
about the quality of services they deliver. It is important to note that St Mary’s Hospice only receives
around 22% of its funding from the NHS while the rest (around £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. However St Mary’s Hospice regards it as important to ensure that all
patients and families using our services are assured of the quality of these and can see easily the
ways in which we strive, year on year, to improve what we offer.
Quality sits at the centre of all that the Hospice does. Our vision is that everyone in South Cumbria
with a life-limiting condition will have high quality care and support at the end of their life in the
place that they choose.
We asked patients, families, volunteers and staff to sum up in one word what St Mary’s means to
them. Their key words form the backbone of our mission statement:
“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
are of the highest quality and meet the aspirations of our mission statement.
This year in our Quality Account we give an update on work we identified in last year’s account as
requiring improvement. We also show where we will focus development work during 2013-14.
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Quality Account 2013/14
Our goals for the next twelve months include:
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Ensuring that our hospice building and staff are managed and equipped in such a way as to
keep our patients and visitors and staff, safe in any eventuality
Trialling a new home based volunteer service able to support people living at home in the
town of Ulverston and the district around it
Developing our building and services in such a way as to provide an ever more useful
resource for people in this locality
We were delighted that external confirmation of our high quality services was delivered in the form
of a very positive report from the Care Quality Commission (CQC) following their unannounced visit
in 2012.
I am responsible for the preparation of this report and its contents. To the best of my knowledge,
the information contained in this Quality Account is accurate and a fair representation of the quality
of healthcare services provided by our Hospice.
Val Stangoe
Chief Executive
May 2013
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Quality Account 2013/14
Part 2
Our priorities for improvement 2012/13
In 2012/13 patients, carers, staff and stakeholders helped us choose 4 priorities for improvement.
Priority 1
Patient Safety & Patient Experience
Improve the In-Patient Unit experience (IPU)
We undertook a regular patient survey across the year which received mostly positive
responses. Comments indicating a problem were referred to the Head of Nursing who
identified changes to practice to make improvements. Comments led to:
 Putting a Hearing Loop into the unit to support people with hearing difficulties. If this
is effective we will identify where else it might be useful.

A grant being successfully won to increase storage facilities in bedrooms and to improve the
courtyard garden, accessible from the unit. Changes to occur during 2013/14.
Priority 2
Patient Experience & Patient Safety
Develop Day Hospice Provision
Currently the only available space in the hospice for day services is a space on the first floor
landing. Despite this we have provided day hospice one day every week, an education
session fortnightly for people living with respiratory difficulties and a quarterly day of
support for people with motor-neurone disease. We plan to expand the range of day
services available by building a new annexe with funds recently agreed from the
Department of Health. Building work will begin mid- year.
Priority 3
Clinical Effectiveness
Develop End of Life Education & Training
Last year our new education department concentrated on delivering necessary education to
our own staff and volunteers. This has been a huge piece of work which included: identifying
who needs which training, carrying out training, checking all learning is practical and
effective and recording attendance and dates for refreshing. From 2013-2014 education for
external organisations will be developed as an additional income stream for the hospice.
Priority 4
Patient Experience
Re-invigorate Volunteer Support
The hospice has been delighted with the community response to this priority. The inpatient unit each week now has both volunteers supporting patients with lunches and
volunteer ward clerks. Complementary therapy is benefitting from volunteers with therapy
skills while a further intake of bereavement volunteers has added to the strength of the
Family Support Service.
We are looking to add to our volunteer team by recruiting evening and weekend
receptionists, and admin support for all clinical departments and projects.
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Quality Account 2013/14
Priorities for Improvement 13/14
Suggestions for priorities for work for the coming year came from our NHS commissioners, our own
audits and the successful application to the Department of Health for money to create a new
building.
Patient safety
In order to maintain high standards of safety for our inpatients in particular we are
undertaking two major pieces of work. These were both brought to our attention through a
review of the flood which affected the building at the end of last year:
Firstly we are updating our building and grounds in order to put in place measures which
will prevent future flooding. Secondly we have bought additional evacuation equipment and
will be providing additional training for staff in the use of this in order to ensure we are able
to safely evacuate patients on IPU in any future emergencies.
Clinical effectiveness
An application was made to the Department of Health for money to improve patient
experience at the hospice with 68% of the money being awarded. This will allow us to bring
about two specific improvements to our clinical services.
The ground floor of the new two storey building will be available for day services allowing us
to extend the support we can offer to local residents, patients and their families.
The top floor of the new building will provide an educational suite which will allow us to
provide increased training and education for our own staff as well as for other local staff
from the NHS, care homes etc. This will support improvement of end of life and palliative
care across both hospice and community settings locally.
Patient and family experience
Some of the money from the Department of Health is also to be used to extend our car
park, something we know is necessary from listening to our visitors and staff.
South Lakes Clinical Commissioning Group has recognised our ability to provide excellent
care for local people and has given us money to set up and support the first months of a
volunteer neighbour service. This service will enlist the help of local people as volunteers to
offer a few hours a week to people who have small tasks they can no longer manage alone,
this might include walking a pet, shopping, small household jobs or just providing some
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Quality Account 2013/14
friendship and company. As the service gains volunteers it will provide support not only for
those currently using hospice services but also to those who do not need hospice services
but do require such support. It is the hope of both the Commissioning Group and the
Hospice that this kind of support will make it easier for people to remain in their own homes
for longer.
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Quality Account 2013/14
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 2012/13 St Mary’s hospice provided the following services:
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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 Clinical Commissioning Groups (CCGs) responsible for South Lakes and Furness.
St Mary’s Hospice has reviewed all the data available to them on the quality of care in all these NHS
services. (This is a mandatory statement)
Participation in Clinical Audits
During 2012/13, St Mary’s Hospice was ineligible to participate in the national clinical audits and
national confidential enquiries. (This is a mandatory statement)
Participation in Local Audits
The Clinical Audit Group oversees a programme of internal audit which uses national, local and
regional audit tools. Where issues are identified during an audit, an action plan is developed to put
any problems right. Progress on this action plan is then monitored by the Clinical Governance Group
to ensure that actions are completed.
The following are examples of audits conducted in the 2012/13 period:
Audit
Completed
Action Plan
Examples of action taken to improve practice
Infection
Prevention &
Control Audit
Yes
Yes
Sign-off sheets for cleaning of vacated rooms on
IPU; replace kitchen floor in IPU kitchen; replace
curtains; Obtain apron dispensers; Remind staff to
use the temporary closure mechanism on the
sharps container and to take a sharps bin to the
bedside.
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Quality Account 2013/14
Controlled Drug
Audit
Yes – but
on-going
on annual
cycle
Yes
CD stock checks increased from weekly to twice
weekly to maintain tidiness of the record; revised
list of approved signatures required; need to
ensure RN signs for receipt of CD’s; tamper
evident packaging for transporting CDs required
OR a risk assessment; consider patients’ address
on CD TTO orders and patient-returned CD’s;
Controlled Drug
Prescribing Audit
Yes:
quarterly
Yes
Minor changes required as above re: CD record
CD Accountable
officer selfassessment
Yes
Re-audit May Limited documented evidence of AO actions in
2013
examining orders and delivery notes, etc.
Medical gases
and oxygen
concentrators
Yes
To ensure filters in concentrators are changed
between patient uses, and “regularly”
Hospice at Home
Documentation
Audit
Yes
No
Small changes made to categories on the
documentation
Nutrition and
Hydration Audit
Yes – but
on-going
Yes
Pilot a new tool which will be more suitable for
our patients
Develop policies and procedures to match new
tool
Pressure Sore
Audit
Yes – but
on-going
Yes
Purchase of pressure relieving mattresses and
chairs with inter-changeable seat cushions and
posture support backs etc.
Pressure ulcers
on IPU
Yes
Yes
notify CQC of all pressure sores of Grade 3 and
above,
Currently in the process of obtaining pressure
relieving recliners.
Bereavement
audit
Yes
YEs
Bereavement policy, how to review Bereavement
Volunteers performance, mandatory training for
volunteers
Verbal orders
Yes
No
To have a core drugs sheet in the drug chart.
Continue to ask for up to date drug chart from
patient’s GP on day of admission or day prior to
admission.
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Quality Account 2013/14
Insomnia
management
Yes
Yes
To change prescriptions used first line to most
appropriate types based on current evidence and
to continue to review all prescribed insomnia
medication weekly for in-patients and monthly for
out-patients
Rate at which
Nights sitters
require calling
Ooh DN service
Yes
No
Gathering numbers to ensure no problematic
issues
Wearing of ID
badges
Yes
Yes
There were genuine reasons for two of the three
who were not. In the case of staff and volunteers
who forget, we should encourage all staff, if they
see a colleague or volunteer without their badge,
to remind them to put it on.
Food and
Nutrition
Yes
Yes
Write integrated nutritional care policy. Write
policy and procedures based on the information
given in the Help the Hospices nutrition and
hydration audit tool. Review the patient
information booklet to provide accessible
information to patients about meals and
arrangements for mealtimes. Provide patients and
carers with information about what constitutes a
healthy balanced diet for their condition. Advice
and information on nutrition and hydration at End
of Life and the last days of life. The food and
nutrition group to review and update the
nutritional assessment tool currently in use. Look
at training and work force development.
To commence protected meal times.
Research
The number of patients receiving NHS services provided or sub-contracted by St Mary’s Hospice in
2012/13 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 2012/13 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
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Quality Account 2013/14
during the reporting period. (This is a mandatory statement in 2012/13 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:
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Treatment of disease, disorder or injury
Diagnostic and screening processes
St Mary’s Hospice has the following conditions on registration:
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Only treat people over 18 years old
Only accommodate a maximum of 9 in-patients
We have agreement from the CQC that we can treat patients aged between 16-18 years of
age if they are not able to access an equivalent service in this area.
An unannounced visit by the CQC in October 2012 found us to be fully compliant on the six
outcomes they measured us against.
Data Quality
St Mary’s 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.
(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 2013/14 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 2012/13.
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Quality Account 2013/14
(Mandatory statement)
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. Whilst 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
2012/13
168
131
73%
53%
11.4 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
Number of new patients
Total number of patient visits
% new patients
% of patients who died at home
2012/13
208
210
1991
97.5%
67%
National Median 2010/11
234
1768 (our figure from 10/11)
90%
79%
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
2012/13
48
63.6%
129.5 days
National Median 10/11
94
60.3%
137 days
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Quality Account 2013/14
This is the first year the family support team have collected stats. This was done for 6 months and
an average for the year worked out from there.
Referrals
Contacts
Caseload
IPU visits
Afternoon tea attendances
Total
(average for the year)
428
1164
70.5
270
73 (2 events)
National median 201-2011
5.8 per client
Feedback from Staff
St Mary’s Hospice is recognised as 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 are
held to ensure staff are kept up-to-date on hospice changes. The top 3 statements from the 2012/13
survey that staff agreed with were:
1. I am pleased to let others know I work at St Mary’s hospice
2. I am happy in my work
3. I get a lot of satisfaction from the work I do
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Quality Account 2013/14
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:
Good at leaving you to sleep in after
a bad night.
….a happy, caring,
loving
environment….
….like freedom of
visitors not being tied
to visiting times….
Cannot improve on
your wonderful work
Very attentive and very
caring without being
intrusive.
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Quality Account 2013/14
Hospice at Home:
they were so calm and
supportive, lovely to have
them couldn't have done
without them
their support kept Dad comfortable and
pain free and gave us confidence to feel
we could also look after him
they helped by sitting with him when I could
not so I could get some rest
cannot thank you enough you are
WONDERFUL
yes, the care was
paramount to Mam being
allowed home to die and
this was her wish and it
was important to fulfil this
they were very helpful and
understanding, they gave me
good advice what to do, they
were fabulous
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Quality Account 2013/14
We monitor all complaints and discuss them at our Clinical Governance and Quality improvement
meetings, complaints are also reported to the Board of Trustees:
Clinical Complaints
Total number of complaints
Number of complaints upheld
in full
Number of complaints upheld
in part
2012/13
5
4
2011/12
1
0
1
1
St Mary’s Hospice is always keen to use formal complaints as a tool for service improvement.
In 2012-13 we had a complaint from the family of a patient who felt the hospice should have
become involved in the care of their relative sooner.
In response to this complaint in 2013-14 the hospice is developing a marketing campaign to ensure
that all professionals working in the locality know about the different kinds of support offered by the
hospice and how they can access this for their patients.
We will also try to ensure patients and their families can find information about our services in order
that they too can raise the question of whether support from St Mary’s would be appropriate.
Opportunities to give feedback on this Quality Account
We welcome feedback on our second Quality Account. If you have comments, please email:
val.stangoe@ stmaryshospice.org.uk
Or write to:
Val Stangoe
Chief Executive
St Mary’s Hospice
Ford Park Crescent
Ulverston
Cumbria
LA12 7JP
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Quality Account 2013/14
Annex – consultation on our Quality Account
Cumbria LINk was disbanded on 31 March 2012 and the body replacing it, Healthwatch, has
not had time or resources to make a comment this year.
Cumbria Overview and Scrutiny Committee was asked to comment on this document and these are
shared below:
St Mary’s Hospice Quality Accounts Feedback
The Cumbria Health Scrutiny Committee welcomes the opportunity to comment on St Mary’s
Hospice’s Draft Quality Accounts for 2012/13.
In reviewing the draft document Members felt that the document was user friendly illustrating
a practical focus on patient safety, the day to day running of the hospice, and clinical
improvement. In relation to part two members felt that it would be useful to highlight if there
were any actions arising from the audits which were still to be implemented and progress
against these.
This is a detailed and comprehensive document, and overall we appreciate the work that has
taken place over the recent year and look forward to continuing to work with the Hospice.
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Quality Account 2013/14