St. Michael’s Hospice (North Hampshire)
Quality Account 2012-13
““
“When you were needed, you were there. When we needed a breather, you sensed it
intuitively. When we needed a hug, your arms were open wide…”
Carer Feedback April 2013
CONTENTS
Part 1
Page
Mission Statement and Vision
3
Chief Executives Statement
3
1.1 Priorities for Improvement 2013 -2014
4
1.2 Priorities for Improvement 2012 -2013
5
Part 2
Statement of Assurance from the St. Michael’s Hospice Board
6
2.1 Review of Services
6
2.2 Participation in Clinical Audit
7
2.3 Research
8
2.4 Quality Improvement and Innovation Agreed with Our Commissioners
8
2.5 What Others Say About Us
9
2.6 Data Quality
9
Part 3
Quality Overview
9
3.1 What Our Patients Say About St. Michael’s Hospice
14
3.2 What our Staff Say About The Organisation
14
3.3 What our Regulators Say About St. Michael’s Hospice
15
3.4 The Board of Trustees Commitment to Quality
15
3.5 Comments from other Stakeholders
15
3.6 References
16
3.7 Quality Account Feedback
16
2
Part 1
Mission Statement
St. Michael’s Hospice (North Hampshire) enables people faced with a life limiting illness,
their families and carers, to attain the highest possible quality of life by providing a choice
of specialist care and support.
Our Vision
St. Michael’s Hospice will endeavor to influence and lead all aspects of palliative care
provision in North Hampshire. It will do this by working in partnership with all stakeholders,
particularly service users, who will be actively involved in the development and delivery of
services which, as far as possible, will be user lead.
Chief Executive’s Statement
St. Michael’s Hospice takes pride in its reputation for providing high quality specialist
palliative and end of life care and support to the people of North Hampshire. Maintaining
and improving excellent quality services for patients and carers is at the heart of our
hospice and it is entirely due to the commitment and dedication of our staff and volunteers
that this is achieved.
In this Quality Account, we identify our priorities for quality improvement for 2013 / 2014
and review our performance against the quality indicators we selected last year.
We have made real progress this year in expanding services, such as hospice at home, so
that more patients can access high quality specialist palliative care from the Basingstoke
and surrounding local community area.
This year we have also received a very positive inspection report from the Care Quality
Commission. This re-enforces our commitment to quality and innovating improvements in
care by continuing to seek input from staff, volunteers, patients and carers in our
development.
To the best of my knowledge, the information in the Quality Account is accurate and a fair
representation of the quality of health care services provided by St. Michael’s Hospice.
David Monkman
Chief Executive
May 2013
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1.1
Priorities for improvement 2013-2014
St. Michael’s Hospice (SMH) continues to develop and improve the quality of services we
offer our patients and relatives. Ensuring we are always striving to improve and innovate
our quality of care is an integral part of our plans and developments for the future.
The quality improvement priorities we have identified for 2013 /14 are set out below. We
have identified three key areas; patient safety, clinical effectiveness and patient
experience. The priorities we have selected will impact directly on each of these areas.
Future Planning
Our high quality improvement priorities for 2013 -2014 will be:
Patient Safety
Priority 1: Benchmark the quality of our services against the Francis Report
Review key recommendations applicable to our services to ensure we meet or exceed the
Francis report recommendations to support high quality care provision.
How was this identified as a priority?
The Francis Report (2013) is a significant national report on quality of care based on
findings from a public enquiry. The implications of this report will be far reaching for all
aspects of the health service.
It is a recommendation that all care providers examine their service against the key
recommendations from this report.
How will priority 1 be achieved?
A systematic review of our services will be undertaken which will include an examination of
the evidence we have that supports key recommendations contained in the report. Areas
for development may be identified and this will inform any future improvements in our
service delivery.
Clinical Effectiveness
Priority 2: Open Out Project – Refurbishment of Day Care Services/Outpatient
Facilities
Implement large scale re-design and development of a new day care services area with
funding received from a Department of Health grant. A multi-function facility is planned to
facilitate innovative new services being planned for day care patients.
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How was this identified as a priority?
Current facilities for day care services were identified as not fit for purpose in line with
service redesign.
How will priority 2 be achieved?
Funding has been obtained for a significant proportion of the re-design. However further
planning will be required to modify design plans in line with the available funds. It is
anticipated that work on the project will commence during the summer of 2013, subject to
the timely release of funds from the Department of Health.
Patient Experience
Priority 3: Expansion of partnership working to enhance and further improve
access to specialist services for our patients
Develop specific projects which will lead to demonstrable service improvements for our
patients and increase the level of support we can provide for them.
How was this identified as a priority?
A key element of our strategic plan was to identify projects to support our aim to become
the lead provider of specialist palliative care to the patients of North Hampshire. Service
improvements that directly impact on improving the quality of care will support us to
achieve this.
How will priority 3 be achieved?
Several key projects have been identified such as the Dementia Challenge Project, the
Therapeutic Rehabilitation Programme for Prostate Cancer Patients and the Relationship
Wellbeing Project. Each of these projects will be evaluated for effectiveness at identified
stages as part of project evaluation.
1.2
Priorities for Improvement 2012-2013
Improvement Priorities
The key improvement priorities undertaken during 2012- 2013 were:
Priority 1: Implementation of the SMH 2011-2014 Strategic Plan
The St. Michael’s Hospice 3 year Strategic Plan was launched in April 2011 and promoted
to all stakeholders involved with the hospice. It will be reviewed again at the end of 2013 to
assess progress against previously identified benchmarks of achievement. The Strategic
Plan is reviewed six monthly by the SMH Board and monthly by senior managers. Key
elements of the plan (for which executive directors have individual responsibility) have
been implemented according to agreed timescales.
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Priority 2: Expansion of the SMH Hospice at Home Service
The successful development of the SMH Hospice at Home Service has been a key
achievement for the hospice in 2013 and this service has seen a 33% increase in the
number of patients it is able to support from October 2012 to March 2013. This means that
SMH Hospice at Home Service has enabled more patients who wished to die at home,
achieve their preferred priority of care, to die with comfort and dignity in their own
surroundings.
Comments from relatives include: .. ‘without the help from you all (Hospice at Home team)
it would not have been possible for dad to die at home which was his wish..I shall be
eternally grateful.’
Priority 3: SMH Clinical Service Review
Work continues on the SMH Clinical Services Strategic Framework and several new
innovations in care and services have developed as a result. It is anticipated that much of
this development work will continue to be on-going during 2013. Key developments as a
result of implementation of the Clinical Services Strategic Framework include:
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Development and improvement of patient information
Improvements in data capture using the MOPS (Management of Palliative Services)
system
Expansion of the Hospice at Home Service
Part 2
Statement of Assurance from the SMH Board.
This section sets out the list of statements that have been mandated by the Department of
Health for inclusion in the quality account, although some of these are not directly
applicable to specialist palliative care providers. Those that are applicable are identified
below.
2.1 Review of services
During 2012 - 2013 St. Michael’s Hospice supported local NHS commissioning priorities
with regard to the provision of specialist palliative care by providing:
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In Patient Unit Services
Day Care
Out Patient Services
Hospice at Home
Complementary Therapy
Physiotherapy
Occupational Therapy
Bereavement Services
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
Chaplaincy
NHS funding covered 18% of the total costs of providing these services, therefore all NHS
funding received has been fully utilised in providing direct patient care and service
provision. Funding to cover the remaining 82% of costs comes from charitable donations.
SMH regularly collects and reviews data on these patient services to ensure that they are
good quality and provide value for money.
2.2 Participation in Clinical Audit
National Audits
During 2012 -2013, no national clinical audits or national confidential enquires were
conducted covering the NHS services directly relating to palliative care. There has
therefore been no requirement to submit cases to national audits and the percentage of
the number of registered cases has not been included in this document.
However, the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (the
Francis Report) published in February 2013, recommends that ‘all commissioning, service
provision regulatory and ancillary organisations in healthcare should consider the findings
and recommendations of this report and decide how to apply them in their own work’
(Report of the Mid Staffordshire NHS Trust 2013 Recommendation 1).
SMH has commenced a systematic review of services, in line with the Francis report,
which will be completed during 2013.
Local Audits
SMH regularly conducts audits which are selected according to local, internal or network
priorities. A selection of audits undertaken and reviewed by SMH during 2012-2013
includes:
Audit Topic
Medicines management:
Quarterly Controlled Drugs
Audit
Infection control (monthly)
Preferred place of death
Implication for
practice/outcomes of audit
 100% compliance found
 Significant reduction in
the number of recording
errors in the last year.
 New commodes now in
place
 Clinic room refurbished
 MOPS (Patient
documentation system)
requires new field to
record more detailed
information
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Follow-up actions
Continue to monitor
Continue to monitor to assess
impact of new initiatives
Work is currently being
undertaken to amend the
MOPS system so more data
can be recorded on this topic
Significant reduction in falls
attributed to new call bell
system and pressure sensor
mats now in place
Falls
National Cancer Peer Review
Program Specialist Palliative
Care MDT – North Hampshire
Locality
RAG ratings (Red, Amber,
Green)
Majority of findings = green, no
significant issues that impact
achievement
Continue to monitor
Action to be taken with staff
attending an advanced
communication skills courses
A comprehensive Clinical Audit Program has been devised for 2013-2014. Topics include:
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Out of Hours calls (Hospice at Home and In-patients)
Patient satisfaction survey
Short term specialist chair loan
Waste
Hoist and slings operation
Infection control (monthly)
Food and drinks (in-patients unit)
Discharge
Documentation (preferred place of death)
Controlled drugs
Bereavement Service patient satisfaction
Complementary Therapies patient satisfaction
2.3 Research
The number of patients receiving NHS services provided by SMH in 2012-2013, recruited
during that period to participate in research approved by a research ethics committee was
zero.
St. Michael’s Hospice is keen to develop its research profile and methods to achieve this
will be considered during 2013.
A research project as part of the End of Life Dementia Programme, is currently being
undertaken and ethics approval has been gained from Kings College University. The
Masters level research topic will explore the experiences of nurses carrying out last
offices, including their views of involving significant others in the process, using a
qualitative approach.
2.4 Quality Improvement and Innovation Agreed with our Commissioners
SMH NHS income in 2012-2013 was not conditional on achieving quality improvement and
innovation goals through the Commissioning for Quality and Innovation Payment
Framework (CQIP Framework).
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2.5 What Others Say About Us
SMH is registered with the Care Quality Commission (CQC) to provide the following
services:
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
Treatment of disease, disorder or injury
Diagnostic and screening procedures.
SMH registration status is unconditional. The CQC made an unannounced visit on 15th
January 2013 and inspected the following standards as part of this routine inspection:
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Respecting and involving people who use services
Care and welfare of people who use services
Safeguarding people who use services from abuse
Management of medicines
Assessing and monitoring the quality of service provision
All of the above standards were met with no areas for improvement identified.
The findings of this inspection were highlighted as:
‘Staff were kind and caring and patients were given support to be independent, learn new
skills and manage their disease’ and ‘Staff with appropriate qualifications and experience
were available during each day to provide the required level of care and support to people
using the service’.
Care Quality Commission Inspection Report St. Michael’s Hospice (North Hampshire) February 2013.
2.6 Data Quality
In accordance with the agreement with the Department of Health, SMH submits a National
Minimum Dataset (MDS) to the National Council for Palliative Care.
Part 3
Quality Overview
3a. Core Quality Indicators (new for 2013)
Domain 4 Ensuring that people have a positive experience of care:
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Responsiveness to in-patient’s personal needs
Percentage of staff who would recommend the provider to friends and family
needing this type of care
A patient satisfaction survey was undertaken during July 2012 which did not specifically
focus on personal needs or recommendations to friends and family. However specific data
on in-patients was collected.
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In-patients data
Q.7 Did you feel the staff made an effort to meet your individual needs and wishes?
Q.7 Responses: were ‘always’ (100%)
Q.9 Did you feel your privacy was respected, for example, when being examined or during
discussions with staff?
Q. 9 Responses: respondents felt that they were treated with dignity and privacy was
preserved always (100%)
Domain 5 Treating and caring for people in a safe environment and protecting them from
avoidable harm
2012-2013
Rate of patient safety incidents and percentage
resulting in severe harm or death (or could of None
lead to)
Incidents of C. difficile (infected whilst on IPU)
None
Patient safety incidents reported per 100 8 per 250 admission to the in-patient unit
admissions
5 patient safety- none resulting in severe harm
or death (or could lead to)
3 drug errors - none resulting in severe harm or
death (or could lead to)
Proportion of incidents that result in severe None
harm or death
3b. Minimum Data Sets for Palliative Care 2011/2012
In Patient Unit
% New Patients
% Occupancy
% Availability
Average length of stay – Cancer
Average length of stay - Non Cancer
% Day Case Admissions
Day Care Service
% New Patients
% Places Used
Outpatients
SMH
National Median
91.9%
82%
100%
10.5 days
11.5 days
3.2%
90.5%
76.4%
70.3%
12.7 days
10.7 days
0%
SMH
National Median
45.9%
72.7%
62.1%
60.6%
2011/12
Cancer Diagnosis
Other Diagnosis
Total
38
20
73
Number of New Patients
10
Number of Continuing
Patients
Number of Patients Rereferred During the Year
Overall Outpatient Total
Breakdown not available
Breakdown not available
15
Breakdown not available
Breakdown not available
1
Breakdown not available
Breakdown not available
89
Hospice at Home
Total Number of Patients
% New Patients
% New patients with a Non Cancer
Diagnosis
Average Length of Care
Specialist Palliative Care Bereavement Service
New Referrals
SMH
National median
312
89.7%
12.9%
511
86.3%
15.1%
26.8
56.3
2012 -2013
2011 -2012
263
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Chaplaincy
Recruitment for a new chaplain continues and it is hoped that an appointment will be made
soon. The SMH chaplaincy role involves meeting complex spiritual and religious needs of
patients and their families, visitors and carers. The chaplain works with all Christian
dominations and can support those of other faiths to access the spiritual support they may
require to ensure all patients have their holistic needs met in this area.
The SMH chaplain also provides a valuable support for staff and can also support staff
exploring ethical issues (if appropriate) that may arise as a result of complex care needs of
patients.
Therapy Services
The physiotherapy service continues to develop the Lymphodema Service offered to
hospice patients and there has been an increase in the number of patients treated. By
accessing this service, patients can receive manual lymphatic drainage therapy, which is
not routinely offered on the NHS. Physiotherapists are working on developing their
specialist knowledge and skills in this area to further enhance the service they provide
patients.
A recent audit of the service demonstrated that all patients accessing this service reported
benefits in terms of function and experienced significant improvement despite advancing
disease.
The occupational therapy service, physiotherapy service and medical director have
developed a Motor Neurone Disease (MND) clinic as part of a joint working initiative. The
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MND Clinic has been very positively evaluated by patients and patient numbers continue
to increase.
A new occupational therapist (OT) has been recruited which has enabled the OT service to
give a more comprehensive and responsive service, particularly to the Hospice at Home
Service and MND patients. This has enhanced the support that patients receive in their
own environment with an extra 39 assessments (compared to the same period 2011-2012)
being completed for the Hospice at Home Service and 68 home assessments for patients
with MND.
Complementary Therapy Service
As part of our commitment to provide a choice of specialist care and support to patients
and their families, SMH offers a range of complementary therapies including: Massage,
Indian Head Massage, Aromatherapy, Reflexology, Reiki, Yoga (day care patients only),
Bach Flower Remedies, Acupuncture and One to One Relaxation. Regular evaluation and
audit show that these therapies help many people with relaxation, symptom control and
induce a sense of physical and emotional well being.
In April 2012 SMH commenced a complementary therapy out patient clinic from Odiham
Cottage Hospital for patients in Odiham, Hook, Old Basing and Hartley Wintney. This has
proved very successful and patients in the area appreciate being able to access a local
and convenient location. Over the year, the clinic has been extended to include carers, the
bereaved and home visits.
This year, Health Care Assistants and Hospice at Home Nurses have been trained to do
simple hand massage for patients which many are finding a useful tool to aid relaxation
In total this year, we have recorded over 2600 complementary therapy sessions, as well as
providing over 150 treatments as taster sessions for the public during fundraising events.
In addition to the quality metrics in the national minimum data set, SMH analyses
additional quality of care indicators as shown below.
014
87
7
Under 16
109
16-18 years
19-24 years
25-64 years
145
65-74 years
138
75-84 years
85 years and over
Not recorded
3c. Table to Show Total Patients (In-Patient and Hospice at Home) Age Analysis 2012/13
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Table to Show Overview of Key Governance and Activity Data
2012 -2013
2011 -2012
2010-2011
Total number of patients admitted
to the In Patient Unit (IPU)
250
273
244
% of patients who went home
42%
41.6%
47.3%
Number of bed days
3,650
3,660
3,549
% Occupancy
Total number of attendances by
patients at Day Care
Total number of Hospice at Home
visits
85.1%
86.5%
80.4%
767
1042
972
1,135
764
784
Total number of complaints
6
5
0
Total number of serious patient
safety incidents (excluding falls)
0
2 patients
collapsed
0
33
(all IPU)
IPU 38
H@H 1
Day Care 3
IPU 27
Not
recorded for
other
services
0
0
0
0
0
0
1
0
0
11.7
10.4
10.4
Slips , trips and falls
Total number of patients known to
be infected with MRSA on
admission to IPU
Total number of patients infected
with MRSA whilst on IPU
Total number of patients who
developed pressure sores whilst
on IPU
Length of stay on IPU in days
SMH is committed to ensuring all of our patients, carers and families receive the highest
quality care and is therefore pleased to highlight that:
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No patients have become infected with MRSA during their stay on the SMH InPatient Unit in the past four years.
No patients have been infected with Clostridium Difficile last year. Hand washing
practices and audit of this is also known to reduce incidence, which are regularly
undertaken at SMH.
There has been a significant reduction in patient falls (21% reduction) partly due to
measures introduced this year, including a new call bell system and pressure sensor mats.
6 complaints were received by the hospice over the past year with 4 of these related to
patient care. The remaining 2 complaints related to non-clinical elements of the service.
All complaints were fully investigated and resolved. All complainants received a letter from
the SMH Chief Executive outlining the action that had been taken in relation to their
complaint.
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SMH actively seeks patients and carers views on the services it provides and regular
patient satisfaction surveys are carried out on various parts of the service i.e. in-patients,
day care, outpatient clinics and Hospice at Home. During 2012, 41 surveys were returned
completed by patients and some carers. The feedback was mainly positive however some
patients and carers were not fully aware of how to make a complaint. There were also
limited responses from the In Patient Unit (IPU) survey, although many positive letters and
cards were received.
As a result, work has been done to raise awareness of making a complaint, for example
through the better availability of leaflets detailing this. Work continues this year to examine
how more formal feedback can be gained from the IPU.
The Carers Focus Group meets 6 times per year and actively contributes input into key
areas of work such as the re-design of patient information leaflets and memorial services.
Work is currently being undertaken to expand the membership of this group.
3.1 What our Patients Say about St. Michael’s Hospice
Included below are some of the comments received from relative and patient feedback via
our ‘How are we doing’ leaflets and from letters and cards. We also receive feedback from
students who have practice placements with our service.
‘How can you improve something so special that you all give to patients and us who visit..’
‘You have been outstanding..’
‘There are no words to express how very grateful we are to you all. The care and support
you give is humbling. X is in a better place now because of you.’
‘Many thanks for the care, respect and dignity you gave X in his last few days. This time
with you allowed us to be his wife and children again rather than carers and has made
saying goodbye a little bit easier..’
Student comment:
‘A comforting sense of strength, knowledge and experience was almost palpable from the
staff on the unit. The calm and reassuring presence of the nurses was so lovely to see and
so evident that patients and their families could obviously sense it..’
‘..no matter what, St. Michael’s was such a positive place to be..’
3.2 What our Staff Say about the Organisation
There have been no formal staff surveys during this period however staff on the in-patient
unit have attend an ‘away day’ where there have been opportunities to voice comments
and concerns regarding any aspect of their job role. The Hospice at Home staff attend an
‘away session’ every 3 months where staff have chance to discuss care issues and voice
comments and concerns. Positive comments from these sessions on ‘what works well on
IPU’ include ‘Having the opportunity to provide high quality care and spend time with the
patients..’ Opportunities identified to improve include reducing the time spent on nursing
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handover. All clinical staff also have access to clinical supervision run by an external
supervisor.
3.3 What our Regulators Say about St. Michael’s Hospice
See section 2.5 for the outcome of our successful Care Quality Commission inspection
visit this year.
3.4 The Board of Trustees Commitment to Quality.
The Board continues to maintain its commitment to ensure that the highest standard of
palliative care is delivered to those in need of our services. This commitment includes
corporate and clinical governance structures that are embedded within SMH. Board
members are represented on appropriate committees to support the quality of care that
patients and relatives receive.
Whilst clinical targets are an important element of our service, it is the essential care and
compassion element that is an integral part of our mission, particularly ensuring that
patients are treated as individuals with respect and dignity.
The Board receives reports from the Chief Executive and senior managers both clinical
and non-clinical, and these are discussed at the quarterly formal Board meetings.
The Chair and Vice Chair meet with the Chief Executive on a monthly basis to discuss any
quality of care issues.
All of these factors combine to ensure the Board remain receptive to all aspects of the
service and have an on-going awareness of key elements of care. The Board are confident
that the care and treatment of patients and relatives continues to be high quality, safe and
cost effective.
3.5 Comments from Other Stakeholders
Comment from North Hampshire Clinical Commissioning Group (CCG):
‘SMH is an invaluable part of the palliative care provision in North Hampshire. It provides
our population with excellent inpatient care when they are unable to be cared for at home
due to increasingly complex problems. The hospice also provides so much more now
….day care, complementary therapy, bereavement support/counselling and increasingly,
expert nursing care in patients homes delivered by the 'Hospice at Home' service. This is
allowing more patients to have their care delivered closer to home and to die in their
preferred place, which is often their own home.
The medical and nursing staff at SMH are also fully engaged with several research
projects that are looking to improve palliative care for the future and are involved with
educating other healthcare professionals in the area.
As commissioners we regularly evaluate the quality of care that SMH provides and the
evidence from CQC, patient feedback and other stakeholders, shows that it provides
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excellent care, particularly with reference to dignity and respect for patients. SMH is an
essential part of healthcare provision in North Hampshire.’
Dr Charlotte Hutchings End of Life lead for North Hampshire CCG
3.6 References
Care Quality Commission (2010) Essential Standards of Quality and Safety
Francis R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry.
London. The Stationery Office.
Department of Health (2013) Quality Accounts Reporting Arrangements for 2012/13
accessed at
https://www.gov.uk/government/publications/changes-to-quality-accounts-reportingarrangements-for-2012-13
3.7 SMH Quality Account Feedback
If you would like to comment on the content or format of the SMH Quality Account for
2012- 2013, then please submit your comments either via the SMH website or to the SMH
Chief Executive at this address:
St Michael’s Hospice (North Hampshire)
Basil de Ferranti House
Aldermaston Road
Basingstoke
Hampshire
RG24 9NB
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