BIRMINGHAM ST MARY’S HOSPICE
QUALITY ACCOUNT 2013-2014
Our quality performance, initiatives and priorities
Our vision is for a future where
the best experience of living
is available to everyone leading
up to and at the end of life
We continually strive to achieve
this through the specialist and practical
range of services we offer to individuals,
families and carers; through education
and partnerships; and through working
with professionals and communities
to share our expertise and
learn from others
Birmingham St Mary’s Hospice
176 Raddlebarn Road, Selly Park, Birmingham, B29 7DA
Registered Charity Number: 503456
www.birminghamhospice.org.uk
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WHO WE ARE AND WHAT WE DO
Birmingham St Mary‟s Hospice is far more than a building or an organisation – we deliver a
philosophy of care, dedicated to helping men and women, living with incurable illness, to make the
very best of their lives.
Through specialist expertise, care, treatment and listening, we make it possible for many people to
enjoy the years, months or days they have left; and when the time comes, have a good death.
Loved ones and carers are fully supported during this difficult time and beyond.
Hospice care is also known as “specialist palliative care”. It is about settling the physical and
psychological symptoms of a person‟s illness and helping them to deal with any emotional distress
and practical difficulties. Everything is done to enable each individual and their family to live life to
the full.
Most of our care is given by our community team in our patients‟ own home. Each year we support
over 1,000 people at home, in our Day Hospice and on our Inpatient Unit. As our elderly population
grows, with more people living alone, the demand for care at home is certain to increase. We will
use our expertise to help more people remain safely and comfortably in their own home if that is
what is best.
As a pioneer in palliative care, and through our education programmes we have trained and
supported many NHS doctors, nurses and other health & social care professionals, to provide
palliative care as part of their role. We work with other organisations to improve the co-ordination
and quality of care people receive and raise awareness within local communities, so that as many
people as possible can get timely help when they need it.
Birmingham St Mary‟s Hospice is an independent charity and a big part of the local community
since our launch in 1979.
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INDEX
Part 1 – Statements
1.1
Statement from the Chairman and Chief Executive
5
Part 2 – Priorities for Improvements and Statements of Assurance
2.1
Priorities for Improvements 2013 – 14 (what we achieved last year)
Priority 1
-
Patient Safety
Staff Nurse Development Programme
Priority 2
-
Clinical Effectiveness
Combined Specialist MDT
Priority 3
-
Patient Experience
Family Centre
7
2.2
Other Hospice achievements 2013 – 2014
12
2.3
Priorities for Improvements 2014 - 2015
14
2.4
Priority 1
-
Patient Safety
Organisation-wide monitoring and review system
for mandatory training
Priority 2
-
Clinical Effectiveness
Implementation of SystmONE electronic records
for Hospice at Home
Priority 3
-
Patient Experience
Day Hospice review
Statement of assurance from the Board
Review of services
Participation in clinical audit
Research
Guideline development and review
Use of CQUIN payment framework 2013-14
Statement from the Care Quality Commission
Data Quality
Information Governance toolkit
Clinical coding error rate
17
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Part 3 – Review of quality of performance
3.1
Clinical Data
24
In Patient Unit
Community Palliative Care Team
Day Hospice
3.2
Quality Markers
27
Patient Slips, Trips and Falls
Pressure Ulcers
Infection Prevention and Control
Complaints
3.3
Clinical Audit
3.4
Feedback from patients and families on services
31
35
Patients‟ Forum
CQUIN
3.5
Benchmarking Activity
39
3.6
Statement on Birmingham St Mary's Hospice Quality Account for
2013/14
40
Cross City CCG
3.7
Feedback and Comments
42
ABBREVIATIONS
CPC
Clinical Practice Committee (part of the Hospice‟s governance framework)
CQUIN
Commissioning for Quality and Innovation (payment)
IPU
In Patient Unit
MHRA
Medicines and Healthcare Products Regulatory Agency
NICE
National Institute for Clinical Excellence
OOH
Out of Hours
RCA
Root Cause Analysis
SCCM
Senior Clinicians Communications Meeting
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Part 1 – Statements
1.1
Endorsement - Chairman and Chief Executive
At Birmingham St Mary‟s Hospice patients and families are at the centre of all we do.
The approach taken for the Quality Account for 2013-14 has been to focus on three specific
priorities across patient safety, clinical effectiveness and patient experience. These relate to
identified aspects of care that may not otherwise have received public attention and yet have made
a difference to quality of care and outcomes for those patients and families. We have also
followed the recommended format to demonstrate compliance with Department of Health
requirements.
Our service quality, standards and approach to care are not limited to simply what is required but
to the needs and aspirations of our service users. This is driven by our own high standards and
specialist expertise in end of life care, and supported by our commitment to maintaining a well run,
sustainable organisation.
A wider picture of successes and improvements along with our approach to governance and
quality can be found in the following public documents:


St Mary‟s Hospice Ltd Annual Report 2013-14
Birmingham St Mary‟s Hospice – The Next Four Years (2012-16) – Reaching More People
Reaching more
people
1.
2.
3.
4.
5.
6.
7.
Strong
foundations
Working in partnership to achieve
high standards in more settings
The priorities for the next four years are shown in below. They reflect our successes and wider
plans for improvement:
Make it easier for people to know how to get help
More care at home
Increase confidence and independence of patients and carers
Expand our expertise across a wider range of conditions and services
Work with communities to foster the contribution of local society
Grow our education so more people are able to deliver & influence care
Pioneer and explore innovative ways to meet changing needs
8. Our impact: prove the difference we make
9. Our people: attract the best workforce and supporters
10. Our funding: continue to build financial strength
11. Our organisation: well run and organised
12. Our reputation: well known, well regarded and influential
We hope that by sharing the more specific improvements and practice in this Quality Account,
there is practical value to all readers of this document.
This Quality Account is produced to inform current and prospective service users, their families and
carers, Hospice staff, our supporters, Commissioners and the public, of our commitment to ensure
quality across all our services.
Trustees have an active role in our Governance Framework. Each Trustee has, as part of his or
her portfolio, a Governance Committee or Board Sub-Committee. This way, Trustees are actively
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engaged in understanding their responsibilities as individuals and conducting them collectively as a
Board.
We confirm that we endorse this Quality Account on behalf of the Board of Trustees.
Judi Millward
Chairman
Tina Swani
Chief Executive
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Part 2 – Priorities for Improvements and Statements of Assurance
2.1
Priorities for improvement 2013-14 - what we achieved last year
Patient Safety - Staff Nurse Development Programme
Priority One:
To provide increased in house training for the Registered Nursing staff on the Inpatient Unit .
Standard:
 All Registered Nurses recruited to the Inpatient Unit within the last twelve months to undertake
a new „development programme‟
 To upskill the nursing staff in teaching skills
 Registered nurses to have up-to-date training records
How was this identified as a priority?
An approved increase in the ward establishment enabled us to recruit two new nurses. This has
been in addition to routine nursing recruitment during the last year, which has resulted in a cohort
of new junior staff. In order to maintain the specialist knowledge of the nursing team, the need for
a development programme was identified in order to sustain the provision of safe clinical practices.
Also, the increased teaching demands on Inpatient Unit staff has highlighted a gap in staff
confidence and competence in relation to their teaching abilities.
How was the priority achieved?
Staff were given the opportunity to attend:
 3-day course studying the essentials in palliative care
 New starter/induction session for Band 5 nursing staff
Staff also undertook:
 Supporting Learning Assessment in Practice
 European Certificate in Palliative Care courses
 Facilitation for European Certificate candidates
 Teaching as part of the education programme
 Supernumerary shifts working with Inpatient Unit Sisters (Band 6)
How was progress monitored and reported?
 The study courses and induction sessions were evaluated and comments taken into account
when determining future delivery
 Attendance was recorded and entered onto individual staff training records
 Development of an Inpatient Unit competency document
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Clinical Effectiveness - Combined Specialist MDT
Priority Two:
Evaluate effectiveness of a Combined Specialist Palliative Care Multidisciplinary Meeting
(SPCMDT) between the Hospice and an Acute Hospital
Standard:
Complete a six monthly pilot and undertake evaluation of a weekly Combined Specialist Palliative
Care Multidisciplinary Meeting
How was this identified as a priority?
The Manual for Cancer Services: Draft Specialist Palliative Care (SPC) Measures was published
in April 2012 by the National Cancer Peer Review National Cancer Action Team. The final
measures are not yet in place. The revised Specialist Palliative Care Measures are based on the
requirements for SPC in Improving Supportive and Palliative Care for Adults with Cancer (2004).
There is a requirement for all inpatient hospital and hospice SPC services to be covered by a
named SPCMDT which is put forward for review against the SPCMDT measures. In order to
achieve compliance the Hospice must demonstrate that they meet the standard under peer review.
How was the priority achieved?
 We ran a Specialist Palliative Care combined MDT with clinicians from the Hospice and
University Hospitals Birmingham NHS Foundation Trust (UHBfT)for a 12 month period
 Outcomes were documented and actions agreed
How was progress monitored and reported?
We held meetings to review the effectiveness of the combined MDT after six months and again at
the end of the full 12 month period. Results were reported to the Hospice‟s Senior Clinicians and
Clinical Governance Committee.
The review meetings recognised the value of the combined MDT, which they felt had helped to
foster more collaborative working and had positively influenced patient outcomes on a number of
occasions. Whilst there was good support for both the idea of collaborative working and joint
discussion of patients, a number of the meetings had been cancelled due to lack of cases for
discussion.
The two organisations expressed a wish to continue to work collaboratively and bi-annual
meetings, to promote reflective practice and enhance communication, were seen as a possible
way forward.
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Patient Experience - Family Centre
Priority Three:
Family Centre
Standard:
New extension to house a „Family Centre‟ will be completed within agreed timeframe and comply
with patient/carer expectations
How was this identified as a priority?
Facilities in the existing „patient flat‟ were identified as needing modernisation and in need of
refurbishment. In addition the location of this facility offers limited privacy to patients and their
family/carers as it overlooks an area designated for receiving deliveries and collections (laundry,
clinical waste, oxygen etc.). Users of the „patient flat‟ could be disturbed by the noise from this
adjacent service area. In addition there was no access to outside space. The new „Family Centre‟
will include space for relatives to stay overnight. There is no such facility at the moment other than
using a camp bed or reclining chair and there are no shower facilities available to visitors.
How was the priority achieved?
 We developed a project plan with detailed timescales and ensured AEDET (Achieving
Excellence Design Evaluation Toolkit) and ASPECT (A Staff and Patient Environment
Calibration Tool) were incorporated into the project
 Through a tender process we:
o Appointed project management for the work
o Appointed contractors for the work
 We continually assessed the risk and impact on patients and relatives for the duration of the
project
 We developed a communication plan
o There was ongoing consultation with our Patients‟ Forum
o Regular bulletins to Trustees, staff and volunteers
The Family Centre has been purpose built to a specification that provides a comfortable and safe
environment for patients and their family/carers. The facilities allow users to be independent but
with the support of staff close by. It includes wheelchair access and an assisted bathroom and will
ensure privacy for families in a homely environment. An important part of the Centre is the easy
access to the Hospice garden so that patients can enjoy the benefits of an outside space.
The Centre has been designed to include self-contained space for relatives to stay overnight.
There is a twin bedded room with ensuite bathroom facilities which can be used independently or
in conjunction with the „Family Centre‟ facility.
How was progress monitored and reported?
Throughout the project the nursing staff, physiotherapists, occupational therapists and the Infection
Prevention and Control Team were consulted. Their guidance and advice was sought in respect of
the layout and specification of the project and this will be ongoing during the Centre‟s use.
There were regular site meetings with the contractor and reports were issued to:
 The Executive Director Team
 Environment & Risk Committee
 Premises Committee
 Board of Trustees
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Tina Swani, Chief Executive, laying the foundation stone for the new Family Centre
(Photograph courtesy of Nicola Gotts)
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Part 2 – Priorities for Improvements and Statements of Assurance
2.2

Other Hospice Achievements 2013 – 2014
Space to breathe
In April 2014 Judges at the Midlands Thoracic Society Annual Meeting awarded first prize to
the collaborative and innovative programme for patients with chronic obstructive pulmonary
disease and their carers set up by Birmingham St Mary‟s Hospice and Respiratory Medicine at
University Hospitals Birmingham Foundation Trust in conjunction with Birmingham and Solihull
Mental Health Foundation Trust. The service arose as a result of a local palliative care needs
analysis carried out across primary and secondary care by the Hospice in 2011. This identified
gaps in the management of anxiety, breathlessness, social isolation, advance planning and
carer support. Patients had high comparative admission rate and length of stay.
In response to this, and with a grant from NHS West Midlands, a supported self-management
programme was developed and delivered by a team, including a psychologist, occupational
therapist, palliative care and respiratory care doctors, physiotherapy and a palliative care
clinical nurse specialist. The programmes focus was behavioural change through psychoeducation, exercise and relaxation, underpinned by cognitive behavioural therapy. Two 5 week
programmes were run at Birmingham St Mary‟s Hospice during 2013 and were open to
patients and their carers.
Patients evaluated the programme well; they described improvement in confidence, quality of
life and improved management of their exacerbations. Although the numbers of patients in the
2 programmes were small the data on use of hospital services showed a reduction in total
admissions from 14 to 8 and reduction in total bed days from 87 to 64 over a 6 month period.
We are now working to try to secure ongoing funding for this programme and will use an award
of £750 from the Harold Thomas Travelling Fellowship to enable the joint team to attend an
appropriate conference on palliative care and breathlessness.
Fiona Campbell (Lead Physiotherapist), Jo Leek (Lead Occupational Therapist), Sharon
Hudson (Clinical Nurse Specialist) et al, had a poster presentation on this programme at the
10th Palliative Care Congress in Harrogate in March 2014.

Hospice at Home
Following a successful pilot programme, we introduced a new core service to our portfolio
during 2013 – „Hospice at Home‟. The Hospice at Home model delivers at-home care for
patients with a limited life expectancy by a small team of registered nurses and care assistants
and is provided seven days a week with night sits where necessary.
We work collaboratively with and receive referrals from District Nurses, local GP practices and
the Discharge Liaison Team at University Hospitals Birmingham Foundation Trust using
Birmingham Community Healthcare Trust‟s Single Point of Access (SPA). The service is
designed to work across health and social care economies to deliver the following outcomes:
o Reduce the number of inappropriate emergency hospital admissions for patients
who have expressed their wish to die at home.
o Increase the number of patients achieving their preferred place of death.
o Facilitate timely discharge of patients who are nearing end of life from hospital who
are awaiting a health and/or social services funded package of care.
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The Hospice at Home team of registered nurses and health care assistants provides:
o
o
o
o
o
o
o
Specialist comfort measures in keeping with the patient‟s unique circumstances
Assistance with personal hygiene and comfort care as required by the patient
Ensures that the patient is comfortable and pain free at the end of each visit
Timely and specific emotional and psychological support to patients and their carers
Assistance with nutrition and hydration as appropriate to the individual patient need
Catheter care, mouth care and/or pressure area care if instructed in the patients care
plan
Referral to appropriate agencies in a timely manner when appropriate. This may include
complex psychological and emotional issues or uncontrolled or complex physical
symptoms.
A short article on our new core service „Hospice at Home‟ will be featured in Cross City Clinical
Commissioning Group‟s Annual Report as a good practice example of integrated working.

Qualitative study
Dr Christina Radcliffe, Consultant in Palliative Medicine, has conducted a qualitative study
exploring the views of Intensive Care Unit (ICU) staff on the use of a supportive care pathway
to guide the care of patients who may not survive their ICU admission. Dr Radcliffe had a
poster presentation on this study at the 10th Palliative Care Congress in Harrogate in March
2014.

Group Education sessions
Day Hospice has introduced Group Education sessions for patients. These are based on the
Expert Patient Programme, whereby patients are encouraged to 'self-manage' a symptom such
as pain, breathlessness, poor appetite. Patients are given information to understand the
symptom, with basic anatomy and physiology and asked as a group, how they manage
symptoms at home. This is discussed by the group, with information given by Day Hospice staff
on management and written information leaflets provided.

Missing patient – mock exercise
The Inpatient Unit Lead Nurse attended a „missing patient exercise‟ run by a local Trust. As a
result, minor changes have been made to the organisation‟s Major Incident Plan.

Food hygiene
In September 2013 Birmingham City Council‟s authorised Environmental Health Officer
conducted an unannounced inspection. The Catering Team achieved 5H rating, which
represents excellent food hygiene standards in our food preparation areas; a level we have
achieved consecutively over the last 4 years.

Condition survey
Hospice appointed Faithful & Gould to conduct a condition survey of the Hospice premises to
help guide and improve our premises preventative maintenance programme.

Help the Hospices Annual Conference 2013
Last year we reported on the publication in the European Journal of Palliative Care of the
article on the „Introduction of electronic patient records in a Hospice Inpatient Unit‟, by Nicola
Butterfield, Lead Nurse on the Inpatient Unit. As a result of this Nicola was invited to present a
poster on the same topic at Help the Hospices Annual Conference in November 2013.
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Part 2 – Priorities for Improvements and Statements of Assurance
2.3
Priorities for Improvements 2014 – 2015 – what we will achieve next year
Patient Safety - Organisation-wide monitoring and review system for mandatory
training
Priority One:
Organisation-wide monitoring and review system for mandatory training
Standard:
 To have an effective monitoring and review system across all disciplines
How was this identified as a priority?


Manual checking of the statutory and mandatory training matrix
Recognising the need for accurate and up-to-date training records in order to readily identify
compliance and training status for each individual
How will the priority be achieved?



Ensuring that staff complete registration documentation for training sessions
Implementing a 3-monthly manual review of the training matrix by the Human Resources
Learning and Development Lead
Progressing to automated reviews and alerts via electronic HR records software within 12
months
How will progress be monitored and reported?



Through regular review of training records/matrix by the Human Resources Learning and
Development Lead
Outcomes reported to the Learning and Development Steering Group
Bi-annual reports to Departmental Managers/Team Leaders to highlight those staff that require
training or refresher courses
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Clinical Effectiveness – Implementation of SystmONE electronic records for
Hospice at Home
Priority Two:
Implementation of SystmONE electronic records for Hospice at Home
Standard:
 In order to improve efficiency and safety and reduce duplication, the Hospice at Home clinical
records database will be transferred onto SystmOne
How was this identified as a priority?
Hospice at Home was initially a pilot and therefore the data collection needed to be separate from
the core services to allow for proper evaluation. However, separate records were identified as a
risk and this was also highlighted in the pilot evaluation report.
How will the priority be achieved?
It will be achieved by developing a project plan which outlines the following deliverables:
 Business requirements
 Solution design
 SystmOne solution
 Test sensitivity and reports
 Training package for staff
 Accommodation
 Equipment
How will progress be monitored and reported?


Through the Project Management Group
The Senior Risk Owner (SRO) for the project and chair of the Project Management Group is
the Director of Nursing and he will be responsible for ensuring that:
o There is appropriate stakeholder engagement for the project, in particular appropriate
clinical representation
o The project will follow Hospice standards and existing established practice
o The Board meets sufficiently regularly to be able to discharge its responsibilities in
managing and mitigating risks, as well as dealing with escalations from the Project
Manager
o The Board responds adequately in a timely manner to issues raised in Project Highlight
Reports
o Progress will be reviewed by the Project Management Board every 4-6 weeks
o Progress will be monitored through the project deliverables
o Any issues highlighted by the Project Board will be escalated to the Executive Director
Team by the SRO.
“Transferring onto SystmONE is a
really positive step for Hospice at
Home as it will improve efficiency
and communication.”
Hospice at Home Manager
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Patient Experience – Day Hospice review
Priority Three:
Day Hospice review
Standard:
 To ensure the Day Hospice service is effective, evidence based and reflects the needs of our
local community
How was this identified as a priority?
The need to develop existing services and ensure they are cost effective as well as patient
focussed is a priority identified for the whole organisation.
Whilst there are a variety of Day Hospice models in existence across the UK, there is no nationally
agreed model of care for service delivery or outcome measures for success, and little validated
evidence to support the existing models of care.
The National Council for Palliative Care, in their most recent annual survey of specialist palliative
care services (2013), found the proportion of people with non-cancer diagnoses accessing
specialist palliative care services is increasing. This, along with the success of the Space to
Breathe pilot, suggests a need to review the Day Hospice model in terms of effectiveness for
patients with cancer and non-cancer diagnosis and the current model used. This also seeks to
address the priority in our 4-Year Plan to „reach out to local communities‟.
Against this backdrop Commissioners are increasingly focused on providers evidencing patient
outcomes and cost effectiveness. Locally, commissioning intentions from our Clinical
Commissioning Groups have highlighted that their priorities in end of life and palliative care will
have a similar focus.
How will the priority be achieved?








Review the current Day Hospice model.
Examine other Day Hospice models/services
Explore existing service specification of other Day Hospice services
Review the evidence base regarding the role of Day Hospice services
Understand local commissioning intentions
Scope of potential / viable models
Identify local population needs
Make recommendations for a future model
How will progress be monitored and reported?
Through a Project Management Group which will regularly report back to the Director of Nursing
and the Executive Director Team
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Part 2 – Priorities for Improvements and Statements of Assurance
2.4
Statement of assurance from the Board
The following are statements that all providers must include in their Quality Account. Many of
these statements are not directly applicable to specialist palliative care providers, and therefore
explanations of what these statements mean are also given.
Review of services
During 2013-14 Birmingham St Mary‟s Hospice supported commissioning priorities in Birmingham
and Sandwell with regard to the provision of local specialist palliative care by providing the
following services which were also part-funded through charitable funding:








Inpatient Unit
Community Palliative Care Team
Day Hospice
Hospice at Home
Occupational therapy
Physiotherapy
Complementary therapies
Family & Carer support services, including bereavement support and spiritual care
Participation in Clinical Audit

During this period Birmingham St Mary‟s Hospice did not participate in any national clinical
audits or confidential enquiries since it was not eligible to do so.

The reports of zero national clinical audits were reviewed by the provider in 2013-14. This is
because there were no national clinical audits relevant to the work of Birmingham St Mary‟s
Hospice.
What this means:
As a provider of specialist palliative care Birmingham St Mary’s Hospice is not
eligible to participate in any of the national clinical audits or national
confidential enquiries. This is because none of the 2012-13 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 2013-14 for the same reason.
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Research
The Hospice participated in the following research study during 2013-14:
Title of Research: Factors associated with successful implementation of a Carer
Support Needs Assessment Tool (CSNAT) in palliative and end of life care practice
Researchers: Professor Gunn Grande, University of Manchester and Dr Gail Ewing,
University of Cambridge Research Associate (RA): Dr Janet Diffin, University of
Manchester
Start date: September 2013
Aim:
Primary aim
To identify the factors associated with level of adoption of the CSNAT in practice
Secondary aim
To aid subsequent dissemination and translation of the intervention into generalist
and specialist end of life home care
Title of Research: Can Art and Design be used in a non-therapeutic setting as a
form expressive catharsis?
Researcher: Jennifer Moseley
Start date: February 2014
Aim: To identify the therapeutic benefits of art
Title of Research: What are trustee‟s attitudes to service user involvement in
hospice governance?
Researcher: Katrina Poulson
Start date: September 2013
Aim: Increased understanding of the attitudes of trustees from independent voluntary
hospices towards the involvement of service users in hospice governance.
Title of Research: Learning disability and palliative care: a case study
Researcher: Katy Ivko
Start date: May 2013
Aim:
Primary aim
To use quantitative analysis to determine the proportion of adults with a learning
disability accessing the services of the hospice compared to the general population.
Secondary aim
To explore different professional attitudes towards, and experiences of, working with
adults with a learning disability who have a terminal illness.
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Guideline development and review
The following NICE and other guidance, applicable to the hospice clinical practice, have been
reviewed:
April 2013
 Tracheotomy and Airways Emergencies
 Delirium – Assessment tool for patients in intensive care
May 2013
 The Epilepsies – The Diagnosis and Management of Epilepsies in Adults and Children in
Primary and Secondary Care
June 2013
 Quality Statement 14 – Spiritual Support
 Draft Spiritual Support and Bereavement Care Quality Markers and Measures for End of Life
Care
September 2013
 The Diagnosis and Management of Suspected Idiopathic Pulmonary Fibrosis
November 2013
 Falls Guidance
January 2014
 Clinical Guideline on Enteral Feeding
February 2014
 Chronic Obstructive Pulmonary Disease – Evidence Update
March 2014
 Neuropathic Pain – Pharmacological Management CG173
Use of CQUIN payment framework 2013 – 2014
A proportion of Birmingham St Mary‟s Hospice income in 2013-14 was conditional on achieving
quality improvement and innovation goals agreed between the Hospice, and the following Clinical
Commissioning Groups: Birmingham Cross City, Birmingham South Central, Sandwell and West
Birmingham. This was achieved through the Commissioning for Quality and Innovation payment
framework. Details of the initiative for 2013-14 are given below:
Description of CQUIN
 To ensure that providers have real-time systems in place to monitor patient/carer experience
 To demonstrate improvements in patient/carer experience
 Demonstrate clear commitment from the Board to improve patient/carer experience
Aim
To ensure patient/carer satisfaction and to measure the outcome of patient care whilst
continuously monitoring the quality of the services provided through the use of questionnaires.
More detail on the methodology and outcomes from these questionnaires is given later in this
Quality Account.
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Statement from the Care Quality Commission
Birmingham St Mary‟s Hospice is registered with the Care Quality Commission to carry out the
following regulated activities:
Diagnostic and screening procedures
Transport services, triage and medical advice provided remotely
Treatment of disease, disorder or injury
Personal care
Nursing care
The following conditions of registration apply to all regulated activities listed above:
 The Registered Provider must ensure that the regulated activities are managed by an individual
who is registered as a manager in respect of the activity, as carried on at or from the location
St Mary’s Hospice Limited
 These regulated activities may only be carried out at or from the following location: 176
Raddlebarn Road, Selly Park, Birmingham B29 7DA
The following additional conditions apply:
 This hospital is registered to provide treatment and care under the following service user
categories only: Hospice for adults H(A).
Reason for condition: To ensure that only treatment and services within the scope of the
providers’ knowledge, skills and experience are offered.
 A maximum of 25 patients may be accommodated overnight.
Reason for condition: To ensure that only treatment and services within the scope of the
providers’ knowledge, skills and experience are offered.
 A maximum of 20 persons only may receive services provided on a day-case basis.
Reason for condition: To ensure that only treatment and services within the scope of the
providers’ knowledge, skills and experience are offered.
 Notification in writing must be provided to the Care Quality Commission at least one month
prior to providing any treatment or service not detailed in your Statement of Purpose
Reason for condition: To ensure that only treatment and services that are safe to be
undertaken in the premises and within the scope of the providers’ statement of purpose are
offered.
The Care Quality Commission has not taken any enforcement action against Birmingham St
Mary‟s Hospice during 2013-14.
Birmingham St Mary‟s Hospice has not participated in any special reviews or investigations by the
Care Quality Commission during 2013-14.
We were last inspected by the Care Quality Commission in January 2014. We were inspected on
the following standards as part of a routine inspection and the inspector found that we met all 5
standards:
 Care and welfare of people who use services
 Staffing
 Supporting workers
 Statement of Purpose
 Assessing and monitoring the quality of service provision
An extract from the Commission‟s report is given below:
Quality Account 2013/14
PG21
Why we carried out this inspection
This was a routine inspection to check that essential standards of quality and safety referred to
above were being met. We sometimes describe this as a scheduled inspection.
This was an unannounced inspection.
How we carried out this inspection
We looked at the personal care or treatment records of people who use the service, carried out a
visit on 31 January 2014, checked how people were cared for at each stage of their treatment and
care and talked with carers and/or family members. We talked with staff.
What people told us and what we found
We inspected the service that was provided in people's own homes, the Hospice at Home
Service. At the time of our visit there were five people receiving this service but over one
hundred and fifty people had used it over the past 12 months.
We found that people's needs were assessed and care and treatment was planned and
delivered in line with their individual care plan. Nurses and nursing assistants from the
service worked with District Nurses from the NHS Community Healthcare Trust to provide
end of life care for people in the their own homes.
There were sufficient numbers of staff on duty to meet people's needs. The service was
staffed by Registered Nurses and nursing assistants who were supported by a manager
and an administrator. The service also had flexible staffing arrangements to meet
demands and people's changing needs. Staff were properly trained, supervised and
appraised. They received support to deal with the challenging nature of their work
providing end of life care in people's homes.
Information about the safety and quality of service that people received was gathered and
scrutinised and used to improve the service. This included gathering the views of people
who used the service and of other stakeholders in the service such as district nursing
teams.
A family member of a person who used the service told us “My [relative] likes them, they are very
thorough and very caring … I don‟t know what we would do without them, they have been great.”
Quote from DLE here
“As this is a new core service for
the Hospice, I was pleased that the
Care Quality Commission chose to
concentrate their inspection on it. “
.
Director of Nursing
Quality Account 2013/14
PG22
Supporting vulnerable patients and families
Our services are developed with local communities to respond to the individual and diverse needs
of our population and free of charge to patients and their families.
The Trustees believe that the quality of the care depends on having a skilled and resourced
workforce of paid and voluntary workers with access to appropriate training and development.
We aim to ensure that we are recognised not only as a leading provider of high quality
compassionate care at end of life, but also as a centre of excellence for the provision and
promotion of education and training for health and social care professionals in palliative care.
We recognise that we work with individuals and families at particularly vulnerable times in their
lives as a result of illness, disability, impairment and emotional stress. In common with all partner
agencies in Birmingham, we share a responsibility to safeguard individuals‟ rights to freedom from
discrimination, exploitation, intimidation and all forms of violence. Through our mandatory training
programme staff are trained to deal appropriately with these patients and their families.
The following improvements have been identified this year:
 Reviewed and updated our policy and procedures on safeguarding of vulnerable adults
 Revised mandatory programme for level 1 for all staff and hospice based volunteers
 Level 2 adult and children safeguarding training for clinical staff and managers
 Specialist level 3 training for all social workers
 New policy on Mental Capacity including Best Interests Decision Making
 The electronic patient record now includes a template for Mental Capacity assessments
and decisions This will:
o enhance patient safety and protection
o enable professional best interests decisions to be communicated effectively
o provide robust data for multi-agency referrals and reports to the Care Quality
Commission and Clinical Commissioning Groups.
To ensure that we are able to welcome and support those patients and families who do not have
English as their first language, we have an agreement with a local interpretation service who are
able to provide support on an ad hoc or regular basis.
The feedback we receive from our patients and their carers demonstrates the unique package of
care each of our patients receives.
Data Quality
Birmingham St Mary‟s Hospice did not submit records during 2013-14 to the Secondary Users
Service.
Information Governance Toolkit
Birmingham St Mary‟s Hospice Information Governance Assessment Report overall score for
2013-14 was 66%. We achieved Attainment Level 2 or above on all requirements and were
graded green (satisfactory).
Quality Account 2013/14
PG23
Clinical coding error rate
Birmingham St Mary‟s Hospice was not subject to the payment by results clinical coding audit
during 2013-14 by the Audit Commission. This is because Birmingham St Mary‟s Hospice receives
payment under a mix of block contracts, and payment on a cost per case basis when delivered, not
through tariff, and therefore clinical coding is not relevant.
This is because:
Birmingham St Mary‟s Hospice is not eligible to participate in this scheme. We have
a Clinical Information Officer who collects and collates data extracted from the
electronic patient records system and a data integrity sub-group reviews the data
quarterly.
Quality Account 2013/14
PG24
Part 3 – Review of quality of Performance
3.1
Clinical Data
Birmingham St Mary‟s Hospice uses „SystmONE‟, an electronic patient records system which all
patients are entered onto. We have, therefore, chosen to present data extracted from that system
for the year 1 April 2013 to 31 March 2014 for the following services:
In Patient Unit (IPU)
There were 454 admissions to our IPU – this includes those patients that may have been
admitted more than once
o
Number of Admissions
Inpatient Unit Admissions 2013 / 14
50
45
40
35
30
25
20
15
10
5
0
Month
Community Palliative Care Team (CPCT)
o
o
o
799 new referrals were received for this service
8,684 patient contacts were made during the year
There were between 250-300 patients per month on the Team‟s caseload during the year
Number of New Referrals
Community Palliative Care Team New Referrals 2013 / 14
90
80
70
60
50
40
30
20
10
0
Month
Quality Account 2013/14
PG25
Number of Contacts
Community Palliative Care Team Patient Contacts 2013 / 14
900
800
700
600
500
400
300
200
100
0
Month
Day Hospice
o
o
Attendance in our Day Hospice was 2,112
Patients were unable to attend Day Hospice for a variety of reasons on 989 occasions (see
the breakdown on the next page)
Number of Patients
Day Hospice Attendance 2013 / 14
250
200
150
100
50
0
Month
Quality Account 2013/14
PG26
Number of Patients
Day Hospice Non-Attendance 2013 / 14
120
100
80
60
40
20
0
Month
Reasons for non-attendance – Day Hospice
Reason
Outpatient appointment
In hospital
In Hospice Inpatient Unit
Unwell
On holiday/away
Other (Visitors – family/district
Total for
2013/14
60
179
167
342
47
189
nurse/friends/workmen/delivery)
Reason unknown
Cancelled by service
Death
TOTAL
0
0
5
989
Quality Account 2013/14
PG27
Part 3 – Review of quality of Performance
3.2
Quality Markers
 Patient Slips, Trips and Falls
 Pressure Ulcers
 Infection Prevention and Control
 Complaints
Patient Slips, Trips and Falls
Patient slips, trips and falls are monitored on a regular basis and reported accordingly. Any
serious incidents are reported to the Care Quality Commission under statutory notifications and a
root cause analysis is undertaken when:





A fall results in hospital assessment or admission
A patient suffers loss of consciousness
A patient has abnormal neurological observations
A patient has repeatedly fallen i.e. more than 4 times on current admission
A patient has died as a result of a fall or within 24 hours of a fall
In 2013/14 there has been a 34% increase in the number of patient slips, trips and falls, with 114
incidents reported compared to 85 last year. This is largely due to a small number of patients, who
at the end of the year, had multiple falls.
Slips, Trips and Falls 2013 - 2014
45
40
40
35
31
30
25
20
April - June
22
19
17
July - Sept
18
16
Oct - Dec
15
10
10
9
8
9
Jan - March
6
5
0 0 0 0
0
1
0 0
0 0 0 0
0
Total No. No Harm
Slip, Trips &
Falls
Low Harm
Moderate
Harm
Severe
Harm
Death
There was 1 serious injury sustained during the year and this was reported to the Care Quality
Commission and Clinical Commissioning Group.
Falls
Many of our patients have complex care needs and are very frail. We plan care with patients on an
individual basis respecting their wishes in relation to maintaining independence whilst at the same
time trying to ensure that this means patients do not suffer undue harm.
We regularly monitor the data collected in respect of falls and use the incidents as a learning
experience and to promote staff awareness.
Quality Account 2013/14
PG28
During the last 12 months we have made the following improvements in our approach to managing
falls:
 improved our documentation
 purchased a „Hoverjack‟ – a piece of equipment to help lift fallen patients off the floor which will have benefits for patients and staff in terms of manual handling
 have had fewer frequent fallers because we have improved the way we manage them
Pressure Ulcers
The overall number of patients admitted to the In Patient Unit (IPU) with pressure ulcers has
increased by 33% this year, with 97 patients admitted with a pressure ulcer compared to 73
patients admitted last year.
There has been a slight decrease this year in the percentage of patients admitted from home with
a pressure ulcer, with 63% of patients being admitted from home this year compared to 68% last
year. Consequently there has been a slight increase in the number of patients admitted from
Hospital with a pressure ulcer, with 37% of patients admitted from Hospital with a pressure ulcer
this year compared to 32% last year.
Pressure Ulcer Admissions 2013-2014
140
20
117
18
120
109
Total no. admitted in the quarter with a
Pressure Ulcer (PU)
No. admitted from Home with PU
108
16
120
100
14
12
80
10
60
No. admitted from Hospital with PU
Total number of admissions to IPU
Developed on IPU Grade 1
8
Developed on IPU Grade 2
6
40
4
33
20
20
18
1300%
7
24
17
20
15
7
July - Sept
Oct - Dec
13
2
Developed on IPU Grade 4
0
Developed on IPU DTI
7
0
April - June
Developed on IPU Grade 3
Jan - March
Information relating to patients with pressure ulcers is regularly monitored and a root cause
analysis (RCA) is undertaken for all patients with a grade three or above developed under our
care. Statutory notifications are made to the Care Quality Commission for all pressure ulcers
grade 3 and above that develop on the IPU and incidence rates are also provided to the Clinical
Commissioning Group.
The number of pressure damage RCAs has increased over 2012-13. Twenty two RCA‟s have
been completed this year compared to ten last year, with seven statutory notifications made to the
Care Quality Commission. It is important to note that the increase is due to RCAs being conducted
for all grade 3 and 4 pressure ulcers whether or not they were aquired at the Hospice. Whilst this
was valuable learning for staff, the Director of Nursing has requested RCAs only for those cases
where the pressure damage was acquired at the Hospice.
Quality Account 2013/14
PG29
Statutory Reporting of Pressure Ulcers
2013-2014
10
9
9
8
8
7
6
No reported to CQC
5
No of RCA Undertaken
4
3
3
3
2
2
1
2
1
1
0
April - June
July - Sept
Oct - Dec
Jan - March
Whilst we are unable to influence the incidence of patients admitted with a pressure ulcer, we have
discussed this with Commissioners. As part of our ongoing commitment to manage patients with
pressure ulcers, during the last 12 months we have:
 arranged tissue viability training for appropriate staff
 based on this training we have reviewed our dressing stock
 have a mattress replacement programme – all our mattresses will be replaced with „Cirrus‟
mattresses which are a higher specification than our current stock
Infection Prevention and Control
Outbreaks
During February 2014 there were a number of cases where staff and patients presented symptoms
of nausea, diarrhoea and vomiting. During this time our guidelines for the recognition and
management of outbreaks was implemented. Public Health England were notified and the In
Patient Unit was closed for admissions as a precaution for 6 days.
Surveillance of MRSA and Clostridium Difficile
The total number of patients known to have MRSA/C-Diff on the In Patient Unit between 1 April
2013 and 31 March 2014 are:
Micro Organism
MRSA
Clostridium Difficile
Total number of
patients known to be
colonised:
4
3
Quality Account 2013/14
PG30
Complaints
Summary of complaints received between 1 April 2013 to 31 March 2014.
Total No. of Complaints
4
Nursing:
 In Patient Unit
 Day Hospice
 Community Palliative Care Team
 Hospice at Home
1*
0
1
0
Medical
1*
Family and Carer Support Team
0
Other
2
* Same complaint for Nursing and Medical
Developing a Learning Culture
The number of complaints continue to be extremely low in relation to the number of patients,
families and carers that are looked after by the Hospice.
The organisation is committed to continually improving the service offered and developing a
continual culture of learning.
Compliments and “Thank You’s”
The Hospice receives numerous thank you cards and letters which are normally received by
individual departments.
Compliments and thank you cards and letters are retained after they
have been displayed in individual departments. Particular phrases and expressions of gratitude
are used in Hospice material, with the permission of the author.
Quality Account 2013/14
PG31
Part 3 – Review of quality of Performance
3.3
Clinical Audit
Audits are important to drive forward practice and help inform improvements in care. Clinical audit
is a process of „measuring‟ care and treatments to see if improvements can be made. We
undertake many clinical audits each year in order to ensure that where there are areas for
development and improvement, these are identified and acted on.
An example of the type of audit that has directly benefited patient care this year is our re-audit of
the diagnosis and management of urinary tract infections. An earlier audit had demonstrated that
there were areas for improvement required in relation to: patients being started on antibiotics
following specific clinical symptoms only; when patients should be started on antibiotics if they
have a urinary catheter; when specimens of urine should be tested if urinary infection is suspected.
Following a period of education and awareness raising for doctors and nurses a re-audit was
undertaken. This showed significant improvements in clinical practice compared to the previous
audit.
The following Clinical audits were completed as part of the 2013 audit programme:
1
Date
Title of Audit
Compliance
January
Integrated Notes –
documentation

2
January
Infection Control – 5 subtopics
3
January
Help the Hospices – “The Health
and Social Care Act 2008, Code
of Practice, Self-Assessment
Audit”








4
5
January
January
6
April
7
April
8
April
Waiting Times – Day Hospice
Timing of offering Day Hospice
place
Patient Slip, Trips and Falls





Recording of pressure ulcer
incidence and monitoring
Documentation of DNAR





9
May
Waiting times – In-Patient Unit
10
May
Waiting Times – CPCT



Significant improvement in overall
standard since 2012
Late shift/night compliance poor
Care plans to be set up for frequency
Subtopics 1, 3, 4, 5 = 100%
compliant
Subtopic 2 – 85.7% compliant
100% compliant in management
systems
100% compliant in control of the
environment
100% compliant in the provision of
information
100% compliant in personnel
screening, protection & training
95% compliant
95% compliant
72% patients attended
Compliant on 3 standards
Non-compliant on post falls care plan
and bed rails
Both standards 100% compliant
Compliant with 1 standard
4 standards non-compliant
95% In-Patients had decision
documented - 50% Hospice patents
overall
All decisions documented on ACP
tool on system
Standard 1 compliant
Standard 2 97.2% compliant
100% compliant
CQC
Outcome
21
8
21
10-11
1-2
13-14
16
16
16
4
1
16
16
Quality Account 2013/14
PG32
Date
Title of Audit
Compliance
11
May

100% compliant
12
13
14
15
16
June
June
June
August
August





100% compliant
5 out of 9 standards achieved
97% compliant
70% standard achieved
Standard 100% achieved
4
16
8
12
12
17
August
Study day evaluation – Medical
students
Hoist Sling and Slide sheet
Blood Transfusion Pathway
Commode Cleanliness
Booked attendance of study days
Study Day Evaluation – individual
sessions
Integrated Care Pathway




ICP commence appropriately
87% reasons commenced
90% Syringe Drove prescribed
100% PRN medication prescribed in
advance
100% family alerted to change in
condition of patient
All care plans discontinued on
commencement of ICP
On patients death – sheet completed
every time
80% compliant
16
35.7% of patients admitted to service
had completed DNAR documentation
50% of patients had DNAR
completed in two weeks of admission
to the service
4/5 standards compliant
1
Standard 1 - 44% compliance
Standard 2 – 93% compliance
Standard 3 – 30 % compliance
16



18
September
19
October
Hospice at Home – response
time to referral
Hospice at Home – DNACPR
discussion documented



20
October
Diagnosis/management of UTI
on In-Patient Unit
Delayed Discharge
21
October
22
23
24
25
December
December
December
January
MDM Attendance
Ward Round Review
Mattress Audit
Consent for Invasive procedures
 Acupuncture
 Paracetesis
26
January
Diabetes Management
27
January
28
January
29
February
Response time to contacting
patients referred to Day Hospice
Recording of next planned
contact – CPCT
Labelling of mobility equipment









Bereavement practice - CPCT
4
16
16
11
2




85% compliant
21

100% compliance – mobility
equipment correctly labelled
75% compliance – IPU qualified
nursing auxiliaries aware of &
understand labelling system
66.66% of qualified and 100% of
auxiliary nursing staff in Day Hospice
aware of & understand labelling
system
Standards 1 & 2 – 97% compliant
Standards 3 & 4 – 100% compliant
Standard 5 – 95% compliant
11

February
16
Standards improved from last year
99.1% compliance
Acupuncture – 100% compliance
Paracetesis – good documentation of
discussion around risk, benefits and
alternative treatments
100% compliant in 3/5 standards
97% compliant in 2/5 standards
100% compliance

30
CQC
Outcome
12



4
16
16
Quality Account 2013/14
31
PG33
Date
Title of Audit
Compliance
February
Waiting times for non-urgent
equipment provision





100% compliant – collections
100% compliant – same day delivery
requests
75% compliant – next day delivery
requests
69% compliant – three day delivery
requests
80% compliant – seven day delivery
requests
CQC
Outcome
16
The following Medicines Management Audits were completed as part of the 2013 audit
programme:
Date
Title of Audit
Compliance
1
March

94% compliance
2
3
4
May
June
June
September
September






4/9 standards compliant
3/7 standards compliant
Standard 1 – 96.2% compliant
Standard 2 – 100% non-compliance
100% compliance
100% compliance
9
9
9
5
6
7
October
Controlled Drug
administration timing
Drug Chart Audit
Electronic Verbal Orders
Stock Controlled Drug
check
Medication Storage
Discharge prescription
turnaround time
Drug Fridge Temperature
November
Patient group directions
9
November
10
11
December
February
12
March
CPCT advice on
appropriate dose of
immediate release Opioid
for breakthrough pain
Controlled Drugs
Oxygen prescription,
administration and
monitoring
Reconciliation of drugs
91% compliance – standard 1
75% compliance – standard 2
100% compliant in 2 standards
90% compliant in 1 standard
84% compliant in 1 standard
36% episodes met standard
57% - no advice given
7% - variation without variation
documented
Compliant in all areas
100% in 3/6 standards
10% in 2/6 standards
19% in 1/6 standards
80% - accurate transcriptions
between medication list and drug
chart
96% - documentation on IPU
SystmOne completed
9
8














CQC
Outcome
9
9
9
9
9
9
9
9
Quality Account 2013/14
PG34
Audit Presentations 2013
12 audit presentations took place in 2013, detailed below. These were attended by staff across a
number of disciplines.
Month
April
July
October
Presentation Title
 Day Hospice Waiting Times
 Preferred Place of Care – CPCT
 CQUIN – Patient Satisfaction
 Breakthrough Pain Medication advice
 Waiting Times – Inpatient Unit Admission
 Documentation of DNAR discussion/decision on the IPU
 Waiting Times for Community Equipment
 Policy/Procedure Sign off
 Diagnosis and Management of UTI
 Diabetes Management
 Drug Chart
 Integrated Care Pathway
Surveys/Reviews in 2013
The following surveys/reviews took place in 2013:
Date
Title
Reported to
January
through to
December
(Monthly)
CQUIN
 In Patient
 Discharged patients from In-Patient Unit
 Day Hospice
 Community Palliative Care Team
Request for emergency admission to In-Patient
Unit

September


Clinical
Commissioning
Groups
Clinical Governance
Committee
Hospice Senior
Clinicians
CQC
Outcome
1
16
Quality Account 2013/14
PG35
Part 3 – Review of quality of Performance
3.4
Feedback from patients and families on services – Patients’ Forum / CQUIN
The views of our patients, families and carers who use our services are important to us and
processes are in place to enable service users to voice their views and experiences in a private
and dignified way. These processes act as a Hospice User Group in an advisory capacity, and
include Patients‟ Forum and CQUIN.
Patients’ Forum
Patients‟ Forum are held on a monthly basis and on different days of the week to enable variable
participation. Membership consists mainly of patients from Day Hospice, although patients from
our In-Patient Unit and Community Palliative Care teams are also invited. The meetings are
supported by the Director of Nursing and a member of the Business Development Team.
During 2013, 9 Patient Forum meetings were held, 3 were postponed due to seasonal constraints
and 56 patients have attended overall.
Topics discussed in the meetings have included:
 Smoking Shelter for Day Hospice Patients
 Views requested on Resuscitation leaflet
 Hospice re-branding – designs, website
 Family Centre Plans
 Pin-board within Day Hospice for patient comments
 Introduction and overview from Head of PR and Communications
 Location of new fish tank within Day Hospice
 Views on new Hospice Menus
 Volunteers for upkeep of terrace garden
They are fantastic –
you cannot improve on
perfection
CQUIN
The key aim of the Commissioning for Quality and Innovation (CQUIN) framework for 2013/14 is to
encourage the demonstration of improvements in quality and innovation of services in specialised
areas of care, consequently ensuring better outcomes for patients.
Birmingham St Marys Hospice demonstrates its commitment to improving quality of service by
circulating a series of questionnaires to both Patients and/or Carers, at specified timescales during
their association with us. The method we used for collecting information is given below:
In-Patient Services
 A questionnaire was given to patients or their carer on the fourth day following admission
Discharged Patients from In-Patient Unit
 A questionnaire was initially given to all patients or their carer on the day of discharge
Day Hospice
 A questionnaire was initially given to all patients attending Day Hospice and thereafter on a
patient‟s fourth visit
Community Services
 A questionnaire was given to the patient/carer after the third community visit. This was
provided in a pre-paid, addressed envelope for them to return to the Hospice
Hospice at Home
 A questionnaire was given to the patient/carer during the first visit with a pre-paid return
envelope.
Quality Account 2013/14
PG36
Number of returned questionnaires
180
160
140
120
100
80
162
60
155
119
40
20
38
11
0
In-Patient Unit
Discharged
Patients
Day Hospice
CPCT
Hospice @
Home
Note: Hospice at Home was included from December for four months only.
Questionnaires returned analysed by month
25
20
In-Patient Unit
15
Discharged Patients
Day Hospice
10
CPCT
5
Hospice @ Home
0
IN-PATIENT UNIT
Question
Strongly
agree
Agree
Strongly
disagree
26
Neither
agree nor
disagree
1
The first three days of my stay have been satisfactory
144
I understand the reasons for my admission and what
the hospice is trying to achieve for me
I have found the staff approachable
139
21
0
0
148
9
0
0
I have been given the opportunity to discuss my care
and treatment
I have been able to express any concerns or issues
that I‟ve had
The In-Patient Unit staff are doing everything I would
expect them to do
If I have a complaint about the care I was receiving I
would know what to do
The service I have received could be improved in
some way
141
21
0
0
137
20
1
1
144
17
1
0
91
51
8
4
32
9
18
94
0
Quality Account 2013/14
PG37
While I have been in
Birmingham St Mary’s, I can
only say my stay has been
pleasurable, the staff are
angels on earth. The Hospice
is an amazing place, the staff
are sooo amazing, my stay
has changed my opinion on
hospices.
PATIENTS DISCHARGED FROM THE IN-PATIENT
UNIT
Question
I was satisfied with the care and treatments I received
Strongly
agree
Agree
Strongly
disagree
10
Neither
agree nor
disagree
1
107
I always felt that I knew what was going on
94
18
4
2
The service I received could be improved in some way
10
14
11
68
COMMUNITY PALLIATIVE CARE TEAM
Question
Strongly
agree
Agree
Strongly
disagree
I have found the staff approachable
145
9
Neither
agree nor
disagree
1
I have been given the opportunity to discuss my care
and treatments
I have been able to express any issues or concerns I
had
The Community Team is doing everything I would
expect them to do
132
18
2
2
135
14
2
2
130
18
3
3
1
1
Wonderful treatment, so
much kindness.
Thank you
Quality Account 2013/14
PG38
At such a difficult time, my
family have found the
support and empathy
shown to be invaluable, I
cannot thank the team of
St Mary‟s enough
DAY HOSPICE
Question
Strongly
agree
Agree
Strongly
disagree
6
Neither
agree nor
disagree
0
My recent visits have been satisfactory
32
I understand the reasons for attending Day Hospice
23
14
0
0
I understand what the hospice is trying to achieve for
me
The service I received could be improved in some way
29
6
2
1
3
4
7
22
HOSPICE AT HOME
Question
Strongly
agree
Agree
Strongly
disagree
I have found the staff approachable
10
0
Neither
agree nor
disagree
0
I have been given the opportunity to discuss my care
or treatments
I have been given the opportunity to express any
issues or concerns I have
Hospice at Home has helped me to stay at home
9
1
0
1
9
1
0
1
10
0
0
1
Hospice at Home have supported my family/carers
10
0
0
1
0
1
Quality Account 2013/14
PG39
Part 3 – Review of quality of Performance
3.5
Benchmarking Activity
Patient safety is a key domain of quality. Patients and their families expect to be cared for in a
safe environment with no harm. Benchmarking enables hospices to report, share, compare and
learn from each other. We are currently participating in the following benchmarking exercises:
West Midlands Hospice Nurse Managers Group
With regard to the safety dimension of quality, the West Midlands region is collating data on a
monthly basis in the following areas:





Percentage occupancy
Pressure ulcers
Slips, trips and falls
Infection control
Deaths and discharges
The West Midlands Hospice Nurse Managers Group (WMHNMG) scrutinise the data on a quarterly
basis. Following reflective discussion, the WMNM are in agreement that there is consistency
between the hospices in the West Midlands region.
Through this process of continuous quality monitoring, the WMHNMG would quickly identify any
significant differences between hospices and act to identify the underlying cause(s).
Help the Hospices Inpatient Unit Quality Metrics (National Project)
We are taking part in a pilot programme with Help the Hospices to benchmark hospice Inpatient
Units on the following three patient safety indicators:



Falls (5 levels of harm: none, low, moderate, severe, death)
Pressure ulcers (avoidable and unavoidable)
Medication incidents (levels 0-6)
Quality Account 2013/14
PG40
Part 3 – Review of quality of Performance
3.6
Statements on Birmingham St Mary’s Hospice Quality Account for 2013/14
Statement of assurance from Birmingham Cross City CCG June 2014
Birmingham Cross City CCG welcomed the opportunity to provide this statement for the 2013/14
Quality Account for Birmingham St Mary‟s Hospice. The Quality Account has been reviewed in
accordance with the Department of Health guidance.
Birmingham Cross City CCG, and its partner CGGs, are committed to ensuring that the service
they commission provides the very highest of standards in respect to clinical quality, patient safety
and patient experience. With this in mind we have worked closely with Birmingham St Mary‟s
Hospice during the year in monitoring service delivery and reviewing performance through regular
Clinical Quality Review Group meetings which are a forum for discussing the quality of services
and the safety of patient care.
Overall the Quality Account appears to be comprehensive and balanced in reflecting the activity
within the Hospice during 2013/14, whilst clearly setting out the planned quality intentions for the
coming year. The document was well presented and was considered to offer an appropriate level
of detail to ensure it was understandable for members of the public. For example the “Who We are
And What We Do” section of the Quality Account read very well, really getting to the heart of the
role, functions and philosophy of the Hospice and the care that it offers.
The Quality Account clearly defined the planned priorities for service development and
improvements in quality for the next four years. These priorities were very clear and appropriate;
demonstrating a commitment by the organisation to continually improve local standards for quality,
patient safety and patient experience.
Whilst reviewing the Quality Account we were pleased to note some of the specific areas of work
which we considered demonstrated positive developments that enhanced clinical care, service
delivery and the wider patient experience. These included:

The investment that has been made in respect to strengthening nursing within the in-patient
unit has clearly demonstrated support for staff development and retention. This will obviously
serve to ultimately benefit patients and the care they receive.

The positive work that has been undertaken between the Hospice and University Hospitals
Birmingham NHS Foundation Trust (UHBFT) to promote Multi-Disciplinary Team working.

The development of the new „Family Centre‟ which will enhance the provision for families using
the services of the Hospice.

The successful delivery of the “Space to breathe” project for patients with chronic obstructive
pulmonary disease and their carers set up by Birmingham St Mary‟s Hospice and Respiratory
Medicine at UHBHFT conjunction with Birmingham and Solihull Mental Health Foundation
Trust.
We were also pleased to note how the Hospice plans to continue their Priorities for Improvement
during 2014-2015 and welcome the following planned developments:
Quality Account 2013/14
PG41

The focus on patient safety and the Organisation-wide monitoring and review of systems for
mandatory training.

The implementation of the SystemONE electronic records for the Hospice at Home service
which should make a positive improvement in efficiency and communication for staff and
patients.

The planned Day Hospice review will provide a positive means of enhancing the evidence to
underpin meaningful patient outcomes, whilst promoting cost effectiveness.
Whilst reviewing the Quality Account we were pleased to notice the inclusion of the section
“Supporting vulnerable patients and families” which outlines actions taken by the hospice to
safeguard and protect vulnerable individuals, and includes how the service ensures that it
responds effectively to individuals with protected characteristics and guides against discrimination.
In reading the Quality Account we recognise the positive work undertaken by the hospice respect
to preventing / reducing avoidable harms from falls, pressure ulcers and healthcare acquired
infections.
We were also pleased that the Quality Account noted the positive involvement the Hospice has
had in respect to participation in research studies and clinical audit activities.
It was positive to note within the Quality Account that Birmingham St Mary‟s Hospice has an
extremely low level of reported complaints, and that the service continues to attract a considerable
number of compliments and thank you‟s.
In summary, we welcomed the opportunity to comment on the 2013/14 Quality Account for
Birmingham St Mary‟s Hospice and generally consider that this report was well written and
provided a balanced view of the activities within the service. As a commissioner Birmingham
CrossCity CCG shall continue to work in partnership with the Hospice to support the delivery the
quality agenda in 2014/15.
Barbara King
Accountable Officer
Birmingham Cross City Clinical Commissioning Group
Quality Account 2013/14
PG42
Part 3 – Review of quality of Performance
3.7
Feedback and Comments
If you would like to provide feedback on the report or make suggestions for content for future
reports, please contact:
Helene Trebinska
Governance Manager
Birmingham St Mary‟s Hospice
Tel: 0212 472 1191
Email: helene.trebinska@birminghamhospice.org.uk