QUALITY ACCOUNT 2013/14
Mildmay Mission Hospital
Registered office;
2 Austin Street
London
E2 7NB
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Company no: 1921087
Charity no: 292058
Part 1 – Responsible Individual’s Statement
Mildmay Mission Hospital (herein after referred to as ‘Mildmay’) is a voluntary charitable
hospital and rehabilitation unit that delivers services to the NHS through the mechanism of a
multilateral contract with 24 London Clinical Commissioning Groups (CCGs) and 2 Local
Authourities. It also accepts duly scrutinised spot purchased referrals from any other UK
source.
Mildmay is registered with the Care Quality Commission to deliver services under two regulated
categories, they are:
Diagnostic and screening procedures
Treatment of disease, disorder or injury
It is a tertiary healthcare provider of specialist care and rehabilitation of people living with
complex HIV related conditions, particularly HIV Associated Neurological Disorder (HAND) also
known as HIV Related Neurological Impairment (HNCI) or AIDS Dementia.
On behalf of the board of trustees, I would like to thank all our staff and volunteers for their
achievements over the past year. Despite the very challenging funding climate, Mildmay has
continued to provide high quality services while at the same time overseeing the construction
of a new hospital which is due to open in mid-2014.
Clinical Excellence, the Patient Experience and Patient Safety are of paramount importance for
Mildmay, as well as developing services appropriate to patient’s needs.
The Board of Mildmay, The Mildmay Clinical Governance Committee (chaired by a board
member), and the Risk Management Committee, all meet regularly (quarterly, quarterly and
monthly respectively) to ensure that there is oversight by the Board of Trustees of the clinical &
nursing care and practice and the rehabilitative care and support delivered by the organisation,
as well as the inherent risks within the organisation. A constant risk theme during the year was
not clinical but financial as Mildmay juggled its day to day operational needs, with a
disaggregation of the organisation’s work overseas (into locally registered NGOs), restructuring
the organisation, and preparing to move into a new hospital. This was compounded by the
huge structural changes which took place at the beginning of the 13/14 year.
The senior management team acknowledge the hard work of staff who continue to embrace
the challenge of change and respond appropriately to maintain and enhance quality within
their practice.
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I am responsible for the preparation of this report and its contents. To the best of my
knowledge, the information reported is accurate.
Dr Ross White
Executive Director
Registered ‘Responsible Individual’
Mildmay Mission Hospital
27thth June 2014
Captured Comments
"This Hospital is very clean, well maintained, patient focused and had a caring environment'
- comment by an independent assessor....Patient Led Assessment of the Care Environment, 30th
May 2013
‘The quality of staff is high, both doctors and nurses’....reported quote from a patient during the
Care Quality Commission unannounced inspection, December 2013
‘The staff sat me down and explained everything’.... reported quote from a patient, Care Quality
Commission unannounced inspection, December 2013
‘I now regularly attend Mildmay's Day Service. I no longer need a crutch and I walk at three miles
per hour on a treadmill. I can't tell you how much this has meant to me, I have my life
back’ ...patient who was bed-bound when first admitted as an in-patient at Mildmay
Part 2 - Planned Priorities for Improvement 2014-15
2.1 Objectives
2.1. 1 Objective 1- Maximise Occupancy & Consolidate services
We will continue maintain occupancy levels appropriate to need in the community we serve.
Demand for our services over recent years has gone hand in hand with increases in complexity
and in greater experience of challenging behaviours. The opening of Mildmay’s new hospital in
2014 will increase capacity from 16 to 26 beds.
Mildmay acknowledges that investment may be needed to significantly change the mechanisms
for patient acquisition in the new architecture of the NHS. Occupancy is the key to financial and
quality stability for Mildmay. As a small unit, subtle variations of referral can have a significant
effect on cash flow and viability.
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2.1.2 Objective 2 - Maximise Voluntary Income
We will seek to increase voluntary income to the charity. Diversification of income can
contribute to achieving other objectives such as developing outreach work & innovation in
service delivery. Work is concluding (as this report is being typed) on a capital fundraising
appeal for our new hospital, relating to fit-out. We will explore scope for sponsoring of some
therapeutic functions of the hospital.
2.1.3 Objective 3 – Awareness Raising
We will seek to raise awareness of the work of Mildmay, by creating a visible presence at key
conferences, enlarging our stakeholder base, and maintaining training and development. We
will seek to develop marketing materials which balance the needs of confidentiality, with those
of awareness.
2.1.4 Objective 4 – A New Hospital...Safe, Patient Focussed and a Centre of Good Clinical
Practice
We seek to achieve an effective and efficient move to the new hospital on part of our former
site in mid-2014/15. We will oversee the fit out and manage the building handover and systems
testing in a four week window to maximise safety and to ensure scope for learning about
systems and equipment in the new unit. We wish to minimise disruption to the patients on site
at the point of the move. We will ensure that the management need and functionality of the
new building meets the needs of our service and enables future flexibilities. We will provide an
environment fit for purpose for patients and their families, clean, safe and with staffing levels
and training appropriate to patient dependency. We will uphold standards of care, learn from
any mistakes, strive for improvement, and place the patient at the centre of our decision
making.
2.1.5 Objective 5 –Innovation
We will continue to explore the design of new services. We will build on our experience of
innovation in the delivery of appropriate services for people living with complex HIV conditions.
We will seek to extend funding for the specialist Black African Male Support Worker to deliver
outreach services.
We shall also explore the potential for an additional mental health service at the new unit that
could respond to the continuing complex experience of late stage HIV infection and which
would seek to address an identifiable gap in current health service provision in London.
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Additionally, we will look to pilot aspects of our day-service provision in other parts of London.
In the first instance this is likely to take the form of a peer support group.
2.2 Statements of Assurance from the Board.
During the period, Mildmay submitted quarterly reports to commissioners, key gatekeeper
stakeholders and referring officers in the form of a traffic light key performance indicator table
with additional narrative and commentary.
Mildmay senior management also submitted quarterly reports to the board including snapshots
of cases, budget statistics and a progress report on meeting key objectives and explanations
about opportunities and obstacles encountered. It received risk management reports and risk
profiles that assist in addressing areas of concern and improving quality in the Unit.
Mildmay delivers services under contract and in accordance with a service specification
embedded within that contract. Four care and treatment pathways are agreed with our
commissioning stakeholders and form part of our service specification.
The Unit Medical Director, Dr Simon Rackstraw, is a Fellow of the Royal College of Physicians of
London and continues to be in demand for knowledge sharing and information exchange.
The closing of the year had no reportable ‘red indicators in the key performance indicator
profile.
The Senior Management Team meets weekly to discuss incidents, staff performance,
operational issues, to drive progress on strategy and the business plan. It oversees the function
of a number of standing committees (Risk Management and Clinical Governance) and it
ensures that a range of monthly internal audits are presented as well as the quarterly Morbidly
Audit.
The 2013-14 year has seen a staff reduction due to a challenging financial environment, and
while the need to achieve more financial efficiencies is essential for the sustainability plan of the
unit, the quality of service experienced by patient and day clients continues to remain the focus
of the service delivery in the hospital.
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Part 3 - Review of Quality Performance 2013 -14
3.1 Objectives
3.1. 1 Objective 1 Maximise Occupancy
We will seek to achieve high occupancy of our beds. Occupancy is the key to stability for Mildmay.
Investment may be needed to significantly change the mechanisms for patient acquisition.
Occupancy levels fell by 2% in 2013-14. However, patient complexity increased. All indications
point to patient numbers increasing due to the profile (age and late diagnosis) of the HIV+
population in the UK.
A part-time Business Development Manager was appointed during the year (now on Maternity
Leave) with a key focus to raise awareness of Mildmay’s new facilities, and our existing services
to Commissioners and health practitioners.
3.1.2 Objective 2 - Maximise Voluntary income
We will seek to increase voluntary income to the charity. Diversification of income is step that can
reduce the risk of dependency on a single contract and can contribute to achieving other
objectives such developing an education and training resource, & innovation in service delivery.
Mildmay’s non-statutory income increased from £559k in 2012-13 to £694k in 2013-14. This was
due in the main to the successful recruitment of a fundraising team and a fundraising appeal,
relating to completing the new Mildmay hospital.
3.1.3 Objective 3 – Awareness Raising
We will seek to raise awareness of the HAND work of Mildmay building our stakeholder base,
creating tranche of training and development materials and develop a medial engagement
strategy. We will focus our marketing on the launch of the new Hospital and will seek to develop
a marketing strategy that balances the needs of confidentiality with those of awareness.
To this end Mildmay was granted the ‘NHS Information Standard’ kite mark in Spring 2013
through being assessed as compliant with the expectations of the provision of information that
is clear, relevant, evidence based, authoritative, complete, secure, accurate, well-designed,
readable, accessible, up-to-date.
Although a small unit, Mildmay continued to be highly commended as a training placement for
18 nursing students, 14 medical students, 6 GP doctors in training and 3 dietetic students, 2 OT
students, and 8 social care students during the period.
The number if external presented talks far exceed those in previous years and therapists were
encouraged to speak in their own professional sub group meetings, conferences and events.
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Talks to non-clinical audiences increased significantly, most notably through churches, where
30 talks took place.
Mildmay representatives invited to speak at a number of regional events to explain its work and
practice.
Mildmay also had a stall at the BHIVA conference in London in November 2013.
3.1.4 Objective 4 – Move to new Site
We seek to achieve an effective and efficient move to the new hospital on part of our former site
at the end of 2013. We will oversee the fit out and manage the building handover and systems
testing in a four week window to maximise safety and to ensure scope for learning about systems
and equipment in the new unit. We wish to minimise disruption to the patients on site at the
point of move but to participate in the build process to ensure the management need and
functionality of the new building meets the needs of our service and enables future flexibilities.
This objective reappears as 2.1.4 (above) as delays have occurred with the build. In is
anticipated that a mid-2014 move will take place.
3.1.5 Objective 5 –Innovation
We will continue to explore the design of new services. We will build on our experience of
innovation in the delivery of appropriate services for people living with complex HIV conditions.
Having achieved funding for a specialist Black African Male Support Worker through MACAIDS
this project has already met its targets for the number of Black African men reached. This is a
high risk group – men are generally poorer than women at accessing health services, and black
African males are further disenfranchised from accessing testing services through stigma in
society. The group is likely to have late diagnosis or be undiagnosed and they are a group most
likely to experience advanced medical and psychological intervention from the NHS as a result
of stigma, discrimination, poor access to health education and complex sociological pressures.
Four volunteers were recruited as part of the programme roll-out (3 are HIV + and two of these
are former Mildmay patients). The programme incorporates a peer support group,
signposting to testing services, HIV awareness education and follow-up. We also began to
explore partnership working with the Action Plus Foundation which has a similar and successful
model for engagement with black African men and women, but via the church network.
We shall also explore the potential for an additional mental health service at the new unit that
could respond to the continuing complex experience of late stage HIV infection and which would
seek to address an identifiable gap in current health service provision in London.
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This was not advanced and will be rolled into 2014-15
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4. Commentary
4.1 Patients and Day Service User feedback
Day service clients have a client forum that can call any officer of Mildmay to account. It can
comment about any aspect of the experience of being a service user and it can hold to account
the programme, policy & management of the day service team.
Feedback from in-patients is obtained from a range of methodologies; Independent Patient
Champion interviews, exit interviews, feedback forms (with anonymity) feedback to key workers,
contribution to care planning and access to senior staff or feedback via their community nurse
specialist are all processes where a patient engagement strategy can be evidenced.
Patient/day client involvement in the Patient Led Assessment of the Care Environment (PLACE)
will occur in the year ahead, drawing the service user perspective into the self assessment and
eternal assessment process of Mildmay.
A new Independent Patient Advocate was recruited to by the board in 2013/14 in the hope of
embedding a patient champion at the heart of the policy, strategy and work of Mildmay.
Feedback from next of kin, carers, friends, visitors, relatives and significant others is encouraged
in face to face encounters and by the provision of feedback forms and suggestion boxes on the
Unit.
4.2 Mandated statements
4.2.1 Review of Services
During 2013-14 Mildmay had capacity for 5840 in-patent bed nights and 3200 day service
placements.
In 2013/14 we provided 4514 in-patient bed nights for 120 people and 2927 day service
placements for 65 community clients and 61 inpatients.
In 2012/13 we provided 4602 in-patient bed nights for 118 people and 2238 day service
placements for 81 community clients and 40 inpatients.
Mildmay has reviewed all the data available to them on the quality of care, and its entire
management team have responded to lessons learned from incidents, admission difficulties &
reviews. The senior management team at Mildmay take account of the reports from its risk
management committee and clinical governance committee as well as the staff unit meetings,
to seek to improve practice on site.
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Patients readmitted to the service
NO patient was readmitted to Mildmay from home within 28 days of being discharged to home
from Mildmay (Mildmay doesn’t receive referrals in the 0-14 reporting category, so this
statement refers to the 15+ category).
Mildmay considers that this data is as described for the following reasons: the patients were
discharged at the correct time, having benefitted from a rehabilitation programme to a point
where they were able to be discharged home to live independently. Each patient’s discharge was
planned with the relevant support agency being involved.
In order to maintain this standard Mildmay will continue to ensure that discharge planning
remains effective and will liaise with referring agencies to ensure that the length of admission is
appropriate to the needs of the patient.
Patient Safety Incident
There was ONE patient safety incident recorded during the year, namely a patient who tried to
leave Mildmay through a window. The patient was apprehended, the situation risk assessed
and the patient was given one to one care. There were NO patient safety incidents which
resulted in any harm, be they mild, severe or death.
Mildmay considers that this data is as described for the following reasons: Patients at Mildmay
have a range of neurocognitive impairments caused through HIV. This can lead to erratic and
unpredictable behaviour. Where assessed as a sufficient risk, patients are given one to one
‘specialling’.
Mildmay is taking the following actions in relation to this type of incident: the new Mildmay
hospital design will have window opening restrictors to prevent any chance of harm arising from
a patient wishing to escape from a window.
Mildmay, as a voluntary sector provider, was not able to identify any nationalised data source to give
accurate comparators.
4.2.2. Clinical Audits
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During 2013-2014 NO national clinical audits and NO national confidential enquiries covered
NHS services that the Mildmay provides. During this period Mildmay UK participated in 0% of
national clinical audits and 0% of national confidential enquiries of the national clinical audits
and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquires that Mildmay was eligible to
participate in during the reporting period are as follows; NIL.
The local clinical audits and local confidential enquires that Mildmay was eligible to participate
in during the reporting period are as follows; NIL
4.2.4. Research
The number of patients receiving NHS services provided or sub contracted by Mildmay in this
period, that were recruited during that period to participate in research approved by a research
ethics committee was NIL
Mildmay was involved in conducting NO clinical research studies in HIV during the reporting
period.
Mildmay did however undertake a pilot study based on a small cohort of patients which looked
at Neuropsychological Profiles on admission and discharge to and from Mildmay, which led to
a poster presentation at the BHIVA 2013 conference, and an oral presentation at 11th
International AIDS Impact Conference in Barcelona (29th Sept-2nd Oct 2013).
A paper by Winston and Rackstraw (the letter being Mildmay’s Medical Director) was published
in Clinical Practice, on the management of HIV-Associated Neurocognitive impairment.
NO clinical staff participated in research approved by a research ethics committee at Mildmay
during this period
4.2.5 CQUIN
NONE of the income of Mildmay Mission Hospital UK in 2013-14 was subject to CQUINs
(Commission for Quality & Innovation payments) due to the complex nature of the service
delivery. Therefore NO income was conditional on achieving quality improvements and
innovation goals through the Commission for Quality and Innovation payment framework.
The 2014/15 contract also contains no CQUIN provisions.
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4.2.6 CQC Inspection
Mildmay received a routine CQC inspection on 13th December 2013 and were assessed across
five areas:
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



Consent to Care and Treatment
Care and Welfare of People who use Services
Safeguarding People who use Services from Abuse
Requirements relating to workers
Complaints
As previously stated Mildmay’s two regulated activities are:
Diagnostic and Screening Procedures
The Treatment of Disease, Disorder or Injury
Mildmay met the published ‘Essential Standards of Quality & Safety’ and its December 2013
unannounced inspection is available for scrutiny to the public on the CQC website.
4.2.7 Data Quality
Mildmay’s in house records system (Palcare) was replaced by iCare in the period. It is compliant
with NHS records good practice requirement but Mildmay maintains a mainly paper based
record system at present. It meets information governance requirements and is a mechanism
used by a range of health & social care providers, including specific NHS bodies, to provide
robust, and accurate outcome data.
Mildmay follows the UK Rehabilitation Outcomes Collective (UKROC) data acquisition processes
and provides data that is compliant with UKROC peer group comparison frameworks and which
contribute to evidencing outcomes for patients who access Mildmay’s services. This reporting
mechanism addresses inpatients only at present and needs to be rolled out to day services in
2014/15.
4.2.8 NHS Number & General Medical Practice code validity
Mildmay has not submitted records during the reporting period to the secondary uses service
for inclusion in the Hospital Episode Statistics which are included in the latest published data as
it is not a requirement of the contract with our commissioners, and it a measure which protects
the confidentiality of people living with a condition which still experiences stigma and
discrimination in the community.
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4.2.9 Clinical Coding error rate
Mildmay was not subject to the Payment by results clinical coding audit in 2013/14 by the Audit
Commission.
4.2.10 Complaints & Incidents
a) There were 6 complaints during the reporting period of which three were formal
b) There were NO deaths of inpatients at Mildmay during the reporting period
c) There were 65 general incidents recorded, of which 40% were falls (26 in total), 17%
were medication/drug chart errors (11 in total), 7.7% were verbal abuse of staff (5), 4.6%
was violence upon staff by patients (3). The remaining 30% (20) included a loss of
phone lines/internet following a storm and on another occasion (2), loss of a personal
item from a patient (2), staff injury caused by chair collapse (1), patient wandering off
the ward without informing a staff member (1), one where a patient was found with
medication which had not been prescribed by Mildmay (1), coercion by a relative on a
patient to sign a direct debit mandate (1), and other sundry items.
d) Two Serious Untoward Incidents (SUI) were downgraded (having had the external
review of the Adult Safeguarding Team). One SUI remained and was reported to the
CQC. This was a power spike which took the phone and internet down over a weekend.
The event itself was not considered to have placed patient safety at risk
e) There was one medically adverse incident.
4.2.11 Summary hospital-level mortality indication (SHMI)
The value, banding and supporting palliative care data which is used as a hospital level
indicator which measures whether mortality associated with hospitalisation was in line with
expectation, does not apply to Mildmay as a tertiary health service provider.
4.2.12 Patient Led Assessment of the Care Environment (PLACE)
A Patient Led Assessment of the Care Environment (PLACE) review by a team of three
independent assessors took place on the 30th May 2013. Findings were as follows:
Mildmay scored 'GOOD' (the highest level) with the exception of:
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Car park - signage bays and surfaces.
No separate treatment room in the ward areas for minor procedures/wound dressing.
Transport management plan – (now complete).
Patient access to IT – (new hospital will have Wifi access for portable devices)
Do patients have access to telephone.
Access to meals/snacks for family, relatives.
An assessor (a Doctor) comment was "This Hospital is very clean, well maintained,
Patient-focused and had a caring environment'
Due to an impending move to the new hospital in mid-2014, it was agreed that a PLACE
inspection would be deferred for a year. Many of the recommendations of the 2013 inspection
are being addressed within the new setting. The previous PEAT assessment of 2012, gave an
aggregate score of 82%.
4.2.13 Infection Control
Infection control standards are regularly audited throughout the year, with any
recommendations either acted on immediately and/or reflected in the procurement of items
being purchased for the new hospital (due to open in mid-2014).
4.2.14 Information Standard Kite Mark
Mildmay was awarded the Information Standard Kite Mark in Spring 2013, a validation which is
reassessed every three years.
4.3 Mildmay’s action in the NHS Outcomes Framework domains;
4.3 1. Domain 1 Preventing people from dying prematurely
The British HIV Association (BHIVA) ‘Standards of Care for People Living with HIV 2013’ states
that late and very late diagnoses is a major cause of diminishing life expectancy for people with
HIV, as well as ‘loss to follow-up’. The vast majority of patients referred to Mildmay are
presenting with neurocognitive impairment relating to either late diagnosis or ‘loss to followup’.
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4.3.2. Domain 2 Enhancing quality of life for people with long-term conditions
Mildmay achieve that goal of enabling people to have access to and engage with specialist care
for these experiencing HIV and chronic related conditions. The service contributes to the
preventing of complications of HIV and if/when they occur initiating prompt and appropriate
management that contribute to the minimisation of HIV morbidity.
The teaching of self management skills in our day service with its expert patient group and
programme of community orientation, physiotherapy and independent living skills all
contribute to the empowerment of the individual to make informed choices about their future
care.
Coordination with community services for those with long term health & social care needs is
part of the purpose for people being discharged from acute units to the Mildmay. As a
discharge pathway of choice for two acute hospital units, part of the function of Mildmay is to
undertake assessment & rehabilitation and or make recommendations for the future long term
care and support of people living with HIV.
4.3.3. Domain 3 Helping people to recover from episode of ill health or injury
Mildmay has particular experience in supporting and treating people with a wide range of
complications resulting from the direct effects of HIV, its treatment, and an increasing range of
associated co morbidities. As part of that provision of prompt and specialist care for complex
treatment, Mildmay contributes by engaging its multidisciplinary team across a wide range of
professions with the person with HIV being at the centre of care planning that address the
physical, psychological and spiritual impact of living with a serious illness.
Helping people acquire self-management skills is an element of this domain and is at the heart
of our service delivery. Rehabilitation is a partnership approach which aims to bring about the
restoration of skills & ability (fully or partially), to enable the individual to have more choices in
their future care and support options.
4.3.4 Domain 4 Ensuring people have a positive experience of care
The use of key working is vital to maintain excellent caring & professional relationships which
are holistic and person centred and places the person living with HIV as the co-constructor of
the care plan for their engagement with Mildmay.
The Mildmay dignity code provides a framework for engagement with all patients/clients and
acts as a beacon of good practice that underpins activity such as protected mealtimes to ensure
effective nutrition and the use of person centred timetables to prompt patients to engage with
a range of therapists while using the services provide evidence of its application.
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The engagement of patients as positive partners in the design of their care, rather than passive
recipients, is at the heart of service delivery but the cognitive and behavioural elements of
neurological disorder can limit the capacity of an individual to engage, a key element of service
delivery and can prompt the use of the Deprivation of Liberty Standards (DOLS) procedures an
the use of an independent capacity assessor and best interests assessors to assist in decision
making where a person lacks capacity.
4.3.5 Domain 5 Treating and caring for people in a safe environment & protecting them from
avoidable harm
Working with patients / day clients to understand the mechanism of passing on the virus can
lead to counselling to consider working to engage with families & partners to ensure
appropriate disclosure and to prevent fear and stigma interfering with safe practice and
knowledge sharing with other services.
Counselling to enable fluid communication between HIV specialist care and other secondary
and primary care teams is part of the approach to prevent the harm. Continued Professional
Development is also a key element of maintaining key skills and the ability to manage a range
of situations.
Confidence in the security of their data and confidentially about their diagnoses, condition or
even their presence in the unit are part of the relationship building that contributes to
protection from harm and mainlining a safe environment for all service users.
5. ANNEX sources of supporting statements
In compliance with the regulations, Mildmay sent copies of our Quality Accounts to the
following stakeholders for comment prior to publication.

The lead commissioners, commissioners and CNS

The Overview & Scrutiny Committee (OSC) of the London Borough of Tower Hamlets or
its Health Board.

Health watch

The Friends of Mildmay
At the point of publication no specific feedback had been received. One lead-commissioner
had met with the author and the document was discussed in general terms.
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Ross White
27th June 2014
End
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