St. Michael’s Hospice (North Hampshire)
Quality Account 2013 - 2014
CONTENTS
Part 1
Page
Chief Executive’s Statement
3
Mission Statement and Vision
4
Priorities for Improvement 2014 -2015
4
Review of Priorities for Improvement 2013 -2014
5
Part 2
Statement of Assurance from the Board
7
Review of Services
7
Participation in Clinical Audit
7
Research
9
Quality Improvement and Innovation Agreed With Our Commissioners
9
What Others Say About Us
9
Data Quality
10
Part 3
Quality Overview
10
What Our Patients Say About St. Michael’s Hospice
13
What our Staff Say About The Organisation
14
What Our Regulators Say About St. Michael’s Hospice
14
The Board of Trustees Commitment to Quality
14
Comments From Other Stakeholders
14
References
15
SMH Quality Account Feedback
16
Page 2 of 16
Part 1
Chief Executive’s Statement
ere
st
st
This Quality Account considers our achievements from 1 April 2013 - 31 March 2014 and looks
forward to some of our priorities for 2014 - 2015, as we demonstrate our commitment to delivering
the best possible experience of specialist palliative care for our patients and their families. We
achieve this by providing high quality individualised care, supported by robust governance systems
across all aspects of the hospice.
This report demonstrates our continued commitment to ensuring patients receive the consistent
highest standards of care which we saw reflected in the excellent feedback from an unannounced
Care Quality Commission inspection visit this year. We were assessed as being fully compliant
with all inspected standards and outcomes.
Our care is based on active collaboration with patients and their families and this ethos is extended
to working in partnerships within North Hampshire, such as Hampshire Hospitals NHS Foundation
Trust and Odiham Cottage Hospital Charitable Trust, to ensure services continue to develop and
improve.
Significant progress has been made with the implementation of the St. Michael’s Hospice strategy,
such as the implementation of our twenty four hour Hospice at Home service. This year will see us
develop a new and innovative strategic plan which will enable us to embrace the new
commissioning and health care environment.
I would like to take this opportunity to thank all of our staff and our volunteers for their dedication to
providing the high standards of care for our patients and families throughout 2013 – 2014. I look
forward to working closely with staff, volunteers and our partners in continuing to improve and
develop our services to meet the specialist palliative care needs of our patients and their families.
David Monkman
Chief Executive
May 2014
Page 3 of 16
Mission Statement
St. Michael’s Hospice (North Hampshire) enables people faced with a life limiting illness, their
families and carers, to attain the highest possible quality of life by providing a choice of specialist
care and support.
Our Vision
St. Michael’s Hospice will endeavour to influence and lead all aspects of palliative care provision in
North Hampshire. It will do this by working in partnership with all stakeholders, particularly service
users, who will be actively involved in the development and delivery of services which, as far as
possible, will be user lead.
Priorities for Improvement 2014 - 2015
Our service quality, standards and approach to care are not limited to simply what is required but
to the needs and aspirations of our patients and families, driven by our own high standards and
specialist expertise in end of life care.
The quality improvement priorities we have identified for 2014 - 15 are set out below. We have
identified three key areas: Patient Safety; Clinical Effectiveness; and Patient Experience. The
priorities we have selected will create significant further improvements in quality of care for our
patients and their families.
Future Planning
Our targeted quality improvement priorities for 2014 - 2015 are:
Patient Safety
Priority 1: Further Enhancement of Risk Management Systems
Implement the use of a central risk register which follows National Patient Safety Assessment
(NPSA) processes to ensure better identification of key risks and provide additional improvement
to risk management processes.
Why was this identified as a priority?
Greater understanding of the risks at St. Michael’s Hospice (SMH) will allow the organisation to
target resources quickly and appropriately to ensure robust risk reduction processes and optimum
resource management.
How will Priority 1 be achieved?
The overall risk management process will be reviewed at SMH. A central risk register will be
created whereby all reported risks are coded according to the latest NPSA guidelines. Risk
reporting feedback mechanisms will be further improved by reviewing and strengthening our
governance processes.
Page 4 of 16
Clinical Effectiveness
Priority 2: Systematic Review of Patient Documentation
Review patient documentation in light of audit results and identify priorities for improvement.
How was this identified as a priority?
A comprehensive documentation audit undertaken during February 2014 identified that
improvements could be made to strengthen the quality of patient documentation, both in written
and electronic formats.
How will Priority 2 be achieved?
A multi-disciplinary steering group will be established to review all patient documentation and take
forward and implement innovative solutions that will enhance the quality of documentation and
record keeping.
Patient Experience
Priority 3: Review Patient and Relative Feedback
To identify further areas for improvement in the patient experience by obtaining more constructive
feedback from patients and relatives.
How was this identified as a priority?
Data, obtained from a successful SMH pilot of a VOICES survey, demonstrated that it
captured significant feedback from relatives and carers that could be benchmarked against
nationally available hospice data.
How will Priority 3 be achieved?
The SMH VOICES survey will be conducted quarterly and findings then presented to the
Clinical Governance Committee, a sub group of the Board of Trustees.
Review of Priorities for Improvement 2013 – 2014
Improvement Priorities
The key improvement priorities undertaken during 2013 - 2014 were:
Priority 1: Benchmark the Quality of our Services Against the Francis Report
This benchmarking project was completed and opportunities for service development were
identified and implemented. These included improvements in multi-disciplinary team
communication, enhancements to the policy management system and piloting an evidenced based
tool to collect feedback on services.
Page 5 of 16
Priority 2:
Open Out Project – Refurbishment of Day Care Services and Outpatient
Facilities
New facilities for Day Service patients have now been completed with the funding received from a
Department of Health grant. An innovative new wellbeing program has been designed which
focuses on providing a therapeutic approach to day hospice services, utilising specialist skills from
the multi-disciplinary team.
A patient survey is also being planned to obtain feedback on the implementation of the new
wellbeing program.
Priority 3:
Expansion of Partnership Working to Enhance and Further Improve
Access to Specialist Services for Our Patients
The Dementia Challenge Project
This project was successfully completed during this period and funding is now currently being
sought from the North Hampshire Clinical Commissioning Group (CCG) to continue work in this
key area.
The dementia challenge project outcomes included:

The quality of end of life care delivered to residents with dementia improved in five nursing
homes, as did the evidencing of this care through documentation.

Staff knowledge and confidence around all aspects of end of life care for patients with
dementia increased.

The evidencing of any impact on place of death and avoidance of acute trust admissions
linked directly to the project was difficult to achieve, however, the hospital admission figures
obtained directly from one home did show a drop in admissions of 36% during the project
period.
Therapeutic Rehabilitation Programme for Prostate Cancer Patients
This programme has been implemented and led by the SMH physiotherapy team. Twenty two men
have successfully completed a comprehensive rehabilitation programme. The third six week
course has now been completed and all three of the programme’s courses have been very well
received by patients and partners.
Comments made by some of the patients include:
“I shall miss the sessions. I have taken so much from them.”
“Very friendly, helpful, professional staff.”
All patients are now being followed up at one, three and six month intervals to assess their
progress.
Page 6 of 16
Part 2
Statement of Assurance from the Board.
This section sets out the list of statements that have been mandated by the Department of Health
for inclusion in the quality account, although some of these are not directly applicable to specialist
palliative care providers. Those that are applicable are identified below.
Review of Services
During 2013 - 2014, St. Michael’s Hospice supported local NHS commissioning priorities with
regard to the provision of specialist palliative care by providing:

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In Patient Unit Services
Day Care
Day Service Programs
Out Patient Services
Hospice at Home
Complementary Therapy
Physiotherapy
Occupational Therapy
Psychological Therapy
Family Support and Bereavement Services
Chaplaincy
NHS funding covers 20% of the total costs of providing these services, therefore all NHS funding
received has been fully utilised in providing direct patient care and service provision. Funding to
cover the remaining 80% of costs is achieved from charitable donations.
SMH reviewed the data available on these services to ensure they provide quality care and
effective use of resources.
Participation in Clinical Audit
National Audits
During 2013 - 2014, no national clinical audits or national confidential enquires were conducted
covering the NHS services directly relating to palliative care. There has therefore been no
requirement to submit cases to national audits and the percentage of the number of registered
cases has therefore not been included in this document.
Local Audits
SMH regularly conducts audits which are selected according to local, internal or national specialist
palliative care priorities. A selection of audits undertaken and reviewed by SMH during 2013 2014 includes:
Page 7 of 16
Audit Topic
Pilot VOICES Survey
Audit Outcomes






Majority of relatives were happy with the care they observed
in the IPU and the Hospice at Home team.
90% were ‘extremely likely’ to recommend SMH to family
and friends, if they needed similar care or treatment.
High levels of patient and relatives satisfaction.
Consider more soft diet options.
Good compliance.
Additional signage now in place.
100% compliance.


Improvements in compliance.
Further work on Standard Operating Procedures (SOPs).


Found to be effective at reducing limb size (small sample).
Consider quality of life indicators pre and post drainage.

Positive feedback from patients who use the service.

82% overall compliance (no major areas of concern
highlighted).
Mattress replacement completed.
New equipment purchased to clean hard to reach areas.
All staff hand washing assessed on mandatory training.
Key areas of improvement identified.
Steering group in place to action key points.
Staff were confident in using the ceiling hoist.
Manual handling training to include correct sling
identification.

Food Satisfaction Survey
Fire Risk Assessment
(external auditors)
Accountable Officer (Help
the Hospices audit)
Quarterly Controlled Drugs
Audits (pharmacist external
auditor)
Measuring Effectiveness of
Manual Lymphatic
Drainage in Upper Limb
Complementary Therapy
Effectiveness
Infection Control Audits
Documentation (includes
DNA CPR)
Hoist and Slings

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A comprehensive clinical audit program has been devised for 2014 - 2015. In addition to routine
topics such as infection control and medicines management (controlled drugs), other topics
include:
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Regular VOICES Surveys
Health and Safety Audit
Therapeutic Rehabilitation Program for Prostate Cancer
Wellbeing tool
Syringe Drivers
Motor Neurone Disease Clinic Patient Satisfaction
Day Care Services Patient Satisfaction
Page 8 of 16
Research
The number of patients receiving NHS services provided by SMH in 2013 - 2014 and recruited
during that period to participate in research approved by a research ethics committee was zero.
A Masters level research project, as part of the End of Life Dementia Programme, was completed
during this period. Key findings included:

Last offices should be viewed as a process as a continuation of care given to the patient in
life. It can be seen as a means of conveying respect for the patient as a person.

Involvement of significant others in the process of last offices needs more careful
consideration.
Quality Improvement
Commissioners
and
Innovation
Agreed
with
Our
SMH NHS income in 2013 - 2014 remains not conditional on achieving quality improvement and
innovation goals through the Commissioning for Quality and Innovation Payment Framework
(CQIN Framework).
What Others Say About Us
SMH is registered with the Care Quality Commission (CQC) to provide the following services:

Treatment of disease, disorder or injury.

Diagnostic and screening procedures.
SMH registration status is unconditional. The Care Quality Commission (CQC) made an
unannounced visit on the 4th February 2014 and SMH was deemed to be fully compliant against
the requirements of the five measures reviewed which were:
-
Care and welfare of people who use services
Meeting nutritional needs
Requirements relating to workers
Supporting workers
Assessing and monitoring the quality of service provision
All of the above standards were met with no areas for improvement identified.
The findings of this inspection were highlighted as:
‘The patient and relatives we spoke with praised the level of care provided by staff. People felt the
staff consulted and involved patients and where appropriate, relatives, in decision making. People
were happy that staff always had time to speak to them.’
Care Quality Commission Inspection Report, St. Michael’s Hospice, February 2014
Page 9 of 16
Data Quality
In accordance with the agreement with the Department of Health, SMH submits a National
Minimum Dataset (MDS) to the National Council for Palliative Care.
Part 3
Quality Overview
Core Quality Indicators
“The percentage of patients re-admitted to a hospital which forms part of the Trust within 28 days
of being discharged from a hospital which forms part of the Trust during the reporting period.”
The NHS traditionally examine measures to reduce re-admission rates and often view ‘emergency
re-admission to hospital within 28 days of discharge’ as having a negative impact on patient care
(NHS Institution of Innovation and Improvement 2013).
However, this model is not necessarily applicable to a hospice setting as it may often be entirely
appropriate that patients are re-admitted to the In Patient Unit (IPU) within 28 days of discharge
due to symptoms worsening at the end of their life. It is good practice to examine the discharge
process in any health care setting to identify learning opportunities which could improve the quality
of discharge planning.
A recent discharge audit of all patients re-admitted to SMH IPU from 1st April 2013 - 31st March
2014 (using the 28 day re-admission indicator), found that of the 16 re-admissions, there were 2
discharges that potentially could have been improved upon. This audit report will be reviewed by
the Clinical Effectiveness Committee.
Minimum Data Set Tables for Palliative Care 2013 - 2014
Table 1 In Patient Unit
In Patient Unit
% New Patients
% Occupancy
% Availability
Average Length of Stay – Cancer
Average Length of Stay – Non-Cancer
% Day Case Admissions
Currently available
national median
2012/13
SMH
SMH
2012/13
2013/14
89%
76.2%
100%
12 days
10.3 days
0%
90%
85.1%
100%
11.3 days
14 days
6%
93.5%
81%
100%
11.8 days
8.2 days
14%
Table 2 Day Care Service
Day Care Service
Currently
Available
National
SMH
SMH
2012/13
2013/14
Page 10 of 16
median
2012/13
% New Patients
% Places Used
61.7%
56.9%
51.4%
62.3%
1
40.5%
51.2%
2
Table 3 Hospice at Home
Hospice at Home
Total Number of Patients
% New Patients
% New patients with a Non-Cancer
Diagnosis
Average Length of Care
Currently
available
national median
2012/13
SMH
SMH
2012/13
2013/14
368
74.7%
15%
286
83.9%
17.4%
302
87.7%
21%
74 days
41.5 days
50.8 days
Chaplaincy
The chaplain covers IPU, the Wellbeing Centre and visits into the community when required. The
chaplain has recently organised a patient wedding in the IPU (within just 4 hours) and she provides
invaluable support to patients, families, volunteers and staff at SMH. She also ministers funerals
for families, when required.
Although the chaplain is Anglican, she practices in a non-denominational way and her role in the
hospice is to listen and offer comfort that is helpful to each individual according to their spiritual
needs. The chaplain ensures that the chapel is the calm and quiet centre of the hospice which
embraces everyone, irrespective of religious beliefs.
Therapy Services
The physiotherapy service for palliative care patients with lymphoedema is continuing with
treatment provided for both day patients and patients admitted to IPU..
Therapists have also been involved in the preparation of the new physiotherapy gym in the new
Wellbeing Centre and development of the new day patient services.
As part of the new day services provision, occupational therapy are assisting with the development
of a patient needs led assessment and referral procedure. In addition, volunteer training has been
provided to those involved in the day services, as well as ensuring that their feedback on patient
progress assists with the evaluation of outcomes of treatment.
The Motor Neurone Disease (MND) clinic continues to be well attended. Patients attending have
input from all therapists and they also receive therapy at home, between clinics visits.
Complementary Therapy Service
As part of our commitment to provide a choice of specialist care and support to patients, their
families and the bereaved, we offer a range of complementary therapies. Regular audit shows that
these therapies help many people with relaxation, symptom control and induce a sense of
wellbeing. The therapies offered include: Massage, Indian Head Massage, Aromatherapy,
1
2
New Patient figure affected by building work in the Wellbeing Centre
Places Used figure affected by building work in the Wellbeing Centre
Page 11 of 16
Reflexology, Reiki, Yoga (patients only), Bach Flower Remedies, Acupuncture and Deep
Relaxation. These therapies are provided both at SMH, Odiham Cottage Hospital and in patient’s
homes.
Ongoing support and training is provided by the Complementary Therapy Manager for 25 volunteer
therapists, as well as education in simple relaxation techniques for Hospice at Home Nurses and
Health Care Assistants. This year we have recorded nearly 3000 Complementary Therapy
Interventions, as well as supporting fundraising events.
Additional Data
In addition to the quality metrics in the national minimum data set, SMH analyses additional quality
of care indicators, as shown below.
Table 4 Number of IPU and Hospice at Home Patients and Age Analysis 2013/14
160
135
146
143
140
120
100
72
80
60
40
20
5
1
0
19-24 years 25-64 years 65-74 years 75-84 years
85 years
and over
Not
recorded
Table 5 Overview of Key Governance and Activity Data
2012 -2013
2013-2014
Total Number of Patients Admitted to the In
Patient Unit (IPU)
250
276
% of Patients Who Went Home
42%
46%
Number of Bed Days
3,660
3650
% Occupancy
85.1%
81%
767
423
1,135
1539
Total Number of Complaints
6
2
Total Number of Serious Patient Safety
Incidents (excluding falls)
0
0
Total Number of Attendances by Patients at
Day Care
Total Number of Hospice at Home Visits
Page 12 of 16
Slips, Trips and Falls
33
30
Total Number of Patients Known to be
Infected with MRSA on Admission to IPU
0
0
Total Number of Patients Infected with
MRSA Whilst on IPU
Total Number of Patients who Developed
Pressure Sores Whilst on IPU
0
0
1
1
11.7
11.2
Average Length of stay on IPU in Days
SMH places quality of care at the heart of our service to patients. We are pleased to highlight that:

There has been a significant reduction in complaints and there were no complaints regarding
patient care this year. Both complaints received this year were related to issues regarding
hospice shops which were resolved.

Infection control continues to be well managed. Staff attend NHS infection control teaching
sessions run by Hampshire Hospitals Foundation Trust.

The 26% increase in H@H visits is due to the development of a 24 hour service.

There has been a 10% increase in admissions to the IPU.
Further work is in progress to reduce patient fall incidents, including policy development and
enhancing the risk assessment process. Additional alarm mats to alert staff to patients getting out
of bed have also been purchased this year.
What Our Patients Say About St. Michael’s Hospice
During January 2014, relatives of patients who died at St. Michael’s Hospice were surveyed using
a modified VOICES questionnaire. Relative’s views were ascertained of both the In Patient Unit
and the Hospice at Home service.
A total of 83 questionnaires were sent out and 29 were returned: a 35% response rate. Key
findings include:

Comparisons with the national VOICES hospice survey data (2011) were very favourable
with the majority of SMH responses more positive than national average responses.

90% (n=26) of relatives were ‘extremely likely’ to recommended St. Michael’s Hospice care
to a friend or family member, if they needed similar care or treatment.
In addition to surveying relatives, we received 12 patient feedback forms during this period. All
comments were very positive and when asked ‘what could we do better?’, responses were still very
positive.
Specific comments from the patient feedback form question, ‘How could we have improved your
experience?’, included:
‘I thought it was a fabulous service, welcoming and accommodating.’
‘You could not improve anything – not one little thing.’
‘We found the whole experience exemplary and a credit to the hospice.’
Page 13 of 16
What Our Staff Say About The Organisation
A staff survey was conducted by Bird Song Charity Consulting in March 2014 with 90 SMH staff
responding, giving a response rate of 56% (response rates for staff surveys across the charity
sector is between 40-60%). Key data to highlight includes:

93% of staff agreed or strongly agreed that ‘If a friend or relative needed treatment I would
be happy with the standard of care provided by this organisation.’

88% of staff responding felt that they were making a difference.
What Our Regulators Say About St. Michael’s Hospice
See section 2.5 for the outcome of our successful Care Quality Commission inspection visit this
year.
The Board of Trustees Commitment to Quality
The Board of Trustees continue to monitor the safety and quality of services, whilst ensuring that
the organisation as a whole has individualised patient care at its core. The overall experience of
patients and relatives is of paramount importance to the Board of Trustees.
Corporate and clinical governance structures are firmly established and embedded at SMH. Board
members are represented on appropriate governance committees and obtain current information
on the quality of care that the patients and relatives receive.
The Board hears and comments on reports from the Chief Executive and senior managers, both
clinical and non-clinical, and these are discussed at the quarterly formal Board meetings.
The Chair and the Chief Executive meet on a monthly basis to discuss any governance issues,
particularly with regard to the quality of services that the hospice provides.
All of these elements unite to ensure that the Board continues to be aware of all key aspects of the
services and that they maintain a real understanding of the quality of care provided. As a result, the
Board is confident that the highest standards of care is delivered to all of our patients and their
relatives, whilst at the same time making sure that a cost effective specialist palliative care service
is being delivered to the people of North Hampshire.
Comments from Other Stakeholders
Comment from the North Hampshire Clinical Commissioning Group (NHCCG):
“NHCCG commissions community and hospice palliative care provision from SMH. One of the
CCG's priorities is enabling people to die in their preferred place of care and often this is at home
or in the hospice. In both situations SMH is a key provider. The expansion of Hospice at Home has
allowed specialist palliative care nursing to be delivered in people's homes - supporting patients
and their relatives. Sometimes dying at home is not possible due to complex nursing and social
needs and that is when the SMH In Patient Unit is invaluable, so that patients do not have to be
admitted to a general hospital, where the time and expertise is not available to look after them
properly.
Page 14 of 16
Providers need to be continuously reviewing their services and changing them according to the
needs of the population and the recent building extension to SMH should allow for future nursing
and medical provision, as well as improving day care services to patients. The potential for
education of both local population and medical professionals is very exciting.
As commissioners, we regularly evaluate the quality of care that SMH provide and the CQC
inspections, patient and relative feedback and our engagement with management and nursing
staff, indicates that it provides excellent care, particularly with regard to dignity and respect for
patients.
SMH continues to take a lead in the delivery of several ongoing projects in the area, including a
prostate cancer survivorship program and improving end of life care for dementia patients in
nursing homes.’
In summary, SMH is an essential part of palliative care provision and education in North
Hampshire.”
Dr Charlotte Hutchings, End of Life Lead , NHCCG
Comment from Healthwatch Hampshire:
“Healthwatch Hampshire are happy to comment on the quality report from St. Michael’s
Hospice. We were invited to visit the centre this year as part of our work to highlight the
importance of patient feedback and consultation in the work of such services.
We were given assurances that the views and experiences of patients form a key part of the work
of the hospice and we believe this is reflected in this quality account. We are also encouraged to
see that it forms one of the priorities for this year. We were impressed by the dedication of the staff
to patient care during our visit and believe that patient feedback is taken seriously by the centre
which will result in better outcomes and experiences for patients.”
Healthwatch Hampshire
References
1.
National Patient Safety Agency (2011)
http://www.npsa.nhs.uk/nrls/improvingpatientsafety/patient-safety-tools-and-guidance/riskassessment-guides/risk-matrix-for-risk-managers/
(accessed 24th April 2014)
2.
Institution for Innovation and Improvement (2013)
http://www.institute.nhs.uk/scenariogenerator/tools/reduce_readmissions.html
(accessed 24th April 2014)
Page 15 of 16
SMH Quality Account Feedback
If you would like to comment on the content or format of the SMH Quality Account for 2013- 2014,
please submit your comments via the SMH website or to the SMH Chief Executive at this address:
St. Michael’s Hospice (North Hampshire)
Basil de Ferranti House
Aldermaston Road
Basingstoke
Hampshire
RG24 9NB
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