ST MARY’S HOSPICE
QUALITY ACCOUNT 2014/15
“Support, care and hope for local people
and those who love them”
1
Quality Account 2013/14
Part 1
Chief Executive’s Statement
Welcome to the 4th Quality Account for St Mary’s Hospice, a document designed to show
stakeholders how we measure quality, involve patients, carers and staff and strive to continually
improve our care.
A Quality Account is required as an annual report to the public from providers of NHS healthcare
about the quality of services they deliver. It is important to note that St Mary’s Hospice only receives
around 22% of its funding from the NHS while the rest (around £2 million each year) is donated by
the local community. The majority of services described in this document are funded by charitable
donation rather than by the NHS. However St Mary’s Hospice regards it as important to ensure that
all patients and families using our services are assured of the quality of these and can see easily the
ways in which we strive, year on year, to improve what we offer.
Quality sits at the centre of all that the Hospice does. Our vision is that everyone in South Cumbria
with a life-limiting condition will have high quality care and support at the end of their life in the
place that they choose.
We asked patients, families, volunteers and staff to sum up in one word what St Mary’s means to
them. Their key words form the backbone of our mission statement:
“Support, care and hope for local people and those who love them”
Our Governance structure ensures that we have both the systems and processes in place to ensure
our clinical services are of the highest quality and meet the aspirations of our mission statement
whilst maintaining a viable and responsible business.
This year in our Quality Account we give an update on work proposed in the Quality Account for
2013-14 as well as showing where we will focus development during 2014-15.
2
Quality Account 2013/14
Our goals for the next twelve months include:



Reaching out into the community to support more people by:
o Providing additional Positive Living courses for patients and carers near their own
homes to enable patients to stay well and reduce hospital admissions
o Delivering Reiki sessions for patients at the local Furness General Hospital to aid
their wellbeing
Give local GPs more access to support from our specialist doctors
Implementing a dementia strategy for the hospice to ensure we are able to cater for all
patients effectively
Care Quality Commission (CQC) - We were delighted that external confirmation of our high quality
services was delivered in the form of a very positive report from the CQC following their
unannounced visit in 2014.
I am responsible for the preparation of this report and its contents. To the best of my knowledge,
the information contained in this Quality Account is accurate and a fair representation of the quality
of healthcare services provided by our Hospice.
Val Stangoe
Chief Executive
June 2014
3
Quality Account 2013/14
Part 2
Our priorities for improvement 2013/14
In 2013/14 we chose 3 priorities for improvement.
Priority 1
Patient & Staff Safety
Assuring patient, visitor and staff safety
Following flooding in the previous year, in 2014 work was done on the hill behind the hospice to
protect the hospice from future flooding.
A review by the new Quality, Health and Safety Manager of our capacity to manage this and other
potential crises resulted in additional training and equipment being introduced to help staff keep
patients safe and if necessary evacuate the building.
Additional work has now also been carried out behind the hospice to reduce the risk of water
ingress.
Priority 2
Clinical Effectiveness
Developing Day Hospice and Education
Autumn 2013 saw an extension to our car park completed while winter 2013- summer 2014 saw the
successful completion of a two storey building, both of these paid for by a Department of Health
capital grant.
In the ground floor of this new building we will provide an improved environment for Day Hospice
services. The increased space will also allow us to extend the services we are able to offer and
increase the resource we can use to benefit the community.
The first floor of the building will be the home of our educational facilities. It is part of the role of the
hospice to provide education on end of life issues for professionals working in the community. This
resource also allows us a base from which to offer patient education in the Ulverston area. Our
Positive Living group education focuses on helping patients and their carers stay well, reduce stress
and avoid hospital admissions.
Priority 3
Patient Experience
Providing additional support at home
Money from South Lakes commissioners has been used to set up a Hospice Neighbours service which
offers people living at home in Ulverston and the South Lakes access to a local volunteer able and
willing to offer practical support such as dog walking, shopping or collecting of prescriptions as well
as friendship and company. This service is being linked to all of our current services to ensure our
service can wrap around a patient and their family to suit their needs.
4
Quality Account 2013/14
Priorities for Improvement 2014/15
Suggestions for priorities for work for the coming year came from our NHS commissioners, our own
audits and growing national awareness of the demographic changes we are to see over the next 10
years.
Reaching out to more people in the community
The hospice is aware that more people are living to an older age and that many people will struggle
with long term illnesses. Previously we developed a patient education programme called ‘Positive
Living’ to help people to stay independent, keep out of hospital and live life to the full. This course
has been available in Ulverston for some time now and in 2014-15 we plan to take it out into local
community venues so people can access it nearer to home.
The hospice has also accessed funds from the Sam Buxton Trust which is paying for 2 days per week
of Reiki therapy. One of these days will be delivered in the hospice itself while the other will be
available for patients at the Furness General Hospital. By facilitating Reiki sessions for patients at the
local Furness General Hospital we hope to support their general well-being as well as raise their
awareness of the hospice and the support it might offer them.
Improving access to Specialist Palliative Care
It is extremely important to the hospice to play a part in the local health community. In order to
support GPs to deliver specialist palliative care for their patients we are going to make our own
highly specialist doctors more available to work alongside them. It is hoped that by strengthening
links between the hospice and community services we can benefit patients and their families.
Implementing a dementia strategy
The hospice is aware that a growing number of people live with dementia. This means that it is more
likely people using hospice services will have dementia as well as physical health conditions. We are
therefore pledged this year to implementing structural and operational changes to ensure the
hospice and hospice staff are equipped to care for people with dementia either themselves or
through liaising with specialist dementia organisations locally.
5
Quality Account 2013/14
Part 2 (Continued)
Statements of Assurance from the Board
Quality Accounts have a series of statements that must be included. Many of these statements do
not apply to St Mary’s Hospice. Explanations of what these statements mean are given where
appropriate.
During 2013/14 St Mary’s hospice provided the following services:








In-Patient Unit
Hospice at Home Service
Day Hospice
Complementary Therapy
Family Support and Bereavement Services
“Drop in” Groups
Education and Training
Hospice Neighbours support
St Mary’s Hospice provides 78% of the funding for these services. The remaining 22% comes from
the NHS via the Clinical Commissioning Groups (CCGs) responsible for South Lakes and Furness.
St Mary’s Hospice has reviewed all the data available to them on the quality of care in all these NHS
services. (This is a mandatory statement)
Participation in Clinical Audits
During 2013/14, St Mary’s Hospice was ineligible to participate in the national clinical audits and
national confidential enquiries. (This is a mandatory statement)
Participation in Local Audits
The Clinical Audit Group oversees a programme of internal audit which uses national, local and
regional audit tools. Where issues are identified during an audit, an action plan is developed to put
any problems right. Progress on this action plan is then monitored by the Governance Group to
ensure that actions are completed.
The hospice struggled to continue with its audit programme following the loss of the Head of
Nursing early in 2014. With a new Head of Nursing now in post the work of this group has been
prioritised and will resume.
Research
The number of patients receiving NHS services provided or sub-contracted by St Mary’s Hospice in
2013/14 that were recruited during that period to participate in research approved by a research
ethics committee was NONE (This is a mandatory statement, this type of research does not apply
to St Mary’s Hospice.)
6
Quality Account 2013/14
Use of the Commissioning for Quality and Innovation (CQUIN) Payment Frame
St Mary’s Hospice NHS income in 2013/14 was not conditional on achieving quality improvement
and innovation goals through the CQIN payment framework because it is a third sector organisation
and as such was not eligible to participate in this scheme during the reporting period. (This is a
mandatory statement in 2013/14 CQUIN payments did not apply to St Mary’s Hospice)
Statement from the Care Quality Commission
St Mary’s Hospice is required to register with the Care Quality Commission to carry out the regulated
activities:


Treatment of disease, disorder or injury
Diagnostic and screening processes
St Mary’s Hospice has the following conditions on registration:



Only treat people over 18 years old
Only accommodate a maximum of 9 in-patients
We have agreement from the CQC that we can treat patients aged between 16-18 years of
age if they are not able to access an equivalent service in this area.
An unannounced visit by the CQC in October 2012 found us to be fully compliant on the six
outcomes they measured us against.
Data Quality
St Mary’s Hospice did not submit records during 2013/14 to the Secondary Users Service for
inclusion in the Hospital Episode Statistics which are included in the latest published data.
(Mandatory statement)
However, St Mary’s Hospice does submit data to the Minimum Data Set (MDS) for Specialist
Palliative Care services collected by the National council for Palliative Care on an annual basis, with
the aim of providing an accurate picture of Hospice and Specialist Palliative Care service activity.
An IT system to allow all healthcare professionals to share patient information was adopted by St
Mary’s Hospice from 1st April 2014. This project was led by the GP Commissioner for Furness
Locality and we believe that over time this will help us to deliver a better service to patients using
our services.
Information Governance Toolkits
The following statement does not apply to St Mary’s Hospice but must be included in our Quality
Account:
St Mary’s hospice Information Governance Assessment Report overall score for 2013-14 was (%) and
was graded (insert colour from IGT grading scheme)
(Mandatory statement)
7
Quality Account 2013/14
Clinical Coding Error
The following statement does not apply to St Mary’s Hospice but must be included in our Quality
Account:
St Mary’s hospice was not subject to the payment by results clinical coding audit during 2012/13.
(Mandatory statement)
Part 3
Review of Quality Performance
In this section, we have chosen to provide data benchmarking St Mary’s Hospice with figures from
the National Council for Palliative Care Minimum Data Set, (MDS.) The figures below provide
information on the activity and outcomes of care for patients. The most recent MDS figures available
to us are from 2010/11 and are used here for benchmarking purposes. Use of MDS figures allows us
to compare our performance against other similar sized hospices in the UK.
St Mary’s Hospice is classified as a small In Patient Unit (fewer than 10 beds.)
In Patient Unit
Total number of
patients
Number of new
patients
% Occupancy
% Patients returning
home
Average length of stay
2012/13
2013/14
National Median
2010/11
National
Median
2012/13
168
160
163
131
(78%)
73%
53%
138
(86%)
70%
51%
116
(71%)
78.5%
48%
78%
44.7%
11.4 days
9.74 days
11.05 days
13.6 days
82%
St Mary’s Hospice is classified as a medium category Hospice at Home provider (between 129 and
297 patients.)
Hospice at Home
Total number of patients
Number of new patients
Total number of patient
visits
% new patients
% of patients who died at
home
2012/13
2013-14
National Median
2010/11
234
National Median
2012/13
208
210
1,991
232
222
1,777
(9.6 per person)
(7.6 per person)
(7.6 per person)
1768
11.4 visits per
person
98%
81%
97.5%
67%
96%
78%
90%
79%
8
Quality Account 2013/14
St Mary’s Hospice is classified as a small category Day Hospice provider (fewer than 126 patients.)
We hope to increase the Day Services we offer in the coming year.
Day Hospice
Total number of patients
% new patients
Average period of
attendance
2012/13
2013-14
National
Median 10/11
48
63.6%
129.5 days
58
65.4%
62.75 days
94
60.3%
137 days
National
Median
2012/13
89%
31-90 days
2012-13 was the first year the family support team collected statistics. This was done for 6 months
and an average for the year worked out from there.
Family Support Service
Total (average for the year)
2013-14
Referrals
428
389
Contacts
1164
2807
Caseload
70.5
78
IPU visits
270
1365 *
73 (2 events)
116 ( 2 events)
Afternoon tea attendances
* NB change in way recorded during this period as now logged as individual visit to each
patient/family and not one overall visit to IPU in which 8 families may have been seen.
Feedback from Staff
St Mary’s Hospice is recognised as a good local employer, staff turnover is low and when we do have
a vacancy, we receive a high volume of applications.
An annual staff survey is conducted. In February 2014 a Staff Forum was formed, there are regular
staff briefings and consultation on issues involving change. This all ensures staff are kept up-to-date
on hospice changes and involved in decision making.
The top 4 statements from the 2013/14 survey that staff agreed with were:
1. I am pleased to let others know I work at St Mary’s hospice.
2. I know what is expected of me in my job.
3. My organisation acts on concerns raised by patients, carers, families and members of the
public.
4. I feel I am part of a team.
9
Quality Account 2013/14
Feedback from Patients and Carers
Feedback from patients and carers is one of the most important ways in which St Mary’s Hospice
measures the quality of its care. Here are some examples of comments in our most recent surveys in
our patients’ and families own words:
We were advised about the family support
bereavement service as soon as my partner was
admitted to the Hospice. My support worker was
marvellous, I cried quite a lot and talked over
everything....eventually my tears become less
and I have nothing but praise for the staff and
the support they gave me.
The Hospice at Home team
supported me and my family
from the 1st contact we had
with them, for which we
cannot thank them enough.
In my experience no improvement
could be made. The service is
excellent and I have never come
across such a dedicated, caring
and compassionate people.
......amazing support, thank you.
When my mum came to stay at the
hospice I found out she wouldn’t
have long to live. I experienced the
best help and support I could ever
wish for. Mum was cared for by your
nurses until the end.
Complementary therapy is a truly
fantastic service, invaluable. It has helped
me enormously .....the staff was
exceptional, not only as a reflexologist
but emotionally empowering and so
encouraging.
...These lovely people
alongside all your wonderful
staff and volunteers are a
credit to you and the loving ,
caring work you do.
I was very tense and stressed
when I started therapy.
Afterwards I was much more
relaxed and calm and able to
deal with everyday tasks.
Thanks to the Hospice.
10
Quality Account 2013/14
We monitor all complaints whether clinical or non-clinical and discuss them at our Governance
meetings, complaints are also reported regularly to the Board of Trustees:
Total number of
complaints
Number of complaints
upheld in full
Number of complaints
upheld in part
Clinical Complaints
2011/12
2012/13
1
5
2013/14
1
0
4
0
1
1
1
St Mary’s Hospice is always keen to use formal complaints as a tool for service improvement.
In 2013-14 we had a complaint from a nurse in community services who had been told by a family
that they were unhappy about aspects of their loved one’s care. Although a formal complaint was
not made we investigated it thoroughly to ensure we could learn how to improve services. After
investigation we agreed that some aspects of care were poorly documented making it hard for the
family to know what had been done and what had not during the times they were absent. The
hospice has therefore implemented improved recording documentation and is also exploring how
we make sure families can raise any worries as soon as they arise.
Opportunities to give feedback on this Quality Account
We welcome feedback on our Quality Account. If you have comments, please email:
val.stangoe@ stmaryshospice.org.uk
Or write to:
Val Stangoe
Chief Executive
St Mary’s Hospice
Ford Park Crescent
Ulverston
Cumbria
LA12 7JP
11
Quality Account 2013/14
Annex – consultation on our Quality Account
Healthwatch Cumbria has responded to this Quality Account as below at Appendix 1.
Cumbria Overview and Scrutiny Committee and Cumbria clinical Commissioning Group were asked
to comment but no responses had been received at the time of uploading the account (2 September
2014).
Appendix 1 - response from Cumbria Healthwatch
‘ Healthwatch Cumbria is pleased to be able to submit the following considered response to
St. Mary’s Hospice Quality Accounts for 2013/14, this has been in consultation with the
Healthwatch Manager and Board Members.
Healthwatch Cumbria welcomes the opportunity to provide feedback in response to the
Quality Account Report and would like to comment on the clear and concise presentation
of the report. The responding group found the report gave a good account of the quality
and safety of care, in an open and transparent manner.
We recognise the benefits of providing Positive Living courses for patients and carers near
their own home and feel this will contribute to the wellbeing of patients and will also
contribute to reducing the demand and pressure placed on hospital admissions and GP
access.
We see the inclusion of complementary therapies as a benefit to patients and understand
that such therapies can improve general wellbeing.
We are pleased to note that the outcome judgement of the recent Care Quality
Commission is very positive and is a clear indication of the high quality of care provided by St
Mary’s Hospice.
We commend the Hospice on their forward planning and actions taken to reduce the risks
from flooding ensuring the Hospice, the patients, visitors and staff are able to remain in a safe
environment.
The Hospice has recognised and acknowledged that they need to provide a wraparound
holistic approach to caring for their patients and family members and staff. Also supporting
the wider community by not only ensuring that their staff are fully trained and competent in
their delivery of care, but also in providing Educational, Therapeutic and Community support
as well as the sharing of resources, e.g Hospice specialist doctors to support local GP’s in the
specialist field of Palliative Care between the Hospice and the Community. As well as
embracing their IT system to help professionals to share patient information more readily, thus
demonstrating and sharing good practice.’
12
Quality Account 2013/14