Support, Care and Hope for Local People

ST MARY’S HOSPICE

QUALITY ACCOUNT 2014/15

“Support, care and hope for local people

and those who love them”

Part 1

Chief Executive’s Statement

Welcome to the 4thQuality Account for St Mary’s Hospice, a document designed to show stakeholders how wemeasure 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 £2million 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 statementwhilst 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.

Our goals for the next twelve months include:

• Reaching out into the community to support more peopleby:
• Providing additional Positive Living courses for patients and carers near their own homes to enable patients to stay well and reduce hospital admissions
• 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

Part 2

Our priorities for improvement 2013/14

In 2013/14we 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 winter2013-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.

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 Ulverstonfor 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.

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 anew 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.)

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)

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 benchmarkingSt 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.)

St Mary’s Hospice is classified as a medium category Hospice at Home provider (between 129 and 297 patients.)

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.

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.

*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 2013/14survey 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.

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 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:

St Mary’s Hospice is always keen to use formal complaints as a tool for service improvement.

In 2013-14we 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:

[email protected]

Or write to:

Val Stangoe

Chief Executive

St Mary’s Hospice

Ford Park Crescent

Ulverston

Cumbria

LA12 7JP

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.’

1

Quality Account 2013/14