Quality Account 2015 to 2016 Vision Patients, families and carers in our community experience a journey towards end of life and into bereavement that is supported, comfortable, safe and personalised and is in a place of their choice Mission The Mary Ann Evans Hospice will provide comprehensive, high quality support and end of life care across our community through all the services we provide to patients and those close to them We will do this in collaboration with others where appropriate We are committed to training, supporting and encouraging our staff and volunteers to achieve our mission The Mary Ann Evans Hospice will be recognised as being the lead provider for comprehensive and high quality community end of life care and support Strategic Aims The Mary Ann Evans Hospice will promote open attitudes in our community towards death and dying and provide bereavement support to all that need it The Mary Ann Evans Hospice will maximise organisational impact through robust financial management and growing support of our community Mary Ann Evans Hospice Eliot Way, Nuneaton Warwickshire CV10 7QL Charity Number: 1014800
Index Description Page No Hospice Board Chair s Statement 3 Priorities for Improvement 2016-2017 4-7 Progress on priorities for improvement 2015-2016 8-12 Statement of Assurance from the Board 2016-2017 13-14 Participation in Clinical Audits 15 Research 15 Statement from the Care Quality Commission 15-16 Data Quality & Review of Quality Performance 16-20 Quality Markers 21 An explanation of those involved in this Quality Account 22 Statements 23-26 2
Part 1: Hospice Board Chair s Statement In this the 25 th anniversary of the Mary Ann Evans Hospice I am delighted to present this Quality Account. As always the Hospice staff strive to provide the very highest quality of care for our patients, their families and their friends and I am absolutely confident that they did just that over the past year. Looking forward to the future I know that with our strong clinical leadership all clinical services will be strengthened even further. The senior leadership team are ensuring that all systems and processes are updated and in place to ensure the best quality service at all times. This report highlights the improvements made in the last year and the proposals for 2016-17. The focus throughout will be to improve and to strengthen. As in previous recent years, financial viability is the only restraining factor in developing further new services. Significant growth in demand for all our services, but particularly in bereavement and lymphodema services, with no additional NHS funding, means that whereas before we needed to raise 70% of our expenditure via fundraising activities, this figure has now risen to 80%. Whilst we have strengthened our fund-raising team, and they do a marvellous job, we still ended the 2015-16 year with a very significant deficit. Demand continues to grow in 2016-17 and it seems likely that despite our best efforts we will again report a deficit in 2016-17. The Senior Leadership Team and the Board of Trustees will develop a plan to ensure a balanced position for 2017-18. To the best of my knowledge the information provided in this Quality Account is an accurate and true account of the quality of services provided by the Mary Ann Evans Hospice. Duncan Phimister Chair of the Board of Trustees 20 th May 2016 3
Part 2: Priorities for Improvement and Statement of Assurance from the Board 2016 to 2017 The Mary Ann Evans Hospice has not received notification of a further inspection since the previous Quality Account report 2014-15. The Hospice was delighted to report receiving an overall rating of Good from the Care Quality Commission inspection under Section 60 of the Health and Social Care Act (2008) in August 2014 for the care services provided. The Hospice Board and all staff and volunteers working at Mary Ann Evans Hospice always strive to improve care outcomes, develop services for the benefit of our local community and demonstrate a positive return on investment for funding received statutory and voluntarily donated. The priorities for improvement that have been identified for 2016/17 are outlined below. These priorities have been identified in conjunction with patients, carers, staff and stakeholders. They have been approved by the Hospice s Senior Leadership Team and the Clinical Governance and Service Development Committee; a working group of the Hospice Board to monitor quality and plan ahead. Future Planning Priority 1 Day Hospice service development Building further on last year s transformation project of Day Hospice to offer contemporary services able to fulfil the needs of the diverse, multiple co-morbidity local population - further developments are required to promote a rehabilitative service offer enabling people to live fully until they die, including supporting their family carers. The Day Hospice care services will continue to fulfil our mission of training, supporting and encouraging staff and also consider the Hospice UK report - Rehabilitative Palliative Care A Challenge for the 21 st century (2015), translating elements of the recommendations within resources and skills available. Furthermore, the Mary Ann Evans Hospice will also be ensuring local people are given an opportunity to optimise their individual well-being and support those with care needs to live as independently as possible a paramount principle of the Care Act 2014. Measures: 1. Recruit and develop existing willing volunteers willing to have a direct role being more involved in fundamental patient care needs. 2. Enhance skills of Healthcare Assistant to an Assistant Practitioner level. 3. Appointment of an Advanced Nurse Practitioner in Palliative Care to directly support patients with progressive clinical expertise and support the development of staff and volunteers in enhancing patient care services provided. 4. Patient, carer and professional feedback regarding services provided will be sought. 4
Future Planning Priority 2 Hospice at Home service review The Mary Ann Evans Hospice wishes to be recognised as being the lead provider for comprehensive and high quality community end of life care and support. As the local community Hospice a key service provided is Hospice at Home taking the caring ethos and culture of the Hospice out into the person s own home environment in the local community. The Mary Ann Evans Hospice at Home team have potential to extend the range of care skills they are able to provide thereby improving the service offer and making a greater impact and difference for the families and carers we serve. Measures: 1. Review of existing service provision and what the team have learnt would help patients and their carers more if staff were trained to assist with further care skills competently. 2. Appointment of an Advanced Nurse Practitioner in Palliative Care to directly support patients with innovative clinical expertise and support the development of staff (and volunteers in future) to further enhance patient care services provided. 3. Staff training and skills analysis to identify personal gaps and enable training plan incorporating Assistant Practitioner role to be established. 4. Skills and training plan developed and initiated. 5. Recognition and involvement as a key stakeholder as part of Warwickshire wide community services review of care pathway provided and outcomes achieved for people in the very end stages of their life limiting illness. Future Planning Priority 3 Clinically effective care services The Mary Ann Evans Hospice is regulated by the Care Quality Commission and under Section 60 of the Health and Social Care Act (2008). To ensure hospice services are clinically effective i.e. safe, caring, responsive, effective and well led the hospice gives serious regard to satisfactorily meeting the Care Quality Commissions requirements. Measures: 1. Review of existing clinical policies and procedures to be completed and development of any policies necessary to fulfil regulation requirements. 2. Clinical audit programme including patient and carer satisfaction, Accountable Officer for Controlled Drug s audit (using Hospice UK audit tool). 3. Draft Provider Information Report to be completed in preparation for forthcoming Care Quality Commission inspection. 5
Future Planning Priority 4 Review and develop Carer support provision The Hospice recognises the invaluable contribution provided by family carers every day they care for their loved ones with a life limiting illness. The National Palliative and End of Life Care Partnership report Ambitions for Palliative and End of Life Care: A national framework for local action 2015-2020 (2015) clearly sets out as part of their recommended framework for local action the importance of ensuring family carers needs are assessed and supported. Measures: 1. The Hospice will review current service provision for carers and develop a strategy for carer support 2017-2022. 2. Staff and volunteers will receive training to assess and support carers from the carers own needs perspective. 3. All clinical and bereavement services will contribute to a service development plan outlining how the Hospice will provide carer support services within available resources and skills, working in conjunction with local key partners such as Guideposts. Future Planning Priority 5 Advance practice in Lymphoedema care The Hospice has a highly successful locally provided lymphoedema service, however on occasions there can be considerable delay for patients to receive the correct hosiery required to treat and manage their lymphoedema. To overcome this and improve the timeliness of treatment commencing, the lymphoedema nurse specialist will undertake further advance practice development. Measures: 1. The lymphoemdema nurse specialist will commence a community non-medical prescribing course in September 2016. 2. The lymphoedema nurse specialist will receive the required mentoring and academic support to successfully complete the course stated previously. 3. The Head of Clinical Services will negotiate for the lymphoedema nurse specialist to receive a prescription pad from the WN CCG. 4. Patients will begin to receive their prescriptions at the time of review by the service. Future Planning Priority 7 Complementary Therapy The Mary Ann Evans Hospice has a dedicated Complementary Therapy Team Leader who, in addition to practicing as a Complementary Therapist co-ordinates a 6
dedicated team of volunteer therapists, however, the team has several key developments planned for 2016-17. Measures: 1. Increase numbers of volunteers to offer service more widely to patients and families across clinical and bereavement services. 2. Review existing Hospice Complementary Therapy policy and procedures to ensure safe and evidence based practice is understood by all volunteers providing therapies on behalf of the Hospice. 3. Consider the introduction of paid well-being sessions for staff and other volunteers when voluntary resources permit to promote health and welfare of those providing emotionally demanding caring services. Future Planning Priority 8 Bereavement services The Mary Ann Evans Hospice has applied for a three year grant from Children in Need to continue its support to children and young people. We will continue to work with the Sycamore Centre which is based in Nuneaton and who specialises in children s work. As our service expands year on year we need to ensure all strands remain sustainable. Measures: 1. Continue to train a larger group of volunteers who will shadow two members of the Sycamore Centre team through eight-week bereavement courses for children and young people. 2. Invite families to a Family Day at the Warren during the next year. 3. Increase the awareness to schools and other agencies of our bereavement support for children and young people. 4. Fine-tune some strands of the service to ensure sustainability. Future Planning Priority 9 Chaplaincy The Mary Ann Evans Hospice Chaplain continues to work with the patients, volunteers and staff offering appropriate support where necessary. A small team of volunteers have been trained up to offer pre-bereavement support for those coming to end of life and for their families. Measures: 1. Increase the pre-bereavement opportunities for the volunteers who have received training for this piece of work. 7
Part 3: Priorities for Improvement 2015 to 2016 This past year has seen the Mary Ann Evans Hospice achieve the following to improve care and support for those accessing our services and also to meet the increasing need of our local during community 2015/16. Outlined below is how we achieved the measures and outcomes aspired for in 2015-16. Planning Priority 1 Further develop existing and new partnership working Recognising the patient and family carer benefits achievable through working with key partners in extending and developing core services for people in Nuneaton, Bedworth and North Warwickshire approaching the end of their lives can be demonstrated by the following measures: Highly positive feedback has been received from our May 2016 hospice care services generic satisfaction survey. An evaluation report (April 2016) evidences how the Hospice has engaged with key partners and collaboration projects/services for the people accessing Mary Ann Evans Hospice care services. An impact analysis report demonstrates the success of the community engagement role initiated April 2015. The Hospice can demonstrate further developing their clinical care and services provided for family carers of those at the end of life through the joint project with GEH Heart Failure Nurse Specialist. This project is a patient and carer group for both GEH heart failure patients/families and Mary Ann Evans Hospice day service patients. Patients and carers attend an education and support group hosted monthly at the Hospice. Planning Priority 2 Day Hospice service review The Day Hospice care services have been fully reviewed involving all staff, volunteer representatives and patients where appropriate. The Day Hospice now offers a 12-16 week programme of care and can demonstrate a 60% increase on previous year (2014/15) for new patients attending and who are now receiving the care programme. The Day Hospice team have visited many other palliative day care services to learn from others successes and glean inspiration for innovation. This led to an exploration 8
report and recommendations for way forward being presented to the Hospice Board of Trustees in September 2015. Since developing the new programme of care, the team have been out to many professional colleagues raising awareness to what the programme now offers and how this can benefit and support patients and their family carers. Initially the programme of care was established to run over 12 weeks, however, through piloting this time frame it was established that 16 weeks was a more reasonable time frame for some patients to enable full range of hospice services to assess and support each patient and their family. Whilst formal professional feedback of changes to day hospice service provision has not yet been undertaken, informally the Hospice has received considerable verbal praise for the transformation to date. Patients and carers have been given the opportunity to feedback via a specific short feedback sheet in addition to the forthcoming formal patient and carer satisfaction survey. Verbal feedback received has been largely positive the only discomfiture being the programme coming to an end. Where clinically appropriate the programme has been extended, and even in some cases, not ceasing or the patient has returned for a second programme at a later date. The Day Hospice environment has been redecorated and has new dining area tables and chairs, and new chairs in the lounge area meeting Infection Prevention standards whilst maintaining a safe, homely and comfortable setting. Planning Priority 3 Widen awareness to care services The Mary Ann Evans Hospice has been working since June 2015 as a key stakeholder in planning an extensive community engagement event in Nuneaton town centre in May 2016. This event provides the Hospice with an enormous opportunity to increase their recognition as being the lead provider for comprehensive and high quality community specialised end of life care and support. This is especially useful as unfortunately many local professionals and general public have remained unaware of the value and impact hospice care may have on individuals. By raising understanding to hospice and other care services the hospice works alongside will widen awareness and enable local people to benefit from the support and care on offer. In the past 12 months the Hospice has participated and contributed in several external key stakeholder events to improve the understanding of hospice care services professional and public. Furthermore, the work and impact of the 9
community engagement officer in Fundraising (report completed 2016) also demonstrates the actions taken by the Hospice to raise awareness and profile of Hospice services available. Additionally, the Clinical services have worked in partnership with fundraising and marketing to ensure full remit and benefits of services are communicated. For example our Hospice at Home team engaged with many local businesses and schools. The care team in conjunction with fundraising colleagues spoke with children at school assemblies. In regards to increases in service activity the Hospice at Home team have seen a 20% increase (2014/15) in the total number of patients and total number of new patients. The percentage of patients being cared for with non-malignant life-limiting illness is on par to the national median statistic. They continue to achieve high percentage of home deaths just fewer than 90% of all deaths occurring at home. Furthermore, the Hospice at Home service has approximately 50% shorter average length of care episode to the national median demonstrating that majority of referrals are accurate regarding the anticipated death of the patient referred. Day Hospice has seen a total number of patients that is on a par with the national median, although despite the number of continuing patients having reduced from previous year, this remains considerably above the national median figure. Also noted is the higher percentage to national median of new patients in the age group 25-64 years. However, the Day Hospice again is on par with national median data for non-cancer patients and the percentage of places used. Work continues on encouraging and welcoming referrals from new cohorts of people who do not typically access hospice care. Our lymphoedema service has seen a significant increase in the total number of patients cared for nearly 30% increase on last year s figure. They are starting to see younger patients aged 16-24 and have seen a slight increase in the numbers of patients aged 84 years. They have provided 662 more appointments than previous year, with just fewer than 97% of all appointments being used. The support groups and Health Steps Exercise classes provided have also continued to be popular with numbers increasing attending these sessions as well. Our bereavement services have experienced over a 30% increase in the total number of clients and total contacts. The service continues to offer a high level of group sessions and has seen a considerable increase in the numbers of people discharged. 10
Planning Priority 4 Clinically effective care services The Mary Ann Evans Hospice gives serious regard to being regulated by the Care Quality Commission and under Section 60 of the Health and Social Care Act (2008). The Hospice has invested in a fixed term quality and governance project post to review and update all clinical policies and procedures. Clinical policies and procedures which are contemporary and understood by staff are one of the cornerstones to ensuring hospice services are clinically effective i.e. safe, caring, effective, responsive and well-led. In addition the Hospice has invested in a bespoke and thorough statutory and mandatory training programme which gives assurance all clinical staff will understand the core requirements to work in a caring, safe and effective hospice setting. In addition the Head of Clinical Services and Team Leads have been reviewing the Care Quality Commissions outcomes for Hospice providers. Furthermore the Head of Clinical Services and Clinical Services Administrator have been preparing a draft Provider Information Report which has assisted with completing a review of current requirements and Hospice compliance. Clinical Governance and Service Development meetings have continued and have developed a report in the form of a clinical dashboard format to ensure all aspects of patient care and safety are monitored and evaluated. The hospice has considered the Care Certificate for all non-registered care staff. The care certificate repeats the work covered by National Vocational Qualifications in Care so priority and support will be given to any non-registered care staff who have not got an NVQ in Care. Currently there are no permanently employed nonregistered care team members without an NVQ in Care. Whilst End of Life Care competencies have not progressed for all levels of care staff, there has been significant investment in training and development opportunities for all clinical team members. Each Registered Nurse employed is fully aware of their revalidation requirements and have taken up opportunities to attend local awareness sessions provided by the local acute Trust, the Nursing and Midwifery Council or the Royal College of Nursing to learn more and share with colleagues. A dedicated clinical risk register has been established and is reviewed and updated on a regular basis. 11
Planning Priority 5 Bereavement services The children s bereavement service is now well established and a good partnership is ongoing with the Sycamore Centre. The Hospice s Bereavement Team have realised that the children needed some extra levels of support after their eight week course so there are now opportunities for 1:1 sessions and a fortnightly Drop-in group. The Mary Ann Evans Hospice continues to invest in this service and more volunteers are being trained to continue to provide this important work. Stakeholders are using the service well and the Hospice acknowledges the increased demand for this service. Planning Priority 6 Chaplaincy The Mary Ann Evans Hospice has increased the pre-bereavement service which has predominantly previously been offered by the Hospice Chaplain. Training has been delivered to a small group of volunteers and they have started to be involved in end of life bereavement support. This has enabled the Hospice to respond to patients and their families where needed, including in their own home setting. 12
Part 4: Statement of Assurance from the Board 2016 to 2017 The following are statements that all providers must include in their Quality Account. 4.1: Review of Services During 2015/16 the Mary Ann Evans Hospice was part funded by the Warwickshire North Clinical Commissioning Group. The commissioning group has priorities with regard to the provision of local End of Life and Palliative Care by supporting the delivery of: Day Hospice Complementary Therapies Hospice at Home Bereavement Service In addition the Hospice has provided the following services solely through charitable funding: Lymphoedema Lymphoedema Support Group Healthy Steps Programme Progressive Relaxation Therapy The income generated by the NHS, reviewed in 2015/16 represents approximately 32% of the cost to provide services by the Mary Ann Evans Hospice. The Mary Ann Evans Hospice values the feedback received from patients and their families/carers as this is an important way in which staff can identify issues, resolve problems and improve the quality of care we provide. Some comments received from patients and their families are shown below: Families of a Hospice at Home patients: So thankful to have this support for mum and us through all of this. I wish we had contacted you sooner.angels! The team offer a holistic service to the patient and carer. As a carer I m not sure I would have wanted to carry on without the support, care and compassion as I had become depressed. 13
Day Hospice patients: I have always found the staff, carers, volunteers always ready to help me with any problems concerning my disabilities. I have every reason to be grateful to the Mary Ann Evans Hospice personnel. Care and attention at the Hospice is excellent a very caring and thoughtful team. Comments from Lymphoedema patients: I use the lymphoedema services they are very good and the staff are very, very good, they have really helped me over a horrible time they are always professional and caring, I also use the healthy steps exercise class which is great. I am always made to feel welcome and relaxed from the minute I walk through the door. The staff have become like friends to me, I don t know what I would do without this treatment. Complementary Therapy client comments: I like the massage, I feel more comfortable and relaxed afterwards. Most days I tell my husband I feel poorly but when I ve had a massage at the hospice I feel totally different. My head massage is WOW, out of this world. Something about it just makes me feel great. Gorgeous. It s brilliant what she [Volunteer Therapist] does. Bereavement client comments: Brilliant support, the team were very kind and attentive, great listeners and so friendly Having someone from the team visit me in my home was a very personal understanding of my grief, being at home helped me release a lot of built up emotions. Thank you for all your support Your team were there and listened, let me talk, cry and were comfortable with what I needed to say. Thank you for helping me to get to where I am today Cannot fault the support that I have had over the last 18 months with 1:1 s and Sanctuary. 14
4.2 Participation in Clinical Audits During 2015/16 there were no national audits or confidential enquiries covering NHS services relating to palliative care. The Mary Ann Evans Hospice only provides palliative care from a hospice perspective and therefore was ineligible to participate. Hospice Audits that occurred during 2015/16 Patient and Carer Satisfaction Survey May 2015 Infection prevention and control July 2015 Clinical Documentation January 2016 Bereavement service users satisfaction questionnaire an evaluation form is sent out to every client once they have finished using the service. 4.3 Research A total of 26 patients receiving NHS Services provided or sub-contracted by the Mary Ann Evans Hospice during the year 2015/16 were participating in research approve by a research ethics committee the PLACE trial (Prevention of Lymphoedema after Axillary Surgery by External Compression) a national trial. Nine of these patients continue to be monitored of these nine, six will continue to be monitored for five years. Three patients have been withdrawn from monitoring as they have been diagnosed with metastatic disease or required treatment with hosiery. 4.4 Statement from the Care Quality Commission The Mary Ann Evans Hospice is required to register with the Care Quality Commission (CQC) and is currently registered for three regulated activities under the Health and Social Care Act (2008). Nursing Care Personal Care Treatment of Disease, Disorder or Injury The Mary Ann Evans Hospice had an announced inspection under Section 60 of the Health and Social Care Act (2008) on 13 August 2014. The CQC looked at the overall quality of the services and rated these as Good. The new inspection process was used which looked at five main parameters: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led? 15
During the visit the inspectors spoke with people who used the hospice and their relatives advised them they were happy with the services provided by the hospice. They felt the staff understood their needs and they felt safe. People s wishes and preferences were taken into account and recorded in care plans. Risk management procedures were in place to ensure people s health risks were identified and plans were in place to manage those risks. Staff demonstrated a good understanding of the needs of people with life limiting illness. They had received good training and support to meet people s needs. The organisation demonstrated they were working well with other health and social care providers to ensure people s needs were met. The CQC found appropriate policies and procedures in place to support people should they ever have a need to complain or raise concerns. When concerns had been raised, they had been dealt with effectively. The CQC also reported they had found systems in place to assess and monitor the quality of support provided for people. The final report was published in January 2015 giving the Mary Ann Evans Hospice a final overall rating of services as Good. 4.5 Data Quality The Mary Ann Evans Hospice did not submit records* during 2015/16 to the Secondary Users service for inclusion in the Hospital Episode Statistics which are included in the latest published data. * The Hospice is not eligible to participate in this scheme The Mary Ann Evans Hospice submits data as requested on an ongoing basis to the National Council of Palliative Care (NCPC): Minimum Data Sets (MDS), local Commissioning Support Unit and Local Intelligence Network. Part 5: Review of Quality Performance The National Council of Palliative Care (NCPC): Minimum Data Sets (MDS) The Mary Ann Evans Hospice has chosen to present information from the NCPC Minimum Data Set, which is the only hospice activity information presently collected on behalf of Hospices nationally The figures below provide information on the activity and outputs in relation to care provided patients and clients of bereavement and lymphoedema. 16
5.1 Day Hospice 2014/15 2013/14 Hospice National median Hospice National median Total patients 76 78 97 84 New patients 29 44 41 43 % New patients 38.2% 59.1% 42.3% 59.9% Continuing patients 47 29 55 31 % New patients 16-24 n/a 0.0% 2.1% 0.0% % New patients 25-64 31.6% 25.5% 27.8% 25.4% % New patients 65-84 55.3% 60.3% 59.8% 58.8% % New patients over 84 9.2% 10.8% 9.3% 12.6% All female patients 46 42 57 45 All male patients 30 37 40 37 All cancer diagnoses 60 57 70 58 All non-cancer diagnoses 16 16 27 15 % New patients with non-cancer diagnoses 21.1% 23.2% 27.8% 21.2% Day care sessions 247 154 241 154 Day care places 3705 1992 3615 1839 Day care attendances 2034 990 2023 1009 % Places used 54.9% 54.4% 56.0% 58.6% Deaths and discharges 32 50 39 41 Average length of attendance (days) 9.5 171.3 n/a 237.5 17
5.2 Hospice at Home 2014/15 2013/14 Hospice National median Hospice National median Total patients 195 234 164 119 New patients 187 217 153 104 % new patients 95.9% 90.1% 93.3% 95.2% Continuing patients 8 16 11 5 % new patients 16-24 n/a 0.0% 0.6% 0% % new patients 25-64 18.5% 19.9% 23.8% 19.2% % new patients 65-84 67.2% 58.2% 59.1% 59.1% % new patients over 84 13.3% 21.8% 16.5% 20.5% All female patients 3 122 68 53 All male patients 5 111 96 62 All cancer diagnoses 169 178 150 87 All non-cancer diagnoses 26 47 14 18 % all patients with non-cancer diagnoses 13.3% 17.5% 8.5% 20.0% Deaths and discharges 192 233 152 108 Deaths 158 150 142 71 % home and care home deaths 88% 90.5% 83.1% 90.1% Average length of care 9.9 21.8 n/a 25.5 18
4.3 Bereavement 2014/15 2013/14 Hospice National median Hospice National median Total service users 193 179 145 159 New service users 107 118 98 121 % new service users 55.4% 69.5% 67.6% 70.8% All female service users 140 118 107 113 All male service users 53 53 38 50 Cancer diagnoses of deceased 144 n/k 123 123 Non-cancer diagnoses of deceased 49 n/k 22 16 % of deceased with a non-cancer diagnoses 25.3% n/k 15.2% 8.5% Total contacts 1585 926 1,206 1,092 Contacts per service user 8.2 6.0 8.3 6.2 Phone calls per service user 0.4 1.5 0.4 1.6 % of contacts which were group sessions 38.2% 4.5% 32.0% 6.9% Discharged 175 131 47 102 % discharged 40.3% 58.3% 32.0% 59.1% 19
5.4 Lymphoedema 2015/16 2014/15 Total patients 275 216 New patients 117 93 % New patients 42.5% 43% % New patients 16-24 1.3% 0% % New patients 25-64 49.4% 55% % New patients 65-84 42.6% 45% % New patients over 84 6.7% 5% All female patients 249 193 All male patients 26 23 All cancer diagnoses 275 216 % New patients with non-cancer diagnoses 0% 0% Clinic H/V Appointments (1 hour average) 3124 2319 143 % Appointments used (including DNA and cancellations) 96.6% 92.7% Support Group Attendance 144 104 Healthy Steps Attendance 582 494 % Places used (maximum of 12 clients per session) 71% 64% Deaths and discharges 49 67 20
Part 6: Quality Markers 6.1: Complaints INDICATOR 2015/16 2014/15 Complaints Number of Complaints (clinical) 2 0 Number of Complaints (nonclinical) 1 6 6.2: Patient Safety INDICATOR 2015/16 2014/15 Patient Safety Incidents Number of Serious Patient Safety Incidents (excluding falls) 0 0 Number of Slips, Trips and falls 0 3 Number of Patients who experience a Fracture or other Serious Injury as a result of a Fall 0 0 Other Incidents 13 4 21
Part 7: An Explanation of those involved in this Quality Account The Clinical Governance and Service Development Group have considered the priorities set out in this Quality Account having previously been discussed by the Hospice Senior Leadership Team and the clinical services Team Leads. The Quality Account was drafted initially by the Head of Clinical Services and circulated to the Chair of Trustees, Chief Executive, Head of Chaplaincy and Bereavement and all clinical services Team Leads. The Quality Account was then finalised and discussed at the full Board meeting on 19 th May 2016. Following this the Quality Account was distributed on 1 st June 2016 inviting feedback by 21 st June 2016 for inclusion in final published report, externally to: Warwickshire North Clinical Commissioning Group Nuneaton and Bedworth Borough Council Warwickshire County Council North Warwickshire Borough Council Warwickshire HealthWatch Coventry & Warwickshire Partnership Trust Chief Executive, George Eliot Hospital, Nuneaton South Warwickshire Foundation Trust 22
Part 8: Statements from Local Stakeholders On 1 st June 2016 a copy of this Quality Account was sent to local stakeholders, as listed above, requesting a response for inclusion by 21 st June 2016 As of the 21 st June 2016, two local stakeholder responses were received relating to this Quality Account. The statements from Warwickshire North Clinical Commissioning Group and Warwickshire County Council & Public Health have been included on pages 24-26 of this Quality Account. The Hospice Board and Senior Leadership Team were delighted to have received these encouraging statements that recognise the vital contributions made by the Hospice for local people. KAY GREENE RGN, DPSN-DN, BSc, MA HEAD OF CLINICAL SERVICES 23
24
Liz Hancock, Chief Executive Mary Ann Evans Hospice Eliot Way Nuneaton CV10 7QL Public Health Warwickshire Communities Group Warwickshire County Council PO Box 43, Shire Hall Barrack Street, Warwick CV34 4RL Tel: 01926 413712 Fax: 01926 410130 21 st June 2016 Dear Liz RE: Mary Ann Evans Quality Account 2015/16 Warwickshire County Council values the opportunity to provide comment on the Mary Ann Evans (MAE) Quality Account for 2015/16. I would like to start by acknowledging the vital contribution that the MAE hospice makes to the local community and in particular the significant impact its services has in improving the End of Life Care experience of patients, families and carers in North Warwickshire. The progress that has been made in relation to all of the hospice s challenging priorities for 2015/16 is commendable but in particular the County Council and local health economy has benefitted from the hospice s priority around partnership working, demonstrated through their contribution to Warwickshire s recent End of Life Care review. A wide range of hospice staff gave their time and expertise to the review with great enthusiasm and commitment. This contribution, alongside that of other local hospices and End of Life Care providers, has directly influenced the Improvement Plan for End of Life Care in Warwickshire and has been greatly appreciated by councillors and officers alike. The commitment of the hospice to partnership working is also exemplified through the wide range of community engagement initiatives that they have led or participated in. The Good Death Café focussed on raising awareness of End of Life Care among the Nuneaton community, local patients, carers and staff has been particularly successful and the ongoing work of the hospice in engaging wider 25
partners such as businesses and schools is recognised as being particularly valuable. The report does provide evidence of some of the challenges faced by hospices and other specialist End of Life Care providers both locally and nationally. For example, the need to ensure equitable access to services, particularly for the elderly and those with non-cancer diagnoses is a challenge for the entire health and social care system. The report demonstrates that there is scope to secure improved access for under-served groups, although the positive progress being made in terms of providing increased access to patients with non-cancer diagnoses in the bereavement and Hospice at Home services is notable. The County Council endorses the priorities identified for 2016/17, which resonate with many of our own priorities and those of the wider health and social care system. The commitment to Rehabilitative Palliative Care and to increasing the provision of community based care together with the strong focus on maximising wellbeing and securing improvements for carers are particularly welcome. There is a recognition that the hospice operates in a financially challenging environment which is compounded by increasing demand for services. Sadly this is a situation that all local public services are experiencing but it is hoped that with the commitment of MAE to continuing effective partnership working the North Warwickshire community will continue to benefit from the valuable services offered by the hospice. Yours sincerely Dr John Linnane MB BCH BAO MBA FFPHM (GMC registration number: 3216600) Director of Public Health, Warwickshire 26