Quality Account 2017/18 - www.mountbatten.org.uk
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Quality
‘A heartfelt thank you
to the most amazing
team of caring people.
Account
Without you we would
not have been able to
fulfil his wishes to die
peacefully in his own
2017/18 home. The support and
kindness you gave to
www.mountbatten.org.uk me helped me through
a very emotional time.’
Feedback from
a family member
Quality Account 2017|18 Quality Account 2017|18
Contents Part One
Part One Part Three
Looking Back
Our Mission,
Vision and
Our Mission, Vision and Values 3
Statement on Quality 4
3.1
Achievement Against our Priorities 24
Part Two
Values
3.2
Looking Forward People’s Experience
of Mountbatten Services 29
2.1 3.3
Priorities for Improvement 2018/19 6 Mountbatten Staff and Volunteers 35
3.4 In July 2015 Mountbatten published its new 2015 - 2020 strategy, outlining its future
2.2
Quality Across our Services 8 Statements of Assurance 37 direction and aspirations against a backdrop of challenges and demands faced by our
services. Our mission, vision and values are at the heart of this strategy and these
2.2.1 3.4.1 guiding principles have been developed in partnership with our staff, volunteers
Review of Services 8 Statement from The Isle of Wight
and trustees.
Clinical Commissioning Group 37
2.2.2 Our Mission • We are innovative and bold. We respond
Goals Agreed with Commissioners 12 3.4.2 quickly and creatively to the changing needs
To promote and to provide good care and of our society, within the scope of our human
Statement from Isle of Wight Healthwatch 38
2.2.3 support for those people living with, affected by, and financial resources.
Statement from the Care Quality Commission 13 3.4.3 or curious about death, dying and bereavement,
across the Isle of Wight. • We respect our community. We exist for our
Independent Statement from Carol Tozer, local population now and into the future, and
2.3
Participation in Clinical Audits 14
Director of Adult Social Services, Our Vision we believe that we can achieve more together
Isle of Wight Council 39 … is of a world where all dying people and by working in partnership with others.
2.4 those close to them have access to expert, Our values, which have been defined by our staff
Data Quality 20 3.5 and volunteers, are underpinned by a set of
Endorsement of Quality Account compassionate and cost effective care of the
2.4.1 highest quality, whatever the illness, whoever expectations and behaviours which we have
by Board of Trustees 40 all agreed to.
Data 20 they are and wherever they happen to be.
2.4.2 Our Values Strategic Aims
Glossary and Further Information 41
Steps to improve data 20 • We care about what we do. We appreciate We will:
How to Give us your Feedback 43 that people are different and we are kind and • Reach more people, to achieve scale
2.4.3 compassionate to our patients and families,
Acknowledgements 43 • Work in partnership, to achieve our aims
Information Governance 22 to our local community and to each other.
• Ensure our services to, and our impact on,
2.4.4 • We are experts in our field. We are
our Island community are sustainable for
professional at all times, aspiring to be the
Outcome Measures 22 the future
best that we can be in everything that we do.
2.4.5
SystmOne Electronic Patient Record 22
2.4.6
DATIX Risk Management System 23
|3
Quality Account 2017|18 Quality Account 2017|18
Statement
on Quality
During the past year, together with staff, volunteers, as well as our Board of Trustees A strong governance system is now in place care and support we deliver is integrated, well
and our local community, we have worked hard to continue to justify and sustain our with a named Caldicott Guardian, a new Data governed and supported in the most effective
‘Outstanding’ rating with the Care Quality Commission. Protection Officer and Senior Information Risk way possible.
Owner working together through a newly formed
As a dynamic and responsive organisation, it is Our strategic aims continue to be to develop Alongside this, you will also read about our new
Integrated Information Governance Committee
inevitable that we will persist in developing new scale, to lead our partners with our specific services and our absolute focus on responding
which reports to our Senior Management
and much-needed services and approaches, expertise and knowledge, and to ensure that to what our users tell us they want and need.
Team and the Board of Trustees. We have
responding to the growing needs of our local we are sustainable for the future. As we continue A new Mountbatten Coordination Centre will
also further developed a suite of Outcome
community through continuing to fill the deficits to grow, it is vital that everything we deliver is of enable us to reach the thousands of people
Measures (OACCS), and we are beginning to
in the local care system. the highest quality and scrutinised meticulously who are living with illness during the last five
be able to prove more strongly our impact on
through developing robust outcome measures, years of life, including those living with long-
people’s living, dying and remembering, as
gaining clear and concise user feedback, term conditions and also older people living with
well as across the wider system through the
developing strong evaluation models to prove increased frailty. Growing our education offering
development of a new set of key and concise
our impact on the wider health and social care also gives us more of an opportunity for us to
reporting dashboards. During the past year
system, and through careful and wise utilisation extend our reach, to touch the living, the dying
we have also implemented a new electronic
of our limited human and financial resources. and the remembering of more people, which is
patient record system, SystmOne. This puts us
essential if we are to cope with the challenges
You will read in this Quality Account that we have in direct relationship with our Health and Social
the future is already bringing to our door.
carried on striving hard to continue to prove our Care partners across our community, enabling
worth and also to ensure that our services are more effective communication and sharing Our intention has always been to give away our
sustainable and available for our community of information for the good of those we care expertise, what we know, to our partners, so
throughout the coming years. I believe that as an for. A new risk management system, DATIX, more people can receive care ‘The Mountbatten
organisation we are indispensable; what I mean enables us to keep accurate records of incidents Way’. We are outstanding, but we also never
by this is that our local community cannot do and complaints, ensuring timely response sit back on our laurels. We need to ensure that
without us, and neither can our local Health and and thorough inspection in the most effective the quality of what we do and what we develop
Social Care system. Our work is our message way possible. is always high; we also need to ensure that
and what we do matters. Creating a positive our partners strive to live up to this standard.
We know that what we do is of a high quality.
working culture, which is achieved by how we There is a value to generosity which is hard to
People tell us that the care they receive is
behave towards each other and by developing articulate. Hopefully our generosity, which is only
exemplary and truly focused on the individual
strong relationships with those who come to possible due to the generosity of our outstanding
and those who matter most to them. Good
us for care, as well as with our other partners, local community, will enable more people to
care is essential both to us and those that
gives us the confidence to be at our best at all receive high quality care, either from ourselves,
we serve, and we strive for it to be the best
times and in all that we do. Hopefully, as you or from those we pledge to support and to
it can be, always and without fail. However,
read this Quality Account, you too will catch this educate throughout the years ahead.
such a commitment to good care needs to
confidence and feel excited and proud of our be underpinned with thorough and effective I am able to confirm that the information in this
achievements and our continuous commitment systems and structures. You will see that this Quality Account is, to the best of my knowledge
to self-critique and focused internal examination. year, as our world becomes more concentrated and understanding, accurate.
A clear and increased focus on Information on regulation and scrutiny, we have focused
Governance during the last year gives us more, in a measured and sensible way, on Nigel Hartley
confidence that the security of information strengthening our systems to ensure that CEO Mountbatten, Isle of Wight
shared with us is both safe and contained. nothing is left to chance and that all of the
4| |5
Quality Account 2017|18 Quality Account 2017|18
Part Two
Looking
Forward Priority 2: Clinical Effectiveness
2.1 Target How we measure success
Priorities for Improvement 2.1 Develop a Mountbatten Care Coordination • Mountbatten Care Coordination Centre
1 April 2018 – 31 March 2019 Centre with Vanguard and private funding launched and fully operational
At Mountbatten, we continually review the for 2018/19. Users of our services, staff, • Able to demonstrate that 100% of patients
quality of our services to improve and develop volunteers, trustees and representatives from on the ‘Share My Care Register’ have a plan
them according to the needs of the community the Isle of Wight Clinical Commissioning Group of care
we serve. Understanding what is important to attended the focus group. A detailed action
our local community is critical to developing plan has been produced, identifying nominated 2.2 Review current Admiral Nurse service • Full review has been untaken and presented
future priorities. Therefore, our priorities were key leads to work with staff, volunteers, and for people living with dementia and develop to the Services Committee
discussed with a wide range of people. This users of the service to drive the identified a Dementia Strategy for future provision • Dementia Strategy in place approved at
has included holding an interactive focus group priorities for improvement. The Quality and of services Board level for the future provision of
in January 2018, where we asked people to Governance Committee will monitor the action services for those living with dementia
consider and discuss priorities for improvement plan quarterly.
Priority 1: Safety Priority 3: People’s Experience
Target How we measure success Target How we measure success
1.1 Develop a strategy, together with service • Risk-taking strategy approved by Services 3.1 Develop an Island community who are • First ‘Death Festival’ delivered on the Isle of
users, which promotes positive risk taking, Committee in place following consultation more at ease talking about death, dying and Wight in November 2018 as part of the ‘Art
enabling as much freedom and choice with service users bereavement, including planning a ‘Death of Dying Well’ programme
as possible • A series of Open Forum sessions Festival’ and using Mountbatten shops as a • A new model and approach piloted
delivered to staff and volunteers to venue for earlier conversations to take place in the Ventnor Shop to enable earlier
launch new strategy conversations about death and dying to
take place within community settings,
1.2 Further develop the volunteer role of • A series of training sessions delivered to with a full review reported to the
‘Mountbatten Neighbours’ working alongside enable development of patient-focused Resources Committee
clinical staff, supporting people and their competencies for volunteers
families in clinical settings. Train and involve • All patient-facing volunteers involved 3.2 Facilitate sessions, every two months, • Sessions held throughout 2018-19 every
volunteers in helping people with eating, in helping people with eating, drinking, inviting staff and volunteers, where stories two months for staff and volunteers to
drinking, personal care and social/leisure personal care and social/leisure activities of those using Mountbatten services are attend and share stories about people
activities have signed off competencies to reviewed. using Mountbatten services
demonstrate confidence and competence Collate a folder of evidence of these stories • A folder of evidence of stories has
in the role with appropriate consent been collated
6| |7
Quality Account 2017|18 Quality Account 2017|18
2.2 The Mountbatten Coordination Centre was Wight, of whom 1,804 have a formal diagnosis
Quality across our Services
launched in January 2018 and works in of dementia (NHS Digital, 2017). People living
partnership with other services, such as General with dementia often have one or more chronic
Practitioners (GP), District Nurses (DNs), long-term condition, highlighting the complexity
2.2.1 Specialist Nurses or Social Workers. Following a of caring for people with dementia and the need
referral to the Coordination Centre the following to consider people’s full range of physical, social
Review of Services services will be provided, depending on the and psychological health needs.
person’s needs:
During 2017-18, the Admiral Nurse has worked
During 2017/18 Mountbatten Hospice These areas are supported by the
• Initial and ongoing assessment by an expert with the wider Admiral Nurse team from the
provided specialist palliative care services following services:
Mountbatten professional Memory Service at the IW NHS Healthcare Trust
within the following areas:
• A comprehensive individualised plan, which to deliver support groups to meet the needs of
articulates and records the person’s wishes people living with dementia and their families.
• Inpatient Unit • Community Team for the future Approximately 18 people attend this group on a
• Day Services at John Cheverton Centre • Domiciliary Care @ Home Team regular basis. A recent evaluation has revealed
• Access to the 24/7 telephone advice and
(JCC) • Mountbatten Coordination Centre that all of those attending have found the
support line
• Community • Medical Team sessions beneficial and would recommend the
• Outpatients • Pharmacy • Access to Mountbatten volunteer services, group to friends and family if they needed similar
• St Mary’s Hospital • Psychological and Bereavement Services which may be able to provide a volunteer to support. A successful weekly Music Group has
• Nursing/Residential homes • Spiritual Care visit and to support at home also been launched in 2017 by the Admiral Nurse
• Social Worker • Access to activities at the John Cheverton and Music Therapist working together. Music
• Admiral Nurse (End of Life Care) Centre which will be discussed during the and emotion are linked in a powerful way and
for Dementia initial assessment people respond to music from a very early age,
• Physiotherapy • Rapid response home visit service for those before words and language are developed, and
• Occupational Therapy people who require urgent care and support this continues even towards the end of life, when
• Complementary Therapy verbal abilities may be lost.
• Creative Therapies – art, music and drama
• Specialist Lymphoedema Service Admiral Nurse (Advanced
• Education
Dementia and End of Life Care) Psychosocial and Spiritual Care
• Voluntary Services We will all experience bereavement at some
The Admiral Nursing service provides specialist
time in our lives, and although grief is a
dementia support, enabling more families living
natural and normal process it can sometimes
with dementia on the Isle of Wight to access
leave people feeling anxious and isolated.
Mountbatten • Introducing a central 24/7 contact telephone high quality palliative and end of life care,
Mountbatten Psychosocial Care leads the
number offering information and support, and wherever they are cared for. Admiral Nurses
Coordination Centre enabling direct access to support for health work alongside people with dementia, their
way with outstanding support for Islanders
Funding to the value of £340k has been received and social care professionals, patients and who are experiencing difficult times through
families and carers, giving one-to-one support,
from a private donor and Vanguard to support their families and carers bereavement. Services are open to anyone, of
expert guidance and practical solutions to face
this innovation for two years. The Mountbatten whatever age and wherever the death may have
• A rapid response out of hours visiting element the challenges with more confidence and less
Coordination Centre is a service for people who taken place. The team works with people who
to support the 24/7 advice line fear. Admiral Nurses also raise awareness
may be identified as being in the last five years have been bereaved through suicide or sudden
• Creation of a ‘Share My Care Register’ – a and increase understanding of dementia with
of life, or who may have palliative care needs. It and unexpected deaths, as well as those who
database that enables clinicians round the professional colleagues. They offer supportive
is for people living with any disease in which a are already under Mountbatten care. The level
clock access to information on the type and education to GPs, district nurses, health visitors,
deterioration may be life threatening. The service of bereavement care people need differs; some
location of care people would like to receive as mental health teams, memory services, and
will support choice by: people use their own existing care network
their illness changes or progresses, including staff in day care, domiciliary care, residential
made up of friends or relatives, others may find
• Improving the coordination and continuity of as they approach the end of life. The register and nursing homes. Admiral Nurses are trained,
it helpful to seek professional support, which
care and support for people and their families is hosted by the Mountbatten Centre and is developed and supported by Dementia UK.
includes one-to-one care and group support as
and carers available through SystmOne, the electronic The proportion of Isle of Wight residents well as therapy for families or couples. Regular
patient record. diagnosed with dementia is the highest in memorial services are also offered where people
England, and double the England average (Isle of can come and remember their loved ones, whilst
Wight Council Public Health Information Team, being supported by Mountbatten spiritual and
2016).There are an estimated 2,494 people bereavement care services.
aged 65+ living with dementia on the Isle of
8| |9
Quality Account 2017|18 Quality Account 2017|18
Mountbatten’s Psychosocial service for meditation and prayer, and building a network Enablement and Palliative • Training and piloting a small team of volunteer
adults includes a wide range of professional with local community clergy to ensure that the community assistants to work alongside
support, including from expert psychologists, spiritual needs of the dying are met. Rehabilitative Care people and their families to help them achieve
psychotherapists, counsellors and bereavement A successful funding application in June 2016 their personal goals and priorities within the
The Young Adults Transition service supports
volunteers, who are trained in supporting people led to the award of a grant from the St. James community
children and young people aged between 14 and
through their loss. Our service for children Foundation through Hospice UK for a total of There is evidence to suggest that this project
25 years, who have a life shortening condition,
and families, which is funded by our partners £35,000. has improved the total rehabilitative palliative
and their families. This service works alongside
KissyPuppy, the Sophie Rolf Trust, offers art, The project has promoted a shift in culture care score from 51/111 (August 2016) to
statutory and other Mountbatten services
music and drama therapy as well as counselling. towards blending compassion and care with 98/111 in February 2018 by using the tool ‘How
improving and enhancing the quality of lives
Again, these services are available in groups or enablement, empowerment, self-management rehabilitative is your hospice? A benchmark for
of those using the service and their families.
individually to suit the person’s individual needs. and rehabilitation of people with advanced best practice’ (Hospice UK, 2015).
The service has evolved to incorporate three
In September 2017 we welcomed a new Spiritual integral themes: illness and at the end of life, across all
Care Lead, ensuring that Mountbatten has a full Mountbatten clinical care settings. The focus
time spiritual care service. This service is vital • Care Co-ordination of the project has been on enabling rather than Patient Services Strategic
The young people and their families have
and central to our work in palliative care. The
identified that having one point of contact is
disabling people and embedding a culture of
empowering people to live well, focusing on their
Implementation Plan Year 3
Spiritual Care Lead works alongside a team of
important to them because they sometimes individual goals. Following the publication of the Mountbatten
volunteers to provide spiritual support to patients
felt overwhelmed by the amount of Strategy 2015-2020 and strategic
and their families across all Mountbatten The Head of Quality, who is an experienced
appointments, phone calls and organisations implementation plan, senior members of the
services. This is provided through memorial physiotherapist from a rehabilitative background
that are involved in managing their care. This clinical teams from across the organisation
services, reflective groups, weekly death chat, in both palliative care and working with older
can be especially difficult during times of joined together to agree the priorities for the
staff support and a weekly Sunday communion people, led the project.
‘crisis’ and if there are other siblings to care development of services during 2017/18. A total
service. The Spiritual Care Lead has taken
for. Families can now contact the Young Adult The project commenced in September 2016 and of thirty-five objectives and over one hundred
funerals for patients seen by Mountbatten
Transition service by phone, text or e-mail was completed in February 2018, achieving the and fifty key actions were agreed under the
services as it has been important for families
and request support. Each young person following outcomes and activities: following themes:
to continue an on-going relationship. Future
developments that are planned in the service receives an initial assessment on referral • Development of training and education for • Demonstrating and evidencing compliance
include: regular relaxation and meditation into the service and will then be reviewed staff and volunteers across all clinical settings and quality improvements across the
sessions, a contemplative prayer group, use of on a three-monthly basis. An individual in an enablement and rehabilitative approach, organisation
the space within the building and its gardens for package of support is developed based on including competency-based training, and • Implementing new national outcome
a person-centred approach, with liaison with embedding the principles into induction and measures in palliative care to evidence and
other services. mandatory training for all staff and volunteers demonstrate the quality of services
• Transition • Implementation of circuit exercise in the gym • Further developing Nurse-Led Palliative Care
Transition between paediatric and adult for people with advanced illness and at end on the Inpatient Unit, including development of
services can be a worrying and uncertain time of life, including development of sessions for the workforce
for young people and their families. The Young those with Lymphoedema • Implementing a new model of planned and
Adult Transition service facilitates a transition unplanned day care services in the John
• Implementation of a self-management
process that aims to be timely and seamless, Cheverton Centre
‘Positive Steps to Well-being’ programme
commencing when young people are 14 years
for people with life limiting and long term • Developing a rehabilitative and enablement
of age.
conditions and their families and carers approach across all clinical services
• Activities • Development of documentation to support • Further developing psychosocial, spiritual and
The Young Adult transition service promotes ‘what matters most to me’ person-focused bereavement services across all ages to meet
time for fun and enjoyment through activities goal and priority setting, across all clinical the needs of users of the services
such as participating in Young People’s care settings
Days or completing a bucket list. The Young • Working in partnership with the IW NHS
• Development of an information leaflet for Trust and Isle of Wight Motor Neurone
People’s days are held one Saturday every
patients and families to help preparation Disease (MND) Association, implementing
month and one day a week in school holidays
for an admission to Mountbatten Hospice, multidisciplinary MND clinics in the John
in the John Cheverton Centre.
emphasising a commitment to normality Cheverton Centre
as much as possible and provision of an • Further developing the Mountbatten
enablement approach, where appropriate Community Service model and provision,
including delivering a 24 hour and seven day
week service
10 | | 11
Quality Account 2017|18 Quality Account 2017|18
• Further developing the Hospital Palliative Care 2.2.2 2.2.3 A synopsis of the CQC’s
Team model and provision
• Developing Mountbatten Volunteers and Goals agreed with Statement from the Care summary of their inspection
Education and Research Commissioners Quality Commission is as follows:
One quality improvement goal was agreed with Mountbatten Hospice is required to register as “The Earl Mountbatten Hospice provided an
the Isle of Wight Clinical Commissioning Group a provider of healthcare services with the Care outstanding service that creatively enabled
Quality Improvement for 2017-19 and this was: Quality Commission (CQC). Earl Mountbatten people to choose where they wanted to receive
end of life care. People spoke of a service that
Action Plan 2017-19 To improve Advance Care Planning (ACP) across
Hospice is currently registered to provide the
was tailor-made for them, highly personalised
following activities:
The Quality Improvement action plan has been the Isle of Wight by: and focussed on their individual needs and that
developed in the latter part of 2017. The plan • Personal care of their families. Earl Mountbatten Hospice
• Agreeing and putting in place systems and
ensures that Mountbatten services continue to processes to ensure that the relevant patient • Treatment of disease, disorder or injury has developed services innovatively with local
demonstrate and evidence quality improvements population can be identified • Diagnostic and screening procedures agencies to ensure their population received the
in line with the Care Quality Commission key support they needed at the time they needed it
lines of enquiry in the domains of, are our • Ensuring that the relevant workforce receive Earl Mountbatten Hospice did not participate
appropriate training and in a place that best suited them.
services safe, effective, caring, responsive and in any special reviews or investigations by the
well-led? • Incorporating Advance Care Planning CQC during 2017/18. The CQC has not taken People, their relatives and staff spoke
conversations into consultations with patients enforcement action against Earl Mountbatten overwhelmingly of the positive support, guidance
A total of forty-three key objectives have been and carers. and healthcare interventions that people had
Hospice during 2017/18.
agreed, which are monitored monthly by a team received. They were full of praise for the staff
of senior staff from across the organisation In year one of the two year project the following Mountbatten services are subject to periodic in terms of their kindness, compassion and
and quarterly at the Quality and Governance has been achieved: inspections by the CQC and the last inspection knowledge about end of life matters.
Committee. was carried out by four inspectors on the 30th
• Recruitment of an ACP Facilitator Managers showed outstanding leadership and
and 31st January 2017. It was an announced
• Submission of a two year project plan and inspection to ensure that the staff the inspectors they recognised, promoted and implemented
key performance indicators to the Clinical
Financial Considerations Commissioning Group
needed to speak with would be available. CQC’s innovative ways of working in order to provide
model of inspection for providers changedLast in rated a high quality service. The management team
Earl Mountbatten Hospice is a registered
.
• Establishing and formalising an agreed new 2014 using a framework of key lines of 22 enquiry
March 2017 promoted a culture of openness, reflection and
charity and our patient and family services are excellence. There was a kindness and warmth
ACP template on SystmOne patient electronic .
encompassing five themes and questions: is the
delivered free of charge to our Island community. Earl Mountbatten Hospice
about the management team that made them
notes and a method of sharing ACPs with GPs service safe, effective, responsive, caring and
Mountbatten services cost over £7 million in the approachable to everyone and people knew them
and district nurses well-led?
Earl Mountbatten Hospice
financial year 2017/18. by their first names and told us they were visible
• An ACP training programme has been devised The CQC’s findings are shown below:
We rely heavily on the support of our community and implemented to improve knowledge, skills and solved matters when they were raised. Staff
through donations, legacies, investments, grants, and confidence of staff in facilitating ACP were involved in the development of the values
and through our charity shops. In addition to conversations. A 2 hour session has been and vision of the service.
Overall
NHS Isle of Wight CCG funding, we raised over delivered monthly to Mountbatten clinical staff rating
Inadequate Requires
improvement
Good Outstanding
Governance of the service was of a high
£4 million, enabling us to continue to deliver and to local health and social care workforce standard and robust quality assurance systems
compassionate and timely care to local people, since September 2017 and will continue to run were in place that showed people were right to
in the place of their choice. monthly throughout 2018. Over 100 staff have have confidence in this local hospice”
Mountbatten services receive an annual attended training (September 2017 – February Are services
(Care Quality Commission, 2017, p. 2)
sum from the NHS Isle of Wight Clinical 2018). Safe? Good
Commissioning Group which equates to Income of £67,666 for each of the two years
approximately 32% of our total income for the ending March 2018 and March 2019 was
Effective? Good
year ended 2017/18. conditional on achieving improvement and Outstanding
Caring?
We review all our services continually to ensure innovation goals through the Commissioning
we are delivering them efficiently and that we for Quality and Innovation Schemes (CQUINS) Responsive?
Outstanding
spend our money wisely. This is particularly payment framework. The work has progressed Outstanding
important in the light of the challenging and implementation of year one’s objectives Well led?
economic climate we currently face. High quality, have been achieved.
compassionate care for our patients and their
families remains our number one priority. The Care Quality Commission is the independent regulator of health and social care in England. You can read our
inspection report at www.cqc.org.uk/location/1-126737931
We would like to hear about your experience of the care you have received, whether good or bad.
Call us on 03000 61 61 61, e-mail enquiries@cqc.org.uk, or go to www.cqc.org.uk/share-your-experience-finder
12 | | 13
Quality Account 2017|18 Quality Account 2017|18
A quarterly comprehensive governance and Visiting Fellow
assurance report informs the Patient Services
Our Chief Executive (CEO) has been asked to
Committee and the local Clinical Commissioning
become a Visiting Fellow at the University of
Group. The report includes completed audits,
Southampton.
experience survey reports, data gathered
from incidents, feedback, mandatory training He currently provides a number of sessions both
compliance, staff sickness rates and a summary in the Palliative Care department and also in the
of the status of the risk register. Management School.
Since January 2014 Mountbatten Hospice has
taken part in Hospice UK’s national benchmarking
scheme. Using benchmarking data enables University of Southampton
hospices to improve quality by comparing Partnership
their performance to identify improvements We continue our development discussions
that have been successful in other hospices. with the University of Southampton, including
The benchmarking reports are used to consideration of the following:
assure and provide evidence of quality to the
Board of Trustees, CQC and our local Clinical • Clinical Doctorate post:
Commissioning Group. Two working groups of This post will be taken from existing vacancies,
clinicians, working across all clinical settings, supported by some funding from the University.
meet regularly to monitor pressure ulcers and It will be a clinical post e.g. Nursing, Social
patient falls. These groups evaluate national Work or Allied Health Professional and the
guidance, review all reported pressure ulcer post-holder will work clinically for part of the
and falls incidents and share good practice and week and spend some time researching into
lessons learnt with their clinical colleagues. key, agreed projects being undertaken by the
hospice. We are hoping to develop these roles
For completed local surveys see section 3.2 of further during 2018
the report: ‘People’s Experience of Mountbatten
• Clinical Teaching Fellowship:
2.3 Services’.
One of our Clinical Nurse Specialist team is
Participation in Clinical Audits a Clinical Teaching Fellow at the University
• Practicum:
National Clinical Audits Regional Audits Participation in We are currently developing a potential
During the period 2017/18 there has been one
national clinical audit relating to Mountbatten
There were no requests from NHS England or the
Isle of Wight Clinical Commissioning Group for
Education and ‘practicum’ programme for a small number of
our more senior clinical staff. This programme
services. The Controlled Drugs Regulation specific audits during 2017/18. Research will support them in teacher training, learning
to write more academically, and prepare them
Team has compiled the Controlled Drug Self-
Assessment Tool. The tool is designed to help Local Audits and Surveys Head of Education and Research to support our education programmes.
the Controlled Drugs Accountable Officer (CDAO) A series of workshops was held in February 2017, We have appointed a new Head of Education and
assess their organisation’s arrangements for where an annual organisational audit programme Research who started in March 2018. The new
controlled drugs governance and identify areas was devised, consisting of 54 different audits. The post holder is a nurse by training and has much
requiring improvement. The tool covers the audit programme is monitored through the Quality experience in the University sector; she joined
following aspects of controlled drugs governance: and Governance Committee on a quarterly basis. us from King’s College, London where she was
access to controlled drugs, standard operating The results of audits undertaken are reported an Associate Professor in the School of Nursing
procedures, management of controlled drugs in and monitored at the Education and Research and Midwifery. We are currently working with the
hospital pharmacy, management of controlled Committee meetings and are displayed on quality University of Southampton regarding how the
drugs in hospital ward/department, transport of information boards for staff, volunteers, patients role will be utilised there.
controlled drugs, auditing (including recording and visitors to view.
and monitoring), and reporting of controlled drug
A chart showing a sample of completed audits
incidents and information sharing.
can be found on pages 17-19 of this report.
Mountbatten Hospice has completed the
controlled drug self-assessment tool and is
compliant in all related areas.
14 | | 15
Quality Account 2017|18 Quality Account 2017|18
Island Better Care Spirituality in Hospice Care Sample of Completed audits during 2017/18
Together Project A new book entitled ‘Spirituality in Hospice
Mountbatten Hospice has been commissioned, Care’ was published in December 2017 and Audit Subject Area Outcome Actions
via funding from the Island Better Care Fund, to co-edited by our CEO. Three chapters within
develop and deliver a new and innovative three the book were contributed by members of the Call Bell Inpatient Unit • Call bell audits were completed in each quarter
year training programme for local nursing and Mountbatten team. of 2017/18. The standard of call bells being
residential homes and domiciliary care providers. answered within 2 minutes was met in 100%
Initially, the programme will support providers of cases. Call bells were found on average to
who have received a Care Quality Commission Hospice UK Conference Posters be answered within 35 seconds (range 1-120
(CQC) rating of ‘Inadequate’ or ‘Requires Six members of the hospice team attended seconds). Quarterly audits will take place in
Improvement’. The programme focuses on two the national Hospice UK annual conference in 2018/19 to monitor
of the CQC’s five Key Lines of Enquiry, ‘Safe’ November 2017. The conference was entitled
and ‘Well-Led’. ‘Leading, Learning and Innovating’. Six posters Mountbatten Community • A Community Equipment Service delivery
were accepted from the Earl Mountbatten team Community Equipment response times audit was completed in quarter 2.
The first programme commenced in January
for presentation as follows: Equipment Service The standard of delivery of prescribed equipment
2018. Ten care providers were represented,
with 23 participants in attendance ranging from • Mountbatten Memories: celebrating 35 years Delivery Response within 12 working hours for urgent equipment and
proprietors to registered managers and deputies. of our hospice Times within 3 working days for non-urgent equipment
Four programmes will be facilitated over the • Bridging the Gap: creation of a lifespan provision was met in 100% of cases other than
course of 2018, with ongoing evaluation and bereavement service when a family member requested a different
programme development as required. delivery date and the equipment was delivered by
• Enabling not Disabling
In addition to the five day classroom based the clinical team on their next visit
• 8 Positive Steps to Wellbeing
training, there is a three month period during • An annual audit will take place in 2018/9 to
which providers will be supported by the • Hospices in Harmony: the community choir monitor. A Community Equipment Service
Mountbatten Team to progress their individual phenomenon collection response time audit is also carried out
quality improvement plans. • Aspiring to be the best we can be – annually
a hospice journey
Controlled Drug Pharmacy • The Pharmacy team audit the CD order book,
35 Anniversary Conference
th (CD) stock register, patients’ own CD register, returns/
disposal, prescribing CDs and discrepancies
Mountbatten’s inaugural conference was held on
quarterly. Feedback is given to the team where
3rd November 2017 and was attended by health
discrepancies are identified, and these are fully
and social care staff from the Isle of Wight and
investigated where applicable. Quarterly audit to
the South Coast. Feedback has been extremely
continue in 2018/19 to monitor
positive. We are planning for this to become
an annual event and we are currently planning
another conference in November 2018. Infection Control Inpatient Unit • Monthly audits carried out − over 90% compliance
demonstrated on each audit other than in five
individual standards over the year − A hand hygiene
audit was introduced for volunteers on the Inpatient
Unit and compliance has increased from 93-100%
over quarter 4
• Actions plans in place after each audit and
work with nursing, housekeeping and facilities
staff to ensure wide ownership of actions and
improvements within practice
• An external audit carried out by Infection Control
Consultancy in September 2017 revealed 91.91%
compliance achieved across all areas. Full action
plan in place & monitored
• Internal monthly audits will continue in 2018/19
with external audits taking place twice a year
16 | | 17
Quality Account 2017|18 Quality Account 2017|18
Sample of Completed audits during 2017/18
Audit Subject Area Outcome Actions Audit Subject Area Outcome Actions
Medical Gases Facilities • An annual Hospice UK audit carried out in Safeguarding Adults Social Work • Local Safeguarding Adults Board audit of
January 2018. 100% compliance in all subtopics arrangements to safeguard adults audit tool
in the audit completed for the first time in quarter 2.
• An annual audit will be repeated in 2018/9 The audit indicated 5 standards were fully met
and 2 standards partially met. An improvements
Nutrition & Inpatient Unit • Nutrition and Hydration audits were completed in action plan was put in place which is monitored
Hydration each quarter of 2017/18 following staff training on by the Social Worker
the Inpatient Unit in 2017. Standards were met in • An annual audit will take place in 2018/19 to
>90% of cases when audited. Results shared with monitor improvements
team for ongoing learning and improvement
• Quarterly audits will continue in 2018/19 Safeguarding Social Work • Local Safeguarding Children’s Board audit of
Children arrangements to safeguard and promote the
Patient Slips, Inpatient • First falls audit carried out in quarters 2 and 4 welfare of children audit tool completed for the
Trips and Falls Unit and following the implementation of a new falls care first time in quarter 2. The audit indicated 21
Community plan within the electronic patient record as part of outstanding, 33 good, 5 requires improvement
Team locally implementing the Hospice UK Falls Toolkit areas. An improvements action plan was put in
• Further work to complete in 2018 to ensure the place which is monitored by the Social Worker
Falls Risk Assessment Tool and care plan is • An annual audit will take place in 2018/19 to
used consistently in the community and patients monitor improvements
are given written/oral falls information across
all services
Venous Medical • Standard of VTE treatment or prophylaxis being
Thromboembolism prescribed where indicated has been met in 100%
Patient Led Inpatient • Teams (including users of Mountbatten services, (VTE) Prevention of cases
Assessment of the Unit & John Trustees, clinical, housekeeping and facilities
Care Environment Cheverton staff) carried out environmental assessments • Quarterly audits will continue in 2018/19
(PLACE) Centre six-monthly in each area. Issues were identified
and a full action plan put in place and reviewed
by the team
• Six-monthly audits will take place in 2018/19
to monitor
Pressure Ulcer Inpatient Unit • An annual Hospice UK audit was carried out in
October 2017. This audit ensures that patients
who are at risk of development pressure ulcers, or
those with an existing pressure ulcer are managed
in line with national guidelines. All standards met
>80% compliance other than for discharge but
only 2 sets of records audited. An action plan in
place for improvements and on-going monthly
internal audits
• An annual audit will be repeated in 2018/19
18 | | 19Quality Account 2017|18 Quality Account 2017|18
2.4 Performance Data Phase of Illness at admission Mountbatten Allied Health
Data Quality A total of 1895 people were seen in 2017/18, with
an average of 709 open cases to services at the end
for all people admitted to the Professions (Occupational
of each month, and 855 people receiving services at Inpatient Unit during 2017-18 Therapy and Physiotherapy)
2.4.1 the end of the year. • 202 patients were referred to Physiotherapy
and 126 patients to Occupational Therapy
Data This compares with 1799 people seen during 36
327
368 during 2017/18.
Mountbatten Hospice is not required to submit 2016/7 and 581 people receiving services at the
• A total of 196 home visits were carried out by
records to the Secondary Uses service for end of 2016/17. 100 169 the Allied Health Professional Team in 2017/8.
inclusion in the Hospital Episode Statistics.
Mountbatten Inpatient Unit 1308
A quarterly service activity report is provided to
the Isle of Wight Clinical Commissioning Group
• There were a total of 447 admissions to the Stable
Mountbatten Lymphoedema
Mountbatten Inpatient Unit during 2017/18, with Unstable
which is first approved though the Quality and
40% being admitted from St Mary’s Hospital
198
3566
Deteriorating
Service
Governance Committee and also presented to • The Lymphoedema Service received a total of
compared to a third in 2016/17.
the Services Committee. Dying
107 referrals in 2017/18. This included those
• The average length of stay in the Mountbatten
Inpatient Unit during 2017/18 was 9.6 days with palliative and non-palliative conditions.
2.4.2 • 35% of people admitted to the Mountbatten Mountbatten at Home • The Lymphoedema service saw an average of
Inpatient Unit returned home (including to 228 people each month during 2017/18.
• A total of 577 new people were seen and
Steps to improve Data Quality nursing and residential homes). supported by the Community Clinical Nurse
During 2017/18 a number of initiatives have Specialist (CNS) team in 2017/18. Mountbatten at St Mary’s Hospital
been put in place to improve data quality. • A total of 3346 visits were made by the wider • 466 people were referred to the Mountbatten
These include: Admissions to Mountbatten Mountbatten Community Nursing team. at St. Mary’s Hospital team and 138 people to
• Implementation of SystmOne Palliative Inpatient Unit the Mountbatten Discharge Coordinator (from
Hospital, an electronic patient record system, September 2017) during 2017/18. The teams
Phase of Illness at first contact for
500
which is shared with the General Practitioners supported people within the hospital setting,
and District Nursing teams on the Isle of Wight
400 82
people referred to Mountbatten arranged transfers to Mountbatten Hospice,
• Implementation of a DATIX Risk Management 83 143 and facilitated discharges home, working with
System 25 At Home during 2017-18 the wider hospital teams.
300
• Data and quality have been realigned to sit 42
within the same department, managed by the Mountbatten Admiral Nurse
Head of Quality 200 158
• The Mountbatten Admiral Nurse was referred
• A full time Data and Quality Assistant has 171 people with dementia during 2017/18.
been recruited to support in the provision of 100
high quality, timely and accurate management 596 • A total of 600 contacts were made with
information that meets both internal and 349 364 359 304 395 Stable people with dementia and their families
external requirements
0
2014/15 2015/16 2016/17 2017/18 Unstable during 2017/18.
• Performance dashboards developed for Other* Deteriorating
the Senior Management Team, Quality Cancer Dying Mountbatten Psychological
and Governance Committee, Resources
and Services Committees and the Clinical
& Bereavement Services
Commissioning Group, which include staff *Other relates to other diseases, including Mountbatten Day Services • 475 people were referred to the Psychological
and Bereavement service during 2017/18,
resource, financial, activity, quality, and patient neurological conditions, heart failure, respiratory
• 112 people were referred to day services compared with 340 people in 2016/17.
safety data disease, Dementia and Motor Neurone Disease
during 2017/18, compared with 72 people
• Team dashboards are currently in during 2016/17. • 229 people received bereavement support
development. during 2017/18.
• 244 people attended planned day services in
2017/18 compared with 104 people during • 140 families were referred to Mountbatten’s
2016/17. Children’s Bereavement service during 2017/18,
compared with 61 families in 2016/17. A total
• A growing number of people attend the John of 350 sessions of support were delivered in
Cheverton Centre socially and for groups. 2017/18, compared with 81 in 2016/17.
20 | | 21Quality Account 2017|18 Quality Account 2017|18
2.4.3 for patients and their families. Four outcome 2.4.6 It streamlines the organisation’s quality reporting,
measures from the OACC suite of measures giving an increased level of data intelligence
Information Governance that capture the phase of illness, the patient’s DATIX Risk Management System and forms part of the development of internal
During 2017/8 the Department of Health functional status, physical symptoms, The DATIX Risk Management system for incident and external performance dashboards. The
Information Governance Toolkit was psychological, emotional and spiritual, and reporting, feedback (complaints, concerns and system will enable the organisation to compare
completed. Level 2 compliance was achieved information and support needs have been written compliments) and the organisation’s Risk trends over time in the future, and become
in eight areas and Level 3 in nine areas, an successfully implemented into clinical practice. Register was implemented in November 2017. more proactive in managing incidents, feedback
improvement in two areas compared with All the outcome measures are embedded within The system has been built, working with DATIX, and risks.
2016/17. the electronic patient record system. tailored to Mountbatten’s unique needs across
Further work is being planned in 2018/19 to clinical and non-clinical areas.
This demonstrates that the organisation has
improved its processes to maintain protection fully incorporate outcome measure data within
and confidentiality of its patient information and performance and team dashboards to help
that it adheres to data protection legislation and inform clinicians and evidence the impact of the
good record keeping practice. care given to patients and their families.
During 2017/18 Mountbatten’s Information
Governance Group met quarterly, chaired by
the Head of Information and Communications 2.4.5
Technology, and information governance is SystmOne Electronic
monitored at every committee and at Board
level. Mountbatten Hospice has its own on-
Patient Record
site Caldicott and Deputy Caldicott Guardians, SystmOne is an electronic patient records
and Data Protection Officer. A new Integrated system. Its implementation in April 2017 across
Information Governance Committee was set all clinical areas was designed by a small team
up in March 2018, which now meets monthly at the hospice who consulted with the clinical
with new terms of reference and is chaired teams as part of this process. The system
by the Data Protection Officer. The Integrated improves links with primary care providers
Information Governance Committee has across the Isle of Wight and provides better co-
commenced work on the new EU General Data ordination of the patient pathway, with improved
Protection Regulations (GDPR) which come communication and more seamless patient care.
into force in May 2018. Action will be taken The GP practices and district nurse teams on the
during 2018/19 to further improve information Isle of Wight have also implemented SystmOne.
governance and data protection within the The transfer from paper patient records to
organisation and a robust action plan is in place Mountbatten’s first electronic patient record
to monitor this. system was successfully implemented with
robust planning, processes, training and on-hand
support from the implementation team during
2.4.4 the first weeks of staff using the system.
The implementation of SystmOne allows
Outcome Measures Mountbatten to control its patient and clinical
During 2017/18 the use of data. All data is now managed in-house ensuring
standardised palliative care a timely reporting and analysis of performance.
specific outcome measures A bi-monthly SystmOne User Group has been
across all clinical areas established with representation from
has further developed. all clinical areas, giving staff an opportunity
The Outcome and Assessment and Complexity to feed back and discuss future system
Collaborative (OACC) project is led by a team developments to improve clinical practice.
at the Cicely Saunders Institute, King’s College,
London working in partnership with Hospice
UK. The OACC project seeks to implement
outcome measures into palliative care services
to measure, demonstrate and improve care
22 | | 23Quality Account 2017|18 Quality Account 2017|18
Part Three • An annual mandatory training programme
for all volunteers across the organisation
Priority 2: Clinical Effectiveness
Looking
Target 2.1 To develop the role of Palliative Care
was delivered every month during 2017-18,
Discharge Coordinator to facilitate responsive,
with over 130 volunteers taking part in the
timely and coordinated discharge of patients
two day sessions. The sessions include
who are at end of life within St Mary’s Hospital,
training and annual updates in the mission,
when their preferred place of care is at home
Back
vision, values of the organisation; health and
safety; food hygiene, moving and handling; The discharge of a person who is nearing the
safeguarding vulnerable adults and children, end of life requires skilled, careful coordination
data protection and looking after yourself. and communication and can be highly time
The commitment to training has increased consuming. Supported by System Resilience
over time, with volunteers reporting the value funding for a period of one year, the Mountbatten
of training. Line managers are encouraged Discharge Facilitator role is responsible for
3.1 to generate participation through monthly actively supporting discharge and care at home
Achievement against our priorities for 2017/18 meetings with volunteers and uptake of
training is closely monitored through the
(or nursing/residential home), as a viable option
for people at the end of life who are admitted
Priority 1: Patient Safety Volunteer Development Group to ensure that to St Mary’s Hospital. Research suggests
Target 1.1 To develop an information leaflet, Target 1.2 To provide annual, mandatory there is a 100% commitment from volunteers that responsive, seamless discharges most
for carers of people with dementia at the end training for all volunteers across the to undertake the training. The sessions have often occur when one person is dedicated to
of life, about services available to them on the organisation consistently received good feedback, with the function to ensure that all aspects of the
Isle of Wight - to educate, inform and signpost an overall rating of the training showing an discharge process have been covered and
Volunteers support our work in every department average upward trend from 3.5 to 4.5 out of nothing has been missed. There are no winners
The information leaflet for family members and service. As part of our work of valuing our the score maximum of 5, over the period April- when a person’s discharge from hospital is
of those living with dementia was developed volunteers we have developed a robust programme September 2017. Evaluation has focused on delayed; the frustration is felt by the person
to ensure that they have relevant and helpful of training for all volunteers, which includes: the quality of the content and delivery of the themselves, their family and the healthcare
information at their fingertips. training rather than confidence in undertaking professionals, and when a person is in the last
• An induction volunteer training programme
The information in the leaflet is wide-ranging for all new volunteers. This was delivered specific volunteer roles. It is recognised that days or weeks of life, time is of the essence.
and highlights the frequent queries that arise during 2017-18, with over 50 volunteers volunteers undertaking the training have Ultimately the entire system is affected; the
when families are caring for someone living with taking part in the six-session programme. The different levels of experience of volunteering person does not want or need to be in hospital
dementia, to empower and enable them. It is programme provides comprehensive training, (from being new to the role to having and the bed cannot be used for other people who
clear and easy to read and navigate. It includes comprising six four-hour sessions covering a volunteered many years) and Mountbatten may need to come into the hospital.
and explains the following information: wide range of topics, including communication services are moving towards having more Early communication with people and their
skills, hospitality, customer care, complaints flexible volunteer roles, where volunteers move families is vital to establish what is important,
• how people are referred to the service
and incidents management and spiritual care. between areas, as required by the service. as many people who are at the end of life would
• groups available at Mountbatten The six session training has been formally choose to be at home or another care setting.
• tips for carers reviewed twice following feedback from
Target 1.3 To provide adequate resting places The Mountbatten Discharge Coordinator works
• further information, including useful resources volunteers, with improvements made to the across all wards and the Emergency Department
and websites. timing of sessions, content and programme, and facilities throughout the building to
assist those who are limited in mobility at St. Mary’s Hospital, having conversations
Information in the leaflet was agreed following and ensuring a facilitator is present at each with the person and their families to ensure the
session. The feedback from volunteers and/or function
consultation with users of the service. It is right decisions are made. This communication
due for approval by the Information Review attending the training has been very positive Patients and service users identified that as the allows them to feel supported and involved in
Group in May 2018. It was crucial to strike and encouraging, with most volunteers saying hospice building has grown and developed they the decisions about their care. The involvement
the right balance in terms of providing all the that they would recommend attending the would value adequate resting places throughout of the Discharge Coordinator with each
detail needed while at the same time making programme to every Mountbatten volunteer. the building to enable accessibility. For example, discharge varies: it can be very active and involve
sure families did not feel overwhelmed by too Feedback received included: the walk from the John Cheverton Centre to the organising equipment for home, arranging
much information. “Good to meet others” Art Gallery is some distance for those limited transport, ensuring medication is prescribed
“Useful to refresh my knowledge of policy in mobility and/or function. The User Group and handing over to district nurses or other
and procedures and to update myself on new and other service users have been consulted to care providers.
subjects” establish the ideal locations of resting places. The
appropriate furniture has been chosen and will be
“I feel included and better informed and
purchased in 2018 following receipt of funding.
updated. I’m encouraged to feel I belong and
to fully participate”
24 | | 25You can also read
