Quality Account 2014/15

QUALITY ACCOUNT 2014/15

Mildmay Mission Hospital Registered office: 19 Tabernacle Gardens London E2 7DZ

Company no: 1921087 Charity no: 292058

Part 1 – Responsible Individual’s Statement Mildmay Mission Hospital (hereafter referred to as ‘Mildmay’) is a voluntary charitable hospital and rehabilitation unit that delivers services to the NHS through the mechanism of multilateral contracts with over 20 London Clinical Commissioning Groups (CCGs) and Local Authourities. It also accepts duly scrutinised spot-purchased referrals from any other UK source.

1 Mildmay is registered with the Care Quality Commission to deliver services under two regulated categories, they are:

Diagnostic and screening procedures Treatment of disease, disorder or injury

It is a tertiary healthcare provider of specialist care and rehabilitation for people living with complex HIV-related conditions, particularly HIV Associated Neurological Disorder (HAND) also known as HIV-Related Neurological Impairment (HNCI) or AIDS Dementia.

On behalf of the Board of Trustees and Senior Management Team, I would like to thank all our staff and volunteers for their achievements over the past year - embracing both the challenge of change and the opportunity to enhance quality. Despite the very challenging funding climate, Mildmay has continued to provide high quality services while at the same time changing settings by moving into a new 26-bed hospital in Shoreditch. This occurred on 1st September 2014.

Clinical excellence, the patient experience and safety are of paramount importance for Mildmay, as well as developing new and existing services appropriate to patient needs.

The Board of Mildmay, The Mildmay Clinical Governance Committee (chaired by a Board member), and the Risk Management Committee, all meet regularly (quarterly, quarterly and monthly respectively) to ensure that there is adequate oversight of the services provided by the organisation, as well as the management of inherent risks.

I am responsible for the preparation of this report and its contents. To the best of my knowledge the information reported is accurate.

Ross White Executive Director CQC Nominated Individual Mildmay Mission Hospital 22nd June 2015

A statement from Mildmay about the quality of the service provided Mildmay provides a modern setting where the safety of patients, visitors and staff; the effectiveness of our interventions; and our responsiveness to patient need, remain the focus of providing a caring and well-led environment.

Patients who are referred into Mildmay come to us in very poor health, with HIV infection and other co-morbidities having caused physical and cognitive impairments, often coupled with psychological ill-health. Through our experience with a multi-disciplinary team approach (which involves nursing, medical and therapeutic interventions, as well as social and spiritual support) over 80% of patients can leave Mildmay’s rehabilitation programme for independent living in their own homes. Even for patients who require a longer-term nursing home placement following their rehabilitation at Mildmay, we can evidence (through the use of UKROC patient data) improvements in their dependency upon other people and gains in cognitive function.

2 Our Friends and Family Test shows that 100% of Mildmay patients surveyed stated that ‘they would recommend our service to a family or friend if they needed it’.

On the basis of the above, I believe that Mildmay provides and maintains a high quality service.

Dr Simon Rackstraw, Medical Director

Captured Comments 2014-15

‘I came here on a trial for four weeks as promised. May God bless the team who have worked with me throughout my stay. This is a place where I won’t forget your kindness’ – Patient Feedback Form on discharge.

‘I have never worked in this kind of setting before (rehabilitation). It was intriguing to see the kind of work that Mildmay does. Today I attended a physiotherapy session, an art therapy group and an inclusive service in the chapel’ – Student Nurse

‘I joined the keep fit class today led by the physiotherapist and was very impressed with the way that the class, while structured, was tailored to each client’s needs’ – Keith, Volunteer

Part 2 - Planned Priorities for Improvement 2015-16 2.1 Objectives 2.1. 1 Objective 1- Maximise Occupancy & Improve Quality We will continue maintain high occupancy levels while maintaining and improving the quality of our work. High occupancy is a key contributor to financial stability for Mildmay. As a small unit, subtle variations of referral can have a significant effect on cash-flow and hence viability. Demand for our services over recent years has gone hand in hand with increases in complexity of the conditions we treat. We see quality as not only being essential in maintaining standards for the people who use our services, but also as a means to an end in ensuring that Mildmay remains a preferred place in the minds of NHS Commissioners, Clinical Nurse Specialists (CNSs) and other referring agencies.

2.1.2 Objective 2 - Maximise Voluntary Income and Awareness Raising

We will seek to increase voluntary income to the charity. Diversification of income, both restricted and unrestricted funds from charitable sources, can contribute to achieving new objectives such as the development of innovative services, purchasing essential items of equipment and long-term stability. We will seek to raise awareness of the work of Mildmay by creating a visible presence at key conferences, and maintaining training and development (both internally and externally). We will seek to develop marketing materials which promote the organisation which protecting patient confidentiality.

3 2.1.3 Objective 3 – Learning and Research To establish a Research Group (chaired by our Medical Director) that will report into the Clinical Governance Group

To establish an Education Committee (chaired by our Medical Director) that will report into the Clinical Governance Group

2.1.4 Objective 4 – Extend the Scope and Activities provided in Day Services:- To extend the opening hours of Day Services to 5 days a week To pilot and roll out a Cognitive Skills Group to Inpatients and Day Services clients

To extend the physiotherapy input into Day Services

To set up a digital inclusion IT-suite and to run a digital inclusion programme as part of ‘Aspects of Daily Living’

2.1.5 Objective 5 –Upper Ward Development We will continue explore options to open the upper 12-bed ward at Mildmay, which will expand the hospital from 14 to 26 operational beds. This upper ward development might involve a diversification to a non-HIV use, OR a diversification of service provision within the HIV-field. Both are being explored.

2.2 Statements of Assurance from the Board. Mildmay delivers services under NHS contracts and in accordance with a service specification embedded within that contract. Four care and treatment pathways form part of our service specification: - These are:  Assessment and Rehabilitation  Complex Symptom Control  Respite Care  End of Life Care The Unit Medical Director, Dr Simon Rackstraw, is a Fellow of the Royal College of Physicians of London and continues to be in demand for knowledge sharing and information exchange. During the period, Mildmay submitted Quarterly Performance Reports to NHS Commissioners and referring clinical nurse specialists (CNSs) in the form of a Key Performance Indicator (KPI) table with additional narrative and commentary. At the closing quarter of the year of the year we had no reportable red indicators in the key performance indicator profile. During the year we had one quarter (Q1) where patient feedback was scant (reportable to commissioners) and one reportable exception in Q2 that our agency spend was 6% (the limit is 5% of the staffing budget)

4 Mildmay’s Senior Management Team also submitted quarterly reports to its own Board including snapshots of cases, statistics, management accounts and progress reports on key objectives. The Board received Risk Management Reports and Risk Profiles as well as reports on actions taken to limit/eliminate risk and improve quality. The Senior Management Team meets fortnightly to discuss incidents, staff performance, operational issues, and to drive forward the business plan. It oversees the function of a number of standing committees (Risk Management and Clinical Governance) and it ensures that a range of monthly internal audits are undertaken as well as the quarterly Morbidly and Mortality meeting. The 2014-15 year has seen a staff restructure as we move to a new hospital. The structure is designed to permanently staff one ward, with surge capacity onto the second ward. (NHS contract levels are not currently large enough to permanently run two wards). A permanent use for the upper ward is a key developmental target. The quality of service experienced by people who use our service is central to the way we work. Financial stability is also an ongoing concern for the Board. We are pleased to report a balanced financial position for the 2014/15 year.

5 Part 3 - Review of Quality Performance 2014 -15 3.1 Objectives 3.1. 1 Objective 1 Maximise Occupancy We will continue maintain occupancy levels appropriate to the needs of the community we serve. Demand for our services over recent years has gone hand in hand with increases in complexity and challenging behaviours. As a small unit, subtle variations of referral can have a significant effect on cash flow and viability. Mildmay maintained a high in-patient occupancy of 82% in 2014/15 and an even higher Day Service take-up of 89%. However, the complexity of patient referrals also increased, meaning that we had more long-stay patients. This meant an overall decrease in patient numbers during the year of 18%, while at the same time an overall increase in the length of admission to Mildmay.

All indications point to patient demand increasing in the future due to the profile of the HIV+ population in the UK (both age and late diagnosis).

Mildmay is currently operating on one of its two wards (a 14-bed ward), due to funding levels. A focus during the 2015/16 year is to open the second 12-bed ward.

3.1.2 Objective 2 - Maximise Voluntary income

We will seek to increase voluntary income to the charity. Diversification of income can contribute to achieving other objectives such as developing outreach work & innovation in service delivery.

Mildmay’s non-statutory income decreased from £692k in 2013-14 to £536k in 2014/15 (- 22.5%). This was due in the main to our hospital development campaign coming to an end in month five when we moved to the new hospital. It also reflects the extremely challenging economic environment in which Mildmay operates. Mildmay has just expanded its fundraising team by one-post in the run up to ‘Mildmay 150’ – a campaign marking 150 years of providing compassionate care from our base in the East End of London.

3.1.3 Objective 3 – Awareness Raising We will seek to raise awareness of the work of Mildmay, by creating a visible presence at key conferences, enlarging our stakeholder base, and maintaining training and development. We will seek to develop marketing materials which promote the organisation while maintaining patient confidentiality. Mildmay was granted the ‘NHS Information Standard’ kite mark in spring 2013 and this was reviewed and re-issued in October 2014. This is a quality mark for information that is clear, relevant, evidence based, authoritative, complete, secure, accurate, well-designed, readable, accessible, and up-to-date. Although a small unit, Mildmay continued to be highly commended as a training placement for 18 nursing students (18 last year), 20 medical students (14 last year), 6 GP doctors in training (6 in 2012/13), 2 dietetic students (3 in 2012/13), 1 OT student (2 in 2012/13), 2 psychology students (0 in 2012/2013) and 3 social care students during the period (8 in the

6 previous period). This helps raise awareness of Mildmay’s services when people qualify and move into their professions. The number of external talks and presentations were maintained at a high level as health professionals were encouraged to speak to their own professional sub-group meetings, conferences and events. Talks to non-clinical audiences also held up, most notably to churches. Mildmay also had promotional stands at the BHIVA (British HIV Association) conferences in Liverpool and London, at the NHIVNA (Nurses HIV Association) conference in Cardiff, PRIDE in London and at the Big Church Day Out in Steyning 2014.

3.1.4 Objective 4 – Move to new Site We seek to achieve an effective and efficient move to the new hospital in mid-2014/15. We will oversee the fit out and manage the building handover and systems testing in a four week window to maximise safety and to allow scope for learning about systems and equipment in the new unit. We wish to minimise disruption to the patients on site at the point of the move. We will ensure that the management and functionality of the new building meets the needs of our service and enables future flexibility. We will provide an environment fit for purpose for patients and their families: clean, safe and with the staffing levels and training appropriate to the setting. We will uphold standards of care, learn from any mistakes, strive for improvement, and place the patient at the centre of our decision making. Following a CQC inspection of the new Mildmay hospital on 7th August 2014, we received the certificate required to occupy the site. We moved on 1st-3rd September 2014. Apart from a challenge with the phone and IT system at the time of moving (for which a temporary solution was identified), the move went smoothly. Each ward room has an on-suite shower room and wc, eight of the 26 en-suites are wet rooms for wheelchair users, and both wards have an assisted bathroom, assisted shower room, a day room, office, etc. The hospital also has a gymnasium, chapel, a large day room, dining room, counselling room and an IT suite. This surrounds a secure and secluded garden. The previous hospital is in the process of being demolished.

3.1.5 Objective 5 –Innovation We will continue to explore the design of new services. We will build on our experience in the delivery of appropriate services for people living with complex HIV conditions. We will seek to extend funding for the specialist Black African Male Support Worker to deliver outreach services. We shall also explore the potential for an additional mental health service at the new unit that could respond to the continuing complex experience of late stage HIV infection and which would seek to address an identifiable gap in current health service provision in London. Additionally, we will look to pilot aspects of our day-service provision in other parts of London. In the first instance this is likely to take the form of a Peer Support Group. Much of objective 3.1.5 was not achieved during the year. We did seek funding to extend the Black African Male Support programme, but this was not forthcoming and the programme was curtailed at the end of the grant period in early 2015. In connection with mental health registration, this was deferred until we had moved into the new setting and had been operating in that setting for over a year. In connection with off-site day services, this has not been possible to fund and has now assumed a lower priority than the development of new Day Service programmes within the new hospital.

7 8 4. Commentary 4.1 Feedback Mechanisms Feedback from patients and day service users is obtained from a range of methodologies:  Anonymous Exit interviews/feedback forms (this includes the Friends and Families Test)  Discussion with Key Workers and front line staff  Our complaints mechanism  Feedback via their clinical nurse specialist  Day service client forum.  Patient/day client involvement in the Patient Led Assessment of the Care Environment (PLACE) will occur in the year ahead, drawing the service user perspective. It did not take place on 2014/15 due to our hospital move in September 2014.  Our Board includes an HIV positive trustee who not only can act as a Patient Champion, but importantly contributes to the governance and strategy within the organisation  Feedback from next of kin, carers, friends, visitors, relatives and significant others is encouraged in face to face encounters and by the provision of a Suggestion Box

4.2 Mandated statements 4.2.1 Review of Services During 2014-15 Mildmay had capacity for 5420 in-patent bed nights and 4320 day service placements. In 2014/15 we provided 4483 in-patient bed nights for 98 people (82% occupancy) and 3880 day service placements (89% occupancy) for 80 community clients and 44 inpatients. Notably Mildmay had more longer-stay patients in 2014/15 than in the previous year. In 2013/14 we provided 4514 in-patient bed nights for 120 people and 2927 day service placements for 65 community clients and 61 inpatients. In 2012/13 we provided 4602 in-patient bed nights for 118 people and 2238 day service placements for 81 community clients and 40 inpatients. Mildmay has reviewed all the data available to them on the quality of care, and have responded to lessons learned from incidents, admission difficulties & reviews.

Patients readmitted to the service NO patient was readmitted to Mildmay from home within 28 days of being discharged to home from Mildmay (Mildmay doesn’t receive referrals in the 0-14 reporting category, so this statement refers to the 15+ category). The figure for 2013/14 was 0. Mildmay considers that this data is as described for the following reasons: the patients were discharged at the correct time, having benefitted from a rehabilitation programme to a point where they were able to be discharged home to live independently. Each patient’s discharge was planned with the relevant support agency being involved. In order to maintain this standard Mildmay will continue to ensure that discharge planning remains effective and will liaise with referring agencies to ensure that the length of admission is appropriate to the needs of the patient.

Patient Safety Incident

9 There was ONE patient safety incident recorded during the year (one last year). A patient was not given fluids for six hours during a referral to an outpatient appointment at another hospital. No permanent damage caused, but concern about a series of disconnected events (which were not within our control) which led to this situation arising. Mildmay reported this as a matter of process. There were NO patient safety incidents which resulted in any harm, be they mild, severe or death. Mildmay, as a voluntary sector provider, was not able to identify any nationalised data source to give accurate comparators.

4.2.2. Clinical Audits During 2014-2015 NO national clinical audits and NO national confidential enquiries covered NHS services that Mildmay provides. During this period Mildmay UK participated in 0% of national clinical audits and 0% of national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquires that Mildmay was eligible to participate in during the reporting period are as follows: NIL. The local (internal) clinical audits and local confidential enquires that Mildmay was eligible to participate in during the reporting period are as follows: 12

4.2.3 Research The number of patients receiving NHS services provided or sub contracted by Mildmay in this period, that were recruited during that period to participate in research approved by a research ethics committee was NIL Mildmay was involved in conducting NO clinical research studies in HIV during the reporting period. NO clinical staff participated in research approved by a research ethics committee at Mildmay during this period Mildmay did participate in a number of conferences throughout the year, participating in panel discussions and presenting posters.

4.2.4 CQUIN NONE of the income of Mildmay Mission Hospital UK in 2014-15 was subject to CQUINs (Commission for Quality & Innovation payments) due to the complex nature of the service delivery. Therefore NO income was conditional on achieving quality improvements and innovation goals through the Commission for Quality and Innovation payment framework. The 2015/16 contract also contains no CQUIN provisions.

4.2.5 CQC Inspection The last unannounced routine CQC inspection occurred on 13th December 2013 (as reported in last year’s Quality Account), and were assessed across five areas:

Consent to Care and Treatment Care and Welfare of People who use Services Safeguarding People who use Services from Abuse Requirements relating to workers Complaints

Mildmay met the published ‘Essential Standards of Quality & Safety’ and its December 2013 unannounced inspection is available for scrutiny to the public on the CQC website.

10 Mildmay moved settings to a new hospital in September 2014, and in connection with this move received a planned CQC inspection on 7th August 2014, which approved the setting as being appropriate for the on-going provision of services.

4.2.6 Capturing and Measuring Data for Measuring Quality Mildmay’s uses iCare for recording some patient information, although it maintains paper- based notes as well - providing an archive which goes back to the first admission of HIV+ patients in 1988. iCare meets information governance requirements and is a programme used by a range of health & social care providers, including specific NHS bodies, to provide robust, and accurate outcome data. Mildmay follows the UK Rehabilitation Outcomes Collective (UKROC) data acquisition processes and provides data that is compliant with UKROC peer group comparison frameworks. This contributes towards the evidencing of outcomes for patients who access Mildmay’s services. The Caldicott Guardian at Mildmay is Dr Simon Rackstraw – Medical Director The Senior Information Risk Owner is Ross White - Executive Director

4.2.7 NHS Number & General Medical Practice Code Validity Mildmay has not submitted records during the reporting period to the secondary uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data as it is not a requirement of the contract with our commissioners. Mildmay safeguards the confidentiality of people living with a condition which still experiences stigma and discrimination in the community.

4.2.8 Clinical Coding error rate Mildmay was not subject to the Payment by Results clinical coding audit in 2014/15 by the Audit Commission.

4.2.9 Complaints & Incidents a) There were 5 complaints during the reporting period (6 last year)

b) There were TWO deaths of inpatients at Mildmay during the reporting period (None in 2013/14)

c) There were 40 general incidents recorded in 2014/15 (65 last year), of which 35% were falls (14 in total (40% the previous year, 26 in total)), 2.5% (1 in total) was a medication/drug chart error (11 last year), 7.5% (or 3 in total) were verbal/physical abuse of staff (8 or 12.4% in 2013/14)

d) One Serious Untoward Incident (SUI) was reported to the CQC which was also a risk to patient health (one SUI last year – no risk to patient health). A patient was not given fluids for six hours during a referral to an outpatient appointment at another hospital. No permanent damage caused, but we had concerns about a series of disconnected events (which were not in our control) which led to this situation arising. Mildmay reported this as a matter of process.

e) There was one medically adverse incident (please see d above AND the patient safely incident in section 4.2.1 (same incident)) – (one in 2013/14)

11 f) There were two applications to Deprive Someone of their Liberty (five in the previous year)

g) Mildmay reported two incidents to the CQC which affected the safe running of the service for more then 24-hours. These related to, respectively, the phone line and internet lines at the point of moving hospitals. The previous year there was one similar incident when a power surge took out some phone lines.

4.2.10 Summary hospital-level mortality indication (SHMI) The value, banding and supporting palliative care data which is used as a hospital level indicator which measures whether mortality associated with hospitalisation, was in line with expectation, does not apply to Mildmay as a tertiary health service provider.

4.2.11 Patient Led Assessment of the Care Environment (PLACE)

Due to an impending move to the new hospital in mid-2014, it was agreed with inspectors that a PLACE inspection would be deferred for a year. Many of the recommendations of the May 2013 inspection were addressed upon moving to the new setting. The previous PEAT assessment of 2012, gave an aggregate score of 82%.

Mildmay scored 'GOOD' in the previous PLACE Assessment in May 2013 (the highest level) with the exception of:

 Car park - signage bays and surfaces (the new hospital doesn’t have visitor parking)  No separate treatment room in the ward areas for minor procedures/wound dressing.  Transport management plan – (now complete).  Patient access to IT – (new hospital has Wi-Fi access for portable devices as well as an IT suite)  Patient access to a telephone.  Access to meals/snacks for family, relatives – (the new hospital has a vending machine)

4.2.12 Infection Control

Infection control standards are regularly externally audited throughout the year, with any recommendations either acted on immediately. These inspections took place in both our old setting and new setting. There are no outstanding concerns in respect of infection control at Mildmay.

4.2.13 Information Standard Kite Mark

Mildmay was awarded the Information Standard Kite Mark in Spring 2013. This was reassessed in October 2014 and a new certificate of compliance awarded on 13th October 2014

4.3 Mildmay’s Action in the NHS Outcomes Framework Domains; 4.3 1 Domain 1: Preventing people from dying prematurely The British HIV Association (BHIVA) ‘Standards of Care for People Living with HIV 2013’ states that late and very late diagnoses is a major cause of diminishing life expectancy for people with HIV, as well as ‘loss to follow-up’. The vast majority of patients referred to Mildmay are presenting with neurocognitive impairment relating to either late diagnosis or ‘loss to follow-up’.

12 Mildmay had two deaths in the reporting period and none in the previous year. This level, which is around 2%, is well within the limits we would expect.

4.3.2 Domain 2: Enhancing quality of life for people with long-term conditions Over 82% of patients referred to Mildmay return home to independent living following Mildmay’s intervention. The service aims to prevent health deterioration caused by HIV, by initiating prompt and appropriate management of HIV morbidity. The teaching of self-management skills and independent living skills contribute to the empowerment of the individual to make informed choices about their future care. As a discharge pathway of choice for two London Hospital Trusts, part of the function of Mildmay is to undertake assessment & rehabilitation and/or make recommendations for the future long term care and support of people living with HIV.

4.3.3 Domain 3: Helping people to recover from episode of ill health or injury Mildmay has particular experience in supporting and treating people with a wide range of complications resulting from the direct effects of HIV, its treatment and prolonged exposure to treatment, age, and an increasing range of associated co morbidities. Mildmay applies a multidisciplinary team approach to care that addresses the physical, psychological and spiritual impact of living with a serious illness. Rehabilitation is a partnership approach (between the team and patient) which aims to bring about the restoration of skills & ability (fully or partially), to enable the individual to have more choices in their future care and support options. Self-management in the long-term is part of this approach.

4.3.4 Domain 4 Ensuring people have a positive experience of care The use of key-working is vital in maintaining tailored care at Mildmay The engagement of patients as positive partners in the design of their care, rather than passive recipients, is at the heart of service delivery, although the cognitive and behavioural elements of neurological disorder can limit the capacity of an individual to engage. In some cases the use of the Deprivation of Liberty (DOLS) procedures can assist in the safe care of patients, in cases where they lack capacity.

4.3.5 Domain 5 Treating and caring for people in a safe environment & protecting them from avoidable harm This is achieved in a number of ways, by:  Providing a safe and secure environment with experienced, trained and caring staff  Working with patients / day clients to educate them about the mechanism of passing on the HIV virus, of the importance of adherence to medication, and the role of nutrition  Discussing issues of disclosure and stigma  Continuing professional development of Mildmay staff and providing mandatory training  Dealing with incidents and complaints quickly yet thoroughly, and seeking ideas for service improvement  Protecting patient data and maintaining confidentiality (HIV still remains stigmatised  Identifying risks and reducing/eliminating them

13 14 5. ANNEX sources of supporting statements In compliance with the regulations, Mildmay sent copies of our Quality Accounts to the following stakeholders for comment prior to publication.  The lead commissioners, commissioners and CNS  The Overview & Scrutiny Committee (OSC) of the London Borough of Tower Hamlets or its Health Board.  Health watch  The Friends of Mildmay

At the point of publication no specific feedback had been received.

Ross White 22nd June 2014 End