The Hillingdon Hospitals NHS Foundation Trust. Meeting of the Board of Directors

Transcription

1 The Hillingdon Hospitals NHS Foundation Trust Meeting of the Board of Directors Wednesday 25 May 2016, 2pm Board Room, Mount Vernon Hospital Paper a) Introductory business 1. Welcome and apologies for absence - 2. Declaration of hospitality or amendments to the Register of Interests - 3. Minutes of the Board meeting held in Public on 27 April Actions Log 5. Declaration of Any Other Business - 6. Patient Story (TM) for information - 7. Chair s Oral Report (RS) for information - 8. Chief Executive s Report (SDG) for information b) Monitoring 9. Safer Staffing: Planned and Actual Staffing Levels (TM) for review 10. Quality & Operational Performance Report (JS / TM / AK) for review 11. Financial Report (MT) for review 12. QIPP Report (JS) for review c) Regulatory 13. Annual Report and Accounts 2015/16 and Quality Report (MT) for approval 14. Annual NHS Improvement Board Statements for approval 15. Annual Patient Advice and Liaison Service (PALS) and Complaints Report (TM) for review 16. CQC Inspection Report and Action Plan (TM) for review

2 d) Other Business 17. Board Committees Appointments for approval 18. Use of Trust Seal/MoUs signed for information 19. Board Agenda Planner for information 20. Any Other Business Questions from the Public This item is an opportunity for members of the public to ask questions to the Board on matters that relate to the Board agenda. Where possible, questions should be sent to Carolyn Cullen, Trust Secretary, by Monday 23 May 2016 in order that the Board can ensure the information is available to answer the question raised. - Date of next meeting: Wednesday 22 June pm at Hillingdon Hospital.

3 ITEM 3 Board Meeting in Public THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS HELD ON WEDNESDAY IN THE BOARD ROOM, HILLINGDON HOSPITAL 27 April 2016 at 5pm Meeting held in public Present: Richard Sumray (RS) Abbas Khakoo (AK) Carol Bode (CB) David Searle (DS) Joe Smyth (JS) Katey Adderley (KA) Lis Paice (LP) Matt Tattersall (MT) Richard Whittington (RW) Shane DeGaris (SDG) Soraya Dhillon (SD) Theresa Murphy (TM) Chair Medical Director Deputy Chair and Non-Executive Director Director of Strategy & Business Development Chief Operating Officer Non-Executive Director Non-Executive Director Director of Finance Non-Executive Director Chief Executive Non-Executive Director Director of the Patient Experience & Nursing Apologies: None. In Attendance: Terry Roberts (TR) Vanessa Saunders (VS) Item 6 only Carolyn Cullen (CC) Also Present: Rekha Wadhwani (RWa) Terry Thompson (TT) Ian Bendall (IB) Armelle Thomas (AT) Vera Cook (VC) Joan Davis (JD) Keith Edelman (KE) Carl Powell (CP) Director of People and Organisational Development Deputy Director of Nursing Trust Secretary (Minutes) Governor Governor Governor Member of the Public Member of the Public Member of the Public Member of the Public Member of the Public ACTION 01/04/2016 Welcome and Apologies for Absence 1

4 RS welcomed Keith Edelman and Carl Powell to the meeting and explained that Keith Edelman and Carl Powell had been appointed Non-Executive Directors of the Trust and will begin their terms of office on 1 May ACTION RS also welcomed Matt Tattersall to the meeting; Matt has been appointed Director of Finance and has already taken up his post. 02/04/2016 Declaration of Hospitality or Amendments to Register of Interests None. 03/04/2016 Minutes of the last Meeting The minutes of the last meeting were agreed as an accurate record of the meeting, subject to correcting the spelling of Terry Roberts name. 04/04/2016 Action Log TM updated the Board on Charlotte s story heard at the November 2015 Board meeting which concerned end of life care. TM reported that the Trust had successfully recruited to an end of life care nursing post and that the outcome of a review on end of life care, including input from MacMillan Cancer Support, will be reported to the July Board Seminar. LP added that it would be useful to include information on end of life care choices on the Hillingdon Care Record. TM will include this suggestion in the review. DS informed the meeting that a revised Annual/Operational Plan and Financial Plan had been submitted to NHS Improvement (NHSI) following the Board s comments. DS explained that NHSI will provide a formal assessment of the plan; and once received, DS will circulate this to the Board. TM DS The Board agreed the alteration and the removal of those actions marked as complete. 05/04/2016 Declaration of Any Other Business There were no declarations of other business. 06/04//03/2 016 Patient Story : Elsie Vanessa Saunders, Deputy Director of Nursing presented 2

5 Elsie s story for her, and her family. Elsie was an inpatient at the beginning of March for a short episode of care. Elsie is 78 years of age and has had a stroke and has limited speech and mobility. Although her family stress that Elsie had good care at the Trust on her second day she was offered a wash by nursing staff. Although Elsie consented to the wash, she later became distressed as she had been washed by a male member of staff. ACTION VS stated that Elsie s story demonstrated two issues: one relating to privacy and dignity and secondly on communication with people with disabilities. On privacy and dignity this case has meant that nurses now ask if it is ok with a patient if a nurse from the opposite sex washes them. VS recognised that there was more to do on communication with people with limited speech; Hillingdon Council has paid for a nurse specialising in people with learning disabilities and much can be learnt from the specialist knowledge regarding this group that can be applied to others. RS asked what can be done today to improve. VS stated that extra time is now given to people with limited speech to understand best how to communicate with them. RS stated that the Board would want to ensure that these changes are consistently applied across the hospital. The Chair thanked Vanessa Saunders and TM for presenting this story.. 07/03/2016 Chair s Oral Report RS reported that he had met the Chair of Chelsea and Westminster NHS Foundation Trust and was now convening a meeting of the chairs of all North West London hospitals to discuss NW London planning and the governance that needs to go with this. The Chair of Lewisham and Greenwich NHS Trust had visited the Trust and RS had met the Chair of Buckinghamshire New University. RS and SDG had met the Chief Medical Officer of McLaren motor racing who had specialised knowledge of flow management useful to A&E departments. 08/04/2016 Chief Executive s Report SDG stated that he and TM had met the junior doctors on the 3

6 picket line. JS updated the Board that the assessment of the impact of the strike, which had finished at 5pm, was that no operations had been cancelled and only approximately 200 outpatient appointments had been cancelled on both days. However, the lists had been frozen, and so there is an estimated 13 working days backlog and significant pressure on meeting the 18 week target. AK pointed out that as April and May both have bank holidays this would make addressing the backlog more challenging. RS thanked JS and his team for their hard work, and a letter is going to all consultants to formally thank them; however, the learning needs to be captured and formally brought to the Board. ACTION JS The Board noted the report. 09/04/2016 Delivering the Strategy DS stated that compliance with the conditions of the NHSI licence is at risk in two areas: financial performance and achieving the required level of performance against the A&E standard. However the Trust was performing well against targets for referral to treatment time, cancer diagnosis and treatment times. KA highlighted that there was still some way to go on fully implementing the Friends and Family Test across the Trust and applying lessons learnt; particularly as although there was emphasis on answering complaints within the target rather than on learning from complaints. TM replied that the Annual Report on Complaints will be coming to the May Board meeting. The Board noted the report. 10/04/2016 A&E Performance Report JS explained that the report provides the Board with an overview of Hillingdon Hospitals' performance against the 4 hour A&E standard and outlines the actions being taken to recover performance. The Trust has been working with Hillingdon CCG on preventing attendance (this is led by the CCG) and reviewing patient flows and processes and procedures with the A&E Department. The report also looks at discharge planning and communication with Social Services and intermediate care. The CCG also commissioned Methods Analytics to undertake a full review of flows into and through the A&E Department. The 4

7 primary recommendation from Methods Analytics is the requirement to have a dedicated resource to deliver improvements to patient flows and implement the action plan. The CCG has agreed to fund a programme manager for 6-8 months to co-ordinate the response to recovering the four hour standard. ACTION JS emphasised to the Board that if demand is not curtailed there remains a considerable risk to achieving the four hour standard in 2016/17. TM added that the size and physical configuration of the department is not fit for purpose. SDG agreed and stated that additional major s capacity was required; and the positioning of the Urgent Care Centre (UCC) and land behind could be considered. KA asked if the IT system in A&E supported the service. JS replied that he was working with Charles Yeomanson to process map how the system could be improved. The Board noted the report and the action taken to recover performance. 11/04/2016 SaHF Paediatric Transition Readiness Assurance JS explained that the report forms part of the assurance process for Shaping a Healthier Future. The North West London Collaboration of Clinical Commissioning Groups requires the boards of sites receiving transferring activity to discuss operational readiness for paediatrics transition. JS stated that: Plans to transfer paediatric services and deliver the necessary associated estates work are well under way Recruitment is under way and significant progress has been made on increasing the paediatric nursing establishment Plans to deliver a resident consultant staffing model have been submitted to SaHF and funding requested. Subject to approval of this funding, the Trust can safely transition services from Ealing from 30 th June CB confirmed that the medical model had been fully considered at the Quality and Safety Committee. SD queried whether there was sufficient consideration of other support from pharmacy and allied health professionals. JS confirmed that this has been considered. 5

8 The Board confirmed its preparedness as at the end of April 2016 and confirmed its intention to proceed with a safe transition, subject to the approval of funding for the resident consultant model. ACTION 12/04//2016 Safer Staffing: Planned and Actual Staffing TM asked the Board to note average night fill rates were at or above 97% against plan at both sites. Patients categorised as high dependency significantly contribute to the higher than average care staff fill rates at night at the Hillingdon site. There were 98 RN/RM vacancies at the end of March. The piloting of the Suboptimal Staffing Incident Reporting Template has been completed but a review by the Director of Nursing and Deputy Director of Nursing (DDoN) has shown that the model is not accurate and has not improved objectivity. The DDoN is continuing to find a solution with a new trial commencing in May. RS commented that recruitment was still static. LP asked how the Italian and Spanish recruited nurses had fared. TM replied that only one of the cohort had left. TR stated that the quality of the induction was important. KA stated that there was an opportunity to increase staff accommodation as part of master planning at the Mount Vernon site. DS stated that the type and configuration of accommodation would be key; there was no conclusion yet as to whether accommodation would be part of the master planning. The Board noted the report. 13/04//2016 Quality and Operational Performance Reports JS outlined the key messages: there were no new cases of Clostridium Difficile infection in March. Response rate to the Friends and Family Test has improved and Maternity achieved their target in March and Inpatients is much improved. Greater focus is still required in A&E where electronic data capture is going to be trailed to improve response rates. March saw good performance against all the key operational metrics with the exception of the 4 hour A&E target. There was continued compliance with the 18 week elective standard. The Trust expects to be compliant with the 31-day and 62-day cancer standards in March. The 4 hour A&E target remains a challenge; with March in month performance at 85.3%. In March the vacancy rate was 8.64% against an 8.0% target 6

9 and the sickness rate was 3.57% against a 3% target. ACTION SD commented on the improvement in completing medical staffing appraisals. AK stated there was continued focus on infection control and informed the Board that he was hopeful to recruit to consultant micro-biologist posts as good candidates had come forward. The Board noted the report. 14/04//2016 Finance Report MT informed the Board that the Trust ended the year with a deficit of 1,488k, which was consistent with our forecast position since Month 9 and aligned with the position discussed throughout quarter 4 with NHSI. The Financial Sustainability Risk Rating (FSRR) remains at 2. The deficit is primarily driven by a 4.9m adverse variation on pay expenditure. Compared to March 2015 there are 89 more whole time equivalent staff. Against the NHSI target of 12% for the proportion of qualified nursing expenditure incurred as agency performance in March was 14.8%. Cash ended the month at 4.1m which is 741k above plan. Significant cash was received in March from Hillingdon CCG, Ealing CCG and East and North Herts NHS Trust. Capital expenditure for 2015/16 is 10,370k which is 780k below plan, reflective of the paediatric scheme moving from the first half of 2016/17. The Board noted the current and forecast financial performance of the Trust. 15/04//2016 QIPP Report JS stated that the forecast QIPP total for 2015/16 of 8m had been achieved. JS stated that there are confirmed schemes to the value of 7.2m for 2016/17 QIPP with a further 2.2m in the pipeline against a target of 9.14m. The Board: Noted the final delivery of the 2015/16 QIPP Noted the progress on the establishment of the 2016/17 QIPP. : 7

10 ACTION 16/04/2016 Clinical Pathology CPA Accreditation JS updated the Board on the outcome of the Clinical Pathology Accreditation (CPA) visit to the Pathology Department and the withdrawal of CPA accreditation status within the Haematology Department. The Biochemistry Department was awarded CPA conditional approval on closure by the end of April 2016 of a relatively small number of non-conformances. Following the clearance visit the assessors were unable to close 15 out of 44 conconformances identified in Haematology. Normally laboratories which have accreditation withdrawn have the opportunity to re-apply; but CPA is being replaced by ISO The Trust is currently assessing whether it should pursue ISO15189 compliance as a standalone Trust or as part of the North West London Pathology joint venture. RS asked whether it should have been anticipated that the Trust would not comply. JS stated that it was thought it was compliant but vacancies caused progress to slip back. RS asked when it is expected that Imperial Healthcare NHS Trust will get approval for the Pathology joint venture. JS anticipated June; JS will update the Board. JS KA stated that this withdrawal of accreditation is also a reputational issue. There should have been a plan to close off the 44 non compliances which should have been regularly monitored. The Board acknowledged withdrawal of CPA accreditation within the Haematology Department.. 17/04/2016 CQC Action Plan TM set out progress on outstanding actions in the CQC improvement plan, which is monitored by the CQC Steering Group and by Divisional Leads. A monthly mock inspection programme will start from 29 th April. Key areas requiring continued focus are: VTE risk assessment compliance Lockable storage solutions for medicines management Compliance with the National Early Warning System (NEWS) policy Discharge letter backlog for 2015/16. 8

11 ACTION The Board noted the report. 18/04/2016 Risk Register TM explained that the following changes had been made to the extreme level internal risk register since the last quarter: One new extreme level risk: Risk Ventilation non- compliant in Maternity Theatre 1 - Hillingdon Hospital Three upgraded risks: Electrical - Single point of failure 41 - The Management of Legionella and Pseudomonas in Trust Premises (Hillingdon Site) Estates: records of compliance with Health Technical Memoranda and statutory standards One down-graded risk: Risk Nursing staffing levels in the Trust The Board noted the changes to risks in the risk register since the last quarter. 19/04/2016 Health and Safety Report MT stated that the report presents information relating both to the period January to March 2016 and for the year April 2015 to March During this quarter the two highest sub-categories of the 68 reported accidents to staff were: contact with a hazard, (18) and Needle stick or sharps injury (23). Overall for the year, the total number of incidents on the Trust Datix system for 2015/16 is 1,315. An internal audit was completed on health and safety compliance in October 2015; the audit assessed key controls as only having limited assurance so an action plan has been put in place to address the recommendations made. KA confirmed that the Audit and Risk Committee will be reviewing progress against the action plan and recommendations at its July meeting. The Board noted the report. 20/04/ /16 Staff Survey TR explained that each year our staff undertake a survey 9

12 asking them key questions about their experience of working in our trust. ACTION Overall the 2015 survey findings present a positive picture. The survey results place many of our findings in the top 20% of acute trusts in England. Additionally, the Trust scored above average (or better) scores in 18 of the 32 key findings of which we were in the top 20% of all acute trusts in 10 key findings. The top five key findings for which the Trust compared most favourably with other acute trusts were: Staff witnessing potentially harmful errors, near misses or incidents Staff suffering work related stress in the last 12 months Staff motivation at work Quality of appraisals Staff appraisals in the last 12 months The Trust compared least favourably in five areas. These are recognised as areas that require improvement: Staff experiencing physical violence from staff/colleagues Staff/colleagues reporting most recent experience of violence Staff experiencing discrimination at work Staff believing that the organisation provides equal opportunities for career progression or promotion Effective team working Actions to address these areas have been included in the corporate action plan and local action will be taken at divisional level as appropriate. RS asked that the action plan be brought for discussion to a Board Seminar. TR KA asked if there was anything innovative that could be done to increase the proportion of staff completing the survey. TR replied that a breakfast session with input terminals in the canteen is being considered. 21/04/2016 Car Parking DS explained that the business case to generate an extra 48 car parking spaces on the Hillingdon Hospital site was approved by the Trust Board in December This paper informs the Board of the parking policy changes which will be pursued to manage the operational consequences of the implementation of the planning consent. 10

13 ACTION The actions planned to manage overall car parking demand are through changes to the staff parking permit distance criteria by increasing the baseline to three miles, site-wide public and staff parking segregation and the updating and refining the Green Travel Plan. The Board: Noted the plans for changes to the barrier entry system Noted the actions planned to manage car parking demand. 22/04/2016 Use of Trust Seal/MoU signed The Board noted the report. 23/04/2016 Board Agenda Planner The Board noted the agenda planner. 24/04/2016 Any other Business None. 25/04/2016 Questions from Governors and the Public JD asked what could be done to reduce the time that patients wait to get their prescription medication. JS replied that there are plans to expand the pharmacy service; and to have a pharmacy dedicated for outpatients to get their medication. VC asked if there are more cases of Clostridium Difficile this year. TM replied that although there are 12 cases recorded; only one is attributable to a lapse in care by the Trust. VC commented that she had visited a patient on Fleming Ward and thought that infection control would be improved by more use of side wards. TM replied that side wards are used; and in outbreaks of the Noro Virus one to one nursing is also used. AT asked if the Trust had sufficient Paediatric Registrars to manage the increased number of patients following the 11

14 transition of paediatric services from Ealing Hospital. ACTION AK replied that the consultant model described in the SaHF Paediatric Transition Readiness Assurance Report would not only help our staffing ratios but also the sector. AT asked if more could be done to get A&E patients to fill in the Friends and Family Test. TM replied that the Trust is actively pursuing this but it is a problem across London. AT was the Board aware that the villages near Sipson have been refused a GP; there is no direct public transport from Sipson to Hayes or Harlington. RS replied that he will take this up with the CCG. RS Date of Next Meeting The next meeting is scheduled to take place on Wednesday 25 May at 2pm at Mount Vernon Hospital. Richard Sumray Chair Date. 12

15 ITEM 4 Board action log - public session Green Complete Amber In hand / not yet due Red Overdue / date to be confirmed NHSI comments/response on our Annual/Operational Plan to be Annual/Operational P circulated to Board members when received. DS May Questions from the Public Inadequate provision of GP services to villages near Sipson. RS Jun Staff Survey Action plan taking forward results of staff survey to be considered at June Board Seminar Patient Story Review the social media policy in relation to patient complaints. TM Jun Safer Medical Staffing Patient Story Report to review the adequacy of medical staffing in terms of numbers and skills and actions being taken to address gaps. AK to report back in June 2016 on progress on improving the transition of care for patients graduating paediatrics to adult services with long term conditions. NHSI has not yet responded with their comments on our Annual/Operational plan. RS to take inadequate provision of GP services with Hillingdon CCG. In Hand Not yet due TR Jun-16 Item on Board Seminar Not yet due AK AK Jun-16 Jun Patient Story TM to review the patient experience for the 17 to 21 age group. TM Jun Maternity Picker Survey Survey of mothers who gave birth at Hillingdon Hospital in February 2016 is being undertaken. The results from this, and an update on progress on the action plan drawn up as a result of the Picker Survey will be presented to the June 2016 Board. TM Jun-16 Revised social media policy to be considered by Not yet due the Board. That the June report include an update on system for gathering reliable information on Not yet due days lost to sickness. Verbal update on improvements on handover and the continuity of care for this patient group. Verbal update on findings of review of patient experience for 17 to 21 age group. Survey results, and update on action plan progress to be presented to June Board. Not yet due Not yet due Not yet due Clinical Pathology CPA accreditation Medical Education Report Chair's Report Action Log Chief Executive's Report JS to update the Board on Pathology Joint Venture. Imperial Verbal update to be given to the Board once JS Jun-16 expect to hear funding decision in June decision known. Not yet due Comparative satisfaction ratings from other AK to include comparative satisfaction ratings in the July update. AK Jul-16 trusts for student experience to be included in Not yet due July report. The art curator from the Homerton Hospital be invited to attend the CC July Board Seminar. Jul-16 Invitation extended. Not yet due End of Life Care to be discussed at the July Board Seminar. Recording end of life choices on Hillingdon Care Record to be TM Jul-16 Item on Board Seminar Not yet due included in this review. Learning from the management of flows and workloads on Strike Knowledge captured and being analysed. JS to Days to be captured and brought for discussion at Board or Board JS Jul-16 bring findings to Board or Board Seminar as Not yet due Seminar. appropriate.

16

17 Meeting of the Board of Directors Public session Wednesday 25 May 2016 Agenda item 8 Chief Executive s Report Reason for item: This is a standard monthly report to the Board that seeks to ensure the Board is informed of key issues not otherwise covered in the agenda papers. Summary: The report updates the Board on a range of issues including local, regional and national strategic developments, recent publications, and developments at the Trust not otherwise covered in the Board reports. As such, it seeks to provide context to the Board s discussions. This month s report includes an update on the junior doctors contracts, NHS England latest performance statistics and feedback from the Future of Health and Care in Hillingdon event. Board Action required: The Board is asked to: Review the report and agree any further actions as required. Report from: Shane DeGaris, Chief Executive Links to Trust strategic priorities: The report is relevant to all of the strategic priorities. Previous consideration at Board or Committees: n/a. Equality and diversity considerations: none. Financial implications: There are no direct financial implications arising from this information report. 1

18 Chief Executive s Report 1. Junior Doctors Contract Last ditch talks to reach agreement on the junior doctors contract in England are being extended. The Department of Health and the British Medical Association (BMA) have agreed to continue negotiating. The main focus of the talks are Saturday pay, although other issues, including funding and the operation of seven-day working are also being discussed. A verbal update will be given at the Board meeting. 2. NHS England Latest Performance Statistics The NHS in England has had the busiest year in its history with nearly 23 million people visiting A&E in the 12 months to March 2016, a rise of more than 500,000 from the previous year. The data released by NHS England covers March, which means there are now complete figures available for the whole of the measured period. The figures show: More than 2m patients visited an A&E in March, the single highest monthly figure on record Delays discharging patients reached record levels with nearly 170,000 days of delays experienced by patients unable to leave because of a lack of support available in the community Ambulances only responded to two in three of the most serious calls - Red 1 - in the target time of eight minutes, the 10th month in a row the target has been missed The number of patients undergoing routine operations jumped by 4% year-on-year, but by March 8.5% of patients on the waiting list had been waiting for more than 18 weeks, the worst level since record-keeping began in Only four hospitals in England hit Government A&E targets in the first three months of NHS England has stated that the ongoing dispute with junior doctors has started having an impact, with the proportion of patients waiting more than 18 weeks for operations such as knee and hip replacements hitting its highest 2

19 level. The number of patients in March who had been on a waiting list for more than 18 weeks was 298,747, up from 206,032 in the same month last year. 3. Managing the Supply of NHS Clinical Staff The Public Accounts Committee (PAC) report, "Managing the supply of NHS clinical staff in England" sets out a number of recommendations to the Department of Health, NHS Improvement and Health Education England, including: Trusts should be supported by the Department of Health, NHS Improvement and Health Education England to reconcile workforce expectations with the need to meet quality and financial targets The Department of Health and NHS Improvement are charged to report back to the PAC in December 2016 on progress around reducing agency staff spend Health Education England and The Department of Health should assess the potential effect of the new education funding system for on applications for nursing, midwifery and allied health professional courses. Over 800,000 doctors, nurses, and allied health professionals are employed by the NHS. Providers have been under pressure to reduce staff numbers in order to address efficiency goals, whilst being under simultaneous pressure to ensure adequate staff cover in light of the Mid Staffordshire inquiry. The PAC also express concern that there does not appear to be a clear action plan to assess the implications on workforce supply of the introduction of a seven day NHS and other initiatives set out in the five year forward view. 4. Future of Health and Care in Hillingdon 18 May 2016 The Trust is working with key partners to develop a Sustainability and Transformation Plan (STP) for the local health and care economy. Staff and public have been invited to discuss the future of your local NHS services for the next five years. An event called the Future of Health and Care in Hillingdon is taking place on Wednesday 18 May. The topics covered will include an overview of the new healthcare planning guidance including integrated care, collaborative working and transformation as well as development, plans and actions. The event is being run by our CCG and will take place at Brunel University. A verbal update will be given at the Board meeting. 5. Place West London SDG attended a Place West London event to contribute to My Vision for West London which was given to Sadiq Khan our new Mayor of London. Place West 3

20 London is a lobby group comprising of both public and private sector organisations that seeks to promote the interests of West London. 6. Hillingdon Healthwatch Hillingdon Healthwatch is recruiting for a new Chair. Applications close on 30 May Healthwatch is a statutory organisation which plays a major role in ensuring adults, young people, children and communities have a stronger voice to influence and challenge how health and social care services are provided within Hillingdon. Shane DeGaris Chief Executive 15 May

21 Meeting of the Board of Directors public session Agenda item 9 Safer Staffing Planned and actual staffing levels Reason for item: Regular monthly report to advise the Board of compliance with planned nurse staffing levels. Summary: The report provides the Board with an overview of the planned and actual staffing levels for May on all substantive inpatient wards. Fill-rates vary against plan in response to fluctuations in activity, patient acuity/dependency levels and when early and late shifts are compressed into long day shifts. The Board should note that: RN vacancies on THH site; MVH site at establishment: Role Vacancies Starters Leavers Hillingdon RN/RMs HCAs MVH RN/RMs HCAs Where fill-rates are below plan during days, gaps that need to be filled are covered by Matrons and other senior nursing staff working clinically. Average night fill rates were at or above 100% of plan for both sites. High patient dependency saw a continued need for additional nights staffing on the THH site. Suboptimal Staffing incidents have been reported this month.the ADoNs/HOM ensured reported staffing deficits were reviewed by senior nurses and were addressed as required. The DDoN and ADoNs are working to design a process for Red Flags, which other Trusts also report as proving challenging. Reporting is by exception where indicators have varied significantly from target and/or increased management action is required to mitigate risk. Board Action required: The Board is asked to: 1. Note the information provided in this report 2. Agree any further actions that are required. Report from: Vanessa Saunders, Interim Deputy Director of Nursing Report sponsor: Theresa Murphy, Director of Patient Experience & Nursing Links to Trust strategic priorities: To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide. Previous consideration at Board or Committees: N/A Equality and diversity considerations: None Financial implications: The continued use of temporary staffing places budgets under pressure; the ongoing drive to recruit substantive staff will have a positive financial impact by reducing reliance on agency staff. 1

22 Planned and Actual staffing levels 1. Information The table and graphs below shows the overall average fill rates for January across both sites and the monthly trends. Site Day Night Summary Average fill Average fill rate Average fill Average fill rate Data rate RN/RM % Care staff % rate RN/RM % Care Staff % Hillingdon 87.8% 95.5% 102.1% 125.7% Mount Vernon 87.7% 89.5% 100.1% 113.0% 2

23 The tables and graphs below show the number of vacancies, new starters and leavers across each site for the last three months. This data was provided by workforce Information and the Recruitment Manager and pertains to the substantive inpatient areas covered by this report. THH 2016 Feb March April RN/RM vacancies HCA vacancies RN/RM starters RN/RM leavers HCA starters HCA leavers MVH 2016 Feb March April RN/RM vacancies HCA vacancies RN/RM starters RN/RM leavers HCA starters HCA leavers

24 2. Insights and Actions Area Insights Actions Recruitment High fill rates for care staff Maternity fill rates FFT responses Pressure ulcers and falls incidents on Hayes, Grange and Kennedy ward Despite continuous recruitment vacancies remain across the divisions. A significant number are within Fleming ward. Divisional ADNs and HOM, together with the DPEN, require that we adopt a clear, transparent and timely process to recruit. Retention requires increased focus. A number of wards had HCA fill rates significantly above plan. This is associated with high patient dependency. CCU template includes HCA. This is only used if appropriate for patient acuity/dependency Average fill-rates continue to calculate at below 90% for day shifts. Jeresy, Drayton and Churchill all attracted less than minimum target of 96% of respondents scoring Likely/extremely likely to recommend. Pressure ulcers were all Grade 1 or 2. Dependent, frail patient cohort associated with increased falls risk. Regular recruitment events continue, both at trust wide level and speciality-specific. Plans for further international recruitment are being finalised. Surgical rotation programme being worked up to improve recruitment and retention and build a skilled, flexible workforce. DPEN recruitment events at BNU. Patient movement sensors reviewed by Clinical Procurement Lead. Selection process by project group due to commence. This may enable reduction in 1:1 care. Risk assements are completed for patients that require specials Error in the shift template held on e-roster sytem identified in April; correction will not impact until June rota, the head of midwifery is taking this action forward. Finance manager and e-roster system manager continuing to review options for creating a flexible shift template. Matrons to ensure increased response rates and review of comments to identify themes or trends and implement relevant improvement actions. ADoN assessing staffing establishment for Kennedy. Acuity and Dependency data collected in Quarter 1 has been reviewed, requires triangulation with outcome metrics and professional judgement. Option for implemented continuous Acuity and Depencency measurements via e-roster being scoped. DPEN leading senior nurse safety rounds 4 times a week. 4

25 Appendix 1 STAFFING LEVELS April 2016 Data - May 2016 Report Environment Fill Rates** Temporary Staffing Reported concerns Nurse Sensitive Outcome Indicators RAG Division Ward Beds Average fill rate: /Midwives % Days RN Average fill rate: Care Staff % Average fill rate: RN /Midwives % Nights Average fill rate: Care Staff % Proportion Bank hours Proportion Agency hours**** Suboptimal staffing Nursing Red Flags***** Hospital Acquired Pressure Ulcers*** Falls with no harm / Falls resulting in harm*** FFT % of patients extremely likely/likely to recommend FFT % of patients extremely unlikely/unlikely to recommend Medicine Surgery Women & Children Ald % 130.1% 103.2% 171.7% 30.26% 2.93% 1 NR 4/1 100% 0% B'East % 86.1% 101.7% 100.0% 18.14% 0.34% NR 1 5/1 100% 0% Bevan % 92.3% 103.3% 146.7% 16.34% 8.55% NR 2/0 100% 0% CCU % 43.3% 100.1% 16.7% 15.00% 7.57% 1 NR 1/1 100% 0% Daniels % 81.6% 100.2% 100.0% 9.99% 3.71% NR 2/1 100% 0% Dray % 89.0% 100.0% 113.3% 8.34% 0.00% NR 2 1/3 85% 0% EAU/AMU % 95.9% 104.0% 95.2% 8.31% 9.98% 2 NR 2 5/6 91% 3% Grange % 90.9% 161.1% 155.0% 32.73% 27.58% 6 NR 5 5/5 100% 0% Hayes % 139.7% 105.6% 189.6% 30.68% 4.93% 2 NR 3 5/4 100% 0% Stroke % 90.5% 103.3% 108.3% 31.29% 3.25% NR 3/1 81% 19% Churchill % 137.1% 101.3% 116.7% 23.54% 0.35% 1 NR 1/1 87% 9% Jersey % 90.2% 103.3% 173.3% 24.33% 15.08% 4 NR 1 0/1 87% 4% Kennedy % 101.1% 101.1% 170.0% 24.86% 9.51% 4 NR 1 6/2 100% 0% ITU/HDU % % % 3.68% NR 1 100% 0% Trinity % 97.5% 100.0% 138.5% 4.81% 0.00% 1 NR 2/2 99% 1% Fleming % 89.2% 98.3% 138.3% 23.49% 27.92% 2 NR 1/1 98% 2% Peter Pan % 62.6% 100.9% % 3.00% NR 100% 0% NNU % 58.1% 86.0% 46.7% 5.32% 0.00% NR 100% 0% Alex % 90.8% 94.2% 117.8% 12.39% 2.45% 2 NR 0/1 96% 1% Kath % 82.8% 88.2% 100.0% 14.29% 6.95% 6 NR 100% 0% Labour % 77.3% 96.9% 100.2% 8.87% 8.73% 5 NR 100% 0% Assurance Key Cause for concern: assertive management interventions in progress Heightened surveillance: some interventions planned/in progress Assured. Usual oversight and support Pinewood is flexible capacity opened temporarily. It is not a substantive ward and therefore is included for completeness and not as a mandatory reporting requirement. It has not been included in Trust averages. **E-rostering report, workforce report ***Incidents reported via datix **** Proportion of bank and agency nursing information provided by temporary staffing office and workforce information *****Reported occurences of specific events validated by NICE as indicating staffing may be inadequate to meet patient needs NR = not reported 5

26 6

27 Meeting of the Board of Directors - public session Wednesday 25 th May 2016 Agenda item 10 Integrated Quality & Performance Report Reason for item: To provide assurance to the Board that the Trust's key quality, operational and experience objectives are being delivered. To direct the Board's attention to significant risks, issues and exceptions ensuring we remain focused on the delivery of our vision "To put compassionate care, safety and quality at the heart of everything we do." Summary: This report provides the Board with an analysis of quality, experience and operational performance to the end of April The report covers performance against the Monitor Risk Assessment Framework as well as national and local key performance indicators. Board Action required: The Board is asked to: 1) To agree any actions arising from the contents of this Report Report Authors: Melissa Mellett, Director of Operational Performance Jacqueline Walker, Deputy Director of Nursing and Integrated Governance Obi Maduako-Ezeanyika, Head of Workforce and OD Report Sponsors: Professor Theresa Murphy - Director of Patient Experience and Nursing Dr Abbas Khakoo - Medical Director Joe Smyth, Chief Operating Officer Terry Roberts, Director of People Links to Trust strategic priorities: To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide. To deliver high quality care in the most efficient way.

28 Previous consideration at Board or Committees: Reviewed monthly as standard Equality and diversity considerations: There is no positive or negative impact from this report. Financial implications: The financial implications of delivering the additional capacity to meet the non-elective demand over and above plan are detailed in the report.

29 Integrated Quality & Performance Report 1. Summary This report reflects on achievements in performance standards for Month 1, April 2016, including the improvements made in delivery against all key standards. The format of the performance dashboard reflects the core principles of the five Domains set out in the Care Quality Commission's Intelligent Monitoring System (i.e. Caring, Well-led, Effective, Safe and Responsive). 2. Key Highlights 2.1 Safe The Trust has not reported any cases of Clostridium difficile infection in April. The threshold for 2016/17 is eight cases where a lapse in care has been identified as part of root cause analysis investigation. Confirmation has been received from Monitor that for cases where no lapse in care has been identified, these cases will not count against the Trust as part of the outcomes metric assessment on the Monitor scorecard or our quality governance rating. Two cases of MRSA blood stream infection have been identified within 48 hours of the patient s admission to the Trust in April 2016; these have been investigated by the CCG with regard to the patients presentation to the hospital with these symptoms. Both cases have gone to arbitration and the Trust awaits the final outcome. The rate of hospital acquired pressure ulcers was above target at a rate of 1.2 in April. To support the Tissue Viability Nurse in delivering enhanced training for nursing staff, a series of bespoke study sessions have been arranged with Bucks New University; these start in May and all places are fully booked. The rate of patient falls increased significantly in April to 5.9 per 1000 bed days. This rate is the highest for many months but does remain lower than national average published by NPSA in 2010 (5.8) and by the RCP in 2015 (6.6). Divisional teams will be reporting back to the Falls Group identified underlying reasons to ensure shared learning and to review preventative strategies. The Clinical Procurement Lead has reviewed suppliers of falls/movement sensors and is arranging product evaluation and ward-based trial. 2.2 Caring The new service provider for collating, analysing and reporting Friends and Family Test results is now fully operational. This system brings improved access for frontline managers to review their results and feedback. As previously agreed the Head of Public Engagement continues let the divisions know at mid-point during the month how many FFT responses had been received in each department in an effort to drive the rate upwards. Disappointingly this has not resulted in improved response rates, with all areas showing reduction in April. It should be noted that Maternity has continued to meet their response rate target and

30 have also achieved 96% of respondents scoring likely or extremely likely to recommend our services. A&E are trialling team-based incentives to drive up performance. The impact of this wil be evident for May results. The Complaints Management Unit were under extreme pressure in April, wit hthe continued sickness of their manager and the resignation of the other full-time staff member. The PALs team supported as much as possible pending appointment of temporary staff into these posts. However, the high volume of responses due in the first half of the month, coupled with the impact of new staff joining and pressures for divisional teams did impact negatively on percentage of complaints responded to within agreed timeframe. However this performance, although below target, was close to the same period last year. Performance varied across divisions, ranging from 50% in CCSS to 91.7% in Surgery. Responsive Areas of concern 1) Allocated Slot Issues (ASI) The progress previously made against this standard has been compromised when sector wide IT system had to be taken down for several months. As previously reported the system has now been re-instated, however, reporting continues to be affected, and data for March and April is yet to be published. The ASIs for February 2016 for the whole trust was 21.4%, and the divisional ASIs are shown below. Trust Total Surgery CSS Medicine Women & Childrens Feb % 24.1% 12.1% 36.8% 6.9% 2) Performance against the 4 hour standard: April has been a particularly challenging month for performance against the 4 hour standard with type 1 attendances up by 7.1%, (paediatrics 14.9%). There was also an increase of 26.7% in emergency blue light activity culminating in an in month performance of 86.5%. The Trust continues to work with HCCG to reconfigure available space in the ED with the aim of increasing capacity and improving patient flow. Plans are currently underway to increase capacity to create a new clinical decisions unit (CDU) once Children s A&E has been repatriated to a newly refurbished and improved facility. Strategies to improve performance against the standard include admission avoidance via ambulatory care, improving inter-departmental flows and expediting discharges from inpatient wards before midday. These strategies are being tracked through the comprehensive action plan which was presented to the Board last month.

31 The focus on ambulating patients where possible has successfully increased activity and is reflected in the decrease in the A&E admission rate by 21.3% (April 16). However clinicians are reporting higher levels of acuity and dependency of patients that are admitted which might explain increasing lengths of stay. Overall, the length of stay for patients over the age of 65 has increased by an average of 0.8 days and despite opening all available escalation capacity this has decreased patient flow and exacerbated exit block from emergency care. Hospital staff, HCCG and community colleagues continue to work collaboratively to re-design services for patients with long term conditions. These integrated services are due to go-live over the next few months with the expectation that managing patients with heart failure, diabetes and respiratory conditions more effectively in the community will reduce hospital attendance and inpatient episodes; all of which will contribute to reducing current pressures on emergency care. 2.4 Well-Led In April 2016 the Trust sickness rate was 3.40% which is a 0.22% reduction in sickness compared to same period in CSS Division was noted for having the highest sickness rate (3.91%). Medicine (3.65%) also reported high sickness absences followed by W&C (3.38%), Corporate (3.18%). Surgery was the only Division whose sickness rate (2.97%) was below the Trust target. The overall cost of sickness April 2016 was 248k, which is a 12% increase in sickness costs over same period last year, despite the sickness rate being lower. This could in part be attributed to the April pay award and also incremental drift (staff progressing through their increments). Medicine Division s sickness costs represented 25% (62k) of the overall sickness costs for April Sickness costs in CCCS Division were 59k (24%) followed by Surgery and Corporate division 45k (18%). W&C reported the lowest sickness costs at 35k (14%) The Trust vacancy rate for April 2016 was 8.64% against a target of 8.00%. Overall Trust vacancies increased in April 2016 by 0.57% compared to April This increase is a reflection of the health workforce market and difficulty recruiting to specialist clinical roles. We continue to robustly manage our vacancies (particularly nurse vacancies) through a number of initiatives. Nurse recruitment is improving and the Trust has put in place plans to recruit from the UK and overseas in the next year to meet demand. In terms of overseas recruitment, the Trust is in the process of selecting a provider for overseas nurse recruitment with the intention of going out to the Philippines in July From April 2015 to April 2016 there has been a continuing trend in reduction in temporary staffing spend (20%) with lowest spend in October Although costs increased in March 16 by 17% over February 2016, this reduced in April 2016 by 15% (to ) compared to previous month. Although the cost of Bank staff in April 2016 was 689,327, an increase of 15% compared to the same period last year, there has been a significant reduction in agency costs, from 1,543,112 in April 2015 to 1,004,120 in April 2016, showing a reduction of 35% in agency spend. The use of off framework agency workers was 0.70% in April 2016 compared to 5.78% in April Although there are still areas where the Trust uses off

32 framework agency workers this is minimal and being gradually phased out. The introduction of the agency price caps in November 2015 has supported a reduction in agency costs and contributed to a reduction in our use of off framework agencies. Since November 2015 the Trust reported breaches in agency usage above the national price cap. Over this period Trust total breaches were lowest in February 2016 (101) compared March 2016 (215) which saw a 53% increase. This increase was due to an increase in usage Medical locums over the price cap. Breaches stabilised in April 16 seeing a 36% reduction over March 2016 (with medical locums breaches lowest in month). Breaches are being better managed and controlled in Administration and Estates and apart from significant breaches in December 2015, breaches have continued to diminish with no reports of breaches in April Breaches within Nursing have fluctuated with breaches lowest in November 2015 peaking in March 2016 (61). Overall breaches have been lowest among AHPs with its highest breach in March 2016 decreasing in April 16. Divisions continue to review their workforce needs to ensure that services can be delivered in a different way to reduce agency spend and consequently breaches. The Trust Staff in Post (SiP) increased in April 16 for all professional groups (aside from healthcare scientists) by 6% compared to the same period in The highest percentage difference between SiP in April 2015 and April 2016 was within Add Prof Scientific and Technic group which saw a 17% increase. This increase was due growth in patient activity which impacted the level of admin functions to support clinical activity. Compared to April 2015, SiP for Estate and Ancillary groups also increased (by 12%) followed by Nursing and Midwifery Registered group by 7% and Medical and Dental by 4% compared to same period. There has been a significant improvement on time to hire in the month of April 2016 with average time to hire of 60 days. This is an improvement of 36% compared to last year which was 81.7 days on average. The Trust is on course to continue to improve TTR to support its recruitment drive and improve the employee onboarding experience. The mean years for staff that left in April 2016 were 4.50 years, 2.17 years less than the April Identifying trends in leavers tenure remains a challenge as leaver tenure has fluctuated over the last year. However the Trust is currently undertaking a detailed analysis of exit interview data and reviewing the process to better understand characteristics of and reasons why staff leave. This work will inform retention initiatives moving forward. In terms of medical appraisals, the window opened on 01 April 2016 and compliance in April %. This is 1.3% increase in compliance compared to the same period last year. In order to meet the Trust s 90% target, a monthly compliance target of 10% has been set. The PDR window opened for non-medical staff on 01 April 2016 and Trust compliance rate in April 2016 was 2.90% which is higher than our compliance during the same period last year. A low compliance in the month of April is not unusual as managers plan PDR meetings and carry out reviews for their teams. The Trust achieved its highest compliance rate since April 2015 in April This was an increase of 1.23% compared to the same period in 2015 and compliance is

33 projected to grow this year. As the Trust continues to build a STAM compliance culture, its focus will shift to improving the quality of training and induction experience to support its retention agenda and practice. Finally, during April 2016, six employee relations cases progressed to a formal stage compared to two during April a 200% increase in activity. Of the 6 cases, 4 were in relation to disciplinary matters. At the end of the last financial year there were 55 employee relations that had progressed to a formal year; this represented a 25% increase in activity compared to the year before.

34 Trust Overview April-2016 Domain Ref Theme Management Priority Last Month This Month Forecast Status [1] Safe [2] Effective [3] Caring [4] Responsive HCAI On Track On Track Improving Stroke & TIA FNOF Minor Minor Minor Minor Stable Stable Maternity Minor Minor Improving Falls Moderate Moderate At Risk Medication Minor Minor Stable VTE Moderate Moderate At Risk Pressure Ulcers On Track Minor Stable Safety Thermometer On Track Minor Stable Serious Incidents On Track On Track Stable Never Events Moderate On Track Stable Patient Safety On Track On Track Stable Mortality On Track On Track Stable Readmissions On Track On Track Improving DNAs Moderate Moderate Improving ASIs Significant Significant Improving FFT (Admitted Care) Moderate Minor Stable FFT (A&E Care) Moderate Moderate At Risk FFT (Maternity Care) On Track On Track Stable Complaints Minor Minor At Risk PALS Minor Minor Stable Accident & Emergency Significant Significant At Risk RTT On Track On Track Improving Cancer Excellent Excellent Improving Mixed Sex Accommodation Excellent Excellent Improving [5] Well Led PDR, Medical Appraisal & STAM Sickness On Track Minor On Track Minor Improving Stable 5.3 LTR, Vacancy, LoS &TtR Minor Minor Stable Employee Relations Establishment On Track On Track On Track On Track Stable Stable

35 Key To Scorecard Assessments April-2016 Management Priority Significant Moderate Minor On Track Excellent Significant interventions are planned or in progress due to one or more factors: an externally-reported metric is off-track; multiple internal metrics are off-track; qualitative experiences are raising significant concerns Moderate interventions are planned or in progress due to one or more factors: an important internal metric is off-track; qualitative experiences are raising concerns; future projections are off-track Some interventions are planned or in progress: stretch targets are off-track; trends are adverse; qualitative experiences suggest performance may be at risk All areas within this theme on track Amongst top performers nationally, with internal stretch targets consistently met Forecast Status At Risk Stable Improving Expected to Worsen by next reporting period Not expected to change significantly by next reporting period Expected to improve by next reporting period Indicator Status Achieving standard Just missing standard Significantly missing standard No Target Set

36 [1] SAFE Domain Scorecard April-2016 Theme Ref Indicator Target RAG Feb-2016 Mar-2016 Apr-2016 YTD 1.01 HCAI 1.02 Stroke & TIA MRSA Cases (Trust Attributable) C.Diff Cases (Trust Attributable) n/a C.Diff Cases (Lapses in Care) MSSA Cases (Trust Attributable) n/a E.Coli Cases (Trust Attributable) n/a % of Time On The Stroke Unit 90% 100.0% 100.0% 100.0% 100.0% High Risk TIA Treated W/I 24 Hours 90% n/a 100.0% 100.0% 100.0% 1.03 FNOF FNOF Patients In Theatre W/I 36 Hours 90% 94.4% 76.9% n/a 0.0% 1.04 Maternity 1.05 Falls Booking 95% 96.4% 96.4% 98.3% 98.3% C-Section Rates (Combined) 29% 28.5% 32.2% 25.1% 25.1% C-Section Rates (Elective) 13% 12.0% 10.8% 8.2% 8.2% C-Section Rates (Emergency) 16% 16.5% 21.4% 16.9% 16.9% Tears 6% 2.3% 1.8% 3.0% 3.0% Rate of Patient Falls (All) Rate of Patient Falls (with Harm) n/a Patient Falls With Fracture <= Medication Incidents as a % of Total Incidents >11% 9.7% 9.1% 8.7% 8.7% 1.07 VTE VTE Compliance 95% 93.5% 90.5% 92.3% 92.3% 1.08 Pressure Ulcers 1.09 Safety Thermometer Pressure Ulcers (Grade 2, 3 & 4) n/a 18,0,0 13,0,0 17,0,0 17,0, Pressure Ulcers per 1,000 Beddays Harm Free Care (All Harms) 95% 95.4% 96.9% 94.2% 94.2% Harm Free Care (New Harms) 95% 98.4% 99.2% 99.1% 99.1% 1.10 Serious Incidents Serious Incidents n/a Never Events Never Events Patient Safety Incidents n/a Reporting Rate per 1,000 Beddays > Incidents Resulting In Harm n/a Percentage Resulting in Harm <6% 2.8% 2.8% 2.3% 2.3%

37 [1] SAFE Domain Scorecard April-2016 Theme Ref Indicator Target RAG Feb-2016 Mar-2016 Apr-2016 YTD 1.13 Mortality Crude Mortality Rate n/a 1.5% 1.3% 1.1% 1.1% Number of Deaths n/a Theme Ref Indicator Target RAG Nov-2015 Dec-2015 Jan-2016 YTD 1.13 Mortality Aggregate HSMR Weekday HSMR Weekend HSMR Limits Limits Limits < n/a ( ) ( ) ( ) ( ) < n/a ( ) ( ) ( ) ( ) < n/a ( ) ( ) ( ) ( )

38 [1.01] SAFE HCAIs April MRSA cases (Annual Target 0 Cases) Where we want to be: targets and benchmarks We want to be able to sustain our zero case objective for 2016/17 Chart : CDiff Cases (Trust Attributable) By Month 2016/ /2016 Where we are: trends and patterns - The Trust reported one case of MRSA for 2013/14, one for 2014/15 and one for 2015/16 (contaminant). The Trust's reporting rate per 100,000 bed-days for 2015/16 = 0.7, the national rate is 1.8 and the London rate is also 1.8. Two cases of MRSA BSI have been identified within 48 hours of admission to the Trust in April 2016 and have been investigated by the CCG. Both cases have gone to arbitration and the Trust awaits the final outcome. Risks or opportunities for the Trust - The trust's aim is to achieve the annual objective for MRSA of zero. There is an inherent risk of the trust breaching this objective with regard to seeing a complex patient case mix with much increased acuity and patients having attended both primary and secondary care providers for linked episodes of care CDiff Cases (Annual Target 8 Cases) Where we want to be: targets and benchmarks - Aim to ensure that C diff infections do not exceed our objective for 2016/17 of eight cases. Where we are: trends and patterns We have had twelve cases of CDiff YTD 2015/16. Our reporting rate per 100,000 beddays for 2015/16 = 8.1, the national rate is 15.1 and the London rate is There have been no cases in April. Confirmation has been received from Monitor that for cases where no lapse in care has been identified, these cases will not count against the Trust as part of the outcomes metric assessment on the Monitor scorecard or our quality governance rating Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Chart : CDiff Cases (Lapses of Care) Cumulative 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Chart : MRSA Cases (Trust Attributable) 2016/ /2016 Target Risks or opportunities for the Trust - There is a governance and financial risk with regard to breaching our CDiff objective. Learning from RCA investigation is in place - this is fully described on the corporate risk register. Additional preventative measures are being implemented with regard to antimicrobial prescribing and stewardship. 1 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

39 [1.01] SAFE HCAIs April-2016 Chart 1.0.3: MSSA Cases (Trust Attributable) 2016/ /2016 Chart : E.Coli Cases (Trust Attributable) 2016/ / Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

40 [1.02 & 1.03] SAFE Stroke, TIA & FNOF April-2016 ( & ) Stroke Fully meeting our Stroke and TIA target. (1.03.1) FNOF March : 76.9% (13 patients, 3 breaches) YTD: 89% (174 patients, 19 breaches) In March 2016, the FNOF 90% target was not met. Three patients this month did not meet the standard of going to Theatre within 36 hrs. Two patients were delayed due to there being several trauma patients awaiting theatre and due to clinical prioritisation, these patients went to theatre the following morning. The third patient was accidently fed food on the ward and therefore not sufficiently starved to be taken for his surgery. The YTD performance is 89% and narrowly misses the target threshold of 90% % 80.0% 60.0% 40.0% 20.0% 0.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 90% of Time On Stroke Unit 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD High Risk TIA Treated w/i 24 Hours 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% FNOF Patients in Theatre w/i 36 Hours 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

41 [1.04] SAFE Maternity April-2016 (1.04.2) C-Section performance - Target: 27% - Performance 32.1% Although the target set for combined LSCS is 27%, from the 1st March it will increase to 29% (16% emergency/13% elective) as part of the London wide target based on demographic and complexity of the population. March showed a significant increase in emergency caesarean section rates at 21.4% against a current target of 16%.The year end final average for emergencies was 18.4%. A recent audit of emergency caesarean sections showed that appropriate planning and management had occurred, however we will be looking at other Trusts in the sector with lower rates to see if there is any learning to be shared and implemented. Elective caesareans remain on target with a YTD average of 10.1% set against a target of 11%. (1.04.1) Booking Target 95% - Performance 96.4% The service continues to achieve the target of 95% with a year-end average of 96.2%. We have seen a significant increase in women using the self-referral tool which was 53% for March. The challenge continues to be late bookers where we are working with the CCG and Public Health to explore options for improvement. (1.04.3) Tears Target 5% - Performance 2.5% We continue to remain within the recommended level of tears. However all 3rd and 4th tears are datixed and reviewed to ensure no clinical practice concerns are identified % 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% % 80.00% 60.00% 40.00% 20.00% 0.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Chart 1.4.2: C-Section Rates (Combined) 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Chart 1.4.1: Booking 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Chart 1.4.3: Tears 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

42 Inpatient falls [1.05] SAFE Falls Rate of Patient Falls (With Harm) April-2016 Where we want to be: targets and benchmarks: NPSA (2010) benchmark rate is 5.4 per 1000 bedddays; RCP benchmark (2015) is 6.6 per 1000 beddays. In line with our Sign up to Safety campaign we want to continue to reduce our overall rate of falls and not see an increase in falls with fracture. Where we are: trends and patterns: In 2012/13 our falls rate was 5.8, in 2013/14 it was 5.0, in 2014/15 it was 4. 4 and in 2015/16 we achieved a rate of 4.3. We have therefore seen a reduction in inpatient falls year-on-year. The falls rate for April increased significantly to 5.9 per 1000 bed days. One fall resulted in a fracture. Risks or opportunities for the Trust: There is a risk that of limited scope for further reduction in falls over coming years having seen a a levelling off ouf our previous downward trend, and given that performance is better than national benchmarks. We do however remain committed to ensuring we minimise this risk to patient safety through the programme of work being taken forward via the Trust-wide Falls Group under the Sign up to Safety campaign / /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Rate of Patient Falls (All) 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Patient Falls With Fracture 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

43 [1.06, 1.07 & 1.08] SAFE Medication, VTE & Pressure Ulcers April Medication Incidents Where we want to be: targets and benchmarks: We want to increase incident reporting of no/low harm incidents for medication errors. This will support us to learn from near misses / low harm incidents to prevent more harmful incidents. Where we are: trends and patterns: Our reporting rate of medication errors has not been in line with the national average for acute (non-specialist) organisations - 8.7% (Apr) against a national average of 11%, however we have seen an improving picture in 2015/16. Risks or opportunities for the Trust: The trust is involved in a pilot programme with the ICHP Patient Safety Collaborative to improve pharmacists provision of feedback to doctors on prescribing errors. A new Medication Safety Officer and the Medication Safety Committee are taking a programme of work forward VTE - Target 95% Compliance was below the 95 % target for March at 90.5% and April at 92.3%, however data is still going through the process of validation. There continue to be a small number of poorly performing areas identified. These areas are where patients often stay for a very short inpatient admission. This adversely affects performance but does not necessarily impact on patient safety.. The risk of VTE is now mitigated by the VTE risk information leaflet which became available on May 10th and has been distributed to all relevant areas. A leaflet will be given to every inpatient explaining the risk of VTE and how individuals can reduce their own risk. The distribution of VTE leaflets to inpatients will be audited. There is imminent implementation of the addition of VTE risk assessment compliance as part of the WHO sign-out in operating theatres Pressure Ulcers: (15% reduction by year end) Where we want to be: targets and benchmarks: We aimed to achieve a 15% reduction of all pressure ulcers during 2015/16. This is in line with our Sign up to Safety campaign to reduce patient harms by 50% over three years. Where we are: trends and patterns: The hospital acquired pressure ulcer rate during 2013/14 was 1.34 per 1,000 bed-days and in 2014/15 this was 1.20 against a target of For 2015/16 we achieved a rate of 1.1, which although an improvement narrowly missed the target rate of 1.0 per 1000 beddays. In April 2016 the rate increased to 1.2 but there were no Grade 3 or 4 ulcers. Risks or opportunities for the trust: This is a priority area of focus for the Sign up to Safety work and there are clear actions as part of the improvement plan including ward based and classroom based teaching, improved systems for referring to the Tissue Viability Nurse and trial of new pressure relieving aids. 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Medication Related Incidents as a Percentage of Total Incidents 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar VTE Compliance 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Pressure Ulcers per 1,000 Beddays 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

44 [1.09, 1.10 & 1.11] SAFE ST, SIs and Never Events April Where we want to be: The target for the Safety Thermometer is 95% harm free care. This includes all harms; old and new (hospital acquired) in 2015/ % of patients surveyed received harm free care (all harms); for new harms we achieved 98.5%. Where we are: Performance for April was 94.2% (all harms) - where harm free care is measured taking just new hospital acquired harm, the harm free rate was 99.1%. Risks or Opportunities: hospital acquired pressure ulcers and falls are included in the Sign up to Safety Campaign, this will ensure that there is focused attention on reducing these harms by 50% over 3 years. This will have an impact on the rate of harm free care recorded on the Safety Thermometer. The high number of community acquired pressure ulcers will impact negatively on our overall harm performance; the TVN is working with community colleagues to support improvements in this aspect of out of hospital care Serious Incidents: There were no new Non-Executive/Executive-led panel serious incidents declared in April Never Events - There have been no never events reported in April. There were two misplaced nasogastric tube never events, one reported in February and one in March One of the investigation reports has been approved at Trust Board and the other investigation is currently Safety Thermometer Harm Free Care (All Harms) 2016/ /2016 Target Safety Thermometer Harm Free Care (New Harms) 2016/ /2016 Target 100.0% 100.0% 80.0% 80.0% 60.0% 60.0% 40.0% 40.0% 20.0% 20.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Serious Incidents Never Events 2016/ /2016 Target 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

45 [1.12] SAFE Patient Safety April Patient Safety Incidents Where we want to be: targets and benchmarks: We aim to be in the top 25% of high reporting trusts. Comparative data from the National Reporting and Learning Service shows the Trust's reporting rate as per 1,000 bed-days (1 April Sept 2015). For acute non-specialist organisations the median reporting rate for this cluster was The Trust is in the middle 50% of reporters. Where we are: trends and patterns: For April we have achieved targets for rate of incidents and percentage resulting in harm in line with and better than the national averages. The number of patient safety incidents that resulted in severe harm or death has remained within target and remains lower than the previous year. Risks or opportunities for the Trust: The Trust will continue to raise awareness of the importance of incident reporting and in particular near misses and no/low harm incidents (this will ensure learning to avoid the more harmful incidents from occurring). NB - note that the Volume of Incidents / Incidents Resulting in Harm are presented as contextual indicators only to support the 'Reporting Rate' and 'Percentage Resulting in Harm' Indicators and as such will not have targets by themselves. Patient Safety Incidents Reporting Rate per 1,000 Beddays 2016/ /2016 Target 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

46 [1.12] SAFE Patient Safety April-2016 Incidents Resulting In Harm 2016/ /2016 Target Percentage Resulting In Harm 2016/ /2016 Target % % % 4.0% % 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

47 [1.13] SAFE Mortality (HSMR) April Mortality: Hospital Standardised Mortality Ratio (HSMR) as provided by Dr Foster provides an in-hospital mortality measure on a monthly basis with a delay of 4 months. The HMSR for the Trust for year 2015/16 was 92.1 ( ) (source Dr Foster data, benchmark period April-Dec 2015) and is below the national benchmark of 100 but is above the London average of 84.7 ( ). The Trust weekday and weekend HSMR have been in the as expected range throughout the year. The latest available HSMR to Jan 2016 is There is a current weekday to weekend variation of 60.9 v with regard to latest figures provided. These results are all within the expected range. Mortality Review Process There is a trust-wide Mortality Review Process (MRP) which reviews every in-hospital death by day of week admitted, looking for any issues of care which could have contributed to the patient s death. Using the latest NHS England guidance on avoidable mortality a Mortality Review Surveillance Group was convened in May 2016 and one of its tasks is to write a Trust Mortality Review Process Policy to clarify and document the roles and responsibilities, governance arrangements and reporting requirements of the process HSMR (Basket of 56) 2015/2016 Benchmark 2015/2016 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Weekday HSMR (Basket of 56) 2015/2016 Benchmark 2015/2016 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar Weekend HSMR (Basket of 56) 2015/2016 Benchmark 2015/ Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

48 [1.13] SAFE Mortality (Crude) April-2016 Crude Mortality Rate 2016/ /2016 Number of Deaths 2016/ / % % % % Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

49 [2] Effective Domain Scorecard April-2016 Theme Ref Indicator Target RAG Feb-2016 Mar-2016 Apr-2016 YTD 2.1 Readmissions Day Readmission Rates 8% 7.3% 8.0% 7.1% 7.1% 2.2 DNAs 2.3 Appointment Slot Issues DNA Rates 9% 9.0% 9.2% 8.9% 8.9% Appointment Slot Issue (ASI) Rate 7% 21.4% 0.0% 0.0% 0.0%

50 [2.1, 2.2 & 2.3] Effective Readmissions, ASIs, DNAs April (2.1) Readmissions Target 8% - March Performance 7.% Several streams of work are active within the Trust and, via a joint CQUIN, we are working collaboratively with Primary Care and Community Services although we do not expect to see measurable outcomes until towards the end of the year. 2) (2.2) Did Not Attend (DNA) Target 9% March Performance - 9.2% The DNA rate for M12 was 9.2% - Most service are on the appointment reminder service. Negotiations with Netcall is still ongoing for adding Maternity clinics to the reminder service. 3) (2.3) Available Slot Issues (ASI) for Choose and Book - Target 7.5% - January Performance 21.4% The ASI for Feb 2016 was 21.4% or 951 Appointments that could not be booked. There is a slight increase in the number of referrals received for Q4 from last year. the main driver in the increase of ASIs is attributed the clinics being moved (made unavailable) for Drs' Strikes. 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 30 Day PBR Readmission Rates 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar DNA Rates 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 20.0% Appointment Slot Issue (ASI) Rate 2016/ /2016 Target 15.0% 10.0% 5.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

51 [3] Caring Domain Scorecard April-2016 Theme Ref Indicator Target RAG Feb-2016 Mar-2016 Apr-2016 YTD Inpatient FFT: Response rate 30% 24.3% 26.0% 22.2% 22.2% 4.1 FFT (Admitted Care) Inpatient FFT: % Recommended n/a 94.6% 96.7% 96.4% 96.4% Inpatient FFT: % Not Recommended n/a 1.2% 1.2% 1.3% 1.3% 4.2 FFT (A&E Care) A&E FFT: Response rate 20% 7.6% 6.7% 5.1% 5.1% A&E FFT: % Recommended n/a 91.5% 97.3% 92.5% 92.5% A&E FFT: % Not Recommended n/a 4.0% 1.9% 5.7% 5.7% Maternity FFT: Response rate 20% 36.0% 32.3% 22.3% 22.3% 4.3 FFT (Maternity Care) Maternity FFT: % Recommended n/a 89.9% 95.7% 95.0% 95.0% Maternity FFT: % Not Recommended n/a 1.4% 1.4% 0.9% 0.9% 4.4 Complaints Complaints: Received n/a Complaints: Due for Response n/a Complaints: Trust Total 90% 84.6% 88.2% 80.0% 80.0% Complaints: CCSS 90% 0.0% 100.0% 50.0% 0.0% Complaints: Medicine 90% 91.7% 90.0% 85.7% 85.7% Complaints: Surgery 90% 80.0% 70.0% 91.7% 91.7% Complaints: W&C 90% 100.0% 100.0% 66.7% 66.7% 4.5 PALS Number of Negative PALS Concerns n/a

52 [3.1] CARING FFT Admitted Care April-2016 Where we want to be: The target response rate is 30%. The target peformance rate is 96%. Where we are: The proportion of patients recommending is 96.4%, a reduction of 0.3% from March The % of those unlikely to recommend is 1.3%. The response rate has decreased by 3.8% to 22.2%. Risks and Opportunities: ADOs, matrons and ward managers continue to receive a mid month report on number of surveys so that remedial action can be taken if response rates are too low. Members of the corporate nursing team continue to discuss the results with ward staff as well as encourage the staff to give out the survey to all patients. Inpatient Friends & Family Test: Response Rate 2016/ /2016 Target Inpatient Friends & Family Test: % Recommended 2016/ / % 100.0% 80.0% 90.0% 60.0% 80.0% 40.0% 70.0% 20.0% 60.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Inpatient Friends & Family Test: % Not Recommended 2016/ / % 8.0% 6.0% 4.0% 2.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

53 [3.2] CARING FFT A&E Care April-2016 Where we want to be: The target response rate is 20% and should be seen as a minimum target. The target % for performance is 96%. Where we are: The proportion of patients recommending has decreased by 4.8% to 92.5% and there has been an increase in the patients unlikely to recommend, 5.7 compared to 1.9% in March The response rate continues to be significantly below the target of 20% at 5.1%. Risks and Opportunities: A&E staff are being encouraged to increase response rates by holding a competition between staff members. Furthermore there is a sumernumerary member of staff in A&E who has been tasked to take responsibility improving the response rates. A&E Friends & Family Test: Response Rate 2016/ /2016 Target A&E Friends & Family Test: % Recommended 2016/ / % 100.0% 80.0% 90.0% 60.0% 80.0% 40.0% 70.0% 20.0% 60.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar A&E Friends & Family Test: % Not Recommended 2016/ / % 8.0% 6.0% 4.0% 2.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

54 [3.3] CARING FFT Maternity Care April-2016 Where do we want to be: The minimum response rate target for 2014/15 for all four maternity FFT surveys combined is 20%. Where we are: In April Maternity exceeded the target with a response rate of 22.3%. The proportion of women recommending the service has decreased slightly from 95.7% to 95%; the percentage of women unlikely to recommend has decreased to 0.9%. Risks and Opportunities: Matron is working closely with the Labour Ward manager to increase the number of responses from ladies who have just delivered a baby in the unit. The Head of Midwifery and Matron receive a mid month report on number of surveys so that remedial action can be taken if response rates are too low. Maternity Friends & Family Test: Response Rate 2016/ /2016 Target Maternity Friends & Family Test: % Recommended 2016/ / % 100.0% 80.0% 90.0% 60.0% 80.0% 40.0% 70.0% 20.0% 60.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Maternity Friends & Family Test: % Not Recommended 2016/ / % 8.0% 6.0% 4.0% 2.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

55 [3.4 & 3.5] CARING Complaints & PALS April-2016 Target: Complaints performance is measured by the percentage of complaints answered within the timescale that has been agreed with the complainant, the target is set at 90%. Where we are: The number of complaints due for responses in March was 34 compared to 26 in February. Reply performance improved by 3.6% to 88.2% within agreed timeframe; we failed to respond to 4 complainants within agreed time. These breeches were spread across Medicine (1) and Surgery(3). The number of complaints received decreased by 16 in March. The PALS team received less negative concerns in April 2016 (82) compared to 93 in March. Risks and Opportunities: Negative concerns may continue over the coming months given increased patient activity across the Trust. This is supported by comparable data from last year. The complaints team has a vacancy providing the opportunity to review skill mix of the team going forward. Complaints Performance 2016/ /2016 Target Number of Complaints Received 2016/ / % % % 40.0% 20.0% % Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Number of Complaints due for Response Number of Negative PALS Concerns 2016/ / / / Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

56 [4] RESPONSIVE Domain Scorecard April-2016 Theme Ref Indicator Target RAG Feb-2016 Mar-2016 Apr-2016 YTD 4.1 Accident & Emergency 4.2 RTT 4.3 Cancer Performance Against 4Hr Target (All) 95% 85.0% 85.3% 86.0% 86.0% Performance Against 4Hr Target (Type 1) 95% 61.2% 61.1% 64.8% 64.8% LAS Handover Times (30 Mins) 100% 75.5% 77.6% 78.0% 78.0% Black Breaches RTT - Admitted Perf. (Unadjusted) 90% 78.4% 77.8% 73.9% 73.9% RTT - Non Admitted Perf. 95% 97.9% 97.7% 96.5% 96.5% RTT - Incomplete Pathways Perf. 92% 94.7% 93.8% 93.3% 93.3% RTT - 52 Week Waiters Cancer Perf.- 2WW (All) 93% 97.0% 96.1% n/a 97.1% Cancer Perf. - 2WW (Breast) 93% 98.8% 96.2% n/a 96.3% Cancer Perf Day (First Treat) 96% 96.8% 97.3% n/a 99.0% Cancer Perf Day (Subsequent Surg.) 94% 100.0% 100.0% n/a 100.0% Cancer Perf Day (Subsequent Drug.) 98% 100.0% 100.0% n/a 100.0% Cancer Perf Day (GP) 85% 84.7% 90.6% n/a 91.3% Cancer Perf Day (Screening) 90% 100.0% 100.0% n/a 98.6% Cancer Perf Day (Upgrade) n/a 94.0% 97.8% n/a 97.6% 4.4 MSA Mixed Sex Accommodation Breaches Cancelled Operations 4.6 Theatres Cancellation Rate 0.5% 0.6% 0.7% 0.6% 0.6% Day Readmission Urgent Cancellation More than Once Utilisation 83% 71.3% 69.7% 72.0% 72.0% Productivity 97% 99.8% 101.2% 95.4% 95.4% Avg Cases Per Session Cancellation Rate 3.6% 3.7% 3.8% 3.8% 3.8%

57 [4.1] RESPONSIVE A&E April A&E Performance April has been a particularly challenging month for performance against the 4 hour standard with type 1 attendances up by 7.1%, (paediatrics 14.9%) and an ongoing increase in emergency blue light activity of 26.7%, culminating in an in month performance of 86.5%. The Trust continues to work with HCCG to reconfigure available space in the ED with the aim of increasing capacity and improving patient flow. Plans are currently underway to increase capacity in what will become a new clinical decisions unit (CDU) once Children s A&E has been repatriated to a newly refurbished and improved facility. Strategies to improve performance against the standard include admission avoidance via ambulatory care, improving inter-departmental flows and expediting discharges from inpatient wards before midday. The focus on ambulating patients where possible has successfully increased this type of activity by 119% and is reflected in the decrease in the A&E admission rate by 27.2%. Subsequently, patients that are admitted to the base wards have an increased complexity of need which is demonstrated by an extended length of stay. Of particular note are those wards caring for elderly patients with complex needs including dementia. Length of stay for this patient group has risen from an average of 15 days in 15/16 to an average of 24 days in 16/17 as hospital staff and community colleagues struggle to identify and secure appropriate placements. Overall, the length of stay for patients over the age of 65 has increased by an average of 0.8 days and despite opening all available escalation capacity this has decreased patient flow and exacerbated exit block from emergency care. Hospital staff, HCCG and community colleagues continue to work collaboratively to re-design services for patients with long term conditions. These integrated services are due to go-live over the next few months with the expectation that managing patients with heart failure, diabetes and respiratory conditions more effectively in the community will reduce hospital attendance and inpatient episodes; all of which will contribute to reducing current pressures on emergency care. A&E Performance Against 4Hr Target (All Types) 2016/ /2016 Target A&E Performance Against 4Hr Target (Type 1) 2016/ /2016 Target 100.0% 100.0% 90.0% 90.0% 80.0% 80.0% 70.0% 70.0% 60.0% 60.0% 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

58 [4.2] RESPONSIVE RTT April RTT Performance Admitted Target 90% - Achieved 77.8% Non Admitted Target 95% - Achieved 98.7% Incomplete Target 92% - Achieved 93.8% Overall performance remains good. The trend in the RTT admitted performance is decreasing due to stopping additional waiting list activity and some recent validation. The Trust Elective Patient Management meeting is monitoring this closely to ensure patient safety and ensure we do not breach the incomplete target RTT Admitted Performance (Unadjusted) 2016/ /2016 Target RTT Non Admitted Performance 2016/ /2016 Target 100.0% 100.0% 90.0% 90.0% 80.0% 80.0% 70.0% 70.0% 60.0% 60.0% 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar RTT Incomplete Pathways Performance 2016/ /2016 Target 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

59 [4.3] RESPONSIVE Cancer (a) April-2016 All operational targets achieved in February excluding 62 day performance Cancer Performance: 2WW (All) 2015/ /2017 Target Cancer Performance: 2WW (Breast) 2015/ /2017 Target 100.0% 100.0% 90.0% 90.0% 80.0% 80.0% 70.0% 70.0% 60.0% 60.0% 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 100.0% 90.0% 80.0% 70.0% Cancer Performance: 31 Day (First Treatment) 2015/ /2017 Target 100.0% 90.0% 80.0% 70.0% Cancer Performance: 31 Day (Subsequent Treatment, Surgery) 2015/ /2017 Target 60.0% 60.0% 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

60 [4.3] RESPONSIVE Cancer (b) April-2016 Cancer performance All operational targets achieved in March. Therefore 62 day performance achieved throughout the year excluding June and February - in the months where the target was not achieved this reflected a low number of treatments thus impacting on the overall percentage. Trends and Patterns Ongoing escalation within divisions with regard to cancer pathways/validations continues, teams have been requested to validate data earlier due to performance in February to ensure that all requiremed treatment have been accounted for. Risks or opportunities for the Trust National Cancer Breach Allocation Guidance April the Trust will be required to ensure patients are transferred by Day 38 of the pathway to a Tertiary Centre is necessary. These new "standards" will impact on the demand for responsive diagnostic services to support patient pathways and capacity for both testing and reporting must be reviewed. THH has applied to become a pilot site for the New Cancer Standard 28 days to diagnosis - that will be introduced in 2020, expression of interest submitted % 90.0% 80.0% 70.0% 60.0% 50.0% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% Cancer Performance: 31 Day (Subsequent Treatment, Drug) 2015/ /2017 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cancer Performance: 62 Day (GP) 2015/ /2017 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cancer Performance: 62 Day (Screening) 2015/ /2017 Target 100.0% 90.0% 80.0% 70.0% 60.0% 100.0% 90.0% 80.0% 70.0% 60.0% Cancer Performance: 62 Day (Consultant Upgrade) 2015/ /2017 Target 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

61 [4.4] RESPONSIVE MSA April-2016 No mixed sex accommodation breaches. 2 Mixed Sex Accommodation Breaches 2016/ /2016 Target 1 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

62 [4.5] RESPONSIVE Cancelled Operations April-2016 Cancelled Operations - April 2016 Cancelled operations: 0.63% (13/2050) Tolerance (0.50%) 28 Day re-admissions: 0 Tolerance (0) Urgent cancellations: 0 Urgents cancelled more than once: 0 YTD Cancelled operations: 0.63% (13/2050) Tolerance (0.50%) 28 Day re-admissions: 0 Tolerance (0) Urgent cancellations: 0 Urgents cancelled more than once: 0 3.0% 2.0% 1.0% Cancelled Operations Rate 2016/ /2016 Target In April 2016, 13 patients had their procedure cancelled on the day of surgery due to the following reasons: Consultant unavailable due to sickness (and no coveravailable - 4 No available ward beds - 2 No available ITU/HDU beds - 1 Unexpected medical complications resulting in the list overrunning and later operations being cancelled - 4 Emergency case added onto list - 1 Lack of availability of appropriate theatre equipment - 1 In April there was considerable pressure on the hospital's inpatient beds. All escalation beds were open and in order to accommodate emergency admissions, we had to place more inpatients than normal in our male day care ward. This resulted in elective patients having to have their surgery cancelled as there was either no capacity to accommodate them. Where possible we notified patients the day before their operation if we were going to be unable to bring them in for surgery due to a lack of beds so at lease they would not have to starve unnecessarily. The figures above (13 in April) represent only the patients cancelled on the day of their operation. In April a further 29 patients had their planned surgery cancelled the day before their operation. The year to date performance for cancelled operations is 0.63% which is above the contract threshold of <0.5% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 28 Day Readmissions 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Urgent Cancelled More Than Once 2016/ /2016 Target 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

63 [4.6] RESPONSIVE Theatres April Theatre Management (nb Targets based on 2013/2014 position) Theatre Management (nb Targets based on 2013/2014 position) Theatre utilisation April: 72% Theatre productivity April: 95.4% Average cases per list April: 3.2 The Division of Surgery is including a Theatre Productivity Project as one of its QIPP schemes this year and work has commenced with one of our largest specialities reviewing in detail the start and finish times of individual lists. We will work with the clinical lead within this area to implement the findings in order to improve productivity across the Division (in line with best practice). Pre-operative assessment capacity has already proved an issue and a rate limiting step. Work is now in progress to deliver a more responsive service, that is capable of reacting to short notice availability. The Division will continue to look at how it maximises its current pre op capacity in a way that better supports theatre utilisation Avg Cases Per Session 2016/ /2016 Target 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 120.0% 110.0% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 5.0% 4.0% 3.0% 2.0% 1.0% Utilisation 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Productivity 2016/ /2016 Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cancellation Rate 2016/ /2016 Target 0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

64 The Hillingdon Hospital Trust Performance Report For the Month of Apr 2016 (Monitor KPIs) Traffic Light Key: [] - On target [] - Narrowly missing target [] - Significantly missing target Performance Movement Key: I - improvement S - static D - deterioration 2015/2016 Performance Apr Performance Year-to-date Performance 2016/2017 Target Year End Forecast 12 Month Trend Lead Exec Monitor governance risk weighting if in breach Current Month weighting Current Month Traffic Light Q1 forecast Q2 forecast Q3 forecast Q4 forecast DQ Badge Monitor Risk Assessment Framework: Access and Outcomes metrics 1a Clostridium Difficile Infection: Trust Attributable n/a 12 TM n/a n/a 1b Clostridium Difficile Infection: Lapses in Care National: 8 (de minimis : 12) 0 TM Cancer: Maintain two week cancer waits (all cancers) +^ 3 Cancer: Maintain two week cancer waits (breast symptoms except suspected cancer) +^ 4 All cancers: 31 days diagnosis to treatment for cancer (1st Treatment) +^ 5 All cancers: 31 days diagnosis to treatment for cancer (2nd or Subsequent Treatment - Surgery) +^ 6 All cancers: 31 days diagnosis to treatment for cancer (2nd or Subsequent Treatment - anti cancer drug treatments) +^ 98.0% 96.1% 97.1% 93% 93.0% JS % 96.2% 96.3% 93% 93.0% JS 99.3% 97.3% 99.0% 96% 96.0% JS % 100.0% 100.0% 94% 94.0% JS % 100.0% 100.0% 98% 98.0% JS 0 7 All cancers: 62 days urgent GP referral to treatment for cancer +^ 92.2% 100.0% 88.2% 85% 85.0% JS 0 8 All cancers: 62 days urgent referral to treatment for cancer (Screening) +^ Referral to treatment waiting times (admitted) Referral to treatment waiting times (non-admitted) Referral to treatment waiting times (incomplete) A&E: Total time in A&E less than 4 hours (A&E, MIU, UCC) Self certification against compliance with requirements regarding access to healthcare for people with a learning disability 98.4% 100.0% 98.6% 90% 90.0% JS % 73.9% 73.9% 90% 90.0% JS n/a n/a 98.1% 96.5% 96.5% 95% 95.0% JS n/a n/a 96.1% 93.3% 93.3% 92% 92.0% JS % 86.0% 86.0% 95% 95.0% JS Fully Compliant Fully Compliant Fully Compliant Fully Compliant Fully Compliant 1.0 S TM N/A Notes: Monitor's Governance Rating under its RAF is now based on 5 categories (CQC Information, Access & Outcomes Metrics, Third Party Reports, Quality Governance Indicators and Financial Risk). The 13 indicators above reflect the Access & Outcomes Metrics only. The Second Page of the Glossary details the triggers for concern and the steps that lead to a specific Governance Rating. As there are numerous sources of information that will be used to derive the rating, it is not possible to give the full rating on this scorecard and so the rating that is reported here is based purely on the 13 indicators above. Key triggers in relation to those 13 indicators are: [a] 3 consecutive quarters' breaches of a single metric or a service performance score of 4 or greater. [b] Breaching pre-determined annual C. difficile threshold (either 3 quarters' breach of the year-to-date threshold or breaching the full year threshold at any time in the year) [c] Breaching the A&E waiting times target in two quarters over any 4 quarter period and in any additional quarter over the subsequent three quarters Monitor identifies potential material causes for concern in one or more No Governance categories (requiring further information Concern Evident or formal investigation), Monitor will replace the green rating with a description of the issue and steps taken to address it Regulatory Action + Indicator reported one month in arrears, ++ Indicator reported two months in arrears ^ Whilst Cancer Indicators are reported with a one month lag, the Current Month Traffic Light Column is based on the latest complete month available

65 Indicator Data Sources Domain: Safe Indicator ID Indicator Description Data Source MRSA Cases (Trust Attributable) Infection Control C.Diff Cases (Trust Attributable) Infection Control MSSA Cases (Trust Attributable) Infection Control E.Coli Cases (Trust Attributable) Infection Control % of Time On The Stroke Unit PAS / Patient Notes High Risk TIA Treated W/I 24 Hours PAS / Patient Notes FNOF Patients In Theatre W/I 36 Hours PAS / Patient Notes Booking Euroking C-Section Rates (Combined) Euroking C-Section Rates (Elective) Euroking C-Section Rates (Emergency) Euroking Tears Euroking Rate of Patient Falls (All) Governance (Datix) Rate of Patient Falls (with Harm) Governance (Datix) Patient Falls With Fracture Governance (Datix) Incidents as a % of Total Incidents VTE Compliance PAS Pressure Ulcers (Grade 2, 3 & 4) Governance (Datix) Pressure Ulcers per 1,000 Beddays Governance (Datix) Harm Free Care (All Harms) Safety Thermometer Harm Free Care (New Harms) Safety Thermometer Serious Incidents Governance (Datix) Never Events Governance (Datix) Incidents Governance (Datix) Reporting Rate per 1,000 Beddays Governance (Datix) / PAS Incidents Resulting In Harm Governance (Datix) Percentage Resulting in Harm Governance (Datix) Domain: Effective Indicator ID Indicator Description Data Source Day Readmission Rates PAS DNA Rates PAS Appointment Slot Issue (ASI) Rate C&B / ereferrals Domain: Caring Indicator ID Indicator Description Data Source Inpatient FFT: Response rate iwantgreatcare / Meridian / Rate / PAS Inpatient FFT: % Recommended iwantgreatcare / Meridian / Rate / PAS Inpatient FFT: % Not Recommended iwantgreatcare / Meridian / Rate / PAS A&E FFT: Response rate iwantgreatcare / Meridian / Rate / PAS A&E FFT: % Recommended iwantgreatcare / Meridian / Rate / PAS A&E FFT: % Not Recommended iwantgreatcare / Meridian / Rate / PAS Maternity FFT: Response rate iwantgreatcare / Meridian / Rate / PAS Maternity FFT: % Recommended iwantgreatcare / Meridian / Rate / PAS Maternity FFT: % Not Recommended iwantgreatcare / Meridian / Rate / PAS Complaints: Trust Total Datix Complaints: CCSS Datix Complaints: Medicine Datix Complaints: Surgery Datix

66 Indicator Data Sources Complaints: W&C Datix Number of Negative PALS Concerns PALS Team Domain: Responsive Indicator ID Indicator Description Data Source Performance Against 4Hr Target (All) PAS Performance Against 4Hr Target (Type 1) PAS LAS Handover Times (30 Mins) LAS Portal Black Breaches LAS Portal RTT - Admitted Perf. (Unadjusted) PAS RTT - Non Admitted Perf. PAS RTT - Incomplete Pathways Perf. PAS RTT - 52 Week Waiters PAS Cancer Perf.- 2WW (All) Somerset Cancer Perf. - 2WW (Breast) Somerset Cancer Perf Day (First Treat) Somerset Cancer Perf Day (Subsequent Surg.) Somerset Cancer Perf Day (Subsequent Drug.) Somerset Cancer Perf Day (GP) Somerset Cancer Perf Day (Screening) Somerset Cancer Perf Day (Upgrade) Somerset Mixed Sex Accommodation Breaches Manual Cancellation Rate PAS Day Readmission PAS Urgent Cancellation More than Once PAS Utilisation PAS Productivity PAS Avg Cases Per Session PAS Cancellation Rate PAS

67 The Hillingdon Hospital NHS Foundation Trust PDR, Medical Appraisals and Mandatory Training Compliance April 2016 Medical Appraisals - The medical appraisal window opened on 01 April 2016 and compliance in April %. This is 1.3% increase in compliance compared to the same period last year. In order to meet the trust's 90% target, a monthly compliance target of 10% has been set. In addition, a letter will be sent out to doctors who missed their appraisal compliance in 2015/2016 with a requirement that they meet with the Responsible Officer to discuss the reasons for non-compliance. Core Skills Training - In April 2016, the trust achieved its highest compliance rate since This was an increase of 1.23% compared to the same period in 2015 and compliance is projected to grow this year. As the trust continues to build a STAM compliance culture, its focus will shift to improving the quality of training and induction experience to support its retention agenda and practice. PDR Compliance - The PDR window for non-medical staff opened on 01 April 2016 and Trust compliance rate in April 2016 was 2.90% which is higher than our compliance during the same period last year. A low compliance in the month of April is not unusual as managers plan PDR meetings and carry out reviews for their teams. Although the trust is below its 20% monthly target, historically 70% of our PDRs are completed in June. We anticipate the trust will meet its annual PDR target of 90% by 30th June 2016 when the window closes. To support compliance a programme of appraiser and appraisee training has been put in place and a comms plan rolled out to encourage compliance. All PDR documentation has also been revised to update changes to the process and improve reporting and recording. 100% 80% 60% 40% 20% 0% PDR compliance % Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ /17 Target (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% Medical Appraisals Compliance % Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ /17 Target (%) 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Mandatory Training compliance % Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ /17 Target

68 The Hillingdon Hospital NHS Foundation Trust Sickness Rate and Sickness Cost April 2016 Sickness - The Trust sickness rate in April 2016 was 3.40% which is a 0.22% reduction compared to same period in A number of initiatives have been put in place to address long and short term sickness absences including dedicated training for managers. CSS Division was noted for having the highest sickness rate (3.91%). Medicine (3.65%) also reported high sickness absences followed by W&C (3.38%), Corporate (3.18%). Surgery was the only Division whose sickness rate (2.97%) was below the trust target. HRBPs are working closely with wards and departments to raise awareness of sickness management and delivering sickness management training locally, or encouraging managers to attend the HR Workshops on managing sickness absence. The HRBP and OH teams are also working on Health & Wellbeing initiatives it is envisaged that these will have a positive impact on helping reduce sickness absence across the Trust. The overall cost of sickness April 2016 was 248k, which is a 12% increase in sickness costs over same period last year, despite the sickness rate being lower. This could in part be attributed to the April pay award and also incremental drift (staff progressing through their increments). Medicine Division s sickness costs represented 25% (62k) of the overall sickness costs for April Sickness costs in CCCS Division were 59k (24%) followed by Surgery and Corporate division 45k (18%). W&C reported the lowest sickness costs at 35k (14%) Trust Sickness Rate % Total Sickness Cost 4.50% 4.00% 3.50% 300, , % 200, % 2.00% 150, % 100, % 0.50% 50, % Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ /17 Target (%) 2015/ /17

69 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The Hillingdon Hospital NHS Foundation Trust LTR and Vacancy Rate April 2016 Trust vacancy rate: The Trust vacancy rate for April 2016 was 8.64% against a target of 8.00%. Overall trust vacancies increased in April 2016 by 0.57% compared to April This increase is a reflection of the health workforce market and difficulty recruiting to specialist clinical roles. We continue to robustly manage our vacancies (particularly nurse vacancies) through a number of initiatives. Nurse recruitment is improving and the trust has put in place plans to recruit from the UK and overseas in the next year to meet demand. In terms of overseas recruitment, the trust is in the process of selecting a provider for overseas nurse recruitment with the intention of going out to the Philippines in July Time to recruit: There has been a significant improvement on time to hire in the month of April 2016 with average time to hire of 60 days. This is an improvement of 36% compared to last year which was 81.7 days on average. The trust is on course to continue to improve TTR to support its recruitment drive and improve the employee onboarding experience. Leavers Tenure: The mean years for staff who left in April 2016 was 4.50 years, 2.17 years less than the April Identifying trends in leavers tenure remains a challenge as leaver tenure has fluctuated over the last year. However the Trust is currently undertaking a detailed analysis of exit interview data and reviewing the process to better understand characteristics of and reasons why staff leave. This work will inform retention initiatives moving forward. Trust Vacancy Rate % Labour Turnover Rate % Time to recruit at point of formal offer (average days) Leavers - Tenure (LoS) Median yrs 15% 10% 5% 0% 20% 15% 10% 5% 0% / /17 Target (%) 2015/ / / /17 Target 2015/ /17

70 The Hillingdon Hospital NHS Foundation Trust Temporary Staffing Usage April 2016 Temporary Staffing: From April 2015 to April 2016 there has been a continuing trend in the reduction of temporary staffing spend (20%) with the lowest spend being in October Although costs increased in March 16 by 17% over February 2016, this reduced in April 2016 by 15% (to ) compared to the previous month. Although the cost of Bank staff in April 2016 was 689,327, an increase of 15% compared to the same period last year, there has been a significant reduction in agency costs, from 1,543,112 in April 2015 to 1,004,120 in April 2016, showing a reduction of 35% in agency spend. The use of off framework agency workers was 0.70% in April 2016 compared to 5.78% in April Although there are still areas where the Trust uses off framework agency workers this is minimal and being gradually phased out. The introduction of the agency price caps in November 2015 has supported a reduction in agency costs and contributed to a reduction in our use of off framework agencies. Bank Cost ( ) Agency Cost ( ) Bank and Agency Total spend 1,000,000 2,000,000 2,500, , , , ,000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 1,500,000 1,000, , ,000,000 1,500,000 1,000, ,000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / / / / /17 %'s filled with bank %'s filled with agency %'s filled with off framework 70.00% 30.00% 8.00% 65.00% 60.00% 20.00% 10.00% 6.00% 4.00% 2.00% 55.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / / / / /17

71 The Hillingdon Hospital NHS Foundation Trust Employee Relations April 2016 Employee Relations During April 2016, 6 employee relations cases progressed to a formal stage compared to 2 during April a 200% increase in activity. Of the 6 cases, 4 were in relation to disciplinary matters. At the end of the last financial year there were 55 employee relations that had progressed to a formal year, this represented a 25% increase in activity compared to the year before. The Directorate is continuing to offer its People Management Modules / HR Workshops to Managers and Supervisors, which have been positively received. Further work is ongoing with an external consultancy which has run focus groups on themes such as bullying and harassment and career progression. This is with a view to listening to the staff voice on these matters and proactively identifying sustainable solutions to manage this issue. Number of Grievances Number of Harrasment Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / / /17 Number of Disciplinary Number of Capability/ Performance Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / / /17

72 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The Hillingdon Hospital NHS Foundation Trust Establishment April 2016 Staff in Post: The Trust SiP increased in April 16 for all professional groups (aside from healthcare scientists) by 6% compared to the same period in The highest percentage difference between SiP in April 2015 and April 2016 was within Add Prof Scientific and Technic group which saw a 17% increase. This increase was due growth in patient activity which impacted the level of admin functions to support clinical activity. Compared to April 2015, SiP for Estate and Ancillary groups also increased (by 12%) followed by Nursing and Midwifery Registered group by 7% and Medical and Dental by 4% compared to same period. As our vacancies continue to increase we anticipate that the percentage of staff in post will stabilise in year. The reduction in SiP for healthcare scientists between April 2015 and April 2016 is due to the ongoing North West London Pathology modernisation programme which will see a centralisation of pathology services across North West London area. This initiative has impacted recruitment and retention within these professional groups. Staff in Post ~ FTE Add Prof Scientific and Technic Staff in Post ~ FTE Additional Clinical Services Staff in Post ~ FTE Admin and Clerical Staff in Post ~ FTE Allied Health Professionals / / / / / / / /17 Staff in Post ~ FTE Nursing and Midwifery Registered Staff in Post ~ FTE Healthcare Scientists Staff in Post ~ FTE Medical and Dental Staff in Post ~ FTE, Estates and Ancillary / / / / / / / /17

73 The Hillingdon Hospital NHS Foundation Trust Price Cap April 2016 Price caps: Since November 2015 the trust reported breaches in agency usage above the national price cap. Over this period trust total breaches were lowest in February 2016 (101) compared March 2016 (215) which saw a 53% increase. This increase was due to an increase in usage Medical locums over the price cap. Breaches stabilised in April 16 seeing a 36% reduction over March 2016 (with medical locums breaches lowest in month). Breaches are being better managed and controlled in Administration and Estates and apart from significant breaches in December 2015, breaches have continued to diminish with no reports of breaches in April Breaches within Nursing have fluctuated with breaches lowest in November 2015 peaking in March 2016 (61). Overall breaches have been lowest among AHPs with its highest breach in March 2016 decreasing in April 16. Divisions continue to review their workforce needs to ensure that services can be delivered in a different way to reduce agency spend and consequently breaches All other clinical Staff (AHPs) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Administration & Estates Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / / / Medical Locums Nursing Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / / /17

74 The Hillingdon Hospital NHS Foundation Trust Glossary April 2016 PDR Compliance - Based on assignment category; active primary assignment, internal secondments and acting up, excluding maternity leave, Medical and Dental, Student Staff Group, staff employed after 1st Nov 2014 and long term sickness. This report also excludes recharge and Senior Management Team. PDR 2014 cycle did not commence until 1st July 2014 therefore no data. Information extracted from ESR through Business Intelligent reporting tool. Medical Apprisals - include all doctors with a connection to the trust for revalidation. This does not include doctors in training or doctors connected to another designated body. This information is provided by the Medical Staffing Team. Mandatory Training - Figures are based on active assignments, internal secondments and acting up. Maternity Leave is excluded. Please note, this figure does not include the following courses: Customer Care, Dementia Awareness, EPLS/APLS annd MCA and DoLs. Data extracted from WIRED. Trust sickness - Figures are based on current month data, across permenant and fixed term employees only. Information extracted from ESR and uploaded by E-rostering and Finance Interface. Trust sickness cost - Figures are based on current month data, across permenant and fixed term employees only. Information extracted from ESR. Trust Vacancy Rate - the percentage of vacancies across all divisions in the trust in the current reporting month. Staff in post data is extracted from ESR and funded establishment data is provided by finance. Labour Turnover Rate - based on current month only across the Trust for Permenant Staff only. Time to recruit at point of formal offer (average days) - this is based on information provided by HR from advert to point of formal offer (average days) Leavers - Tenure (LoS) Median yrs - Information extracted from ESR, information on permanent staff only. Temporary Staffing useage - Information extracted from E-rostering and provided by Employee Services. Employee relations - this information is extracted from employee relations log and cases recorded in ESR, and is provided by the HRC's Establishment (SiP) - Information extracted from ESR for permenant and fixed term employees only as a snapshot of the last day of the reporting month

75 Measures of Infection Prevention and Control April 2016 Mandatory Reporting Performance in 2015/16 April Performance Year-to-Date Performance 2016/17 Target 2016/17 traffic light Clinical Support Services Medicine Surgery Women & Children's Comments MRSA blood stream infections (attributed to the Trust) 1 TBC TBC 0 2 cases of MRSA BSI have been identified within 48 hours of admission to the Trust and have been investigated by the CCG. Both cases have gone to arbitration and the Trust awaits the final outcome. Clostridium difficile infections (attributed to the Trust) or less No cases for April 2016 MSSA blood stream infections (attributed to the Trust) NT E Coli blood stream infections (attributed to the Trust) NT Local Reporting Compliance with MRSA screening policy (elective) 94% 103% 103% 100% Compliance with MRSA screening policy (non elective) Number of needle stick injuries and inoculations reported Local Monthly IP&C performance indicators 88% 79% 79% 100% NT MRSA Screening data are taken from i-reporter. The figures can fluctuate slightly as clinical coding data are entered retrospectively. Unlabelled specimens contribute to a lower compliance outcome, but are not the only cause. Sharps and splash injuries reported either directly to occupational health or indirectly through the A&E department during the period 1st April st May All incidents were dealt with as per the Trusts Sharps Injury Policy. 2 splash injuries and 8 needle injuries (cause by: injection needle - 4, butterfly - 1, scalpel - 1, lancet - 1, acupuncture needle - 1). Uptake of mandatory IP&C training (clinical level 2) 84% 84% 84% >90% 91% 82% 83% 88% Uptake of mandatory IP&C training (clinical level 1) 94% 96% 96% >90% 99% 91% 100% 97% Compliance in IPC training has significantly improved, however the new CCG target of 90% will present a further challenge. On line assessment and training is available and this will ensure that there is easy access for all staff at all levels. Technical Audit Domestic Cleaning - VHR 98% 99% 99% >98% 98% 100% 99% Technical Audit Domestic Cleaning - HR 96% 98% 98% >95% 97% 98% 99% 98% Technical Audit Nurse Cleaning - VHR 89% 91% 91% >98% 88% 99% 86% Technical Audit Nurse Cleaning - HR 87% 90% 90% >95% 88% 97% 100% 74% Technical Nurse Cleaning compliance has improved slightly and a meeting with Matrons and Associate Directors of Nursing has addressed some issues relating to the audit processes. Ward level cleaning equipment will be trialled in May to ensure that nursing staff have the appropriate equipment and instruction available. Compliance with restricted antibiotic policy 87% NA NA >95% Compliance with hand hygiene policy 95% 91% 91% >95% 96% 92% 83% 92% Compliance with Bare Below Elbows 98% 95% 95% >95% 94% 99% 91% 95% Audits of Hand Hygiene show that non compliance is predominantly after leaving a patient environment and after removal of gloves. Education and monitoring at the point of care continues to address this. Contamination of Blood Cultures 4% 3% 3% NT ANTT training in all areas continues to be emphasised. Monthly High Impact Interventions (HIIs) HII No. 1 - Central venous catheter care 99% 87% 87% >97% Documentation of insertion was identified as the key factor for non-compliance HII No. 2 - Peripheral line care (VIP) 97% NM NM >97% HII No. 5 - Ventilator care 99% 99% 99% >97% HII No. 6 - Urethral catheter care HII No. 7 - Clostridium difficile care bundle 93% NM NM >95% 96% 93% 93% >95% 87% 91% 100% Documentation of catheter insertion has been identified as a problem on the admitting wards and subsequent wards are being audited down. IPC advise that in the absence of clear insertion documentation a note is written on the notes to support this information. Matrons Quick Question Assessment 95% 94% 94% >90% 95% 93% 95% 93% Bi-annual / Annual IP&C local measures Compliance with Isolation Policy 91% NM NM >90% Compliance to linen policy 79% NM NM >95% HII No. 4 - Preventing surgical site infection 84% NM NM >85% NM = not measured NA = not available NT = No Target IP&C RAG rating for compliance of: 95% 90% 80% Compliance 95% Compliance >90% Compliance >80% Partial Compliance 70%-94% Partial Compliance 70%-89% Partial Compliance >60% Minimal Compliance < 69% Minimal Compliance <69% Minimal Compliance <60%

76

77 Meeting of the Board of Directors Public Session Financial Report Wednesday 25 th May 2016 Agenda item 11 Reason for item: This is a standing monthly report to the Board in respect of its key regulatory financial responsibilities in compliance to the terms of its provider licence. Summary: This is the financial report and commentary to the end of April 2016 (month 1), quarter 1 of the 2016/17 financial year. The Trust ended the month with a deficit of 1,303k, 660k behind plan. The adverse revenue position has driven a Financial Sustainability Risk Rating (FSRR) of 1 with a score of 1 for every metric. The key drivers for the Trust s adverse financial position in April are adverse variances of 0.4m on NHS Clinical Income and 0.2m on pay. The adverse variance on NHS Clinical Income includes the impact of the junior doctors strikes on the Trust s activity and therefore income, though further detailed analysis is being undertaken on this. The adverse variance on pay is primarily driven by the level of emergency activity requiring the Trust to allocate additional resources in A&E and AMU, as well as having to keep open escalation beds. The continuation of additional costs to meet the demands of growing emergency activity limited the Trust s ability to deliver the anticipated efficiency cost reductions in April. Efficiency savings achieved for the month were 286k, 141k lower than April last year. This was 1.5% of operating expenses and 194k behind target. The Board should note compared to April last year there was a net increase of 102 whole time equivalent (wte) staff; 190wte more substantive staff and 88 fewer nonsubstantive staff. Compared to April last year the Trust had 7 fewer beds available due to the closure of 29 beds on Edmunds ward, 8 additional beds open on Daniels ward, and 14 additional beds to manage emergency activity. The Trust has a target set by NHS Improvement to reduce agency expenditure for 2016/17 below 10.5m, compared to 14.6m for 2015/16. Agency expenditure for April was 985k against a phased plan of 1,082k, 97k below plan. Agency expenditure in month was the lowest since August Cash ended the month at 1.6m, which was 2.5 below plan. Constructive discussions have progressed with Hillingdon CCG to receive all the cash for the transitional support early in the financial year. Page 1 of 6

78 The Board should note that the 7.3m cash envelope agreed for capital for 2016/17 allows the Trust to purchase 8.4m of assets, as a number of assets will be financed by leases. The impact of leases is to reduce the pressure on cash during this financial year, but it does create a cash commitment for the remained of the lease period. 561k of the leased assets had previously been leased, with their capital repayments incorporated into a base cashflow, and therefore were not a pressure on the 7.3m cash envelope. Capital expenditure was 306k, 347k below plan. This reflects the slippage on Estate schemes at the start of the financial year. The Board should note that the Trustwide budget has been agreed by the Board, and is reflected in the report, but the Budget Setting exercise to agree Divisional and Directorate budgets will not be completed for all Divisions until next month s report. The variances reported in Appendix C reflect rollover budgets, agreed funding to align with control totals, inflation pressure funding, removal for budgets for QIPP, and funding for agreed Quality Investments. Given the scale of the deficit for Medicine, Surgery, and CCSS in 2015/16 they have been set control total deficits of 1.55m, 1.0m, and 0.25m respectively for 2016/17, with a compensating reserve held centrally. The control total deficits have been set with additional budget allocated to allow each Division to halve its underlying deficit from 2015/16 provided they fully achieve their QIPP target, and internally manage any unplanned cost pressures. Should the Divisions achieve their control total deficit in year, further budget will be allocated to them in 2017/18 to allow them to achieve a balanced financial position Board Action required: The Board is asked to: 1. Note the current financial performance of the Trust. Report from: Matt Tattersall, Director of Finance Links to Trust strategic priorities: To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide. To deliver high quality care in the most efficient way. Previous consideration at Board or Committees: n/a Equality and diversity considerations: none. Financial implications: The Trust s ability to comply with the terms of its provider licence in respect of financial sustainability is critical to the organisation being able to continue to provide the fullest range of high quality health services. Page 2 of 6

79 EXECUTIVE SUMMARY FINANCIAL REPORT APRIL 2016 (MONTH 1) QUARTER 1, 2016/17 The April financial position was a deficit of 1,303k, 660k worse than plan. EBITDA was - 24k, -0.1% of revenue and 700k worse than plan. Pay expenditure increased to 13,449k in-month, 167k higher than the average for quarter /16, and 457k higher than April last year. The estimated impact of pay awards and increased employers NI in month was 341k in month. The overall increase in pay is despite a reduction in agency expenditure in April, 81k lower than the average for the previous quarter, and 596k lower than last April. Drugs over-spent in month by 45k, though this is offset by an increase in charges to commissioners for tariff excluded drugs. Clinical Supplies overspent by 35k, whilst the adverse variance for Other Operating Expenses was primarily driven by increased Estate related expenditure. Operating revenue for the month was 295k below plan; the adverse variance for NHS Clinical Income partially offset by increases in non-nhs Clinical Income and Other Operating Income. The increase in non-nhs Clinical Income is driven by overseas visitor income. The table below shows: the planned Finance and Sustainability Risk Rating (FSRR); the FSRR for April, and the level of year end deficit that would be required to deliver a rating of 1 in each individual metric. Metric Annual Plan April rating Year-end deficit value that generates a rating of 1 Liquidity 1 1 Capital Service Capacity m Underlying Performance m Variance from Plan m Weighted average FSRR 2 1 The Board should note that the Trust s weighted average FSRR rating will remain 2 provided no more than 2 metrics score 1. Consequently, all else being equal, the Trust s year end FSRR would reduce to a 1 should the deficit reach 4.8m. KEY MESSAGES Commissioning income under-performed by 385k for the month, with underperformance for NWL commissioners, excluding Hillingdon, NHSE, and noncommissioned activity. Activity was reduced for Hillingdon CCG, but the Trust was protected from the immediate financial impact by the Minimum Income Guarantee. Compared with September 2015, the last non-winter 30 day month without a Bank Holiday, inpatient spells for non-hillingdon CCG activity fell by 167, and outpatients reduced by 260. Page 3 of 6

80 Non-NHS Clinical revenue was above plan by 57k for the month due to overseas visitor income, and Other Operating Income 33k above plan. Efficiency savings of 286k were delivered in April 2016, 194k (40.4%) below plan. This compared with 427k of savings delivered in April DIVISIONAL FINANCES Women & Children achieved a 69k under-spend for the month, whilst Medicine ( 361k), Surgery ( 215k) and CCSS ( 73K), all delivered significant variances outside of their control totals. Expenditure for Medicine and Surgery is aligned with inflated expenditure for 2015/16, which would indicate that any gains from efficiency have been offset by other cost pressures. CCSS incurred a 25k increase in pay expenditure above inflation. Estates and Facilities have an adverse variance of 179k in month, driven by increased non-pay and a 20k increase in pay expenditure above inflation. CASH AND BALANCES The Trust ended the month with a 1.6m cash balance. This was 2.5m below plan. The balance sheet reported a 7.2m net current liability; an adverse movement of 0.8m in-year primarily due to the deficit incurred. Capital expenditure was 306k year-to-date and 347k below plan. Page 4 of 6

81 OTHER KEY STRATEGIC POINTS Births at 407 were 57 higher than April last year, fully explained by the increase in births from Ealing following the reconfiguration. The Board should note that as Easter fell in April last year, the Trust would have ordinarily have expected to see a significant month on month increase in activity in April 2016 New GP outpatient referrals were 540 (8.6%) higher than April last year. Emergency Department attendances increased by 460 (6.7%) compared to April last year, despite lower activity on the junior doctor strike days, this equates to more than an additional 15 patients per day Non-Maternity Emergency inpatient spells decreased by 459 (22.0%) compared to April last year. The expansion of ambulatory care during 2016/17 has prevented the increase in emergency department attendances converting into more emergency admissions. Elective inpatient and day cases decreased by 57 (2.2%) compared to March last year. Equality Impact Assessment: N/A there is no positive or negative impact from this report. Matt Tattersall Director of Finance May 2016 Page 5 of 6

82 Page 6 of 6

83 Appendix A THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Statement of Comprehensive Income Period Ending 30th April 2016 (Month 1) Annual Yr on Yr Actual Actual Var Actual Var Plan Growth to to-date Yr on Yr to-date This Yr on Yr This Outturn Growth Month Growth Month 000s % 000s % 000s 000s % 000s Operating Income NHS Clinical Income 212, % 17, % (385) 17, % (385) Non-NHS Clinical Income 3,610 (2.0%) % % 57 Other Operating Income 25,824 (12.3%) 2,083 (15.6%) 33 2,083 (15.6%) 33 Total Operating Income 242, % 19, % (295) 19, % (295) Operating Expenses Employee Expenses (158,052) 0.9% (13,449) 3.5% (218) (13,449) 3.5% (218) Drugs (19,328) 7.2% (1,669) 30.6% (45) (1,669) 30.6% (45) Clinical Supplies and Services (23,846) (0.4%) (2,042) 1.1% (35) (2,042) 1.1% (35) Other Operating Expenses (27,100) 1.8% (2,362) 12.0% (107) (2,362) 12.0% (107) Total Operating Expenses (228,326) 1.4% (19,522) 6.1% (405) (19,522) 6.1% (405) EBITDA 13, % (24) (102.4%) (700) (24) (102.4%) (700) PFI & Lease Depreciation (2,036) (0.1%) (172) 14.7% 7 (172) 14.7% 7 Other Depreciation (7,838) 6.9% (617) (12.6%) 27 (617) (12.6%) 27 Interest Income % 2 0.0% % 0 Other Finance Costs (78) (0.4%) (7) 16.7% 0 (7) 16.7% 0 Interest Expense on Capital Investment Loans (240) 0.0% (19) (5.0%) 1 (19) (5.0%) 1 Interest Expense on Working Capital Loans (168) 2.4% (13) (7.1%) 0 (13) (7.1%) 0 Interest Expense on LIFT Contract (1,394) (0.5%) (115) 0.9% 4 (115) 0.9% 4 Interest Expense on Other Finance Leases (268) (2.9%) (19) (9.5%) 1 (19) (9.5%) 1 PDC Dividend Expense (3,832) (3.2%) (319) 0.3% 0 (319) 0.3% 0 Surplus(Deficit) before Exceptionals (1,900) - (1,303) - (660) (1,303) - (660) Gains/(Loss) on Investment Properties Profit/(Loss) on the Disposal of Assets Impairments Surplus(Deficit) after Exceptionals (1,900) - (1,303) - (660) (1,303) - (660) EBITDA % 5.8% (0.1%) (0.1%) Normalised Surplus (Deficit) % (0.8%) (6.7%) (3.4%) (6.7%) (3.4%) ( ) variance indicates it is adverse

84 Appendix B Income and Expenditure Trend Analysis 000s Income Trend Analysis February 2014 to June ,000 20,500 20,000 19,500 19,000 18,500 18,000 17,500 17,000 16,500 16,000 15,500 15,000 Feb Apr Jun Aug Oct Dec Feb Apr Jun 000s Operating Expenses Trend Analysis February 2014 to June ,000 20,500 20,000 19,500 19,000 18,500 18,000 17,500 17,000 16,500 16,000 15,500 15,000 Feb Apr Jun Aug Oct Dec Feb Apr Jun Last Year This Year Trend Last Year This Year Trend 000s 1,800 1,600 1,400 1,200 1, EBITDA Trend Analysis February 2014 to June Feb Apr Jun Aug Oct Dec Feb Apr Jun Last Year This Year Trend 000s Surplus/(Deficit) Against Plan April 2016 to March 2017 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Plan Actual

85 Appendix C THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Divisional Performance Summary Period Ending 30th April 2016 (Month 1) Annual Plan Actual Variance Variance Year-End Risk WTE's WTE's WTE's Change Plan Forecast to Substantive Other Total from To-Date To-Date To-Date Last Month Variance Achieving Last 000's 000's 000's 000's % 000's 000's Plan Month Cancer & Clinical Support Services (26,595) (2,254) (2,327) (73) 3.2% 0 (252) High (17) Medicine and Emergency Care (45,022) (3,814) (4,175) (361) 9.5% 0 (1,547) High (48) Surgery (46,258) (3,881) (4,096) (215) 5.5% 0 (1,001) High (26) Women & Children (23,245) (1,989) (1,920) 69 (3.5%) 0 0 Low (13) Estates and Facilities & Corporate Devt. (13,526) (1,175) (1,354) (179) 15.2% 0 0 High Finance and Information (8,970) (763) (789) (26) 3.4% 0 0 Low (2) Corporate Nursing (6,979) (582) (592) (10) 1.7% 0 0 Low (1) Senior Management (2,321) (193) (193) 0 0.0% 0 0 Low (1) People & Development (2,077) (173) (176) (3) 1.7% 0 0 Low (4) Education Centre (355) (30) (23) 7 (23.3%) 0 0 Low Director of Operations (2,519) (210) (224) (14) 6.7% 0 0 Low Other Corporate and Reserves 175,967 14,421 14, (1.0%) 0 2,800 Low (4) Total (1,900) (643) (1,303) (660) (102.6%) 0 0 High 2, ,306 (110) Efficiency Savings Delivery by Division Period Ending 30th April 2016 (Month 1) Last Year Plan Plan Actual Variance Variance Actual For Year To-Date To-Date To-Date To-Date 000's 000's 000's 000's 000's % Cancer & Clinical Support Services 1,132 1, (25) (37.7%) Medicine and Emergency Care 1,822 2, (52) (35.1%) Surgery 733 2, (24) (21.2%) Women & Children 1, (42) (85.7%) Estates and Facilities & Corporate Devt , (33) (46.1%) Finance and Information (7) (45.4%) Corporate Nursing (4) (100.0%) People & Development (5) (100.0%) Director of Operations % Senior Management (4) (100.0%) Trustwide Savings 2, Total 8,014 9, (194) (40.4%)

86 Appendix D THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Efficiency Savings Delivery by Programme Period Ending 30th April 2016 (Month 1) Plan for the Year Plan To-Date Actual To-Date Variance To-Date Variance To-Date Efficiency Saving Project 000's 000's 000's 000's % Reduction in Temporary Staffing (bank & agency) 3, (64) (25.7%) Reduction in Other Pay Costs % Reduction in ALOS Procurement (9) (100.0%) Medicines Optimisation Pharmacy/Diagnostics Other Non-Pay (24) (42.9%) Contribution from NHS Income 1, (15) (22.7%) Contribution from Non-NHS Income % Schemes in Development 1, (82) (100.0%) Total 9, (194) (40.4%)

87 Appendix E THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Analysis of Operating Expenses Period Ending 30th April 2016 (Month 1) Last Annual Budget Actual Var Actual Year Plan To-date To-date To-date Yr on Yr Actual Growth 000s 000s 000s 000s 000s % Pay Medical Staffing - Non-Training Grades (27,705) (27,958) (2,340) (2,359) (19) 6.8% Medical Staffing - Training Grades (15,362) (15,502) (1,298) (1,303) (5) 6.8% Nurses & Midwives (46,906) (47,334) (3,962) (4,011) (49) (0.6%) Scientific, Therapeutic & Technical Staff (12,361) (12,474) (1,044) (1,039) 5 (2.3%) Other Clinical Staff (25,617) (25,851) (2,164) (2,223) (59) 8.0% Non-Clinical Staff (28,673) (28,934) (2,422) (2,514) (92) 4.5% Total Pay Costs (156,624) (158,052) (13,231) (13,449) (218) 3.5% To note on Pay Agency Staff (14,635) (10,499) (1,082) (985) 97 (37.7%) Bank Staff (7,578) (7,578) (634) (689) (55) 17.6% Discretionary Pay (4,626) (4,626) (387) (377) 10 (30.8%) Total (26,839) (22,703) (2,104) (2,051) 53 (24.4%) Non-Pay Clinical Supplies & Services (41,976) (43,174) (3,631) (3,711) (80) 12.6% General Supplies & Sevices (3,987) (4,060) (338) (352) (14) 9.3% Establishment (5,089) (5,182) (431) (447) (16) 23.5% Premises and Fixed Plant (7,793) (7,935) (660) (698) (38) 5.4% Ambulance Services (894) (910) (76) (74) 2 4.2% Other Non-Pay (8,853) (9,014) (750) (791) (41) 14.5% Total Non-Pay Costs (68,592) (70,274) (5,886) (6,073) (187) 12.4% Total Expenses (225,216) (228,326) (19,117) (19,522) (405) 6.1%

88 Appendix F THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Thirteen Month Rolling Cashflow Report & Forecast Period Ending 30th April 2016 (Month 1) Monthly Analysis 2016/ / / / / / / / / / / / /18 April May June July August September October November December January February March April 2016/17 Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Actual Forecast 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s Opening Cash 4,092 1,602 1,362 1,622 1,882 2, ,551 1,811 2,571 3,331 4,091 2,903 4,092 Receipts Healthcare Contracts 14,219 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15, ,219 Other NHS 3,733 2,500 2,500 2,500 2,500 3,000 3,000 3,000 3,000 3,000 3,000 3,000 3,000 34,733 Commercial 1,523 2,000 2,000 2,000 2,000 2,000 2,000 2,000 2,000 2,000 2,000 2,000 2,000 23,523 PDC Dividend Receipt Payments Salaries & Wages (6,995) (7,000) (7,000) (7,000) (7,000) (7,000) (7,000) (7,000) (7,000) (7,000) (7,000) (7,000) (7,000) (83,995) Tax, N.I. & Pensions (5,022) (5,100) (5,100) (5,100) (5,100) (5,100) (5,100) (5,100) (5,100) (5,100) (5,100) (5,100) (5,100) (61,122) Other Expenses (9,008) (6,200) (6,200) (6,200) (6,200) (6,200) (6,200) (6,200) (6,200) (6,200) (6,200) (6,033) (6,033) (77,041) Dividend Payable (1,916) (1,916) 0 (3,832) LIFT and Lease Payments (169) (169) (169) (169) (169) (169) (169) (169) (169) (169) (169) (173) (173) (2,032) Capital Payments (771) (771) (771) (771) (771) (771) (771) (771) (771) (771) (771) (771) (771) (9,252) Working Capital Loan Repayment 0 (500) (500) (1,000) Existing Loans Repayments (195) (195) 0 (390) Closing Cash 1,602 1,362 1,622 1,882 2, ,551 1,811 2,571 3,331 4,091 2,903 3,826 2, Weekly Analysis Week Week Week Week Week Week Week Week Week Week Comm Week Comm Week Comm Comm Comm Comm Comm Comm Comm Comm Comm Comm 13 Week Rolling Forecast 1/4/16 8/4/16 15/4/16 22/4/16 29/4/16 6/5/16 13/5/16 20/5/16 27/5/16 3/6/16 10/6/16 17/6/16 Opening Cash 4,092 3,122 16,391 8,479 1,602 1,982 10,782 7,942 1,362 1,412 10,962 8,922 Receipts Healthcare Contracts 0 14, , , Other NHS ,483 1, Commercial Payments Salaries & Wages (120) (100) (100) (6,675) (120) (100) (100) (6,680) (100) (100) (100) (6,700) Tax, N.I. & Pensions 0 0 (5,022) 0 0 (5,100) (5,100) 0 0 Other Expenses (2,000) (2,000) (3,000) (2,008) (1,500) (1,700) (2,000) (1,000) (1,000) (1,400) (1,800) (2,000) Dividend Payable Lease Payments 0 0 (169) (169) (169) 0 Capital Expenditure 0 0 (771) 0 (771) (771) 0 Working Capital Loan Repayment (500) Existing Loans Repayments Closing Cash 3,122 16,391 8,479 1,602 1,982 10,782 7,942 1,362 1,412 10,962 8,922 1,622 Creditor Stretch b/f (4,521) (4,771) (5,021) (3,331) (3,573) (4,323) (4,723) (3,383) (4,483) (5,583) (6,283) (5,643) Expenditure (2,250) (2,250) (2,250) (2,250) (2,250) (2,100) (2,100) (2,100) (2,100) (2,100) (2,100) (2,100) Payments 2,000 2,000 3,940 2,008 1,500 1,700 3,440 1,000 1,000 1,400 2,740 2,000 Creditor Stretch c/f (4,771) (5,021) (3,331) (3,573) (4,323) (4,723) (3,383) (4,483) (5,583) (6,283) (5,643) (5,743)

89 Appendix G THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Statement of Financial Position Period Ending 30th April 2016 (Month 1) 31-Mar Apr-16 Movement Actual Actual Actual 000's 000's 000's Non-Current Assets Intangible Assets 2,832 2,775 (57) Plant, Property and Equipment (Owned) 122, ,157 (255) Plant, Property and Equipment (Leased) 15,427 15,256 (171) Investment Property 19,641 19,641 0 Trade and other receivables (197) Total Non-Current Assets 161, ,472 (680) Current Assets Inventories 3,171 3,139 (32) NHS Trade Receivables 11,940 11, PDC Dividend Receivable Non-NHS Trade Receivables 1,339 1, Prepayments and Accrued Income 5,357 8,839 3,482 Cash and Cash Equivalents 4,092 1,602 (2,490) Total Current Assets 26,015 27,383 1,368 Total Assets 187, , Current Liabilities Trade Payables 8,296 8, Capital Payables and Accruals (411) Other Payables 5,357 6,391 1,034 Accruals and Deferred Income 10,979 10,828 (151) PDC Dividend Payable Provisions Payments Received on Account 3,604 4,640 1,036 Other Liabilities Borrowing Capital Investment Loans Working Capital Loan 1,000 1,000 0 LIFT Finance Leases 1,643 1,643 0 Net Current Assets/(Liabilities) (6,401) (7,228) (827) Total Assets Less Current Liabilities 154, ,244 (1,507) Non-Current Liabilities (amounts falling due after more than one year) Provisions 2,320 2,317 (3) Borrowing Capital Investment Loans 5,905 5,905 0 Working Capital Loan 8,000 8,000 0 LIFT 12,174 12,114 (60) Finance Leases 3,714 3,573 (141) Total Assets Employed 122, ,335 (1,303) Taxpayers Equity Public Dividend Capital 71,479 71,479 0 Retained Earnings 17,994 16,742 (1,252) Revaluation Reserve 33,165 33,114 (51) Total Taxpayers' Equity 122, ,335 (1,303)

90 THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Statement of Cash Flows Period Ending 30th April 2016 (Month 1) Cash flow generated from operating activities 30-Apr-16 Actual 000's Appendix H EBITDA (24) Inventories 32 NHS Trade Receivables (14) Non-NHS Trade Receivables (394) Other Receivables (3,482) PDC Receivable 0 Movement in Long-Term Receivables 197 Trade Payables 326 Capital Payables and accruals (411) Other Payables 1,202 Provisions (3) Payments on account 1,036 Total cash flow generated from operating activities (1,535) Cash Flow from investing activities : capital expenditure and receipts (306) Cash Receipt from Asset Sales 0 Cash flow from financing activities Interest Interest Received on Cash Balance 2 Other Interest Payable (7) Interest Paid on Capital Investment Loans (19) Interest Paid on Working Capital Loans (13) Interest Paid on LIFT Contract (115) Interest Paid on Finance Leases (19) Capital Loans and Leases Repayment of Capital Investment Loans 0 Repayment of Working Capital Loans 0 Repayment of LIFT Contract (18) Additional funding by Finance Leases 0 Repayment of Finance Lease Capital (141) PDC Dividends Paid (319) Dividend Received 0 Total cash Flow from financing activities (649) Net cash (Outflow)/Inflow (2,490) Opening Cash Balance 4,092 Closing Cash Balance 1,602

91 Appendix I THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Capital Expenditure Report Period Ending 30th April 2016 (Month 1) 2016/ /17 Actual Plan Cash Asset Value Asset Value Asset Value Variance Year-End Year-End Plan Plan To-Date To-Date To-Date Forecast Variance 000s 000s 000s 000s 000s 000s 000s Information Management Technology - Outright Purchase Estates - Outright Purchase 6,022 6, (344) 6, Major Medical Equipment - Outright Purchase Contingency (23) Sub-Total Outright Purchase 7,117 7, (320) 7, Major Medical Equipment - New Lease Funded (26) Information Management Technology - New Lease Funded (33) Sub-Total inc. New Lease Funded 7,300 7, (379) 7, Replacement Lease Funded Capital Donated Assets Grand Total 7,300 8, (379) 8,

92 Appendix J THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Annual Forward Financial Plan Financial Risk Management - Base Plan Downside Scenarios Downside Impact Worst Case Impact Value Risk Events 000s Probability 000s Probability 000s Risks to Financial Plan Non-delivery of efficiency savings 2, , ,000 Under-achievement of CQUIN Contract penalties Quality Investment required above 1.5m in Plan 1, ,000 Increased Expenditure to manage Emergency Activity 3, ,000 Lost Revenue and Increased Expenditure associated with on-going Industrial Action 2, ,000 Commissioner Challenge activity charges Non-Hillingdon Activity Growth Margin Non-Pay inflation Value of Financial Risks 10,151 3,431 10,151 Mitigating Actions Use of annual plan General contingency Delay Quality Investment Additional Commissioner Support to manage Emergency Activity 3, Central Support to compensate Providers for losses associated with Industrial Action 2, Gain from the Revaluation of Investment Properties 2, , Additional Operational Resilience Funding Value of Mitigating Actions 8,100 2,825 0 Residual Risk ,151 Normalised surplus (deficit) as a result of residual risk (2,506) (12,051)

93 Appendix K THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Financial Sustainability Risk Rating Period Ending 30th April 2016 (Month 1) 15/16 Continuity of Service Risk Rating 16/17 16/17 To-Date Actual Rating Metric Plan Rating Actual Rating Capital Service Capacity (25%) (0.0) 1 (6.5) 1 Liquidity (25%) (22.3) 1 (15.9) 1 0.6% 2 Underlying Performance (25%) (0.8%) 2 (6.7%) 1 0.6% 3 Variance from Plan (25%) (0.6%) 3 (3.4%) Weighted Average Overriding Rules Impact 2 2

94 Appendix L Activity Trend Analysis Spells/ Attendances A&E Activity April 2013 to August ,200 8,000 7,800 7,600 7,400 7,200 7,000 6,800 6,600 6,400 6,200 6,000 5,800 5,600 Apr Jun Aug Oct Dec Feb Apr Jun Aug This year Last Year Trend Spells/ Attendances All New Outpatient Referrals April 2013 to August ,400 7,200 7,000 6,800 6,600 6,400 6,200 6,000 5,800 5,600 5,400 5,200 Apr Jun Aug Oct Dec Feb Apr Jun Aug This year Last Year Trend Spells Inpatient Activity April 2013 to August ,000 2,900 2,800 2,700 2,600 2,500 2,400 2,300 2,200 2,100 2,000 1,900 1,800 1,700 Apr Jun Aug Oct Dec Feb Apr Jun Aug Elective This year Emergency This year Elective Last Year Emergency Last Year Births Births April 2013 to August Apr Jun Aug Oct Dec Feb Apr Jun Aug This year Last Year Trend

95 Meeting of the Board of Directors public session 2016/17 Month 1 Transformation and QIPP update Wednesday 25th May 2016 Agenda item 12 Reason for item: The purpose of this paper is to report on the status of the 2016/17 QIPP Programme and the work underway in the Transformation programme. Summary: The plans for the 2016/17 QIPP delivery are now in place. The target is 9.04m and the organisation has sufficient schemes identified (but not yet signed off or risk adjusted all schemes) to meet this target. The significant majority ( 8m) of the programme has been formally signed off with the divisional leadership teams, and schemes have commenced. The scope and implementation of the remaining 1m of schemes continues to be progressed by divisions, with support from the PMO. Board Action required: The Board is asked to: Note the development of the 2016/17 QIPP Agree any further steps that need to be undertaken Report from: James Ross, Director of Transformation Report sponsor: Joe Smyth, Chief Operating Officer (COO) Links to Trust strategic priorities: - To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide - To deliver high quality care in the most efficient way Previous consideration at Board or Committees: N/A Equality and diversity considerations: N/A Financial implications: There may be financial implications for some of the changes. These will be worked through with regards to their impact/benefit and prioritised for consideration within the appropriate governance framework. Page 1 of 4

96 1 2016/17 QIPP Programme Delivery of the 2016/17 QIPP programme is a key operational requirement of the organisation. Considerable energy, time and effort has been directed into producing a comprehensive QIPP programme which the divisions have confidence in being able to deliver. The programme, once fully validated will achieve the values necessary to meet the control totals required by the organisation. As previously reported, the planning for this year s QIPP began in autumn 2015, with the identification of potential savings. Opportunities were assessed using projected out-turn expenditure and income, analysis of efficiencies afforded thorough the trust transformation programmes, analysis of the effects of planned service developments, and consideration of extra-ordinary and discretionary expenditure in 2015/16 that could be reasonably avoided in 2016/17. This process gave rise to an initial QIPP programme for each division, which was handed over to the divisional management teams during Q4 2015/16. The divisional management teams worked through these opportunities, determined realistic and risk rated values, and created operational plans for delivery. The total value required by the organisation from QIPP delivery in 2016/17 is 9.038m. Schemes identified totalled a potential opportunity of 14.9m. Following operational delivery planning and risk adjustment the current signed off value is 8.056m. The PMO has strong confidence in the delivery of this value. This leaves an un-signed off gap of 982k. Schemes remaining in the delivery pipeline have a potential opportunity of 1.6m. The PMO has reasonable confidence that these pipeline opportunities will deliver the full value of the required QIPP. Figure 1 shows the current position of QIPP schemes by division. Figure 1 Trust Overall Target ( k) Signed Off Value ( k) Remaining Gap ( k) Pipeline Scheme Opportunities ( k) 9,038 8, ,600 Division Target ( k) Signed Off Value ( k) Remaining Gap ( k) Pipeline Scheme Opportunities ( k) Medicine 2,790 2, Surgery 2,128 1, W&Ch CCSS 1,270 1, Facilities Estates Corporate Total 9,038 8, ,600 The identified QIPP savings are split by pay (58%), non-pay (21%) and income (21%). This split is in line with expectation and the initial assessment of opportunities. The pay domain is divided between Nursing (51%), Medicine (27%), and AHP & Other (22%). As part of the RCA work of holding people to account, the sign off process included identification of accountable individuals for each scheme. Each individual has agreed with the assessment of the actions to be taken to deliver the agreed savings. Challenge has been applied in relation to the pace of delivery and the work required to deliver the quantum of saving promised for each scheme. All Page 2 of 4

97 signed off schemes have been profiled across the year, based on expected commencement dates, and the actions required for delivery. Each divisional QIPP programme has been signed off by the Divisional Director, Assistant Director of Operations and the Assistant Director of Nursing. Month 1 performance remains subject to completion of finance reporting at the time of writing this report. Financial reporting has been delayed due to month 1 processes. 2 Monitoring and Reporting of QIPP Programme Going forwards, the QIPP programme will be monitored against three sectors; savings achieved, actions taken, and control total position. In addition, the divisions will be monitored for changes to service delivery and/or unforeseen challenges (e.g. the junior doctor s strike) which will have a material effect on their achievement of control totals. Monitoring will be managed at PMO QIPP review sessions with each division, and will form part of the divisional review programme. The divisional reviews will link QIPP performance into the organisational governance structure. Reporting, including monthly board reporting, will focus on savings achieved, and will split progress by division, and also against the main themes. This will enable the board to have sight of progress in each operational area, and also to have clear vision of the split by functional theme (figure 2). Figure 2 Underperforming schemes will be highlighted in the board report by exception, and additional schemes developed during the year will also be identified. 3 Summary The Trust QIPP programme for 2016/17 has identified assured savings to the value of 8.056m against the target of 9.038m. An additional 1.6m of schemes are being evaluated to assure delivery of the full requirement. The development of the programme has been subject to detailed scrutiny, and the sign off process has ensured that divisions have clear sight of the actions required to deliver the QIPP for this year. Month 1 QIPP delivery has met expectations in line with the saving profile across the year. Ongoing monitoring, governance and reporting processes for the programme have been agreed and will be implemented in May. Page 3 of 4

98 Page 4 of 4

99 Meeting of the Board of Directors public session Wednesday 25 May 2016 Agenda item 13 Annual Report and Accounts 2015/16 Reason for item: To enable the Board to approve the annual report and accounts. Summary: This paper presents the annual report and accounts for 2015/16 for the Board s formal approval, prior to submission to NHS Improvement on 27 th May 2016 and subsequent laying before Parliament. The quality report will also separately be published as the Trust s Quality Report on the NHS Choices website as per Department of Health requirements. Board action required: The Board is asked to: 1. Review and approve the audited annual report and accounts 2015/16 2. Authorise the Chair and Chief Executive to sign the strategic report, statement of financial position, annual report, foreword to the accounts and annual governance statement 3. Authorise the Chair and Chief Executive to sign the statement of Directors responsibilities in respect of the quality report. Report from: Shane DeGaris, Chief Executive and Matt Tattersall, Director of Finance with input from all Executive Directors. Links to Trust strategic priorities: n/a Previous consideration at Board or Committees: Audit & Risk and Quality & Safety Committees in May Equality and diversity considerations: none. Financial implications: none. 1

100 Background and process Annual Report and Accounts 2015/16 1. In line with the NHS Act 2006, the Foundation Trust Constitution requires the Trust to prepare an annual report and submit it to NHS Improvement. The required content for the annual report is laid out in the Annual Reporting Manual (ARM) which is published by NHS Improvement (NHSI). The ARM states that the annual report and accounts must consist of: The annual report which includes the performance report, accountability report, quality report and accounts The accounting officer s statement of responsibilities The auditor s opinion and certificate The annual governance statement The foreword to the accounts which should state that the accounts are prepared in accordance with paragraphs 24 and 25 of Schedule 7 to the 2006 Act Four primary financial statements (Statement of Comprehensive Income, Statement of Financial Position, Statement of Changes in Taxpayers Equity and a Statement of Cash Flows) The notes to the accounts. The Annual Report and Accounts 2015/16 are presented to the Board today in the format required for submission to NHS Improvement on 27 May Subsequent to submission to NHSI, the report will be professionally type set, page numbered and photographs included. As at the time of despatch, Trust officers have met with Deloitte s, our external auditors, for a closedown meeting. No material matters were raised. However, Deloitte will not formally complete their audit until Friday 20 May when Deloitte will issue their report on the audit of the Annual Report and Accounts 2015/16. Changes may or may not result as an outcome of the Deloitte report. The Audit and Risk Committee will formally consider the Deloitte report and the Annual Report and Accounts 2015/16 on Tuesday 24 May A report on the outcome of the considerations at the Audit and Risk Committee will be tabled at the Board Meeting on Wednesday 25 May. 2. The timescale for this submission of the Annual Report and Accounts and subsequent circulation is shown below. The key deadlines and dates are: 2

101 Submission of audited annual report and accounts, and external audit reports to NHS Improvement Laying of annual report and accounts before Parliament Copy of the annual report and accounts that was laid before Parliament to be submitted to NHS Improvement Annual report, accounts and auditor s report presented to the Council of Governors 27 th May 2016 Posted to arrive before 24 th June th July th July After adoption by the Board, the Chief Executive, as the Accounting Officer, must sign and date the Statement of Financial Position and annual report as evidence of this. As Accounting Officer, the Chief Executive must also sign the foreword to the accounts, the annual governance statement and the remuneration report. The signed documents will then be sent to the external auditor for signature, and then returned back to the Trust for submission on 27 th May. 4. The annual report submitted on 27 th May must include all of the text which will be included in the final publication submitted to Parliament. This is because the auditors need to see the form of the annual report prior to signing their opinions. The period between 27 th May and submission to Parliament is to allow FTs time to format the document to the standards required for publication. Until the annual report and accounts have been laid before Parliament nothing can be published by the FT for the wider public. Once laid before Parliament the annual report and accounts cannot be changed. Annual report 5. A draft of the annual report will be reviewed at the Audit & Risk Committee (ARC) on 24 May The document has also been reviewed by the external auditor as required by the ARM. Quality report 6. The draft quality report has been reviewed by Quality & Safety Committee (QSC). The quality report includes the comments from the consulted stakeholders: the Overview & Scrutiny Committee, Hillingdon Healthwatch, and the host commissioner. The Council of Governors also reviewed the draft at their meeting on 10 May

102 Annual accounts 7. The draft annual accounts were submitted to NHS Improvement and external audit in line with the 22 nd April deadline. 8. The draft annual accounts are consistent with the monthly reporting to the Board. 9. A going concern report has been written and was considered at the April Audit and Risk Committee meeting. Post balance sheet events 10. The annual report and accounts should also include any important events since the end of the 2015/16 financial year affecting the Foundation Trust. The Board is asked to confirm that there have been no subsequent events that require disclosure. Disclosures to the external auditors 11. The Directors report must contain a statement to the effect that for each individual who was a Director at the time that this report was approved: so far as the Director is aware, there is no relevant audit information of which the NHS Foundation Trust s auditor is unaware; and the Director has taken all the steps that they ought to have taken as a Director in order to make themselves aware of any relevant audit information and to establish that the NHS Foundation Trust s auditor is aware of that information. 12. The Annual Reporting Manual states that relevant audit information means information needed by the auditor in connection with preparing their report, and that a director is regarded as having taken all the steps that they ought to have taken as a director in order to do the things mentioned above, and: made such enquiries of his/her fellow directors and of the company s auditors for that purpose; and taken such other steps (if any) for that purpose, as are required by his/her duty as a director of the company to exercise reasonable care, skill and diligence. Balanced and comprehensive picture 13. The Board must also confirm that the Directors consider that the annual report and accounts taken as a whole, is fair, balanced, and understandable and provides the information necessary for patients, regulators and stakeholders to assess the Trust s performance, business model and strategy. In signing off the annual report and accounts at this meeting the Board is asked to formally note this requirement and confirm this statement. 4

103 Annual Report and Accounts 2015/16 WORKING DRAFT 1

104 CONTENTS Performance Report Page Accountability Report Page Directors Report Page Remuneration Report Page Staff Report Page Compliance with NHS Foundation Trust code of Governance Page Regulatory Ratings Page Statement of Accounting Officer s Responsibilities Page Annual Governance Statement Page Quality Report Page Statement of Directors Responsibilities in Respect of the Accounts Page Independent Auditor s Report Page Annual Accounts 2015/16 Page 2

105 Performance Report Introduction from the Chair and Chief Executive It s been both an exciting and challenging year for the Trust. We ve seen demand for some of our services reach an all-time high and we ve also seen a number of new developments and improvements come to fruition. A marked increase in demand for services was experienced across the whole of the NHS over the last year. As with most trusts, the surge in demand was most keenly felt in the A&E department - where our staff coped admirably despite having to manage unprecedented patient numbers. The ongoing junior doctors dispute also had an impact on the number of operations and procedures we were able to undertake during the course of the year. However, disruption to patients was kept to an absolute minimum thanks to careful forward planning and the support of all our staff but particularly our consultants, other clinical staff and our junior doctors who worked additional hours. Despite the challenges, our Trust has had a great many notable developments in the last 12 months. In 2015/16 around 3 million was invested in the expansion of our Maternity and Children s Services. This was to accommodate the increase in demand following the closure of the Maternity Unit at Ealing Hospital, which was planned for under the Shaping a Healthier Future programme. Our maternity improvements included: the introduction of a new midwifery-led service for low risk women, the opening of new en-suite birthing rooms, and the establishment of a new transitional care service for babies that need a bit of additional support before going home. Staffing numbers have been increased to support the expansion. We ve also undertaken an extensive programme of development in Paediatric Services; our Children s A&E is entering the final stages of a major upgrade that will see it completely rebuilt to high-spec, modern-day standards, featuring bigger bed spaces and a new step-down resuscitation bay. We are also at an advanced stage of building a new extension to our Peter Pan children s ward which will provide an additional four beds, again built to modern standards. This will be complete by the end of this summer. 3

106 In addition, six of our seven operating theatres at Hillingdon underwent an extensive programme of refurbishment during last year. They now have new flooring, improved ventilation, lighting and storage. The Trust continued with its scheduled procedures throughout the re-fit by making greater use of its four theatres at Mount Vernon. Towards the end of the financial year we were privileged to play host to HRH The Princess Royal who paid a visit to formally open our newly expanded Nuclear Medicine department. The department now boasts a brand new 1 million SPECT CT scanner. One of only two of its kind in the country, the new scanner enables both nuclear and MRI scans to be carried out simultaneously. This not only reduces the number of patient appointments required, but minimises stress for patients by speeding-up the process of diagnoses and the start of any course of treatment. Elsewhere, we continue to work hard to improve our patient services. The adoption of our Ambulatory Care model in the Acute Medical Unit (AMU) means many more patients are now able to get the care they need without being admitted to hospital. This is welcomed by those who are able to stay at home while accessing the clinics, tests and treatment they need, and good for the Trust as it means that we are more able to provide hospital beds for those that need them most. Our highly-regarded rehabilitation service continues to go from strength to strength with Daniels Ward at Mount Vernon - which opened last year - now operating at full capacity. The Trust was also successful in securing a partnership contract with Imperial College Healthcare Trust and Central London Community Healthcare NHS Trust to provide Level 2 specialist neuro-rehabilitation beds at Charing Cross Hospital. This is an important step for the Trust and makes us one of the largest providers of specialist rehabilitation in London. In 2015/16 the Trust continued investing in its clinical leadership; this investment is to ensure that the highest quality clinical services are provided to our patients. This included the launch of a brand new 240k state-of-the-art simulation centre at Hillingdon Hospital. The centre is kitted out with the most up-to-date robotic patients currently available. It provides an excellent training facility for staff, enabling them to enhance and develop their hands-on clinical skills in a safe and supportive environment. Our clinical leaders, both medical and nursing staff, receive individual and team coaching and mentoring; also focussed succession planning identifies our future 4

107 clinical leaders who are then supported to achieve excellence. The Trust hopes that this investment will help us retain and develop our clinical staff. In 2015/16, the Trust established the Equality, Diversity and Inclusion (EDI) group chaired by a Non-Executive to champion EDI issues. The group provides oversight of key EDI priorities and actions for both patients and staff. In 2015/16 the Trust also joined Inclusive Employers (IE) which provides access to advice and support on EDI issues. Working in collaboration with IE, the Trust will be piloting its work experience programme for people with learning disabilities in the autumn The Trust held a number of EDI listening exercises which attracted strong engagement from staff resulting in a number of key initiatives including establishment of the EDI strategic group and the development of an EDI training course to support recruitment and selection and talent management within the organisation. We strive to provide the best possible care all times and our CARES Values remain at the heart of our approach to patient care. This year saw us maintain high standards of care as demonstrated by our good patient outcomes, key quality performance indicators and the positive feedback we get from patients. The Trust was rated green (compliant) throughout the year in all but one (A&E four-hour target) of Monitor s key performance targets. We maintained our high performance for Referral to Treatment waiting time standards and we performed better than the London and national average for the key cancer performance indicators waiting time standards. We have also seen an improvement in our mortality rates with a reduction in the variability between weekdays and weekends. We received more than 25,000 responses to the Friends and Family test (FFT) during the year with 93% of patients saying they were happy to recommend our services to their friends and family. And we once again scored well in the national staff survey, with above average results in 18 out of 32 areas and 10 of those were ranked in the top 20% of all acute Trusts in England. While many improvements were made to our buildings over the year, much of our estate is old and remains in poor condition. We have been frank in stating that it will require substantial investment in the near future and we will continue to work the Department of Health, NHS Improvement, local GP commissioners and our MPs to secure the funding needed. To support the Trust s long term aim for its estate and the 5

108 health needs of the local community, we have begun the process of developing a master plan for both of our hospital sites. We will be talking to local people about these proposals in the coming year. This year has also seen us further strengthen our partnership working. At the beginning of the year we embarked on an ambitious project with other Hillingdon care providers to deliver an integrated care model for patients over 65 years old. Significant progress has been made and plans are in place to expand the programme in the year ahead. A major milestone all the main care providers are working towards is the formal establishment of an Accountable Care Partnership (ACP) to support this work. Another critical piece of partnership work will be the final sign-off of Hillingdon s Sustainability and Transformation Plan (STP) which will support our collective delivery of better health care services for local people in the years ahead. There will inevitably be new challenges ahead but we are confident that the Trust has built a solid foundation from which to face them. We are grateful to our staff, governors, volunteers, and fellow Board members for their hard work and commitment to the Trust and the people who depend on us. Richard Sumray Chair The Hillingdon Hospitals NHS Foundation Trust Shane DeGaris Chief Executive 6

109 Key achievements : Improving women s and children s services The Trust secured more than 3 million to improve and expand our children s services as part of the Shaping a Healthier Future programme. Improvements include a new children s A&E; four new beds on Peter Pan Ward; establishing a midwifery-led service with new en-suite birthing rooms and a new transitional care service for babies that need a bit more support before going home. Securing new contracts The Trust successfully secured an 11 million contract, in partnership with Imperial College Healthcare and Central London Community Healthcare, to provide specialist neurorehabilitation at Charing Cross Hospital. New scanning service More than 1 million was invested in establishing a new Nuclear Medical Facility housing the latest SPECT CT scanner. This enables nuclear and CT scans to be carried out at the same time reducing the need for multiple patient scans. Performing well The Trust rated green (compliant) throughout the year in all but one (A&E four-hour target) of Monitor s performance targets. Key cancer indicators are well maintained for all the national waiting times standards, and performing better than the London and national average. We have also seen a reduction in variation between weekend/weekday mortality; Friends and Family Test We received More than 25,000 responses to the FFT 93% of patients would recommend our services to their friends and family - higher than the England and London score. Annual NHS Staff Survey 2015 Annual NHS Staff Survey 65% of our staff said they 'would recommend the Trust as a place to work - 4% higher than the average for acute Trusts. Overall, we scored above average in 18 areas with 10 of these being in the top 20% of all acute Trusts in England. Innovation in health care support This year the Trust launched the Hillingdon Care Record (HCR). The first of its kind in the country, HCR is a digital in-house system that provides clinicians with electronic access to patient records at the bedside. Investing in staff training The Trust created a 240k state-of-the-art simulation suite, featuring high-spec robotic model patients, ensuring staff can develop and improve their skills in a safe and supportive environment. Refurbished facilities An extensive programme of refurbishment was carried out on our operating theatres at Hillingdon and significant upgrades were made to our pathology lab and restaurants at both sites. Improving PLACE scores The Trust developed a new Cleaning Strategy supporting the drive to maintain the highest standards of cleanliness. We also improved our cleaning and patient food scores in the 2015 PLACE assessment. 7

110 Trust History and Purpose The Hillingdon Hospitals NHS Foundation Trust was established on 1st April 2011 when Monitor authorised the organisation as an NHS Foundation Trust. The Trust provides health services at two hospitals in North West London: Hillingdon and Mount Vernon. Hillingdon Hospital is the only acute hospital in the London Borough of Hillingdon and offers a wide range of services including accident and emergency, inpatient care, day surgery, outpatient clinics and maternity services. The Trust s services at Mount Vernon Hospital include routine day surgery at a modern treatment centre, a minor injuries unit, and outpatient clinics. The Trust also acts as a landlord to a number of other organisations that provide health services at Mount Vernon, including East & North Hertfordshire NHS Trust s Cancer Centre. The Trust s income in 2015/16 was over 238m and we employed over 3,000 staff. The majority of our patients live in the London Borough of Hillingdon but as part of our strategy we are seeking to provide healthcare to a wider area. In 2015/16: 85,630 attendances were made to our Accident & Emergency department and Minor Injuries Unit. 4,725 babies were born in our Maternity Unit. 336,011 attendances were made as outpatients. 25,440 admissions were made for emergency treatment across all parts of the Trust. 25,256 admissions were made for planned operations and day surgery. 8

111 Overview of the Trust s strategy The Trust s Strategy and Business Model The Trust s Vision and Mission statements were re-formulated in 2013 as follows: Vision: To put compassionate care, safety and quality at the heart of everything we do. Mission: To be the preferred, integrated provider of healthcare for Hillingdon and the surrounding population, with a major acute hospital as a hub. Strategic intent Our long term strategy (3-5 years) remains focused on the development of an organisation of sufficient scale to continue to provide responsive, high quality clinical care in the most appropriate setting for patients. Our ambition is to continue to be seen as both a major acute hospital provider and an important part of a more integrated health and social care system. A key part of our longer term strategy is to obtain capital finance support to upgrade the estates infrastructure on the Hillingdon site, in the context of the Shaping a Healthier Future (SaHF) reconfiguration of healthcare services in North West London. We also need to broaden our service offering, acknowledging that healthcare is unsustainable based on the current model of care. We will increasingly see services delivered in community settings, with a much stronger focus on early intervention, either as the prime provider or as part of a network solution. Our objective is to be the main provider of health services in Hillingdon, but also to grow our presence and service offering in neighbouring boroughs. The medium term strategy (next 1-3 years) is to continue to deliver safe, high quality services and be a top quartile performer for small-medium size acute Foundation Trusts across quality, operational and finance performance indicators. In order to achieve this, we will transform our current delivery model, ensuring we increase quality and safety and drive down cost wherever possible. Most immediately we are working to address the quality concerns raised by the Care Quality Commission (CQC) in its report of February We will also support the transition to a more integrated and affordable healthcare system through much closer collaboration with Hillingdon Clinical Commissioning Group (HCCG) the main commissioner of our services and through the development of strategic partnership arrangements with other providers. We have established four strategic priorities for the future to help deliver our strategic intent and these remain unchanged since last year s report: 1. To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide 2. To deliver a clinically led service strategy that responds to the needs of patients and other health and social care partners 9

112 3. To deliver high quality care in the most efficient way 4. To develop sufficient sustainable scale to enable us to improve and grow healthcare services for our communities. These priorities are underpinned by more detailed strategic objectives and actions, which are refreshed each year, to ensure we deliver our strategic plan. Further information is available in the Trust s strategic and annual plans. 10

113 Key Issues and Risks The key issues and risk facing the Trust as at 31 March 2016 can be summarised as: The Trust may fail to achieve 95% A&E target leading to a breach of its Licence. The Trust is working with Hillingdon Clinical Commissioning Group, Hillingdon Borough Council, Hillingdon Community Health and the third sector to integrate care and ensure that admissions to hospital are avoided where possible; and, that time spent in the A&E department is reduced. Action will be taken, following a recent independent review of patient flows, to and through the A&E department and into the Acute Medical Unit, to improve patients waits in A&E Failure to deliver high quality patient care as a result of inadequate staffing provision and specifically inadequate staffing provision to meet the 7-day workforce initiative. The Trust is reviewing its clinical and support service workforce using acuity and dependency tools and other mechanisms; to improve frontline clinical staff numbers and care at the bedside seven days a week. The Trust will continue to drive forward a robust recruitment and retention work programme to reduce the number of vacancies and to support the increased activity that the Trust has seen during this past year. Failure to comply with the expected standards set out by our regulators which could impact on the Trust achieving a good rating with the CQC. The Trust continues to strengthen its governance arrangements and its compliance with the Health and Social Care Act regulations through a programme of internal peer reviews and mock inspections to ensure there is evidence of improvement against a refreshed CQC action plan for 2016/17. There will be increased scrutiny of operational performance and quality data and a new accountability framework to ensure compliance with policy and delivery of statutory targets. Particular attention will be devoted to areas of outstanding compliance notices, most notable of which is infection control. Financial risks: Commissioning risk that Hillingdon CCG s out of hospital strategy results in Trust deficit. This will be mitigated by continuing to agree contracts with Hillingdon CCG that promote robust collaborative working and financial risk sharing to redesign clinical pathways, yet at the same time provide sufficient revenue to cover the Trust s costs; including guaranteed minimum financial values that can be enhanced and or fixed cost transitional support. Commissioning risk if the cost of activity is not paid for in full. The form of healthcare contract the Trust will agree with its lead commissioner will guarantee a minimum payment with an agreed rate of over performance. However, as was the case in 2015/16 the minimum value can be enhanced by negotiation to cover justifiable excess costs of delivering service levels above the agreed contract. Monthly formal contract meetings with Hillingdon CCG as lead commissioner are in place so financial and service issues can be flagged and addressed quickly is necessary. Recruitment to fill vacancy levels is insufficient to enable the Trust to significantly reduce its agency costs. 11

114 This is being addressed by a focused recruitment and retention programme including overseas initiatives and is subject to continual management review. The level savings required in 2016/17 has an adverse impact on the quality of care provided. To give the Trust the very best opportunity of delivering its savings, a Project Management Office (PMO) is in place to support managers and clinicians to achieve identified savings plans. Throughout the year weekly/fortnightly risk assessment allows early sign of potential areas of non-delivery to be identified and ensure mitigating actions are put in place to prevent slippage or non-delivery. Increasing cost of compliance to meet statutory and regulatory service and infrastructure standards particularly in light of the recent CQC report. This risk is being addressed by management with a phased approach to both revenue and capital investment over the next two financial years. The Medical Director, Nurse Director and Chief Operating Officer have together reviewed the required investment and prioritised first expenditure to rectify and sustain warning notice and must-do compliance issues. Cash required for day to day operations and for investment could fall short of what is required and start to impede on service delivery. To manage this risk in addition to the 4.1m cash balance at the start of the year and 6.0m of assessed working capital headroom available, management have the ability to access 6m of working capital facility. In addition, a routine monthly payment has been agreed with East and North Hertfordshire Hospitals NHS Trust for services received on the Mount Vernon site thereby increasing monthly cash flow. The estate has suffered from under-investment over an extended period and many building services have failed or are beyond their economic and design life cycle. There is a risk that the Trust is unable to access sufficient funding to sustain safe services in the short to long term. Key facilities such as Theatres, Critical Care and many Wards are of a design and condition that does not lend itself to the delivery of modern high quality healthcare. A waste incinerator that provides the majority of heat to the Hillingdon acute site has a remaining operational life of only 2-3 years. I Overall, the Trust will remain focused on the tension between quality, safety, financial efficiency, and risk to ensure that patient care remains uncompromised. The Trust will do this by having regular Board and Executive reviews of progress and delivery of agreed plans and check that all schemes are quality impact assessed. Going Concern After making enquiries, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. 12

115 Operational Performance analysis Approach to measuring performance The Trust has developed an intergraded pyramid structure of meetings supported by a number of dashboards to allow it to track all quality and performance standards. Detailed department/speciality level performance is tracked through a number of weekly and monthly meetings. These include monthly divisional reviews and Trust wide performance management meetings, in addition to weekly review by the Chief Operating Officer/Director of Operations with the Assistant Directors of Operations. These meetings report by exception through to various sub committees for the board, where further scrutiny is applied to action plans to designed to improve quality and performance. A monthly intergraded quality and performance reported is presented to the board which covers five key domains. 1. Safe, which includes infection Control, falls, maternity indicators, safety thermometer, SI s/never events, all patient safety and mortality standards 2. Effective, this covers readmissions and DNA s as well as monitoring performance on the use of Choose and Book. 3. Caring, this domain monitors outputs and delivery of Friends and Family surveys, as complaints and feedback from the Trusts PALS. 4. Responsive, focuses predominately on the access targets reporting on A&E, Cancer and RTT 5. Well Led, monitors recruitment and retention as well as sickness rates and PDR performance. Overview of Performance Key Targets The Trust maintained strong performance against all key performance targets with the exception of the A&E 4 hour standard. A 12% growth in demand over two years has now compromised the physical capacity of the department and achieving the 4 hour standard has become increasingly difficult. There were 12 reported incidents of Clostridium difficile; however following robust root-cause analysis by the CCG and Trust it was established that there was only 1 lapse in care. Indicator Performance in Performance Performance in Target 2013/14 In 2014/ /2016 Achieved Clostridium difficile (Total) n/a Clostridium difficile (Lapses of Care) All cancers: 31 days for second or subsequent treatment (surgery) All cancers: 31 days for second or subsequent n/a n/a 1 100% 100.0% 100% 100% 100.0% 100% 13

116 treatment (anti-cancer drug treatments) All cancers: 62 days for first treatment from urgent GP referral for suspected cancer All cancers: 62 days for first treatment from NHS Cancer Screening Service referral All cancers: 31 days diagnosis to first treatment Cancer: two week wait from referral to date first seen for all urgent referrals (cancer suspected) Cancer: two week wait from referral to date first seen for symptomatic breast patients (cancer not initially suspected) Maximum time of 18 weeks from point of referral to treatment admitted patients Maximum time of 18 weeks from point of referral to treatment non admitted patients Maximum time of 18 weeks from point of referral to treatment patients on an incomplete pathway A&E: Total time in A&E less than 4 hours (Accident & Emergency, Minor Injuries Unit, Urgent Care Centre) Self-certification against compliance with requirements regards access to healthcare for people with a learning disability 90.3% 92.2% 91.8% 97.8% 97.8% 98.6% 99.3% 99.3% 99.2% 97.9% 98.0% 97.0% 94.7% 95.7% 96.3% 97.1% 95.2% n/a 98.6% 98.4% n/a 92% 97.4% 96.1% 95% 94.1% 92.0% X Fully Compliant Fully Compliant Fully Compliant 3.2 Clostridium difficile As illustrated by the graph below the Trust has made good progress in reducing the incident of reported Clostridium difficile Infection (CDI) over the past 8 years. The figures for 15/16 include the cases where the CCG have undertaken a root-cause analysis and determined that the Trust acted in the patient s best interest. There was 1 case in 15/16 where there was deemed to be lapse in care in relation to a prescription for antibiotics which was not in line with Trust antimicrobial prescribing guidelines. 14

117 3.3 Cancer Performance The Trust successfully achieved all of the cancer access targets for the fourth successive year. The introduction of new systems to provide greater oversight of the patient s pathway by all members of the multi-disciplinary team has continued to drive strong performance against these targets. 3.4 Referral to Treatment During 15/16 compliance against the admitted and non-admitted waiting time standards were replaced by performance on incomplete pathways. The Trust continued to perform well against this standard and ended the year with a performance of 96.1%. 3.5 A&E 4 Hour Standard The Trust did not meet the 4 hour A&E standard during 15/16. Continuous growth in demand up by over 12% in two years has now compromised the physical capacity of the department. During 15/16 type 1 attendance increased by 4.9% with activity peaking in the final quarter increasing by 12% over the same period last year; as illustrated by the graph below. 15

118 Another significant contributing factor affecting the A&E performance was the consistent increase in the number of blue light (category 1) ambulances attending the Trust. During 15/16 the number of blue light ambulances arriving at A&E increased by 24.6%. Attendances over the past two years is up by 53% The increase in blue light arrivals put considerable pressure on the Trusts Resuscitation Unit consequently activity increased by 17.4% during 15/16. The department s physical capacity was compromised most days as demand increased by an average of 30% during quarter 4, when compared to the previous year. 16

119 Paediatric activity has also up and increased by 6.2% across the year, again Q4 was particularly challenging with approximately 14% growth in demand. A&E Response Additional funds were made available to A&E throughout the year and extra staff were employed both in the department and in supporting services. The Trust invested in improving consultant and senior managerial on site cover over the weekend. Winter escalation capacity was opened early and investments made into a new medical role to work between A&E and Ambulatory care. Additional investments were made in Ambulatory Care and there was a corresponding increase in the number of patients seen in the clinic as illustrated by the graph below 17

120 AEC Activity (M1-11) - Total Total The Trust has also being working closely with Hillingdon CCG and together commissioned Method Analytics to undertake a review of flows and processes in A&E. Recommendations from this review have been incorporated into a comprehensive A&E recovery action plan. 3.6 Access to healthcare for people with learning disabilities The Trust continues to fully comply with the requirements regarding access to healthcare for people with a learning disability. Financial performance analysis Overall performance It was known that 2015/16 would be a particularly financially challenging year for the Trust; however, it proved to be more demanding than had originally been anticipated. The impact of the changes made to services following the CQC report published in February 2015 increased costs by more than had been planned. In addition, the Trust did not achieve all the savings that it needed to deliver a breakeven position. Despite the financial pressures on the Trust it nevertheless still managed to deliver a 10.4m programme for much-needed capital investment. Trading for the year The Trust ended the 2015/16 financial year with a financial deficit of 1.5m. This was a worse position than 2014/15 ( 2.9m surplus) and worse than the plan for the year (breakeven). The on-going increase in demand for the Trust s services led to a 10m increase in its income in 2015/16 when compared with the previous year. This included the transfer of some maternity activity from Ealing, though this was partly offset by the closure of step down beds previously used by patients from Northwick Park Hospital. Pay costs increased by more than the growth in activity reflecting the Trust s efforts in recruiting to vacancies. In contrast, non-pay costs increased at a slower rate than the growth in revenue, reflecting the impact of the Trust s savings programme. The Trust achieved 8m of savings in 2015/16 (3.4% of total annual operating income), this being an increase of 0.5m on 2014/15. However, this fell short of the 9.5m target the Trust had set, thus contributing to the worsening financial position. Cash flow The Trust generated 17.3m cash during the financial year, predominantly from direct healthcare related activities. Of this 5.4m was utilised to service outstanding debt and interest 18

121 commitments from loans and leases, and to pay 4.2m Public Dividend Capital to the Department of Health. The 9.1m cash remaining was used to finance the Trust s capital investment programme. The year-end retained cash balance of 4.1m was a reduction of 1.4m compared to 2014/15, largely reflecting the impact of the Trust s deficit. Capital investment During the financial year the Trust invested significantly in a capital programme totalling 10.4m on the facilities, equipment and technology used by the Trust to deliver healthcare, of which 1.4m was financed through leases. Trust physical estate infrastructure again remained by far the largest area of investment. This was targeted toward prioritised risk-based investment to ensure operational buildings remained safe, fit for purpose, and compliant with statutory legislation. The Trust received funding through the North West London Shaping a Healthier Future programme to invest prior to the anticipated reconfiguration of Paediatric services in Ealing during 2016/17 to increase the capacity and significantly improve the environment for inpatient and emergency services. During 2015/16 1.4m has been invested in these areas, with a further 2.6m planned for 2016/17. Apart from the physical infrastructure, the Trust also continued to invest in updating its medical equipment impacting on a wide range of clinical services and on information technology infrastructure and capability. Of most significance was procurement of a SPECT/CT scanner and an on-going major project to develop a Hillingdon Care Record. Looking ahead Given the overall 2015/16 deficit position of the NHS in England and acute providers in particular, 2016/17 was always going to be extremely financially challenging. Despite the 1.8bn of additional resource announced in the 2015 Autumn Statement all providers of NHS commissioner requested services will continue to have to manage with a national tariff that will embed an efficiency saving requirement of 2% merely to standstill. In addition to the national efficiency requirement, the Trust faces a number of other cost pressures in 2016/17, not least the requirement to invest in service quality and deliver compliance with CQC standards. The target savings from the Quality, Innovation, and Productivity and Prevention (QIPP) plan are 9.0m. The QIPP plan is supported by national work streams on capping rates paid to agencies and the work of Lord Carter of Coles to improve operational productivity. There is also coordinated work across North West London to maximise savings across a wider footprint where this is practicable. Over the medium term, the Trust will achieve financial balance as the acute services reconfiguration in North West London is completed. Achieving financial balance, however, will require additional funding for a number of one-off investments to reduce overall running costs. These include: Sector-wide pathology joint venture start-up and transition costs Interim A&E expansion CDU Health-economy outpatient prescribing transformation Hospital electronic prescribing Electronic document management. 19

122 Given its age and condition, managing the Trust s estate infrastructure is an ever increasingly difficult and expensive task. The cost of maintaining current facilities to meet compliance standards and service requirements remains high. Environmental Issues The Trust is committed to acting as a good corporate citizen. All Trust tenders include a section for prospective suppliers to provide narrative on environmental, sustainability, and ethical issues relating to their offer. This includes information on the suppliers adherence to environmental standards and policies; information on carbon reduction initiatives; and evidence that the supplier s procurement is conducted in an ethical manner that is compliant with current legislation and takes account of relevant environment and sustainability standards. The Trust s contracts with suppliers contain clauses relevant to these issues. The Trust continues to make progress in its commitment to realising the benefits arising from carbon management, reducing harmful impacts to the environment, improving efficiency and resilience in the way that we operate our hospitals, and promoting health and well-being of staff and local population. The Trust is refreshing the Sustainable Development Management Plan in order to minimise the organisation s impact on the environment. A key element of the Sustainable Development Management Plan is to reduce the Trust s energy use. The Carbon Reduction Commitment Energy Efficiency Scheme (often referred to as the CRC ) is a mandatory scheme aimed at improving energy efficiency and cutting emissions in large public and private sector organisations. The scheme features a range of reputational, behavioural and financial drivers, which aim to encourage organisations to develop energy management strategies that promote a better understanding of energy usage. With increased electrical demand from rising clinical activity and the addition of a new 48 bed Acute Medical Unit, the electricity consumption for the period 2015/16 increased to 60,213 Gigajoules (GJ) from 57,517 GJ in 2014/15, an increase of almost 4.41%. In addition, total gas consumption for the year rose by 2.32% against 2014/15 figures. The Trust s contract with SRCL (Part of Stericycle Inc.) to operate the incinerator based on The Hillingdon Hospital site ensures our clinical waste travels a minimal distance before entering the incinerator process. It helps minimise the impact on the environment in that the steam created from burning clinical waste is used to provide 70% of the energy needed to heat the radiators and provide hot water at Hillingdon Hospital, therefore significantly reducing our need for energy sources such as gas and oil. The incinerator takes most of the waste from Hillingdon, and clinical waste from Mount Vernon Hospital. Looking ahead On its energy efficiency journey, the Trust is keen to work with an approved energy efficiency organisation to fund and support energy projects in the NHS. Leveraging external expertise based on other commercial environmental projects, the Trust will be able to upgrade its energy infrastructure at no net cost. The benefits of this approach would be in the way of implementing turnkey projects via simplified procurement, and skilled advisors at reduced costs, funding options and guaranteed savings. The projects being considered include, but are not limited to: Feasibility of a Combined Heating and Power plant Lighting upgrades Electrical system enhancements Metering strategy and associated energy monitoring and targeting software These initiatives will help the Trust become a more efficient user of energy and thereby lower its associated carbon emissions. In addition, the Trust will benefit from a reduction in both direct 20

123 energy costs and non-energy charges in the form of lower carbon levies, operational, maintenance, and service costs. Waste reduction and minimisation The Trust s Waste Group has met on a regular basis during the year. Part of its role is to ensure waste is segregated, managed, recycled and disposed of effectively in line with the Department of Health publication Safe Management of Healthcare Waste and Waste Hierarchy of the Department for Environment, Food & Rural Affairs. The Facilities waste & recycling service provides the safe collection, management and disposal of materials from our sites. This has been a challenge over the past year due to the high volume of occupied beds over the past year and this too has generated an increase in clinical and domestic waste. There was a decrease in the amount of waste sent to landfill in comparison to the previous year. During the year there has been considerable focus on improving waste segregation and processing and in the coming year s programme there will be an increased drive to improve our recycling and reduce landfill working in partnership with the local authority. The Trust also hosted a conference of waste experts across London and the South East to share good practice in the safe management of waste. 2012/ / / /16 Total waste generated at Hillingdon and Mount Vernon Hospitals 1,363 tonnes 1,476 tonnes 1,881 tonnes 1,736 tonnes Waste recycled 351 tonnes (26%) 437 tonnes (30%) 441 tonnes (23%) 409 tonnes (24%) Clinical waste incinerated to produce steam that generated heat and hot water at Hillingdon Hospital 545 tonnes (40%) 537 tonnes (36%) 574 tonnes (31%) 659 tonnes (38%) Waste sent to landfill 467 tonnes (34%) 502 tonnes (34%) 866 tonnes (46%) 668 tonnes (38%) Green travel The Trust has continued to promote green travel for staff and service users. A Travel Plan Coordinator was appointed to lead the work to undertake a range of initiatives to encourage green travel in liaison with the local authority. A major survey of how people travel to the Hillingdon Hospital site was undertaken using a nationally recognised standard system for data collection and analysis. The Trust was also successful in locating and leasing off-site parking spaces for 21

124 staff working closely with two local organisations to utilise spare parking capacity they had available. 22

125 Accountability Report 1. DIRECTORS REPORT 2015/16 Board of Directors As at 31 st March 2016 the Board comprised six Non-Executive Directors, a Non-Executive Chairman and six Executive Directors. One Non-Executive Director, Pradip Patel, resigned on 29 February and so there has been a vacancy for one month, during the financial year 2015/16. Interviews for this vacant Non-Executive Directorship were held on 12 April 2016 and a candidate was appointed. Details of Board members as at 31 st March 2016 are outlined below. Richard Sumray: Trust Chair Richard Sumray was appointed in November Richard has been involved for over 30 years as a Non-Executive Director in the NHS and is an experienced Chair. He chaired NHS Haringey (Primary Care Trust) for ten years from 2001 to 2011 and during that period also chaired the Joint Committee of London PCTs that supported Healthcare for London and the significant reforms to stroke and trauma services. He was also a member of the London Health Commission for eight years. Richard is a magistrate and has been chairing family and youth courts for 25 years in inner London. He was chair of the London 2012 Forum working with the London Organising Committee of the Olympic Games and was a leading figure in sport in London, starting the work on an Olympic bid in the early 1990s. He currently chairs Alcohol Concern and recently stood down from the Chair of The National Centre for Circus Arts. He was also a member of the Metropolitan Police Authority for eight years. In addition to chairing the Board of Hillingdon Hospitals, he chairs the Trust's Charitable Funds Committee and the Board of Directors' Nominations Committee. His term of office expires on 31 October Katey Adderley: Non-Executive Director Katey Adderley was appointed in December Katey is a former Director and Partner of Charterhouse Capital Partners, one of Europe s largest private equity companies, where she worked for 11 years. Katey is also a Non-Executive Director of BPP University. She has a first class Honours degree in Economics from Cambridge University and a Master s degree (distinction) in Economic Evaluation in Healthcare. Katey is a Chartered Management Accountant. Katey is Chair of the Trust s Audit & Risk Committee. Her term of office expires on 30 th November Carol Bode: Non-Executive Director Carol was appointed in April Carol s professional background is in organisational development and governance and she has 35 years experience operating in the commercial sector, public sector and not for profit sector in retail, customer services, financial services, health housing and education. Previous Directorships have included Non-Executive Chair at Southern Health NHS FT, Trustee of Foundation Trust Network Board, Corporate Director with a General Motors Company, Director of The Costello School (an Academy Trust). Currently, Carol is Non-Executive Chair of Radian Housing Group, Independent Chair of Hampshire 23

126 Safeguarding Adults Board, Associate Trainer with NHS Providers, Associate Director with The Rialto Consultancy and Senior Adviser to Newton Europe. Carol is also a serving magistrate in North Hampshire. Carol was appointed Deputy Chairman in March 2016, Chair of Remuneration Committee and the Board s Quality & Safety Committee. Carol s term of office expires on 31 st March Professor Soraya Dhillon MBE: Non-Executive Director Soraya Dhillon was appointed in February Soraya is a clinical academic and Dean of School of Life and Medical Sciences at the University of Hertfordshire. Soraya has a PhD in clinical pharmacology and has held a number of key senior academic posts. Her research interests are in chronic disease management, prescribing, medicines optimisation and patient safety. Soraya is the former Non-Executive Chairman of Luton and Dunstable Hospital NHS Foundation Trust and a member of the General Pharmaceutical Council. Soraya is a fellow of the Royal Pharmaceutical Society and was awarded an MBE for her contribution to health services in Bedfordshire. Soraya brings expertise in strategic leadership, academia and patient safety to the Board. Soraya has been appointed Chair of the Board s Transformation Committee from March 2016, a member of the Board s Audit & Risk Committee and Quality and Safety Committee. Soraya s term of office expires on 31 st January Professor Elisabeth (Lis) Paice OBE: Non-Executive Director Lis Paice was appointed in February Lis trained as a doctor at Trinity College Dublin and Westminster Medical School before being appointed as a Consultant Rheumatologist at the Whittington Hospital. For 15 years Lis was Dean Director of London Deanery, overseeing the postgraduate training of doctors. Previously Chair of the Inner and Outer North West London Care Programmes and Co-Chair of the Integrated Care Programmes Lis currently has a leading role in developing integrated care in North West London and has special responsibility for encouraging partnerships with people using health and social care services. Lis holds the ILM Diploma in Executive Coaching and Leadership Mentoring, and was named NHS Mentor of the Year In 2011 she received an OBE for services to Medicine. Lis is a Fellow of the Royal College of Physicians. Lis term of office expires on 31 st January Pradip Patel: Non-Executive Director Pradip Patel was appointed in August Pradip Patel resigned from the Trust on 29 February 2016 to become Chair of Frimley Park NHS Foundation Trust, and so was with the Trust for 11 out of 12 months in 2015/16. Pradip qualified with a First Class Honours degree in Pharmacy from the London School of Pharmacy and has an MBA from Nottingham University. He worked for Boots for over 34 years, of which the last 18 years were at senior and Board levels; where he was Managing Director for Boots Opticians and Executive Chairman following its merger with Dolland and Atchison. Pradip was employed as Director of Healthcare Strategy for Walgreens Boots Alliance. He is a Fellow of the Chartered Institute of Management and a Member of the Royal Pharmaceutical Society of Great Britain. Pradip was the Trust s Deputy Chair and Senior Independent Director, and was chair of the Board of Directors Remuneration Committee and Transformation Committee. Richard Whittington: Non-Executive Director Richard Whittington was appointed on 1st October Richard is a chartered accountant (FCA) who was a Senior Partner at KPMG, where he was latterly in charge of the Infrastructure, 24

127 Government and Healthcare Audit Group which provided audit services to the health and public sectors and building and construction companies. Richard is Non-Executive Director and Chairman of the Audit Committee at ISG Plc, a 1.4 billion turnover international construction services group, and Chairman of ISG Middle East LLC. Until January 2015 he was Chairman of the Magstim Company Limited, a high-tech business in the neuro-science field. Richard is a Director, Trustee and Honorary Treasurer of the Community Foundation of Surrey and Chair of Governors and Director of the Gordon's School Academy Trust Limited and a Trustee of the Gordon Foundation. Richard was appointed High Sheriff of Surrey from April Richard brings senior financial, audit and corporate governance experience to the Board, together with estates and capital investment expertise. Richard is chair of the Capital Investment Committee and a member of the Audit and Risk and Transformation Committees. Richard's term of office expires on 30th September Shane DeGaris: Chief Executive Shane DeGaris was appointed Trust Chief Executive in May 2012 having previously been the Trust s Deputy Chief Executive & Chief Operating Officer. Shane is an experienced NHS Director having worked in a number of London Trusts in senior management roles including as Director of Operations at Barnet & Chase Farm Hospitals NHS Trust and as Deputy Chief Executive at Epsom & St Helier University Hospitals NHS Trust. Australian by birth, he began his healthcare career in 1990 after training as a Physiotherapist in Adelaide, South Australia. Shane has been appointed by the Board as the Trust s Director of Imperial College Health Partners, and is also a Board member of the North West London Local Education & Training Board (a sub-committee of Health Education England), which is a Non-Executive role. Dr Abbas Khakoo: Medical Director Abbas Khakoo was appointed as Medical Director in October 2014 having held the position on a job-share basis since in January Abbas is a Consultant in Paediatrics and the care of new born babies. Abbas also runs a children's allergy service at Hillingdon Hospital and at St Mary's Hospital, part of Imperial College Healthcare NHS Trust. Since July 2015, Abbas has been the Chair of the Paediatric Project Delivery Board and Joint Senior Responsible Officer for the Paediatric Transition, Shaping a Healthier Future." Professor Theresa Murphy: Director of the Patient Experience & Nursing Theresa joined the Trust in May 2013 having been the Director of Nursing at North Middlesex University Hospital NHS Trust. Theresa qualified in general nursing in 1987, before specialising in Neuroscience and Critical Care nursing. Theresa has also held a number of clinical and managerial posts in both teaching and general hospitals. Theresa was awarded the Florence Nightingale leadership scholarship for 2012, and is an Honorary Professor for the City of London University, and has an LLB. Theresa holds Board level responsibility for nursing, governance and risk management, infection prevention and control, safeguarding people, patient experience and engagement. David Searle: Director of Strategy & Business Development David Searle was appointed in David had a 20 year career in the Royal Navy as a Fleet Air Arm pilot, where senior roles included second in command of a major Air Defence warship and the Commanding Officer of a large front line Naval Air Squadron. David subsequently worked in the aerospace and defence industries where he held senior positions in procurement, 25

128 commercial management, business development and marketing. He was latterly Director, Wider Markets in the Defence Aviation Repair Agency before joining the Trust. David has Board-level responsibility for estates and facilities, business development, strategy, business planning, communications and marketing. He is a Trustee of St David s Care Home for ex-servicemen and women. Joe Smyth: Chief Operating Officer Joe Smyth was appointed Chief Operating Officer in March 2015; having previously been the Trust s Director of Operational Performance. Joe has over 20 years senior managerial healthcare experience, including Deputy Chief Operating Officer at Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and Director of Service Improvement at Epsom and St Helier University Hospitals NHS Foundation Trust. Joe holds Board level responsibility for the management of the clinical divisions, emergency planning, Integration and the QIPP programme (Quality, Innovation, Productivity and Prevention). One of Joe s key responsibilities is to ensure that the Trust meets and exceeds all national and local patient access standards. Paul Wratten: Finance Director (to 15 February 2016) Paul Wratten was appointed Finance Director in Paul is a member of the Chartered Institute of Public Finance and Accountancy, and has spent almost all his working life within the NHS, including working in performance management for the NHS in London. Paul also held Board level responsibility for purchasing and supplies; the Trust's information services and information technology functions, which includes the clinical coding team; health and safety; and is the Trust s Senior Information Risk Owner (SIRO). Trevor Mayhew: Acting Finance Director (from 16 February 2016) Trevor Mayhew was appointed Interim Finance Director from 15th February to 3 rd April Trevor is a member of the Association of Chartered Certified Accountants, and has spent all his working life within the NHS, with previous positions at Royal Free and Great Ormond Street Hospitals. Trevor has worked at the Trust since April 2000, and has been the substantive Deputy Director of Finance since May Trevor also held Board level responsibility for purchasing and supplies; the Trust's information services and information technology functions, which includes the clinical coding team; health and safety; and is the Trust s Senior Information Risk Owner (SIRO). In attendance at Board meetings: Claire Gore: Director of People (to 29 February 2016) Claire Gore joined the Trust in 2010 as Director of People. Clair attended Board meetings in a non-voting capacity. Claire is a Fellow of the Chartered Institute of Personnel and Development (FCIPD) and has worked at a senior level in human resources and training and development in a number of public sector organisations including the London Borough of Brent and the Metropolitan Police Service. Claire had Board level responsibility for human resources (including recruitment, employee relations and temporary staffing), occupational health, nurse training, and workforce and organisational development. Terry Roberts: Director of People and OD (from 1 March 2016) 26

129 Terry joined the Trust in March 2016 as Director of People and Organisational Development and attended Board meetings in a non-voting capacity. Prior to this post he was the Director of Workforce at Kingston Hospital Foundation Trust and has held senior HR positions at Bart s Health, Ealing Hospital, St Mary s Hospital and North West London Hospital as well as working at the Department of Health as a National HR Advisor. Terry holds a Master s Degree in Human Resources Management and is a Fellow of the Chartered Institute of Personnel and Development (FCIPD). He has completed the Top Managers Programme with the Kings Fund and is a certified Coach and Mediator. Terry has Board level responsibility for human resources (including recruitment, employee relations and temporary staffing), occupational health, nurse training, and workforce and organisational development. Board members other commitments and Register of Interests Company directorships and other significant commitments held by Board members are outlined above. Board members are required to enter their relevant interests in the Register of Directors Interests which is formally reviewed by the Board annually. The full register is available from the Trust Secretary on Statement on the balance, completeness and appropriateness of the membership of the Board The Board of Directors Nominations Committee is responsible for reviewing the structure, size and composition of the Board and makes recommendations to the Council of Governors on the skills required for any upcoming Non-Executive Director appointments. As outlined in the biographies of Board members, the Board comprises individuals with senior level experience in the public and private sectors, across a range of disciplines including clinical and patient care; health service leadership; commercial development; business transformation and change management; finance; governance; risk management; and human resources. The Board therefore confirms that the current composition is considered to be appropriate. Taking account of the NHS Foundation Trust Code of Governance published by Monitor, the Board considers the current Chairman and all of the Non-Executive Directors to be independent. Performance evaluation of the Board its Committees In October 2015 the Board, in line with good practice in corporate governance as recommended by Monitor, the Financial Reporting Council and our external auditors, reviewed the Board s Committees terms of reference. This review sought to give enhanced emphasis to areas which the Board deemed priorities: capital investment, risk and patient safety. The review also clarified the roles of individual committees to avoid duplication and to make their remit more manageable. The Board agreed that: Quality and Risk Committee become the Quality and Safety Committee in order to give increased emphasis to patient safety Audit and Assurance Committee become the Audit and Risk Committee The Capital Investment Group become a Committee of the Board, known as the Capital Investment Committee These changes came into immediate effect. 27

130 Meetings of the Board, its Committees and the Council of Governors in 2015/16 The Board The Board met 12 times during 2015/16. The Board comprises of a Non-Executive Chairman, six Non-Executive Directors and five Executive Directors. The Director of People is also in attendance. In order to make Board meetings accessible to the public and Governors, four Board meetings were held at Mount Vernon Hospital and eight at Hillingdon Hospital. Two of the meetings at Hillingdon Hospital were held at 5 pm. Committees of the Board The Board has seven committees: Audit & Risk Committee, Quality and Safety Committee, Transformation Committee, Capital Investment Committee, Board of Directors Nomination Committee, Board of Directors Remuneration Committee and the Charitable Funds Committee. Each of these is chaired by a Non-Executive Director. Audit & Assurance Committee, becoming Audit & Risk Committee in October 2015 The Audit & Risk Committee met five times during 2015/16. As at 31 st March 2016, the Trust s Audit & Risk Committee comprises four Non-Executive Directors (1 vacancy from 29 February 2016); two of whom (including the Committee Chair) have recent and relevant financial experience. The Committee is usually attended by the internal and external auditors, the Finance Director and the Director of Patient Experience & Nursing as the Executive Director responsible for clinical and corporate governance. The Local Counter Fraud Specialist attends at least two meetings a year, and other Directors and senior managers attend when invited by the Committee. The Committee is responsible for providing an independent and objective review of the Trust s systems of internal control (both financial and non-financial) and the underlying assurance processes in place at the Trust. The Committee is also responsible for ensuring that the Trust has independent and effective internal and external audit functions. External audit The Audit & Risk Committee (ARC) is responsible for making recommendations to the Council of Governors on the appointment and removal of the external auditor. In October 2013 the Council of Governors appointed Deloitte as the Trust s external auditors for a three year period starting with the 2013/14 audit with an option for two one year extensions. In line with the Code of Governance this reappointment is subject to annual review. This annual review involves the Audit & Risk Committee (ARC) members completing a structured review of external audit against the areas of work set out in Monitor s Audit Code: Financial statements Annual governance statement The Trust s arrangements for securing economy, efficiency and effectiveness in the use of resources; and The quality report. Plus review of external audit against 46 criteria across the following domains: 28

131 The audit partner The audit team The audit approach planning and then execution Communications by the auditor to the ARC External audit s support to the work of the ARC Insights and adding value Formal reporting by the auditors. The Chair of the ARC then presents a report to the July meeting of the Council of Governors on the outcomes of this review and whether external audit s appointment should be confirmed. The audit fee for 2015/16 was 79,000 plus VAT ( 64,500 plus VAT for the financial statement audit and 14,500 plus VAT for work on the quality report). In October 2013 the Council of Governors agreed an updated policy on the engagement of the external auditors to undertake additional services. Under this policy, any such work is reported to the Council of Governors. No such additional work was commissioned in 2015/16. Internal audit The Trust s internal audit service is provided by TIAA (The Internal Audit Agency). During 2015/16 the Trust followed good practice and market tested its contract for internal audit. KPMG has been appointed and will provide internal audit services from July Internal audit provides an independent and objective opinion on risk management, control and governance by measuring and evaluating the effectiveness by which organisational objectives are achieved. Through detailed examination, evaluation and testing of the Trust s systems, internal audit play a key role in the Trust s assurance processes. The scope and work of the Trust s internal auditors, is set out in a charter approved by the Audit & Risk Committee. The Audit & Risk Committee agree a work plan for internal audit at the start of each financial year, taking account of the risk assessment undertaken by internal audit. The Committee review the findings of internal audit s work against this plan at its quarterly meetings. Audits undertaken in 2015/16 included: medicines management, health and safety and financial reporting and budgetary control. The Head of Internal Audit reports to the Committee and is managed by the Finance Director. The Head of Internal Audit has a right of direct access to Committee members. Key issues considered by the Committee Key elements of the Committee s work include reviewing the Board Assurance Framework, the Risk Register and reviewing the findings of the Trust s internal and external auditors and Local Counter Fraud Specialist. The Committee is responsible for reviewing the annual financial statements, with particular focus given to major areas of judgement and changes in accounting policies, determining that the Trust remains a going concern, and reviewing the draft annual report including the annual governance statement. The Committee also reviews the assurance in place in respect of data quality. In addition the Committee monitored estates compliance, the data universe, compliance with information governance standards, reviewed contingent liabilities, reviewed debtors and 29

132 examined the Trusts processes for securing value for securing economy, efficiency and effectiveness in its use of resources. Quality and Risk Committee that became Quality and Safety Committee in October 2015 The Quality and Safety Committee met five times during 2015/16. As at 31 st March 2016, the Trust s Quality & Safety Committee comprises four Non-Executive Directors and four Executive Directors. The Committee s remit is to review the clinical divisions in relation to the clinical governance and quality agenda including what arrangements they have put in place to make any necessary improvements. Review and challenge clinical quality and patient safety and ensure that action plans are developed and implemented to address any areas of concern. The Committee also monitor s the Trust s compliance with Care Quality Commission registration requirements. Key issues considered by the Committee The Committee is developing a Quality and Improvement Strategy; to drive improved quality of service and to ensure patient focus. Divisional quality performance reporting is to be aligned to provide improved analysis and triangulation of data. A deep dive review to achieve no preventable deaths was undertaken; particularly looking at narrowing the death rate between weekday and weekends; and considerable progress has been made in reducing the weekend death rate. There has been active focus on A&E nursing and leadership, understanding why there are gaps in the nursing workforce of Band 6 and 7s and ensuring there are sufficient staff of appropriate skill mix in maternity. Transformation Committee meetings in 2015/16 The Transformation Committee met four times during 2015/16. As at the 31 March 2016, The Trust s Transformation Committee comprises of three Non-Executive Directors and five Executive Directors. The Committee s remit is to shape, challenge and review the development and implementation of the Trust s transformation programme with a particular focus on the multi-year schemes that improve quality whilst reducing cost. Key issues considered by the Committee The work of the Committee has focussed on the Trust s need to identify 50.7m of recurrent savings over the period from 2014/15 to 2020/21. 8m of savings in 2015/16 have been made; which although is a considerable achievement, is 1.5m below its target; so targets for subsequent years have been revised to re-coup this shortfall. The Committee also focussed on developing a workforce transformation programme; this includes working with HENWL (Health education North West London) to develop workforce models to better meet the needs of the Trust in terms of skills and future workforce requirements. Capital Investment Group that became the Capital Investment Committee in October 2015 The Capital Investment Committee met eight times during 2015/16. As at the 31 March 2016, The Trust s Capital Investment Committee comprises of two Non-Executive Directors and four Executive Directors. The Committee s primary remit is to shape, challenge and review the development and implementation of the Trust s strategic redevelopment programme. 30

133 Key issues considered by the Committee The Committee appointed master planners in September 2015 to develop detailed options for hospital development at both the Hillingdon and Mount Vernon sites. Phase 1 has involved data gathering and identifying options; this has included working with our CCG. The Committee is leading negotiations with East and North Hertfordshire NHS Trust on future land use at Mount Vernon. The Capital Investment Committee also monitored the capital investment programme for 2015/16 and identified priorities for capital spending for 2016/17. Schemes that have been prioritised are improvement to the building infrastructure, repairing what is needed and purchasing medical equipment. Board of Directors Nominations Committee meetings 2015/16 The Board of Directors Nomination Committee met three times during 2015/16. As at the 31 March 2016, the Trust s Board of Directors Nomination Committee comprises of seven Non- Executive Directors (1 vacancy from 29 February 2016) and is attended by the Director of People and Organisational Development. The Board of Directors Nomination Committee leads the process for Board appointments. Key issues considered by the Committee During 2015/16, the Committee recruited and appointed a new Director of Finance and a new Director of People and Organisational Development. The Committee also reviewed the succession pipeline and agreed that the Trust should focus on developing staff that have the ability to take on director-level posts in the next three years. Board of Directors Remuneration Committee meetings 2015/16 The Board of Directors Remuneration Committee met three times during 2015/16. As at the 31 March 2016, the Trust s Board of Directors Nomination Committee comprises of seven Non- Executive Directors (1 vacancy from 29 February 2016). This Committee is attended by the Chief Executive and the Director of People and Organisational Development. This Committee sets executive pay, based on a thorough appraisal of executive performance. Key issues considered by the Committee The Committee formally appraised the Chief Executive and all Executive Directors, agreed their pay and set target for 2016/17. Charitable Funds Committee meetings 2015/16 The Charitable Funds Committee met three times during 2015/16. As at the 31 March 2016, the Trust s Board of Directors Charitable Funds Committee comprises of three Non-Executive Directors and two Executive Directors. The Charitable Funds Committee assists the Trust in its role as corporate trustee for The Hillingdon Hospitals NHS Foundation Trust charity and has been established to make and monitor arrangements for the control and management of the Trust s charitable funds. Rekha Wandhwani (Lead Governor) joined the Committee in October Key issues considered by the Committee 31

134 The Committee actively reviewed income and expenditure within the fund and the performance of the fund managers, Brewin Dolphin. An Annual Report and Accounts were produced, reviewed and lodged with the Charity Commission. The Committee recruited a Charity Director, who is paid through the fund, to lead the work of the Charity. Also in 2015/16 the Committee worked on developing an ethical investment strategy in line with good practice as stated by the Association of NHS Charities, which will be published in July The Committee reviewed bids for allocation of funds; and of particular note, approved the purchase of mannequins for the Simulation Centre including the SimMom, a mannequin for obstetric training. Attendance at Board and Board Committee meetings The following table outlines Board members attendance at Board and Committee meetings during 2015/16 against the total possible number of meetings for which an individual was a member. Committee attendance is shown in relation to those Committees of which a Director is a formal a member. Katey Adderley Carol Bode Shane DeGaris Soraya Dhillon Abbas Khakoo Theresa Murphy Lis Paice Pradip Patel David Searle Joe Smyth Richard Sumray Richard Whittington Paul Wratten Trevor Mayhew (Acting Finance Director) Board of Directors (12 meetings) Audit & Risk Committee (5 meetings) Board Nominations Committee (3 meetings) Board Remuneration Committee (3 meetings) Charitable Funds Committee (3 meetings) Quality & Safety Committee (5 meetings) Transformation Committee (3 meetings) Council of Governors The role and powers of the Council of Governors are outlined earlier in the report. The composition of the Council of Governors is outlined in the Trust s Constitution. 32

135 As at 31 st March 2015 there were 24 positions on the Council of Governors: 13 elected to represent the public members, seven elected to represent the staff members, and four appointed by partner organisations (Hillingdon Council, Hillingdon Clinical Commissioning Group, the London Ambulance Service, and the Trust s Joint Negotiating & Consultative Committee). The members of the Council of Governors who served during 2015/16 are outlined below: Name Date took office and method (see key below) Term of office expires Public Governors Graham Bartram 01/04/2014 (CE) 31/03/2017 North (4) Ian Bendall 01/04/2014 (CE) 31/03/2017 David Bishop 01/04/2014 (CE) 31/03/2017 Tony Ellis 01/04/2014 (CE) 31/03/2017 Harkishan Chander 01/04/2014 (CE) 31/03/2017 Central (4) Donald Dakin 01/04/2014 (CE) 31/03/2017 Terry Thompson 01/07/2015 (CE) 30/06/2018 Roger Shipton 01/04/2014 (CE) 31/03/2017 Raymond Smith 01/03/ /02/2019 South (4) Keith Saunders 01/04/2014 (CE) 31/03/2017 Doreen West 01/04/2014 (CE) 31/03/2017 Rekha Wadhwani 01/04/2014 (CE) 31/03/2017 Rest of England Daphne Magidi 01/07/2015 (CE) 30/06/2018 Staff Governors Doctors & Dentists (1) Nurses, Midwives, Healthcare Assistants (3) Alvan Pope 01/04/2014 (UE) 31/03/2017 Sheila Bacon 08/04/2014 (UE) 31/03/2017 Sheila Kehoe 08/04/2014 (UE) 31/03/2017 Amanda O Brien (resigned 31/3/2016) 01/04/2014 (UE) 31/03/

136 Allied Health Professionals (1) Support Staff (2) Graham Coombs 01/04/2014 (CE) 31/03/2017 Paul Cornford 01/04/2014 (UE) 31/03/2017 Jack Creagh 01/04/2014 (UE) 31/03/2017 Appointed Governors Hillingdon Clinical Commissioning Group (1) London Borough of Hillingdon (1) London Ambulance Service (1) Joint Negotiating & Consultative Committee (1) Dr Mayur Nanavati 01/04/2014 (A) 01/04/2017 Mary O Connor 01/04/2014 (A) 01/04/2017 Pauline Cranmer 01/04/2014 (A) 01/04/2017 Nicola Batley 01/07/ /06/2018 Key: CE contested election UE uncontested election A appointed by partner organisation In 2015/16 the Council of Governors formally met four times. Governor attendance at these meetings is outlined below. Where a Governor was not in office for all four meetings, the maximum possible attendance is shown. Governor Meetings attended Graham Bartram (Public) 4 of 4 Ian Bendall (Public) 3 of 4 David Bishop (Public) 4 of 4 Tony Ellis (Public) 4 of 4 Harkishan Chander (Public) 3 of 4 Donald Dakin (Public) 3 of 4 Raymond Smith (Public) Started March 34

137 2016 Roger Shipton (Public) 4 of 4 John Coleman (Public) 3 of 3 Keith Saunders (Public) 4 of 4 Rekha Wadhwani (Public) 4 of 4 Doreen West (Public) 3 of 4 Terry Thompson (Public) 1 of 2 Daphne Magadi (Rest of England) 2 of 2 Alvan Pope (Staff) 3 of 4 Sheila Bacon (Staff) 4 of 4 Sheila Kehoe (Staff) 3 of 4 Amanda O Brien (Staff) 4 of 4 Graham Coombs (Staff) 4 of 4 Paul Cornford (Staff) 2 of 4 Jack Creagh (Staff) 4 of 4 Dr Mayur Nanavati (Appointed) 2 of 4 Mary O Connor (Appointed) 4 of 4 Pauline Cranmer (Appointed) 1 of 4 Nicola Batley (Appointed) 1 of 3 Rachel Hyman (Appointed) 1 of 1 Governors are required to declare any relevant interests which are then entered into the publicly available Register of Governors Interests. The Register is formally reviewed by the Council of Governors annually and is available from the Trust Secretary on Lead Governor In line with Monitor s Code of Governance, the Council of Governors elects one of the Public Governors to be the Lead Governor. The main duties of the Lead Governor are to: Act as a point of contact for Monitor should the Regulator wish to contact the Council of Governors on an issue for which the normal channels of communication are not appropriate. 35

138 Be the conduit for raising with Monitor any Governor concerns that the Foundation Trust is at risk of significantly breaching its Licence, having made every attempt to resolve any such concerns locally. Chair such parts of meetings of the Council of Governors which cannot be chaired by the Trust Chair or Deputy Chair due to a conflict of interest in relation to the business being discussed. In September 2015 John Coleman resigned as Lead Governor. An election was held in November 2015; the Council of Governors elected Rekha Wadhwani as their Lead Governor for the remainder of 2015/16 and for the.2016/17 financial year. Council of Governors Nominations & Remuneration Committee The Committee met three times during 2015/16. The Committee comprises of the Chairman of the Trust, three public Governors and two staff Governors. The Council of Governors Nomination & Remuneration Committee leads the process for appointing the Chairman and all Non-Executive Directors; it also is responsible for agreeing their remuneration, appraising their performance and setting their targets. The Committee s main areas of work during the year were to appraise the Chairman and Non- Executives, agree their remuneration and set their targets. Pradip Patel announced his resignation in November 2015 (and left the Trust on 29 February 2016); the Committee oversaw the appointment processes for the vacant Non-Executive Director (NED) position. The Committee engaged the executive search agency, Gatenby Sanderson, to assist with these processes. Pradip Patel was both Deputy Chairman and Senior Independent Director; the Committee deliberated on how best to fill these roles and appointed Carol Bode to be the Deputy Chairman of the Trust and Lis Paice to be the Senior Independent Director. Both began their roles from 1 March The Committee s work in relation to non-executive remuneration is outlined in the remuneration report. The Board s liaison with Governors and members All Board members have a standing invitation to attend Council of Governors meetings in order to ensure they understand the views of Governors and members. Throughout the year the Chairman and each Non-Executive Director has addressed the Council Governors outlining their experience, and what they are focussing on at the Trust. In addition a monthly briefing session for Governors is held with the Chairman where Governors are updated on matters at the Trust and have the opportunity to ask questions of the Executive Directors. The Council of Governors meetings are held in public and there is an opportunity for members of the public to ask Governors and members of the Board questions. Governors and Members of the Board also attend the Trust s People in Partnership meetings and Annual Members Meeting to liaise with members and Governors. Attendance by Board members at the four meetings of the Council of Governors and the joint meeting between the Board and Council of Governors in 2015/16 is outlined below: 36

139 Board Member No of Council of Governor meetings attended in 2015/16 (4 meetings held) Katey Adderley (Non-Executive Director) 3 Carol Bode (Non-Executive Director and Deputy Chair from 1 March 2016)) 3 Shane DeGaris (Chief Executive) 4 Soraya Dhillon (Non-Executive Director) 4 Abbas Khakoo (Medical Director) 1 Theresa Murphy (Director of the Patient Experience & Nursing) Lis Paice (Non-Executive Director and Senior Independent Director from 1 March 2016) Pradip Patel (Deputy Chair, Senior Independent Director & Non-Executive Director left the Trust on 29 February 2016)) David Searle (Director of Strategy & Business Development) Joe Smyth (Chief Operating Officer) 2 Richard Sumray (Chair) 4 Richard Whittington (Non-Executive Director) 2 Paul Wratten (Finance Director) 3 Membership The Foundation Trust membership is divided into two categories: public membership and staff membership. Public membership There are four public constituencies, which are collectively known as the Public Constituency. The majority of the public members are drawn from the three public constituencies which cover the electoral wards in Hillingdon borough together with several neighbouring electoral wards. The fourth public constituency covers all other electoral areas in the rest of England. Public membership is open to individuals aged 16 years or over living within the Public Constituency, 37

140 who are not eligible to be a staff member of the Foundation Trust. The Constitution includes two further disqualifications on public membership. 1 Staff membership The staff constituency is a single constituency divided into the following classes: Doctors and dentists Nurses and midwives (including health care assistants) Allied Health Professionals Support staff. 1 An individual may not become or remain a member of the Trust if during the five years prior to their application, they have demonstrated aggressive or violent behaviour at any hospital or towards any person working for a health service body and following such behaviour has been excluded from any hospital or other health service body under either the Trust s or other health service body s policy for withholding treatment from violent/aggressive patients, or equivalent. Nor can anyone become or continue as a member of the Trust if they have been confirmed as a vexatious complainant in accordance with the Trust s complaints handling policy. 38

141 Staff membership is open to all those employed by the Trust on a permanent basis, those who have a fixed term contract of at least 12 months, and those who have been working at the Trust for at least 12 months. These staff are automatically members of the Staff Constituency unless they opt-out from membership. In addition, those working at the Trust through the temporary staffing bank become staff members providing they have been registered on the Trust s bank for at least 12 months and continue to be registered. So far no staff have opted out from being a member of the Foundation Trust. Staff membership will cease at the point that the member leaves the service of the Trust. Anyone eligible to be a staff member of the Foundation Trust cannot be a public member. Public Membership as at 31 st March 2016 As at 31 st March 2016, the Trust had 6,976 public members. The table below illustrates the number of public members for each constituency compared to the total population. 31 st March 2016 % of membership Population Base % of area Central , North , South , Rest of England Total 6, During 2015/16, the Foundation Trust recruited 203 new public members and lost 263 public members due to bereavement, moving away without providing a new address or cancelling their membership. The Trust has established a Council of Governors Membership Development and Engagement Group to enable Governors to become engaged in a programme of focused recruitment and engagement with members. Key actions agreed by the group included setting up Governor surgeries in the hospital, identifying community events for the Governors to attend, redesigning the welcome letter to be sent to new members from the Governors, and encouraging Governors to suggest content for the Pulse Foundation Trust newsletter. Staff Membership as at 31 st March

142 As at 31 st March 2016 the Trust had 3600 staff members. The following table provides a breakdown by staff group. Each staff group includes bank staff who meet the Trust s eligibility criteria for staff membership: Staff Class Number of members Doctors and Dentists 473 Nurses, Midwives & Healthcare 1492 Allied Health Professionals, Scientific and Technical 515 Support staff 1072 Total 3552 Membership Development and Engagement Strategy (not yet approved by the Trust Board) The Trust with the Council of Governors has updated and approved the Membership Development and Engagement Strategy at its meeting in February The Strategy describes the Trust s objectives for the membership and the approach we will use to ensure the Trust develops and engages with a representative membership. It outlines our plans for raising awareness about membership and for the recruitment, retention and involvement of members. It also defines how we will measure the success of the strategy. The strategy was produced with the guidance and input of the Council of Governors. A high level action plan to deliver the Membership Development and Engagement Strategy has been developed each year with progress periodically reported to the Council of Governors and the Board. The Hillingdon Hospitals NHS Foundation Trust is committed to recruiting members from the diverse population served by the Trust. Membership is open to all those eligible to be a member regardless of gender, race, disability, ethnicity, religion or any other groups covered under the Equality Act The membership base is regularly reviewed to ensure that the membership is representative of those eligible to be members. Specific groups that appear to be underrepresented are targeted in recruitment campaigns in order to seek to increase membership representation in these areas, such as young people between the ages of 16 and 45. Key actions to grow membership and improve engagement: Key actions to grow membership: Encourage Governors to attend local groups and events (e.g. Resident Associations and Community Voice) to engage with the public and recruit new members Support fund-raising events organized by the Trust or other local organisations Attract new members visiting the hospitals during monthly Governor/ member surgeries Organise membership recruitment events at Hillingdon and Mount Vernon Hospitals 40

143 Encourage Governors and members to sign up family, friends and members of the public Promote membership with staff working for the London Borough of Hillingdon Invite ex-staff, their family and friends to become public members Utilise existing networks in promoting membership with staff and students at local universities and schools Encourage all volunteers to sign up as public members Use social media (e.g. Twitter) to attract new members. Engagement between Governors and members The Trust organises People in Partnership meetings which enable the Governors, particularly the Public Governors, to engage with the members they represent. The meetings are held at a variety of locations 4 times during the year and are chaired by a Governor. They are preceded by an opportunity for members and Governors to meet over refreshments. The Trust encourages and facilitates linkages between the Council of Governors and groups and organisations which represent patients, public and the wider community. During 2015/16, Public Governors attended various community events throughout the year, including the May Fair in West Drayton, RAF Northolt centenary open day, Ruislip Manor Fun Day and the Harmondsworth and Sipson Open House. Many Governors participate in activities unrelated to health i.e. local churches, volunteer driving and education and are therefore able to communicate with local residents and public members at these events and report back to the wider Council of Governors in order to ensure that the Council of Governors is aware of public comments and concerns which have been raised. The Trust provides Governors with information on the Trust s strategy and performance at various meetings such as the formal quarterly Council of Governors meetings, monthly informal meetings with the Chair and Chief Executive, and the joint meetings between the Board and Council of Governors. Governors can then feed this information back to the members and organisations they represent. These meetings also provide the opportunity for Governors to feedback issues of concern raised by members. During 2015/16 such issues included carparking at the Hillingdon site, staffing, and the estate. Governors are also able to communicate with members through the quarterly members newsletter the Pulse which regularly features a Governor article. The Membership Development & Engagement Strategy outlines the Trust s policy on the involvement of members, patients and wider public, including a statement on the Trust s approach to consultation, and addressing the overlap and interaction between the Governors and other consultative and representative groups. The strategy is available on the Trust s website. Political Donations The Trust has not made any donations to political parties. 41

144 Payment of creditors The Trust aims to comply with the Better Payment Practice Code which is that 95% of invoices in terms of numbers and value are paid by the due date of payment, though has been unable to achieve the target in 2015/16. Details of the Trust s compliance in this matter can be found in note 7.1 of the accounts. The Trust paid out 3k in 2015/16 for interest on late payments under the Commercial Debts (Interest) Act 1998 ( 10k in 2014/15) Quality Governance To insert paragraph Income Disclosure Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) requires that the Trust s income from the provision of goods and services for the purposes of the health service in England must be greater than its income from the provision of goods and services for any other purposes. In 2015/16, the Trust met this requirement, with 96.9% ( 231m) of the Trust s income generated by activities for the purpose of the health service in England. As the vast majority of Trust income is categorised as generated by activities for the purpose of the health service in England, it is the Board s view that other income does not detract from NHS provision to any material extent. Where other income is generated it supports the Trust to make optimum use of its assets and is used to directly support principal patient care activities. Directors Disclosure to Auditors For each individual who was a director at the time that this report was approved: - so far as the director was aware, there was no relevant audit information of which the NHS foundation trust s auditor was unaware and - the director has taken all the steps that they ought to have taken as a director in order to make themselves aware of any relevant audit information and to establish that the NHS foundation trust s auditor was aware of that information. 2. REMUNERATION REPORT The Trust s pay policy is to set executive remuneration between the median and upper quartile of comparator Trusts when individuals have a demonstrable track record of high performance against agreed objectives and in their overall contribution to the Trust over a sustained period of time. In making decisions on executive remuneration the Remuneration Committee will also consider the organisation s performance, and the individual s experience, marketability and likelihood of moving elsewhere. Executive remuneration does not currently include provisions for bonus payments linked to the delivery of performance targets. No executive pay should be below the maximum scale for Agenda for Change Band 9. 42

145 In March 2015 the Remuneration Committee agreed the median and upper quartile range for each of the executive directors pay, and individual directors were placed within that range as per the above pay policy. In addition, it was agreed that the Chief Executive, the Director of Patient Experience and the Director of Finance pay award should be phased in over a two year period, the first portion paid in 2015/16 and the second is due to for implementation in 2016/17 subject to continued good performance. A recent benchmarking exercise undertaken by the Hay Group suggests that the current salaries paid by the Trust to the Chief Executive and its Executive Directors are generally around the median level paid by Foundation Trusts that are of a similar size to the Trust. Details on senior manager pay, the future policy table and fair pay multiple are in tables

146 Table 1 Senior Managers (The Chair, Executive and Non-Executive Directors) Remuneration Current Year Ending 31 March 2016 NOTE NAME AND TITLE Salary and fees 2015/16 Taxable Benefits 2015/16 (Note 6) Notes Executive Directors (bands of 5000) (To the nearest 100) Annual Performance Related Bonuses 2015/16 Long Term Performance Related Bonuses 2015/16 (bands of 5000) (bands of 5000) Pension Related Benefits 2015/16 (bands of 2500) Total Remuneration 2015/16 Salary and fees 2014/15 Taxable Benefits 2014/15 (bands of 5000) (bands of 5000) (To the nearest 100) Annual Long Term Performance Performance Related Related Bonuses Bonuses 2014/ /15 (excluding (bands of 5000) (bands of 5000) Pension Related Benefits 2014/15 (bands of 2500) Total Remuneration 2014/15 000s s 000s 000s 000s 000s 000s s 000s 000s 000s 000s Shane Degaris, Chief Executive N/A N/A N/A N/A Claire Gore, Director of People N/A N/A N/A N/A N/A N/A Abbas Khakoo, Medical Director N/A N/A N/A N/A Trevor Mayhew, Interim Finance Director N/A N/A N/A N/A N/A 0 Theresa Murphy, Director of the Patient Experience and Nursing N/A N/A N/A N/A Terry Roberts, Director of People N/A N/A N/A N/A N/A 0 0 David Searle, Director of Strategy & Business Development N/A N/A N/A N/A Joe Smyth, Chief Operating Officer N/A N/A N/A N/A Paul Wratten, Finance Director N/A N/A N/A N/A Non Executive Directors Previous Year Ending 31 March 2015 Richard Sumray, Chair N/A N/A N/A N/A N/A N/A Katey Adderley, Non-Executive Director N/A N/A N/A N/A N/A N/A Carol Bode, Non-Executive Director N/A N/A N/A N/A N/A N/A Soraya Dhillon, Non-Executive Director N/A N/A N/A N/A N/A N/A Pradip Patel, Non-Executive Director N/A N/A N/A N/A N/A N/A Lis Paice, Non-Executive Director N/A N/A N/A N/A N/A N/A Richard Whittington, Non-Executive Director N/A N/A N/A N/A N/A N/A 5-10 (bands of 5000) Notes on Table 1 Annual and Long Term Performance Related bonuses have not been paid by the Trust and are not applicable. Pension Related Benefits have been calculated using the HMRC method advised by Monitor in the Annual Reporting Manual. Pension Related benefits were not reported for the prior year as the figures were not available. 44

147 Table 2 Senior Managers' Pension Entitlements Real increase in pension at age 60 at 31 March 2016 Real increase in pension lump sum at age 60 at 31 March 2016 Total accrued pension at age 60 at 31 March 2016 Lump Sum at age 60 related to accrued pension at 31 March 2016 Cash Equivalent Transfer Value at 1st April 2015 Real Increase in Cash Equivalent Transfer Value Cash Equivalent Transfer Value at 31 March 2016 Employer's contribution to stakeholder pension NAME AND TITLE Executive Directors (Bands of 2500) (Bands of 2500) (Bands of 5000) (Bands of 5000) 000s 000s 000s 000s 000s 000s 000s 000s Shane Degaris, Chief Executive N/A Abbas Khakoo, Medical Director N/A Trevor Mayhew, Interim Finance Director N/A Theresa Murphy, Director of the Patient Experience and Nursing N/A David Searle, Director of Strategy & Business Development N/A Joe Smyth, Chief Operating Officer N/A Paul Wratten, Finance Director N/A Notes on Table 2 The Trust is a member of the NHS Pension Scheme which is a defined benefit Scheme, though accounted for locally as a defined contribution scheme. The Trust does not operate nor contribute to a stakeholders pension scheme. This is therefore shown as not applicable (N/A) Non Executive Directors are not members of the Trust pension scheme. CETV (Cash Equivalent Transfer Value) is the value of a members pension fund at 31st March if he/she were to transfer that pension fund on that date. 45

148 Table 3 Fair Pay Multiple 2015/ /2015 Band of Highest Paid Director's Total Remuneration ( 000) Median Total Remuneration 30,501 30,206 Ratio Notes on Table 3 The HM Treasury Financial Reporting Manual (FReM), requires the Trust to disclose the median remuneration of the Trust staff and the ratio between this and the mid-point of the banded total remuneration of the highest paid director. The calculation is based on full-time equivalent staff of the Trust at 31st March 2016 on an annualised basis. In 2015/16 no employee received remuneration in excess of the highest paid director (2014/15 two employees received remuneration in excess of the highest-paid Director). Remuneration in table 3 excludes pension related benefits in accordance with Monitor instructions. The ratio for 15/16 was 5.98.The ratio for 2014/2015 has been restated as the calculation incorrectly included pension related benefits. This reduced the ratio in 14/15from 6.70 to On this basis, there has been a very marginal increase of 0.1. Table 4 Senior Managers earning more than the Prime Minister 2015/ /2015 (Bands of 5000) (Bands of 5000) Shane Degaris, Chief Executive Abbas Khakoo, Medical Director Notes on Table 4 The Annual Reporting Manual (ARM) for NHS Foundation Trusts from 2015/16 requires the Trust to disclose all Senior Managers receiving grater remuneration than the Prime Minister (currently 142,500). For the purpose of table 4 Prime Minister comparatives, the average of the banding of Total Remuneration in Table 1 is used. The remuneration in table 4 must be disclosed on a full time, part time, or any other pro rata basis. Furthermore the Trust must disclose what steps it has taken to satisfy itself that the remuneration is reasonable. The process the Trust follows is explained below: The Trust's exec pay policy is to set executive remuneration between the median and upper quartile of comparator Trusts when individuals have a demonstrable track record of high performance against agreed objectives and in their overall contribution to the Trust over a sustained period of time. In making decisions on executive remuneration the Remuneration Committee will also consider the organisation's performance, the individual's experience, marketability, the pay of senior managers on Agenda for Change terms and conditions and the likelihood of them moving elsewhere. Executive remuneration does not currently include provisions for bonus payments linked to the delivery of performance targets. Executive pay was last benchmarked in 2015 by Hay Group who examined data from annual reports and a national survey conducted by the Foundation Trust Network. The Remuneration then considered all executives and the CEO's salary against the benchmark report and in accordance with the pay policy as set out above. Remuneration in table 4 excludes pension related benefits in accordance with Monitor instructions. 46

149 3. STAFF REPORT An analysis of average staff numbers As at 31 st March 2016, the Trust employed over 2,900 staff. Of this 75% of staff were female and 25%. We have a growing female workforce which is consistent with the health sector. In 2015/2016, female staff represented 75% of our overall workforce with female staff dominating professional groups such as nursing and midwifery (89% female) and allied health professionals. There was an almost equal balance of gender representation within Medical and dental workforce which although historically male has over the last five years seen an increase in female medical doctors to 53%. Whilst our male workforce is declining, there is stronger gender representation of male staff within admin and clerical and estates and ancillary group. A breakdown at the end of the year of the number of male and female directors, senior managers, employees The Trust Board has thirteen members, eight Male and five are Female. Women represent 90% of senior managers at band 8 and above. This is above their representation within the workforce and London borough of Hillingdon population. Sickness absence data The Trust completed the financial year with a YTD sickness rate of 3.53% - although this rate is higher than the Trust target of 3%, it was less than the 15/16 YTD figure of 3.59%. The Corporate Division completed the year with the highest YTD sickness rate (3.78%), followed by W&C (3.68%), Surgery (3.65%), CCSS (3.64%), and Medicine (3.21%). The estimated YTD cost of sickness to March 2016 was 2,868,697 The overall reduction in the sickness rate for 15/16 (3.53% compared to 3.59%), can be partly attributed to the focussed work carried out by the People Management & Productivity Working Group, (a sub group of the Workforce Transformation Board); which undertook a wholesale review of the managing sickness absence policy, worked with the Divisions to ensure that they captured greater levels of doctors sickness, and delivered sickness absence training to managers as part of the HR Workshops. Further work and initiatives are being planned to help reduce the sickness rate further during 16/17. Staff policies and actions applied during the financial year: Policies applied during the financial year for giving full and fair consideration to applications for employment made by disabled persons, having regard to their particular aptitudes and abilities. The following policies apply in relation to the above question; Recruitment & Selection Policy, Equality & Human Rights Policy, Employment Checks Policy 47

150 The Trust has a positive approach to disability and subscribes to the Two Ticks Scheme. We aim to encourage and support the inclusion of disabled people in accessing the full range of opportunities open to staff, and to promote greater participation in public life. In line with the policies governing recruitment, selection, disability and the Guaranteed Interview Scheme, disabled candidates for any selection process, who meet the essential criteria, will be short-listed for interview. Managers responsible for conducting any selection or assessment processes are also responsible for ensuring that reasonable adjustments are made to any candidates who require them, in line with the Trust s Recruitment and Selection Policy/Resourcing Policy. Policies applied during the financial year for continuing the employment of, and for arranging appropriate training for, employees who have become disabled persons during the period. The following policies apply in relation to the above question; Equality & Human Rights Policy Managers are responsible for ensuring that staff are able to carry out their work in appropriate conditions, including participation in learning and development initiatives and local induction processes. Where necessary, Reasonable Adjustments must be made to equipment, working or learning arrangements and the physical environment to ensure that disabled staff can carry out their work, and access the full range of learning and development opportunities. These adjustments will be carried out with advice from the occupational health department. In certain circumstances the Equality Act 2010 provides that a reasonable adjustment can include treating disabled staff more favourably, such as appointing a disabled member of staff into a role without undergoing a competitive selection process. Policies applied during the financial year for the training, career development and promotion of disabled employees. The following policies apply in relation to the above question; Recruitment & Selection Policy, Equality & Human Rights Policy The Trust has a positive approach to disability and subscribes to the Two Ticks Scheme. We aim to encourage and support the inclusion of disabled people in accessing the full range of opportunities open to staff, and to promote greater participation in public life. 48

151 In line with the policies governing recruitment, selection, disability and the Guaranteed Interview Scheme, disabled candidates for any selection process, who meet the essential criteria, will be short-listed for interview. Where appropriate the principles of Positive Action are applied to support the career development and promotion of disabled employees. Actions taken in the financial year to provide employees systematically with information on matters of concern to them as employees. The Trust sends out regular bulletins to staff to keep them informed of matters which may be of concern to them. Managers are encouraged to disseminate such information at Team Meetings and or 1:1 meetings as appropriate. Should employees have concerns which they wish to raise, a number of channels are open to them to do so. These include but are not limited to the following; Raising Concerns at Work Policy, Dignity at Work Policy, Grievance Policy, SpeakInConfidence, escalating concerns to their manager or manager s manager. Actions taken in the financial year to consult employees or their representatives on a regular basis so that the views of employees can be taken into account in making decisions which are likely to affect their interests. The Trust has a number of forums in place to consult with employees or their representatives on a regular basis, so that the views of employees can be taken into account in making decisions which are likely to affect their interests. These forums include; the JNCC (Joint Negotiating Consultative Committee), JLNC (Joint Local Negotiating Committee), Terms & Conditions Committee and subgroups such as the PDR Working Group. The Trust also acts upon information received from the results of the Staff Survey and Staff Friends & Family Test. Other initiatives include the monthly Chief Executive briefing and the Team Brief. Where appropriate the principles of the managing Organisational Change Policy are also applied, especially in relation to changes which impact on working arrangements. Actions taken in the financial year to encourage the involvement of employees in the NHS foundation trust s performance. The trust has a culture of engagement and routes through which it involves and listens to its workforce. The senior team is actively involved in welcoming new employees. The CEO uses his monthly briefings to listen to and engage with the workforce. These briefings are held at both the Hillingdon and Mount Vernon sites. 49

152 Trust employees are involved and contribute to clinical decision making at all levels of the organisation through representation on various committees particularly clinical audit committees. These provide a forum for discussion, problem solving, action planning and review of trust performance. The trust has a culture of regular one to one meetings between managers and direct reports and their teams. The performance development review meetings provide an additional forum through which staff are involved in decisions about their work, service and performance of the trust. Staff are encouraged through our Bright ideas scheme to submit ideas and activities for improving the quality of the workplace and patient care. This is actively promoted through and via the trust bulletin. In addition, staff governors take a full part in the governors role and will bring matters forward from staff to governors meetings. We continue to use the findings from the annual staff survey report to engage our staff. With the involvement of staff and teams, action plans are developed from its findings and taken forward for the benefit of staff and patients. The trust has a culture of partnership working with its staff and staff side colleagues. This relationship is supported via three main forums through which staff are consulted in decisions about the organisation. Information on health and safety performance and occupational health The Trust has an Occupational Health Department which provides information and support to staff. In addition the Trust has an Employee Assistance Program in place, which is open to all Trust Employees details are published in the Trust Intranet page. Occupational Health and Managers will refer staff to the service as appropriate. The Trust also promotes Occupational Health services at internal health promotion events and the Trust s New Joiners Event. Health and safety Through its Health and Safety Strategy the Trust continues work towards best practice standards of health and safety for all our staff in the workplace, for members of the public, patients, and others who come in to our premises. In February 2015 the Trust was issued with an improvement notice for failing to implement the Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 in a timely manner. To meet the regulations fully the Trust substituted all traditional unprotected medical sharps with a safer sharp where it was practicable to do so by 29 th May

153 Health and safety governance: The Health and Safety Committee has met quarterly and the Board has received quarterly reports on health and safety issues and performance throughout the year. Training: All new members of staff receive health and safety training during their corporate induction. Fire safety training has been completely reviewed and as a result, attendance has increased. Performance: During this reporting period there were a total of 1,315 incidents reported indicating a downward trajectory in incident reporting. Information on policies and procedures with respect to countering fraud and corruption The Trust has a Counter Fraud Policy in place which highlights to staff what they should do in the event that they suspect fraud or corruption. The Trust also has in place a Raising Concerns at Work Policy (Whistleblowing), and an anonymous dialogue system called SpeakInConfidence, which can also be used for the purposes of raising concerns. Staff survey results The Trust received a positive staff survey with a majority of the survey s key findings reporting improvements in performance and placing the trust in the top 20% of acute trusts. Historically the trust has a well engaged workforce and the 2015 survey findings were no exception with the trust receiving high engagement and motivation scores compared with all NHS organisations and acute trusts. At a local level, most divisions and directorates reported engagement scores above the national average. We received high ranking scores in areas such as appraisals and staff motivation at work. The survey also indicates that our quality of patient care is improving with a reduction in the number of staff witnessing potentially harmful errors, near misses or incidents. Our staff also reported positive experiences of their work environment seeing us ranking highly in findings relating to health and wellbeing with less staff suffering work related stress. The trust continues to implement measures to improve the working lives of its staff. a. Consultancy The Trust expenditure on consultancy services was 160k. This was for a range of activities including recruitment searches, advice and benchmarking. b.off payroll engagements 51

154 See appendix B c.exit packages There were 3 non -compulsory packages at a total value of 10k d.reporting of high paid off-payroll arrangements. See appendix B 52

155 Appendix A Breakdown Workforce by Gender Total Female Male Medical and Dental % 47% Nursing and Midwifery Registered % 11% Allied Health Professionals % 21% Female % Male % Add Prof Scientific and Technic % % Additional Clinical Services % % Administrative and Clerical % % Allied Health Professionals % % Estates and Ancillary % % Healthcare Scientists % % Medical and Dental % % Nursing and Midwifery Registered % % Students % % Staff Group Summary Total 2,

156 54

157 Appendix B Table 4B: For all off-payroll engagements as of 31 Mar 2016, for more than 220 per day and that last for longer than six months 8A1 Maincode 2015/16 Expected Number of engagements Number Subcode Sign Checks No. of existing engagements as of 31 Mar Of which: Number that have existed for less than one year at the time of reporting Number that have existed for between one and two years at the time of reporting Number that have existed for between two and three years at the time of reporting Number that have existed for between three and four years at the time of reporting Number that have existed for four or more years at the time of reporting Confirmation: Please confirm that all existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought. Yes 160 Please select Pass 55

158 Table 4C: For all new off-payroll engagements, or those that reached six months in duration, between 01 Apr 2015 and 31 Mar 2016, for more than 220 per day and that last for longer than six months 8A2 Maincode 2015/16 Expected Number of engagements Number Subcode Sign Checks Number of new engagements, or those that reached six months in duration between 01 Apr 2015 and 31 Mar Number of the above which include contractual clauses giving the trust the right to request assurance in relation to income tax and national insurance obligations Pass Number for whom assurance has been requested Pass Of which: Number for whom assurance has been received Number for whom assurance has not been received * Number that have been terminated as a result of assurance not being received Pass 56

159 In any cases where, exceptionally: - the trust has engaged without including contractual clauses allowing the trust to seek assurance as to their tax obligations; or - where assurance has been requested and not received, without a contract termination In 3 cases the Trust has made engagements without including clauses allowing the Trust to seek assurance as to their tax obligations. These are staff that have been engaged at relatively short notice due to very pressing operational service needs and to deal with waiting list issues. Where relevant, The Trust is still in the process of putting contracts in place with the required clauses and of seeking the required assurances. please specify the reasons for this. Table 4D: For any off-payroll engagements of board members, and/or senior officials with significant financial responsibility, between 1 Apr 2015 and 31 Mar A3 Maincode 2015/16 Expected Number of engagements Number Subcode Sign Checks Number of off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year Pass Number of individuals that have been deemed "board members and/or senior officials with significant financial responsibility". This figure should include both offpayroll and on-payroll engagements Pass In any cases where individuals are included within the first row of this table, please set out: Details of the exceptional circumstances that led to each of these engagements. Details of the length of time each of these exceptional engagements lasted. Pass Pass Checks 57

160 4. COMPLIANCE WITH NHS FOUNDATION TRUST CODE OF GOVERNANCE The Hillingdon Hospitals NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014 is based on the principles of the UK Corporate Governance Code issued in Following review, the Board has identified that the Trust is currently non-compliant with the following provisions of the updated Code. Provision A.1.1: The Trust is compliant with this provision in that the Trust s scheme of delegation includes a schedule of matters reserved for the Board and for the Council of Governors. This document was last reviewed in February The Trust is however not fully compliant with this provision in that the procedure for how conflicts between the Board and Council of Governors is contained in a separate document that covers the engagement between the Board and Council of Governors. The Trust s arrangements are consistent with the principles of the Code in that a clear written conflict resolution process is in place and regularly reviewed. 5. REGULATORY RATINGS Monitor, the independent regulator, assigns Foundation Trusts two risk ratings each quarter. These risk ratings cover finance risk and governance risk. During quarter 2 of 2015/16, Monitor introduced the Financial Sustainability Risk Rating which replaced the Continuity of Services Risk Rating for assessing finance risk. The continuity of services risk rating identified the level of risk to the ongoing availability of key services. The continuity of services risk rating incorporated two measures of financial robustness: a) liquidity: days of operating costs held in cash or cash-equivalent forms, including wholly committed lines of credit available for drawdown; and b) capital servicing capacity: the degree to which the organisation s generated income covers its financing obligations. The Financial Sustainability Risk Rating incorporates liquidity and capital service capacity but also adds two further measures. These are: c) income and expenditure (I&E) margin: the degree to which the organisation is operating at a surplus/deficit d) variance from plan in relation to I&E margin: variance between a foundation trust s planned I&E margin in its annual forward plan and its actual I&E margin within the year. As before, the governance risk rating continues to be generated by Monitor considering a range of information about an FT. This information covers the following areas: Performance against national access and outcomes requirements Care Quality Commission judgements Third party information Quality governance indicators Continuity of services and aspects of financial governance. Monitor can also consider any other relevant information when calculating the governance risk rating. 58

161 Where there are no grounds for concern at a Trust, Monitor will assign a green rating. Where Monitor has identified a concern at a Trust but not yet taken action, it will provide a written description stating the issue at hand and the action it is considering. A red rating will be assigned when Monitor has begun enforcement action. The governance rating in 2015/16 remained under review as it had been since Q3 of 2014/15 following the CQC inspection of the Trust. Monitor advised that the risk rating would remain under review until the CQC had concluded a follow-up inspection of the warning notices that had been issued. A full quarter by quarter breakdown of the Trust s financial risk ratings in 2014/15 and 2015/16 is presented below. 2015/16 Annual Q1 Q2 Q3 Q4 2 Plan Continuity of Service rating 2 2 Financial Sustainability rating Governance rating Under review Under Review Under review Under review 2014/15 Annual Q1 Q2 Q3 Q4 Plan Continuity of service rating Governance rating Green Green Green Under review Under Review There have been no formal interventions by Monitor at the Trust. 2 The Q4 risk ratings are based on the Trust s submission to Monitor at the end of April 2016: the Trust does not have Monitor s confirmed Q4 ratings at the time of finalisation of the report (May 2016). 59

162 STATEMENT OF THE CHIEF EXECUTIVE'S RESPONSIBILITIES AS THE ACCOUNTING OFFICER OF THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor. Under the NHS Act 2006, Monitor has directed The Hillingdon Hospitals NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of The Hillingdon Hospitals NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: Observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; Make judgements and estimates on a reasonable basis; State whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; Ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance; and Prepare the financial statements on a going concern basis. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum. Signed.. Shane DeGaris Chief Executive Date.. 60

163 Annual Governance Statement 2015/16 1. Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. 2. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of The Hillingdon Hospitals NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in The Hillingdon Hospitals NHS Foundation Trust for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts. 3. Capacity to handle risk The Board is responsible for reviewing the effectiveness of the system of internal control including systems and resources for managing all types of risk. The Trust Board approved Risk Management Strategy and Policy (including Board Assurance Framework) ensures that the Trust approaches the control of risk in a strategic and organised manner. It sets out the responsibilities of Executive Directors and Senior Managers in relation to their leadership in risk management and makes it clear that all employees have a role to play in risk management appropriate to their level. The Board reviewed it s a committee structure to provide assurance and challenge to the Trust s risk management process in October 2015 and established an Audit and Risk Committee to provide improved focus on risk management and a Quality and Safety Committee to provide improved focus on clinical quality and patient safety. A new Board Committee was put in place to focus on capital investment and our estate. Each of these committees are chaired by a Non-Executive Director to enhance this challenge, and the chairs report formally to the Board to escalate issues that require further Board discussion. Following a fundamental review of how governance and clinical quality could be placed at the heart of our culture, the Trust moved to a new clinically led organisation with the 61

164 appointment of four Divisional Directors in April The Divisional Directors, (who are Medical Consultants) are accountable to the Chief Operating Officer and responsible for the safe and efficient management of the clinical divisions within the Trust. Each Divisional Team comprises of a Divisional Director, who line manages Assistant Directors of Operations and Assistant Directors of Nursing. The team work together to provide robust management and high quality and efficient care. Divisional Directors are professionally accountable to the Medical Director. The Director of Patient Experience and Nursing provides professional accountability and support to the Assistant Directors of Nursing. Risk management and awareness training is mandatory to all Trust employees and is included in the New Employees Week programme. The Trust s Health and Safety team deliver risk management training appropriate to all levels across the Trust including the Trust Board. The Nursing Education Skills Programme is reviewed three monthly, and updated to ensure the latest evidence-based/best practice is incorporated. 4. Risk control framework 4.1 Risk Management Strategy The Trust Board approved the Risk Management Strategy and Policy (including Board Assurance Framework) at its meeting on 29th April This strategy ensures that the Trust approaches the control of risk in a strategic and organised manner and sets out the responsibilities of Executive Directors and Senior Managers in relation to risk management and makes it clear that all employees have a role to play in risk management appropriate to their level. The Audit & Risk Committee (ARC) provides assurance that there is a sound system of internal control and governance, ensuring that risks to the delivery of the Trust s services are identified and addressed. Corporate risks are reported from ward to Board via Divisional Governance Boards and using the online risk register managed by the Trust s Governance department. The Board Assurance Framework (BAF) is a key proactive risk identification tool for the Trust. The Trust s strategic objectives are reviewed annually, and mapped into the BAF. The BAF provides the Board with assurance that significant threats to achieving Trust objectives have been identified and are being appropriately controlled. Actions within the BAF address how assurances will be provided; or, where assurances have identified inadequate controls, how controls will be improved. The BAF also cross references to the corporate risk register and to regulatory standards e.g. CQC, that the Trust needs to comply with. In 2015/16 The Trust commissioned an internal audit of the BAF to ensure that the BAF effectively identifies risk and provides effective risk management control. The outcome of the internal audit was received in April 2016 and provided reasonable assurance. The Trust has reviewed the recommendations and prepared a management action plan to further strengthen the BAF in 2016/17. The ARC reviews the BAF at their quarterly 62

165 meeting. The Trust Board reviews the BAF twice a year and there is an annual Board Seminar to refresh the BAF. Risk appetite, as well as risk tolerance, is addressed in the Risk Management Strategy & Policy. At the Board Seminar in March 2015, which reviewed the Risk Management Strategy & Policy, amendments were made to risk appetite and risk tolerance strengthened. These changes are summarised: Adoption of the NPSA risk evaluation matrix Target risk levels, including the date by which this should be attained and frequency of risk review agreed. 4.2 Quality Governance Arrangements The key quality governance and leadership structures that support the Trust in ensuring that the quality of care is being routinely monitored across all services and that poor performance or variation in quality is challenged are as follows: There is monthly reporting to the Board via the integrated quality and performance report with exception narrative. At each Quality and Safety Committee (QSC) meeting a clinical division, presents on clinical and quality governance issues, discusses areas of risk, reviews performance against key quality indicators and progress of work in relation to learning from clinical incidents and clinical audit. There is now a deep dive review at each QSC meeting on the key aims of a new Quality Improvement Strategy. Any external quality and safety intelligence is presented at the QSC on a bi-monthly basis, and a summary of performance against KPIs in the Annual Quality Report Look forward section are also reported with escalation to the Board where required. The Trust has a Clinical Governance Committee (CGC) which receives bi-monthly reports from each clinical division outlining areas of risk, progress against national audit requirements, reviews key patient safety indicators, clinical effectiveness and patient experience data. A detailed quarterly overview of complaints in terms of themes, lessons learned and actions taken; claims and litigation data; incidents numbers, severity and themes by clinical division and corporate level clinical risk and actions being taken to address is also received at CGC with performance exception reporting at QSC. Clinical divisions review their quality data in relation to patient safety, patient experience and clinical effectiveness on a monthly basis at their divisional governance boards; a divisional exception report is received by the CGC and any concerns on quality are escalated via this Committee to the QSC. 63

166 The Board has developed a structured process of reporting the investigation of Serious Incidents and the follow up of outcomes and action plans resulting from Serious Incidents (SIs). SIs have a named Executive lead and panel reports are presented to the Board with resulting actions reviewed bi-monthly until complete. Root cause analysis is used and forms the basis of the report together with the creation of action plans. There is a programme of regular inspections of clinical areas by the DPEN, Chief Executive and other Board members giving them the opportunity to talk to staff and patients about their experience. In addition, re-vamped Patient Safety walkarounds, involving Board members, are to be introduced during 2016/17. Clinical Fridays allow the corporate nursing team and divisional senior nurses, alongside the DPEN, to work with clinical staff on wards and in departments to experience the environment and delivery of care, engaging with staff and patients and their carers. Any issues or concerns are escalated accordingly to the Executive Team and Trust Board. There is a robust framework to ensure that all service changes have a Quality Impact Assessment (QIA) which is then reviewed by the Medical Director. Any schemes where there are quality concerns are reviewed at a multi-professional Clinical Assurance Panel (CAP), with the project leads presenting the scheme and the actions being taken to mitigate any associated risks to quality. Listening to Patients/Governors: it is important that there is a range of opportunities to support patients in providing feedback and raising their concerns. This is welcomed by the Trust as a learning organisation which is always striving for quality improvement. Patients can complete local patient experience surveys, including the Friends and Family Test, provide feedback via NHS Choices, in person directly to department managers and matrons or via the PALS/Complaints offices. There is opportunity for patients and members of the public to attend the Trust s People in Partnership (PiP) meetings, Council of Governors meetings and the Trust Board meeting. There are also specialty-based focus and support groups where patient feedback can be obtained. The Board receives patient stories as part of understanding the patient experience; this ensures that the voice of the patient and their families/carers is heard first hand by Board members; stories are captured directly from patients via 1:1 interviews, complaints and PALS feedback. The Learning from Mistakes league table recently published by Monitor and the Trust Development Authority has ranked the Trust as good for levels of openness and transparency based on assessment of key criteria from the Staff Survey Data 2015 and NRLS reporting. 4.3 Quality of Performance Information 64

167 The Trust s Data Quality Steering group reports into the Audit and Risk Committee on a quarterly basis to provide assurance on accuracy of information provided to the Board. In addition, the divisional data quality groups and elective performance meetings review data quality risks on a monthly basis and report to the steering group on progress and actions to address them. Through these groups risks are actively reviewed and addressed through the data quality framework that has been established. 4.4 Care Quality Commission (CQC) Compliance The Trust was inspected by the CQC in October 2014, and received its final rating in February The CQC rated the Trust overall as Requires Improvement (with inadequate for safe ; requires improvement for effective, responsive and well-led ; and a good rating for caring ). Two Warning Notices were received on Regulation 12: Cleanliness and Infection Control and Regulation 10: Assessing and Monitoring the Quality of Service Provision. A targeted re-inspection, in May 2015, resulted in the lifting of the two warning notices and an improved rating for patient safety. However, a requirement notice, against regulation 12; safe care and treatment, specifically focused on infection and prevention and control, was applied. During 2015/16 an intensive improvement programme, driven by Executive leads, strengthened governance and assurance arrangements. This included Executive-led CQC Sit-rep meetings, monthly updates to the Trust Management Executive and Trust Board and the Clinical Quality Group (CQG) arm of the Clinical Commissioning Group. The Trust aspires to be rated as good or above in future inspections. 4.5 Data Security The Trust has had no data cyber-security/information governance incidents categorised at level 2 in 2015/16, therefore is not subject to any investigations by the Information Commissioners Office. Low scoring minor incidents are reported and monitored at the Information Governance Steering Group which meets a minimum of four times a year and is chaired by the Trust s Senior Information Risk Owner. 4.6 The organisation s major risks Clinical risks 2015/16: Suboptimal staffing issues in relation to potential risk of inadequate nursing levels due to a combination of vacancies, due to national shortages and additional capacity being opened to meet surge in demand. This risk is mitigated in real-time by proactive review of staffing by senior nurses and midwives to ensure each area is staffed in line with actual need. Average shift-fills rates are also reviewed 65

168 retrospectively alongside patient-centred outcome indicators. There has, and continues to be, ongoing and frequent recruitment, with each divisional team working in partnership with the recruitment manager to progress plans specific to the needs of their specialities. Failure to meet hospital acquired infection targets: Clostridium difficile infection (CDI). In 2015/16 the Trust exceeded the trajectory of eight with a total of 12 cases. Mitigations included: Delivery of the Infection Prevention & Control annual action plan and continuing to embed the Start Smart, Then Focus antimicrobial prescribing guidance. Each Trust attributed CDI case, through the Root Cause Analysis (RCA) process, was assessed with actions generated by this process being implemented in a timely way. Only one case was deemed a Lapse in Care as agreed with our commissioners; the other eleven cases were deemed treated appropriately and there was no evidence of cross infection or inappropriate infection control practice. Infection control rates are reviewed by the Infection Control Committee, QSC and the Board. Through an inability to meet the clinical standards, deliver the requisite workforce, deliver behavioural change, sustain expected patient experience and an unsustainable demand on the system, Shaping a Healthier Future (SaHF) does not deliver the planned benefits to improve quality and safety of health and care across NW London. Clinical standards were approved in the Decision Making Business Case and all providers are now creating plans which support the delivery of these standards this will remain under review by the Clinical Board. CT scanner at Hillingdon Hospital: This risk was mitigated via the acquisition of a Spec CT Scanner which will allow a degree of cover for the main CT scanner when service or repair is required and also allow us some increase productivity. Vacancies within the senior management pathology structure: This risk was mitigated through the use of interim cover during the recruitment process. All vacant posts have now been filled substantively. Care of psychiatric patients in A&E: This risk was controlled to a reasonable level by implementation of more robust processes for monitoring and risk assessing patients with mental health issues presenting to A&E. Number and experience of paediatric staff in A&E: This risk was controlled to a reasonable level through the recruitment of additional specialist medical and nursing posts and via the implementation of a competency framework assessment process for newly recruited nursing staff as well as incorporating paediatric specialist training sessions provided by consultant paediatricians as part of the Junior Doctors training programme. The following clinical risks were also managed in 2015/16 and mitigating actions continue into 2016/17: The Trust Provision of 24/7 Interventional radiology service: High dependency care for children. Escalation of deteriorating patients. Medicine security and storage. 66

169 Each of the risks described above has a detailed mitigation plan, with actions and timescales in place to achieve a level of risk that the Trust considered manageable for that risk. Finance risks in 2015/16: Under delivery planned savings from the Quality Innovation Productivity and Prevention (QIPP) due to increased demand for services and unplanned costs relating to CQC compliance. This risk is mitigated by robust project planning supported by a rigorous monthly and quarterly performance management framework, monthly formal QIPP reviews and monthly Trust Board reporting. The under deliver of QIPP savings had a consequential effect on our liquidity. The Trust has a committed working capital facility with the Independent Trust Financing Facility (ITFF) and an agreed contract with Hillingdon Clinical Commissioning Group (CCG) that reduces the risk of cash flow problems. The risk of healthcare revenue falling and leaving the Trust with a deficit in-year was in part mitigated by an agreed contract based on a guaranteed minimum financial value, with an agreed marginal rate for over performance with additional support agreed in-year due to the on-going need to staff escalation beds. Due to the mitigations put in place by management during the year the Trust reduced to a deficit of 1.5m what otherwise would have been a far greater financial shortfall. The scale of investment required to improve the Trust s fragile estate infrastructure exceeds the Trust s financial capacity. Remedial work and repairs have been assessed at 67m. Failure to maintain the estate comes under Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: Safety and Suitability of Premises. The condition of key building systems is assessed by a 5 yearly survey, and is risk assessed and rated against available capital. However, the available funds are insufficient to systems. This funding shortfall has been raised with both Monitor and the Department of Health. The main future risks facing the Trust are summarised: Future clinical risks: The Trust may fail to achieve 95% A&E target leading to a breach of the Monitor Licence: The Trust is working with Hillingdon Clinical Commissioning Group, Hillingdon Borough Council, Hillingdon Community Health and the third sector to integrate care and ensure that admissions to hospital are avoided where possible; and, that time spent in the A&E department is reduced. Action will be taken, following a recent independent review of patient flows, to and through the A&E department and into the Acute Medical Unit, to improve patients waits in A&E. We fail to deliver high quality patient care as a result of inadequate staffing provision and in line with the 7-day workforce initiative: The Trust is reviewing its 67

170 clinical and support service workforce using acuity and dependency tools and other mechanisms; to improve frontline clinical staff numbers and care at the bedside seven days a week. The Trust will continue to drive forward a robust recruitment and retention work programme to reduce the number of vacancies and to support the increased activity that the Trust has seen during this past year. We fail to meet compliance with the expected standards set out by our regulators this could impact on the Trust achieving a good rating with the CQC. The Trust continues to strengthen its governance arrangements and its compliance with the Health and Social Care Act regulations through a programme of internal peer reviews and mock inspections to ensure there is evidence of improvement against a refreshed CQC action plan for 2016/17. There will be increased scrutiny of operational performance and quality data and a new accountability framework to ensure compliance with policy and delivery of statutory targets. Particular attention will be devoted to areas of outstanding compliance notices, most notable of which is infection control. Future financial risks: Commissioning risk that Hillingdon CCG s out of hospital strategy results in Trust deficit. This will be mitigated by continuing to agree contracts with Hillingdon CCG that promote robust collaborative working and financial risk sharing to redesign clinical pathways, yet at the same time provide sufficient revenue to cover the Trust s costs; including guaranteed minimum financial values that can be enhanced and or fixed cost transitional support. Commissioning risk if the cost of activity is not paid for in full. The form of healthcare contract the Trust will agree with its lead commissioner will guarantee a minimum payment with an agreed rate of over performance. However, as was the case in 2015/16 the minimum value can be enhanced by negotiation to cover justifiable excess costs of delivering service levels above the agreed contract. Monthly formal contract meetings with Hillingdon CCG as lead commissioner are in place so financial and service issues can be flagged and addressed quickly is necessary. Recruitment to fill vacancy levels is insufficient to enable the Trust to significantly reduce its agency costs. This is being addressed by a focused recruitment and retention programme including overseas initiatives and is subject to continual management review. The level savings required in 2016/17 has an adverse impact on the quality of care provided. To give the Trust the very best opportunity of delivering its savings, a Project Management Office (PMO) is in place to support managers and clinicians to achieve identified savings plans. Throughout the year weekly/fortnightly risk assessment allows early sign of potential areas of nondelivery to be identified and ensure mitigating actions are put in place to prevent 68

171 slippage or non-delivery. To manage the service risk as robustly as possible all savings schemes have a project initiation document that requires risk assessment. Any significant risks identified need a comprehensive Quality Impact Assessment (QIA) that is reviewed by the Clinical Assurance Panel (CAP) led by the Medical Director. The CAP reviews, approves or rejects any schemes, thereby assuring the organisation that change and transformation programmes do not pose a material risk to the delivery of safe, high quality care. The CAP also reviews quality KPIs related to projects to track any changes alongside key changes to service delivery. Increasing cost of compliance to meet statutory and regulatory service and infrastructure standards particularly in light of the recent CQC report and the need for major investment in staff and the estate. This risk is being addressed by management with a phased approach to both revenue and capital investment over the next two financial years. The Medical Director, Nurse Director and Chief Operating Officer have together reviewed the required investment and prioritised first expenditure to rectify and sustain warning notice and must-do compliance issues. The financial consequences of this process have been built into the Trust s 2016/17 annual financial planning. Cash required for day to day operations and for investment could fall short of what is required and start to impede on service delivery. To manage this risk in addition to the 4.1m cash balance at the start of the year and 6.0m of assessed working capital headroom available, management have the ability to access 6m of working capital facility. In addition, a routine monthly payment has been agreed with East and North Hertfordshire Hospitals NHS Trust for services received on the Mount Vernon site thereby increasing monthly cash flow. Future Estate Risk: The estate has suffered from under-investment over an extended period and many building services have failed or are beyond their economic and design life cycle. There is a risk that the Trust is unable to access sufficient funding to sustain safe services in the short to long term. Key facilities such as Theatres, Critical Care and many Wards are of a design and condition that does not lend itself to the delivery of modern high quality healthcare. A waste incinerator that provides the majority of heat to the Hillingdon acute site has a remaining operational life of only 2-3 years. Investment in energy efficiency has been very low and a major replacement energy centre will be needed. Most of the engineering plant is of 1960s vintage, and some has fallen into disuse while others are increasingly prone to failure. The optimum long-term solution is likely to entail re-providing core facilities in a modern form, but this may require capital beyond the capacity of the Trust. Public access to services and car parking. Local Council Planning approval has been granted to enable a modest increase in the number of car parking spaces 69

172 available which will relieve the current pressure with other initiatives being explored to reduce demand. Overall, the Trust will remain focused on the tension between quality, safety, financial efficiency, and risk to ensure that patient care remains uncompromised. The Trust will do this by having regular Board and Executive reviews of progress and delivery of agreed plans and check that all schemes are quality impact assessed. 4.7 Compliance and Validity of the NHS Foundation Trust condition 4 (FT Governance): Corporate Governance Statement The Trust has a system in place to ensure that compliance with the NHS Foundation Trust condition 4 (FT Governance) is reviewed at least every six months. In October 2015 and April 2016 the ARC received an assurance report that risks, identified by the Executive team, relating to the delivery of the Annual Monitor Corporate Governance Board Statements are being managed appropriately. All statements were confirmed. These assurances were then re-reviewed by the Executive Team prior to their presentation at the May 2016 ARC; ahead of Trust Board review to confirm or notconfirm the Corporate Governance Statement. There have been some Internal Audit reports reviewed by ARC giving limited assurance this year. In most cases actions have been taken to close down the gaps; however further diligence is required to drive them to timely completion. Outstanding issues reside with some internal audit actions and these are followed up by Internal Audit and reported accordingly to ARC. The Trust believes that effective systems and processes are in place to maintain and monitor the following: The effectiveness of governance structures. The responsibilities of Directors and sub-committees. Reporting lines and accountabilities between the board, its sub-committees and the executive team. The submission of timely and accurate information to assess risks to compliance with the Trust s licence. The degree and rigour of oversight the board has over the Trust s performance. 4.8 Equality, Diversity and Human Rights Control measures are in place to ensure that all the organisation s obligations under equality, diversity and human rights legislation are complied with. Equality impact analysis/assessments are carried out as standard procedure for all Trust policies and new developments/service changes. An equality and diversity toolkit is available for staff on the Trust s intranet to support them with completing an EIA. The Trust has an Equality and Diversity Steering Group and an annual report is presented to the Trust 70

173 Board. The Trust has published its statutory equality & diversity report providing assurance that the Trust is compliant with equality legislation. 4.9 Engagement with Stakeholders The Trust works with its key public stakeholders to manage its risks. This is done through the following mechanisms: Engagement with the local Health Overview and Scrutiny Committee Engagement with the Local Healthwatch The Council of Governors is consulted on key issues and risks as part of the annual plan Regular People in Partnership Forums enables the Trust to listen to the views and opinions of the communities we serve, share information about what the Trust is doing, and planned future developments, and provides an opportunity for members to meet and communicate with staff, Governors and fellow members Annual Members Meeting Engagement with user and support groups e.g. Fighting Infection Together, Maternity Services Liaison Committee, People Improving Cancer Services and the Patient-led Assessment of the Care Environment (PLACE). Inviting public members and local stakeholders to identify priorities for our Quality Report Incident Reporting There are structured processes in place for incident reporting, the investigation of Serious Incidents and following up outcomes from Board commissioned external reports. The Trust Board, through the Risk Management Strategy & Policy (including BAF) and the Incident Policy (including Serious Incident (SI)), promotes open and honest reporting of incidents, risks and hazards. The Trust has a positive culture of reporting incidents enhanced by accessible online reporting systems available across the Trust. The latest available National Reporting Learning System (NRLS) report (covering 1st April th September 2015) has shown the Trust to be in the middle 50th percentile for incident reporting. The Learning from Mistakes league table recently published by Monitor and the Trust Development Authority has ranked the Trust as good for levels of openness and transparency based on assessment of key criteria from the Staff Survey Data 2015 and NRLS reporting Registration with CQC The Trust is fully registered with the CQC. The Trust has been issued with its certificate for 2015/16: Reference number: RGP Pension Scheme 71

174 As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations Assessing our Impact on the Environment The Hillingdon Hospitals NHS Foundation Trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Adaptation reporting uses a risk assessment approach; coupled with regular detailed buildings condition survey, in conjunction with resilience planning, based on weather-based risks e.g. heat wave, extreme cold, drought, and flood. 5. Review of economy, efficiency and effectiveness of the use of resources The following key processes are in place to ensure that resources are used economically, efficiently and effectively: Scheme of Delegation and Reservation of Powers approved by the Board sets out the decisions, authorities and duties delegated to officers of the Trust. Standing Financial Instructions detail the financial responsibilities, policies and procedures adopted by the Trust. They are designed to ensure that an organisation s financial transactions are carried out in accordance with the law and Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. Robust competitive processes are used for procuring non-staff expenditure items. Above 25k, procurement involves competitive tendering. All procurement tendering activities are published within nominated publications and in line with Public Contracts Regulations Saving schemes are assessed for their impact on quality with local clinical ownership and accountability. Use of National and London benchmarking for non-clinical support functions. Use of Lord Carter review and Model Hospital Information for Clinical specialties and support services. The Trust Board has gained assurance from the ARC that financial and budgetary management is robust across the organisation. The ARC also receives quarterly reports regarding losses, special payments and compensations (with high value over 50K approved by the Board), write-off of bad debts and contingent liabilities. The value of losses and special payments has reduced this year and remain immaterial at less than 0.2% of the Trust's turnover. 72

175 The Trust has a Transformation Committee that meets quarterly to review the Trust s transformation programme and major strategic service change business cases. This includes the use of information technology to lever change. Value for money discussions take place at a management group chaired by the Chief Operating Officer where the discussion is based on service line reporting reviewing how much a service costs to run versus the income it generates and how it is performing both clinically and operationally. Further information with reference to the Trust s financial future regarding the Going Concern assessment, is included in the Performance Report of this Annual Report. There are a range of internal and external audits that provide further assurance on the quality of financial data, economy, efficiency and effectiveness, these include internal audit reports on creditors, financial reporting and budgetary control, healthcare contracting & payment by results, cash management, cost improvement programmes, and financial and activity data and clinical coding. These are all reported to ARC. 5.1 Compliance with the Code of Governance The Board has reviewed itself against the NHS Foundation Code of Governance. The Board has made the disclosures required by the Code in the governance section of the Directors Report, including explanations for non-compliance with provisions of the Code. Attendance records and coverage of work for each Board committee is also included in this section of the annual report. 6. Information Governance The Trust has an established Information Security Management System (ISMS) similar to that defined within the International Standard (ISO) This entails the identification and classification of information assets, risk assessing those assets and then establishing control frameworks to keep those assets secure. The Trust is committed to establishing ISMS through its compliance with the Information Governance (IG) Toolkit. The Information Governance Strategy sets out the arrangements for governing information risk, i.e. the framework of accountability and the roles and the responsibilities of staff, management and committees. Together these help the organisation meet its legislative and regulatory requirements, including the requirements from the Health and Social Care Information Centre (HSCIC) for organisations to manage the security of their information. Compliance evidence for Version 13 of the IG Toolkit has been uploaded to HSCIC and all requirements are at a level 2 or 3. Additionally, Internal Audit re-audited the IG toolkit in February 2016 and gave reasonable assurance. The ICT department has effective policies, procedures and process in place to ensure that the information processed by information assets and users are kept secure and confidential. This includes the implementation of technical controls such as industry 73

176 standard next-generation firewalls, Intruder Prevention System, Internet Security Systems and Content Filtering Systems. The technical security systems are configured to provide appropriate security protection as well as being monitored on a regular basis to ensure their effectiveness and include non-technical security controls for authorisation before granting users and systems access to data. ICT security staff work closely with the Information Governance team to ensure that ISMS is maintained and any new risks are addressed. The Trust has had no data cyber-security/information governance incidents categorised at level 2 in 2015/16, therefore is not subject to any investigations by the Information Commissioners Office. 7. Annual Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. The Trust s commitment to quality improvement and quality governance is clearly outlined in its current clinical quality strategy; this describes a system of quality performance management, and a clear risk management process. Having the right structures and processes in place allied to an appropriate culture with supporting values and behaviours is strongly emphasised. In 2016/17 the Trust will be launching a new Quality and Safety Improvement Strategy which will drive the governance and leadership on quality improvement over the next three years. The 2015/16 Quality Report provides evidence of progress and priorities for improvement and is aligned with our clinical quality strategy objectives and our overall Trust Strategy. As part of its consultation on priorities for improvement for the Annual Quality Report the Trust has liaised with clinical and managerial staff via divisional governance board meetings and divisional review meetings. Key stakeholders, such as our FT membership, our Governors, our local Healthwatch and local organisations from the third sector have been engaged via a stakeholder event to discuss current year s progress and priorities for the forthcoming year. The Information Team has also undertaken a triangulation exercise examining data sources that they regularly analyse for potential underlying issues of quality related to performance or data, not otherwise identified. All of the above has assisted the Trust be clear on its targets. Determining SMART objectives against our priorities is underway. The Trust uses its systems for quality performance management to assess its performance in relation to regional and national comparators for the key quality indicators and associated narrative in the Quality Report. Information on quality is supplied to the Board, its committees and the management team by the Information and 74

177 the Clinical Governance teams who collect and maintain an oversight of quality information. Alongside key quality indicators as part of the integrated quality and performance report, information is also included on clinical audit, clinical incidents, SIs and the learning from them, complaints and claims. This flow of information ensures that key risks to quality are identified. The findings of the CQC inspection conducted in October 2014 raised concern over existing processes and systems that maintain patient safety and ensure the delivery of quality care this included the robustness and critical scrutiny of the corporate risk register by senior management and the tolerance of poor performance against local and national standards and targets. The Trust has a robust improvement plan since this inspection, outlined previously in this report, as recognised by the CQC on its reinspection of the Trust in May The Trust can now demonstrate a more effective and robust implementation of policy and procedure to ensure risks to patient safety are reduced alongside achieving positive outcomes for patients. The Trust has a comprehensive clinical audit work plan covering both national and local audits. Regular updates on clinical audit are reported to the CGC on a quarterly basis with exception reporting to the QSC. Progress against national and local audits and actions being taken are detailed in the Quality Report to ensure transparency on our performance against these. A quarterly meeting with our local Healthwatch has supported discussion on the progress of our quality priorities and key quality indicators alongside hearing feedback form service users who access our services and who interact with Healthwatch. This assists in informing our quality improvement work. A framework exists for the management and accountability of quality of performance data and data quality. This is supported by a comprehensive audit programme and the Data Quality Policy, which consist of a set of quality data groups that run across the organisation. These groups report to an Executive Director-led steering group which feeds quarterly into the ARC. These quarterly data quality and performance quality reports cover the Monitor compliance data, reported to the Board, and other key data sets used at key committees. This, together with the data audit results, and the use of Data Quality Badges which are described in each monthly performance report, provides assurance to the Board on data quality and data performance issues and strength of internal control. The integrated performance report in 2016/17 gives indications over quality metrics, early warning and trends to enable swift intervention to keep performance on track. The quality of elective waiting time data in particular will continue to be reviewed monthly at the elective performance meeting and divisional data quality groups, ensuring all elective lists are managed and assessed on electronic systems. Areas that have been identified this year where further actions are being implemented: 1) NHS Number coverage on clinical systems the programme to integrate information systems is continuing to address this with seven remaining systems identified for 2015/16. 75

178 2) Trust Board Indicator assurance regular review and local auditing. 3) A definitive list of all key datasets and associated data quality assurance has been devised. This will direct the focus for the audit programme which will incorporate non patient datasets and those used for the quality accounts over 16/ Review of 2015/16 effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the NHS foundation trust that have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the board, the Audit and Risk Committee, the Quality and Safety Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. The process that is used to maintain and review the effectiveness of the system of internal control centres on: Development, review and challenge of the BAF which is compiled by Corporate Governance in conjunction with the relevant Executive Directors and their senior managers; the BAF is then scrutinised quarterly at the ARC prior to being reviewed by the Board twice yearly. The BAF is reviewed and challenged as described in section 4 above. There is then an annual examination and refreshing of the principal risks. Internal audit have reviewed the BAF and risk management arrangements in 2015/16 and given reasonable assurance that the Trust has in place adequate and appropriate arrangements for gaining assurances about the effectiveness of the organisation's system of internal control. The work of Internal Audit to review the Trust s key processes of financial and non-financial internal control. The work-programme is risk based, and findings reported to the ARC. The Head of Internal Audit Opinion has given reasonable assurance that there is a generally sound system of internal control designed to meet the organisation s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls put the achievement of particular objectives at risk. A framework exists for the management and accountability of quality of performance data and data quality as detailed in section 7 above. This, together 76

179 with the data audit results and input to the ARC, provides assurance to the Board on data quality and data performance issues and strength of internal control. The cost improvement plan is always a challenge, however the CAP and appropriate KPI s provides me with assurance that clinical quality should not be compromised. The 4 hour A&E target was under pressure throughout the financial year despite joined up work across the Health and Social Care system. The Trust exceeded the zero tolerance threshold for MRSA with one positive case reported. On further investigation however this case was found to be a blood culture specimen contaminate rather than a true MRSA bacteraemia. The Trust exceeded the C. difficile trajectory of eight with a total of 12 cases. Mitigations included: Delivery of the Infection Prevention & Control annual action plan and continuing to embed the Start Smart, Then Focus antimicrobial prescribing guidance. Each Trust attributed CDI case, through the Root Cause Analysis (RCA) process, was assessed with actions generated by this process being implemented in a timely way. Only one of these cases was deemed a Lapse in Care as agreed with our commissioners; the other eleven cases were treated appropriately and there was no evidence of cross infection or inappropriate infection control practice. Infection control rates are reviewed by the Infection Control Committee, QSC and the Board. The Trust managed to attain a Financial Sustainability Risk Rating score of at least 2 throughout the year. On balance, I therefore conclude that the Board has conducted a review of the effectiveness of the Trust s system on internal control and found them to be effective. I am satisfied that the measures that have been put in place following the CQC inspection findings addresses the issues raised with respect to regulatory compliance. Given the National and London position with regard to the A&E 4 hour target, if the current levels of high demand continue into 2016/17 this will remain a significant challenge for our Trust alongside the threshold for C. difficile, which has been set at 8 cases for 2016/17. 77

180 9. Conclusion My review confirms that The Hillingdon Hospitals NHS Foundation Trust has a generally sound system of internal control that supports the achievement of its policies, aims and objectives. No significant internal control issues have been identified, however a requirement notice against regulation 12; safe care and treatment, specifically focused on infection and prevention has been applied to our Trust. The Trust Board continues to proactively drive forward agreed actions to attain compliance with CQC regulations. I can also confirm that, having taken all appropriate steps to be aware of any relevant audit information that should be communicated, and to the best of my knowledge, there is no relevant audit information of which our external auditor, Deloitte LLP has not been made aware. I consider that any significant issues are included in the report, namely: condition of the Trust estate; The CQC requirement notice, against regulation 12; safe care and treatment, specifically focused on infection and prevention and increased demand affecting emergency department performance. Signed.. Shane DeGaris Chief Executive Date: 78

181 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts STATEMENT OF COMPREHENSIVE INCOME NOTE 31 March March 2015 FOR THE YEAR ENDED 31 MARCH Operating Income from patient care operations 3 209, ,347 Other operating income 3 29,465 27,482 Total operating income from continuing operations 3 238, ,829 Operating expenses of continuing activities (234,592) (225,839) OPERATING SURPLUS/DEFICIT 4,115 (4,010) FINANCE COSTS Finance income Finance expense - financial liabilities 9 (2,084) (2,014) Finance expense - unwinding of discount on provisions 25 (75) (73) PDC Dividend expense (3,957) (3,897) NET FINANCE COSTS (6,097) (5,967) OTHER NON OPERATING INCOME Increase in fair value of investment property ,874 DEFICIT FOR THE YEAR (1,488) (6,103) Other comprehensive income Impairments charged to Reserves 12 - (567) Revaluations credited to reserves 12-12,744 TOTAL COMPREHENSIVE (EXPENSE)/INCOME FOR THE YEAR (1,488) 6,074 The notes on pages 5 to 42 form part of these accounts. Page 1

182 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts STATEMENT OF FINANCIAL POSITION NOTE 31 March March 2015 AS AT 31 MARCH Non-current assets Intangible Assets 11 2,832 2,980 Property, plant and equipment , ,708 Investment property 14 19,641 19,137 Trade and other receivables Total non-current assets 161, ,792 Current assets Inventories 17 3,171 2,778 Trade and other receivables 18 18,752 16,790 Cash and cash equivalents 19 4,092 5,483 Total current assets 26,015 25,051 Total assets 187, ,843 Current liabilities Trade and other payables 20 (29,043) (22,427) Borrowings 21 (3,250) (3,239) Provisions 25 (125) (957) Total Current Liabilities (32,418) (26,623) Net current (liabilities) (6,403) (1,572) Total assets less current liabilities 154, ,220 Non-current liabilities Borrowings 21 (29,792) (31,804) Provisions 25 (2,320) (2,314) Total assets employed 122, ,102 Financed by taxpayers' equity: Public dividend capital 71,479 71,456 Revaluation reserve ,165 33,799 Income and expenditure reserve 17,993 18,847 Total taxpayers' equity 122, ,102 The financial statements on pages 1 to 42 were approved by the Board and authorised for issue on and signed on its behalf by: Signed:.. (Chief Executive) Date:..... Page 2

183 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts STATEMENT OF CHANGES IN TAXPAYERS' EQUITY AS AT 31 MARCH 2016 Total Public Dividend Capital Revaluation Reserve Income and Expenditure Reserve Taxpayers' Equity at 1 April ,102 71,456 33,799 18,847 Deficit for the year (1,488) (1,488) Transfers between reserves* - (634) 634 Public dividend capital received Impairments - Revaluations - Taxpayers' Equity at 31 March ,637 71,479 33,165 17,993 Taxpayers' Equity at 1 April ,028 71,456 22,362 24,210 Deficit for the year (6,103) (6,103) Transfers between reserves* - (740) 740 Impairments (567) (567) Revaluations 12,744 12,744 Taxpayers' Equity at 31 March ,102 71,456 33,799 18,847 * Transfers between reserves is a depreciation adjustment required due to revaluations of land and buildings. Page 3

184 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts STATEMENT OF CASH FLOWS For the Year Ended For the Year Ended FOR THE YEAR ENDED 31 MARCH 2016 NOTE 31 March March Cash flows from operating activities Operating (Deficit)/Surplus 4,115 (4,010) Non-cash income and expense: Depreciation and amortisation 9,371 8,648 Impairments - 6,933 (Gain) on disposal 5 - Receipt of Donated Assets (187) (44) (Increase)/Decrease in Trade and Other Receivables (1,719) 459 (Increase)/Decrease in Inventories (393) 165 Increase/(Decrease) in Trade and Other Payables 7,044 (1,127) (Decrease)/Increase in Provisions (901) 758 Net cash generated from operations 17,335 11,782 Cash flows from investing activities Interest received Purchase of intangible assets (506) (999) Purchase of Property, Plant and Equipment Exchequer Financed (8,618) (13,573) Net cash used in investing activities (9,105) (14,555) Cash flows from financing activities Loans received from the Department of Health - 10,000 Loans repaid to the Department of Health (1,390) (390) Capital element of finance lease rental payments (1,652) (1,368) Capital element of LIFT (328) (181) Interest paid (407) (329) Interest Element on Finance Lease (276) (286) Interest Element on LIFT (1,401) (1,399) Public dividend capital received 23 - PDC dividend paid (4,190) (3,523) Net Cash (Utilised)/Generated from financing activities (9,621) 2,524 (Decrease)/Increase in cash and cash equivalents (1,391) (250) Cash and Cash equivalents at start of year 5,483 5,733 Cash and Cash equivalents at end of year 19 4,092 5,483 Page 4

185 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies 1.1 Basis of Preparation Monitor, the Independent Regulator of NHS Foundation Trusts has directed that the financial statements of NHS Foundation Trusts shall meet the accounting requirements of the NHS Foundation Trusts Annual Reporting Manual (FT ARM), as agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the FT ARM. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and the HM Treasury's Financial Reporting Manual (FReM) to the extent that they are meaningful and appropriate to NHS Foundation Trusts. The particular policies adopted by the Trust are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.2 Accounting judgments and key sources of estimation and uncertainty In the application of the Trust s accounting policies management is required to make judgments, estimates, and assumptions about the carrying amount of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors considered of relevance. Actual results may differ from those estimates and underlying assumptions are continually reviewed. Revisions to estimates are recognised in the period in which the estimate is revised, if the revision affects only that period, or in the period of revision and future periods if the revision affects both current and future periods. The following are the areas where critical judgements have been made in the process of applying accounting policies at the end of the reporting period that have a risk of causing a material adjustment to the carrying amount of assets and liabilities within the next financial year:- Going Concern Asset valuation and lives Impairments of receivables Provisions Accruals The critical judgements are addressed in the accounting policies that follow. 1.3 Going Concern After making enquiries, the directors have a reasonable expectation that the Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. There is a degree of uncertainty regarding outcomes which may affect incoming resources to the Trust. Readers of these accounts are advised to refer to the Annual Governance Statement of the Trust for more detail. The Trust has produced these accounts on a going concern basis. 1.4 Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. 1.5 Current / non-current classification Assets and liabilities are classified as current if they are expected to be realised within twelve months from the Statement of Financial Position date, the primary purpose of the asset and liability is to be traded, or of loans and receivables where they have a maturity of less than twelve months from the Statement of Financial Position date. All other assets and liabilities are classified as non-current. Page 5

186 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (continued) 1.6 Consolidation The Trusts charitable funds would ordinarily under IAS 27 be considered as a subsidiary entity in that the Hillingdon Hospitals NHS Foundation Trust are corporate trustees and as such exert control over the uses of these funds. The Trust has decided not to consolidate the charitable funds due to the immaterial nature of the balances and instead the summary details are shown by way of a separate note. 1.7 Income Recognition Income in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable. The main source of revenue for the Trust is from NHS commissioners for healthcare services. Where income is received for a specific activity that is to be delivered in the following year, that income is deferred. Income from the sales of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract. 1.8 Partially Completed Spells The Partial Spells accrual relates to patients who remain undischarged at 31/03/2016. The Trust reflects income at the point of discharge in line with the matching concept. The Trust have accrued income on a per patient basis to 31/03/2016 based on average tariff rates for the speciality. Ordinarily this activity is coded once the patient has been discharged and generated a Health Resource Grouper code to which National Tariff rates are applied to calculate the income. Hence an average tariff is applied based on point of delivery and length of stay by speciality. 1.9 Expenditure on employee benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees Pensions and other retirement benefits Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable can be found on the NHS Pensions website at The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify its share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer Other expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. Expenditure is recognised in operating expenses except where it results in the creation of a non current asset such as property, plant and equipment. Page 6

187 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.12 Property, plant and equipment Recognition Property, plant and equipment is capitalised if: it is held for use in delivering services or for administrative purposes; it is probable that future economic benefits will flow to, or service potential will be supplied to, the Trust; the cost of the item can be measured reliably; and the item has cost of at least 5,000; or collectively, a number of items have a cost of at least 5,000 and individually have a cost of more than 250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Componentisation Where a large asset, for example a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives. Valuation All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at fair value. Land and buildings used for the Trust s services or for administrative purposes are stated in the Statement of Financial Position at their revalued amounts, being the fair value at the date of revaluation less any subsequent accumulated depreciation and impairment losses. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows: Land and non-specialised buildings market value for existing use Investment Properties - market value and or net rental income stream Specialised buildings depreciated replacement cost HM Treasury has adopted a standard approach to depreciated replacement cost valuations based on modern equivalent assets and, where it would meet the location requirements of the service being provided, an alternative site can be valued. Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets depreciation commences when they are brought into use. The last full revaluation exercise took place in the 2014/15 financial year. In line with Treasury guidance, where appropriate the revaluation was based on a Modern Equivalent Assets replacement basis. The valuation was carried out in accordance with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual insofar as these terms are consistent with the agreed requirements of the Department of Health and HM Treasury. The Surveyors were Gerald Eve.LLP. The Trust carries out a full revaluation exercise at least every five years unless the Trust considers there has been significant market movement In the intervening years. Page 7

188 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.12 Property, plant and equipment (continued) New fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from fair value. Subsequent expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. Depreciation, amortisation and impairment Freehold land, properties under construction, and assets held for sale are not depreciated. Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the Trust expects to obtain economic benefits or service potential from the asset. This is specific to the Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over the lease period. In accordance with the Foundation Trust Annual Reporting Manual (FT ARM), impairments that are due to a loss of economic benefits or service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment. Other impairments are treated as revaluation losses. Reversals of other impairments are treated as revaluation gains. An impairment arising from a loss of economic benefit or service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised. Page 8

189 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.12 Property, plant and equipment (continued) Revaluation Gains, Losses and De-Recognition Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised in operating income. Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of other comprehensive income. De-Recognition Assets intended for disposal are reclassified as Held for Sale once all of the following criteria are met: 1) the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; 2) the sale must be highly probable i.e. management are committed to a plan to sell the asset; or an active programme has begun to find a buyer and complete the sale; 3) the asset is being actively marketed at a reasonable price; 4) the sale is expected to be completed within 12 months of the date of classification as Held for Sale ; and the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it. Following reclassification, the assets are measured at the lower of their existing carrying amount and their fair value less costs to sell. Depreciation ceases to be charged. Assets are de-recognised when all material sale contract conditions have been met. Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as Held for Sale and instead is retained as an operational asset and the asset s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs Investment Property Investment property is property held to earn rentals or for capital appreciation or both. A key factor in determining classification would be whether property was saleable separately. In considering whether land meets this criteria the Trust would consider whether property had direct public access. Investment property is accounted for underinternational Accounting Standard 40. A gain or loss arising from a change in the fair value of investment property is recognised in profit or loss for the period in which it arises Donated assets Donated property, plant and equipment assets are capitalised at their fair value on receipt. The donation is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the donation are to be consumed in a manner specified by the donor, in which case, the donation is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met. The donated assets are subsequently accounted for in the same manner as other items of property, plant and equipment Assets no longer in use The Trust regularly reviews assets not in use for the purpose of revaluing them. The relevant accounting standard that affecting this is IFRS 13. The Trust is required to re value any asset found not to be in use to market value or if no market exists, scrap value. Due to the large number of assets involved the Trust has agreed with its auditor to review assets above a net book value of 10k. page 9

190 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.16 Intangible Assets Recognition Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the Trust's business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust and where the cost of the asset can be measured reliably: The project is technically feasible to the point of completion and will result in an intangible asset for sale or use; The Foundation Trust (FT) intends to complete the asset and sell or use it; The FT has the ability to sell or use the asset; How the asset will generate probable future economic benefits e.g. the presence of a market for its output or where it is to be used for internal use, the usefulness of the asset; Adequate financial, technical, and other resources are available to the FT to complete the development and sell or use the asset during development. Internally generated intangible assets Internally generated goodwill, brands, mastheads, publishing titles, customer lists, and similar items are not capitalised as intangible assets, neither is expenditure on research. Impairments Assets that are subject to amortisation are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount may not be recoverable. Any impairment loss is recognised in the Statement of Comprehensive Income to reduce the carrying amount to the recoverable amount. Software Software which is integral to the operation of hardware e.g. an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to the operation of hardware e.g. application software is capitalised as an intangible asset. Measurement Intangible assets are recognised initially at cost, comprising of all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management. Subsequently intangible assets are measured at fair value. Revaluation gains and losses and impairments are treated in the same manner as for property, plant and equipment. Intangible assets held for sale are measured at the lower of their carrying amount or fair value less costs to sell. Amortisation Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits Development expenditure up to 5 years Software up to 5 years Page 10

191 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.17 Leases The Trust as lessee Finance leases Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease. The implicit interest rate is that which produces a constant periodic rate of interest on the outstanding liability. The asset and liability are recognised at the commencement of the lease. Thereafter, the asset is accounted for as an item of property plant and equipment. The annual rental is split between the repayment of the liability and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance cost is charged to finance costs in the Statement of Comprehensive Income. The lease liability, is de-recognised when the liability is discharged, cancelled or expires. Operating leases Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease. Leases of land and buildings Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. The Trust as Lessor Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term. Page 11

192 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.18 Local Improvement Finance Trust (LIFT) transactions HM Treasury has determined that government bodies shall account for infrastructure LIFT schemes where the government body controls the use of the infrastructure and the residual interest in the infrastructure at the end of the arrangement as service concession arrangements, following the principles of the requirements of IFRIC 12. The Trust therefore recognises the LIFT asset as an item of property, plant and equipment together with a liability to pay for it. The services received under the contract are recorded as operating expenses. The annual lease plus payment is separated into the following component parts, using appropriate estimation techniques where necessary: a) Payment for the fair value of services received; b) Payment for the LIFT asset, including finance costs; The Trust is currently party to a 25-year LIFT lease plus contract. Services received The fair value of services received in the year is recorded under the relevant expenditure headings within operating expenses. LIFT Asset LIFT assets are recognised as property, plant and equipment, when they come into use. The assets are measured initially at fair value in accordance with the principles of IAS 17. Subsequently, the assets are measured at fair value, which is kept up to date in accordance with the Trust s approach for each relevant class of asset in accordance with the principles of IAS 16. LIFT liability A LIFT liability is recognised at the same time as the LIFT assets are recognised. It is measured initially at the same amount as the fair value of the LIFT assets and is subsequently measured as a finance lease liability in accordance with IAS 17. An annual finance cost is calculated by applying the implicit interest rate in the lease to the opening lease liability for the period, and is charged to Finance Costs within the Statement of Comprehensive Income. The element of the lease plus payment that is allocated as a finance lease rental is applied to meet the annual finance cost and to repay the lease liability over the contract term. An element of the lease plus payment increase due to cumulative indexation is allocated to the finance lease. In accordance with IAS 17, this amount is not included in the minimum lease payments, but is instead treated as contingent rent and is expensed as incurred. In substance, this amount is a finance cost in respect of the liability and the expense is presented as a contingent finance cost in the Statement of Comprehensive Income Inventories Inventories are stated at the lower of cost or net realisable value. Cost is calculated on a FIFO basis (First In First Out) Cash and cash equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Trust s cash management. Page 12

193 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.21 Provisions The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Injury Benefits and Early Retirement: Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury s discount rates. From 2012/13 The Treasury publishes three discount rates that are to be employed. These are short term less than 5 years. Medium term 5 to 10 years and long term over 10 years. Where cash flows are expected to fall into more than one on these time frames, then multiple discount rates will need to be used when calculating the carrying value of the provision. The Trust will continue using its long term rate of 3% as there is no material effect in changing the rate used. The period over which future cash flows will be paid is estimated using the England life expense tables as published by the Office of National Statistics Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the Trust pays an annual contribution to the NHSLA which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHSLA is administratively responsible for all clinical negligence cases the legal liability remains with the Trust Non-clinical risk pooling The Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Trust pays an annual contribution to the NHS Litigation Authority and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excess payable in respect of particular claims are charged to operating expenses as and when they become due Contingencies A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Trust, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is not recognised but is disclosed unless the possibility of a payment is remote. A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Trust. A contingent asset is not recognised but is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingencies are disclosed at their present value. Page 13

194 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.25 Public Dividend Capital (PDC) and PDC dividend Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32. A charge, reflecting the cost of capital utilised by the NHS Foundation Trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS Foundation Trust during the financial year. Average relevant net assets is defined as the average of the opening and closing reserves less the average of the opening and closing net book value of donated assets, less the average cleared/available balance of the Government Banking Service balances over the year. The dividend thus calculated is not revised should any adjustment to net assets occur as a result of the audit of the annual accounts Value Added Tax Most of the activities of the Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT. The Trust makes both taxable and exempt supplies and incurs input tax that relates to both kinds of supply. The Trust is therefore classified as 'partly exempt'. Partly exempt businesses must undertake calculations which work out how much input tax they may recover. The percentage relating to partially exempt supplies is currently 1.25% which reduces the Trust's VAT recovery. This percentage is reviewed annually Corporation Tax The Trust is a Health Service body within the meaning of s519a ICTA 1988 and accordingly in relation to specified activities of a Foundation Trust (s519a (3) to (8) ICTA 1988). None of the Trust's activities in the period are subject to a corporation tax liability Third party assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the Trust has no beneficial interest in them Losses and Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis. Page 14

195 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.30 Financial instruments and financial liabilities Recognition Financial assets and financial liabilities which arise from contracts to the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the Foundation Trust's normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or delivery of the goods or services is made. Financial assets or financial liabilities in respect of assets required or disposed of through finance leases are recognised and measured in accordance with the accounting policy for leases described below. De-Recognition All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the Trust has transferred substantially all of the risks and rewards of ownership. Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires. Classification and Measurement Financial assets are categorised as loans and receivables or available for sale as financial assets. Financial liabilities are classified as other financial liabilities Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets if receivable in the current reporting period, or in non current assets if outside the current reporting period. The Trust's loans and receivables comprise cash and cash equivalents, NHS debtors, accrued income and other debtors. Loans and receivables are recognised initially at fair value, net of transaction costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset. Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income Other financial liabilities All other financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability. They are included in current liabilities except for amounts payable more than 12 months after the reporting period, which reclassified as long-term liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to finance costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets. Page 15

196 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.33 Impairment of financial assets At the end of the reporting period, the Trust assesses whether any financial assets, other than those held at fair value through profit and loss are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset s carrying amount and the present value of the revised future cash flows discounted at the asset s original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and the carrying amount of the asset is reduced directly or through the use of a bad debt provision Foreign currencies The Trust's functional currency and presentational currency is sterling. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. Resulting exchange gains and losses are recognised in the Trust s surplus/deficit in the period in which they arise Government Grants Government grants are grants from Government bodies other than income from Clinical Commissioning Groups or NHS trusts for the provision of services. Where a grant is used to fund revenue or capital expenditure it is taken to the Statement of Comprehensive Income to match that expenditure. The exception to this is where specific grant conditions apply regarding the recognition of income. Page 16

197 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.36 Financial risk management International Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the NHS Foundation Trust has with Clinical Commissioning Groups and the way those Clinical Commissioning Groups are financed, the NHS Foundation Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The NHS Foundation Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the NHS Foundation Trust in undertaking its activities. The Trust s treasury management operations are carried out by the finance department, within parameters defined formally within the Trust s standing financial instructions and policies agreed by the board of directors. Trust treasury activity is subject to review by the Trust s internal auditor. Currency risk The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Trust has no overseas operations. The Trust therefore has low exposure to currency rate fluctuations. Interest rate risk To date, the Trust has only borrowed from UK Government for capital expenditure. The borrowings were for 1-25 years, in line with the life of the associated assets, and interest charged at the National Loans Fund rate, fixed for the life of the loan. The Trust therefore has low exposure to interest rate fluctuations. Credit risk Because the majority of the Trust s income comes from contracts with other public sector bodies, the Trust has low exposure to credit risk. The maximum exposures as at 31 March 2015 are in receivables from customers, as disclosed in the trade and other receivables note 18. Liquidity risk The majority of the Trust s operating costs are incurred under contracts with Clinical Commissioning Groups, which are financed from resources voted annually by Parliament The Trust is not, therefore, exposed to significant liquidity risks Events after the reporting period There are no post balance sheet events to report. Page 17

198 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 1 Accounting Policies (Continued) 1.38 Research and Development Research and development expenditure is charged against income in the year in which it is incurred, except insofar as development expenditure relates to a clearly defined project and the benefits of it can reasonably be regarded as assured. Expenditure so deferred is limited to the value of future benefits expected and is amortised through the Operating Cost Statement on a systematic basis over the period expected to benefit from the project. It should be revalued on the basis of current cost. The amortisation is calculated on the same basis as depreciation, on a quarterly basis Accounting standards and amendments issued but not yet adopted in the ARM The following new and revised standards and interpretations were in issue but not yet adopted in the ARM. None of these new and revised standards and interpretations have been adopted early by the Trust. The Trust do not expect that the adoption of the standards listed in the table below will have a material impact on the financial statements of the Trust in future periods. Change published Published by IASB Financial year for which the change first applies IFRS 11 (amendment) - acquisition of an interest in a joint operatiom Fair Value Measurement May-14 Not yet EU adopted. Expected to be effective from 2016/17 IFRS 16 (amendment) and IAS 38 (amendment) - depreciation and amortisation May-14 Not yet EU adopted. Expected to be effective from 2016/17 IFRS 16 (amendment) and IAS 41 (amendment) - bearer plants IAS 27 (amendment) - equity method in separate financial statements IFRS 10 (amendment) and IAS 28 (amendment) - sale or conribution of assets Jun-14 May-13 Aug-14 Not yet EU adopted. Expected to be effective from 2016/17 Not yet EU adopted. Expected to be effective from 2016/17 Not yet EU adopted. Expected to be effective from 2016/17 IFRS 10 (amendment) and IAS 28 (amendment) - investment entities applying the consolidation exception Sep-14 Not yet EU adopted. Expected to be effective from 2016/17 IAS 1 (amendment) - disclosure initiative Dec-14 Not yet EU adopted. Expected to be effective from 2016/17 IFRS 15 Revenue from contracts with customers May-14 Not yet EU adopted. Expected to be effective from 2016/17 Annual improvements to IFRS: cycle Sep-14 Not yet EU adopted. Expected to be effective from 2016/17 IFRS 9 Financial Instruments Jul-14 Not yet EU adopted. Expected to be effective from 2016/17 Page 18

199 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 2 Segmental Analysis Operating segments Surgical Division Medical Division Women & Children's Division Cancer & Clinical Support Services Corporate Division Unallocated Income 31 March March March March March March 2016 ( '000) ( '000) ( '000) ( '000) ( '000) ( '000) NHS Clinical Income 59,028 82,192 40,163 24, ,591 Non NHS Clinical Income 1, ,621 3,683 Other Income 2,563 2,212 1,471 2,075 12,473 20,794 Unallocated Income 8,639 8,639 Total Operating Revenue 62,959 84,837 41,895 27,904 12,473 8, ,707 Pay (35,715) (43,539) (20,797) (29,137) (26,825) (156,013) Non Pay (13,308) (16,814) (2,963) (12,570) (22,583) (68,238) Internal Recharges (2,415) (2,529) (922) 5,850 (27) (43) Unallocated Expenses (921) (921) Total Operating Expenditure before Depreciation, Impairments and Interest (51,438) (62,882) (24,682) (35,857) (49,435) 7,718 (225,215) Total Earnings before Interest, Taxation, Depreciation and Amortisation 11,521 21,955 17,213 (7,953) (36,962) 16,357 13,492 Allocated Depreciation & Amortisation (451) (299) (43) (508) (633) (1,934) Unallocated Depreciation & Amortisation (7,438) (7,438) Unallocated Impairments (5) (5) Operating Surplus/(Deficit) 11,070 21,656 17,170 (8,461) (37,595) 8,914 4,115 Surgical Division Medical Division Women & Children's Division Cancer & Clinical Support Services Corporate Division Unallocated Income 31 March March March March March March 2015 ( '000) ( '000) ( '000) ( '000) ( '000) ( '000) NHS Clinical Income 61,208 76,274 34,187 18, ,307 Non NHS Clinical Income 1, , ,040 Other Income 2,405 2,249 1,277 2,264 11,703 19,898 Unallocated Income 7,584-19,898 Total Operating Revenue 64,729 79,230 35,769 22,809 11,708 7, ,347 Pay (33,023) (39,945) (19,058) (26,653) (25,072) (143,751) Non Pay (13,809) (13,736) (2,685) (12,108) (20,644) (62,982) Internal Recharges (2,334) (2,316) (850) 5, Unallocated Expenses (3,525) 206,733 Total Operating Expenditure before Depreciation, Impairments and Interest (49,166) (55,997) (22,593) (33,282) (45,695) (3,525) 0 Earnings before Interest, Taxation, Depreciation and Amortisation 15,563 23,233 13,176 (10,473) (33,987) 4, ,347 Total Allocated Depreciation & Amortisation (419) (226) (28) (354) (565) (1,592) Unallocated Depreciation & Amortisation (7,056) 1,592 Unallocated Impairments (6,933) 0 Operating Surplus/(Deficit) 15,144 23,007 13,148 (10,827) (34,552) (9,930) 194,347 The only activity of the NHS Foundation Trust is Healthcare and its primary customer is NHS Hillingdon CCG. However, segmental information has been included on the basis the following information is reported regularly to the Chief Executive for the purpose of allocating resources to that segment and assessing its performance. Transactions between divisions would reflect the re-allocation of shared costs. All services relating to transactions shown below were provided to external customers of the Trust. Segmental net assets are not recorded as part of the internal reporting process and as such are not disclosed. The reportable segments are different operational divisions within the Trust, which provide different groups of service. They are managed separately as they involve different medical disciplines and patient groups. Segments have not been aggregated The major external customer is NHS Hillingdon CCG which accounted for revenue of 136,701k and features in all segments. No other customer accounted for more than 7.25% of revenue. The split of Clinical Income in has been restated so that it is comparable with Page 19

200 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts NOTE 3 OPERATING INCOME Note 3.1 Operating income (by nature) 31 March March 2015 Income From Activities Acute Trusts NHS Clinical Income Elective income 29,200 32,053 Non elective income 61,184 60,620 Outpatient income 55,354 50,984 A & E income 8,365 7,844 Other NHS clinical income 51,488 38,806 All Trusts Private patient income Other clinical income 3,458 3,816 Total income from activities 209, ,347 Total other operating income 29,465 27,482 Total Operating Income 238, ,829 Note 3.2 Operating lease income 31 March March Operating Lease Income Rents recognised as income in the year 1,683 1,611 Contingent rents recognised as income in the year 535 1,812 TOTAL 2,218 3,423 Future minimum lease payments due on leases of Land expiring - not later than one year; 1,321 1,321 - later than one year and not later than five years; 5,283 5,283 - later than five years. 91,131 92,451 sub total 97,735 99,055 on leases of Buildings expiring - not later than one year; later than one year and not later than five years; later than five years. 1, sub total 3,188 1,020 TOTAL 100, ,075 Leasing arrangements are all with bodies external to the UK Government. Leasing arrangements relate significantly to land rental on both the Hillingdon and Mount Vernon sites. Page 20

201 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 3.3 Operating Income (by source) 31 March March Income from activities NHS Foundation Trusts NHS Trusts CCGs and NHS England* 204, ,191 Local Authorities 1,400 1,669 Non NHS: Private patients Non-NHS: Overseas patients (non-reciprocal) NHS injury scheme (formerly RTA) Non NHS: Other Total income from activities 209, ,347 Other operating income Research and development Education and training 8,901 9,044 Grants and Donations Non-patient care services to other bodies 8,875 8,002 Rental revenue from operating leases - minimum lease receipts 1,683 1,611 Rental revenue from operating leases - contingent rent 535 1,812 Other * 8,415 6,062 Income in respect of staff costs where accounted on gross basis Total other operating income 29,465 27,482 Total Operating Income 238, ,829 *Income from Commissioner requested Services Commissioner Requested Services 204, ,191 Other Services 33,894 31,638 Total Operating Income 238, ,829 * Analysis of Other Operating Income: Other Car parking 1,665 1,762 Estates recharges Pharmacy sales Staff accommodation rentals Clinical tests 41 - Clinical excellence awards Catering 1, Property rentals Other 3,988 2,045 Total 8,415 6,062 Note 3.4 Overseas visitors (relating to patients charged directly by the foundation trust) 31 March Mar Income recognised this year Cash payments received in-year (relating to invoices raised in current and previous years) Amounts added to provision for impairment of receivables (relating to invoices raised in current and prior years) Amounts written off in-year (relating to invoices raised in current and previous years) Page (102) (9)

202 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 4 Operating Expenses Services from NHS Foundation Trusts 1,281 1,063 Services from NHS Trusts Employee Expenses - Executive directors 1,054 1,075 Employee Expenses - Non-executive directors Employee Expenses - Staff 155, ,055 Supplies and services - clinical (excluding drug costs) 9,799 8,951 Supplies and services - general 2,101 1,876 Establishment 4,914 4,443 Transport - business travel Transport - other 1,364 1,223 Premises - Business rates payable to Local Authorities Premises - Other 6,360 6,752 Increase/(decrease) in provision for impairment of receivables (Decrease)/Increase in provisions* (494) 925 Inventories written down (net, including inventory drugs) Drugs costs (non inventories) 1,327 1,085 Inventories consumed (excluding drugs) 16,183 15,851 Drugs inventories consumed 16,654 14,383 Rentals under operating leases - minimum lease receipts Rentals under operating leases - contingent rent 9 4 Depreciation on property, plant and equipment 8,717 8,162 Amortisation on intangible assets Impairments of property, plant and equipment - 6,933 Audit services- Financial Statements Audit services - Quality Accounts Clinical negligence - amounts payable to the NHSLA (premiums) 3,997 4,121 Loss on disposal of other property, plant and equipment 5 - Legal fees Consultancy costs Internal audit costs - (not included in employee expenses) Training, courses and conferences Patient travel 3 4 Car parking & Security Redundancy - (Included in employee expenses) Hospitality Insurance Other services 1,220 1,156 Losses, ex gratia & special payments- (Not included in employee expenses) Other TOTAL OPERATING EXPENSES 234, ,839 * The provision credit relates to (1) a ( 555k) credit due to a reversal of an unused tax and NI provision and (2) a charge arising in the year in the Pensions Provision of 61k which nets off to the 494k credit. All expenses above related to continuing operations. Page 22

203 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 5 Operating lease Expenditure Payments recognised as an expense 31 March March Minimum lease payments Contingent rents Total future minimum lease payments 31 March March Payable: Not later than one year Between one and five years 1,258 1,245 Later than five years ,090 Total 2,358 2,646 The Trust is party to a ten year lease agreement for a modular healthcare building on the Hillingdon Hospital site ending October Page 23

204 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 6 Employee costs and numbers 6.1 Employee costs 31 March March 2015 Total Permanently employed Other Total Permanently employed Other Salaries and wages 120, ,483 6, , ,159 5,988 Social security costs 10,403 10, ,721 9, Employer contributions to NHS Pension scheme 13,621 13, ,158 11, Termination benefits Agency/contract staff 14,725-14,725 13,623-13,623 Recoveries from DH Group bodies in respect of staff cost netted off expenditure (1,465) (1,465) - (1,336) (1,336) - Employee benefits expense 157, ,247 22, , ,114 20,331 Of the total above: Charged to capital 1, ,206 1, Charged to revenue 156, ,282 22, , ,003 20, , ,247 22, , ,114 20, Directors aggregate remuneration 31 March March March March 2015 Remuneration Number of Remuneration Number of 000 Directors ** 000 Directors ** Executive Directors 1, ,075 9 Non Executive Directors* Total** 1, , **Analysis of Directors Remuneration ( 000) Gross pay Employer Pension Contributions Employer National Insurance Contributions Total 1,185 1,210 *Non Executive Directors are not members of the NHS pension scheme. ** The number of directors denotes the number of individuals employed in a director position at some point during the financial year, not the number of directors simultaneously employed. 6.3 Average number of people employed 31 March March 2015 Total Permanently employed Other Total Permanently employed Other Number Number Number Number Number Number Medical and dental Administration and estates Healthcare assistants and other support staff Nursing, midwifery and health visiting staff Scientific, therapeutic and technical staff Healthcare science staff Total 3,269 2, ,042 2, Of the above: Number of whole time equivalent staff engaged on capital projects Page 24

205 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Employee costs and numbers (continued) 6.4 Early Retirements due to ill health 31 March March 2015 Number Number There were five early retirements on the grounds of ill-health during 2015/16 (Prior year nil) 5 - The cost of early retirement due to ill health is borne by the NHS Business Services Authority who administer NHS pensions. 6.5 Exit Packages 31 March 2016 Number of compulsory redundancies Cost of compulsory redundancies Number of other departures agreed Cost of other departures agreed Total number of exit packages Total cost of exit packages Number 000s Number 000s Number 000s < 10, Total Exit Packages 31 March 2015 Number of compulsory redundancies Cost of compulsory redundancies Number of other departures agreed Cost of other departures agreed Total cost of exit packages Total number of exit packages Number 000s Number 000s Number 000s < 10, ,001-25, , , Total Exit packages: other (non-compulsory) departure payments Agreed number Total value of Agreed Total value of agreements number agreements Contractual payments in lieu of notice Total Staff sickness absence 31 March March 2015 Total days lost 37,242 34,627 Total staff years* 2,965 2,750 Average working days lost *Staff years is a calculation based on the number of working days of full time and part time staff employed by the Trust converted into composite staff years. Page 25

206 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 7 Better Payment Practice Code 7.1 Better Payment Practice Code - measure of compliance 31 March March 2015 Number 000 Number 000 Total Non-NHS trade invoices paid in the year 88,988 89,926 88,903 98,243 Total Non NHS trade invoices paid within target 51,025 48,847 43,047 51,990 Percentage of Non-NHS trade invoices paid within target 57% 54% 48% 53% Total NHS trade invoices paid in the year 2,633 9,366 2,951 10,606 Total NHS trade invoices paid within target 1,363 5,592 1,174 4,929 Percentage of NHS trade invoices paid within target 52% 60% 40% 46% The Better Payment Practice Code requires the Trust to aim to pay all undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later. 7.2 The Late Payment of Commercial Debts (Interest) Act March March Amounts included in finance costs from claims made under this legislation 3 10 Note 8 Finance income 31 March March Interest on bank accounts Note 9 Finance expenses 31 March March Interest expense: Interest paid on Finance leases Interest on late payment of commercial debt 3 10 Interest paid on Capital loans from the Department of Health Interest due on Working Capital loans from the Department of Health Interest on LIFT contract 1,401 1,399 Total 2,084 2,014 Note 10 Other non - operating income 31 March March Increase in fair value of investment property 494 3,874 Page 26

207 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 11 Intangible Assets Cost or valuation brought forward at 1st April ,907 4,582 Other Reclassifications Additions - purchased Cost or valuation at 31 March ,413 5,907 Amortisation Brought Forward at 1st April ,927 2,441 Amortisation provided in Year Amortisation at 31 March ,581 2,927 Net Book Value at 31 March ,832 2,980 Intangible Assets consists of Software Licences. Page 27

208 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts NOTE 12 PROPERTY PLANT AND EQUIPMENT 12.1 Property, plant and equipment Total Land Buildings excluding dwellings Dwellings Assets under construction Plant and machinery Transport equipment Information technology Furniture & fittings Current Year Cost or valuation at 1 April ,842 37,292 79,911 1,070 2,068 25, , Additions - purchased 8, , ,092 1, Additions - Leased 1, , Additions - donated Reclassifications * (10) 6 1, (1,968) Disposals (96) (96) Cost or valuation at 31 March 2016 (A) 170,599 37,327 85,012 1,193 3,192 27, , Depreciation at 1 April , , , Provided During the Year 8,717 4, ,414-1,903 5 Disposals / derecognition (91) (91) Depreciation at 31 March 2016 (B) 32,760-4, , , Net Book Value (A - B) 137,839 37,327 80, ,192 10,867-5, Financed as follows: Owned 121,453 36,927 68, ,192 6,994-5, Finance leased 3, , LIFT 10, , Donated 2,799-2, Total 31 March ,839 37,327 80, ,192 10,867-5, Page 28

209 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Property, plant and equipment (Continued) Total Land Buildings excluding dwellings Dwellings Assets under construction Plant and machinery Transport equipment Information technology Furniture & fittings Previous Year Cost or valuation at 1 April ,671 32,469 70, ,436 22, , Additions - purchased 13,774-10,490-1,884 1, Additions - Leased 1, , Additions - donated Impairments charged to operating expenses (6,933) - (6,933) Impairments charged to the revaluation rese (567) - (567) Reclassifications * (4,435) - 9,334 (36) (11,252) (2,741) - Revaluations 2,344 4,823 (2,769) Cost or valuation at 31 March 2015 (A) 160,841 37,292 79,910 1,070 2,068 25, , Depreciation at 1 April ,034-7, , , Provided During the Year 8,161-3, ,197-1,892 5 Reclassifications * (3,662) - (1,045) - (72) (2,793) 4 Revaluations (10,400) - (9,937) (463) Depreciation at 31 March 2015 (B) 24, , , Net Book Value (A - B) 136,708 37,292 79,236 1,034 2,068 10,304-6, Financed as follows: Owned 117,810 36,892 66,743 1,034 2,068 6,543-4, Finance leased 5, ,451-2,244 - LIFT 10, , Donated 2,885-2, Total 31 March ,708 37,292 79,236 1,034 2,068 10,304-6, * Reclassification balance of 773k relates to 326k within Note 11 (Intangible Assets) and 447k within Note 14 (Investment Property). Page 29

210 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Revaluation reserve balance for property, plant & equipment Total Current Year 000 At 1 April ,799 Depreciation adjustment* (634) At 31 March ,165 Total Previous Year 000 At 1 April ,362 Depreciation adjustment* (740) Impairments (567) Revaluations 12,744 At 31 March ,799 * The depreciation adjustment is required due to revaluations of land and buildings. Page 30

211 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 13 ECONOMIC LIVES OF PROPERTY PLANT AND EQUIPMENT Min life Max life 13.1 Economic lives of property, plant and equipment Years Years Intangible assets - internally generated Information technology 5 15 Intangible assets - purchased Software 5 15 Licences & trademarks Economic lives of property, plant and equipment Min life Max life Years Years Buildings exc Dwellings 2 60 Dwellings 5 5 Plant and Machinery 5 20 Transport equipment 5 5 Information Technology 5 15 Furniture and Fittings 5 15 Note 14 Investment Property 31 March March Balance at Beginning of year 19,137 14,816 Reclassification from Operational Buildings Net gain from Fair Value Adjustments 494 3,874 Balance at End of Year 19,641 19,137 Income from Occupied Investment Properties 1,950 2,667 Expenses of Investment Properties (1,028) (1,021) Surplus 922 1,646 Expenses of unoccupied Investment Properties 3 3 Note 15 Impairment of assets 31 March March Changes in market price. Operating Expenses - 6,933 Changes in market price. Revaluation Reserve Total Gross Impairments - 7,500 Note 16 Capital Commitments 31 March March Property, plant and equipment 4,465 1,063 Page 31

212 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts NOTE 17 INVENTORIES 17 Inventory Movement Total Drugs Consumables Energy Other Current Year 2015/ Carrying Value at 1st April , , Additions 33,280 16,859 14,384-2,037 Inventories recognised as expenses (32,837) (16,654) (14,150) - (2,033) Write-down of inventories recognised as an expense (50) (46) (4) - - Carrying Value at 31st March ,171 1,036 1, Total Drugs Consumables Energy Other Prior Year 2014/ Carrying Value at 1st April ,943 1,123 1, Additions 28,432 14,180 14, Inventories recognised as expenses (28,515) (14,383) (13,916) (1) (215) Write-down of inventories recognised as an expense (82) (43) (39) - - Carrying Value at 31st March , , Page 32

213 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts NOTE 18 TRADE AND OTHER RECEIVABLES 18.1 Trade and other receivables 31 March March Current NHS receivables - revenue 20,073 17,902 NHS receivables - accrued income 1,643 1,212 NHS provision for credit notes (6,569) (6,323) Sub Total NHS 15,147 12,791 Prepayments 1,909 1,662 PDC dividend receivable VAT receivable Other receivables 2,677 2,993 Provision for impaired receivables (1,513) (1,321) Total current trade and other receivables 18,752 16,790 Non-Current Other receivables 1,077 1,192 Less Provision for impaired receivables (237) (225) Total non-current trade and other receivables Provision for impairment of receivables 31 March March At 1 April 1, Increase in provision Amounts Utilised (120) (260) At end of year 1,750 1, Ageing of impaired receivables 31 March March days days days days over 180 days 1, Total 1,750 1, Ageing of non-impaired receivables 31 March March 2015 past their due date days 1,329 3, days 1,191 3, days days 4,244 2,393 over 180 days 5,907 5,392 Total 13,586 15,614 Note 19 Cash and cash equivalents 31 March March Balance at 1 April 5,483 5,733 Net (decrease)/increase in year (1,391) (250) Balance at end of Year 4,092 5,483 Made up of Cash with Government banking services 2,866 4,658 Commercial banks and cash in hand 1, Cash and cash equivalents as in statement of financial position 4,092 5,483 Cash and cash equivalents as in statement of cash flows 4,092 5,483 Page 33

214 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 20 Trade and other payables 31 March March Current Receipts in advance 3,604 2,163 NHS payables - revenue 2,963 1,600 Pensions 1,967 1,791 Other trade payables - capital 806 1,117 Other trade payables - revenue 8,299 4,271 Social Security costs 3,060 2,968 Other payables PDC dividend payable Accruals and deferred income 8,014 8,123 Total Trade and Other payables 29,043 22,427 Note 21 Borrowings 31 March March Current Capital loans from Department of Health Working capital loan from Department of Health 1,000 1,000 Obligations under finance leases 1,644 1,521 Obligations under LIFT contract Total current borrowings 3,250 3,239 Non-current Capital loans from Department of Health 5,905 6,295 Working capital loan from Department of Health 8,000 9,000 Obligations under finance leases 3,713 4,119 Obligations under LIFT contract 12,174 12,390 Total non current borrowings 29,792 31,804 The Trust is party to three Department of Health loans as follows: - Loan 1 (for capital investment) received 15th December 2009 for 4.0m. Repayments commenced on 15th March 2010 and will continue until 15th September The loan carries a fixed interest rate at 4.11%. - Loan 2 (for capital investment) received 15th September 2010 for 4.6m. Repayments commenced on 15th March 2011 and will continue until 15th September The loan carries a fixed interest rate at 3.25%. - Loan 3 (for working capital) received 16th November 2014 for 10.0m. Repayments commence on 17th May 2015 and will continue until 15th November The loan carries a fixed interest rate at 1.74%. Page 34

215 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 22 Finance lease liabilities The lease arrangements relate to a number of equipment leases which vary in length from three to seven years. All leases are with bodies external to government. Details of the accounting for finance leases can be found in note 1 - accounting policies. Amounts payable under finance leases Gross lease liabilities 31 March March Within one year 1,867 1,771 Between one and five years 3,895 4,214 Later than five years Sub total gross finance lease liabilities 5,904 6,200 Future Finance Charges (547) (560) Total net finance lease liabilities 5,357 5,640 Net lease liabilities 31 March March Within one year 1,644 1,521 Between one and five years 3,581 3,916 Later than five years Total net finance lease liabilities 5,357 5,640 Note 23 NHS Local Improvement Finance Trust (LIFT) contract The LIFT agreement is for a 25 year period which commenced in December The scheme is for the provision of clinical accommodation on the Mount Vernon Hospital site which comprises four surgical theatres and outpatient suites. The annual lease payment (inclusive of interest, capital and services) is 1,557k per annum. The LIFT agreement is with a body external to government. Details of the accounting for the LIFT contract can be found in note 1 - accounting policies LIFT liabilities Finance lease obligations payable under the LIFT contract Gross liabilities 31 March March Not later than one year 1,088 1,221 Later than one year, not later than five years 4,287 4,371 Later than five years 19,096 20,099 Sub total gross liability Future Finance Charges 24,471 25,691 (12,081) (12,973) Total net liability 12,390 12,718 Net LIFT liabilities 31 March March Not later than one year Later than one year, not later than five years Later than five years 11,214 11,466 Total net LIFT liability 12,390 12, Total Future Commited Expenditure in respect of LIFT LIFT commited total future expenditure 31 March March Not later than one year 2,065 2,045 Later than one year, not later than five years 6,228 6,228 Later than five years 24,152 25,729 Total 32,445 34, Payments in year to Operator in respect of LIFT The Trust paid the following amounts during the year in respect of LIFT LIFT expenditure 31 March March Interest charge 1,401 1,399 Repayment of finance lease liability Service element Total 2,065 2,047 Page 35

216 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 24 Related party transactions and balances During the year none of the Trust board members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with The Hillingdon Hospitals NHS Foundation Trust. The United Kingdom Government is regarded as a related party to the extent that it controls the Department of Health and National Health Organisations through legislation and funding by the taxpayer. During the year The Hillingdon Hospitals NHS Foundation Trust has had a significant number of material transactions with the Department, and with other NHS entities as well as directly with the UK Government. These transactions are itemised below subject to a minimum of 100k for transactions and balances for the year to 31st March These limits are in accordance with the Agreement of balances exercise for Whole Government Accounts Balances Current Current Receivables as Receivables as at at 31 March 31 March Current Payables as at 31 March 2016 Current Payables as at 31 March 2015 Entities 000s 000s 000s 000s Central And North West London MH NHS Foundation Trust Royal Brompton And Harefield NHS Foundation Trust Royal Free London NHS Foundation Trust University College London East And North Hertfordshire NHS Trust 2,280 3, Imperial College Healthcare NHS Trust NHS Ealing CCG 3,042 1,262 - London North West Healthcare NHS Trust 1, NHS Barnet CCG NHS Brent CCG NHS Central London (Westminster) CCG NHS Harrow CCG NHS Herts Valleys CCG NHS Hillingdon CCG 6,858 7, NHS Hounslow CCG 1, NHS North West Surrey CCG NHS Slough CCG NHS England Department of Health (PDC dividend only) Other NHS (Balances below 100k) 2,328 2, Central and Local Government ,029 4,759 Total Related Parties Balances 20,688 19,933 7,992 6,586 Page 36

217 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Transactions Revenue Year to 31 March 2016 Revenue Year to 31 March 2015 Expenditure Year to 31 March 2016 Expenditure Year to 31 March 2015 Entities 000s 000s 000s 000s Royal Free London NHS Foundation Trust Central And North West London MH NHS Foundation Trust , Frimley Heath 120 N E London 103 Kings College Hospital NHS Foundation Trust Royal Brompton And Harefield NHS Foundation Trust East And North Hertfordshire NHS Trust 9,075 6, Imperial College Healthcare NHS Trust Health Education England 9,203 9, London North West Healthcare NHS Trust 1, NHS Aylesbury Vale CCG NHS Barnet CCG NHS Bracknell and Ascot CCG 110 NHS Brent CCG 1,141 2,434 - NHS Camden CCG 115 NHS Central London (Westminster) CCG NHS Dorset CCG 118 NHS Chiltern CCG 3,533 3,402 - NHS Ealing CCG 21,097 15,249 - NHS East and North Hertfordshire CCG 189 NHS England 18,138 16,109 - NHS Hammersmith And Fulham CCG NHS Haringey CCG 104 NHS Harrow CCG 7,211 7,734 - NHS Herts Valleys CCG 5,044 4, NHS Hillingdon CCG 142, ,657 - NHS Hounslow CCG 4,363 3,687 - NHS Litigation Authority - 4,146 4,360 NHS Luton CCG 107 NHS North West Surrey CCG NHS Richmond CCG NHS Slough CCG NHS West London (K&C & Qpp) CCG NHS Windsor, Ascot And Maidenhead CCG West Hertfordshire Hospitals NHS Trust Other NHS 2,622 3, ,522 Total NHS 232, ,576 9,433 8,731 Central and Local Government 1,459 1,563 23,819 22,968 Total Whole Government Accounts (WGA) 233, ,139 33,252 31,699 Non WGA Entities* British Telecommunications plc Other non WGA entities Total Related Parties Transactions 233, ,139 33,372 32,010 * No transactions were noted with related parties of any Directors of THH, these transactions were conducted with related parties of senior managers in the Department of Health. Page 37

218 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 25 Provisions 31 March March Provisions at start of year 3,271 2,440 Arising during the year Utilised during the year- accruals (50) (39) Utilised during the year- cash (357) (128) Unwinding of discount Reversed unused (555) Provisions at end of year 2,445 3,271 Expected timing of cash flows: Within one year Between one and five years After five years 1,820 1,610 Total 2,445 3,271 Provisions are liabilities that are of uncertain timing or amounts which the Trust expects to be settled by a transfer of economic benefits. The provision for staff pensions has been calculated using information supplied by NHS Business Service Authority Pensions Division. A provision for repayment of national Insurance and tax of 781k was cleared in year by a payment of 226k and reversing the unused balance of 555k. Clinical Negligence liabilities 31 March March Amount included in provisions of the NHSLA in respect of clinical negligence liabilities of The Hillingdon Hospitals NHS Foundation Trust 144,415 47,918 Page 38

219 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 26 Contingent liabilities 31 March March Contingent liabilities The Trust's contingent liabilities include relating to employee work injuries and relating to public slips or falls. Note 27 Financial instruments 31 March March Financial Assets * Trade and other receivables 17,683 17,757 Cash and cash equivalents (at bank and in hand) 4,092 5,483 Total at end of year 21,775 23, March March Financial Liabilities * Borrowings excluding Finance lease and LIFT liabilities 15,295 16,685 Obligations under finance leases 5,357 5,640 Obligations under LIFT contract 12,390 12,718 Trade and other payables excluding non financial liabilities 22,379 15,228 Provisions Under Contract 2,445 3,271 Total at end of year 57,866 53,542 * Book value is equivalent to fair value 31 March March Maturity of Financial Liabilities In one year or less 25,754 19,416 In more than one year but not more than two years 5,437 5,707 In more than two years but not more than five years 5,296 5,608 In more than five years 21,379 22,811 Total 57,866 53,542 Book value Fair value 27.4 Fair values of financial assets at 31st March Non current trade and other receivables excluding non financial assets Fair values of financial liabilities at 31st March 2016 Book value Fair value Non current trade and other payables excluding non financial liabilities Provisions under contract 2,320 2,320 Loans 13,905 13,905 LIFT Contract and Finance Leases 15,887 15,887 Total 32,112 32,112 For current financial instruments (less than one year), fair values are assumed to be equal to book values. Notes 27.3 and 27.4 include only non-current financial assets and financial liabilities. Page 39

220 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 28. Financial Sustainability Risk Rating 31 March March Metric Criteria Actual Rating Weighting Actual Rating Capital Service PDC Dividends payable 3,957 3,897 Interest Payments 2,159 2,087 Loans repaid to the Department of Health 1, Capital element of LIFT Capital element of finance lease rental payments 1,652 1,368 Total Capital Service 9,486 7,923 Revenue Available for Debt Service Deficit for the year (1,488) (6,103) Depreciation on property, plant and equipment 8,717 8,162 Amortisation on intangible assets Impairments of property, plant and equipment 0 6,933 Interest Expense 2,084 2,014 Unwinding of Discount Provisions PDC Dividends payable 3,957 3,897 Loss on disposal 5 0 Total Revenue Available for Debt Service 14,004 15,462 Capital Service Cover % Cash available for Liquidity Purposes Current Assets 26,015 25,051 Current Liabilities (32,418) (26,623) Inventories (3,171) (2,778) Total Cash available for Liquidity Purposes (9,574) (4,350) Operating Expenses within EBITDA Operating Expenses 234, ,839 Depreciation on property, plant and equipment (8,717) (8,162) Amortisation on intangible assets (654) (486) Impairments of property, plant and equipment 0 (6,933) Loss on disposal (5) 0 Total Operating Expenses within EBITDA 225, ,258 Liquidity (15.30) 1 25% (7.4) 2 Deficit for the year (1,488) (6,103) Loss on disposal 5 0 Impairments 0 6,933 Normalised Deficit (1,483) 830 Total Operating Income 238, ,829 Increase in fair value of investment prop 494 3,874 Finance income (Interest) , ,720 I&E Margin -0.62% 2 25% 0.37% 3 Deficit for the year (1,483) 768 Plan 30 Variance from Plan (1,513) Total Operating Income 239, ,750 I&E Margin Variance from Plan -0.63% 3 25% 0.34% 4 Capital Service Cover Rating 2 3 Liquidity Rating 1 2 I&E Margin Rating 2 3 I&E Margin Variance from Plan Rating 3 4 Overall Financial Sustainability Risk Rating 2 3 Financial Sustainability Risk Rating boundaries: Weighting Capital Service Cover Rating 25% >2.5 <2.5 <1.75 <1.25 Liquidity Rating 25% >0 <0 <-7 <-14 I&E Margin Rating 25% >1% <1% <0 <-1% I&E Margin Variance from Plan Rating 25% >0% <0% <1% <-2% 100% In the Financial Sustainability Risk Rating replaced the Continuity of Service Risk Rating. To facilitate comparison has been restated in the same format. Page 40

221 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 29 Third party assets The Trust held 11k cash and cash equivalents at 31 March 2016 ( 11k at 31 March 2015) which relates to monies held by the NHS Trust on behalf of patients. This has been excluded from the cash and cash equivalents figure reported in the accounts. 31 March March 2015 Note 30 Losses and Special Payments Numbers Value Numbers Value Losses Losses of cash: Theft/Fraud - Overpayment of salaries, wages, fees and allowances Other causes Bad debts and claims abandoned Private patients 3-5 overseas visitors Other Stores Stores Losses Total Losses Special payments Compensation payments Personal Injury with advice Other Total Special Payments Total Losses and Special Payments Amounts Recovered 8 9 The amounts reported in this note were incurred as actual costs for the year to date and do not contain any accrued costs. These sums have been reported to and approved by the Audit Committee of the Trust. Page 41

222 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Note 31 NHS Hosted charities Name of Charity: - The Hillingdon Hospitals Foundation Trust General Amenities Fund and Other Related Charities (The Charity) Charity Registration Number : Corporate Trustee: The Hillingdon Hospitals NHS Foundation Trust 31 March March 2015 From Charity's Statement of Financial Activities 000s 000s Total Incoming Resources* Resources Expended (388) (258) Resource surplus Gains on revaluation and disposal (50) 18 Net Movement in funds From Charity's Balance Sheet 31 March March s 000s Investments (Non Current Assets) Current Assets: Cash Other Current Assets Current Liabilities - - Net assets Represented By:- Restricted Reserves Unrestricted Reserves Total reserves The Charity is controlled by The Hillingdon Hospitals NHS Foundation Trust (The Trust) which acts as Corporate Trustee. Under the accounting standard IFRS 10, the Charity is required to be consolidated within the Trust accounts However the Trust has decided to depart from this standard on the grounds of materiality (Income from the Charity is equivalent to 0.5% of Trust Income); the lack of any meaningful benefit to users of the accounts and the potential excessive costs in terms of management and systems redesign. The detailed accounts of the charity can be found on the Charity Commission website or contacting the Trust's Finance Department to request a copy. * The Charitable Funds received a leagacy in year of 400k Page 42

223 Quality Report 2015/16 Putting Compassionate Care, Safety and Quality at the Heart of Everything we do WORKING DRAFT To be checked, formatted and formerly presented by Communications Team

224 CONTENTS PAGE About the Trust s Quality Report 3 Executive summary 3 Part 1: Statement from the Chief Executive 6 Part 2: Priorities for improvement and statements of assurance from the board 9 Key Quality Achievements for 2015/ Looking back 9 o Quality priorities for improvement 2015/16 How did we do? 9 o Looking Forward 16 Quality priorities for improvement in 2016/ : Formal statements of assurance from the Board 26 Provision of NHS Services 26 Participation in clinical audit 26 Participation in research 31 Lessons learned from Serious Incidents 32 Duty of Candour 34 Goals agreed with our commissioners 35 Care Quality Commission registration 36 Data quality 39 Information governance toolkit 39 Clinical coding error rate : Performance against Core Quality Indicators 2015/16 40 Part 3: Other key quality improvements we have made in 2015/16 46 Annex 1: Statements from our stakeholders 63 Statement from Hillingdon Clinical Commissioning Group (CCG) 63 Statement from our local Healthwatch 66 Statement from External Services Scrutiny Committee 69 The Hillingdon Hospitals NHS Foundation Trust response to the consultation 70 Independent Auditor s Report 71 Annex 2: Statement of Directors responsibilities in respect of the Quality Report 71 Glossary 73 2

225 About the Trust s Quality Report What is the Quality Report? The Quality Report is produced by NHS healthcare providers to inform the public about the quality of services they deliver. As a Trust we strive to achieve high quality care for our patients. The Quality Report provides an opportunity for us to demonstrate our commitment to quality improvement and show what progress we have made in 2015/16 against our quality priorities and national requirements. The Quality Report is a mandated document which is laid before Parliament before being made available on the NHS Choices website and our own website ( What is included in the Quality Report? The Quality Report is a statutory document that contains specific, mandatory statements and sections. There are also three categories mandated by the Department of Health (DH) that give us a framework in which to focus our quality improvement programme. These are patient safety, patient experience and clinical effectiveness. The Trust undertook extensive consultation in developing this report to ensure that the quality improvement priorities reflect those of our patients, our staff, our partners and the local community. Part 2 of the report highlights the Trust s quality priorities and includes: The areas identified for improvement in 2015/16; How we performed against these improvement targets and what this means for our patients. There is also a section in Part 2 on the quality priorities that have been identified for improvement projects in 2016/17. A glossary is available at the back of the report which lists the abbreviations and terms in the document. Executive summary This Executive Summary provides a very brief overview of the information in this year s report. The report provides a summary of performance during 2015/16 in relation to quality priorities and national requirements. Overall, the Trust has performed very well in 2015/16 across a wide range of quality indicators. Particular successes include: An improvement in our mortality rates with a reduction in the variability between weekdays and weekends A reduction of more than 30% for Clostridium difficile infections from last year s figures Cancer performance indicators demonstrating better than London and national averages Improved patient satisfaction as measured by the Friends and Family Test (FFT) An improved patient safety incident reporting rate and a good rating in the Learning from Mistakes League. We have also performed well in other areas including increasing our uptake of statutory and mandatory training and achieving the requirements of the National Specifications for Cleaning across the Trust as part of our Care Quality Commission (CQC) improvement programme. 3

226 However 2015/16 has been a challenging year for the Trust. We have seen increased patient activity and throughput with 32 additional beds open. This has put pressure on our internal systems and has stretched our manpower resources during a very challenging staffing market nationally. It has therefore been difficult to realise some of the stretching quality targets that we set ourselves at the beginning of the year. Some examples of our achievements and progress against key priority areas are listed below: Quality Priority How did we do? Priority 1: Ensuring the safety of vulnerable and older people Increase number of relevant staff receiving the We have achieved 81% against a target of >80%. enhanced Mental Capacity Act/Deprivation of Liberty Safeguards (DoLS) training. Establish an Equality and Diversity (E&D) An E&D steering group has been established and a steering group with representation from people task and finish group focusing specifically on with different disabilities. physical and sensory disability is to be established. Improve the engagement with people who have a disability by attending local groups for people with disabilities. Priority 2: Improving the safety of medicines management Increase reporting of medicine errors - Medication Related Incidents as a % of all Patient Safety Incidents* Develop a pharmacy services patient questionnaire, establish a baseline, audit quarterly and realise improvement for 2015/16 on the baseline. Priority 3: Improving Maternity Services 10% reduction in complaints received on maternity triage service once this has moved to its new clinical environment. A very positive experience for women in the new birth centre monitored via the FFT. Maintain current numbers of Hillingdon Borough women choosing to continue to use the Hillingdon Hospital Priority 4: Improving Communication with our patients Improvement on communication and information provided to patients in Accident & Emergency (A&E) department Discharge summaries from inpatient episodes will be completed within 24 hours - >80% target We have attended local disability groups & information has been provided on areas for improvement for physical and sensory disabilities. Behind plan. We have achieved 9% against a target of >11%. However this is an improvement from 2014/15 performance of 7.8%. Achieved. We have achieved 85% satisfaction with the service against a target of 75%. We have seen an improvement in women s satisfaction of the service with approximately 30% fewer complaints received. We achieved 97% satisfaction against a target of >88%. All Hillingdon women have been able to access the service during 2015/16. Achieved. We continue to receive very positive feedback about people s experience in our A&E department via the Friends and Family Test. We are behind plan at 57% compliance. 98.7% of discharge summaries are completed but further work is required to ensure this happens within a 24 hr timeframe. Involved as much as you wanted to be: Behind plan. Achieved 84% against a target of 89%. It is disappointing that we have not been able to achieve the stretching target that we set ourselves based on an improved position in 2014/15. Activity and demand for A&E and inpatient services has put pressure on existing staffing resources and impacted upon our ability to make improvement in this key area of patient experience. Nurses - Clear answers to questions Behind plan. Achieved 87% against a target of 90%. Commentary as above. Doctors - Clear answers to questions Behind plan. Achieved 86% against a target of 90%. Commentary as above. *A higher reporting rate represents a stronger patient safety culture 4

227 Some elements of improvement work in the key priority areas have not been realised and the clinical teams will continue to drive forward improvement during 2016/17 to ensure the improvement targets are achieved. In addition the Trust will develop a refreshed CQC action plan for 2016/17 based on the outcomes of mock CQC inspections conducted by our staff during the year. Our ambition will be to achieve an outstanding rating, with a minimum of good, at a future CQC inspection. We have set out our quality priorities for 2016/17 and we aim to achieve the following: 1. Achieving NEWS compliance to support early escalation of the deteriorating patient 2. Achieving improvement in relation to seven day working priorities 3. Delivering compassionate care and improving communication 4. Safer staffing improved recruitment and retention to ensure delivery of safe care NEWS National Early Warning Scoring System (see glossary at end of report) The key indicators that we are aiming to achieve under these priorities are outlined in the main report. During 2015/16 there has continued to be increased focus on measuring and monitoring the quality of our services and the care that is delivered to our patients and their families. The Trust s Clinical Quality Strategy has supported this work and helped us to achieve our vision: To put compassionate care, safety and quality at the heart of everything we do. The Trust will implement a revised Quality and Safety Improvement Strategy for as informed by the Trust Quality and Safety Committee s own review of effectiveness and recommendations arising from the Trust s CQC inspection in October The strategy will clearly articulate our ambitious aims across the domains of patient safety, clinical effectiveness and patient experience. Our quality improvement work will be informed and supported by the learning from and collaboration with colleagues as part of the Imperial College Healthcare Partners Academic Health Science Network. During 2015/16 the Trust has taken forward a detailed action plan to support its Sign up to Safety (SU2S) campaign. SU2S aims to strengthen patient safety in the NHS with a three year objective to reduce avoidable harm by 50% and save 6,000 lives. The Trust s campaign has been aligned to our clinical quality strategy and our commitment to listen to patients, carers and staff, to learn from what they say and to take action to improve patient safety. We have also been working closely with our partners in health and social care and key stakeholders to deliver improvements in the services delivered across North West London with regard to the Shaping a Healthier Future (SaHF) programme and the Whole Systems Integrated Care (WSIC) project supporting new care models to ensure an improved quality of personcentred care. The mandated sections within this Quality Report include information on our participation in national audits and our research activity during 2015/16. In addition, information is provided on our registration as a healthcare provider with the Care Quality Commission (CQC) and the progress we have made in response to the findings of their inspection of October 2014 and their re-visit of May This Quality Report and the priorities for 2016/17 are presented as a result of consultation and engagement with Foundation Trust members, our Governors, patients and the public, our staff, our local Healthwatch and our Commissioners. 5

228 Part 1: Statement from the Chief Executive This Quality Report provides the Trust with an opportunity to demonstrate its commitment to delivering high quality care and outlines the improvements that have been made during 2015/16. Nationally, the NHS has had a difficult year, and has struggled to meet key performance targets in the face of unprecedented levels of emergency demand. Locally, it has also been a challenging year for the Trust in continuing to drive forward key improvements in response to the findings of the CQC inspection of October 2014 alongside higher activity. Our staff have worked tirelessly to implement improvements alongside continuing to deliver high quality and safe care for patients. The Trust has responded extremely well in the last year to the requirements outlined in the CQC report of January By May 2015 we were able to demonstrate significant improvements and the two Warning Notices, issued for Regulation 10 Assessing and Monitoring the Quality of Service Provision and Regulation 12 Cleanliness and Infection Control, were removed by the CQC. In addition, the inadequate rating for the safety domain was upgraded to requires improvement. I am pleased with the great progress that was made in a relatively short space of time; this was due to the commitment and dedication of our staff. Many examples of good practice are highlighted within this report and I welcome the very positive feedback provided by patients and staff. Whilst it is important to acknowledge the challenges we have faced and where we have not been able to fully achieve the targets we have set, we must also remember that there is a great deal to celebrate and commend and our staff should feel proud of their effort and achievements. The last year has seen the Trust perform well in many areas. This includes: The Referral to Treatment (18 weeks) waiting times performance standards were changed this year and the Trust continues to maintain its high performance against this standard Key cancer performance indicators are being well maintained for all the national waiting times standards, and performing better than the London and national average An improvement in our mortality rates with a reduction in the variability between weekdays and weekends We received more than 25,000 responses to the Friends and Family Test (FFT) during 2015 and 93% of patients said they were happy to recommend our services to their friends and family Our score for staff engagement was 3.86 out of 5, an increase on our 2014 score but also above the national average. Overall, we scored above average in 18 areas out of a total of 32 with 10 of these being in the top 20% of all acute Trusts in England. We have also continued to invest in our services, some exciting developments include: More than 3 million investment to improve and expand our children s services as part of the Shaping a Healthier Future programme. Improvements include delivering a new children s A&E, and four new beds on Peter Pan Ward. 6

229 More than 1 million was invested in establishing a new Nuclear Medicine Facility housing the latest SPECT CT scanner. This enables nuclear and CT scans to be carried out at the same time reducing the need for multiple patient scans. The Trust created a 240k state-of-the-art simulation suite, featuring high-specification robotic model patients, ensuring staff can develop and improve their skills in a safe and supportive environment. I am proud that we have also received national recognition for outstanding core skills compliance by the London Streamlining Programme (collaboration between HR for London, NHS Employers and Skills for Health). This recognises that we raised our mandatory training compliance levels to over 90% and maintained this over the last year. The Trust rated green (compliant) throughout the year in all but one (A&E four-hour target) of Monitor s key performance targets. Overall demand for our emergency services has increased by 2.6% during 2015/16; this is in addition to a 9% growth seen in emergency attendances in 2014/15. The number of category 1 (blue light) ambulances attending the Trust has increased by 22.8% year to-date. This upward trend began in April Since that time blue light activity has increased by 53%. The Trust has expanded and developed its maternity services to accommodate changes as a result of the closure of Ealing Maternity Services under the Shaping a Healthier Future (SaHF) agenda. We have responded effectively to the increase in demand resulting from the changes including the development of a midwifery-led unit and expansion of the maternity triage service and the community midwifery and specialist teams. We have also seen an increase in both obstetric and midwifery staffing numbers to support the expansion, including obstetric consultant cover and the appointment of a consultant midwife. Currently the Women and Children s Division is planning the transition of the Paediatric services as part of the SaHF programme which is due to complete in June In April 2015 we saw the launch of the Hillingdon s Whole Systems Integrated Care project (WSIC) - a comprehensive new care model coordinating care across all providers, centred around patients over 65 years old. The Trust has been a significant partner in developing and delivering the programme to date and will continue to work hard to ensure the model is further refined and rolled-out across the borough to benefit as many people as possible. Substantial progress was made during 2015/16, and plans are in place to accelerate the programme during the coming year. A key milestone in this work was the establishment of an Accountable Care Partnership (ACP) involving all of the main care providers in Hillingdon. In developing our quality priorities for 2016/17 we have made reference to our latest CQC report, national best practice and reviewed our current quality performance in line with local, regional and national performance. We have also consulted with a wide group of stakeholders, including our Governors, Commissioners, People in Partnership and our local Healthwatch. Our aim is to continue to focus on the essentials of care in order to continue to improve clinical outcomes and to ensure that our patients have a positive experience. We remain, as always, grateful for the ongoing commitment and contribution of patients, staff, governors, members, commissioners and other stakeholders in supporting our quality improvement goals. We are working at a time of challenging financial constraints in the NHS and it has never been more important to focus on our patients experience of their care and evidence of clinical effectiveness to improve quality continually. 7

230 I am clear that our hospitals have staff who are committed to the highest possible standards of care for our patients. I hope that this Quality Report confirms our commitment to you to achieve improvement in the quality of our services to patients and ensures that we always put our patients at the forefront of service development and improvement. There are a number of inherent limitations in the preparation of this Quality Report which may impact the reliability or accuracy of the data reported. These include: Data is derived from a large number of different systems and processes. Only some of these are subject to external assurance, or included in internal audits programme of work each year. Data is collected by a large number of teams across the Trust alongside their main responsibilities, which may lead to differences in how policies are applied or interpreted. In many cases, data reported reflects clinical judgement about individual cases, where another clinician might have reasonably have classified a case differently. National data definitions do not necessarily cover all circumstances, and local interpretations may differ. Data collection practices and data definitions are evolving, which may lead to differences over time, both within and between years. The volume of data means that, where changes are made, it is usually not practical to reanalyse historic data. The Trust's Board and management have sought to take all reasonable steps and exercise appropriate due diligence to ensure the accuracy of the data reported, but recognises that it is nonetheless subject to the inherent limitations noted above. Following these steps, to my knowledge, the information in the document is accurate. Shane Degaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 8

231 Part 2 Priorities for improvement and statements of assurance from the board 2.1 Review of Quality Priorities for Improvement In this part of the report we tell you about the quality of our services and how we have performed in the areas identified for improvement in 2015/16. These areas are called our quality priorities and they fall into the three areas of quality as mandated by the Department of Health (DH): patient safety, patient experience and clinical effectiveness; we are required to have a minimum of one priority in each area. Firstly, the information below provides an overview of some of our key quality achievements in 2015/16. These are important indicators for the public and our key stakeholders to provide assurance on the quality of care and services that are delivered at the Trust: Key Quality Achievements in 2015/16 An improvement in our mortality rates with regard to levelling weekend and weekday mortality rates compared to last year A reduction of more than 30% for Clostridium difficile infections from last year s figures Cancer performance indicators demonstrating better than London and national averages High patient satisfaction with 95.2% recommending an inpatient ward and 93.4% recommending our Accident and Emergency department as measured by the Friends and Family Test An improved patient safety incident reporting rate and a good rating in the Learning from Mistakes League published by Monitor and the NHS Trust Development Authority in March LOOKING BACK Quality priorities for improvement 2015/16 How did we do? PRIORITY 1 Safeguarding - Ensuring the safety of vulnerable and older people We said: We wanted to work with social care and community colleagues on improving discharge management for vulnerable and older people. We said we wanted to identify improvements for people with disabilities and the frail elderly in hospital and for those people who may lack the capacity to consent or who lack advocacy. This element of care was identified by our key stakeholders as requiring improvement and concerns were also referenced via our complaints service in the feedback we get from patients and their families/carers. 9

232 How did we do? The specific goals that we set and the performance during 2015/16 are outlined below: Quality Priority indicators Establish a baseline on the number of referrals to the Independent Mental Capacity Advocacy (IMCA) service and realise an increase in these numbers. Establish a baseline on the number of referrals to the Disablement Association Hillingdon (DASH) service and realise an increase in these numbers. Further increase the number of staff receiving the enhanced MCA/Deprivation of Liberty Safeguards (DoLS) training - >80% for relevant staff. Establish an Equality and Diversity steering group with representation from people with different disabilities. Improve our facilities for those people with physical and sensory disabilities, such as increased number of hearing loops in use, improved signage and improved access to interpreting services, especially British Sign Language Improve the engagement with people who have a disability by attending local groups for people with disabilities (DASH and the Hillingdon Disabled Tenants and Residents Group). 2015/16 performance Referrals generated to the IMCA service during 2015/16 totalled 14 cases across Q1-Q3, Q4 figures awaited (Q1=6, Q2=3 and Q3=5) This information has not been collected previously so this supports the Trust in now having a baseline to monitor use of the service. Data source: PohWER report to London Borough of Hillingdon. We have been unable to access this information via the DASH service however the Trust regularly involves DASH in discussions and when designing and developing new services. Achieved 81% against a target of 80%. An E&D steering group has been established and a task and finish group focussing specifically on physical and sensory disability is soon to be established. A hearing loop system has been installed in more areas across the hospital; signage improved based on feedback; translation services reviewed. We have attended local disability groups and information from these has been provided on areas for improvement with regard to physical and sensory disability. What does this mean for our patients? These changes mean that our patients now experience a service which is more responsive to their specific needs, especially where patients are more vulnerable and may lack the capacity or the ability to advocate for themselves. In relation to the IMCA service, awareness has been raised in many ways across the Trust. The importance of using an IMCA for patients without capacity is discussed within Safeguarding Adult training sessions and information about the referral process and forms are available on the safeguarding adults intranet page for staff to access. The Head of Safeguarding has good links with the local IMCA service delivered by POhWER (advocacy agency) on behalf of the local authority. The local IMCA liaises directly with wards and departments who have referred patients for the service. Their workload has significantly increased since the Deprivation of Liberty Safeguards (DoLS) Cheshire West judgement and the subsequent increase in DoLS referrals nationwide. The role of the IMCA is clearly stipulated within the Trust s Mental Capacity Act (MCA) and 10

233 DoLs policy. Contact details are also given for the Disablement Association Hillingdon (DASH) advocacy service for patients who need support and do have capacity to make decisions. One of the focus groups looking at physical and sensory disability and accessibility to our services took place at DASH and was attended by service users providing valuable feedback on the Trust services. This will support us taking forward our improvement plan around disability. Following the 2015 PLACE (Patient Led Assessments of the Care Environment) inspections, the patient assessors identified that many patient/public reception areas did not have hearing induction loops. The hearing loop is a special type of sound system for use by people with hearing aids to enable them to hear more clearly. As a result the Facilities department arranged for the installation of sixteen new hearing loops across both hospital sites. The introduction of the hearing loop system both improves privacy, dignity and well-being under PLACE and meets the requirements of the Equality Act (2010) requiring organisations to make all reasonable adjustments to provide deaf or hard of hearing people with full access to services. Signage has been improved across both sites to reflect feedback on new services, clinical department moves and much of the signage (particularly for toilets, entrances, exits, lifts) has been altered to 'black text on a yellow background' to support people with dementia. In addition the Trust now has a contract with One Stop Language Services for the provision of British Sign Language (BSL) for patients using our services. Focus groups have been held with a group of service users who have either a sensory or physical disability. Representatives from the Hillingdon Disabled Tenants and Residents Group have been invited to be involved in the relocation project for the outpatient pharmacy. A new Disability Discrimination Act (DDA)/Equality Act survey for both hospital sites is to be commissioned in the forthcoming year. Once this survey has been carried out the key actions will be evaluated, risk assessed and prioritised for funding along with other legislative requirements. PRIORITY 2 We said: Improving the safety of medicines management and improve the experience of people requiring medicines in the inpatient and outpatient setting The Trust is committed to ensuring that patients are able to continue to take their medicines safely after leaving the hospital. We highlighted that allowing patients to continue to take their medicines themselves (self-administration) whilst they are in hospital (where they are able to do so) is an important element of medicines adherence and compliance. Maintaining independence in this way means that there is a reduced risk of readmission to the hospital due to medicinesrelated reasons. In addition we reported that the Trust is committed to optimise the safe use of medicines and central to this is to ensure that learning from most errors/near misses of no harm are applied to reduce the risk of errors/near misses occurring that may cause harm. 11

234 How did we do? The specific goals that we set and the performance during 2015/16 are outlined below: Quality Priority Indicators 2015/16 Performance Pilot the use of the revised patient selfadministration of medicines policy and roll out its implementation across the Trust. Develop survey and receive qualitative feedback from staff and patients on self-administration of medicines (SAM) in hospital and demonstrate evidence of changes to the process based on this feedback. Increase the reporting of medicines errors, via our incident reporting system, that constitute no/low harm incidents so that learning from these can avoid more harmful incidents from occurring. The Trust aim will be to improve on current performance to achieve the national average of 11%*. Develop a pharmacy services patient questionnaire, establish a baseline, audit quarterly and realise improvement for 2015/16 on the baseline. *A higher reporting rate represents a stronger patient safety culture What does this mean for our patients? This work remains in progress. The pilot was completed. Feedback from staff varied highlighting issues in process and or shortfall in facilities to safely implement the existing Self Administration Medicines (SAM) Policy. Therefore roll out has been delayed until the revised policy has been ratified by end of May This work is in progress. A structured staff survey was devised and has been completed. The information was used to inform the revision of the SAM Policy as above. This work remains in progress. We have achieved 9% against a target of >11%. This is an improvement from 2014/15 performance of 7.8%. A Medication Safety Officer has now been employed to lead this work to achieve our target during 2016/17. Recent data published in April 2016 from the National Reporting and Learning System (NRLS) shows that we are now near to the national average. We have achieved 85% satisfaction with the service against a target of 75%. Improving the safety of medicines management in hospital is key to ensuring patient harm is reduced and that patients receive the medicines they are prescribed. Ensuring patients are empowered to take their own medicines whilst in hospital where this is appropriate will help adherence to medicines especially when the patient is being discharged home. The Self Administration of Medicines (SAM) policy will be published once ratified in May 2016 based on feedback we have received with roll out of self-administration of medicines thereafter across the Trust. The work to ensure improved safety in relation to patients medicines will continue in this forthcoming year with our new Medication Safety Officer leading this agenda and working with key clinical and management leads. Key actions will include improved training, establishing medicine safety champions, prescribing tips for doctors based on learning from prescribing errors and a drive to further increase medicine incidents reporting to aid learning and improvement. 12

235 PRIORITY 3 Improving Maternity Services We said: The Trust wanted to ensure that all of the women accessing our maternity services would have a positive experience in relation to their care and treatment. This was particularly important in relation to increasing the number of deliveries at Hillingdon from 4,100 to 5,000 babies. This was due to the re-allocation of Ealing maternity services to other maternity units across North West London including Hillingdon as part of the Shaping a Healthier Future (SaHF) programme. How did we do? Key aims we want to achieve in relation to the women s experience: Quality priority Indicator A 10 % reduction in the complaints received on the maternity triage service once this has moved to its new clinical environment A very positive experience for women in the new birth centre monitored via the Friends and Family Test target of >/88% extremely likely/likely to recommend Very positive feedback from women on the new neonatal transitional care model - target of >88% extremely likely/likely to recommend via the FFT Maintain current numbers of Hillingdon Borough women choosing to continue to use the Hillingdon Hospital service, despite the increase in Ealing women accessing the maternity services at Hillingdon. 2015/16 Performance We have seen an improvement in women s satisfaction of the service with approximately 30% fewer complaints received. We achieved 97% satisfaction against a target of >88%. We achieved 97% satisfaction against a target of >88%. All Hillingdon women have been able to access the service during 2015/16. What does this mean for our patients? The substantial increase in activity as part of the transition of Ealing Maternity services has required in-depth planning and robust implementation to ensure a safe and effective service. This work has involved the implementation of new service models such as a midwifery-led birthing centre, ambulatory pathways, a new community team and a transitional care unit. The Trust has wanted to ensure that all women accessing maternity services at Hillingdon whether they are from within or outside of the borough have a positive experience in relation to their care and treatment. We believe the changes we have implemented have improved the quality of care and choice for all women choosing to have their baby with us. The service currently receives positive feedback through the Friends and Family Test (FFT) across all our services. The challenge so far has been the limited number of respondents from service users in the community following the delivery of their baby. A lot of work has been undertaken to increase the number of responses in order to obtain adequate feedback to help shape our services. Following this work there has been a steady increase in the number of respondents providing feedback. We have started displaying you said, we did posters based on the feedback received from FFT, NHS Choices, verbal feedback and complaints. We will continue to encourage responses and act on feedback going forward. All complaints have an 13

236 action plan, where concerns have been identified and learning from the investigations is shared with all staff groups to further improve the quality of the service. Maternity Experience Survey The Maternity Picker Survey, published in October 2015, was sent to women who delivered their baby in February Unfortunately the 2015 survey showed a decline in the women s experience compared to the previous report of This is in contrast with the results received via the Maternity FFT. Although not complacent with regard to the results of the Picker survey, the service has identified that there were mitigating circumstances linked to the SaHF transition planning where vacancies for senior midwifery posts were not allowed to be filled as part of TUPE (Transfer of Undertakings (Protection of Employment) Regulations) - Ealing Senior Midwives were offered vacant posts across the sector. This meant that key leadership roles were left vacant. This included the Postnatal Ward Sister, Infant feeding Midwife and two community team leader posts. A couple of common themes identified in the survey were: not always able to get help from a member of staff particularly in relation to breastfeeding support - now rectified by the employment of Infant Feeding lead and a robust training programme which has helped us achieve a month on month improvement in initiation rates and six-week postnatal rates Hospital rooms/toilets/bathrooms not clean- we are working closely with the cleaning teams and ward sisters to ensure compliance with cleaning standards. This remains an ongoing work in progress. We will be undertaking a mock Picker Survey for women who delivered this February (2016) to measure any improvement in service following the transition of Ealing patients and having filled the senior posts that had been left vacant. As outlined above the service receives highly positive responses in the Friends and Family Test. The service has worked hard to improve response numbers which has been a challenge however it is now achieving above the planned target each month. PRIORITY 4 Improving Communication with our patients We said: We wanted to ensure that there is continuing focus on improving the patient experience and that services that are delivered are truly responsive to individual patient needs. Feedback from a variety of sources including our complaints service indicated that communication from the healthcare team to the patient and their family/carers, as a key patient experience element, still needed to improve. How did we do? The specific goals that we set and the performance during 2015/16 are outlined below: Quality priority Indicator 2015/16 Performance Improved communication from the A&E department: Quarterly audit of quality of A&E discharge summary, demonstrating improvement in standard of information provided. Staff have been unable to complete the quarterly audit as planned due to the increase in activity within the department. There has however been 14

237 Improvement on communication and information provided to patients in A&E Copy of discharge summary provided to patients attending A&E department before they leave Discharge summaries from inpatient episodes will be completed within 24 hours - >80% target discussion and progress within the department on further improvements required as a result of the previous audit undertaken earlier in We continue to receive very positive feedback via the FFT about the A&E service % satisfaction YTD (March). Behind plan. Despite our best efforts this proves to be a very challenging standard to meet with the current activity of the service. The patient s GP receives an electronic summary within 12 hrs of the patient s attendance. Behind plan. We have achieved 57% within 24 hrs. 98.7% of discharge summaries are finally completed but not within the 24 hrs. Improvement in the results of the local quarterly patient experience survey in the following areas*: Involved as much as you wanted to be (Target - 89%) Nurses - Clear answers to questions (Target - 90%) Doctors - Clear answers to questions (Target - 90%) If waiting more than 20 mins, informed and updated of waiting times (Target - 80%) *Based on data available July 2015 and March responses Behind plan. Achieved 84% against a target of 89%. It is disappointing that we have not been able to achieve the stretching target that we set ourselves based on an improved position in 2014/15. Activity and demand for A&E and inpatient services has put pressure on existing staffing resources and impacted upon our ability to make improvement in this key area of patient experience. Behind plan. Achieved 87%. As above. Behind plan. Achieved 86%. As above. Behind plan. We achieved 63.3% against a target of 80%. Further improvements are required in specific departments to improve this score across the Outpatient department as a whole (namely the Eye department and the Mount Vernon Treatment Centre). Within the A&E we continue to receive in the main very positive feedback about people s experience of using our services via the Friends and Family Test survey. We are mindful however that we need to increase the number of patients who provide this feedback and act upon it in a meaningful way. Ensuring patients are involved and that they receive clear answers to questions by all healthcare professionals continues to be a key priority for the Trust as part of our patient experience improvement work. It is disappointing that we have been unable to improve our performance in the key patient experience indicators that we identified for improvement in 2015/16. As a result we will be continuing to focus on these areas and aim to achieve an improvement in 2016/17 as part of Priority 3 Delivering compassionate care and improving communication. The new A&E nurse consultant is going to undertake some specific projects to improve communication with patients and their families and to increase the opportunities for feedback from patients and carers in the first quarter of 2016/17. These include introducing electronic tablets to capture feedback alongside the paper survey, more thorough review of patient responses and actions being taken and a league table for A&E teams with regard to numbers and results of responses received by each team. 15

238 Despite our best efforts in ensuring a discharge summary is provided to each patient that has attended A&E, and within 24 hours to their GP, this remains a very challenging standard to meet within the activity of the A&E service. Overall there has been a steady improvement and now 98.7% of patients leaving the Clinical Decisions Unit within the A&E department receive a copy of their discharge summary albeit not within 24 hours of discharge. Moving forward it has been agreed that each doctor is allocated 30 minutes at the end of their shift to ensure compliance with this standard. The completion of inpatient discharge summaries (letters) within an acceptable timeframe has proved to be a challenge during 2015/16 across the Trust. This causes delayed communication to GPs and potential delay in further follow-up or treatment. A detailed investigation has been undertaken into why delays are occurring and a comprehensive action plan will be taken forward in 2016/17 to resolve the backlog of summaries and ensure a robust system moving forward. With regard to waiting time in the Outpatient department we achieved 63.3% against the 80% target for patients being informed and updated about delays. There are two clinical areas that contribute significantly to this position which are the Eye department and the MVH Treatment centre. Some of the contributing factors that affect the results for these two areas include the environment of the eye department which is very restricted and fragmented. There are three separate waiting areas and as a result the patient s journey is complex. When a clinic delay is announced the patient may just have been moved to another area for clinical input and may miss the announcement. At the Mount Vernon Treatment centre we rely on the Savience system display to advise patients of delays. There are TV screens for patients to see this display which are positioned in two different areas however patients may miss this display depending on where they are sitting. Actions moving forward include Mount Vernon Treatment Centre staff using a Tannoy system in addition to the displays via the Savience system. Staff in the eye department will be encouraged to inform patients at each step of their journey through the department. The Trust participates in the annual national patient survey programme and in addition a number of local patient surveys have also been developed and implemented. The Friends and Family Test has also been fully rolled out to all patient areas. We aim to be a listening and learning organisation, in which concerns that are raised by patients are understood, shared and responded too. Listening to feedback enables our staff to gain a real insight into the patient s experience of care. Involving the patient as much as possible in their care supports an improved experience for patients and assists in maintaining their patient safety; effective communication is a key part of this. LOOKING FORWARD Our Clinical Quality Strategy During 2015/16 we have continued to focus on measuring and monitoring the quality of our services and the care that is delivered to our patients and their families. The Trust s three-year Clinical Quality Strategy has supported this work and has helped us to achieve our vision To put compassionate care, safety and quality at the heart of everything we do. The strategy has provided a structure for ensuring strong clinical governance and ongoing improvement in the quality and safety of patient care. A clinical quality strategy action plan has been reviewed on a quarterly basis at the Quality and Safety Committee (Board committee). Clinical divisions developed local quality actions plans based on the overarching Trust action plan. These formed 16

239 part of their business plans and were used to monitor progress at their divisional performance reviews. The clinical quality strategy also outlines the responsibilities of Trust staff and is supported by our culture and values framework, CARES (Communication, Attitude, Responsibility, Equity and Safety) which embraces a culture that empowers staff to report incidents and raise concerns about quality and patient safety in an open, blame-free working environment. This is supported by the statutory Duty of Candour and best practice guidance such as Freedom to Speak. The Trust will implement a revised Quality and Safety Improvement Strategy for as informed by the Trust Quality and Safety Committee s own review of effectiveness and recommendations arising from the Trust s CQC inspection in October The strategy will clearly articulate our ambitious aims across the domains of patient safety, clinical effectiveness and patient experience. Our quality improvement work will be informed and supported by the learning from and collaboration with colleagues from across the North West London sector as part of the Imperial College Healthcare Partners Academic Health Science Network. Our six quality aims as part our new strategy are as follows: 1. No Preventable Deaths 2. Proactively improving systems to reduce harm 3. Improving patient experience as defined by our patients 4. Achieving the best possible outcomes for patients 5. Ensuring people receive care in the right place 6. Developing a safety culture in which safety is everyone s business Our Sign up to Safety Campaign Towards the latter part of 2014 the Trust signed up to the national patient safety campaign that was launched by the Secretary of State for Health. Sign up to Safety is a campaign to strengthen patient safety in the NHS. Its three year objective is to reduce avoidable harm by 50% and save 6,000 lives. In 2015/16 the Trust developed a detailed plan outlining the work we would take forward to reduce harm and save lives; this was aligned with the Trust s clinical quality strategy. As part of this work the Trust has committed to: listen to patients, carers and staff, learn from what they say when things go wrong and take action to improve patients safety. We want to give patients confidence that we are doing all we can to ensure that the care they receive will be safe and effective at all times. The five key Sign up to Safety campaign pledges are listed below: Put safety first - commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally. Continually learn - make organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe their services are. Honesty - be transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong. Collaborate - take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use. Support - help people understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress. The Trust is continuing to drive forward this work. A steering group has been meeting regularly to review progress and key actions that have been completed include: 17

240 A Sign up to Safety launch event was held in June 2015 to raise awareness of the campaign. Clinical teams were able to share the excellent patient safety improvement work that is already in progress with our patients. A patient engagement event focusing on patient safety and the patient safety champion role was held in October 2015 A staff workshop was held in November 2015 focusing on patient safety incident reporting and the role of the staff champion for safety A staff safety culture survey and a patient engagement in safety survey were conducted We have seen improvements in the key indicators as part of our patient safety priorities and these include: A 2% improvement in medication safety incident reporting during 2015/16 and the employment of a Medication Safety Officer to drive forward our improvement campaign There has been a small reduction in inpatient falls and hospital acquired pressure ulcers; we have not achieved the stretching targets that we set ourselves for the year Improvements in the care for people with dementia (outlined later in report) Improvement in staff awareness of malnutrition in hospital and completion of nutritional risk assessments with staff taking specific actions to address patients needs. Introduction of nutritional link nurses with delivery of training and resource folders for the wards. In addition the Trust held a week long campaign during Nutrition and Hydration week to focus patients, visitors and staff on the importance of nutrition and hydration. Quality priorities for improvement in 2016/17 In this section of the report, we tell you about the areas for improvement for the next year in relation to the quality of our services and how we intend to assess them. To develop these priorities, the Trust held an engagement exercise with key stakeholders (Foundation Trust members, HealthWatch, Governors, local voluntary organisations) on 24th November This event included a review of our current position against this year s priorities and a discussion on the quality priorities for the forthcoming year. Results from the discussions on the day show that some areas of improvement that we have focused on during 2015/16 still need further work which includes improving the experience of people requiring medicines in the inpatient and outpatient settings and ensuring the safety of vulnerable and older people, particularly in relation to discharge management and for those with disabilities. It was recognised that this work will continue outside of the priorities identified in this year s Quality Report as there are key working groups that continue to focus on these improvement areas further. An outline of the key results from the consultation is included in the table below: Quality Report 2015/16 Consultation Respondent Category Quality Priority Topic 2016/17 Patient Safety Staff Healthwatch Governors and Foundation Trust (FT) members NEWS compliance testing the knowledge and understanding of the staff Improve recruitment and retain staff Improved communication about medications and the needs of individual patients Reduce patient harms, such as patient falls 18

241 Clinical Effectiveness Staff Healthwatch Governors and FT members Patient Experience Staff Healthwatch Governors & FT members Ensure integrated care systems and collaboration Need to have electronic records Care of the elderly not well co-ordinated and communication can be ineffective Delayed discharges - prioritise patients for discharge Processes for patients with mental health issues need improving Improved communication and staff attitude, ensuring robust CARES programme - delivery of customer care training Lack of positive response from staff to suggestions made by patients All patients must receive individualised care thorough assessment of needs Sensitivity with giving information that is tailored to individual patients Keeping people updated in A&E There is no loop system for hard of hearing patients. Staff have to raise their voices and the environment can be noisy Visual information often not suitable for people with eyesight problems. Clinic organisation not good too many cancellations Patients waiting for TTAs. Better co-ordination with the Pharmacy department In addition, the Trust triangulated data from several sources to identify themes and recurring trends. The Trust has engaged with clinical and management staff via divisional governance board meetings and divisional reviews to establish priorities. During the last year there has continued to be active engagement with our local Healthwatch including its members on several of our Trust working groups. The Trust has also met with Healthwatch on a quarterly basis to review quality and patient safety data and progress on the quality report priorities. This engagement has proved invaluable in being able to hear the feedback that Healthwatch receives from people with which it engages. The Board has considered all of the suggestions put forward and the review of data and the priorities below have been recommended for inclusion in the Quality Report for 2016/17. These have been identified as falling under the three domains of safety, clinical effectiveness and patient experience as follows: No. Priority Safety Clinical Effectiveness Patient Experience 1 Achieving NEWS compliance to support early escalation of the deteriorating patient 2 Achieving improvement in relation to seven day working priorities 3 Delivering compassionate care and improving communication 4 Safer staffing improved recruitment and retention to ensure delivery of safe care. 19

242 Achieving NEWS (National Early Warning Score) compliance to support early escalation of the deteriorating patient Why is this one of our priorities? Maintaining patient safety is a key priority for the Trust. The National Early Warning Score (NEWS) is a simple physiological scoring system that can be calculated at the patient's bedside, using agreed parameters which are measured in all patients who attend hospital. It alerts health care staff to abnormal physiological parameters and triggers an escalation of care and review of the patient. Clinical deterioration can occur at any stage of a patient s illness. There will be certain periods when a patient is more vulnerable to deterioration for example, the onset of illness, during surgical or medical interventions and during recovery from critical illness. Patients on general adult wards and emergency departments who are at risk of deteriorating may be identified before a serious adverse event by changes in their physiological observations. Timely interpretation and escalation of recognised deterioration is of crucial importance in minimising the likelihood of serious and adverse events including cardiac arrest and death. NEWS audits conducted during 2015/16 have shown that staff are not fully compliant with our Trust NEWS policy with regard to fully documenting the evidence of escalation and the review of the acutely unwell patient. There needs to be increased training in this area and there also needs to be a better understanding of when it is appropriate to make physiological parameter changes dependent on the patient s condition. This was also a safety priority identified by our stakeholders at the Quality Report consultation event. How are we doing so far? Our NEWS compliance audit scores have not demonstrated significant improvement during this past year. In addition, patient safety incidents concerning NEWS compliance continue to be reported via our incident reporting system. There have also been two serious incidents concerning NEWS and the escalation of the deteriorating patient that have been investigated using detailed Root Cause Analysis investigation by a multi-professional panel. Inadequate NEWS compliance has now been put onto the Trust s corporate risk register. Identifying improvement in NEWS compliance to support the care of the deteriorating patient as one of our quality priorities will assist in driving up performance to ensure our patients receive safer care. Our aims for 2016/17 are: All aspects of the NEWS process and the outcome measures need to be addressed. This includes education to all healthcare professionals, policy review and continuing audit. Key objectives: Review the NEWS education programme this includes revisiting what is taught, how it is taught and by whom. Explicit learning outcomes to be made transparent and to ensure that evaluation of education reflects learning outcomes. Continue NEWS audits regarding completion of NEWS charts and also compliance with escalation policy via monthly 24 hour snapshot NEWS audits. To aim to achieve greater than 90% in all audited criteria as a minimum. 20

243 Reduction in the number of patient safety incident forms completed of moderate severity or higher. Achieving improvement in relation to seven day working priorities Why is this one of our priorities? NHS England has committed to offering a much more patient-focused service moving towards routine NHS services being made available seven days a week. Evidence shows that the limited availability of some hospital services at weekends can have a detrimental impact on outcomes for patients, including raising the risk of mortality. North West London (NWL) as a sector accepted the opportunity to be a national First Wave Delivery Site for the new seven day services programme. As part of this programme, all acute trusts have agreed to achieve delivery of four prioritised Clinical Standards by April NHS England, Monitor & the Trust Development Authority wrote to all acute trusts in England to ask that they establish a 2015/16 baseline for four of the 10 Clinical Standards for seven day service. The four standards were selected with the Academy of Medical Royal Colleges as having the most impact on reducing weekend mortality: Standard 2: Time to First Consultant Review Standard 5: Access to Diagnostics Standard 6: Access to Consultant Directed Interventions Standard 8: On-going Review (planned for 2016/17) How are we doing so far? Our aims for 2015/16 were: No. Item /2016 CQUIN standard 3 Multi professional team review for 95% of patients in Medicine and Surgery /2016 CQUIN standard 4 Shift handovers with 95% to meet national standards in Medicine and Surgery /2016 CQUIN standard 5 7 day consultant presence in radiology, quarter 4 report showing 95% of all urgent tests and 95% of all non-urgent tests are reported within the London and national standards time frame /2016 contract standard 2 Time to first consultant review Progress The Trust has achieved 70% of targets for working towards providing 7 day services. There is still room for further improvement in some areas for example, faster reporting of diagnostic test results and multidisciplinary assessment for patients admitted in the evening THHFT has participated in a repeat national audit to establish baseline results and is yet to be analysed and published. 15/16 saw physicians being resident on call at weekends, and a/e consultants working extended hours 7 days a week. 21

244 5. Better Care Fund (BCF) standard 9 Transfer to Community, Primary and Social Care A multi provider action plan has been agreed examples of some of the achievements include management of complex wound care is now available for elective patients in the community, the establishment of an integrated discharge team in pilot form based in the acute medical unit. Our aims for 2016/17, in addition to embedding and building on the achievements from 2015/16, are: Model of Care required to deliver Standards 2 & 8 Define clinical outcomes Develop model of care to meet clinical outcomes and determine consultant requirement Test proposed model of care against current clinical capacity and evidence base Plan delivery of agreed model of care Radiology & Diagnostics (Standard 5) Imaging inpatients within 24 hours of request Timely reporting compliant with national standards Practical and functional pathways for radiological diagnostics & interventions agreed Formalised network across NWL for specialised reporting Interventions (Standard 6) Robust pathways for inpatient access to interventions in place 24 hours a day, 7 days a week (critical care, interventional radiology, interventional endoscopy, emergency general surgery, renal replacement therapy, urgent radiotherapy, thrombolysis, Percutaneous Coronary Intervention (PCI coronary angioplasty) and cardiac pacing. Discharge Improvement (Standard 9) Single NWL-wide discharge assessment form Current state overview of each Clinical Commissioning Group (CCG) Individual CCG Implementation Plans/ Roadmaps Delivery of workshops required as part of the implementation roadmap Single Points of Access in place for each CCG that include the minimum required services and that accept & use the common NWL assessment form THHFT has appointed a lead Clinician to help achieve the key milestones outlined above. Delivering compassionate care and improving communication Why is this one of our priorities? We have received feedback from patients and their families that this is an area that we need to continue to focus on. Listening to feedback, as part of our communication with patients, enables 22

245 our staff to gain a real insight into the patient s experience of care and make further improvements. Ensuring staff are responsive to patients needs and communicate effectively is a key priority. How are we doing so far? The CQC found during their inspection in October 2014 that patients reported that they felt well cared for and the Trust was given a good rating for the caring domain as part of their assessment process. We have implemented John s Campaign, a national initiative to enable carers to support their loved ones outside of visiting times in accordance with their wishes. This provides for a better patient experience and can alleviate patient anxiety during a hospital stay. Key staff from different professional groups have undertaken the Alzheimers Society Foundation Certificate in Dementia Awareness which focuses on providing patient-centred care. The Trust has continued to deliver training for our staff on improving the patient experience of care via a Customer Care training programme. To date 47% of our staff have attended this training. The elements of compassionate care and communication continue to be monitored via our local patient experience survey and the aim will be to realise improvement in this area. Initiatives introduced include patient stories being presented at every Trust Board meeting, a refreshed Experience and Engagement Group involving public governors, Healthwatch Hillingdon and representation from the voluntary sector and improvements made to the availability of written information for patients. With regard to improving communication and accessibility to information all organisations that provide NHS or adult social care must implement the Accessible Information Standard by law with effect from 31 st July The aim of the accessible information standard is to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand and any communication support that they need. This includes making sure that people get information in different formats if they need it, for example in large print, braille, easy read or via . The standard also includes providing support from a British Sign Language (BSL) interpreter, deaf-blind manual interpreter or an advocate. In addition, the Trust participates in the annual national patient survey programme (awaiting results for 2015 CQC have confirmed that there are to be published early June). The Friends and Family Test has also been fully rolled out to all patient areas with valuable feedback being provided in the commentary from patients and their families. During 2015/16 over 25,000 patients took up this opportunity and answered the FFT question. Results from our local surveys and the FFT can be seen in Part 3 of this report; also included are some of the themes from the feedback which include elements of communication and what we have done to improve on this. There will be an increased focus on staff undertaking customer care training in 2016/17 to ensure more of our staff are better equipped to enhance communication with our patients and their families. Our aims for 2016/17 are: To achieve >96% satisfaction in the Friends and Family Test survey by March

246 Realise a 5% reduction in complaints related to key themes including communication and staff attitude by March Improvement in national patient survey metrics for areas related to compassionate care and communication target 90% by March The Trust is currently working towards implementing the Accessible Information Standard by reviewing current processes and undertaking a gap analysis to fully deliver the standard in 2016/17. 24

247 Safer staffing improved recruitment and retention to ensure safe care delivery of Why is this one of our priorities? We need to ensure that we have safe staffing levels for medical, nursing and allied health professional (AHP) staff groups. This allows for improved continuity of care, effective communication and improved quality and safety of care for our patients. There are significant recruitment challenges with these staff groups across London and nationally. The Trust needs to agree a more effective and robust recruitment and retention strategy to meet these challenges and to be the employer of choice for staff. We also need to reduce our vacancies in these staff groups and our reliance on agency staffing. We also want to ensure that staff appointed at the Trust are recruited to our values and deliver safe and compassionate care to our patients. This is a priority as it assists with staff morale and it ensures a higher quality of care. It also improves retention with regard to a better staff experience with their environment of work and the teams they work within. This was a safety priority identified by our stakeholders at the Quality Report consultation event. How are we doing so far? The Medical Staffing department are currently working with the surgical division providing information on vacancies and examining new ways of working. Further work is being taken forward in 2016/17 with the other clinical divisions on planning recruitment to their outstanding vacancies. For AHPs, numerous initiatives have already been introduced. Some of these include promoting our hospitals at University Open Days and via recruitment flyers for use at local events. Attendance at Careers Fairs has led to candidates applying for roles, and being interviewed for posts. In Occupational Therapy (OT) and Physiotherapy (PT), graduate Mailing Lists have been compiled to create personal links with potential candidates. Services have continued to take AHP students as many of our AHPs have been attracted to work here having been with us on clinical placement Therapies have also successfully piloted a buddy scheme to support new joiners and rotational positions for staff have been expanded across dietetics, OT and PT. Rotations with other Trusts have been explored although not yet established. Advanced roles have been developed with an additional Extended Scope Physiotherapist trained to work alongside the orthopaedic team. For nurse staffing there has been a continuous drive to reduce nurse vacancies throughout the year with a rolling programme of recruitment days at the Trust, attendance at university job fairs and targeted European campaigns. The recruitment team has worked closely with the medical and surgical divisions to implement bespoke recruitment plans for areas with specialised needs. We have however continued to have staffing gaps and we have relied on agency staff to ensure our additional wards (open to meet the demand for inpatient beds) are safely staffed. Where agency staff are utilised our recruitment teams ensure that approved agencies are used and that all agency nurses have had the appropriate checks and have the appropriate safety training. All agency staff are monitored by the wards for their competences including their verbal communication skills, should any short falls be identified then it would be reported to the 25

248 Temporary staffing manager for investigation and the agency nurse would be suspended from working at the Trust. Enhanced nurse induction programmes have been developed to support the newly qualified nursing staff that we have been able to recruit and those staff recruited from overseas. Literacy and numeracy skills are tested alongside spoken English and language skills. Our aims for 2016/17 are: Nurse Staffing To significantly reduce vacancy levels in specific clinical areas: A&E, the Acute Medical Unit and Fleming ward (surgery and gynaecology) aim to achieve this by end of July 2016 To develop a peripatetic (flexible, responsive and targeting gaps) nursing team to respond to additional short-notice staffing requirements (TBC) To embed a proactive recruitment programme based on anticipated demand surge aim to achieve recruitment programme by end of June Planning for international recruitment to the Philippines by end of July To achieve a vacancy rate for nursing of no more than 8% in line with the Trust target and a turnover rate no greater than 10% To continue to develop and implement retention initiatives (TBC) Medical Staffing To have a Medical Locums bank in place where gaps can be filled with our own Trust doctor to reduce the need for agency workers and be within the caps for agency usage aim to achieve a phased launch by July Booking staff currently being recruited. To recruit to the outstanding vacancies once the divisions have developed their recruitment plan and shared this with Medical Staffing aim to achieve this by end of May Allied Health Professionals A workforce review will be completed within sonography and radiographers will complete sonography training - aim to achieve the review by end of August 2016 and two trainee sonographers to complete the course by September A shared competency framework will be established for OTs and PTs on the acute wards aim to achieve this by end of August 2016 A development programme to support Band 5 OTs and PTs to move to Band 6 posts within the Trust - aim to achieve this by end of October 2016 Pharmacy will be a pilot for central recruitment of pre-registration pharmacists which is envisaged to improve recruitment. We will be participating in the HEE centralised recruitment for the intake in August 2017 with interviews for this will being held in September 2016 with a recruitment fayre for the candidates in July Our quality priorities will be monitored by clinical and management teams through their divisional performance reviews and via reports to the relevant sub-board Committee. The results will also be published in the 2016/17 Trust Annual Report. 26

249 Part 2.2 Formal statements of assurance from the Board Information for our regulators Our regulators need to understand how we are working to improve quality so the following pages include specific messages they have asked us to provide: Provision of NHS Services During 2015/16 The Hillingdon Hospitals NHS Foundation Trust provided medicine, surgery, clinical support services and women s and children s NHS services. The Hillingdon Hospitals NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by these relevant health services reviewed in 2015/16 represents 100% of the total income generated from the provision of the relevant health services by the Hillingdon Hospitals NHS Foundation Trust for 2015/16. Participation in clinical audit National audits During 2015/16 37 national clinical audits and three national confidential enquiries covered relevant health services that The Hillingdon Hospitals NHS Foundation Trust provides. During that period The Hillingdon Hospitals NHS Foundation Trust participated in 95% of national clinical audits and 100% of national confidential enquiries of the national clinical audits and confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that The Hillingdon Hospital NHS Foundation Trust was eligible to participate in during 2015/16, and for which data collection was completed during 2015/16, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Audit Participated Cases submitted Acute Myocardial Infarction Yes 100% Bowel Cancer Audit Programme Yes 100% Adult Critical Care Case Mix Programme Yes 50% National Paediatric Diabetes Audit (Royal Yes 100% College of Paediatric and Child Health) Elective Surgery (National Patient Reported Outcome Measures (PROMS) Programme) Yes Hip 255 Knee 377 Hernia 43 Varicose Veins - 26 Emergency Use of Oxygen Yes 100% Falls and Fragility Fractures Audit Programme National Hip Fracture Database Yes 100% Falls and Fragility Fractures Audit Programme National Inpatient Falls Audit Falls and Fragility Fractures Audit Programme (FFFAP): Fracture Liaison Service Database Yes 100% Yes Audit launched in January Trust has registered to participate for data collection commencing March Yes 100% Inflammatory Bowel Disease (Biologic Audit) Major Trauma Audit Yes 31% National Audit of Intermediate Care N/A Service not in place to enable Trust to submit to this audit 27

250 National Cardiac Arrest Audit Yes 100% National Chronic Obstructive Pulmonary N/A Disease (COPD) Audit Programme (pulmonary rehabilitation) National Comparative Audit of Blood Yes 100% Transfusion: Audit of Transfusion in Children and Adults with Sickle Cell Disease National Comparative Audit of Blood Yes 100% Transfusion: Audit of Patient Blood Management in Scheduled Surgery National Comparative Audit of Blood Yes 100% Transfusion: Audit of Lower Gastrointestinal Bleeding and the Use of Blood National Complicated Diverticulitis Audit Yes 100% National Adult Diabetes Audit : National Yes Trust commenced participation in July 2016 Foot Ulcer audit National Adult Diabetes Audit : National Inpatient Yes 100% Diabetes Audit National Adult Diabetes Audit : National Yes 100% Pregnancy in Diabetes Audit National Adult Diabetes Audit : Out-patient Management No IT requirements are under review to enable future participation. Mortality and Morbidity in Diabetes Yes 100% National Emergency Laparotomy Audit Yes 84 cases submitted (NELA) National Heart Failure Audit Yes 72% National Joint Registry Yes Hillingdon 56% Mount Vernon 88% National Lung Cancer Audit Yes 100% National Ophthalmology Audit Yes Audit commenced in September 2015, Trust is participating National Prostate Cancer Audit Yes 100% National Intensive and Special Care Yes 100% (NNAP) National Oesophago-gastric Cancer Audit Yes 100% Paediatric Asthma Yes 100% National Audit of VTE risk in lower limb Yes 100% immobilisation (College of Emergency Medicine) National Audit of Vital signs in children Yes 100% (College of Emergency Medicine) National Audit of procedural sedation in Yes 100% adults (College of Emergency Medicine) Rheumatoid and early inflammatory arthritis No Medical Director and Divisional Director for Medicine have agreed with our Rheumatology team that participation in this audit would not contribute significantly to the quality of the service provided by the Trust. Sentinel Stroke National Audit Programme Yes 100% UK Parkinson s Audit Yes 100% Head and Neck Oncology (Data for Head N/A and Neck Oncologists) Clinical Outcome Review Programmes This is N/A to the Trust - for 2015/16 this audit was only applicable to Trusts who have data published as part of the Consultant Outcome Publication process. 28

251 MBRRACE-UK: Mothers and Babies: Yes 100% Reducing Risk through Audits and Confidential Enquiries across the UK National Confidential Enquiry into Patient Yes 100% Outcome and Death (NCEPOD) Acute Pancreatitis NCEPOD Sepsis Yes 50% The reports of 13 national clinical audits were reviewed by the provider in 2015/16 and The Hillingdon Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided. Audit National Pregnancy in Diabetes Audit BTS Adult Community Acquired Pneumonia National Cardiac Arrest Audit National Emergency Laparotomy Audit (NELA) National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme Initial management of the fitting child in the Emergency Department Mental health in the Emergency Department Assessing for cognitive impairment in older people in the Emergency Department National Paediatric Diabetes Audit Actions A masterclass on diabetes in pregnancy has been given to local GPs. Shared GP guidelines have been updated and are available on the Extranet. Local hospital diabetes in pregnancy guidelines are currently being updated. The Trust has an antibiotic guideline app. To support scoring the severity of pneumonia, the CURB score, has been incorporated into the antibiotic guidelines app. The Trust is regularly in line with NCAA National average for cardiac arrest standards. On the one occasion the hospital was identified as having higher cardiac arrests at the weekend, a review of all cases was undertaken. This was completed by the Lead Resuscitation Officer no issues were identified. A local protocol and pathway is in development to support formalising a consultant-delivered service for emergency laparotomy patients. This will cover cross disciplinary roles between surgeons, anaesthetists, radiological and laboratory services and theatre and critical care staff To help ensure COPD patients receive specialist respiratory review a COPD hotline (mobile number staffed during working hours) has been put in place since Jan This has been distributed to all appropriate clinical areas including A&E. To increase the number of patients offered specialist respiratory follow up on discharge, an Integrated care COPD clinic set up as of Feb All patients seen by the COPD outreach team are offered an appointment. Guidelines for clinic referrals to be circulated to acute medical consultants for all other patients. This audit highlighted that blood glucose is not always measured/documented in the fitting child. Current guidelines are being reviewed for update. Following this education will take place. Discussion to take place with Central North West London NHS Foundation Trust to review documentation regarding risk assessment and mental state examination. A&E leads are working with Trust Dementia leads to review what assessment proforma is to be used in the Emergency Department. Diabetes poor control action board and meetings in place. Paediatric diabetes team have all been trained as a team in health coaching to encourage self-management. A transitional service survey is underway. A flow chart for management of high blood pressure and microalbuminuria is in development. 29

252 National Audit of Mortality and Morbidity in Diabetes National Inpatient Falls Audit National BTS Emergency Use of Oxygen Audit NCEPOD Just Say Sepsis For nurse training around diabetes management, weekly walk-in sessions have been put in place, topics include management of high blood sugar (hyperglycaemia) and low blood sugar (hypoglycaemia). In addition to this insulin education training is being provided to junior doctors. The blood glucose and hypoglycaemia management charts are currently being revised so that both the charts can be incorporated into a single chart for ease of use for staff. All diabetes protocols are widely available on the hospital intranet and are promoted by the diabetes specialist team. Following this audit we have continued our bi-monthly Falls Steering group, with executive lead support, to oversee the Trust wide strategy for a reduction in Falls. A Falls Working Group is being set up within each Division to report back to the Steering Group and share local learning. A quality improvement project dedicated to the assessment of patients having had a fall and their aftercare is currently ongoing to standardise and streamline our approach. The Trust is looking at training needs and documentation improvements. A specific oxygen monitoring chart is being considered to be used alongside the existing section within the prescription chart. An inpatient Sepsis Lead is being identified to work alongside the consultant lead in A&E. The sepsis proforma and guidelines will be reviewed and re-published. The reports of 82 local clinical audits were reviewed by the provider in 2015/16 and examples of The Hillingdon Hospitals NHS Foundation Trust actions to improve the quality of healthcare provided are as follows: Audit Audit of details regarding Acute Kidney Injury (AKI) on Discharge Summaries to GPs Clinical Record Keeping Standards Safe Sedation at Hillingdon Hospital Actions This audit is against the national standard for patients with a confirmed diagnosis of AK which is that the hospital discharge letter to the GP should contain advice regarding the stage of AKI along with any recommendations for repeat blood tests. During 2015/16 the hospitals' Consultant Lead for AKI has been undertaking the audit and providing targeted clinical training and awareness sessions to support improvement where required. The Trust has also included mandatory questions in the electronic discharge summary system to prompt doctors to include appropriate information. As an improvement in identifying authors of specific entries within clinical notes stamps have been provided to doctors and nurses To raise awareness of Trust standards for record keeping poster has been developed and has been made available within the hospital We are going to agree the 5 main areas for improvement as key indicators for monitoring, these will include documenting date, documenting time, identifying who has written in the notes/use of the name stamp, documenting bleep number. Safe Sedation guidelines have been updated to include sedation in Emergency Department, Endoscopy and Radiology. A pre-procedure checklist is also being developed for use in areas providing sedation. 30

253 Post-operative Bowel Monitoring Timing of Discharges from ITU and the audit of ITU handback Protocol/discharge summary Compliance with the Recommendations on Monitoring following Epidural Catheter Removal Bedside Blood Transfusion Practice Delirium WHO Checklist Dementia Carers Survey Bowel surgery is part of an Enhanced Recovery Programme (ERP). To support improved documentation of post-operative bowel monitoring the ERP proforma has been updated to include daily post-operative documentation of bowel actions. This audit has resulted in the improvement in the level of detail and the quality of medical and nursing handover when a patient is discharged from ITU to a ward. Following implementation of the improved discharge document, a reaudit has shown a significant increase in the audit results, including improved documentation of: ceilings of care, nutritional needs, physiotherapy / Rehabilitation needs, psychological/emotional needs, communication/speech and language needs. Overall, there has been positive feedback from staff using the revised discharge summary. Teaching on the Management of Leg Weakness/Motor Block with Epidural/Spinal Analgesia guideline is included on the Acute Pain study days which are held regularly 3 or 4 times a year. The Acute Pain nurses also educate ward staff during their daily Acute Pain rounds on the Surgical wards and ITU. The Consultant Lead for Acute Pain has provided study sessions to the junior doctors as part of their Foundation Programme training. The Trust Transfusion Practitioner has undertaken targeted awareness and training on the transfusion process and has updated the mandatory training to focus on the areas identified for improvement within this audit. To continue to drive improvement in standards, the Transfusion Practitioner has increased visibility on the wards and undertakes snapshot checks on transfusion charts - real time feedback is given to the nurse in charge of the shift. New delirium assessment form is being designed & agreed with clinical leads for dementia, this will then be issued for use in the hospital. Additional delirium awareness training will be provided to support implementation of the revised form. A Trust-wide WHO Checklist Policy is going to be produced. This will include all areas of the hospital that use safety checklists (as well as theatres) for example, interventional radiology. The dementia cares survey is part of a larger project to improve dementia care in the Trust. Actions taken to make improvements have been Dementia Resource folders are in place within the Trust, John s campaign was launched in the Trust. The survey has been amended to include the ward, so the Dementia Specialist Nurse where required, can target awareness and training to raise standards. Do Not Actively Resuscitate (DNACPR) The hospital Resuscitation Officers, undertake monthly DNACPR snapshot audits looking at completion of the forms, this takes place alongside an annual DNACPR standards audit. Actions taken include more emphasis on DNACPR in existing life support training and on induction. Awareness raising, for nursing staff, to support meeting DNACPR standards Paediatric CAS Card Safeguarding Audit - A&E To improve awareness of the safeguarding checklist, specifically the requirement to refer to the Health Visiting Team if the child has had more than 3 attendances in 6 months, local 31

254 communication has taken place within A&E. This has also been added to existing training sessions to improve this standard. Commitment to research as a driver for improving the quality of care and patient experience The number of patients, receiving relevant NHS health services provided by The Hillingdon Hospitals NHS Foundation Trust in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was 444 patients. The Hillingdon Hospitals NHS Foundation Trust has a good research track record for a hospital of its size. Our main research activity is recruiting patients into high quality National Institute for Health Research (NIHR) portfolio adopted multi-centre trials. We participate in commercial research funded by the pharmaceutical industry and non-commercial research which is funded from the Department of Health via the NIHR North West London (NWL) Clinical Research Network (CRN). In 2015/16 we received 380,528 from the NWL CRN for this work. The funding enables the Trust to employ research nurses and data managers to support the clinicians in this work. Our Strategic Aims for 2014 to 2019 are: To expand the number of patients recruited into high quality clinical trials To expand the number of Specialties that are actively participating in clinical trials To adapt to the changing National and Regional organisation of clinical research and funding. This has enabled us to offer a greater number of patients, from different clinical areas, the opportunity to participate in research. In 2015/16 we opened our first research study in Critical Care. We also employed our first Research Midwife and we now have a number of studies running in our Maternity Unit. Participation in clinical research demonstrates The Hillingdon Hospitals NHS Foundation Trust s commitment to improving the quality of care we offer and to making our contribution to the nation s wider health improvement. This also allows clinical staff to stay abreast of the latest treatment possibilities giving patients access to new treatments that they otherwise would not have. The Trust has an extensive research portfolio with a balance of observational and treatment trials across many clinical areas including cancer, stroke, haematology, paediatrics, and many of the general medicine and surgical specialities. In 2016/17 we plan to become more research active in musculoskeletal disorders and Diabetes. We also support PhD and Masters Students from the local universities giving them access to our patients and staff for their projects. In 2015/16 we approved and supported eight such university student projects. These are due for completion during 2016/17. During 2015/16 we had approximately 65 NIHR Portfolio Studies open or in follow-up and we recruited 480 patients into 39 trials. All of our research activity is scrutinised for quality and compliance to the standards expected by the Research Governance Framework. In addition we work to comply with the Department of Health NIHR objectives. 32

255 Lessons learned from Serious Incidents During 2015/16, the Trust reported 35 Serious Incidents in accordance with the national Serious Incident (SI) reporting framework and the categorisation of SI cases. Seven of these cases were subsequently de-escalated as not meeting the SI criteria on further investigation. Two Never Events (both misplaced nasogastric tubes) were reported, one in February and one in March These investigations are currently underway. Serious Incident cases include unexpected admissions to neonatal care, grade 3 or 4 pressure ulcers and categories such as unexpected death, sub-optimal care of the deteriorating patient, delayed diagnosis, drug incidents and surgical error. Nine of these cases have been Non-Executive/Executive Director led panel investigations (these are usually formed for Never Event and unexpected death cases). There were two Grade 3 and two Grade 4 pressure ulcers (these involve partial or full thickness skin loss and damage to the deepest layer of skin) reported during the period. Protecting patients from avoidable harm is something to which there is universal agreement and the Trust has clearly defined processes and procedures to follow to help to reduce the risk of these events occurring. However where a serious incident does occur lessons need to be learnt through a process of root cause analysis investigation and actions taken to prevent reoccurrence. Some of the learning from these Serious Incidents during 2015/16 includes the following: Area Division Summary Effective communication Maternity Communication in both verbal and written format should be effective. This refers to communication between staff, across the ward and between organisations. Record keeping Maternity Documentation completed in retrospect, must be marked as such in the patient s notes. It is also best practice to complete records immediately following the event. Following best practice and guidelines Maternity Staff must follow best practice guidelines at all times, for consent, maternal observations, vaginal examination and management of post postpartum haemorrhage. Clinical Leadership Maternity Leadership of the emergency procedure must be clear and concise. Patient pathway of care Maternity It is essential that women are moved from Maternity Triage within an appropriate timeframe to the relevant care setting. Translation services Maternity Necessity to provide an appropriately trained translator to minimise disruption to the patient s diagnosis and treatment pathway Early warning scoring systems Maternity MEWS charts must be routinely used by all staff when women are admitted to Maternity Triage. Blood sampling Maternity When haemolysed blood results are recorded, the full clinical picture should be taken into account and reviewed as if it was an abnormal result. Clinical handover Maternity Current structure of patient handover needs to be improved Review of diagnostic imaging Medicine There should be a process in place that ensures the requesting consultant, or an appropriate member of their team, review the final radiology report prior to discharging a patient. Escalation of diagnostic findings Medicine There should be consistent pathways and processes in place to communicate and escalate suspected cancer findings in diagnostic reporting. Identification of patients Medicine When requesting a diagnostic test via the Trust s electronic system staff must always search using the patient s hospital/nhs number. Information on a request number should be triangulated using the patient s surname, date of birth, hospital or NHS number. Triangulating patient Medicine identifiers Labelling of samples Medicine Self-adhesive addressograph labels which detail the patient s demographics should be used when sending samples for processing to histopathology. Handwritten labels should not be accepted from departments within the Trust. Manual handling requirements Medicine Greater consideration should be given to meeting the care/moving and handling requirements of all obese/bariatric patients, where the patient has suffered a stroke these needs will be amplified. 33

256 Pressure ulcer prevention Medicine The procedure for recording pre-existing tissue damage, assessing risk, developing a management plan, and escalating concerns should be reviewed; tissue viability needs should be reviewed by the MDT as an intrinsic component of the patient s health status. Pressure ulcer prevention Medicine Access to specialist expertise in tissue viability and manual handling should be reviewed and sourced. Pressure ulcer prevention Medicine Information about the range of technical equipment available to support obese or bariatric stroke patients should be readily available on the ward. Staffing Medicine Recognising the impact on the safety and quality of care for all patients if patients with specific needs are accepted without having the required equipment and/or staffing level. Escalation within the Resus room in A&E Medicine There needs to be clear definition of the roles and responsibilities of the nurse in charge of Resus. NEWS compliance Medicine As an addition to the next steps implementing NEWS into the hospital, designate a clinical governance meeting to embed a framework for reviewing NEWS policy, practice and effectiveness. Care of the patient with Sepsis Medicine Identify a Trust-wide Sepsis lead to champion Sepsis management and compliance. ITU Referral process Surgery The ITU referral pathway should be reviewed and disseminated Trust-wide. Review the Trust s process of communication with family and friends. Communication with Surgery families ITU team Surgery Review current ITU nursing roles and responsibilities regarding handover practices. Medication history Surgery Medication records are to be ratified as soon as possible following a patient s admission to hospital, including contact with the GP. Omitted medicines Surgery Nursing staff need to record in the prescription chart the reason why prescribed medication has been omitted. Record keeping Surgery Medical staff should document reasons for prescription changes in the patient s record. Nutritional assessments Surgery Nutritional assessments need to be completed and clear clarification made on recommended oral intake of solids and fluids. Diabetic management Surgery Early referral of eligible patients for specialist diabetes advice and management is vital for safe glucose management. Patient transfers Surgery Evening patient transfers to other wards to be arranged and completed before the day shift nurses finish duty. Resuscitation procedure Surgery If in doubt of the resuscitation status of a patient staff must put the cardiac arrest call out and start basic life support. Patient care and management Surgery The importance of team working, clinical handover and effective leadership in holistic patient care and management. Staffing Surgery Agency staffing should be kept to a minimum to support continuity of care and high quality care. Clinical pathway Surgery Standardised post-operative care of the patient having a reversal of ileostomy is required Prescription charts Surgery All drugs prescribed for inpatients should be written on a single inpatient drug chart Discharge communication Surgery Clear communication is required with the patient and their family regarding discharge Referral pathways Surgery The Clinical Team who are referring to tertiary centres need to ensure that they follow the agreed referral process and make it clear when the referral is of an urgent nature. Medical referrals Surgery There needs to be clarity on what constitutes a routine referral as opposed to an urgent, critical or life-threatening referral and the acceptable timeframe for these to happen. Communication with patients Surgery There should be a detailed, documented, discussion with patients about their diagnosis, the severity and what to do if symptoms worsen. Support for patients Surgery Clinicians should consider asking for a nurse to be part of the medical consultation to provide support to the patient when breaking bad news. Patient letters Surgery The communication processes for dictating/sending referral letters 34

257 should be reviewed and all letters should be uploaded to PAS and copies filed in the patient s notes in a timely manner. Review of imaging results Radiology / Surgery Radiology and Surgical teams should jointly review contrast enema results before the decision for surgery is made Review of x-rays Radiology All routine x-rays to be examined holistically looking for anything else that may be present not just the reason for original request. Patient symptoms Radiology The need to explore symptoms being described by the patient and not rely entirely on imaging. Supervision of practice Radiology Procedures undertaken by Radiology Registrars should be authorised by a consultant radiologist unless the Radiology Registrar is deemed competent to act without consultant input in specified procedures Serious incident and never event actions plans based on the learning from investigations are implemented and monitored via clinical divisional governance boards until fully completed. Director-led panel investigation reports and action plans are approved and reviewed by the Trust Board until fully completed. A recent audit conducted by the Trust s internal auditor, Tiaa, gave reasonable assurance on the processes and systems that are in place within the Trust to adequately learn from patient safety incidents. An action plan has been developed to ensure investigations are completed within acceptable timeframes and that the learning is shared more widely across the organisation. As part of our duty in being open and honest with patients and their families, the findings from serious incident investigations are shared with them and information is provided on the learning and the actions that the Trust is taking forward to prevent reoccurrence. Statutory Duty of Candour Key recommendation from the Francis Inquiry The Duty of Candour was passed by Parliament 6 th November 2014 and took effect 27 th November This places a requirement on providers of healthcare to be open with patients when things go wrong. Providers are required to establish the duty throughout their organisation ensuring honesty and transparency are the norm.. What is the Statutory Duty of Candour? Where a notifiable safety incident has happened a health service organisation must as soon as reasonably practicable: Notify the patient that a safety incident has happened and apologise Provide an account of all the facts known about the incident Advise the patient what further enquiries into the incident are appropriate Provide reasonable support to the patient Follow up in writing confirming the information and results of further enquiries and an apology What is a notifiable safety incident? Any unintended or unexpected incident that occurred in the organisation s care that resulted in or appears to have resulted in: Death directly related to the incident; or Severe harm, moderate harm or prolonged psychological harm (at least 28 days) What does moderate harm mean? Moderate harm means: Harm that requires a moderate increase in treatment, and 35

258 Significant, but not permanent, harm; Moderate increase in treatment means: an unplanned return to surgery, an unplanned readmission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling treatment, or transfer to another treatment area (e.g. intensive care). How is the Trust implementing the Duty of Candour? The Trust has ensured that the Duty of Candour has been fully integrated into the Trust s Incident Reporting and Being Open policies. Processes and systems have been implemented to ensure the legal and contractual requirements of the Duty are met. Staff awareness on the Duty has been raised via training and discussions at divisional meetings. Moderate and above severity incidents and action plans are monitored at divisional governance meetings and learning is shared via divisional governance forums and through team discussions. The Trust has put in place a robust monitoring system managed by the governance department staff with performance reports to divisional governance boards and the Clinical Governance Committee. Goals agreed with our commissioners (CQUINs) The key aim of the Commissioning for Quality and Innovation (CQUIN) framework is to secure improvements in the quality of services and better outcomes for patients, whilst also maintaining strong financial management. In 2015/16 there were ten acute CQUIN schemes agreed, of which 5 were national and 5 were locally derived with Hillingdon Clinical Commissioning Group. 4 of the latter were regional schemes, mirrored in other hospitals across NW London. In 2015/16 we have achieved 85% of our acute CQUIN target demonstrating a steady and consistently good performance. In 2014/15 we achieved 87.1%. Having either fully or partially achieved all of our CQUINs for 2015/16 will mean that the quality of our services and the care that we deliver to our patients has improved. CQUIN Targets 2015/16 Achievement Commentary National Schemes Improving communication with GPs for patients with kidney damage Improving services for patients attending the ED with a sepsis Partial (30%) achievement Partial (70%) achievement This is the first year that the Trust has been working on this CQUIN and results have improved significantly over time. By the end of the year the Trust was achieving 64% compliance with the national target. This is another first year CQUIN. The Trust is now consistently screening >90% of eligible emergency attendances for possible sepsis and, by the end of the year, administration of antibiotics in less than one hour was being achieved in >75% of cases. Improving services for patients with dementia and their relatives/carers. Partial (96%) achievement Developing IT systems to support integrated care Reducing unnecessary admissions and A&E attendances 100% achievement 100% achievement 36

259 Regional Schemes Reducing unnecessary follow-up appointments for outpatients 100% achievement Working towards implementation of 7 day services Improving communication with GPs for patients who have long term conditions (COPD, Diabetes, Dementia, Heart Failure) Timely referral to specialist cancer centres for patients with a positive diagnosis Local Scheme Providing 'recovery at home' for appropriate elderly patients (HomeSafe) Partial (70%) achievement 100% achievement 100% achievement 100% achievement The Trust has achieved 70% of targets for working towards providing 7 day services. There is still room for further improvement in some areas for example, faster reporting of diagnostic test results and multidisciplinary assessment for patients admitted in the evening The CQUIN framework enables commissioners to reward excellence, by linking a proportion of healthcare providers income to achievement. 2.5% of The Hillingdon Hospitals NHS Foundation Trust s income in 2015/16 was conditional on achieving quality improvement and innovation goals agreed between The Hillingdon Hospitals NHS Foundation Trust and any person or body we entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Total CQUIN income for 2015/16, is expected to be 2,835,226 (85%) for National and Local schemes and 83,022 (100% of potential available income) for Specialised CQUIN schemes. In the previous year (2014/15) total income was 2,968,267 (87.1% of potential available income) for National and Local schemes and 126,404 (95.9% of potential available income) for Specialised Commissioning. In January 2015 Tiaa (our internal auditors) conducted an audit to form an opinion on the design and operation of controls over the Trust s procedures for achieving CQUIN targets. They looked in detail at processes employed and governance arrangements as well as the systems used to provide evidence of achievement. Their overall assessment was of substantial assurance. Further details of the agreed goals for 2016/17 are available electronically at: Care Quality Commission registration The Hillingdon Hospitals NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is that it is registered without conditions. The Trust was inspected by the CQC in October 2014 as part of its planned and more detailed inspection regime. The final reports were published on 10 February 2015.The Trust was rated 37

260 as Requires Improvement overall. The Trust received a good rating for the caring domain across all of its services; staff were observed to be kind and had a caring and compassionate manner. Most of the people that the inspection team spoke with said that care was given in a kind and respectful way. The Trust was issued with formal warning notices against: Regulation 10 Assessing and Monitoring the Quality of Service Provisions Regulation 12 Cleanliness and Infection Control The Trust was also issued with five Compliance Notices against: Regulation 13 Management of Medicines Regulation 15 Safety and Suitability of Premises Regulation 16 Safety, Availability and Suitability of Equipment Regulation 20 Records Regulation 22 Staffing. The Board considered the overall rating ( Requires Improvement ) to be fair. All of the recommendations were accepted and the Board was determined to make the necessary improvements. The concerns raised by the CQC in relation to the systems to assess and monitor the quality of service provision with robust and effective processes to ensure minimal risk to patient safety were of immediate concern to the Board. The findings provided a real impetus to ensure our assessment of the quality of our services fully encompassed review of systems and processes that our staff members follow, in addition to achieving key quality indicators and positive patient outcomes. As a result of the Trust actions against the Warning Notices the Trust increased compliance rates for staff training for all statutory and mandatory training and achieved >80% compliance as per Trust targets. The Trust also adopted cleaning targets in line with the National Specification for Cleaning standards (NSC) and met or exceeded the NSC targets across all clinical areas during 2015/16. The Trust undertook significant work to upgrade ventilation systems in the main theatres and it also completed overseas recruitment visits to attract nursing staff to the Trust whilst reducing the turnover of nurses. Our safeguarding children and adults arrangements and processes have also been strengthened. The CQC re-visited the Trust on 5th and 7th May 2015 which resulted in: The de-escalation of the Warning Notices against regulations 10 and 12 Changing the four red inadequate ratings in the safety domain against A&E, Medicine, Surgery and Services for Children to requires improvement An overall rating for safety as requires improvement A requirement notice against Regulation 12: Safe Care and Treatment for Cleanliness and Infection Control The grid below provides an overview of our ratings based on re-inspection of the Trust on 5 th and 7 th May 2016; report was published on 7 th August

261 The Trust has been working through a detailed improvement plan since the Care Quality Commission (CQC) published its report and this has been presented to the Trust Board and to our commissioners on a monthly basis and is available for view via the Public Board papers on the Trust website. 39

262 A root cause analysis review, was undertaken to examine how the situation, which was identified by the CQC, arose. This was overseen by the Board. There has been important learning for the Trust and for the Board. As a result an accountability framework is now being developed to ensure there is clarity of responsibilities and accountabilities at every level. The Trust s ambition is to achieve an outstanding (with good as a minimum) CQC rating at future inspection. Moving forward, the Trust has agreed a programme of mock inspection using internal peer review supported by TIAA, the Trust s internal auditor. Several internal audits being conducted as part of the Trust s internal audit programme examine practice and processes that support the regulations of the Health and Social Care Act (HSCA). A workshop was also held for ward sisters / charge nurses and department managers to ensure they fully understand the responsibilities of their role in achieving the fundamental standards and the requirements of the HSCA. The Hillingdon Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period. Data quality The Hillingdon Hospitals NHS Foundation Trust submitted records during April 2015 to December 2015 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: which included the patient s valid NHS number was: 98.6% for admitted patient care 99.8% for out-patient care and 96.3% for accident and emergency care. which included the patient s valid General Medical Practice Code was: 100% for admitted patient care; 100% for out-patient care; and 100% for accident and emergency care. The Trust's Board and management seek to take all reasonable steps and exercise appropriate due diligence to ensure the accuracy of the data reported in relation to the quality indicators outlined in the Quality Report, but recognises that it is nonetheless subject to the inherent limitations outlined within the statement from the Chief Executive Officer earlier in this report. Information Governance Toolkit The Hillingdon Hospitals NHS Foundation Trust s Information Governance Assessment Report overall score for 2015/16 was 82%. This is termed as satisfactory (green) with all requirements level 2 or above. 40

263 Clinical coding error rate The Hillingdon Hospitals NHS Foundation Trust was not subject to the Payment by Results Clinical Coding Audit during 2015/16 by the Audit Commission. Action taken to improve data quality The Hillingdon Hospitals NHS Foundation Trust will be taking the following actions to improve data quality: Continue the comprehensive monitoring programme for data quality across the organisation through divisional based groups led by the Director of Operational Performance. The quality of RTT 18 week incomplete pathway data will continue to be reviewed monthly at the elective performance meetings and divisional data quality groups including diagnostic waiting lists. Trust Board Indicators assurance - regular review and local auditing Expanding the Data Quality Programme to include other key datasets used at key committees. A focus on 18 week Referral To Treatment (RTT) training across the Trust for new and existing staff members. Part 2.3 Performance against Core Quality Indicators 2015/16 In this part of the report the Trust is required to report against a core set of national quality indicators to provide an overview of performance in 2015/16. The following page provides information which has been obtained from the recommended sources and is presented in line with the detailed Monitor guidance. 41

264 1: Summary Hospital-Level Mortality (SHMI) 2: the percentage of patient deaths with palliative care coded at diagnosis 3: Emergency readmissions to hospital within 28 days of discharge from hospital: children of ages 0-15 [Standardised] (Crude) 4: Emergency readmissions to hospital within 28 days of discharge from hospital: Adults of ages 16+ [Standardised] (Crude) 5: Clostridium difficile 2014/15 Performance 0.88 [Lower Than Expected] 2015/16 Target n/a 2015/16 Performance 0.89 [Lower Than Expected] London Trusts National Benchmark Source Benchmark Period Lowest Performing Trust Highest Performing Trust n/a n/a HSCIC Oct-2014 to Sep % n/a 29.1% n/a 26.5% HSCIC Oct-2014 to Sep Cases (12.7 Cases per 100,000 Beddays) 8 Cases (Lapes of Care Only) 12 Cases (8.1 Cases per 100,000 Beddays) 15.9 Cases per 100,000 Beddays 15.1 Cases per 100,000 Beddays PHE Apr-2014 to Mar : Venous Thromboemolism (VTE) E2B6% ED% E4BD% EDB7% EDB8% NHS EnglMnd Apr-201D Po Gec-201D 7: PROMS (Health Gain), Groin Hernia, EQ- 5D Index/VAS 8: PROMS (Health Gain), Hip Replacement (Primary), EQ-5D Index/VAS 9: PROMS (Health Gain), Knee Replacement (Primary), EQ-5D Index/VAS 10: Percentage of staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust as a provider of care to their family of friends 11: Trust s responsiveness to personal needs of our patients 12: [a] The number, and where available, rate of patient safety incidents reported within the period, and; [b] the number and percentage of such patient safety incidents that resulted in severe harm or death 13: Self certification against compliance with requirements regarding access to healthcare for people with a learning disability / n/a / n/a / HSCIC Apr-2014 to Mar / n/a / n/a / HSCIC Apr-2014 to Mar / n/a 0.23 / n/a / HSCIC Apr-2014 to Mar-2015 n/a Q1 & Q2-77%; Q3 - not completed; Q4 - TBC Not available Q1 - % Q2 - % Q3 - % Q4 - not available NORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST Band 1 (Higher Than Expected) THE WHITTINGTON HOSPITAL NHS TRUST 0.2% The Royal Marsden 37 Cases (62.2 Cases per 100,000 Beddays) WARRHNGTON ANG HAITON HOSPHTAIS NHS FOUNGATHON TRUST (201DC2016 Q3 only) 61BD% ASHFORD AND ST PETER'S HOSPITALS NHS FOUNDATION TRUST BARTS HEALTH NHS TRUST HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST EAST CHESHIRE NHS TRUST SOUTH TYNESIDE NHS FOUNDATION TRUST COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST THE WHITTINGTON HOSPITAL NHS TRUST Band 3 (Lower Than Expected) IMPERIAL COLLEGE HEALTHCARE NHS TRUST 53.5% Alder Hey Children's (+3 other Trusts) 0 Cases (0 Cases per 100,000 Beddays) THE ROBERT JONES ANG AGNES HUNT ORTHOPAEGHF HOSPHTAI NHS FOUNGATHON TRUST (+3 opoer TrusPs) (201DC2016 Q3 only) 100% WESTON AREA HEALTH NHS TRUST CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST MID ESSEX HOSPITAL SERVICES NHS TRUST BARNSLEY HOSPITAL NHS FOUNDATION TRUST CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST IMPERIAL COLLEGE HEALTHCARE NHS TRUST NHS England TBC TBC TBC 72% n/a TBC n/a n/a HSCIC Apr-2014 to Mar-2015 Croydon 68.8% QueenVictoria Hospital 88.2% 5679 (34.86/1000 beddays) 47 (0.8%) Fully Compliant n/a Fully Compliant 5891 (35.31/1000 beddays) 23 (0.4%) Fully compliant 34.27/1000 beddays 0.6% 36.24/1000 beddays 0.5% The latest HSCIC publication was on Dec-2013 covering 2011/2012 data The next publication is due Aug-2016 see Section Compendium of population health indicators > Hospital Care > Outcomes > Readmissions NPSA Last Checked 14/04/2016 Oct-2014 to Mar-2015 THE DUDLEY GROUP NHS FOUNDATION TRUST 3.57/1000 beddays SOUTH WARWICKSHIRE NHS FOUNDATION TRUST 5.19% WYE VALLEY NHS TRUST 82.21/1000 beddays POOLE HOSPITAL NHS FOUNDATION TRUST 0.05% n/a n/a n/a n/a n/a n/a 42

265 Data Inconsistencies A number of indicators are showing changes to 2015/16 data that was published in last year s Quality Report. There are several reasons for this as follows: 1. The statutory timescale within which the Quality Report is published is very tight. Not all of the latest data was available at the time of publication last year and so the Trust has taken the opportunity to update 2014/15 indicators with full year updates which are now available. 2. National Indicators based on statistical methods by definition require re-basing (e.g. standardised readmissions, HSMR, SHMI). 3. Data quality or data completeness issues may have affected last year s indicators. If these have been identified then they have been rectified in this year s report. Supporting Information about the indicators required in accordance with the Quality Account regulations Update The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: Indicator 1: SHMI The Summary Hospital-level Mortality Indicator (SHMI) for the Trust for year 2015/16 is 0.89 (source HSCIC, benchmark period October September 2015) and is within the lower than expected range. The Trust intends to maintain this position and so the quality of its services by continuing to progress the implementation of the London Quality Standards, which should be reflected in a sustained SHMI performance. Indicator 2: Palliative Care Coding Use of the palliative care codes has stabilised over the last few years and our coding rate (for deaths specifically) is marginally higher than last year and in line with the national average. The Trust intends to improve this percentage and so the quality of its services by continuing to monitor performance via the integrated quality and performance report (reviewed monthly by the Board) and continue to ensure that reporting systems are robust and efficient through audit. Indicator 5: Clostridium difficile The Trust has seen a reduction in the incidence of Clostridium difficile (C.diff) infection since 2014/15 with a total of 12 cases in 2015/16 against a trajectory of eight compared with the previous year end total of 18 cases against a trajectory of 16. A Root Cause Analysis (RCA) is undertaken for all cases of Trust attributed C.diff and the Consultant in charge of care, Consultant Microbiologist, Infection Control Nurse, Ward Sister and responsible Matron are generally part of this process. During 2015/16 all RCA investigation reports were presented to the Clinical Commissioning Group (CCG) representative for review and scrutiny and to establish agreement regarding any lapses in care. Of the 12 cases presented to the CCG only one case was considered to be due to a lapse in care and therefore potentially avoidable as antibiotics were not prescribed in accordance with the Trust Antimicrobial Guidelines. The remaining 11 cases were predominantly elderly patients presenting as emergency admissions, acutely unwell with a history of clinically indicated antibiotic treatment in line with Trust Antimicrobial Guidelines. Antimicrobial Stewardship is an important element in the prevention of hospital acquired C.diff and there is now a full time antimicrobial pharmacist working in the Trust helping to increase awareness and knowledge of good prescribing practice and stewardship. The infection control team is now fully established and this has strengthened surveillance opportunities and ward based teaching. The Trust intends to improve performance on this indicator and so the quality of 43

266 its services by progressing a refreshed annual infection control action plan with robust oversight by the Infection Control Committee during 2016/17. Indicator 6: Venous Thromboembolism (VTE) The VTE risk assessment compliance for 2015/16 is 94.5% compared with 92.6% for 2014/15. After the previous year s root cause analysis (RCA) of reasons for difficulty in delivering on the target an action plan was developed and is monitored within the Trust clinical governance system up to the Quality and Safety Committee. The Trust has taken actions to further improve performance on this indicator and so the quality of its services which includes: improved staff education including junior doctors during their induction and nursing staff during education on documentation and drug administration; improved documentation with checklists, which include VTE assessment, in medical notes; involvement of ward pharmacists as part of the multidisciplinary team to draw attention to any omissions on drug charts; modification of the drug chart to aid in ease of VTE risk assessment has been approved; and standard clinical practice that no patient is admitted to a clinical area without a VTE assessment completed. The Trust has mitigated the risk of VTE to patients by producing an information leaflet distributed to every inpatient regarding the risk of VTE during their hospital stay and postdischarge and how to minimize that risk. The Trust has taken steps to understand the risk to patients and to share learning by RCA of all identified cases of VTE during the past year found to be Hospital Acquired Thrombosis (HAT) - defined as a VTE which occurs during admission or within 90 days of discharge from hospital. Of 33 cases of HAT identified: more than 80% had a VTE risk assessment on admission; even those without documented assessment had appropriate thromboprophylaxis (TP) except in one case. 64% developed a VTE despite appropriate TP and a number were complex cases where re-assessment of VTE risk status and adjustment of TP might have prevented development of VTE. A few cases might have benefitted from extended TP post-surgery although this would not have been a NICE guideline or evidence-based practice. Prescribing and documentation of TED stockings which might have reduced the risk of VTE was poor. This information has been shared with the teams involved in order that lessons can be learned and future performance improved. Indicator 7, 8 and 9: Patient Reported Outcome Measures (PROMS) Health Gain For the purposes of the Annual Quality Report the PROMS data being reviewed is for the full year 2014/15. This is due to the fact that the 2015/16 data is not yet available for review due to post-operative patients still submitting post-operative information. In 2014/15 the Trust saw an increase in the number of patients being issued with pre-operative questionnaires. This is the first questionnaire that is issued pre-operatively to patients in the process and is issued by the hospital. Subsequent PROMS questionnaires are issued by an external company that administers the post-operative PROMS data collection for the Trust. 44

267 Our PROMS pre-operative issue rates for hip and knee replacements are higher than for groin hernia and varicose veins and this is due to the fact that questionnaires are given to patients at the pre-operative joint school. Indicator 7: Groin hernia There was an improvement in the hospital's PROMS results for groin hernia between 2013/14 and 2014/15 and the Trust is performing higher than the national average. The Trust intends to improve performance on this indicator and so the quality of its services where the pre-operative nursing teams at both hospital sites will try and improve the issue rates for groin hernia and varicose veins in particular. Indicator 8: Hip replacement: There has been a slight improvement in two of the three hip replacement outcomes (EQ5D VAS and Oxford Hip Score) and the performance against the remaining outcome (EQ5D- Index) is very similar to the previous 12 months results. When benchmarked, the hospital's results are very similar to the national average. The Trust intends to improve performance on this indicator and so the quality of its services by monitoring issue rates and improving the patient s overall experience. Indicator 9: Knee replacement: The PROMs results for knee replacements have deteriorated compared with the previous 12 months and currently sit below the national average. The Trust intends improve on this indicator and so the quality of its services; the reasons for the deterioration are being further investigated by the clinical and managerial teams and the required actions will be taken forward during 2016/17. The EQ5D outcome measures report a patient's overall experience of surgery whereas the Oxford Knee Score (OKS) is more of an objective clinical measure. The results for the OKS are very similar to that of the national average which may indicate that there is further work to be done on improving the patient's overall experience and managing their expectation of surgery. Indicator 10: Friends and Family Test question 12d Staff Survey The narrative provided covers two quarters; due to this year s staff survey there was no quarter three survey and quarter four is still live and we are yet to receive the findings: For the two quarters of 2015/16, during which the Staff FFT operated, the results show an average of 77% of staff are likely to recommend the Trust as a place in which to receive treatment whilst 72% are 'likely' to recommend the Trust as a place to work The Trust intends to take the following actions to improve staff response rates and performance and so the quality of its services: Increase electronic access to the questionnaire to increase participation rate Promote action taken as a result of feedback provided by staff through the Bulletin, intranet, staff meetings and team briefings Continue to implement the staff engagement initiatives detailed in the strategy. Indicator 11: Responsiveness to personal needs of our patients This is a composite score from 5 questions taken from the 2015 national survey of inpatients: (Last year figure 63.4%) TBC for 2015/16 in June

268 Being involved in decisions about your care and treatment Finding someone to talk to about worries and concerns Being given enough privacy when discussing your condition and treatment Informing patients about medication side effects to watch out for after going home Knowing who to contact if worried about condition or treatment after leaving hospital The Trust intends to take the following actions to improve performance on this indicator and so the quality of its services: Actions to be agreed once NPS results available from CQC in June. Indicator 12: Patient Safety Incidents The Trust s rate of reporting for patient safety incidents has increased from (per 1000 bed days) in 2014/15 to 35.31* (per 1000 bed days) in 2015/16. This is a positive improvement as part of an improved patient safety culture. Comparative data from the National Reporting and Learning Service (NRLS) shows that the Trust is in the middle 50% of reporters for Acute (Non-Specialist) Organisations with a rate of (per 1000 bed days)**. This compared to a median reporting rate of (per 1000 bed days) for the reporting period (between 01 October 2014 to 31 March 2015). Organisations that report more incidents usually have a better and more effective safety culture. It is well recognised that you can't learn and improve if you don't know what the problems are. The number of patient safety incidents that resulted in severe harm or death has decreased from the previous year by 0.4%. The Trust intends to take the following actions to improve further on this key patient safety indicator and so the quality of its services: Continue to raise awareness of the importance of incident reporting and in particular near misses and no/low harm incidents (this will ensure learning to avoid the more harmful incidents from occurring) Ensure there is more robust feedback on actions taken provided to reporters to ensure staff see the value of reporting patient safety incidents Continue to ensure there is detailed root cause analysis investigation of all moderate/severe/death reported incidents to support learning and changes in practice. *Excluding Pressure Ulcers Internal Transfers (PUIT) and Pressure Ulcers Admitted With (PUADM) **Unable to compare NRLS data with previous reporting periods as indicator changed during 2015 from incidents per 100 admissions to incidents per 1,000 bed days. Indicator 13: Access to healthcare for people with a learning disability The Trust has remained fully compliant with this key indicator as part of its quarterly and annual declaration to Monitor. The Trust intends to continue to raise awareness amongst its staff and ensure that its best practice guidance on caring for patients with a learning disability is followed so as to maintain performance on this indicator and so the quality of its services. Definitions of the two mandated indicators for substantive sample testing by the Trust s auditors are: 1. Referral to Treatment Time within 18 weeks for patients on incomplete pathway (18 week RTT) 2. Accident and Emergency department 4 hour target 46

269 Part 3 Other key quality information and improvements we have made in 2015/16 In this part of the report we have included other key quality indicators which have been selected by the Board in consultation with stakeholders. They represent those indicators that are of national importance that patients will want to know about and they include targets used by Monitor as part of Monitor s Risk Assurance Framework. The indicator set includes patient experience, patient safety and clinical effectiveness indicators. The indicators covered in this year s report are consistent with those from last year s Quality Report. Narrative has been provided on some of these indicators to outline our performance. 1: In Hospital Standardised Mortality Ratio 2: Readmissions to hospital within 28 days 3: Non clinically justified single sex accommodation breach, rate per 1,000 finished consultant episodes 4: Cancer: Two week wait from GP referral to seeing a specialist (suspected cancer)/(breast symptoms) 5: Cancer: 31 day maximum wait from diagnosis to first treatment 6: Cancer: 31 day maximum wait from diagnosis to subsequent treatment, drug or surgery 7: Cancer: 62-day maximum wait from referral by GP/screening service/consultant upgrade to treatment 8: Referral to treatment waiting times - admitted 9: Referral to treatment waiting times - non admitted 10: Referral to treatment waiting times - Incomplete 11: Fractured neck of femur emergency patients in theatre within 36 hours 12: Total time in A&E: 4 hours or less (All Types/ Type 1) 13: Number of last minute elective operations cancelled for non clinical reasons 14: Percentage of patients not treated within 28 days of having operation cancelled for nonclinical reasons 15: Percentage of women in the relevant PCT population who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 weeks and 6 days of pregnancy 16: Percentage of women in the relevant PCT population who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 weeks and 6 days of pregnancy (excluding late Referrals) 17: Stroke patients: Percentage of Patients that have spent at least 90% of their time on the stroke unit 18: Stroke patients: Percentage of high risk Transient Ischaemic Attack (TIA)/mini stroke patients who are treated within 24 hours 19: Meticillin-Resistant Staphylococcus Aureusis (MRSA) 20: Inpatient Experience Programme (local survey results) 21: Outpatient Experience Programme (local survey results) 22: Maternity Experience Programme (Local survey results) 23: Independent assessment of cleanliness of hospital* - Very High Risk areas - High risk areas 24: Percentage of complaints responded to within agreed timescale 2014/15 Performance ( ) ( ) 2015/16 Target <100 < /16 Performance 92.1 ( ) ( ) London Trusts National Benchmark Source Benchmark Period 84.7 ( ) 100 Dr Foster Apr-2015 to Dec ( ) 100 Dr Foster Apr-2015 to Sep NHS England Apr-2015 to Feb % 95.7% E3% E3% E7B0% E6B3% 94.4% 93.2% 94.8% 93.4% NHS EnglMnd Oct-2015 to Dec % E6% EEB2% 97.6% E7BE% NHS EnglMnd Oct-2015 to Dec % 100% 92.2% 97.8% 98.7% 95.2% 98.5% E7% E4% 8D% E0% ncm 90% (Up to end Sep- 2015) 95% (Up to end Sep- 2015) 100% 100% E1B8% E8B6% E7B6% 99.7% 96.4% 81.6% 93.5% 92.3% 99.6% 96.2% 83.5% 93.5% 90.6% NHS EnglMnd NHS EnglMnd Oct-2015 to Dec-2015 Oct-2015 to Dec % 88.2% 87.8% UNIFY2 Apr-2015 to Jun % 95.2% 95.3% UNIFY2 Apr-2015 to Jun % 92% 96.1% 92.3% 92.4% UNIFY2 Apr-2015 to Feb % 90% 90.0% n/a n/a Local Indicator n/a E4B1% 84B2% ED% ED% E2B0% 7EB2% 92.7% 88.3% E2B4% 88B6% NHS EnglMnd Apr-2015 to Feb % 0.50% 0.51% 0.78% 0.82% NHS England Apr-2015 to Dec % 0% 1.57% 8.10% 6.30% NHS England Apr-2015 to Dec % 95% 80.3% n/a n/a Local Indicator Ceased Qtr / % 95% 96.1% n/a n/a Local Indicator Ceased Qtr / % 80% 99.1% Local Indicator Ceased Qtr / % n/a 100% Local Indicator Ceased Qtr / Cases per 100,000 Beddays Cases per 100,000 beddays 1.8 Cases per 100,000 beddays 1.8 Cases per 100,000 beddays PHE Apr-2014 to Mar % >/= 88% 87% n/a n/a Local Indicator Apr-2014 to Mar % >/= 88% 87% n/a n/a Local Indicator Apr-2014 to Mar % >/=87% 86% n/a n/a Local Indicator Apr-2014 to Mar % 97% 98% 95% 98% 96% n/a n/a Local Indicator Apr-2014 to Mar % 90% 70.7% n/a n/a Local Indicator Apr-2014 to Mar : Pressure Ulcers per 1,000 bed days 1.2% 1% 1.1% n/a n/a Local Indicator n/a Definitions for the indicators are included in Monitor s Risk Assessment Framework (available on 47

270 Indicator 1 Hospital Standardised Mortality Rate The Hospital Standardised Mortality Ratio (HMSR) for the Trust for year 2015/16 is 92.1 ( ) (source Dr Foster data, benchmark period April-Dec 2015) and is below the national benchmark of 100 but is above the London average of 84.7 ( ). The Trust weekday and weekend HSMR have been in the as expected range throughout the year and weekend mortality is now the same as weekday. The Trust is tracking the HSMR monthly and has a robust Mortality Review Process in place for all deaths occurring in hospital. In line with the recent NHS England Guidance: Avoidable Mortality, the Trust has formed a Mortality Surveillance Group to oversee the Mortality Review Process and draw up a policy which will clarify and document the roles and responsibilities, governance arrangements and reporting requirements of the process. Indicator 2 Re-admissions to hospital within 28 days It remains a key priority for Hillingdon Hospitals to manage risk of readmission for our patients. Over a period of ten months in 2015/16 (January to October) THHFT implemented an ambitious project to gather information regarding the underlying causes of readmissions; information that would help to give both the hospital and our commissioners a more detailed understanding of the multiple factors contributing to current readmissions rates. More than 500 ward-based investigations were conducted, from which 75 were selected for more in-depth analysis. The majority of readmissions were found to be unavoidable due to deterioration or exacerbation of existing long term conditions such as chronic obstructive pulmonary disease (COPD). In some cases, lifestyle choices of the patient (e.g. smoking or alcohol consumption) were found to be significant contributory factors. Where it was felt that readmissions may, potentially, have been avoided, for example by providing new or improved services, suggestions for improvement were captured and shared with relevant stakeholders both in the Trust and in the wider health and social care environment. Themes included: improving communication between the hospital and community matrons, providing excellent end of life support for patients and their families/carers, and focusing on supporting patients and carers to develop and enhance the knowledge, skills and confidence required to manage key aspects of their own care and potentially prevent them from needing to go into hospital. The Trust has also implemented a risk stratification tool that is being used to identify patients with the highest risks of readmission so that they can be given additional support to help keep them at home when they are ready to leave hospital. Indicators Cancer performance Cancer performance is being well maintained for all the national waiting times standards. The quality of services is monitored annually via the national peer review programme. Tumour specific work programmes also reflect areas for service development. Indictors Referral to treatment waiting times (Further narrative to be included post Deloitte external testing) Simon Stevens (CEO of NHSE) informed NHS providers of changes in the RTT performance target during 2015/16. Following a review, undertaken by Sir Bruce Keogh, a decision has been made to rationalise the way RTT times are tracked and therefore the reporting against the admitted and non-admitted performance is no longer required. 48

271 The focus has been on incomplete pathway performance as it is felt that this is the measure that tracks the complete patient experience. The Trust continues to sustain excellent performance against the RTT incomplete treatment pathways standard. Indicator 11 Fractured neck of Femur 2014/15 performance: 86.4% 2015/16 performance: 90% There has been an improvement this year in the number of patients that have sustained a fractured neck of femur receiving surgery within 36 hours. The main reason for the delay in taking patients to theatre is patients having multiple co-morbidities which requires them to have a longer preoperative period to optimise medical fitness prior to surgery. The multi-disciplinary team continue to review each patient that has a delay to theatre so ensuring that any avoidable delays can be identified and lessons learnt. The fractured neck of femur data is also presented and reviewed in the Orthopaedic Audit morning. Indicator 12 - Accident and Emergency (A&E) waiting times (Further narrative to be included post Deloitte external testing) The year-end performance against the A&E access target was 92%. Overall demand increased by 2.6%, in addition to 9% growth in emergency attendances in 2014/15. In recognition of the challenges facing the Trust, a detailed diagnostic piece of work was jointly commissioned by Hillingdon CCG and THH to identify areas for improvement that would serve to enhance patient flow. The live action plan utilises a three pronged approach which focuses on: Reducing inappropriate attendances Achieving the four hour standard and reducing admissions Safely and effectively discharging patients Average attendances of greater than 160 patients per day presents an ongoing challenge for the clinical team working in a confined physical space. Initiatives have therefore been targeted at reducing attendances from the community, diverting patients to ambulatory care pathways and expediting discharge from the base wards to reduce the amount of time each patient spends in the Emergency department. Further learning is expected from The Cumberland Initiative (a movement to encourage systems thinking, simulation and modelling of healthcare scenarios to improve NHS quality of care delivery and save money) whose leads are reviewing patient discharge from hospital to home or to community / social care. Indicator 13 - Number of last minute elective operations cancelled for non-clinical reasons 2013/14 performance: 0.85% 2014/15 performance: 0.70% 2015/16 performance: 0.51% 49

272 The Trust continues to improve performance with regards to reducing the number of operations / procedures cancelled on the day. This remains a priority for the Trust and each month a detailed report is provided to the Trust Board regarding the reason for each cancellation. In 2015/16 the most common reason for cancelling a patient's operation was due to a medical complication with a previous patient which resulted in their operation taking longer than expected, leaving insufficient theatre time to finish all the cases. Indicator 15 Percentage of women who have seen a midwife or maternity healthcare professional within 12 weeks and six days of pregnancy Although we continue to achieve a greater than 95% target to book women within the 12+6 week time frame there continues to be a challenge with regard to late bookers. The CCG and Hillingdon Public Health have committed to working with us to find a solution as the main challenges lie within the community and with public messaging regarding education and information provision. The main challenge involves the key engagement required from Public Health where there is currently some service reconfiguration. This has been raised as a significant concern with Hillingdon Clinical Commissioning Group. As a Trust we will continue to work with commissioners to enable this piece of work to commence. Indicator 21- Outpatient local patient experience survey There continues to be detailed analysis of the FFT and local patient experience survey provided by patients attending outpatient departments. During April 2015 outpatient departments commenced a pilot to capture FFT feedback electronically; this has proved to be successful and it is now embedded into practice. It offers patients choice as an alternative to completing paper surveys and it has proved to be beneficial to the outpatient teams in capturing real time patient experience feedback. Current feedback is very positive regarding staff attitude and the service that they provide. There are a high number of comments received via FFT and local surveys stating staff are friendly and welcoming and that they communicate clinic delays to patients plus offer them beverages, which patients feel offers a personal touch. Top priority for patients is to be seen at their appointed clinic time, due to the nature and demand on some clinics this remains a challenge. The outpatient matrons are continually working with service managers exploring ways of increasing clinic capacity; which can then lead to patients being seen on time. To support this there has been an increase in the number of specialities running weekend and evening clinics. Utilisation of ad hoc clinic rooms and the provision of staff to provide additional clinic activity is also better utilised and provides additional clinic capacity to reduce over booked clinics and reduction of waiting times enabling more patients to be seen on time. Indicator 22 - Maternity local patient experience survey We have strengthened the Maternity Services Liaison Committee and have been able to recruit three new user representatives to work with us in ensuring the woman s voice is heard. Significant work has been done by the team to drive up the Friends and Family responses which had dropped during SaHF transition. We continue to display you said-we did information learning from FFT comments and complaints as well as sharing learning with the staff. We are hoping to continue to progress our programme of liaising with hard to reach groups as this has proved a valuable exercise in understanding expectation and culture. 50

273 Indicator 23 - Independent assessment of cleanliness of hospital Since adopting the NSC {National Specifications for Cleanliness in the NHS} and audit frequencies in February 2015 the Trust-wide score has consistently met or exceeded the NSC targets for Very High Risk areas i.e. 98% achievement against a target of 98%; for High Risk areas i.e. an achievement of 96% against a target of 95%; Significant Risk areas i.e. an achievement of 90% against a target of 85%; and Low Risk areas i.e. an achievement of 85% against a target of 75%. Managerial audits undertaken by the Trust have verified the scores achieved in the regular technical cleaning audits and furthermore, two six-monthly external audits undertaken by independent assessors have also validated the Trust s technical cleaning scores. Indicator 24 - Percentage of complaints responded to within agreed timescales In 2015/16 the Trust received 457 complaints, of which 89.1% were acknowledged within three working days. As the investigation period is typically 30 working days, the number of complaints on which responses were due during the financial year differs because of investigation time overlap at the beginning and end of the year. There were 430 complaint responses due during 2015/16, of which 70.7% (304) were completed within the timescale agreed with the complainant. This is disappointingly lower than achieved last year. Underlying reasons include increased overall volume in complaints received and also staffing challenges due to sickness absence and vacancies within the complaints management team and the operational divisions. This led to significantly low performance in June and July; this recovered in subsequent months. The monthly performance ranged from a low of 12.7% in June through to 100% in both August and December. To ensure a similar situation does not happen in the future, and to build on the service improvement already implemented to improve the timeliness and quality of responses to complainants, the following actions are underway: Complaints management process being strengthened to ensure quality-focused time-driven investigatory reports. Up-skilling of individual staff within the complaints team and closer working between the PALs and Complaints teams to create a flexible, multi-skilled workforce. Activity monitoring to identify surges in activity at an early stage to ensure appropriate allocation of resources. Divisional teams taking a proactive role in resolving concerns at an early stage, with increased personal contact with complainant. Provision of complaints investigation training for divisional and clinical teams. Indicator 25 Hospital Acquired pressure Ulcers We aimed to achieve a 15% reduction of all pressure ulcers during 2015/16. This is in line with our Sign up to Safety campaign to reduce patient harms by 50% over three years. The hospital acquired pressure ulcer rate during 2013/14 was 1.34 per 1,000 bed-days and in 2014/15 this was For 2015/16 we narrowly missed the target with a rate of 1.1; this represents a slight reduction on the rate for 2014/15. The reduction of hospital acquired pressure ulcers is a priority area of focus for the Sign up to Safety work and there are clear actions as part of the improvement plan. These include ward based teaching and staff attending pressure ulcer and prevention teaching sessions with Buckinghamshire New University all sessions are fully booked for the rest 51

274 of the year. There is work being taken forward on improving the availability of pressure relieving mattresses including a business case for a bed replacement programme. Improving Patient Safety During 2015/16 the Hillingdon Hospitals NHS Foundation Trust has continued to be a member of the Imperial College Health Partners (ICHP) Patient Safety Collaborative (PSC). This is one of 15 PSCs set up to help improve the safety of patients and ensure continual learning sits at the heart of healthcare in England. As the Academic Health Science Network (AHSN) for North West London, ICHP works with its partner organisations and service users to focus on specific areas of local clinical need. Its vision is to support its partners to embed safety in every aspect of their work. This means that: Patient and carer views are obtained and heard at all levels as a critical indicator of safety There is a strong ethic of team working and shared responsibility for patient safety Effective safety measurement and monitoring systems are in place in all clinical settings Clinical processes, practices, equipment and environment ate standardised and simplified Our PSC is forging ahead and making great progress with a number of initiatives already underway. The Hillingdon Hospitals NHS Foundation Trust is involved in some of these key patient safety programmes of work and these include membership at the Foundations of Safety best practice forum, developing the role of the patient safety champion, supporting a prescribing improvement model and work to ensure effective medicines optimisation. The PSC programme of work is aligned with and supports the national Sign up to Safety campaign which the Trust signed up to in the latter part of 2014 and is outlined earlier in this report. Infection Control Prevention and Control Meticillin Resistant Staphylococcus aureus Following a Post Infection Review (PIR) undertaken by the community the Trust was attributed one Meticillin Resistant Staphylococcus aureus (MRSA) positive case. The blood culture was taken within 48 hours of admission and was originally attributed to the community, however following the PIR it was agreed with the Consultant Microbiologist and Consultant Paediatrician that the positive blood culture was due to specimen contamination not a bacteraemia in the absence of clinical symptoms and a second negative culture (Table 1). Annual compliance measured with the MRSA screening policy for elective and emergency cases was 94% and 88% respectively. 52

275 2 Trust attributed MRSA bloodstream infections 1 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/ / Table 1: Trust Attributed MRSA BSI Clostridium difficile infection The Trust has seen a reduction in the incidence of Clostridium difficile (C.diff) infection since 2014/15 with a total of 12 cases in 2015/16 against an annual trajectory of eight compared with the previous year end total of 18 cases against a trajectory of 16. A Root Cause Analysis (RCA) is undertaken for all cases of Trust attributed C.diff and the Consultant in charge of care, Consultant Microbiologist, Infection Control Nurse, Ward Sister and responsible Matron are generally part of this process (Table 2). During 2015/16 all RCA were presented to the Clinical Commissioning Group (CCG) representative for review and scrutiny and to establish agreement regarding any lapses in care. Of the 12 cases presented to the CCG one case was considered to be due to a lapse in care and therefore potentially avoidable as antibiotics were not prescribed in accordance with the Trust Antimicrobial Guidelines. The remaining 11 cases were predominantly elderly patients presenting as emergency admissions, acutely unwell with a history of clinically indicated antibiotic treatment in line with Trust Antimicrobial Guidelines. Antimicrobial Stewardship is an important element in the prevention of hospital acquired C.diff and there is now a full time antimicrobial pharmacist working in the Trust helping to increase awareness and knowledge of good prescribing practice and stewardship. The infection control team is now fully established and this has strengthened surveillance opportunities and ward based teaching. Table 2: Trust Attributed C. diff Infections 53

276 Meticillin Sensitive Staphylococcus aureus In Q4 one case of Meticillin Sensitive Staphylococcus aureus (MSSA) was attributed to the Trust, taking the total reported to seven MSSA cases in 2015/16. There is no mandated threshold for MSSA. Patient Experience - Listening to our patients We aim to be a listening and learning organisation, in which concerns that are raised by patients are understood, shared and responded too. Listening to feedback enables our staff to gain a real insight into the patient s experience of care. We use a number of different approaches, all of which provide us with information about what we are doing well and where we need to improve. National and local surveys Friends and Family Test Compliments/Complaints PALS concerns What our inpatients have told us: 92% for treating patients with dignity and respect 86% for communication, involvement and information 91% for confidence and trust in our doctors and nurses 86 % for meeting physical needs Source: 2015/16 local inpatient survey based on 9 months data on responses from 1832 inpatients 54

277 How we have responded to our patients feedback about their experience? Complaints Although often uncomfortable to hear, complaints provide us with the opportunity to learn from our patients and their families and improve the services and care we provide. When reviewing a complaint, an action plan is drawn up to address failings identified. Examples of specific improvement actions implemented as a result of complaints include: Issue identified A patient suffered delay in receiving their follow up appointment following a urodynamic test What we have done about it: A formal pathway has been developed by the gynaecology service to ensure all patients receive a follow up appointment within 6 weeks of a urodynamic study. Issue identified A patient did not receive adequate pain relief after an operation What we have done about it: New pain relief administration pumps have been purchased Staff have received additional training on pain relief and the use of the new pumps. National Patient Survey A survey of inpatients is part of the annual mandatory survey programme for acute trusts; this assists organisations to find out about the experience of patients when receiving care and treatment at their hospitals. The results of the 2015 survey are based on responses from 453 patients who completed the survey, giving a response rate of 37%, the average response rate of all trusts was 45%. This survey has highlighted the many positive aspects of the patient experience: Overall: 79% rated care 7+ out of 10 Overall: treated with respect and dignity 76% Doctors: always had confidence and trust 73% Hospital: room or ward was very/fairly clean 95% Hospital: toilets and bathrooms were very/fairly clean 93% Care: always enough privacy when being examined or treated 87% Based on the patients responses to the survey the Trust scored: (Awaiting CQC National Patient Survey report for this information) There are 5 questions where the Trust has a score that is significantly higher than the 2014 score. These are: 55

278 A&E Department: not given enough privacy when being examined or treated Hospital: room or ward not very or not at all clean Hospital: felt threatened by other patients or visitors Discharge: not told who to contact if worried Discharge: Staff did not discuss need for further health or social care services The Trust scored significantly lower than the 2014 score in 1 question: Surgery: results not explained in clear way There were 2 areas where the trust scored better than most other hospitals: Planned admission: not offered a choice of hospitals Hospital: patients using bath or shower area who shared it with opposite sex In comparison with others the Trust has been rated as worse in questions associated with: Admission Environment and food Clinical care Surgery Discharge The CQC adult inpatient survey provides a helpful annual check of our inpatients experience and enables the trust to compare our performance with that of other trusts. Overall the 2015 survey results show that there are a number of areas where patients have reported a worse experience compared to the previous year. The survey results have been triangulated with other sources of feedback to help identify the themes that should be our focus for improvement during 2016/17. There are a number of transformational programmes underway that have links to the areas for improvement to some of the themes set out above including Transforming Inpatient Care and workforce transformation. Improving patient experience is identified as a positive outcome from these programmes. Improving communication with patients is embedded in priority three on this report, we will be scoping out specific initiatives and actions that will make a difference to these areas. The local survey programme will enable the Trust to monitor progress on any initiatives and report into the Trust s Experience and Engagement Forum. Friends and Family Test The Friends and Family Test (FFT) provides a simple and standardised way of collecting patient experience feedback. The FFT question asks patients to consider their recent experience in the hospital ward/department or clinic and rate how likely they would be to recommend the area to a friend or family member. Patients should be given the opportunity to complete an FFT survey. During 2015/16 over 25,000 (April 2015 to March 2016) took up this opportunity and answered the FFT question. Our results for this period are set out below: 56

279 Positive Responses Negative Responses Inpatient: 94.4% Inpatient: 1.4% Outpatient: 93.5% Outpatient: 0.6% Maternity: 95.8% Maternity: 1.4% A&E: 93.4% A&E: 3.0% Paediatrics: 97.6% Paediatrics: 0% Day care: 98% Day care: 0.34% Minor Injuries: 98.2% Minor Injuries: 0.5% How do our FFT results compare with others? The graphs below show the FFT results and response rate for A&E and inpatients for 2016 (the most recently published data February 2016). Response rate and percentage of positive and negative results for A&E The response rate for A&E in February is lower than the England and London rate. We do significantly better however than England and London in relation to the percentage of people who recommend the service and a positively lower percentage for those who do not recommend. 57

280 Response rate and percentage of positive and negative results for Inpatients The percentage of people who would recommend is equal to the England and London score. We have a lower percentage of patients who would not recommend in relation to London and England. The response rate for inpatients in February was in line with the London and England rates. We have not achieved our FFT response rate targets for 2015/16 with inpatients at 21% against a target of 30%, A&E 9.6% and Maternity 16.4%, both against a target of 20%. The Head of Public Engagement has been working closely with divisional leads to identify how they can ensure patients are consistently given the opportunity to complete the survey. This has led to significant improvement for inpatient and maternity returns received in recent months: Maternity exceeded their 20% target in February (36%) and March (32.3%); inpatient response rates have been on an upward trend for the last three consecutive months. A&E will shortly be trialling electronic data capture as an alternative to paper-based systems. In February we contracted a new provider for collating and analysing our FFT responses. We are confident this will improve both response rates and the quality and scope of intelligence we derive from the returns due to: Feedback available at departmental level, for all staff User-friendly system, with capability to drill-down across a range of themes, age-ranges and demographic groups Ability to create visually stimulating poster reports to aid patient interest and engagement Multiple options for obtaining responses such as texting and online systems 58

281 What patients have told us is good about their experience What patients have told us could be improved Accident & Emergency Staff were very helpful and attentive. We were well informed of what was happening. We felt confident that everything that was needed was done Inpatient ward They made my stay an absolute pleasure. I wish to thank everyone for their compassion and care Maternity Excellent care, couldn t fault anything. Thank you so much, felt completely safe and in excellent hands Waiting times in Accident & Emergency are too long Action Hospital wards have become specialty based enabling doctors to undertake timely ward rounds leading to earlier discharge of patients in the day and improved patient flow from A&E. Patients feel that they are asked the same questions by different professionals Action The development of the Hillingdon Care Record which is a mobile application running on Trust ipads will enable clinical staff to view the medical history of patients reducing the need for patients to provide the same information to different professionals. Antenatal clinic is very busy, waiting area is very small with a lack of seating. Better system required for informing about clinic delays Action A review of antenatal capacity is being undertaken to look at numbers of patients attending and appropriateness of appointments. 59

282 Staff Survey Headlines In 2015, the Trust delivered overall an encouraging staff survey result. In terms of the standard and quality of care we provide, 65% of our staff said they 'would recommend the Trust as a place to work'. This is 4% higher than the average for acute Trusts. There was a slight increase (66% in 2015) in the percentage of staff that would be happy with the standard of care provided by the Trust to friends or relatives. However, this was lower (4%) than the average for acute Trusts (70%). The Trust will take the following actions to maintain and further improve its performance: Build on work to date on developing highly effective teams to continue to improve quality of care Increase access to learning and development opportunities at all levels within the Trust to build clinical skills sets and improve the patient experience Increase opportunities for work based learning to promote learning and broaden clinical skills to elevate the standard of care Continue to work collaboratively with divisions to devise and implement bespoke local initiatives to drive learning, knowledge and innovation. As requested by Monitor the following are our most recent results on key findings (KF) from the staff survey: KF19:Organisation and management interest in and action on health/well-being: The Trust scored 3.61 on this question and compared with other Trusts our score is above (better than) average compared with other acute Trusts who scored 3.57 KF21: Percentage of staff believing the organisation provides equal opportunities for career progression/promotion: Over the last three years the number of staff responding positively to this finding has increased with 83% this year. Other acute trusts reported 87%. In terms of breakdown by ethnic categorisation, 90% of staff by White ethnic backgrounds said they believed that the organisation provided equal opportunities for career progression/promotion compared to 73% of BME (Black and minority ethnic) staff. Benchmarked against other acute Trusts, they reported 89% (White) and 75% (BME) respectively. KF25 - Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months: 31% for white staff and 25% for BME staff. This is a 4% increase for both groups over the previous year. KF26: Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months: 23% of staff who answered this question in the survey said they had experienced this in the last 12 months. This is below (better) than average compared to other similarly sized Trusts that reported 26%. This was a slight increase on our performance in 2014 (22%). In terms of breakdown by ethnic categorisation, 24% of staff by White ethnic backgrounds said they had experienced harassment compared to 22% of BME staff. Benchmarked against other acute Trusts, they reported 25% (White) and 28% (BME) respectively. 60

283 KF27: Percentage of staff reporting most recent experience of bullying, harassment or abuse: 43% of staff who answered this question in the survey said they had reported bullying, harassment or abuse in the last 12 months. The Trust was in the highest (best) 20% of Trusts. Other acute Trusts reported 37% of staff reporting on this. Equality and Diversity Our Staff More than 92% of staff completed their core equality and diversity training and remain compliant with refresher training. Over the last year the Trust has invested in a range of interventions to address feedback from the 2014 staff survey response. This has included: Promoted the Ready Now NHS Leadership Academy programme for black and minority ethnic communities (BME) staff Rolled out our popular Customer Care programme Included Employee relations cases in Board level KPIs Work with external consultants to scrutinise Trust systems and process against the nine protected characteristics. This emanated in focus groups which have provided rich data that will formulate an action plan in 2016 Implemented new development programmes for Agenda for Change Bands 3-5 and 6-7, previously not included in internal Leadership Programme, and rolled out the Leadership 100 programme to additional cohorts at Bands 8 and above In response to experiences of discrimination, the Trust is embarking on a variety of projects including Establish Equality, Diversity and Inclusion (EDI) Steering Group with Board level leadership to drive Trust EDI priorities Rollout of Speak In Confidence anonymous dialogue system which enables staff to raise concerns they may have and to escalate anonymously The Trust has a growing BME workforce broadening the talent and diversity of our workforce. The Trust is committed to creating a working environment in which its employees are treated fairly, feel valued and are engaged. It is working hard to promote equality in everything it does by embedding its CARES values of which equity is one. The Staff survey results enable us to compare metrics for the responses from white and BME staff and the new Workforce Race Equality Standard (WRES) provides a measure of the experiences of our White and BME workforce in accessing learning and development and career opportunities. Action on staff survey results and equality and diversity issues for the workforce Data: There is ongoing work to improve our data collection and reporting and recent work with external consultants to review our procedures and processes along the nine protected characteristics. Findings will be implemented. 61

284 Bullying and Harassment: Build on the work with Speak In Confidence which has prioritised the issue of bullying and harassment. At a local level broaden the capacity and capability of our CARES Ambassadors in providing individual and local support to victims of bullying and harassment. Review our zero tolerance campaign around the issue Increase range of learning and development opportunities offered to staff particularly those at bands 1-4 Improve education and training governance including the improving of access to learning opportunities along the nine protected characteristics. Broaden our range of cultural awareness and Equality and diversity training to support recruitment and selection and key decision points. Patients The Trust is committed to equality, diversity and human rights. This means we work to make sure our staff and patients and communities are treated fairly and with respect. We aim to develop an inclusive culture where diversity is fully embedded into business practice. We also aim to influence change around reducing health inequalities and improving the patient experience whilst promoting a culture that embraces diversity and delivers measurable benefits. The Trust prides itself in the fact that it does engage and will continue to engage the service users and staff to deepen its understanding of the equality themes. Engaging with our local communities that we serve and providing opportunities for service users to feed back on their experience is an important feature of our work. Our equality objectives for 2015/16 were: 1. Caring for patients with dementia Improvements in dementia care have continued throughout the year. Ensuring all relevant patients are screened for potential signs of dementia, and referred for follow up as indicated, has remained a priority, with over 1950 patients over 75 years admitted as an emergency having been assessed within 72 hours of admission. Staff education has similarly remained a priority, with all staff receiving dementia awareness training on joining the Trust. This is delivered by the Dementia Clinical Nurse Specialist and is presented from the eyes of a patient, using the critically acclaimed Barbara s Story DVD; this has now been seen by 3569 staff. Doctors, nurse and therapists receive more detailed bespoke clinical training and several go on to undertake the Alzheimers certificate or, for specific staff, a specialist module at university. As well as welcoming cares to support their loved ones outside of visiting hours, experience for inpatients with dementia has been improved by the provision of more activities such as reminiscence rummage boxes, fidget blankets, singing and music sessions and provision of books, puzzles and board games. We continue to advocate an inclusive approach for patients with dementia, and aim to incorporate dementia-friendly design and facilities across all the Trust. 62

285 Future work is being driven by patient and carer feedback. All carers are offered the opportunity to complete a short survey about their experience while at the Trust. We will be participating in the National Dementia Audit early in 2016/17, the results of which will provide more guidance about which service developments we should prioritise. 2. Caring for people with a learning disability In order to provide assurance that the Trust is listening and responding to the needs of patients with a Learning Disability, the Head of Safeguarding has attended a variety of forums where there are carers and service users. This is an excellent opportunity to hear the views of people to respond to their questions, and improve outcomes. The Trust ensures staff awareness with regard to the need to listen and make reasonable adjustments for those with learning disability. Clinical and non-clinical staff receive awareness training as part of their mandatory safeguarding training making them more aware of the needs of learning disability patients and their carers. The Good Practice Guidelines for staff working with people with learning disabilities remain in place. There are also care pathways for patients with learning disabilities in A&E, outpatients and the radiology department which continue to be used for patients with learning disabilities. Patients with a learning disability can provide feedback to the Trust on their experience through completing an easy-read survey. 3. Improving services for people with a sensory disability The Trust has engaged with service users with a sensory disability to capture their feedback on their experiences of accessing our services and receiving care. These included both positive and negative viewpoints. This has been invaluable in terms of ensuring our services are responsive to the needs of this group of service users. Some of these service users have expressed an interest to be involved in the design of new services. This will be taken forward by a task and finish group in 2016/17. In 2015/16 the Trust has installed additional hearing induction loops based on feedback from patients. The introduction of the hearing loop system not only improves communication for these patients but also ensures their privacy, dignity and well-being. Signage has been improved across both sites to ensure easier way-finding for patients and visitors. In addition the Trust has a contract with One Stop Language Services for the provision of BSL for patients using our services. Annex 1 Statements from our stakeholders 63

286 Hillingdon CCG 2 nd Floor, Boundary House Cricket Field Road Uxbridge Middlesex, UB8 1QG Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust Pield Heath Road Uxbridge UB8 3NN SENT BY ONLY (shane.degaris@thh.nhs.uk) 12 th May 2016 Dear Shane The Hillingdon Hospitals NHS Foundation Trust Quality Report We confirm that we have reviewed the information contained within the Report and checked this against data sources where this is available to us as part of existing contract/performance monitoring discussions and is accurate in relation to the services provided. We believe that the Account represents an open, fair and robust summary of the overview of the quality of care at the Trust for the services covered in the report. In terms of the quality priorities for 2015/6 the Trust set itself, we note the following; Priority 1 - Ensuring the safety of vulnerable and older people. The Trust met all the targets it set itself. Priority 2 - Improving the safety of medicines management. The Trust is behind plan for the rates of medication incident reporting, however achieved patient satisfaction in pharmacy. We expect the Trust to continue their drive on medication incident reporting and look to see continued improvement to reach the 11% reporting rate in 2016/17. Priority 3 - Improving Maternity Services. We acknowledge that 2015/16 has been a challenging year for the maternity services, in particular, the unpredictable demand the Trust has seen for its services. Despite this, the Trust has met all the quality priorities it set itself for maternity care. We will continue to work closely with you in monitoring the quality of maternity care through 2016/17. Priority 4 - Improving Communication with our patients. We are disappointed that the Trust are mostly behind their plans in this area and expect to see a work plan to address this. The CCG note the 57% performance in terms of inpatient discharge summaries being completed within 24 64

287 hours. This issue was also highlighted in the CQC report and the CCG have raised concern over the backlog. The CCG would like the Trust to highlight how they will be monitoring this going forward into 2016/17. From the work we undertake with our GPs, we are acutely aware of the importance of this level of communication between health professionals. We are disappointed in the patient survey results of nurses and doctors giving clear answers to questions and the patient being involved in their care as much as they wanted to be and again would like to see what the Trust are doing to address this. The CCG endorse the Trusts four quality priorities for 2016/17 and we look forward to working with the Trust in these areas. However, we would like the Trust to outline under Priority 2 - Achieving improvement in relation to seven day working priorities what working in progress means and we expect to see a timeline for achieving these standards. Under the same priority area, the CCG would like the Trust to outline the targets and timelines for completion of standards 2& 8 model of care and 6 Interventions and set out how you monitor these pathways going forward. In terms of statement 5 radiology and diagnostics, we ask the Trust to clarify their expectation in terms of imaging inpatients within 24 hours of request. Likewise, the CCG would like the Trust to set out timelines and targets under Priority 4 - Safer staffing improved recruitment and retention to ensure delivery of safe care for the reduction in vacancy levels of nurses in the specific clinical areas identified. The CCG are satisfied of the achievements the Trust has set out in the report. We appreciate the Trust has further work to do in order to achieve the targets and quality performance in the following areas: Performance in the accident and emergency department. The CCG appreciate the challenges the Trust has faced in meeting the 4 hour target. This is offset by the overall demand for your emergency services, particularly given the increase in the number of category 1 (blue light) ambulances. The CCG will continue to support the Trust to monitor the A&E activity and to work with the Trust to review systems and processes which may impact the performance in the department in terms of managing the demand more effectively. Improving the response rates for FFT, particularly in the A&E setting Improvement in the response rates to complaints Despite the increased levels of training in safeguarding adults (>80%), the Trust has a low rate of MCA and DoLs referrals. In terms of serious incidents, the CCG welcome the Trust sharing the learning from the cases in 2015/16. We note the two reported Never Events and will work with the organisation once the investigations are complete to ensure lessons are learnt and action taken to prevent reoccurrence. We ask the Trust to review how they identify and escalate incidents that would meet the criteria for reporting as a Serious Incident and welcome working closely to ensure the Trusts open and honest approach in this area. The CCG acknowledge the work the Trust has undertaken following the findings of the CQC inspection in October 2014 and are pleased the majority of work is either complete or on track to complete. The CCG welcome being involved in the mock CQC inspection programme through 2016/17. The CCG are encouraged by work on equality and diversity and would welcome joint ventures together in line with improving engagement for people who have a disability. We endorse the 65

288 equality achievements from 2015/16 in terms of caring for patients with dementia, learning disability and a sensory disability. We support the Trust in its sign up to safety campaign and we anticipate seeing the continued improvements in patient safety the Trust is setting out to achieve. Overall we welcome the vision described within the Quality Report, agree on the priority areas and will continue to work with the Trust in an open and honest manner to continually improve the quality of services provided to patients and the local population. We look forward to receiving the final version. Yours Sincerely Dr Ian Goodman Chair, Hillingdon CCG Cc: Jan Norman, Director of Quality and Safety, BHH CCGs Jonathan Webster, Director for Quality, Nursing and Patient Safety, CWHHE CCGs Joan Veysey, Acting Chief Operating Officer, Hillingdon CCG Stephen Dixon, Contract Director Hillingdon CCG Theresa Murphy, Director of Nursing, THHFT 66

289 Healthwatch Hillingdon s response to The Hillingdon Hospitals Foundation Trust (the Trust) Quality Report NHS Introduction Healthwatch Hillingdon wishes to thank the Trust for the opportunity to comment on the Trust s Quality Report for the year Healthwatch Hillingdon continues to have a close professional relationship with the Trust. We are in regular dialogue, meet with The Chief Executive Officer and other members of the hospital staff frequently, contribute to a number of working groups and committees and provide lay assessors for the Patient Led Assessment of the Care Environment. Through our valued partnership with the Trust, we work together throughout the year, to monitor and improve patient experience, and service quality and safety. Quality Report We must congratulate the Trust again this year on producing a Quality Report which reflects an honest and balanced assessment of the Trust s performance on the quality of their services. As we continue to see, even under the immense pressures of unprecedented activity, the Trust are committed to improve the quality of the services they provide and impact positively upon the experiences of their patients. Overall it has been pleasing to see improvement in a number of important quality indicators, such as mortality rates, cancer performance, and Clostridium difficile infections. It must be very satisfying for the Trust to report the Friends and Family Test (FFT) results, where 95.2% and 93.4% of patients recommended the Inpatient services and Accident and Emergency respectively. We must also congratulate the Trust on its good rating in the Learning from Mistakes League published by Monitor and the NHS Trust Development Authority in March When we compare safety reporting in this year s Quality Report with last years, it was good to see that only one element was repeated, which indicates to us that lessons are truly being learnt. We know the Trust will certainly not be happy with the level of Serious Incidents outlined in the report, but it is reassuring to see a culture which encourages reporting and the learning from them. 67

290 Quality Priorities Looking Back Priority 1 We were pleased to see that there have been some positive steps taken in safeguarding adults with the introduction of hearing loops, increased awareness and training. We are also pleased to see that residents have been engaged and their views will influence future plans. There is still some work to be done to improve the discharge management for vulnerable and older people and Healthwatch have committed to work with the Trust to achieve this. Priority 2 This priority is still very much a work in progress and as we have seen is very important, especially with our older residents, who are at greater risk of readmission due to medication errors in the home. The introduction of the Medical Safety Officer is a positive step in achieving this priority. Priority 3 There has been a large focus on maternity services due to the changes that occurred under Shaping a Healthier Future. We would congratulate the Trust on the way in which the transition has been managed. On the whole this has been very positive and that is reflected in the FFT feedback from women giving birth at the Trust. We are particularly pleased with the improved experience for women at triage, as this is one area we had consistently received adverse feedback in the past. We are glad to see that all Hillingdon women who chose to give birth at the Trust have been able to access the service, we have however highlighted to the Trust the importance of all women, regardless of their locality, being able to give birth at their choice of hospital, especially due to the correlation of this with post-natal depression. We have also highlighted to the Trust the increased importance of translation services for women. At Ealing maternity, they had a dedicated translation team which did not transfer as part of the changes. This has been raised by Ealing women and as this is a learning point from this year s Serious Incidents in maternity we are urging the Trust to look at this closely. Priority 4 We know the Trust is as disappointed as Healthwatch on the progress of this priority and that they recognise it as one of the highest quality priorities for We welcome this continued focus. As seen in the FFT results, Patients relate to us that the care and compassion received at the Trust is excellent. They continue however to raise communication as a major reason for angst and frustration in a number of areas. 68

291 The progress on providing prompt delivery of discharge summaries to patients, and especially GPs, is a particular disappointment. In addition to the safety issues this raises, we also see the impact delays have on patients and resources within GP surgeries. Quality Priorities Looking Forward The Clinical Quality Strategy and its principles are a clear reflection of the commitment we see from the Trust during our work, to improve quality and their patients experience of care. We are very pleased that the Trust consults widely when establishing their forthcoming priorities and that Healthwatch and the wider general public have an opportunity to input into the priority setting process. Through this selection methodology we are assured that the Trust Board are completely informed when selecting the priorities and we can support the Trust fully on their decision. When reflecting on those priorities chosen for the coming year, we certainly see the value and merits of each priority. Each will have its own challenges to deliver, with a low probability of in-year completion. We feel it would be useful for the public to be able to see a plan on a page for each priority, which outlines milestones and targets of how each priority will be delivered, over a realistic period. This will manage expectation and allow the public to gain a good understanding of progress. We have already defined how important improving the communication with patients and their families is. Not only in the inpatient setting, but in A&E and the numerous outpatient clinics that are held. Within this priority we would also like the Trust to consider including their implementation of the new Accessible Information Standards, which become law in July We see the priority around safer staffing as a key element to improving patient experience. In recent years we have documented the negative effects, on both staff and patients, that the over reliance on agency staff has had across the NHS. We fully support all efforts made by the Trust to improve recruitment and retention. Finally, we would conclude this year s response, by acknowledging again the close working relationship we enjoy with the Trust, which enables us to deliver our statutory duties, in a true spirit of partnership. Healthwatch Hillingdon 6 th May 2016 Graham Hawkes, Chief Executive Officer 69

292 THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Consultation on the Trust s Quality Report /2016 Response on behalf of the External Services Scrutiny Committee at the London Borough of Hillingdon The External Services Scrutiny Committee welcomes the opportunity to comment on the Trust s 2015/2016 Quality Report and acknowledges the Trust s commitment to attend its meetings when requested. The Committee is delighted that the Trust has received national recognition for outstanding core skills compliance by the London Streamlining Programme, which recognises that the Trust has raised its mandatory training compliance levels to over 90% and maintained this over the year. The Trust's four Quality Priorities during 2015/2016 were: 1. Ensuring the safety of vulnerable and older people 2. Improving the safety of medicines management 3. Improving maternity services 4. Improving Communication with our patients Following the October 2014 inspection, the CQC undertook its re-inspection of the Trust in May As a robust improvement plan had been put in place, this visit resulted in a de-escalation of warning notices in relation to regulations 10 and 12. Although there had been significant improvements with regard to Safe Care and Treatment for Cleanliness and Infection Control in relation to bare below the elbows and hand hygiene since the last CQC visit, the Trust has received a requirement notice against regulation 12. The Committee appreciates that the Trust has put a lot of time and resources into addressing the issues raised by the CQC during its inspections and that the resultant improvement plan is regularly audited and monitored. Members are encouraged to see that the Trust has made progress in relation to increasing the number of patients receiving enhanced MCA/DoLS training as well as establishing an Equality and Diversity group and attending local disability groups. In addition, the Trust has achieved 85% satisfaction with pharmacy services (against a target of 75%) and 97% satisfaction in relation to women experiencing a positive experience in the new birth centre (against a target of >88%). Although there has been an improvement in relation to an increase in reporting of medicine errors from 7.8% to 9%, the Trust has not met its >11% target this year. Furthermore, 63.3% of FFT respondents advised that they had been informed and updated of waiting times, if they had been waiting for more than 20 minutes, against a target of 80%. Members are also aware that consideration has been given to communication with patients and staff, particularly with regard to delays and 7 day working. The Committee looks forward to receiving updates on the effectiveness of measures put in place to address these issues. The Committee is aware that there has been a significant increase in activity at the Trust in the last two years and that it has one of the smallest A&E departments in London. As Hillingdon Hospital's A&E department is working at capacity, the Trust is having to work more smartly whilst also being conscious of keeping momentum going in relation to the drive for quality and delivering against financial targets. In addition, the Urgent Care Centre regularly becomes very busy, which has a knock on effect on A&E, and the number of patients arriving by ambulance is increasing across London (although the cause is unclear). The Committee is aware that an audit of the patient pathway will be undertaken in the next few months, from blue light arrival through to discharge. It is hoped that this audit will also consider what has had happened to 70

293 each patient prior to being transported under blue lights, to ensure that a fuller picture can be gleaned and analysed. The Committee looks forward to receiving an update on any action that is taken as a result of this audit to reduce activity. It is noted that the Trust has developed four key areas for improvement in 2016/2017 on which the following draft Quality Priorities for the forthcoming year have been based: 1. Achieving NEWS compliant to support early escalation of the deteriorating patient 2. Achieving improvement in relation to seven day working priorities 3. Delivering compassionate care and improving communication 4. Safer staffing - improved recruitment and retention to ensure delivery of safe care Looking forward, there are areas where the Trust continues to demonstrate that progress and improvements have been made but the Committee notes that there are a number of areas where further improvements are still required. We look forward to being updated on the progress of the implementation of priorities outlined in the Quality Report over the course of 2015/16. The Hillingdon Hospitals NHS Foundation Trust response to the consultation The Hillingdon Hospitals NHS Foundation Trust thanks all its stakeholders for their comments about the 2015/16 Quality Report. The Trust is pleased that our key stakeholders recognise the Trust s commitment to improve the quality of the care and services that we provide and to work closely with them in achieving further improvement. The Trust enjoys a good working relationship with both Healthwatch Hillingdon and with the Hillingdon Clinical Commissioning Group and it looks forward to further collaborative working to help shape the quality agenda and the delivery of safe, high quality care. The Trust is also pleased that its key stakeholders are in agreement with its quality priorities for 2016/17, recognising where we have made good progress in quality improvement across a range of quality indicators and also where further work needs to be driven forward to realise the expected outcomes that we wish to achieve. The Trust has taken comments on board as part of the consultation for the Quality Report and as such these are aligned with our partners views on where we need to focus our efforts. These are recognised by our key stakeholders and it is very positive that both Healthwatch Hillingdon and our local commissioners wish to continue to work closely with us. Our stakeholders have recognised and commended our excellent scores on the FFT, our improved mortality rates, our cancer performance and the reduction in Clostridium difficile infections. It has also been acknowledged that the Trust has progressed extensive work following the Care Quality Commission inspection to further improve the quality of its services. Areas of underperformance have been acknowledged and the Trust would like to reassure its stakeholders that these areas will continue to be a key priority for the Trust and a focus in the forthcoming year. This includes A&E performance against the 4-hour target, response rates for FFT and complaints response rates. The Trust is pleased that the ESSC recognises the amount of work that has been undertaken by the Trust over the last year with regard to achieving its quality priority targets. The Trust also welcomes the acknowledgement by the ESSC of the activity that we have seen through our A&E department and the work that is being taken forward to understand the reasons for the increase and how this is going to be managed. 71

294 The Trust acknowledges and welcomes the recommendations put forward by Healthwatch Hillingdon and our local commissioners with regard to strengthening its quality priorities. The Trust has reviewed the targets outlined and provided timelines for achievement. The Trust has also included the Accessible Information Standard under Priority 3 (Improving Communication) as a key target to achieve. This will ensure that that people who have a disability, impairment or sensory loss get information that they can access and understand and any communication support that they need. Our stakeholders have recognised that we have presented an honest and robust summary of the overview of quality of care at the Trust, acknowledging, alongside our achievements, that some targets have not been met with regard to the quality priorities set for 2015/16. It has also been recognised that the Trust has been committed to continuing to improve the quality of its services and impact positively on the patients experience of care despite the unprecedented activity that the Trust has seen in the last year. Improving communication with our patients will continue to be a key priority in 2016/17. We recognise the concern raised by our stakeholders on the progress of improvement in this area during 2015/16. We acknowledge, as outlined by Healthwatch Hillingdon, that our patients report that the care they receive and the compassion shown by our staff is excellent but that communication issues can be an area of frustration and angst. We look forward to continuing our very positive working relationships with our key stakeholders to support the delivery of improved quality of care and patient experience. Independent Auditor s Report to the Council of Governors of The Hillingdon Hospitals NHS Foundation Trust on the Quality Report (awaited) Annex 2 - Statement of Directors responsibilities in respect of the Quality Report The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation Trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation Trust boards should put in place to support the data quality for the preparation of the Quality Report. In preparing the Quality Report, Directors are required to take steps to satisfy themselves that: the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16 and supporting guidance the content of the Quality Report is not inconsistent with internal and external sources of information including: board minutes and papers for the period April 2015 to 27 th May 2016 (date of statement) papers relating to quality reported to the Board over the period April 2015 to 27 th May 2016 (date of statement) feedback from commissioners dated 12 th May 2016 feedback from governors dated 10 th May 2016 feedback from local Healthwatch organisations dated 6 th May 2016 feedback from the External Services Scrutiny Committee dated 15 th May 2016 the Trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 25 th May 2016 the latest national patient survey published June 2016 the latest national staff survey dated 23 rd February

295 the Head of Internal Audit s annual opinion over the Trust s control environment dated 19 th April 2016 CQC Report dated (May 2015 re-inspection) 7 th August 2015 the Quality Report presents a balanced picture of the NHS foundation Trust s performance over the period covered the performance information reported in the Quality Report is reliable and accurate there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and the Quality Report has been prepared in accordance with Monitor s annual reporting manual and supporting guidance (which incorporates the Quality Accounts Regulations) as well as the standards to support data quality for the preparation of the Quality Report. The directors confirm to the best of their knowledge and belief they have complied with the above requirement in preparing the Quality Report. By order of the board.. Date Chairman.. Date Chief Executive 73

296 Glossary A Accountable Care Partnership (ACP) Acute Myocardial Infarction Allied Health Professionals (AHPs) Ambulatory Care Pathway Analgaesia B Berwick Review Better Care Fund (BCF) British Sign Language (BSL) British Thoracic Society (BTS) C Care Pathway Care Quality Commission (CQC) Care Quality Commission (CQC) Intelligent Monitoring System CAS card Category 1 (blue-light) ambulances Cheshire West judgement The ACP is a new organisational form which integrates care around patients. It is a partnership between primary, acute, community, social care and third sector providers who have agreed to take responsibility for providing all care for a given population for a defined (and long) period of time. Most importantly, the partnership is held to account for achieving a set of pre-agreed quality outcomes within a given budget. Acute myocardial infarction is the medical name for a heart attack. Heart attacks occur when the flow of blood to the heart becomes blocked. They can cause tissue damage and can even be life-threatening. These are health care professions distinct from nursing, medicine, and pharmacy. AHPs include everything from podiatrist, dietitian, and physiotherapist, diagnostic radiographer to Occupational Therapist, Orthoptist and Speech and Language Therapist. Allows patients who are safe to go home to be managed promptly as outpatients, without the need for admission to hospital, following an agreed plan of care for certain conditions. Medication that acts to relieve pain. Commissioned following the Mid Staffordshire Hospitals enquiry and publication of the Francis Report. The review includes recommendations to ensure a robust nationwide system for patient safety. This is a programme spanning both the NHS and local government. It has been created to improve the lives of some of the most vulnerable people in our society, placing them at the centre of their care and support, and providing them with wraparound fully integrated health and social care, resulting in an improved experience and better quality of life. BSL is the sign language used in the United Kingdom (UK), and is the first or preferred language of some deaf people in the UK. The British Thoracic Society exists to improve standards of care for people who have respiratory diseases and to support and develop those who provide that care. Anticipated care placed in an appropriate time frame which is written and agreed by a multidisciplinary team. The independent regulator of health and social care in England. A form of monitoring to give CQC inspectors a clear picture of the areas of care that need to be followed up within an NHS acute Trust. Together with local information from partners and the public, this monitoring helps the CQC to decide when, where and what to inspect. 160 acute NHS Trusts are grouped into six priority bands for inspection based on the likelihood that people may not be receiving safe, effective, high quality care. Band 1 is the highest priority Trusts and band 6 the lowest. Casualty Card patient record that is completed within the Accident and Emergency department Ambulance response category for presenting conditions, which may be immediately life threatening and should receive an emergency response. This judgment clarified the test and definition for Deprivation of Liberty for adults who lack capacity to make decisions about whether to be accommodated in care. This means that a much greater number of service users and patients will now be subject to a deprivation of liberty and will come under the protection of 74

297 Chronic Obstructive Pulmonary Disease (COPD) Clinical audit Clinical Negligence Scheme for Trusts (CNST) Maternity Clostridium Difficile infection (C-Diff) Commissioning for Quality and Innovation (CQUIN) Community Acquired Pneumonia Complicated Diverticulitis Computerised Tomography (CT) D Delirium the DOLS procedure. COPD is a group of progressive lung diseases (more commonly chronic bronchitis and emphysema) that obstruct airflow. Symptoms develop slowly and over time, COPD can make it hard to perform routine tasks. The most common cause of COPD is smoking. A quality improvement process that seeks to improve patient care and outcomes by measuring the quality of care and services against agreed standards and making improvements where necessary. Administered by the NHS Litigation Authority (NHSLA), provides an indemnity to members / their employees in respect of clinical negligence claims. Trusts are assessed on their level of risk management against detailed standards. A type of infection that occurs in the bowel that can be fatal. There is a national indicator to measure the number of C. Difficile infections that occur in hospital. A payment framework enabling commissioners to reward quality by linking a proportion of the Trust s income to the achievement of local quality improvement goals. Inflammatory condition of the lung usually caused by infection and acquired from normal social contact (that is, in the community) as opposed to being acquired during hospitalisation. Complicated diverticulitis refers to the clinical presentation of acute diverticulitis with inflammatory manifestations and complications, such as perforation or obstruction. This is an X-ray procedure that combines many X-ray images with the aid of a computer to generate cross-sectional views and, if needed, threedimensional images of the internal organs and structures of the body Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of your environment. The start of delirium is usually rapid within hours or a few days. Department of Health (DH) The government department that provides strategic leadership to the NHS Deprivation of Liberty Safeguards (DoLS) Diabetic Ketoacidosis (DKA) Dr Foster E Eighteen (18) week wait Electronic Document Records System and social care organisations in England. The Deprivation of Liberty Safeguards are part of the Mental Capacity Act They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. Consistently high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA). This happens when a severe lack of insulin means the body cannot use glucose for energy, and the body starts to break down other body tissue as an alternative energy source. Ketones are the byproduct of this process. Ketones are poisonous chemicals which build up and, if left unchecked, and will cause the body to become acidic hence the name 'acidosis' An organisation that provides healthcare information enabling healthcare organisations to benchmark and monitor performance against key indicators of quality and efficiency. A national target to ensure that no patient waits more than 18 weeks from GP referral to treatment. It is designed to improve patients experience of the NHS, delivering quality care without unnecessary delays. This helps the Trust to manage clinical records in electronic format making records management more efficient and ensuring patient records are more accessible to clinicians. 75

298 Epidural Catheter Equality Act (2010) F FAIR assessment for dementia Foundation Trust (FT) Fragility Fracture Freedom to Speak Friends and Family Test (FFT) G Gastro-intestinal (GI) Getting it right first time (GIRFT) Governors GP Commissioners H Health and Social Care Information centre (HSCIC) Healthwatch (formerly LINk) Hospital Episode Statistics (HES) Hospital Standardised Mortality Ratio (HSMR) An epidural catheter is a very thin, flexible tube that is inserted into the spine (specifically, the epidural space). Through it, the patient can receive doses of medication that stops nerves in the spinal cord from sensing pain. The Equality Act became law in October, It replaced previous legislation (such as the Race Relations Act 1976 and the Disability Discrimination Act 1995) and ensures consistency in what employers and employees need to do to make their workplaces a fair environment and comply with the law. Find, Assess, Investigate and Refer (FAIR) - The identification of patients with dementia and other causes of cognitive impairment that prompts appropriate referral and follow up after they leave hospital and ensures that hospitals deliver high quality care to people with dementia and support their carers. NHS foundation Trusts were created to devolve decision making from central government to local organisations and communities. They still provide and develop health care according to core NHS principles - free care, based on need and not ability to pay. Healthy bones should be able to withstand a fall from standing height; a bone that breaks in these circumstances is known as a fragility fracture. The Freedom to Speak Up Review was a review into whistleblowing in the NHS in England and it was chaired by Sir Robert Francis. An opportunity for patients to provide feedback on the care and treatment they receive. Introduced in 2013 the survey asks patients whether they would recommend hospital wards, A&E departments and maternity services to their friends and family if they needed similar care or treatment. The GI tract is a long hollow tube that extends from your oral cavity where food enters your body, via the oesophagus, stomach, small intestine, large intestine, rectum, and finally to the anus where undigested food is expelled. The Getting it right first time (GIRFT) report published by Professor Briggs in late 2012, considered the current state of England s orthopaedic surgery provision and suggested that changes can be made to improve pathways of care, patient experience, and outcomes with significant cost savings. The Hillingdon Hospitals NHS Foundation Trust has a Council of Governors. Governors are central to the local accountability of our foundation Trust and helps ensure the Trust board takes account of members and stakeholders views when making important decisions. GP Commissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. The HSCIC is an Executive Non Departmental Public Body (ENDPB) set up in April It collects; analyses and presents national health and social care data helping health and care organisations to assess their performance compared to other organisations. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. The national statistical data warehouse for the NHS in England. HES is the data source for a wide range of healthcare analysis for the NHS, government and many other organisations. A national indicator that compares the actual number of deaths against the expected number of deaths in each hospital and then compares Trusts against a national average. 76

299 I Independent Mental Capacity Advocate (IMCA) Indicator Inpatient Inpatient Survey K Keogh Review L Laparotomy (Emergency) Learning from Mistakes League Local Clinical Audit London Health Programme Standards M Major Trauma Mandatory Mental Capacity Act (MCA) Meticillin-resistant staphylococcus aureus (MRSA) Meticillin-sensitive Staphylococcus aureus (MSSA) Monitor Morbidity IMCAs are a legal safeguard for people who lack the capacity to make specific important decisions: including making decisions about where they live and about serious medical treatment options. IMCAs are mainly instructed to represent people where there is no one independent of services, such as a family member or friend, who is able to represent the person. A measure that determines whether the goal or an element of the goal has been achieved. A patient who is admitted to a ward and staying in the hospital. An annual, national survey of the experiences of patients who have stayed in hospital. All NHS Trusts are required to participate. A review of the quality of care and treatment provided by those NHS Trusts and NHS foundation Trusts that were persistent outliers on mortality indicators. A total of 14 hospital Trusts were investigated as part of this review. An emergency laparotomy is a surgical operation that is used for people with severe abdominal pain to find the cause of the problem and in many cases to treat it. A general anaesthetic is given and the surgeon makes an incision (cut) to open the abdomen (stomach area). Often the damaged part of an organ is removed and the abdomen washed out to limit any infection. A league table identifying levels of openness and transparency within NHS Trusts and Foundation Trusts. A type of quality improvement project involving individual healthcare professionals evaluating aspects of care that they themselves have selected as being important to them and/or their team. Programme to improve the quality and safety of acute emergency and maternity services based on achieving key standards of practice. Major trauma is any injury that has the potential to cause prolonged disability or death; this includes head injuries, life-threatening wounds and multiple fractures. Mandatory means must as outlined by an organisation for the role of the staff member. The Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over. Examples of people who may lack capacity include those with: dementia, severe learning disability, brain injury, a mental health condition, a stroke or may experience unconsciousness caused by an anaesthetic or sudden accident A type of infection that can be fatal. There is a national indicator to measure the number of MRSA infections that occur in hospitals. MSSA can cause serious infections, however unlike MRSA MSSA is more sensitive to antibiotics. The independent regulator of NHS foundation Trusts. Term used to describe how often a disease occurs in a specific area or is a term used to describe a focus on death. An example of morbidity is the 77

300 number of people who have cancer. Mortality rate Multidisciplinary team meeting (MDT) N National Clinical Audit National Confidential Enquiry into Patient Outcome and Death (NCEPOD) National Early Warning Scoring system National Joint Registry (NJR) National Reporting and Learning System (NRLS) Neonatal transitional care model Never events NHS Litigation Authority (NHSLA) NHS number O Oesophago-gastric The number of deaths in a given area or period, or from a particular cause. A meeting involving healthcare professionals with different areas of expertise to discuss and plan the care and treatment of specific patients. A clinical audit that engages healthcare professionals across England and Wales in the systematic evaluation of their clinical practice against standards and to support and encourage improvement and deliver better outcomes in the quality of treatment and care. The priorities for national audits are set centrally by the Department of Health and all NHS Trusts are expected to participate in the national audit programme. NCEPOD's purpose is to assist in maintaining and improving standards of care for adults and children for the benefit of the public by reviewing the management of patients, by undertaking confidential surveys and research, by maintaining and improving the quality of patient care and by publishing and generally making available the results of such activities. An early warning scoring system used to track patient deterioration and to trigger escalations in clinical monitoring and rapid response by the critical care outreach team. The scoring system used to trigger escalation is based on routine observations of respiratory rate, oxygen saturation levels, blood pressure, temperature, pulse rate and level of consciousness combined to give weighted scores that in turn trigger graded clinical responses. The NJR collects information on all hip, knee, ankle, elbow and shoulder replacement operations, to monitor the performance of joint replacement implants and the effectiveness of different types of surgery, improving clinical standards and benefiting patients, clinicians and the orthopaedic sector as a whole. The National Reporting and Learning System (NRLS) is a central database of patient safety incident reports submitted from health care organisations. Since the NRLS was set up in 2003, over four million incident reports have been submitted. All information submitted is analysed to identify hazards, risks and opportunities to continuously improve the safety of patient care. The neonatal unit provides expert, round-the-clock care for new-born babies who are ill or born prematurely. The transitional care model supports preparation for babies discharge home. Transitional care gives the parent a chance to take care of the baby, but with nurses nearby. This sometimes means staying on the neonatal ward with the baby for a while. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Trusts are required to report nationally if a never event occurs. Established to indemnify NHS Trusts in respect of both clinical negligence and non-clinical risks. It manages both claims and litigation and has established risk management programmes against which NHS Trusts are assessed. A 12 digit number that is unique to an individual, and can be used to track NHS patients between organisations and different areas of the country. Use of the NHS number should ensure continuity of care. Refers to the oesophagus (tube that food passes through when we swallow) and to the stomach. 78

301 Operating Framework Ophthalmology Outpatient Overview and Scrutiny Committee (OSC) P Pancreatitis PAS- Patient Administration System Patient-Led Assessment if the Care Environment (PLACE) Patient Safety Incident Picker patient experience survey Pressure ulcers Priorities for improvement PROMs (Patient Reported Outcome Measures) Pulmonary Embolism (PE) R Re-admissions Referral to Treatment Time Rheumatoid and early inflammatory arthritis An NHS- wide document outlining the business and planning arrangements for the NHS. It describes the national priorities, system levers and enablers needed to build strong foundations whilst keeping tight financial control. The branch of medicine that deals with the anatomy, physiology and diseases of the eye. A patient who goes to a hospital and is seen by a doctor or nurse in a clinic, but is not admitted to a ward and is not staying in this hospital. OSC looks at the work of NHS Trusts and acts as a critical friend by suggesting ways that health-related services might be improved. It also looks at the way the health service interacts with social care services, the voluntary sector, independent providers and other Council services to jointly provide better health services to meet the diverse needs of the area. This is a disease in which the pancreas becomes inflamed. Pancreatic damage happens when the digestive enzymes are activated before they are released into the small intestine and begin attacking the pancreas. The system used across the Trust to electronically record patient information e.g. contact details, appointment, admissions. A system for assessing the quality of the patient environment, replacing the old Patient Environment Action Team (PEAT) inspections. The assessments apply to hospitals, hospices and day treatment centres providing NHS funded care. The assessment includes local people as part of teams to assess how the environment supports patient s privacy and dignity, food, cleanliness and general building maintenance. It focuses entirely on the care environment and does not cover clinical care provision or how well staff do their job. The assessments take place every year, and results are reported publicly to help drive improvements in the care environment. A patient safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care. Picker Institute Europe is a leading international charity in the field of person centred care. It supports those working across health and social care systems to use people s experiences to improve care quality. Sores that develop from sustained pressure on a particular point of the body. Pressure ulcers are more common in patients than in people who are fit and well, as patients are often not able to move about as normal. There is a national requirement for Trusts to select three to five priorities for quality improvement each year. This must reflect the three key areas of patient safety, patient experience and patient outcomes. PROMs collect information on the effectiveness of care delivered to NHS patients as perceived by the patients themselves. Hospitals providing four key elective surgeries invite patients to complete questionnaires before and after their surgery The PROMs programme covers four common elective surgical procedures: groin hernia operations, hip replacements, knee replacements and varicose vein operations. A blood clot in the lung. A national indicator. Assesses the number of patients who have to go back to hospital within 30 days of discharge from hospital. Non-emergency NHS consultant-led treatment waiting times; monitors the length of time from referral through to elective treatment. Rheumatoid arthritis is an autoimmune disease that causes inflammation in the joints. The main symptoms are joint pain and swelling. Inflammatory arthritis is a term used to describe a group of conditions which affect the immune system. The body's defence system starts attacking tissues instead 79

302 Root Cause Analysis (RCA) S Safety Thermometer Secondary Uses Service (SUS) Sentinel Stroke National Audit Sepsis Serious Incidents Shaping a Healthier Future (SaHF) Sickle Cell Anaemia (Disease) Single sex accommodation SPECT (Single photon emission computed tomography) scanner Statutory Streamlining for London Programme Summary Hospital-level Mortality Indicator (SHMI) T TTAs Tablets to take away V of germs, viruses and other foreign substances, which can cause pain, stiffness and joint damage. A method of problem solving that looks deeper into problems to identify the root causes and find out why they're happening. The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and harm free care. A national NHS database of activity in Trusts, used for performance monitoring, reconciliation and payments. The Sentinel Stroke National Audit Programme (SSNAP) aims to improve the quality of stroke care by auditing stroke services against evidence-based standards, and national and local benchmarks. A potentially fatal whole-body inflammation (a systemic inflammatory response syndrome) caused by severe infection. An incident requiring investigation that results in one of the following: Unexpected or avoidable death Serious harm Prevents an organisation s ability to continue to deliver healthcare services Allegations of abuse Adverse media coverage or public concern Never events A programme to improve NHS services for people who live in North West London bringing as much care as possible nearer to patients. It includes centralising specialist hospital care onto specific sites so that more expertise is available more of the time; and incorporating this into one co-ordinated system of care so that all the organisations and facilities involved in caring for patients can deliver high-quality care and an excellent experience. Sickle cell anaemia is a serious inherited blood disorder where the red blood cells, which carry oxygen around the body, develop abnormally. A national indicator which monitors whether ward accommodation has been segregated by gender. SPECT images are obtained following an injection of a radiopharmaceutical that is used for nuclear medicine scans. The injected medication sticks to specific areas in the body, depending on what radiopharmaceutical is used and the type of scan being performed, for example, it will show bone for a bone scan, and gall bladder and bile ducts for a hepatobiliary scan. Statutory means by law. Collaboration between HR for London, NHS Employers and Skills for Health. The focus is on bringing people together to compare performance, share best practices, overcome issues and work collectively to drive change that leads to improved efficiency and patient safety. The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which reports on mortality at Trust level across the NHS in England. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. Medication that is to be taken home on a patient s discharge from hospital. 80

303 Venous thromboembolism (VTE) W WHO (World Health Organisation) Safe Surgery checklist Whole Systems Integrated Care (WSIC) An umbrella term to describe venous thrombus and pulmonary embolism. Venous thrombus is a blood clot in a vein (often leg or pelvis) and a pulmonary embolism is a blood clot in the lung. There is a national indicator to monitor the number of patients admitted to hospital who have had an assessment made of the risk of them developing a VTE The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia ( sign in ), before the incision of the skin ( time out ) and before the patient leaves the operating room ( sign out ). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation. The Whole Systems Integrated Care programme aims to improve the quality and experience of care for patients and service users, save money across the local health and social care system, and enhance professional experience by helping people n health and social care work more effectively together. Languages/ Alternative Formats Please call the Patient Advice and Liaison Service (PALS) if you require this information in other languages, large print or audio format on: Fadlan waydii haddii aad warbixintan ku rabto luqad ama hab kale. Fadlan la xidhiidh Jeżeli chcialbyś uzyskać te informacje w innym języku, w dużej czcionce lub w formacie audio, poproś pracownika oddzialu o kontakt z biurem informacji pacjenta (patient information) pod numerem telefonu: 如果你需要這些資料的其他語言版本 大字体 或音頻格式, 請致電 查詢 إذا كنت تود الحصول على ھذه المعلومات بلغة أخرى بالا حرف یرجى الاتصال بالرقم التالي الكبیرة أو بشكل شریط صوتي 81

304

305 Meeting of the Board of Directors public session Annual NHS Improvement Board Statements Wednesday 25 th May 2016 Agenda item 14 Reason for item: The Annual NHS Improvement Board Statements relating to the financial year 2015/16 are presented to the Board for approval and sign off in preparation for submission to NHS Improvement by 31 st May Summary: The NHS Improvement Risk Assessment Framework (RAF) requires the Trust to make the following annual declarations: 1 & 2 Systems for compliance with licence conditions - in accordance with General condition 6 of the NHS provider licence (appendix 1) 4 Corporate Governance Statement - in accordance with the Risk Assessment Framework Statements (appendix 2) 5 Certification on AHSCs and governance - in accordance with Appendix E of the Risk Assessment Framework (appendix 3) 6 Certification on training of Governors - in accordance with s151(5) of the Health and Social Care Act (appendix 3) The Corporate Governance Statements (appendix 2) as well as the assurances to support the validity and identification of risk for each statement have been reviewed by the Audit and Risk Committee (ARC) in October 2015 and April Certification on AHSCs and governance (appendix 3) is not applicable. The Trust Secretary has recommended that the training of Governors (appendix 3) can be confirmed. The Executive Team considered all declaration returns on 11 th May 2016 and recommend that the Board statements can be signed as specified in this paper. Board Action required: The Board is asked to: 1. Approve the declarations 1&2 (appendix 1), 4 (appendix 2), 5 and 6 (appendix 3) 2. Where a statement has been proposed as not confirmed ; the Board need to accordingly declare the reasoning for this. Report from: Vikas Sharma, Acting Head of Corporate Governance Report sponsor: Theresa Murphy, Director of the Patient Experience & Nursing Links to Trust strategic priorities: The Annual NHSI Board Statements impacts across all Trust strategic priorities Previous consideration at Board or Committees: ARC - Oct 15 and April 16 Equality and diversity considerations: None Financial implications: No direct implications Page 1 of 10

306 Appendix 1 Declarations required by General condition 6 of the NHS provider license The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another option). Explanatory information should be provided where required. 1& 2 General condition 6 - Systems for compliance with license conditions 1 Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Confirmed Licensee are satisfied, as the case may be that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution. AND 2 The board declares that the Licensee continues to meet the criteria for holding a licence. Confirmed Signed on behalf of the board of directors, and having regard to the views of the governors Signature Signature Name Name Capacity [job title here] Capacity [job title here] Date Date Page 2 of 10

307 Further explanatory information should be provided below where the Board has been unable to confirm declarations 1 or 2 above. A B Page 3 of 10

308 Appendix 2 Corporate Governance Statement The Board are required to respond "Confirmed" or "Not confirmed" to the following statements, setting out any risks and mitigating actions planned for each one 4 Corporate Governance Statement Response Risks and mitigating actions 1 The Board is satisfied that the Trust applies those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS. Confirmed 2 The Board has regard to such guidance on good corporate governance as may be issued by NHS Improvement from time to time Confirmed 3 The Board is satisfied that the Trust implements: (a) Effective board and committee structures; (b) Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and (c) Clear reporting lines and accountabilities throughout its organisation. Confirmed Risk & Action: The CQC Root Cause Analysis highlighted a need to strengthen and provide clarity around the roles and reporting lines of the committees. In response the Trust Chief Operating Officer and Programme Management Office have developed a programme for implementation of an accountability and responsibility framework. This programme includes structural, procedural and developmental elements. 4 The Board is satisfied that the Trust effectively implements systems and/or processes: (a) To ensure compliance with the Licensee s duty to operate efficiently, economically and effectively; (b) For timely and effective scrutiny and oversight by the Board of the Licensee s operations; (c) To ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators Page 4 of 10 Confirmed Risk & Actions: Re-inspection by CQC in May warning notices for Regulation 10 and 12 were removed. The Trust was issued with a requirement notice against Regulation 12: Safe Care and Treatment - Health and Social Care Act (Regulated Activities) Regulations 2014 with regard to: Assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated. Improvement actions have

309 of health care professions; (d) For effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee s ability to continue as a going concern); (e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making; (f) To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence; (g) To generate and NHS Improvement delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and (h) To ensure compliance with all applicable legal requirements. been outlined in the Trust s response on the requirement notice to the CQC. These are being progressed via the CQC steering group with monthly reporting to the Trust Board. There is a continuing CQC Improvement Programme in place, including internal CQC mock inspections (initially facilitated by tiaa) with a plan to address sustained change and a review of structures/processes and governance arrangements. Risks & Actions: The Trust is at risk of not being able to comply with its NHS Improvement licence in two areas: financial performance, and achieving the required level of performance against A&E targets. Finance: The Trust is forecast to deliver a 1.5m deficit in 15/16, a position NHS Improvement have been aware of since the start of quarter 4. Despite the delivery of the Trust s Recovery Plan, a deficit is forecast primarily due to the need to open more escalation beds than planned during quarter 4. The Trust has not met the 95% A&E standard in quarter 3 & quarter 4. Contributing factors have included significant increase in blue light activity, high demand and the ability of the physical capacity of the department to effectively manage flows. Challenges around Suboptimal pathways and staffing were also contributing factors. Page 5 of 10

310 5 The Board is satisfied that the systems and/or processes referred to in paragraph 4 (above) should include but not be restricted to systems and/or processes to ensure: Confirmed (a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided; (b) That the Board s planning and decision-making processes take timely and appropriate account of quality of care considerations; (c) The collection of accurate, comprehensive, timely and up to date information on quality of care; (d) That the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care; (e) That the Trust, including its Board, actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and (f) That there is clear accountability for quality of care throughout the Trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate. 6 The Board is satisfied that there are systems to ensure that the Trust has in place personnel on the Board, reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS provider licence. Confirmed Signed on behalf of the board of directors, and having regard to the views of the governors Signature Signature Name Name Page 6 of 10

311 The board are unable make one of more of the above confirmations and accordingly declare: A B C Page 7 of 10

312 Appendix 3 - Certification on AHSCs and governance and training of Governors The Board are required to respond "Confirmed" or "Not confirmed" to the following statements. Explanatory information should be provided where required. 5 Certification on AHSCs and governance Response For NHS foundation trusts: that are part of a major Joint Venture or Academic Health Science Centre (AHSC); or whose Boards are considering entering into either a major Joint Venture or an AHSC. The Board is satisfied it has or continues to: ensure that the partnership will not inhibit the trust from remaining at all times compliant with the conditions of its licence; have appropriate governance structures in place to maintain the decision making autonomy of the trust; conduct an appropriate level of due diligence relating to the partners when required; consider implications of the partnership on the trust s financial risk rating having taken full account of any contingent liabilities arising and reasonable downside sensitivities; consider implications of the partnership on the trust s governance processes; conduct appropriate inquiry about the nature of services provided by the partnership, especially clinical, research and education services, and consider reputational risk; comply with any consultation requirements; have in place the organisational and management capacity to deliver the benefits of the partnership; involve senior clinicians at appropriate levels in the decision-making process and receive assurance from them that there are no material concerns in relation to the partnership, including consideration of any re-configuration of clinical, research or education services; address any relevant legal and regulatory issues (including any relevant to staff, intellectual property and compliance of the partners with their own regulatory and legal framework); ensure appropriate commercial risks are reviewed; maintain the register of interests and no residual material conflicts identified; and engage the governors of the trust in the development of plans and give them an opportunity to express a view on these plans. N/A Page 8 of 10

313 6 Training of Governors The Board is satisfied that during the financial year most recently ended the Trust has provided the necessary training to its Governors, as required in s151(5) of the Health and Social Care Act, to ensure they are equipped with the skills and knowledge they need to undertake their role. Confirmed Signed on behalf of the Board of directors, and having regard to the views of the governors Signature Signature Name Name Capacity [job title here] Capacity [job title here] Date Date Where boards are unable to self-certify, they should make an alternative declaration by amending the self-certification as necessary, and including any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective quality governance Page 9 of 10

314 The Board are unable make one of more of the confirmations on the preceding page and accordingly declare: A B C Page 10 of 10

315 Meeting of the Board of Directors public session Annual Patient Advice and Liaison Service (PALS) and Complaints Report Agenda Item 15 Reason for item: The Local Authority Social Services and National Health Services Complaints (England) Regulations 2009, require NHS organisations to publish an annual report on complaints received by the Trust. Summary: This annual report presents information on informal concerns and formal complaints received by the Trust though the Patient Advice and Liaison Service (PALS) or via the formal complaints process between 1st April 2015 and 31st March Main Points to note: In 2015/ complaints were received and 1004 PALS concerns were recorded End of year performance an average of 70.8% of complaints were responded to within agreed timeframe There were 10 complaints taken forward by the Parliamentary and Health Service Ombudsman and 1 complaint was upheld in the period. Top three subjects for complaints and learning were Clinical care, Communication/Information to Patients and Attitude. Board Action required: The Board is asked to: 1. Note the information provided in this report Report from: Sally Taylor, PALS Manager Vanessa Saunders, Interim Deputy Director of Nursing Report sponsor: Theresa Murphy, Director of the Patient Experience & Nursing Links to Trust strategic priorities: To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide. Previous consideration at Board or Committees: N/A. Equality and diversity considerations: none. Financial implications: Failure to prevent and, when they do occur, respond appropriately to complaints could lead to financial sanction being levied against the Trust.. 1

316 Introduction This report provides a summary of concerns and complaints raised against the Trust between 1 April 2015 and 31 March The report also highlights a selection of service improvements that have been implemented as a result of learning from concerns and complaints. The report is produced in line with the requirements of section 18 of the NHS Complaints (England) Regulations The prevention, and speedy resolution, of concerns and complaints is considered an essential component of improving patient experience. The Director of Patient Experience and Nursing and the Deputy Director of Nursing personally see and relatives in and out of hospital to resolve complaints. 2. PALS The Patient Advice and Liaison Service (PALS) provides an on-the-spot service for patients, relatives and carers. The team can be contacted by either coming to the office or via telephone, , fax or letter; an on line form is also available through the Trust website. If an in patient is unable to come to the office, PALS are more than happy to visit a ward. 2.1 Analysis of PALS contacts Each PALS contact is logged onto the Trust risk management database (Datix). Table 1 below shows the casework of PALS by type. For the year a total of 1,234 contacts were recorded compared to 1,157 in the previous year. Of these, 1004 were expression of concern. Table 1 PALS contact 2015/16 Q1 Q2 Q3 Q4 Total Request for advice Expression of concern Request for directions Suggestion for improvement Request for Information Positive Comment Totals Chart 1 below provides a breakdown of the top ten subjects; some concerns included more than one subject. The highest numbers of contacts are related to appointments, followed by communication/information. Chart 1 PALS contacts by top ten subjects

317 3. Complaints When service users request formal investigation, or where issues raised are complex and cannot be resolved within 24 hours, the complaint is handled by the Complaint Management Unit. All complaints are logged on Datix. During 2015/146 the Trust received 448 complaints, compared to 401 in 2014/15. The number of complaints due for response was 431 compared to 419 in 2014/15. The reason for the difference in figures for complaints received and those due for answer is a reflection of the fact a complaint can be opened in one financial year and closed in another. Table 2 below shows the number of complaints received per quarter over the year, with the previous year s figures shown in brackets for comparison. Below this is shown the number of complaints due for response per quarter, again with the previous year s figures given for comparison. Table 2 Quarterly complaint activity 2015/16 Q 1 Q 2 Q 3 Q 4 Totals Number of complaints received 150 (94) 108 (103) 88(114) 102 (90) 448 (401) Number of responses due 128 (117) 123(93) 89(122) 91 (87) 431 (419) 3.1 Complaint response rate On receiving a complaint, the CMU contact the complainant and agree a timeframe for completion of the response. We have agreed with our commissioners a target of 90% completion within the timeframe agreed. Of the complaints due for response in 2015/16, 70.8% were completed within agreed timeframe. Disappointingly this was deterioration on last year s reply performance, caused by the impact of high volume of responses required in June and July which coincided with reduced staffing capacity in CMU. To reduce likelihood of this happening again in the future, the CMU team have been upskilled to work across all aspects of the service and there is now flexible working across the PALS and complaints teams in order to respond better to fluctuations in demand. Operational divisions are working closely with the Deputy Director of Nursing to review their role in complaint management and the Assistant Directors of Nursing are Complaint Champions within the divisional management teams. Table 3 and Graph 1 below illustrate the variation in performance between years and across months for 2015/16. Table 3 Response performance 2015/16 Graph 1 Monthly response performance % 2014/ /16 Complaints due for response Responses within timeframe Reply performance % 88% 70.8% 3