Salford Royal NHS Foundation Trust

Transcription

1 Salford Royal NHS Foundation Trust Annual Report and Accounts 1 April 2016 to 31 March 2017

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3 Salford Royal NHS Foundation Trust Annual Report and Accounts 1 April 2016 to 31 March 2017 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006

4 2017 Salford Royal NHS Foundation Trust

5 Contents Performance report Page 6 Introduction to Salford Royal NHS Foundation Trust Page 7 Performance overview from the Chairman and Chief Executive Page 10 Performance analysis Page 13 Delivery of the 2016/17 Annual Plan Page 13 Looking forward to 2017/18 Page 42 Quality Report 2016/17 Page 49 Accountability report Page 138 Directors report Page 139 Remuneration report Page 143 Staff report Page 156 Compliance with NHS Foundation Trust Code of Governance Page 166 Governance and organisational arrangements Page 170 Council of Governors Page 170 Board of Directors Page 177 NHS improvement s single oversight framework Page 191 Statement of Accounting Officers responsibilities Page 193 Annual Governance statement Page 194 Independent Auditor s report Page 203 Annual accounts for the period 1 April 2016 to 31 March 2017 Page Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

6 1 Performance report 6 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

7 1 Performance Report Performance overview The purpose of this Performance overview is to provide a brief introduction to Salford Royal NHS Foundation Trust (Salford Royal). This includes an outline of the purpose and activities of Salford Royal and a glimpse back at our history. The Chief Executive and Chairman s perspective is presented, including the key issues and risks to the delivery of our principal objectives. An introduction to Salford Royal NHS Foundation Trust Salford Royal NHS Foundation Trust is a statutory body, which became a public benefit corporation on 1 August Our core purpose is to provide clinical, academic and service excellence with patient and service user experience at the heart of our care. Salford Royal remains steadfastly committed to its aim to be the safest organisation in the NHS, providing safe, clean and personal care to every patient and service user, every time. We have a strong track record of delivering improvements in patient outcomes, patient experience and safe transformational efficiencies. This was evidenced by the award of an Outstanding rating by the Care Quality Commission (CQC), following formal inspection in January Salford Royal is an integrated provider of hospital, community, primary care and adult social care services with 750 beds and over 7000 staff. We provide a comprehensive range of local services to the City of Salford, as well as specialist services to Greater Manchester, the North West and beyond, meeting the explicit and often complex needs of a wide range of patients. Through its supply chain partners, Salford Royal provides mental health services to adults and older adults in Salford. We provide over one million hospital and community contacts for patients and service users across: Emergency and elective inpatient services Day case services Outpatient services Diagnostic and therapeutic services Adult and children s community services Adult Social Care Assessment and Care Planning services Mental Health Inpatient and Community Services for Adults and Older Adults The majority of acute services are provided at the main Salford Royal site and Salford Royal also provides: Community healthcare services, across Salford Specialist services at The Maples Neurorehabilitation Centre in Boothstown, Greater Manchester Renal dialysis services at satellite units in Wigan, Bolton and Rochdale Elective orthopaedic services at the Manchester Elective Orthopaedic Centre (MEOC) on the Trafford General Hospital site Outpatient neurology and dermatology clinics across Greater Manchester and into Cheshire Mental health inpatient services at the Meadowbrook Unit, on the main Salford Royal Site, and community mental health services across Salford Adult Social Care services are delivered in partnership with Salford City Council to maintain a diverse and sustainable market of social care providers who meet the needs of Salford citizens. This includes Residential Care, Supported Tenancies and Learning Disability and Home Care services all across Salford. Salford Royal s Head Office is at: Chief Executive s Office Salford Royal NHS Foundation Trust Stott Lane, Salford, Greater Manchester, M6 8HD Tel: enquiries@srft.nhs.uk 7 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

8 1 Performance Report Salford Royal is registered with the Care Quality Commission without conditions and provides the following Regulated Activities: Accommodation for persons who require nursing or personal care Accommodation for persons who require treatment for substance misuse Treatment of disease, disorder or injury Assessment or medical treatment for persons detained under the 1983 (Mental Health) Act Surgical procedures Diagnostic and screening procedures Transport services, triage and medical advice provided remotely Termination of pregnancies Nursing care Family planning services Management of blood supplies and blood derived products Salford Royal has a divisional management structure to coordinate and deliver high quality services for specific patient population groups. Division of Salford Health & Social Care The Division of Salford Health and Social Care was established on 1 July 2016 (previously the Division of Salford Healthcare) and provides a range of acute, community, social care and mental health services to the population of Salford. Acute services include; Emergency Department, Acute Medicine, Specialist Medicine and Aging and Complex Medicine. The Division also provides the majority of Salford Royal s community based services, including Children s services with PANDA (Paediatric Assessment and Decision Area), Health Visiting and School Nursing, Community and District Nursing, Intermediate Care, GP out of hours and the Salford Care Homes Medical Practice. The division includes a range of social care teams and services which undertake assessments and provide information, advice and support to people with social care needs. These teams include: Contact Team Integrated Health and Social Care Teams Salford Royal Hospital Social Work service Intermediate Care social work Intermediate Home Support Service (Reablement) Adult Safeguarding, Extra Care and Review Team (including MCA DoLS) Learning Disabilities Team Learning Disability Allied Health Professionals Mental Health Adult Social Care Community Occupational Therapy Team Sensory Team In addition, the division manages, through its supply chain partners, mental health services for adults and older adults in Salford. 8 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

9 1 Performance Report Division of Surgery and Neurosciences The Division of Surgery and Neurosciences provides a range of general and specialist surgical services, including neurosurgery, spinal surgery, complex elective and emergency surgery. The division delivers Greater Manchester neuroscience services and is one of the busiest stroke service in Greater Manchester and one of the busiest neurology centres in the country. The Division also include the second largest Intestinal Failure Unit (IFU) in the country. The division also provides services including Urology, Gynaecology, Orthopaedics ENT, Pain, Neuro Rehabilitation, Clinical Health Psychology, Neuro Psychology and Oral Services to the population of Salford and beyond. Division of Clinical Support Services and Tertiary Medicine The Division of Clinical Support Services and Tertiary Medicine provides a comprehensive range of both clinical and support services including Radiology, Pharmacy, Allied Health Professionals, Cancer Services, Pathology and Hotel Services. It also provides Critical Care Services including the Intensive Care, Surgical High Dependency and Neuro High Dependency Units. Tertiary medical services provided include Rheumatology, Clinical Haematology, Clinical Immunology and Dermatology. Dermatology services are provided in Bury, Radcliffe and Stockport. Clinical Haematology, including Oncology services, is provided for patients in the north west sector of Greater Manchester. This division also includes Renal Services with the Renal Department providing an inpatient and outpatient service to the western sector of Greater Manchester and satellite dialysis services in Salford, Wigan, Bolton and Rochdale. 9 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

10 1 Performance Report Performance overview from the Chairman and Chief Executive This report provides opportunity for us to highlight some of the significant developments to services and improvements to care and outcomes that have occurred over the last year. It provides a fair review of the business of Salford Royal, including a balanced and comprehensive analysis of developments and operational and financial performance during 2016/ /17 saw the completion of a pioneering journey at Salford Royal, to transform health and social care services across the City of Salford. This resulted in the launch of Salford Royal s Integrated Care Organisation (ICO) on 1 July 2016, when c.450 colleagues joined us from what was Salford City Council s Adult Social Care Service. Salford Royal took on the role of Prime Provider for all adult health and social care services for the residents of Salford. This new role includes taking a lead on mental health for the first time, which is provided in partnership with the Greater Manchester Mental Health NHS Foundation Trust. Salford Royal s Division of Salford Healthcare became the Division of Salford Health and Social Care, with operational responsibility for the implementation and delivery of the objectives of the ICO. The ICO at Salford is considered to be ground breaking, attracting national and international interest, and aimed directly at making a positive difference for patients and service users. During 2016/17, Salford Royal has provided leadership and operational support to The Pennine Acute Hospitals NHS Trust (Pennine). The Chairman and Chief Executive, and subsequently the Executive Nurse Director and two further Non Executive Directors, were appointed to the Board of Pennine and have developed and implemented a robust improvement plan across the hospitals of North Manchester, Bury, Rochdale and Oldham. Also during 2016/17, Salford Royal was accredited as a NHS Foundation Trust leader and one of only four Foundation Trusts in the country to lead the development of hospital groups or chains, as part of a vanguard NHS programme. Salford Royal has worked in collaboration with Pennine to develop a Group, which will operate from 1 April The Group will oversee the delivery of reliable, high quality, evidencebased care and services through Care Organisations, initially Salford, Oldham, Bury & Rochdale, and North Manchester. Further information about this groundbreaking development can be found on page 22. We understand that over the coming years, advancements in technology will play a pivotal role in assisting the Group to keep pace with the increasing demand for its services. In recognition of our innovative digital work to date, Salford Royal was proud to be chosen by NHS England in 2016/17 to establish a Centre of Global Digital Excellence and to act as a global exemplar for the use of digital technology in healthcare management. The additional funding attached to this innovative new project will enable significant investment in our information and technology (IT) infrastructure during 2017/18, and the creation of a new generation of Chief Clinical Information Officers. The context, nationally, during 2016/17 was one of major financial deficit for the NHS accompanied by unprecedented levels of demand for services. Salford Royal s financial plan was set at a deficit for the year, however, the robust financial controls and strong programme management arrangements in place resulted in an improved year end position and the achievement of 4.4m surplus. The Trust s ambitious and well managed cost improvement programme Better Care at Lower Cost contributed to this position, delivering 20m of savings during 2016/ Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

11 1 Performance Report During the year, accident and emergency services across the country have experienced significant increases in demand and struggled to maintain high standards of care. The Accident and Emergency Department at Salford Royal has been impacted by a reduction in the flow out of the department to our wards who are experiencing significant delays in transfers of care for patients to other hospitals and care settings because of the effect of increased demand on all health and social care providers. This, at times, caused internal delays in admitting patients to our wards. Our primary focus, during such challenging times, is always to maintain high standards of care for each and every patient. Our staff work tirelessly, in the face of increased demand, to ensure patients continue to receive the high quality of care they should expect from Salford Royal. In comparison with other providers, the Trust has maintained a highperforming position with respect to Accident and Emergency national standards. Alongside unprecedented demand for services in 2016/17, the limited availability of clinical staffing has continued as an additional pressure for the Trust. This has been particularly the case for registered nurses, as is the case across the country. We have a strong recruitment and retention strategy with dedicated nursing recruitment microsites, a targeted Facebook recruitment campaign, recruitment open days and fast track processes for candidates. The proactive implementation of this strategy will continue as a high priority for Salford Royal, as part of Group, in 2017/18. It is pleasing to note that the Trust recorded an increase in the number of graduates and junior doctors working at the Trust during 2016/17. We believe this is a direct result of work undertaken to ensure Salford Royal is considered an attractive place for professionals to work and progress their careers. In September 2017 we launched our vision of Saving Lives, Improving Lives as a reminder to all that our priority of becoming the safest organisation in the NHS is still at the forefront of everything that we do. We have placed particular focus on involving and engaging staff at all levels of the organisation. As a result, we have seen a improvement in 2016/17 in the satisfaction of our staff with respect to key elements of engagement, as recorded in Salford Royal s Annual Staff Survey, as part of the national NHS Staff Survey, with an increase of 8% in those staff who felt they were kept informed of what s going on at the Trust and, although we have seen a positive increase in the number of staff who would recommend Salford Royal as a place to work, we have seen a slight decrease in the number of staff who would recommend Salford Royal as place to receive care. We have taken this very seriously, have implemented robust action and will monitor this closely in the coming year. Research is an important part of the Trust s business and is key to ensuring that the care the Trust provides is keeping pace with developments in practice and advancements in technology. In 2016/17 we were delighted to note an increase in the number of patients enrolling in the research trials that we undertake at Salford. 11 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

12 1 Performance Report Our Board Assurance Framework (BAF) is a tool for our Board of Directors to assure itself (gain confidence, based on evidence) about the successful delivery of the organisation s principal objectives. The risks identified in the Board Assurance Framework are based on a collective assessment by the Directors of the environment in which the Trust operates. They are also informed by highscoring risks identified locally through the day to day operation of the Trust which may impact on the achievement of the Trust s principal objectives. The key risks to which the Trust was exposed to in 2016/17 were in relation to the following areas: Management of the transition of Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust to a new Group model of Hospitals Maintaining financial balance whilst delivering agreed cost savings Achieving operational performance targets in the face of increasing demand Maintaining adequate clinical staffing levels Managing the cost of agency staffing Maintaining safe, high quality services in the face of increased demand Defending the Trust s systems against an increasing cyber security threat Developing and maintaining an estate to meet the needs of current and future services The Board Assurance Framework was maintained by the Board of Directors and Divisional leaders throughout 2016/17, enabling the identification, analysis and management of risk to the delivery of principal objectives inyear. Controls and assurances were assessed and action plans were developed and implemented appropriately. This has provided clear sight of significant risks and has ensured action was prioritised appropriately and completed to achieve the designed impact. Going concern assessment Salford Royal NHS Foundation Trust has prepared its 2016/17 Annual Accounts on a going concern basis. After making enquiries, the Directors have a reasonable expectation that Salford Royal 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. We would like to end by recognising the many staff that have won awards either individually or as a team; there are too many to list here but the accolades have ranged from MBE s and CBE s to Public Health awards and being named Digital Trust of the Year. We are incredibly proud of the hard work and dedication all our staff display and wish to thank them for continuously providing safe, clean and personal care for our patients, service users and their families. Signed: Sir David Dalton Chief Executive & Accounting Officer Signed: James J Potter Chairman 12 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

13 1 Performance Report Performance analysis Delivery of the 2016/17 Annual Plan Salford Royal has developed Strategic Priorities, Principal Objectives and Board Level Key Performance Indicators (KPIs) to effectively monitor the delivery of aims and objectives described within its 2016/17 Annual Business Plan. The Board of Directors has an established Assurance Framework to ensure robust monitoring of operational and strategic progress against its principal objectives. Effective reporting and assurance flows to the Board of Directors are embedded, including a monthly Integrated Performance Dashboard and Chief Executive s Report, supported by detailed reports with respect to the delivery of the Better Care at Lower Cost Programme, Finance and Activity and Strategic Programmes. A quarterly Quality Improvement Dashboard and sixmonthly Patient Experience, Adverse Events and Patient Responsiveness Report are also reviewed. The 2016/17 Annual Business Plan is clearly communicated and interpreted at all levels across Salford Royal. Objectives and targets were agreed and allocated to Divisions, along with activity and financial plans, including income and expenditure budgets. Strategic priorities were launched to all staff via a personal , reinforced by a regular spotlight on the intranet to raise awareness of key priorities throughout the year, as well as regular articles appearing across all internal channels. This section of the Performance Report provides a detailed analysis of performance in relation to each strategic priority and objective, conveying achievements, challenges and any actions taken to address these. THEME 1 Pursuing Quality Improvement to become the safest, highest quality health and care service 1.1 Save and improve lives through reliable and safe care In 2016/17 Salford Royal continued to relentlessly pursue its Quality Improvement Strategy and aim to be the safest organisation in the NHS. Our principal objective for 2016/17 was to save and improve lives through reliable and safe care by: Maintaining the relative risk of mortality to be within the top 10% of the NHS 95% of our patients to receive harm free care Each of these aims were achieved, with many projects surrounding them that supported the delivery of our Quality Improvement Strategy. Our projects to reduce harm and mortality, improve patient experience and make the care that we give to our patients reliable and grounded in the foundations of evidence based care are more fully detailed in the Quality Report. Key achievements against our aims during 2016/17 were as follows: Hospital Standardised Mortality Ratio (HSMR) remained in the top 10% of the NHS and was statistically better than expected; (December 2015 November 2016 most recent data available) Summary Hospital Level Mortality Indicator (SHMI) was in the top 10% of the NHS and statistically better than expected; (April June 2016 most recent data available) 97.75% of patients received harm free care as measured by the safety thermometer, acute and community combined. (February 2016 February 2017) 13 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

14 1 Performance Report 1.2 Delivering personalised care: Maintain patient experience indicators in the top 20% nationally Delivering personalised care is a key priority for Salford Royal; it is part of our vision and is reflected within our values. We aim to be a listening and learning organisation, providing user driven care focused on What Matters Most to our service users. To ensure we are improving service users experience, we use a variety of methods to continually monitor performance, progress and obtain feedback. These include local and national surveys, patient stories, engagement events and focus groups, internal assessment processes and Quality Improvement projects. National Inpatient Survey The National Inpatient Survey is conducted every year. The Picker Institute conducts the survey on behalf of Salford Royal, and other NHS organisations (83 in total for 2016), and the results allow us to identify where we are performing better or worse than the average and, most importantly, where we can improve. Compared to the average, Salford Royal scored: Significantly better on 13 questions Significantly worse on 2 questions 87% of respondents rated their care as 7+ out of 10 86% reported being treated with dignity and respect Later in the year we will receive further information about how the above results compare with Trusts from across the country. Nursing Assessment and Accreditation System Salford Royal s Nursing Assessment and Accreditation System (NAAS) is used to monitor nursing care through a range of standards in both acute and community settings. The system involves the whole team, not just nurses and puts patient care at the centre. It highlights best practice which is shared throughout the organisation and identifies areas for improvement. At the end of 2016 /17, 33 out of 44 acute areas had achieved SCAPE status (Safe, Clean and Personal Every time), demonstrating excellent leadership and high quality care. During 2016 we saw the first of Salford Royal s community teams achieving SCAPE status through the Community Assessment and Accreditation System (CAAS). There are currently two Children s Community teams and two District Nursing teams that have celebrated achieving this status. Patient, Family and Carer Experience Collaborative The Patient, Family and Carer Experience (PFCE) collaborative has been running for a number of years, involving over 40 teams from across Salford Royal, shifting the focus of relationships with patients from what s the matter? to what matters most to you? Teams have used feedback from patients and service users, learning from leading organisations and shared best practice to develop tests of change such as an active introduction process on wards; key staff now introduce themselves to inpatients and check if the What Matters to Me Most boards have been completed. Further details and tests of change are included in the Quality Report. continued next page 14 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

15 1 Performance Report We have also seen a number of initiatives to improve patient experience beyond the collaborative. This is encouraged across the organisation. Some examples include: To help to reduce stress and anxiety for Renal patients complementary therapy is being offered to patients whilst receiving dialysis in collaboration with the British Kidney Patient Association (BKPA) Development of short films to improve access to key health and care information for users and families Development of bespoke communication cards for individuals with additional support needs Symbol and colour of building included on outpatient appointment confirmation letters to improve wayfinding Meet and greet service so users, carers or visitors that need additional support to attend the hospital site, can book a volunteer to guide them to and from their outpatient appointment Areas for further development and improvement include: Continuing to develop the Patient, Family and Carer Experience collaborative across community services Review the Patient, Family and Carer Experience Strategy to ensure it is fit for purpose and reflective of all services and areas served by the Trust Listening and responding to patients Salford Royal is committed to responding to issues of concern raised by a patient, relative or carer and learning from these. We provide an accessible and impartial service, with all issues raised being handled not only with the seriousness they deserve, but also in a way that provides answers that are full, frank and honest. 212 Compliments 376 Complaints 2403 PALS contacts Complaints performance 2016/ % 72.6% Complaints performance 2015/ % Percentage of complaints acknowledged within 3 working days Percentage of responses provided to complainant by agreed deadline Percentage of complaints acknowledged within 3 working days 89.4% Percentage of responses provided to complainant by agreed deadline 15 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

16 1 Performance Report What were our patients main concerns? Diagnosis Length of wait for admission discharge Length of wait for investigation Attitude Lost property Length of wait for results Cancelled operation/procedure Information Cancelled/rescheduled clinic/appointment Length of wait for appointment Communication Written/Oral Length of wait in A&E Length of wait for follow up appointment Length of wait for Outpatients clinic Treatment Hospital Policy Discharge medication Confirmation of attendance/admission/appointment enquiry Administration error Learning from complaints and concerns Salford Royal welcomes feedback of any type and views complaints as an opportunity to review the care and treatment we provide our patients. We investigate all complaints and concerns in order to identify any learning and make any necessary changes. Action plans are always developed when corrective actions are identified during complaint investigations. These are regularly reviewed and monitored within the divisions. This process ensures that information provided by the users of our service influences future service improvements. Salford Royal s Complaints Review Panel provides assurance to the Board of Directors that complaints are handled in line with NHS complaints regulations and in a robust, open, and timely manner. The Complaints Review Panel is chaired by the Senior Independent Director and encourages learning with a particular emphasis on Salford Royal s values of Patient and Customer Focus, Accountability, Continuous Improvement and Respect. THEME 2 Better Care at Lower Cost 2.1 Drive efficiency and sustain financial performance, reducing costs by 20m The Better Care at Lower Cost (BCLC) Programme has an ambitious three year goal to achieve 75m cost savings, with a requirement that 30m (full year effect) was delivered in 2016/17. The programme delivered 20m of savings, in year and 15.3m recurrently. During the year the Better Care at Lower Cost Project Management Office refined and improved its reporting processes. In line with recommendations from an internal audit, the quality governance framework was strengthened to support the safe implementation of cost reducing schemes. continued next page 16 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

17 1 Performance Report A series of transformational initiatives contributed to savings during 2016/17, including beneficial changes to how, and where, patients are treated within the organisation, securing the best deal possible on clinical and nonclinical supplies, continued focus on reducing premium rate pay spend, maximising value of contractual agreements, reduction in energy costs and improvements to the prescription and administration of drugs. During 2017/18 Salford Royal intends to concentrate on improving systems and processes within the community, improve patient communication and treatment using digital health technologies, introduce a Command Centre to further improve patient flow and implement an inventory management system to continue to drive down nonpay costs. THEME 3 Supporting high performance and improvement 3.1 Deliver the Workforce Strategy A Workforce Strategy was approved by the Board of Directors in April 2016 focused on addressing the concerning clinical and nurse staffing levels, reducing spend on premium rate locum staff, ensuring we have an appropriate blend of workforce and finding alternative ways of filling hard to recruit to vacancies. The Workforce Strategy is supported by Divisional Workforce Plans that are now being actioned to increase the substantive medical workforce at Consultant and Sub Consultant level and significant work continues to better match supply and demand for nursing. In January 2017, the Trust secured 11 trainees onto the Nurse Associate Programme, a new role to deliver handson care for patients that will sit alongside existing healthcare support workers and fullyqualified registered nurses. Trainees attend university one day a week and work the remaining time on their placement, supported in practice by ward based assessors and clinical educators. The training takes 2 years at which point trainees will have achieved a Nursing Associate foundation degree. We have increased apprenticeships provided from 58 to 68 and have also received accreditation through the Skills Funding Agency as an Employee Provider for Apprenticeship Training. A comparison of key indicators is highlighted in the below table: 2015/ /17 Trust Grade Doctors Advanced Practitioners Assistant Practitioners Apprentices % Nonfrontline Staff In 2016/17 we aimed to reduce our premium noncontracted pay by 20% compared to 2015/16 levels and achieved a 2.54% reduction. We continue to have some of the lowest levels of premium noncontracted pay in the region. Workforce costs as a % of clinical income (excluding non PBR drugs and devices) improved from 79.60% in 2015/16 to 66.68% in 2016/17 and we continue to target a further improvement in this metric in 2017/18. In addition to recruiting staff, we have worked hard to retain our people, and have seen a decrease in staff turnover to 12.8% in 2016/17 from 13.3% in 2015/16. Despite many positive indicators, the concern regarding clinical and nurse staffing in the face of national shortages and increased demand remains a concern, and during 2017/18 we will rapidly pursue a new approach to workforce recruitment and retention. 17 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

18 1 Performance Report 3.2 Support and develop our people to deliver safe, clean and personal care We continue to deliver, through the Quality Improvement (QI) directorate, training and development opportunities to grow capability in QI methodology. Our regular QI collaboratives are the main vehicle to teach quality improvement methodology to our frontline staff. In addition, we actively encourage our people to access the many and varied courses provided by our partners at both the Advancing Quality Alliance (AQuA) and Haelo. 3.3 Improve engagement with and wellbeing of our people The management of sickness absence serves to reduce costs and maintain the quality of our services. Salford Royal acknowledges that at times, staff may become ill and managers are always expected to provide appropriate and sympathetic support to staff during such times. It is our aim to reduce sickness absence to a target level of 3.6% by the end of 2017/18. During 2016/2017, absence levels were 4.28%, compared to the previous year s level of 4.25%. Further information is included in the Staff Report on page Implement the membership development strategy Membership is a key vehicle through which Salford Royal embraces patient and public engagement. Salford Royal s membership scheme provides an opportunity for people to share their experiences and help redesign and improve services. Engaging with members and the public ensures views of local people, and those further afield, are taken into consideration when making plans for the year ahead. Salford Royal NHS Foundation Trust membership is made up of public and staff members. Public members We have nine public member constituencies. Eight of those reflect Salford City Council s neighbourhood wards; the ninth is for people living outside of Salford. All members of the public who are 16 years old or over and living in one of the following constituencies can become a member: Claremont, Weaste and Seedley East Salford Eccles Irlam and Cadishead Little Hulton and Walkden Ordsall and Langworthy Swinton Worsley and Boothstown Out of Salford Staff members We have five staff member constituencies, largely reflective of Salford Royal s corporate and clinical divisional structure. During 2016/17, Salford Royal endeavoured to maintain its significant membership, and the Council of Governors focused on improving representation from underrepresented constituencies of Salford and young people. How many members do we have? The table below highlights Salford Royal s actual and target membership figures for Constituency Actual 31 March 2017 Target 31 March 2017 Public Salford residents 9,699 9,650 Public Out of Salford 5,946 5,850 Staff TOTAL 7,543 23,188 7,000 22, Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

19 1 Performance Report The following tables analyse the current and estimated membership figures for a number of indicators to highlight areas of representation. Public constituency breakdown Actual 31 March 2017 Claremont, Weaste and Seedley 1,323 East Salford 1,215 Eccles 1,851 Irlam and Cadishead 791 Little Hulton and Walkden 1,180 Ordsall and Langworthy 1,121 Swinton 1,370 Worsley and Boothstown 848 Out of Salford 5,946 TOTAL 15,645 Staff constituency breakdown Actual 31 March ,238 Clinical Support Services and Tertiary Medicine Corporate and General Services Salford Health and Social Care Neurosciences and Renal Surgery TOTAL Public constituency At year start (April 1) New members Members leaving At year end (March 31) Staff constituency At year start (April 1) New members Members leaving At year end (March 31) 2016/17 15, ,645 7,200 1, ,543 1,096 2,093 1, , /18 (estimated) 15, ,600 7, ,200 Public constituency Age (years) Unknown Ethnicity White Mixed Asian or Asian British Black or Black British Other Unknown Socioeconomic grouping AB C1 C2 DE Unknown Gender Male Female Unknown Number of members 31 March ,788 1,409 12, ,476 4,371 3,426 4, ,845 9, Eligible membership 51,787 16, , ,327 4,616 9,429 6,541 2, ,468 26,201 15,230 25, ,616 During 2016/17, we communicated with members, patients and the public regularly using a range of communication channels and feedback mechanisms, these include: Members Newsletter The Loop ECommunications Salford Royal s website Medicine for Members Seminars Patient Focus Groups Online surveys Open Day and Annual Members Meeting 2016 Social Media Twitter and Facebook Partner communications including Salford Clinical Commissioning Group, Salford HealthWatch and Salford City Council Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

20 1 Performance Report During 2016/17 Governors, supported by the Salford Royal Membership Team, utilised a number of opportunities to listen to the views of members and the public. In December 2016 Governors attended the Black & Minority Ethnic (BME) Big Listen Event at Salford Royal, aimed at listening to the views of BME staff across the organisation and identifying ways to improve staff experiences. In October 2016 we hosted a new look Open Day, running a series of seminars throughout the day looking at ground breaking developments currently taking place at Salford Royal. In addition, we continued our Medicine for Members seminar events. At these popular events professionals from hospital, community and social care services provided thought provoking and stimulating discussions on a range of topics including clinical health psychology, critical care and chair based yoga. In the latter months of 2016, over 350 members responded to our Annual Membership Survey, developed along with Salford CCG to inform the Salford Locality Plan. This year the focus was on gathering views on illness prevention and finding out what our members knew about the national NHS campaigns that aim to improve health and keep people well. The responses, available at have supported Salford CCG in planning engagement campaigns for the year ahead, and provided focus for member communications. Each year Salford Royals Governors carry out a Governor Led Engagement Programme; a timespecific programme, gathering the views of members, patients and the public on a single service or department, and share this information with the Board of Directors. This year Governors chose to focus on our district nursing service, which supports people in their homes and communities. We had a great response, with over 170 people telling us their thoughts via an online survey or speaking with Governors at various District Nursing Clinics. Headline results included: 80% of respondents were happy with the service of both home and clinic visits 86% said that staff treated them with dignity and respect 56% of respondents were given information from the GP/Hospital about what to expect Our District Nursing Team developed a number of ideas and actions directly from the feedback including: A patient handout is being developed to inform service users about the service and what to expect Information on the website has been updated to highlight clinic venues and car parking information The District Nursing Team will be part of our Action for Hearing Loss assessment The Council of Governors, via their Quality Subgroup, will continue to receive updates from the District Nursing Team about the actions being taken and how these have improved the experience for service users. We continue to work collaboratively with our partners at Salford CCG, Salford HealthWatch and Salford City Council to share information, provide opportunity and encourage people to share their views on the health and social care economy in Salford. Members who wish to communicate with the Council of Governors can do so in a number of ways via the Membership Team: Website: Telephone: foundation@srft.nhs.uk 20 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

21 1 Performance Report THEME 4 Improving care & services through integration & collaboration 4.1 Deliver the Integrated Care Organisation providing population based care Salford Royal has a long history of working with partners; Salford CCG, Salford City Council, Greater Manchester West Mental Health NHS Foundation Trust and General Practice, as Salford Together, to improve the health and wellbeing of the people of Salford. Partners initially focused on integrating commissioning and services for older people and implementing a preventative model of care to improve experience, quality and outcomes and reducing costs. During 2016/17 work has continued to embed these changes whilst also developing an integrated model of care for all adults in Salford with the same aims, focused on a neighbourhood population health model. To support this work, a key part of Salford s Locality Plan, Salford Together secured 18.2m investment from Greater Manchester s Transformation Fund over a three year period. On 1 July 2016, following regulatory approval, we created one of England s first Integrated Care Organisations (ICOs), bringing together adult social care with community and acute mental and physical health, with Salford Royal as the prime provider. This exciting and innovative development is key to the further integration and transformation of services for the people of Salford. The ICO forms part of a new integrated care system that includes expanded joint commissioning and pooled budget arrangements and the subsequent establishment, by our partners, of Salford Primary Care Together; Salford s GP provider organisation. Further information regarding this groundbreaking development can be found in the Integrated Care Organisation Report on page Work with partners to reconfigure services across the NW sector In July 2015, the Greater Manchester Healthier Together Committee in Common identified Salford Royal as one of four single services in Greater Manchester to treat high acuity patients. In December 2015 the Greater Manchester Health and Social Care Strategic Partnership Board plan Taking Charge of our Health and Social Care in Greater Manchester was approved. This plan also identified the development of shared hospital services and standardisation. In the North West sector of Greater Manchester (Salford, Bolton and Wigan), Salford Royal has been working with its partners to develop a local response to these plans, overseen by a Partnership Board, comprised of the Bolton NHS Foundation Trust, Wrightington Wigan and Leigh NHS Foundation Trust and Salford Royal NHS Foundation Trust, as well as Bolton, Ashton, Wigan & Leigh and Salford CCGs. The NHS Foundation Trusts have been working closely to develop plans within the scope of Healthier Together covering acute and emergency medicine, radiology and general surgery. This work includes development of single services with shared governance, establishment of multidisciplinary team working and plans for increasing capacity on the Salford Royal site. In addition the North West sector has developed a wider programme of work to develop shared working across a range of priority services including Breast Services, Elective Orthopaedics and Paediatric Services, to ensure long term resilience. This work has been aligned to the Greater Manchester standardisation and specialist hospitals agenda. Shared governance arrangements have been established to oversee operational, financial and clinical performance as shared services become operational. 21 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

22 1 Performance Report 4.3 The development of Healthcare Groups As part of building a sustainable future, Salford Royal has committed to developing a healthcare Group which will enable us to deliver reliable, high quality care at lower cost across a wider patient population. Following a CQC rating of Inadequate at Pennine Acute Hospitals NHS Trust, Sir David Dalton and Mr James Potter commenced the year as acting Chief Executive and Chairman respectively of Pennine Acute Hospitals NHS Trust. This was to provide leadership and support to initially stabilise, and ultimately transform, services, patient safety and quality. In August 2016 Salford Royal was one of the first Trusts in the country to be accredited by NHS Improvement (NHSI) to lead a group or chain of NHS providers. Members of Salford Royal s Executive and Senior Leadership Team started to work across both organisations to standardise and embed reliable high quality care at scale, and develop shared corporate services. In November 2016 the Board of Directors at Salford Royal and the Trust Board at Pennine Acute Hospitals NHS Trust approved transitional Group governance arrangements. This included the establishment of a Group Committees in Common (Group CiC) responsible for the management and development of all hospitals and services within the Group. From April 2017 both Trusts will further formalise joint working through a management agreement. The management agreement will see the approved change in leadership across the Trusts enacted, introducing the Group Committees in Common and four Care Organisations Salford, North Manchester, Oldham and Bury & Rochdale, each with their own leadership teams who are responsible for the day to day running of each hospital and its community, primary care, social care and mental health services. As part of Group we are developing a blueprint called the Standard Operating Model (SOM) which leverages Salford Royal s unique capabilities to deliver patient centred, highly reliable care. This SOM will be implemented across health and care sites to deliver benefits such as improved clinical outcomes and better patient experience. Salford Royal s strongest locally developed assets including our Nursing Accreditation and Assessment System and Emergency Department delivery models, which have been described as Outstanding by the Care Quality Commission will feature in the SOM. The SOM also incorporates our digital strategy, the Digital Health Enterprise (DHE). This builds on our leading digital health credentials; this year Salford Royal was evaluated as the most digitally mature NHS organisation by the Health Services Journal, awarded the EHI Digital NHS Trust of the Year 2016 and secured funding to develop as a Centre of Global Digital Excellence. The DHE strategy is at the heart of delivering our Group model and will support transformational health care through breakthrough digital standards and technology. It will redefine ways of working and how patient flow is managed through our hospitals, and will reduce variation through paperless processes and digitised best practice standards. The DHE will also deliver a Digital Health and Care Centre for sharing digital knowledge and experience across Greater Manchester and nationally, and an Allscripts Electronic Patient Record (EPR) Experience Centre which will share progress being made with our EPR. continued next page 22 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

23 1 Performance Report We are increasing our local contribution to supporting Small and Medium Enterprises (SMEs) through mentoring and advice, and have successfully secured a place on the Crown Commercial Service Digital Outcomes and Specialists 2 Framework allowing us to offer digital, media and health outcomes products to the market supported by our Salford partners such as NWEH, The Landing at Media City and Haelo. 4.4 Develop specialist services in partnership with provider organisations During the past year Salford Royal has continued to develop its major trauma services as the lead provider for Greater Manchester Major Trauma Services, in collaboration with Central Manchester NHS Foundation Trust. Major Trauma Services at Salford have maintained their position in the top quartile nationally, measured on survival rates. Presently over 1000 seriously injured patients each year are cared for at Salford Royal. This year has seen the strengthening of the clinical pathways for the shared services: In August a pelvic surgeon from Wrightington, Wigan and Leigh NHS Foundation Trust commenced weekly sessions at Salford, enabling patients requiring pelvic surgery to be managed on site without the need for transfer Vascular pathways between Central Manchester and Salford have been further smoothed, and a direct telephone link between the two Emergency Departments is now in place for speedy communication between the Trauma teams University Hospital of South Manchester continues to support patients requiring plastic surgery For the third year running clinical staff from the Emergency Department and the Major Trauma Team, in conjunction with the other emergency services in Greater Manchester, have participated in the organisation and the delivery of the hugely successful Safe Drive Stay Alive attended by year olds. Salford Royal is also fully engaged in the Greater Manchester Acute and Specialist Services programme leading work to implement the Greater Manchester single service for Oesophagogastric Cancer and NeuroRehabilitation and is working closely with partners to develop plans for Urology including UroOncology, Paediatric services, Orthopaedic and MSK services. 23 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

24 1 Performance Report THEME 5 Demonstrate compliance with Mandatory Standards 5.1 Clinical and quality standards and 5.4 Access standards Salford Royal continued to perform positively against many patient safety and experience indicators during 2016/17. Further information can be found in the Quality Report on pages Standards of quality and safety Salford Royal was rated as Outstanding in the 2015 Care Quality Commission (CQC) inspection and continues to assure itself in relation to the CQC standards through 9 key steps: 1. Ward/Departmental Fundamental Standards Self Assessments 2. Divisional Senior Review 3. Outcome leads identified for each standard for specialist input 4. Corporate assurance visits to measure robustness of the selfassessment process with outcome leads in attendance 5. Outcome of corporate assurance visits reported to Divisional Assurance and Risk Committees and Corporate Quality and People Experience Governance Committee 6. Outcome of corporate assurance visits with divisional response reviewed via Audit Committee 7. Annual assurance reports for individual standards compiled by outcome leads and presented at the Corporate Clinical Effectiveness or Quality & People Experience Governance Committee 8. Divisional Annual Governance Reports 9. Annual CQC Fundamental Standards Assurance Report reviewed via the Executive Assurance and Risk Committee and Audit Committee. In November 2016, an internal CQC style mock inspection was conducted. The Salford Royal inspection team consisted of 40 clinical and nonclinical staff placed into assessment teams as per the CQC identified services; Urgent and emergency services, we included EAU and AAA Medical care, including Ageing complex medicine Surgery Critical care Services for children and young people End of Life Care Outpatients and diagnostic imaging Adult community care Children s community care A total of 33 wards and departments were visited and information was collated from a variety of sources, including Quality Improvement dashboards and governance reports. A report was produced following the mock inspection which identified both areas of good practice and learning. Salford Royal has an established quality impact assessment process. All business cases and project initiation documents prompt staff involved in developing changes to consider the following: Patient safety Clinical effectiveness Patient experience Staff experience Equality and Diversity Targets/Performance Each assessment is scored, reviewed, signed off and challenged, if necessary, by the Executive Medical and Nurse Director. Robust processes are in place to monitor, through the divisional and corporate assurance committees and performance reports, the impact of service changes. 24 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

25 1 Performance Report Joint Targeted Area Inspection of the multiagency response to abuse and neglect of children in Salford The new Joint Targeted Area Inspections (JTAI) of services for vulnerable children and young people, involving the Care Quality Commission (CQC), Ofsted, Her Majesty s Inspectorate of Constabulary (HMIC) and Her Majesty s Inspectorate of Probation (HMIP) launched in February In September 2016 Salford Royal, along with partner agencies across Salford, was subject to a JTAI of arrangements and services for children in need of help and protection. Each JTAI is undertaken in two parts: A review of the multi agency front door A specific deep dive investigation The theme of the deep dive investigation during this inspection was children living with domestic abuse. For Salford Royal the key focus areas were the Health Visiting Service and Accident and Emergency. There are no ratings attached to this type of inspection, however, the overall findings were very positive across all agencies and there were no areas requiring immediate action. Key strengths and areas for improvement directly related to Salford Royal included: Key strengths A particular strength across all agencies was the commitment of resources to tackle this domestic abuse and a clear determination to remove barriers to effective joint working Timely and effective information sharing between midwives and health visitors supports effective assessment of the child s risk and needs and the appropriate application of thresholds Salford Royal NHS Foundation Trust has a robust supervision policy Areas for improvement Flagging of health records to indicate children are living in households where domestic abuse occurs A Joint Health Action Plan has been agreed, under the lead of Salford CCG, to address the areas of improvement for all health agencies involved and was submitted to the inspectorates in January Financial standards Financial performance Summary of financial performance The main headlines of financial performance for the Foundation Trust in 2016/17. The operating surplus (after adjusting for impairment charges and nonoperating transactions) is a surplus of 4.5 million which is 8.8 million better than planned The overall income and expenditure position shows a surplus of 9.9 million, but this is after accounting for a number of nonoperational items and the financial performance of the charity into Salford Royal surplus. These are set out below The financial risk rating (Use of Resources Rating UoR) using NHS Improvement s methodology to assess the level of financial risk based on the position as at the end of March 2017 is a 2 25 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

26 1 Performance Report Statement of comprehensive income position This statement within the Annual Accounts shows the total value of Income and Expenditure for the year ended 31 March The following table summarises the actual income and expenditure performance as at the 31 March Actual results s Income 646,151 Expenditure (622,070) EBITDA 24,081 Exceptional Income / costs and impairments 5,486 Depreciation and amortisation (11,626) Total interest receivable / (payable) (7,483) PDC dividends (501) Net surplus (per annual accounts) 9,957 Normalising Adjustments: Net impairments and accelerated depreciation of noncurrent assets Hosted services outturn Operating surplus (5,486) On 1 July 2016 Salford Royal NHS Foundation Trust became the provider of adult social care and adult mental health services for the City of Salford. A number of employees providing adult social care services transferred from Salford City Council to the Foundation Trust and responsibility for contracts to provide social care services also transferred. Mental health services are provided through a subcontract with Greater Manchester Mental Health NHS Foundation Trust. As a result, Foundation Trust income and expenditure has risen substantially compared to 2015/16. (3) 4,468 Our annual Foundation Trust income in 2015/16 was 514,110k compared to 646,151k in 2016/17. Income for adult social care and mental health services account for 88,179k of this increase. No Salford City Council assets or liabilities were transferred to the Foundation Trust as part of this arrangement; however, the Foundation Trust became an admitted member of the Greater Manchester Pension Fund (GMPF) with responsibility for making payments of employees and employers pension contributions for staff that transferred who remain members of the GMPF. Accounting standards require that the Foundation Trust accounts for pension fund assets and liabilities for the transferring staff applying International Accounting Standard number 19 (Employee Benefits). The effect of applying this standard is that the Foundation Trust recognised an opening transfer of 35,318k of pension fund assets and 42,030k of liabilities making a net liability of 6,712k as at 1 July During the year the value of pension fund assets and liabilities were remeasured and the liability increased by a further 3,834k. The Foundation Trust has included noncurrent other liabilities of 10,546k in its 2016/17 annual accounts. A noncurrent other asset valued at 10,546k has also been reported in the 2016/17 annual accounts to reflect the terms of the Business Transfer Agreement, Pension Fund Admission Agreement and Risk Share Agreement for the transfer of adult social care and mental health services to the Foundation Trust which give rise to a right to reimbursement for pension costs. A 1.8 billion Sustainability and Transformation Fund (STF) was made available to NHS providers in 2016/17, linked to the achievement of financial controls and performance targets. The Foundation Trust received 11.4m of core funding, 5.0m STF incentive payment and 1.5m STF bonus payment which is reported as income in the annual accounts. 26 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

27 1 Performance Report Normalising adjustments Salford Royal has an operating surplus of 4.5 million, which has come from the delivery of operational healthcare services. Whilst the bottom line of the Annual Accounts shows a surplus of 9.9 million this is due to the charging of nonoperating income and expenditure items during the year which need to be removed from the financial results ( normalised ) when assessing the Foundation Trust s performance against the NHS Improvement financial regime to identify the operating surplus achieved by Salford Royal from operating activities i.e. the provision of healthcare. The most significant nonoperating income and expenditure adjustment (normalising adjustment) made to the results reported in the Statement of Comprehensive Income is to exclude the impact of impairment charges recognised in the Annual Accounts in respect of land and building assets. The Salford Royal accounting policies require that land and building assets are revalued with sufficient regularity to ensure that the carrying amounts are not materially different to those that would be determined at the end of the reporting period following a valuation. Owing to indications that market conditions have changed since the end of last financial year, the Valuation Office was commissioned to undertaken a revaluation of the Salford Royal land and building assets. The outcome of the valuation was an overall increase of 19.3 million in the value of our asset base and an exceptional net benefit of 5.5 million was recorded in the Statement of Comprehensive Income. There was also an associated 13.8 million net increase in the balances recorded in the revaluation reserve. Trust income The Foundation Trust receives the majority of its income for the delivery of health and social care ( million 85%) from commissioners of NHS and social care services. In addition the Foundation Trust received 76.2 million for the delivery of nonpatient care services, with 17.9 million coming from Health Education North West to support the costs of providing education and training to medical and other NHS staff. In the year the Foundation Trust also received income of 17.9 million from the Sustainability and Transformation Fund, 15.2 million on behalf of Hosted Services and 12.9 million in respect of Research and Development activities. The Foundation Trust s income from the provision of goods and services for the purposes of the health service in 2016/17 (commissioner requested services) was million compared to 3.4 million received for other patient care activities i.e. private patients, overseas visitor charges and compensation paid by the NHS Injury Costs Recovery Scheme to the Foundation Trust for treatment costs for patients who have sustained injuries and claim and receive personal injury compensation. Income from the provision of goods and services for health and social care service represents over 99% of the Foundation Trust s total income from clinical activities. Income from nonmandatory patient care activities at under 1% of the total income received is reinvested in health and care services for Salford. The following graph sets out the income received by Salford Royal during the financial year. continued next page 27 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

28 1 Performance Report 2% 3% 2% 3% 2% 3% 2% 3% 6% 5% 5% 11% 17% 4% 49% 9% 74% Clinical Commissioning Groups and NHS England Income for social care and public health Employee costs including Research & Development staff Puchase of social care Other income for patient care services Research and development Sustainability and transformation funding Education and training Puchase of mental health services Supplies and services clinical supplies Supplies and services drugs costs Other supplies and services Income received on behalf of hosted services Other operating income Research & development Other expenses Services from other NHS bodies including the NHSLA Operating expenses Salford Royal employs almost 7,000 wholetime equivalent staff and expenditure on pay costs (including directors costs) is the single largest item of expenditure for Salford Royal with million spent during the year representing 49% of total operating expenses. Of the nonpay related expenditure, drugs costs accounts for million (17% of operating expenses), with expenditure on purchase of social care the next largest item of spend at 55.8 million (9%) and clinical supplies 38.1 million (6% of operating expenses). The following graph sets out the major headings of operating expenses for Salford Royal. Jointly controlled operations The Foundation Trust is a party to two jointly controlled operations (i.e. an arrangement is established without the creation of a separate corporate entity) with the purpose to deliver NHS services. Salford Royal has a 50% interest in each jointly controlled asset and these are: Sterile Services Decontamination Unit jointly controlled with Wrightington, Wigan and Leigh NHS Foundation Trust that cleans and sterilises reusable medical equipment on behalf of the two Foundation Trusts. Pathology At Wigan and Salford (PAWS) jointly controlled with Wrightington, Wigan and Leigh NHS Foundation Trust to provide pathology services to the two Foundation Trusts. 28 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

29 1 Performance Report Salford Royal s share of the costs of each of these jointly controlled operations is included in the operating financial results reported in the Annual Accounts. The Foundation Trust also has a 40% interest in North West ehealth. The other shareholders are the University of Manchester and Salford CCG. This was established as a separate legal entity on 1 November 2016 with a combination of ordinary share capital and preference share capital (where the preference shares have preference on a return of capital but no rights to dividends or voting rights). The Foundation Trust has voting rights in NWEH of 33%. Capital expenditure investments The Foundation Trust has continued to invest in its estate and equipment assets in 2016/17. Capital expenditure totalled 8.6 million in 2016/17, and the table below summarises the main themes of capital expenditure for across Salford Royal during the year. Heading Improving clinical and nonclinical environment Medical and IM&T equipment Improving operating theatres Refurbish patients kitchen Backlog maintenance and site infrastructure m s Description Including expanding capacity in our Emergency Assessment Unit and decanting services from our Clinical Sciences Buildings to more suitable accommodation. Including replacing essential diagnostic and imaging equipment. To refurbish theatres including replacing all endoflife plant Upgrading the patients kitchen and replacing equipment Investments in ensuring the site infrastructure remains in safe working order Liquidity and short term investments The Foundation Trust s cash balance remains strong at 57.9 million at the financial year end, with interest receivable of 0.2 million earned. The interest received total remains low entirely due to the current economic conditions and the low rates of interest being offered by low risk investment organisations including the National Loans Fund. Salford Royal continues to holds the majority of its cash within the Government Banking Service (GBS). Accounting policies The Foundation Trust reviews its accounting policies on a regular basis following the requirements of International Financial Reporting Standards and the Department of Health Group Accounting Manual. These policies are reviewed and agreed by the Audit Committee and reflect the changing nature of the guidance and the external environment within which the Foundation Trust functions. The Foundation Trust s key accounting policies are set out from page 220 of the annual accounts included in this report. There were a small number changes made to the accounting policies during 2016/17. Accounting policies for pensions (including the NHS pension scheme, the National Employment Savings Trust and the Local Authority pension scheme) and other retirement benefits are set out in a note to the accounts (note 1.3). Details of senior employees remuneration can be found in the Remuneration Report. Post balance sheet events There are no significant post balance sheet events. Total Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

30 1 Performance Report A look forward The financial outlook for the NHS continues to be challenging with continued requirements to reduce public expenditure. A substantial and widening gap over the next few years is forecast between income and expenditure. With a continued increase in demand for NHS and social care services, this leads to a requirement to deliver significant cost savings without detriment to the quality of our standards of care. Salford Royal has submitted its Annual Plan to NHS Improvement that covers the financial years 2017/18 and 2018/19. Our operational plans for 2017/18 forecast a normalised net deficit, after costs of financing and depreciation, of 1.6 million. Our financial plan for 2017/18 has been set in the context of an offer from the general element of the National Sustainability and Transformation Fund of 10.4m; the conditions of which continue link this to delivering an income and expenditure control total of a 1.4m deficit (excluding depreciation of and receipt of donated assets) and 1.6m deficit including depreciation and receipt of donated assets. We must deliver 28.7 million of cost savings in 2017/18 to deliver this plan. Investment will continue in Salford Royal s asset base with the investment of an estimated 13.6 million in 2017/18. This will include investments in replacing essential medical and IT equipment assets and providing necessary maintenance and upkeep of building assets. Subject to HM Treasury approval, further expenditure is planned for 2017/18 and 2018/19 of c. 48 million to build a new surgical centre to provide additional operating theatre, critical care and diagnostic capacity to allow SRFT to become the single receiving site for Greater Manchester major trauma activity and to be the provider of high risk general surgical activity for the North West sector of Greater Manchester. Each of these developments is in response to commissionerled requirements with clinical activity flows expected to start in 2019/ IM&T standards Cyber security Since the observed increase in cyber security events from December 2015 onwards, Salford Royal embarked on a journey of lowering the overall cyber security risk in 2 stages: Stage 1: Addressing immediate security risks Achieved by employing a Network Traffic Analyser from NCC Group to analyse and report on suspicious activity over a 4 month period, and Installation of a Security Information and Event Management System and Intrusion Prevention System to provide visibility and block suspicious activity This resulted in a reduction from an average of 15 reported incidents per week to approximately 23 recorded contacts per week with known malware, that could be dealt with in a timely manner. Stage 2: Raising the Trust s security maturity by creating a security program to support business objectives Modelled around the National Cyber Security Centre s 10 Steps to Cybersecurity Framework, this is a wide ranging and ongoing set of tasks to align our security operations with this model. The maturity assessment via internal audit and assessment by NCC Group placed the Trust s security maturity at Controls partly to fully Implemented and AdHoc (Level 1) respectively. The Trust is aiming to raise our maturity level from AdHoc (Level 1), through Managed (Level 2) to Defined/Established (Level 3) based on the Capability Maturity Model Integration (CMMI) scale applied by the NCC Group s assessment by the first quarter of 2017/ Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

31 1 Performance Report Data quality and clinical coding The quality of the data to accurately reflect clinical activity depends on: Clear, accurate and timely information provided in the patient notes Accurate and consistent clinical coding by the clinical coding team liaising with clinicians Good management processes surrounding the collection and processing of the data such as an organisation s policy and procedures plus a committed investment in training and accreditation. Salford Royal has established a regular clinical coding internal audit cycle. Further information regarding data completeness and clinical coding and Salford Royal s attainment level for the Information Governance Toolkit is included in the Quality Report. 5.4 Workforce standards Salford Royal has established policies in place for the management of conduct, behaviour, attendance and performance and provides training to managers on the use of these policies. In 2016/17 Salford Royal achieved a compliance level of 95.15%, against a target of 95% for key mandatory training and an appraisal rate of over 90%. Medical staff have an annual whole practice Medical Appraisal which supports revalidation recommendations, whilst other staff have a review under Salford Royal s contribution framework arrangements which also facilitates nurse revalidation. The Contribution Framework helps ensure goals and objectives are closely linked to Salford Royal s Annual Plan for all staff, with pay progression linked to a successful contribution framework review and to the completion of mandatory training. Under the Contribution Framework all members of staff should have regular conversations with their manager about their contribution, both in relation to how they are doing their job and what they are achieving. Regular training sessions have been provided throughout the year in respect of the contribution framework for both Reviewers and Reviewees. Salford Royal has an internal target of 60 working days to complete recruitment, from authorisation of a post to the confirmation offer being made to the successful candidate. Performance during 2016/17 was 61.3 working days. 31 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

32 1 Performance Report 5.5 Buildings and facilities standards This year our Estates and Facilities teams have been working with our service improvement partner, Haelo, to develop an improved reporting and monitoring system for building standards. This will enable more efficient and effective monitoring against all standards. Work to refurbish the Inpatient kitchen started in 2016, 1.4million investment has created a modern, state of the art kitchen. Just days after the refurbishment was complete, the Environmental Health Office carried out an unannounced visit, which saw Salford Royal maintain its 5 star food hygiene rating. Whilst they provided some recommendations to help the Trust improve even further, the overall view of the inspectors was the Trust s newly refurbished Inpatient kitchen gave the catering team a fantastic environment in which to carry on delivering such high standards. The areas assessed were: Compliance with food hygiene and safety 5 procedures Compliance with structural requirements 5 Confidence in management control 5 procedures Overall score 5 PatientLed Assessment of the Care Environment (PLACE) 2016 PLACE assessments put patient views at the centre of the process and use information gleaned directly from Patient Assessors. It focuses entirely on the care environment and does not cover care provision or staff behaviour. The hospital is assessed against five key areas: Privacy and Dignity Cleanliness General Building Maintenance Food Dementia Once again, over 20 public members stepped forward to become part of the PLACE assessment team which took place from 21 March to 1 April For the first time this year, the assessment took place over a two week period so a more thorough evaluation could be completed. Areas assessed Cleanliness Appearance maintenance Food Privacy and Dignity Dementia SRFT scores national average 95.66% 98.10% 94.87% 93.40% 81.64% 88.50% 87.52% 84.20% 81.40% 75.30% Salford Royal performed better than the national average in three of the five areas assessed but disappointingly scoring lower in 2 areas. In September 2016, the Trust began the roll out of a new patient catering operation which would ensure compliance with the standards set out in the NHS standard contract for hospitals regarding nutrition and hydration and, additionally, increase the choice of ethnically diverse meals by over 50%, provide a dementia friendly menu, choice from over 200 main dishes and provide the ability to have different menus for different wards. A comprehensive action plan was developed to address the issues raised and progress is being monitored by the Corporate Quality and People Experience Governance Committee. 32 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

33 1 Performance Report THEME 6 Implement enabling strategies 6.1 Research and development strategy Salford Royal is committed to research as a driver for improving the quality of care we provide to our patients. Only by carrying out research into what works can we continually improve treatment for patients, and understand how to focus NHS resources where they will be most effective. Research activity at Salford Royal remains high. We presently support over 500 studies and opened 175 new research studies during 2016/17. Over 4,000 patients were recruited to 150 National Institute for Health Research Clinical Research Network (NIHR CRN) clinical research studies. This level of participation demonstrates the Trusts commitment to high quality research. Our engagement with industry partners remains excellent, with 1 in 5 of our studies being industrysponsored, demonstrating the Trust s commitment to testing and offering the very latest medical treatments and techniques. Several large NIHR grants are now being hosted at Salford Royal and over 390 articles and book chapters were published by our staff. Performance against national standards for study setup and delivery remains below the national average. A process of restructuring and expanding the Research and Development Department has started and resulted in a 10% improvement in performance in the last two quarters. We fully expect this positive progress to continue into next year. From March 2016, all new studies have been processed through the new system of Health Research Authority Approval. This has represented a major change in the way research is set up within the NHS. In addition to the above, we have maintained our programme of patient and public engagement and successfully delivered a third Salford Research Week in October The Research and Development Departments of Salford Royal and Pennine Acute Hospitals NHS Trust have agreed to work more collaboratively as part of our ambition to develop a Group. This provides an enormous opportunity to expand our research activity and offer improved access to cutting edge research across a population of over 1.3 million people. Indeed, this initiative will enable more people to benefit from the very latest medicines, devices, diagnostics and treatments and provide better, safer care for the population we serve. 33 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

34 1 Performance Report 6.2 Under and post graduate education 6.2 Align designated education Programme Activities (PAs) to Job Plan allocation and ensure these are reliably delivered Undergraduate education Key achievements in 2016/17 included the successful implementation of a completely revised Year 3 MB ChB programme. This involved a major recruitment drive and staff development for expert Consultants to deliver the new components of the course, as well as significant change to the clinical placement and educational supervision model. The Trust needed to increase general medical placements and achieved this by working collaboratively with many supervisors in Salford and our clinical education providers in Wigan, Bolton and Pennine. Training standards have been improved via the introduction of service level agreements with directorates, specifying the educational activity and time that needs to be protected in Consultant and Specialty Doctor job plans to deliver the programme. Postgraduate education Postgraduate Medical Education processes and reporting have been aligned to Promoting Excellence, General Medical Council (GMC) standards for medical education and training. The Clinical Leadership of Postgraduate Medical Education has been strengthened by the appointment of Associate Directors with divisional responsibility for education and training, supporting the Specialty Training Leads to deliver high quality training. This will support further integration of clinical and educational governance impacting both on patient safety and medical training. In 2016, Salford Royal received a Health Education England (NW) Quality Monitoring Visit which highlighted four areas of noteworthy practice: effective and educationally valuable handover, support for quality improvement projects undertaken by trainees, early completion of GMC requirement to ensure that all trainers achieve full recognition for training and delivery of Foundation Training Programme. Of particular note, trainees described excellent working relationships with consultants and these working relationships were reflected in consultant awareness of the issues and concerns affecting trainees. 6.3 Hospital redevelopment / Estates strategy Patients and staff have benefited from the 200 million redevelopment on site over the past decade and during 2016/17 the Trust made significant progress in addressing maintenance issues around its estate. Work began late in 2016 to demolish parts of the Clinical Sciences Building and refurbish the remaining block. The Victorian building was initially constructed as a Nurses Home and training rooms and has been used for many different functions over the years. It is no longer energy efficient and would require extensive refurbishment to bring it up to a satisfactory standard. As a result, blocks A, C and D will be demolished whilst block B is being refurbished. It is planned that the space created by the demolition will be used for the expansion of the Major Trauma Centre and the implementation of Healthier Together. 34 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

35 1 Performance Report 6.4 IM&T strategy Ongoing enhancements to the Electronic Patient Record (EPR) to improve functionality have continued to be rolled out this year, alongside the delivery of other key projects and upgrades to smaller systems including: The roll out of proximity cards to the A&E Department, removing the need for staff to log onto each computer separately Automatic referral to the Tissue Donation Service when an inpatient dies by completion of the current End of Life Care After Death document Electronic IV Chemotherapy Prescribing Interfaces created for the Trafford Care Coordination Centre and the deployment of EPR in Wigan Modification of the electronic discharge summary and clinical letters in line with CCG and national requirements 6.5 Corporate social responsibility and public health strategy Salford Royal is committed to improving the health and wellbeing of patients and staff, ensuring it contributes positively to the lives of local people, and the environment and society in which they live. This was well illustrated in 2016/17 as detailed within the Sustainability Report. In addition, the following major programmes of work have been initiated: Replacement of the Salford Integrated Record (SIR) is ongoing with the project being extended due to the complexity of delivering this first of type product into the UK Full rollout of Trendcare, a nursing support and workload management software system to calculate patient acuity and manage ward staffing levels Roll out of the Genesis Inventory Management System in Theatres, an automated stock and procurement process that means clinical staff spend the minimum amount of time reordering and handling stock. The time is then given back for patient care and will potentially release cash and efficiency savings 35 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

36 1 Performance Report Sustainability report Salford Royal undertakes its responsibility for improving the health and wellbeing of our patients, service users and staff, and making a positive contribution to the lives of local people through our approach to leadership and engagement, use of resources, travel, procurement, adaptation and transformation. This work is overseen by the Corporate Quality and People Experience Governance Committee and examples of our work during 2016/17 are highlighted below. Leadership and engagement Staff engagement in sustainability agenda / supportive of wellbeing in the workforce Salford Royal recognises that maintaining the health and wellbeing of staff creates a happy, healthy and motivated workforce, and a whole host of support and information is available to help improve general health and wellbeing and reduce sickness rates, which will ultimately contribute to even better patient care. A staff survey was undertaken to understand what issues staff felt were a priority in developing a sustainable workforce of the future, and shape the Trust s Health and Wellbeing Strategy. The strategy was relaunched to tackle a range of issues including resilience, sickness levels and access to timely support and advice when required. Community engagement and local community support As a major employer in Salford, we work closely with a number of local community and voluntary organisations to share information and encourage membership of Salford Royal. Via our Governors we work closely with Salford Community Committees and the Salford CCGs Citizen and Patient Panel to promote opportunities for local people, and those further afield, to become involved in the design and planning of services across the Salford health and social care economy. We have a hosted a number of events for members and the public in 2016/17 on topics from the future of medical education to chair based yoga, supporting the people of Salford to get more involved in their own health and promoting healthier living. Furthermore, we understand that not all interactions have to be done in person and have a range of online engagement through our social media channels where we promote engagement opportunities, job and events. Partnerships Salford Royal has an excellent track record of working in partnership with other organisations with respect to sustainability, delivering the Public Health and Corporate Social Responsibility Strategy (Live Well, Work Well), and working on the Social Value agenda. Social value is about making sure there is relevant social, environmental and economic value from everything we do, including service delivery, commissioning of services and procurement of goods and services. Salford Royal is a member of the Social Value Alliance and signed up to the Social Value Charter. The pledge to Be Social in Salford has been developed by the Salford Social Value Group, which includes representatives from a broad spectrum of commissioning, procuring and providing organisations. The Social Value Charter sits alongside the City Mayor s City Plan, a strategy which sets out the priorities and the actions for the next three years that will help support local residents, grow local businesses and build a better, more prosperous future for everyone. 36 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

37 1 Performance Report The City Mayor s City Plan includes four domains and these are reflected in the Live Well, Work Well Strategy action plan: A growing city Reducing worklessness Promoting use of local labour Improving education and skills Buying Salford goods and services Increasing resilience of the workforce Facilitating good links between local businesses Salford Royal has added social value weighting into the procurement process to assess an organisations contribution to social value. An innovative city Using products from sustainable sources Increasing recycling and reuse of resources Reducing energy use Improving the place public spaces, parks and community facilities Making services accessible to everyone A cooperative city Increasing opportunities for and valuing volunteering Increased ownership and involvement of service users and wider communities Actively promoting inequalities and community cohesion Increasing positive role models in the community Salford Royal has over 250 volunteers working across the Trust to help improve patient s experience of care. We provide ongoing support and training for our volunteers. Our volunteers range from those making that first step back onto the road to employment, others who are preparing to apply for a health related training course and those who are able to give their time generously after retiring or while bringing up their families. In the final quarter of 2016/17, 2 of our volunteers successfully gained paid employment in the Trust. We also introduced a number of new volunteer roles including: Volunteer in the Panda Unit Welcome Volunteer in Pendleton Gateway Volunteer in A&E Patient Activity Volunteer for patients with Dementia Volunteer at Mayo 2nd Floor reception A caring city Tackling health inequalities closing the health gap both within Salford and the rest of the country Raising people s aspirations in education, employment, living standards, and social interaction Monthly events for local schools in Salford, provide school children with the opportunity to see, feel and experience what it is like to work in the NHS and raise local aspirations. 6.9m has been committed to a programme of energy saving measures for Salford Royal. The project is expected to reduce the Trust s energy and water use by around 1.9 million per year and reduce the main sites carbon emissions by around 6,500 tonnes per year over the next 15 years. 37 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

38 1 Performance Report Resources Waste Our use of resources and production of waste is shown in the table below: Field Clinical waste cost Clinical waste volume Special waste cost Special waste volume Domestic waste cost Waste recovery/recycling cost Units 253, tonnes 1, tonnes 133, ,457 Definition Cost of off site disposal including transport. Excludes on site collection and handling costs associated with moving waste to a central collection point. Clinical waste produced. Where the weight is not available from the contractor an assessment should be made using available information e.g. average weight of bag multiplied by the number of bags per annum. Cost of off site disposal including transport. Excludes on site collection and handling costs associated with moving waste to a central collection point. Special waste produced regardless of type. Where the weight is not available from the contractor an assessment should be made using available information e.g. average weight of bag multiplied by the number of bags per annum. Cost of off site disposal including transport. Excludes on site collection and handling costs associated with moving waste to a central collection point. Percentage of the total domestic/commercial waste cost that is attributable to recovered/ recycled waste. Working with a new supplier for both our clinical and domestic waste streams, Salford Royal has implemented a number of energy efficient innovations and industry best practice, which has resulted in a saving of over 100 tons of clinical waste in 2016/17. Schemes have included: Use of a new sharps management system to decrease the costs of burning and reduce the amount of carbon produced Decreased our carbon footprint by changing the number of waste collections we have per week with a more modern fleet Implemented an onsite mixed recycling facility Implemented an onsite compaction and cardboard bailing to reduce the amount of vehicles accessing the site Handled our clinical waste via a different recognised waste stream to reduce costs by over 50% and make the byproduct reusable as alternative fuel Implemented a food waste strategy that utilises biodigesters to turn food waste into biofuel that generates an income stream 38 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

39 1 Performance Report Energy Resource 2013/ / /16 Gas Electricty Water Oil Coal Green energy Total energy CO2e Total energy spend (water not included) Total energy spend (water included) Use (kwh) tco2a 38,066, , ,769, , ,118, , Use (kwh) tco2a 23,256, , ,116, , ,329, , Use (m3) 179, , , CO2 N/A N/A N/A Use (kwh) tco2a Use (m3) CO2 Use (kwh) tco2a 19, ,083, ,664, , ,338, ,930, , ,236, ,831, We continue to take further action to reduce our use of resources and the production of water. 6.9m has been committed to a programme of energy saving measures for Salford Royal during 2016/17. The project was procured and funded through the Carbon & Energy Fund Framework, with Vital Energi appointed as the partner. Vital Energi have designed and installed a series of energy reduction measures across the site. These include: LED Lighting and improved lighting controls Replacement of old or damaged thermal insulation Installation of high efficiency variable speed pumps Replacement of the hospital main boilers with 3 modern high efficiency boilers Installation of a 2.5MWe Combined Heat and Power (CHP) unit in the boiler house The CHP unit will generate around half the amount of electricity used on site, whilst waste heat from the CHP engine will produce steam and hot water which will be utilised in the hospital. Besides energy savings the project will deliver significant cost reductions in the water charges and clinical waste disposal services. 39 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

40 1 Performance Report Travel Staff travel plans Staff are offered personalised travel plans (PTPs) at induction and at events throughout the year, delivered by Transport for Greater Manchester (TfGM). During 2016/17 a travel plan was developed with our partner Aecom to identify ways of increasing the use of sustainable modes of transport for staffs daily commute and visitors. In December 2016, we asked staff to complete a Travel Survey was undertaken amongst staff and results compared with a previous survey taken in 2012, to identify any changes in preferred modes of travel. Mode of travel 2013 Car / van as driver Car / van as passenger 65.5% 5.6% Motorcyle Train 1.1% 1.6% Bus Metrolink 10.7% 1.3% Taxi 0.5% Bicycle 5.2% Walk 7.0% Other 1.6% Results 2016 % change 2019 target 67.0% 3.8% 0.8% 1/9% 10.1% 1.8% 0.5% 5.9% 7.0% 1.3% +1.5% 53% 1.8% 9% 0.3% 1.5% +0.3% 2.5% 0.8% 13% +0.5% 4% +0.0% 1% +0.7% 8% +0.0% 8% 0.3% Since 2012, there has been a slight increase of 1.5% in the proportion of vehicle drivers, while travel by sustainable modes has been relatively consistent. While it would appear that previous travel plans have had minimal impact on travel choices, the survey indicated a number of areas where staff felt they would be encouraged to change travel choices if incentivised. An ambitious plan has been developed to achieve these challenging shifts in modal split by 2019, including incentives such as: Expanding bus ticket incentives to cover all bus operators Dedicated parking areas for staff who drive occasionally, to encourage cycling etc Introduction of a guaranteed ride home service for car sharers to alleviate concerns about being stranded at work due to unforeseen circumstances Increased car sharing bays Introduction of loan bikes for staff Increased provision of facilities and storage for cyclists 40 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

41 1 Performance Report Procurement Social value has been integrated into the procurement process, by including a social value question, with appropriate weighting, into tender documentation, assessing the Trust s commitment to social value. For example, a contract was recently awarded to a taxi company demonstrating how they would provide their drivers with dementia training, adding social value into their contract. Adaptation and transformation Salford Royal is participating in the national Vanguard programme, as a Primary and Acute Care provider site, developing new models of care with sustainable objectives in mind. These include: Redesigning new integrated pathways of care to deliver care closer to home to ensure patients and service users receive just enough care, at the right time, in the right place, using the right resources Developing enhanced neighbourhood teams to deliver care on a smaller geographical footprint, with access to specialist services when required. This includes the promotion of technology to facilitate selfcare, supporting people to manage their own health and using local communities as an asset to promote wellbeing Developing a one call number for citizens and professionals, to access advice and support 24/7, to facilitate professional decision making, and ensure patients and carers have access to the support they need to manage their health and wellbeing safely, including timely access to services when required 41 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

42 1 Performance Report Looking forward to 2017/18 The 2017/18 and 2018/19 Salford Royal Operational Plan builds on the priorities identified in Saving Lives, Improving Lives, the Trust s Service Development Strategy for the period It also incorporates priorities contained within the: Five Year Forward View and NHS Mandate Taking Charge of our Health and Social Care in Greater Manchester ; Greater Manchester s Devolution and Sustainability and Transformation Plan (STP) Salford s Locality Plan (jointly developed by the statutory health and social care partners) Organisationspecific plans to address financial and operational pressures In 2017/18 Salford Royal forecasts: An operating surplus of 9.3m A normalised net deficit, after costs of financing and depreciation, of 1.6m A deficit excluding depreciation on donated assets of 1.4m Our key priorities are highlighted below. In addition, as part of the establishment of the Group, work will continue with Pennine Acute Hospitals NHS Trust to develop an aligned and integrated planning framework. Strategic theme 1. Pursuing Quality Improvement to become the safest, highest quality health and care service 2. Better Lower Cost 3. Supporting high performance and improvement 4. Improving care and services through Integration & Collaboration 5. Demonstrate Compliance with Mandatory Standards Strategic priority 1.1 Save and improve lives through reliable and safe care 1.2 Delivering personalised care 2.1 Drive efficiency and sustain financial performance, reducing costs by 45m over 2017/18 and 2018/ Deliver the Workforce Strategy 3.2 Support and develop our people to deliver safe, clean & personal care 3.3 Improve engagement with and the wellbeing of our people 3.4 Implement the Membership Development Strategy 4.1 Work with partners across the Salford Locality to transform community based care and upgrade population health 4.2 Work with partners to reconfigure services across the NW Sector 4.3 Work with partners across GM to reconfigure and develop specialist services 4.4 Develop the Royal Health Group improving services through standardisation at scale in association with Pennine Acute 5.1 Clinical and Quality Standards 5.2 Financial Standards 5.3 IM&T Standards 5.4 Access Standards 5.5 Workforce Standards 5.6 Buildings and facilities Standards 6. Implement Enabling Strategies 6.1 Research and Development Strategy 6.2 Under and Post Graduate Education 6.3 Hospital and Estates Redevelopment 6.4 IM&T and Innovation Strategy 6.5 Corporate Social Responsibility and Public Health Strategy 42 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

43 1 Performance Report Linking Greater Manchester Devolution and Sustainability and Transformation Plan (STP) and Salford Locality Plan Salford s Locality Plan has been jointly developed by partners in Salford, including: Salford Clinical Commissioning Group (SCCG) Salford City Council (SCC) Greater Manchester West Mental Health NHS Foundation Trust (GMW) Salford Royal The priority themes identified in the Locality Plan reflect those in Salford Royal s Operational Plan, and are directly aligned to the five Greater Manchester STP themes. GM theme Salford theme Salford work area Salford Royal NHS Foundation Trust IT priorities Radical upgrade in population health prevention Transforming community based care & support Standardising acute & specialist care Standardising clinical support & back office services Prevention Upgrading population health, prevention and self care Better care Transforming community based care and support and standardising acute and specialist care Enabling transformation Standardising clinical support and back office services and enabling better public services Social Movement for Change Place based working Best start in life Promoting healthy lifestyles and improving mental wellbeing Screening and early detection Wider determinants of health and wellbeing The role of carers Quality of Care Integrated Care Hospital Based Care Enabling better public services The creation of innovative organisation forms, new ways of commissioning, contracting and payment design and standardised information management and technology to incentivise ways of working across GM, so that our ambitious aims can be realised Transforming Community Based Care Long term conditions Mental health Integrated commissioning & streamlining back office support Information management and technology Estates Workforce Coproduction and social value Research and innovation Public engagement Work with partners across the Salford Locality to transform community based care and upgrade population health. Corporate Social Responsibility & Public Health Strategy. Pursuing Quality Improvement to become the safest, highest quality health and care service. Work with partners across the Salford Locality to transform community based care and upgrade population health. Work with partners to reconfigure services across the NW Sector. Work with partners across GM to reconfigure and develop specialist services. Develop the Royal Health Group improving services through standardisation at scale in association with Pennine Acute. Work with partners across the Salford Locality to transform community based care and upgrade population health. Develop the Royal Health Group improving services through standardisation at scale in association with Pennine Acute. IM&T & Innovation Strategy. Hospital Redevelopment/Estates Strategy. Deliver the Workforce Strategy. IM&T & Innovation Strategy. Corporate Social Responsibility & Public Health Strategy. Research & Development Strategy. Implement the Membership Development Stratgey. Signed: Date: 26 May 2017 Sir David Dalton Chief Executive & Accounting Officer Salford Royal NHS Foundation Trust 43 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

44 1 Performance Report Integrated Care Organisation We are here Salford health and social care partners have a long history of working together to improve health and wellbeing for the people of Salford and since 2012 have been working together to create a more integrated care system in Salford as a platform for improving population health. This journey began with changes to services for older people and has now extended to services for the full adult population of Salford, creating one of the first Integrated Care Organisations in the country. 1 ICP for Older People Alliance Agreement Pooled budget for Older People 2 ICP for Adults Integrated Care Organisation Pooled budget for Adults Systemwide Governance Arrangements GP Provider Development 3 Integrated Neighbourhood Model Accountable Care Population Health Management Collaborative Development of Neighbourhood Model for Population health Integrated Care Organisation During April and May 2016, Salford Together partners came together to create an ICO. One of the first in the country, this involved bringing together the provision of adult social care, acute and community healthcare and local mental health services into one organisation, Salford Royal. In parallel, partners agreed commissioning changes; an expanded pooled budget for adult services and new integrated governance arrangements to support and provide constructive challenge to the crucial and necessary changes and transformation that partners committed to. Partners agreed that transformation would be delivered together as an ongoing partnership, based on joint principles, which are firmly rooted in the values of each organisation. Whilst each partner brings a different perspective, each makes a unique contribution to the whole: Salford City Council Population access to adult social care Live at home for longer Safeguarding with just enogh care Invest in health and wellbeing Salford CCG Improve health and wellbeing Greater equity of care and outcomes Citywide standards with neighbourhood provision Developing model for GP services Building on the ICP and from the best of each partner ICO Vision To deliver significant improvements in experiencing and outcomes for service users by: Promoting prevention and independence Providing personcentred health and care services Delivering more care in our communities Supporting our staff through new models and integrated systems Using pooled resources more efficiently Salford Royal NHS Foundation Trust Safe, clean and personal care Endtoend provision based around patients and users Better management of transitions Developing the new workforce and integrating care records Greater Manchester West Delivery of Improved Lives and Optimistic Futures for people Focus on early intervention, prevention and recovery integrated approach to care, supporting physical, mental health and social care needs 44 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

45 1 Performance Report Stages of work There were three key stages of work: Shadow and transfer arrangements Technical integration Transformation April June 2016 July 206 March 2017 November 2016 Onwards Shadow and transfer Between April and June 2016 partners worked together to secure NHS Improvement (NHSI) Authorisation and complete all the necessary legal agreements to create the ICO and establish the local integrated care system. In parallel, the services coming together in the ICO formed shadow arrangements, with senior service leaders coming together to develop shared values. On 15 June 2016 NHSI granted Salford Royal authorisation to proceed with the first Greater Manchester Integrated Care Organisation combining health, social care and mental health under a formal contractual arrangement. On 30 June 2016 all partners signed the legal agreements to establish the ICO and on 1 July 2016, almost 450 adult social care staff were welcomed to Salford Royal as employees, and the next stage of work began. Technical integration A key commitment from Salford Royal was the safelanding of staff, services and responsibilities to ensure service continuity, quality and safety, and align key technologies and processes across health, social care and mental health services in preparation for transformation. The approach to alignment was based on the principal of taking the best from each partner to deliver integrated services that can meet the future needs of the population as part of a sustainable local health and care system. Key achievements Within 100 days, Salford Royal had: Transferred all staff into a single organisational structure under a single leadership, governance and management model Migrated IM&T systems Implemented new commissioning and contracting arrangements for subcontracted services Aligned key processes for sustaining and improving the quality and safety of all services By the end of the stage, in March 2017, we had successfully embedded change and commenced work to develop long term programmes to drive population health improvement at a neighbourhood level including: Implementation of a new Integrated Care Record, combining GP, Hospital, Adult Social Care and Mental Health Data; and A population centric workforce planning and organisational development model for staff. New ICO staff were surveyed at 100 days and at 6 months, which confirmed the success of connecting different groups of staff and building positive relationships and behaviours. Of note was the warmth of staff relationships and wealth of goodwill in the new Salford Health and Social Care ICO and sensitive adaptation of Salford Royal processes to reflect its new responsibilities. The first ICO in England is ideally placed to work with partners to integrate and transform services further and deliver plans to radically improve the health and wellbeing of adults in Salford. 45 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

46 1 Performance Report Transformation Promoting independence for adults & older people Better health & social care outcomes Improved experience for services users & carers Reduced health & social care costs Local community assets Centre of contact Multi disciplinary groups Care homes standards Social prescribing Health and housing Malnutrition taskforce Homesafe Health coaching and telehealth Carers Shared care record Salford integrated record Older people s citizens reference group Adults citizens reference group Care standards We have continued to work with partners to embed our integrated care model for older people, through neighbourhood based MultiDisciplinary Groups (MDGs), community assets and a Centre of Contact. This is supported by a range of programmes including a Shared Care Record, volunteer wellbeing champions, work with care homes and the use of the awardwinning Malnutrition Armband (developed through the programme) across the UK. There have been a number of encouraging signs, such as reduced A&E attendance and admission for people with a Shared Care Record. We will continue to refine and adapt our approach in 2017/18 to embed learning and benefit at a greater scale. The Older People s programme and work to create the ICO was shortlisted for a Health Service Journal award in Salford Together volunteers have been delivering the wellbeing message across the city. They are actively involved in conversations with local people encouraging involvement in tech and tea groups, postural stability classes and completion of wellbeing plans. 46 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

47 1 Performance Report Integrated care for adults Our transformation plans for integrated care for adults have been developed with partners during 2016/17. They have the same triple aim as the older people s programme to improve quality, experience and efficiency and are a key part of Salford s Locality Plan to address anticipated demand on the local health and social care economy by 2020/21. Working collaboratively with partners our plans seek to improve population health using a neighbourhood model focusing on engagement, selfcare and prevention, care coordination, neighbourhood and community care underpinned by a focus on quality and safety. In particular we will be working with local people and our staff to create integrated neighbourhoods with enhanced primary and community care and redesigned pathways of care for Long Term Conditions/Mental Health. Work has already commenced on: Identifying people with highest need Falls prevention and integrated pathway redesign MusculoSkeletal Spinal services redesign Redesign of transitional, step up step down care, including intermediate care services Improved dementia diagnosis and support (with the rate of diagnosis in Salford being one of the highest in the country) Better support for carers Redesign of our model of Domiciliary Homecare Improving Quality and Safety of our system through the Safer Salford initiative Developing a system wide workforce strategy to support new ways of working and new roles to support population health and wellbeing in neighbourhoods Building on our national Vanguard status to support this work, in October 2016 we secured funding from the Greater Manchester Transformation Fund. This is a three year programme investing 18.2m in the new model of working and deliver the integrated care programme set out in the Locality Plan. We have actively supported the establishment of a single GP provider organisation, Salford Primary Care Together, to develop neighbourhood working in Salford and facilitate deeper integration with the ICO. Work has also continued with health and social care partners to explore accountable care models, bringing primary, community, acute mental and physical care and adult social care more closely together to further support integrated neighbourhood population health and wellbeing. 47 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

48 1 Performance Report Here is an example of how the work we have been doing is impacting on people s lives: Mrs R lives alone in Salford and has significant anxiety relating to COPD and heart failure, two common long term conditions that can lead to breathlessness. Her symptoms had become so severe she had become housebound, spending long periods in bed, reliant on high levels of medication and her family for support. She had frequent attendances at A&E driven by anxiety and fear of breathlessness. This often happened at night when she was alone and she frequently called for an ambulance. Her daughter, her main carer, was struggling to support Mrs R as well as care for her own young family. Through her neighbourhood s MultiDisciplinary Group (MDG) Mrs R received a holistic assessment and coordinated programme of care that improved her anxiety and mobility. A short term reablement package of care was introduced with 24/7 ongoing support from Care on Call, a mobile warden service. The MDG nurse focused on helping Mrs R to control her symptoms through better use of medication and together with her daughter jointly agreed a plan of care aimed at reducing further deterioration and need to attend A&E. Her daughter also received a carer s assessment and support from Salford Carers Centre. Mrs R is now more mobile in the house and better able to care for herself. The MDG improved both Mrs R and her daughter s wellbeing and Mrs R has had no further A&E attendances. 48 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

49 Salford Royal NHS Foundation Trust Quality Report

50 Contents Achievements in quality Page /17 achievements Page 52 Statement on quality from the Chief Executive Page 53 Our aims Page 56 A review of quality improvement projects 2016/17 Page 58 Our plans for the future Page 93 The quality improvement strategy Page 94 Our quality priorities 2017/18 Page 94 Statements of assurance from the Board Page 97 Review of services Page 97 Participation in clinical audits Page 97 Participation in clinical research Page 106 Goals agreed with commissioners: use of the CQUIN payment framework Page 106 Data quality: relevance of data quality and action to improve data quality Page 106 NHS number of general medical practice code validity Page 107 Information governance toolkit attainment level Page 107 Clinical coding error rate Page 107 What others and the Care Quality Commission say about Salford Royal NHS Foundation Trust Page 108 Review of quality performance Page 112 The NHS outcomes framework indicators Page 113 Performance against Trust selected metrics Page 116 Performance against national targets and regulatory requirements 2016/17 Page 117 NHS England patient safety alerts information 2016/17 Page 118 Never Events Page 119 How we keep everyone informed Page 121 Statements from Clinical Commissioning Group, Healthwatch and Overview and Health and Page 122 Adults Scrutiny Panel Statement of Directors responsibilities in respect of the quality report Page 125 Independent auditor s report to the Council of Governors of Salford Royal NHS Foundation Trust Page 126 on the annual quality report Appendices Page 130 Appendix A: Commissioning for quality and innovation payment framework Page 131 Appendix B: Glossary of definitions Page 134 If you require any further information about the 2016/17 Quality Report please contact: The Quality Improvement Team on or Paul Hughes at Paul.Hughes@srft.nhs.uk 50 Salford Royal NHS Foundation Trust Quality Report 2016/17

51 1 Achievements in quality Highlights over 10 years: 2016/17 achievements: in the best 10 % nationally we have continued to maintain our position for risk adjusted mortality 97 % of our patients receive harm free care in both the hospital & community setting creation of the Integrated Care Organisation between Salford Together partners bringing together the provision of adult social care, acute and community healthcare and local mental health services 41 % reduction in cardiac arrests 73 % reductions in days waiting for a scan for suspected DVT in the emergency department 15 % reduction in falls per thousand bed days 92.5 % reduction in Clostridium difficile infections 58 % reduction in community acquired grade 2 pressure ulcers 23 % reduction in patients developing AKI in hospital in collaborative wards since the collaborative began 71 % reduction in Catheter Urinary Tract infection rate across the hospital 39 % reduction in patients with an early stage 1 AKI progressing to more severe stage 2 or3 AKI since the collaborative began 23 % reduction ( 7,500 per month) saving in stock spend across district nursing services 97.5 % of Salford Royal outpatients rate their care as excellent or very good 64.5 % reduction in grade 2 pressure ulcers 100 % of patients in the emergency department are currently screened for sepsis 99 % compliance with the 5 steps to safer surgery 51 Salford Royal NHS Foundation Trust Quality Report 2016/17 51 Salford Royal NHS Foundation Trust Quality Report 2016/17

52 1 Some 2016/17 achievements Acute Kidney Injury app The AKI Care app developed by doctors from the Salford Royal Renal Team and Extravision, a local software developer, won the Best Healthcare App award at the 2016 Building Better Healthcare awards. Professor Donal O Donoghue and Professor Phil Kalra Two of Salford Royal s kidney specialists have been appointed to two of the highest positions in the UK s Renal Association. Professor Donal O Donoghue became President of the Association in June, while Professor Phil Kalra became Academic Vice President in September. Angela McDonald Angela McDonald, Bereavement trainer for children and families at Salford Royal, was crowned winner in the Supporting Carers category at the 2016 RCNi Nurse Awards, the profession s top accolade for nursing excellence. Excellence in Public Health and Wellbeing award The Salford Malnutrition Task Force were presented with the award at the House of Commons after being nominated by local MP Barbara Keeley. The team created nationally recognised tools which has led to a reduction in admissions for malnutrition. The task force is made up of Salford Royal, Salford CCG, the city council, GMW NHS Mental Health Trust and Age UK Salford. Salford Royal accredited as a foundation group leader Salford Royal has been named as one of four high performing Foundation Trusts, to become the first Trusts in the country to be accredited by NHS Improvement to lead groups or chains of NHS providers. Debra Worthington Our Maxillofacial Unit Manager at Salford Royal has been honoured with the Distinguished Service Award 2016 at the recent British Orthodontic Conference in Brighton. The award is given each year by the British Orthodontic Society (BOS) to the nurse whom they believe has contributed the most to the profession. Minimally Invasive Surgery Plus rtpa for Intracerebral Haemorrhage Evacuation (MISTIE) team honoured again Salford Royal s team has won the MISTIE trial s European Hanley Cup for the second year running. The study is an international clinical trial looking to define a treatment for intracerebral haemorrhage. Speech and Language Therapists awarded a Giving Voice award Speech and Language Therapists Naomi Sirkett, Nikki Clark and Laura O Shea have been awarded a Giving Voice Award from the Royal College of Speech and Language Therapists. Multiple Sclerosis Team success at QuDoS in MS (recognising Quality in the Delivery of Services in Multiple Sclerosis) Awards programme The MS team, ward M2 infusion nurses, Wes Parks (business analyst) and Carl Birtwhistle (electronic patient record (EPR) services) won the Evidence in Practice award for developing a comprehensive database and diseasespecific EPR for MS patients. Dr Paul Talbot, Consultant Neurologist, also won the Outstanding Neurologist in MS at the awards. Fiona Murphy Fiona Murphy, Assistant Director of Nursing for Bereavement and Donor Support at Bolton, Salford and Wigan has been awarded an MBE. Fiona, has dedicated much of her 30 year nursing career to care for dying patients and their families and has led innovative bereavement and donor work in Greater Manchester and shared it across the country. Healthcare Financial Management Association (HFMA) awards Tara Kearney was recognised as Working with Finance Clinician of the Year at the Healthcare Financial Management Association (HFMA) Awards. In a very successful evening for Salford Royal, Clare Mason was highly commended in the same category, and the Trust was also highly commended in the Innovation Award, for our work on the Integrated Care Organisation. The prestigious annual HFMA Awards celebrate excellence in financial departments across the NHS. Digital Trust of the year Salford Royal was named Digital Trust of the Year for the Roadmap to a Digital Health Enterprise project at the the EHI Awards, the UK s only dedicated healthcare IT award scheme. The Anaesthesia Clinical Services Accreditation (ACSA) The anaesthetics department took part in a unique peerreview scheme developed by the Royal College of Anaesthetists (RCoA), which enables departments to demonstrate quality in key areas, including patient experience and safe care. The ACSA is based on a robust set of standards set by the profession, for the profession, delivering a benchmark for anaesthetic services. Five stars for Salford Royal s food hygiene Environmental Health Inspectors carried out an unannounced visit to the Trust s newly refurbished Inpatient kitchen recently and after considering certain criteria such as cleanliness, policies and food preparation and storage practices, they confirmed that the Trust would retain its 5star food hygiene rating. Innovation success NHS Research and Development North West was a winner at the North West Coast Research and Innovation Awards The team won the category for Most Innovative NHS Team. 52 Salford Royal NHS Foundation Trust Quality Report 2016/17

53 1 Statement on quality from the Chief Executive 53 Salford Royal NHS Foundation Trust Quality Report 2016/17

54 1 Statement on quality from the Chief Executive As 2016/17 draws to a close, we can reflect on a year in which the organisation has continued to grow, whilst achieving better care at lower cost. We have continued to hold the gains achieved in our quest to become the safest organisation in the NHS. Again, Salford s HSMR (Hospital Standardised Mortality Rate) remains in the lowest 10% of NHS Organisations, and our performance on the NHS Safety Thermometer, which measures the amount of patients free from harm under our care, continues to be above the national average. Our work on reducing harm across the organisation has again paid dividends in 2016/17. Alongside maintaining our low rates of infection, pressure ulcers, and cardiac arrests, we have made inroads into preventing harm from Acute Kidney Injury (AKI). Wards involved in the AKI improvement work have seen a 23% reduction in patients developing AKI whilst in hospital. We have also seen a continued reduction in catheter rates and catheter associated urinary tract infections despite increasing patient numbers. Since the quality improvement work began we have seen a 71% reduction in catheter associated urinary tract infection rate, with a 15.69% reduction in the infection rate this financial year when compared to the previous 12 months. As we continue our drive for better care at lower cost, I would also like to highlight some fantastic work on reducing spend by our district nursing teams. The team have achieved a massive 23% reduction in their stock spend by carefully standardising the equipment they use day to day. You can find out more detail on all these projects within the relevant sections of this document. Achieving our care standards for patients is of the utmost importance, and as we enter the 2017/18 financial year I am pleased to say that, in the face of unprecedented demand over 2016/17, we have seen continued improvement against the 95% A&E target, with almost 85% of patients receiving their care in 4 hours during March 2017 and 90% in April. In terms of what the annual NHS surveys are telling us, our levels of patient satisfaction remain high, and I am really pleased to see that, on looking at the staff survey, levels of engagement and commitment have stayed consistent in the midst of what can only be described as exceptionally challenging times for everyone, not only in our Trust but also across the entire National Health Service. I would like to acknowledge that the climate has been particularly demanding for our nursing colleagues, as we have faced significant challenges in recruiting to nursing vacancies. We have been working hard to reduce the number of vacancies, and we are pleased to report that these efforts are starting to pay off. With this in mind, we are even more appreciative of the contribution that our staff continue to make in displaying our values and goals. This year we were named Digital Trust of the Year by EHI, the only dedicated healthcare IT awards. This win recognises our outstanding achievements to improve technology so we can provide a better patient experience and cements our reputation as a digital leader. Indeed, Salford Royal has recently been awarded NHS Global Digital Exemplar status. This means that we have been selected to further develop our digital capability, as one of twelve NHS Trusts that have been awarded 10 million to support this work. We know from talking to our patients that they want care that is effectively organised and coordinated around them as individuals. In 2016, we brought together the services of the City of Salford to create Salford Together a partnership between NHS Salford Clinical Commissioning Group, Salford City Council, Salford Royal and Greater Manchester West Mental Health NHS Foundation Trust. 54 Salford Royal NHS Foundation Trust Quality Report 2016/17

55 1 Statement on quality from the Chief Executive Since then we have continued to knit the contributions of GPs, district nurses, social workers, mental health professionals, care homes, voluntary organisations and local hospitals into a single system to support the health and wellbeing of the people of Salford. The official launch of what we call our Integrated Care Organisation (ICO) took place on 1 July 2016, marking the culmination of many months of preparation. Salford has secured 16.9m from the Greater Manchester Transformation Fund to support improving care and services in neighbourhoods across the city over the next three years. A lot of fantastic work is going on as we move from creating our ICO to developing plans to improve care and services. Importantly, we continue to learn from each other to ensure we go from strength to strength. We are also planning for significant expansion as part of the Greater Manchester wide hospital reconfiguration plans; these include us undertaking our full role as the regional trauma centre, and our role as the high acuity centre to serve the populations of Wigan, Bolton and Salford for high risk emergency and nonemergency surgery, and also for our role as the single Greater Manchester centre for oesophagogastric cancer surgery. Further afield, Salford Royal has been selected as one of only four Trusts to be a foundation group leader. This means that we are accredited by NHS Improvement to lead groups or chains of NHS providers. This accolade recognises the excellent results of our staff and gives us the green light to share our outstanding experience with others. This new way of working will offer our staff numerous opportunities to spread learning and innovation with others so that Salford Royal remains at the forefront of transforming healthcare in Greater Manchester. The key aim of leading a group of NHS providers is to deliver high quality care that is standardised and replicated across all organisations to improve patient outcomes and deliver better value for money. Assuring the reliable delivery of high standards, at scale to a greater population, allows quicker decision making and ensures that those decisions are taken in the interest of the population. This contrasts with delays in decision making which often occur when multiple organisations are assessing the impact of changes on themselves rather than the wider interests of the population they should be serving. Our first major partnership under the group model with Pennine Acute Hospitals NHS Trust continues to strengthen and significant work has been undertaken to ensure that all the organisations involved were appropriately developed for a safe launch on 1 April I am pleased to confirm that the Board of Directors has reviewed the 2016/17 Quality Account and confirm that it is an accurate and fair reflection of our performance. We hope that this Quality Report provides you with a clear picture of how important quality improvement, patient safety and patient and carer experience are to us at Salford Royal. Finally, I want to take this opportunity to thank the Salford Royal staff whose dedication through challenging times never fails to amaze and inspire me. Signed: Date: 26 May 2017 Sir David Dalton Chief Executive Salford Royal NHS Foundation Trust 55 Salford Royal NHS Foundation Trust Quality Report 2016/17

56 2 Our aims 56 Salford Royal NHS Foundation Trust Quality Report 2016/17

57 2 Our aims Our aims Since 2008, we have had in place a clear Quality Improvement Strategy which aims to make us the safest organisation in the NHS. The current version of our strategy, which covers the period from , details how we plan to accomplish this. No preventable deaths Estimating preventable deaths is complex. However, we are certain through the mortality reviews we carry out on all patients who die whilst under our care, that not all patients receive all ideal aspects of care for their conditions in a timely manner. We use these mortality reviews to find defects in care that we can fix in service of pursuing our aim of having no preventable deaths. In 2016/17, we have maintained our position for HSMR (risk adjusted mortality) and are in the best 10% of the NHS for this measure. Continuously seek out and reduce patient harm Harm is suboptimal care which reaches the patient either because of something we shouldn t have done, or something we didn t do that we should have done. 97% of our patients receive harm free care, as measured by the safety thermometer. Achieve the highest level of reliability for clinical care At Salford Royal we use the principles of reliability science to maintain high performance, and ensure that care is reliably high quality for every patient, every time. In the pages that follow, we detail several projects worked on over the past year in the pursuit of high reliability. Deliver what matters most: work in partnership with patients, carers and families to meet all their needs and better their lives The views of our patients and staff are very important to us and we receive feedback through a number of methods, including surveys and patient and staff stories, all of which provide us with vital information on how to improve. In 2016/17: 90% of Salford Royal inpatients rated their care as excellent or very good. 97.5% of Salford Royal outpatients rated their care as excellent or very good. 88% of patients using Salford Royal s community services rated their care as excellent or very good. Deliver innovative and integrated care close to home which supports and improves health, wellbeing and independent living Caring for patients, their families and carers, is just as important out of hospital as it is when they re staying with us as an inpatient. Community based teams such as district nurses, community allied health professions, social care staff and intermediate care teams provide care and social support closer to or in patients homes. Our Salford Together programme is bringing the contributions of GPs, district nurses, social workers, mental health professionals, care homes, voluntary organisations and local hospitals into a single system to support the health and wellbeing of the people of Salford. 57 Salford Royal NHS Foundation Trust Quality Report 2016/17

58 2 Our aims A review of quality improvement projects 2016/17 Below is a list of quality initiatives in progress and their current status. Projects are explained in more detail in the individual project pages. Harm free care Acute kidney injury (AKI) Create an Integrated Care Organisation with Salford partners to provide population based health and care services Productive Community Services Patient, Family and Carer experience : To be in the top 20% for patient satisfaction in the NHS Patient, Family and Carer experience : 95% of patients to rate their care as very good or excellent Service user and staff feedback Thrombosis Dementia and delirium Sepsis Medication safety Safer Salford Sign up to safety Social care Patient flow Theatre improvement Technology assisted service redesign Target achieved / On plan Close to target Behind plan 58 Salford Royal NHS Foundation Trust Quality Report 2016/17

59 2 Our aims Harm free care 97% of our patients receive harm free care in both the hospital and community setting At Salford Royal we are committed to ensuring we deliver safe care for all our patients. What: Patients will be 95% harm free from falls, pressure ulcers, CAUTI and blood clots as measured by the safety thermometer By when: April 2017 Outcome: 97% of our patients do not suffer any new harm whilst under the care of community and acute teams Progress: Target achieved To help us monitor the safety of our patients we use a Department of Health tool called the Safety Thermometer. Each month we use this tool to audit the care given to our patients in both the hospital and community. The Safety Thermometer records how many of our patients suffer from types of harm traditionally associated with health care including catheter associated urinary tract infection, pressure ulcers and falls whilst in hospital. The improvement work undertaken at Salford Royal to prevent patients suffering these harms is listed in the following pages. The Safety Thermometer also measures patients who have suffered blood clots (VTE). This improvement work is featured on page 77 as part of the thrombosis improvement project. 59 Salford Royal NHS Foundation Trust Quality Report 2016/17

60 2 Our aims Catheter Associated Urinary Tract Infections (CaUTI) 71% reduction in Catheter Urinary Tract Infections (CaUTI) rate Teams from across ward areas, emergency care, critical care and community were invited to work together with the aim to reduce catheterisation. The area of indwelling urinary catheters and associated dangers is a complex and difficult area to change but the award winning team have been responsible for significant drops in catheter rates leading to an overall significant reduction in the number of urinary catheter infections throughout the Trust. Catheter UTIs per 10,000 bed days What: To spread the CAUTI change package to 100% of wards By when: July 2017 Outcome: In progress Progress: On plan Chart: Trust catheter associated UTI rate (per 10,000 bed days) /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/2014 Inspected Mean = 2.53, Counts Mean = /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/2015 Month Data from Electronic Patient Record Lower is better 71% 01/04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/2016 reduction in CaUTI rate 71% Reduction in CaUTI Rate /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/2017 In order to get an accurate picture of infections, the Trust calculates the number of infections divided by the number of bed days across the organisation to get a rate. This means that the figure won t be influenced by changes in the number of hospital admissions. This chart shows how many infections the Trust has, for every 10,000 bed days. Improvements achieved The project team won the Salford Royal staff award for Improving Safety based on the success of the work undertaken in reducing harm across the Trust. Continued reduction in catheter rates and CaUTI infections despite increasing patient numbers. Completion of the CAUTI change package. The change package lists the changes that teams need to implement in order to reduce CAUTI. It is broken down into 6 parts: Measurement of catheters and infection Patient experience of being catheterised Avoiding unnecessary catheter insertion Aseptic Non Touch Technique (ANTT) insertion by trained staff Catheter care techniques Remove catheters as soon as possible Further improvements identified The Trust change package will be spread further across both acute and community teams across Salford. Increased sharing of work nationally and internationally. 60 Salford Royal NHS Foundation Trust Quality Report 2016/17

61 2 Our aims Catheter Associated Urinary Tract Infections (CaUTI) continued My name is Julia Taylor and I work as a Consultant Nurse in Urology. As part of a team enrolled into the Clinical Quality Academy I had the opportunity to develop my own personal knowledge and skills whilst working with the Quality Improvement (QI) department at Salford Royal. The project that the team commenced in 2010 looked at developing a way to capture data on catheters and catheter associated urinary tract infections (CaUTI). The academy ran for 12 months and I have been using QI methodology ever since, subsequently leading me to lead on the Trust wide CaUTI strategic project. As part of the QI approach we utilised and reinforced the importance of the impact nursing interventions can have for our patients. The use of patient stories has had a huge impact on the success of the CaUTI project that has undoubtedly been driven by our front line staff by developing ideas and testing them on their wards. As part of the CaUTI work, 50 patients were surveyed with catheters to evaluate their experience. This subsequently was published in the International Journal of Urological Nursing to continue sharing this work nationally and internationally. Following this, our learning session used video patient stories from the Trust s patients (inclusive of my mothers experiences) to ensure the patient voice was in the room with us when we worked to reduce CaUTI. This continues to be an approach I have taken with all of the work I continue to be involved in with my clinical practice whilst developing the role of the specialist nursing team within Urology. In 2015/16 the CaUTI work was acknowledged nationally and I was privileged to be presented with the Inaugural British Association of Urological Nurses (BAUN) and the Urology Foundation (TUF) Nurse of the year. This recognises the impact that nursing can have on the improvement of patient safety, reduction of harm and improvement in patient satisfaction. The appointment as current BAUN President provides a great platform to continue to spread the message on the success of our work and the importance of the QI work, giving patients a voice and enabling front line staff to drive improvements. This is consistent with the overall aim to be the safest organisation in the NHS by reducing patient harm, reducing mortality, improving reliability and improving patient experience. 61 Salford Royal NHS Foundation Trust Quality Report 2016/17

62 2 Our aims Pressure ulcers 58% reduction in community acquired Grade 2 pressure ulcers It s estimated that just under half a million people in the UK will develop at least one pressure ulcer in any given year. Pressure ulcers tend to affect people with health conditions that make it difficult to move, especially those confined to lying in a bed or sitting for prolonged periods of time. Conditions that affect the flow of blood through the body, such as type 2 diabetes, can also make a person more vulnerable to pressure ulcers.* Number of Community Grade 2 Pressure Ulcers What: Reduce community acquired pressure ulcers by 50% By when: April 2017 Outcome: 58% reduction in community acquired Grade 2 pressure ulcers Progress: Target achieved Chart: Community grade 2 pressure ulcers /03/2013 UCL = Mean = LCL = /09/ /03/2014 Set 1: UCL = 13.83, Mean = 6.30, LCL = none (28 37) 01/09/ /03/2015 Data from Electronic Patient Record 01/09/2015 UCL = Mean = 6.30 Lower is better 58% reduction 01/03/ % Reduction 01/09/ /02/2017 Pressure ulcers occur when an area of skin is placed under pressure and the skin and tissue breaks down. Pressure ulcers can develop when a large amount of pressure is applied to an area of skin over a short period of time. They can also occur when less pressure is applied over a longer period of time. The extra pressure disrupts the flow of blood through the skin. Without a blood supply, the affected skin becomes starved of oxygen and nutrients, and begins to break down, leading to an ulcer forming. Salford Royal NHS Foundation Trust ran a Breakthrough Series Collaborative (BTS) to reduce pressure ulcers in the hospital. Since the collaborative to began, the Trust has: Reduced Grade 2 hospital acquired pressure ulcers (HAPU) by 73% (current average of 3.52 per month). 58% reduction in community acquired Grade 2 pressure ulcers. Since September 2012 there has been just four Grade 3 hospital acquired pressure ulcers (HAPU). Over the same time period we have had only two Grade 4 HAPU with the last one occurring in March * Taken from the NHS Choices Website, Pressure Ulcer page 62 Salford Royal NHS Foundation Trust Quality Report 2016/17

63 2 Our aims Pressure ulcers continued Improvements achieved Pressure ulcers that develop in the community are verified at the weekly harm free care meeting with specialist tissue viability nurses. District nurses bring pictures of the pressure ulcers and details on the patient and the circumstances leading to their skin being damaged. The learning from the harm free care meeting is spread across the city via the team leads. The hospital conducts monthly pressure ulcer review panels. The panel review every hospital acquired pressure ulcer and every grade 3 & 4 community acquired pressure ulcer. The teams produce action plans for the next steps and share the learning from the panel across their teams. Further improvements identified The tissue viability team, are currently running a weekly quality improvement meeting to improve their processes across both the community and acute setting. 63 Salford Royal NHS Foundation Trust Quality Report 2016/17

64 2 Our aims Falls whilst in hospital 19% reduction in falls per 1000 bed days since the launch of the new Falls Change Package in May 2016 What: To reduce inpatient falls How much: 10% reduction in falls per 1000 bed days a 5% reduction in falls with major, moderate or catastrophic harm By when: April 2017 Outcome: 19% reduction in falls per 1000 bed days since May % reduction in falls with major, moderate or catastrophic harm since May 2016 Progress: Target achieved 7 Chart: Falls rate UCL = 7.33 Improvements achieved The revised Falls Change Package was launched in May 2016 to multidisciplinary teams across the organisation. A new falls management tool was launched alongside the change package. The tool sits in our electronic patient record and is action based as opposed to risk focussed and has received positive feedback from doctors, nurses, pharmacists, physiotherapists and occupational therapists. The new Falls Panel has been meeting for the last 6 months with a remit to review falls which did not result in harm to encourage learning from these events. The Falls Working Group was revamped and has now been meeting for over 6 months. The CCG have joined us in this group and we review improvement activity whilst identifying learning and potential areas for improvement. Falls rate per 1000 bed days 6 5 CTL = LCL = /04/ /05/ /06/2015 Lower is better 01/07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/ /05/2016 Data from Electronic Patient Record 19% reduction 01/06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/2017 UCL = 6.05 CTL = /02/2017 LCL = /03/2017 Further improvements identified The Falls Working Group is linking with colleagues from Haelo in the development of a health system wide measurement dashboard which will include falls. A significant number of our falls occur on the way to or in the bathroom. A new work stream has been established which will look at the interior design of our bathrooms. 64 Salford Royal NHS Foundation Trust Quality Report 2016/17

65 2 Our aims Acute kidney injury (AKI) 23% 39% reduction in patients developing AKI whilst in hospital in collaborative wards reduction in the number of patients progressing from an early stage 1 AKI to a more severe stage 2 or 3 AKI in collaborative wards Acute kidney injury (AKI) means your kidneys have suddenly stopped working as well as they were. What: To reduce the number of patients who develop acute kidney injury (AKI) How much: 25% reduction in preventable hospital acquired acute kidney injury By when: December 2017 Outcome: In progress Progress: On plan What: To reduce the number of patients who develop acute kidney injury (AKI) How much: 50% reduction in the number of early (stage 1) progressing to stage 2/3 By when: December 2017 Outcome: In progress Progress: On plan One in five people admitted to hospital each year as an emergency have an AKI*. AKI normally happens as a complication of another serious illness and can happen for a variety of reasons including infection, severe dehydration or side effects of some medications. Salford Royal is working on a quality improvement project to improve the care of patients who develop an AKI and reduce the number of patients who develop the condition to begin with. Think SALFORD Sepsis and other causestreat ACE/ARB and NSAIDS suspend/review drugs Labs & L Fluid assessment and response O R Dip the urine and record it * Wang HE, Muntner P, Chertow GM, Warnock DG. Acute kidney injury and mortality in hospitalised patients. American journal of Nephrology 2012;35(4): * Think Kidneys 65 Salford Royal NHS Foundation Trust Quality Report 2016/17

66 UCL = UCL = Our aims Acute kidney injury (AKI) continued Improvements achieved Wards involved in the AKI improvement work have seen a 23% reduction in patients developing AKI whilst in hospital. In these same wards there has been a 39% reduction in the number of patients progressing from an early stage 1 AKI to a more severe stage 2 or 3 AKI. A change package has been developed by pilot wards identifying 6 changes that have supported the improvements in AKI care. These are: Change 1: AKI score highlighted by the nurse coordinator Change 2: AKI patients discussed via safety huddle Change 3: Nurse communicates AKI score with medical team Change 4: Use of the SALFORD care bundle Change 5: Pharmacy AKI Review Number of patients Chart: AKI stages (stage 1 to 2 or 3) by month with 48 hour exclusions for phase 1 collaborative wards /12/2014 Mean = /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/2015 Mean = /09/ /10/2015 Set 2: UCL = 11.05, Mean = 4.61, LCL = none (10 27) 01/11/ /12/ /01/2016 Month 01/02/ /03/2016 Data from Electronic Patient Record 01/04/ /05/ /06/ /07/ /08/ /09/2016 Lower is better Chart: Hospital acquired AKI (0 to stage 1,2,3 whilst inpatient) by month with 48 hour exclusion for phase 1 collaborative wards UCL = Set 2: UCL = 59.04, Mean = 40.06, LCL = (10 27) UCL = % reduction 23% reduction 01/10/ /11/2016 Lower is better 01/12/ /01/ /02/2017 Change 6: AKI Education Further improvements identified Number of patients Mean = Mean = The AKI change package to be spread further across the organisation. LCL = LCL = Developing a bespoke AKI training package for Health Care Assistants and a review of the current training package offered to nurses, doctors and pharmacists. 01/12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/2016 Data from Electronic Patient Record 01/04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/2017 Launch of further patient information, helping to support patients understanding of their kidneys and AKI. Continue to work with GPs and community partners to improve the care of AKI patients across health care boundaries. 66 Salford Royal NHS Foundation Trust Quality Report 2016/17

67 2 Our aims Integrated Care Organisation Salford Together partners* have been working together since 2012 to create a more integrated health and care system in Salford to improve population health outcomes, improve experience and reduce cost. What: Outcome: Progress: Create an Integrated Care Organisation (ICO) with Salford partners to provide a population based health care service Target achieved Ongoing work to integrate social care within the ICO Partners agreed to create an Integrated Care Organisation (ICO) as part of the extension of our successful integrated care approach for older people to all adults. Established on 1 July 2016, the ICO brings together the provision of adult social care, acute and community healthcare and local mental health services with Salford Royal NHS Foundation Trust as lead provider, creating great opportunities to commission and provide more integrated, standardsdriven services, closer to home. Creating the ICO Now Mar Apr May June Jul Ongoing Approach Leadership Shadow Leadership Team Leadership Team Decisions Steering Groups ICO, Commissioning, Service & Business Model, Support Final Business Case Engagement Sessions re: TUPE TUPE Workforce * Salford Together is a partnership comprised of Salford Clinical Commissioning Group, Salford City Council, Salford Royal Foundation Trust, Greater Manchester Mental Health Foundation Trust and Salford Primary Care Together, the newly established GP Provider Organisation. 67 Salford Royal NHS Foundation Trust Quality Report 2016/17

68 2 Our aims Integrated Care Organisation continued Improvements achieved Transferred 450 adult social care staff into Salford Royal within a single organisational, management and governance structure. Extensive programme of workforce engagement and organisational development before integration of staff. Integrated commissioning and contracting arrangements for subcontracted services e.g. Mental Health and Adult Social Care services. Worked with partners to develop a comprehensive service transformation framework, and deliver initial project workstreams. Transforming to improve lives together our road map for delivering better care and better experience and better value and Better Value Improved Population Health supported by Neighbourhood Teams promoting independence and community resilience Further improvements identified Creation of accountable, enhanced multidisciplinary teams working in neighbourhoods. Implement a population centric workforce planning model for the ICO by continuing to work with partners to develop the integrated care system further, in particular working with GP partners to support the new GP provider organisation, Salford Primary Care Together, and working with all health and social care partners on future plans for accountable care. Redesigned end to end integrated care pathways e.g. pathways for long term conditions such as heart disease. Redesigned step up and step down pathways available to manage patients care during periods of increased need. Embed and sustain datadriven population health management techniques e.g. risk stratification. Redesigned Domiciliary homecare provision and Care Home support within a neighbourhood model Responsive transitional step up step down care and urgent response during periods of increased need Reduced hospital based care for Long Term Conditions, Mental health & Social Care need through redesigned pathways of care focused on neighbourhood delivery 68 Salford Royal NHS Foundation Trust Quality Report 2016/17

69 2 Our aims Productive Community Services 7,500 per month saving in stock spend across district nursing services since March 2016 by reducing waste. It is a 23% reduction against baseline. The Productive Series was a NHS Institute for Innovation and Improvement initiative and includes modules for both Acute and Community services. Its focus was safer care and delivering quality and value. The modules are simple to navigate and allow clinical colleagues to review current practice and to follow steps to improve on this. What: To introduce Well Organised Working Environment; Patient Status at a Glance and Planning Our Workload modules from the Productive Community Series across the city of Salford How much: 100% completion of the modules By when: January 2018 Outcome: In progress Progress: On plan Improvements achieved Space saving stacker units have been introduced in district nursing bases across the city and are presented in a standard way so that any nurse can find what they need in any base. Minimum stock levels in the district nursing bases have been agreed and maintained through collaboration amongst the housekeepers. Bags to Go have been introduced in all district nurse bases in the city which have standardised district nurse stock levels on visits and aid in making these visits more efficient. Chart: Total spend for district nursing 50,000 45,000 40,000 35,000 UCL = % reduction Lower is better UCL = Further improvements identified Minimum stock levels for our treatment rooms are being developed and will be maintained by the housekeeper role, thus allowing clinical staff to increase direct patient contact time. Spend in 's Mean = ,000 25,000 20,000 15,000 LCL = Mean = LCL = Daily safety huddles are being reviewed with the intention of making these efficient and standardised across the city. This will support patient safety and increase direct patient contact time. 01/03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/2017 Data from Electronic Patient Record 69 Salford Royal NHS Foundation Trust Quality Report 2016/17

70 2 Our aims Productive Community Services continued Case study Irene Savage and Kelly Norton (housekeepers, district nursing team) We began working on the Productive Community Services project shortly after coming in to post as brand new district nursing housekeepers. We had previous experience of housekeeping on the wards but the role in district nursing has been very different and extremely varied. The weekly meetings have been good and our input has been crucial in the success of the Well Organised Working Environment (WOWE) module. We had both seen Productive Ward from our time in the hospital and so the stock room tidying and standardisation was nothing new to us. It was good to get the stacker units in and to be able to work with the other housekeepers to decide on how to do things in a standardised way. The bags to go were the next big thing and they have been a big success in our teams. It wasn t easy at the start and the district nurses and care support workers didn t like the proposed changes. We did a lot of information sharing on the idea behind the bags and once we trialled with a few nurses then the others were able to see both the money we could save and the amount of stock we were wasting. We were both heavily involved in testing new ways of restocking the bags and what should be included in them as a base stock level. We engaged with the nurses and care support workers and were eventually able to pull together a standard operating procedure. It has been lots of fun being involved in the Productive Community Services and even though we initially saw ourselves as only housekeepers, we have been key in making things work in the best possible way. We are proud of the savings we have made but more importantly we are working better as a team and removing waste means we are able to provide the best possible service to our patients. 70 Salford Royal NHS Foundation Trust Quality Report 2016/17

71 2 Our aims Patient, Family and Carer Experience Collaborative 90% of Salford Royal inpatients rate their care as excellent or very good 97.5% of Salford Royal outpatients rate their care as excellent or very good 88% of Salford Royal adult community patients rate their care as excellent or very good Patient, Family and Carer experience is at the heart of everything we do at Salford Royal. Our patient, family and carer experience work aims to ensure we deliver what matters most to our patients. Underpinning the improvement work is the delivery of the Trust Always Events which patients should expect are embedded in the care we provide. Teams continue to develop tests of change around the always events and patient feedback to help improve patients experience. What: To be in the top 20% for patient satisfaction in the NHS 95% of patients to rate their care as very good or excellent Progress: Top 20% for patient satisfaction Target achieved 90% of inpatients to rate their care as very good or excellent Close to target Improvements achieved The 12th Trust wide learning session for the patient, family and carer experience work took place in August The learning session was attended by patients with complex communication needs and tests of change were developed around the issues these patients face when visiting the hospital and clinics. Through both one to one and group quality improvement meetings with a variety of community teams the Trust Always Events have been further embedded with community teams. Teams across our organisation are working towards having local always events established. A range of patient information films are in development to support patient s knowledge of services and ways to selfcare. Films are being developed with both hospital based and community based teams. Our Intestinal Failure Unit (Ward H8), has already launched a film on the Trust s website. As a specialist area, the ward receives patients from across the country. The film introduces the patients to the ward and provides answers to some frequently asked questions from patients. In collaboration with the British Kidney Patient Association (BKPA) complementary therapy is being offered to patients whilst receiving dialysis. This involves a variety of treatments including massage, reflexology, Indian Head massage, and reiki. This can help ease stress, tension and anxiety as well as easing symptoms associated with dialysis such as muscle cramps. The feedback from patients has been very positive and the project has grown to include all five dialysis units within the Salford renal unit. continued next page 71 Salford Royal NHS Foundation Trust Quality Report 2016/17

72 2 Our aims Patient, Family and Carer Experience Collaborative continued Improvements achieved continued At Salford Royals Equality and Disability forum, concerns had been raise that older people with hearing difficulties are often unable to take part in discussions about their care and plans for their discharge. A new digital listening kit, with a headset and amplifier to enable patients to hear conversations properly was purchased for use within the Trust. Patient feedback has been positive and thanks to the device one patient commented how he was able to take part fully in discussions about his recovery and make good use of the support and information he received. In response to the Accessible Information Standard and working with Salford Royals Disability Champions forum, the Trust developed a bespoke communication card system. Service users/carers can have a standard or personalised card which is printed on a plastic credit sized card. These are then used to prompt to staff to their communication needs, for example I lip read, please look directly at me. Further improvements identified Events planned where small groups of wards and services will come together to each discuss 3 pieces of specific service user feedback and develop changes from this feedback. A new service user, family and carer experience strategy will be developed. Following a review of survey questions in early 2016, the adult community patient feedback survey now aligns to similar questions that are asked in the outpatient and inpatient department. As such, we have been able to report for the first time in the quality accounts, the percentage of community patients who rate their care as excellent or very good. Work has now commenced to understand individual patient experience data collection processes within community teams and how this feeds into governance processes. Chart: Inpatient % of patients rating their care as excellent Outcome or Inpatient very % of patients good rating their care as Excellent or Very Good % of Patients Who Rate Their Care as Excellent or Very Good Chart: Community % of patients rating their Community 8b. Rate Experience Excellent and very good care as excellent or very good p' chart % of Patients Who Rate Their Care as Excellent or Very Good Chart: Outpatients % of patients rating their care as excellent or very good % of Patients Who Rate Their Care as Excellent or Very Good /11/ /03/ /11/2012 UCL = CTL = LCL = UCL = CTL = LCL = /04/ /03/ /06/ /05/ /07/ /12/ /06/ /11/2013 Set 1: CTL = 88.34, LCL = (1 13) (Lloyd Nelson option) Inspected Mean = , Counts Mean = /07/2016 UCL = CTL = LCL = /03/ /07/ /08/2016 Inspected Mean = , Counts Mean = /07/2014 Month Date 01/11/2014 p chart 01/01/2015 Data from Electronic Patient Record 01/09/2016 Month 01/03/ /10/2016 Data from Electronic Patient Record 01/08/ /07/2015 Data from Electronic Patient Record 01/11/ /11/ /02/ /12/2016 Higher is better 01/03/ /01/ /09/2016 Higher is better 01/07/ /02/ % increase Higher is better 01/11/ /03/ /03/2017 UCL = CTL = LCL = /03/ Salford Royal NHS Foundation Trust Quality Report 2016/17

73 2 Our aims Patient, Family and Carer Experience Collaborative continued Intestinal Failure patient story I was first diagnosed with Crohns disease when I was 18 years old and had just started studying at Wolverhampton Polytechnic. I had to return home and was admitted into my local hospital. My Crohns proved to be very virulent and within three months of diagnosis I had an ileostomy. After a long period in the hospital and a year out I restarted my studies but at Manchester Polytechnic. After graduation I pursued a career in IT, reaching the position of Senior Analyst Programmer. My work life was periodically interrupted by spells in hospital and many further bouts of surgery. In 1996, after my condition had deteriorated severely I was once again admitted to hospital. A final episode of surgery was curtailed after the surgeons thought it was too dangerous to proceed, and would have had a catastrophic impact on my quality of life. At this point I was advised to give up work and I was put on palliative care taking large doses of morphine to control the pain. I was placed under the care of a new physician who had previously worked on the Intestinal Failure Unit (IFU) at Salford Royal, which led to my transfer to Salford and the care of the IFU team. At this point I naively thought that I could just go onto HPN as a simple solution to my problems, and that it was just a matter of being plugged into a machine for a few hours a day. (Home Parental Nutrition (HPN) is where a patient is given a special form of food, through a vein, outside the hospital). However, following an emergency admission into Salford Royal, I had a series of very difficult operations to remove a huge abscess and virtually all of my remaining intestines. I was moved from ICU to the IFU where I spent months recovering and being trained on the complexities of HPN. In late August 1998, after four and a half months in hospital everything was in place for me to finally start my life on HPN at home. Since then I have lived a life selfcaring on HPN seven nights a week for eighteen years, and coped with a high output jejunostomy. There have been setbacks as a result of my illness and living on HPN. I suffer from osteoporosis, and have 3 collapsed vertebrae, and I have fractured both of my femurs plus multiple other minor fractures. Most recently I suffered from biliary sepsis, and was very poorly prior to having my gall bladder removed. I also have several other medical problems to cope with. However, with family support, I have led an active life, and enjoy a good social life. Despite the difficulties of life on HPN and having a very high output stoma, I have been able to pursue my favourite pastime of sailing. I first learnt to dinghy sail before I had Crohns disease and continued to sail dinghies into my twenties, despite having an ileostomy. Sadly my deteriorating health made me give up dinghy sailing, but after going on HPN, my interest in sailing was reawakened whilst going out to sea on my uncle s boat off the Welsh coast. Thanks to a generous relative I was able acquire my share of a small second hand yacht with an old school friend, who had a lot of dinghy sailing experience and was keen to get back on the water. In order to facilitate the sailing, my parents bought a static caravan in Wales, where I am able to sort out my medical needs. We could now go out sailing for the day, but the boat was not big enough for me to contemplate staying on overnight. After a few years of being restricted to just day sailing my friend and I were keen to go sailing for a longer duration and to be able to venture further. With the aid of my family I was able to pay for my half of a larger yacht. Although old and only thirty one feet long, after a bit of work the new boat had the facilities and space that I needed to set up my HPN and manage my jejunostomy. Fortunately the friend I share the boat with understands my medical problems and gives me the space and privacy I need. Over the last six years we have been on many sailing trips up and down the Welsh coast, staying for up to seven nights on the boat. We always aim to spend the nights moored in a marina alongside a pontoon with mains power, which gives us hot water. Setting up the HPN is not easy on the boat in the restricted space, but by being well organised and extra careful with my aseptic technique I manage. Whenever possible I use the off the shelf bags of HPN, because they do not require refrigeration. Obviously some aspects of sailing can be quite strenuous, although sailing a yacht like ours is a lot easier than dinghy sailing ever was. I am neither fit nor agile enough to do much of the work and so my friend takes on most of the tasks, leaving me to helm the boat, which is my favourite part anyway. Whilst sailing we get to see the most stunning views of the Welsh coast, with the mountains of Snowdonia in the background. We often come across schools of dolphins that love to show off racing alongside the boat, and leaping out of the water. Of course it s not always like that, and the weather and sea state can make it quite challenging. We have both been on sailing/navigation courses and know to respect the sea. We tend to be more cautious about what conditions we will sail in, knowing the limitations caused by my health. I hope my story shows other patients who are in a similar state to me that your condition does not necessarily mean that you have to give up on the activities you enjoyed before you were ill. I couldn t sail without the support of my family and friends, but with their help I hope to carry on, and aim to sail further, possibly across to Ireland this summer. 73 Salford Royal NHS Foundation Trust Quality Report 2016/17

74 2 Our aims Service user and staff feedback The views of our service users and staff are very important to us. We receive feedback through a number of methods, including national surveys, patient stories and patient service user experience surveys taken at the point of discharge. This feedback provides us with vital information to improve services. Service user feedback Salford Royal takes part in the National Picker Survey. In total 409 patients completed the survey, which was based on a sample of consecutively discharged inpatients who attended the Trust in July Trusts from across the country took part in the survey. We did significantly better in 13 questions than the average Picker Trust. These included: Patients not being bothered by noise at night from staff. Patients knowing which nurse was in charge of their care. Doctors not talking in front of patients as if they were not there. Patients being involved in decisions. Having risks and benefits explained before surgery. The two areas where we did worse than the national Picker average were: Planned admission: not offered a choice of hospitals Hospital: not offered a choice of food A new supplier has been sourced to provide inpatient catering. The kitchens have been refurbished to accommodate new catering processes and there are future plans for a new rotational menu with more choice for patients. Our teams also run engagement events, focus groups and service focused questionnaires to help review their services and to gain feedback from seldom heard groups or individuals with complex communication support needs. Some examples include: In September 2016 Salford Clinical Commissioning Group (CCG) carried out a review of the Learning Disability Children s nursing service using patient experience surveys in clinics as well as a focus group. The feedback was overwhelmingly positive however, patients did comment that waiting times were long. As a result of this feedback a whole caseload review was completed and a new referral to treatment pathway devised. The team introduced triage clinics to help reduce the back log of new referrals, a text reminder service for clinic appointments was introduced and weekly clinics for initial assessment and therapy interventions will commence in April Traditional patient feedback methods often make it difficult for areas to gather feedback directly from children. Talking Mats is a tool that has been used by teams in our community who care for children to capture their experiences. The mats have been used in community clinics and in special schools. The mats are an interactive resourse that discusses a topic e.g. appointments, and allows children to express an opinion using symbols and a visual scale. Services are using the feedback to develop practice and service delivery and improve the patient experience. Action plans are developed in a child centred, simplified way to show the children how their feedback is being used. 74 Salford Royal NHS Foundation Trust Quality Report 2016/17

75 2 Our aims Service user and staff feedback continued Improvements include Children report that rewards are positive and they want a sticker for attending. They do not always get them in some clinics. Stickers have now been ordered and are made available in all clinic settings. The Children s Outpatients Department manager has been working with the children who attend to get ideas on how to improve the waiting room experience. In satellite clinics the toy box will be refreshed with appropriate (largely donated) toys and books. Staff feedback The national staff survey was undertaken between October and December 2016 with all staff invited to participate. 3,722 (or 52%) of staff chose to participate in the survey an improvement from 44% in Salford Royal was identified as being better than the national average in the following areas: KF1 Staff recommendation of the organisation as a place to work or receive treatment. KF6 % reporting good communication between senior management and staff. KF15 % satisfied with the opportunities for flexible working patterns. KF18 % attending work in last 3 months despite feeling unwell because they felt pressure. KF23 % experiencing physical violence from staff in last 12 months. Talking mats used to capture feedback from children In response to our staff survey findings the key priorities for action in the coming year will be: Improving service user/patient safety, flow and experience to reduce pressure on services at times of increasing demand. Increasing our quality improvement activities. Better supporting colleagues filling vacancies across community sites and in the hospital. Developing and implementing new workforce plans. 75 Salford Royal NHS Foundation Trust Quality Report 2016/17

76 2 Our aims Service user and staff feedback continued Additionally, we are required to report on the below two key findings as part of the Quality Account guidance. Salford Royal is below average for Key Finding 21 and average for Key Finding 26. Work has already begun to better understand the data returned on equality of opportunity through the engagement of BME staff linked to the development of the Workforce Race Equality Standard (WRES). At a recent Big Listen event, themes and goals were identified to support career progression beyond Band 5 for these staff groups, and further analysis of recruitment data is taking place. This is part of the ongoing work under the WRES recognising that there is an underrepresentation of BME staff at senior levels across the organisation. The HR team will be identifying ways that areas with a high percentage of staff reporting bullying and harassment can be supported to promote better communication and support from managers. The Trust has recently introduced local freedom to speak up guardians to support ongoing work encouraging staff to report incidents in their department. Additionally, we are required to report on the below two key findings as part of the Quality Account guidance. Salford Royal is below average for Key Finding 21 and average for Key Finding 26. KEY FINDING 21: Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion (the higher the score the better) Percentage score Trust score 2016 Trust score % 85% National 2016 average for combined acute and community trusts Best 2016 score for combined acute and community trusts 0 KEY FINDING 26: Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months (the lower the score the better) Percentage score % 94% Trust score % Trust score % National 2016 average for combined acute and community trusts Best 2016 score for combined acute and community trusts 23% 19% Salford Royal NHS Foundation Trust Quality Report 2016/17

77 2 Our aims Thrombosis 73% reduction in number of days waiting for a scan for suspected DVT in the Emergency Department Every year, thousands of people in the UK develop blood clots. These clots can remain in the deep veins (deep vein thrombosis) or break off and travel to the lungs (pulmonary embolism). Together, these problems are known collectively as venous thromboembolism (VTE). This is a serious and potentially fatal condition. Anticoagulants are medicines that help prevent blood clots. Anticoagulant medicines reduce the chances of developing clots, or stop clots getting bigger but can also increase the risk of bleeding. Balancing the risks of clots and the risks of anticoagulant medicines can be tricky and needs careful attention. What: Outcome: Progress: Chart: Numbers of days wait until a scan for suspected DVT, identified at an emergency department attendance Days 120 UCL = Mean = /07/ /07/ /07/ /07/ /08/ /08/ /08/2016 To become an exemplar centre for Thrombosis by April 2018 In progress On plan 22/08/ /08/ /09/ /09/ /09/ /09/ /10/ /10/2016 UCL = Mean = % Reduction 17/10/ /10/ /10/ /11/ /11/2016 Data from Electronic Patient Record 21/11/ /11/ /12/ /12/2016 Lower is better 19/12/ /12/ /01/ /01/ /01/ /01/ /01/ /02/ /02/ /02/ /02/2017 During an attendance at the Emergency Department, if a suspected DVT was identified in the past, a patient would be discharged home with a follow up appointment for a scan. The patient would be given anticoagulation to be taken until the date of the scan. The Trust set up a scanning area in the Emergency Assessment Unit to facilitate same day scanning for this patient cohort. Improvements achieved Improved VTE pathway on the Electronic Patient Record system. New surgical listing form with greater emphasis on anticoagulation to improve communication across the patient surgical pathway. Creation of the Trust Thrombosis Committee. Improving the efficiency of the Anticoagulation clinic process. Refresh of Trust wide policies relating to thrombosis. Established Root Cause Analysis for patients who experience bleeds and strokes whilst on anticoagulation, enabling shared learning across the organisation when these incidents occur. Further improvements identified Establish Trust wide thrombosis champions. Achieve exemplar status in treating and preventing VTE. Reduction in the number of anticoagulation incidents. Increase in the number of INR selftesting kits. The kits provide point of care blood testing to help ensure correct medication dose. Reduce medication and prescribing errors by 50% using focussed microsystems. 77 Salford Royal NHS Foundation Trust Quality Report 2016/17

78 2 Our aims Dementia and delirium Dementia and delirium are areas of high priority for the organisation. There were 2,491 people with dementia admitted to Salford Royal for the financial year 2016/2017. The dementia and delirium steering group provides oversight on the work within this area in the Trust. The group has undergone significant expansion in membership including leading staff from many directorates, the mental health liaison team, community services, therapy and allied health care staff, CCG, memory assessment and treatment service, critical care, research and development and social services. In May 2016 the group outlined plans for work around dementia and delirium. In the last financial year the group has focussed on the following elements: John s Campaign: The Trust supports John s Campaign; a national initiative for the right for people with dementia to have their carers with them at any time. People with dementia often become frightened and fail to thrive when admitted to hospital. Salford Royal is committed to ensuring that John s Campaign is embedded across the organisation ensuring that carers for people with dementia are welcomed and visiting hours are relaxed. National Audit of Dementia: The National Audit of Dementia collects data to assess care delivery for people with dementia admitted to hospital. We completed data submission for round 3 in October 2016; including staff questionnaires and a survey of carer experience. Complete results will be provided to Salford Royal by the Royal College of Psychiatrists later in However, feedback provided from carers include: The staff are very friendly and attentive. The hospital is very clean and has pleasant surroundings and in the near future I will be having an operation in this hospital. I know that I will have nothing to worry about. I was very impressed when the doctor caring for my husband and performing the surgery contacted our GP to ask if there was anything they could do to help whilst he was under sedation. I collected the flu vaccine from the surgery and delivered it to the department at the hospital for them to administer. Happy to have a long detailed discussion with a doctor, psychiatric nurse, social worker and two family members to discuss patient s arrangements that were in patients best interest. continued next page 78 Salford Royal NHS Foundation Trust Quality Report 2016/17

79 2 Our aims Dementia and delirium continued General themes identified as areas for improvement related to ward moves and communication. It is well recognised that moving wards can have a detrimental effect on patients who have a dementia or a delirium and can significantly increase their length of stay. As part of World Delirium Day on the 15 March we asked staff to take a pledge as to how they could reduce the risk of a patient developing a delirium, and a number of staff pledged to help reduce the number of ward moves. An action plan is being developed to look at this and other feedback from the National Audit in more detail. Delirium screening: Delirium is an acute confusional state common in hospital inpatients and is associated with a number of poor clinical outcomes. This year we have introduced a delirium screening tool (4AT) to be completed in those at risk on admission. This involves close working with the EPR (electronic patient record) team. A quality improvement project for delirium detection and management is planned for this year including further development of EPR. Guidelines and pathways: The guideline for the assessment and management of delirium was revised and updated in January A guideline for the assessment and management of dementia is being finalised for imminent launch. Care transitions and information sharing: The steering group has worked to join up pathways to enhance information sharing for those professionals caring for people with dementia between Salford Royal and Greater Manchester Mental Health NHS Foundation Trust. The first steps included enhanced access to healthcare records to relevant clinical staff and direct pathways for referral for diagnostic assessment to the Memory Assessment and Treatment Service in Salford. The year ahead promises exciting opportunities to improve the care for people with dementia in Salford. Opportunities for development and transformation exist within the Integrated Care Organisation and Dementia United, a transformation programme for care across Greater Manchester. 79 Salford Royal NHS Foundation Trust Quality Report 2016/17

80 2 Our aims Sepsis 100% of patients in the emergency department are currently screened for sepsis Sepsis is a life threatening condition that arises when the body s response to an infection injures its own tissues and organs. Sepsis leads to shock, multiple organ failure and death especially if not recognised early and treated promptly* Sepsis is caused by the way the body responds to germs, such as bacteria getting into your body. The infection may have started anywhere in a sufferer s body, and may be only in one part of the body or it may be widespread. Sepsis can occur following chest or water infections, problems in the abdomen like burst ulcers, or simple skin injuries like cuts and bites. What: To reliably administer timely antibiotics to sepsis patients in the emergency department How much: 65% of patients to receive the antibiotics in 1 hour 75% of patients receive antibiotics within 2 hours in the emergency department Outcome: 51.70% of patients receive antibiotics within 1 hour 81.63% of patients receive antibiotics within 2 hours in the emergency department Progress: Close to target Improvements achieved EPR tool is embedded in the emergency department with all patients triaged being screened for sepsis. Patients diagnosed with sepsis are highlighted to staff in the emergency department via the electronic patient tracking board. All patients on our Emergency Assessment Unit are screened for sepsis every time their observations are taken and patients identified are highlighted via the patient tracking board. Training on sepsis and the EPR tool has been rolled out across the unit. Futher improvements identified Using the data, we can now identify where there are delays in the patient pathway and then work to reduce those delays. A plan is being prepared to roll out the EPR tool across the hospital. * Taken from the UK Sepsis Trust Website 80 Salford Royal NHS Foundation Trust Quality Report 2016/17

81 2 Our aims Medication safety 77% 58% of patients admitted to Salford Royal have a medicines reconciliation completed by a pharmacist within 24 hours of admission, with 85% of patients being admitted to EAU have an accurate drug history at 24 hours increase in the percentage of prescriptions from the Emergency Admissions Unit with no errors at discharge Medication errors at Salford Royal rarely cause harm to patients because our systems are designed to stop this from happening. However, medication errors that have the potential to cause harm do sometimes occur. We aim to design a system which removes the potential for harm and delivers a reliable medication process to patients. This is from the point of prescribing, through dispensing and finally in the administration of the medicine to the patient. What: Reduce the number of medication errors and omissions when patients are discharged from Salford Royal back to the community How much: 50% decrease in the number of errors regarding medication changes on discharges from Salford Royal By when: March 2018 Outcome: In progress Progress: On plan Improvements achieved A multidisciplinary working group has been established to improve the management of anticoagulation at Salford Royal and have introduced a number of new systems to protect patients. Salford Royal now employs 23 pharmacists who work in the GP practices in Salford to help patients get the most from their medicines. Salford Royal s Medicines Safety Committee now has membership from the community as well as the hospital. Salford Royal in conjunction with Greater Manchester Academic Health Science Network (GMAHSN) has been awarded an innovation bid from NHS Salford CCG to develop an electronic system to enable hospital pharmacists to refer patients to their community pharmacist for counselling and support with their medicines. An automated drug cupboard has been tested on a medical ward and has reduced the number of drug administration error and missed medication doses. This has released nurse time for clinical duties. A business case is now being developed to introduce more automated drug cupboards across the Trust. As a result of a CQUIN agreed with the CCG a project has been has been undertaken to identify patients admitted to hospital because of an adverse incident with their medicines. This is communicated to the patients GP and community pharmacist. Prescribing pharmacists are attending weekend ward rounds to prescribe take home medicines for patients so they can go home sooner rather than waiting for discharge medicines. 81 Salford Royal NHS Foundation Trust Quality Report 2016/17

82 2 Our aims Medication safety continued Further improvements identified The introduction of barcode medicines administration on the wards to reduce the number of administration errors. To increase the number of pharmacy technicians working in the intermediate care units to increase the number of patients with accurate drug histories. % of patients admitted to EAU & AAA with a meds rec at 24 hours Chart: Weekday % of patients with a MedsRec on EAU and AAA within 24 hours UCL = CTL = LCL = UCL = CTL = LCL = UCL = CTL = LCL = p chart Higher is better UCL = CTL = LCL = th July 17th Aug 14th Sept 12th Oct 9th Nov 7th Dec 4th Jan 1st Feb 1st Mar 5th April 3rd May 31st May 28th June 26th July 23rd Aug 20th Sept 18th Oct 15th Nov 13th Dec 10th Jan 7th Feb 6th Mar 3rd Apr 1st May 29th May 26th June 24th July 21st August 18th Sept 16th Oct 13th Nov 11th Dec 8th Jan 5th Feb Date 5th March 19th March Data from Electronic Patient Record 82 Salford Royal NHS Foundation Trust Quality Report 2016/17

83 2 Our aims Safer Salford (previously named Making Safety Visible) This programme brings together members of Salford CCG Governing Body, Salford Royal NHS Foundation Trust Board of Directors, and the Public Health Team from Salford City Council. These partners agreed six principles for a Safer Salford : 1. Salford will be the safest health and care economy in the UK by The Measuring and Monitoring of Safety (MMS) Framework (in particular predictive tools) should underpin the development of the integrated care system. 3. Medication, communication and handover (within and across care settings) should be the focus for improvement efforts. 4. Safety indicators will shift from lagging to leading measures. Assessments of safety will be person not provider centred. 5. The safety improvement plan should integrate with and build on existing quality improvement and safety strategies. 6. Engagement of frontline staff is fundamental to hardwire a culture of safety across health and social care. Safer leadership This workstream will build on the successful collaboration of the Making Safety Visible Programme. There will be a rerun of the Making Safety Visible programme to socialise the measurement framework with leaders from the next tier down from Board level. Safer care homes The care homes workstream will build on the established relationships between the CCG, Salford Royal NHS Foundation Trust and dualregistered care homes. The safety of medication, communication and handover at transfer of care have been identified as key points of improvement across multiple providers, including dualregistered care homes. Safer handover Early engagement with clinical staff has confirmed that these areas are important to patient and clinician safety and wellbeing. Our initial focus will be on gaining indepth knowledge of these safety issues through the use of surveys, 1:1 interviews, focus groups and document reviews (e.g. incident reports). This information will be used to agree an appropriate improvement model and outcome measures for this work and to help evaluate the impact of improvements. 83 Salford Royal NHS Foundation Trust Quality Report 2016/17

84 2 Our aims Safer Salford continued Safer intelligence Using latest findings from implementation of the measurement framework, we will develop a proactive measurement strategy, to support and embed learning across the system. A measurement tool and dashboard will be designed to allow health and social care partners across Salford to listen in realtime to the system, review past harms and use predictive analysis to prevent future harm. These tools will enable Salford to demonstrate achievement of its aim to be the safest health economy. Safer culture Safety culture assessment tools will be tested within primary care to understand the potential barriers to, and incentives for participation. Once an assessment tool is agreed we will confirm survey cohorts with partners and extend our agreed methodology to understand the current safety culture across the health economy. We will collect and analyse the data across the system whilst providing feedback directly to the teams involved. We will develop an options appraisal for building a Salford safety culture assessment and learning system. Safer medicines The aim of the workstream will be to bring together the findings of the many medicine safety improvement programmes across Salford and then share learning across the system. 84 Salford Royal NHS Foundation Trust Quality Report 2016/17

85 2 Our aims Safer Salford continued Programme Driver Diagram 1 Leadership Building a guiding coalition Socialising the MMS Framework for all leaders in Salford Form a leadership collaborative to develop a driver diagram to form the basis of a safety improvement plan for Salford Build QI and safety capability among partners 2 Safety Culture Establishing a Continuous Learning System Deliver a sustainable programme of safety culture assessment and learning Scope barriers and incentives to participation Provide a tested framework for understanding and monitoring the safety climate across health and social care, with an initial focus on primary care To produce collaboratively and test a roadmap to enable Salford to become the safest health and social care system in the UK by Care Homes Reducing harm through collaborative learning 4 Safer Handover Improving the safety of transfers of care, focussed on medications, communication and handover Deliver a safety improvement collaborative for up to 12 dual registered care homes across Salford Codesign minimum standards for safety culture in care homes, through production of an intervention bundle Gain an in depth knowledge of safety issues through surveys, 1:1 interviews, focus groups and document reviews Review learning and agree an improvement approach, working with the Salford Clinical Standards Board Deliver improvement approach and evaluate impact 5 Intelligence Proactive measurement strategy of safety in Salford, using the MMS Framework Create a shared measurement dashboard of agreed outcomes, based on existing measures (Yr 1) Build an interactive dashboard to support data interrogation and learning in realtime, focussed on medicines safety, handovers and communication (Yr 2) 6 Scaling Up Campaigning to build momentum and hardwiring a climate of safety and successful change Share the Safer Salford vision and learning with frontline health and social care staff and service users Produce a toolkit of bespoke reference materials, case studies, films, digital and social media Design and facilitate an online platform for staff to interact and learn together 85 Salford Royal NHS Foundation Trust Quality Report 2016/17

86 2 Our aims Sign up to safety 25% reduction in length of stay for spinal patients in the Emergency Village Our goal in this piece of work, which is supported by the NHS Litigation Authority, was to focus on improving quality within our Spinal Service. A biweekly improvement group was established and elected to focus their efforts on improving flow for spinal patients at Salford Royal. The group consisted of Consultant Surgeon, Advanced Nurse Practitioner (ANP), Enhanced Recovery Nurse, Specialist Nurse, Consultant Physio, and Ward Physio. Improvements achieved Role development and skill mix Increased physio capacity on the unit enabling patients to be rehabilitated in a more timely manner as demonstrated by the average number of missed physio contacts per week being reduced from 19 to 2 following increase in capacity. Development of Advanced Nurse Practitioner role to improve ward flow and help expedite unit transfers. Process improvement Improve effectiveness of Assessment Bed process i.e. quick turnaround for patients for emergency scan/assessment from other hospitals via use of a ring fenced assessment bed on the spinal unit with a view to preventing inappropriate transfers. Development of an integrated approach to management of patients attending A&E with single column spinal fractures. New approach involves working with Complex Older Persons Evaluation team who are able to provide a holistic MDT assessment and management plan if the patient requires acute hospital admission. All with a view to these patients being managed in the safest, most cost effective way to minimise their length of stay and reduce their risk of a secondary fractures. Theatres Revised correct level surgery policy agreed and applied. Introduction of new imaging displays for theatres where complex spine surgery is performed. Establishment of new services outside Spinal Unit Physio led spinal service within the Emergency Village which has seen the following improvements: 25% reduction in length of stay 100% reduction in official complaints 0.8% readmission rate Appropriate surgical referrals Annual saving 338,617 Reduction in inappropriate admissions Futher improvements identified The spinal service will be subject to one of the comprehensive service reviews as described in the 2017/18 quality priorities section of this report. As this 2 year project comes to a close, we reflect on our successes and learning and aim to use what we ve learned in a Trustwide effort to work on key pathways in each speciality. 86 Salford Royal NHS Foundation Trust Quality Report 2016/17

87 2 Our aims Social care Background As part of our vision to improve health and social care services for the people of Salford we created an Integrated Care Organisation (ICO) in July Salford Royal became the provider of care and support services when social care staff and functions, previously delivered by Salford City Council, transferred to Salford Royal as part of the newly formed Salford Health and Social Care Division. This is enabling us to work much more closely in partnership to improve health and social care outcomes for people and enable them to have a better experience and use our resources more effectively. The purpose of adult social care is to support people to promote wellbeing, maximise their independence and enable them to have choice and control to achieve the outcomes they want in their life. When people have ongoing needs arising from illness or disability that has a significant impact on their wellbeing there are a range of services that may be provided to meet the person s needs and outcomes. Performance measures The Adult Social Care Outcomes Framework (ASCOF) is a range of national measures providing information on the outcomes for people using social care services and their carers. It is used to set priorities for care and support, measure progress and strengthen transparency and accountability. The ASCOF measures are grouped under four domains: 1. Enhancing quality of life for people with care and support needs. 2. Delaying and reducing the need for care and support. 3. Ensuring people have a positive experience of care and support. 4. Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harm. This newly commissioned ICO arrangement is one of the first nationally of its kind and as a consequence a data and quality improvement plan is in place to expand the number of ASC performance measures. New measures will be developed and reviewed, and future quality accounts will reflect this. 87 Salford Royal NHS Foundation Trust Quality Report 2016/17

88 2 Our aims Social care continued Key achievements in 2016/17 Supported over 4,000 people with eligible social care needs. Delivered greater numbers of people supported through the Making Safeguarding Personal procedures to improve outcomes for vulnerable people. Increased the number of carers assessments in the year by approx 24%. Successfully achieved the NHS England performance target for Transforming Care to move people with a learning disability from long stay hospital placements. Improved support for young people with additional needs moving towards adulthood. Started using specialist assistive technology to support people with complex physical and learning disabilities to meet communication needs. Launched a new selfneglect and hoarding policy to improve support for vulnerable people. Established a robust system to meet the legal requirements regarding Deprivation of Liberty Safeguards. Successfully transferred over 400 staff from Salford City Council to Salford Royal. Established a data quality reporting system as part of the new contract arrangements. Delivered a leadership programme to support transfer of staff and integration. 88 Salford Royal NHS Foundation Trust Quality Report 2016/17

89 2 Our aims Patient flow Redesigning our organisation to avoid admissions and improve flow. Salford Royal has the ambition to be the safest organisation in the NHS, and as we work towards this we are faced with many challenges. We acknowledge that the demand for our services will continue to increase, that bed occupancy levels are running at over 95% and that patients are on occasion cared for in wards and departments that are outside of their speciality, which has an effect on patient care and length of stay. What: Successful delivery of the 3 Better Care at Lower Cost Patient Flow projects How much: 3 projects complete By when: April 2017 Outcome: Projects successfully completed These difficulties cause increasing pressure on clinical teams. To alleviate this pressure, and ensure that patients are cared for in the right place at the right time, our focus is increasingly on ensuring what we would call whole system flow. That is, looking outside the hospital, we need to understand and redesign the pathways that take patients from their place of residence, into the healthcare system, and back home again sometimes preventing this journey even occurring in the first place if home is the more appropriate place to be. Improvements achieved and further improvements identified Emergency Village Many patients who arrive in our Emergency Department and Village do not require an acute environment or a bed, however on occasions these patients are admitted as such and subsequently deteriorate in both physical and mental health. In 2016, we developed an admission avoidance scheme which provides care for patients that arrive at Salford Royal with subacute conditions and will ensure their safety. A key part of this strategy was creation of a new Ambulatory Care Area within the Emergency Admission Unit (EAU). We have tested having GPs in our A&E 9am6pm in attempt to reduce potentially inappropriate admissions. Trials have occurred with acute physician ward rounds starting at 7am, to identify patients appropriate for early transfer. We continue to test interventions at all levels with the aim of reducing potentially harmful waits and delays in the delivery of care to our patients. 89 Salford Royal NHS Foundation Trust Quality Report 2016/17

90 2 Our aims Patient flow continued Inpatient areas Groups of patients are admitted to the Trust from a range of specialties for tests, investigations and treatments, and in order to release bed capacity we have created a new Corporate Planned Investigations Unit (CPIU) by merging two existing wards. This has enabled us to free up one of the wards which now provides beds for escalation during times of need. The CPIU provides improved care by extending the working day, and by streamlining care, so that beds will be used more effectively, and patients management should be more efficient. There is capacity for increasing CPIU activity from 5 to 7 days should there be a need to increase activity in the future. Additionally, a new care area was opened named The Pendleton Suite, made up of 49 beds with a focus on patients requiring subacute care, but with the flexibility to accommodate other patient groups should demand change. Community Our Community Home Safe scheme to support independence at home and avoid admissions or enable early safe transfer continues to develop. Technological solutions We continue to explore use of technology to enhance patient flow, including: Trendcare is a software that has now been rolled out across the Trust and allows wards to change their staffing skills and levels based on demand and the complexity of patient needs. Work is underway to test and embed a series of Trendcare Change Packages on the following subjects: Small team nursing and Fair work allocation Work analysis Roster reengineering Strategies for a reduction in late discharges Strategies for a reduction in 1:1 care incidences Also embedded is our Clinical Utilisation Review software, enabling wards and departments to review current status of patients across the hospital and if they are on the most appropriate ward for their needs. There will be significant work on analysis and redesign of pathways within the community. 90 Salford Royal NHS Foundation Trust Quality Report 2016/17

91 2 Our aims Theatre improvement 99% compliance with the 5 Steps to Safer Surgery Safety First launches at Salford Royal What: Final versions of Local Safety Standards for Invasive Procedure (LocSSIPs) to be confirmed By when: May 2017 Outcome: In progress Progress: On plan The Division of Surgery and Neurosciences is embarking on an ambitious programme of work to improve the safety and experience of all our patients who choose to have their procedure here at Salford Royal, under the banner Safety First. The programme has been inspired by the publication of the National Safety Standards for Invasive Procedures (NatSSIPs) by NHS England and the recent Never Events that have occurred in our operating theatres and treatment rooms. One of the recommendations of the National Surgical Never Events Taskforce report was to develop a set of highlevel national standards of operating department practice that will support all providers of NHSfunded care to develop and maintain their own more detailed standardised local procedures. The National Safety Standards for Invasive Procedures (NatSSIPs) were published in September 2015 to support NHS organisations in providing safer care and to reduce the number of patient safety incidents related to invasive procedures in which surgical Never Events can occur. The NatSSIPs cover all invasive procedures including those performed outside of the operating department. On the very few occasions when we do not get it right for our patients it is imperative that we take time out and focus on how we can make it safer for all patients who opt to have their procedure here at Salford Royal. Staff are in the process of testing and finalising a local version of the NatSSIPs (LocSSIPs), and will explore how we can start to roll this out in our everyday practice over the coming year. Looking back over 2016/17 we have maintained our focus on the World Health Organisation s 5 Steps to Safer Surgery. An audit conducted within the Division showed that we are at 99% compliance with the 5 Steps to Safer Surgery (4 months data from AprilJuly 2016 was reviewed). Strategies that we had undertaken to improve compliance had included: Team briefing whiteboards with data to enable correct process and data displayed, this enables staff to follow correct processes when performing team briefs. It also allows operational status at a glance to enable all staff within the theatre to anticipate issues and concerns. Staff are receiving Human Factors training to enable them to effectively execute the 5 steps and are encouraged through the training to raise concerns and speak up if they have any concerns. Staff have had engagements events for theatre leadership to give feedback and actions that have been presented through the collation of the 5 steps data, in particular debrief information. Actions resulting from debrief data are being collated by the theatre leadership, actioned and then a weekly feedback is sent to the whole theatre team detailing any issues and actions. It is hoped that with staff seeing action from the debrief data they are submitting, they will engage with the process fully. A standard operating policy for the safe and efficient use of the 5 steps has been produced and disseminated to all theatre staff and surgical staff. 91 Salford Royal NHS Foundation Trust Quality Report 2016/17

92 2 Our aims Technology assisted service redesign What: Outcome: To develop and deploy innovative technological solutions to improve patient experience In progress Salford Royal continues to be at the forefront of using technology to improve the way we care for patients and patient experience. Technology Assisted Service Redesign (TASR) work stream is responsible for implementing projects under the Better Care at Lower Cost (BCLC) programme. Implementing a selfcheck in system in main outpatients has been a priority over the last 12 months; the key objectives being: Patient check in through terminals and kiosks or via mobile applications. Automated systems around patient pathway and flow management. Electronic recording of attendance and outcomes. Integrated electronic room booking, scheduling and slot utilisation. Progress A selfcheck in system has been procured and the system will be embedded throughout 2017/18. This will allow for electronic recording, room booking and scheduling. The Command Centre project has been launched and will bring IT systems together to predict and react to changes within patient flow. The command centre is a dedicated physical space which will allow us to track patient status across the whole Trust via various technological solutions. Further improvements achieved Throughout 2017/18 focus remains on using advanced technological solutions to improve patient and staff experience. Teleconsultation for some appointments for a number of pilot specialities across the Trust is another priority for 2017/18. Salford Royal NHS Foundation Trust is one of 10 Trusts in the Country to become a Centre of Global Digital Excellence. The department will be responsible for producing an escalated programme of works over 2 years that can be migrated out to support other Trusts. Example check in system that is in used at Sheffield Children s hospital. Salford Royal system may look different when in situ 92 Salford Royal NHS Foundation Trust Quality Report 2016/17

93 3 Our plans for the future 93 Salford Royal NHS Foundation Trust Quality Report 2016/17

94 3 Our plans for the future The quality improvement strategy Our quality improvement strategy ( ) sets the ambitious aim to be the safest organisation within the NHS. This third edition of the strategy was developed building on the successful work from the two previous strategies and took into account the recommendations of the Francis Report and Berwick Review. The quality improvement strategy can be found at: Quality Improvement Strategy Saving Lives, Improving Lives: The Safest Organisation in the NHS Our quality priorities 2017/18 The quality improvement strategy outlines a number of projects which we will be focussing on in the coming years. We would however, like to highlight the following pieces of work as key priorities for 2017/18. For all our quality priorities, we will ensure that measurable outcomes are reported in the Quality Account for 2017/18. Harm and mortality reduction Through the Quality Improvement strategy we aim to lower our mortality rates and ensure that fewer patients experience harm whilst in our care. One of the ways to reduce harm and lower mortality rates is through review of deaths. Salford Royal has a policy of clinical review of all deaths which occur in the acute Trust as part of our commitment to becoming the safest acute Trust in the UK. We have established a mortality review group to implement a process of independent detailed structured judgement reviews of deaths which were unexpected or where there is thought to have been possible healthcare associated harm (whether this was related to the death or not). The learning from these reviews will help identify areas to focus attention on to further reduce harm and premature death, and the board will oversee shared learning to ensure that the organisation as a whole can learn from these reviews. The Mortality Review board will also oversee all work relating to mortality and mortality reduction including responding to particular alerts, ensuring participation in national reviews of learning disability deaths and solidifying our commitment to the right place of care & end of life quality standards for those patients who are expected to die. Another way we plan to reduce harm is through the Safer Salford Programme. The programme brings together members of Salford CCG Governing body, Salford Royal NHS Foundation Trust Board of Director and the Public Health Team from Salford City Council and aims to make Salford the Safest health and social care economy by The project started in April 2016 and will continue to be a quality priority for the Trust. 94 Salford Royal NHS Foundation Trust Quality Report 2016/17

95 3 Our plans for the future Our quality priorities 2017/18 continued Integrated Care Organisation (ICO) Established on 1 July 2016, the ICO brings together the provision of adult social care, acute and community healthcare and local mental health services with Salford Royal NHS Foundation Trust as lead provider. More information on the work can be found on the Integrated Care Organisation project page. The ICO work continues to be a key priority for the organisation and the areas of priority are shown in the graphic below. 95 Salford Royal NHS Foundation Trust Quality Report 2016/17

96 3 Our plans for the future Our quality priorities 2017/18 continued Flow and pathway redesign We know that poor experiences of care and patient harm can occur wherever there are blockages in the smooth flow of treatments and service to our patients. Taking a critical look at the interlinked systems and pathways that cut across our organisation, and redesigning them where necessary, is fundamental to ensuring we deliver safe, clean, personal and effective care. Our ultimate ambition is to review and redesign pathways of care across the whole system for which we are responsible. We have a huge opportunity to do this successfully given our status as an Integrated Care Organisation with responsibility for acute, community and social services. Part of how we plan to do this is by a series of 90 day reviews of services provided across our Clinical Divisions. A large part of this process will rely on mapping out how we currently deliver these services from the perspective of the patients who flow through them. Clinical teams will then analyse the current processes for areas where efforts are currently wasted or duplicated with a view to redesigning their own systems with this waste removed. Global digital exemplar programme Information Technology is increasingly recognised as a key enabler of change and transformation. As a national health system we have a unique opportunity to create a digitally advanced health and care system that will eclipse the best in the rest of the world, giving clinician s timely access to accurate information and joining up health systems to support service redesign and improve outcomes for patients. We are one of 12 acute trusts who are recognised as most advanced in their use of technology, who have been selected to receive funding to help us go from national leaders to world leaders at an accelerated pace. We want to be an exemplar that will inspire others by really showing how information technology can deliver both improved patient outcomes and enhance business efficiencies. We were identified as meeting the following criteria: High Digital Maturity selfassessment scores for readiness and capability. Involvement in innovative digital healthcare initiatives. Representation of a range of different solution types. NHS Improvement confirmation that we will not be hindered in our ambitions due to other issues. 96 Salford Royal NHS Foundation Trust Quality Report 2016/17

97 3 Our plans for the future Statements of assurance from the Board Review of services During 2016/17 Salford Royal NHS Foundation Trust provided and/or subcontracted the following relevant health services: Acute care services. Community care services. A range of contractual arrangements for the provision of intermediate care service. These arrangements changed in year with transfer of services from the Council to Salford Royal with the implementation of the ICO and supporting contractual and governance processes have been put in place. A sub contract as part of the implementation of the ICO with Greater Manchester Mental Health Trust. This constitutes 4.28% of this total. Contracts with Fresenius for dialysis units and use of healthcare at home companies including Baxter home care service for home dialysis. Use of NHS and private hospitals to support the delivery of activity and access targets. This has included Orthopaedic surgery, Bariatric and General Surgery. Use of NHS and private hospitals to support delivery of diagnostics. This includes radiology scanning (MRI, Ultrasound and Plain Film), Nuclear Medicine and remote reporting, Specialist Pathology, EEG/EMG and Dental Laboratories. Service Level agreements are also in place to support the model across Greater Manchester and this largely includes the provision of support services for Neurosciences and Dermatology. Salford Royal has reviewed all the data available to them on the quality of care in all relevant health services. The income generated by the relevant health services reviewed in 2016/17 represents 100% of the total income generated from the provision of relevant health services by Salford Royal for 2016/17. All arrangements are subject to quality assurance as part of the Trust assurance framework and are routinely reviewed. Participation in clinical audit National clinical audit During 2016/17, 36 national clinical audits and 5 national confidential enquiries covered NHS services that Salford Royal NHS Foundation Trust provides. During that period Salford Royal NHS Foundation Trust participated in 34 [94%] national clinical audits and 5 [100%] national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. 97 Salford Royal NHS Foundation Trust Quality Report 2016/17

98 3 Our plans for the future National clinical audit The table below shows: The national clinical audits and national confidential enquiries that Salford Royal NHS Foundation Trust was eligible to participate in during 2016/17. The national clinical audits and national confidential enquiries that Salford Royal NHS Foundation Trust participated in during 2016/17. The national clinical audits and national confidential enquiries that Salford Royal NHS Foundation Trust participated in, and for which data collection was completed during 2016/17, 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. Title Eligible Participated % Submitted Acute Myocardial Infarction (MINAP) National BTS Adult Asthma Audit National CEM Audit of Asthma (paediatric and adult) care in EDs National Bowel Cancer Audit (NBOCAP) National Cardiac Rhythm Management Audit (CRM) Intensive Care National Audit & Research Centre Case Mix Programme (ICNARC) National Diabetes Paediatric Audit Elective Surgery (National PROMs Programme) British Association of Endocrine and Thyroid Surgery member audit requirements National Hip Fracture Database National Fracture Liaison Service Database (FLSBD) 2016 National Head and Neck Cancer Audit (DAHNO) UK IBD Registry (IBD) Biologics Audit UK Trauma Audit and Research Network (UKTARN) National Audit of Dementia National Cardiac Arrest National Chronic Obstructive Pulmonary Disease (COPD) Audit programme Secondary Care National Chronic Obstructive Pulmonary Disease (COPD) Audit programme Pulmonary Rehabilitation National Comparative Audit of Blood Transfusion Use of blood in Haematology National Diabetes Audit (Adults) Core Includes National Insulin Pump Audit National Emergency Laparotomy Audit (NELA) National Heart Failure Audit (NHF) National Joint Registry (NJR) National Lung Cancer Audit NNAP Neurosurgical National Audit Programme (Society of British Neurological Surgeons) Consultant Level Outcomes Publication National Prostate Cancer Audit (NPCA) National Nephrectomy Audit BAUS Published Outcomes National Oesophageal Cancer Audit (NOCGA) National BTS Paediatric Pneumonia National Percutaneous Nephrolithotomy (PCNL) BAUS Published Outcomes National Renal Registry National Rheumatoid and Early Inflammatory Arthritis National Sentinel Stroke Audit Programme (SSNAP) National CEM Audit of Severe Sepsis and Septic Shock care in EDs The National Clinical Audit of Specialist Rehabilitation for Patients with Complex Needs Following Major Injury (June 2015 June 2018) National Stress Urinary Incontinence Audit BAUS Published Outcomes Note: For information on nonparticipation please see the Trust s Clinical Audit Annual Report Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100% In progress 100% 100% 100% 100% Ongoing Ongoing Ongoing >90% In progress Ongoing N/A 100% 100% N/A In progress In progress 100% Ongoing >70% 100% Ongoing Ongoing 100% Ongoing Ongoing Ongoing In progress Ongoing Ongoing Ongoing Ongoing 100% In progress Ongoing 98 Salford Royal NHS Foundation Trust Quality Report 2016/17

99 3 Our plans for the future NCEPOD confidential enquiries Title Eligible Participated % Submitted NCEPOD Mental Health NCEPOD Acute Pancreatitis NCEPOD Non Invasive Ventilation NCEPOD Chronic Neurodisability NCEPOD Young People s Mental Health Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100% 78% 100% Ongoing Ongoing National clinical audit: actions to improve quality The reports of 25 national clinical audits were reviewed by the provider in 2016 and Salford Royal NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided. Title National Heart Failure (HF) Audit Outcome The HF team are proactive in identifying patients admitted with HF. They receive automatic alerts for patients admitted with a known diagnosis of HF, known to HF service, with a Health Issue of HF put on EPR or an echo demonstrating LVSD. They also visit EAU 5 days a week. Specialist HF nurses will see patients irrespective of admitting ward. The hospital operates an active outreach service to ensure that patients are seen by appropriate health professionals and ensures that patients with multiple comorbidities receive the best care (often ACM). HF patients not on a cardiology ward will be seen by Cardiologist if: Referred by responsible Consultant Identified by HF nurse as requiring specialist input Data from the audit demonstrates that 84.9% of patients received specialist input and as a result more than 92% of patients were discharged on ACE inhibitors/arb and more than 95% on betablockers. The majority of patients not seen by a specialist were short stay patients (less than 48 hours). Echocardiograms are requested on patients who have not had a previous abnormal echo and should be performed as an inpatient. 71% of patients had either had an echo 6 months prior to admission or during their stay (National average 91.7%). Recent AQ data suggests that performance in this indicator has fallen due to increased demands on the echo service. As a result, the echo templates have been significantly revised with a 3 fold increase in inpatient echo provision (from Feb 16) and this is currently being monitored. The Trust performs lower than average in relation to Referral to Cardiology follow up but higher than average in relation to Referral to HFN follow up and the team are confident that patients are captured for followup in this way. 99 Salford Royal NHS Foundation Trust Quality Report 2016/17

100 3 Our plans for the future National clinical audit: actions to improve quality continued Title National Sentinel Stroke Audit Programme (SSNAP) and Acute organisational report National Oesophageal Cancer Audit (NOCGA) National Cardiac Rhythm Management Audit (CRM) National Diabetes Foot Care Audit National Diabetes Audit (Adults) Outcome SRFT has a SSNAP Action Group with a designated clinical lead supporting improvement work. Findings from the Action Group are fed back to the weekly Stroke Operational group which was established in September Actions taken /planned to improve the service include: We have improved our thrombolysis rate by reviewing our thrombolysis policy and updating with the latest evidence, introduced at local induction a 2 day induction program including SIM training sessions for our Junior Doctors since August Specialist Assessment good performance maintained. We are working on improving time to nurse water swallow screen with the nursing / medical team. The change in pathway makes this increasingly dependent on good communication / team working. We are currently reviewing the Stroke Emergency Department nurses competencies and are hoping to improve as now these nurses are protected and not counted into ward numbers. Occupational Therapy comfortable within A score. OT team continue to monitor this and have plans to increase minutes of therapy given which may lead to further improvement in Q3. Negotiation with commissioners regarding additional funding for SALT and expanding the availability of ESD or CRT rehabilitation sessions following discharge. The national report was received by the Trust in September 2016, the clinical team are in the process of reviewing the audit results and will then develop an action plan to address any areas requiring improvement. The results of the audit have been reviewed by the Trust and the Clinical Audit Team is working with the Clinical Team to improve the timeliness and completeness of data collection and submission to the national audit. The results of the audit have been reviewed by the Trust and the Team has retrospectively reviewed all delayed referrals. In particular all Salford patients who went beyond 2 month interval from development to MDT. The audit results have been reviewed by a multidisciplinary, cross organisational (SRFT, NHS Salford CCG) patient and professional group (Salford Diabetes Care). Priorities for action were planned to be implemented throughout 2016/17 with bimonthly reviews by SDC. The service development priorities for 2016 for SRFT roll over from 2015 and include: Focused improvements on smoking assessment and blood pressure management. Work to be done on comparing glucose control targets by age and deprivation in comparison to other specialist services. Structured Patient Education Record of attendance for education and completion of education. Possible collaboration with other CCG s in respect of education for specific unusual groups e.g. those with other languages. Development work on how best to change to individualised targets as recommended in new NICE guidance. 100 Salford Royal NHS Foundation Trust Quality Report 2016/17

101 3 Our plans for the future National clinical audit: actions to improve quality continued Title National Emergency Laparotomy Audit (NELA) National UK Parkinson s Disease Audit National Diabetes Inpatient Audit National Rheumatoid and Early Inflammatory Arthritis Audit Year2 Outcome The results of the audit have been reviewed by the Trust and a local action plan is currently being implemented. This includes: Implementing a number of actions to improve case ascertainment including the development of an EPR pathway to improve patient outcomes and facilitate easier data collection. Improving CT reported before surgery by ensuring radiologists are aware of the need to report CT results prior to surgery. Audit Lead to discuss with radiology Improving Assessment by MCOP specialist in patient >70 years Changes have been made to the Theatre Booking Form (Theatreman) to id emergency bowel surgery patients more easily. The results of the audit have been reviewed by the Trust and a local action plan is currently being implemented. This includes: Investigating ways to improve addressing EoL care/lpa discussions in the OPC with Palliative Care colleagues. Reviewing pain symptoms in OPC setting. Ensuring PD UK patient information leaflets/posters are available in the OPC waiting area. The results of the audit have been reviewed by the Trust and a local action plan is currently being implemented. This includes: Reviewing the audit data relating to foot risk assessment which appears to be an error in data collection. This will be addressed for the next round of the audit. This audit has been shared with the Division of Surgery with a view to identifying funding for an additional diabetes specialist nurse to target surgical wards. The Trust s results are better than the national average in relation to Patients with diabetes experiencing more than one or more medication errors. However, our figures have increased since the 2013 audit and actions taken to address this include: Continuing a proactive approach on the medical wards by DSNs who will pick up where medication errors are occurring and take action to prevent this. Regular training of ward nurses the DSNs run educational courses throughout the year for ward nurses and in particular the link nurses. Diabetes team to be notified of any patients coded with T1DM diabetes who are admitted. DSNs will then ensure basal insulin is prescribed to prevent patient harm. This notification system is still being setup. Investigating whether an alert could be sent to the clerking doctor to ensure insulins are prescribed for any patient with a diagnosis of type 1 diabetes. VRII prescribing online. We are still waiting for this to be set up but once in place will reduce the number of errors as it will prompt basal insulin prescription. The Trust now has an early arthritis clinic in place which sees patients on a fasttrack basis. Although not set up as a direct result of the national audit it will improve patient access/care and increase the Trust s compliance with the audit standards. The Team is also looking at ways of liaising with primary care to encourage early referrals. 101 Salford Royal NHS Foundation Trust Quality Report 2016/17

102 3 Our plans for the future National clinical audit: actions to improve quality continued Title Audit of Patient Blood Management in Adults undergoing Scheduled Surgery NCEPOD Acute pancreatitis National BTS Emergency Use of Oxygen Audit National CEM Audit of Vital signs in children in Emergency Departments National CEM Audit of Procedural sedation in Emergency Departments Outcome The results of the audit have been reviewed by the Trust and a local action plan is currently being implemented. This includes: If a stable nonbleeding patient has a posttransfusion Hb >80g/L, the transfusion laboratory staff to query the request prior to issuing blood. The team will work with clinicians to conduct further audits of the proportions of patients receiving transfusion outside recommendations. The team to consider how best to work with clinical trainers to ensure that induction and ongoing education programmes for clinical staff include randomised trial findings which compare the patient outcomes of different red cell transfusion strategies. If >1 unit transfusions are being requested for routine postop patients, laboratory staff to challenge the request before issuing the blood. This also strengthens team working rather than clinicians and lab staff working in silos. The national report was received by the Trust, the clinical team are in the process of reviewing the study results and will then develop an action plan to address any areas requiring improvement. The audit results showed that oxygen prescribing at Salford Royal is much better than the UK average. However, there is a small opportunity for improvement which is addressed in the local action plan. Summary data and results for all wards will be sent to senor nurse managers along with comparative national data for feedback to ward managers and all matrons. Salford NEWS has been introduced Trust Wide since December This requires every patient to have a clear target range with EWS scores if above or below range. Nurse education leads to continue high level training in oxygen use amongst nursing staff. The results of the audit have been reviewed by the Trust and a local action plan is currently being implemented. This includes: Actions to improve vital signs taken & noted <15 mins of arrival or triage action is being led by the PANDA ward manager. Action to ensure that vital signs are repeated <30 mins if previously abnormal Triage nurse to inform Panda nurses of abnormal vital signs. Action to improve documentation regarding clinician recognition of abnormal vital signs action is being led by the Consultant Audit Lead and will be included in GPVTS induction teaching. Action to ensure the appropriate treatment of the abnormal vital signs Guidance & education as to be included in the GPVTS induction. The results of the audit have been reviewed by the Trust and a local action plan is currently being implemented. This includes: Clinical Guideline developed and implemented, with Sedation Proforma as appendix, to be completed for all cases of procedural sedation unertaken within the Emergecy Department This proforma will in due course be implemented as an EPR (electronic patient record) document. 102 Salford Royal NHS Foundation Trust Quality Report 2016/17

103 3 Our plans for the future National clinical audit: actions to improve quality continued Title National CEM Audit of VTE risk in patients with lower limb immobilisation in Emergency Departments National End of Life Care Audit (Combined Clinical and Organisational audit.) National Comparative Audit of Lower Gastrointestinal Bleeding and the Use of Blood National Diabetes in Pregnancy Audit BTS Paediatric Asthma National Bowel Cancer Audits National Smoking Cessation Audit Outcome In response to the national audit results the emergecy deprtment team liaised with the orthopaedic and pharmacy teams before implementing new guidance based on Royal College of Emergency Medicine Guidance. In addition a patient information leaflet has been developed and is awaiting Trust Document Control approval. The results of the audit have been reviewed by the Trust and a local action plan is currently being implemented. This includes: Acquisition of funds for advanced communication skills training. Dissemination of End of Life Care Quality Markers Compliance. SRFT commissioned film to demonstrate effective communication regarding issues specific to end of life. Publicise the use of the booklet Care and Support in the Last Days of Life at all formal and bespoke training. Ongoing education across the Trust on the principles of care for the dying patient and the medications to be used. Development of specific symptom management training course. A local action plan is in place which includes the development of Trust guidelines for the management of LGIB. Once the new guidelines have been developed and rolled out a reaudit of the management of LGIB patients will be undertaken. The national report showed that SRFT is doing well against most of the national audit standards. However, there is still an opportunity for improvement and a local action plan is in place which includes Investigation of sources of funding for continuous glucose sensors. Prepregnancy advice leaflet to be sent out to relevant females once resource to support this has been identified. The national report was received by the Trust in December 2016, the clinical team are in the process of reviewing the audit results and will then develop an action plan to address any areas requiring improvement. The national report was received by the Trust in December 2016, the clinical team are in the process of reviewing the audit results and will then develop an action plan to address any areas requiring improvement. The national audit results showed that documentation of smoking status in SRFT was significantly higher than the national average. However, there is still an opportunity for improvement and a local action plan is in place which includes improving the awareness of documenting smoking status via SIREN, Synapse. 103 Salford Royal NHS Foundation Trust Quality Report 2016/17

104 3 Our plans for the future National clinical audit: actions to improve quality continued Title National Prostate Cancer Audit National Lung Cancer Audit National Hip Fracture Database Outcome The national report was received by the Trust in December 2016, the clinical team are in the process of reviewing the audit results and will then develop an action plan to address any areas requiring improvement. The national report was received by the Trust in December 2016, the clinical team are in the process of reviewing the audit results and will then develop an action plan to address any areas requiring improvement. The national report was received by the Trust in December 2016, the clinical team are in the process of reviewing the audit results and will then develop an action plan to address any areas requiring improvement. Local clinical audit The reports of 82 local clinical audits were reviewed by the provider in 2016/17 and Salford Royal NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided. See table below. The table below includes examples of local audits reported in 2016/17. Further actions planned and undertaken in response to the audit findings will be detailed in the Trust s 2016/17 Clinical Audit Annual Report. Audit title Safe Storage of Medicines at Ward Level Infection Control Ward Audits Actions planned/undertaken The findings of the audit are broken down to ward level in order to identify specific areas requiring action. The data allows us to identify any issues that exist regarding ward infrastructure, e.g. broken locks that may be preventing compliance with the required standards and these can be acted upon in real time. The Infection Control Team undertakes a rolling programme of ward and community area infection control audits. Wards/areas are audited annually and individual reports are returned to the ward manager / lead manager for action. Reports highlight areas of concern which require improvement. Wards/areas are required to produce an action plan to address any issues of concern and submit these to the IC Team. Wards/areas are RAG Rated as Green, Amber or Red. Any areas receiving a Red Rating is followed up within one week, any area receiving an Amber Rating with 6 months to ensure improvements have been made. continued next page 104 Salford Royal NHS Foundation Trust Quality Report 2016/17

105 3 Our plans for the future Local clinical audit: actions to improve quality continued Audit title Audit of the timeliness of administration of prophylactic antibiotics for patients with open limb fractures presenting to the Emergency Department (ED) as a major trauma An Audit of Histopathological reporting of Oesophageal and Stomach cancers in resection specimens Reauditing Cephalometric Diagnostic Quality at Salford Royal Foundation Trust Patient Positioning and Collimation Audit of Unified Do Not Attempt Cardio Pulmonary Resuscitation (udnacpr) Management of Strong Potassium for parenteral use 2016 Primary Immunodeficiency (PID) annual audit Audit of the management pathway for ankle fracture fixation Actions planned/undertaken Poster to be displayed in ED staff room to educate nursing staff on the importance of administering prophylactic antibiotics within 1 hour for patients with open fracture in major trauma. ED clinicians to prescribe the prophylactic antibiotic for patients with an open fracture in major trauma. Investigate to be undertaken around the evidence base and costings associated with Prophylactic antibiotic administered as a bolus rather than infusion. Inclusion of RC Pathology datasets in all cancer resection reports for which they are available. This work programme is in progress. We are currently addressing technical aspects of completing and transferring information into both the path lab electronic report and into an XML file for the cancer registry (COSD). The Team are looking at recruitment to an existing post and business case development in order to increase reporting capacity. The reaudit highlighted increased compliance in some areas following implementation of a collimator. Further actions planned in response to the reaudit include: Education session with departmental staff responsible for taking radiographs including demonstration to staff on correct positioning. Education in correct positioning of patient and collimator to ensure all cephalometric landmarks are visible. Continued programme of education and support in hospital and in the community. Provision of resources on palliative care website to support staff awareness. The audit results demonstrate that the Trust has a robust framework in place to contain the risks associated with the distribution of ampoules of strong potassium to clinical areas not specialist in it s clinical use. Pharmacy records clearly show that stock is only issued to authorised areas and that accurate stock balances have been maintained. The audit of the clinical units demonstrated the same findings. There was no evidence of any of the authorised units issuing strong potassium ampoules to any unauthorised units. It was also noted that the strong potassium ampoules were only being used to prepare nonstock formulations for administration to patients. PID slots increased from May The Trust has already seen a reduction in the waiting list from increasing clinic slots. All PID clinics have support from a CNS who can advise and support regarding home therapy. Closer management of DNAs Home therapy assessments/home visits assessments are to be carried out 1224 months on each patient with regular phone calls to monitor support and request logs/blood samples. Continuing to improve the communication by using NHS net account. The team is working on the development and roll out of a new Ankle Fracture Management Pathway with the aim of reducing time to surgery, total length of stay and patient satisfaction. 105 Salford Royal NHS Foundation Trust Quality Report 2016/17

106 3 Our plans for the future Participation in clinical research The number of patients receiving NHS services provided or subcontracted by Salford Royal NHS Foundation Trust in 2016/17 that were recruited during that period to participate in research approved by a research ethics committee was Goals agreed with commissioners: use of the CQUIN payment framework A proportion of Salford Royal NHS Foundation Trust s income in 2016/17 was conditional on achieving quality improvement and innovation goals agreed between Salford Royal NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. For 2016/17 the baseline value of the CQUIN was 2.5% of the contract value (excluding drugs and devices etc) for CCGs and NHS England (public health and dental). This equates to 5m. For NHS England (specialised commissioners) the CQUIN baseline value equated to 2% of the contract value (excluding drugs and devices etc ) which was 2m. If the agreed milestones were not achieved during the year or the outturn contract value was lower than the baseline contract, then a proportion of CQUIN monies would be withheld. If activity in 2016/17 is higher than the plan, the additional activity also attracts a CQUIN payment of 2.5% or 2% depending on commissioner. For 2016/17, Salford Royal has received signoff that the milestones for all CQUINs (with the exception of the Sepsis CQUIN) relating to quarters 13 of 2016/17 have been achieved. Commissioners will make a decision on the achievement, or otherwise, of the quarter 3 Sepsis CQUIN once the quarter 4 evidence has been submitted. The quarter 4 performance for all CQUINs will be shared with commissioners at the end of April; a response is expected from commissioners by the end of May. Further details of the CQUIN performance in 2016/17 and the goals for 2017/18 are available on request via joanne.entwistle@srft.nhs.uk. Appendix A provides a breakdown of CQUIN goals for 2016/17. For 2015/16 the baseline value of the CQUIN was 7.7m. The Trust achieved 99.7% of its CQUIN goals but as there was a variance against the activity / income targets and CQUIN reflects 2.5% of the outturn value the actual CQUIN income received for 2015/16 was 7.8m. Data quality: relevance of data quality and action to improve data quality Good quality information underpins the effective delivery of improvements to the quality of patient care. Improving data quality will therefore improve patient care and improve value for money. High quality information means better patient care and patient safety. High quality information is: Complete Accurate Relevant Accessible Uptodate (timely) Free from duplication (for example, where two or more different records exist for the same patient) Salford Royal NHS Foundation Trust will be taking the following actions to improve data quality: Validation to improve ethnicity recording for acute and community activity. Validation of new registrations to reduce the number of duplicate registrations. continued next page 106 Salford Royal NHS Foundation Trust Quality Report 2016/17

107 3 Our plans for the future Submissions to demographic batch service to trace records against the National Spine portal to ensure accurate data. Monitoring of day case activity and regular attenders to improve live ADT. Ward audits and monitoring of 11pm to 6am discharges to improve ADT. Review of outpatient activity to ensure attendance outcome is recorded timely and to ensure patients who did not attend have correct postal addresses in comparison to National Spine portal. Review of outpatient activity to ensure attendance outcome is recorded in a timely manner. Review of a proportion of outpatients who did not attend their appointments to ensure correct postal addresses in comparison to national portal. Monitoring of undelivered and invalid address correspondence reported by the Trust mail handler. Review of rejected GP correspondence sent via electronic document transfer. Review of patient related correspondence to the Trust to ensure correct demographic data is held. Review of any inpatient, outpatient and A&E activity that has not undergone automatic contract allocation. Review of death reports from National Spine portal to ensure out of hospital deaths are recorded on the Trust s Patient Administration System (PAS). Gathering user feedback of an efficient and effective service to the wider organisation. NHS number of General Medical Practice code validity Salford Royal NHS Foundation Trust submitted records during 2016/17 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: 99.7% for admitted patient care; 99.9% for outpatient care; and 98.8% for Accident and Emergency care Which included the patient s valid General Medical Practice Code was: 99.6% for admitted patient care; 99.4% for outpatient care; and 99.5% for Accident and Emergency care Information governance toolkit attainment level The IG Toolkit is an online system which allows NHS organisations and partners to access themselves against Department of Health Information Governance policies and standards. It is fundamental to access to the NHS N3 network and to promote safe data sharing. It also allows members of the public to view participating organisations IG Toolkit assessments. Salford Royal NHS Foundation Trust Information Governance Assessment Report score overall for 2016/17 was 90% and was graded Green. Clinical coding error rate Salford Royal NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2016/17. During the course of 2016/17, a number of internal clinical coding audits took place as part of form part of our overall clinical coding assurance programme. Primary Diagnosis Coding Correct 92.50% Secondary Diagnoses Coding Correct 91.85% Primary Procedure Coding Correct 93.26% Secondary Procedure Coding Correct 91.89% Audits were carried out across a number of specialties representative of Trust activity. The Clinical Coding results should not be extrapolated further than the actual sample size audited. 107 Salford Royal NHS Foundation Trust Quality Report 2016/17

108 3 Our plans for the future What others say about Salford Royal NHS Foundation Trust: Statements from the Care Quality Commission Salford Royal NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. Salford Royal NHS Foundation Trust has the following conditions on registration none. The Care Quality Commission has not taken enforcement action against Salford Royal NHS Foundation Trust during 2016/17. Salford Royal NHS Foundation Trust has participated in special reviews or investigations by the Care Quality Commission relating to the following areas during 2016/17: Joint targeted area inspection (JTAI) of the multiagency response to abuse and neglect of children in Salford. Between 12 and 16 September 2016, ofsted, the Care Quality Commission, HMI constabulary and HMI probation undertook a joint inspection of the multiagency response to abuse and neglect in Salford. This inspection included a deep dive focus on the response to children living with domestic abuse. The main focus areas in Salford Royal NHS Foundation Trust for the CQC inspectors were the health visiting service and the accident and emergency department. There are no ratings attached to this type of inspection. The final report indicates key strengths and areas for improvement. Key strengths directly related to Salford Royal are as follows: A particular strength across all agencies is the commitment of resources to tackle this domestic abuse and a clear determination to remove barriers to effective joint working. Timely and effective information sharing between midwives and health visitors supports effective assessment of the child s risk and needs and the appropriate application of thresholds. Salford Royal NHS Foundation Trust has a robust safeguarding supervision policy. 108 Salford Royal NHS Foundation Trust Quality Report 2016/17

109 3 Our plans for the future Salford Royal intends to take the following action to address the conclusion or requirements reported by the CQC: Key areas for improvement Salford Royal intends to take the following action to address the conclusion or requirements reported by the CQC Lead Target completion date Salford Royal has made the following progress by the 31 March 2017 in taking such actions Health practitioners are underutilised in the Bridge. The Bridge is a Multiagency safeguarding hub (MASH) which aims to bring representatives from a range of key agencies, including health, together to improve decision making and outcomes for children and young people who have been referred to Children social care with concerns that they may be at risk from harm through abuse or neglect. This relates to all health providers including SRFT. SRFT / CCG developing a proposal for a permanent SRFT presence in the Bridge. Recruitment to a band 6 secondment to the bridge is in progress. ADNS safeguarding. ADNS s safeguarding / Childrens services. June 2017 March 2017 Meeting arranged to commence proposal development for 05/04/17. Secondment recruitment completed. Health practitioner to commence in post 03/04/17. Practitioner to be supported by specialist nurse for safeguarding children whilst in post. Flagging of health records to indicate children are living in households where domestic abuse occurs. Child Protection Information System (CP IS) planning is underway. ADNS safeguarding. April 2017 Meeting completed with key staff from A&E. Plan agreed to visit local hospital that is using CPIS to establish impact on service and how system applies to practice. Links to EPR planning for SRFT children s services includes review of significant events and coding. ADNS safeguarding /Named Dr safeguarding. June 2017 ADNS and Named doctor completing review of significant events and coding aim to complete by June 2017 as planned. Lack of consideration of impact of coercive control. Review of domestic abuse training to ensure inclusion of coercive control. Links to Institute of health visiting (IHV) training. ADNS safeguarding / Domestic abuse lead nurse / HV leads. June 2017 Actions ongoing to complete by June 2017 as planned. 109 Salford Royal NHS Foundation Trust Quality Report 2016/17

110 3 Our plans for the future In March 2015 the CQC published the results of their inspection of Salford Royal rating the Trust as Outstanding In the areas that were rated as requires improvement we have taken the following actions: Surgery, Safe: WHO checklist: Assurance is provided by the Division of Surgery and Neurosciences that audits are now undertaken across all theatres to monitor compliance and a final checking process has been introduced in theatre recovery whereby patients are not transferred unless the checklist has been fully completed. Audit results and information from team debriefs is disseminated to all staff to speed learning. We have recently devised a WHO qualitative observational tool that is carried out by the staff within the department which has specific elements to review values, behaviours and cultures within theatres. We are currently in the process of reviewing data to identify actions needed to make improvements. These will then be ongoing. Assurance is given that a checklist is now in place where the coordinator is responsible for checking theatre equipment daily and any shortfalls addressed as they occur. Any areas of concern are escalated to the Assistant Director of Nursing immediately. The checklist is monitored by the Team Leader and Lead Nurse weekly. Several processes within theatres have been reviewed and additional steps added to engage staff and make improvements. For example, all personnel within the theatre complex whether scrub, care support worker or anaesthetic support are aware of their daily responsibilities and the need to ensure they perform the necessary safety checks and quality standards. These are audited and observed daily by the coordinator of the day. There is an escalation tool in place for noncompliance. The audit information is sent weekly and reviewed at the senior operational team meeting. Week commencing 13 March 2017 the results are as follows: Fridge temperature recording 99% Warmer temperature recording 100% Freezer temperature recording 100% Anaesthetic machine checks in 100% anaesthetic room Anaesthetic machine checks in theatre 100% 110 Salford Royal NHS Foundation Trust Quality Report 2016/17

111 3 Our plans for the future Surgery, Well Led: Theatre culture and morale: Assurance is given that there are now Executive led steering group, work streams meetings and communications via s, newsletter and governance mornings to ensure that the programme of Quality Improvement remains embedded. Other initiatives include: Weekly huddles led by the Band 7 team which follow an agenda to ensure consistent messaging across the levels. Newsletter produced and disseminated monthly. Clinical governance meetings completed every other month. On the alternate month to the governance meeting there is a theatre engagement event for one hour to improve and support communication. All relevant information is circulated via , information screens and displayed on the notice boards on both levels. Employee of the month identified and celebrated monthly. Surgery procedure cancellations: The Division now hold weekly combined theatre scheduling meetings with representation from each speciality, patient flow, Day Surgery Unit, Theatre Lead Managers, Anaesthetics and wherever possible Consultants to minimise the risk of cancellations of surgical procedures. From March 2015 there has also been the implementation of a theatre scheduling protocol which has structured scheduling across the organisation. Services for children and young people required improvement in one area: Well led: The division immediately redesigned its assurance system for paediatrics and a Childrens board was formed chaired by the Trust s Medical Director which reports into the Salford Health Care Assurance and Risk Committee. Outpatients required improvement in two areas, both were addressed immediately: Safe: Assurance was provided that an escalation process is in place for areas affected by a leaking roof, this escalation process was completed with the guidance of infection control team to managed, monitor and report any further sewage leaks. Any incidents are monitored through the Surgery and Clinical Support Services Divisional Assurance committees as a standing agenda and are also reported thorough the Health & Safety committee monthly. Responsive: Assurance given that a staffing review was completed immediately for the outpatient discharge area with extra staff to support at peak times. An escalation process was developed for when help is required and an hourly round is undertaken of the whole of the outpatient areas by the nurse in charge. 111 Salford Royal NHS Foundation Trust Quality Report 2016/17

112 4 Review of quality performance 112 Salford Royal NHS Foundation Trust Quality Report 2016/17

113 4 Review of quality performance The NHS outcomes framework indicators The NHS Outcomes Framework sets out high level national outcomes which the NHS should be aiming to improve. The Framework provides indicators which have been chosen to measure these outcomes. An overview of the indicators is provided in the table. It is important to note that whilst these indicators must be included in the Quality Accounts the most recent national data available for the reporting period is not always for the most recent financial year. Where this is the case the time period used is noted underneath the indicator description. It is not always possible to provide the national average and best and worst performers for some indicators due to the way data is provided. Domain Indicator 2016/17 National Where applicable Where applicable average Trust statement 2015/ / /14 Best performer Worst performer Preventing SHMI value and SHMI value = 1.00 The Whittington WYE Valley NHS Trust The Salford Royal NHS Foundation Trust considers that this data SHMI value = people banding Hospital NHS = is as described for the following reasons. Mortality reduction 0.93 As As from dying (most recent: Lower than Foundation Trust Higher than expected has been a constant focus for the Trust over the course of As expected expected expected prematurely October 2015 expected = successive Quality Improvement Strategies. September 2016 Lower than expected The Salford Royal NHS Foundation Trust has taken the following actions to improve this rate, and so the quality of its services, by the implementation of wide ranging Quality Improvement Strategies which have aimed to improve mortality and harm by focussing on a series of interventions including: Trust wide harm reduction Quality Improvement Collaboratives (as can be seen through the content of this Quality Account). Enhancing quality of life for people with longterm conditions Helping people recover from episodes of ill health or following injury Helping people to recover from episodes of ill health or following injury % patients deaths with palliative care coded at either diagnosis or speciality level (October 2015 September 2016) Patient reported outcome scores for groin hernia surgery (April 14 March 15 is the most up to date finalised full year data provided on NHS digital) Patient reported outcome scores for varicose vein surgery Patient reported outcome scores for hip replacement surgery (April 14 March 15 is the most up to date finalised full year data provided on NHS digital) Patient reported outcome scores for knee replacement surgery (April 15 September 2015 most recent data release) 28 day readmission rate for patients aged day readmission rate for patients aged 16 or over 45.7% 29.7% N/A N/A The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. The Trust has a very well established Palliative Care Team, who provide in reach to all areas of the hospital. The Salford Royal NHS Foundation Trust continues to take the actions highlighted in this Quality Account to improve this percentage and so the quality of its services, by continuing to place the upmost importance on high quality palliative care for our patients. 45% 47% 40% Full year 2016/17 data currently not available SRFT continue to participate in audit Full year 2016/17 data currently not available SRFT continue to participate in audit Full year 2016/17 data currently not available SRFT continue to participate in audit (April 15 Sept 16 provisional data reported by NHS digital) This procedure is not carried out at the Trust (April 16 Sept 16 provisional year data reported by NHS digital) (April 16 Sept 16 provisional year data reported by NHS digital) N/A N/A The Salford Royal NHS Foundation Trust considers that this Adjusted average data is as described for the following reasons. health gain not (April 14 The Trust has undertaken a significant amount of work in the published by NHS March 15) area of Theatres Improvement. digital due to low numbers The Salford Royal NHS Foundation Trust has taken the following actions to improve this outcome and so the quality of its services, by implementation of our Quality Improvement strategy. This procedure is not carried out at the Trust. N/A N/A The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. (Provisional data only (April 14 The Trust has undertaken a significant amount of work in the for April 15 March 16 March 15) area of Theatres Improvement. reported on NHS digital) The Salford Royal NHS Foundation Trust continues to take the (Updated from last following actions to improve this outcome and so the quality year s quality accounts of its services, by implementation of our Quality Improvement due to more recent strategy. data being available) N/A N/A The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons (Provisional data only The Trust has undertaken a significant amount of work in the for April 15 March 16 area of Theatres Improvement. reported on NHS digital) The Salford Royal NHS Foundation Trust continues to take the (Updated from last following actions to improve this outcome and so the quality year s quality accounts of its services, by implementation of our Quality Improvement due to more recent strategy. data being available) NHS Digital hasn t updated this metric since 2013, therefore we have included our own data on readmissions on the Trust Selected Metrics page. NHS Digital hasn t updated this metric since 2013, therefore we have included our own data on readmissions on the Trust Selected Metrics page. N/A N/A N/A Salford Royal NHS Foundation Trust Quality Report 2016/17

114 4 Review of quality performance The NHS outcomes framework indicators continued Domain Indicator 2016/17 National Where applicable Where applicable average Trust statement Best performer Worst performer 2015/16 Ensuring that people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm Treating and caring for people in a safe environment and protecting them from avoidable harm Ensuring that people have a positive experience of care Ensuring that people have a positive experience of care Responsiveness to inpatients personal needs: CQC national inpatient survey score Percentage of staff who would recommend the provider to friends or family needing care 2016 Staff Survey % of admitted patients riskassessed for Venous Thromboembolism (April December 2016) Rate of C. difficile per 100,000 bed days (Trust apportioned cases) (2015/16, is the most recent data release, please see Trust reported data pages for more current data)) Rate of patient safety incidents per 1000 bed days Prior to 2014/15 rate was based on 100 admissions Rate of patient safety incidents that resulted in severe harm or death per 1000 bed Prior to 2014/15 rate was based on 100 admissions Inpatient Friends and Family Test Accident and Emergency Friends and Family Test 72.7% (2015/16 data cited, this is the most recent data release) 78% 2016 Staff Survey 95.7% (average of Q1Q3) 6 (rate) 14 Count of Trust apportioned cases (2015/16) 37.5 (count of incidents = 4,406) (October 2015 March 2016) 0.07 (count of incidents = 8) (October 2015 March 2016 is the most recent data release) 90% (February 2017) 90% (February 2017) 69.6% (2015/16 data cited, this is the most recent data release) 69% (All Trusts) 68% (Combined Acute and Community Trusts) 95.6% (average of Q1Q3) 14.9 (rate) Not given Not given 96% (February 2017) 87% (February 2017) 86.2% The Royal Marsden NHS Foundation Trust 90% (In the Combined Acute and Community Trust Category The Newcastle Upon Tyne Hospitals NHS Foundation Trust) 100% (multiple Trusts Q3) 0 (several Trusts) N/A N/A 100% (several Trusts) 100% (Liverpool Women s NHS Foundation Trust) 58.9% Croydon Health Services NHS Trust 49% (In the Combined Acute and Community Trust Category: Mid Yorkshire Hospital NHS Trust) 76.48% (Weston Area Health NHS Trust Q3) 66 (rate) (Royal Marsden) N/A N/A 76% (Sheffield Children s NHS Foundation Trust) 48% (North Middlesex University Hospital NHS Trust) The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. The Trust has undertaken a Patient Family and Carer Experience Collaborative which was started in January 2013 and aims to improve all elements of experience. The Salford Royal NHS Foundation Trust continues to take the following actions to improve this outcome and so the quality of its services, by continuing to deliver a Patient, Family and Carer Experience strategy. The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. The Trust has undertaken a Patient Family and Carer Experience Collaborative which was started in January 2013 and aims to improve all elements of experience. The Salford Royal NHS Foundation Trust continues to take the following actions to improve this outcome and so the quality of its services, by continuing to deliver a Patient, Family and Carer Experience strategy. The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. The Trust reviews all cases of hospital acquired Venous Thromboembolism to ensure that all elements of best practice are adhered to. The Salford Royal NHS Foundation Trust continues to take the following actions to improve this outcome and so the quality of its services, by developing systems to ensure that patients receive risk assessments for venous thromboembolism. VTE forms part of the thrombosis improvement project which is descried within the project pages of the quality accounts. The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. Infection control remains one of the Trust s highest priorities with all cases of Hospital Acquired C.Difficile reviewed and opportunities for learning are shared. The Salford Royal NHS Foundation Trust continues to take the following actions to improve this outcome and so the quality of its services, by placing infection control as the highest priorities and ensuring that all staff are fully compliant with mandatory training for antiseptic nontouch technique. The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. The Trust continues to promote a culture of open and honest reporting and endorsing a fair blame culture. The Salford Royal NHS Foundation Trust continues to take the following actions to improve this outcome and so the quality of its services, by encouraging a culture of voluntary reporting and endorsing a fair blame culture. The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. The Trust continues to promote a culture of open and honest reporting and endorsing a fair blame culture. The Salford Royal NHS Foundation Trust continues to take the following actions to improve this outcome and so the quality of its services, by encouraging a culture of voluntary reporting and endorsing a fair blame culture. The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. The Trust continues to promote a culture of open and honest reporting and endorsing a fair blame culture. The Salford Royal NHS Foundation Trust continues to take the following actions to improve this outcome and so the quality of its services, by continuing to deliver a Patient, Family and Carer Experience Strategy. The Salford Royal NHS Foundation Trust considers that this data is as described for the following reasons. The Trust has undertaken a Patient Family and Carer Experience Collaborative which was started in January 2013 and aims to improve all elements of experience. The Salford Royal NHS Foundation Trust continues to take the following actions to improve this outcome and so the quality of its services, by continuing to deliver a Patient, Family and Carer Experience Strategy. 72.7% 82% 96% 6 (rate) 14 Trust apportioned cases 37.5 (count of incidents = 4,406) (October 2015 March 2016) 0.07 (count of incidents = 8) (October 2015 March 2016) 90% (January 2016) 91% (January 2016) 2014/ / % 87% 96% 11 (rate) 26 Trust apportioned cases 42.5 (count of incidents = 4,970) (October 2014 March 2015) 0.09 (count of incidents = 10) (October 2014 March 2015) 94% (February 2015) 91% (February 2015) 74.5% 88.5% 96% 8 (rate) 18 Trust apportioned cases 9.9 (count of incidents = 3,685) (October 2013 March 2014) 0.05 (count of incidents = 17) (October 2013 March 2014) 72% 58% 114 Salford Royal NHS Foundation Trust Quality Report 2016/17

115 4 Review of quality performance The NHS outcomes framework indicators continued Domain: preventing people from dying prematurely The Standardised Hospital Level Mortality Indicator (SHMI) is a measure of mortality developed by the Department of Health, which compares our actual number of deaths with our predicted number of deaths. Each hospital is placed into a band based upon their SHMI; Salford Royal is in band 1 which is lower than expected. Domain: helping people to recover from episodes of ill health or following injury A patient reported outcome measure is a series of questions that patients are asked in order to gauge their views on their own health. In the examples of groin hernia, knee replacement, hip replacement and varicose vein surgery, patients are asked to score their health before and after surgery. We are then able to understand whether patients see a health gain following surgery. The data provided gives the average difference between the first score (presurgery) and second score (postsurgery) that patients give themselves. In all procedures where data is available there are improvements in the average score. However, it is important to note that the sample size for all patient reported outcome scores is very small which may impact upon the meaningfulness of the data, this is rectified when the full year data is provided. Domain: Ensuring that people have a positive experience of care responsiveness to inpatients personal needs This indicator provides a measure of quality, based on the Care Quality Commission s National Inpatient Survey. The score is calculated by averaging the answers to five questions in the inpatient survey. The highest score achievable is 100%. Salford Royal launched a Patient Experience Strategy in January 2013, which provides a structure for all work streams fitting under this heading. Salford Royal is proud that the number of staff members who would recommend us to friends and family needing treatments is higher than the national average. Domain: Treating and caring for people in a safe environment and protecting them from avoidable harm Risk assessing inpatients for venous thromboembolism (VTE) is important in reducing hospital acquired VTE. Salford Royal has worked hard to ensure that not only are our patients risk assessed promptly but that any prophylaxis is given reliably. Domain: Treating and caring for people in a safe environment and protecting them from avoidable harm Patient safety incidents are reported to NHS England. The rate of patient safety incidents per 1000 bed days reported by Salford Royal is Organisations that report more incidents usually have a better and more effective safety culture. We believe you cannot learn and improve if you do not know what the problems are. Salford Royal will continue to encourage a culture of open reporting in order to learn and improve. 115 Salford Royal NHS Foundation Trust Quality Report 2016/17

116 4 Review of quality performance Performance against Trust selected metrics Patient Safety Outcomes Clinical Effectiveness Patient Experience Target/benchmark 2016/ / / / /13 Hospital Standardised Mortality Ratio (Calculated using annual benchmark)* Expected ratio=100. Under 100 is better than expected Stroke Mortality Rates (Acute Cerebral Vascular Disease)* Expected rate=100. Under 100 is better than expected Cardiac arrests outside critical care units per 1,000 admissions Local measure not nationally benchmarked Orthopaedic Surgical Site Infections (inpatients & readmissions)** Latest data release relates to 2015/ % 4.83% 2.5% 3.0% 3.37% Safety Thermometer acute % patients free from new harm Local Target: Above 95% 97.5% 97.9% 98.2% 98.6% 98.1% Safety Thermometer community % patients free from new harm Local Target: Above 95% 96.8% 97.2% 96.6% 96.9% 97.3% Pressure ulcers acute Local count not nationally benchmarked *** MRSA Local Target Local Trajectory: C. diff (all cases including unavoidable) 21 avoidable cases Day Readmissions Dr.Foster data* Advancing Quality^ Composite Quality Score for Acute Myocardial Infarction**** Advancing Quality^ Appropriate Care Score for Acute Myocardial Infarction**** Advancing Quality^ Composite Quality Score for Hip and Knee Surgery***** Advancing Quality^ Appropriate Care Score for Hip and Knee Surgery***** Advancing Quality^ Composite Quality Score for Congestive Heart Failure Advancing Quality^ Appropriate Care Score for Congestive Heart Failure Advancing Quality^ Composite Quality Score for Pneumonia Advancing Quality^ Appropriate Care Score for Pneumonia Advancing Quality^ Composite Quality Score for Stroke****** Advancing Quality^ Appropriate Care Score for Stroke****** N/A VTE risk assessment 95.63% (National average of Q1/2/3 data 2016/17) % of adult inpatients who felt they were treated with respect and dignity^^^ National picker score average 84% % of adult inpatients who had confidence in the Trust doctors treating them^^^ National picker score average 82% Count of patients who waited greater than 52 weeks for treatment Local target is 0 GP Out of Hours Time from case active to definitive telephone clinical assessment. Urgent calls within 20 minutes^^^^ GP Out of Hours Time from case active to definitive telephone clinical assessment. Nonurgent calls within 60 minutes^^^^ Relative Risk=100. Under 100 is better than expected N/A N/A Regional Average Jan Mar 98.6% AprSept 89.2% Regional Average Jan Mar 94.0% AprSept 56.8% Regional Average 71.2% Regional Average 46.8% Regional Average 87% Regional Average 62.6% N/A Local target: full compliance is 95100% Local target: full compliance is 95100% Rate: 8.55% Relative Risk: N/A N/A 99.6% JanMar % AprSept % JanMar % AprSept % 69.2% 92.1% 72.3% N/A N/A 95.73% 86% 84% 85% 87% % 100% 95.38% Rate: 8.41% Relative Risk: % AprilJuly % AprilJuly % 96.8% 90% 74.8% 92% 75.8% N/A N/A 96% 95.06% Rate: 8.49% Relative Risk: % 92.53% 98.65% 94.62% 94.61% 85.64% 92.11% 76.74% 96.98% 86.63% 96% 85% 89% % 96.53% Rate: 7.89% Relative Risk: % 89.1% 98.4%^^ 92.5%^ 83.11% 61.22% 89.42% 74.88% 91.9% 92.56% 96% 88% 88% % 98.06% Rate: 8.03% Relative Risk: % N/A 99.04% N/A 83.22% N/A 90.37% N/A 97.88% N/A 97% 82% 84% N/A 96.38% 96.26% * Data covers the period April 2016December 2016 as there is a time delay in the reporting system. ** From 2014/15 onwards data includes procedures Hip Replacement, Knee Replacement, Reduction of Long Bone Fracture, Repair of Neck of Femur. 2015/16 onwards data includes Reduction of Long Bone Fracture and Repair of Neck of Femur as Salford Royal no longer performs sufficient numbers of hip or knee replacements to produce meaningful data. 2015/16 data changed from the figure reported in the 2015/16 accounts as full years data now available. *** Reported as 48 in 2015/16 accounts as this was not full year data due to reporting delays. **** The Trust withdrew from AQ AMI in August However, the Trust continues to measure its AMI performance through the ongoing National Myocardial Infarction (MINAP) audit. ***** AQ Hip and Knee measures changed in April 2016 therefore data is presented separately for JanMar 16 and AprSept 16. ****** AQ Stroke ceased to collect data in 2014/15. The AQ Programme is now using data from the National Sentinel Stroke Audit program which SRFT continues to participate in. ^ Traditionally the AQ data reported in the quality accounts covers the first three quarters of the AQ reporting year. In previous years AQ reported on a financial year basis and therefore we included the period April to December in the quality accounts. However, as AQ have changed their reporting period this year from a financial to a calendar year, our data reporting has changed to reflect this. Therefore, the table above includes AQ data for the period Jan to Sept 2016 where available. ^^ This figure was mistakenly reported in 2016/17 Quality Accounts as 84.86%, which was the Trust s AQ target rather than the actual figure. ^^^ Data taken from the inpatient survey 2016 (Picker). ^^^^ Data from Adastra system. + A further 4 breaches were reported locally. 116 Salford Royal NHS Foundation Trust Quality Report 2016/17

117 4 Review of quality performance Performance against national targets and regulatory requirements 2016/17 Salford Royal aims to meet all national targets and priorities. We have provided an overview of the national targets and minimum standards including those set out within Monitor s Compliance Framework below. Further indicators of performance can be found in section 4 of the Quality Report. National targets and minimum standards Infection Control Access to Cancer Services Access to Treatment Access to A&E Access to patients with a learning disability Cancelled operations Cancelled operations not treated within 28 days Target Target (2016/17) 2016/ /16* 2014/ / /13 Number of clostridium difficile cases cases 3 were deemed avoidable i.e. lapse of care identified Number of MRSA blood stream infection cases % of cancer patients waiting a maximum of 31 days from diagnosis to first definitive treatment % of cancer patients waiting a maximum of 31 days for subsequent treatment (anticancer drugs) % of cancer patients waiting a maximum of 31 days for subsequent treatment (surgery) % of cancer patients waiting a maximum of 31 days for subsequent treatment (radiotherapy) % of cancer patients waiting a maximum of 2 months from urgent GP referral to treatment % of cancer patients waiting a maximum of 2 months from the consultant screening service referral to treatment % of cancer patients waiting a maximum of 2 weeks from urgent GP referral to date first seen % of symptomatic breast patients (cancer not initially suspected) waiting a maximum of 2 weeks from urgent GP referral to date first seen 18 weeks Referral to Treatment admitted patients 18 weeks Referral to Treatment nonadmitted patients 18 weeks Referral to Treatment patients on an incomplete pathway % of patients waiting a maximum of 4 hours in A&E from arrival to admission, transfer or discharge The Trust provides selfcertification that it meets the requirements to provide access to healthcare for patients with a learning disability % of inpatients whose operations were cancelled by the hospital for nonclinical reasons on day of or after admission to hospital % of those patients whose operations were cancelled by the hospital for nonclinical reasons on day of or after admission to hospital, and were not treated within 28 days 0 96% 98.8% and target achieved each quarter to date 97.5% and target achieved each quarter to date 88.7% and target achieved each quarter to date 95.5% Target was not achieved in quarter 1 but the number of applicable patients was below the de minimis and there was only a 0.5% breach 95.5% and target achieved each quarter cases 4 were deemed avoidable i.e. lapse of care identified cases 19 where there has been some lapse of care * Whilst the NHS Operational standard for 4 hour waits in A&E is 95%, for 2016/17 the Trust agreed a revised trajectory as part of the Sustainability and Transformation Fund. The position against the S&T trajectory is shown below. The Trust achieved its STF trajectory for quarter 1. For quarter 2 the Trust was cumulatively within the 1% tolerance for the A&E Sustainability and Transformation Fund target. In quarter 3, the Trust s appeal relating to A&E performance was upheld. In quarter 4, 100% of the final quarter s STF is predicated on achieving the Trust s financial control total rather than performance. 2 98% 100% 94% 94% 100% 85% 90% 93% 93% 92% 92.9% 95% 85.95%* 0% 1.33% 0% Breast service now managed on behalf of SRFT by University Hospitals of South Manchester No longer a national target No longer a national target No longer a national target 7.45% % 100% 96.3% 100% 88.2% 95.8% 94.7% 88.6% 94.4% 93.3% Yes 0.9% 2.62% 0 97% 100% 96.5% 100% 86.2% 82.6% 96.4% (however, there have been less than 5 applicable patients per quarter) 96% 96.2% 86.99% 92.8% 94.27% 95.01% Yes 0.66% 3.44% % 100% 98.3% 100% 86.8% 97.9% 95.6% 93% 96.2% 95.1% 95.9% Yes 0.56% 0.78% % 100% 99.4% 100% 88.7% 85.2% 98.4% 97.5% 94.5% 96.79% 96.4% 95.46% Yes 0.52% 0.89% 117 Salford Royal NHS Foundation Trust Quality Report 2016/17

118 4 Review of quality performance NHS England patient safety alerts information Through the analysis of reports of safety incidents, and safety information from other sources, NHS England develops advice for the NHS that can help to ensure the safety of patients, visitors and staff. As advice becomes available, NHS England issues alerts on potential and identified risks to safety. At Salford Royal, these alerts are coordinated and monitored by the governance team who work with clinicians and managers in the appropriate areas to confirm compliance or to form an action plan to monitor compliance against it. Salford Royal is fully compliant with all alerts for which compliance deadlines have passed. The following table shows those alerts issued by NHS England during 2016/17, and progress against them. Reference Alert title Issue date Response Deadline NHS/ PSA/W/2016/002 Risk of death from failure to prioritise home visits in general practice Alert disseminated and assurance of compliance received NHS/PSA/ RE/2016/003 Patient safety incident reporting and responding to Patient Safety Alerts Alert disseminated and monitored by the risk team NHS/ PSA/W/2016/004 Risk of death and severe harm from failure to recognise acute coronary syndromes in Kawasaki disease Alert disseminated and assurance of compliance received. Policy written for Paediatric and Adult section of the notice was deemed to be extremely rare. Managed by A&E Consultant NHS/PSA/ RE/2016/005 Resources to support safer care of the deteriorating patient (adults and children) Alert disseminated and assurance of compliance received. Managed through Executive Clinical Effectiveness Committee NHS/PSA/ RE/2016/006 Nasogastric tube misplacement: continuing risk of death and severe harm Ongoing. Managed through Executive Clinical Effectiveness Committee NHS/PSA/ RE/2016/007 Resources to support the care of patients with acute kidney injury Alert disseminated and assurance of compliance received NHS/ PSA/D/2016/008 Restricted use of open systems for injectable medication Assessing Relevance. Managed through Medicine Safety committee NHS/ PSA/D/2016/009 Reducing the risk of oxygen tubing being connected to air flowmeters Assessing Relevance. Disseminated to Estates. Managed through Medical Gases Committee NHS/ PSA/W/2016/010 Risk of death and severe harm from error with injectable phenytoin Alert disseminated and assurance of compliance received. Managed through Medicine Safety committee NHS/ PSA/W/2016/011 Risk of severe harm and death due to withdrawing insulin from pen devices Alert disseminated and assurance of compliance received. Managed through Medicine Safety committee NHS/PSA/ RE/2017/001 Resources to support safer care for fullterm babies Not Relevant Salford Royal NHS Foundation Trust Quality Report 2016/17

119 4 Review of quality performance Never Events Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event. Never Events include incidents such as: Wrong site surgery Retained foreign object postprocedure Full listing can be found on the NHS England web site. Through our governance processes and QI work we aim to prevent never events happening within the organisation. When a never event occurs a thorough executive led investigation in undertaken and robust action plans put in place and regularly monitored. Between April 2016 and April 2017 Salford Royal had 3 Never Events. Initially the Trust declared a fourth Never Event but upon investigation this is in the process of being downgraded. The details of the Salford Royal Never Events are in the table below together with the key findings from the review of the events and the actions taken to prevent future recurrence. Never Event Wrong site surgery Retained foreign object postprocedure Description A patient was marked for a left sided surgical intervention. The operation was commenced on the right side. The issue was identified intraoperatively and the operation performed on the correct side. A patient had a spinal wound closed, during which a wound drain was used, which needed to be removed 48 hours after surgery. 11 months later it was identified that part of this wound drain was still in the wound, and the patient required surgery to remove this. Key findings from root casue analysis The Doctor who consented the patient believed that he had identified the side to be operated on because he had marked the patient s skin and completed the body map in the surgical pathway with the correct side. The side was not documented on the consent form or the listing form. The registrar that performed the operation was not the registrar who marked or consented the patient. Laterality was not indicated on the theatre man scheduling system Collective approach to the WHO checklist and the quality of completion of each stage, there is no identified lead for time out. At no stage did any member of the theatre team say STOP when the surgeon began the procedure on the wrong side. When the consultant surgeon attended there was a breakdown in communication between the consultant and the registrar. The investigation has identified issues around the consent process and application of the WHO checklist. No current Trust guidance for the documentation of a wound drain in either the operation note at the time of insertion, or during the subsequent care and removal. All entries relating to a wound drain are free text, and rely on staff remembering to document care provided. Satisfaction of search when reviewing an xray image. Occurs when the qualified reviewer fails to continue to search for subsequent abnormalities after identifying or checking for what they originally requested the image for. Therefore the review is prematurely ended. Actions to prevent recurrence Review of Theatre Man system; the listing of emergency surgery now includes laterality that must be identified before submission. Review being undertaken of listings process and how information is pulled through to Theatre Man including laterality for nonemergency surgery. WHO checklist is now being trialled electronically and the standard operating policy has been written and will be presented at the Surgery and Neurosciences DARC in January 2017, this includes identification of a member of staff to lead time out. Safety First launch day to be held 6th January Debate and agree a local version of NatSSIPs LocSSIPs, and explore how we can start to roll this out in our everyday practice The cover of the emergency list has been discussed at directorate and governance and we are discussing how we can restructure our working week to ensure the consultant does not have conflicting duties that detract from each one. The recording of the discussions of the emergency list were deficient in this case and has been identified and standard operating procedure in place for handover of emergency list now in place. Share the incident widely across all divisions and directorates where wound drains are used. Add wound drains to nursing evaluation on EPR to capture when they are there and date removed. This incident will be shared wildly across the trust to communicate the message that when checking xray images clinicians need to look at the whole of the xray image, and not 1 element of the image, to ensure unexpected findings are not missed. continued next page 119 Salford Royal NHS Foundation Trust Quality Report 2016/17

120 4 Review of quality performance Never Events continued Never Event Wrong site surgery Description A patient who was to have surgery on the 2nd, 3rd, and 4th toes, also had surgery on the 5th toe which was not consented for. Key findings from root casue analysis An Orthopaedic SHO had not completed delegated consent training as part of his induction. Failure to follow the Organisations consent policy, in that the Orthopaedic consultant operated on the patient s 5th toe without the patient s written consent. Failure by the Orthopaedic consultant to document adequately potential treatment plans and conversations held with the patient in the clinical notes and the operation note. Actions to prevent recurrence Audit to be carried out of the compliance with delegated consent training within the Orthopaedic directorate. Review of the Orthopaedic junior doctor induction process. Review of the trust delegated consent policy. Sharing of the report with the team. Wrong site surgery (this is in the process of being downgraded) A Patient was admitted for excision of a lesion to the left shoulder. The wrong lesion on the left shoulder was removed. The error was identified the following day and the patient relisted for removal of the correct lesion. An investigation was launched into this incident which identified that both lesions required removal, therefore this was not considered wrong site surgery. A downgrade of this incident from its never event status has been requested. At the time of writing this report confirmation of the downgrade had not been received Although it was the lesion laterally located on the left shoulder that the initial consultant had requested be removed, on clinical review at the time of the theatre appointment the lesion closer to the scapular edge was felt to be the most suspicious lesion. This was removed on that visit and proven histologically to be a dysplastic naevus. 5 days later the original lesion was also removed and found to be a dysplastic naevus. It is important to note that both these lesions warranted excision. Duty of Candour The Duty of Candour has been implemented across the Trust. In support of this a revised policy was produced and a quick reference guide to help those undertaking the Duty of Candour to quickly and simply identify what they are expected to do. The initial roll out of the regulatory requirements focused on Serious Untoward Incidents to ensure there are robust systems in place to support and monitor the undertaking. With these systems in place the roll out of the regulatory requirements was extended to all incidents of Moderate harm and above. This was undertaken successfully. The levels of compliance has been good, with current monitoring now looking at the quality of the communications and written confirmation of the conversations with patients or their relevant person. Compliance at all levels is monitored weekly, via the Serious Untoward Incident Assurance meeting, monthly via the SUI register presented to Executive Assurance and Risk Committee and reported six monthly via the 6 month adverse event report. During 2016/17 the Trust maintained 100% compliance for the initiation of the Duty of Candour by means of contacting the patient, or their relevant person. The main focus of work during 2017/18 will focus on the written confirmation of the discussions with the patients, or their relevant persons. During 2016/17 the Trust achieved 68% compliance with the documentation requirement including confirmation letters to the patient or relevant person. 120 Salford Royal NHS Foundation Trust Quality Report 2016/17

121 G , Design Services 4 Review of quality performance How we keep everyone informed There are a number of communications channels used at Salford Royal to ensure our colleagues, patients and the public are kept up to date on all the latest news and developments. The methods of reaching our staff include the more traditional methods of posters and leaflets as well as electronic channels such as our weekly ebulletin SiREN, the intranet and screensavers, which are particularly useful for alerting staff to new initiatives or patient safety messages. We also have a monthly message and video blog from the Chief Executive to all staff to keep them informed of the more strategic issues. Face to face communication is incredibly important and we hold a monthly Leaders forum where various topics are presented, such as our operational performance for the month and how we can improve patient care. The presentations are shared with all teams following the forum. We also hold regular dropin sessions with senior managers and clinical senates to discuss the latest issues. We engage with our patients and members of the public via Twitter feed and share news of our successes to our 12,000+ followers. This year we also launched a Facebook page to engage with our patients, public and staff. Our weekly page in the Manchester Weekly News is another way we share our news and is also a useful channel to advertise up and coming membership events, such as the regular seminars held at the Trust. Our annual open day is always a huge success with staff from across the organisation hosting stalls to showcase our outstanding services to members of the public. For our Foundation Trust members we have a biannual magazine called The Loop, which includes details about events and meetings they can get involved in along with informative articles on the latest Trust news. 12,000+ followers Date Location Booking Salford Royal Staff Medicine for Members Seminars 2015 Come and find out from Salford s community multidisciplinary team about how you can stay well during winter. The team will be providing information about how health and social care services are working together to provide a coordinated approach to care and support for people in the community. Thursday 19 November 2015, 10.30am 11.30am Online Booking Form: foundation@srft.nhs.uk Telephone: Places are limited, we would advise you book in advance Want to attend and currently not a member? Why not complete our online membership form? Stay well in winter If you have any special requirements (including communication or access needs), please let the Membership Team know when booking. Humphrey Booth Lecture Theatre (Level 1), Mayo Building, Salford Royal, Stott Lane, Salford, M6 8HD. 121 Salford Royal NHS Foundation Trust Quality Report 2016/17

122 4 Review of quality performance Statements from Clinical Commissioning Group, Healthwatch and Overview and Health and Adults Scrutiny Panel CCG statement for 2016/17 Quality Report NHS Salford Clinical Commissioning Group (CCG) welcomes the opportunity to comment on the 2016/17 Quality Accounts for Salford Royal NHS Foundation Trust. We work closely with the Trust during the year reviewing a range of indicators in relation to quality, safety and performance; gaining assurance of the delivery of safe and effective services. We are pleased to confirm that the material presented within the Quality Accounts is consistent with information supplied to the commissioners throughout the year. One of the CCG s objectives relating to quality is to seek out the experience of patients using services and use this as a mechanism to drive improvement. We welcome the emphasis placed on this work by the Trust and acknowledge the achievements that have been highlighted through their Patient, Family and Carer Experience Collaborative. The improvements that are outlined in relation to feedback from service users with a hearing impairment are particularly welcome and we anticipate that these will be implemented across community settings as well as within the hospital environment. The emphasis placed upon patient safety is very evident throughout the document and the areas of focus are consistent with our partnership approach through the Safer Salford programme. Our joint commitment to improving medicines safety is highlighted and it is heartening to see that that CQUIN s and innovation initiatives introduced by NHS Salford CCG are supporting the Trust in driving improvements in this key area. The sustained commitment to reducing avoidable harm by the Trust is commendable. The outcome of harm reduction initiatives relating to pressure ulcers within the community, falls incurred whilst in hospital and catheter associated urinary tract infection are excellent examples of how the organisation delivers tangible benefits to people using their services. As a key stakeholder in the Salford Together programme we are pleased to see reference to the outcome of our partnership work in developing the Integrated Care Organisation. The Trust s commitment to integrating adult health and social care provision into a single organisation will achieve significant benefits for people using these services. The attention paid by the Trust to staff support and engagement throughout this process is acknowledged. We look forward to the benefits that will be realised as progress is made in transforming services during 2017/18. The emphasis that has been placed on supporting patients with dementia during 2016/17 is of particular note. The expansion of the steering group overseeing this work to include staff from all parts of the system is a welcome development along with capitalising on the benefits of closer working with mental health services. Participating in the national dementia audit provides the opportunity for the Trust to benchmark their performance and continue to drive improvement. We look forwards to receiving feedback on the results of this audit during Continued next page 122 Salford Royal NHS Foundation Trust Quality Report 2016/17

123 4 Review of quality performance CCG statement for 2016/17 Quality Report continued Members of the CCG Governing Body have undertaken commissionerled walk arounds during the year and our direct observations of the care provided to people using services has been very positive. Feedback from patients and staff during these visits resonates with the information included in this report. The document includes a range of areas where NHS Salford CCG has been working in conjunction with the Trust to support quality improvement. We remain fully committed to continued collaboration on this important aspect of patient care. We are pleased to endorse these Quality Accounts for 2016/17and look forward to continued partnership working on driving improvements in safety and quality for the benefit of our population. Anthony Hassall Chief Accountable Officer NHS Salford Clinical Commissioning Group Healthwatch Salford Thank you for sharing the Draft Quality Report with Healthwatch Salford. Local Healthwatch are best placed to provide meaningful comment on draft Quality Accounts where engagement with the provider around Quality Accounts, including codesign of the provider s priorities for improvement, is an ongoing exercise. We are assured that going forward this year that our relationship will be developed further to enable this to happen. Healthwatch Salford aim to have a proactive role in seeking views on what quality priorities should be selected for the Quality Account. Healthwatch Salford have circulated the draft accounts 2016/17 to our membership and volunteers and find that overall it is a good reflection of the services provided by the Trust. We are particularly pleased to see that: 90% of patients rated their care as excellent or very good 97.5% of outpatients rated their care as excellent or very good 88% of patients using community services rated them as excellent or very good The above statistics also reflect the positive feedback Healthwatch Salford have received during this period on Salford Royal NHS Foundation Trust. We are also pleased to see the progress made in the delivery of harm free care, the reduction of catheter associated urinary tract infections, reduction in pressure ulcers, reduction in falls and acute kidney injury. continued next page 123 Salford Royal NHS Foundation Trust Quality Report 2016/17

124 4 Review of quality performance Healthwatch Salford continued We also congratulate Salford Royal NHS Foundation Trust on the establishment of the Integrated Care Organisation. We have received negative feedback on people s experiences of home care and the transition between home and hospital, so we very much welcome the development of the data quality improvement plan to develop new measures which will form part of these quality accounts in future. In reviewing quality accounts, we look at If the Accounts reflect some of the feedback given to Healthwatch. From the questions raised by our members, we feedback queries which have been made to us on the consistency, clarity and content of what is included in the Draft Quality Accounts. We are pleased that in response to queries from members, finalised figures for A&E are now included and that following member s feedback regards clarity for the CAUTI chart, you have now added an explanation of the measure to the final quality account report. On behalf of Healthwatch Salford, I would like to congratulate your staff and volunteers for continuing to provide excellent services and we look forward to developing our relationship further. Health and Adults Scrutiny Panel Our work with Salford Royal NHS Foundation Trust over the past 12 months has provided a demonstration of the ongoing commitment to provide of Safe, Clean and Personal. The delivery of these standards shows the clear dedication of the Trust to its staff, patients and visitors. With further challenges in the coming and future years, the ongoing development of partnership working is essential. The Health and Adults Scrutiny Panel would like to offer its congratulations and thanks to all employees of the Trust, without whose resolve and steadfastness, the results and development would not be possible. Councillor Margaret Morris Chair of the Health and Adults Scrutiny Panel Salford City Council Delana Lawson Chief Officer Healthwatch Salford 124 Salford Royal NHS Foundation Trust Quality Report 2016/17

125 4 Review of quality performance 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. NHS Improvement 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 2016/17 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 2016 to April Papers relating to quality reported to the board over the period April 2016 to April Feedback from commissioners dated May Feedback from governors dated May Feedback from local Healthwatch organisations dated May Feedback from Overview and Scrutiny Committee dated May The Trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated May The 2016 national patient survey. The 2016 national staff survey. The Head of Internal Audit s annual opinion of the Trust s control environment dated March CQC inspection report dated May 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. The Quality Report has been prepared in accordance with NHS Improvement 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 requirements in preparing the Quality Report. By order of the board. Date: 26 May 2017 Date: 26 May 2017 James J Potter Chairman Sir David Dalton Chief Executive & Accounting Officer 125 Salford Royal NHS Foundation Trust Quality Report 2016/17

126 4 Review of quality performance Independent Practitioner s Limited Assurance Report to the Council of Governors of Salford Royal NHS Foundation Trust on the Quality Report We have been engaged by the Council of Governors of Salford Royal NHS Foundation Trust to perform an independent limited assurance engagement in respect of Salford Royal NHS Foundation Trust s Quality Report for the year ended 31 March 2017 (the Quality Report ) and certain performance indicators contained therein against the criteria set out in the NHS Foundation Trust annual reporting manual 2016/17 and additional supporting guidance in the Detailed requirements for quality reports for Foundation Trusts 2016/17 (the Criteria ). Scope and subject matter The indicators for the year ended 31 March 2017 subject to the limited assurance engagement consist of the national priority indicators as mandated by NHS Improvement: Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period Percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge We refer to these national priority indicators collectively as the Indicators. Respective responsibilities of the directors and Practitioner The directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust annual reporting manual 2016/17 and supporting guidance issued by NHS Improvement. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: The Quality Report is not prepared in all material respects in line with the Criteria set out in the NHS Foundation Trust annual reporting manual 2016/17 and supporting guidance The Quality Report is not consistent in all material respects with the sources specified in NHS Improvement s Detailed requirements for external assurance for quality reports for Foundation Trusts 2016/17 and The indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust annual reporting manual 2016/17 and supporting guidance and the six dimensions of data quality set out in the Detailed requirements for external assurance for quality reports for Foundation Trusts 2016/17 We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust annual reporting manual 2016/17 and supporting guidance, and consider the implications for our report if we become aware of any material omissions. Continued next page 126 Salford Royal NHS Foundation Trust Quality Report 2016/17

127 4 Review of quality performance We read the other information contained in the Quality Report and consider whether it is materially inconsistent with: Board minutes for the period April 2016 to April 2017 Papers relating to quality reported to the Board over the period 1 April 2016 to April 2017 Feedback from Commissioners dated May 2017 Feedback from Governors dated May 2017 Feedback from local Healthwatch organisations dated May 2017 Feedback from Overview and Scrutiny Committee dated May 2017 The Trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated May 2017 The 2016 national patient survey The 2016 national staff survey and The Head of Internal Audit s annual opinion over the Trust s control environment dated March 2017 We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the documents ). Our responsibilities do not extend to any other information. The firm applies International Standard on Quality Control 1 and accordingly maintains a comprehensive system of quality control including documented policies and procedures regarding compliance with ethical requirements, professional standards and applicable legal and regulatory requirements. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. This report, including the conclusion, has been prepared solely for the Council of Governors of Salford Royal NHS Foundation Trust as a body, to assist the Council of Governors in reporting Salford Royal NHS Foundation Trust s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2017, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body, and Salford Royal NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing. Continued next page 127 Salford Royal NHS Foundation Trust Quality Report 2016/17

128 4 Review of quality performance Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) Assurance Engagements other than Audits or Reviews of Historical Financial Information issued by the International Auditing and Assurance Standards Board ( ISAE 3000 ). Our limited assurance procedures included: Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; Making enquiries of management; Limited testing, on a selective basis, of the data used to calculate the indicators tested back to supporting documentation; Comparing the content requirements of the NHS Foundation Trust annual reporting manual 2016/17 and supporting guidance to the categories reported in the Quality Report; and reading the documents. A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Nonfinancial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the Quality Report in the context of the criteria set out in the NHS Foundation Trust annual reporting manual 2016/17 and supporting guidance. The scope of our limited assurance work has not included governance over quality or nonmandated indicators which have been determined locally by Salford Royal NHS Foundation Trust. Our audit work on the financial statements of Salford Royal NHS Foundation Trust is carried out in accordance with our statutory obligations and is subject to separate terms and conditions. This engagement will not be treated as having any effect on our separate duties and responsibilities as Salford Royal NHS Foundation Trust s external auditors. Our audit reports on the financial statements are made solely to Salford Royal NHS Foundation Trust s members, as a body, in accordance with paragraph 24(5) of Schedule 7 of the National Health Service Act Our audit work is undertaken so that we might state to Salford Royal NHS Foundation Trust s members those matters we are required to state to them in an auditor s report and for no other purpose. Our audits of Salford Royal NHS Foundation Trust s financial statements are not planned or conducted to address or reflect matters in which anyone other than such members as a body may be interested for such purpose. In these circumstances, to the fullest extent permitted by law, we do not accept or assume any responsibility to anyone other than Salford Royal NHS Foundation Trust] and Salford Royal NHS Foundation Trust s members as a body, for our audit work, for our audit reports, or for the opinions we have formed in respect of those audits. Continued next page 128 Salford Royal NHS Foundation Trust Quality Report 2016/17

129 4 Review of quality performance Conclusion Based on the work described in this report, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2017: The Quality Report is not prepared in all material respects in line with the Criteria set out in the NHS Foundation Trust annual reporting manual 2016/17 and supporting guidance The Quality Report is not consistent in all material respects with the sources specified in NHS Improvement s Detailed requirements for external assurance for quality reports for Foundation Trusts 2016/17 and The indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust annual reporting manual 2016/17 and supporting guidance Grant Thornton UK LLP Chartered Accountants 4 Hardman Square Spinningfields Manchester M3 3EB Date: May Salford Royal NHS Foundation Trust Quality Report 2016/17

130 5 Appendices 130 Salford Royal NHS Foundation Trust Quality Report 2016/17

131 5 Appendices Appendix A Goals agreed with commissioners: commissioning for Quality and Innovation Payment Framework (CQUIN) Indicator number Indicator name Comments Achievement Opening CQUIN value (based on planned activity and assumes 100% of CQUINs will be delivered) 1a NHS Staff Health and Wellbeing This CQUIN focusses on the introduction of health and wellbeing initiatives covering physical activity, mental health and improving access to physiotherapy for people with MSK issues. Quarters 1 3 achieved. 495,798 1b Healthy Food for NHS Staff, visitors and patients This CQUIN is about achieving a stepchange in the health of the food offered on Trust premises in 2016/17. Quarters 1 3 achieved. 495,798 1c Improving the uptake of flu vaccinations for front line staff This CQUIN aims to improve the uptake of flu vaccinations for frontline clinical staff (75% by the end of December). CQUIN achieved by December ,798 NATIONAL CQUINs 2a 2b Timely identification and treatment of Sepsis emergency Timely identification and treatment of Sepsis inpatients This CQUIN supports the identification and treatment for sepsis in emergency department. This CQUIN supports the identification and treatment for sepsis in inpatient settings. Quarters 1 2 achieved. The decision on Q3 and Q4 achievement for Sepsis will be made following the Q4 evidence. Quarters 1 2 achieved. The decision on Q3 and Q4 achievement for Sepsis will be made following the Q4 evidence. 247, ,899 3a Antimicrobial Resistance and Antimicrobial Stewardship reduction in antibiotic consumption This CQUIN aims to reduce antibiotic consumption per 1,000 admissions. Quarters 1 3 achieved. 396,639 4,957,980 3b Antimicrobial Resistance and Antimicrobial Stewardship empiric review on antibiotic prescriptions Trust required to carry out empiric reviews of antibiotic prescriptions. Quarters 1 3 achieved. 99,159 4 Improving care to patients with learning disabilities This CQUIN aims to improve care for patients with LD with regards to: (A) Giving Consent. (B) Reasonable Adjustments provided by District Nurses. (C) Experience of outpatient appointments. Quarters 1 3 achieved. 247,899 LOCAL CQUINs 5 6 Reducing the risk of stroke and bleeds in patients who are receiving anticoagulation therapy Children s CQUIN The aim with this CQUIN is to continually improve the care of patients at risk of, or with, confirmed thrombosis. This CQUIN requires the implementation of the talking mats tool to gain patient feedback in selected childrens services. Quarters 1 3 achieved. Quarters 1 3 achieved. 247, ,899 7 Cancer Communications This CQUIN builds on the previous year s CQUIN to improve the provision of treatment summaries for patients, GPs and other relevant clinicians at the end of cancer treatment. Quarters 1 3 achieved. 247,899 8 Surgical Triage Unit Assess to admit not admit to assess This Surgical Triage Unit CQUIN aims to evaluate the ambulatory care model ie. admissions avoidance by Assess to admit not admit to assess. Quarters 1 3 achieved. 247, Salford Royal NHS Foundation Trust Quality Report 2016/17

132 5 Appendices Appendix A Goals agreed with commissioners: commissioning for Quality and Innovation Payment Framework (CQUIN) continued Indicator number Indicator name Comments Achievement Opening CQUIN value (based on planned activity and assumes 100% of CQUINs will be delivered) 9 ICO (1) transitions Through this CQUIN we are developing mechanisms to enable the transition between in hospital settings and community care or care home settings for adults with social care needs. Quarters 1 3 achieved. 247,899 SPECIALIST CQUINs LOCAL CQUINs continued a 15b 16 ICO (2) delayed discharges Medicines Optimisation and Medicines Reconciliation on Discharge Safer Handover Stroke Rehab Nationally Standardised Dose Banding Adult Intravenour Systemic Anticancer Therapy (SACT) Clinical Utilisation Review Clinical Utilisation Review facilitating site visits Activation System for patients with LTC Reduction in delayed discharges from inpatient hospital to community or care home settings is the aim of this CQUIN. This CQUIN focusses on Medicines Optimisation and Medicines Reconciliation on Discharge. This CQUIN continues the work on improving communications between clinicians ensuring patients receive standardised, quality of care that is not compromised by poor communication or ambiguity. The aim of this CQUIN is to ensure effective delivery of Stroke Rehabilitation Services to Salford CCG patients in line with NICE Clinical Guidance CG162. This is part of a national incentive to standardise the doses of SACT in all units across England in order to increase safety, to increase efficiency and to support the parity of care across all NHS providers of SACT in England. Continuing the work which commenced in 2015/16 to use CUR on a daily basis, to provide evidencebased decision support for clinicians to ensure that patients receive the right level of care, in the right place at the right time according to their clinical needs and best practice, highlighting on a live basis where patients may be better treated in an alternative level of care. Through this CQUIN SRFT is supporting other Trusts who are implementing CUR in 2016/17 for the first time with advice and guidance including lessons learnt and hosting site visits. The CQUIN scheme aims to encourage the use of the patient activation measurement (PAM) survey instrument, to measure patients skills, knowledge and confidence in the selfmanagement of their long term conditions, in order to support adherence to medication and treatment and to improve patient outcomes and experience. Quarters 1 3 achieved. Quarters 1 3 achieved. Quarters 1 3 achieved. Quarters 1 3 achieved. Quarters 1 3 achieved. Quarters 1 3 achieved. Quarters 1 3 achieved. Quarters 1 3 achieved. 247, , , ,899 10, , , ,000 2,022, Highly Specialised Services Audit This CQUIN is about participation in Highly specialised services (HSS) clinical outcome collaborative audit workshop to deliver improved patient outcome aspirations. Quarters 1 3 achieved. 20, Adult Critical Care Timely Discharge Here the aim is to reduce delayed discharges from Adult Critical Care to ward level care by improving bed management in ward based care, thus removing delays and improving flow. Quarters 1 3 achieved. 615, Salford Royal NHS Foundation Trust Quality Report 2016/17

133 5 Appendices Appendix A Goals agreed with commissioners: commissioning for Quality and Innovation Payment Framework (CQUIN) continued NHS ENGLAND (PUBLIC HEALTH AND DENTAL) CQUINs SPECIALIST CQUINs continued Indicator number 22 Indicator name Dental managed clinical networks Comments Salford Royal through this CQUIN are committed to participating in the Managed clinical networks (MCNs) linking groups of health professionals and organisations from primary, secondary, and tertiary care working in a coordinated manner, unconstrained by existing professional and organisational boundaries to ensure equitable provision of high quality, clinically effective services. Achievement 19 Spinal Surgery Networks This CQUIN aims to promote the better management Quarters 1 3 achieved. 100,000 MDT oversight of spinal surgery by creating and supporting a regional network of a hub centre and partner providers that will ensure data is collected to enable evaluation of practice effectiveness and that elective surgery only takes place following MDT review. 20 QIPP Schemes Through this CQUIN we are aiming to support neurology patients who require immunoglobulin therapy to be managed under a homecare arrangement. Quarters 1 3 achieved. 200, Dental Consistent Coding This indicator builds on the work undertaken in previous years to implement consistent coding within secondary care dentistry services. Quarters 1 3 achieved. 22,633 Quarters 1 3 achieved. Opening CQUIN value (based on planned activity and assumes 100% of CQUINs will be delivered) 22, Diabetic Eye Screening This CQUIN requires the preparation of a comprehensive Quarters 1 3 achieved. 15,610 Patient and Public Engagement summary of Patient and Public Engagement plans and how this is utilised to improve access and outcomes in respect of the Diabetic Eye Screening Service within the Diabetic Eye Screening Programme. 24 Immunisation Patient and Public Engagement This CQUIN requires the preparation of a comprehensive summary of Patient and Public Engagement plans and how this is utilised to improve access and outcomes in respect of the Diabetic Eye Screening Service within the Immunisation Service. Quarters 1 3 achieved. 2,486 63,362 TOTAL 7,043,842 7,043, Salford Royal NHS Foundation Trust Quality Report 2016/17

134 5 Appendices Appendix B Glossary of definitions Term Advancing Quality Anaesthesia Clinical Services Accreditation (ACSA) ADNS ADT AKI Always Events Aseptic Aseptic Non Touch Technique (ANTT) Accessible Information Standard Bay tagging Bed days Better Care Lower Cost (BCLC) Berwick Report Breakthrough Series Collaborative (BTS) British Kidney Patient Association (BKPA) Care bundle Catheter Catheter associated urinary tract infection (CaUTI) CCG Change Package Crohns Disease Explanantion Is a regional quality improvement programme facilitated by AQuA. Its stated aim is to improve standards of healthcare provided in NHS hospitals across the North West of England and to reduce variation in clinical practice. There are 2 scores provided in the quality accounts Appropriate Care Score (ACS) shows the Percentage of the AQ population receiving the whole bundle of AQ defined best practice measures. Composite Process Score (CPS) shows the Percentage of AQ measures met across the whole AQ population. Anaesthesia Clinical Services Accreditation is a voluntary scheme for NHS and independent sector organisations that offers quality improvement through peer review. Assistant Director of Nursing Services. A job role in the hospital relating to nursing management. Admission, discharge and transfer system. Salford Royal uses and electronic patient record system. Acute Kidney Injury, previously known as acute renal failure is damaged to kidneys which prevents them from functioning properly. What patients should always receive when they use our services. If something is aseptic it is sterile, sanitized, or otherwise clean of infectious organisms. The Aseptic Non Touch Technique (ANTT) is the standard intravenous technique used for the accessing of all venous access devices. The standard aims to make sure that people who have a disability, impairment or sensory loss are provided with information that they can easily read or understand and with support so they can communicate effectively with health and social care services. Is the default position adopted by ward teams when working on their wards. The change concept is that we are safer with increased visibility of our wards and this can both prevent falls and assist patients with requests they may have. We have either a nurse or a care support worker present in each bay with others covering our side rooms. If a nurse or care support worker needs to leave the bay then they must get coverage from another healthcare professional before doing so. A bedday is a day during which a person is confined to a bed and in which the patient stays overnight in a hospital. Productivity improvement programme at Salford Royal tasked with reducing financial spending whilst maintaining the quality of services. Review of the Francis Report to give recommendations on how the NHS should improve patient safety continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning. Quality Improvement method undertaken at Salford Royal. Providing direct support for kidney patients and working hard to improve health and care services across the UK. A group of interventions which are proven to treat a particular condition. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Catheters are used for many reasons, for example, draining urine and in the process of haemodialysis. An infection which it is believed has been caused by a urinary catheter. Clinical Commissioning Group responsible for most healthcare services available within a specific geographical area. A group of changes or interventions developed to help tackle a particular problem. A type of inflammatory bowel disease. 134 Salford Royal NHS Foundation Trust Quality Report 2016/17

135 5 Appendices Appendix B Glossary of definitions (continued) Term Clostridium difficile Collaborative Control Chart/ SPC Charts COPD CQC CQUIN Deep vein thrombosis (DVT) Delirium Dementia Department of Health Dispensing Duty of candor EAU EHI Electronic patient record Emergency village Executive Team Francis Report General Medical Practice Code GMW GP Harm HomeSafe Hospital Standard Mortality Ratio (HSMR) HPN HSMR Explanantion A type of infection. Working together towards a shared purpose. Control charts, also known as Shewhart charts or process control charts (SPC Charts), are graphs used to determine whether or not a process is stable. This is helpful in monitoring performance and monitoring improvement work. If there is an active improvement effort going on, these tools can also be used to determine if an improvement has indeed been made. Chronic obstructive pulmonary disease. The name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. Care Quality Commission The independent regulator of all health and social care services in England. Commissioning for Quality and Innovation. This is a system introduced in 2009 to make a proportion of healthcare providers income conditional on demonstrating improvements in quality and innovation in specified areas of care. A blood clot occurring in the deep veins of the leg. State of mental confusion. Condition includes symptoms such as memory loss and confusion. Ministerial department responsible for government policy for health care in England. The provision of medications by the pharmacy. Duty imposed by law on public authorities to provide to relevant information upon harm caused in the Trust. Emergency Admissions Unit. EHealth Insider. An organisation involved in digital health, hospital information and healthcare innovation. A software program which is used to enter information about a patient which is accessible by members of staff at the Trust. A ward of the hospital which receives different types of patients into the hospital for example from the emergency department. The most senior managers in the Trust consisting of the Chief Executive, The Deputy Chief Executive, The Executive Medical Director, The Executive Nurse, Executive Director of Organisational Development & Corporate Affairs and The Executive Director of Strategy and Development Report led by Robert Francis QC, of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The report was highlight areas of concerns relating to patient safety to aid organisational learning. Organisation code of the GP Practice that a patient is registered with. Greater Manchester West NHS Foundation Trust, Provider of mental health services in Salford. General Practitioner An unwanted outcome of care intended to treat a patient. HomeSafe is an improvement piece of work in the Trust concerned with treating more patients at home. A system which compares expected mortality of patients to actual mortality based on a patients risk of dying Home Parenteral Nutrition is feeding directly into the blood stream. Hospital Standard Mortality Ratio an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would expect. 135 Salford Royal NHS Foundation Trust Quality Report 2016/17

136 5 Appendices Appendix B Glossary of definitions (continued) Term Huddle Human Factors IG toolkit Integrated Care Organisation (ICO) Ileostomy Intervention Intermediate care units LocSSIP S Medicines reconciliations Morbidity Mortality MRSA blood stream infection Multidisciplinary Multiple Sclerosis NatSSIP S NCEPOD Never Event NHS England NHS Improvement NHS Quest NICE Oesophagogastric cancer Open (flexible) visiting hours Pennine Acute Hospitals NHS Trust Explanantion A brief meeting often at the start and finish of shifts in care areas. Study of human behaviour and influence this has on an environment. Information Governance Toolkit is a performance tool produced by the Department of Health. Organisation within the Trust integrating hospital, community and social care. An ileostomy is where the small intestine is diverted through an opening in the abdomen. A treatment which is intended to improve a patient s condition. Units which patients go to when they no longer require the acute care of the hospital but are not yet ready to go home. Local Safety Standards for Invasive Procedures. A process to ensure medicines prescribed on admission correspond to those taking before admission. Morbidity comes from the word morbid, which means of or relating to disease,. Mortality relates to death. In health care mortality rates means death rate. Methicillinresistant Staphylococcus aureus (MRSA) is a type of infection. Consisting of members of staff from different professional groups, for example doctors, nurses, physiotherapists and pharmacists. Multiple sclerosis (MS) is a neurological condition of the brain and spinal cord, affecting muscle control, vision, balance and causing fatigue, loss of sensation or numbness. National Safety Standards for Invasive Procedures. The National Confidential Enquiry into Patient Outcome and Death reviews clinical practice following a patient death. Never Events are patient safety incidents that are preventable and should not occur because: there is guidance that explains what the care or treatment should be; there is guidance to explain how risks and harm can be prevented; There has been adequate notice and support to put systems in place to prevent them from happening. Executive nondepartmental public body, sponsored by the Department of Health. Responsible for overseeing Foundation Trusts and NHS Trusts, as well as independent providers that provide NHSfunded care. NHS QUEST is a network for Foundation Trusts who wish to focus relentlessly on improving quality and safety. National Institute of Clinical Excellence. An independent organisation that provides national guidance and standards on the promotion of good health and the prevention and treatment of ill health. Refers to cancers of the oesophagus (gullet). Visiting hours extended beyond traditional set times to allow carer and relatives to visit patients at more convenient times. An acute hospital Trust which operates Fairfield General Hospital in Bury, North Manchester General Hospital, the Royal Oldham Hospital and Rochdale Infirmary, in Greater Manchester. 136 Salford Royal NHS Foundation Trust Quality Report 2016/17

137 5 Appendices Appendix B Glossary of definitions (continued) Term Prophylaxis Pulmonary embolism (PE) Quality Improvement Strategy Reliability science Root Cause Analysis (RCA) Run Charts Safety Thermometer Safer Salford Salford Together Partnership Selftesting Sepsis SHMI Sign up to Safety SSI (Surgical Site Infection) Steering group Stepdown Technology Assisted Service Redesign The Trust Thrombosis Urinary catheter Venous Thromboembolism (VTE) WHO Preventative medicine or care. A blood clot which has become lodged in the lungs. Explanantion A document which outlines the aims and objectives of the Trust relating to patients safety and improving quality. The science relating to ensuring that all processes and procedures perform their intended function. A method of problem solving that tries to identify the root causes of issues and why they are happening. Run charts are graphs used to display data for quality improvement purposes. Run charts are easier for teams to work with than control charts, although they may be less statistically sensitive. Run charts helpful in monitoring performance and monitoring improvement work. If there is an active improvement effort going on, these tools can also be used to determine if an improvement has indeed been made. A point of care survey which is used to record the occurrence of four types of harm (pressure ulcers, falls, catheter associated urinary tract infection and venous thromboembolism). Previously named Making Safety Visible, this programme brings together colleagues from Salford CCG, Salford Royal FT and the city council with the joint aim of being the safest health and care economy in the UK by The Salford Together Partnership an alliance formed by NHS Salford Clinical Commissioning Group, Salford City Council, Salford Royal NHS Foundation Trust and Greater Manchester West Mental Health NHS Foundation Trust. The Partnership aims to bring together home care, mental health and community nursing, hospital and outofhospital services together, ushering in a new era of joinedup care Tests which patients are able to perform for themselves, for example taking blood sugar readings. Life threatening condition caused when the body is overcome by infection. The Summary Hospitallevel Mortality Indicator reports on mortality at trust level across the NHS in England. National initiative to help NHS organisations and their staff achieve their patient safety aspirations and care for their patients in the safest way possible. A healthcareassociated infection in which a wound infection occurs after an invasive (surgical) procedure. A group of people who are involved in the management of a piece of work or a project. The transition from one level of care from one ward to another ward. For example, from critical care to regular inpatient ward. Improvement project in the Trust focusing on improving patient experience via technological solutions. Salford Royal NHS Foundation Trust. A Foundation Trust is part of the National Health Service in England and has to meet national targets and standards. NHS Foundation Trust status also gives us greater freedom from central Government control and new financial flexibility. Formation of blood clots within a vessel. A device which is placed into a patient s bladder for the purpose of draining urine. A blood clot forming within a vein. World Health Organisation. 137 Salford Royal NHS Foundation Trust Quality Report 2016/17

138 2 Accountability report 138 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

139 2 Accountability Report Directors report Composition of the Board of Directors Salford Royal s Board of Directors has responsibility for the exercise of the powers and the performance of the NHS Foundation Trust. Mr Jim Potter Chairman Sir David Dalton Chief Executive Mr Peter Murphy Salford Director of Nursing (Advisory) Mr Paul Renshaw Director of Organisational Development and Corporate Affairs (Advisory from 30 November 2016) Dr Peter Turkington Salford Medical Director (Advisory) Executive Directors Mrs Elaine InglesbyBurke CBE Executive Nurse Director and Deputy Chief Executive Mr Chris Brookes Executive Medical Director Mr Ian Moston Executive Director of Finance Mrs Judith Adams Executive Director of Group Delivery (Commenced 1 April 2017) Mr Raj Jain Executive Director of Corporate Strategy and Business Development Mr Jack Sharp Executive Director of Service Strategy and Development (Advisory from 1 April 2017) Mr James Sumner Executive Director of Performance and Improvement (Commenced 1 December Advisory from 1 April 2017) Mrs Stephanie Gibson Interim Director of Performance and Improvement (Advisory until 31 December 2016) Mrs Diane Morrison Salford Director of Finance (Advisory) NonExecutive Directors Mr John Willis CBE ViceChairman/Chairman of the Audit Committee Mrs Diane Brown Senior Independent Director Dr Joanna Bibby NonExecutive Director (until 31 March 2017) Mrs Rowena Burns NonExecutive Director Mrs Chris Mayer CBE NonExecutive Director (from 1 April 2017) Dr Chris Reilly NonExecutive Director Dr Hamish Stedman NonExecutive Director (from 1 September 2016) Mrs Anne Williams CBE NonExecutive Director (until 31 July 2016) 139 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

140 2 Accountability Report Declaration of interests of the Board of Directors The Board of Directors undertakes an annual review of its Register of Declared Interests. At each meeting of the Board of Directors a standing agenda item also requires all Executive and Non Executive Directors to make known any interest in relation to the agenda, and any changes to their declared interests. The Register of Declared Interests is made available to the public via the Board Meeting Minutes and within the Declarations of Interests Register available on Salford Royal s website. Members of the public can also gain access by contacting the Group Secretary: Mrs Jane Burns Director of Corporate Services Group Secretary Offices 3rd Floor, Mayo Building Salford Royal NHS Foundation Trust Stott Lane Salford M6 8HD. Tel: jane.burns@srft.nhs.uk Statutory statements required within the Directors Report Salford Royal has complied with the cost allocation and charging requirements set out in HM Treasury and Office of Public Sector Information guidance. A statement describing adoption of the Better Practice Payment Code is included within the Annual Accounts. Income disclosures as required by Section 43 2(A) of the NHS Act 2006 are included within the Financial Performance section of the Performance Report. All Directors of Salford Royal have undertaken to abide by the provisions of the Code of Conduct for the Directors at Salford Royal NHS Foundation Trust, this includes ensuring that each Director at the time that this Annual Report is approved: So far as each director is aware, there is no relevant audit information of which the NHS Foundation Trust s auditor is unaware; and Each 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. The provisions of the Code of Conduct also confirm, and directors have undertaken to have 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 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. 140 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

141 2 Accountability Report Quality Governance During 2016/17 the Board of Directors commissioned an independent review of governance arrangements in accordance with NHS Improvement s (NHSI), formerly Monitor s publication Wellled framework for governance reviews: Guidance for NHS Foundation Trust s Updated April Alert to the transitional leadership and governance arrangements being put in place as Salford Royal started to work more closely with PAT within a Group setting, the Board of Directors recognised the value of an independent review attuned to this array of change. The review was delivered by Mersey Internal Audit Agency, in partnership with the Advancing Quality Alliance. The review encompassed four domains: Strategy and Planning, Capability and Culture, Process and Structure and Measurement. The overall conclusion from the review was that Salford Royal is exceptionally wellled and above all, an organisation that sets itself apart in terms of its sustained focus upon safety and quality led by the Board. The review determined that it is a Board that is open to the necessity for transformation and a Board that has the clearest of commitments to quality; safety; patient experience; improvement; and robust risk management and governance processes. A key requirement of the Well Led Review is to provide a summary assessment utilising the risk rating definitions provided in NHSI s Well Led framework. The below tables describe the risk rating definitions and the outcome from Salford Royal s assessment: Table 1: Scoring criteria Risk rating Definition Evidence Green AmberGreen Meets or exceeds expectations Partially meets expectations, but confident Many elements of good practice and no major omissions Some elements of good practice, some minor omissions and in management s capacity to deliver green robust action plans to address perceived gaps with proven performance within a reasonable timeframe track record of delivery AmberRed Red Partially meets expectations, but with some concerns on capacity to deliver within a reasonable timeframe Does not meet expectations Some elements of good practice, has no major omissions. Action plans to address perecived gaps are in early stage development with limited evidence of track record of delivery Major omission in governance identified. Significant volume of action plans required with concerns regarding management s capacity to deliver 141 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

142 2 Accountability Report Table 2: Salford Royal risk rating assessment Detailed criterion Review Rating Strategy and planning Capability and culture Process and structures Measurement Credible strategy and robust plan high quality/ sustainable Aware of risks to the quality, sustainability and delivery of current /future services Skills and capability to lead the organisation Shape an open, transparent, quality focused culture Roles and accountability quality governance Escalating and resolving issues and managing performance Stakeholders engaged on quality, financial and operational performance Appropriate information on performance is analysed and challenged Robustness of information The Well Led Review provided a green rating in all but one area; Capability and Culture: Skills and capability to lead the organisation, where an amber/green rating was assigned. Inevitably, closer working with Pennine Acute Hospitals NHS Trust has created a set of pressures as well as opportunities. The most significant of those from the perspective of the Well Led Review related to the stretch on current capacity. The Board of Directors have remained acutely aware of the pace and scale of transition and have managed, to a very significant degree, this pressure with a number of Salford Director appointments made early in the year, reflecting the depth of talent that had been nurtured at the Trust. The Quality Report describes quality improvements and quality governance in more detail. 142 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

143 2 Accountability Report Remuneration report Annual statement from the Chairman of Salford Royal s remuneration committees I am pleased to present the Directors Remuneration Report for the financial year 2016/17 on behalf of Salford Royal s two remuneration committees. The Nominations, Remuneration and Terms of Service (NRTS) Committee is established by the Board of Directors, with primary regard to Executive Directors, and the Nominations, Remuneration and Terms of Office (NRTO) Committee is established by the Council of Governors, with regard to NonExecutive Directors. In accordance with the requirements of the HM Treasury Financial Reporting Manual (FReM) and NHS Improvement, we have divided this Remuneration Report into the following parts: The Directors Remuneration Policy sets out Salford Royal s senior managers remuneration policy, and The Annual Report on Remuneration includes details about the Directors service contracts and sets out Governance matters, such as the Committee membership, attendance and the business undertook. Major decisions on remuneration During 2016, the NRTS Committee applied a 1% increase to the basic salaries of Executive Directors and Senior Leaders for 2016/17, effective from 1 October 2016, where personal contribution has been assessed as successful or above for the 2015/16 financial year. No bonus payments were awarded. NRTS Committee also introduced an allowance banding of between 15,000 and 20,000 for Chairs of Clinical Divisions, dependent on the size and complexity of the Clinical Division. Annual review of nonexecutive director remuneration by the NRTO Committee in 2016/17 took into consideration the size, complexity and performance of the organisation, and that nonexecutive director remuneration had remained at the same level since 2011/12. At two consecutive meetings, the Committee reviewed available benchmarking data/analyses of rates paid by comparable organisations and subsequently made recommendation to the Council of Governors to bring the remuneration level of NonExecutive Directors, including the Chairman, into the top quartile in comparison with similar organisations. This recommendation was approved, to apply from 1 April As described earlier in this year s Annual Report, Salford Royal NHS Foundation Trust has provided executive support to The Pennine Acute Hospitals NHS Trust throughout 2016/17 to stabilise services and ensure safe patient care across the NHS hospitals of North Manchester, Oldham, Bury and Rochdale. During this period, the Chief Executive and Executive Nurse Director/ Deputy Chief Executive have held responsibility and worked across both organisations. To reflect these arrangements, the salaries of the Chief Executive and Executive Nurse Director/Deputy Chief Executive has been split and paid equitably by Salford Royal and Pennine. Salford Royal s remuneration committees aim to ensure that NonExecutive and Executive Directors remuneration is set appropriately, taking in to account relevant market conditions, and Executive Directors and Senior Managers are appropriately rewarded for their performance against goals and objectives linked directly to Salford Royal s principal objectives. The Committees fulfil their responsibilities and report directly either to the Board of Directors or Council of Governors. Signed: Date: 26 May 2017 Mr James Potter Trust Chairman and Chairman of Salford Royal s Remuneration Committees 143 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

144 2 Accountability Report Senior managers remuneration report Salford Royal has a stated intention for pay to be in the upper quartile of equivalent NHS organisations and that improvements to individual remuneration should consider Trust performance as a leading provider, achievement of annual plan, affordability and consideration of national issues as well as personal performance. Principles for wider Executive and senior manager reward incentives are that they should be designed to reward sustained high performance at a team and individual level. Future policy table Element of pay Purpose and link to company s strategy How operated in practice Maximum opportunity Description of performance metrics Changes to 2016/17 remuneration policy from the previous year Base salary To help promote the long term success of Salford Royal and to attract and retain highcalibre Executive Directors to implement Salford Royal s strategy. To provide a competitive salary relative to comparable healthcare organisations in terms of size and complexity. As determined by salary bands. Increments reviewed annually and approval based upon successful performance. The highest point of bands are only reached for sustained high performance and pay at this level can cease in light of poor personal performance The Committee considers: Individual responsibilities, skills, experience and performance Salary levels for similar positions in other Foundation Trusts The level of pay increases awarded across Salford Royal (with the exception of promotions) Economic and market conditions, and The performance of Salford Royal The Committee retains the right to approve a higher increase in exceptional cases, such as major changes to the Executive Director s role/duties or internal promotions to the position of Director. In these circumstances a full explanation of the increases awarded will be provided in the Annual Report on Remuneration. Salaries are paid monthly in arrears. There is no prescribed maximum annual increase. The Committee on occasions may need to recognise changes in the role and/or duties of a Director; movement in comparator salaries; and salary progression for newly appointed directors. N/A No change Benefits (taxable) To help promote the long term success of Salford Royal and to attract and retain highcalibre Executive Directors and to remain competitive in the market place. To help promote the long term success of Salford Royal and the NHS. To attract and retain highcalibre Executive Directors and to remain competitive in the market place. Benefits for Executive Directors include: Lease car or personal car allowance Pension related benefits annual increase in NHS pension entitlement NonExecutive Directors do not receive benefits There is no formal maximum. N/A No change Pension Salford Royal operates the standard NHS pension scheme without any exceptions. As per standard NHS pension scheme N/A No change 144 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

145 2 Accountability Report Future policy table continued Element of pay Purpose and link to company s strategy How operated in practice Maximum opportunity Description of performance metrics Changes to 2016/17 remuneration policy from the previous year Annual bonus To motivate and reward Executive Directors for the achievement of demanding financial objectives and key strategic measures over the financial year. The performance targets set are stretching whilst having regard to the nature and risk profile of Salford Royal. Variable remuneration allows Salford Royal to manage its cost base by giving it the flexibility to react to changes in the health economy and any unforeseen events. To attract and retain high quality and experienced Non Executive Directors (including the Chairman). The Committee reviews individual performance as measured at the end of the financial year and the level of bonus payable is calculated at that point. Bonus payments remain between 010% of base salary, dependent upon organisational and individual performance and paid in cash. Annual bonus is not pensionable. Maximum earning potential of up to 10% of base salary. As defined by Salford Royal s Contribution Framework No change Non Executive Directors fees (including the Chairman) The remuneration of the NonExecutive Directors, including the Chairman, is set by the Council of Governors on the recommendation of a NRTO Committee having regard to the time commitment and responsibilities associated with the role. The remuneration of the Chairman and the NonExecutive Directors is reviewed annually taking into account the fees paid by other Foundation Trusts. NonExecutive Director fees are paid in cash. The NonExecutive Directors do not participate in any performance related schemes (e.g. annual bonus or incentive schemes) nor do they receive any pension or private medical insurance or taxable benefits. No additional fees are payable for membership of Board Committees however, additional fees are paid to the Chairman of the Audit, Committee and the Senior Independent Director. NonExecutive Director fees take into account fees paid by other Foundation Trusts. N/A No change 145 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

146 2 Accountability Report Bonus scheme Salford Royal has operated a nonrecurrent annual reward scheme since This has been in operation to reward sustained high performance at a team and individual level and for short and long term organisational performance. The scheme has been designed to make payments of between 0% and 10% of base salary and considers organisational performance in the following areas: patient safety against national standards; financial performance; and contractual obligations, along with NHSI s Single Oversight Framework performance measures. Senior managers are only eligible for a payment under this scheme if they achieve at least a successful rating and will not receive any payment if they leave Salford Royal (other than for retirement at normal retirement age) before the completion of the financial year in question. A revised annual reward scheme was introduced in 2015/16, which formally describes a structure for determining overall Trust performance across a number of measures aligned to the Annual Plan. In accordance with this policy and as 2015/16 resulted in financial deficit, it was confirmed by NRTS Committee that the formal reward scheme would not run for this year, irrespective of performance in the other domains. No new components have been introduced to senior manager remuneration packages. Our general policy for employee remuneration is to follow nationally set terms and conditions and salary bands. Salford Royal senior managers are employed on local Trust terms and conditions, which seek to ensure we remain within the upper quartile of equivalent NHS Trusts. In addition to base salaries, we also offer a car allowance and annual reward schemes that have been previously described. The following tables and the fair pay multiple, which are subject to external audit, shows Directors remuneration for the year. Taxable benefits in column B were for lease car or personal car allowances. The following table includes performance related bonuses. These are awarded nonrecurrently and are excluded from pension calculations. Non Executive Directors are not eligible to join the pension scheme. 146 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

147 2 Accountability Report The following tables and the fair pay multiple, which are subject to external audit, shows Directors remuneration for the year. Taxable benefits in column B were for lease car or personal car allowances. The following table includes performance related bonuses. These are awarded nonrecurrently and are excluded from pension calculations. NonExecutive Directors are not eligible to join the pension scheme. Remuneration for the year to 31 March 2017 Executive and Advisory Boardlevel Directors D. Dalton Chief Executive , E. InglesbyBurke CBE Deputy Chief Executive and Executive Nurse Director 2 Salary bands of 5000 Taxable benefits (lease car or car allowance) rounded to nearest 100 Annual performancerelated bonuses bands of 5000 Longterm performancerelated bonuses Pension related benefits annual increase in NHS pension entitlement bands of 2500 Total salary bands of , C. Brookes Executive Medical Director I. Moston Exutive Director of Finance , S. Gibson Interim Director Performance and Improvement R. Jain Executive Director of Corporate Strategy , D. Morrison Salford Director of Finance Note P. Murphy Salford Director of Nursing P. Renshaw Director of Organisational Development and Corporate Affairs J. Sharp Executive Director of Service Strategy and Development J. Sumner Executive Director of Performance and Improvement P. Turkington Salford Medical Director Chairman and NonExecutive Directors , , J. Potter Chairman N/A 4550 J. Bibby NonExecutive Director N/A 1015 D. Brown NonExecutive Director N/A 1015 R. Burns NonExecutive Director N/A 1015 C. Reilly NonExecutive Director N/A 1015 H. Stedman NonExecutive Director N/A 510 A. Williams NonExecutive Director N/A 05 J. Willis CBE Vice Chairman / NonExecutive Director N/A 1520 Note 1 Sir David Dalton is represented in this statement for the proportion of time attributable to Salford Royal NHS Foundation Trust (60%). During 2016/17 Sir David Dalton also held the role of Chief Executive for Pennine Acute Hospitals NHS Trust and is represented in their accounts accordingly (40%) 2 Mrs E InglesbyBurke CBE is represented in this statement for the proportion of time attributable to Salford Royal Foundation Trust (100% until 31 July 2016 and 40% from 1st August 2016). From 1 August 2016 Mrs E InglesbyBurke CBE also held the role of Executive Nurse Director for Pennine Acute Hospitals NHS Trust and is represented in their accounts accordingly (60% from 1 August 2016) 3 Commenced in role 1 December Ceased to be a Board member at Salford Royal NHS Foundation Trust on 31 December Ceased to be a NonExecutive Director 31 March Ceased to be a NonExecutive Director 31 July Commenced in role 1 September Included in the salary figure is the amount received by Mr C Brookes and Dr P Turkington for their clinical duties ( 71k and 67k respectively) 9 All NonExecutive Director s remuneration relates to their services to Salford Royal NHS Foundation Trust 147 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

148 2 Accountability Report Remuneration for the year to 31 March 2016 Executive and Advisory Boardlevel Directors Note Salary bands of 5000 Taxable benefits (lease car or car allowance) rounded to nearest 100 Annual performancerelated bonuses bands of 5000 Longterm performancerelated bonuses Pension related benefits annual increase in NHS pension entitlement bands of 2500 Total salary bands of 5000 D. Dalton Chief Executive E. InglesbyBurke Deputy Chief Executive / Executive Nurse Director C. Brookes Executive Medical Director I. Moston Director of Finance R. Jain Executive Director of Corporate Strategy and Business Development J. Holmes Director of Productivity and Improvement/Interim Director of Performance and Improvement P. Renshaw Director of Organisational Development and Corporate Affairs J. Sharp Executive Director of Service Strategy and Development P. Turkington Medical Director of Standards and Performance Chairman and NonExecutive Directors J. Potter Chairman N/A 4550 J. Bibby NonExecutive Director N/A 1015 D. Brown NonExecutive Member N/A 1015 R. Burns NonExecutive Member N/A 1015 C. Reilly NonExecutive Director N/A 1015 A. Williams NonExecutive Director N/A 1015 J. Willis CBE Vice Chairman and NonExecutive Director N/A 1520 Notes 1 Ceased to be a Board member at Salford Royal NHS Foundation Trust on 31 March Included in the salary figure is the amount received by Mr C Brookes and Dr P Turkington for their clinical duties ( 54k and 67k respectively) 148 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

149 2 Accountability Report Pension benefits for the year to 31 March 2017 Executive and Advisory Boardlevel Directors Note Real increase in pension at pension age (Bands of 2500) Real increase in pension lump sum at pension age (Bands of 2500) Total accrued pension at age 60 at 31 March 2016 (Bands of 5000) Lump sum at age 60 related to accrued pension as at 31 March 2016 (Bands of 5000) Cash equivalent transfer value at 31 March 2016 D. Dalton Chief Executive , ,058 Cash equivalent transfer value at 31 March 2015 Real increase in cash equivalent transfer value E. InglesbyBurke Deputy Chief Executive and Executive Nurse Director , ,534 C. Brookes Executive Medical Director ,133 1,133 I. Moston Executive Director of Finance S. Gibson Interim Director of Performance and Improvement R. Jain Executive Director of Corporate Strategy and Business Development ,001 D. Morrison Salford Director of Finance P. Murphy Salford Director of Nursing P. Renshaw Director of Organisational Development and Corporate Affairs J. Sharp Executive Director of Service Strategy and Development J. Sumner Executive Director of Performance and Improvement P. Turkington Salford Medical Director Notes 1 The pension values shown relate to the individual for period ending 31 March 2017 and have not been apportioned for duties outside of Salford Royal NHS Foundation Trust at Pennine Acute Hospitals NHS Trust 2 The pension values shown relate to the individual for period ending 31 March 2017 and have not been apportioned for duties outside of Salford Royal NHS Foundation Trust at Pennine Acute Hospitals NHS Trust 3 Commenced in role 1 December Pension value shown relate to the individual for the full year ending 31 March Ceased to be a Board member at Salford Royal Foundation Trust on 31 December Pension value shown relate to the individual for the full year ending 31 March 2017 * Please note pension figures relate to the full year entitlements for each Board Member 149 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

150 2 Accountability Report Pension benefits for the year to 31 March 2016 Executive and Advisory Boardlevel Directors D. Dalton Chief Executive E. InglesbyBurke CBE Deputy Chief Executive and Executive Nurse Director C. Brookes Executive Medical Director I. Moston Executive Director of Finance R.Jain Director of Corporate Strategy and Business Development J Holmes Director Operations and Performance P. Renshaw Director of Organisational Development and Corporate Affairs J. Sharp Executive Director of Service Strategy and Development P. Turkington Medical Director of Standards and Performance Note Real increase in pension at pension age (Bands of 2500) Real increase in pension lump sum at pension age (Bands of 2500) , , Total accrued pension at age 60 at 31 March 2016 Lump sum at age 60 related to accrued pension as at 31 March 2016 Cash equivalent transfer value at 31 March 2016 Cash equivalent transfer value at 31 March 2015 Real increase in cash equivalent transfer value (Bands of 5000) (Bands of 5000) , , , , Notes 1 Ceased to be a Board member at Salford Royal NHS Foundation Trust on 31 March 2016 This Remuneration Report confirms that where Salford Royal has released an Executive Director, for example to serve as a NonExecutive Director elsewhere, and payment is provided to Salford Royal, the Director does not retain such earnings with the exception of the below: Mr Chris Brookes is released as the Principal Medical Advisor to the Greater Manchester Multi Specialty Community Provider Vanguard. The Trust is reimbursed 2 Programmed Activities (PAs) for this position, 1 of which is retained by Mr Chris Brookes 150 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

151 2 Accountability Report Fair pay multiples Reporting bodies are required to disclose the relationship between the remuneration of the highest paid director in their organisation and the median remuneration of the organisation s workforce. The midpoint banded remuneration of the highest paid director in Salford Royal NHS Foundation Trust in the financial year 2016/17 was 207.5k* (2015/16, 222.5k). This was 7.3 times (2015/16, 8.5) the median remuneration of the workforce, which was 28k (2015/16, 26k). In 2016/17, no employees received remuneration in excess of the highestpaid director although the Trust paid a higher rate on a full time equivalent basis to a number of locum medical staff during the year. Remuneration paid to employees ranged from 15k to 219k (2015/16, 15k 221k). Total remuneration includes salary, nonconsolidated performancerelated pay and benefitsinkind. It does not include employer pension contributions and the cash equivalent transfer value of pensions. The calculation is based on fulltime equivalent staff employed as at 31 March 2017 paid via Salford Royal s own payroll and also includes costs of staff recharged from other NHS or university organisations and the costs of bank and agency nursing staff and locum medical staff as at 31 March 2017 multiplied by 12 to estimate an annualised total pay cost per fulltime equivalent. * The highest paid director in 2016/17 is C.Brookes, Executive Medical Director as 40% of D.Dalton, Chief Executive s time is attributable to Pennine Acute Hopitals NHS Trust. The remuneration for the Executive Medical Director includes payment for clinical duties of 71k. Salford Royal has robust processes in place to ensure remuneration paid to senior managers is reasonable. Salford Royal has a Nominations, Remuneration and Terms of Service (NRTS) Committee, as described within the Annual Report on Remuneration, comprised wholly of NonExecutive Directors that assesses remuneration for Executive Directors and Senior Leaders and ensures they are set commensurate to roles and responsibilities. Expenses During the year, Executive and NonExecutive Directors were reimbursed expenses incurred on travel and other costs associated with their work for Salford Royal. The total amounts paid are summarised below. Total expenses paid to Executive Directors who served during the financial year Total expenses paid to NonExecutive Directors who served during the financial year TOTAL During the year, Governors were reimbursed expenses incurred on travel and hospitality. The total amounts paid are summarised below. Total expenses paid to Governors who served during the financial year Total eligible Total eligible Total received Total received 2016/17 expenses rounded to the nearest /17 expenses rounded to the nearest /16 expenses rounded to the nearest /16 expenses rounded to the nearest Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

152 2 Accountability Report Service contract obligations The contracts of employment for all senior managers are substantive (permanent), continuation of which is subject to regular and rigorous review of performance. All such contracts contain a notice period of six months. Policy on payment for loss of office All senior manager contracts contain a notice period of six months. In relation to loss of office; if this is on the grounds of redundancy, then this would be calculated in line with agenda for change methodology. Loss of office on the grounds of gross misconduct will result in a dismissal without payment of notice. Loss of office on the grounds of personal capability will result in dismissal with notice. Statement of consideration of employment conditions elsewhere in the Foundation Trust The remuneration policy for senior managers has been set to ensure Salford Royal is in the upper quartile of comparative Trusts to ensure we can attract and retain high calibre leaders. Salford Royal has not consulted with employees when preparing the senior manager remuneration policy, however a benchmarking exercise comparing Salford Royal remuneration packages to comparative NHS Foundation Trusts was carried out in 2013 using published data and was used by the NRTS to set senior manager salary bandings. 152 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

153 2 Accountability Report Annual report on remuneration Service contracts As described above, all senior manager contracts contain a notice period of six months. Openended (permanent) contracts are issued to senior managers. NonExecutive Directors serve terms of three years, up until six years have been served. The Council of Governors will consider and set terms of office for NonExecutive Directors beyond that point that meet the needs of the organisation, taking into account NHS Improvement s guidance that terms beyond that point should be set on an annual basis. Further details about the terms of office of each individual NonExecutive Director can be found in the Directors Report within this Annual Report and Accounts. Further information about the Remuneration Committees Nominations, Remuneration and Terms of Service (NRTS) Committee The Board of Directors has established a Nominations, Remuneration and Terms of Service Committee. Its responsibilities include consideration of matters pertinent to the nomination, remuneration and associated terms of service for Executive Directors (including the Chief Executive), matters associated with the nomination of NonExecutive Directors and remuneration of senior managers/clinical leaders. The Committee comprises Salford Royal s Chairman and all NonExecutive Directors of Salford Royal. Attendance during 2016/17 was as follows: Mr Jim Potter 5/5 Mr John Willis CBE 3/5 Mrs Diane Brown 5/5 Mrs Anne Williams CBE 1/2 Mrs Rowena Burns 4/5 Dr Joanna Bibby 3/5 Dr Chris Reilly 4/5 Dr Hamish Stedman 2/3 The Chief Executive attends the Committee in relation to discussions about Board composition, succession planning, remuneration and performance of Executive Directors. The Chief Executive is not present during discussions relating to his own performance, remuneration and terms of service. The Director of Organisational Development and Corporate Affairs provided employment advice and guidance, and withdrew from the meeting when discussions about his/ her own performance, remuneration and terms of service were held. Salford Royal s Trust Secretary was the Committee Secretary. The Committee meets its responsibilities, as set out in its terms of reference, by: Monitoring and evaluating the performance of the Chief Executive and Executive Directors Determining appropriate remuneration, relative to individual and Trust performance Evaluating the balance of skills, knowledge and experience on the Board and approving descriptions of roles, and appointment processes, for the appointment of Executive Directors Implementing and keeping under review local remuneration and performancerelated pay/bonus arrangements for the most senior managers (subexecutive Director level) within Salford Royal 153 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

154 2 Accountability Report Nominations, Remuneration and Terms of Office Committee (NRTO) The Committee comprises Salford Royal Chairman (or the ViceChairman, when matters associated with the Chairman s nomination are being considered), the Lead Governor, one other elected Governor and one appointed Governor. All elected governors, both public and staff, are invited to express an interest in taking one place on the Committee. All appointed governors are invited to express an interest in taking one further place on the Committee. In the event of more than one elected, or more than one appointed governor expressing an interest, the Council of Governors has directed that the Lead Governor decide which elected governor and/or which appointed governor will attend ensuring rotation of governors. When the Chairman s performance of remuneration is being considered the Chairman withdraws from the meeting and the Lead Governor chairs the Committee. When the Chairman s nomination is being considered the ViceChairman chairs the Committee. Only members of the Committee are entitled to attend Committee meetings. However, the Committee can invite members of the Board of Directors to attend, in particular the Chief Executive and Director of Organisational Development and Corporate Affairs. The Trust Secretary, acting as Committee Secretary, will normally be in attendance. The Senior Independent Director will attend when matters associated with the Chairman s performance are being discussed. The Committee may invite others to attend for the purpose of receiving specialist and/or independent advice on any matter, relevant to its scope and function. The Committee has taken into account available benchmarking information and specialist reports with respect to the remuneration of NonExecutive Directors and Chairman in similar organisations including benchmarking information collated by NHS Providers and Capita (specialist advisers). The Council of Governors, through the Committee ensured appropriate oversight and decision relating to: The Chairman s 2015/16 performance appraisal The 2015/16 performance appraisals for Non Executive Directors The remuneration levels for all NonExecutive Directors, including the Chairman The appointment of Dr Hamish Stedman as NonExecutive Director with expertise in leading and influencing policy development and service in health and social care At its meeting in February 2017 the NRTO Committee reviewed the role description/ person specification and the potential candidate pool for a new nonexecutive position; a senior NonExecutive Director at the Pennine Acute Hospitals NHS Trust, with established connections and involvement in Greater Manchester developments. The Committee confirmed that there was one suitably qualified and experienced person that met the requirements; Mrs Chris Mayer, CBE. In light of this, the Committee agreed that neither an external search consultancy nor open advertising was required. The Committee agreed and conducted an appointment process that complied with the provisions of the Trust s Constitution and the NHS FT Code of Governance and recommended the appointment of Mrs Chris Mayer, CBE as Non Executive Director continued next page 154 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

155 2 Accountability Report Reappointment of Mrs Diane Brown and Mr John Willis CBE for an additional one year term Reappointment of Mrs Rowena Burns and Dr Chris Reilly for an additional three year term Extension to the tenure for the Chairman, Vice Chairman and Senior Independent Director, to support the transition to Group Attendance during 2016/17 was as follows: Date 16 May June November February 2017 Items Shortlisting for the appointment of NonExecutive Director with expertise in leading and influencing policy development and service in primary health and social care (process agreed in March 2016) Selection process for the appointment of NonExecutive Director with expertise in leading and influencing policy development and service in primary health and social care Reappointment of NonExecutive Directors: John Willis CBE and Diane Brown Review of Chairman s Performance 2015/16 Review of NonExecutive Directors Performance 2015/16 Review of remuneration of the Chairman and NonExecutive Directors Review of appointment process and interview of NonExecutive Director with experience as a senior NonExecutive Director at the Pennine Acute Hospitals NHS Trust, with established connections and involvement in Greater Manchester developments Reappointment of NonExecutive Directors: Chris Reilly and Rowena Burns. Review of remuneration of the Chairman and NonExecutive Directors Noted appointment of NonExecutive Directors to the Group Committees in Common and agreed extension of tenure to the terms of office of the Chairman, Vice Chairman and Senior Independent Director Attendees Chairman Lead Governor Elected Governor (Albert Rooms) Appointed Governor (Jackie Leigh) Deputy Director of Human Resources Deputy Trust Secretary Trust Secretary Chairman Lead Governor Elected Governor (Albert Rooms) Appointed Governor (Jackie Leigh) Chairman of Wrightington, Wigan & Leigh NHS Foundation Trust Chief Executive Officer Director of Organisational Development and Corporate Affairs Trust Secretary Chairman Lead Governor Elected Governor (Angela Railton) Senior Independent Director Director of Organisational Development and Corporate Affairs Deputy Trust Secretary Trust Secretary Apologies: Dr Deji Adeyeye Chairman Lead Governor Elected Governor (Angela Railton) Appointed Governor (Dr Deji Adeyeye) Deputy Trust Secretary Trust Secretary Director of Organisational Development and Corporate Affairs Chairman of Wrightington, Wigan & Leigh NHS Foundation Trust Signed: Date: 26 May 2017 Sir David Dalton Chief Executive 155 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

156 2 Accountability Report Staff Report At the end of 2016/17 Salford Royal NHS Foundation Trust employed 7,573 people. Details of our workforce are provided below. These tables have been audited. Staff costs Average number of employees (WTE basis) Salaries and wages Social security costs Employer s contributions to NHS pensions Termination benefits Agency/contract staff NHS charitable funds staff Total gross staff costs Permanent 250,522 22,041 24,810 Other 2, /17 Total 2015/16 Total Pension cost other 1,526 Other post employment benefits Other employment benefits Recoveries in respect of seconded staff Total staff costs 298,899 (10,290) 288,609 21,050 23,085 23, , ,331 22,041 13,702 24,810 25,649 21,050 19, , ,681 (10,290) (8,326) 311, ,355 Medical and dental Ambulance staff Administration and estates Healthcare assistants and other support staff Nursing, midwifery and health visiting staff Nursing, midwifery and health visiting learners Scientific, therapeutic and technical staff Healthcare science staff Social care staff Agency and contract staff Bank staff Other Permanent Number 731 1,634 1,259 1,763 1, /17 Other Total Number Number /16 Total Number ,634 1,259 1,763 1,183 1,406 1,234 1, Of which: Costs capitalised as part of assets. Total average numbers 6, ,982 6,508 Of which: Number of employees (WTE) engaged on capital projects. 156 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

157 2 Accountability Report Inclusion and equality Salford Royal s Board of Directors recognises that delivering on inclusion and equality is a key driver to achieving the Trust s ambition to be the safest organisation in the NHS. It gives us a real opportunity to place people at the centre of the work we undertake, recognising how actively involving individuals from diverse groups enables us to prioritise and address health and employment inequalities. The Trust s Board level lead for Inclusion and Equality is the Director of Organisational Development and Corporate Affairs. However, the Trust s approach is that all staff and managers have responsibility. We continually work to embed robust systems that support everyone to deliver this agenda throughout their working lives. We will continue to engage and involve our staff to ensure they have the necessary skills and confidence to understand the root causes of health and employment inequalities of protected groups, review their services to improve outcomes and enable them to support the diverse needs of service users and colleagues. The Trust has outlined its commitment to this agenda through ensuring Inclusion and Equality training is mandatory for all staff. The Trust is fully committed to meeting its requirements of the Equality Act 2010 and the Public Sector Equality Duty. The Trust s Annual Equality Reports, monitoring data/statistics and other relevant information can also be viewed on the Trust website ( diversityequality). This information enables the Trust to review and monitor outcomes for both its workforce and service user data by protected groups. It also includes the Trust s report and action plan on the Workforce Race Equality Standard (WRES). The Trust is working with a designated Staff Governor to support this work. From the Annual Equality Report the Trust has reviewed and refreshed its equality objectives. This has enabled us to develop an evidence based approach to identifying key areas for improvement. The Trust s Single Equality Scheme is also published on the website. This outlines and promotes the Trust s commitment to this agenda, ensuring that the organisation clearly defines it assurance, governance and engagement strategy. In year achievements Service user disability champions forum This forum has been in existence since It has become invaluable in leading key pieces of work to improve outcomes for patients with disabilities, and has been a key partner in the Trust s Patient, Family and Carer Experience Quality Improvement collaborative. The forum has enabled the Trust to listen directly to user s experiences and develop improved outcomes for our most vulnerable groups. Initiatives that have been implemented as a result of feedback from the forum include the Meet & Greet Service, training staff in basic British Sign Language, trialling the use of communication boards and improving hands on training for staff including guided sight training. Accessible information standard Salford Royal has made good progress on delivering against the Accessible Information Standard. A joint technology development day was held, which brought together the IM&T teams and individuals with communication support needs to identify joint solutions. The recording of patient communication needs inline with the standard was commenced following this development day along with inhouse solutions that will allow us to pilot patient letters in easy read and large print. 157 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

158 2 Accountability Report Meet and greet service This service is a great example of using service users experience to improve the service for others. After listening to concerns raised by the Service User Disability Champions Forum about how vulnerable groups access services at the hospital, the Trust launched its Meet and greet service. This service enables individuals to prebook a volunteer to assist them to attend their outpatient appointment, or to visit family members in hospital enabling them to support in their family member s care. Access to an electronic scooter can also be arranged if required. All volunteers have received specialised training about supporting individuals with additional needs. In 2016 the service supported over 600 visits and we continue to see a rise in requests each month. Supporting the Council of Governors The Inclusion & Equality Team continues to support the Council of Governors to develop their knowledge and understanding of equality standards and engagement with protected groups through training and sharing good practice. Governors are always invited to attend events and have been active participants in several events run throughout the year, including introducing and supporting our EDS2 community scoring event. Workforce Race Equality Standards (WRES) In line with the WRES action plan, Salford Royal held its first Black and Minority Ethnic (BME) Big Listen event in December We invited key note speakers from the national WRES Implementation Team and local Trust s to share good practice. The event enabled any member of staff with an interest to discuss the Trust s current results and develop next steps. Training and development After listening to both service users and staff the Trust developed and delivered a series of training and awareness sessions throughout the year to improve outcomes for diverse groups. These have enabled staff to have face to face conversations with a number of representatives from diverse groups and develop practical ways to support these individuals. Future priorities and targets Through the active engagement and data analysis we have developed a comprehensive Inclusion and Equality Performance Report and Action Plan. The plan is continually reviewed and updated through regular engagement with key stakeholder groups, current priorities are: Ensure that the Trust improves how it embeds equality analysis within its internal governance arrangements for Board of Directors papers and service transformation/redesign, ensuring that due regard is paid to the public sector equality duty. Continue to develop systems to deliver on the Accessible Information Standard, including working with services and departments to apply for accreditation with Action on Hearing Loss for its Louder than Words standard. Work towards improving the reporting of patient experience data by protected groups. In partnership with Salford CCG, develop an umbrella policy to improve the support for patients from the transgender community to update their health records. Take action to ensure equality of outcomes in recruitment/selection and career development as outlined in the Workforce Race Equality Standard action plan, and prepare for the introduction of the Workforce Disability Equality Standard in continued next page 158 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

159 2 Accountability Report Develop improved analysis of the staff survey results, with a focus on bullying and harassment/ discrimination by protected groups, to identify high impact actions. Performance and monitoring of these targets will be undertaken by the Inclusion and Equality Group and key stakeholders through various engagement forums and the Equality Delivery System (EDS2). 2016/ /16 Age band Headcount % Headcount % % % , % 1, % , % 5, % 6074 Over % 0.04% % 0.00% TOTAL 7, % 6, % Ethnic group White British & Irish 6, % 5, % Asian % % White Other % % Black % % Any other Ethnic Group % % Mixed % % Not Specified % % Chinese % % TOTAL 7, % 6, % Gender Female 5, % 5, % Male 1, % 1, % TOTAL 7, % 6, % Disabled No 5, % 4, % Not Declared 1, % 1, % Yes % % TOTAL 7, % 6, % Directors Senior Managers (excluding hosted services) Other Employees Male ,699 Female ,830 TOTAL 1,724 5,849 Sickness absence It is our aim to reduce sickness to a target level of 3.6% by the end of 2017/18. During 2016/17 absence levels were 4.28% compared to the previous year s level of 4.25%. Within this figure, 1.77% related to short term absence whilst long term absence accounts for 2.51%. In total, almost 27% of our staff recorded no sickness absence. Staff sickness absence has remained broadly constant and whilst it has not increased in line with other organisations, we have not seen the envisioned reduction towards the 2017 target of 3.6%. One of the ways in which we have started to tackle this stubborn position, is the establishment of a Health and Wellbeing Steering Group to oversee implementation of Salford Royal s newly established Health and Wellbeing Strategy. As part of this strategy, the Trust is working towards Workforce Wellbeing Charter accreditation. Salford Royal now provides access to counselling, mental health advice and staff physiotherapy services as part of its Health and Wellbeing offering. Following extensive discussions with our trade union partners a policy to have all staff with a musculoskeletal issue are referred to the Occupational Health Physiotherapy Service. Staff are seen in Occupational Health and advice and adjustments to duties made. Staff have fast access to a number of other clinical services, along with healthy eating advice through dietetics. An external Employee Assistance Programme (EAP) was introduced in 2017, complementing the in house counselling service and providing a 24/7 support service. The EAP also provides out of hours support for traumatic incidents and will provide a trauma debriefing service where necessary. The EAP has provided a website for staff to access additional information on mental health, money, relationship issues and other topics. continued next page 159 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

160 2 Accountability Report Sickness is reviewed with managers on a regular basis and Salford Royal has a number of supportive policies to assist staff to return to work or remain in employment. We have introduced an electronic return to work form to capture the occurrence of return to work interviews. Such interviews are a key tool for managers to better understand absences and to enable them to work proactively with staff on ensuring appropriate health interventions are accessed. The Salford Royal values and Disciplinary Rules underpin our expectations for staff behaviour, whilst we are explicit on attendance in terms of established triggers for formal intervention due to absences. Staff sickness absence Days lost long term Days lost short term Total days lost Total staff years Average working days lost Total staff employed in period (headcount) Total staff employed In period with no absence (headcount) Percentage staff with no sick leave 2016/ / / /14 84,317 79,630 81,986 69,901 32,836 30,450 31,898 27, , , ,884 97,760 7,335 6,943 6,885 6, ,574 6,974 6,994 6,704 2, % 2, % 2, % 2, % 2016/ / / / /13 01 April 3.89% 4.27% 4.35% 3.83% 3.87% 02 May 3.85% 3.89% 3.94% 3.73% 3.89% 03 June 3.77% 3.85% 4.06% 3.85% 3.73% 04 July 3.84% 3.88% 4.22% 4.01% 3.98% 05 August 4.07% 4.13% 4.07% 3.68% 3.91% 06 September 4.14% 4.31% 4.26% 4.02% 3.92% 07 October 4.53% 4.38% 4.46% 4.16% 3.98% 08 November 4.52% 4.55% 4.83% 4.28% 4.24% 09 December 4.90% 4.59% 5.28% 4.31% 4.46% 10 January 5.01% 4.76% 4.98% 4.64% 4.50% 11 February 4.71% 4.39% 4.32% 4.26% 4.13% 12 March 4.03% 4.03% 4.53% 4.09% 3.96% Overall percentage 4.28% 4.25% 4.40% 4.07% 4.05% Systems are in place to allow for a timely and professional review of long term sickness leave from Salford Royal, with referral to the Occupational Health Service. Managers are expected to make reasonable adjustments for staff to facilitate an early return to duty from long term sickness or to enable an employee who has acquired a disability to continue in work. Salford Royal recognises its duty to provide care to patients in an effective and economic manner and, where there is no reasonable prospect of a return to work, it may be appropriate to retire or dismiss employees who remain absent from work on an extended basis. 160 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

161 2 Accountability Report Engaging with our people Salford Royal has policies on employing individuals with disabilities, long term conditions and those on ill health and disability redeployment, along with permanent adjustments in order to help maintain the employment of staff with disabilities or long term conditions. Salford Royal has a Single Equality Scheme and action plan and ensures that as a positive about disabled people employer those applicants with a disability who apply for a post with Salford Royal and meet the essential criteria are shortlisted. Through Salford Royal s annual Contribution Framework, there is consideration of any reasonable adjustments required in relation to the training and development opportunities for people with a disability or long term health condition. Salford Royal systematically provides employees with information on matters of concern to them as employees: Leaders are invited to attend the monthly Leaders Forum receiving a briefing on key issues and developments, messages and information are then cascaded outwards to their wider teams SiREN, Salford Royal s enewsletter is distributed to all staff on a weekly basis Regular and relevant information is posted for staff on Salford Royals intranet, including a Performance Section A Medical Senate has been established to communicate with Consultant colleagues Directors regularly spend time with colleagues on the frontline, providing the opportunity to find out more about the issues that matter most to our people In addition, Salford Royal has an agreed Organisational Change Policy with trade union colleagues which sets out a framework to consult and manage organisational change within Salford Royal. Formal consultations have taken place on a number of service changes in the past year including changes to catering services, the transfer of sexual health services to Bolton and the transfer of breast services to South Manchester. Salford Royal s formal consultation processes include managers meeting on a regular basis with trade union representatives. There are regular meetings of the Staff Partnership Forum, Joint Local Negotiating Committee and the Health and Safety Committee. The Leaders Conference brings together senior managers and clinical leaders from across the organisation to ensure the views of Trust staff are taken into account in the development of Salford Royal s strategic direction. Contribution framework Salford Royal s Contribution Framework ensures our people s goals and objectives are aligned to Salford Royal s Annual Plan, thus encouraging the involvement of all employees in Salford Royal s performance. Pay progression is linked to a successful Contribution Framework review. Under the Contribution Framework all members of staff are encouraged to have regular conversations with their manager, both in relation to how they are doing their job and what they are achieving. 161 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

162 2 Accountability Report Helping our people stay healthy and safe Salford Royal s Health and Safety Committee and Security Committee meet regularly to provide a forum for managers and trade unions to work together to promote health and safety and improve the working environment to aid a reduction in the number of serious incidents per year. The below table describes Health and Safety incidents reported during 2015/16. Category Manual Handling Violence and aggression Slip, trip and fall Struck by object Fall from height Exposure to harmful substance Total Countering fraud Total Salford Royal has an established AntiFraud Service provided by Mersey Internal Audit Agency (MIAA), with a nominated AntiFraud Specialist (AFS) who undertakes a variety of activities in accordance with the Standards for Providers for Fraud, Bribery and Corruption. Salford Royal is absolutely committed in embedding an anticrime culture throughout the organisation and this is supported in full by the Board of Directors and monitored on a regular basis by Salford Royal s Audit Committee. Salford Royal s commitment to protecting valuable public funds from the risks of fraud, bribery and corruption is unwavering and we continue to invest significantly in our efforts to proactively counter criminal activity A number of key tasks were undertaken this year to combat fraud, bribery and corruption in accordance with the Standards for Providers for Fraud, Bribery and Corruption: Inform and involve Salford Royal has agreed with the AFS a Communications Strategy and has an AntiFraud page on the Intranet which is used to publicise a variety of fraud related articles as well as other appropriate information appertaining to fraud, bribery and corruption. AntiFraud, Bribery and Corruption awareness presentations are delivered personally by the AFS at organised training events to raise awareness of fraud, bribery and corruption and includes interaction from attendees. This approach contributes towards creating and embedding an anticrime culture across the organisation. Anticrime awareness campaigns have been undertaken in partnership with Salford Royal s Human Resources (HR) Department, Information Governance, representation from Greater Manchester Police and Victim Support to raise awareness around criminal activities, raise the profile of the AFS, promote whistleblowing and inform people on the variety of safe and secure routes available to report all types of concerns. continued next page 162 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

163 2 Accountability Report Prevent and deter The AFS issues guidance and preventative material to Salford Royal and publicises outcomes of both local and national fraud investigations to inform staff of the consequences of committing fraud to deter people who may be tempted themselves. The AFS reviews a variety of policies and procedures to ensure these are robust, help to minimise the opportunities for crime to occur as well as contributing to maintaining an adequate procedures defence in respect of bribery offences. Salford Royal has participated in the National Fraud Initiative exercise aimed at crossreferencing a variety of data to identify fraudulent activities. The AFS has also conducted proactive exercises aimed at detecting potential or apparent fraud in relation to procurement and preemployment. The AFS has a follow up process in place to ensure that recommendations are actioned as per the management responses received in respect of proactive and investigation reports. Hold to account The AFS ensures that all reports of suspected fraud, bribery and corruption are recorded on the Fraud Information Reporting System Toolkit (FIRST), investigated and redress sought when appropriate so that money misappropriated through fraud and/or error can be recovered and put back into patient care. A key part of Salford Royal s vision and values is accountability and that is why we assure you that we will do everything in our power to protect the public funds with which we have been entrusted. Staff survey Salford Royal s approach to staff engagement is described throughout the Annual Report. Specific mechanisms are in place to monitor and learn from staff feedback which includes participation in the national NHS Staff Survey. The 2016 staff survey was undertaken between October and December 2016 with the results being published by NHS England on 7 March Salford Royal used the mixed mode method providing most staff with the opportunity to complete the survey online with paper surveys provided where access to s was limited. The survey was sent to all staff and 3,722 staff completed, a response rate of 52% which is an improvement on 44% in From the 2015 national staff survey onwards, the comparator group for Salford Royal was changed from Acute Trusts to Combined Acute and Community Trusts, reflecting the integrated nature of Salford Royal. The staff engagement score reported for Salford Royal was within the average band for those comparator Trusts, with performance across Salford Royal being relatively uniform. Whilst a top 10% comparator is not given for this group of organisations, it is accepted that the engagement levels reported remain lower than desired by Salford Royal s own very high standards, with the overall engagement score remaining static from 2015 at 3.80 out of 5, which was a reduction from our score in The Board of Directors acknowledge the continued impact of the Better Care at Lower Cost programme on the staff engagement score, coupled with unprecedented operational demand and national staff shortages. A series of formal and informal communication and engagement activities were implemented in 2016/17 with respect to Salford Royal s transformational vision and opportunities this brings for the organisation and its people. continued next page 163 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

164 2 Accountability Report Trust 2015/ /17 National average (medical) Trust National average (medical) Trust improvement / deterioration Response Rate 44% 41% 52% 44% +8% Top ranking scores KF23 % experiencing physical violence from staff in last 12 months KF18 % attending work in last 3 mths despite feeling unwell because they felt pressure from their manager, colleagues or themselves KF15 % satisfied with the opportunities for flexible working patterns KF6 % reporting good communication between senior management and staff KF1 Staff recommendation of the organisation as a place to work or receive treatment Bottom ranking scores KF3 % of staff agreeing that their role makes a difference to patients / service users KF2 Staff satisfaction with the quality of work and care they are able to deliver KF17 % of staff feeling unwell due to work related stress in the last 12 months KF9 Effective team working KF12 Quality of appraisals 2015/ /17 Trust National Trust average 2% 55% 51% 26% % 58% 50% 30% % 53% 54% 34% 3.79 National average 2% 55% 51% 32% / /17 Trust National Trust average 93% % % % % % National average 91% % Trust improvement / deterioration +1% +2% +3% +8% 0.09 Trust improvement / deterioration 5% % In response to the 2016 National Staff Survey, Divisional and Trustwide action plans are in development and actions will be diligently monitored throughout 2017/18. Salford Royal also undertakes an extended quarterly Family and Friends survey to reduce reliance on the National Staff Survey and monitor staff satisfaction across the course of the year. The National Staff Family and Friends Test will continue to be utilised to seek views on key issues of involvement, engagement and communication. Expenditure on consultancy Expenditure on consultancy during 2016/17 was 2.89m. This related to further developments to our electronic patient record and global digital excellence exemplar programme and costs to support transformation of health and social care through our integrated care organisation. Consultancy costs incurred by Salford Royal s hosted services were 2.77m. Offpayroll engagements Salford Royal limits the use of offpayroll arrangements for highly paid staff. Executive Director approval is required. In all cases, except where the appointment of medical staff is to be made on a locum basis, in these circumstances approval is required from the relevant Divisional Managing Director or Divisional Chairman. For all offpayroll engagements as of 31 March 2017, for more than 220 per day and that last for longer than six months No. of existing engagements as of 31 March Of which: No. that have existed for less than one year at time of reporting 29 No. that have existed for between one and two years at time 4 of reporting No. that have existed for between two and three years at time 1 of reporting No. that have existed for between three and four years at time 0 of reporting No. that have existed for four or more years at time of reporting Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

165 2 Accountability Report All new offpayroll engagements, or those that reached six months in duration, between 1 April 2016 and 31 March 2017, for more than 220 per day and that last for longer than six months. No. of new engagements, or those that reached six months in duration, between 1 April 2016 and 31 March 2017 No. of the above which include contractual clauses giving Salford Royal the right to request assurance in relation to income tax and national insurance obligations No. for whom assurance has been requested Of which: No. for whom assurance has been received No. for whom assurance has not been received No. that have been terminated as a result of assurance not being received. Offpayroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2016 and 31 March No. of offpayroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year No. of individuals that have been deemed board members and/or senior officials with significant financial responsibility during the financial year. This figure must include both offpayroll and onpayroll engagements. In any cases where individuals are included within the first row of this table the trust should 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 Exit packages During 2016/17, Salford Royal did not agree any exit packages. Voluntary redundancies including early retirement contractual costs Mutually agreed resignations (MARS) contractual costs Early retirements in the efficiency of the service contractual costs Contractual payments in lieu of notice Exit payments following Employment Tribunals or court orders Noncontractual payments requiring HMT approval Total Of which: Noncontractual payments requiring HMT approval made to individuals where the payment value was more than 12 months of their annual salary Payments agreed number /17 Total value of agreements 1 Payments agreed number /16 Total value of agreements These tables have been audited. 165 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

166 2 Accountability Report Compliance with NHS Foundation Trust Code of Governance Salford Royal 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 During 2016/17 the Board of Directors had established governance policies and processes that reflected the principles of the NHS Foundation Trust Code of Governance, these included: Service Development Strategy and Operational Plan Corporate Governance Framework Manual incorporating the Standing Orders of the Board of Directors, Standing Orders of the Council of Governors, Scheme of Reservation and Delegation of Powers, and Standing Financial Instructions Established role of Senior Independent Director Regular private meeting between the Chairman and the NonExecutive Directors Robust performance appraisal process for all NonExecutive Directors, including the Chairman, developed and approved by the Council of Governors Formal induction programme for Non Executive and Executive Directors Attendance records for Directors and Governors at key meetings Comprehensive Induction Programme and continuing Training and Development Programme for Governors Publicly available Register of Interests for Directors, Governors and Senior Staff Council of Governors Policy for Raising Serious Concerns and Resolving Disagreements between the Council of Governors and Board of Directors Established roles of Lead and DeputyLead Governor Monthly private meeting between the Chairman and Governors to review matters reviewed at the Board of Directors meetings Comprehensive Integrated Performance Dashboard and assurance reports developed by the Council of Governors and provided to all meetings of the Council of Governors Effective Council of Governors subcommittee structure Council of Governors Agendasetting process involving Chairman, Lead and Deputy Lead Governor, ViceChairman and Senior Independent Director Collective regular performance evaluation mechanism for the Council of Governors Membership and Public Engagement Strategy, Implementation Plan and Key Performance Indicators; Nominations, Remuneration and Terms of Service Committee of the Board of Directors; Nominations, Remuneration and Terms of Office Committee of the Council of Governors; Agreed recruitment process for NonExecutive Directors High quality reports to the Board of Directors and Council of Governors Board evaluation and development plan continued next page 166 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

167 2 Accountability Report Selfassessment against the WellLed Framework for Governance and cyclical triennial governance review programme, including independent Well Led Governance Review in 2016/17 Council of Governors presentation of performance and achievement at Annual Members Meeting Annual Fit and Proper Persons Declarations and Checks Proforma to ensure compliance with Fit and Proper Persons Requirement for Directors Code of Conduct for Boardlevel Directors Annual review of NonExecutive Directors independence Code of Conduct for Council of Governors Going Concern Report Robust Audit Committee arrangements Governorled appointment process for External Auditor Whistleblowing Policy and Counter Fraud Policy and Plan The Board of Directors conducts an annual review of the Code of Governance to monitor compliance and identify areas for further development. The Board of Directors has confirmed that, with the exception of the following provisions Salford Royal complies with the provisions of the NHS Foundation Trust Code of Governance issued by NHS Improvement (formerly Monitor) and updated in July 2014 Salford Royal departed from the following provisions of the Code during 2016/17: B.1.2 At least half the BoD, excluding chairperson, should comprise independent NEDs In 2014/15 the Board approved the establishment of an additional Executive Director, and in doing so confirmed that creating additional Executive Director capacity, which would enable Salford Royal to explore and actively pursue opportunities for Salford Royal s growth and development, was an appropriate development for the composition of the Board of Directors. At the time, the Board confirmed that this was constitutionally permissible in that: beyond the statutory positions (CEO, Finance, Nurse and Medical Practitioner) Salford Royal s Board of Directors can comprise of up to three other Executive Directors; and that the number of Executive Directors will not exceed the number of established NonExecutive Directors. The Board recognised, however, that this presented a departure from B.1.2, and with this in mind, and wishing to take account of best practice within the Code of Governance, the Board considered the creation of additional NonExecutive Director capacity, noting this would require amendment to Salford Royal s Constitution. The size of the Board was taken into account, in particular to ensure and prevent unwieldiness. It was agreed that this development would not be pursued and the size of the Board would stand at 7 Executive Directors and 7 Non Executive Directors, including the Chairman. The Board is aware that the reasons for deviation from a particular provision should be explained, with an aim to illustrate how its actual practices are consistent with the principle to which the provision relates, in this case the principle is: B.1.A) The board of directors and its committees should have the appropriate balance of skills, experience, independence and knowledge of the NHS Foundation Trust to enable them to discharge their respective duties and responsibilities effectively. continued next page 167 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

168 2 Accountability Report With all NonExecutive Directors, including the Chairman determined as independent, following annual review, the Board believes appropriate balance of independence is sustained with a Board composition, comprising 7 Executive Directors and 7 NonExecutive Directors including the Chairman. Voting by the Board of Directors would consist of: 1 vote from each of the Executive Director = 7 1 vote from each of the NonExecutive Directors, including the Chairman = 7 votes; and 1 casting vote from the Chairman if required. NHS Improvement (NHSI) have verified that the right behaviours and approach are in place, confirmed that there are no governance concerns in relation to these matters and that the arrangements described are acceptable. Further review of the Board s balance of skills, experience, completeness and appropriateness to the requirements of Salford Royal was undertaken in February The review concluded that a new position, Executive Director of Performance and Improvement, should be established as a formal member of the Board of Directors. In light of this, the Board recognised that revisions to the composition of the Board of Directors, and in particular the Executive Directors, would be required to ensure compliance with Salford Royal s Constitution. It was agreed that from the commencement of the new Executive Director of Performance and Improvement, the Executive members of the Board of Directors should be: Chief Executive Executive Nurse/Deputy Chief Executive Executive Medical Director Executive Director of Finance Executive Director of Service Strategy and Development Executive Director of Corporate Strategy and Business Development Executive Director of Performance and Improvement. In December 2016, following a robust search and recruitment process, Mr James Sumner commenced as the Executive Director of Performance and Improvement. At this time, the Executive Director of Organisational Development and Corporate Affairs, assumed the position of Director of Organisational Development and Corporate Affairs and became an advisory nonvoting member of the Board. During November 2016, the Board of Directors at Salford Royal and the Trust Board at Pennine Acute Hospitals NHS Trust approved a plan to establish a Group Committees in Common (Group CiC). The Group CiC would comprise the Chairman and six NonExecutive Directors along with a number of Executive leadership roles spanning both Trusts Chief Executive, Chief Medical Officer, Chief Nursing Officer, Chief Financial Officer, Chief Strategy and Organisational Development Officer and Chief Delivery Officer. continued next page 168 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

169 2 Accountability Report As the membership of the Group CiC must be common to both the Salford Royal Board of Directors and the Group Committees in Common (CiC) (under paragraph 15 of Schedule 7 of the National Health Service Act 2006), in January 2017, the Board concluded that that a new Executive Director position; Executive Director of Group Delivery should be established from 1 April From 1 April 2017 the Executive Director of Service Strategy and Development and the Executive Director of Performance and Improvement became advisory, nonvoting members of the Salford Royal Board of Directors. B.7.1 In exceptional circumstances, NEDs may serve longer than six years (two threeyear terms following authorisation of the FT) but subject to annual reappointment. The Chairman was reappointed by the Council of Governors in December His term of office was set to expire at the end of the Annual Members Meeting 2017, at which point he will have served 11 years as NonExecutive Director/ Chairman. The Council of Governors decision in this regard was based on the Chairman s outstanding contribution and performance, and as the Board of Directors had seen refresh of both Executive and NonExecutive Directors over recent years, the reappointment of the Chairman beyond one year would provide stability during a significantly challenging period. Subsequently, the tenure of the Chairman was extended until 30 June 2018 (extending current term of office to three years) by the Council of Governors in March The Council of Governors recognised the exceptional circumstances and importance of stability during Group transitional arrangements, and acknowledged the significant experience and expertise of the Chairman. Two NonExecutive Directors were reappointed beyond 6 years during 2014/15 for a period of 1 year and 2 years respectively. The reappointment for a 2 year term of office was made in order to stagger future reappointments. Two NonExecutive Directors were reappointed beyond 6 years during 2015/16, however, this was for a period of 1 year only, this included the NED reappointed for a 1 year period in 2014/15. Two NonExecutive Directors were again reappointed during 2016/17 for a 1 year period. In March 2017, the Council of Governors extended the tenure of the two NonExecutive Directors, described above, until 31 March 2019 (extending their current term of office to two years and three months). At 31 March 2019, one of the above NonExecutive Directors will have served eleven years and three months and the other, ten years and three months. Again, governors recognised the exceptional circumstances and the importance of stability during Group transitional arrangements, and the significant experience and expertise of these particular NonExecutive Directors. 169 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

170 2 Accountability Report Governance and organisational arrangements The basic governance structure of all NHS Foundation Trusts includes: Public and staff membership A Council of Governors A Board of Directors. This structure is well developed at Salford Royal, and is set out in Salford Royal s Constitution that is published at and in the in the NHS Foundation Trust directory on Monitor s website: government/publications/nhsfoundationtrustdirectory. Detailed information regarding Salford Royal s membership can be found in the Performance Report. Council of Governors Governors are the direct representatives of staff, stakeholders, members and public interests and form an integral part of the governance structures that exists in all NHS Foundation Trusts. The overriding role of the Council of Governors is to appoint and hold the NonExecutive Directors individually and collectively to account for the performance of the Board of Directors. Additionally the Council of Governors is to represent the interests of NHS Foundation Trusts members and of the public. Other statutory aspects of the Council of Governors role include: Approving the appointment of the Chief Executive Appointing and removing the Chairman and other NonExecutive Directors Deciding the remuneration of the Chairman and NonExecutive Directors Appointing and removing the NHS Foundation Trusts Auditors. The Council of Governors appointed Grant Thornton as the Trusts External Auditor in December 2016 for a period of three years Contributing to the forward plans of the organisation Receiving the NHS Foundation Trust s Annual Accounts, Auditors Report and Annual Report Reviewing the Foundation Trust Membership and Public Engagement Strategy When appropriate, making recommendations and/or approving revisions of the Foundation Trust Constitution. Salford Royal s Governors listen to the views of patients, public, members, staff and partner organisations, particularly in relation to the strategic direction of Salford Royal. Salford Royal s Council of Governors comprises of 21 Governors: Eight governors each represent the neighbourhood wards of Salford Four governors represent people living outside of Salford Five governors represent staff Four governors are appointed and represent the views from partner organisation. 170 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

171 2 Accountability Report The following table provides detail of Salford Royal s Council of Governors throughout 2016/17. The composition of the Council of Governors from 1 April 2016 to 31 March Consituency / Name organisation Public elected governors Claremont, Weaste & Seedley Mr James Collins Mrs AnnMarie Pickup Mrs Michelle Watson Mr David Pike (Lead Governor) Dr Albert Rooms Dr Martin Seely 1 Ms Karen Morris 2 East Salford Eccles Irlam & Cadishead Swinton Worsley & Boothstown Ordsall & Langworthy Term of office (end of the annual members meeting) 3 years (2019) 3 years (2019) 3 years (2019) 3 years (2017) 3 years (2017) 3 years (2017) 3 years (2019) Mr Peter Halliwell 3 Ordsall & Langworthy 3 years (2016) Mr Steven North Little Hulton & Walkden 3 years (2017) Mrs Sandra Breen Out of Salford 3 years (2019) Mrs Janet Booth Out of Salford 3 years (2017) Dr Angela Railton Out of Salford 3 years (2017) Mr David Trenbath Out of Salford 3 years (2019) Staff elected governors Mr David Hill Clinical Support & Tertiary Services 3 years (2017) Mrs Nicola Kent Corporate & General Services 3 years (2019) Mrs Agnes LeopoldJames Salford Healthcare 3 years (2019) Mrs Joanne Hubert Surgery 3 years (2017) Dr Sheila Tose Neurosciences & Renal 3 years (2017) Appointed governors Councillor Ronnie Wilson 4 Salford City Council 3 years (2016) Cllr Gina Reynolds 5 Salford City Council 3 years (2016) Cllr Paul Longshaw Salford City Council 3 years (2019) Dr Jackie Leigh 6 University of Salford 3 years (2016) Dr Brian Boag University of Salford 3 years (2019) Professor Nick Grey University of Manchester 3 years (2019) Dr Deji Adeyeye General Medical Practitioner 3 years (2019) 1 Dr Martin Seely resigned February Ms Karen Morris resigned February Mr Peter Halliwell stood down in October Cllr Ronnie Wilson stood down in June Cllr Gina Reynolds stood down in October Dr Jackie Leigh stood down in July 2016 The following table summarises Governor attendance at Council of Governor meetings. Name Title Attendance Public elected governors Mr James Collins Claremont, Weaste and Seedley 4/4 East Salford 4/4 Eccles 4/4 Irlam & Cadishead 4/4 Mrs AnneMarie Pickup Mrs Michelle Watson Mr David Pike (Lead Governor) Dr Albert Rooms Dr Martin Seely Ms Karen Morris Mr Peter Halliwell Mr Steven North Mrs Sandra Breen Mrs Janet Booth Swinton Worsley and Boothstown Ordsall & Langworthy Ordsall & Langworthy Little Hulton & Walkden Out of Salford Out of Salford 4/4 2/3 1/1 2/2 2/2 4/4 4/4 Dr Angela Railton Out of Salford 4/4 Mr David Trenbath Out of Salford 4/4 Staff elected governors Mr David Hill Clinical Support & Tertiary Medicine 2/4 Mrs Nicola Kent Corporate & General Services 3/4 Mrs Agnes Leopold Salford Healthcare James 4/4 Mrs Joanne Hubert Surgery 3/4 Dr Sheila Tose Neurosciences & Renal 3/4 Staff elected governors Cllr Ronnie Wilson Salford City Council 2/2 Cllr Gina Reynolds Salford City Council 0/0 Cllr Paul Longshaw Salford City Council 1/1 Dr Jackie Leigh University of Salford 2/2 Dr Brian Boag University of Salford 1/2 Dr Nick Grey University of Salford 1/4 Dr Deli Adeyeye General Medical Practitioner 4/4 Mr David Pike was nominated as Lead Governor at the Council of Governors meeting in June 2016 for a period of two years, ending in June Mr David Trenbath was nominated as Deputy Lead Governor at the Council of Governors meeting in June 2015 for a period of two years ending in June At the Council of Governors meeting in March 2017 the appointment process for appointing the Deputy Lead Governor was approved. 171 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

172 2 Accountability Report Council of Governors register of interests All governors are required to comply with the Council of Governor s Code of Conduct and declare any interests that may result in a potential conflict of interest in their role as governor of Salford Royal. The Register of Interests is publicly available via the Council of Governors Meeting Minutes on Salford Royal s website. In addition, the register can be obtained via Salford Royal s Trust Secretary at the following address: Trust Headquarters Salford Royal NHS Foundation Trust Stott Lane Salford M6 8HD Tel: jane.burns@srft.nhs.uk Engagement Subgroup The Engagement Subgroup is responsible for monitoring the progress of Salford Royal s Membership and Public Engagement Strategy. It does this by developing an Annual Membership and Engagement Plan with key performance indicators each year. This includes ensuring the Foundation Trust s membership is representative of the local population of Salford and ensuring members and the public have opportunities to share their experiences. During 2016/17, the Engagement Subgroup supported the design of the Annual Membership Survey 2016; suggested and developed ideas for recruiting more members and scrutinised Salford Royal s communications strategy, driving the greater use of social media to engage with members. Council of Governors Subgroups The Council of Governors have established a Nominations, Remuneration and Term of Office (NRTO) Committee that meets to discuss the formal aspects of the NonExecutive Directors role, this includes pay, period of employment and their annual performance evaluation. Membership comprises two elected and one appointed governor, as well as the Chairman and advisory Trust Officers. More information on the work of the committee is described within the Remuneration Report. The Council of Governors has also established three subgroups covering Engagement, Quality and Strategic Direction. These subgroups support governors to carry out both their statutory and nonstatutory duties, as well as receiving information on key programmes of work. Quality Subgroup The Council of Governor s Patient and Public Experience Register is used to record all experiences and comments gathered from and by governors. This includes feedback received from family and friends and feedback gathered from patient forums and surveys, including Patient Opinion and NHS Choices websites, as well as our own social media channels. The Quality Subgroup is responsible for reviewing these experiences and identifying any themes for improvement. This is followed by seeking assurance from the relevant Service Lead that appropriate action is being taken to address these matters, ensuring the public are heard and acted upon. As an example of this work governors recognised that A&E performance was below the 95% standard and had received feedback that some patients were waiting over four hours to be seen in A&E. continued next page 172 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

173 2 Accountability Report Governors requested, and received a detailed presentation from the Executive Director of Performance and Improvement including analysis of the challenges in A&E, issues driving this, and actions the Trust was taking to alleviate pressures and improve patient flow in both the short and long term. These include making as best use of the space on wards as possible, having GPs based in A&E and working with partners in Trafford to make sure that patients are discharged to back to community setting as soon as possible. This is an example of how governors seek assurance on issues they hear about from members of the public. Governors also received information on: Actions to improve car parking and travel congestion on the main hospital site Actions from the PatientLed Assessment of the Care Environment 2016 Improving access to the Patient Advice and Liaison Service The effectiveness of the Complaints Review Panel Strategic Direction Subgroup The Strategic Direction Subgroup is responsible for making sure the views of members and the public are considered in Salford Royal s plans for the year ahead, as well receiving assurance on key strategic programmes. Each year the Subgroup reviews the development of Salford Royal s Annual Plan, and following approval, selects three priority areas to receive information and further assurance. During 2016/17 governors selected the Integrated Care Organisation, the development of a healthcare Group and Greater Manchester Devolution, receiving comprehensive progress updates describing staff engagement, proposed timelines and operational detail. In line with the Trust developing and making preparation for Group arrangements, the Council of Governors, at its general meeting on 1 December 2016, agreed to consider the future structure of a Group membership and transitional arrangements to enable the subsequent establishment of a Group Council of Governors; and ensure Salford Royal s Council of Governors continued to function as a central component of the developing Group governance structure. The Strategic Direction Subgroup (open to all Governors) was determined as the forum through which a recommendation would be developed for presentation to the Council of Governors. The Strategic Direction Subgroup met in December 2016 and considered the context and transitional Group arrangements being put in place by the Salford Royal and Pennine Acute Hospitals NHS Trust Boards; and initial discussion took place regarding the future composition of a Group Council of Governors and a Shadow Group Council of Governors as a transitional arrangement. The Strategic Direction Subgroup met again in January 2017, and as part of an externally facilitated meeting, developed a proposal that was presented to the Council of Governors. In March 2017, the Council of Governors approved bold changes to its own composition; and agreed to establish a subcommittee of the Salford Royal Council of Governors, to be known as the Shadow Group Council of Governors Committee. This committee would comprise of all Salford Royal Governors and newly elected Shadow Governors from the Pennine constituencies. These changes reflect the legal reality that Salford Royal will continue to be a NHS Foundation Trust with its statutory Council of Governors, who will continue to have their own specific duties and responsibilities as set out in the NHS Act. continued next page 173 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

174 2 Accountability Report Salford Royal s Council of Governors will be made up of: In March 2017, the Council of Governors approved changes to the Salford Royal NHS Foundation Trust Constitution to reflect the aforementioned changes to the composition of the Council of Governors. The Constitution includes a transition schedule that allows elections to take place during the summer of 2017 and the Shadow Council of Governors to effective from the date of the Annual Members meeting in In addition, the Constitution was amended to: Allow membership to any individual who is fourteen years of age or older, in line with PAHT s membership criteria Public Governors: 5 x Salford 2 x Rest of England and Wales Staff Governors: 1 x Salford Health and Social Care 1 x Clinical Support Service and Tertiary Medicine 1 x Surgery and Neurosciences 1 x Corporate and General Services Appointed Governors: 1 x University of Manchester 1 x Salford City Council The Shadow Group Council of Governors Committee will include all of the Salford Royal Governors along with: Shadow Public Governors: 5 x Bury and Rochdale 3 x Oldham 2 x North Manchester Shadow Staff Governors 2 x Bury and Rochdale 2 x North Manchester 2 x Royal Oldham Shadow Appointed Governors: 2 x Local Authority (from Manchester, Bury, Rochdale and Oldham local authorities) 1 x University of Salford Align disqualification from membership with the Foundation Trust s Violence and Aggression policy Include Model Election Rules 2014, permitting Trusts to use electronic voting methods for the purposes of their Council of Governors elections Revise quorum of the Council of Governor to eight Governors (i.e. approximately two thirds of the Council) Extend the timeline for calling an election, if there is no next highest polling candidate for that seat, from three to six months Revise the quorum of the Board of Directors to five Directors (from four) 174 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

175 2 Accountability Report Training and development for Governors During 2016/17 Salford Royal provided Governors with access to a range of training and development opportunities to further support them in their role. Governors are given access to externally provided training and development sessions, in addition to joint training with other NHS Foundation Trusts and bespoke training inhouse. A full list of training and development opportunities provided is below. Event Understanding Mortality: Insight for Governors (MIAA) Recruitment Training for NRTO Committee Governor Induction (NHS Providers) Governor induction (Local) Significant Transactions: Insight for Governors (MIAA) Understanding Patient Experience and Quality Improvement Measures NHS Providers: Membership and Public Engagement Date May 2016 June 2016 October 2016 October 2016 November 2016 January 2017 January 2017 Communicating with Governors There are a number of easy ways for members and the public to communicate with the Council of Governors. foundation@srft.nhs.uk Tel: Website: councilofgovernors/contactyourgovernor Write to your Governor at: Membership Department Group Headquarters Salford Royal NHS Foundation Trust Stott Lane Salford M6 8HD The Board of Directors relationship with the Council of Governors and members The Board of Directors and Council of Governors work together closely throughout the year and, in their respective roles, seek to avoid unconstructive adversarial interaction. To this effect the Board of Directors and Council of Governors have established a clear policy detailing how disagreements between the Council of Governors and Board of Directors will be resolved. The types of decisions taken by each are set out within Salford Royal s schemes of reservation and delegation of powers which form part of the Corporate Governance Framework Manual, available on Salford Royal s website Salford Royal s Chairman is also the Chairman of the Council of Governors. During the year, the Chairman, Senior Independent Director and Trust Secretary work closely with the Lead Governor to review all relevant issues and prior to each Council of Governors meeting, they also meet with the Vice Chairman and Deputy Lead Governor to produce the agenda for the upcoming Council of Governors meeting. The Executive and Non Executive Directors attend meetings of the Council of Governors as observers and take part when further information is required. In addition to Council of Governors meetings, Governors have the opportunity to meet with the Board of Directors twice a year. In June 2016, Council of Governors met with the Board of Directors to discuss key objectives, priorities and risks from Salford Royal s Annual Plan for 2016/17. In November 2016 the Council of Governors and Board of Directors came together to review progress against those priorities. Governors and Board members interact at the Council of Governors Subgroups where relevant NonExecutives, Executives and their deputies attend. 175 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

176 2 Accountability Report The following table summarises Board of Director s attendance at Council of Governors meetings: Name Title Attendance Mr Jim Potter Sir David Dalton Chairman Chief Executive 4/4 0/4 Mrs Elaine Inglesby Burke CBE Deputy Chief Executive/Executive Nurse Director 2/4 Mr Chris Brookes Executive Medical Director 2/4 Mr Ian Moston Executive Director of Finance 4/4 Mr Raj Jain Executive Director of Corporate Strategy and Business Development 1/4 Mrs Stephanie Gibson Interim Director of Performance and Improvement 3/3 Mrs Diane Morrison Salford Director of Finance 1/4 Mr Peter Murphy Salford Director of Nursing 3/4 Mr Paul Renshaw Director of Organisational 4/4 Development and Corporate Affairs Mr Jack Sharp Executive Director of Service Strategy and Development 4/4 Mr James Sumner Executive Director of Performance and Improvement 1/1 Mr Peter Turkington Salford Medical Director 0/4 Mrs Diane Brown Senior Independent Director 4/4 Dr Joanna Bibby NonExecutive Director 2/4 Mrs Rowena Burns NonExecutive Director 0/4 Dr Chris Reilly NonExecutive Director 2/4 Dr Hamish Stedman NonExecutive Director 2/3 Mrs Anne Williams CBE NonExecutive Director 0/1 Mr John Willis CBE Vice Chairman / 3/4 Chairman of the Audit Committee In addition to the Council of Governor s meetings and Subgroups, Salford Royal s governors are also encouraged to attend the public Board of Director meetings to gain a broader understanding of the reviews taking place at Board level and observation of the decision making processes and challenge from NonExecutive Directors. The Chairman regularly provides full feedback for all Governors from Board meetings with detailed description of items and decisions made in both public and private sections of the Board meetings. Within this forum the Chairman interacts with Governors and responds to any questions or concerns they may have. 176 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

177 2 Accountability Report Board of Directors The Board of Directors operates according to the highest corporate governance standards. It is a unitary Board with collective responsibility for all aspects of the performance of Salford Royal, including financial performance, clinical and service quality, management and governance. The Board of Directors is legally accountable for the services provided by Salford Royal and key responsibilities include: Setting the strategic direction (having taken into account the Council of Governors views) Ensuring that adequate systems and processes are maintained to deliver Salford Royal s Annual Plan Ensuring that services provide safe, clean, personal care for patients Ensuring robust governance arrangements are in place supported by an effective assurance framework that supports sound systems of internal control Ensuring rigorous performance management which ensures that Salford Royal continues to achieve all local and national targets Seeking continuous improvement and innovation Measuring and monitoring Salford Royal s effectiveness and efficiency Ensuring that Salford Royal, at all times, is compliant with its Licence, as issued by the sector regulator NHS Improvement (formerly Monitor) Exercising the powers of Salford Royal established under statute, as described within Salford Royal s Constitution available at The Board of Directors is also responsible for establishing the values and standards of conduct for Salford Royal and its staff in accordance with NHS values and accepted standards of behaviour in public life including selflessness, integrity, objectivity, accountability, openness, honesty and leadership (The Nolan Principles). This is clearly set out within the Corporate Governance Framework Manual, publicly available on the website. The Board of Directors has resolved that certain powers and decisions may only be exercised or made by the Board in formal session. These powers and decisions, and those of Salford Royal s Council of Governors, are set out in the Reservation of Powers to the Board and Scheme of Delegation within Salford Royal s Corporate Governance Framework Manual. The Board of Directors met in formal session on ten occasions during 2016/17. Each session was held in public apart from where the Board resolved to meet in private session due to the confidential nature of business. The Board of Directors is of sufficient size and the balance of skills and experience is appropriate for the requirements of the business and the future direction of Salford Royal. Arrangements are in place to enable appropriate review of the Board s balance, completeness and appropriateness to the requirements of Salford Royal. All Executive and NonExecutive Directors undergo annual performance evaluation and appraisal. The outcomes of the Executive Director appraisals are provided to NonExecutive Directors at a meeting of the Nominations, Remuneration and Terms of Service Committee. The outcomes of NonExecutive Director appraisals are provided to the Council of Governors Nominations, Remuneration and Terms of Office Committee in detail, and in summary to the general meeting of the Council of Governors In addition to this independent review, Board performance is evaluated further through focussed discussions at Board Away Days, strategic meetings and ongoing, inyear review of the Board Assurance Framework. The performance of the committees of the Board is evaluated and reported annually to Board of Directors. 177 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

178 2 Accountability Report The Board s Profile NonExecutive Directors Mr Jim Potter Chairman Jim Potter was born and raised in the Greater Manchester area, educated at Ambrose Barlow School and subsequently Salford Technical College and Moston College of Further Education. He has spent most of his working life in electrical engineering, initially as an engineer then later moving into management, relocating to the West Midlands in 1969 and then to the Middle East in 1980 where he lived and worked until Jim moved back to the UK in 1988 to join a packaging company based on Salford Quays working as Export Sales Director and in 1990 he was made Managing Director, the position he held until July From the 1 April 2016, Jim was also the Chairman of the Pennine Acute Hospitals NHS Trust. Dr Joanna Bibby NonExecutive Director Jo has worked in healthcare at national and local level for the past 17 years, with a focus on quality improvement and performance. Jo has a PhD in Medical Biophysics. Jo joined the Health Foundation in November 2007 and is responsible for providing direction and leadership to ensure the organisation maximises its impact on improving quality across the UK. Before joining the Health Foundation, Jo was most recently the Director for the Calderdale and Kirklees Integrated Service Strategy where she led a major service reconfiguration programme to deliver improvements in quality, safety and patient experience. Jo s career has included 10 years at the Department of Health working in public spending, workforce planning and health technology assessment. As Head of NHS Performance, she oversaw the implementation of the policy agenda set out in the NHS Plan. At the NHS Modernisation Agency, Jo led an international quality improvement initiative Pursuing Perfection and at the NHS Institute for Innovation and Improvement she worked in an associate role to develop models to support mass participation in quality improvement. Jo stood down as a NonExecutive Director on 31 March Mrs Diane Brown Senior Independent Director Diane has over 30 years experience as HR Director, Talent Director and Global Business Partner. She has worked with Senior Global Leaders in FTSE 100 companies such as AstraZeneca Pharmaceuticals, M&S Money and Marks & Spencer PLC. Diane has developed a commercial understanding of both business and peoplerelated issues as a key member of executive teams working across the UK, Europe and North America. She has played a significant role in introducing Talent and Performance Management frameworks across continents as well as driving transformational change and continuous improvement. Diane is a Fellow of the Chartered Institute of Personnel and Development. She mentors leaders in the arts, NHS and small businesses. Diane is the Board of Directors Senior Independent Director, as appointed by the Board in conjunction with the Council of Governors and Chairman of the Complaints Review Panel. From 1 October 2016, Diane was also appointed as a NonExecutive Director of Pennine Acute Hospitals NHS Trust. 178 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

179 2 Accountability Report NonExecutive Directors continued Mrs Rowena Burns NonExecutive Director Rowena took up the role of Chief Executive at Manchester Science Parks in summer 2012, and remains a Non Executive Director at Bruntwood, and Chairman of Cityco. Educated at the University of Wales and at University College London, and having trained in nursing, Rowena s early career was spent with the Greater Manchester Passenger Transport Authority and Manchester City Council, working in a variety of transport and economic development roles, including the first phase of Manchester s Metrolink light rail system. Over 10 years she moved through a number of roles within the Manchester Airport Group, including latterly that of Group Commercial Director, where her brief included airport acquisitions, economic regulation and overall business strategy, as well as responsibility for revenue generation. Rowena returned to the city in March 2008, as Chief Operating Officer in commercial property company Bruntwood, a role which takes her into every part of the business, with a strong focus on service improvement and organisational development. She took up the reins at Manchester Science Park after Bruntwood acquired a 51% stake in the company earlier this year. She describes the role as perfect, a public/private sector partnership focused on driving growth and opportunity in the most vibrant and innovative sectors of the economy. Rowena s professional feet are very firmly planted in city life, where she is active on several boards and initiatives, including the role of Chairman of CityCo, Manchester city centre management organisation. Away from work, she has a passion for all things rural, and is rarely found indoors other than round a dining table with family or friends. Mrs Chris Mayer CBE NonExecutive Director (from 1 April 2017) Chris was Chief Executive of her Majesty s Courts Service, accountable for the day to day operation of 550 Court Centres across England and Wales until She is a consultant in leadership and executive coaching and is an associate with Fiona MacNeill Associates. She has also begun working with the Slynn Foundation whose aim is to provide links between the English Legal System and the legal systems in Central and Eastern Europe. She has been a NonExecutive Director and Vice Chairman of Pennine Acute Hospital NHS Trust since 2011 and represents the Trust on panmanchester committees and through this has established connections and involvement in Greater Manchester developments. Chris is a Trustee of The Royal Armouries. Dr Chris Reilly NonExecutive Director Chris is a scientist and business leader with over 30 years experience in medical research, life science consultancy and venture capital in the UK, USA and Sweden. He began his career as a research scientist and retired in 2011 as Global Vice President, Discovery Strategy, Performance and Project Evaluation at AstraZeneca, a large international pharmaceutical company. In this role, Chris was responsible for developing AstraZeneca s research strategy, business plan and performance improvement activities. He has considerable experience in managing and leading large complex organisations. Chris also spent two years with a venture capital firm in Boston that invested in new life science companies. He currently provides a consultancy service focused on translational medicine for medical charities, academic institutions, biotechnology companies and life science orientated government agencies. He has a PhD in Biochemistry from the University of Georgia and performed his postdoctoral work at the Massachusetts Institute of Technology. He moved from the USA to Cheshire in 1993 and is married with three children. Chris is the Chairman of Research and Development Steering Group. 179 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

180 2 Accountability Report NonExecutive Directors continued Dr Hamish Stedman NonExecutive Director (from 1 September 2016) Hamish is a product of St Andrews and Victoria Universities, qualifying in He has worked in most of Salford s hospitals and has just retired after thirty five years as a General Practitioner in Swinton. He continues as a part time medical officer at St Ann s Hospice in Little Hulton. He recently stepped down from the Chairman roles of Salford CCG and the Association of Greater Manchester CCGs. He had been in post since the inception of both bodies. In the Greater Manchester role he helped steer the combined CCGs towards the reconfiguration of acute sector services under the Healthier Together project and was a cosignatory to the health and social care powers devolved to Greater Manchester. Latterly he was a member of the Greater Manchester Reform Board, a forum tasked with aligning public services across Greater Manchester to improve population health. This and improving quality of care remain his two passions. He describes the collaborative work within Salford and the developing Integrated Care Organisation as the perfect way to demonstrate how this can be done. Mrs Anne Williams CBE NonExecutive Director Anne has over 30 years of experience in social care working in the NHS, voluntary sector and Local Authorities. From 1999 to 2005 she was Director of Community and Social Services at Salford City Council managing Neighbourhood Services and Children s and Adult Social Care. Between September 2005 and September 2008, as Strategic Director, she managed Neighbourhood Services, Adult Social Care and Culture and Leisure Services. She has an Honorary Doctorate from the University of Salford. Anne was an active member, firstly of the Association of Directors of Social Services and then of the Association of Directors of Adult Social Services (ADASS), both local and nationally. She became Vice President of ADASS from October 2006 and was the first President of ADASS from its launch on 26 March During her presidential year she was closely involved in work with the Department of Health on a number of fundamental initiatives across adult social care and health, such as Putting People First, the Darzi Review and World Class Commissioning. Anne was awarded a CBE in June 2009 for services to Local Government. Between 2008 and June 2011 Anne was the National Director for Learning Disabilities at the Department of Health. She was extensively involved with the development of the national policy Valuing People Now and its implementation. From November 2011, she was a NonExecutive Director of HCONE, a new company providing care homes for older people and those with disabilities. Anne stood down as a NonExecutive Director in July Mr John Willis CBE ViceChairman/Chairman of Audit Committee John is a qualified accountant and was Chief Executive of Salford City Council from 1993 until his retirement in John led the team that secured funding for the Lowry, and oversaw much of the regeneration of Salford. In 2006, he was appointed a Commander of the British Empire for services to local government in Salford. John has considerable experience of managing large, complex public sector organisations with substantial revenue and capital budgets. The Board of Directors elected John to be the Trust s ViceChairman in July 2008 and Chairman of Audit Committee. From 1 October 2016, John was also appointed as a NonExecutive Director at Pennine Acute Hospitals NHS Trust. 180 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

181 2 Accountability Report Independence of NonExecutive Directors The Board of Directors undertakes an annual review of the independence of its NonExecutive Directors. The Board determines whether each director is independent in character and judgement and whether there are relationships or circumstances which are likely to affect, or could appear to affect, the director s judgement. At its meeting in April 2016, the Board acknowledged that some NonExecutive Directors had served terms of more than six years at Salford Royal and that, uniquely, NonExecutive Directors at Salford Royal were members only of the Board and statutory committees and were not members of the Trust s management or assurance committees and therefore retained significant independence from the operational management of the Trust. During 2016/17 the Board of Directors confirmed that it considers all NonExecutive Directors to be independent, namely: Mr Jim Potter Mr John Willis CBE Mrs Diane Brown Mrs Rowena Burns Dr Chris Reilly Dr Hamish Stedman Mrs Anne Williams CBE 181 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

182 2 Accountability Report Executive and Advisory Boardlevel Directors Sir David Dalton Chief Executive Sir David Dalton has been a Chief Executive for 20 years and joined Salford Royal in July He has a strong profile, both locally within Greater Manchester, and also nationally in the areas of quality improvement and patient safety. Under Sir David s leadership, the Trust set out its clear ambition to be the safest organisation in the NHS and has adopted a disciplined approach of applied improvement science coupled with deep staff involvement. Sir David s other interest is in sustaining an organisational culture which delivers high reliability of clinical standards, this has included supporting clinical leaders and creating a new framework for aligning an individual s contribution to the goals and values of the organisation. Sir David chairs a network organisation of Foundation Trusts NHS QUEST which aims to achieve unprecedented levels of quality improvement and he is Vice Chairman of the Greater Manchester Academic Health Science Network, which aims to improve health through better adoption of evidence of best practice. Sir David received his knighthood in 2014 for his services to the NHS. Sir David led the Dalton Review, a review into how leading NHS hospitals can expand their reach to benefit more patients. Mrs Elaine InglesbyBurke CBE Executive Nurse Director and Deputy Chief Executive Elaine joined Salford Royal NHS Foundation Trust in April Elaine has held Executive Nurse Director positions since 1996 in both specialist and large acute Trusts. She qualified as a registered nurse in 1980 at Warrington District General Hospital and specialised in critical care and general medicine. She has held various clinical positions at ward level and nurse specialist. Educated to postgraduate degree level, Elaine maintains her professional and clinical development through regular clinical shifts and executive safety shifts with frontline staff. She is a Florence Nightingale leadership Scholar and took the opportunity to undertake a women s leadership programme for global executives at Harvard University as well as the Executive Quality Academy at the Institute of Healthcare Improvement, Boston. She has a strong track record in professional nursing and operational management. Elaine is the Executive Lead for Nursing, Governance, Patient Safety and Quality Improvement. Elaine was appointed Deputy Chief Executive in Elaine is a NonExecutive Director for NICE and the Executive Nurse on the Governing Body of St Helens Clinical Commissioning Group. Mr Chris Brookes Executive Medical Director Chris commenced as Executive Medical Director on 1 May Chris has continued to focus his efforts on infection control, and through the contribution of all staff members in Salford Royal, there has been significant progress made in ensuring our patients receive care which is safe and does not expose them to Hospital Acquired Infections (HAI). Chris continues to practice as a Senior Consultant in A&E. Away from the hospital, Chris is married with three children and provides medical care to the Wigan Warriors and England Rugby League Teams. 182 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

183 2 Accountability Report Executive and Advisory Boardlevel Directors continued Mr Ian Moston Executive Director of Finance Ian joined Salford Royal Board of Directors in May 2014 from the NHS Trust Development authority where he was the Business Finance Director for London. Ian started his NHS career in 1991 as a Regional Financial Management Trainee and has held Finance Director positions in Primary Care, Acute and Intermediate Tier Organisations since During this time he has worked on a number of large scale transactions including the development of a new national service for cancer treatment, organisational merger and acquisition and the development of a joint venture company to deliver commercial benefits to the NHS. Ian brings a range of other experience from both the private and charitable sectors. He is also a keen advocate of finance staff development and is Chairman of the Towards Excellence Programme which accredits NHS North West Finance functions. Ian is the Executive Lead for Finance, Information, Procurement, Contracting and Commissioning. Mrs Judith Adams Executive Director of Group Delivery Jude rejoined Salford Royal in April 2016 having previously worked for the Trust in Jude has over 30 years experience working in the NHS and with Trust Boards, starting her career as a nurse in the North West and then working in London hospitals and overseas before moving into operational management. She has delivered on improvements to operational performance and major change programmes including the development and move to the new Alder Hey Children s Hospital in 2015, where she held the post of Chief operating Officer. Her clinical and operational experience is underpinned by a strong commitment to both patients and staff. Stephanie Gibson Interim Director of Performance and Improvement (until 31 December 2016) Stephanie was appointed as the Interim Director of Performance and Improvement in January 2016, following her role as Divisional Managing Director from May Prior to this she was a Senior Operational Manager for the Medicine Division gaining experience in Dermatology, Rheumatology, Gastroenterology and Renal Services. She qualified in 1982 as a registered nurse and for the next 18 years worked in the emergency department at North Manchester General Hospital undertaking a variety of roles including clinical nurse specialist and latterly Clinical Manager. Stephanie s general management experience began in 2000 in the Surgical Division at North Manchester and, following the formation of Pennine Acute Hospitals NHS Trust she became the Service Manager for Unscheduled Care, working across four hospital sites. She completed a MSC in Management Studies in Stephanie commenced as the Managing Director of North Manchester General Hospital from 1 January Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

184 2 Accountability Report Executive and Advisory Boardlevel Directors continued Mr Raj Jain Executive Director of Corporate Strategy and Business Development Raj joined Salford Royal in January 2015 and he will lead the development of the Trust s corporate strategy over the next 10 years. He previously held the post of Managing Director of Greater Manchester Academic Health Science Network (AHSN), which was created to bring together healthcare and academic organisations in partnership with industry, local authorities and other agencies to improve health and economic wealth through the spread of innovation. Raj was Chief Executive of an NHS Foundation Trust that was named Hospital of the Year in 2012 and he has held senior roles in teaching and general hospitals. He spent the early part of his career in the oil and gas industry and is an economist by training and a Human Resources and Organisational Development professional. Raj has been a director of two research organisations and has held regional and national leadership positions in health development and planning. Diane Morrison Salford Director of Finance (Advisory) Diane joined Salford Royal in 2005 as part of the team who coordinated the Foundation Trust application. Diane was appointed as the Salford Director of Finance in April 2017, having previously been the Deputy Director of Finance at the Trust. Diane started her NHS career as a Regional Finance Management Trainee on the North West training scheme and has worked in a number of NHS Trusts and at a Strategic Health Authority across a broad range of financial services. More recently as part of the team at Salford Royal, Diane has been involved in a number of developments working within and outside the Trust to help deliver changes to the way care is provided including the work to establish the Salford Integrated Care Organisation. Diane chairs the Finance Delivery Group to oversee the financial arrangements for the reconfiguration of high risk surgery across the North West sector of Greater Manchester and is involved in the development of locality plans to support the Greater Manchester Combined Authority application. Diane is committed to continuing professional development both personally and for the finance teams. The Salford Royal teams have level 3 Finance Skills Development Accreditation (highest level) and level 2 NHS Standards of Procurement. 184 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

185 2 Accountability Report Executive and Advisory Boardlevel Directors continued Mr Peter Murphy Salford Director of Nursing (Advisory) Peter commenced his nursing career in 1987 and qualified as a Registered Nurse in He has 20 years experience within the critical care speciality. He joined Salford Royal in 2007, initially as a Nurse Consultant for Critical Care and following promotion as the Assistant Director of Nursing for Quality Improvement. He is passionate about the nursing profession and is determined that nursing should be recognised for the vital role it plays in the delivery of safe, clean and personal care. He has led a number of initiatives within Salford Royal including a collaborative project to improve the management of acutely unwell patients which won a BUPA Foundation Award in 2009 and a HSJ Award for Quality and Productivity in Mr Paul Renshaw Director of Organisational Development and Corporate Affairs (Advisory) Paul joined Salford Royal in April He is a senior HR leader with more than 20 years experience of HR strategy development and service delivery, including leading significant change management initiatives. He joined Salford Royal from the management team at the National Nuclear Laboratory, the leading nuclear technology services provider in the UK. He started his career with Marks and Spencer in 1988 and has also worked for Matalan and BUPA. He joined Serco Technical Assurance Services in 2007; here he led the HR team during a challenging and ultimately successful period of unprecedented organisational change and growth. Paul s role is crucial in encouraging a strong and motivated team at Salford Royal, where people feel motivated to provide high quality care to patients. He has a deep interest in coaching and mentoring and is passionate about linking personal award to individual contribution. Throughout 2016/17 Paul held responsibility for a number of the Trust s departments, including Human Resources and Communications. Mr Jack Sharp Executive Director of Service Strategy and Development Jack joined Salford Royal in May 2008 and was appointed to the Board of Directors in May 2014 as Executive Director of Service Strategy and Development. Originally from Newcastle upon Tyne, Jack moved to the North West to complete a Masters degree. He started his career in the NHS as graduate management trainee and has held a wide range of general management posts. Jack has worked in Salford since 2003, having previously been employed by the organisation formerly known as NHS Salford. He has led the development of a number of large scale change programmes, including the transfer and integration of community services within the Trust and the development of Salford s strategy to integrate health and social care services for older people. Jack is the Executive Lead for Strategic and Operational Planning, Integrated Care, Cancer Services, Estates and Facilities. 185 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

186 2 Accountability Report Executive and Advisory Boardlevel Directors continued Mr James Sumner Executive Director of Performance and Improvement (Advisory, from 1 April 2017) James joined Salford Royal in December He started his career in Primary Care and has held a number of roles in commissioning, provider and regional organisations. He brings years of experience in general operational management, Board Level Executive roles and, for the last two years, was Deputy Chief Executive at a nearby NHS Foundation Trust. James is the Executive Lead for the clinical divisions and assumes responsibility as Chief Officer of Salford Royal as a Care Organisation with Group from 1 April 217. Dr Peter Turkington Salford Medical Director (Advisory) Originally from Northern Ireland, Pete completed his medical training in Yorkshire before moving to Salford Royal in 2003 to take up his Consultant Post in Respiratory Medicine. His main subspecialty interests are Obstructive Sleep Apnoea, Ventilatory Failure and NonInvasive Ventilation (NIV). He has set up a Sleep Clinic in Salford for patients with all forms of sleep disorder and has published several papers in peer reviewed journals on Sleep Apnoea. Pete was Clinical Director of Respiratory Medicine between 2007 and 2010 and Chairman of the Division of Salford Healthcare between 2010 and 2013 during which time he led the development of the Emergency Village and seven day working for acute medicine. He has led a number of initiatives within Salford Royal including a collaborative project to improve the management of acutely unwell patients which won a BUPA Foundation Award in 2009 and a HSJ Award for Quality and Productivity in Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

187 2 Accountability Report Executive Directors and Advisory Boardlevel Members Appointment date Board Name Responsibilities From To attendance Sir David Dalton Chief Executive 2001 Present 10/10 Mrs Elaine Inglesby Executive Nurse Director / Deputy Chief Executive 2004 Present 10/10 Burke CBE Mr Chris Brookes Executive Medical Director 2010 Present 10/10 Mr Ian Moston Mrs Judith Adams Executive Director of Finance Executive Director of Group Delivery Present Present 9/10 N/A Mrs Stephanie Gibson Interim Director of Performance and Improvement 2016 Nov /7 Mr Raj Jain Executive Director of Corporate Strategy and Business Development 2015 Present 9/10 Mrs Diane Morrison Mr Peter Murphy Salford Director of Finance (Advisory) Salford Director of Nursing (Advisory) Present Present 9/10 9/10 Mr Paul Renshaw Director of Organisational Development and Corporate Affairs (Advisory) 2013 Present 9/10 Mr Jack Sharp Executive Director of Service Strategy and Development (Advisory) 2014 Present 10/10 Mr James Sumner Executive Director of Performance and Improvement (Advisory) 2016 Present 3/3 Dr Peter Turkington Salford Medical Director (Advisory) 2014 Present 10/10 NonExecutive Directors Name Mr Jim Potter Responsibilities Chairman Appointment In post as ViceChairman when Salford Royal became a Foundation Trust in August Appointed as Chairman on Reappointed from until Reappointed from until 2017 AMM. Tenure extended until Jim is now in his 11th year with Salford Royal. Board attendance 9/10 Mrs Diane Brown Senior Independent Director Appointed Reappointed until Reappointed to Reappointed to Tenure extended until Diane is now in her 9th year with Salford Royal. 8/10 Dr Joanna Bibby NonExecutive Director Appointed until Reappointed to Jo stood down on 31st March /10 Mrs Rowena Burns NonExecutive Director Appointed until Reappointed to Reappointed to Rowena is in her 4th year with Salford Royal. 7/10 Mrs Chris Mayer CBE NonExecutive Director Appointed N/A Dr Chris Reilly NonExecutive Director Appointed to Reappointed to Chris is in his 3rd year with Salford Royal 9/10 Dr Hamish Stedman NonExecutive Director Appointed to /6 Mrs Anne Williams CBE NonExecutive Director Appointed Reappointed until Reappointed until Anne stood down on 31st July /4 Mr John Willis CBE Vice Chairman / Chairman of Audit and Charitable Funds Committees Appointed to Reappointed to Reappointed to Reappointed to Reappointed to Reappointed to Tenure extended until John is now in his 10th year with Salford Royal. 10/ Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

188 2 Accountability Report Committees of the Board of Directors The Board of Directors has established the following committees: Audit Committee Nominations, Remuneration and Terms of Service (NRTS) Committee Charitable Funds Committee Executive Assurance and Risk Committee Productivity Improvement Board Strategy and Investment Committee And other key committees, include: Joint Research and Development Steering Group Alliance Board for Integrated Care Shared Services Board (Salford Royal NHS Foundation Trust and Wrightington, Wigan and Leigh NHS Foundation Trust s joint ventures to provide sterile services and pathology services) The Board of Directors approved the disestablishment of the Shared Services Board in January 2017, and approved the establishment of a single Shared Services Board between Bolton NHS Foundation Trust, Wrightington, Wigan and Leigh NHS Foundation Trust and Salford Royal Joint Management Board (Salford Royal NHS Foundation Trust and Central Manchester NHS Foundation Trust). In November 2016, the Board of Directors agreed to discontinue the Joint Management Board in light of new Greater Manchester governance arrangements and organisational priorities Audit Committee Audit Committee plays a key role in supporting the Board by critically reviewing and reporting on the adequacy and effectiveness of internal controls, risk management, and governance. As well as the economy, efficiency and effectiveness across the whole of the organisation s activities (both clinical and nonclinical). In carrying out this work, the Audit Committee primarily utilises the work of internal and external audit, and the Trust s Executive Assurance and Risk and Corporate Governance Committees. Audit Committee also obtains assurance from the views of other external agencies such as the Care Quality Commission. Salford Royal s NonExecutive Directors (with the exception of the Chairman) are members of Audit Committee. Attendance during 2016/17 was as follows: Mr John Willis CBE 5/5 Dr Joanna Bibby 3/5 Mrs Diane Brown 4/5 Mrs Anne Williams CBE 2/2 Mrs Rowena Burns 0/5 Dr Chris Reilly 5/5 Dr Hamish Stedman 3/3 Support for the committee was provided by the Trust Secretariat and meetings were attended by the Executive Director of Finance, Salford Director of Finance, Associate Director of Governance, Trust Secretary and Internal and External Audit Teams. At its meeting in April 2016, the Audit Committee reviewed the first draft of the Annual Report, including the Annual Governance Statement, Quality Report and unaudited Accounts 2015/16. This was followed by further review and approval of the Annual Report and Accounts, including the Quality Report, prior to submission to Monitor (NHSI), at its meeting in May Furthermore, Audit Committee received the External Auditors Findings Report (ISA 260). continued next page 188 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

189 2 Accountability Report During 2016/17, the Trust s Internal Audit function was carried out by Mersey Internal Audit Agency (MIAA). Internal Audit provides an independent assurance service to the Board, Audit Committee and management, focused on reviewing the effectiveness and extent of compliance with the governance, risk management and control processes that Salford Royal has put in place. Audit Committee approved the Internal Audit and AntiFraud Work Plans for 2016/17 and received regular progress updates with respect to the work and findings of the respective plans. In May 2016, the Board of Directors supported Audit Committee s recommendation to commission MIAA, in collaboration with AQuA, to conduct an independent review utilising Monitor s Well Led Framework for Governance during 2016/17. Audit Committee reviewed the proposed approach to delivering the review and, in light of the strategic developments to be progressed during the year, ensuring best benefit and value for the organisation confirmed key areas for specific focus following consultation with the Board of Directors. Further information regarding the Well Led Review can be found on pages During the year, Audit Committee reviewed the Trust s Board Assurance Framework/Corporate Risk Register and conducted a detailed review of the risk management arrangements for the Integrated Care Organisation (ICO), alongside a review of the transformation, implementation and operational risks being monitored via the ICO Programme Board. Audit Committee acknowledged that risk systems must be managed appropriately within different environments. To supplement the above, Audit Committee also reviewed and sought assurance with regard to the ICO governance arrangements and Care Quality Commission Assurance Systems associated with Salford Royal s new responsibilities for adult social care and mental health. The Audit Committee is authorised by the Board of Directors to investigate any activity within its terms of reference and to seek any information it requires from staff. Senior managers from the Trust (including the Managing Director of Surgery and Neurosciences, Divisional Director of Nursing for Clinical Support Services and Tertiary Medicine, Head of Procurement and Deputy Director of Human Resources) attended meetings during 2016/17 to provide a deeper level of insight into key issues within their respective areas of expertise. In addition to reviewing key finance related matters, including losses and special payments reports and reviewing and approving writeoff of nonnhs debtors, Audit Committee undertook a detailed midyear financial review in the form of an updated Going Concern Report, providing financial outlook until March NonExecutive Directors continued to undertake a programme of Adult and Children s community visits during 2016/17 providing open dialogue with frontline staff, whilst broadening their knowledge and understanding of the Trust s community services. This series of visits was complemented by detailed internal CQC Corporate Assurance Reviews presented to each meeting of Audit Committee. It is the responsibility of the Audit Committee to make recommendation to the Council of Governors about the appointment or reappointment of Salford Royal s external auditor. In June 2016, the Council of Governors were informed that as five years will have elapsed at the end of the current External Auditor contract, Salford Royal would be required to undertake a markettesting exercise during As Salford Royal envisaged closer working with PAT, the Council of Governors supported the two organisations aligning their selection processes for an External Auditor, with the objective of awarding the two organisational contracts to a single External Auditor Firm. continued next page 189 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

190 2 Accountability Report The Audit Committees at Salford Royal and PAHT developed a specification, defining the role, capabilities and contract length required for appointment of an External Auditor. This was approved by the established Joint (Salford Royal and Pennine) Audit Working Group including appropriate representation from the Audit Committees of both organisations and Salford Royal s Council of Governors. In line with the specification, a minicompetition under the NHS Shared Business Services (SBS) framework agreement Internal/External Audit, Counter Fraud & Well Led Governance Review was undertaken. In December 2016, the Chairman of Audit Committee, in collaboration with the Joint Audit Working Group, confirmed to the Council of Governors that all proper steps had been taken to evaluate and appropriately select an External Auditor and recommended that Grant Thornton was appointed by Salford Royal NHS Foundation Trust for a period of three years (conducting the 2017/18, 2018/19 and 2019/20 audits), with an option for this to be extended by a further 1 year subject to mutual agreement. Grant Thornton proposed the annual cost to Salford Royal would be 51,575, 50,000 and 48,425 (net of VAT) respectively. This recommendation was unanimously approved by the Council of Governors. The Board of Directors at Pennine Acute Hospitals NHS Trust also awarded its contract to Grant Thornton. Salford Royal has a robust policy in place for the engagement of the External Auditor for Non Audit Work. There have been no significant facts or matters that may impact on the External Auditors independence drawn to Audit Committee s attention during 2016/17. In March 2017, Audit Committee took part in an externally facilitated Assurance Development Workshop, specifically considering the role of the NonExecutive and assurance principles in a Group setting. Audit Committee considered how a Group Assurance Framework may work, sustaining a local focus upon governance, risk management, audit, antifraud and compliance, a Group Audit Committee Work Plan, and Internal Audit Work Plan 2017/18. Salford Royal s External Auditors regularly attend Audit Committee, providing an opportunity for the committee to assess their effectiveness. The Audit Plan for Salford Royal was presented to Audit Committee in December 2016, confirming the audit would be conducted with an understanding of the key challenges and opportunities Salford Royal was facing. The Audit Committee received assurance that the audit would consider the impact of key developments in the sector and take account of national audit requirements and ensure compliance with International Standards on Auditing (ISAs). At its meeting in April 2017, Audit Committee engaged in detailed discussion with Salford Royal officers and the External Auditor regarding the accounting for the pension reimbursement asset relating to the pension liabilities of adult social care staff transferred as part of the ICO. Audit Committee acknowledged the complexity and application of multi public sector and national accounting regulation and the assurances with respect to this matter. In April 2017, the Audit Committee confirmed that during 2016/17, based on the work performed by, and reports received from Internal and External Auditors, plus additional internal assurance that all reasonable steps had been taken to establish and maintain an effective system of integrated governance, risk management and internal control, across the whole of the organisation s activities (both clinical and nonclinical). The Audit Committee confirmed that it had met its key responsibilities as set out in the terms of reference during 2016/ Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

191 2 Accountability Report Nominations, Remuneration and Terms of Service (NRTS) Committee The Board of Directors has established a Nominations, Remuneration and Terms of Service Committee to consider matters pertinent to the nomination, remuneration and associated terms of service for Executive Directors (including the Chief Executive), matters associated with the nomination of NonExecutive Directors and remuneration of senior managers/clinical leaders. Further information regarding the NRTS Committee can be found in the Remuneration Report. Charitable Funds Committee The Board of Directors has devolved responsibility for the ongoing management of the funds to the Charitable Funds Committee which administers these funds on behalf of the Corporate Trustees. The membership of the Charitable Funds Committee comprises all NonExecutive Directors. Executive Assurance and Risk Committee The Executive Assurance and Risk Committee ensures serious risks to Salford Royal s principal objectives are managed effectively and efficiently and that adequate assurance mechanisms exist and are appropriately monitored to enable selfcertifications and declarations of compliance with national standards and guidance to be confidently given. Productivity Improvement Board The Productivity Improvement Board monitors implementation of the Better Care at Lower Cost (BCLC) programme, as required to deliver the Salford Royal s financial plan. Strategy and Investment Committee The Strategy and Investment Committee provides independent and objective review of, and assurances, in relation to major strategic initiatives, including investments/divestments of activities which significantly broaden, diversify or reduce Salford Royal activity base, and ensure their alignment with the Board of Directors approved strategy and risk framework. NHS Improvement s Single Oversight Framework NHS Improvement s (NHSI) Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: Quality of care Finance and use of resources Operational performance Strategic change Leadership and improvement capability (wellled) Based on information from these themes, providers are segmented from 1 to 4, where 4 reflects providers receiving the most support, and 1 reflects providers with maximum autonomy. A Foundation Trust will only be in segments 3 or 4 where it has been found to be in breach, or suspected breach, of its licence. The Single Oversight Framework applied from Quarter 3 of 2016/17. Prior to this, Monitor s Risk Assessment Framework (RAF) was in place. Information for the prior year and first two quarters relating to the RAF has not been presented as the basis of accountability was different. This is in line with NHSI s guidance for annual reports. 191 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

192 2 Accountability Report Segmentation Salford Royal is currently placed in segment 2 (providers offered targeted support potential support needed in one or more of the five themes, but not in breach of licence (or equivalent for NHS Trusts) and/or formal action is not needed) as notified by NHSI. This segmentation information is Salford Royal s position as at April Current segmentation information for NHS Trusts and Foundation Trusts is published on NHSI s website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from 1 to 4, where 1 reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Salford Royal is currently placed in segment 2 (providers offered targeted support potential support needed in one or more of the five themes, but not in breach of licence (or equivalent for NHS trusts) and/or formal action is not needed). Area Financial sustainability Financial efficiency Financial controls Overall scoring Metric Capital service capacity Liquidity I&E margin Distance from financial plan Agency spend 2016/17 Q3 score /17 Q4 score Signed: Date: 26 May 2017 Sir David Dalton Chief Executive & Accounting Officer Salford Royal NHS Foundation Trust 192 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

193 2 Accountability Report Statement of the Chief Executive s responsibilities as the Accounting Officer of Salford Royal 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 NHS Improvement. NHS Improvement, in exercise of the powers conferred on Monitor by the NHS Act 2006, has given Accounts Directions which require Salford Royal NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis required by those Directions. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Salford Royal 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 Department of Health Group Accounting Manual and in particular to: Observe the Accounts Direction issued by NHS Improvement, 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 (and the Department of Health Group Accounting 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 the NHS Foundation Trust Accounting Officer Memorandum. Signed: Date: 26 May 2017 Sir David Dalton Chief Executive 193 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

194 2 Accountability Report Annual Governance statement 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. 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 Salford Royal 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 Salford Royal NHS Foundation Trust for the year ended 31 March 2017 and up to the date of approval of the annual report and accounts. Capacity to handle risk 2016/17 has been a year of significant leadership and governance transition as Salford Royal was accredited by NHS Improvement to lead the development of a Group as an Acute Care Collaborative vanguard. This work coincided with the Trust supporting the Pennine Acute Hospitals NHS Trust, and has progressed to the Board setting out parameters and subsequently establishing a Group, with Pennine Acute Hospitals NHS Trust being the first member. The Board commissioned an independent Wellled Governance Review during 2016/17, recognising the essential importance of robust governance systems during a period of significant change and challenge. The Review was reported formally to the Board of Directors in March 2017 and concluded that the Trust is exceptionally wellled. with robust risk management and governance processes, the processes underpinning risk identification, understanding, monitoring and management are welldesigned, operating effectively and owned at all levels. Dynamic risk registers and a Board Assurance Framework are in place. These arrangements will need to be reset in group but the culture and processes from which to do this are very robust. Notably, It is a Board that is open to the necessity for transformation and a Board that has the clearest of commitments to quality; safety; patient experience; improvement; and robust risk management and governance processes. continued next page 194 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

195 2 Accountability Report I am responsible for risk management across all organisational, financial and clinical activities. The Executive Assurance and Risk Committee as established by the Board of Directors to review and set the Risk Management Strategy for the Trust, has continued to operate throughout 2016/17. The Risk Management Strategy provides a framework for managing risks across the organisation which is consistent with best practice and Department of Health guidance. The Strategy provides a clear, systematic approach to the management of risks to ensure that risk assessment is an integral part of clinical, managerial and financial processes across the organisation. The Strategy reflected the role of the Board and its Standing Committees during 2016/17 together with the individual responsibilities of the Chief Executive, Executive Directors, other Senior Leaders and all staff in managing risk. In particular, the Executive Assurance and Risk Committee, through its Corporate Governance Committees of Quality and Patient Experience; Clinical Effectiveness; Finance, Capital and Information; Operations and Performance; and Education and Research, provided the mechanism for managing and monitoring risk throughout the Trust and reporting through to the Board. Established Divisional governance arrangements maintained effective risk management arrangements across all Directorates, maintain Divisional Assurance Frameworks and Risk Registers and reported directly to the Executive Assurance and Risk Committee via quarterly, Directorled Divisional Assurance and Risk Committees. The Audit Committee, comprising all NonExecutive Directors other than the Chairman, has continued to oversee the systems of internal control and overall assurance process associated with managing risk. The Board of Directors routinely received summary reports of all Standing Committees. The Board received assurances from the Executive Assurance and Risk Committee relating to the management of all serious untoward incidents, including Never Events, as well as receiving integrated reports on complaints, claims and incidents, which it received twice a year. The Trust has mechanisms to receive and act upon alerts and recommendations made by all relevant central bodies. Risk management training was provided through the induction programme for new staff. In addition, tailored training for individual roles continued to be identified by managers and agreed with staff through personal development plans. The corporate induction programme ensures that all new staff were provided with details of the Trust s risk management systems and processes and was augmented by local induction organised by line managers. This included the comprehensive induction of all junior doctors with regard to key policies, standards and practice prior to commencement in clinical areas. Mandatory training reflected essential training needs, and continued to include risk management processes such as fire safety, health and safety, manual handling, resuscitation, infection control, safeguarding patients, blood transfusion and information governance. Each of these processes is included within an elearning programme available to staff. Root Cause Analysis training is provided to staff members who have direct responsibility for risk management within their area of work. Lessons learned when things go wrong are shared via Corporate and Divisional governance systems. 195 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

196 2 Accountability Report The risk and control framework Risk management requires participation, commitment and collaboration from all staff. The process starts with the systematic identification of risks via structured risk assessments. Identified risks are documented on risk registers. These risks are then analysed in order to determine their relative importance using a risk scoring matrix. Low scoring risks are managed by the area in which they are found whilst higher scoring risks are managed at progressively higher levels within the organisation. Achieving control of the higher scoring risks is given priority over lower scoring risks. Risk control measures are identified and implemented to reduce the potential for harm. The potential severity (consequence) and the likelihood of the risk occurring are scored along with the existing control measures. It is the sum of these scores which determine the level in the organisation at which the risk is reported and the monitoring of further actions to mitigate against the risk is performed. Incident Reporting is openly encouraged through staff training and further embedded by the Trust s adoption and promotion of a fair blame culture. Risks identified from serious incidents that impact upon public stakeholders are managed by involving the relevant patient and/or their family and ensuring that they are satisfied that all lessons have been learned. The Trust has a Board Assurance Framework, which is based on six key elements: Clearly defined principal objectives agreed with stakeholders together with clear lines of responsibility and accountability Clearly defined principal risks to the achievement of these objectives together with assessment of their potential impact and likelihood Key controls by which these risks can be managed, this includes involvement of stakeholders in agreeing controls where risks impact on them Management and independent assurances that risks are being managed effectively Board reports identifying that risks are being reasonably managed and objectives being met together with gaps in assurances and gaps in risk control Board action plans which ensure the delivery of objectives, control of risk and improvements in assurances Quality Improvement drives the Trust s strategy and annual plan and, via the processes described above, the Board of Directors are aware of potential risks to quality. The Trust has strong quality governance arrangements in place, which include a quality improvement strategy with ambitious Trustwide quality goals, designed, approved and monitored by the Board of Directors; an Corporate Quality and Patient Experience Governance Committee which reports directly to the Executive Assurance and Risk Committee; Quality Dashboards at all levels throughout the organisation that track performance against key quality indicators; standardised risk assessment (Quality and Safety Impact Assessment) of all productivity improvement workstreams, as part of the Trust s Better Care at Lower Cost Programme; and robust arrangements for staff, patients and members of the public to raise concerns with respect to the quality of care. The Trust has a Freedom to Speak Up (FTSU) Guardian to act in a genuinely independent and impartial capacity to support staff who raise concerns and will have access to the Chief Executive and the Trust s nominated nonexecutive director for Freedom to Speak Up. This individual is supported by a number of Freedom to Speak Up Departmental Guardians who work across the Trust and ensure staff have easy access to practical support. continued next page 196 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

197 2 Accountability Report The Board has nominated the Senior Independent Director (SID) as SRFT s nominated nonexecutive director. A quarterly report of all concerns raised and themes is produced for the Corporate Quality and People Experience (QPE) Governance Committee, and summary information provided for the Executive Assurance and Risk Committee and the Board of Directors. The Trust FTSU Guardian attends the QPE Governance Committee meeting to discuss all concerns raised and also meets with the nominated nonexecutive director on a quarterly basis. The Trust has, in previous years, conducted annual selfassessments against Monitor s Quality Governance Framework. During 2014/15, 2015/16 and 2016/17, selfassessment took place against Monitor s Wellled Governance Framework, which fully incorporates, and builds on, the Quality Governance Framework. As described earlier an independent Wellled Governance review was conducted towards the end of 2016/17 and reported There is a confident understanding at Board level of how services are performing in relation to quality. QI [Quality Improvement] is notable in terms of the breadth and depth of its embeddedness across the Trust. The Quality Accounts, within this Annual Report and Accounts, describe quality improvements and quality governance in more detail. The Trust is registered with the Care Quality Commission and systems exist to ensure compliance with the registration requirements. A process of selfassessment is in place and undertaken annually by each service following the prompts within the CQC s Fundamental Standards of Quality and Safety. The outcomes of each assessment are discussed through the Service Review process twice yearly and via the Corporate Governance Committees. Any areas of concern are risk assessed and applied where necessary to the local and corporate risk registers. All of the CQC Fundamental Standards of Quality and Safety have an identified lead within the organisation and it is their responsibility to provide compliance evidence and evaluation to relevant Corporate Governance Committee on an annual basis. An internal CQC mock assessment programme is in operation whereby unannounced visits take place across each of the Divisions. In addition, further assurance is provided by Audit Committee, which monitors the outcome of the mock assessment programme inyear and commissions specific reviews by the Trust s internal auditors. A summary report that collates assurance from each of these controls is presented to the Executive Assurance and Risk Committee at the end of each financial year. Significant assurance was obtained following the successful outcome of the CQC inspection in January 2015, where the Trust was assigned an outstanding rating. Actions required and recommended by the CQC were promptly managed and monitored by Executive Assurance and Risk Committee and reported directly to the Board. Data quality and data security risks are managed and controlled via the risk management system. Risks to data quality and data security are continuously assessed and added to the IM&T risk register, which is reviewed periodically by the Executive Assurance and Risk Committee. In addition, independent assurance is provided by the Audit Commission s PbR (Payment by Results) Data Assurance Framework review and the Information Governance Toolkit selfassessment review by internal audit and external auditors, for example MIAA and Capita, who review the Trust s data and data systems. continued next page 197 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

198 2 Accountability Report During 2016/17, the Board ensured ongoing assessment of inyear and future risks. Major risks related to: Effectiveness of financial control systems Delivery of Salford Royal s Better Care at Lower Cost programme A&E performance Open / Incomplete Referral to Treatment Performance Vascular Radiology services Radiology turnaround times Compliance with Core Standards for Intensive Care Units Adequacy of neurorehabilitation pathways Impact of trauma admissions on theatre capacity Supporting paediatric emergencies and trauma Maintaining Trust wide clinical staffing Compliance with capped agency rates Cyber security threat Capital solutions for major strategic programmes Additional bed capacity Sufficient operational estate capacity for future service developments Transformation funding to support the development of Group The Board oversees the management of all major risks, which are actively addressed by the Executive Assurance and Risk Committee. Key controls and assurances, and any identified gaps are continually reviewed and action plans developed and progressed accordingly. Outcomes are confirmed via this process and reported routinely to the Board, via the Board s Integrated Performance Dashboard. Audit Committee reviews the Board Assurance Framework/Corporate Risk Register and commissions additional reviews where appropriate in order to provide necessary assurance to the Board. Significantly, the Trust has developed a Productivity Improvement Programme titled Better Care at Lower Cost with robust project management arrangements via a central project management office (PMO) and oversight via the Productivity Improvement Board, an established standing committee of the Board that is chaired by the Executive Director of Finance. Executiveled workstreams, with formally established projects, form the basis of the programme that is reported each month in detail to the Board of Directors. This programme is fully aligned to the objectives of the Trust s financial and operational plan. The Trust has assessed compliance with the NHS Foundation Trust condition 4 (FT governance). Audit Committee reviewed the assessment in detail at its meeting on 24 May 2017 and confirmed that [no material risks had been identified]. The Trust believes that effective systems and processes are in place to maintain and monitor the following conditions: The effectiveness of governance structures The responsibilities of Directors and subcommittees Reporting lines and accountabilities between the board, its subcommittees and the executive team; The submission of timely and accurate information to assess risks to compliance with the Trust s licence; and The degree and rigour of oversight the board has over the Trust s performance. These conditions are detailed within the Corporate Governance Statement, the validity of which is assured via the Board of Directors Audit Committee. Risk management is embedded in the activity of the organisation. The risk management systems are fully incorporated within the Trust s Assurance Framework. continued next page 198 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

199 2 Accountability Report The Trust s corporate risk register is integrated with the Board Assurance Framework thereby ensuring that risks are not only managed and communicated efficiently, but that the management of them is embedded in the Trust s practice. When things do go wrong the Trust encourages its staff to report incidents whether there was any consequence resulting from the incident or not. Anonymous reporting is accepted to mitigate against any concerns the reporter of an incident may have. However, if the reporter of an incident does include who they are, then they receive automated feedback for every incident they report. This is to help demonstrate the value of reporting and that things have changed as a result, with the intent on encouraging staff to report more incidents. Public stakeholders are involved in managing risks which impact on them. When serious incidents are investigated, members of the Trust speak and if possible meet with those who were affected. Relevant feedback from these discussions would be considered during the investigation and a copy of the final report is shared. This gives the opportunity for comment on the report to be considered and if appropriate included. The Salford Clinical Commissioning Group (CCG) receives a copy of the completed Serious Incident Investigation report and a member of the CCG attends the Trust s Serious Incident Assessment and Review Committee (SIARC) meetings, thereby ensuring public oversight of the investigation and learning process following patient safety incidents that have caused moderate harm. The Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission. As an employer with staff entitled to membership of the NHS Pension Scheme and the Greater Manchester 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. Control measures are in place to ensure that all the organisation s obligations under equality, diversity and human rights legislation are complied with. The 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. Review of economy, efficiency and effectiveness of the use of resources The financial plan is approved by the Board of Directors and submitted to Monitor. The plan, including forward projections, is monitored in detail on a monthly basis by the Corporate Governance Finance, Information and Capital Committee with key performance indicators and financial sustainability metrics also reviewed monthly by the Board. The Trust s resources are managed within the framework set by the Corporate Governance Framework Manual, which includes Standing Financial Instructions. Financial governance arrangements are supported by internal and external audit to ensure economic, efficient and effective use of resources and monitored through Audit Committee. Clinical Divisions and Corporate Departments are responsible for the delivery of financial and other performance targets via a performance management framework incorporating service reviews with the Executive Team. 199 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

200 2 Accountability Report Information Governance Information governance risks are managed as part of the processes described above and assessed using the Information Governance Tool kit. The risk register is updated with the currently identified information risks. In line with national requirements, the Trust information risks are assessed using the HSCIC IG SIRI s (Information Governance Serious Incidents Requiring Investigation) assessment criteria and reported through to the Department of Health via the Information Governance (IG) Incident Reporting Tool. During 2016/17, the Trust reported two information governance incidents to the Information Governance Commissioner, which had been scored at level 2. The first incident was identified when a family made contact with Salford Royal and suggested that patient sensitive information may have been shared without the licence, authority or consent of the Trust or the individual data subjects with a third party. An internal investigation was initiated but was inconclusive. This case was closed by the ICO. The second was a supplier IT security incident which had impact on our staff, the incident was outside the control of the Trust, however was reportable, with the Trust taking direct action to notify affected staff. Salford Royal NHS Foundation Trust will continue to monitor and assess its information risks, in light of the events noted above, in order to identify and address any weaknesses and ensure continuous improvement in its systems. 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 Annual Quality Report 2016/17 has been developed in line with relevant national guidance and is supported internally through the Board Assurance Framework. The Trust has a dedicated Corporate Quality and Patient Experience Governance Committee. All data and information within the Quality Report is reviewed through this committee and is supported through a comprehensive documented three year Quality Improvement Strategy. The Board of Directors regularly review the Quality Improvement Dashboard and progress against identified projects. The Trust has an identified Quality Improvement Department with relevantly skilled individuals to support the execution of the Quality Improvement Strategy across the organisation. Capability building in Quality Improvement techniques and skills has been and remains a key objective of the organisation. Staff at all levels are exposed to either collaborative working, clinical microsystems or specific quality improvement educational programmes both internally and externally to ensure skills are developed and maintained. In addition, some members of the Board have completed the Board on Boards training programme in Quality Improvement awareness and skills. The quality report has been reviewed through both internal and external audit processes and comments have been provided by local stakeholders including commissioners, patients and the local authority. continued next page 200 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

201 2 Accountability Report The Trust assures the quality and accuracy of elective waiting time data, and the risks to the quality and accuracy of this data. The quality of performance information is continually assessed. Each Division operates a weekly Access & Performance meeting where Patient Tracking Lists are scrutinised in detail by the service team and the Divisional Managing Director. The Patient Tracking Lists include all patients currently part of a Referral To Treatment (RTT) pathway. The Divisions have processes that validate patient pathways prior to any monthly performance information being produced and/or submitted externally. This validation is reviewed and signed off by a Divisional Managing Director and subsequently by a member of the Executive Team. Any issues that are highlighted within the data are reported by the Service team through to the Data Quality team for investigation and are acted on appropriately. Review of 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 who 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 and the audit committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Trust s Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. Internal Audit provides me with an opinion about the effectiveness of the assurance framework and the internal controls reviewed as part of the internal audit plan. Work undertaken by internal audit is reviewed by the Assurance Framework s Committees and the Audit Committee. The Board Assurance Framework/ Corporate Risk Register is presented to the Executive Assurance and Risk Committee on a quarterly basis and all significant risks are detailed within the monthly Integrated Performance Dashboard presented to the Board by the Chief Executive. This provides me and the Board with evidence of the effectiveness of controls in place to manage risks to achieve the organisations principal objectives. My review is also informed by External Audit opinion, inspections carried out by the Care Quality Commission and other external inspections, accreditations and reviews. The processes outlined below are well established and ensure the effectiveness of the systems of internal control through: Executive Assurance and Risk Committee review of the Board Assurance Framework, including risk registers and action plans Board oversight of all significant risks Audit Committee scrutiny of controls in place; Review of serious untoward incidents and learning by the Assurance Framework committees, including those for risk management and clinical effectiveness Review of progress in meeting the Care Quality Commission s Fundamental Standards by the Corporate Governance Committees Internal audits of effectiveness of systems of internal control 201 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

202 2 Accountability Report Conclusion The Board has extensive and effective governance assurance systems in operation. These systems enable the identification and control of risks reported through the Board Assurance Framework and Corporate Risk Register. Internal and external reviews, audits and inspections provide sufficient evidence to state that no significant internal control issues have been identified during 2016/17, and that these control systems are fit for purpose. Signed: Date: 26 May 2017 Sir David Dalton Chief Executive 202 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

203 3 Independent Auditor s report 203 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

204 3 Independent Auditor s Report Independent Auditor s Report to the Council of Governors of Salford Royal NHS Foundation Trust Our opinion on the financial statements is unmodified In our opinion: The financial statements give a true and fair view of the financial position of the Salford Royal NHS Foundation Trust (the Trust) and group as at 31 March 2017 and of the Trust s and group s expenditure and income for the year then ended; and The financial statements have been prepared properly in accordance with International Financial Reporting Standards (IFRSs) as adopted by the European Union, as interpreted and adapted by the NHS Foundation Trust annual reporting manual 2016/2017 and the requirements of the National Health Service Act Who we are reporting to This report is made solely to the Council of Governors of the Trust, as a body, in accordance with Schedule 10 of the National Health Service Act Our audit work has been undertaken so that we might state to the Trust s Council of Governors those matters we are required to state to them in an auditor s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Trust and the Trust s Council of Governors, as a body, for our audit work, for this report, or for the opinions we have formed. What we have audited We have audited the financial statements of Salford Royal NHS Foundation Trust for the year ended 31 March 2017 which comprise the group and Trust statement of comprehensive income, the group and Trust statement of financial position, the group and Trust statement of changes in taxpayers equity, the group and Trust statement of cash flows and the related notes. The financial reporting framework that has been applied in their preparation is applicable law and the NHS Foundation Trust annual reporting manual 2016/17. Overview of our audit approach Overall group materiality: 9,100,000 which represents 1.4% of the group s gross operating expenses; We performed a fullscope audit of Salford Royal NHS Foundation Trust and targeted audit procedures at its component Salford Royal NHS Foundation Trust General Charitable Fund (the Charity); Key audit risks were identified as: Change in accounting system Accounting for membership of Greater Manchester Pension Fund and the associated reimbursement right Occurrence of income from patient care activities and existence of associated receivables 204 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

205 3 Independent Auditor s Report Our assessment of risk In arriving at our opinions set out in this report, we highlight the following risks that, in our judgement, had the greatest effect on our audit and how we tailored our procedures to address these risks in order to provide an opinion on the financial statements as a whole. This is not a complete list of all the risks we identified: Audit risk Change in accounting system In December 2016 the group moved its financial accounting from Integra to the efinancials run by ELFS Shared Services, a division of the Trust. In any such largescale transfer of data, there is a risk that misstatements or omissions may occur. We therefore identified the change in accounting system as a significant risk requiring special audit consideration. Accounting for membership of Greater Manchester Pension Fund (GMPF) and the associated reimbursement right. Following the creation of the Integrated Care Organisation (ICO) of which the Trust is a member a number of social care staff who were members of the GMPF transferred from Salford City Council (the Council) to the Trust. The Trust became an admitted member of the GMPF, a defined benefit pension scheme. The Council agreed to remain liable for any historic pension deficit relating to the staff transferred and so the Trust has a right to reimbursement for this from the Council. This is the first time the Trust is required to account for a defined benefit pension scheme where its share of the underlying assets and liabilities are identifiable. We therefore identified the accounting for membership of the GMPF and the associated reimbursement right as significant risks requiring special audit consideration. How we responded to the risk Our audit work included, but was not restricted to: Documenting our understanding of the group s arrangements for the transfer of data from Integra to efinancials Assessing the risk of material misstatement in the financial statements that may arise as a result of the transfer of data from Integra to efinancials including the use of our IT specialists Obtaining and inspecting, on a sample basis, the reconciliation files showing the transfers of balances from Integra to efinancials account codes Documenting our understanding of the new system and carrying out walk throughs to assess the design of controls Our audit work included, but was not restricted to: Obtaining an understanding of the agreement between the Trust and the Council Evaluating the group s accounting policy for accounting for the Trust s membership of the GMPF for appropriateness Assessing the Trust s accounting entries against the requirements of International Accounting Standard (IAS) 19 Employee benefits Assessing the work of the actuarial expert employed by the Trust, including the assumptions used and the base data on which they are based Inspecting the actuary s report of opening and closing pension fund liabilities attributable to the Trust and the movements in the year and agreeing them to the Trust s financial statements, and Assessing the evidence provided by the Trust to support the existence, valuation and disclosure of the asset associated with the Trust s reimbursement right from the Council The group s accounting policy on the GMPF is shown in note 1.3 to the financial statements. Related disclosures are included in notes 26 Other assets, 31 Other liabilities, 38 Defined benefit pension schemes, and 43 transfers by absorption. continued next page 205 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

206 3 Independent Auditor s Report Audit risk Occurrence of income from patient care activities and existence of associated receivables 74% of the group s income is derived from contracts with NHS commissioners for patient care activities and a further 11% is derived from contracts with Local Authority commissioners. The Trust recognises patient care activity income during the year based on the completion of these activities. For 2016/17, there is additional pressure on the Trust to recognise income because of the need to achieve an agreed outturn to secure a budgeted 11 million share of the Sustainability and Transformation Fund (STF). We therefore identified occurrence of income from patient care activities and the existence of associated receivables as a significant risk requiring special audit consideration. How we responded to the risk Our audit work included but was not restricted to: Evaluating the group s accounting policy for recognition of income from patient care activities for appropriateness Gaining an understanding of the group s system for accounting for income from patient care activities and evaluating the design of the associated controls Agreeing, on a sample basis, contract income from patient care activities to contract documentation including signed contracts, contract variations or other supporting documentation Agreeing, on a sample basis, income from patient care activities to receipts in year, or subsequently, or alternative evidence Testing a sample of income from patient care activities recognised in March 2017, checking whether it has been accounted for in the correct financial year Obtaining an exception report from the Department of Health (DoH) that details differences in reported income and expenditure; and receivables and payables between NHS bodies; agreeing the figures in the exception report to the Trust s financial records on a sample basis; and for differences calculated by the DoH as being in excess of 250,000, obtaining corroborating evidence to support the amount recorded in the financial statements by the Trust The group s accounting policy on income from patient care activities is shown in note 1.2 to the financial statements and related disclosures are included in notes 3.1 and Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

207 3 Independent Auditor s Report Our application of materiality and an overview of the scope of our audit Materiality We define materiality as the magnitude of misstatement in the financial statements that makes it probable that the economic decisions of a reasonably knowledgeable person would be changed or influenced. We use materiality in determining the nature, timing and extent of our audit work and in evaluating the results of that work. We determined materiality for the audit of the group financial statements as a whole to be 9,100,000, which is 1.4% of the group s gross operating expenses. This benchmark is considered the most appropriate because we consider users of the group s financial statements to be most interested in how it has expended its revenue and other funding. Materiality for the current year is at the same percentage level of gross operating expenses as we determined for the year ended 31 March 2016 as we did not identify any significant changes in the group s business or the environment in which it operates. We use a different level of materiality, performance materiality, to drive the extent of our testing and this was set at 70% of financial statement materiality for the audit of the group financial statements. We also determined a lower level of specific materiality for certain areas such as disclosures of senior manager remuneration in the Remuneration Report. We determined the threshold at which we will communicate misstatements to the Audit Committee to be 250,000. In addition we will communicate misstatements below that threshold that, in our view, warrant reporting on qualitative grounds. Overview of the scope of our audit An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: Whether the accounting policies are appropriate to the Trust s and group s circumstances and have been consistently applied and adequately disclosed; The reasonableness of significant accounting estimates made by the Chief Executive as Accounting Officer; and The overall presentation of the financial statements. In addition, we read all the financial and nonfinancial information in the annual report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. We conducted our audit in accordance with International Standards on Auditing (ISAs) (UK and Ireland) having regard to the Financial Reporting Council s Practice Note 10 Audit of financial statements of public sector bodies in the United Kingdom. Our responsibilities under the Code of Audit Practice published by the National Audit Office on behalf of the Comptroller and Auditor General (the Code) and those standards are further described in the Responsibilities for the financial statements and the audit section of our report. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion. continued next page 207 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

208 3 Independent Auditor s Report We are independent of the group in accordance with the Auditing Practices Board s Ethical Standards for Auditors, and we have fulfilled our other ethical responsibilities in accordance with those Ethical Standards. Our audit approach was based on a thorough understanding of the group s business and is risk based, and in particular included: Evaluation of the group s internal control relevant to the audit including its relevant IT systems and controls over key financial systems; Evaluation of the identified component (the Charity) to assess its significance and to determine the planned audit response; and Performance of targeted audit procedures on the financial statements of the component, Salford Royal NHS Foundation Trust General Charitable Fund focusing on investments and cash balances, and analytical procedures on other items. Overview of the scope of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code, having regard to the guidance on the specified criteria issued by the Comptroller and Auditor General in November 2016, as to whether the Trust had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined these criteria as that necessary for us to consider under the Code in satisfying ourselves whether the Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2017, and to report by exception where we are not satisfied. We planned our work in accordance with the Code. Based on our risk assessment, we undertook such work as we considered necessary. Other reporting required by regulations Our opinion on other matters required by the Code is unmodified In our opinion: The parts of the Remuneration Report and Staff Report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the NHS Foundation Trust annual reporting manual 2016/17 and the requirements of the National Health Service Act 2006; and The other information published together with the audited financial statements in the annual report for the financial year for which the financial statements are prepared is consistent with the audited financial statements. 208 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

209 3 Independent Auditor s Report Matters on which we are required to report by exception Under the ISAs (UK and Ireland), we are required to report to you if, in our opinion, information in the annual report is: Materially inconsistent with the information in the audited financial statements; or Apparently materially incorrect based on, or materially inconsistent with, our knowledge of the group acquired in the course of performing our audit; or Otherwise misleading. In particular, we are required to report to you if: We have identified any inconsistencies between our knowledge acquired during the audit and the Directors statement that they consider the annual report is fair, balanced and understandable; or The annual report does not appropriately disclose those matters that we communicated to the Audit Committee which we consider should have been disclosed. Under the Code we are required to report to you if, in our opinion: The Annual Governance Statement does not meet the disclosure requirements set out in the NHS Foundation Trust annual reporting manual 2016/17 or is misleading or inconsistent with the information of which we are aware from our audit. We are not required to consider whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls; or We have reported a matter in the public interest under Schedule 10 (3) of the National Health Service Act 2006 in the course of, or at the conclusion of the audit; or We have referred a matter to the regulator under Schedule 10 (6) of the National Health Service Act 2006 because we had reason to believe that the Trust, or a director or officer of the Trust, was about to make, or had made, a decision which involved or would involve the incurring of expenditure that was unlawful, or was about to take, or had taken a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or We have not been able to satisfy ourselves that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March We have nothing to report in respect of the above matters. 209 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

210 3 Independent Auditor s Report Responsibilities for the financial statements and the audit What the Chief Executive, as Accounting Officer, is responsible for: As explained more fully in the Statement of the Chief Executive s responsibilities as the Accounting Officer of Salford Royal NHS Foundation Trust, the Chief Executive, as Accounting Officer, is responsible for the preparation of the financial statements in the form and on the basis set out in the Accounts Directions included in the NHS Foundation Trust annual reporting manual 2016/17 and for being satisfied that they give a true and fair view. The Accounting Officer is also responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the Trust s resources. What we are responsible for: Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law, the Code and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board s Ethical Standards for Auditors. We are required under Section 1 of Schedule 10 of the National Health Service Act 2006 to satisfy ourselves that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report where we have not been able to satisfy ourselves that it has done so. We are not required to consider, nor have we considered, whether all aspects of the Trust s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. Certificate We certify that we have completed the audit of the financial statements of Salford Royal NHS Foundation Trust in accordance with the requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Code. Sarah Howard Partner for and on behalf of Grant Thornton UK LLP 4 Hardman Square Spinningfields Manchester M3 3EB 30 May Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17

211 4 Annual accounts 211 Salford Royal NHS Foundation Trust Annual Report and Accounts 2016/17